Complete Pediatric Objectives

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Describe the hearing screening and evaluation in infants and children.

(Picture: Hearing assessment algorithm) HEARING: -*Yearly starting at age 3 yrs* Do it last because the kid will probably complain about it. Pull ear up and outward. *Always use an insufflator. -Key is to recognize at risk children (infections, ototoxic drugs, recurrent acute otitis media)

Become familiar with important aspects of development and behavior in the early school years: *ages 5-7.*

*5 y/o:* brain is 90% of its adult weight language: tell age ("this many" on fingers is okay), know colors, names monetary coins, complex sentences, pronouns, modifiers, preposition personal-social: dress & undress w/o help, asks meanings of words, print few words motor: skip smoothly, stand on one foot for 10 secs fine motor: know right vs left, do home chores, copy triangle, draws recognizable person, count 10 objects, good motor ability but little awareness of dangers *6-7 y/o:* language: 6-7 word sentences, 2500 word vocabulary, read many one-syllable words, tie shoes, count to 30, add and subtract within 5, copy diamond

Become familiar with important aspects of development and behavior in the middle school years: *ages 7-11.*

*8-11:* -language is adult proficiency -can make a sentence given 3 words -know months & date -add and subtracts 1 digit numbers -knows simple multiplication

3. Be able to proactively discuss the benefits of childhood vaccination with parents of your patients.

*Autism worry:* Dr. Andrew Wakefield developed a study in 1998 that looked at 12 kids with developmental disorders + Gastroenteritis. He was looking for a common thread between them and in 8/12 children they had recently been given the MMR vaccine. He falsified his data and made up information about the children and concluded that MMR vaccine causes Autism..... -He was funded by trial lawyers who had a case in vaccine injury.... -He patented a singular measles vaccine that was "safe" 2 months prior to submitting his study $$$$ -He is in jail and no longer a doctor *Mercury risk:* -two studies came out in egypt recently showing that thiomersal (mercury found in some vaccines) was found in higher concentration in children with autism. These studies do not show that MMR is the cause (because MMR never contained thiomersal) but it can scare parents. The studies really suggest that kids with autism have a genetic problem eliminating mercury as well as healthy kids. correlation vs causation. *Kids immune systems will be overloaded:* -This is bullshit, not a thing parents are stupid *I want to spread out the shots given* -There is no evidence supporting this decision is safe. It increases there potential exposure to life threatening diseases with no added benefit -Many vaccines come in combinations so the children won't be stuck so many times *If my child gets the HPV vaccine they will turn into a Ho Fo Sho* -Studies have shown that getting this vaccine has no effect on how likely a person is to have premarital sex. -Try being a better parent if this concerns you *There are so many bad ingredients in vaccines like formaldehyde* -There has never been data that suggests these are harmful in the levels given in vaccines. They only contain the smallest amount needed to keep vaccine stable. -The body produces more formaldehyde from cellular metabolism in a day than is in a vaccine *We don't know the long term effects of vaccines* -Well we kinda do. You don't die from a preventable disease, you don't have chronic organ damage. -We have years of data now supporting that vaccines are safe and do not cause any problems to your health. *Parent refuses to vaccinate* -Tell them the risks of doing so and continue to try and converse about the benefits -The parent needs to be educated on early signs of all diseases there child is at risk of -The parents must call ahead anytime they go to a practice, ED, or hospital to make staff aware so staff can take precautions to keep staff and other patients safe.

7. Compare and contrast bronchiolitis and asthma.

*Bronchiolitis* *Pathophysiology: Clinical syndrome affecting children *<2 y/o*, characterized by rhinorrhea and inflammation of the small airways (bronchioles) resulting in wheezing and/or crackles. -Edema, mucous secretion and sloughed epithelial cells cause obstruction or small airways and atelectasis -Most commonly caused by *RSV* (respiratory syncytial virus). Can perform nasal swab to determine which virus. *Risk factors* for severe disease include prematurity, age <12wks, chronic pulmonary dz, congenital heart/airway defects, immunodeficiency and neurologic dz. -Often results in hospitalization during the fall, winter and early spring. *Presentation* -Pt have 1-3 days of nasal discharge followed by fever, cough and sometimes respiratory distress. Symptoms peak on day 5-7 of illness and usually resolve in 8-14 days *Treatment* is supportive: nasal saline/suction, increased PO fluids, humidifier, shower steam -Cyanosis/decreased pO2, severe respiratory distress or dehydration are indications for admission -Lots of discussion over the years about albuterol, racemic epi and steroids but these are not generally recommended. *Prevention* in pre-mature babies with certain risk factors with palivizumab (a monoclonal antibody against RSV) every month during peak seasons VS *Asthma* Most common chronic disease affecting 7 million US children. *Pathophysiology*: -Up to 80% of children with asthma develop symptoms before 5 y/o. -A chronic variable irritation of the airways with resultant inflammation, bronchospasm, edema, and mucous production -Exacerbated by allergies, infections, irritants, emotions, temperature, exercise -Atopy (hereditary allergy) biggest predisposing factor -Severe RSV bronchiolitis in infancy has been linked to asthma and allergy in childhood. Presentation: -Symptoms include *wheezing*, coughing, shortness of breath, rapid breathing and chest tightness -Physical exam findings include tachypnea, tachycardia, cough, wheeze, prolonged expiratory phase and decreased air entry (severe attacks include cyanosis, retractions, agitation, inability to speak, tripoding positioning and diaphoresis) -Dx usually includes H&P and trial of medication (spirometry in patients older than 5 years of age, consider CXR in first time wheezers, often shows hyperinflation during exacerbation) -Management: bronchodilators (rescue medication) and controller meds (inhaled corticosteroids and long acting beta-agonists) -ER/Hospital management (use scoring system called PACE based off of distress- decide management)

List and describe common developmental concerns including colic, feeding disorders, sleep disorders, temper tantrums and breath-holding spells.

*COLIC:* -An otherwise *healthy 2-3 month old seems to be in pain, cries for ≥3 hours/day on ≥3 days per week for ≥3 weeks. ("rule of threes")* -characterized by severe & sudden crying that *occurs mainly in the late afternoon.* The knees are drawn up and fists are clenched, gas is expelled, they look like they are in pain, and there is minimal response to attempts at soothing. -*benign and spontaneously resolves in 90% by 4 months of age* -must r/o all disorders: allergic response to cows milk, GERD, corneal abrasion, UTI, child abuse. -tx: parental support is mainstay- help them cope & soothe child. reassurance that kid is not sick. optimize the parent-child relationship. work on feeding techniques *FEEDING DISORDERS:* -Inadequate or disordered food intake -causes: Poor oral-motor coordination (trouble chewing/swallowing), fatigue d/t chronic disease, lack of appetite, behavioral issues relating to parent-child interaction, pain associated with feeding (oral candidiasis). -must r/o causes +/- speech therapy, swallowing eval. -tx: establish typical pattern of weight-gain. Supportive UNLESS failure to thrive. *SLEEP DISORDERS:* --infants are not born with a sleep-wake cycle. -so much fluff and many disorders mentioned in book but the tx for all is promote sleep hygiene *TEMPER TANTRUMS:* -throwing on ground/kick/scream/hit; common btwn. 12 mo- 4 yrs -reflection of immaturity as the child strives to accomplish age-appropriate tasks and has difficulty with experiences beyond their developmental level -tx: supportive- don't hold grudge; realize they're out of control and praise when they regains control. *BREATH-HOLDING SPELLS:* -name is a MISNOMER in that it connotes prolonged inspiration. -It occurs during *expiration (prolonged expiration) and is reflexive—not volitional—in nature.* -often start in first year of life, in response to anger or a mild injury. -cry then falls silent in the expiratory phase of respiration followed by a color change (pale or blue). -The spell may resolve spontaneously, or the child may lose consciousness. -workup: r/o pica & Fe-deficiency anemia, seizure disorder, orthostatic hypotension, CNS tumor -tx: behavioral- help control their responses to frustration. IF LOC occurs, place child on side and protect head and prevent aspiration by maintaining airway.

