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Pediatric Health Supervision Flashcards

1
Q

<p>What are the 7 steps of the <strong>well child visit</strong>?</p>

A 
<ol>
	<li>History</li>
	<li>Developmental surveillance</li>
	<li>Observation of parent-child interaction</li>
	<li>Physical examination</li>
	<li>Additional screening tests</li>
	<li>Immunizations</li>
	<li>Anticipatory guidance</li>
</ol>
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2
Q

<p>What are the 6 components of <strong>well child care</strong>?</p>

A

<ul>
<li>Anticipatory guidance (diet, healthy lifestyle promotion)</li>
<li>Specific preventative measures (immunizations)</li>
<li>Screening tests to detect a symptomatic diseases (vision, hearing, newborn metabolic screening, tuberculosis screening)</li>
<li>Early detection and treatment of symptomatic acute illness to prevent complications</li>
<li>Prevention of disability in chronic disease</li>
<li>Assessment of growth and development</li>
</ul>

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3
Q

<p>What is routinely monitored for normal growth?</p>

A 
<ul>
	<li>Weight</li>
	<li>Height</li>
	<li>Head circumference (until age 2)</li>
	<li>Sexual maturity</li>
</ul>
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4
Q

<p>Standardized Growth Curves</p>

A

<ul>
<li>Represent normal values for age for 95% of children</li>
<li>Used to plot weight, height, BMI, head circumference</li>
<li>Special growth curves exist for children w/ particular genetic conditions (Down syndrome, achondroplasia)</li>
</ul>

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5
Q

<p><strong>Growth disturbances</strong></p>

<p>Definition</p>

<p>Types</p>

A 
<ul>
	<li>Growth outside of the usual pattern</li>
	<li>Types
	<ul>
		<li>Failure to thrive</li>
		<li>Head growth abnormalities</li>
	</ul>
	</li>
</ul>
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6
Q

<p><strong>Failure to Thrive</strong></p>

<p>definition</p>

<p>growth parameters</p>

<p>weight vs. length</p>

A

<ul>
<li>Growth rate of less than expected for a child</li>
<li>Concerning when child's weight crosses 2 major %ile isobars</li>
<li>May involve all growth parameters, but <strong>WEIGHT GAIN</strong> is the most abnormal</li>
<li><u>Weight</u> affected before <u>length</u> before <u>head circumference</u></li>
</ul>

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7
Q

<p><strong>Rules of Thumb for Expected Increase in Weight </strong></p>

<ul>
	<li>Birth-3 mo</li>
	<li>3-6 mo</li>
	<li>6-12 mo</li>
	<li>1-2 yrs</li>
	<li>2 yrs-adolescence</li>
</ul>
A

<ul>
<li>Birth-3 mo: 30 g/day (regain birth weight by 2 wks)</li>
<li>3-6 mo: 20 g/day (double birth weight by 4-6 mo)</li>
<li>6-12 mo: 10 g/day (triple birth weight by 12 mo)</li>
<li>1-2 yrs: 250 g/mo</li>
<li>2 yrs-adolescence: 2.3 kg/yr</li>
</ul>

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8
Q

<p><strong>Rules of Thumb for Expected Increase in Height </strong></p>

<ul>
	<li>0-12 mo</li>
	<li>13-24 mo</li>
	<li>2 yrs-adolescence</li>
</ul>
A 
<ul>
	<li>0-12 mo: 25 cm/yr
	<ul>
		<li>birth length increases by 50% at 12 mo</li>
	</ul>
	</li>
	<li>12-24 mo: 12.5 cm/yr</li>
	<li>2 yrs-adolescence: 6.25 cm/yr
	<ul>
		<li>birth length doubles by age 4</li>
		<li>birth length triples by age 13</li>
	</ul>
	</li>
</ul>
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9
Q

<p>What are the 2 etiologies of failure to thrive?</p>

<p>Which is the most common?</p>

A

<ul>
<li><strong>Inorganic FTT</strong>

~~~
<ul>
<li><strong>​</strong>a disturbed parent-child bond that results in inadequate caloric intake or retention (most common)</li>
</ul>
</li>
<li><strong>Organic FTT</strong>
<ul>
<li>suggest underlying organ system pathology, infection, chromosomal disorders or systemic illness</li>
</ul>
</li>
</ul>

