Pediatrics Flashcards
1
Q
Routine management of the newborn
A
physical exam
apgar
eye care
dz prevention and screeing
2
Q
Routine management of the newborn
right after birth
A
mouth and nose are suctioned
clamping and cutting of umpbilical cord
dried wrapeed in clean towels and placed under a warmer
gentle rubbing or sitmulating hte heels helps to stimulate crying and breathing
3
Q
Routine management of the newborn
intubation and ABG analysis are indicated if
A
resp distress
4
Q
Routine management of the newborn
nasogastric tube
A
indicated when GI decompression isneeded
5
Q
Routine management of the newborn
antibiotics
A
indicated for sepsis
6
Q
late preterm neonate
A
34-37 weeks
7
Q
Term neonate
A
38 weeks or more
8
Q
Normal vital signs in a newborn
A
RR - 40-60
HR - 120-160
9
Q
vital signs in a newborn are always
A
higher, babies are faster
10
Q
APGAR Score: Newborn Assessment
overview
A
measurement for the need and effectiveness of resuscitation, it does not predict mortality
11
Q
APGAR Score: Newborn Assessment
one minute score
A
evaluates conditions during labor and delivery
12
Q
APGAR Score: Newborn Assessment
five minute score
A
evaluates the response to resuscitative efforts
13
Q
a low apgar score is not associated with
A
cerebral palsy
14
Q
APGAR Score: Newborn Assessment
what it stands for
A
appearance pulse grimace activity respiration
15
Q
APGAR Score: Newborn Assessment
appearance
A
skin color/complexion
0 - blue all over
1 - normal except extremities
2 - normal all over
16
Q
APGAR Score: Newborn Assessment
pulse
A
pulse rate
0 - <60bpm or asystole
1 - >60 bpm but <100bpm
2 - >100bpm
17
Q
APGAR Score: Newborn Assessment
grimace
A
reflex irritability
0 - no response
1 - grimae/feeble cry
2 - sneeze/cough
18
Q
APGAR Score: Newborn Assessment
activity
A
Muscle tone
0 - none
1 - some flexion
2 - active movement
19
Q
APGAR Score: Newborn Assessment
respiration
A
breathing
0 - absent
1 - weak or irregular
2 - strong
20
Q
Newborn Eyecare
conjunctivitis day 1
A
mostl iley cause is chemical irritation (silver nitrate, this is not an allergy)
21
Q
Newborn Eyecare
conjunctivitis days 2-7
A
most likely neisseria gonorrhoeae (gram neg diplo, prevent w/ ointments, treattwith ceftriaxone)
22
Q
Newborn Eyecare
conjunctivitis day more than 7 days after deliver
A
most likely due to chlamydia trachomatis (not effectively prevented by prophylaxis, treate with oral erythromycin)
23
Q
Newborn Eyecare
conjunctivitis 3 weeks or more after delivery
A
mostl likely due to herpes infection (treate with systemic acyclovir and topical vidarabine)
24
Q
Newborn Eyecare
conjunctivitis treatment
A
2 types of ab drops to prevent ophtamoa neonatuorum which is attributed to neisseria gonorrhoeae or chlamydia trachomatis:
erythroycin or tetracycline ointments
silver nitrate solution
25
Vitamin K Deficient Bleeding
Definition
as the neonates colonic flora has not adequately colonized, E coli is not present in suffcient quantities to make neough vitamin k to produce clottting factors II, VII, IX, and X and proteins C and S. W/o tese factors the newborn is omrel ikely to have bleeding fromt he GI tract, belly button, and urinar tract
26
Vitamin K Deficient Bleeding
prophylactic treatment
to prevent Vitamin K Deficient Bleeding (formerly know as hemorrhagic disease of the newborn), a single im dose of vit k is recommended and has been shown to decrease the incidence of Vitamin K Deficient Bleeding
27
Screening Tests
all neonates must be screened for wht prior to discharge?
```
PKU
congenital adrenal hyperplasia (CAH)
biotinidase
beta thalassemia
galactosemia
hypothyroidism
homocysteinuria
cystic fibrosis
```
28
Most commonly tested disorders in newborns
```
g6pd deficiency
pku
galactosemia
congenital adrenal hyperplacia
congenital hypothyroidism
hearing test
cystic fibrosis
```
29
G6PD deficiency
x linked recessive disease, characterized by hemolytic crises.
treatment involves reducing oxidative stress and specialized diets
30
PKU
autosomal recessive genetic disorder characterized by a deficiency in the enzyme phenylalanine hydroxylase (PAH) that leads to mental retardation.
Treatement is with a special diet low in phylalanine for at least the first 16 years of the patient's life
31
Galactosemia
rare genetic disorder that precludes normal metabolism of galactose.
Treatment is to cut out all lactose-containing products
32
Congenital Adrenal hyperplasia
any of several autosomal recessive diseases resulting in errors of steroidogenesis.
treatment is to replace mineralocorticoids and glucocorticoid deficiencies and possible genital reconstructive surgery.
33
Congenital hypothyroidism
a condition affecting 1 in 4000 infants that can result in cretinism
34
Hearing test
excludes congenital sensory-neural hearing loss. necessary for early detection to maintain speech patterns and assess the need for cochlear implantation
35
Cystic Fibrosis
autosomal disorder causing abnoramlly thick mucus.
36
Cystic Fibrosis
Best initialtest:
sweat chloride
37
Cystic Fibrosis
Most accurate test:
genetic analysis of the CFTR gene
38
Cystic Fibrosis
Classic findings on the USMLE
Combination of an elevated sweat hloride, presence of mutationsin CFTR gener, and/or abnormal functioning in at least one organ system
39
Hepatitis B Vaccination
Every child gets a hepatitis B vaccination, but only those with HBsAG-Positive mothers should receive hepatitis B IG (HBIG) in addition to the vaccine
40
Transient polycythemia of the newborn
hypoxia during delivery stimulates erythropoeitin and acaues an increase in ciriculating red blood cells. the newborn's first breathwill increase O2 and cause a drop in erythropoeitin,which in turn will ead to normalization of hb
splenomegaly is a normal finding in newborns
41
Transient Tachypnea of the newborn
compression of the rib cage by passin throuh the omther's vaginal canal helpt so remove fluid in the lungs. Newborns who are delivered bia cesarean birth may have excess fluid in the lungs and therefore by hypoxic. if tachypnea lasts more than 4 hours, it is considered sepsis and must be evaluated with blood and urine culutres.lumbar puncture with csf analysis and culture is done when the newborn displays neurological signs such as irritability,lethargy, temp irregularity, and feeding problems.
42
transient hyperbilirubinemia
over 60% of all newborn infants are jaundiced. This is due to the infant's spleen removing excess red blood cells that carry Hgb F. This excess breakdown or RBCs leads to a physiological release of hb and in turn a rise in bilirubin.
43
Deliver-Associated injury in the newborn
Subconjunctival hemorrhage
minute hemorrhages may be present in the eyes of the infant due to a rapid rise in intrathoracic pressure as the chest is compressed while passing through the canal. no treatment is indicated
44
Deliver-Associated injury in the newborn
skull fractures
Linear: most common
Depressed: can cause further cortical damage w/o surgical intervention
Basilar: most fatal
45
Deliver-Associated injury in the newborn
scalp injuries
Caput succedaneum is a swelling of thesoft tissues of the scalp that does notcross suture lines. cephalohematoma is a subperiostealhemorrhage that does not cross suture lines. diagnosis is made clinically and improvement occurs gradually without treatment over a few weeks to months
46
Deliver-Associated injury in the newborn
Brachial Palsy
Etiology
brachial plexus injuries are secondary to births with traction in the event of shoulder dystocia. Brachial palsy is most commonly seen in macrosomic infants of diabetic mothers and has 2 major forms:
duchenne-erb paralysis: C5-C6
klumpke paralysis: c7-c8+/-T1
47
Deliver-Associated injury in the newborn
duchenne-erb paralysis: C5-C6
waiter tip appearance; secondary to shoulder dystocia
the infant is unabelt o uabduct the shoulder or externally rotate and supinate the arm
diagnosis is made clincially and immobilization is the best treatment
48
Deliver-Associated injury in the newborn
klumpke paralysis: c7-c8+/-T1
claw hand due to a lack of grasp reflex
paralyzed hand with horner syndrome (ptosis, miosis, and anhydrosis)
diagnosis is made clincially and immobilization is the best treatment
49
Deliver-Associated injury in the newborn
clavicular fracture
this is the most common newborn fracture as a result of hsoulder dystocia. xray is the best diagnostic test, and the fracture is treated with immobilization, splinting, and physical therapy
50
Deliver-Associated injury in the newborn
facial nerve palsy
facial nervye palsy is paralysis of structures innervated by the facial nerve, caused by trauma secondary to forcep use in deliver. diagnosis is made clinically and improvement occurs gradually over a few weeks to months. however, if no recovery is seen, then surgical nerve repair is necessary.
51
Deliver-Associated injury in the newborn
amnioticfluid abnormalities and associated manifestations
in amniotic fluid, 80% is a filtrateof the mothers plasma
the baby produces the remianing 20% by swallowing, absorbing, filtering, and urinating
52
Deliver-Associated injury in the newborn
amnioticfluid abnormalities and associated manifestations
polyhydramnios
too much fluid secondary to fetus not swallowing
causes:
neuro, werdnighoffman (infant unable to swallow)
GI, intestinal atresia
53
Deliver-Associated injury in the newborn
amnioticfluid abnormalities and associated manifestations
oligohydramnios
too little fluid bc fetus cannot urinate
causes:
prune-belly: lack of abdominalm uscles so unablet o bear down and urinate. treat with serial foley catheter placements but carries high risk of UTI
renal agenesis: incompatible with life, associated with potter syndrome
flat facies due to high atmospheric pressure causing compressio of the fetus that is normally buffered by the amniotic fluid
54
When does shoulder dystocia occur?
after delivery of the head when the babys anterior shoulder gets stuck behind the mother's pubic bone
55
Abnormal abdominalf findings
diaphragmatic hernia
omphalocele
umbilical hernia
gastroschisis
wilms tumor
neuroblastoma
56
diaphragmatic hernia
a hole in the diaphragm that allows the abdominal contents to move into the thorax
bowel sound int he chest can be heard
air fluid levels are seen on chest xray
two types:
- morgagni: defect is restrosternal or parasternal
- bochdalek: defect is posterolateral
57
bochdalek
most common diaphragmatic hernia
commonly occur on the left side
58
Omphalocele
defect in which intestines and organs from beyond the abdominal wall with a sac covering. Results from failure of the GI sac to retract at 10-12 weeks gestation
screening is conducted by maternal alpha fetoprotein levels and us. surgical reintroduction of contents in needed. highly associated with edwards syndrome (tri 18)
59
elevated afp levels indicate
neural tube defects and abdominalw all defects
60
most common cause of elevated afp is
incorrect dating
61
Umbilical hernia
there is a congenital wall weakness of the rectus abdominis muscle which allows for protrusion of vessels and bowel. it is highly associated with congenital hypothyroidism. ninety percent close spontaneously by age 3. after the age of 4, surgical intervention is indicated to prevent bowel strangulation and subsequent necrosis
62
Gastroschisis
a wall defect lateral to midline with intestines and organs forming byoned the abdominal wall with no sac covering. multiple intesintal atresias can occur. treatment calls for immediates surgical itnervetnion with gradual introduction of bowel and silo formation. overly agressive surgical reintroduction of the bowel will ead to third psacing and bowel infarction.
