Pediatric 1 Flashcards
At which age the normal HR range is similar to that of adults?
12
Infant visit schedule
Within 1 wk post-discharge 1mo 2mo 4mo 6mo 9mo 12mo 15mo 18mo 24mo Annually between 2-5 yr Every 1-2 y between 6-12 yr
Publicly funded immunization schedule for:
DTaP-IPV-Hib
2mo
4mo
6mo
18mo
Publicly funded immunization schedule for:
dTaP-IPV
4-6 y
Publicly funded immunization schedule for:
Pneu-C-13
2mo
4mo
12mo
Publicly funded immunization schedule for:
Rot-1
2mo
4mo
Publicly funded immunization schedule for:
Men-C-C
Men-C-ACYW
Men-C-C: 12mo
Men-C-ACYW: Grade7
Publicly funded immunization schedule for:
MMR
Var
MMRV
MMR: 12 SC
Var:15 mo
MMRV: 4-6 yr
Publicly funded immunization schedule for:
HepB
0-1-6 mo
Grade 7
Publicly funded immunization schedule for:
HPV-4
Grade 7
0-2-6 mo
Publicly funded immunization schedule for:
Tdap
14-16 y
Publicly funded immunization schedule for:
Inf
Yearly, every autumn
Contraindications to DTaP-IPV
Evolving unstable neurologic disease
Hyporesponsive/hypotonic following previous vaccine
Anaphylactic reaction to neomycin, streptomycin
Contraindications to Rot-1
Hx of intussusception
ImComp
Abdominal disorder (Meckel…)
Received blood products within 42d
MMR contraindications
Pregnancy
ImComp
Anaphylactic reaction to gelatin
MMR for HIV + children
Allowed if healthy
Var vaccine contraindications
Pregnant
Planning to get pregnant within 3 mo
Anaphylactic reaction to gelatin
Hep B contraindication
Anaphylaxis to baker’s yeast
dTaP contra
1st trimester of pregnancy
Contraindications to flu vaccine
<6mo
ImComp
Egg-allergic (live attenuated)
Egg allergy and flu vaccine
Live attenuated vaccine not recommended
Trivalent/quadrivalent vaccine can be given in environment where anaphylaxis can be managed
MenB
Publicly funded only for selected groups: Asplenia Ab/Compliment deficiencies Cochlear implant recipients HIV Close contacts with infected individuals
Contra: anaphylactic reaction to components
Vaccination in case of asplenia/hyposplenia
All routine vaccines
Yearly flu (among routines)
Men-C-C at age 2 or older
Men-P-ACYW at least 2 wk later, booster q 2-5y
Pneu-P-23: 2y or older
Pneu-P-23: single booster, at age 3 yr or older
Hib: single booster at age 5 or older
Organisms causing infection more frequently in asplenia
Hib Pneumococ Meningococ E.coli Klebsiella Salmonella GBS
Vaccine injection site in infants
Anterolateral thigh
All IM
Except:
SQ: MMR, Var, MMRV
Oral: rota
Corrected GA for premature infants is used up to age
2 yr
Most lymphatic, gonad, CNS growth time period
CNS: first 2 years
Lymphoid: mid-childhood
Gonads: puberty
Upper/lower body proportion
Newborn: 1.7
Adult:
0.9 male
1 female
When does newborn lose and regain weight?