~~~

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10
Q

<p>How do you evaluate <strong>FTT</strong>?</p>

A

<ul>
<li>Careful history &amp; physical</li>
<li>Complete dietary history</li>
<li>Observation of parent-child interaction</li>
<li>Routine screening tests usually not useful</li>
<li>Evaluation of organic etiology directed at timing/onset</li>
</ul>

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11
Q

<p>What are the 4 main <strong>head growth </strong>abnormalities?</p>

A 
<ul>
	<li>Microcephaly</li>
	<li>Craniosynostosis</li>
	<li>Deformational plagiocephaly</li>
	<li>Macrocephaly</li>
</ul>
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12
Q

Almost all head growth occurs prenatally & during the first ____ years of life.
Head circumference at birth is __% of the normal adult head size, and it increases to __% of the normal adult head size by 1 yr of age.

A

2 years

25%, 75%

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13
Q

<p>What is a <strong>cephalohematoma</strong>?</p>

A

<ul>
<li>Subperiosteal hemorrhage of the newborn cranium after a traumatic delivery</li>
<li>May interfere w/ accurate head circumference measurement (as well as scalp edema)</li>
</ul>

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14
Q

<p><strong>Rules of Thumb for Expected Increase in Head Circumference </strong></p>

<ul>
	<li>0-2 mo</li>
	<li>2-6 mo</li>
	<li>By 12 mo</li>
</ul>
A 
<ul>
	<li>0-2 mo: 0.5 cm/wk</li>
	<li>2-6 mo: 0.25 cm/wk</li>
	<li>By 12 mo: total increase = 12 cm since birth</li>
</ul>
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15
Q

<p>What are the <strong>inorganic</strong> causes of failure to thrive?</p>

A 
<ul>
	<li>Poor formula preparation</li>
	<li>Poor feeding techniques</li>
	<li>Child abuse &amp; neglect</li>
	<li>Parental immaturity</li>
	<li>Maternal depression</li>
	<li>Alcohol or drug use</li>
	<li>Marital discord</li>
	<li>Mental illness</li>
	<li>Family violence</li>
	<li>Poverty</li>
	<li>Isolation from support systems</li>
</ul>
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16
Q

<p><strong>Microcephaly</strong></p>

<p>definition</p>

<p>incidence</p>

A

<ul>
<li>Head circumference 2-3 standard deviations below the mean for age</li>
<li>1-2/1,000 children</li>
</ul>

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17
Q

<p>What are the etiologies of <strong>microcephaly</strong>?</p>

A

<ul>
<li><strong>Congenital</strong>

<ul>
<li>associated w/ abnormal induction &amp; migration of brain tissue</li>
</ul>
</li>
<li><strong>Acquired</strong>
<ul>
<li>caused by a cerebral insult in the late 3rd trimester, perinatal period, or 1st yr of life</li>
<li>affected children are born w/ a normal head circumference that does not growth after the cerebral insult</li>
</ul>
</li>
</ul>

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18
Q

<p>What are the clinical features of <strong>microcephaly</strong>?</p>

A 
<ul>
	<li>Small brain</li>
	<li>Developmental delay</li>
	<li>Intellectual impairment</li>
	<li>Cerebral palsy or seizures</li>
</ul>
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19
Q

<p><strong>Craniosynostosis</strong></p>

<p>definition</p>

<p>etiology</p>

A 
<ul>
	<li>Premature closure of one or more of the cranial sutures</li>
	<li>Unknown etiology
	<ul>
		<li>80-90% sporadic </li>
		<li>10-20% familial or part of a genetic syndrome (Crouzon, Apert)</li>
	</ul>
	</li>
</ul>
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20
Q

<p>Risk factors for <strong>craniosynostosis</strong></p>

A 
<ul>
	<li>Intrauterine constraint or crowding</li>
	<li>Metabolic abnormalities
	<ul>
		<li>hyperthyroidism, hypercalcemia</li>
	</ul>
	</li>
</ul>
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21
Q

<p>What are the clinical features of craniosynostosis? What is the most common form?</p>

A 
<ul>
	<li>Cranial sutures remain open until cessation of brain growth
	<ul>
		<li>90% completed by age 2</li>
		<li>complete by age 5</li>
	</ul>
	</li>
	<li>Head shape is based on which suture closes prematurely</li>
</ul>
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22
Q

