Pediatric Wellness/Mary Gallagher Lectures Flashcards
1
Q
Most victims of child abuse are below what age?
A
85% of victims are < 3 yo
2
Q
What is the most common fracture of child abuse?
A
Femur fracture = most common fracture of child abuse
3
Q
What are some red flags associated with Sexual Abuse in children?
A
- difficulty walking or sitting
- signs of trauma in external genitalia
- injury or STI that is unusual for age group
- Frequent UTI/yeast infections
- Pregnancy at a young age
4
Q
What is the primary risk factor for infant head trauma or other forms of physical abuse?
A
infant crying
5
Q
At what age does crying peak?
A
2-4 months
6
Q
Why do neonates have low levels of vitamin K?
A
- vitamin K is synthesized by bacteria in gut → absence of gut flora
- inability of the fetal liver to store vitamin K
7
Q
Why do we apply erythromycin to infants?
A
- prevents ophthalmia neonatorum from N. gonorrhoeae & C. trachomatis
- Gets applied topically onto the conjunctival sacs immediately after birth
8
Q
Why do we give Hep B iz in newborns?
A
- Prevent transmission of Hep B
If birth parent = Hep B surface antigen positive → infant needs hep B Iz AND hep B immune globulin
9
Q
Exclusive Breastfeeding & Hyperbilirubinemia
A
- “Breastfeeding Jaundice”
- Related to suboptimal milk intake
- Peaks at 3-5 days of life
- Frequently associated with excess weight loss
- “Breast Milk Jaundice”
- Hyperbilirubinemia that persists with adequate human milk intake and weight gain
- Prolonged unconjugated hyperbilirubinemia
- Can last up to 3 months (Mary said she hasn’t seen it last longer than 6-8 weeks)
- Almost always nonpathologic and not associated with direct or conjugated
10
Q
Risk factors for significant hyperbilirubinemia
A
- Lower gestational age
- G6PD deficiency
- Hemolysis from any cause
11
Q
Hyperbilirubinemia Neurotoxicity Risk Factors
A
- Gestational age < 38 wk
- Albumin < 3.0 g/dL
- Isoimmune hemolytic disease (i.e. positive direct antiglobulin test), G6PD deficiency, or other hemolytic conditions
- Sepsis
- Significant clinical instability in the previous 24H
12
Q
Gestational Age Classifications
A
Term: GA 37+ weeks
- Late Preterm: GA 34- <37 weeks
- Moderate Preterm: GA 32- <34 weeks
- Very Preterm: GA < 32 weeks
- Extremely Preterm: GA = 25weeks
13
Q
What is prolonged Jaundice and what do you do?
A
- 3-4 weeks in breastfed infants ; 2 weeks on formula fed infants
- Check NB screen for conditions that can lead to persistent jaundice
- Consider GI consult with any formula fed infant with prolonged jaundice or breastfed infant with direct hyperbilirubinemia
14
Q
Preterm Infant Birth Weight Classification
A
Infants are classified by birthweight:
- Low Birth Weight: BW < 2500g
- Very Low Birth Weight: BW < 1500g
- Extremely Low Birth Weight: BW < 1000g
15
Q
APGAR Scores: When and how to calculate?
A
*Done at 1 & 5 minutes*
-Preterm infants and emergency c-section babies = more likely to have low scores
16
Q
Newborn Weight Loss
A
- Weight loss is NORMAL
- -Weight loss 10% + needs to be investigated
- > 7% in the first few days after birth should be monitored and investigated!
