Pediatrics: School-Age Children Flashcards
Danger Signals! Kawasaki Disease/Syndrome
- Onset of high fever (up to 104.0º F) for ≥ 5 days
Presence of at least 4 of the following clinical signs:
- enlarged lymph nodes in neck
- bright-red rash (more obvious on groin area)
- bilateral conjunctivitis (dry, no discharge)
- oral mucosal changes (e.g., dry cracked lips, “strawberry tongue”)
- swollen hands/feet
After fever subsides, skin peels off hands and feet
Tx:
- high-dose aspirin
- IV gamma globulin
- ~75% of cases occur in children <5 yo
- resolves within 1-3 weeks
- may have serious sequelae: aortic dissection, dilation or aneurysms of coronary arteries, and hearing loss
- requires close follow-up w/ p[ediatric cardiologist for several years d/t effects may not be apparent until child is older (or an adult)
Danger Signals! Leukemia
- c/o extreme fatigue and weakness
- pale skin
- easy bruising
- may have petechial bleeding (pinpoint to small red spots)
- may have bleeding gums/nosebleeds
- some have bone/joint pain
- lymphadenopathy
- abdominal swelling
- Most common type of CA in children/adolescents
- most common type: ALL
Danger Signals! Acute Lymphocytic Leukemia (ALL)
- most common form of leukemia in childhood (75%)
- fast-growing CA of the lymphoblasts, which are immature lymphocytes
- peak occurrence at 2-4 years
- CBC will show very HIGH WBC (>50,000 cells/mm3)
- girls have higher chance of cure
- African Americans, Hispanic children tend to have lower cure rate compared to other races
Danger Signals! Acute Myelogenous Leukemia (AML)
- fast-growing CA of bone marrow, affecting immature or precursor blood cells such as myeloblasts (WBCs), monoblasts (macrophages, monocytes), erythroblasts (RBCs), megakaryoblasts (platelets)
- Children w/ Down syndrome who have AML tend to have better cure rates, esp; if child is <4 years
Danger Signals! Reye’s Syndrome
Clinical Staging: Mild to Moderate, Severe
- Hx of febrile viral illness (chickenpox, influenza) and aspirin or salicylate intake (e.g., Pepto-Bismol) in child
- Theoretical risk of Reye’s syndrome after varicella immunization
- Avoid using aspiring before, during, and after immunization
- Abrupt onset w/ quick progression
- death can occur within a few hrs to a few days
- mortality rate up to 52%
- Although most cases are in children, teenagers and adults may be diagnosed; disease is now rare
Mild to Moderate
* Stage 1
- Severe vomiting
- lethargic/sleepy
- elevated ALT and AST
- Stage 2
- deeply lethargic
- restless
- confused/delirious/combative
- hyperactive reflexes
- hyperventilation
- Stage 3
- obtunded or in light coma
- decorticate rigidity
Severe
* Stage 4
- Coma
- seizure
- decerebrate rigidity
- fixed pupils
- loss of reflexes
- Stage 5
- Seizures
- deep coma
- flaccid paralysis
- absent DTRs
- respiratory arrest
- death
Down Syndrome: Atlantoaxial Instability
- Up to 15% of Down Syndrome pts have atlantoaxial instability
- Medical clearance is recommended for some sports participation
- children/adolescents (or older) w/ Dwon syndrome who want to participate in sports sneed cervical spine x-rays (including lateral view)
- pts w/ atlantoxial instability are restricted from playing contact sports 9e.g., basketball, tackle football, soccer) and other high-risk activities (e.g., trampoline jumping)
- persons w/ Down syndrome w/out evidence of atlantoaxial instability may participate in low-impact sports and sports not requiring extreme balance
atlantoaxial instability
excessive mobility at the articulation of C1 and C2)
Medical Conditions that May Disqualify Youth From Sports Participation + Rationale: Hypertrophic Cardiomyopathy
- Risk of sudden cardiac death w/ intense exercise
Medical Conditions that May Disqualify Youth From Sports Participation + Rationale: Atlantoaxial instability (Down syndrome, juvenile RA)
- Instability b/w C1 and C2 can cause spinal cord compression
Medical Conditions that May Disqualify Youth From Sports Participation + Rationale: Marfan syndrome
- Risk of aortic aneurysm and cardiac death