<p>5 <strong>congenital</strong> causes of microcephaly</p>

A

<ul>
<li>Early prenatal infection (HIV, TORCH)</li>
<li>Maternal exposure to drugs &amp; toxins (fetal alcohol syndrome)</li>
<li>Chromosomal abnormality (trisomy 13, 18, 21)</li>
<li>Familial microcephaly (autosomal dominant or autosomal recessive)</li>
<li>Maternal PKU</li>
</ul>

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23
Q

<p>4 <strong>acquired</strong> causes of microcephaly</p>

A

<ul>
<li>Late 3rd trimester or perinatal infections</li>
<li>Meningitis or meningoencephalitis during 1st yr of life</li>
<li>Hypoxic or ischemic cerebral insult</li>
<li>Metabolic derangements (hypothyroidism, inborn errors of metabolism)</li>
</ul>

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24
Q

<p>What is dolichocephaly or scaphocephaly?</p>

A

<ul>
<li>Premature closure of the sagittal suture</li>
<li>Results in an elongated skull</li>
<li>Most common form of craniosynostosis</li>
</ul>

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25

What is brachycephaly?

  • Premature closure of the coronal suture
  • Results in a shortened skull
  • More common in boys
  • May be associated w/ neurological complications (optic nerve atrophy)
26

What is trigonocephaly?

  • Premature closure of the metopic suture
  • Leads to a triangular-shaped head
27

What happens with premature closure of MULTIPLE sutures?

  • Rare
  • Associated w/ severe neurologic compromise
28

Craniosynostosis 

diagnosis 

treatment

  • Physical exam of the head
  • Note by 6 mo of age
  • Confirmation by skull radiographs & head CT
  • Surgical repair (esp when significant cosmetic concerns)
29

What is the definition of plagiocephaly?

Asymmetry of the infant head shape NOT associated with premature suture closure

30

What is the most common type of plagiocephaly?

Positional plagiocephaly

Flattening of the occiput

Prominence of the ipsilateral frontal area

Viewed from the top, skull shaped like parallelogram

31

Plagiocephaly 

associations 

incidence

  • Association w/ congenital muscular torticollis
  • Increased incidence, more infants sleep on back to prevent SIDS
32

Management of plagiocephaly 

  • ROM exercises for associated torticollis
  • Repositioning the head during sleep
  • Helmet therapy
  • Increased time in the prone position when awake ("tummy time")
33

GI causes of FTT

```
  • Craniofacial problems
  • TE fistula
  • GERD
  • GI obstruction 
    • Pyloric stenosis, malrotation, Hirschsprung's disease
  • Acute/chronic diarrhea
  • Inflammatory bowel disease
  • Celiac disease
  • Cystic fibrosis 
```
34

Cardiac causes of FTT

Pulmonary causes of FTT

Heme-Onc causes of FTT

```
  • Cardiac
    • Congenital heart disease 
  • Pulmonary
    • Bronchopulmonary dysplasia
    • Cystic fibrosis
  • Heme-Onc
    • Iron deficiency anemia
    • Malignancy 
```
35

Renal causes of FTT

```
  • Chronic renal failure
  • Renal tubular acidosis 
  • Recurrent UTI
  • Fanconic syndrome 
```
36

Neurologic causes of FTT 

```
  • Hydrocephalus
  • Intracranial tumors
  • Generalized muscle weakness
  • Increased/decreased tone 
```
37

Genetic, congenital & metabolic causes of FTT

  • Fetal alcohol syndrome
  • Inborn errors of metabolism 
38

Immunologic causes of FTT

Infectious causes of FTT

Endocrine causes of FTT

Toxin causes of FTT

```
  • Immuno
    • Immunodeficiency status
  • Infectious
    • TB, HIV, Hepatitis
  • Endocrine
    • Hypothyroidism, Rickets 
  • Toxin
    • Lead poisoning 
```
39

What is macrocephaly?

  • Head circumference >95% for age 
  • Unlike microcephaly, the size of the head in patients w/ macrocephaly does not necessarily reflect brain size 
40

What are the etiologies of Macrocephaly?

```
  • Familial 
  • Overgrowth syndromes (Sotos syndrome)
  • Metabolic storage disorders
    • Canavan syndrome, gangliosidoses 
  • Neurofibromatosis
  • Achondroplasia 
  • Hydrocephalus
  • Space-occupying lesions 
```
41

What are the steps in evaluating macrocephaly?

