Preventative Pediatrics / Well Child Care Flashcards
Causes of delayed dental eruption
- Infants born before 30 weeks, birth weight < 1000 g
- Delay is mostly in primary teeth
HPV vaccine facts
- Provides protection against cervical and noncervical HPV-associated cancers
- Includes HPV 6, 11, 16, 18, 31, 33, 45, 52, and 58
- For ages 9-14: 2 dose schedule
- For ages 15-26: 3 dose schedule
- Adverse effects: injection site pain, erythema, edema, headache, dizziness, fever, fatigue
Weight changes in 1st year of life
- Lose 10% at birth, regain by 2 weeks (some may be delayed to 3 weeks)
- Birth weight doubles by 5 months
- Birth weight triples by 1 year
Length changes in young kids
- Average birth length is 50 cm
- Birth length is doubled by age 4
- Growth rate is 20 cm/year
- Okay to cross percentiles in first 12-18 months
- Shifts across 2 or more percentile lines after age 2 should be worked up
Head circumference changes
- Normal at birth is 35 cm
- Grow 1 cm/month in first 6 months then 1/2 cm/month for 6-12 months
Macrocephaly definition and differential
- > 97th percentile
- Big head but normal development - measure parent’s heads (familial macrocephaly)
- Hydrocephalus: irritability, vomiting, impaired upward gaze, bulging fontanelle
Microcephaly definition/workup
- < 3rd percentile for age
- Primary: born with small heads and stay small (genetic conditions and in utero infections)
- Acquired: normal at birth and then decrease (perinatal or postnatal insults, genetic, infectious)
Growth changes in inadequate caloric intake
Weight drops initially followed by decreased length, spares head circumference
Growth changes in endocrine disorders
Presents with short stature with normal or elevated weight
Growth changes in chromosomal abnormalities
Microcephalic and dysmorphic features
Growth changes in chronic medical conditions
Weight and height fall together
Failure to thrive definitions
- Weight < 5th percentile
- Weight that drops down two major percentile channels
- Weight less than 80% of ideal weight for age
- Weight below 5th percentile on weight for length curve
2 month milestones
- Track to both sides (2 sides)
- Lift head and chest while prone
- Coo
4 month milestones
- Grab clothes
- Clutch/hold onto a rattle
- Put objects in mouth
6 month milestones
- Sit up on own
- Transfer a cube from one hand to another
9 month milestones
- Crawling
- Stranger danger
- Babbling with syllables
- Pulls to stand, cruising
12 month milestones
- Walk holding onto one hand
- Point with ONE finger (ONE year of age)
- Say ONE word besides mama and dada
18 month milestones
- Walks fast, falls occasionally
- Stairs with hand held
- Climbs onto a chair and sits in it
- Feed themselves
- 4 cube tower
- Throw a ball standing (but not overhand)
2 year milestones
- Single line train of cubes
- Copies a circle
- Can understand 50% of what they say
- Throws ball overhand
- Walks down steps holding rail with both feet on each step
3 year milestones
- Walk up stairs alternating feet
- Ride a tricycle (3 wheels)
- Hop 3 times
- Draw a triangle
- 3 word sentences
- Knows name, sex, age (3 things)
- Understand 3/4 of what they say
4 year milestones
- Identify opposites
- Can draw 4 body parts
- 4 word sentences, can say first and last name, asks why a lot
- Identify 5-6 primary colors
- Copies a square (4 sides)
- Cuts on a line
- Understand everything they say
- Balances on 1 foot for 4 seconds
- Dresses self but can’t tie shoes
- Potty trained, brushes teeth
- Shows increased cooperativity
5 year milestones
- Tie a knot
- Correctly grab a pen
- Print letters
- Walk backward heel to toe
When does stuttering need worked up
- Normal up to age 3 or 4
- Persistence beyond preschool age will require a workup or if it persists for more than 6-8 weeks or associated with facial tics
Workup for language deficits
- Bilingual home is not an acceptable reason for language delay
- Hearing evaluation is often the first thing to do
Developmental screening tests
- 9, 18, 24 (or 30) month need developmental screening
- ASD screening at 18 and 24 months
- Kindergarten readiness at 4 years
- Social/emotional, mental health at every visit from 5-18 years
Potty training by what age
75% of kids have bladder and bowel control by age 3
Nocturnal enuresis age and workup
- Primary nocturnal enuresis is a child who has never been dry on consecutive nights for 6 months - only after age 5
- Secondary is when they start wetting after being dry for 6 months
- Workup: urinalysis
- Primary Causes (SUDS): Sickle cell trait, Urinary tract infection, Diabetes, Seizure
- Secondary causes: UTI, diabetes, stress, sleep disruption, constipation
- Treatment: enuresis alarms are the most effective, limiting nighttime fluids 2 hours before bed, double voiding before bed
- Can try DDAVP (desmopressin) but only in tablet form - take nightly for 6 months and then stop for 2 weeks to see if it has improved
