Pediatrics 2 Flashcards
____ in the early 1900s was the first person to closely observe infants and establish developmental norms
Gesell
By mid-century, theories that stressed the importance of nurture began to prevail by ___, ___, and ___
Pavlov
Watson
Skinner
Prior to the 1900s, most people thought infants were a _____
blank tablet
because they coudln’t tell us what they’re thinking, we assumed they were devoid of intelligence
____ was the first to describe the infant as having intelligence (in the second half of the century)
Piaget
he said that children actually have the ability to learn, they actively explore the environment and learn how the world works this way
Infant development occurs in an ___ and ___ manner
orderly
predictable
infant development occurs from ____ to ____ and ____ to _____
cephalic to caudal
proximal to distal
responses to stimuli proceed from general reflexes involving ____ to discreet voluntary actions under _____
entire body
cortical control
Why is development important? early development lays the foundation for ___ and ___
learning ability
mental health
early language skill predicts
later language complexity
growing evidence suggests that early signs of autism can be identified ___.
before the first birthday
early temperament predicts
later disruptive behavior disorders
> _____% of adults with mental health disorders had Sx in early childhood
50%
MC concern presented to PCPs:
developmental and/or mental health concerns
formal developmental screening is now recommended by the AAP at ___, ____, and ____ month well child visits and developmental surveillance at the other visits
9, 18, 24-30
What major problems should we be looking for in time of development? (9)
cerebral palsy speech/language impairment hearing impairment visual impairment ADHD intellectual disability autism learning disabilities social-emotional or behavioral disorders
why is screening important?
Early intervention has proven success
4 early intervention options
- early child hood intervention (ECI) at 0-3 years old.. most important.. includes PT, OT, speech therapy, etc
- head start program at 2-5 years old
- preschool programs for children with disabilities at age 3-5 years
- special education programs through the local school district at age 5-21 years old
when screening development, look for at the 5 major areas of development:
- physical growth
- gross motor
- visual perception and fine motor skills
- language
- social-emotional
normal weight patterns: birthweight is... regained by \_\_\_\_ doubled by \_\_\_\_ tripled by \_\_\_\_ quadrupled by \_\_\_\_
2 weeks
5 months
12 months
24 months
head growth is measured by ___
FOC
head growth during the first 5-6 months is due to ____.
neuronal cell division
later head growth is due to ____ and _____.
neuronal cell growth
support tissue proliferation
head is approximately adult-sized by how old?
5 years
4 physical growth RED FLAGS
- short stature or poor weight gain
- small head or microcephaly (almost always reflects cerebral pathology with cognitive implications)
- large head or macrocephaly (50% is familial and benign, but WATCH OUT FOR HYDROCEPHALUS)
- dysmorphisms: minor variations or abnormalities on PE
> ___ dysmorphisms is highly associated with genetic syndromes
3
most dysmorphisms are ____.
non-consequential and normal
gross motor skills proceed from a sequence of ____ to _____ and then through a _____ sequence
prone milestones
sitting
standing/ambulating
gross motor skills must always be considered in context of a ______
neurological exam
It’s important to look at ____ and ____ in addition to a regular neurological exam
postural reactions
primitive reflexes
What’s the tonic labyrinthine reflex?
when you flex the head and neck»_space; UE go into flexion too
when you extend the head and neck»_space; UE go into extension too
What’s the asymmetrical tonic neck reflex?
when you turn the head to the side, that side goes into extension and the other side flexes
What’s the positive support reflex?
put a little pressure on their feet and they’ll push against the ground
Name 3 primitive reflexes. These go away at what age?
- tonic labyrinthine reflex
- asymmetrical tonic neck reflex
- positive support
4-6 months
what are 2 postural reactions?
- parachute response
- righting postural reflex (put arm out if get off balance when sitting)
5 gross motor RED FLAGS
- persistent fisting beyond 3 months
- spontaneous postures (frog-legging is low tone, scissoring is high tone)
- delays in postural reactions
- abnormal movement patterns
- hand dominance prior to 18 months
What are some abnormal movement patterns that would be a red flag for gross motor development (5)
- persistent head lag/floppy baby
- pulling directly to a stand at 4 months (hypertonicity)
- W-sitting (low tone)
- walking without ever crawling
- persistent toe walking (hypertonicity)
what happens as balance improves in the sitting position and as the infant begins to walk?
the hands become more available for manipulation of objects
In the first year of life, fine motor development is highlighted by what?
the evolution of the pincer grasp and learning to grasp and explore objects
In the second year of life, fine motor development is highlighted by what?
the hands using objects as tools
visual perception and fine motor skills in the first year of life allow the infant to _____ through _____.
problem solve
sensory-motor play
What are the three elements of “learning to manipulate”?
