Pediatric Health Supervision Flashcards
<p>What are the 7 steps of the <strong>well child visit</strong>?</p>
<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>
<p>What are the 6 components of <strong>well child care</strong>?</p>
<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>
<p>What is routinely monitored for normal growth?</p>
<ul> <li>Weight</li> <li>Height</li> <li>Head circumference (until age 2)</li> <li>Sexual maturity</li> </ul>
<p>Standardized Growth Curves</p>
<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>
<p><strong>Growth disturbances</strong></p>
<p>Definition</p>
<p>Types</p>
<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>
<p><strong>Failure to Thrive</strong></p>
<p>definition</p>
<p>growth parameters</p>
<p>weight vs. length</p>
<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>
<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>
<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>
<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>
<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>
<p>What are the 2 etiologies of failure to thrive?</p>
<p>Which is the most common?</p>
<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>
~~~
<p>How do you evaluate <strong>FTT</strong>?</p>
<ul>
<li>Careful history & 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>
<p>What are the 4 main <strong>head growth </strong>abnormalities?</p>
<ul> <li>Microcephaly</li> <li>Craniosynostosis</li> <li>Deformational plagiocephaly</li> <li>Macrocephaly</li> </ul>
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.
2 years
25%, 75%
<p>What is a <strong>cephalohematoma</strong>?</p>
<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>
<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>
<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>
<p>What are the <strong>inorganic</strong> causes of failure to thrive?</p>
<ul> <li>Poor formula preparation</li> <li>Poor feeding techniques</li> <li>Child abuse & 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>
<p><strong>Microcephaly</strong></p>
<p>definition</p>
<p>incidence</p>
<ul>
<li>Head circumference 2-3 standard deviations below the mean for age</li>
<li>1-2/1,000 children</li>
</ul>
<p>What are the etiologies of <strong>microcephaly</strong>?</p>
<ul>
<li><strong>Congenital</strong>
<ul>
<li>associated w/ abnormal induction & 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>
<p>What are the clinical features of <strong>microcephaly</strong>?</p>
<ul> <li>Small brain</li> <li>Developmental delay</li> <li>Intellectual impairment</li> <li>Cerebral palsy or seizures</li> </ul>
<p><strong>Craniosynostosis</strong></p>
<p>definition</p>
<p>etiology</p>
<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>
<p>Risk factors for <strong>craniosynostosis</strong></p>
<ul> <li>Intrauterine constraint or crowding</li> <li>Metabolic abnormalities <ul> <li>hyperthyroidism, hypercalcemia</li> </ul> </li> </ul>
<p>What are the clinical features of craniosynostosis? What is the most common form?</p>
<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>
<p>5 <strong>congenital</strong> causes of microcephaly</p>
<ul>
<li>Early prenatal infection (HIV, TORCH)</li>
<li>Maternal exposure to drugs & 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>
<p>4 <strong>acquired</strong> causes of microcephaly</p>
<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>
<p>What is dolichocephaly or scaphocephaly?</p>
<ul>
<li>Premature closure of the sagittal suture</li>
<li>Results in an elongated skull</li>
<li>Most common form of craniosynostosis</li>
</ul>
<p>What is brachycephaly?</p>
<ul>
<li>Premature closure of the coronal suture</li>
<li>Results in a shortened skull</li>
<li>More common in boys</li>
<li>May be associated w/ neurological complications (optic nerve atrophy)</li>
</ul>
<p>What is trigonocephaly?</p>
<ul>
<li>Premature closure of the metopic suture</li>
<li>Leads to a triangular-shaped head</li>
</ul>
<p>What happens with premature closure of MULTIPLE sutures?</p>
<ul>
<li>Rare</li>
<li>Associated w/ severe neurologic compromise</li>
</ul>
<p><strong>Craniosynostosis</strong></p>
<p>diagnosis</p>
<p>treatment</p>
<ul>
<li>Physical exam of the head</li>
<li>Note by 6 mo of age</li>
<li>Confirmation by skull radiographs & head CT</li>
<li>Surgical repair (esp when significant cosmetic concerns)</li>
</ul>
