Pediatrics: Toddlers

Question 1

Danger Signals: Neuroblastoma

Answer 1

Most common presentation:
- abdominal (retroperitoneal or hepatic) mass; fixed, firm, and irregular, frequently crosses midline

most common site: adrenal medulla (sits on top of kidneys)

~50% of pts present w/ metastatic disease

May be accompanied by:
- fever
- weight loss
- subcutaneous nodules
- Horner’s syndrome
- periorbital ecchymoses (“racoon eyes”)
- bone pain
- HTN
- rarely, opsoclonus myoclonus syndrome

Most diagnosed children are ages 1-4
- US is initial imaging choice for abdominal masses
→ Refer to general pediatric surgeon

Question 2

Danger Signals: Wilms’ Tumor (Nephroblastoma)

Answer 2

• Asymptomatic abdominal mass extending from flank toward midline
• nontender and smooth mass rarely crosses midline (of abdomen)
• Some pts have abdominal pain & hematuria
• 1/4 pts have HTN
• higher incidence in black, female children
• Peak age: 2-3 years
• Most common renal malignancy in children
• While performing abdominal exam, palpate gently to avoid rupturing renal capsule → causes bleeding and seeding of abdomen w/ CA cells
• Initial imaging: abdominal US
  → Refer to nephrologist
• Wilms’ tumor is a congenital tumor of the kidneys
• More common in African American girls

Question 3

Danger Signals: Epiglottitis

Answer 3

• acute and rapid onset of high fever, chills, and toxicity
• usually b/w 2-6 years
• Before Hib vaccine, most cases are d/t Haemophilus influenzae type b (75%) → now rare d/t vaccine (Hib)

other pathogens:
- Staphylococcus aureus
- Streptococcus pyogenes
- fungi

Child c/o:
- severe sore throat
- drooling saliva
- will not eat/drink
- has muffled (“hot potato”) voice
- anxiety

Characteristic tripod sitting posture w/ hyperextended neck and open-mouth breathing
- stridor
- tachycardia
- tachypnea

Prophylaxis:
- rifampin (4 days) for close contacts
* Reportable ds to public health department
!! Medical emergency !! Call 911!

• Presentation: Sitting posture w/ hyperextended neck nd open-mouth breathing

Question 4

Danger Signals: Osteomyelitis

Answer 4

• most common in children
• boys 2x more likely than girls
• infections usually occur a metaphyses, so area overlying the metaphysis is often exquisitely tender to touch

S/Sx
- will not weight bear or move extremity d/t pain

Tx:
- Emergent hospitalization!
- IV antibiotics
- OR debridement

Growth plate infection → growth stunting of affected limb

Question 5

Danger Signals: Septic Arthritis

Answer 5

• Primarily ds of infants and toddlers
• Can occur if osteomyelitis spreads to joint space but is more commonly from hematogenous spread
• Most common organism: S. aureus

S/Sx
- abrupt onset of unilateral hip/knee pain (most common presentation)
- knee may present w/ swelling and warmth
- hip rarely presents w/ palpable findings

• If pt tolerates weight bearing, antalgic limp noted
• at rest, pt will prefer hip flexion, abduction, and external rotation or knee in partial flexion

Tx
- Emergent joint aspiration
- empiric IV antibiotics

Question 6

Danger Signals: Orbital Cellulitis

Answer 6

S/sx
- c/o abrupt onset of deep eye pain
- aggravated by eye movements
- accompanied by high fever, chills
- affected eye will appear bulging (proptosis or exophthalmos)
- EOMs abnormal d/t ophthalmoplegia from infection of ocular fat pads and muscles

• more common in younger children
• Ethmoid sinusitis is more likely to cause orbital cellulitis compared w/ frontal/maxillary sinusitis
• CAN BE LIFE-THREATENING!
• A serious complication of rhinosinusitis, AOM, or dental infections

Tx:
- Refer to ED!
- CT scan or MRI is done

Question 7

Ophthalmoplegia

Answer 7

limited movement of eyeball (d/t infection of ocular fat pads and muscles)