Wt loss, 10%, in first 7 days
Regain by 10-14 d of age
Infant wt
Birth: 3250
x2: 4-5 mo
x3: 1y
x4: 2y
Height of infant
Birth: 50 cm
Growth during 1st yr: 25 cm
2nd yr: 12 cm
3rd yr: 8 cm
Then: 4-7 cm/y until puberty
Measurement:
Supine until 2
Then standing
Head circumference
Birth: 35cm
2 cm/mo x 3mo (0-3 mo)
1 cm/mo x 3mo (3-6mo)
0.5 cm/mo x 6 mo (6-12mo)
Upgoing plantar reflex in infants
Normal until 2 yr
Age of disappearance of moro reflex
4-6 mo
Galant reflex
Infant held in ventral suspension and one side of back is stroked along paravertebral line
Pelvis moves in the direction of stimulated side
Age of disappearance of galant reflex
2-3 mo
Age of disappearance of grasp reflex
3-4 mo
ANTR reflex (asymmetric tonic neck reflex)
Turn infant’s head to one site
Response: fencing posture
Age of disappearance of ATNR reflex
4-6 mo
Age of disappearance of placing reflex
Variable
Age of disappearance of sucking reflex
2-3 mo
Age of disappearance of parachute reflex
Never
Developmental red flags
Not walking at 18 mo
Rolling too early at < 3 mo
Hand preference at < 18 mo
Speech < 10 words at 18 mo
Not smiling at 3 mo
Not pointing at 15-18mo
Growth motor at 1 mo
Turns head from side to side when supine
Fine motor at 1 mo
Hands fisted
Thumb in fist
Speech/language at 1 mo
Cries
Startles to loud noise
Adaptive/social skills at 1 mo
Calms when comforted
Gross motor at 2 mo
Briefly raises head when prone
Holds head erect when upright
Fine motor at 2 mo
Pulls at cloths
Speech/language at 2 mo
Coos
Gurgles
Adaptive and social skills at 2 mo
Smiles responsively
Recognizes/calms down to familiar voice
Follows movements with eyes
Gross motor at 4 mo
Lifts head and chest when prone
Holds head steady when supported sitting
Rolls prone to supine
Fine motor at 4 mo
Briefly holds object when placed in hand
Reaches for midline objects
Speech/language at 4 mo
Turns head towards sounds
Adaptive/social skills at 4 mo
Laughs responsively
Follows with eyes
Responds to people with excitement
Gross motor at 6 mo
Tripod sit
Pivots in prone position
Fine motor at 6 mo
Transfers objects from hand to hand
Bring objects to mouth
Ulnar or raking grasp
Speech and language at 6 mo
Babbles
Adaptive/social at 6 mo
Stranger anxiety
Beginning of object permanence
Gross motor at 9 mo
Sits well without support
Crawls
Pulls to stand
Stands with support
Fine motor at 9 mo
Early pincer grasp with straight wrist
Speech/language at 9
Mama, dada
Imitates 1 word
Responds to no regardless of tone
Adaptive/social at 9 mo
Plays games (peek-a-boo)
Reaches to be picked up
Gross motor at 12 mo
Gets into sitting without help
Stands without support
Walks while holding on
Fine motor at 12 mo
Neat pincer grasp
Releases ball with throw
Speech and language at 12 mo
2 words
Follows 1 step commands
Uses facial expression, sounds, actions to make needs known
Gross motor at 15 mo
Walks without support
Crawls upstairs/steps
Fine motor at 15 mo
Picks up and eats finger foods
Scribbles
Stacks 2 blocks
Speech at 15 mo
4-5 words
Points to needs/wants
Adaptive/social at 15
Looks to see how others react (after falling…)
Adaptive/social at 12 mo
Responds to own name
Separation anxiety begins
Gross motor at 18 mo
Runs
Walks forward pulling toys/objects
Fine motor at 18 mo
Tower of 3 cubes
Scribbling
Eats with spoon
Speech at 18 mo
10 words
Follows simple commands
Adaptive/social at 18 mo
Shows affection towards others
Points to show interest in something
Gross motor at 24 mo
Climb up and down steps with 2 feet per step
Runs
Kicks ball
Fine motor at age 24
Tower of 6 cubes
Undresses
Speech at 24 mo
2-3 word phrases
50% intelligible
I, me, you
Understands 2-step commands
Adaptive/social at 24 mo
Parallel play
Helps to dress
Gross at 36 mo
Rides tricycle
Climbs 1 foot per step
Down 2 feet per step
Stands on one foot briefly
Fine motor at 36 mo
Copies a circle
Turns pages one at a time
Puts on shoes
Dress/undress fully, except bottoms
Language/speech at 36 mo
Combines 3 or more words into sentence
Recognizes colors, prepositions, plurals, counts to 10
75% intelligible
Adaptive/social at 36 mo
Knows sex and age
Shares some of the time
Plays make-believe games
Gross at 4 yr
Hops on 1 foot
Climbs down 1 foot per step
Fine motor at age 4 yr
Copies a cross
Uses scissors
Buttons cloths
Speech/language at 4 yr
100% intelligible
Uses past tense
Understands 3 part directions
Adaptive/social skills at age 4
Cooperative play
Fully toilet trained by day
Tries to comfort someone who is upset
Gross motor at 5 y
Skips
Rides bicycle
Fine motor at age 4
Copies of triangle and square
Prints name
Ties shoelaces
Speech at 5 y
Fluent speech
Future tense
Alphabet
Retells sequence of a story
Adaptive skills at age 5
Cooperates with adult requests most of the time
Separate easily from caregiver
Baby daily calorie needs
<10 kg: 100 kcal/kg/d
10-20: 1000 + 50 kcal/kg/d for each kg above 10
> 20: 1500 + 20 kcal/kg/d for each kg above 20
100-50-20
Supplements in BF infants
Vit D 400 IU/d
Iron (6-12 mo if not receiving fortified cereals/meat/meat alternatives) CDC: start at 4 mo
Fluoride (if not sufficient in water)
How to introduce solid food?
