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Pediatric Primary Care Exam 2 > Lead Poisoning and Autism > Flashcards

Lead Poisoning and Autism Flashcards

1
Q

10 Major Points about Lead Poisoning

A
  1. Lead is found in the ground and once in the ground it never leaves the ground; it doesn’t decompose
  2. Lead is all over the environment especially old buildings
  3. Most common source is pain and it is also found in X-rays, computer monitors, etc. (see slide)
  4. If child is lead burden or lead burden risk give adequate calcium and iron
  5. Lead is absorbed poorly so if the child eats it, only 10% gets absorbed (but low calcium and iron will cause more to get absorbed)
  6. Developmental delays/PICA is one of the biggest risk factors for lead poisoning
  7. Children with lead burden as a child may have been treated with lead and the lead stays in long bones and once pregnant, the lead will mobilize out of the long bones and go to the fetus; lead follows calcium in and out of bones
  8. If lead stays in bones and patient gets osteoporosis, the lead will leave the bone and go to the brain
  9. No matter how much lead poisoning is treated, it can never get completely out of the person (never be 0 again)
  10. Developing world still uses lead and it is not degradable
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2
Q

Lead Poisoning (6)

A
  1. Lead has no known biological function.
  2. There is no proven safe lower limit for lead.
  3. Lead Pb++, competes with Ca++, Fe++
  4. It is cheap, useful, easy to mine
  5. Lead is ubiquitous- in air, food, water, soil, ceilings etc.
  6. Leaded petrol means that all environmental dusts are high in lead- contaminating ceiling dust, topsoil, window wells etc
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3
Q

Uses and Sources of Lead (9)

A
  1. TV’s, Computer monitors
  2. Batteries, Bullets Sinkers
  3. Aviation
  4. X-ray shields
  5. Crystal-ware (high levels in decanters)
  6. Explosives
  7. Non-stick linings of pots (in the past)
  8. Plastic coloring (wire, blinds)
  9. Pewter
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4
Q

Absorption of Lead (6)

A
  1. Lead goes down iron or calcium absorption pathway.
  2. Children absorb lead well orally (~50%) of adults poorly (~10%). Children also have more hand to mouth activity.
  3. Lead absorption is enhanced if diet is poor in iron or calcium.
  4. Pica is one of the worst risk factors.
  5. Lead can be inhaled.
  6. Tetraethyl lead can be absorbed via skin.
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5
Q

Release of Lead During Osteolysis (5)

A
  1. Pregnancy increases mobilization of lead from maternal skeleton
  2. Mobilization of lead from the skeleton during the post-natal period is larger than during pregnancy.
  3. Lead is released in menopausal bone loss
  4. Lead levels have second peak in middle age- more in men than women (NHANES 3).
  5. Lead follows calcium into and out of bone
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6
Q

Lead Movement (2)

A
  1. In childhood, blood lead levels reflect the environmental lead level ie exogenous lead
    * Protection requires placing barriers between the child and the lead.
  2. In adults, lead levels reflect the release of endogenous lead from bone, as well as the intake of exogenous lead.
    * Protection requires prevention of exposure plus preservation of bone density.
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7
Q

AAP Recommendations for Lead Poisoning (6)

A
  1. Shift focus to primary prevention
    * Term Blood level of concern was phased out
  2. Any lead is associated with AHDH, decrease IQ, poor academic achievement
  3. Assess for iron deficiency and general nutrition (e.g. calcium and vitamin C levels).
  4. Iron-deficient children should be provided with iron supplements.
  5. Communicate results with families.
  6. Children with elevated BLLs will need to be followed over time
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8
Q

Methods to prevent lead exposure (7)

A
  1. If renovating, get child out of house and remove shoes before going inside due to dust on them
  2. Plant grass where you have soil
  3. House down front steps to avoid dirt getting inside
  4. Pets should be washed if they go outside
  5. Toys should be washed and should not be bought from China
  6. Lead paint should be removed from house
  7. Wash fruits and vegetables well from dust/dirt
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9
Q