<p>What is the definition of plagiocephaly?</p>
<p>Asymmetry of the infant head shape NOT associated with premature suture closure</p>
<p>What is the most common type of plagiocephaly?</p>
<p>Positional plagiocephaly</p>
<p>Flattening of the occiput</p>
<p>Prominence of the ipsilateral frontal area</p>
<p>Viewed from the top, skull shaped like parallelogram</p>
<p><strong>Plagiocephaly</strong></p>
<p>associations</p>
<p>incidence</p>
<ul>
<li>Association w/ congenital muscular torticollis</li>
<li>Increased incidence, more infants sleep on back to prevent SIDS</li>
</ul>
<p>Management of plagiocephaly</p>
<ul>
<li>ROM exercises for associated torticollis</li>
<li>Repositioning the head during sleep</li>
<li>Helmet therapy</li>
<li>Increased time in the prone position when awake ("tummy time")</li>
</ul>
<p>GI causes of FTT</p>
<ul> <li>Craniofacial problems</li> <li>TE fistula</li> <li>GERD</li> <li>GI obstruction <ul> <li>Pyloric stenosis, malrotation, Hirschsprung's disease</li> </ul> </li> <li>Acute/chronic diarrhea</li> <li>Inflammatory bowel disease</li> <li>Celiac disease</li> <li>Cystic fibrosis</li> </ul>
<p>Cardiac causes of FTT</p>
<p>Pulmonary causes of FTT</p>
<p>Heme-Onc causes of FTT</p>
<ul> <li>Cardiac <ul> <li>Congenital heart disease</li> </ul> </li> <li>Pulmonary <ul> <li>Bronchopulmonary dysplasia</li> <li>Cystic fibrosis</li> </ul> </li> <li>Heme-Onc <ul> <li>Iron deficiency anemia</li> <li>Malignancy</li> </ul> </li> </ul>
<p>Renal causes of FTT</p>
<ul> <li>Chronic renal failure</li> <li>Renal tubular acidosis</li> <li>Recurrent UTI</li> <li>Fanconic syndrome</li> </ul>
<p>Neurologic causes of FTT</p>
<ul> <li>Hydrocephalus</li> <li>Intracranial tumors</li> <li>Generalized muscle weakness</li> <li>Increased/decreased tone</li> </ul>
<p>Genetic, congenital & metabolic causes of FTT</p>
<ul>
<li>Fetal alcohol syndrome</li>
<li>Inborn errors of metabolism</li>
</ul>
<p>Immunologic causes of FTT</p>
<p>Infectious causes of FTT</p>
<p>Endocrine causes of FTT</p>
<p>Toxin causes of FTT</p>
<ul> <li>Immuno <ul> <li>Immunodeficiency status</li> </ul> </li> <li>Infectious <ul> <li>TB, HIV, Hepatitis</li> </ul> </li> <li>Endocrine <ul> <li>Hypothyroidism, Rickets</li> </ul> </li> <li>Toxin <ul> <li>Lead poisoning</li> </ul> </li> </ul>
<p>What is macrocephaly?</p>
<ul>
<li>Head circumference >95% for age</li>
<li>Unlike microcephaly, the size of the head in patients w/ macrocephaly <u>does not</u> necessarily reflect brain size</li>
</ul>
<p>What are the <strong>etiologies</strong> of Macrocephaly?</p>
<ul> <li>Familial</li> <li>Overgrowth syndromes (Sotos syndrome)</li> <li>Metabolic storage disorders <ul> <li>Canavan syndrome, gangliosidoses</li> </ul> </li> <li>Neurofibromatosis</li> <li>Achondroplasia</li> <li>Hydrocephalus</li> <li>Space-occupying lesions</li> </ul>
<p>What are the steps in evaluating macrocephaly?</p>
<ul>
<li>Measurement of parental head circumferences</li>
<li>Careful physical examination
<ul>
<li>Observation for split cranial sutures</li>
<li>Bulging anterior fontanelle</li>
<li>Irritability</li>
<li>Vomiting</li>
<li>Indications of <strong>elevated ICP</strong></li>
</ul>
</li>
<li>Head US or CT to rule out hydrocephalus</li>
<li>Genetic evaluation (if suspected)</li>
</ul>
<p>\_\_\_\_\_\_\_\_\_\_\_\_ are on of the most important components of well child care & are the cornerstone of pediatric preventative care.</p>
<p><strong>Immunizations</strong></p>
<p>What is <strong>active</strong> immunization?</p>
<p>Induction of long-term immunity through exposure to live attenuated or killed (inactivated) infectious agents</p>
<p>What is <strong>passive</strong> immunization?</p>
<p>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.</p>
<p><strong>Live vaccines</strong></p>
<p>type of immunity</p>
<p>who should avoid them</p>
<p>examples</p>
<ul>
<li><strong>Long-lasting immunity</strong></li>
<li>Risk of vaccine-associated disease in the recipient or secondary host</li>
<li>Avoid in patients w/ <strong>compromised immunity</strong>
<ul>
<li>cancer, congenital/drug-induced immunodeficiencies</li>
</ul>
</li>
<li>Oral polio (OPV), varicella, measles mumps rubella (MMR)</li>
</ul>
<p><strong>Non-live vaccines</strong></p>
<p>type of immunity</p>
<p>examples</p>
<ul>
<li>Not infectious</li>
<li>Induced immunity for shorter periods</li>
<li>Require <strong>booster immunizations</strong></li>