Question 8

Danger Signals: Preseptal Cellulitis

Answer 8

(Periorbital Cellulitis)
- more common than orbital cellulitis
- an infection of anterior portion of eyelid that does NOT involve orbit/globe or the eyes
- rarely causes serious complications (compared w/ orbital cellulitis)
- younger children are most likely to be affected

S/Sx
- new onset of red, swollen eyelids
- eye pain
- sometimes none (no sx)
- eye movements do not cause pain
- EOM exam is normal (both are abnormal w/ orbital cellulitis)
- no visual impairment
- may be hard to distinguish from orbital cellulitis

Tx:
- Refer to ED!

Question 9

Danger Signals: Nonaccidental Trauma

Answer 9

(Child Abuse)
- majority of perpetrators are parents (82%)
- ~16% of perpetrators are persons child is exposed to such as day-care staff and unmarried partners

Red flags:
- posteromedial rib fractures
- metaphyseal avulsion fractures
- bruises or fractures in various stages of healing
- delay in seeking medical care
- injuries inconsistent w/ explanation

• Infants/children who are developmentally or physically disabled are at higher risk
• RNs, NP, and several other professionals are required to report suspected or actual child abuse to authorities

Question 10

US Health Statistics: Toddlers - Top 3 Causes of Death
1. Ages 1-4 years
2. Top 3 cancers

Answer 10

1. • Drowning
     - Congenital anomalies
     - MVA
2. • Leukemia (28%)
     - Brain and NS tumors (26%)
     - Lymphomas (8%)
     * Most common CA in children is leukemia!
     * Most common type of leukemia in children is ALL!

• Remaining causes are d/t AML.
• Medulloblastomas are the most common type of childhood brian CA ( most occur before 10 years)

Question 11

Growth and Development: Infancy through Preschool - Normal Characteristics vs Abnormal
1. Neonate
2. 3rd month
3. 6th month

Answer 11

1. Normal:
   - strong reflexes
   - minimum of 6-8 BMs daily
   - urinates 8x daily

Abnormal:
- Jaundice at birth (hemolysis)
- High-pitched cry
- Irritable
- “Floppy” (hypotonic)
- Poor reflexes

2. Normal:
   - Smiles
   - Able to coo
   - makes gurgling sounds
   - can hold head up
   - starts to recognize parents

Abnormal:
- Inability to hold head up
- avoids eye contact
- floppy

3. Normal:
   - Sits up without support
   - rolls in both directions (front to back, back to front)
   - says single-syllable sounds: “ba, da, ma”
   - tries to get things out of reach by “raking” (uses palms to reach)

Abnormal:
- lack of babbling
- does not laugh
- inability to turn head paste midline (180º)

Question 12

Growth and Development: Infancy through Preschool - Normal Characteristics vs Abnormal
4. 9th month
5. 1 year (12 months)
6. 2 years

Answer 12

4. Normal:
   - Pincer grasp (fine motor)
   - plays pat-a-cake and peek-a-boo
   - says “good-bye”
   - may be afraid of strangers (can be clingy)
   - can stand holding on
   - crawls

Abnormal:
- infantile reflexes strong
- persistence of primitive reflexes (e.g., startle, fencing)
- does not babble
- does not bear weight on legs w/ support
- unable to sit w/ help

5. Normal:
   - Supports own weight
   - walks w/ hands held
   - parallel play
   - separation anxiety
   - can “climb” stairs by crawling up/down
   - starts to cruise (moves from one piece of furniture to the other for support)

Abnormal:
- unable to support own weight
- lack of babbling
- nor response to smiles
- poor eye contact
- loss of previously learned skills (autism)

6. Normal:
   - Walks
   - runs
   - climbs stairs up and down on own by holding onto handrails
   - speech mostly understood by family
   - follows 2- to 3-step instructions
   - copies a line

Abnormal:
- unable to speak meaningful 2-word “sentences”
- does not understand simple commands
- loss of speech, social skills, or previously learned behaviors and/or does not say words by 16 months (autism)