At 6 mo (don’t delay beyond 9 mo)
2-3 new foods/w
At least 2 day in between each food
When to introduce highly allergenic foods?
Early
Most common allergenic foods
Egg Milk Mustard Sesame Wheat See food Tree nuts Soy Peanut
When to introduce vegetables, fruits, grains, full-fat milk?
After iron-rich foods are given
When and how to switch to cow milk?
9-24 mo:
Homogenized, 3.25% milk
16 oz/d to NBF infants
No more than 24 oz (750 cc) after 1 yr
2-6 yr:
2% milk
500 ml/d
Amount of feeding meals
Up to 3 large meals
1-2 smaller snacks
When to encourage self-feeding?
By 18 mo
Foods to avoid
Honey until past 12 mo
Added salt/sugar
Excessive milk
Limit juice (max: 4-6 oz: 1/2 cup daily)
Anything with choking hazard
Role of dietary restrictions during pregnancy and breast-feeding in reducing allergy rate in infants
No role
Colostrum properties
High protein
Low fat
High Ig content
Mature breast milk content
Whey/casein : 70/30
Fat: dietary butterfat
Carb: lactose
Advantages of breastmilk
Easily digested
Low renal solute load
IgA
Macrophage
Lymphocyte
Lysozymes
Lactoferrin (inhibits E. Coli growth in intestine)
Lower pH (promotes growth of lactobacillus in GI)
Parent child bonding
Economical
Convenient
Contraindications to breast-feeding
Maternal: Chemo Radioactive compounds HIV Active untreated TB Herpes in breast region Illicit drugs Alcohol > 0.5 g/kg/d Certain meds
Breast feeding jaundice time
1-2 wk
Cause of breastfeeding jaundice
Infant dehydration due to low milk production
Breast milk jaundice time
Persists up to 4-6 mo
Glucuronyl transferase inhibitor in breast milk
Decrease Bil conjugation
Increased enterohepatic circulation of Bil
Healthy, thriving baby
Jaundice resolves
Signs of inadequate intake
Jaundice
Wt loss > 10%
<6 wet diapers/d after 1st week
<7 feeds/d
Sleepy/lethargic
Sleeping throughout the night < 6 wk
Normal number of wet diapers/stools in newborn
1 wet diaper/d of age for first wk
1-2 black or dark green stools/d on day 1-2
3+ brown/green/yellow stool/d on day 3-4
3+ yellow, seedy stools/d on day 5+
Soy protein milk indications
Galactosemia
Desire for vegetarian/vegan diet
(Sucrose instead of lactose)
Indications for aa formula
Short gut
Food allergy
(No lactose)
Indications for protein hydrolysate formula
Food allergy
Malabsorption
(100% casein, no lactose)
Partially hyrolyzed proteins formula indications
Delayed gastric emptying
Cow milk protein allergy
(100% whey)
Fortified formula indications
LBW
Prematurity
(Higher calories and vit A, C, D, K)
Mainly used in hospital (risk of fat-soluble vit toxicity)
Indications for cow’s milk-based formula
Prematurity
Transition into breastfeeding
Contra to breastfeeding
(Lower whey/casein, plant fat)
Allergy rate to soy protein in cow’s milk protein allergic children
10-35%
Appropriate age for swimming lessons
> 4 yr
Age of sunscreen use
From 6 mo
Age of breath holding spells
6mo-4yr
Usually starts during first year of life
Trigger of breath holding spells
Anger, injury, fear
Holds breath and becomes silent
Spontaneously resolves or loses consciousness
Breath holding spell types
Cyanotic
Following anger/frustration
Less commonly pallid
Following pain/surprise
Mx of breath holding spells
Help child control response to frustration
Avoid drawing attention to spell
My be associated with IDA (improves with supplemental iron)
Usually resolves spontaneously (rarely progresses to seizure)
Benefits of circumcision
Slightly decreased: UTI STI Balanitis Cancer of the penis
Contraindications to circumcision
Genital abnormalities
Bleeding disorders
Definition of infantile colic