<li>Diphtheria, tetanus, acellular pertussis (DTaP), Hepatitis A & B, inactivated polio (IPV), H. influenzae type B (HIB), pneumococcal & meningococcal vaccines</li>
</ul>
<p>What are some examples of passive immunization?</p>
<ul>
<li>Varicella zoster immune globulin (<strong>VZIG</strong>) for immunocompromised patients who have been exposed to varicella & are at high risk for severe varicella infection</li>
<li>Newborns born to Hepatitis B+ mothers receive <strong>Hepatitis B immune globulin</strong> at birth</li>
<li>Visitors to high-risk areas may receive <strong>Hepatitis A immune globulin</strong> before travel</li>
</ul>
<p><strong>Hepatitis B vaccine (HBV)</strong></p>
<p>rationale</p>
<p>type</p>
<p>timing</p>
<ul>
<li>Hepatitis B infects 300 million worldwide</li>
<li><strong>Recombinant</strong> vaccine w/ particles of HepB surface antigen (HBsAg)</li>
<li>Given as a 3-shot series w/i the <strong>1st year of life</strong></li>
</ul>
<p>What is the <strong>rationale</strong> for the DTaP vaccine?</p>
<p></p>
<p>Diphtheria, tetanus & pertussis all may cause series disease, especially in young infants</p>
<p>What <strong>type</strong> of vaccine is DTaP?</p>
<ul>
<li>Inactivated</li>
<li>Historical: DTP w/ <strong>whole-cell killed</strong> <em>Bordetella pertussis</em>, high rate of side effects</li>
<li>Current: DTaP w/ <strong>purified acellular</strong> <em>B. pertussis</em>, lower rates of vaccine associated fever, seizures, local rxns</li>
</ul>
<p>What is the <strong>timing</strong> of the DTaP vaccination?</p>
<ul>
<li>DTaP recommended at 2, 4, & 6 mo w/ boosters at 12-18 mo & 4-6 yrs</li>
<li>dT (diphtheria & tetanus) contains 1/10 diphtheria toxoid & is recommended at age 11-12 and every 10 yrs thereafter</li>
<li>Note that dT rather than DTaP is given to children<u>></u>7 yrs of age</li>
</ul>
<p>What is the <strong>rationale</strong> for the oral & inactivated polio vaccines(OPV/IPV)?</p>
<ul>
<li>Poliovirus is an <strong>enterovirus</strong> w/ propensity for the CNS, causing transient or permanent paresis of the extremities & meningoencephalitis</li>
<li>Eradicated from the Western hemisphere & South Pacific but <strong>remains</strong> in isolated pockets throughout the world</li>
</ul>
<p><strong>Live attentuated OPV</strong></p>
<p>advantages</p>
<p>disadvantages</p>
<ul>
<li><u>Advantages</u>: induction of both host immunity & secondary immunity b/c it is excreted in the stool of the recipient & may infect (immunize) close contacts (<strong>herd immunity</strong>)</li>
<li><u>Disadvantages</u>: possibility of <strong>vaccine-related polio</strong>; in recent years, the only cases of polio in the USA have been associated w/ OPV</li>
</ul>
<p><strong>Non-live (inactivated) IPV</strong></p>
<p>advantages/disadvantages</p>
<p>timing</p>
<ul> <li>SubQ or IM</li> <li><u>Advantage</u>: no vaccine-related polio</li> <li><u>Disadvantage</u>: no secondary immunity</li> <li>Timing (USA) <ul> <li>Only IPV is now recommended</li> <li>Given at 2 & 4 mo</li> <li>Boosters at 6-18 mo & 4-6 yrs</li> </ul> </li> </ul>
<p>What is the <strong>rationale</strong> for the Haemophilus influenzae type b vaccine (HIB)?</p>
<p></p>
<ul>
<li><em>H. influenzae</em> type b was a serious cause of <strong>invasive bacterial infection </strong>before vaccine licensure in 1985
~~~
<ul>
<li>Meningitis, epiglottitis, sepsis</li>
</ul>
</li>
<li>Now more rare since vaccine</li>
</ul>
~~~
<p>What <strong>type</strong> of vaccine is HIB?</p>
<ul>
<li><strong>Conjugate vaccine</strong></li>
<li><em>H. influenzae</em> polysaccharide linked to various protein antigens (diphtheria or tetanus toxoids) to augment immunogenicity</li>
</ul>
<p>What is the <strong>timing</strong> of the HIB vaccine?</p>
<ul>
<li>Recommended either at 2, 4, & 6 mo w/ booster at 12-15 mo or at 2, 4, & 12 mo</li>
<li>Depends on type of vaccine conjugate</li>
</ul>
<p>What is the <strong>rationale</strong> for the MMR vaccine?</p>
<ul>
<li><strong>Measles</strong>
<ul>
<li><strong></strong>severe illness w/ complications that include pneumonia associated w/ significant mortality</li>
</ul>
</li>
<li><strong>Mumps</strong>
<ul>
<li>Commonly associated w/ parotitis</li>
<li>Meningoencephalitis & orchitis</li>
</ul>
</li>
<li><strong>Rubella</strong>
<ul>
<li>Mild viral syndrome in children</li>
<li>Severe birth defects in offspring of susceptible women infected during pregnancy</li>