Question 13

Growth and Development: Infancy through Preschool - Normal Characteristics vs Abnormal
7. 3 years
8. 4 years
9. 5 years

Answer 13

7. Normal:
   - speaks 3- to 5- sentences
   - understood by strangers
   - copies a circle w/ crayon or pencil
   - rides tricycle
   - builds towers of more than 6 blocks
   - runs and climbs easily

Abnormal:
- speech hard to understand or unclear speech
- unable to understand simple commands
- falls down often
- does not speak in sentences
- no eye contact
- loses skills they once had

8. Normal:
   - copies a cross w/ crayon or pencil
   - draws person w/ 3 body parts
   - plays “mom” and “dad”
   - hops and stands on 1 foot up to 2 seconds
   - cooperates w/ other children
   - names some colors and some numbers

Abnormal:
- unable to speak in full sentences
- inability to skip, run, hop
- cannot put on clothes w/out help
- unable to play w/ other kids
- unable to follow 3-part commands

9. Normal:
   - can draw a person w/ 6 body parts
   - counts 10 or more things
   - is aware of gender
   - speaks clearly

Abnormal:
- unusually withdrawn
- not active
- trouble focusing on one activity for >5 minutes

Question 14

2 year old:
1. Language
2. Fine Motor
3. Gross Motor
4. Behaviors
5. What to report

Answer 14

1. • speaks in 2- or 3-word sentences (intelligible mostly by family)
     - follows 2-step commands
     - knows common pictures in a book
2. • stacks 5-6 cubes
     - can copy straight line
3. • goes up stairs using same foot; uses railing for support
     - runs, jumps, and climbs
     - is very active and energetic
4. • temper tantrums are common
     - easily frustrated and says “no” often; defiant behaviors
     - may have favorite stuffed toy (transitional object)
     - toilet training is now in progress
5. • loss of speech
     - social skills
     - previously learned skills
     - flapping hands
     - avoidance of social interaction (R/O autism)
     - unsteady walking
     - inability to speak in 2-word sentences

Question 15

3 year old:
1. Language
2. Fine Motor
3. Gross Motor
4. Behaviors
5. What to report

Answer 15

1. • speaks in sentences using 3-5 words
     - most speech is understood by strangers
     - knows first name, age
     - magical thinking is prominent at this age (ages 3-5 years); may have imaginary friend; a girl may think she is a fairy w/ special powers
2. • copies a circle
     - can stack more than 6 cubes
3. • pedals a tricycle
     - can throw a ball overhand
     - walks up and down stairs w/ alternating feet
4. • Freud classified age as “Oedipal stage” (phallic stage) → child expresses desire to marry the parent of opposite sex; occurs b/t ages 3-5 (preschool)
     - plays w/ other children (group play) but does not like to share toys or take turns
     - imagination is becoming more active (pretends that broom is a “horse”)
5. • any regression in previously learned skills
     - “clumsy” q/ frequent falls
     - minimal vocabulary or speech difficult to understand
     - speech dysfluencies
     - no or poor eye contact

Question 16

Health Education, Safety, and Screening: Nutrition

Answer 16

• have regular mealtimes (3 meals/day) + snacks (2-3 daily)
• food jags are common
• transition from whole milk to lower fat milk at 2 years of age
• limit fruit juice intake
• cut solid food into bite-size pieces
• avoid hard foods (nuts, raw carrots,a nd hard candies)
  + other choking hazards (gum drops, jelly beans, whole grapes [cut into quarters if offering], and whole hot dogs [cut into slices that are than quartered])

Question 17

Health Education, Safety, and Screening: Toilet Training

Answer 17

Clues that a child is ready include:
- when child is walking
- can reach potty chair
- knows the difference b/w wet and dry
- can communicate when having a BM
- can pull down own pants
- can stay dry for up to 2 hrs at a time
- shows interest in toilet or potty seat