Paroxysms of irritability and crying
> 3h/d
3d/w
3w
Healthy, well-fed infant
Onset and duration of infantile colin
Onset: 10d- 3 mo
Peak: 6-8 wk
Duration: all resolve, mostly by 3-6 mo
Mx of infantile colic
Parental relief, rest, reassurrance
Hold baby Soother Car ride Music Vacuum Check diaper
Probiotics
Maintain breastfeeding but eliminate allergens from mother’s diet (cow’s milk protein, eggs, wheat, nuts)
Try casein hydrolysate formula
Time of first dentition
5-9 mo
Lower incisors
Then 1/mo
1st assessment by dentist
6 mo after 1st tooth
Definitely by 1 yr of age
Secondary dentition time and first tooth
6 yr
1st molar then lower incisors
Cause of milk caries
Prolonged feeding
Superior front teeth and back molars in first 4 yr
Prevention of milk caries
No bottle at bedtime
Clean teeth after last feed
Minimize juice/sweetened pacifier
Clean teeth with soft damp cloth or toothbrush and water
Water fluoridation
Definition of enuresis
Involuntary urinary incontinence by day and/or night in child > 5
When to evaluate enuresis?
If: Dysuria Change in urine color, odor, stream Secondary Diurnal Change in gait Stool incontinence
Primary nocturnal enuresis etiology
Boys>
Developmental disorder
Maturational lag in bladder control while asleep
Mx of primary nocturnal enuresis
Time and reassurance
Limiting fluid
Voiding prior to sleep
Bladder retention exercises
Scheduled toileting overnight (limited effectiveness)
Conditioning wet alarm (70% success rate)
2nd line:
medications: oral DDAVP, imipramine
Children > 7 y
For sleepovers/camps
DDAVP vs Conditioning alarm for nocturnal enuresis
Similar effectiveness
Higher relapse rate for DDAVP
Secondary enuresis definition
After a period of bladder control >6 mo
Etiology of secondary enuresis
Inorganic regression due to anxiety/stress
Or
Organic causes: UTI, DM, DI, sleep apnea, neurogenic bladder, CP, seizure, pinworm
Tx: underlying
Diurnal enuresis definition and etiology
Day time wetting
Mostly also have night time wetting
Etiology:
Micturition deferral
Structural anomalies: ectopic ureteral site, neurogenic bladder
UTI, constipation, CNS disorders, DM
Tx of diurnal enuresis
Treat underlying
Behavioral (scheduled toileting, double voiding, good bowel program, sitting backwards on toilet, charting/incentive system, relaxation/biofeedback), pharmacotherapy
Definition of encopresis
Fecal incontinence in child > 4 yr
At least once/mo
For 3 mo
M>F
causes of encopresis
Chronic constipation
Hirschprung
Hypothyroidism
Hypercalcemia
Spinal cord lesions
Anorectal malformations
Bowel obstruction
Etiology of retentive encopresis
Painful stooling secondary to constipation
Disturbed paren-child relationship
Coercive toilet training
Mx of encopresis
Complete bowel clean-out:
PEG 3350, oral
(2nd line: enema, supp)
Regular bowel movements
Assessing psychosocial stressors
Behavioral modification
Complications of encopresis
Recurrence
Toxic megacolon
Bowel perforation
Toilet training
Girls earlier than boys
Bladder before bowel
98% daytime bladder control by 3 yr
Signs of toilet readiness
Ambulating independently
Stable on potty
Desire to be independent or to please caregiver
Sufficient expressive and receptive language skill (2-step command level)
Can stay dry for several h
Can recognize need to go
Able to remove clothing
Definition of failure to thrive
Wt < 3rd percentile
Or
Falls across two major percentile curves,
Or
< 80% of expected weight for height and age
Most common factor in poor wt gain
Inadequate calorie intake
Inv for FTT