</ul>
</li>
</ul>
<p><strong>MMR vaccine</strong></p>
<p>type of vaccine</p>
<p>timing</p>
<ul>
<li><strong>Live attenuated vaccine</strong></li>
<li>12-15 mo w/ a booster either at 4-6 yrs or 11-12 yrs</li>
</ul>
<p><strong>Varicella vaccine</strong></p>
<p>rationale</p>
<p>type</p>
<p>timing</p>
<ul>
<li>Virus responsible for chicken pox & zoster</li>
<li>Uncomplicated illness but severe disease in very young & older patients</li>
<li><strong>Live attenuated vaccine</strong></li>
<li>12-18 mo</li>
</ul>
<p>What is the <strong>rationale</strong> for the Hepatitis A vaccine?</p>
<ul>
<li>Hepatitis A is the <strong>most common viral cause of hepatitis</strong> worldwide</li>
<li>Asymptomatic in up to 70% of infected children younger than 6 yrs of age</li>
<li>Most severe disease in older children & adults, but rarely associated w/ fulminant hepatitis</li>
</ul>
<p><strong>Hepatitis A vaccine</strong></p>
<p>type</p>
<p>timing</p>
<ul>
<li><strong>Inactivated vaccine</strong></li>
<li>2 yrs of age or older, with a booster 6 mo later for the following:
<ul>
<li><strong>susceptible children</strong> living in communities w/ high hepatitis A rates (2x national rate) & those traveling to endemic areas</li>
<li>individuals in <strong>other groups </strong>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</li>
</ul>
</li>
</ul>
<p>What is the <strong>composition</strong> &<strong>rationale</strong> for the Pneumococcal vaccines (Pneumovax/Prevnar)?</p>
<ul>
<li>Composed of polysaccharide capsular antigens from 23 pneumococal serotypes</li>
<li>Pneumococcus (<em>Strep pneumoniae</em>)</li>
<li>Most common cause of <strong>acute otitis media</strong> & <strong>invasive bacterial infections </strong>in children younger than 3 yrs of age</li>
</ul>
<p><strong>Pneumovax</strong></p>
<p>advantage</p>
<p>disadvantage</p>
<p></p>
<ul>
<li><u>Advantage</u>: vaccine contains <strong>antigens</strong> from pneumococcal strains causing almost all cases of bacteremia & meningitis during childhood</li>
<li><u>Disadvantage</u>: vaccine has <strong>little immunogenicity </strong>in children <2 YO</li>
</ul>
<p>What are the <strong>indications</strong> for the Pneumovax vaccine?</p>
<ul> <li><strong>Older children & adults at high risk for pneumococcal disease</strong></li> <li>Patients w/ sickle cell anemia who are functionally asplenic</li> <li>Immunodeficiency</li> <li>Chronic liver disease</li> <li>Nephrotic syndrome</li> <li>Patients w/ anatomic asplenia</li> </ul>
<p><strong>Prevnar vaccine</strong></p>
<p>advantages</p>
<p>disadvantage</p>
<ul>
<li>7 pneumococcal serotypes</li>
<li><u>Advantages</u>: immunogenicity & efficacy in preventing meningitis, pneumonia, bacteremia & otitis media from the most common pneumococcal strains in children <2 YO</li>
<li><u>Disadvantage</u>: does not confer as broad coverage against pneumococcal strains as Pneumovax</li>
</ul>
<p>What are the <strong>indications</strong> for the Prevnar vaccine?</p>
<ul>
<li><strong>All children <2 YO</strong></li>
<li>Selected children >2 YO who are at high risk for pneumococcal disease</li>
<li>Prevnar recommended at 2, 4, & 6 mo w/ a booster at 12-15 mo</li>
</ul>
<p>What are some <strong>adverse effects</strong> of immunization?</p>
<ul>
<li>Most mild-moderate, w/i first 24 hrs
<ul>
<li><strong>Local inflammation, low-grade fever</strong></li>
</ul>
</li>
<li><strong>MMR & varicella </strong>are live attenuated vaccines
<ul>
<li>Fever & rash 1-2 wks after immunization</li>
<li>After the incubation period of the virus</li>
</ul>
</li>
<li>Serious side effects that may result in permanent disability or be life-threatening are rare
<ul>
<li>Vaccine-related polio after OPV</li>
</ul>
</li>
</ul>
<p>What are some <strong>contraindications</strong> to immunization?</p>
<ul>
<li><strong>Anaphylaxis</strong> to a vaccine or its constituents</li>
<li><strong>Encephalopathy</strong> w/i 7 days after DTaP vaccine</li>
<li>Patients w/ progressive <strong>neurologic disorders </strong>(uncontrolled epilepsy) should not receive DTaP vaccine until neuro status is stabilized</li>
<li><strong>Immunodeficient</strong> patients should not receive OPV, MMR & varicella vaccines. Household contacts shouldn't receive OPV as it is shed in the stool</li>
<li><strong>Pregnant</strong> patients should not receive live vaccines</li>
</ul>