Recognize the clinical manifestations, assessment, diagnosis and the management of disorders of the nose and sinuses to include viral rhinitis, allergic rhinitis, acute and chronic sinusitis, *nasal infection* and nasal trauma.

*Clinical Manifestations* *Nasal furuncle in the anterior nares* ○ Caused by hair plucking or nose picking ○ Common organism → S aureus ○ Exquisitely tender, firm red lump *Nasal septal abscess:* ○ Usually follows trauma or a nasal furuncle ○ PE: fluctuant gray septal swelling, usually bilaterally ○ Complications: nasal septal hematoma (see photo) or spread of infection of CNS *Management* *Nasal furuncle:* ○ Dicloxacillin or cephalexin for 5 days to prevent spread ○ I&D ○ Topical antibiotic ○ Educate patient: never pick or squeeze a furuncle in this location→ potential to spread to CNS *Nasal septal abscess:* ○ Immediate hospitalization ○ I&D by ENT ○ Antibiotic therapy

Recognize the clinical manifestations, assessment, diagnosis and the management of *Chronic Sinusitis*.

*Clinical manifestations* • Episodes of acute bacterial rhinosinusitis clear with antibiotic therapy but recur with each or most URIs • If the child doesn't clear the infection in expected time, and hasn't developed new acute symptoms, consider Chronic Sinusitis *Assessment/Diagnosis* - CT may be helpful *Treatment* - Same as acute but longer Abx course, 3-4 wks - Nasal saline irrigations and intranasal steroid sprays for sx

Enuresis & Encopresis (not an objective)

*Enuresis-* repeated urination in clothes during day and in the bed at night by a child at least twice a week for 3 months in a *5 year old.* -2 subtypes: monosymptomatic or non-monosymptomatic. -*Monosymptomatic enuresis* is uncomplicated nocturnal enuresis (NE) aka no daytime accidents; reflects a maturational disorder and there is no underlying organic problem. There's a delay in the maturation of the urologic and neurologic systems -->workup: r/o anatomical problem, constipation present?, UA and urine cx --> tx: supportive/reassurance, limit liquid intake, DDAVP is last resort -*Complicated or non-monosymptomatic enuresis* involves NE and daytime incontinence and often reflects an underlying disorder. -->workup: r/o disorders such as DI, DM, seizures, anatomical abnmlities *Encoporesis*- the repeated passage of stool in inappropriate places by child who is *older than 4 years.* It occurs each month for at least 3 months -more than 90% of cases are d/t constipation. but r/o hypothyroidism, neuro disorders (CP), stress or maltreatment -tx: supportive, tx constipation if thats the cause

Identify major developmental milestones in the first and second years of life.

*From a motor perspective, children develop in a cephalocaudal (head to toe) direction. They can lift their heads with good control at 3 months, sit independently at 6 months, crawl at 9 months, walk at 1 year, and run by 18 months.* *1 month:* -alert to sounds/search for source of sounds *2 months:* -*smile reciprocally*,cooing sounds (musical long vowels) hold their chest up by placing their hands together while on stomach *3 months:* -*reach and swipe/hit objects*, *raking motion grasp i.e. eat w/ whole hand* *4 months:* -*sit with support, roll one way, reach and grasp for things*, *LOL, oriented to voice (look for mom when they hear her voice)* *6 months:* -*sit independently (6-7 mos.)*, transfer objects btwn. hands, place both hands on bottle, *roll both ways*, tripod sitting propped on hands, babble "ma, da" *8 months*: *crawl* (some babies skip this step) *8-12 months stranger anxiety then again from 18 mos- 2 yrs* *9 months:* -pull to stand, *fine pincer grasp to pick up cheerios*, bang objects together, *say mama and dada but don't know who they're referring to*, wave bye bye *10 months:* *creep* (hands and knees) *11 months:* *cruise*: i.e. walking along couch *12 mos:* -stand well, *50% of babies can walk*, *say mama & dada specifically and 2 other words*, follow one-step command w/ gestures (i.e. you show them what to grab and they at least look at the object) *15 mos:* -*speak 4-6 words*, follow one step command w/o gesture, *stoop to pick up toy*, creeps up stairs, run stiff legged, scribble, build 3-4 cube tower, *put objects in and out of a cup, spoon feed independently* *18 mos:* -*7-10 words, know 5 body parts* *2 yrs:* -*50+ words, 2 word sentences, 50% of speech should be understandable to stranger*, uses pronouns inappropriately, stacks 6 cubes, climb up stairs 2 ft. at a time, walk backwards, *throw and kick ball*, hard-headed "MINE" *2.5 years:* -copy crude circle, walk tiptoes *3 yrs:* -*250 words, 3 word sentences, 75% of speech should be understandable*, knows pronouns & uses plurals, jump down from curb, climb up stairs alternating feet, ride tricycle, use scissors, copy circle, majority (70%) have daytime continence (90% by 6 y/o) *3.5 yrs:* -hop on foot, copy crude square, catch a bounced ball *4 yrs:* -*1000+ vocabulary, 100% of speech should be understandable, speak in fulll sentences, asks questions, knows colors, sings song from memory*, balance and skip on one foot, climb DOWN stairs alternating feet, draw a 3/4 part person *4.5 yrs:* -dress themselves (not tie shoes), copy crude triangle, leap over objects *5 yrs:* -start school, writes first name, asks shit ton of questions, button & unbutton well, catch w/ 2 hands, skip rope, draw a 6 part person

List and describe common problems in the newborn infant: HEART MURMURS

- Extremely common during first 24 hours - If present right at delivery, assume valvular problem Transitional murmurs (ex: PDA): - *not audible until minutes to hours after birth* - infant will be pink, well-perfused, no distress - soft murmur heard at left upper to midsternal border - If there is a *difference of > 15 mm Hg* between arm and leg or if lower extremity pulses are difficult to palpate --> *evaluate for coarctation of the aorta*

1. Understand the concept of inborn errors of metabolism and specifically the clinical presentation, diagnosis, and management of the following specific disorder: *phenylketonuria (PKU)*

-*Autosomal recessive* disorder of *amino acid metabolism* in which phenylalanine can not be converted to tyrosine because there is an enzyme defect in Phenylalanine Hydroxylase (chromosome 12q24.1) in the liver. -Phe in high amounts is toxic to CNS. -1/10-20,000 live births in the US *Clinical presentation* Normal at birth. >50% affected infants present with the following signs: vomiting, irritability, eczematoid rash, *peculiar odor 'musty'* (due to phenylacetic acid in urine), *fair hair and skin* *Diagnosis* -Newborn screening (in all 50 states): test for elevated levels of phenylalanine -Diagnostic studies: If positive screen, quantitative analysis of serum phenylalanine and tyrosine. *Management* -Treatment: Limit dietary intake of phenylalanine for life (found in meats and aspartame). Followed by dietician and Phe levels are monitored closely. -Long term prognosis: If untreated, severe intellectual disability (IQ<30), damage becomes irreversible by 8 weeks of age