- -should return to birth weight by 2 weeks
- -30 grams = 1 ounce
17
Q
Feeding
A
18
Q
Normal Ins and Outs for newborns
A
- Feeds: 8-12x/24 hours
*
19
Q
Newborn Metabolic Screening
A
State Specific
in CA → 80 disorders that are genetic or congenital
20
Q
critical Congenital Heart Disease
A
- Usually initially identified by low pulse ox levels
- Screening for: hypoplastic L heart syndrome, pulmonary atresia, tetralogy of Fallot, total anomalous pulmonary venous return, transposition of the great arteries, tricuspid atresia, truncus arteriosus
21
Q
Hearing Screening in Newborns
A
- **all infants should be screened by 1 mo old**
- Those who fail initial screening → need to be assessed by audiologist by 3 months of age, with intervention by 6 months
-
Automated auditory brainstem response:
- Click or chirp stimuli at 35dB → surface electrodes on forehead, nape, and mastoid or shoulder
- Measures waveforms in response to stimuli and then compares them to normal neonatal templates → pass or fail
-
Otoacoustic Emission:
- Measure the presence or absence of sound waves generated by the cochlear outer hair cells of the inner ear in response to sound stimuli
-
Risk Factors for Hearing Loss:
- NICU for 5+ days
- Hearing loss syndromes
- Family hx of hereditary childhood hearing loss
- Craniofacial anomalies
- Congenital infx
- Severe hyperbilirubinemia → serum bili > 35 mg/dL (599 micro/L) or requiring exchange transfusion on a preterm infant
- Delivery Complications: perinatal asphyxia, cooling, or problems during delivery (e.g. 5 min APGAR score < 6)
- Ototoxic Meds: ampicillin, gentamicin, oxacillin, tobramycin
22
Q
Newborn Reflexes
A
-
Crawling Reflex (Baur Crawling): disappears at weeks-months after birth
- place infant on stomach, apply pressure with hand onto bottom of foot → baby will try to “crawl”
-
Step Reflex: disappears at 3-4 mo
- infant will try to take steps when held upright with slight weight on feet
-
Tonic Neck Reflex (Fencing): disappears at 4 mo
- infant on back with head turned to right → R arm will extend, L arm will bend.
- reverse if head turned to L → L arm will extend, R arm will bend
- infant on back with head turned to right → R arm will extend, L arm will bend.
-
Rooting Reflex: disappears at 4 months
- touch corner of infant’s mouth
- Sucking Reflex: disappears at 4 mo
- Palmar grasp: disappears at 4-6 months
-
Moro Reflex (Startle): disappears at 6 months
- When startled, baby will throw head, back extend arms and legs, then retract arms and legs
- Plantar Grasp: disappears at 9mo -1 year
- Babinski Reflex: disappears at 1 yr
- ”
23
Q
Acrocyanosis
A
- immediately after birth in healthy infants
- Lasts 24-48 hours
24
Q
When do you do an anemia screening?
A
12 mo
25
Autism Screening: How to and when?
* **_M-CHAT/MCHAT-RF_:** \*\*This tool is valid for **ages 16-30 months**\*\*
* Items 2, 5, 12 → YES = indicates ASD risk
* For all other items → NO = indicates ASD risk
* Low risk: score 0-2
* Medium Risk: score 3-7 → administer f/u (2+ = positive)
* High Risk: score 8-20 → reasonable to skip the f/u and refer to early intervention immediately
* 18 & 24 months
26
Depression (Adolescent) Screening: How to and when?
* **_PHQ-9_** = commonly used:
* Score 0-4 = no or minimal depression
* 5-9 = mild depression
* 10-14 = moderate depression
* 15-19 = moderately severe depression
* 20-27 = severe depression
* _When?_
* 12 yo +, screen annually during WCC
27
Depression (Maternal) Screening: How to and when?
* Commonly Used Tools:
* -**PHQ-9**
* **-PHQ-2**
* **-Edinburgh Postpartum**
* **-Depression Scale**
* → scores \> 12-13 = likely depression
* _When_?
* 1, 2, 4, 6mo
28
Commonly used Developmental Screening Tools & WHEN you use them
* **Ages and Stages Questionnaire- 3 (ASQ-3)** → $
* → age range: 1 month - 5 ½ years
* -**Survey of Well-Being of Young Children (SWYC)**
* **→** Free
* _When_?
* 9, 18, 30 mo
29
When to screen for dyslipidemia in Peds
Once between 9 - 11 years
Once between 17 & 21 years
30
When to Screen for HIV in PEDS
Once between 15- 18 years
31
When to refer to audiology for kids?
* **_When to Refer to Audiology:_**
* -Children \< 3 yo with concerns for hearing impairment (e.g. speech delay)
* -Children \> 3 yo who fail screening at **25 db or higher**
32
When to screen for lead in PEDS?
12 & 24 months
33
How/When to screen for tobacco, Alcohol, substances in PEDS ?
* CRAFFT
* 11-21 yo
34
When to refer for failed vision screening in PEDS
* **_When to Refer (age based)_**:
* **-3 years old:**
* missing 3+ symbols on 20/50, or any line about 20/50 with either eye
* -**4 years old:**
* missing 3+ symbols on 20/40 line, or any live above the 20/40, with either eye
* -**5 years old:**
* missing 3+ symbols on the 20/32 (20/30) line, or any line above the 20/32 (20/30) line, with either eye
* **-****Two line difference between the eyes**, even within the passing range (e.g. 20/20 & 20/32)
35
When to complete an oral health screening exam in PEDS?