<p>What are some <strong>precautions</strong> for all vaccines?</p>
<ul>
<li>Moderate to severe illness (w/ or w/o fever)</li>
<li>Mild illnesses, including febrile illnesses, are <strong>not</strong> contraindications to immunization</li>
</ul>
<p>What are some <strong>precautions</strong> fro the DTaP vaccine?</p>
<ul>
<li>Temp of 40.5oC w/i 48 hrs after prior vaccination</li>
<li>Collapse or shocklike state w/i 48 hrs after prior vaccination</li>
<li>Seizures w/i 3 days after prior vaccination</li>
<li>Persistent, inconsolable crying lasting<u>></u>3 hrs occuring w/i 48 hrs after prior vaccination</li>
</ul>
<p>What are some <strong>precautions</strong> for MMR & varicella vaccines?</p>
<ul>
<li>Immunoglobulin (<strong>IVIG</strong>) administration w/i the preceding 3-11 mo, which might interfere w/ the patient's immune response to these vaccines</li>
</ul>
<p>What is the focus of each well child visit?</p>
<p>To <strong>identify</strong> undetected problems &the <strong>risks</strong> of such problems</p>
<p>What are some examples of screening assessments?</p>
<ul>
<li>Complete history & physical examination</li>
<li>Growth measurements</li>
<li>Blood pressure measurements</li>
<li>Strabismus & vision screening</li>
<li>Hearing screening</li>
<li>Tuberculosis screening</li>
<li>Laboratory screening</li>
<li>*Vision screening for ophthalmologic disorders begins after birth</li>
</ul>
<p>Hearing screening recommendations</p>
<ul>
<li><strong>Universal newborn hearing screening </strong>(before hospital discharge) is now recommended</li>
<li>Evidence that moderate-to-profound hearing loss in early infancy is associated w/ <strong>impaired language development</strong></li>
<li>Early detection & intervention for hearing loss may improve speech & language acquisition</li>
</ul>
<p>What types of <strong>audiometric tests</strong> are used for hearing screening?</p>
<ul>
<li>Brainstem auditory evoked response (BAER)</li>
<li>Evoked otoacoustic emission (EOE)</li>
</ul>
<p>Most effective screening is to use <strong>both</strong> of the above tests in combination</p>
<p>What is the brainstem auditory evoked response (<strong>BAER</strong>) test?</p>
<ul>
<li>Measures the <strong>EEG</strong> waves generated in response to clicks via electrodes pasted to the infant's scalp</li>
<li>The <strong>most accurate test</strong>, but requires costly equipment & trained operators</li>
</ul>
<p>What is the evoked otoacoustic emission (<strong>EOE</strong>) test?</p>
<ul>
<li>Measures sounds generated by <strong>normal cochlear hair cells</strong> that are detected by a microphone placed into the external auditory canal</li>
<li>EOE accuracy may be affected by debris or fluid w/i the external or middle ear</li>
<li>It <strong>requires less</strong> expensive equipment & less operator training</li>
</ul>
<p><strong>Neonatal metabolic state screenings</strong></p>
<p>diseases</p>
<p>reasoning</p>
<ul>
<li>Treatable, prevention of irreversible brain injury
<ul>
<li><strong>Congenital hypothyroidism</strong></li>
<li><strong>Phenylketonuria</strong></li>
<li><strong>Galactosemia</strong></li>
</ul>
</li>
<li>Early intervention (penicillin prophylaxis) significantly decreases morbidity & mortality
<ul>
<li><strong>Sickle cell anemia</strong></li>
<li>Other hemoglobinopathies</li>
</ul>
</li>
</ul>
<p>Routine screening of <strong>cholesterol & lipid</strong> panels (are/aren't) recommended because.....</p>
<ul>
<li>Are <strong>NOT</strong> recommended</li>
<li>Lack of information about the risks & benefits of treating hyperlipidemia during childhood</li>
<li>Costs & limitations of currently available screening tests</li>
</ul>
<p>When is cholesterol & lipid screening <strong>recommended</strong>?</p>
<ul>
<li>Children <strong>>2 YO</strong> w/ fahx of hypercholesterolemia, hyperlipidemia or early MI</li>
<li>Protocol
<ul>
<li>Screening cholesterol if either parent has a hx of hypercholesterolemia</li>
<li>Screening fasting lipid panel if either parents or grandparents have a hx of CVD or sudden death</li>
</ul>
</li>
</ul>
<p>If a child has elevated cholesterol levels (75th-90th percentile), what <strong>lab test</strong> should they have?</p>
<ul>
<li><strong>Fasting lipid panel</strong>
~~~
<ul>
<li>Total cholesterol</li>
<li>TGs</li>
<li>HDL</li>
<li>LDL</li>
</ul>
</li>
</ul>
~~~
<p>At what age is <strong>iron deficiency anemia</strong> most common?</p>