OJC

-Children are measured laying down til 2 y/o. Then they are measured standed up (the standing can often shrink their measurements) so they are checked again at 2.5 y/os -Transient growth parameter plateaus may occur between 4-18 months, but a child should reach a stable rate of growth by 1.5 years of age -Growth is seasonal - with growth velocities increased during spring and summer

Normal Head Circumference Development in the Neonate

12-18 mos: fontanels close puberty: sutures close

*Clinical Manifestations* *Newborns with subluxation of the quadrangular cartilage of the septum* ○ Top of the nose deviates to one side, inferior to the other, nasal tip is unstable ○ Must distinguish subluxation with common flattening of the nose caused by birthing process *Nasal trauma:* ○ Examine the inside of the nose, r/o hematoma of the septum (potential to cause septal necrosis) ○ Abrupt onset of nasal obstruction following trauma *Assessment/Diagnosis* ● Rule out fracture with x-ray for all nasal trauma ■ Always important to rule out septal hematoma because this can lead to septal necrosis. Septum should only be 2-4mm. Look for widening, boggy septum. *Management* *Newborn subluxation:* ○ Reduction can occur in the nursery and more severe cases by the ENT under anesthesiology *Nasal trauma:* ○ If frx, needs to be seen by ENT in 48-72 hrs because nose bones health quicly. ○ Refer to ENT for packing

List and describe the clinical manifestations, complications and treatment of common pediatric skin diseases, including those caused by *superficial fungal infections (tinea infections and candidiasis)*. CANDIDIASIS

*Clinical Manifestations/Diagnosis* 1. Diaper dermatitis caused by C. Albicans 2. Thick white patches on oral mucosa - Thrush 3. Fissures at the angles of the mouth - perleche 4. Periungual erythema and nail plate abnormalities - Chronic Paronychia 5. Candida dermatitis: sharply defined erythematous patches with some eroded areas. Esp. moist areas, axillae and neck folds. More common in children who just had abx recently. *Treatment* 1. C. Albicans - topical imidazole, bid 2. Oral Thrush - nystatin suspension 3. Paronychia - antifungal topical, wrap in plastic and leave overnight 4. Refractory candida - oral fluconazole¬

List and describe the clinical manifestations, complications and treatment of common pediatric skin diseases, including those caused by *bacterial infections (impetigo, cellulitis, folliculitis, abscess and scalded skin syndrome)*. IMPETIGO

*Clinical Manifestations/Diagnosis* ○ Erosions covered by honey-colored crusts ○ Caused by Staph and Group A strep - If there are borders to the erosions filled with clear fluid, like a blister, then it's called Bullous Impetigo, mostly commonly found in diaper area. *Treatment* ○ Oral beta lactamase resistant penicillins (augmentin), Cephalosporins, Clindamycin, Amoxicillin, x 7-10 days ○ Topical mupirocin and fusidic acid - Cool compress to debride crust can help with discomfort

List and describe the clinical manifestations, complications and treatment of common pediatric skin diseases, including those caused by *viral skin infections (varicella zoster, herpes simplex)* VARICELLA ZOSTER

*Clinical Manifestations/Diagnosis* ○ Grouped vesicles in a dermatome in various stages of healing - Usually on trunk or face - Suggestive of varicella-zoster reactivation ○ Series of changes: papule, vesicle, pustule, crust, slightly depressed scar ○ *"Dew drop" on a rose petal* ○ Zoster in children may not be painful and has a mild course ○ Erythematous border around vesicle is good prognostic sign ○ Large bullae without crusting, and systemic illness is poor prognostic sign ○ Diagnosis: rapid immunofluorescent test for VZV, Tzanck smear *Complications* ○ Children: Bacterial infections of the skin and soft tissues ○ The older the child, the more severe the case; Scarring ○ Adults: Pneumonia ○ Long term complication → Reactivation later: Shingles, or herpes zoster *Treatment* ○ Supportive ○ Acyclovir may be needed for severe cases ○ Never Aspirin, children recovering from Flu or Chicken pox can develop Reye's Syndrome if given ASA. Swelling in liver and brain. ○ Vaccination available

*Clinical Manifestations/Diagnosis* ○ Painful, grouped vesicles or erosions on a red base ○ Diagnosis: Rapid immunofluorescent test for HSV, Tzanck smear ○ Lesions common on gingiva, lips, and face ○ Herpes whitlow occurs in thumbsuckers *Complications* ○ Cutaneous dissemination occurs in patients with atopic dermatitis (eczema herpeticum) ■ Very tender, punched-out erosions among the eczematous skin changes *Treatment* ○ Acyclovir and antivirals

*Clinical Manifestations/Diagnosis* ○ Pustule at a follicular opening ○ Deep follicular infection→ furuncle (single follicle) and carbuncle (multiple follicles) ○ Lesions are painless and red ○ Tend to occur in crops; usually on buttocks and extremities *Complications* ○ Methicillin-resistant staphylococcus aureus (MRSA) ■ Now a leading cause of folliculitis and abscesses *Treatment* ○ Remove follicular obstruction ○ Warm, wet compresses for 24 hours ○ Keratolytics, like those used for acne (contain salicylic acid) ○ Topical or oral antibiotics

*Clinical Manifestations/Diagnosis* ○ Red and scaly lesion ○ Tinea capitis: Black dot appearance on scalp from thickened and broken off hairs, Kerion (inflamed) mass may form ○ Tinea corporis: annular marginated plaque with a thin scale and clear center ○ Tinea Cruris: symmetrical, sharply marginated lesions in inguinal areas ○ Tinea pedis: postpubertal males, red scaly soles and blisters, fissuring between the toes ○ Tinea Unguium: Onycholysis, yellow discoloration, scaling and crumbling of nail plate surface ○ Multiple forms: Tinea capitis, corporis, cruris, pedis *Treatment* ○ Hair involved → Griseofulvin for 4 weeks ○ Skin → topical clotrimazole BID x 14 days

*Clinical Manifestations/Diagnosis* ○ Sudden onset of bright red, acutely painful skin ○ Most obvious periorally, periorbitally, and in the flexural areas of the neck, axilla, popliteal, antecubital areas, and the groin ○ Pressure on skin results in severe pain and separation of the epidermis - *Nikolsky's Sign* ○ Circulating toxin (exfoliatin) is causative agent - Toxin of group II staphylococci ○ Staph infection of nasopharyngeal, abscess, sinus, blood, joint or other→ produces the toxin *Treatment* ○ Antibiotics against staph (oxacillin, cephalosporins, clindamycin) Top is SSS, bottom is impetigo: Photo

Describe the important aspects of newborn and early childhood growth and development.