  • Measurement of parental head circumferences 
  • Careful physical examination
    • Observation for split cranial sutures
    • Bulging anterior fontanelle
    • Irritability
    • Vomiting 
    • Indications of elevated ICP
  • Head US or CT to rule out hydrocephalus 
  • Genetic evaluation (if suspected)
42

____________ are on of the most important components of well child care & are the cornerstone of pediatric preventative care. 

Immunizations 

43

What is active immunization?

Induction of long-term immunity through exposure to live attenuated or killed (inactivated) infectious agents

44

What is passive immunization?

Delivery of preformed ab to individuals who have no active immunity against a particular disease but who have either been exposed to or are at high risk for exposure to the infectious agent. 

45

Live vaccines

type of immunity

who should avoid them

examples 

  • Long-lasting immunity
  • Risk of vaccine-associated disease in the recipient or secondary host 
  • Avoid in patients w/ compromised immunity
    • cancer, congenital/drug-induced immunodeficiencies 
  • Oral polio (OPV), varicella, measles mumps rubella (MMR)
46

Non-live vaccines

type of immunity 

examples 

  • Not infectious
  • Induced immunity for shorter periods
  • Require booster immunizations
  • Diphtheria, tetanus, acellular pertussis (DTaP), Hepatitis A & B, inactivated polio (IPV), H. influenzae type B (HIB), pneumococcal & meningococcal vaccines 
47

What are some examples of passive immunization?

  • Varicella zoster immune globulin (VZIG) for immunocompromised patients who have been exposed to varicella & are at high risk for severe varicella infection 
  • Newborns born to Hepatitis B+ mothers receive Hepatitis B immune globulin at birth 
  • Visitors to high-risk areas may receive Hepatitis A immune globulin before travel 
48

Hepatitis B vaccine (HBV)

rationale

type 

timing 

  • Hepatitis B infects 300 million worldwide 
  • Recombinant vaccine w/ particles of HepB surface antigen (HBsAg)
  • Given as a 3-shot series w/i the 1st year of life 
49

What is the rationale for the DTaP vaccine?

 

Diphtheria, tetanus & pertussis all may cause series disease, especially in young infants 

50

What type of vaccine is DTaP?

  • Inactivated
  • Historical: DTP w/ whole-cell killed Bordetella pertussis, high rate of side effects
  • Current: DTaP w/ purified acellular B. pertussis, lower rates of vaccine associated fever, seizures, local rxns 
51

What is the timing of the DTaP vaccination?

  • DTaP recommended at 2, 4, & 6 mo w/ boosters at 12-18 mo & 4-6 yrs 
  • dT (diphtheria & tetanus) contains 1/10 diphtheria toxoid & is recommended at age 11-12 and every 10 yrs thereafter
  • Note that dT rather than DTaP is given to children > 7 yrs of age 
52

What is the rationale for the oral & inactivated polio vaccines (OPV/IPV)?

  • Poliovirus is an enterovirus w/ propensity for the CNS, causing transient or permanent paresis of the extremities & meningoencephalitis 
  • Eradicated from the Western hemisphere & South Pacific but remains in isolated pockets throughout the world 
53

Live attentuated OPV

advantages

disadvantages 

  • Advantages: induction of both host immunity & secondary immunity b/c it is excreted in the stool of the recipient & may infect (immunize) close contacts (herd immunity)
  • Disadvantages: possibility of vaccine-related polio; in recent years, the only cases of polio in the USA have been associated w/ OPV
54

Non-live (inactivated) IPV

advantages/disadvantages

timing 

```
  • SubQ or IM
  • Advantage: no vaccine-related polio
  • Disadvantage: no secondary immunity
  • Timing (USA)
    • Only IPV is now recommended 
    • Given at 2 & 4 mo
    • Boosters at 6-18 mo & 4-6 yrs 
```
55

What is the rationale for the Haemophilus influenzae type b vaccine (HIB)?