6 & 9 months
36
Oral healthcare for Kiddos
* brush teeth BID when first tooth appears:
* Rice grain sized smear of toothpaste (fluoride toothpaste is okay)
* Pea sized amount after **age 3**
* Kids need assistance with brushing until **age 9**
* -Establish a dental home by **age 1**
* Dental visit q 6 months
* -Fluoride varnish
* Recommended 2-4x/year for kids age **6mo- 5 years**.
37
What do the milestones mean?
* -ages by which at least 75% of children would be expected to exhibit them
* -There are checklists for all WCCs from **2 mo - 5 years**
* \*\***Any loss of milestones is a red flag\*\***
38
RED FLAGS for language Delay
39
Newborn Development Milestones (?)
* Makes brief eye contact
* Cries with discomfort
* Calms to adult voice
* Reflexively moves arms and legs
* Turns head to side when on stomach
* Holds fingers closed
* Grasps reflexively
40
What do you do about Milestone Concerns?
* Screen
* Provide activities for families to encourage development
* **Referral to early intervention if \< 3 yo**
* **Referral to school district if \> 3 yo**
* Can write a letter on behalf of child requesting IEP
* Referral to developmental behavioral pediatrician
41
What are the hunger Vital Signs?
1. “Within the past 12 months did you worry whether your food would out before you got the money to buy more?”
2. “Within the past 12 months did the food you bought not last and did you not have enough money to get more?”
42
Infant Nutrition: what does the AAP recommend for breastfeeding, when to introduce solids, and vitamin D supplementation
AAP recommends exclusively breastfeeding **until 6 months** then introduce complementary foods
* Feeding on demand at least q2-3 hours
* *Infants generally do not need nutrition overnight **between 6-9 months***
- Formula when breastfeeding is not an option
- When are infants ready for solids?
* Baby needs to able to sit up with support and turn head back and forth
* Generally, full-term infants are ready at **4-6 months**
- Vitamin D supplementation
* **400 IU of Vitamin D** once a day to infants who are fully or partially breastfed (Mary said to know this in class)
- Breastmilk/Formula = 20kcal/oz
43
Benefits vs Contraindications of Breastfeeding
* _Benefits:_
* Decreased risk of infx, atopic conditions, obesity, DM
* _-_**_Contraindications to breastfeeding_**:
* Infant galactosemia
* Breastfeeding parent with:
* Human t-cell lymphotropic virus I/II infx
* Untreated brucellosis
* HIV
* Use of illicit street drugs
* Diagnostic or therapeutic radioactive isotopes/chemotherapeutic agents
* Active HSV inx on breast
44
Recommended amount of formula (by age)
45
Specialty Infant Formulas: Just general important info
46
Complementary (Solid) Food Introduction in Infants
* Introduce common allergens ***at ~ 6 months*** (esp for those at high risk
* Peanuts, fish, eggs, soy, wheat, milk
* -offer Iron rich foods (iron stores decrease at **4-6 mo**)
* -Avoid honey until **12 mo** (risk of botulism)
* -Dairy products like cheese and yogurt are okay, but milk source should be formula or breastmilk
* -Introduce a variety of textures
* -Alls feedings should be supervised
* -Should stop breastfeeding by approx **age 2**
47
Toddlers & Young Children: Milk
* Introduce whole milk at **~12mo**
* Ca2+ and fats → most important so okay to drink other alternative milks so long as they get these components
* Limit to **16oz/day**
* Do not need toddler formula
* Should start introducing cup with goal to wean bottle by **15-18mo**
* Why? Teeth. Milk can cause dental caries and bottles can alter jaw formation.
48
Toddlers & Children: Juice, Iron Rich Foods, and how many meals/snacks
- Juice:
* Limit to 4oz/day → recommend 100% fruit juice
- Iron Rich Foods:
* 2x/day
- 3 meals with 2 snacks
49
Adolescents and Nutrition
* -Encourage breakfast
* -Watch for restrictive eating habits
* -Use sports physical as opportunities to discuss nutrition and how it relates to performance
* -Vegan?
* B12 supplementation
50
Sleep: Infants
* Sleep location (NOT with a parent)/ position (on back), longest stretch overnight, wake time during the day
* Establish circadian rhythm by **4 mo**
* Sleep interventions prior to this = NOT helpful
* _Recommendations_:
* Put the baby to sleep drowsy but awake to avoid association with rocking/feeding etc.