63
Wilms Tumor
A large palpable abdominal mass is felt. it is caused by hemihypertrophy of one kidney due to its increased vascular demands. aniridia is highly associated wtih this malignancy and is usually the clinicians most valuable clue. an affected child will show signs of consitpation and complain of abdominal pain that is accompanied by nausea and vomiting
64
wilms tumor
diagnostic tests
best initial: abdominal us
most accurate: contrast-enhanced CT
65
Wilms tumor
treatment
total nephrectomy with chemotherapy and radiation may be indicated based upon staging. bilateral kidney inolvement indicated partial nephrectomy
66
most common abdominal mass in children
wilms tumor
67
Wagr
Wilms tumor
aniridia
genitourinary malformations
retardation
results from a deletion on chromosome 11
68
Neuroblastoma
adrneal medullar tumor similar o a pheochormocytoma but with fewer cardiac manifestation. the percentageof cases presenting with metastases ranges from 50% to 60%
69
Neuroblastoma
highly tested findings
Hypsarrhythmia (on EEG) and opsomyoclonus are hallmark findings.the prefix opso- refersto the presenceof intermittent jerky eye movements (dancing eyes) and the root myoclonus refers to myoclonic jerks andcerebellar ataxia (dancing feet).
increased vanillyl mandelic acid (VMA) and meanephrines on urin collection are diagnostic.
70
most common cancers in infancy and the most common extracranial slid malignancy
neuroblastoma
71
Abnormal genitourinary findings
hydrocele
varicocele
cryptorchidism
hypospadias
epispadias
72
development achievements
1. sucking reflex - baby will automatically suck on a nipplelike object
2. grasping reflex
3. babinski reflex - toe extension
4. rooting reflex - if you touch the baby's cheek, the baby will turn to that side.
5. moro reflex - arms spread symmetrically when the baby is scared
6. stepping reflex - walking like maneuvers when toes touch the ground
7. superman reflex - when held facing the floor, arms go out
73
Hydrocele
hydrocele is a painless, swollen gluid filled sac along the spermatic cords within the scrotum that transilluminates upon inspection
- remnant of tunica vaginalis
- usually will resolve within 6 months
- must differentiatefrom inguinal hernia
74
Varicocele
varicocele isa varicose wein in the scrotal veinscausing swelling of pampiniform plexus and increased pressure. the most common compalint is a dull ache and heaviness in the scrotum
75
Varicocele
testing
best initial testis pe coinciding with bag of worms sensation
most accurate test is us of the scrotal sac showing dilatation of the vessels of the pampiniform plexus >2mm. (always us the other testicle, it is a b/l disease and so if present on one side it is probably indolent on the other side)
76
varicocele
treatment
indicated for delayed growth of the testes or in the those with evidence of testicular atrophy
77
Cryptorchidism
is the absence on one testicle in the scrotum, and is usually found within the inguinal canal
- 90%of cases can be felt in the inguinal canal
- orchipexy is indicated to bring the testicle down into the scortum after the age of 1 to avoid sterility
78
Cryptorchidism is associated with
an increased risk for malignancy regardless of surgical intervention
79
Hypospadias
the opening of the urethra is found ont he ventral surgace of the penis
- high association with cryptorchidism and inguinal hernias
- needssurgical correction
- circumcision is ci due to difficulties in surgical correction of the hypospadias
80
epispadias
the opening of the urethra is found on the dorsal surface
- high association with urinary incontinence
- must evaluate for concomitant bladder exstrophy
- needs surgical correction
81
Cyanotic lesions
tetrology of fallot
transposition of the great vessels
hypoplastic left heart syndrome
truncus arteriosus
total anomalous pulmonary venous return
82
squatting and exercise intolerance are pathognomonic for
tetralogy of fallot
83
most common cyanotic heart defect in kids
tetralogy of fallot
84
Tetralogy of Fallot
definition
overriding aorta
pulmonary stenosis
Right ventricular hypertrophy
ventricular septal defect (VSD)
85
Tetralogy of Fallot
etiology
cause is thorugh to be due to genetic facors and enfironemenal factors. is is associated iwth Chromosome 22 deletions
86
Tetralogy of Fallot
presentation
Cyanosis of the lips and extremities
holosystolic murmur best heard at the lower left sternal border
squatting after exertive exercises
-causes and increased preload and increased systemic vascular resistance. this decreases the right to left shunting, leading to increased pulmonary blood oxygen saturation.
87
Tetralogy of Fallot
diagnostic tests
cxr showing boot shaped heart
decreased pulmonary vascular marking
88
Tetralogy of Fallot
treatment
surgery is the only definitive therapy
89
VSD is common in
Down (tri21)
edwards (tri 18)
patau (tri 13)
90
3 holosystolic murmurs
mitral regurg
tricuspid regurg
VSD
91
most common congenital heart defect in Down Syndrome
endocardial cushion defect of atrioventricular canal
92
Transposition of the great vessels
this condition is characterized by an aorta that origniates fromt he right ventricel and pulmonay artery that comes fromt he left ventricle.no oxygenation of blood can occur without a patent ductus arteriosus (PDA), ASD or VSD.
93
Transposition of the great vessels
presentation/diagnostic tests
Early and severe cyanosis is seen. A single S2 isheard. CXR will show an egg on a string
94
Transposition of the great vessels
treatment
neonates must have an open ductus arteriosus (PDA). they require prostaglandin E1 to keep the ductus open, and NSAIDS (especially indomethacin) are ci bc they will cause closure of the ductus.
2 seperate surgeris are necessary; however, each surgery carries a 50% mortality rate. Therefore, only 1 in 4 will survive the surgeries.
95
Tetralogy of Fallot is the most common cyanotic lesion in children after
the neonatal period
96
Transposition of the great vessels is the most common cyanotic lesion during
the neonatal period
97
pulsus alternans
sign of left ventricular systolid dysfunction
98
pulsus bigeminus
sign of hypertrophic obstructive cardioyopathy (HOCM)
99
pulsus bisferians
in aortic regurgitation
100
pulsus tardus et parvus
aortic stenosis
101
pulsus paradoxus
cardiac tamponade and tension pneumothorax
102
irregularly irregular
atria fibrillation
103
Hypoplastic Left Heart Syndrome
this is a syndrome consisting of left ventricualr hypoplasia, mitral valve atresia, and aortic valve lesions
104
Hypoplastic Left Heart Syndrome
presentation
absent pulses with a single S2
increased right ventricular impulse
gray rather than bluish cyanosis
105
Hypoplastic Left Heart Syndrome
diasnotic tests
cxr will show a globular shaped hehart with pulnonary edema.
echo is the most accurate diagnostic test
106
Hypoplastic Left Heart Syndrome
treatment
only therapy is 3 seperate surgeries or a heart transplant. each surgery carries and extremely high mortality
107
Truncus Arteriosus
occurs when a single trunk emerges from both right and left ventricles and gives rise to all major circulations.
108
Truncus Arteriosus
presentation
symptoms occur whtin the first few days of life and are characterized by
- severe sypnea
- early and frequent respiratory infections
- single s2 is heard as there in only one semilunar valvee and a systolic ejction murmur is heard bc these valve leaflets are usually abnormal in functionality.
- peripheral pulses are bounding
109
Truncus Arteriosus
diagnostic tests
cxr will show cardiomegaly with increasedpulmonary markings
110
Truncus Arteriosus
treatment
the omst severe sequela of this condition is
111
Total Anomalous Pulmonary Venous Return
congenital condition in which there is no venous return between pulmonary veins and the left atrium, oxygenated blood instead returns to the superior vena cava. there are 2 forms: with or wihtout obstruction of the venous return. obstruction refers to the anlge at which the veins enter the sinus.
112
TAPVR with obstuction
signs/symptoms
early in life with respiratory distress and severe cyanosis
113
TAPVR with obstuction
diagnostic tests
xcr shows pulmonary edema
echo is definitive
114
TAPVR with obstuction
treatment
surgery is the definitive choice for treatment
115
TAPVR w/o obstuction
signs/symptoms
age 1-2 years with right heart failure and tachypnea
116
TAPVR w/o obstuction
diagnostic tests
cxr shows snowman or figure 8 sign
mosta ccurate test is echo (diagnosed by echo and not cxr)
117
TAPVR w/o obstuction
treatment
surgical intervention to restore proper blood flow
118
a child who was healthy but now presents with a holosystolic murmur and ftt
vsd with right ventricular hypertrophy
119
Summary of cyanotic heart defects
tof
r to l shunt
vsd
surgery
120
Summary of cyanotic heart defects
tGV
r to l shunt
pda dependent
surgery
121
Summary of cyanotic heart defects
hypoplastic left heart syndrome
r to l shunt
pda dependent
surgery
122
Summary of cyanotic heart defects
truncus arteriosus
r to l shunt
vsd
surgery
123
Summary of cyanotic heart defects
tapvr
r to l shunt
surgery
124
Ventricular septal defect
most common congenital heart lesion
125
Ventricular septal defect
presentation
dyspnea with respiratory distress
high-pitched holosystolic murmur over lower left sternal border
loud pulmonic s3
126
Ventricular septal defect
diagnostic tests
cxr shows increased vascular markings
echocardiogram is diagnostic and cardiac catheterization is definitive
127
Ventricular septal defect
treatment
smaller lesions usually close in the first 1 to 2 years while larger or more symptomatic lesions require surgical intervention. diuretics and digoxin can be used for more conservative treatment. if left untreated complications can lead to chf, endocarditis, and plumonary htn
128
pansystolic=
holosystolic=throughout systole
129
Atrial Septal Defect
a hole in the septum between both atria that is twice as common in women as in men
130
Atrial Septal Defect
3 main types
1. primum defect: concomitatnt mitral valve abnormalities
2. secundum defect: most common and located in the center of the atrial septum
3. sinus venosus defect: least common
131
Atrial Septal Defect
presentation
usually asyptomatic except for a fixed wide splitting of s2
132
Atrial Septal Defect
diagnostic tests
the most definitive test is cardiac catheterization. However, echo is less invasive and can be just as effective
cxr shows increased vascular markings and cardiomegaly
133
Atrial Septal Defect
treatment
vast majority close spontaneously
surgery or transcatheter closure is indicated for all symptomatic pts
dysrhytmias and possible paradoxical emobli from dvts later in life
134
PDA
defined as the failure of spontaneous closure of the ductus. it usually closes when PO2 rises above 50 mmhg. low po2 can be caused by pulmonary compromise due to prematurity. areas of high altitude have an increased occurrence of PDA due to low levels of atmospheric oxygen
135
When is pda a normal finding
first 12 hours of life, after 24 it is considered pathologic
136
PDA
Presentation
machinery like murmur
wide pulse pressure
bounding pulses
137
PDA
most common complication later in the childs life
high occurrence of respiratory infections and infective endocarditis
138
mitral elsions radiate to teh
axilla
139
tricuspid and pulmonary lesions radiate to the
back
140
aorticl lesions radiate to the
neck
141
PDA
best initial test
echo
142
PDA
most accurate test
cardiac catheterization
143
PDA
ekg
may show lvh secondary to high systemic resistance
144
PDA
treatment
give indomehtacin (nsaid inhibits prostaglandins) to close the pda unless it is needed to live in convurrent conditions like tof
145
give prostaglandins to
pop open a pda
146
giv indomethacin
inhibit popping open of pda
147
cxr
pear hsaped heart
pericardial effusion
148
cxr
boot-shaped heart
tof
149
cxr
jug handle appearance heart
primary pulmonary artery htn
150
cxr
3 like appearance or rib notching
coarctation of the aorta
151
Long QT syndrome
hearing loss, syncope, normal vitals and exam, fam hx of sudden cardiac death
152
coarctation of the aorta
congenital narrowing of the aorta in the area of the ductus arteriosus. it has a grequent assocation iwth turner syndrome
153
coarctation of the aorta
presentation
severe CHF and resp distress withint he first few months of life
diffpresuresa ndpulses betweenthe upper and lower extremities
reduced pulses in the lower extremities and htn in the upper extremities due to narrowing
154
coarctation of the aorta
diagnostic tests
rib nothcing and 3 sign are seen on cxr
cardiac catheterization is the omst accurate test
155
coarctation of the aorta
treatment
primary treatment is surgical resection of the narrowed segment and then balloon dilation if recurrent stenosis occurs
156
if the exam question mentions short gir with webbed neck shierld chest streak gonads horseshoe kidneys or shortened fourth metacarpal think
turner and coarctation of the aorta
157
Pathologic Jaundic of the newborn
hyperbilirubinemia is considered pathological when
it appears on the first day of life
bilirubin rises more than 5 mg/dl/day
bilirbuin rises above 19.5 mg/dl in a term child
direct bilirubin rises above 2 mg/dl at any time
hyperbilirubinemia persists after the second week of life
158
Pathologic Jaundic of the newborn
most serious complication
the deposition of bilirubin the basal ganglia called kernicterus.