Daytime enuresis organic causes
- Uti, diabetes mellitus or DI, kidney disease
Screen time recommendations
- 2 hours per day
- Younger than 2 should not watch TV
At what age is day/night schedule established
- 2 months
How much sleep does a 1 year old need
13-14 hours per day
What age is appropriate to start sleep training
4-6 months of age
Night terrors
- Occur in the first third of the night
- More common in boys
- Don’t remember the episode
- Tx: keep surrounding environment safe, don’t wake them during it because it can worsen the agitation, but can try pre-waking the child before the episode usually happens
Nightmares
- Last third of the night
- Can easily be woken up and they remember the nightmare
International adoption screenings
- Developmental assessment every 3-4 months during the first year
- Hearing/vision at first visit
- Immunizations
- CBC, lead level, hepatitis B, HIV, TB testing, and syphilis are all recommended (hepatitis C if from endemic area)
- TB testing is indicated regardless of whether or not they received BCG vaccination
DTap vs Tdap
- Little d has less diphtheria toxoid in it (Tdap is the booster)
- DTap up through kindergarten, never over age 7
DTap/Tdap vaccination schedule
- DTap at 2, 4, 6, 15-18 months, and kindergarten (D for diapers)
- Tdap at age 11-12 (T for teens)
- Catch up: Tdap should be substituted for a single dose of Td in the catch-up series but it then counts as the booster so don’t need another one at age 11-12
DTap/Tdap contraindications
- Serious allergic reaction
- Encephalopathy within 7 days of receiving pertussis-containing vaccine
- Things that are NOT contraindications: extensive limb swelling after vaccine, stable neurologic conditions, brachial neuritis, pregnancy/breast feeding, immunosuppression
Tetanus vaccine in clean wounds
- Give it if kid has < 3 tetanus vaccines or if it has been more than 10 years since the last one
Tetanus management in dirty wounds
- If less than 3 tetanus vaccines or history is unknown, give tetanus vaccine and tetanus immune globulin
- If more than 5 years since last vaccine given a booster
- If adolescent has already received the Tdap then just give Td (but if they haven’t then give Tdap)
Haemophilus influenza B vaccine
- Reduced incidence of invasive Hib including meningitis and epiglottitis
- 3 doses at 2, 4, and 6 months with a booster at 12-15 months
Hepatitis B vaccine
- In 1/3 of cases of hepatitis B, no identifiable risk factors are found
- Children are at risk of hepatitis B: intrapartum, early childhood (household contacts), or adolescence (STDs and IV drugs)
- Vaccine schedule: at birth, 2 months, third dose 6-18 months after the first dose
- Preemies less than 2kg: give at 30 days of life or before discharge (if given at less than 2kg it doesn’t count towards the series)
- If any child hasn’t been fully immunized you should complete the 3 part series
- Only absolute contraindication is severe allergic reaction to prior dose
Mother infected with hepatitis B (HBsAg) positive or unknown hepatitis status, baby should receive what
Hepatitis B immunoglobulin in the first 12 hours of life in addition to the regular vaccine
What high risk groups need hepatitis B serologic testing after vaccine
- Infants born to positive mothers (at 9-18 months of age)
- High risk groups: immunocompromised patients, hemodialysis patients, health care workers
Hepatitis B post-exposure prophylaxis
- Infants/unvaccinated people: hepatitis B immunoglobulin and start the vaccine series
- If fully vaccinated and antibody positive: nothing
- If fully vaccinated and antibody negative: HBIG and full revaccination
Hepatitis A vaccine
- Give at 12 and 18 months
- Contraindications: allergy to aluminum hydroxide and phenoxyehtanol
- If traveling to endemic area: give immune globulin if < 1 year old or vaccine if > 1 year old
Meningococcal vaccine
- Protection against A, C, Y, and W-135 strains
- Vaccine series: at 11-12 year visit, booster at age 16, when entering college dorm if previously unvaccinated
- If immunodeficient or traveling to prevalent areas need vaccine series
MMR vaccine
- Vaccine at 12-15 months and then again 4-6 years of age
- Second dose enhances immunity among nonresponders, it does not serve as a booster
- Vaccines given before 12 months of age for travel don’t count toward completion of the series
MMR vaccine with other live vaccines
Okay to give on same day or in a combined vaccine but can’t be given within 4 weeks of each other (varicella and intranasal influenza)
- Similarly, can place a PPD with MMR vaccine but not for 4-6 weeks after vaccine
MMR side effects
- 15% of kids develop high fever within 12 days of vaccine and lasts 1-2 days, 5% can also get a rash
MMR absolute contraindications
- Severe allergic reaction to vaccine component, neomycin, or gelatin
- Pregnancy