<ul>
<li>Children <6 YO</li>
<li>Peaking btwn 9-15 mo</li>
</ul>
<p>What are the <strong>risk factors </strong>for iron deficiency anemia?</p>
<ul>
<li>Prematurity</li>
<li>Low birth weight</li>
<li>Early introduction of cow's milk (<9 mo)</li>
<li>Insufficiency dietary intake of iron</li>
<li>Low SES</li>
</ul>
<p>Universal screening of hemoglobin levels is recommended........</p>
<p>btwn 9-15 mo</p>
<p>btwn 4-6 years</p>
<p>When is <strong>urinalysis</strong> warranted in a child?</p>
<ul>
<li><strong>Little evidence</strong> that routine surveillance of urinalysis or routine urine cultures are efficacious or cost effective</li>
<li>Urine studies are recommended only when clinically warranted or when required for school entry or by local health departments</li>
</ul>
<p>How is <strong>Tuberculosis</strong> screened?</p>
<p>Who should receive it?</p>
<ul>
<li>Intradermal injection of purified protein derivative
<ul>
<li><strong>PPD, Mantoux skin test</strong></li>
</ul>
</li>
<li>Skins tests analyzed at 48-72 hrs after placement & interpreted on the basis of the level of risk for TB in the particular child</li>
<li>Recommended for children at <u>risk</u> for TB</li>
</ul>
<p>What types of children are at <strong>risk for TB</strong>?</p>
<ul>
<li><strong>Contacts</strong> of persons w/ confirmed or suspected infectious tuberculosis</li>
<li>Children in contact w/ high-risk groups
<ul>
<li>Adults <strong>incarcerated</strong> or institutionalized during the preceding 5 yrs</li>
<li><strong>HIV</strong>-infected household members</li>
<li><strong>Homeless</strong> persons</li>
<li>Users of illicit <strong>drugs</strong></li>
<li>Migrant <strong>farm</strong> workers</li>
</ul>
</li>
<li>Children w/ <strong>radiographic or clinical findings </strong>suggestive of tuberculosis</li>
<li>Children who have <strong>immigrated</strong> 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)</li>
<li>Children w/ <strong>HIV</strong></li>
<li>Children w/o specific risk factors who reside in <strong>high prevalence areas</strong></li>
</ul>
<p>How common is lead intoxication (<strong>plumbism</strong>)?</p>
<ul>
<li>Public health risk among children <5 YO</li>
<li>Up to <strong>4%</strong> of all children in the US have evidence of increased lead absorption, including up to <strong>20%</strong> of inner city children</li>
</ul>
<p>What are the <strong>risk</strong> factors of lead intoxication?</p>
<ul>
<li>Ingestion of lead-containing paint or putty from <strong>homes built before 1978</strong></li>
<li>Drinking water from lead<strong> pipes</strong> or pipes w/ lead-containing solder</li>
<li>Exposure to lead smelters or lead-painted commercial structures during <strong>demolition</strong></li>
<li>Use of lead-glazed <strong>pottery</strong> in food preparation</li>
<li>Use of lead-containing <strong>folk remedies</strong></li>
</ul>
<p>At what age are children most susceptible to lead intoxication?</p>
Children
<p>Describe <strong>acute</strong> lead intoxication</p>
<ul> <li>Anorexia</li> <li>Apathy</li> <li>Lethargy</li> <li>Anemia</li> <li>Irritability</li> <li>Vomiting</li> <li>May progress to encephalopathy</li> </ul>
<p>Describe <strong>chronic</strong> lead intoxication</p>
<ul> <li>Most commonly <strong>asymptomatic</strong></li> <li>Neurologic sequelae <ul> <li>Developmental delay</li> <li>Learning problems</li> <li>Mental retardation</li> </ul> </li> </ul>
<p>What age groups are recommended to have <strong>lead screening</strong>?</p>
<ul>
<li>All children 9 mo - 6 yrs of age living in <strong>older, dilapidated housing</strong></li>
<li>All children 9 mo - 6 yrs of age who are siblings, visitors, playmates of children w/ lead <strong>intoxication</strong></li>
<li>All children 9 mo - 6 yrs of age living near lead <strong>smelters</strong> or lead processing plants or whose parents/family have a lead-related <strong>occupation</strong> or hobby</li>
<li>Children of any age living in older housing where <strong>renovation</strong> is occuring</li>
<li>All children of any age living in areas in which the percentage of 1-2 year olds w/ elevated lead levels exceeds <strong>12%</strong></li>
</ul>
<p><strong>Blood lead levels</strong> of \_\_\_\_\_\_\_ have been associated w/ effects on cognition in young children.</p>
<p>Management?</p>
<ul>
<li><u><</u>10 ug/dL</li>
<li>Based on serum levels after repeat testing