kernicterus presents with hypotonia, seizures, choreoathetosis, and hearing loss
159
Pathologic Jaundic of the newborn
diagnostic tests
direct and indirect bilirubin levels
check blood type of infant and mother for ABO and Rh incompatibility
analyze peripheral blood smear and retic count for hemolysis
160
Pathologic Jaundic of the newborn
treatment
phototherapy with blue-green light helps break down bilirubin to excretable components. consider exhcange transfusion if bilirubin rises to 20-25 mg/dl
161
Esophageal Atresia
in esophageal atresia, the esophagus ends blindly. in nearly 90% or cases it communicates with the trachea through a fistula known as a tracheoesophageal fistula (TEF)
162
Esophageal Atresia
presentation
the child willtypically exhibit vomiting with first feeding or choking/coughing and cyanosis due to the TEF. there will be a hx of possible polyhdramnios
163
Esophageal Atresia
diagnostic tests
a gastric air bubble and esophageal air bubble can be seen on cxr
coiling of the ng tube seen on cxr and an inability to pass it into the stomach are diagnostic
ct or esophagram can also be used
164
Esophageal Atresia
treatment
surgical repair must be done in 2 steps to correct the anomaly
antibiotic coerage for anaerobes must also be considered due to high risk of lung abscess formation secondary to aspiration
fluid resuscitation before surgery must be done to prevent dehydration of the infant
165
Esophageal Atresia
a
ea with distal tef (80-90% of cases)
166
Esophageal Atresia
b
isolated ea w/o tef
167
Esophageal Atresia
c
ea with both proxiam and distal tefs
168
Esophageal Atresia
d
h type tef
169
string sign
pyloric stenosis
170
doughnut sign
intussuusceptions
171
birds beak
achalasia
172
steeple sign
croup
173
Pyloric Stenosis
a hypertrophic pyliric sphincter prevents proper passage of GI contents from the stomach intot he duodenum. ost comon cuase is idiopathic
174
Pyloric Stenosis
presentation
hypertrophy of the pylorus is not commonly found at birth but rather becomes more pronounced by the first month of life. and an present as alst as 6 months old
auscultation will reveal a succussion splash, which is the sound of stomach contents slapping into thepylorus like waves on a beach.
nonbiilous projectile vomiting is the hallmark feature. metabolic imbalance demonstrates a hypcholoremichypokamiec metabolic alkalosis due to the vast loss of hydrogen ionsi n the vomitus. the potassium loss also worsens from aldosterone realease in response to hypovolemia. aldosterone increases urinary excretion of potassium
olive sign, which delineates aplapabe mass the size on an olive felt in the epigastric region, is highly associated with this condition
175
what sign is frequently tested on USMLE
olive sign
176
Pyloric Stenosis
best initial test
abdominal us that will show a thickened pyloric sphincter
177
Pyloric Stenosis
mosta ccurate test
upper gi series that will show 4 signs:
string sign: thin column of barium leaking through the tightened muscle
shoulder sing: filling defect in the antrum due to prolapse ofmuscle inward
mushroom sign: hypertophic pylorus against the duodenum
railroad trach sign: excess mucosa int he pyloric lumen resulting in 2 columns of barium
178
what does vomiting cause
hypochloremic, hypokalemic metabolic alkalosis
179
Esophageal atresia
blind esophagus
no resp distress at rest
180
Esophageal atresia
presents with:
frothing, cough, cyanosis, and respiratory distress with feeds
no resp distress at rest
181
Esophageal atresia
best intial test
cxr
182
Esophageal atresia
concerns
aspiration pneumonia
183
Choanal atresia
byccopharyngeal membrane wtih resp distress
184
Choanal atresia
best initial step
pass ng tube
185
Choanal atresia
most diagnostic
ct scan
186
Choanal atresia
first step in management
secure airway
187
Duodenal atresia
failed duodenal canalization
188
Duodenal atresia
presents with
no resp distress
bilious vomiting
189
Duodenal atresia
initial test
axr
double-bubble
common in tri 21
190
Duodenal atresia
first step in management
IV fluids
191
Pyloric Stenosis
treatment
prelace lost volume with iv fluids, replace lost electorlytes, specifically postassium, as the closure of the anion gap is crucial. ngt must be used to decompress the bowel. surgical myotomy must follow
192
CHARGE syndrome is
commonly tested know it
193
CHARGE syndrome is a set of congenital defects seen in conjuction
C: coloboma of the eye, cns amomalies
H: heart defects
A: atresia of the choanae
R: retardation of growth and/or development
G: genital and/or urinary defects (hypogonadism)
E: ear anomalies and/or deafness
194
Choanal atresia
the infant is born witha membrane between the nostrils and pharyngeal space that prevents breathing during feeding. this condition is associaed with charge syndrome
195
Choanal atresia
presentation
child will turn blue when feeding and then pink when crying.this recurrent series of events is clinically diagnostic
196
Choanal atresia
diagnostic test
ct
197
Choanal atresia
treatment
surgery to perforate the membrane and reconnect the pharynx to teh nostrils
198
Hirschspurng disease
a congenital alck o innervatios of the distal bowel by the auerback plexus.this lack causes a constant contracture of muscle tone. there is frequent assocations with down sydnrome and it is more common in boys than in girls (4:1)
199
Hirschspurng disease
presentation
of unaffected infatns, 90% pass first meconium within 24 hours, wehras children with Hirschspurng disease do not pass meocnium for over 48 hours or fail to pass meconiun at all
extreme constipation is followed by large bowel obstruction
rectal exam shows an extremely tight sphincter, an inability to pass flatus is also common
200
Hirschspurng disease
diagnostic tests
plain zrays hosw distended bowel loops with lack of air in the rectum. contraxt enemas swill show retention of barium for greater than 24 hours
manometry will show high pressures int he anal sphincter
the mainstay of diagnosis is a full thckness biopsy that reveals a lack of ganglionic cells in the submucosa
201
Hirschspurng disease
treatment
a 3 stage surgery procedure is curative
202
Imperforate Anus
the opening tot eh anus is missing and the rectum ends ina blind pouch with conservation of the sphincter. the cause is unkknown but has a high assocation wth down syndrome
203
Imperforate Anus
presentation
complete failure to pass meconium
204
Imperforate Anus
diagnostic test
pe with no anus, not barium or manometry
205
Imperforate Anus
treatment
surgery is curative
206
VACTERL
```
V: vertebral anomalies
A: anal atresia
C: cardiovascular anomalies
T: tracheoesophageal fistula
E: esophageal atresia
R: renal anomalies
L: limb anomalies
```
207
Duodenal Atresia
a lack or absence of apoptosis (programmed cell death) hat leads to improper canalization of the lumen of the duodenum.
208
Duodenal Atresia
associated with
annular pancreas and down syndrome
209
Duodenal Atresia
presentation
onset of bilious vomiting 12 hours after birth
210
Duodenal Atresia
tests
cxr shows double bubble sign
211
Duodenal Atresia
treatment
replace lsot volume with IV fluids, taking special care to replace lost electrolytes . potassium is often low from vomiting. NGT must be used to decompress the bowel. surgucal duodenostomy is the most common surgical procedure and definitive treatment
212
Volvulus
A volvulus is a bowel obstruction in which a loop of bowel has twisted on itself abnormally
213
volvulus occurs where in children
midgut, usually ileus
214
Volvulus
presentation
the signs are nonspecific and include vomiting and colicky abdominal pain
215
Volvulus
diagnostic tests
multiple air fluid levels can be seen and on upper GI series a bird beadk appearance is typically seen at the site of rotation
216
Volvulus
treatment
surgucal or endoscopic untwitsting is emergently needed; bowel necrosis with perforation can lead to life-threatening sepsis
217
Volvulus
best initial teraphy
endoscopic deompression and the omst effect therapy is surgical decompression
218
Intussusception is assocatied with
rotavirus vaccine and henoch schonlein purpura
219
Intussusception presetns with
currant jelly stool, sausage-sahped mass, neurologic signs, and abdominal pain.
220
Intussusception
a condition in which part of the bowel telexcopes into another segment of bowl distal to it. it can be caused by a polyp, hard stool, or lymphoma, or even have a viral origin. most often however there is no clear etiology.