- visual inspection
- reaching, grasping, mouthing
- refinement of the pincer grasp for closer inspection
When does object permanence occur?
9 months
Visual perception and fine motor skills in the first year is described as:
in the second year it is described as:
learning to manipulate
manipulating to learn
what are the two elements of “manipulating to learn”?
- recognition of objects and their use through imitative and symbolic play
- matching and categorizing objects
5 visual perception and fine motor RED FLAGS
- failure to alert to environmental stimuli may indicate sensory impairment
- failure to reach for objects may indicate motor, visual, or cognitive deficit
- persistent mouthing past ~12 months
- lack of imitation by 16 months (AUTISM!)
- absent symbolic play by 24 months (AUTISM!)
MC type of delay in development
language
what is the best indicator of future intelligence?
language
____ is the most difficult to screen in the office and relies heavily on history
language
what are the 2 domains of language?
expressive: Broca’s
receptive: Wernicke’s
what are the 3 periods of language development during infancy?
- prespeech period (0-10 months)
- naming period (10-18 months)
- word combination period (18-24 months)
What 3 things occur in the pre-speech period (0-10 months)??
- sound localization
- cooing
- babbling
What 5 things occur in the naming period (10-18 months)?
- the infant realizes that people and objects have labels
- word counts are important to measure expressive language
- receptive language reflected in understanding simple commands
- pointing (protoimperitive and protodeclarative)
- jargoning
protoimperitive vs protodeclarative pointing
protoimperitive= help getting what I want (12 months)
protodeclarative= joint attention (15 months)
T/F: autistic kids don’t use many gestures
true
What 4 things occur in the word combination period (18-24 months)?
- kids typically begin to combine words 6-8 months after they say their first word
- giant words: “let’s go” “gimme” “thank you” “stop it” (18-21 months)
- holophrases.. Ex: point to keys and say “mama” to communicate that those are mom’s keys (18-21 months)
- word combinations, need an expressive vocab of at least 50 words at 24 months
5 language development RED FLAGS
- inability to localize sound by 4-6 months
- absent babbling or consonant production by 6-8 months
- lack of pointing by 12-18 months (AUTISM!)
- low word counts at 18-24 months
- advanced, non-communicative speech (AUTISM!)
4 parent-completed tests for cognitive, language, motor development:
- Ages and stages questionaire (ASQ-3)
- Parent’s evaluation of developmental status (PEDS)
- Child development inventory (CDI)
- Survey of wellbeing of young children (SWYC)
2 parent- completed tests for social-emotional behavior:
- Ages and stages questionnaire (ASQ-SE)
- Pediatric symptom checklist (PSC)
A parent-completed tests for autism:
Modified checklist for autism in toddlers (M-CHAT)
What are the AAP recommendations for M-CHAT?
do at the 15-18 month visit and the 24-30 month visit
6 clinician-administered screening/eval test for cognitive and language development
- Denver developmental screening test (DDST-2)
- Battelle developmental inventory screening tool
- Gesell
- Bayley infant developmental screen (BINS)
- Cognitive adaptive test (CAT)
- Clinical linguistic auditory milestone scale (CLAMS)
T/F: we should watch for red flags of development and make referrals early rather than employ “watchful waiting”
true
the 3 types of abuse are:
neglect (70%) physical abuse (20%) sexual abuse (10%)
what age group has the highest rate of victimization?
<1 year
most fatalities of abuse happen to what age group?
< 3 years
what percentage of abuse cases are due to parents?
80%
how many children die per year from maltreatment/
1,720
ethical consideration:
parents have an ethical and legal responsibility to…
protect the life and health of their kids
ethical consideration:
the legal responsibility is spelled out in the…
legal codes of states
ethical consideration:
when there is variance between parental action and stated legal responsibility to protect their minor children, the state is empowered to…
take action to restore health and safety to the child
ethical consideration:
al healthcare personnel have moral and legal professional responsibilities and expectations to…
protect the well being of their patients
this is stated in professional codes of ethics and in licensing regulations put forth by licensing and credentialing bodies as a condition of practice
ethical consideration:
it is ethically and legally the responsibility of professionals to…
protect their patients
ethical consideration:
pediatric PC provides a unique opportunity to…
tackle child abuse and neglect
ethical consideration: pediatricians, at their core, are essentially ____ for children
advocates
ethical consideration:
many practitioners identify a concern about what may happen to children after a CPS report is made as a reason for…
choosing not to report suspected maltreatment
ethical consideration:
AAP states, “HIPAA permits disclosure of information without legal guardian authorization in matters that affect ____ and ____ the child and intervention and investigation of matters that relate to abuse or neglect, public health, and safety.”