Effects of lead

A
  1. 95% of lead is in long bones and matrices of long bones
  2. During any event of osteolysis lead releases and crosses BBB and affects neurodevelopment
  3. Can go into coma or status epilepticus from lead poisoning
  4. At level of 40 you can get kidney damange etc
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10
Q

2 major sources of lead

A
  1. Paint in homes—lead dust and paint chips

2. Soil

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11
Q

Minor sources of lead (8)

A
  1. Water pumped through leaded pipes (Schools with old lead pipes.
  2. Imported items including clay pots, imported food, toys
  3. Chocolate is higher in lead
  4. Spices and herb
  5. Lead – soldered cans
  6. Certain consumer products such as candies (particularly from Mexico), make-up (Kohl, surma), South Asian
  7. Ayurvedic remedies, and jewelry.
  8. Ceramics, professions with lead exposure
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12
Q

Testing for Lead (6)

A
  1. Lead Level testing is currently required at 12 and 24 months for all Medicaid-enrolled children, regardless of known lead-exposure risk.
  2. Testing will often occur during routine well-child care.
  3. Children younger or equal to 72 months who missed recommended screening at a younger age should be screened
  4. All immigrant, refugee and internationally-adopted children when they arrive in the U.S., due to their increased risk
  5. Screen neonates and infants born to women with lead exposure during pregnancy and lactation
  6. Children younger than 4 need to have screening if they haven’t already
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13
Q

Autism

A

Autism spectrum disorder includes a continuum of neurodevelopmental disorders characterized by deficits in social communication and interaction along with restrictive patterns of behaviors, interests, and activities

  • Restricted interest, will do the same activity over & over again
  • Will have a special gift
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14
Q

Overview of autism (4)

A
  1. CDC: 1 in 68 children.
  2. 1 in 54 males and 1 in 252 females
  3. Genetic and environmental factors likely have an equal effect with sibling risk rates at or above 25%
  4. All children need a chromosomal micro array if they have a sibling with ASD or if they look like they have it; Need fragile X-testing done if they look like they have fragile-X (long faces, ig ears)
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15
Q

Why the increase in autism? (3)

A
  1. Diagnostic substitution
    * Child formerly diagnosed as developmentally delayed or intellectually disabled
  2. Broadening of the definition
  3. Better screening
    * Improved recommendation to screen at 18 and 24 months
    * Biggest increase is among higher functioning patients with less severe disease in African Americans and Hispanics.
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16
Q

DSM Criteria A for Autism (7)

A

Persistent deficit in social communication and social interaction across multiple context

  1. Deficits in social emotion reciprocity
    - Social interaction deficit
  2. Deficits in nonverbal communicative behaviors
    - Poor verbal and non verbal behavior
    - Lack of facial expression
  3. Deficits in developing, maintaining and understanding relationship
  4. Problem with social communication (goes across multiple domains)
  5. May be lack of verbal, lack of expression, difficulty in relationships, etc.
  6. Early signs may include trouble with modulating voice tone
  7. Lack of give and take during communication (doesn’t look at you or reciprocate)
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17
Q

DSM Criteria B for Autism (4)

A

Restricted, repetitive pattern of behavior, interest, or activities as manifested by:

  1. Stereotyped or repetitive motor movements, echolalia, idiosyncratic phrases
  2. Insistence or sameness, inflexible adherence to routines, ritualized patterns of verbal or nonverbal behavior
  3. Highly restricted, fixed interests that are abnormal intensity or focus
  4. Hypo or hyperractivity to sensory input
18
Q

DSM Criteria C for Autism (4)

A

Severity is based on the degree of social communication impairment (A) and restricted, repetitive patterns of behavior (B)

c) Symptoms must be present in early development (may become more manifest as social demands exceed capacity)
d) Symptom cause significantly different impairment in social, occupational or other important areas of current functioning
e) These disturbances are not better explained by intellectual developmental disability