221
Intussusception
presentation
colicky abdominal pain, bilious vomiting, and currant jelly stool. a right quadrant sausage-shaped mass can be palpated
222
Intussusception
best initial test
ultrasound and it iwll showa dougnut sign or toarget sign, which is generated by concentric alternating echogenic (mucoas) and hypechogenic (submucosa) bands.
223
Intussusception
barium enema
is both diagnostic and theapeutic and therefore the most accurate test. however, it is ci ifthe child has signs of peritonitis, shock, or perforation.
224
Intussusception
treatment
fluid resuscitation and balancing of electorlytes (k ca and mg) are the most improtatn initial steps followed by ngt decompression of the bowel.
barium enema
child must be observed bc about 10% of them recur whiing 24 hours, if barium enema doesnt work then need to go into surgery
225
painless brbpr in a male child under 2
meckesl diverticulum, do a meckesl scan (technetium 99m pertechnetate scan is the most accurate test
226
3 conditions with bilious vomiting
duodenal atresia
volvulus
intussusception
227
Duodenal atresia
Onset -
initial test -
first step -
treatment -
Onset - within the first day of life
initial test - axr
first step - double bubble iv fluids
treatment - surgery
228
Volvulus
Onset -
initial test -
first step -
treatment -
Onset - within the first year of life
initial test - axr
first step - iv fluids
treatment - surgery
229
Intussusception
Onset -
initial test -
first step -
treatment -
Onset - within the first year of life
initial test - us doughnut
first step - iv fluids
treatment - air enema
230
Meckel's Diverticulum
the only true congenital diveritculum in which the vitellin duct persists int he small intestinal tract, it can contain ectopic gastric tissue
231
Meckel's Diverticulum
Presentation
the classic presentation is with painless rectal bleeding. assive frank bright red blood per recutm is due to gastric acid secrtion by the extopic titssue causing searing of the nearby small bowel tissue
232
Meckel's Diverticulum
diagnosti test
most accurate test is a technetium 99m scan is it so accurate that is has been dubbed teh meckel scan
233
Meckel's Diverticulum
treatment
surgery
234
meckels diverticulaum is what kind of diverticulum
true and involves all layers of the bowel
235
Meckel's Diverticulum
rule of 2s
2% of population
within 2 feet of the ileocecal valve
2 types of tissue (gastric and pancreatic)
males 2x more effected
Pt<2 yo
2% symptomatic
2 inches long
236
Diarrhea and Gastroenteritis
acute diarrhea-the acute loss of lfuids and electoryluyes in the stool due to underlying pahtologic process- is the second most common cause of infant death worldwide. gastroenteritis is the inflammation of the GI tract secondary to microbiologic infiltrate and spread
237
Diarrhea and Gastroenteritis
presentation
infalmmatory diarrhea will have fever, abdoinal pain, and possibly blood diarrhea
noninflammatory diarrhea will have vomiting, carampy pain and water diarrhea
238
Diarrhea and Gastroenteritis
diagnostic tests
send stool for blood and leukocyte count to detect the presence of invasive toxins
stool cultures with O&P for identifiying hte causative agent
possible sigmoioscopy to exam in for pseudomembranes int eh setting of cdiff
239
Diarrhea and Gastroenteritis
treatment
most improtant next step is rehydration
mild cases: oral fluids
severe cases: IV fluids
240
anidiarrheal compouinds such as loperamid
are always the wrong answer
241
Viral infectious diarrhea
3 types
rotavirus
adenovirus
small,round
242
Viral infectious diarrhea
rotavirus
most common in winter
fever,emesis, no blood, <7 days
viral prodrome
vaccine
243
Viral infectious diarrhea
adenoirus
endemic, year round
fever, emesis, no blood, <7 days
viral prodrome
244
Viral infectious diarrhea
small,round
norwalk
epi-demic
explosive, cramping, pain
1-2 days
245
when there is confirmed necrotizing enterocolitis
start abs right away
vanco, gentamixin, and metro
get xrays to dtermine if perforation has happened
246
Necrotizing Enterocolitis
a condition seen in premature infants where the bowel undergoes necrosis and bacteria invade the intestinal wall. the condition carries a mortality of up to 30%
247
Necrotizing Enterocolitis
presentation
child vorn severely premature with low birth weight
vomiting and abdominal distension
fever
248
Necrotizing Enterocolitis
diagnostic tests
axr will reveal the pathonomonic "pneumatosis intestinalis" or air wihin the bowel wall and ct will reveal air in the portal vein, dilted bowel loops, and pneumoperitoneum
frank or occult blood in stool
249
Necrotizing Enterocolitis
treatment
1. feeding must be dced for bowel rest
2. iv fluids must be started immediately
3. ngt must be placed for bowel deocmpression
4. if medical management does not lead to resolution, then surgery is indicated to remove the affected bowel
250
Infants of Diabetic Mothers
macrosomia
small left colon syndrome
cardiac abnomralities
renal vein thrombosis
metabolic findings and effects
251
Infants of Diabetic Mothers
macrosomia
with macrosomia all organs are enlarged except for the brain. an increased output fromt he bone marrow leads to polycythemia and hyperviscosit. possible left shoulder dystocia and brachial plexus palsy can also be in the history
252
Infants of Diabetic Mothers
small left colon syndrome
a congenitally smaller descending colon leads to distension from constipation. it can be diagnosed by a barium study and treated with saller and more frequent feeds
253
Infants of Diabetic Mothers
cardiac abnormalities
the major cardiac change in idm is asymmetric septal hypertrophy due to boliteration of the left ventricular lumen, leading to decreased cardiac output. it is diagnosed with ekg and echo and treated with bblockers and iv fluids
254
Infants of Diabetic Mothers
renal vein thrombosis
flank mass and possible buit can be appreciated
hematuria and thrombocytopenia
255
Infants of Diabetic Mothers
metabolic findings and effects
hypoglycemia: seizures
hypocalcemia: tetany, lethargy
Hypomagnesemia: hypocalcemia and pth decrease
hyperbilirubinemia: icterus and kernicterus
256
In congenital adreanl hyperplasia 90% or more are due to
21 hydroxylase deficiency
257
Congenital Adrenal Hyperplasia
an inherited defect of steroids synthesis tha thas 3 forms
1. 21 hydroxylase
2. 17 hydroxylase
3. 11beta hydroxylase
258
Congenital Adrenal Hyperplasia
presentation
most comomn is a hypotensive child with severe electrolyte abnormalities
genitalia are ambiguos in girls, boys do not itnially exhibit any abnormalities, but begin to lose their defining sexual features as they age. inappropriate facial hari, virilization, and menstural abnormalitites are also seen
hyponatremia, hypcholeremia, hypglycemia, and hyperkalemia are seen as a result of decreased aldosterone and cortisol production. this also results in acidosis due to hydrogen ion retention
259
Congenital Adrenal Hyperplasia
diagnostic tests
cah is diagnosed at birth by serum electorlytes and increased 17ohprogesterone levels
260
Congenital Adrenal Hyperplasia
treatment
fluid and electrolyte replacement along iwth lifelong steroids to maintain adequate levels of mineral/gluc levels
specific psychiatric couanseling to aid with gender identity issues
261
17a hydroxylase deficiency
```
aldosterone level -
cortisol level -
sex hormone levels -
11doc -
hypertensive/hyptensive -
sex development girls -
sex development boys -
electrolyte abnormalities -
```
```
aldosterone level - i
cortisol level - d
sex hormone levels -d
11doc -
hypertensive/hyptensive - hyper
sex development girls - normal at birth
sex development boys - pseudo-hermaphroditism
electrolyte abnormalities - hypokalemia
```
262
21-hydroxylase deficiency
```
aldosterone level -
cortisol level -
sex hormone levels -
11doc -
hypertensive/hyptensive -
sex development girls -
sex development boys -
electrolyte abnormalities -
```
```
aldosterone level - d
cortisol level - d
sex hormone levels - i
11doc -
hypertensive/hyptensive - hypo salt wasting shock
sex development girls - virlized
sex development boys - normal at virth
electrolyte abnormalities - hypo-na,cl and k
```
263
11-hydroxylase deficiency
```
aldosterone level -
cortisol level -
sex hormone levels -
11doc -
hypertensive/hyptensive -
sex development girls -
sex development boys -
electrolyte abnormalities -
```
```
aldosterone level - d
cortisol level - d
sex hormone levels - i
11doc - i
hypertensive/hyptensive - hyper
sex development girls - virilized
sex development boys - normal at birth
electrolyte abnormalities - few
```
264
Rickets
disroder caused by a lack of biamin d, calcium, or phosphate.it leads to softening and weakening of the bones, making there more susceptible to fractures. children 6 to 24 months are at highest risk bc their bones are rapidly forwing
265
Rickets
etiology
1. vitamin d deficient rickets caused by a lack of enough vitamin di ni the childs diet
2. vitamin d dependent rickets is the inability to convert 250h to 1,25oh and therefore the infant is dependent on vitamin d supplementation
3. xlinked hypophosphatemia ricketsoccurs when an innated kiney defect results in the inability to reain phosphate. whitout phosophate , adeuate bone mineralization cannot take place and bones are weakened
266
Rickets
presentation
child will present with ulnar/radial bowing and a waddling gait due to tibial/femoral bowing
267
Rickets
diagnostic tests
rachitic rosary like appearance on cxr of the costochondral joints with cupping and fraying of the epihyses
bowlegs is a characteristic sign
268
Rickets
treatment
rpelacement of phosphate, calcium, and vitamin D in the form of ergocalciferol or 1,25oh, calcitrol and annual blood vitamine d montioring
269
aap recommends that children who are exclusively reatfed should receive vit d supplementation
at age 2 montsh
270
Rickets
vitamine d deficient
calcium -
phosphate -
1,25oh -
25oh -
calcium - normal or d
phosphate - d
1,25oh - d
25oh - d
271
Rickets
vitamind dependent
calcium -
phosphate -
1,25oh -
25oh -
calcium - d
phosphate - n
1,25oh - d
25oh - n
272
Rickets
xlinked hypophosphatemia
calcium -
phosphate -
1,25oh -
25oh -
calcium - n
phosphate - d
1,25oh - n
25oh - n
273
Sepsis
evaluation
```
cbc with diff
blood and urine cultures
ua
cxr
lumbar puncture
```
274
Sepsis
most commoncause
pneymonia
| meningitis
275
Sepsis
most common organisms
gropu b strep
e coli
s aureus
listeria
276
Sepsis
diagnostic tests
blood cultures and urin cultures
| cxr
277
Sepsis
treatment
ampicillin and gentamicin
278
Sepsis
early causes
gropu b strep
ecoli
listeria
279
Sepsis
late causes
staph
ecoli
group b strep
280
first step in sepsis
fluids
281
TORCH
```
T: toxoplasmosis
O:other infections such as syphilis
R: rubella
C: cytomegalovirus
H: herpes simplex virus
```
282
Toxoplasmosis
Presentation
chorioretinitis, hydrocephalus, and multiple ring-enhancing lesions on ct caused by toxoplasma condii
283
Toxoplasmosis
Diagnostic Tests
best initial test is elevated igm to toxoplasm
most accurate is pcr for toxo
284
Toxoplasmosis
Treatment
pyrimethamine and sulfadiazine
285
Syphilis
Presentation
rash on the palms and osled, snuffles, frontal bossing, hutchingson eight nerve palsy, and saddle nose
286
Syphilis
Diagnostic Tests
best initial test is VDRL or RPR