treatment of and medical intervention for
according to the law: professionals have ___ hours to make a report
48
according to the law:
reports about child abuse are confidential or not?
confidential
according to the law:
reporting child abuse does or does not breach patient confidentiality?
does not
according to the law:
you are ____ from criminal and civil liability
immune
according to the law:
it is a _____ for failure to report suspected abuse
class B misdemeanor
according to the law:
it is a _____ for failure to stop or report sexual assault of a child
class A misdemeanor
“professional” means an individual who is _____ or who is an employee of a facility licensed, certified, or operated by the state and who, in the normal course of official duties or duties for which a license or certification is required, has direct contact with children.
licensed or certified by the state
5 reasons to report suspected or child abuse
- to prevent further injury or death of a child
- maltreatment is linked to life-long health consequences
- healthcare staff have a moral and legal responsibility to ensure the safety and well-being of patients
- legal obligation to report child maltreatment
- consequences for not taking action may include criminal and civil actions against the professional and/or license and institution
What’s a sentinel injury?
commonly missed, minor injuries that should pique your suspicion for abuse.
ex: bruises, subconjunctival hemorrhages
What is meant by “escalation of injury”?
when sentinel injuries are missed, the patient then comes back with more serious injuries later
what kind of family does child abuse occur in?
ALL KINDS OF FAMILIES
4 common characteristics of missed abuse:
- young infants
- caucasian children
- 2 parent households
- children without seizures or respiratory problems
for every Dx of child abuse that’s made, ___ are missed
2
When ___ in the family increases, there is a decrease in the caretaker’s ability to _____
stress
cope
maternal ___ is another big factor in cases of child maltreatment
depression
2/3 of children in the child welfare system in the US have ______ as a contributing factor
substance abuse
(abuse) things to remember when taking a history from a parent
- remain non-judgemental
- obtain a detailed Hx
- use open ended questions
- ask about other children in the home
- speak to the parent WITHOUT the child
(abuse) things to remember when taking a history from a child
- use age-appropriate language
- do not suggest persons or actions or probe
- use open ended questions
- document the child’s words
- speak to the patient WITHOUT the parent
Definition of physical abuse
a non-accidental physical injury that leaves: bruises burns cuts broken bones other injuries
Bruises and lacerations that raise abuse suspicion (5 things)
- on a non-mobile infant (usually <6 months)
- on central or fleshy areas
- patterned or unusually distributed
- of different stages of healing
- frenulum laceration is almost always due to abuse (a commonly missed sentinel injury)
TEN-4 rule for bruising:
T: torso E: ears N: neck 4: - bruising in TEN regions if < 4 years old - any bruising if <4 months old - >4 bruises in general
How do you tell the age of a bruise by looking at it?
YOU CAN’T
only way to tell is if you know when the incident happened
What’s the most common presentation of abuse?
bruising
what percentage of kids < 6 months have non-abuse bruises?
<1%
bruising is a precursor to
AHT
bruising is missed in ____% of fatal or near-fatal cases of abuse
39%
if an infant has facial bruising, they will most likely return with ___.
abusive head trauma
2 types of burns common in child abuse:
- forced immersion scald
- patterned contact burns
____ burns are less likely to be abusive
splatter
forced immersion burns are
- usually seen during ____.
- pattern includes: (3 things)
toilet training;
- zebra striping
- doughnut sparing
- stocking feet
intra-abdominal injury S/Sx
- abdominal pain, tenderness
- abdominal abrasions or bruising
- palpitation of hematoma
- blood in urine
- decreased hematocrit on CBC
- elevated transaminase
- abnormal vitals (SBP <90, RR <10 or >29)
____ is the MC thing to cause presentation
skeletal fracture
children with abusive Fx are often too young to ____.
provide history
the history for skeletal fractures due to abuse may be ____ or ____.
lacking
intentionally misleading
missed abusive Fx can result in ____.
repeated abuse, sometimes with devastating consequences
misidentifying an accidental fracture as abuse can have detrimental effects for ___.
patient and family
incidence of skeletal fractures due to abuse decreases as ___ increases
age
3 things to Dx abuse in skeletal Fx patient
- skeletal survey
- bone chemistries
- history
When would you do a skeletal survey in a 0-24 month old, 2-5 year old, and 5+ year old?