- lens eyes displacement
- joint hypermobility
Medical Conditions that May Disqualify Youth From Sports Participation + Rationale: Ehlers-Danlos syndrome (Vascular form)
- risk of cerebral or cervical artery aneurysm
- spondylolisthesis
- joint hypermobility
Medical Conditions that May Disqualify Youth From Sports Participation + Rationale: Acute rheumatic fever w/ carditis
- Worsens condition
- heart inflamed
Medical Conditions that May Disqualify Youth From Sports Participation + Rationale: Mitral Valve prolapse, esp if significant MV pathology
- risk of sudden cardiac death
Medical Conditions that May Disqualify Youth From Sports Participation + Rationale: Fever
- Risk of heart illness, hypotension, and ↑ cardiopulmonary effort
Medical Conditions that May Disqualify Youth From Sports Participation + Rationale: Infectious diarrhea
- risk of dehydration and heat illness; contagious
Medical Conditions that May Disqualify Youth From Sports Participation + Rationale: Pink Eye
- contagious
Absence Seizures
- brief episodes during which child suddenly stops whatever they are doing and stares
- if in school, teacher may tell parent that child is daydreaming and inattentive
- common type of pediatric seizure
- AKA: petit mal seizure
First-line therapy: ethosuximide
→ Refer to pediatric neurologist
Still’s Murmur
- benign systolic murmur, described as having a vibratory or musical quality
- becomes louder in supine position or w/ fever
- minimal radiation
- Grade I/II intensity
- most common in school-age children
- usually resolves by adolescence
US Health Statistics: School-Age Children
Top Causes of Death: Age 5-9 years (Early school age)
- Malignant neoplasms
- MVA
- Congenital abnormalities
Immunizations: Preschool Children (age 4-6 years)
Administer vaccines:
- MMR
- varicella
- IPV
- DTaP
If hx of chickenpox documented in chart, do not need varicelle
Immunizations: School-Age Children (age 7-12 years)
- If 7-9 years w/ incompleted immunization record for DTaP, give Tdap as first catch-up dose; followed by tetanus-diphtheria (Td) vaccine)
- Tdap booster should be administered to all 11-12 years (regardless of whether it was used in catch-up schedule)
Most common “middle school” vaccines at 11-12 years are:
- Tdap
- meningococcal conjugate vaccine (MCV4; Menacdtra or Menveo)
- HPV vaccine (Gardasil)
- HPV vaccine can be administered as young as 9 years
- HPV vaccine is recommended for both and girls; Gardasil is used for both genders
→ If first dose of HPV given b/w 9-14 years, ONLY 2 doses are needed; 3 doses needed if series started at ≥ 15 years
Age 13-14 (or older): give Tdap if did not receive at 11-12 years
If no hx of varicella immunization or disease, give varicella vaccine
- If child did not complete Hep A/B series, administer next dose and resume interval dosing; Do NOT restarted Hep A/B series
Meningococcal Vaccines
6 types of menogo0coccal vaccines; only 2 are discussed here
- MenACWY-D (Menactra): Youngest age is 9 months
- MenACWY-CRM (Menveo): Youngest age is 2 months
- Administer Menactra/Menveo vaccine 1st dose at 11-12 years; if missing, catch-u0p age is 13-15 years; booster (2nd dose) at 16-18 years
- Also used for high-risk children w/ asplenia, functional asplenia (sickle cell), splenectomy, HIV infection, and complement deficiencies
- All 11-12 years should be vaccinated w/ single dose of quadrivalent meningococcal vaccine (MenACWY); brand names are Menactra and Menveo
Primary Series of Vaccination: Missing or Not Done after 7th Birthday (Never been vaccinated)
Tetanus (3 doses):
- First dose should be Tdap
- then subsequent 2 doses should be given as TRd (repeat Td Q10 years)
- IPV (3 doses)
- Hep B (3 doses)
- Hep A (2 doses)
- MMR (2 doses)
- Varicella (2 doses) if no hx of chickenpox
- HPV (2-3 doses based on age given; administer of <26 years)
Routine and Catch-Up Immunizations: ≥7 years - Hepatitis B
Total of 3 doses over 6 months
- If missing booster, give until total of 3 doses
- Do NOT repeat series
Routine and Catch-Up Immunizations: ≥7 years - MMR