 

  • H. influenzae type b was a serious cause of invasive bacterial infection before vaccine licensure in 1985 ```
    • Meningitis, epiglottitis, sepsis
  • Now more rare since vaccine 
```
56

What type of vaccine is HIB?

  • Conjugate vaccine 
  • H. influenzae polysaccharide linked to various protein antigens (diphtheria or tetanus toxoids) to augment immunogenicity 
57

What is the timing of the HIB vaccine?

  • Recommended either at 2, 4, & 6 mo w/ booster at 12-15 mo or at 2, 4, & 12 mo
  • Depends on type of vaccine conjugate 
58

What is the rationale for the MMR vaccine?

  • Measles
    • ​severe illness w/ complications that include pneumonia associated w/ significant mortality 
  • Mumps
    • Commonly associated w/ parotitis 
    • Meningoencephalitis & orchitis 
  • Rubella
    • Mild viral syndrome in children
    • Severe birth defects in offspring of susceptible women infected during pregnancy 
59

MMR vaccine

type of vaccine

timing 

  • Live attenuated vaccine
  • 12-15 mo w/ a booster either at 4-6 yrs or 11-12 yrs
60

Varicella vaccine

rationale

type 

timing 

  • Virus responsible for chicken pox & zoster
  • Uncomplicated illness but severe disease in very young & older patients 
  • Live attenuated vaccine
  • 12-18 mo 
61

What is the rationale for the Hepatitis A vaccine? 

  • Hepatitis A is the most common viral cause of hepatitis worldwide 
  • Asymptomatic in up to 70% of infected children younger than 6 yrs of age 
  • Most severe disease in older children & adults, but rarely associated w/ fulminant hepatitis 
62

Hepatitis A vaccine 

type 

timing 

  • Inactivated vaccine
  • 2 yrs of age or older, with a booster 6 mo later for the following:
    • susceptible children living in communities w/ high hepatitis A rates (2x national rate) & those traveling to endemic areas 
    • individuals in other groups w/ high hepatitis A rates, including those w/ chronic liver disease, homosexual & bisexual men, users of illicit drugs, patients w/ clotting factor disorders receiving blood products, & patients at high risk  for occupational exposure 
63

What is the composition & rationale for the Pneumococcal vaccines (Pneumovax/Prevnar)?

  • Composed of polysaccharide capsular antigens from 23 pneumococal serotypes 
  • Pneumococcus (Strep pneumoniae) 
  • Most common cause of acute otitis media & invasive bacterial infections in children younger than 3 yrs of age 
64

Pneumovax 

advantage

disadvantage

 

  • Advantage: vaccine contains antigens from pneumococcal strains causing almost all cases of bacteremia & meningitis during childhood 
  • Disadvantage: vaccine has little immunogenicity in children <2 YO 
65

What are the indications for the Pneumovax vaccine?