0-24 months: anytime there is concern for abuse
2-5 years: when abuse is strongly suspected or the child is unable to communicate
5+ years: radiographs of individual sites of injury suspected on clinical grounds
high specificity radiologic findings for abuse
CMLs rib fx, esp posteromedial scapular fx spinous process fx sternal fx
greater proportion of children with NAT have multiple fractures as compared to children with accidental fractures.
as the number of fractures _____, the likelihood of NAT _____.
increased
increased
MC type of fracture seen at TCH
skull fx
____ skull fractures should raise suspicion for abuse
complex
complex vs simple skull fractures
simple/linear:
single fracture line
usually don’t cross suture lines
< 3 mm separation
complex: linear, crossing suture lines branching, stellate depressed comminuted
suspicion of abuse should arise whenever a caregiver gives an explanation of an injury that: (2 things)
- seems unlikely due to the child’s developmental abilities
- changes or is implausable
2 other red flags for abuse…
- delay in seeking treatment
- frequent changes in healthcare facilities
3 things to help date fractures
- resolution of soft tissue swelling
- loss of fracture definition
- callus formation
most kids with inflicted fractures have ____ bruises
ZERO
7 things that are not abuse
- birth injury
- accidents
- children with weak bones (bedridden)
- prematurity (osteopenia)
- nutritional (scurvy, rickets)
- infection (osteomyelitis)
- metabolic (osteogenesis imperfecta)
______ is one of the leading child maltreatment-related fatalities
AHT
____% of head trauma-related deaths in the USA in children <2 years old result from abuse
50-80%
the majority of abusive head trauma victims are ____ old
<2 years
peak incidence of AHT:
3 months
put AHT in the DDx anytime an infant has ____
vomiting without illness
2 common findings in shaken baby syndrome
- retinal hemorrhages
- skeletal Fx
AHT does not propose a ____
MOI
non-specific Sx of AHT
vomiting or poor feeding extreme irritability breathing problems seizures lethargy
specific signs of AHT
subdural hematoma
retinal hemorrhages
skeletal fractures
AHT is often mis-diagnosed as
reflux/colic
viral infection
AHT: physical signs of subdural hemorrhage, subarachnoid hemorrhage, parenchymal injury (contusion), and/or DAI in the context of ____
an absent or implausible history
comment on 3 things when examining retinal hemorrhages:
- description
- distribution
- extent
____% of children with AHT DO NOT have retinal hemorrhages. When they do have them, ____% are unilateral
20%
15%
____ is defined as “act of omission or commission which constitutes a failure to provide conditions that are essential for the healthy physical and emotional development of a child.”
neglect
6 types of neglect
physical medical dental supervisional emotional educational
consider the following studies in neglect cases:
radiographic skeletal survey CT scan bleeding eval: CBC, PT, PTT toxicology screens urinalysis transaminases
new name for Munchausen by Proxy
medical child abuse
definition of medical child abuse
fabrication, exaggeration, or induction of Sx resulting in the child receiving harmful or potentially harmful medical Tx at the instigation of the caregiver
IMPORTANT in determining MEDICAL CHILD ABUSE
RESOLUTION OF SX WHEN SEPARATION OCCURS
general concepts of MCA presentation:
- no typical presentation
- all organ systems are targets
- Sx presentation is limited only by the perpetrator’s medical knowledge, sophistication and imagination
Sx in MOA can be:
- ______ of existing problem
- ______ of Sx/disorder, lab reports/specimens
- ____
- ____
- ____
exaggeration fabrication persuasion simulation induction
Dx of MCA
- multidisciplinary approach
- child’s safety is most important
- separate caregiver and child to confirm
- meticulous documentation!!