most accurate test is FTA ABS or dark field microscopy
287
Syphilis
Treatment
penicillin
288
Rubella
Presentation
pda, cataracts, deafness, hepatosplenomegaly, thrombocytopenia, blueberry muffin rash, and hyperbilirubinemia
289
Rubella
Diagnostic Tests
maternal igm status along with clinical diagnosis. each disease manifestioan must be individually addressed
290
Rubella
Treatment
supportive
291
CMV
Presentation
periventricular calcifications with microencephaly, chorioretinitis, hearing loss, and petechiae
292
CMV
Diagnostic Tests
best initial test is urin or saliva viral titers
most accurate test is urine or salive pcr for viral dna
293
CMV
Treatment
ganciclovir with signs of end organ damage
294
Herpes
Presentation
week1 - shock and dic
week2 - vesicular skin lesions
week3 - encephalitis
295
Herpes
Diagnostic Tests
best initial test is tzanck smear
most accurate test is pcr
296
Herpes
Treatment
acyclovir and supportive care
297
Varicella
Etiology
varicella zoster virus
298
Varicella
Presentation
multipole highly pruritic vesicular rash begins ont he face, possible fever and malaies
299
Varicella
Diagnostic Tests
best initial test is tzanck smear showing multinucleated giant cells
most accurate test is viral culture
300
Rubeiola or measles
Etiology
paramyxovirus
301
Rubeiola or measles
Presentation
the 3 cs, cough, coryza, andconjucntivitis with koplik spots (grayish macule on buccal surgace)
302
Rubeiola or measles
Diagnostic Tests
clincial diagnosis
mosta ccurate is measles igm anitbodies
303
Fifth disease or erythema infectiosum
Etiology
parovirus b19
304
Fifth disease or erythema infectiosum
Presentation
starts with fever and uri andprogresses to rash with slapped cheek appearance
305
Fifth disease or erythema infectiosum
Diagnostic Tests
clinical
306
Roseola
Etiology
hhv 6 and 7
307
Roseola
Presentation
fever and uri progressing to diffuse rash
308
Roseola
Diagnostic Tests
clinical
309
Mumps
Etiology
paramyxovirus
310
Mumps
Presentation
fever precedes classic parotid gland swelling with possible orchitis
311
Mumps
Diagnostic Tests
clniical
312
treat all viruses with
supportive care
313
Scarlet fever
a diffuse erythematous eruption that is ocncurrent with pharyngitis.it is caused by erythrogenic toxin made by strep pyogenes and typically lasts 3 to 6 days
314
Scarlet fever
presentation
presents wtih a classic pentad of
```
fever
pharyngitis
sandpaper rash over trunk and extremities
strawberry tongue
cervical lymphadenopathy
```
315
Scarlet fever
diagnosis
clinical
can be with elevated antistreptolysin o titer, esr and crp
316
Scarlet fever
treatment
penicllin, azithromycin, or cephalosporins
317
Croup
infectious upper airway condition characterized by severe inflammation. it is mostly commonly cause dby parainfluenza virus types 1 and 2, rsv is the second most common cause
318
Croup
presentation
barking cough, coryza, and inspiratory stridor
the child will have more difficulty breathing when lying down and may show signs of hypoxia such as peripheral cyanosis and accessory muscle use
319
Croup
cxr
hsowes the classic steeple sign, a narrowing of the air column in the trachea. however, xray is rarely done and is always the wrong answer
320
Croup
diagnostic tests
clinically but can be helped by rads if the sx are mild
hypoxia aids in diff croup from epiglottitis
321
Croup
treatment
for mild disease give steroids
for moderate and severe sx give racemic epinephrine
322
croup=hypoxia
on presentation
323
epiglottitis= hypoxia
imminent
324
Eppiglottitis
severe, life-threatening welling of the epiglottis and arytenoids due to haemophilus influenzatype B
325
Eppiglottitis
presentation
vaccination delinquency with
hot potatto voice
fever
drooling in the tripod psotions
refusal to lie flat
326
Eppiglottitis
diagnostic tests
pe shows extremely hot cherry-red epiglottis
xray may show classive thumbprint sign
327
Eppiglottitis
treatment
intubate the hcild in the or, the or is preferred setting in case unsuccessful intubation makes tra necessary
administer ceftriaxone for 7-10 days
rifampin must be given to all close contacts
328
Whooping Cough
from bonchitits caused by bordetella pertussis
329
Whooping Cough
presentation
Catarrhal stage: severe congestion and rhinorrhea-14 day sin duration
paroxysmal stage: severe coughing episodes with extreme gasp for aire (inspiratory whoop) followed by vomiting - 14-30 day sinduration
convalescent stage decrease in frequency of coughing, 14 days in duration
330
Whooping Cough
diagnostic tests
clinically made diagnosis with whooping inspiration, vomiting, and burst blood vessels in eyes
buttergly patter on cxr
pcr of nasal secrestion or bordeteela pertussis toxin ELISA
331
Whooping Cough
treatment
erythromycin or azithromycin aids only in the catarrhal stage, not in the paroxysmal stage.
isolate the hcild and macrlides must be gien fro all cose contatcts
dtap vaccin had decreased incidency
332
Bronchitis
etiology
various bacteria and viruses causing inflammation of the airways
333
Bronchitis
presentation
productive cough lasting 7-10 days with fever
334
Bronchitis
diagnosis
clinical
335
Bronchitis
treatment
supportive
336
Pharyngitis
etiology
infalmmation of the phayrnx and adjacent structures caused by froup a beta hemolytic strep
337
Pharyngitis
presentation
cervical adenopathy, petechiae, fever above 104F, and othe ruri sx; acute rhumatic fever and glomerulonephritis
338
Pharyngitis
diagnosis
rapid dnase antigen detection test
339
Pharyngitis
treatment
oral penicclin for 10 days or maclides for penicillina llergy
340
Diphtheria
etiology
membranous infalmmation of the phayrnx due to bacterial invasion by Corynebacterium diphteriae
341
Diphtheria
presentation
gray hgihly vascular pseudomembanouns plaques on teh pahrygneal wall
do not scrape
342
Diphtheria
diagnosis
culture of a small portion of superficial membrane
343
Diphtheria
treatment
antitoxin, remember antibiotics do not work
344
Congenital Hip Dysplasia
Age-
presntation-
diagnosis-
treatment-
Age- infants
presntation- usually found on newborn exam screening
diagnosis- orolani and barlow maneuver with a click or clunk in the hip
treatment- pavlik harness
345
legg-clave-perthedisease (avascular necrosis of femoral head)
Age-
presntation-
diagnosis-
treatment-
Age- 2-8
presntation- panful limp
diagnosis- xrays show joint effusions and widening
treatment- rest of nsaids follow eith surgery on both hiops, if one necroses eventually so will theo other
346
Slipped capital femoral epiphysis
Age-
presntation-
diagnosis-
treatment-
Age- adolescence, especially in obese pts
presntation- painful limp, externally rotated leg
diagnosis- xray shows wiedning of joint space
treatment- internal fixation with pinnin
347
Vitamin A
deficiency -
toxicity -
deficiency - poor night vision, hypoparathyroidsism
toxicity - pseudotumor cerebir, hyperparathyroidsism
348
vitamin B1 (thiamine)
deficiency -
toxicity -
deficiency - beriberi, wernickes encepalpathy
toxicity - water sluble, thereforeno toxicity
349
Vtitamin B2 (riboflavin)
deficiency -
toxicity -
deficiency - angula chelosis, stomatitis, glossitis
toxicity - water soluble, no toxicity
350
Vitamine B3 (niacin)
deficiency -
toxicity -
deficiency - pellagra (4 ds, diarrhea, ermatitis, dementia, death)
toxicity - water soluble, no toxicity
351
Vitamin B5 (pantothenic acid)
deficiency -
toxicity -
deficiency - burning feet syndrome
toxicity - water soluble, no toxicity
352
Vitamin B6 (pyridoxine)
deficiency -
toxicity -
deficiency - peripheral neuropathy, must be given with INH
toxicity - water soluble, no toxicity
353
Vitamine B9 (folate)
deficiency -
toxicity -
deficiency - megaloblstic anemia, hypersegmented neutrophils
toxicity - water soluble, no toxicity
354
Vitamin B12 (cyanocobalamin)
deficiency -
toxicity -
deficiency - megaloblastic anemia, hypersegmeneted neutorphils, peripheral neuropathy of the dorsal column tracts
toxicity - water soluble, no toxicity
355
Vitamin C
deficiency -
toxicity -
deficiency - scurvy (ecchymosis, bleeding gums, and petechiae
toxicity - water soluble, no toxicity
356
Vitamine D
deficiency -
toxicity -
deficiency - rickets in kids
toxicity - hypercalcemia, polyurea, polydipsiea
357
Vitamine K
deficiency -
toxicity -
deficiency - increaed pt/inr, signsn and sx of mild to severe bleeding, analogous to warfarin therapy
toxicity - toxicity is rare and an upper limit has not ben established
358
1 Month WC
Movement Milestones
Makes jerky, quivering arm thrusts
Brings hands within range of eyes and mouth
Moves head from side to side while lying on stomach
Head flops backward if unsupported
Keeps hands in tight fists
Strong reflex movements
359
1 Month WC
Visual and Hearing Milestones
Focuses 8 to 12 inches (20.3 to 30.4 cm) away
Eyes wander and occasionally cross
Prefers black-and-white or high-contrast patterns
Prefers the human face to all other patterns
Hearing is fully mature
Recognizes some sounds
May turn toward familiar sounds and voices
360
1 Month WC
Smell and Touch Milestones
```
Prefers sweet smells
Avoids bitter or acidic smells
Recognizes the scent of his own mother’s breastmilk
Prefers soft to coarse sensations
Dislikes rough or abrupt handling
```
361
1 Month WC
Developmental Health Watch
Sucks poorly and feeds slowly
Doesn’t blink when shown a bright light
Doesn’t focus and follow a nearby object moving side to side
Rarely moves arms and legs; seems stiff
Seems excessively loose in the limbs, or floppy
Lower jaw trembles constantly, even when not crying or excited
Doesn’t respond to loud sounds
362
3 Month WC
Movement Milestones
Raises head and chest when lying on stomach
Supports upper body with arms when lying on stomach
Stretches legs out and kicks when lying on stomach or back
Opens and shuts hands
Pushes down on legs when feet are placed on a firm surface
Brings hand to mouth
Takes swipes at dangling objects with hands
Grasps and shakes hand toys
363
3 Month WC
Visual and Hearing Milestones
```
Watches faces intently
Follows moving objects
Recognizes familiar objects and people at a distance
Starts using hands and eyes in coordination
Smiles at the sound of your voice
Begins to babble
Begins to imitate some sounds
Turns head toward direction of sound
```
364
3 Month WC
Social and Emotional Milestones
Begins to develop a social smile
Enjoys playing with other people and may cry when playing stops
Becomes more communicative and expressive with face and body
Imitates some movements and facial expressions
365
3 Month WC
Developmental Health Watch
Doesn’t seem to respond to loud sounds
Doesn’t notice her hands by two months
Doesn’t smile at the sound of your voice by two months
Doesn’t follow moving objects with her eyes by two to three months
Doesn’t grasp and hold objects by three months
Doesn’t smile at people by three months
Cannot support her head well at three months
Doesn’t reach for and grasp toys by three to four months
Doesn’t babble by three to four months
Doesn’t bring objects to her mouth by four months
Begins babbling, but doesn’t try to imitate any of your sounds by four months
Doesn’t push down with her legs when her feet are placed on a firm surface by four months
Has trouble moving one or both eyes in all directions
Crosses her eyes most of the time (Occasional crossing of the eyes is normal in these first months.)