```
  • Older children & adults at high risk for pneumococcal disease 
  • Patients w/ sickle cell anemia who are functionally asplenic
  • Immunodeficiency
  • Chronic liver disease 
  • Nephrotic syndrome
  • Patients w/ anatomic asplenia 
```
66

Prevnar vaccine

advantages

disadvantage 

  • 7 pneumococcal serotypes 
  • Advantages: immunogenicity & efficacy in preventing meningitis, pneumonia, bacteremia & otitis media from the most common pneumococcal strains in children <2 YO 
  • Disadvantage: does not confer as broad coverage against pneumococcal strains as Pneumovax 
67

What are the indications for the Prevnar vaccine?

  • All children <2 YO 
  • Selected children >2 YO who are at high risk for pneumococcal disease
  • Prevnar recommended at 2, 4, & 6 mo w/ a booster at 12-15 mo 
68

What are some adverse effects of immunization?

  • Most mild-moderate, w/i first 24 hrs 
    • Local inflammation, low-grade fever 
  • MMR & varicella are live attenuated vaccines
    • Fever & rash 1-2 wks after immunization
    • After the incubation period of the virus
  • Serious side effects that may result in permanent disability or be life-threatening are rare 
    • Vaccine-related polio after OPV 
69

What are some contraindications to immunization?

  • Anaphylaxis to a vaccine or its constituents 
  • Encephalopathy w/i 7 days after DTaP vaccine
  • Patients w/ progressive neurologic disorders (uncontrolled epilepsy) should not receive DTaP vaccine until neuro status is stabilized 
  • Immunodeficient patients should not receive OPV, MMR & varicella vaccines. Household contacts shouldn't receive OPV as it is shed in the stool
  • Pregnant patients should not receive live vaccines 
70

What are some precautions for all vaccines?

  • Moderate to severe illness (w/ or w/o fever) 
  • Mild illnesses, including febrile illnesses, are not contraindications to immunization 
71

What are some precautions fro the DTaP vaccine?

  • Temp of 40.5oC w/i 48 hrs after prior vaccination
  • Collapse or shocklike state w/i 48 hrs after prior vaccination 
  • Seizures w/i 3 days after prior vaccination 
  • Persistent, inconsolable crying lasting >3 hrs occuring w/i 48 hrs after prior vaccination 
72

What are some precautions for MMR & varicella vaccines?

  • Immunoglobulin (IVIG) administration w/i the preceding 3-11 mo, which might interfere w/ the patient's immune response to these vaccines 
73

What is the focus of each well child visit?

To identify undetected problems & the risks of such problems 

74

What are some examples of screening assessments?

  • Complete history & physical examination
  • Growth measurements 
  • Blood pressure measurements
  • Strabismus & vision screening 
  • Hearing screening 
  • Tuberculosis screening 
  • Laboratory screening 
  • *Vision screening for ophthalmologic disorders begins after birth 
75

Hearing screening recommendations

  • Universal newborn hearing screening (before hospital discharge) is now recommended
  • Evidence that moderate-to-profound hearing loss in early infancy is associated w/ impaired language development 
  • Early detection & intervention for hearing loss may improve speech & language acquisition 
76

What types of audiometric tests are used for hearing screening?

  • Brainstem auditory evoked response (BAER)
  • Evoked otoacoustic emission (EOE)

Most effective screening is to use both of the above tests in combination 

77

What is the brainstem auditory evoked response (BAER) test?

  • Measures the EEG waves generated in response to clicks via electrodes pasted to the infant's scalp
  • The most accurate test, but requires costly equipment & trained operators 
78

What is the evoked otoacoustic emission (EOE) test?

  • Measures sounds generated by normal cochlear hair cells that are detected by a microphone placed into the external auditory canal
  • EOE accuracy may be affected by debris or fluid w/i the external or middle ear 
  • It requires less expensive equipment & less operator training 
79

Neonatal metabolic state screenings

diseases

reasoning 

  • Treatable, prevention of irreversible brain injury
    • Congenital hypothyroidism 
    • Phenylketonuria
    • Galactosemia
  • Early intervention (penicillin prophylaxis) significantly decreases morbidity & mortality 
    • Sickle cell anemia
    • Other hemoglobinopathies 
80

Routine screening of cholesterol & lipid panels (are/aren't) recommended because.....

  • Are NOT recommended
  • Lack of information about the risks & benefits of treating hyperlipidemia during childhood
  • Costs & limitations of currently available screening tests 
81

When is cholesterol & lipid screening recommended?

  • Children >2 YO w/ fahx of hypercholesterolemia, hyperlipidemia or early MI 
  • Protocol
    • Screening cholesterol if either parent has a hx of hypercholesterolemia
    • Screening fasting lipid panel if either parents or grandparents have a hx of CVD or sudden death 
82

If a child has elevated cholesterol levels (75th-90th percentile), what lab test should they have?

  • Fasting lipid panel  ```
    • Total cholesterol
    • TGs 
    • HDL
    • LDL 
```
83

At what age is iron deficiency anemia most common?

  • Children <6 YO 
  • Peaking btwn 9-15 mo 
84

What are the risk factors for iron deficiency anemia?

  • Prematurity
  • Low birth weight
  • Early introduction of cow's milk (<9 mo)
  • Insufficiency dietary intake of iron 
  • Low SES
85

Universal screening of hemoglobin levels is recommended........

btwn 9-15 mo

btwn 4-6 years

86

When is urinalysis warranted in a child?

  • Little evidence that routine surveillance of urinalysis or routine urine cultures are efficacious or cost effective
  • Urine studies are recommended only when clinically warranted or when required for school entry or by local health departments 
87

How is Tuberculosis screened?

Who should receive it? 

  • Intradermal injection of purified protein derivative
    • PPD, Mantoux skin test 
  • Skins tests analyzed at 48-72 hrs after placement & interpreted on the basis of the level of risk for TB in the particular child 
  • Recommended for children at risk for TB 
88

What types of children are at risk for TB?