- Give 2nd dose (if needs to catch up)
- Live virus precautions
Routine and Catch-Up Immunizations: ≥7 years - Varicella
Give 2nd dose (if needs to catch up) if no proof of varicella
- Live virus precautions
Routine and Catch-Up Immunizations: ≥7 years - Hepatitis A
Give 2nd dose (if needs to catch up)
- recommended for children w/ certain health or lifestyle conditions placing them at risk
Routine and Catch-Up Immunizations: ≥7 years - Influenza
Needed annually after 6 months
Routine and Catch-Up Immunizations: ≥7 years - HPV
Give 1st dose at 11-12 years (can start at age 9)
- Catch-up dose at 13 years if missed
- Indicated for boys and girls
Initial vaccinate at 9-14 years → 2 dose series (6-12 months apart)
* HPV vaccine (Gardasil) → know that the youngest age group for vaccination is 9 years and can be given up to 26 years
→ HPV may cause CAs of the cervix, vagina, vulva, penis, anus, pharynx, and base of tongue/tonsils (oropharynx) in both men and women
Initial vaccinate at ≥ 15 years → 3-dose series (give 2nd dose 1-2 months after first; give 3rd dose 6 months after first dose)
Gardasil: can be given up tp age 26 years for high-risk patients
Routine and Catch-Up Immunizations: ≥7 years - Meningococcal
- Give 1st dose at 11-12 years
- give booster at 16 years
- Meningococcal conjugate vaccine (MCV4) recommended for all college freshmen living in dormitories
Vaccines needed at age 11-12 years:
- Tdap
- HPV
- MCV4
Growth and Development: 4 years old (Preschool)
1. Fine Motor
2. Gross Motor
3. Other
- mature pencil grasp
- can copy a cross
- draws a person w/ 3 body parts
- mature pencil grasp
- rides a bicycle w/ training wheels
- hops on both feet
- dresses w/ little assitance
- rides a bicycle w/ training wheels
- according to Piaget, children aged 1-4 are preoperational stage
- ready to learn the alphabet, spell or read short words, and learn basic math concepts
- according to Piaget, children aged 1-4 are preoperational stage
Growth and Development: 5 years old (Preschool)
1. Fine Motor
2. Gross Mother
3. Other
- copies square
- can draw a person w/ 6 body parts
- begins to print some letters and numbers
- copies square
- can ride a bicycle (use bike helmet)
- hops on one foot
- can dress and undress self
- can ride a bicycle (use bike helmet)
- likes to help parents w/ certain household chores
- likes to help adults
- likes to help parents w/ certain household chores
Growth and Development: 6 years old (Kindergarten)
1. Fine Motor
2. Gross Motor
3. Other
- copies a triangle (copies a diamond at age 7)
- ties shoes
- copies a triangle (copies a diamond at age 7)
- climbs trees
- skips
- climbs trees
- begins more formal schooling w/ instruction in basic math and reading skills
Growth and Development: 7-11 years old (Middle Childhood)
- Freud classified this age group under “latency stage”
- major task for this age group is to succeed in school and interact w/ their peer group
- may have a “best” friend(s)
- some girls may start puberty at age 8
- according to Paget, this age group is in concrete operations stage
*- early abstract thinking starts at about 11 years (Piaget) - starts to think of the future
TV and Electronics Use
- Limit to 2 hours a day or less
- use parental-control software
Jean Piaget’s Stages of Cognitive Development
Sensorimotor
Age: Birth - 2 years
Goal: Object permanence
Preoperational
Age: 2-7 years
Goal: Egocentric, pretend play
Concrete opertional
Age: 7-11 years
Goal: Conservation, math, numbers
Formal operational
Age: 12 years to adulthood
Goal: Abstract thinking, logic, ethics, morals
Autism Spectrum Disorder (ASD)
1. Definition/Etiology
2. Clinical Presentation
3. Diagnostics/Treatment
- neurodevelopmental disorder affecting normal development of communication and social skills
- exact cause is unknown
- affects more boys than girls
- several theories about cause, but they are unproven (thimerosal, mercury, vaccines, etc).
- difficult to diagnose before 18 months
- neurodevelopmental disorder affecting normal development of communication and social skills
- A child..