* Wake windows change with age.
* Babies may be hard to put to sleep if they miss their wake window
* **AAP Safe Sleep Recommendations** **→ to prevent SIDS**
* Should be on back for all naps and night time sleep
* Firm, flat sleep surface
* Avoid co-sleeping
* Share a room with infant for **1st 6 months**
* Avoid overheating
51
Sleep: Toddlers & Preschoolers General Info
Night time awakening (VERY common), nap, bedtime/wake time, snoring, apnea, restless sleep
52
Sleep: Toddlers
* 12-14 hours of sleep in a 24 hour period
* Usually transition to one nap by **approx 18 mo**
* Sleep difficulties = NORMAL
* Resisting bedtime
* Getting out of bed/ night time awakenings
* Separation anxiety
53
Sleep: Preschoolers
* 11-13 hours of sleep each night
* Napping is usually stopped **before age 5**
* Nightmares = common b/c of development of imagination
* sleeping walking/night terrors = common
* Regular daytime routine helps promoter regular nighttime sleep
54
Sleep: School-Aged and Adolescents (General info)
bedtime/wake time, trouble falling asleep or staying asleep, snoring, apnea (pts with sleep apnea can have sxs during day that mimic ADHD), restless sleep
55
Sleep: Middle Childhood
* 10-11 hours of sleep
* Napping in elementary school? → consider further eval
* Assess for caffeine use, screen time, homework time, extracurriculars
56
Sleep: Adolescents
* 8-9 hours of sleep
* Biological shift in their internal clock → difficulty falling asleep early
* Early high school start cuts into sleep
* Social, school obligations
57
Avg Sleep Duration (By Age) Chart
58
Age Specific Recommendations for Screen Time
* \<18mo:
* Avoid use of screen media except video-chatting
* 18-24 mo:
* IF introduced → high quality programming/co-watch with child
* 2-5 years:
* Limit to 1h/day of high quality programs; co-watch with child
* \>6yo:
* Consistent limits, making sure it does not interfere with sleep, exercise, nutrition, school
59
Normal Elimination for Kids as they age (Chart): Infant, toddler/Preschooler, School-Aged Child, Adolescent
60
Assessing Potty Training Readiness
* Child is dry at least 2 hours at a time or dry after naps
* Shows signs they are about to pee/poop
* Follows simple directions
* Walks to and from bathroom/ helps undress themselves
* Does not like to be in wet/soiled diapers & asks to be changed
* Shows interest
* Asks to use potty or wear big kid underwear
61
How to Potty Train
* Use a kid-sized potty
* Establish a routine
* Lots of praise/ positive reinforcement
* Anticipate hesitancy
* Avoid during times of transition or stress
* Book Recommendation: “Oh Crap! Potty Training” by Jamie Glowacki
62
Enuresis
* _Definition_: Voluntary or involuntary urination at an age when toilet training should be complete
* _Primary_:
* No hx of of bladder control (common until age 5-6)
* _Secondary:_
* Enuresis that occurs after children have been dry for a period of 6 mo or more
* _Causes:_
* Causes are varied → **ALWAYS RULE OUT CONSTIPATION**
* _Dx_:
* UA, urinary cath if sxs are suggestive of UTI
* _Tx_:
* goal is establish normal function
* **Urotherapy**
* -**Bedwetting alarms** → more effective than desmopressin
* -**Desmopressin** → antidiuretic effect but NOT for long term use → helpful for nights child wants to stay dru (e.g. summer camps)
63
Pediatric Constipation
* _Definition_:
* Persistent infrequent bowel movements (**\< 3 bm/week** **for adults/adolescents**) or feeling of incomplete voiding
* _Chronic_ = \> 3 months
* _Causes_:
* **Most common cause = dietary**
* _Dx_:
* **Clinical** though a KUB xray can be considered
* **History is key!** (timing of new drugs and symptoms)
* _Tx_:
* Infants: 100% fruit juice (prune juice, pear nectar, apple juice, **4**mo = **4** oz of water)
* Bowel Cleanout + retraining to establish a regular pattern of stool
* Miralax works well → can consult **Seattle Children’s Bowel Cleanout** handout (been recommended to me by multiple peds providers)
64
Encopresis
* _Definition_: Repetitive, voluntary or involuntary fecal soiling or fecal incontinence. Must occur at least **1x/month** for **at least 2 mo**
* Most commonly associated with constipation
* _Causes_:
* Retention, colon stretching, decreased peristalsis, impacting, leaking
* _Tx_:
* Bowel Cleanout + retraining to establish a regular pattern of stool
* Miralax works well → can consult **Seattle Children’s Bowel Cleanout** handout (been recommended to me by multiple peds providers)
* Behavioral health consult
* Educate that encopresis is not the child’s fault/ there is no blame
65
Fever in Peds: def, ddx, PE, tx (general)
* _Definition_: in children **\< 2 mo** = 100.4F (38c)+; in children **\> 2 mo** = 101F (38.3C)+
* _Ddx_:
* MCC = viral
* Bacterial infx
* Rxn to Izs
* Autoimmune & inflammatory
* Cancer
* Medication
* Tissue Damage
* _PE_:
* Overall clinical appearance = more important than the fever itself!!