  • Contacts of persons w/ confirmed or suspected infectious tuberculosis
  • Children in contact w/ high-risk groups
    • Adults incarcerated or institutionalized during the preceding 5 yrs 
    • HIV-infected household members 
    • Homeless persons 
    • Users of illicit drugs
    • Migrant farm workers 
  • Children w/ radiographic or clinical findings suggestive of tuberculosis 
  • Children who have immigrated from endemic areas, those w/ hx of travel to endemic areas, or those w/ significant contact w/ indigenous persons from endemic areas (Asia, Africa, Middel East, Latin America)
  • Children w/ HIV
  • Children w/o specific risk factors who reside in high prevalence areas 
89

How common is lead intoxication (plumbism)?

  • Public health risk among children <5 YO
  • Up to 4% of all children in the US have evidence of increased lead absorption, including up to 20% of inner city children 
90

What are the risk factors of lead intoxication?

  • Ingestion of lead-containing paint or putty from homes built before 1978
  • Drinking water from lead pipes or pipes w/ lead-containing solder
  • Exposure to lead smelters or lead-painted commercial structures during demolition
  • Use of lead-glazed pottery in food preparation
  • Use of lead-containing folk remedies 
91

At what age are children most susceptible to lead intoxication?

Children
92

Describe acute lead intoxication 

```
  • Anorexia
  • Apathy
  • Lethargy
  • Anemia
  • Irritability
  • Vomiting
  • May progress to encephalopathy  
```
93

Describe chronic lead intoxication 

```
  • Most commonly asymptomatic 
  • Neurologic sequelae 
    • Developmental delay
    • Learning problems
    • Mental retardation 
```
94

What age groups are recommended to have lead screening?

  • All children 9 mo - 6 yrs of age living in older, dilapidated housing
  • All children 9 mo - 6 yrs of age who are siblings, visitors, playmates of children w/ lead intoxication
  • All children 9 mo - 6 yrs of age  living near lead smelters or lead processing plants or whose parents/family have a lead-related occupation or hobby
  • Children of any age living in older housing where renovation is occuring
  • All children of any age living in areas in which the percentage of 1-2 year olds w/ elevated lead levels exceeds 12%
95

Blood lead levels of _______ have been associated w/ effects on cognition in young children. 

Management?

  • <10 ug/dL
  • Based on serum levels after repeat testing
    • Education to decrease exposure
    • Chelation for very high lead levels 
96

Approximately ___% of male infants in the US are circumcised. 

Circumcision for medical reasons (is/is not) recomended by the American Academy of Pediatrics.

60%

is NOT

97

What are the medical benefits of circumcision?

  • Increased incidence of penile cancer in uncircumcised adult men (HPV)
  • Increased incidence of cervical cancer in female sexual partners of uncircumcised men 
  • UTI's are 10x more common in uncircumcised male infants 
98

What are the 3 reasons an uncircumcised male may ultimately require circumcision? 

 

*10% of uncircumcised males*

```
  • Phimosis
  • Paraphimosis 
  • Balanitis 
```
99

define Phimosis 

  • Inability to retract the foreskin 
  • Normal up to age 6
  • Always abnormal if ballooning of foreskin occurs during urination 
100

define Paraphimosis

  • When the retracted foreskin can't be returned to its normal position & acts as a tourniquet, resulting in obstruction to lymphatic flow & edema 
  • Obstruction of venous return --> emergent surgery 
101

define Balanitis 

  • Inflammation of the glans of the penis
  • Infants: Candida spp or gram-neg infections
  • Adults: STIs
102

_______ & _______ are strongly recommended during circumcision. 

Anesthesia & analgesia 

103

What are the potential complications from a circumcision?

```
  • Bleeding
  • Infection
  • Poor cosmesis
  • Phimosis (secondary to insufficient foreskin removal)
  • Urinary retention
  • Injury to 
```
104

What are some contraindications to circumcision?

```
  • Penile abnormalities (hypospadias)
  • Prematurity
  • Bleeding diatheses 
```
105

Tooth eruption

age range

first tooth

primary vs. secondary 

```
  • 3-16 mo (average 6 mo)
  • First tooth: lower central incisor 
  • Primary teeth
    • 20 teeth
    • established by 2 yrs of age 
  • Secondary teeth
    • begins w/ lower central incisor 
    • 6-8 yrs of age 
    • 32 secondary ("permanent") teeth 
```
106

Delayed dental eruption

definition

causes

```
  • Primary eruption occuring after 16 mo of age
  • Causes
    • Familial
    • Hypothyroidism
    • Hypopituitarism
    • Genetic syndromes
      • Down syndrome
      • Ectodermal dysplasia 
        • Conical-shaped teeth
        • Dysmorphic facial features 
        • Decreased sweat glands
        • Alopecia 
```
107

Early dental eruption

definition

causes 

```
  • Primary eruption before 3 mo
  • Causes
    • Familial
    • Hyperthyroidism
    • Precocious puberty 
    • Growth hormone excess 
```
108

When should tooth brushing be started?