*Growth*: progression of changes in *height, weight, and head circumference* according to established standards for a given population and within the context of individual genetic potentials (i.e. Down Syndrome, Turner Syndrome, Cerebral Palsy, skeletal dz, endocrine dsfxn babies have less growth potential) *Development*: refers to neuro-maturation -encompasses language, cognition, motor, personal/social, and problem-solving abilities *Growth velocity*= the change in growth over time; it's a more sensitive index of growth rather than a single measurement ex: child in 75th% on one visit then in 25th% on next is abnml these are measured and assessed at EVERY well-child visit *Consider evaluation if a child has:* Growth values outside ± 2 SD range on a normal distribution curve *factors that affect growth:* 1. earliest factor= maternal nutrition & intrauterine environment (effects first 3-6 months) 2. genetics= affect later (after 6 months of age)

16. Understand the clinical approach to a child with micro-/macrohematuria, including the pathophysiology, presentation and management of post-Strep glomerulonephritis.

*Hematuria* is excess RBCs in urine-> can be macro or microscopic; looking at RBC morphology can tell you where blood is coming from. *Remember*: 0-2 RBCs/hpf is NOT hematuria. -Sources of hematuria: Glomerulo-tubular nephritis (crenated RBCs, urine red/brown; usually proteinuria present), ureter bleeding (red urine & often causes clots but NO proteinuria), Bladder (post-renal bleeding doesn't have distorted RBCs) -*RBC casts* -> HUGE HINT, indication of glomerular bleeding but they aren't always present; casts are formed when enough RBCs collect in tubules. -Pro tip: must look under microscope to ensure it's actual RBCs b/c myoglobin and Hb also show up on dip! -Pt w/ hemoglobinuria will also be jaundiced and present w/ anemia. -Athletic types in "dark urine" but no/few RBCs on hpf likely have have myoglobinuria *Post streptococcal Glomerulonephritis* *Pathophysiology*: 7-4 days post group A B-hemolytic strep infection *Dx/Clinical presentation*: -High titers of antistreptococcal antibodies (ASO) or renal biopsy (if renal function deteriorates) -Gross hematuria (tea colored) -Microscopic RBCs -*RBC casts* -Low serum C3 complement -Periorbital of facial edema -Increased serum creatinine -Hypertension (beta blocker) *Prognosis/Treatment* -Course generally 2-3 weeks -Sodium restriction, diuretics/antihypertensives as needed -95% children recover fully with some having hematuria over a year

Killed Vaccines -Which ones are killed -Benefits -Contraindications -Side effects

*Killed* vaccines create active *humoral* immunity. *Benefits:* -given sooner in life then live vaccines due to mothers Ab's not attacking vaccine. *Downside:* -Need multiple doses to develop enough antibodies to give protection -first dose is a primer dose and provides NO PROTECTION *Contraindications:* -Serious reaction to previous dose -Fever in last 24 hrs -Current ABX use -*Guillain-barre or unstable neurological problem (DTaP/TdaP/Flu)* *Side effects:* -Injection site reaction (redness, soreness, lump) -Because it does not replicate in body you usually don't get systemic reactions (fever, malaise)

6. Compare and contrast laryngomalacia and foreign body aspiration.

*Laryngomalacia*: collapse of the supraglottic structures during inspiration. -Usually presents in the neonatal period with *intermittent inspiratory stridor* -Peaks at 4-8mo of age and resolves by 12-18mo (worsened by infection) -Most pt have mild to moderate dz (loudest when sleeping or eating, gaining weight well) Dx with h&p, treat reflux if present, follow clinically -Pt w/ severe disease should be referred to ENT (loudest when crying, may have suprasternal or substernal retractions, poor feeding and failure to thrive. ENT can perform endoscopy, possible surgical correction) VS *Foreign Body Aspiration* -Most lodge in right or left mainstem. (typically supraglottic airway) History often difficult to elicit and dx may be delayed. -S/Sx: choking, coughing, wheezing, SOB, stridor, asymmetric breath sounds -Dx: CXR may show *asymmetric hyperinflation* (in up to 60%) +/- *mediastinal shift away* from affected side, +/- radiopaque object. CXR is normal in 10-25%. -*Lateral decubitus* films in young infants/kids may show same findings as expiratory film. -Tx: <1y/o try back blows, >1y/o try heimlich. If these fail, Jaw trust. If object is visualized, try to remove with forceps. If child is *unconscious*, establish surgical airway. If foreign body is w/i airway, *rigid bronchoscopy* to remove (gold standard). No abx therapy usually required. *Never* do a blind finger sweep.

Live Attenuated Vaccines -Which ones are live -Benefits -Downside -Contraindications -Side effects

*Live* vaccines create *Cell-mediated* active immunization -The vaccine is weakened -Your immune system mounts a reaction and memory cells are created *Benefits:* -Life-long immunity after 1 dose -Benefit due to memory T& B cells *Downside:* -Cannot be given in first 12 months of life due to protection from mothers Antibodies that will prevent immune response. -Severe reactions possible *Contraindications:* -Immunocompromised (Transplant, steroids, chemo, HIV) -Antiviral therapy -Antibiotic use -Fever in last 24 hours -If another live vaccine has been given in last 28 days -Allergy to neomycin or Gelatin (MMR/ Varicella) *Side effects:* -Local site injection pain, redness, swelling -Fever, malaise, headache, loss of appetite, rash (will occur 7-21 days post injection) -Anaphylaxis (1 in 1/2 million) IgE mediated.

8. Recognize milk protein allergy

*Most common food allergy* in young children. - Usually presents first year of life. Casein and whey (not lactose) allergy 10x MC in formula vs breast fed Broad clinical presentation because allergy can be IgE mediated, mixed, or non IgE mediated. *IgE*: flushing, edema, SOB, nausea, emesis, diarrhea *Mixed*: atopic dermatitis, allergic eosinophilic GI disorders *Non-IgE*: enterocolitis, proctocolitis, GER, constipation, colic? Treat with hydrolyzed formula (Alimentum or Nutramigem)

4. Understand pathophysiology, presentation and management of the following other congenital diseases: *Wilson's disease*

*Pathophysiology* -*Autosomal recessive* disease cause by mutation in ATP7B gene, which codes for an ATP driven copper pump (impaired bile excretion of copper) -Copper is stored abnormally in the liver leading to hepatocellular injury, CNS dysfunction and hemolytic anemia *Presentation* -Clinical presentation usually occurs after 3 years of age -*Neurologic* abnormalities: declining school performance and handwriting, psychiatric disturbances -*Liver* dysfunction: jaundice, spider hemangiomas, portal hypertension, liver failure -Anemia: pallor, fatigue -*Kayser-Fleischer rings* (absence does not exclude diagnosis) *Management* -Diagnosis includes PE findings, low serum ceruloplasmin and Cu, elevated urine copper excretion and liver copper. -Treatment is life long and includes copper chelating drugs (penicillimine, zinc salts) whether or not pt. is asx (noncompliance = liver failure or death)

10. • Understand pathophysiology, presentation, and management of common pediatric GI problems: GERD, *pyloric stenosis*, constipation, acute diarrhea, volvulus, intussusception, and Hirschsprung disease.