19
Q

ASD Communication Signs and Symptoms (3)

A

Early sign is delay or abnormal use of language

  1. Echolalia - meaningless repetition of another person’s spoken words as a symptom of psychiatric disorder.
  2. Speak tangentially about specific interests without any concerns to listener’s response
  3. Trouble modulating vocal tone
20
Q

ASD Social Reciprocity Signs and Symptoms (9)

A
  1. Give and take of social interaction—must recognize another person’s perspective
  2. Trouble establishing relationship with peers
  3. May not empathize well
  4. Joint attention or ability to attend to an activity with another person is lacking
  5. Can’t point to an object (protoimperative pointing)
  6. Pointing to draw something to the attention of another (Protodeclarative point) more important
  7. Looks at mouth not eyes
  8. Repetitive behaviors, may not be able to stop themselves
  9. Sensitive to sounds or doesn’t pay attention to a loud sound (can be either spectrum)
21
Q

ASD earliest signs and symptoms include delays/abnormalities in.. (4)

A
  1. Joint attention (smiling, pointing, showing objects)
  2. Social interaction (interest in others, responds to name, uses gestures—waving, shaking head)
  3. Play behavior (using toy as intended, pretend play)
  4. Language (babbling, use of words, understanding commands)
    * Any loss of language or social skills
22
Q

ASD Early Signs of Deficits in social communication and social interaction (4)

A
  1. No/reduced smiling
  2. No cuddling
  3. No/reduced eye contact
  4. Tunes others out
    * But hears environmental sounds
    * Appears not to hear
23
Q

ASD Signs by age (8, 9, 12, 16, 24, and over 24 months)

A
  1. 8 months: No response to name
  2. 9 months: no babbling
  3. 12 months: no pointing or other gestures (rudimentary pointing)
  4. 16 months: no single words
  5. 24 months: no functional 2 word phrases (not echolala)
  6. Over 24 months: advanced talk, echolalia, neologism, videospeak, abnormal speech delivery
24
Q

ASD Early Signs and Play/Behavior (5)

A
  1. Persistent sensory motor play
  2. Likes routines
  3. Plays with parts of toys
  4. Unusual or intense but narrow interests or attachments: prefers objects (pens, keys, lights)
  5. Unusual interest in specific objects: trains, characters from videos, computerized puzzles
25
Q

Body movement signs of ASD

A
  1. stereotypic motor mannerisms (spins, flapping, bouncing, spinning) after 3 years old
  2. Clumsiness
26
Q

Behavioral Signs of ASD (7)

A
  1. Inattentive/hyperactive
  2. Impulsive behavior
  3. Anxiety
  4. Self-injurious behaviors (biting, head banging)
    * Occurs mainly with severe ASD
  5. Unusual sensory seeking or avoiding
  6. Doesn’t cry if in pain
  7. Severe tantrums
27
Q

Cognitive Deficits of ASD

A
  1. Hyperlexia: reads without understanding
  2. Cognitive impairment (moderate IQ in 35-50 range) 50%
  3. Unevenness of skills
  4. Splinter skills/savant skills
28
Q

Less than 12 month old ASD signs (5)

A
  1. Perceived as different
  2. Decreased eye contact
  3. No big smiles/no joyful expression at 4-5 months
  4. Extremes of temperament (marked irritability to alarming passivity)
  5. Failure to mold)
29
Q

12 month old ASD signs (4)

A
  1. No back and forth sharing/gestures (pointing, waving)
  2. Decrease eye contact and response to name
  3. No babbling
  4. Regressions
30
Q

15-18 month old ASD signs (5)

A
  1. No pointing or showing
  2. Lack of eye contact, poor orienting to name
  3. No words by 16 months
  4. Regression
  5. Lack of pretend play/lack of imitation
31
Q

24 months old ASD signs (4)

A
  1. Abnormal gaze monitoring
  2. Lack of response to name
  3. No spontaneous meaningful 2 word phrases
  4. Repetitive movements with objects (flicking light switches on and off, same movement with same toy)
32
Q