What can be used?

When can children do it on their own?

  • Should begin as soon as teeth erupt
  • Moist washcloth or gauze pad initially
  • Soft toothbrush as early as tolerated 
  • 2-3 YO: able to assist in brushing their own teeth
    • Fluoride toothpaste may be used 
109

Dental floss to remove plaque from btwn teeth should be initiated when.....

tight contact exists btwn teeth

110

Fluoride

benefits

sources

```
  • Children who consume optimal amts from birth until adolescence have 50-75% less dental decay than expected
  • Sources
    • Fluoridated water (not in USA)
    • Fluoride supplements
    • Fluoride toothpaste 
```
111

What is fluorosis?

What are the effects?

```
  • Caused by excess fluoride 
  • Affects permanent teeth 
  • Leads to abnormalities in dental enamel & dentin
  • Effects are cosmetic only
    • White streaks
    • Pitting
    • Gray-brown staining 
  • Most critical time for dental vulnerability to excess fluoride: 2-4 yrs of age 
```
112

In what population of children is fluoride supplementation important?

  • Exclusively breastfed children >6 mo
    • Breast milk has little fluoride 
  • Children who live in areas where tap water contains <0.3 ppm fluoride 
113

What are natal teeth?

What are neonatal teeth?

  • Natal teeth ```
    • those that are present at birth 
  • Neonatal teeth
    • those that emerge during the 1st mo 
```
114

What are the most common teeth that erupt early?

  • Mandibular central incisors 
  • >90% primary teeth 
  • <10% supernumerary teeth (teeth in excess of usual number) 
115

What is the etiology & management of early teeth?

  • Etiology often unknown
    • Exposure to environmental toxins
    • Familial 
  • No intervention unless..
    • Hypermobile teeth
    • Breastfeeding difficulty 
    • Trauma to infant's lip/tongue 
  • Aspiration of natal/neonatal tooth feared but very unlikely 
116

___% of children have nursing/bottle caries. 

Most often seen at ____ months of age. 

3-6%

24-30

117

What are the etiologies of nursing/bottle caries?

Most common bacterial agent?

  • Associations 
    • falling asleep w/ nipple (breast or bottle) in the mouth
    • children who breastfeed excessively or who carry around a bottle as a habit 
  • Streptococcus mutans 
    • Doesn't appear in oral cavity until teeth erupt 
    • Acquired from colonized parents/siblings 
118

Nursing/bottle caries

clinical features

management 

  • Clinical features ```
    • Maxillary incisors
    • Canines
    • Primary 1st molars 
    • Lower teeth spared initially b/c covered by the tongue 
  • Rx: placement of dental crowns or extraction 
```
119

What is dental trauma?

What are the prognostic factors?

  • A permanent tooth that has been traumatically avulsed may be re-implanted if placed into the socket rapidly 
  • Most important factor: extraoral time
  • Prognosis highest if avulsed tooth is stored in liquids (especially milk)
  • Dry-stored tooth has poor prognosis, even after 30 minutes 
120

How is dental trauma managed?

What about primary teeth?

```
  • Management
    • Gentle rinsing of an avulsed tooth w/ saline
    • Placement into the socket
    • Referral to a dentist 
  • Avulsed primary teeth do not require re-implantation 
```
121

What is the timing of developmental screening?

  • Assessed at each well child visit from infancy through school age
  • School performance substitutes in developmentally normal children >5-6 YO
122

What is anticipatory guidance?

  • Patient & parent education
  • Provided during each well child visit 
  • Tailored to the child's current developmental level & to anticipated changes in the child's development in the interim before the next scheduled visit 
123

What are the 9 topics covered by anticipatory guidance? 

  1. Health habits (tobacco, drug, alcohol counseling)
  2. Prevention of illness & injury (safety)
  3. Nutrition
  4. Dental care
  5. Social development & family relationships 
  6. Sexuality
  7. Parental health 
  8. Self responsibility 
  9. School & vocational achievement 

Pediatrics (24 decks)

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