Peds Health Supervision

Question 1

FTT

Answer 1

Less than 2nd percentile weight

Weight down first, then length, then head circ

Question 2

Expected weight increases

Answer 2

Birth-3 mo: 30g/day, regain bw by 2 weeks
3-6 mo: 20g/day, double bw by 4-6 mo
6-12 mo: 10g/day, triple bw by 12 mo
1-2 years: 250g/month
2-adolescence: 2.3 kg/year

Question 3

Expected height increases

Answer 3

0-12 mo: 25 cm/ year, BL up by 50% at 1 year
13-24 mo: 12.5 cm/year
2yrs-adolesence- 6.25 cm/ year, birth length 2x by age 4, 3x by 13

Question 4

FTT etiologies

Answer 4

Inorganic (disturbed parent/child bond), MOST COMMOn

Organic = underlying pathology/chromo systemic illness

Question 5

Eval of FTT

Answer 5

hx/pe, diet hx, obs, routine tests NOT useful, focused lab eval. Look for IUGR vs. postnatal.

Question 6

Head growth abnormal

Answer 6

Almost all head growth prental, during first 2 years. At birth 25% of adult head, 75% adult by 1 year age. cephalohematoma can screw up head circ measure

Question 7

Expected head circ increase

Answer 7

0-2 mo- .5 cm/wk
2-6 mo- .25 cm/ wk
by 1 year, 12 cm increase since birth!

Question 8

Inorganic FTT?

Answer 8

Bad formula, bad feeding, neglect, young mom/sad mom, alcohol/drugs, marital discord, mental illness, fam violence, poverty, isolation

Question 9

Microcephaly

Answer 9

Head cir 2-3 STDs below mean, incidence 1-2/1000
congen = abnormal induction/migration of brain tissue
acquired = cerebral insult in late third tri/perinatal/first year. head stops growing too soon
clin fx= SMALL brain! developmental delay/intellectual impair/CP/seizures

Question 10

Craniosynostosis

Answer 10

Premature closure of 1+ sutures
Why? unknown/sporadic 80-90%, few = genetic syndrome (Crouzon/Apert), or IU constraint, hyperthy or hypercalcemia
Clin fx- normal sutures open until brain growht stops…90% done at 2, done at 5. Head shape depend on which suture closes early.
dx = phys exam, by 6 months noted, confirm w/ head CT + skull XR
MGMT = surgical repair, esp for cosmetics

Question 11

Which suture closes early?

Answer 11

Sag suture => elongated skull (dolicho/scaphoceph) = most common
Coronal suture => shortened skull (brachyceph), bos, neuro complications like optic nerve atrophy
Metopic suture => hey arnold! trignocephaly
Multiple sutures => severe neuro compromise

Question 12

Organic FTT

Answer 12

Think about all of the systems. Many infectious diseases, naemia, kidney failure, GI abnormalities, immunodef, etc

Question 13

Plagiocephaly

Answer 13

Asymmetry not assoc with suture closure. Positional plagio = flattened occiput + prominence of ipsi frontal area, skull = parallelogram
Assoc w/ congen musc torticollis, increased b/c infants told to sleep on backs
MGMT = ROM exercise for torticolis, tummy time, helment, reposition head

Question 14

Macroceph

Answer 14

head circ > 95%, not necessariily big brain
Why? Familial, overgrowth sotos syndrome, mets issues (canavan/gangliosidoses), NFM, achondroplasia, hydroceph, SOL (tumor)
Eval- measure parents heads, obs for bulging fontanelle/vom/irritable/split sutures b/c ICP concern. R/o hydroceph w/ CT/head u/s. genetic eval maybe

Question 15

Active immunization

Answer 15

Live vaccine = more likely long-lasting immunity, avoid if immunocomp. Varicella, oral polio, MMR
Non-live: not infectious, need boosters- DTaP, hep A and B, IPV, HIB, flu, pneumococ/meningococ

Question 16

Passive immunization

Answer 16

Delivery of preformed abs if no active immunity…

VZIG for immunocomp pts, newborns to hepB+ mommas get HBIG. Travel to high risk area, HepAIG

Question 17

HBV

Answer 17

Hep B hits 300 mil worldwide, give as recombo vaccine in us with HBsAg. 3 shots in first year of life

Question 18

DTaP

Answer 18

Diph, tet, pertussis, inactivated vaccine. DTP = whole cell bordetella, now replaced w/ DTaP w/ acellular bits, less s/e. Give at 2,4,6, mo w/ boost at 12-18 mo and 4-6 yrs. dT = 1/10 dose of dipth toxoid, give at 11-12 years and ever 10 years after. dT not DTaP if >= 7 y/o

Question 19

OPV/IPV

Answer 19

OPV = good b/c host immunity + secondary (comes out in stool, may immunize others), but maybe => polio
IPV = subq/IM, give at 2 and 4 mo, boost 6-18 mo and 4-6 years

Question 20

HIB

Answer 20

H flu => invasive bac infection, meningitis, epiglot, sepsis before vaccine
Conjugate vaccine- h flu polysach + protein antigens (diph toxoid/tetanus). Give at 2,4,6 mo w/ 12-15 mo boos, or 2,4,12 (dep on conjugate)

Question 21

MMR

Answer 21

Measles = pneumonia+ mortality, mumps = parotitis + meningoenceph + orchitis. Rubella = mild viral, but birth defects
Live attenated, give at 12-15 mo w/ boost at 4-6 years or 11-12 years

Question 22

Varicella

Answer 22

Chicken pox! Severe in very young/old. Live attenu, give at 12-18 mo

Question 23

Hep A

Answer 23

Most common viral hep, though 70% asx, severe in older kids/adults, rare fulm hep
Inactive, give at 2 y/o or older, boost 6 mo later if high incidence in area or risk fx (liver, homo sexula/bisexual, IVD, clotting factor/blood products, occupational)

Question 24

Pneumococcal vaccine (Pneumovax/Prevnarr)

Answer 24

Most common cause of OM/invasive bacterial if younger than 3
Pneumovax = polysach antigen from 23 serotypes, cover everything, but little immunogen under 2 y/o, use for older kids/adults w/ high risk (aspelnic ppl, Chronic Liver, immuno def, nephrotic snydnrome)
Prevnar = 7 serotypes, immunogenic in kids under two, not as broad, give it to all kids under 2, some kids older, 2,4,6, mo and 12-15 booster

Question 25

Why immunizations bad?