*Pathophysiology* -Acquired muscular hypertrophy of the pyloric muscle at the opening from the stomach into the duodenum that causes a narrowing of the lumen *Presentation* -MC in 1st born male infants between 2-6wk of age -Patients present with projectile *non-bilious* vomiting, palpable "olive" on abdominal exam and visible peristaltic wave -Dehydration and *hypochloremic*, *hypokalemic metabolic alkalosis* -Associated with macrolide use *Management* -Diagnosis with ultrasound (UGI can show the "string sign") -Treat with fluids and surgery (laproscopic pyloromyotomy)

15. Understand pathophysiology, presentation, and management of common pediatric GI problems: GERD, pyloric stenosis, constipation, acute diarrhea, volvulus, intussusception, and *Hirschsprung disease*. (Congenital aganglionic megacolon)

*Pathophysiology* -Caused by failure of ganglion cells to migrate into the distal bowel resulting in *spasm* and *functional obstruction* of the segment -MC chromosomal abnormality associated with this disease is Down syndrome -75% are limited to rectosigmoid colon but can involve entire colon or just a few cm of rectum *Presentation* -Babies usually fail to pass meconium in first 24h and can become rapidly ill with enterocolitis or obstruction -Bowel distension develops *proximal* to affected segment -Sometimes presentation is not this severe and dx is made later on *Management* -Dx is made by suction bx -Treatment is surgical resection

12. Understand pathophysiology, presentation, and management of common pediatric GI problems: GERD, pyloric stenosis, constipation, *acute diarrhea*, volvulus, intussusception, and Hirschsprung disease.

*Pathophysiology* -Rotavirus is the most common cause of acute diarrhea in pediatric population (infants between 3 and 15 months of age). There's a vaccine for this. -As with most viral pathogens, rotavirus affects the small intestine, causing *voluminous watery diarrhea without leukocytes or blood* -Transmitted via the fecal-oral route and survives for hours on hands and for days on environmental surfaces *Diagnosis/Presentation* -Most often diagnosed on clinical grounds alone, but can be identified in stool or via electron microscopy -Incubation of 1-3days -Vomiting following by low grade fever and diarrhea within 24h -Illness usually lasts 4-8 days (dehydration, metabolic acidosis due to bicarb loss in stool) *Treatment* -Replacement of fluid and electrolyte deficits (pedialyte) *Other causes* Malnutrition, allergy, extra intestinal infections, antibiotic therapy

14. Understand pathophysiology, presentation, and management of common pediatric GI problems: GERD, pyloric stenosis, constipation, acute diarrhea, volvulus, *intussusception*, and Hirschsprung disease.

*Pathophysiology* -Telescoping of a segment of proximal bowel into a segment of downstream bowel (ileocolic MC) -MC cause of bowel obstruction in first 2 years of life -85% cases idiopathic *Presentation* -Usually occurs in *1 to 2y/o* patients with viral induced lymphadenopathy -Patient with sudden onset of crampy abdominal pain, pt cries out in pain and *pulls up their legs* about every 10-15min. (intermittent) -Obstruction and ischemia result in emesis and *currant jelly stools* -May have sausage shaped mass in right upper quadrant or epigastrum (not easy to palpate) *Management* -*Diagnose and treat* with air contrast enema (u/s most sensitive and specific) -If unable to reduce or ischemic, needs surgery

13. Understand pathophysiology, presentation, and management of common pediatric GI problems: GERD, pyloric stenosis, constipation, acute diarrhea, *volvulus*, intussusception, and Hirschsprung disease.

*Pathophysiology* -Torsion of the intestines around the mesenteric artery causing obstruction and ischemia -50% of pt with malrotation present with volvulus <1 moa *Presentation* -Bilious emesis, abdominal distention, pain, constipation or blood stools -Pt can appear septic -Xray can be normal (or see bird's beak *see picture*) -Get upper GI, US, CT in older pt *Management* -Surgical *emergency* to untwist the bowel as patients can develop necrosis, peritonitis, and death -Resection can result in "short gut syndrome"

9. Understand pathophysiology, presentation, and management of common pediatric GI problems: *GERD*, pyloric stenosis, constipation, acute diarrhea, volvulus, intussusception, and Hirschsprung disease.

*Pathophysiology* GERD is when GER (card below) has pathologic complications. *Presentation* -Poor weight gain, feeding refusal, severe irritability, failure to thrive, GI bleeding, upper/lower airway respiratory sx -Pain can also result in *Sandifer's Syndrome*: Generalized stiffening and back arching that can be assoc. with apnea -Dx usually based on history and physical -Other studies include pH probe, impedance probe, endoscopy and upper GI *Management* Thickening feeds with rice cereal, positioning, H2 blockers, PPIs -Nissen fundoplication: surgery to reinforce lower sphincter

Describe the management of ear canal and nasal *foreign bodies*

*Signs and Symptoms* → Foul odor, purulent drainage, pain, bleeding, halitosis *Management* ■ Gator clips, Dermabond, Suction, bean bag immobilizer helps ■ Parent can blow on 1 side of the nose.... Yikes. ■ If You can't see it, call ENT ■ May have to treat the inflammation first ■ Batteries - must be removed emergently! (<4 hours)

• Describe the approach to management of fever in the pediatric population.

*The most common reason for an pediatric ER visit!* WHAT: -*38.0 C or 100.4 degrees F in otherwise healthy child* (In infants <3 months of age threshold is 38.0 or 100.4). Warrants more extensive workup and management especially if <1 month old (CSF, urine and blood) CAUSES: -LARGE differential *infection most common* EVALUATION: -Based on history, physical and overall clinical picture -A well appearing, well hydrated child w/ evidence of a routine viral infection can be safely sent home w/ symptomatic treatment and careful return policies -Fever w/o focus of infection: consider likelihood of serious but hidden/occult bacterial infection -Infants 28 days+ : tx conservatively. Hospitalize and parenteral abx, can lead to possible perinatal HSV infection *Treat the child not the fever* *Fever is not a diagnosis, it is a symptom* TREATMENT: -Depends on etiology and patient's age -*Symptomatic care: antipyretics, hydration, rest, parental education and anticipatory guidance* -*Reassure that fevers lower than 41.7 do not cause brain damage!* -Can give acetaminophen (indicated over 2 mo) who have fever over 39 or are uncomfortable -Ibuprofen can be used over 6 mo, longer lasting -*Do not use aspirin b/c of Reye syndrome*

Know the complications associated with otitis media *(tympanosclerosis, cholesteatoma, perforation, chronic suppurative OM)*.

*Tympanosclerosis* ■ Calcification and scarring of the TM and middle ear structures from inflammation ■ If it involves the ossicles, conductive hearing loss can occur *Cholesteatoma* ■ Greasy-looking or pearly white mass seen in a retraction pocket or perforation. Cheese like discharge ■ Infection may be superimposed *Perforation* ■ Risk for infection ■ If it does not heal spontaneously with antibiotics, surgical repair may be needed *Chronic suppurative (pus forming) OM* ■ Present when persistent otorrhea occurs in a child with tympanostomy tubes or TM perforation. Start with an acute infection that becomes chronic with mucosal edema, ulceration, and granulation tissue.

Demonstrate the use of standard growth charts.