CBC, Blood smear Electrolytes T4,TSH Bone Xray Chromosome, karyotype Chronic illness: CXR, sweat Cl-, ECG, echo, celiac, inflammation, malabsorption, U/A, liver enzymes, alb
Calculation of mid-parental height
Boys: (Father ht + Mother ht + 13)/2
Girls: (Father ht + Mother ht -13 13)/2
FTT with decreased Wt but normal Ht and HC
Insufficient calorie intake
Hypermetabolic state
FTT with decreased Wt and Ht but normal HC
Structural dystrophy
Endocrine disorder
Constitutional growth delay (bone age < chronological age)
Familial short stature (BA=CA)
FTT with decreased Wt, Ht, HC
Intrauterine insult
Genetic abnormalities
Mx of FTT
Multidisciplinary
Treating underlying
Educate about:
Age-appropriate foods
Calorie boosting
Mealtime schedules and environment
Goal: to reach 90-110% IBW
Correct nutritional deficiencies
Promote catch up growth and development
Increased upper/lower segment ration DDx
Achondroplasia
Short limb syndrome
Hypothyroidism
Storage diseases
Decreased upper/lower segment DDx
Marfan
Kleinfelter
Kallman
Testosterone deficiency
Obesity definition
Overweight: BMI > 85th percentile
Obesity: BMI >95th for age and Ht
Organic causes of obesity
Rare (5%)
Prader-Willi
Carpenter
Turner
Cushing
Hypothyroidism
Complications of obesity
HTN Dyslipidemia SCFE DM2 Asthma Obstructive sleep apnea Gynecomastia PCOS Early menarche Irregular menses Psychological trauma
Inv for obesity
BP
Pulse
Lipid profile
Mx of obesity
Long-term gial: maintain BMI <85th percentile
Encouragement
Reassurance
Engagement of family
Diet:
Quantitative changes
DO NOT ENCOURAGE WEIGHT LOSS (allow linear growth to catchup with wt)
DO NOT ENCOURAGE ADULT DIETS OR VERY LOW CALORIE DIET.
Behavioral modification: Increase activity Change eating habit/meal patterns Limit juice/sugary drinks Adequate sleep Increase physical activity (1h/d) Reduce screen time (<2h/d)
Extra management in obese children who have RFs or complications
AST/ALT
DM screening
Small changes in energy expenditure and intake (lose 1 lb/mo)
factors affecting Child wt
Associated with obesity:
Maternal smoking during pregnancy,
Birth wt
Factors negatively associated with obesity:
Exclusive breast-feeding for six months,
Adequate sleep hours,
Being physically active
Recommended screen time for children
Not recommended for children under 2 yr
<1h for 2-5 yr
<2g for 5-17
CS in diaper dermatitis
Short-term, low-potency, for severe ICD and SD
Limit setting sleep disorder
Bedtime resistance
Preschool and older children
Exacerbated by child’s oppositional behavior
Due to caregiver’s inability to set consistent bedtime rules and routines
Sleep-onset association disorder
Infants and toddlers
Child learns to fall asleep only under certain conditions or associations
During the normal brief arousals of sleep, child cannot fall back sleep because same conditions are not present
First-line Tx for OSA
1st line:
Adenotonsillectomy
Wt Mx
CPAP:
If adenotonsillectomy is contraindicated
Minimal adenotonsillar tissue
Residual OSA
Mild-mod:
Watchful waiting
Avoid pollutants, smoke, allergens
Avoid CS, AB
Effects of adenotonsillectomy on OSA
Improved behavior
Improved QOL
Improved polysomnographic findings
No improvement in:
Attention
Executive function
Mx of sleep disturbances
Set strict bedtimes and wind-down routines
Do not send child to bed hungry
Positive reinforcement for limit setting sleep disorder
Always sleep in own bed, in a dark, quiet, and comfortable room
Do not use bedroom for timeouts
Systematic ignoring and gradual extinction for: sleep onset association disorder
Nightmares
Boys 4-7 yr
REM
Upon awakening, child is alert and clearly recalls frightening dream.