Doesn’t pay attention to new faces, or seems very frightened by new faces or surroundings
Still has the tonic neck reflex at four to five months
366
7 Month WC
Movement Milestones
Rolls both ways (front to back, back to front)
Sits with, and then without, support of her hands
Supports her whole weight on her legs
Reaches with one hand
Transfers object from hand to hand
Uses raking grasp (not pincer)
367
7 Month WC
Visual Milestones
Develops full color vision
Distance vision matures
Ability to track moving objects improves
368
7 Month WC
Language Milestones
```
Responds to own name
Begins to respond to “no”
Distinguishes emotions by tone of voice
Responds to sound by making sounds
Uses voice to express joy and displeasure
Babbles chains of consonants
```
369
7 Month WC
Cognitive Milestones
Finds partially hidden object
Explores with hands and mouth
Struggles to get objects that are out of reach
370
7 Month WC
Social and Emotional Milestones
Enjoys social play
Interested in mirror images
Responds to other people’s expressions of emotion and appears joyful often
371
7 Month WC
Developmental Health Watch
Seems very stiff, with tight muscles
Seems very floppy, like a rag doll
Head still flops back when body is pulled up to a sitting position
Reaches with one hand only
Refuses to cuddle
Shows no affection for the person who cares for him
Doesn’t seem to enjoy being around people
One or both eyes consistently turn in or out
Persistent tearing, eye drainage, or sensitivity to light
Does not respond to sounds around him
Has difficulty getting objects to his mouth
Does not turn his head to locate sounds by four months
Doesn’t roll over in either direction (front to back or back to front) by five months
Seems inconsolable at night after five months
Doesn’t smile spontaneously by five months
Cannot sit with help by six months
Does not laugh or make squealing sounds by six months
Does not actively reach for objects by six to seven months
Doesn’t follow objects with both eyes at near (1 foot) [30 cm] and far (6 feet) [180 cm] ranges by seven months
Does not bear some weight on legs by seven months
Does not try to attract attention through actions by seven months
Does not babble by eight months
Shows no interest in games of peekaboo by eight months
372
2 Month WC
Physical and motor-skill markers:
Closing of soft spot at the back of the head (posterior fontanelle)
Several newborn reflexes, such as the stepping reflex (baby appears to dance or step when placed upright on solid surface) and grasp reflex (grasping a finger), disappear
Less head lag (head is less wobbly on the neck)
When on stomach, able to lift head almost 45 degrees
Less flexing of the arms and legs while lying on the stomach
373
2 Month WC
Sensory and cognitive markers:
Beginning to look at close objects
Coos
Different cries means different things
Head turns from side to side with sound at the level of the ear
Smiles
Responds to familiar voices
Healthy babies can cry up to 3 hours per day. If you are worried that you baby cries too much, talk to you doctor.
374
2 Month WC
Play recommendations:
Expose your baby to sounds outside those of the home
Take your baby for rides in the car or walks in the neighborhood
The room should be bright with pictures and mirrors
Toys and objects should be bright colors
Read to your baby
Talk to your baby about objects and people in his or her environment
Hold and comfort you baby if they are upset or crying. DO NOT worry about spoiling your 2-month-old.
375
4 Month WC
PHYSICAL AND MOTOR SKILLS
Slow in weight gain to about 20 grams (almost two thirds of an ounce) per day
Weigh 2 times more than their birth weight
Have almost no head droop while in a sitting position
Be able to sit straight if propped up
Raise head 90 degrees when placed on stomach
Be able to roll from front to back
Hold and let go of an object
Play with a rattle when it's placed in their hands, but won't be able to pick it up if dropped
Be able to grasp a rattle with both hands
Be able to place objects in the mouth
Sleep 9 to 10 hours at night with 2 naps during the day (total of 14 to 16 hours per day)
376
4 Month WC
SENSORY AND COGNITIVE SKILLS
```
Have well-established close vision
Increase eye contact with parents and others
Have beginning hand-eye coordination
Be able to coo
Be able to laugh out loud
Anticipate feeding when able to see a bottle (if bottle-fed)
Begin to show memory
Demand attention by fussing
Recognize parent's voice or touch
```
377
4 Month WC
PLAY
```
Place the baby in front of a mirror.
Provide bright-colored toys to hold.
Repeat sounds the infant makes.
Help the infant roll over.
Use an infant swing at the park if the baby has head control.
Play on the stomach (tummy time)
```
378
6 Month WC
Physical and motor skill markers:
Able to hold almost all weight when supported in a standing position
Able to transfer objects from one hand to the other
Able to lift chest and head while on stomach, holding the weight on hands (often occurs by 4 months)
Able to pick up a dropped object
Able to roll from back to stomach (by 7 months)
Able to sit in a high chair with a straight back
Able to sit on the floor with lower back support
Beginning of teething
Increased drooling
Should be able to sleep 6 to 8 hour stretches at night
Should have doubled birth weight (birth weight often doubles by 4 months, and it would be cause for concern if this hasn't happened by 6 months)
379
6 Month WC
Sensory and cognitive markers:
Begins to fear strangers
Begins to imitate actions and sounds
Begins to realize that if an object is dropped, it is still there and just needs to be picked up
Can locate sounds not made directly at the ear level
Enjoys hearing own voice
Makes sounds (vocalizes) to mirror and toys
Makes sounds resembling one-syllable words (example: da-da, ba-ba)
Prefers more complex sounds
Recognizes parents
Vision is between 20/60 and 20/40
380
6 Month WC
Play recommendations
Read, sing, and talk to your child
Imitate words such as "mama" to help baby learn language
Play peek-a-boo
Provide an unbreakable mirror
Provide large, bright-colored toys that make noise or have moving parts (avoid toys with small parts)
Provide paper to tear
Blow bubbles
Speak clearly
Start pointing to and naming parts of the body and the environment
Use body movements and actions to teach language
Use the word "no" infrequently
381
9 Month WC
PHYSICAL CHARACTERISTICS AND MOTOR SKILLS
Gains weight at a slower rate, about 15 grams (half an ounce) per day, 1 pound (450 grams) per month
Increases in length by 1.5 centimeters (a little over one-half inch) per month
Bowel and bladder become more regular
Puts hands forward when the head is pointed to the ground (parachute reflex) to protect self from falling
Is able to crawl
Sits for long periods
Pulls self to standing position
Reaches for objects while sitting
Bangs objects together
Can grasp objects between the tip of the thumb and index finger
Feeds self with fingers
Throws or shakes objects
382
9 Month WC
SENSORY AND COGNITIVE SKILLS
Babbles
Has separation anxiety and may cling to parents
Is developing depth perception
Understands that objects continue to exist, even when they are not seen (object constancy)
Responds to simple commands
Responds to name
Understands the meaning of "no"
Imitates speech sounds
May be afraid of being left alone
Plays interactive games, such as peek-a-boo and pat-a-cake
Waves bye
383
9 Month WC
PLAY
Provide picture books.
Provide different stimuli by going to the mall to see people, or to the zoo to see animals.
Build vocabulary by reading and naming people and objects in the environment.
Teach hot and cold through play.
Provide large toys that can be pushed to encourage walking.
Sing songs together.
Avoid television time until age 2.
Try using a transition object to help decrease separation anxiety.
384
12 Month WC
PHYSICAL AND MOTOR SKILLS
Be 3 times their birth weight
Grow to a height of 50% over birth length
Have a head circumference equal to that of their chest
Have 1 to 8 teeth
Stand without holding on to anything
Walk alone or when holding 1 hand
Sit down without help
Bang 2 blocks together
Turn through the pages of a book by flipping many pages at a time
Pick up a small object using the tip of their thumb and index finger
Sleep 8 to 10 hours a night and take 1 to 2 naps during the day
385
12 Month WC
SENSORY AND COGNITIVE DEVELOPMENT
Begins pretend play (such as pretending to drink from a cup)
Follows a fast moving object
Responds to their name
Can say momma, papa, and at least 1 or 2 other words
Understands simple commands
Tries to imitate animal sounds
Connects names with objects
Understands that objects continue to exist, even when they can't be seen
Participates in getting dressed (raises arms)
Plays simple back and forth games (ball game)
Points to objects with the index finger
Waves bye
May develop attachment to a toy or object
Experiences separation anxiety and may cling to parents
May make brief journeys away from parents to explore in familiar settings
386
12 Month WC
PLAY
Provide picture books.
Provide different stimuli, such as going to the mall or zoo.
Play ball.
Build vocabulary by reading and naming people and objects in the environment.
Teach hot and cold through play.
Provide large toys that can be pushed to encourage walking.
Sing songs.
Have a play date with a child of a similar age.
Avoid television and other screen time until age 2.
Try using a transitional object to help with separation anxiety.
387
18 Month WC
PHYSICAL AND MOTOR SKILLS
Has a closed soft spot on the front of the head
Is growing at a slower rate and has less of an appetite compared to the months before
Is able to control the muscles used to urinate and have bowel movements, but may not be ready to use the toilet
Runs stiffly and falls often
Is able to get onto small chairs without help
Walks up stairs while holding on with 1 hand
Can build a tower of 2 to 4 blocks
Can use a spoon and cup with help to feed self
Imitates scribbling
Can turn 2 or 3 pages of a book at a time
388
18 Month WC
SENSORY AND COGNITIVE DEVELOPMENT
Shows affection
Has separation anxiety
Listens to a story or looks at pictures
Can say 10 or more words when asked
Kisses parents with lips puckered
Identifies 1 or more parts of the body
Understands and is able to point to and identify common objects
Often imitates
Is able to take off some clothing items, such as gloves, hats, and socks
Begins to feel a sense of ownership, identifying people and objects by saying "my"
389
18 Month WC
PLAY
Encourage and provide the necessary space for physical activity.