Possible causes of ASD (4)

A
  1. Certain genetic disorders are more likely to be associated with autism
    * Fragile X, neurofibromatosis, Tuberous sclerosis, Angelman, Rett
  2. Vaccines are NOT the cause
  3. Advanced maternal and paternal age
  4. Premature and twin gestation
33
Q

Screening for ASD (4)

A
  1. MCHAT-R at 18 and 24 months
  2. Autism toolkit
  3. Infant Toddler check list at 9-24 months
    * Screening for communication delay
  4. Childhood Autism Screening test at 4 year to 11 yearsS
34
Q

Social indications for immediate neuro eval (3)

A
  1. Abnormal gaze monitoring (joint attention)
  2. No pointing/gestures by 12 months
  3. LOSS OF LANGUAGE OR SOCIAL SKILL AT ANY TIME
35
Q

Communication indications for immediate neuro eval (4)

A
  1. Absent babbling by 12 months
  2. No single words by 16 months
  3. No spontaneous (not echolalic) phrases by 24 months
  4. LOSS OF LANGUAGE OR SOCIAL SKILL AT ANY TIME
36
Q

Recommendations for children with ASD(5)

A
  1. Clinicians should coordinate an appropriate multidisciplinary assessment of children with ASD.
  2. Physical examination, a hearing screen, a Wood’s lamp examination for signs of tuberous sclerosis, and genetic testing, which may include G-banded karyotype, fragile X testing, or chromosomal microarray
  3. Chromosomal microarray and fragile X are key tests
  4. Multi-disciplinary team is key
  5. Dysmorphology — refer to genetics
37
Q

Do additional ASD evaluations if child has..(4)

A
  1. History of regression
  2. Dysmorphology
  3. Staring spells
  4. Family history
38
Q

ASD Differential Dx (7)

A
  1. Infectious (e.g., encephalitis or meningitis),
  2. Endocrinologic (e.g., hypothyroidism)
  3. Metabolic (e.g., homocystinuria)
  4. Traumatic (e.g., head injury)
  5. Toxic (e.g., fetal alcohol syndrome)
  6. Genetic (e.g., chromosomal abnormality)
  7. Developmental disorder (e. g. Landau-Kleffner syndrome)
39
Q

ASD Treatment: applied behavior analysis

A
  1. Based on learning theory
  2. Early models aimed at teaching skills using discrete trial (comprehensive structured behavioral interventions)
  3. More recent models involve naturalistic behavioral interventions that are more child centered:
    * Promotes generalization of skills, include incidental teaching
    * Direct relationship between child’s response and reinforce
    * Less prompt dependent
40
Q

Pharmacotherapy for ASD (4)

A
  1. Pharmacotherapy may be offered to children with ASD when there is a specific target symptom or comorbid condition
  2. Pharmacologic intervention of comorbid conditions (anxiety, depression) or for aggression, self-injurious behavior, hyperactivity, inattention, compulsive-like behaviors, repetitive or stereotypic behaviors, and sleep disturbances
  3. Risperidone/aripiprazole approved for the treatment of irritability– physical aggression and severe tantrum behavior
  4. Medication should be combined with parent training
41
Q

Alt treatments for ASD (2)

A
  1. Clinicians should specifically inquire about the use of alternative/complementary treatments and be prepared to discuss their risk and potential benefits
  2. Parents are using gluten elimination diets
    * Be aware of apps available for parents to track behavior and food sensitivity
42
Q

Normal development by age (6)

A
  1. Reciprocal smiling @ 2 months
  2. Gaze monitoring @ 8 months
  3. Follows a point @ 9 months
  4. Showing objects @ 10 months
  5. Pointing to obtain an object (protoimperative) @ 12 months
  6. Pointing to indicate another object of interest (protodeclarative) @ 14 months

Pediatric Primary Care Exam 2 (12 decks)

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