* Toxic vs Well Appearing
* _Tx_:
* tx the child, not the fever
* meds for comfort → Ibu/ acetaminophen
66
Ibuprofen in kids: dosing, max dose, contraindications
**_Ibuprofen_**
* **\> 6 mo**
* Dosing: **5-10 mg/kg q 6-8 hours**
* Max dose: **400mg/dose OR 40 mg/ kg/24 hours**
* Contraindications: GI bleed/ulcer disease
* Oral suspension (children’s): 100mg/ 5mL
* Oral Drops (infants): 50mg/1.25ml
***Pay attention to concentration when prescribing***
67
Acetaminophen in Kids: Dosing, max dose
**_Acetaminophen_**
* No age restriction
* Dosing: **10-15mg/kg q 4-6 hours**
* Max dose **4g/24 hours**; no more than 5 doses in 24 hours
* Oral suspension/elixir/liquid/syrup: 160mg/5ml
68
Aspirin in Kids
**No aspirin in \<18 yo due to risk of REYES syndrome** **(**swelling of brain, damage to liver, decreased blood glucose and increased blood ammonia and acidity)
ALSO NOT FOR ASTHMA
69
Non-Pharm Management for Fever
* -Keep them hydrated
* -Lightly dressed → avoid bundling
* -Tepid baths
* -**No ice water or alcohol baths**
70
Anticipatory Guidance for Pediatric Fevers
* Normalize fever
* -Caregivers of infants
* \< 2mo should consult provider before treating fever → except after IZs
* -Avoid multi-symptom ingredient meds!
* -_Return to care precautions_:
* Fever \> 104F
* Fever\> 5 days
* Fever associated with lethargy, trouble breathing, dehydration
71
Febrile Seizures: Epidemiology, Tx, & Anticipatory Guidance
* _Epidemiology_: 3-4 out of 100 kiddos
* -occurs in kids 6mo -5 yrs; most common in 12-18 mos
* -Kids \< 1 yr at time of 1st seizure have about a 50% chance of having another
* -**Most common with** **fever \> 102F**
* _Tx_:
* Supportive care
* _Anticipatory Guidance_:
* -Normalize
* -no permanent damage or lasting effects
* Notify parents of 50% of repeat occurrence
* Usually lasts 1-2 minutes
* Usually occurs within the 1st few hours of fever, as temperature is rising
72
Neonatal Early Onset Sepsis (EOS): Def, Patho, Risk Factors, & Sxs
* _Definition_:
* when a blood or CSF cx obtained within 72 hours of birth grows pathogenic bacterial species.
* _Pathogenesis_:
* ascending intrauterine infx from GU/GI system of mother.
* GBS **= MCC (40-45% of cases)**, E.coli = 10-15% of cases
* Incidence prior to intrapartum abx prophylaxis = 3-4/1000 live births → now 0.5/1000 live births
* _Risk Factors_:
* -Preterm delivery (before they were tested for GBS)
* -Pregnant mama with intra-amniotic infx
* -intrapartum maternal fever
* -Prolonged rupture of membranes
* -Pregnant mama with GBS colonization
* -Other risk factors/early indicators:
* → fetal tachycardia
* → meconium stained amniotic fluid
* → *Apgar score ≤ 6*
* _S/sxs_:
* fever, irritability, poor feeding, lethargy, tachycardia, poor perfusion, respiratory distress, hypotension
73
Neonatal Early Onset Sepsis (EOS): Dx & Tx
* _Dx_:
* Blood cultures
* -CBC with diff
* -CSF cx for those at highest risk of EOS OR in those with positive blood cultures
* do NOT generally need inflammatory markers
* _Tx_:
* 1st line empirical tx: **ampicillin & gentamicin**
* LP if blood cultures are positive
* Serial daily blood cxs until they come back clean
* “In cases where blood cultures are sterile, antibiotics should be discontinued at 36-48 hours of incubation”
74
HEEADSSS Assessment
Adolescent Psychosocial Interview
* H: Home & Environment
* Who lives at home? Unsafe at home? Changes in the home? *Ever run away or get kicked out of the home*? Do your parents use your pronouns & name?