Provide safe copies of adult tools and equipment for the child to play with.
Allow the child to help around the house and participate in the family's daily responsibilities.
Encourage play that involves building and creativity.
Read to the child.
Encourage play dates with children of the same age.
Avoid television and other screen time before age 2.
Play simple games together, such as puzzles and shape sorting.
Use a transitional object to help with separation anxiety.
390
2 Year WC
PHYSICAL AND MOTOR SKILLS
Able to turn a door knob.
Can look through a book turning one page at a time.
Can build a tower of 6 to 7 cubes.
Can kick a ball without losing balance.
Can pick up objects while standing, without losing balance. (This often occurs by 15 months. It is a cause for concern if not seen by 2 years.)
Can run with better coordination. (May still have a wide stance.)
May be ready for toilet training.
Should have the first 16 teeth, but the actual number of teeth can vary widely.
At 24 months, will reach about half final adult height.
391
2 Year WC
SENSORY AND COGNITIVE DEVELOPMENT
Able to put on simple clothes without help. (The child is often better at removing clothes than putting them on.)
Able to communicate needs such as thirst, hunger, need to go to the bathroom.
Can organize phrases of 2 to 3 words.
Can understand 2-step command such as, "Give me the ball and then get your shoes."
Has increased attention span.
Vision is fully developed.
Vocabulary has increased to about 50 to 300 words, but healthy children's vocabulary can vary widely.
392
2 Year WC
PLAY
Allow the child to help around the house and take part in the daily family chores.
Encourage active play and provide enough space for healthy physical activity.
Encourage play that involves building and creativity.
Provide safe copies of adult tools and equipment. Many children like to mimic activities such as cutting the grass or sweeping the floor.
Read to the child.
Try to avoid television watching at this age (recommendation of the American Academy of Pediatrics).
Control both the content and quantity of television viewing. Limit screen time to less than 3 hours per day. One hour or less is better. Avoid programming with violent content. Redirect the child to reading or play activities.
Control the type of games the child plays.
393
3 Year WC
Physical and motor milestones for a typical 3-year-old include:
Gains about 4 to 5 pounds (1.8 to 2.25 kilograms)
Grows about 2 to 3 inches (5 to 7.5 centimeters)
Reaches about half of his or her adult height
Has improved balance
Has improved vision (20/30)
Has all 20 primary teeth
Needs 11 to 13 hours of sleep a day
May have daytime control over bowel and bladder functions (may have nighttime control as well)
Can briefly balance and hop on one foot
May walk up stairs with alternating feet (without holding the rail)
Can build a block tower of more than 9 cubes
Can easily place small objects in a small opening
Can copy a circle
Can pedal a tricycle
394
3 Year WC
Sensory, mental, and social milestones include:
Has a vocabulary of several hundred words
Speaks in sentences of 3 words
Counts 3 objects
Uses plurals and pronouns (he/she)
Often asks questions
Can dress self, only needing help with shoelaces, buttons, and other fasteners in awkward places
Can stay focused for a longer period of time
Has a longer attention span
Feeds self easily
Acts out social encounters through play activities
Becomes less afraid when separated from mother or caregiver for short periods of time
Fears imaginary things
Knows own name, age, and gender (boy/girl)
Starts to share
Has some cooperative play (building tower of blocks together)
At age 3, almost all of a child's speech should be understandable.
Temper tantrums are common at this age. Children who have tantrums that often last for more than 15 minutes or that occur more than 3 times a day should be seen by a health care provider.
395
3 Year WC
Ways to encourage a 3-year-old's development include:
Provide a safe play area and constant supervision.
Provide the necessary space for physical activity.
Help your child take part in -- and learn the rules of -- sports and games.
Limit both the time and content of television and computer viewing.
Visit local areas of interest.
Encourage your child to help with small household chores, such as helping set the table or picking up toys.
Encourage play with other children to help develop social skills.
Encourage creative play.
Read together.
Encourage your child to learn by answering his or her questions.
Provide activities related to your child's interests.
Encourage your child to use words to express feelings (rather than acting out).
396
4 Year WC
PHYSICAL AND MOTOR
Gains weight at the rate of about 6 grams (less than one quarter of an ounce) per day
Weighs 40 pounds (18 kilograms) and is 40 inches (1 meter) tall
Has 20/20 vision
Sleeps 11 to 13 hours at night, usually without a daytime nap
Grows to a height that is double the birth length
Shows improved balance
Hops on one foot without losing balance
Throws a ball overhand with coordination
Can cut out a picture using scissors
May still wet the bed
397
4 Year WC
SENSORY AND COGNITIVE
Has a vocabulary of more than 1,000 words
Easily puts together sentences of four or five words
Can use the past tense
Can count to four
Will be curious and ask a lot of questions
May use words they do not fully understand
May begin using vulgar words
Learns and sings simple songs
Tries to be very independent
May show increased aggressive behavior
Talks about personal family matters to others
Commonly has imaginary playmates
Has an increased understanding of time
Is able to tell the difference between two objects based on things like size and weight
Lacks moral concepts of right and wrong
Rebels if too much is expected of them
398
4 Year WC
PLAY
Encourage and provide space for physical activity.
Show your child how to participate in and follow the rules of sporting activities.
Encourage play and sharing with other children.
Encourage creative play.
Teach your child to do small chores, such as setting the table.
Read together.
Limit screen time (television and other media) to 2 hours a day of quality programs.
Expose your child to different stimuli by visiting local areas of interest.
399
5 Year WC
Physical and motor skill milestones for a typical 5-year-old child include:
Gains about 4 to 5 pounds (1.8 to 2.25 kilograms)
Grows about 2 to 3 inches (5 to 7.5 centimeters)
Vision reaches 20/20
First adult teeth start breaking through the gum (most children do not get their first adult teeth until age 6)
Has better coordination (getting the arms, legs, and body to work together)
Skips, jumps, and hops with good balance
Stays balanced while standing on one foot with eyes closed
Shows more skill with simple tools and writing utensils
Can copy a triangle
Can use a knife to spread soft foods
400
5 Year WC
Sensory and mental milestones:
Has a vocabulary of more than 2,000 words
Speaks in sentences of 5 or more words, and with all parts of speech
Can identify different coins
Can count to 10
Knows telephone number
Can properly name the primary colors, and possibly many more colors
Asks deeper questions that address meaning and purpose
Can answer "why" questions
Is more responsible and says "I'm sorry" when he or she makes mistakes
Shows less aggressive behavior
Outgrows earlier childhood fears
Accepts other points of view (but may not understand them)
Has improved math skills
Questions others, including parents
Strongly identifies with the parent of the same sex
Has a group of friends
Likes to imagine and pretend while playing (for example, pretends to take a trip to the moon)
401
5 Year WC
Ways to encourage a 5-year-old's development include:
Reading together
Providing enough space for the child to be active
Teaching the child how to take part in -- and learn the rules of -- sports and games
Encouraging the child to play with other children, which helps develop social skills
Playing creatively with the child
Limiting both the time and content of television and computer viewing
Visiting local areas of interest
Encouraging the child to perform small household chores, such as helping set the table or picking up toys after playing
402
School Age Children 6-12
PHYSICAL DEVELOPMENT
School-age children usually have smooth and strong motor skills. However, their coordination (especially eye-hand), endurance, balance, and physical abilities vary.
Fine motor skills may also vary widely. These skills can affect a child's ability to write neatly, dress appropriately, and perform certain chores, such as making beds or doing dishes.
There will be big differences in height, weight, and build among children of this age range. It is important to remember that genetic background, as well as nutrition and exercise, may affect a child's growth.
A sense of body image begins developing around age 6. Sedentary habits in school-age children are linked to a risk for obesity and heart disease in adults. Children in this age group should get 1 hour of physical activity per day.
There can also be a big difference in the age at which children begin to develop secondary sexual characteristics. For girls, secondary sex characteristics include:
Breast development
Underarm and pubic hair growth
For boys, they include:
Growth of underarm, chest, and pubic hair
Growth of testicles and penis
403
School Age Children 6-12
SCHOOL
By age 5, most children are ready to start learning in a school setting. The first few years focus on learning the fundamentals.
In 3rd grade, the focus becomes more complex. Reading becomes more about the content than identifying letters and words.
An ability to pay attention is important for success both at school and at home. A 6-year-old should be able to focus on a task for at least 15 minutes. By age 9, a child should be able to focus attention for about an hour.
It is important for the child to learn how to deal with failure or frustration without losing self-esteem. There are many causes of school failure, including:
Learning disabilities, such a reading disability
Stressors, such as bullying
Mental health issues, such as anxiety or depression
If you suspect any of these in your child, talk to your child's teacher or health care provider.
404
School Age Children 6-12
LANGUAGE DEVELOPMENT
Early school-age children should be able to use simple, but complete, sentences that contain an average of 5 to 7 words. As the child goes through the elementary school years, grammar and pronunciation become normal. Children use more complex sentences as they grow.
Language delays may be due to hearing or intelligence problems. In addition, children who are unable to express themselves well may be more likely to have aggressive behavior or temper tantrums.
A 6-year-old child normally can follow a series of 3 commands in a row. By age 10, most children can follow 5 commands in a row. Children who have a problem in this area may try to cover it up with backtalk or clowning around. They will rarely ask for help because they are afraid of being teased.
405
School Age Children 6-12
BEHAVIOR
Frequent physical complaints (such as sore throats, tummy aches, or arm or leg pain) may simply be due to a child's increased body awareness. Although there is often no physical evidence for such complaints, the complaints should be investigated to rule out possible health conditions. This will also assure the child that the parent is concerned about their well-being.
Peer acceptance becomes more important during the school-age years. Children may take part in certain behaviors to be part of "the group." Talking about these behaviors with your child will allow the child to feel accepted in the group, without crossing the boundaries of the family's behavior standards.
Friendships at this age tend to be mainly with members of the same sex. In fact, younger school-age children often talk about members of the opposite sex as being "strange" or "awful." Children become less negative about the opposite sex as they get closer to adolescence.
Lying, cheating, and stealing are all examples of behaviors that school-age children may "try on" as they learn how to negotiate the expectations and rules placed on them by family, friends, school, and society. Parents should deal with these behaviors in private with their child (so that the child's friends don't tease them). Parents should show forgiveness, and punish in a way that is related to the behavior.
It is important for the child to learn how to deal with failure or frustration without losing self-esteem.
406
School Age Children 6-12
SAFETY
School-age children are highly active. They need physical activity and peer approval, and want to try more daring and adventurous behaviors.
Children should be taught to play sports in appropriate, safe, supervised areas, with proper equipment and rules. Bicycles, skateboards, in-line skates, and other types of recreational sports equipment should fit the child. They should be used only while following traffic and pedestrian rules, and while using safety equipment such as knee, elbow, and wrist pads or braces, and helmets. Sports equipment should not be used at night or in extreme weather conditions.