*growth charts are used from birth to 24 months* -boys and girls have their own charts - y-axis: weight & length OR weight & head circumference - x-axis: age in months *from 24 months to 20 y/o, a different growth curve with stature and weight is used AND BMI is measured* *Normal human growth is pulsatile* - periods of rapid growth (growth spurts) followed by periods of little measurable growth

Normal Height Development in the Neonate

*special scenarios:* -children with marked deformity of the spine or lower extremity, predict hight via measuring arm span -children with bilateral lower ext. atrophy due to LMN lesion, a sitting height may be a better indicator of general growth than total height (ie CP) *Midparental height:* accuracy +/- 2 inches Girls - take average of dads height minus 13 cm with moms height Boys - take average of moms height plus 12cm with dads height

Special considerations for preterm infants

- *If delivered < 34 wks*, can't coordinate sucking, swallowing, and breathing --> *enteral feedings* - Lack of body fat - *Minimize heat loss* (pre-warmed towels/blankets) - PDA compromises pulmonary gas exchange because of overperfusion and edema of the lungs _ Impaired substrate absorption by the GI tract compromises nutritional status - Immature renal function --> *fluid/electrolyte management* - Increased susceptibility to infection - Immaturity of metabolic processes predisposes to *hypoglycemia and hypocalcemia* - Lungs of preterm infants are prone to injury from PPV --> *use CPAP* instead - If extremely low gestational age (< 27 weeks), *immediate intubation for administration of surfactant* - If *apneic* (20 second pause in breathing) - *Methylxanthines! (caffeine)* - Give *volume expanders* to minimize swings in BP

List and describe common problems in the newborn infant: NECROTIZING ENTEROCOLITIS

- *Intestinal mucosal injury* --> breakdown in mucosal lining and bacterial invasion → sick baby! - Symptoms: abdominal distention, bloody stool, diarrhea, lethargy, temp instability, and vomiting - *Get an xray!* - Treatment: gut rest, Parenteral feeding, IV fluids, antibiotics *Pneumotosis intestinalis* - air in the bowl wall - If free air is present --> surgical emergency!

Identify common congenital anomalies and birth traumas depicted in slides.

- Congenital Diaphragmatic Hernia - *intestine invades lung space* - Omphalocele - *intestines, stomach, & liver* come out of abdomen w/ umbilical cord (genetic) - Gastochisis - *intestines only* outside of the abdomen (non-genetic) - Omphalitis - umbilical infection - Umbilical hernia - not concerning; surgery if not resolved by age 5 - Club foot - treated easily with a hard cast that gradually alters angles - Sacral sinus(*hole down to spinal cord*) or dimple --> spinal defect - Hair tuft or pigmentation change --> spinal defect - *Erythema toxicum neonatorum - 30-40% of newborns* in 1st week (papules w/ eosinophils) - Transient pustular melanosis - 2% of infants (3 stages: pustules --> rash) - DON'T MISS THE HERP!!! *Amber pustules on erythematous base* - Caput succadaneum -*blood collects under skin* (squishy, spongy head) - Cephalhematoma - blood collects under periosteum & *WILL NOT cross suture lines* - *Scleral hemorrhages - common & benign* - Abnormal red reflex is concerning! (cataracts, glaucoma, retinal blastoma)

3. Understand pathophysiology, presentation and management of the following other congenital diseases: *hypothyroidism* It can be due to defects in the thyroid gland (*primary hypothyroidism*) or in the hypothalamus or pituitary (central hypothyroidism).

-Congenital hypothyroidism is included in the newborn screen (TSH and T4 levels) -Occurs in ~1 in 3000 live births *Pathophysiology* Usually caused by agenesis (absence of organ), aplasia (defective development or absence) or ectopia (malpositioning/failure of gland to migrate to anatomic location) of the thyroid gland *Presentation* -Not always present right at birth (even when thyroid is absent). -Thyroid testing is included in newborn screening (TSH elevated in primary hypo) -Clinical manifestations present over the first few days to months and include *hypothermia, respiratory distress, large fontanels, abdominal distention, lethargy, poor feeding, prolonged jaundice, edema, umbilical hernia, constipation, large tongue, dry skin, hoarse cry *Management* -If treatment with levothyroxine is initiated within 1 month or less after birth, prognosis for normal intellectual development is excellent.

Not an objective: Gastroesophageal Reflex (GER)

-Infants will "spit up" -> regurgitation without complications -Esophageal sphincter is immature -Can be assoc. with over-feeding, but is normal and happens to a lot -GER generally peaks at 4mo and resolves by 12mo (clinical presentation can vary by age) Treatment: Do not overfeed, burp often, positioning *See picture* for DDx of neonatal vomiting.

(ORC) but would recommend reading once

-Most commonly aspirated objects: seeds, nuts, popcorn; others are corn, hot dogs, small toys, balloons, jewelry. -Stridor is a high pitched breathing sound during inspiration from narrowing of the larynx or trachea (inspiratory stridor -> Laryngomalacia) -Wheezing is a high pitched musical sound made when air is forced through narrow airways (asthma) -Rule of 2's is used to assess asthma control via symptom frequency. Think frequency of symptoms, nighttime awakenings, short acting beta agonist use, and interference with normal activities. Categories include intermittent, mild persistent, moderate persistent, and severe persistent. -Specific medications for Asthma: *Bronchodilators*: albuterol, xopenex *Inhaled corticosteroids*: budesonide, fluticason, beclomethasone, mometasone *Long acting beta agonist steroid combos*: fluticasone/salmeterol (Adavair), budesonide/formoterol (symbicord) -Other therapies include leukotriene receptor antagonists, antihistamines -For ER/Hospital management, think beta agonists or IV corticosteroids, ipratropium bromide, magnesium sulfate, respiratory support (hypoxia), and IVFs -Bronchiolitis is MC caused by RSV but others include rhinovirus, parainfluenza, human metapneumovirus, influenza, adenovirus -RSV infection has been associated with apnea in patient less than 2 months of age -Patients may go on to develop bronchial hyperactivity -Florida State Newborn Screen: Florida currently screens for 36 conditions. Blood results for metabolic tests are usually red within 5 days after sample is collected (after 24 hours, few drops of blood are taken from heel stick) -Agitation and lethargy may be signs of impending respiratory failure. -meconium: dark green mucilaginous material in the intestine of the full-term fetus; this is the first type of feces passed by the newborn infant. -Most children are infected with rotavirus more than once, with the first infection being the most severe. Some protective immunity is imparted by the first infection. Prevention of infection occurs primarily by good hygiene and prevention of fecal-oral contamination. As treatment for rotavirus is nonspecific, prevention of illness is critical. The American Academy of Pediatrics issued guidelines in January 2007 recommending the routine use of bovine-based pentavalent rotavirus vaccine to be given orally to infants at 2, 4, and possibly 6 months of age, depending on which vaccine is used. ddx- norovirus, CMV

How to remember when kids should be able to draw what shapes (not an objective)

3 yoa Circle= pie is *3*.14. 4 yoa Square= Square has *4* sides 5 yoa Triangle= just remember it....

• Understand the components involved in pediatric history taking, physical exam (toddler, child and sports physical), and health supervision visits.