- extremely sensitive to noises, touch, smells, and/or textures
- will refuse to wear tight or rough-textured clothes because they feel “itchy”
- prefers to be alone
- has poor eye contac
- does not interact w/ others
- slow-to-poor language development
- has repeated body movements such as flapping arms
- some may appear to be progressing normally but suddenly regress
- l anguage, physical, and social skills disintegrate - Refer to psychiatrist or psychologist for testing and evaluation
- Intensive rehabilitation needed at younger age (i.e., OT, PT, SLP)
- Refer to psychiatrist or psychologist for testing and evaluation
meds:
- Risperidone (Risperdal) is an antipsychotic that is prescribed for some older patients
Fragile X Syndrome
1. Definition/Etiology
2. Clinical Presentation
3. Diagnostics/Treatment Plan
1/2. - child has macrocephaly (>50th percentile for age/sex) and global developmental delays
- skills and behavior acquisition slow compared w/ peers
- hyperactive behavior or specific learning disabilities (particularly involving math and problem-solving)
- high correlation w/ autism and anxiety
- tends to avoid eye contact
- pt has a long face w/ prominent forehead, jaw, and large/protruding eyes
- large body w/ flexible flat feet
- Rfer for molecular genetic testing
- Refer pt to developmental pediatrician or psychiatrist/psychologist for interdisciplinary evaluation and multimodal interventions
- Rfer for molecular genetic testing
Hand-Foot-Mouth Disease
1. Definition/Etiology
2. Clinical Presentation
3. Diagnostics/Treatment Plan
- common acute viral illness
- mainly affecting children <10 years
- most common cause: coxsackievirus
- spread through direct contact w/ nasal discharge, saliva, blister fluid, or stool
- most contagious during first week of illness
- common acute viral illness
- acute onset of fever, severe sore throat, headache, and anorexia
- multiple small blisters appear on hands, feet, and around rectum
- ulcers are present inside mouth, throat, tonsils, and tongue
- child will c/o sore throat and mouth pain w/ acidic foods
- acute onset of fever, severe sore throat, headache, and anorexia
- Tx is symptomatic; self-limited illness
- complete recovery usually within 5-7 days
- Ibuprofen/acetaminophen for pain and fever Q4-6 hours; do NOT use aspirin
- use salt-water gargle (1/2 teaspoon salt in one glass of warm water)
- drink cold fluids (avoid soda, orange, or lemon juice, tomato juice)
- Tx is symptomatic; self-limited illness
Childhood Rashes + Appearances: Hand-foot-mouth disease
multiple small blisters appear on the hands, feet, and around rectum
- small ulcers inside the mouth, throat, tonsils, and tongue
Childhood Rashes + Appearances: Impetigo
“honey-colored” crusted lesions
- fragile bullae (bullous type)
Childhood Rashes + Appearances: Measles (Rubeola)
Koplik’s spot (small white papules) inside the cheeks (buccal mucosa) by the rear molars
- erythematous maculopapular rash beginning on face and spreads from head to feet, but spares palms and soles
- Remember that Rubeola is measles!
Childhood Rashes + Appearances: Varicella
- generalized rash in different stages
- new lesions appear daily for ~5 days
Papules → vesicles → pustules → crusts
- pruritic
- very contagious
Childhood Rashes + Appearances: Scarlet Fever
- “sandpaper” rash w/ sore throat
- strawberry tongue is not specific (also seen in Kawasaki disease)
Childhood Rashes + Appearances: Pediculosis capitis
Head lice
- ovoid white nits on hair hard to dislaodge
- rad papules that are very itchy and nits are initially located in hairline area behind the neck and ears
Childhood Rashes + Appearances: Molluscum contagiosum
- smooth waxlike round (dome-shaped) papules ranging in size from pinhead to the size of a pencil eraser (2-5mm)
- central umbilication w/ white plug
Childhood Rashes + Appearances: Scabies
- maculopapular rash located in interdigital webs of hands, feet, waist, axillae, groin
- very pruritic, esp at night
- can resemble pimples, eczema, and insect bites
Functional Constipation
1. Definition/Etiology
2. Criteria
3. Diagnostics
- ROME IV criteria diagnosis of functional constipation in children (≥4 years; criteria are slightly different for infants and toddlers up to 4 years)
- up to 80% of children w/ functional fecal incontinence may also have constipation
- must meet ≥2 of the following criteria at least once per week (for at least 1 month)
- Hx of withholding of stool
- Hx of painful or hard BMs
- Hx of large-diameter stools that may obstruct toilet
- presence of large fecal mass in rectum
- 2 or fewer defecations in toilet/week
- at least 1 episode of fecal incontinence per week (thin fluid w/ feces that bypasses a large stool mass and leaks around it) → ask patient whether fecal soiling of underwear
- Hx of withholding of stool
- Plan film (x-ray) of abdomen to check for retained stool