* E: Education & Employment
* What grade are you in? Do you like school? Grades? Eat/use bathroom at school? Job/ how many hours? What do you do with that money? Future plans? Safe/bullying at school?
* E: Eating
* eating/exercise habits? Changes in diet/weight?
* A: Activities
* What do you do for fun? Screen time? Cyberbullying? Spend time with friends/family?
* D: Drugs
* Tobacco use/ alcohol/ other drugs? Do your friends use/know of anyone who uses?
* CRAFFT: Car, Relax, Alone, Friends, Forget, Trouble
* S: Sexuality
* Who are you attracted to? Sex? forced/pressured into sexual acts? Consent Discussion. What do you use for protection? Want info about contraception/STI testing?
* S: Suicide & Depression
* PHQ-9 screening, sad, down depressed? Self harm/ thoughts of suicide? How do you cope?
* S: Safety
* 3 leading causes of adolescent death: unintentional injuries (Accidents), homicide, suicide
* Wear a seatbelt? Wear a helmet when riding a bike/scooter/skateboarding/skiing? Ever ridden in a car with someone using substances? Feel unsafe in home/neighborhood/school?
75
Minors of **Any Age** may consent to:
* -Medical care related to prevention or tx of pregnancy
* -Birth control
* -Abortion
* -Sexual assault services \*\*
* -Rape service for minors under 12 years old\*\*
* -Emergency medical services
* -Skeletal xray to diagnose child abuse → neither nor parent consent is needed
* * \*\*Reportable: must make effort to inform caregiver unless they are thought to be the perpetrator
76
Minors **12+ years of age** may consent to
* -infectious, contagious communicable diseases (if they are required by law to be reported)
* -Sexually transmitted diseases
* -HIV testing & tx
* -Rape services for minors 12 yo & older
* → reportable
* → providers cannot inform parents/caregivers without consent from the adolescent
* -outpt mental health services
* -drug and alcohol use tx services
77
Tanner Stages of Development
78
Fontanelles and when they close
79
Evolution of Neurological Disorders in Peds: Static, Progressive, Intermittent & Brief, & Saltatory
80
How much weight would you expect a newborn to gain per day?
20-30 g/day
81
When does bilirubin peak?
4-14 days
82
At what age does an infant sit up?
6 mo
83
Puberty in females: when to worry
breast development by age 8 or \> 13 yo
84
How long is the time period from initiation of puberty to start of menarche in females?
approx 2-2.5 years
85
At what age do infants recognize their name and respond?
6 mo
86
When do infants develop stranger danger?
9 mo
87
When do infants socially smile and coo?
~2 mo
88
When do infants babble?
6-9 mo
89
When should you be concerned about lack of teeth in toddlers?
15-18 mo
90
Physiologic Gynecomastia in males
* middle to late stages of puberty
* peaks at tanner 3
* occurs in 50% of males
* usually regresses over 2 year period
91
When do you evaluate for delayed puberty in males?
no testicle enlargement by age 14
92
Female Pubertal Development: When, what begins first, when does menarche occur, leukorrhea, and how much growth post menarche, when to eval for delayed puberty
93
Define Thelarche vs. Menarche
* thelarche: onset of breast development
* Menarche: onset of menstruation
94
What is the female athlete triad?
Associated with eating disorders
* Amenorrhea, stress fractures, bradycardia
95
Weight gain in infants and prepubertal children
\*\*20-30g/DAY
96
Evaluating Height in Kids
97
The Menstrual Cycle: When further eval is needed
98
Orthostatic HTN
Take BP and HR after 5 minutes of supine rest
* repeat after 3 min of standing
* Concerns:
* systolic BP drop greater than 20 mm Hg
* Diastolic BP drop greater than 10 mm Hg
99
At what age do kids run?
2 years
100
How to mix standard formula
mix **one scoop formula** with ***two ounces of water***