A COMPREHENSIVE EXAM INCLUDES: -Chief Complaint or parental/child concerns -Birth History -Development -Past Medical History -Immunizations -Surgeries/hospitalizations -Allergies -Medications -Social History -Family Medical History -Review of Systems -->*Let the child see and touch the exam tools you will be using* -->Demonstrate on self, parent or doll before using tools on child -->*Start with lungs, heart, belly—most invasive/painful last (example: ear exam)* -->Distract with toys or books SPORTS PHYSICAL INCLUDES: -*Identify medical problems with risks of life-threatening complications* (ex: past concussions, exertional syncope, family history of sudden death in young individuals) -*Identify pertinent medical conditions* (ex: hypertension, asthma, diabetes, allergies, seizures). Identify and treat conditions that could interfere with performance! -Identify and rehabilitate old musculoskeletal injuries -Look for asymmetry, pain with movement, and pain with restriction of movement. HEALTH SUPERVISION VISITS: -There is a guideline for how often to do your exams based on "Bright Futures" *Year 0-1* -Newborn -3-5 days -2-4 weeks -1 month -2 months -4 months -6 months -9 months *Year 1-2* -12 months -15 months -18 months *Year 2-3* -24 months -30 months *Year 3-21* -Yearly

Normal Weight Development in the Neonate

avg. full term neonate weighs 3.4 kg <2.5 kg newborns= low birth weight <37 wks= premie

Recognize the clinical manifestations, diagnosis and management of *acute otitis media. AOM*

Acute infection of the middle ear space associated with inflammation. Eustachian tube is more horizontal so fluid doesn't drain well. #1 reason abx prescribed in peds. *Clinical Manifestations* • Bulging tympanic membrane • Presence of middle ear effusion *Diagnosis* Defined as 1) moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea accompanied by 2) acute signs of illness and 3) signs or symptoms of middle ear inflammation • Acute onset of symptoms (<48 hours) -Ear holding, tugging, or rubbing -Intense erythema of the TM • Middle ear effusion must be present • Pneumatic Otoscopic findings: bulging TM, impaired visibility of ossicular landmarks, yellow or white effusion, opacified and inflamed eardrum, squamous exudate or bullae on eardrum, • Tympanometry... seems pretty mean. Get a good seal and puff air and see if the TM moves. *Management* • Amoxicillin 1st line <6 months old: immediate treatment with an appropriate antibiotic 6 months to 2 years: consider watchful waiting if unilateral and not severe; otherwise appropriate antibiotics >2 years with mild symptoms - can utilize watchful waiting >2 years with moderate or severe symptoms - immediate treatment (Not in our lecture- Augmentin 2nd line (no improvement in 48-72 hours) • Cephalosporin 3rd line (PCN allergy, only 10% overlap) • If vomiting and can't tolerate PO, IV Ceftriaxone x 3 days o 10 days for children with severe disease and all children < 2 years of age o 5-7 days for children > 6 years with mild to moderate disease o Exception: Ceftriaxone IM x3 days (Rocephin) Tylenol or Ibuprofen for pain control) *Chronic* If >3 months of AOM, begin to consider TM tubes. Especially if hearing loss is present.

List and describe the elements of the physical examination of the newborn.

CARDIOPULMONARY EXAM: - Symmetry - Retractions - *Nasal flaring* - Parasternal heave - *Expiratory grunting* - Hyaline Membrane Disease - Which side is the heart on? Note from book: *irregularly irregular heart rate*, due to premature atrial contractions, is *common and benign* and resolves. *2 most common neonatal heart problems*: 1. Cyanosis 2. CHF with abnormal pulses & perfusion ABDOMINAL EXAM: - Inspect - *Scaphoid abdomen + respiratory distress* --> *diaphragmatic hernia* - Listen to bowel sounds - Palpate for organs and masses MALE GENITOURINARY EXAM: - *Phimosis is normal*!!! - Do not retract the foreskin - Look for *epi/hypospadias - do not circumcise!* - Feel both testes(hydroceles, hernias, etc) - Look for ambiguous genitalia - Check anal for patency and placement FEMALE GENITOURINARY EXAM: - Large labia, hymenal tags, & vaginal discharge are common due to *maternal hormones* - Look for ambiguous genitalia - Check for anal patency and placement EXTREMITIES/SKELETAL EXAM: - Number and appearance of digits - *Extra digits - polydactyly* - *Webbed/fused digits - syndactyly* - *Mis-shapen digits - clinodactyly* - Single palmar creases (Down's Syndrome) - Range of motion, tone, asymmetry of limbs - Feel for clavicle fractures - Barlow and Ortaloni exam for hip dislocation/relocation (developmental dysplasia of the hips) *Barlow* - try to dislocate the hip (should not work) *Ortaloni* - relocate a dislocated hip SPINE EXAM: - Feel the vertebral column for bony defects - Examine sacral area for hairy tufts & pigmentation - Look for meningomyelocele, teratoma, sinus tract SKIN EXAM: - Bruising - Petechiae (common) - Meconium staining - *Mongolian spots* (black/blue stain - document!) - Jaundice (never normal in first 24 hours) - Generalized cyanosis --> immediate eval! HEENT EXAM: - Head circumference (average 34-35cm) - Observe ears: rotation, position, size - Nares patent bilaterally (close 1 nostril at a time) - Check for clefts (lip and palate - open mouth) - Neonatal teeth - Epstein pearls (benign cysts on gum margin) - Look for scleral hemorrhages, icterus, discharge(STIs), pupil size, EOMs, red reflex - Observe neck range of motion, goiter, cysts NEURO EXAM: - Symmetry of motion, tone and bulk of muscle - Response to stimulation, repetitive motions, palsies - Primitive Reflexes: Moro, suck, rooting, palmar/plantar grasp, stepping

Not an objective: Tracheomalacia

Poorly formed tracheal (cartilage) rings cause the airway to *collapse on expiration* -Can also be caused by damage to airway from prolonged intubation. -Patients have noisy breathing that can include stridor and sometimes a barking cough. -Symptoms are usually worse with infections -Most patients generally outgrow by 24 months -If narrowed by scarring, may need surgery

• Understand anticipatory guidance measures for discussion with parents in the prevention of drowning, fire and burn injuries.

DROWNING: -*2nd leading cause of injury related death in kids* -*1-3 yo have highest rate of drowning* *How does it happen?* -Younger than 1 = bathtub -1-4 yo = swimming pools -Kids/teens = large bodies of water -In the words of Jesse LeBaron, put a fence around your damn pool. FIRE/BURN: -*Leading cause of injury related death in homes* -Smoke inhalation, flame contact, scalding, electrical, chemical, UV burns -*Scalding is most common type (1/4 from tap water)* -Hot water max is 120 for kids -Use sunscreen, hats, sunglasses -*Don't use sunscreen in babies under 6 mo, use sun avoidance, appropriate clothing, hats*

List the various aspects of the new-born/neonatal exam, including Apgar scoring.

