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>