• Make sure child can understand basic instructions
• Most are ready for potty training at 18-24 months
• some may not be ready until 36 months

During toilet training, signs that a child is ready to use:
- sq

Question 18

Health Education, Safety, and Screening: Toilet Training

Answer 18

Clues that a child is ready include:
- when child is walking
- can reach potty chair
- knows the difference b/w wet and dry
- can communicate when having a BM
- can pull down own pants
- can stay dry for up to 2 hrs at a time
- shows interest in toilet or potty seat

• Make sure child can understand basic instructions
• Most are ready for potty training at 18-24 months
• some may not be ready until 36 months

During toilet training, signs that a child is ready to use:
- squirming
- holding genital area
- squatting

• Most children master daytime bladder and bowel control by 3-4 years
• Nighttime control of urine is usually last toileting skill mastered
• complete nighttime control may not happen until 4-5 years

** children 5-6 years w/ primary nocturnal enuresis should be evaluated and interventions started

Question 19

Health Education, Safety, and Screening: Car Safety

Answer 19

• Toddlers should be placed in back seat in a forward-facing safety seat w/ harness system until they outgrow the height and weight limits of seat
• make sure anchors and tethers are used correctly
• Children <12 years should be restrained in back seat

Question 20

Health Education, Safety, and Screening: Safety Education

Answer 20

• Child should be supervised at all times
• Hold child’s hand when crossing street or when shopping
• Use rear burners on stove; turn pot handles away from reach
• Keep tools and sharp objects out of reach
• Inspect toys for loose parts or breakage
• water safety education needed; put fences around pools; never leave child alone in pool

Question 21

Autism
1. Definition/Etiology/Screening
2. Clinical Presentation
3. Diagnosis/Treatment

Answer 21

1. Signs of autism spectrum ds may appear in early childhood
   - Screening starts at 18 months

Five behaviors to look for:
- Does not point/wave/grasp/reach (by 12 months)
- No babbling (by 12 months)
- does not say single words (by 16 months)
- Does not say 2-word phrases on their own (by 24 months)
- loss of language or social skills (at any age)

2. • Autistic 3-year-old boy enrolled in preschool program; The mother goes inside school to drop child off. After she gives him a hug, she leaves room. How would the child react after his mother leaves?
     - At this age, non-autistic 3-year-old would most likely cry, protest, and cling to his mother’s legs when she tries to leave
     - An autistic child may not protest, cling, or cry when his mother leaves (as would be expected in a child who does not have autism); if mother hugs him, an autistic 3-year-old child may hold his body stiffly and not return hug; some may push mother away d/t they do not like being touched
3. • Typically diagnosed by developmental pediatrician using highly specialized diagnostic stools
     - multimodal interventions used to ameliorate some cognitive and behavioral issues

Question 22

Epiglottitis presentation

Answer 22

Sitting posture w/ hyperextended neck and open-mouth breathing

Question 23

What the difference in speech between a 2-year-old and a 3-year-old?

Answer 23

2-year-old
- speech includes 2-word phrases mostly understood by family members

3-year-old
- speech includes 3- to 5-sentences that can be mostly understood by strangers

Question 24

At what age can the child ride a tricycle? Bicycle?

Answer 24

3 yo → tricycle
6-7 yo → bicycle

Question 25

At what age can a child copy a circle?

Answer 25

3 yo

An easy way to memorize this is that when you take the “3” and join the 2 halves, it forms a circle

Question 26

At what age can a child copy a cross? draw a body w/ 3 body parts?

Answer 26

the #4 resembles a cross at the center
- can also draw a “stick person” w/ 3 body parts

Question 27

At what age can a child draw a person with at least 6 body parts?

Answer 27

5

Question 28

What is the Oedipal stage?

Answer 28

When the child (age 3-6) expresses the desire to marry the parent of the opposite sex

Question 29

What are red flags for autistic behavior?

Answer 29

• loss of skills at any age
• no pointing, reaching, or babbling by 1 year
• no words by 16 months
• no 2-word phrases by 2 years