<ul>
<li><strong>Education</strong> to decrease exposure</li>
<li><strong>Chelation</strong> for very high lead levels</li>
</ul>
</li>
</ul>
<p>Approximately \_\_\_% of male infants in the US are circumcised.</p>
<p>Circumcision for medical reasons (is/is not) recomended by the American Academy of Pediatrics.</p>
<p><strong>60%</strong></p>
<p><strong>is NOT</strong></p>
<p>What are the medical <strong>benefits</strong> of circumcision?</p>
<ul>
<li>Increased incidence of<strong> penile cancer </strong>in uncircumcised adult men (HPV)</li>
<li>Increased incidence of <strong>cervical cancer</strong> in female sexual partners of uncircumcised men</li>
<li><strong>UTI's</strong> are 10x more common in uncircumcised male infants</li>
</ul>
<p>What are the <strong>3 reasons</strong> an uncircumcised male may ultimately require circumcision?</p>
<p></p>
<p>*10% of uncircumcised males*</p>
<ul> <li>Phimosis</li> <li>Paraphimosis</li> <li>Balanitis</li> </ul>
<p>define Phimosis</p>
<ul>
<li><strong>Inability to retract the foreskin</strong></li>
<li>Normal up to age 6</li>
<li>Always abnormal if ballooning of foreskin occurs during urination</li>
</ul>
<p>define Paraphimosis</p>
<ul>
<li>When the retracted foreskin can't be returned to its normal position & acts as a <strong>tourniquet</strong>, resulting in obstruction to lymphatic flow & edema</li>
<li>Obstruction of venous return --> emergent surgery</li>
</ul>
<p>define Balanitis</p>
<ul>
<li><strong>Inflammation of the glans of the penis</strong></li>
<li><u>Infants</u>: <em>Candida</em> spp or gram-neg infections</li>
<li><u>Adults</u>: STIs</li>
</ul>
<p>\_\_\_\_\_\_\_ & \_\_\_\_\_\_\_ are strongly recommended during circumcision.</p>
<p>Anesthesia & analgesia</p>
<p>What are the potential <strong>complications</strong> from a circumcision?</p>
<ul> <li>Bleeding</li> <li>Infection</li> <li>Poor cosmesis</li> <li>Phimosis (secondary to insufficient foreskin removal)</li> <li>Urinary retention</li> <li>Injury to</li> </ul>
<p>What are some <strong>contraindications</strong> to circumcision?</p>
<ul> <li>Penile abnormalities (hypospadias)</li> <li>Prematurity</li> <li>Bleeding diatheses</li> </ul>
<p><strong>Tooth eruption</strong></p>
<p>age range</p>
<p>first tooth</p>
<p>primary vs. secondary</p>
<ul>
<li>3-16 mo (average 6 mo)</li>
<li>First tooth: lower central incisor</li>
<li><strong>Primary teeth</strong>
<ul>
<li>20 teeth</li>
<li>established by 2 yrs of age</li>
</ul>
</li>
<li><strong>Secondary teeth</strong>
<ul>
<li>begins w/ lower central incisor</li>
<li>6-8 yrs of age</li>
<li>32 secondary ("permanent") teeth</li>
</ul>
</li>
</ul><p><strong>Delayed dental eruption</strong></p>
<p>definition</p>
<p>causes</p>
<ul> <li>Primary eruption occuring <strong>after 16 mo </strong>of age</li> <li>Causes <ul> <li>Familial</li> <li>Hypothyroidism</li> <li>Hypopituitarism</li> <li>Genetic syndromes <ul> <li>Down syndrome</li> <li>Ectodermal dysplasia <ul> <li>Conical-shaped teeth</li> <li>Dysmorphic facial features</li> <li>Decreased sweat glands</li> <li>Alopecia</li> </ul> </li> </ul> </li> </ul> </li> </ul>
<p><strong>Early dental eruption</strong></p>
<p>definition</p>
<p>causes</p>
<ul> <li>Primary eruption <strong>before 3 mo</strong></li> <li>Causes <ul> <li>Familial</li> <li>Hyperthyroidism</li> <li>Precocious puberty</li> <li>Growth hormone excess</li> </ul> </li> </ul>
<p>When should <strong>tooth brushing</strong> be started?</p>
<p>What can be used?</p>
<p>When can children do it on their own?</p>
<ul>
<li>Should begin <strong>as soon as teeth erupt</strong></li>
<li>Moist washcloth or gauze pad initially</li>
<li>Soft toothbrush as early as tolerated</li>
<li><strong>2-3 YO</strong>: able to assist in brushing their own teeth
<ul>
<li>Fluoride toothpaste may be used</li>
</ul>
</li>
</ul>
<p><strong>Dental floss</strong> to remove plaque from btwn teeth should be initiated when.....</p>
<p>tight contact exists btwn teeth</p>
<p><strong>Fluoride</strong></p>
<p>benefits</p>
<p>sources</p>
<ul> <li>Children who consume optimal amts from birth until adolescence have <strong>50-75%</strong> less dental decay than expected</li> <li>Sources <ul> <li>Fluoridated water (not in USA)</li> <li>Fluoride supplements</li> <li>Fluoride toothpaste</li> </ul> </li> </ul>
<p>What is <strong>fluorosis</strong>?</p>
<p>What are the effects?</p>