+/- daytime anxiety
Mx: reassurance
Night terrors
Early hours of sleep, stage 4 sleep
Abrupt sitting up, eyes open, screaming. Inconsolable
Signs of panic and autonomic arousal
No memory of event
Stress/anxiety can aggravate them
Remits spontaneously at puberty
Mx of night terror
Reassurance of parents
Ensure child is safe
Leading cause of death between 1 to 12 months of age
SIDS
Sudden infant death syndrome
M>F
Prone position>
Peak age (in term infant): 2-4 mo
Increased during RSV peak
Midnight-8 am
RFs for SIDS
Prematurity
Early bed sharing (<12 wk)
Alcohol during pregnancy
Soft bedding
LBW
Aboriginal
Male
No prenatal care
Smoking in household
Prone sleep position
Poverty
Sibling of infant with SIDS
Sleeping on a surface with a fixed wall
Sleeping with an infant after consumption of alcohol/drugs or extreme fatigue
Infant sleeping with someone other than the primary caregiver
Prevention of SIDS
Place infant on back when sleeping
Avoid sharing bed
Allow supervised tummy time
Avoid overheating, overdressing
Appropriate infant bedding
No smoking
Exclusive BF in first month
Pacifier
NO ALARMS/MONITORS
Appropriate bedding for infant
Firm mattress
No loose bedding
No pillows
No stuffed animals
No crib bumper pad
RFs for child abuse
Social isolation
Poverty
Domestic violence
Caregiver: Personal history of abuse Psychiatrist illness Postpartum depression Substance abuse Single parent family Poor social and vocational skills Below average intelligence
Child Difficult temperament Disability Special needs Prematurity
Mx of child abuse/neglect
Report all suspicions to CAS: request emergency visit if imminent risk to child/siblings
Acute medical care
Arrange consultation to social work, appropriate F/U
May need to discharge child directly to CAS supervision
Bruises suspicious if child abuse
Not explained by accidental injury or child development level
Locations:
Abdomen, buttocks, genitalia, fleshy part of cheek, ears, neck or feet
Baby not yet cruising
Bruising not on the front of the body and/or overlying bones
Large/numerous, clustered/patterned
Fx suspicious of abuse
Not explain why history or child’s development level
Posterior rib Metaphyseal Scapular Vertebral Sternal
The most common cause of death and child abuse
Head trauma
Inv for child abuse
Document all injuries
Photography of skin injuries is ideal (with police or hospital photography)
Rule out medical causes:
If fx: Ca, Mg, PO4, ALP, PTH, vitD, alb
If bruising: CBC, INR, PTT, vWF, F VIII/IX
Screen for abd trauma:
AST, ALT, amylase
CT if required
Lytes, U/A
Toxicity screen
Skeletal survey if <2yr
Imaging based on Hx in child > 5yr
Neuroimaging (if subdural hemorrhage detected, eye exam by ophthalmologist)
Peak age of sexual abuse
2-6y
12-16y
Complications of sexual abuse
As adults:
Obesity, sexual problems, IBS, fibromyalgia, STI, substance use disorder
More likely to experience intimate partner violence and sexual assault
Order of sexual abuse committers
Family member>
Non-relative known to victim
Stranger
Hx taking in sexual abuse
DO NOT TAKE Hx FROM A YOUNG CHILD
MUST BE DONE BY TRAINED PERSONNEL
PEx findings suggestive of sexual abuse
Recurrent UTI
Pregnancy
STI
Vaginitis
Vaginal bleeding
Pain
Genital injury
Enuresis
SPECULUM CONTRAINDICATED IN PREPUBERTAL GIRLS
Inv for sexual assault
Sexual assault examination kit:
Within 24 h if prepubertal
Within 72h if pubertal
R/O:
STI, pregnancy, UTI
Consider STI prophylaxis, emergency contraception
R/O other injuries
R/O drug, alcohol screen
Adolescence Hx
HEEADSSS
Home Education/Employment Eating Activities Drugs Sexuality Suicide and depression Safety/violence
Clues to beglect
FTT developmental delay Inadequate/dirty clothing Poor hygiene Poor attachment to parents No stranger anxiety
Findings suggestive of physical abuse
Retinal hemorrhage Frenulum tear Patchy hair loss Immersion burns Altered mental status