Answer 25

Most s/e mild/mod, local inflamm/low-grade. MMR/Varicella might => fever/rash 1-2 weeks post shot, serious s/e RARE. DONT give if...anaphylaxis, encephalo within 1 week of DTaP, pts w/ progressive neuro disorders shouldnt get dTaP, Immunodef? no give live guys

Question 26

Precautions for immunizations

Answer 26

Be careful givin shots w/ mod/severe illness. w/ DTaP, careful if temp of 40.5, collapse/shocklike, or inconsolable crying for > 3 hour within 48 hours, seizures within 3 days

Question 27

Hearing screening

Answer 27

Universal newborn hearing screening b/c hearing loss => impaired language Brainstem aud evoked response measures EEG waves in response to clicks, most accurate but $$ Evoked otoacoustic emission measures sound made by choclear cells detected by microphone in external aud canal...may be messed up by debris/fluid Most effective = use both tests

Question 28

Metabolic Screening

Answer 28

all states screen hypothy, PKU, many do galactosemia Sickle cell + other hemoglob issues- penicillin prophylaxis => down mort/morbid Some states do CAH too

Question 29

Cholesterol/Lipid Screen?

Answer 29

Not recommended for routine. IF kids > 2 have fam hx, do cholesterol if either parent w/ hyperchol, or fasting lipid if either parents/gpas have hx of CVD or sudden death < 55 y/o kids with elevated chol 75-90th percentile do fasting LP with total chol, tg, HDL, LDL

Question 30

Iron Def Anemia screen

Answer 30

Most common under 6 y/o, peak 9-15 mo, risks = premature, low bw, early cows milk pre 9 mo, insufficient diet iron, low SES Universal hb screen at 9-15 mo and 4-6 years UA- recc by some docs, but lil evidence. only if school needs it

Question 31

TB Screen

Answer 31

For at risk kids- contacts w/ tb or high risk (jail, insitutionalized, HIV, homeless, IVD). For kids w/ XR findings, immigration, HIV, high prev areas Skin test analyzed 48-72 hrs after plaement, interpret on basis of level for risk

Question 32

Lead Toxicity

Answer 32

Plumbism = risk for kids arex, apathy, lethargy, amemia, irritable, vom, maybe enceh Chronic => asx, maybe neuro isues (delay, mr, learning probs)

Question 33

Lead Screen

Answer 33

For all kids 9mo-6years in old housing, for same age kids w/ contacts who are intoxicated w/ lead, same age if near smelters, any age kids w/ old house being renovated, all kids if >12% 1-2y/o with elevated lead Lead levels <10ug/dL still bad, MGMT based on levels, decrease exposure, chelate if very high

Question 34

Circumcise

Answer 34

60% males circ, unclear health benefits, maybe good for penile cancer/cervical cancer, not recommended. UTI more common in uncirc. 10% uncirc eventually need it for Phimosis (normal up to age 6, can't retract foreskin), or paraphimosis- retracted skin gets stuck and tourniquets, or balanitis- inflamm of penis glans (candida or g neg infections or STI) Use anesthesia/analgesia in circ, can have bleeding compx, phimosis or injury, dont do it w/ penile abnormal/prematurity or bleeding diatheses

Question 35

Tooth eruption

Answer 35

Inital between 3-16 mo, avg 6 mo, usually lower central incisor first 20 primary teeth by age 2, secondary eruption w/ lower incisor between 6-8, 32 teeth Delayed eruption if after 16 mo, familiar, hypothy, hypopit, genetics like downs/ectodermal dysplasia (con teeth, less sweat glands) Early teeth = before 3 mo- familia, hyperthy, precocious pub, growth hormone too much

Question 36

Dental Hygiene

Answer 36

Brush as soon as teeth erupt, at 2-3 years kiddos can help, use floss, get fluoride, but too much = flurosis, abnormal brown-gray fugly teeth. vulnerable at 2-4 years. Make sure you give fluoride fi kids are only getting bf, or kids with bad tap water

Question 37

Dental weird things

Answer 37

Natal teeth = at birth they're there! Neonatal = in first month! Most common = mandibu central incisors, more than 90% erupt early. Why = unclear, mgmt = nbd unless teeth are hypermobile, cause bf issues or trauma to baby's tongue. aspiration risk pretty low

Question 38

Nursing/bottle caries

Answer 38

3-6% kids, often at 2-30 mo age, especially if fall asleep w/ nipple in mouth or kids that carry around bottle, or any other liquid given. Strepto mutans = most common agent. Max incisors, canines, primary molars. MGMT = dental crowns/extraction

Question 39

Dental Trauma

Answer 39

Perm tooth that is avulsed can be reimplanted if you place it back quick! Extraoral time = biggest prog factor, best if avulsed tooth kept in milk (WEIRD), dry tooth doesnt do so hot. Avulsed primary teeth just leave em

Question 40

Feeding schedule

Answer 40

Newborm= on demand 8-12x/day for 4-6 weeks 2 mo- feed every 3-4 hours 4 mo- 4-5 hours 6 mo- feedings spaced out!