<ul> <li>Caused by excess fluoride</li> <li><strong>Affects permanent teeth</strong></li> <li>Leads to abnormalities in dental enamel & dentin</li> <li>Effects are <u>cosmetic</u> only <ul> <li>White streaks</li> <li>Pitting</li> <li>Gray-brown staining</li> </ul> </li> <li>Most critical time for dental vulnerability to excess fluoride: <strong>2-4 yrs of age</strong></li> </ul>
<p>In what population of children is fluoride supplementation important?</p>
<ul>
<li>Exclusively breastfed children <strong>>6 mo</strong>
<ul>
<li>Breast milk has little fluoride</li>
</ul>
</li>
<li>Children who live in areas where tap water contains <strong><0.3 ppm</strong> fluoride</li>
</ul>
<p>What are <strong>natal</strong> teeth?</p>
<p>What are <strong>neonatal</strong> teeth?</p>
<ul>
<li><strong>Natal teeth</strong>
~~~
<ul>
<li>those that are present at birth</li>
</ul>
</li>
<li><strong>Neonatal teeth</strong>
<ul>
<li>those that emerge during the 1st mo</li>
</ul>
</li>
</ul>
~~~
<p>What are the most common teeth that erupt early?</p>
<ul>
<li><strong>Mandibular central incisors</strong></li>
<li>>90% primary teeth</li>
<li><10% supernumerary teeth (teeth in excess of usual number)</li>
</ul>
<p>What is the <strong>etiology</strong> & <strong>management</strong> of early teeth?</p>
<ul>
<li>Etiology often unknown
<ul>
<li>Exposure to environmental toxins</li>
<li>Familial</li>
</ul>
</li>
<li>No intervention unless..
<ul>
<li><strong>Hypermobile teeth</strong></li>
<li><strong>Breastfeeding difficulty</strong></li>
<li><strong>Trauma to infant's lip/tongue</strong></li>
</ul>
</li>
<li><u>Aspiration</u> of natal/neonatal tooth feared but very unlikely</li>
</ul>
<p>\_\_\_% of children have<strong> nursing/bottle caries</strong>.</p>
<p>Most often seen at \_\_\_\_ months of age.</p>
<p><strong>3-6%</strong></p>
<p><strong>24-30</strong></p>
<p>What are the <strong>etiologies</strong> of nursing/bottle caries?</p>
<p>Most common bacterial agent?</p>
<ul>
<li>Associations
<ul>
<li>falling asleep w/ nipple (breast or bottle) in the mouth</li>
<li>children who breastfeed excessively or who carry around a bottle as a habit</li>
</ul>
</li>
<li><strong><em>Streptococcus mutans</em></strong>
<ul>
<li>Doesn'tappear in oral cavity until teeth erupt</li>
<li>Acquired from colonized parents/siblings</li>
</ul>
</li>
</ul>
<p><strong>Nursing/bottle caries</strong></p>
<p>clinical features</p>
<p>management</p>
<ul>
<li><strong>Clinical features</strong>
~~~
<ul>
<li>Maxillary incisors</li>
<li>Canines</li>
<li>Primary 1st molars</li>
<li>Lower teeth spared initially b/c covered by the tongue</li>
</ul>
</li>
<li>Rx: placement of dental crowns or extraction</li>
</ul>
~~~
<p>What is<strong> dental trauma</strong>?</p>
<p>What are the prognostic factors?</p>
<ul>
<li>A permanent tooth that has been <strong>traumatically avulsed</strong> may be re-implanted if placed into the socket rapidly</li>
<li>Most important factor: <strong>extraoral time</strong></li>
<li>Prognosis highest if avulsed tooth is stored in liquids (especially <strong>milk</strong>)</li>
<li>Dry-stored tooth has poor prognosis, even after 30 minutes</li>
</ul>
<p>How is dental trauma managed?</p>
<p>What about primary teeth?</p>
<ul> <li>Management <ul> <li>Gentle rinsing of an avulsed tooth w/ saline</li> <li>Placement into the socket</li> <li>Referral to a dentist</li> </ul> </li> <li>Avulsed primary teeth do not require re-implantation</li> </ul>
<p>What is the timing of <strong>developmental screening</strong>?</p>
<ul>
<li>Assessed at each well child visit from infancy through school age</li>
<li>School performance substitutes in developmentally normal children<u> >5-6 YO</u></li>
</ul>
<p>What is <strong>anticipatory guidance</strong>?</p>
<ul>
<li><strong>Patient & parent education</strong></li>
<li>Provided during each well child visit</li>
<li>Tailored to the child's current developmental level & to anticipated changes in the child's development in the interim before the next scheduled visit</li>
</ul>
<p>What are the 9 topics covered by anticipatory guidance?</p>
<ol>
<li>Health habits (tobacco, drug, alcohol counseling)</li>
<li>Prevention of illness & injury (safety)</li>
<li>Nutrition</li>
<li>Dental care</li>
<li>Social development & family relationships</li>
<li>Sexuality</li>
<li>Parental health</li>
<li>Self responsibility</li>
<li>School & vocational achievement</li>
</ol>