- Severely immunocompromised
MMRV side effect
Increased risk of febrile seizures when given to kids 12-23 months of age
Live vaccines in HIV positive patients
- Measles vaccine is indicated for those who are symptomatic but not severely immunocompromised or asymptomatic (no MMRV vaccine)
- Varicella vaccine if CD4 counts are high enough
- Give only inactivated influenza vaccine
Varicella vaccine
- Give at 12-15 months and then again at 4-6 years
- Contraindications: pregnancy, prior allergic reaction, substantial suppression of cellular immunity
Varicella post-exposure prophylaxis
- Give vaccine within 3-5 days of exposure if healthy and over 12 months of age (at least 3 months after first vaccine dose)
Give immunoglobulin and acyclovir if:
- immunocompromised child with no prior varicella infection/immunization
- pregnant woman without immunity
- hospitalized preemies of 28 or more weeks if mom doesn’t have immunity
- hospitalized preemies of < 28 weeks
- newborns if mom had varicella 5 days before up to 2 days after birth
Varicella vaccine and aspirin
- Stop aspirin for 6 weeks after vaccine due to risk of Reye syndrome
Chemotherapy and vaccines
- No live vaccines for 3-6 months after chemo has ended
- Except varicella vaccine is given to children in ALL remission because of risk of varicella
Pneumococcal vaccine
- PCV13 or conjugate vaccine (prevnar) given at 2, 4, 6, and 12-15 months
- PPSV23 or polysaccharide is not recommended for healthy kids because it is less immunogenic but it does cover more strains
- Give 23 valent to any chronic disease/asplenic kid at or after age 2 and at least 8 weeks after 13 valent
- Also give polysaccharide vaccine to kids at risk for invasive pneumoccal disease including CSF leaks, chronic heart/lung disease, diabetes, or cochlear implants
- Asplenia, sickle cell, HIV infection, malignancy, transplants, or immunodeficient patients need a second 23 valent after 5 years
Polio vaccine
- Given at 2, 4, 6 month, and age 4-6
- Technical rules: first two given at 2 month intervals beginning no earlier than 6 weeks, 3rd dose is 6-18 months of age, 4th dose after age 4 but at least 6 months after 3rd dose
- Can give on accelerated schedule 4 weeks apart
Rotavirus vaccine
- RV5 vaccine given at 2, 4, 6 months but RV1 vaccine given at 2 and 4 months
- First dose of rotavirus should not be given after 15 weeks of age
- Once it’s started the series needs to be completed by 8 months of age
- Contraindications: SCID or history of intussusception
- Preemies should still get the vaccine as long as they are 6 weeks of age old
Vaccines in solid organ transplant patients
- Inactivated vaccines should be given at least 2 weeks before transplantation and live should be given at least 1 month before for best immune response
Influenza vaccine
- Annually for everyone over 6 months of age
- Nasal spray is live and approved for kids over 2 years of age
Egg allergy and vaccines
- Yellow fever is the only vaccine that has enough egg protein to cause an allergic reaction
- MMR does not
- Influenza does not in most cases but it is contraindicated in kids with ANAPHYLACTIC reaction to egg
Cholesterol screening guidelines
- Universal screening for kids age 9-11
- Children age 5-9 if family history or risk factors: BMI > 85th percentile, poor diet, chronic steroid medications, anticonvulsants, beta blockers, alcohol abuse, anorexia
Car seat guidelines
- Infants < 2 and weighing < 20 lbs: infant or rear facing car seat
- Toddlers > 2 and more than 20 lbs: convertible car seat forward facing in back seat
- School age children up to 4’9” tall: booster seat forward facing in back seat
- Older children until age 13: back seat with seatbelt
Bicycle safety facts
- Most bicycle deaths are in kids < age 15
- Helmets are worn by < 10% of kids
- Helmets reduce serious injury by 85%
- 75% of deaths are due to head injury
- Reflectors are required on pedals, tire sidewalls or rims, and front/rear of bicycle
Water heater temperature
- 120 degrees F
- Hot liquid burns are the most common in the house (pay attention to demarcation burns)
Drowning facts
- Infants are most likely to drown in a bathtub
- Kids < 5 are most likely to drown in a residential pool
- Adolescents are most likely to drown in fresh water
- Higher rates in african american males
- MCC of death in kids with epilepsy
- AAP recommendations: 4 sided fence around the pool with a self locking and slef latching gate
Tobacco use in adolescents
- School based eduation programs are effective if they focus on role playing refusal skills and the health impact
- Nicotine replacement therapy is not FDA approved in adolescents
- Buproprion with counseling is another option
Workup for abnormal head shape/growth
- HUS if anterior fontnaelle is open, MRI if not
- Head CT with 3D reconstruction for craniosynostosis
- Helmet orthosis/PT for positional plagiocephaly if > 6 months