- maintain chain of custody with lab specimens
prognosis for MCA
can run the entire spectrum of physical and psychiatric sequelae
secondary gains in MCA
attention financial gain involve an absent parent/reconnect fascination with all things medical sympathy from the community
definition of sexual abuse
sexual activity with a child by an adult or an older youth
non-touching sexual abuse:
- exposure to porn
- indecent exposure
- photographing a child in sexual poses
- making a child watch or hear sexual acts
- voyeurism
- online sexual solicitation
touching sexual abuse:
- touching a child’s genitals, anus, or breasts for sexual pleasure
- making a child touch someone’s genitals
- playing sexual games
- putting objects or body parts inside the vulva, vagina, mouth, or anus of a child
worrisome behaviors for sexual abuse:
- new words for private body parts
- sexual behavior inappropriate for age or adult-like
- simulating sexual activities with toys
- excessive masturbation
- persistent and/or aggressive sexual play with other children
- refusing to talk about a secret, esp one with an adult friend
- prominent genitals in drawings
non-specific symptoms of sexual abuse
- genital discharge
- anogenital redness
- urinary pain/itching
- enuresis
- encopresis
- chronic abdominal pain
- asymptomatic
signs that are specific for trauma
genital/anal bleeding
anogenital bruising
signs that are specific for sexual abuse
STIs
pregnancy
____ of physical exams of children suspected of being physically abused are without definitive findings
3/4ths
why aren’t there usually definitive findings of abuse?
- the child generally knows the perpetrator and physical force is not often used
- disclosure of abuse is usually delayed
- mucous membranes heal quickly often without scarring
5 elements of medical exam
- STI/HIV testing
- photographic documentation with colposcope
- rape kit if under 96 hours since assault
- blue maxx light for evidence collection in acute cases
- health care facilities must be able to handle emergency care for sexual assault and provide survivors with emergency contraception info
signs of domestic violence
- facial bruising
- injuries inconsistent with Hx
- depression/anxiety
- reluctant to explain discipline in the home
- repeatedly misses apts
- frequently asks for medical advice not related to child’s medical needs
what to do in domestic violence cases:
- use ____ screening regularly
- speak with the ____ alone
- reinforce _____
- discretely provide info on _____
- inform mother of ____
RADAR mother confidentiality community resources precautionary measures to take to avoid injury to her or her child
what is RADAR screening?
R: routinely screen mothers A: ask direct ?? D: document findings A: assess her safety R: respond
behavioral effects of parental substance abuse on child
- delayed in development as result of neglect
- may blame themselves for parent’s use
- may be reluctant to bring friends home
psychiatric effects of parental substance abuse on child
increased incidence of depression, anxiety, ED, suicide attempts
educational effects of parental substance abuse on child
- inability to concentrate at school or home
- may be tired due to chaos at home and inability to sleep or lack of structure for nutrition and rest
emotional effects of parental substance abuse on child
exhibit mistrust, guilt, shame, ambivalence, fear
____ and ____ account for most of the top drugs abused by 12th graders in the past year
marijuana, prescription and OTC meds
after several years of decline, current and past year use of ____ has risen among 8th and 10th graders
ecstasy
alcohol use has continued to ____ among high school seniors
decline
screening for teen substance use:
CRAFFT
C: have you ever ridden in a CAR driven by someone (including self) that was high or drunk?
R: do you ever use alcohol or drugs to RELAX, feel better about yourself, etc
A: do you ever use alcohol/drugs while by yourself, ALONE
F: do you ever FORGET things you did while using alcohol or drugs
F: do your family or FRIENDS ever tell you that you should cut down on your drinking/drug use?
T: have you gotten into TROUBLE while you were using alcohol, drugs?
physical warning signs of teen alcohol/drug use
fatigue
repeated health complaints
red and glazed eyes
lasting cough
emotional warning signs of teen alcohol/drug use
personality change sudden mood changes irritability irresponsible behavior low self-esteem poor judgement depression general lack of interest
family warning signs of teen alcohol/drug use
starting arguments
breaking rules
withdrawing from the fam
school warning signs of teen alcohol/drug use
decreased interest negative attitude drop in grades many absences truancy discipline problems
RF for child abuse/neglect
parental depression substance abuse intimate partner violence parent stress harsh punishment food security
3 protective factors for abuse/neglect
social support
self-efficacy
parenting competence
2 challenging behaviors and developmental issues that ay increase the risk for child maltreatment:
infant crying
toilet training
help parents become more skilled communication about sexuality and sexual abuse in order to ___
prevent sexual abuse
2 things to do with resources
- understand their availability and effectiveness
- advocate for implementation and sustaining of community-based services to help families prevent maltreatment
the law does not require health care professionals to be certain that abuse has occurred before they report, but merely “____.”
have a cause to believe
3 services offered by CPS
investigation
placement assessment
court approves permanency for child