Swimming and water safety lessons may help prevent drowning.
Safety instruction regarding matches, lighters, barbecues, stoves, and open fires can prevent major burns.
Wearing seat belts is the most important way to prevent major injury or death from a motor vehicle accident.
407
School Age Children 6-12
PARENTING TIPS
f your child's physical development appears to be outside the norm, talk to your health care provider.
If language skills appear to be lagging, request a speech and language evaluation.
Keep close communication with teachers, other school employees, and parents of your child's friends so you are aware of possible problems.
Encourage children to express themselves openly and talk about concerns without fear of punishment.
While encouraging children to participate in a variety of social and physical experiences, be careful not to over-schedule free time. Free play or simple, quiet time is important so the child does not always feel pushed to perform.
Children today are exposed, through the media and their peers, to many issues dealing with violence, sexuality, and substance abuse. Discuss these issues openly with your children to share concerns or correct misconceptions. You may need to set limits to ensure children will be exposed to certain issues only when they are ready.
Encourage children to participate in constructive activities such as sports, clubs, arts, music, and scouts. Being inactive at this age increases the risk of lifetime obesity. However, it is important not to over-schedule your child. Try to find a balance between family time, school work, free play, and structured activities.
School-age children should participate in family chores such as setting the table and cleaning up.
Limit screen time (television and other media) to 2 hours a day.
408
Adolescent development 12-18
During adolescence, children develop the ability to:
Understand abstract ideas. These include grasping higher math concepts, and developing moral philosophies, including rights and privileges.
Establish and maintain satisfying relationships. Adolescents will learn to share intimacy without feeling worried or inhibited.
Move toward a more mature sense of themselves and their purpose.
Question old values without losing their identity.
409
Adolescent development 12-18
PHYSICAL DEVELOPMENT
girls
Girls may begin to develop breast buds as early as 8 years old. Breasts develop fully between ages 12 and 18.
Pubic hair, armpit and leg hair usually begin to grow at about age 9 or 10, and reach adult patterns at about 13 to 14 years.
Menarche (the beginning of menstrual periods) typically occurs about 2 years after early breast and pubic hair appear. It may occur as early as age 9, or as late as age 16. The average age of menstruation in the United States is about 12 years.
Girls growth spurt peaks around age 11.5 and slows around age 16.
410
Adolescent development 12-18
PHYSICAL DEVELOPMENT
boys
Boys may begin to notice that their testicles and scrotum grow as early as age 9. Soon, the penis begins to lengthen. By age 17 or 18, their genitals are usually at their adult size and shape.
Pubic hair growth, as well as armpit, leg, chest, and facial hair, begins in boys at about age 12, and reaches adult patterns at about 17 to 18 years.
Boys do not start puberty with a sudden incident, like the beginning of menstrual periods in girls. Having regular nocturnal emissions (wet dreams) marks the beginning of puberty in boys. Wet dreams typically start between ages 13 and 17. The average age is about 14 and a half years.
Boys' voices change at the same time as the penis grows. Nocturnal emissions occur with the peak of the height spurt.
Boys' growth spurt peaks around age 13 and a half and slows around age 18.
411
Adolescent development 12-18
BEHAVIOR
The sudden and rapid physical changes that adolescents go through make adolescents very self-conscious. They are sensitive, and worried about their own body changes. They may make painful comparisons about themselves with their peers.
Physical changes may not occur in a smooth, regular schedule. Therefore, adolescents may go through awkward stages, both in their appearance and physical coordination. Girls may be anxious if they are not ready for the beginning of their menstrual periods. Boys may worry if they do not know about nocturnal emissions.
During adolescence, it is normal for young people to begin to separate from their parents and make their own identity. In some cases, this may occur without a problem from their parents and other family members. However, this may lead to conflict in some families as the parents try to keep control.
Friends become more important as adolescents pull away from their parents in a search for their own identity.
Their peer group may become a safe haven. This allows the adolescent can test new ideas.
In early adolescence, the peer group most often consists of non-romantic friendships. These often include "cliques," gangs, or clubs. Members of the peer group often try to act alike, dress alike, have secret codes or rituals, and participate in the same activities.
As the youth moves into mid-adolescence (14 to 16 years) and beyond, the peer group expands to include romantic friendships.
In mid- to late adolescence, young people often feel the need to establish their sexual identity. They need to become comfortable with their body and sexual feelings. Adolescents learn to express and receive intimate or sexual advances. Young people who do not have the chance for such experiences may have a harder time with intimate relationships when they are adults.
412
Adolescent development 12-18
Adolescents very often have behaviors that are consistent with several myths of adolescence:
The first myth is that they are "on stage" and other people's attention is constantly centered on their appearance or actions. This is normal self-centeredness. However, it may appear (especially to adults) to border on paranoia, self-love (narcissism), or even hysteria.
Another myth of adolescence is the idea that "it will never happen to me, only the other person." "It" may represent becoming pregnant or catching a sexually-transmitted disease after having unprotected sex, causing a car crash while driving under the influence of alcohol or drugs, or any of the many other negative effects of risk-taking behaviors.
413
Adolescent development 12-18
SAFETY
Adolescents become stronger and more independent before they have developed good decision-making skills. A strong need for peer approval may tempt a young person to take part in risky behaviors.
Motor vehicle safety should be stressed. It should focus on the role of the driver/passenger/pedestrian, the risks of substance abuse, and the importance of using seat belts. Adolescents should not have the privilege of using motor vehicles unless they can show that they can do so safely.
Other safety issues are:
Adolescents who are involved in sports should learn to use equipment and protective gear or clothing. They should be taught the rules of safe play and how to approach more advanced activities.
Young people need to be very aware of possible dangers including sudden death. These threats can occur with regular substance abuse, and with the experimental use of drugs and alcohol.
Adolescents who are allowed to use or have access to firearms need to learn how to use them properly.
If adolescents need to be evaluated if they appear to be isolated from their peers, uninterested in school or social activities, or doing poorly at school, work, or sports.
Many adolescents are at increased risk for depression and potential suicide attempts. This can be due to pressures and conflicts in their family, school or social organizations, peer groups, and intimate relationships.
414
Adolescent development 12-18
PARENTING TIPS ABOUT SEXUALITY
Adolescents most often need privacy to understand the changes taking place in their bodies. Ideally, they should be allowed to have their own bedroom. If this is not possible, they should have at least some private space.
Teasing an adolescent child about physical changes is inappropriate. It may lead to self-consciousness and embarrassment.
Parents need to remember that it is natural and normal for their adolescent to be interested in body changes and sexual topics. It does not mean that their child is involved in sexual activity.
Adolescents may experiment with a wide range of sexual orientations or behaviors before feeling comfortable with their own sexual identity. Parents must be careful not to call new behaviors "wrong," "sick," or "immoral."
The Oedipal complex (a child's attraction to the parent of the opposite sex) is common during the adolescent years. Parents can deal with this by acknowledging the child's physical changes and attractiveness without crossing parent-child boundaries. Parents can also take pride in the youth's growth into maturity.
It is normal for the parent to find the adolescent attractive. This often happens because the teen often looks very much like the other (same-sex) parent did at a younger age. This attraction may cause the parent to feel awkward. The parent should be careful not to create a distance that may make the adolescent feel responsible. It is inappropriate for a parent's attraction to a child to be anything more than an attraction as a parent. Attraction that crosses the parent-child boundaries may lead to inappropriately intimate behavior with the adolescent. This is known as incest.
415
Adolescent development 12-18
INDEPENDENCE AND POWER STRUGGLES
The teenager's quest to become independent is a normal part of development. The parent should not see it as a rejection or loss of control. Parents need to be constant and consistent. They should be available to listen to the child's ideas without dominating his or her independent identity.
Although adolescents always challenge authority figures, they need or want limits. Limits provide a safe boundary for them to grow and function. Limit-setting means having pre-set rules and regulations about their behavior.
Power struggles begin when authority is at stake or "being right" is the main issue. These situations should be avoided, if possible. One of the parties (typically the teen) will be overpowered. This will cause the youth to lose face. The adolescent may feel embarrassed, inadequate, resentful, and bitter as a result.
Parents should be ready for and recognize common conflicts that may develop while parenting adolescents. The experience may be affected by unresolved issues from the parent's own childhood, or from the adolescent's early years.
Parents should know that their adolescents will repeatedly challenge their authority. Keeping open lines of communication and clear, yet negotiable, limits or boundaries may help reduce major conflicts.
Most parents feel like they have more wisdom and self-growth as they rise to the challenges of parenting adolescents.
416
Immunization Schedule
2 Month
#1 DTAP, IPV, HIB=(pentacel), HepB, Prevnar, Rotavirus
417
Immunization Schedule
4 Month
#2 DTAP, IPV, HIB=(pentacel), HepB, Prevnar, Rotavirus (HepB if not at birth)
418
Immunization Schedule
6 Month
#3 DTAP, IPV, HIB=(pentacel), HepB, Prevnar, Rotavirus
419
Immunization Schedule
9 Month
No Shots - hemoglobin (check iron)
420
Immunization Schedule
12 Month
#4 Prevnar, HepA#1
421
Immunization Schedule
15 Month
MMR, Varivax (proquad)
422
Immunization Schedule
18 Month
#4 DTAP, IPV, HIB=(pentacel), (HepA optional)
423
Immunization Schedule
2-3 year
HepA#2
424
Immunization Schedule
4-6 year
DTAP, IPV, MMR (Varivax and HepA if not yet given)
425
Immunization Schedule
11 and older
Tdap, meningitis, HepB series, HepA series, Varivax if needed, Gardasil
426
Dixie Peds
P5 day
Jaundice check
427
Dixie Peds
2 week
PKU#2
| Random smile
428
Dixie Peds
1 months
Routine Check
| Follows
429
Dixie Peds
2 month
```
Pentacel (DtAP), IPV, HIB)
Prevnar
HBV
Rotavirus
Goos and Coos
```
430
Dixie Peds
4 month
```
Pentacel (DtAP), IPV, HIB)
Prevnar
HBV
Rotavirus
Laughs/Sometimes Rolls
```
431
Dixie Peds
6 month
```
Pentacel (DtAP), IPV, HIB)
Prevnar
HBV
Rotavirus
Sits
```
432
Dixie Peds
9 month
HgB
Pulls to stand
Separation anxiety
stranger anxiety
433
Dixie Peds
12 months
HAV
Prevnar
Walks
2-5 Words
434
Dixie Peds
15 month
Proquad (MMR/Varivax)
| Climbs
435
Dixie Peds
18 months
Pentacel (DtAP), IPV, HIB)
| Runs
436
Dixie Peds
24 months
HAV
| Sentences
437
Dixie Peds
5 yr
```
DtAP
IPV
MMR varivax (proquad)
HgB
UA
vision check
```
438
Dixie Peds
11 yr
Tdap
Meningococcal (menveo)
Gardasil #1 (start series)
Varivax if series not complete