Delivery Room Exam: - look and listen to heart and lungs - inspection for congenital anomalies & trauma - look for cyanosis or pallor - examine umbilical cord (2 arteries + 1 vein) - this should be a quick exam b/c of infant stress Newborn Nursery Exam: - *LOOK - LISTEN - FEEL* - Observe --> Auscultate chest --> Palpate Abd - Eyes, ears, throat, and hips should be performed last --> ANGRY BABY Normal Vitals: - HR 120 - 160 bpm - RR 30 - 60 bpm - Systolic bp on day 1: 50 - 70 mmHg APGAR: (named for Dr. Apgar - SEE PIC) - Should be evaluated at *1 & 5 minutes* after birth - *Score < 7* at 5 minutes --> repeat at 10 minutes - Score < 7 at 10 minutes --> Send to NICU

Inborn errors of metabolism (objective is to understand concept)

Disorders in which single gene defects cause clinically significant blocks in metabolic pathways are called inborn errors of metabolism. Inborn errors should be suspected when *(1)* symptoms accompany changes in diet, *(2)* the child's development regresses, -Could be normal @ birth, but present ill w/i first 48hr. -Asx infants who become sick typically have met d/o assoc w/ intox effects -> organic acidemia, urea cycle defect -Lethargy, coma, seizures, changes in tone/reflexes, hepatosplenomegaly, dysmorphic features, cataracts *(3)* the child shows specific food preferences or aversions, (poor oral intake/vomiting) *(4)* the family has a history of parental consanguinity or problems suggestive of inborn error such as retardation or unexplained deaths in first- and second-degree relatives, hx of miscarriages (but most met dz are autosomal recessive, so typically no FHx is known)

• List and describe the clinical manifestations and diagnostic approach to a child of suspected physical abuse or neglect

FORMS OF MALTREATMENT: -Physical Abuse -Sexual Abuse -Emotional/Psychological Abuse -Physical Neglect -Emotional Neglect -Medical Neglect -Medical Child Abuse (formerly Munchausen Syndrome by Proxy) DIAGNOSING PHYSICAL ABUSE: -*The history is crucial in differentiating an abusive injury from an accidental injury* -Unexplained injury -Discrepant history -*Delay in seeking medical attention* -*Repeated suspicious injuries* -*Injuries that are developmentally inappropriate* RED FLAGS: -*No explanation or vague explanation for a significant injury OR history of injury is not plausible* -*Inconsistent or changing histories* -An explanation that is inconsistent with the pattern, age, or severity of the injury -An explanation that is inconsistent with the child's physical and/or developmental capabilities -*Different witnesses provide markedly different explanations for the injury* -*Suspicious Fractures: multiple, different ages, in non-ambulatory children*

Recognize the clinical manifestations, assessment, diagnosis and the management of disorders of the nose and sinuses to include viral rhinitis,* allergic rhinitis*, acute and chronic sinusitis, nasal infection and nasal trauma.

IgE mediated reactions to allergens in the nasal mucosa. Chronic disorder *Clinical Manifestations* Nasal itching, clear nasal discharge, sneezing, postnasal drip, congestion *Assessment/Diagnosis* - Allergic shiners, Dennie-Morgan lines, allergic salute, pale bluish/boggy nasal mucosa, nasal crease *Management* - *Intranasal - steroids GOLD* - cromolyn (mast cell stabilizier) - anticholinergics. - Oral - anti-leukotrienes - SIngulair - antihistamines - Benadryl, Claritin - Allergen immunotherapy

List and describe common problems in the newborn infant: HYPOGLYCEMIA

Infants are at increased risk for hypoglycemia if: - diabetic mother - intrauterine growth restriction Symptoms: - lethargy - poor feeding - irritability - tremors/jitters - apnea - seizures Most severe form --> *Hypoglycemia due to increased insulin* Treatment: *enteral or parenteral glucose*

Invasion of microorganisms into the lower dermis *Clinical Manifestations/Diagnosis* ○ Erythematous, hot, tender, ill-defined, edematous plaques ○ Accompanied by regional LAD ○ Group A B-hemolytic streptococci and coagulase- positive staphylococci→ most common causes ○ Staph infections are usually more localized, likely to have a purulent center ○ Strep spread more quickly ○ Entry site of prior trauma or infection is common *Treatment* ○ Pathogen appropriate systemic antibiotic

Describe the appropriate steps in the evaluation and management of neonatal jaundice.

Jaundice - Yellow discoloration of the skin due to an *increase of bilirubin* --> deposits in the tissues - 65% of newborns get jaundice *bilirubin >6* Pathophysiology - RBC death --> heme released --> bilirubin formed - Bilirubin binds to albumin in blood --> to liver - Excess bilirubin b/c of increased production or decreased excretion rate Evaluation Steps: - Feeding/elimination history - Birth weight and weight change since birth - Look for sources of excessive heme breakdown - *Blood type, Coombs test, CBC, albumin, and TSB* (total serum bili) - *G6PD test* if jaundice is otherwise unexplained - Fractionated bilirubin level Treatment: *Phototherapy* for indirect hyperbilirubinemia - converts bilirubin to water soluble stereoisomer that can be excreted in urine *Shield their eyes!*

5. Understand disorders of mucous clearance: *cystic fibrosis* and bronchiectasis.

MC life limiting genetic dz in whites *Pathophysiology* -*Autosomal recessive* disease caused by an alteration in the CFTR (CF transmembrane regulator) gene in chromosome 7 -Most common is a 3 base pair deletion called *delta F508* There's >15,000 mutations identified -> variable severity -Abnormal Cl and Na distribution across cell membranes in the epithelium -Problems occur most often in the lungs, digestive system and sweat glands. -Excessive reabsorption of sodium causing dehydrating of airway secretions -Most mortality is often caused by progressive lung dz (was initially failure to thrive). -Lungs become chronically infected with pseudomonas and staph. Inflammatory response causes plugging (atelectasis) *Diagnosis* -*Genetic testing* is available in utero and newborn screen w/ immunoreactive trypsin (IRT) -> a pancreatic enzyme -Positive screening -> confirmed with *sweat testing*(>60mmol/L), mutation analysis, or both (Sweat test is gold standard!! Always repeat to confirm!! ->) -Presence of a *meconium ileus* (15%) is the earliest sign of CF (no stooling within 24h after birth ->obstructive) This is virtually diagnostic -> tx and get sweat test. *Clinical Findings* -*Failure to thrive* (from pancreatic insufficiency (85%)-> poor digestion of fat/protein) despite good appetite, also reports of bulky foul-smelling, oily stools (malabsorption) -*Recurrent respiratory infections*: increased anterior-posterior chest diameter, clubbing of fingers (chronic infections -> progressive airway and lung destruction -> *bronchiectasis*) -*Nasal polyps* -*Rectal prolapse* *Treatment* -*Airway clearance therapy* or chest PT: "The vest", oscillatory positive expiratory pressure -Aggressive "abx therapy" for lung infections -*Respiratory treatments* can include recombinant DNAse, hypertonic saline and antibiotics -Treatment consists of high calorie, high protein and high fat diet and *pancreatic enzyme supplementation*(taken immediately prior to each meal and snacks) -Vitamin (A, D, E, and K) and salt supplementation (prevents hyponatremia) -*Anti-inflammatories* (azithromycin and ibuprophen) can slow the process -While life expectancy used to be late childhood, CF patients can be expected to live to early to mid-30s. (Book says 40) -Long term->Liver failure and ascites. Infertility in males. Decreased fertility in females. *New* Treatments -Improve function of defective CFTR protein -4% of CF have G551D mutation of the CFTR protein that does not allow adequate chloride flow through the channels in the cell membrance, *Ivacaftor*improves the protein function and allows for better Cl- flow, improved lung function and wt. gain. (Pt 6+y/o) -70-75% of CF patients have the Delta F508 mutation which has a problem with protein folding and channel gating activity. *Lumacaftor* partically corrects the misfolding and *Ivacaftor* improves the gating abnormality. (ORKAMBI is combination drug) ALSO- remember, autosomal recessive disorder means that if each parent is a carrier- the child has a 25% chance of being affected.

• Understand anticipatory guidance measures for discussion with parents in the prevention of motor vehicle, bicycle and firearm injuries.

MOTOR VEHICLE: -Primary cause of death in US (46% were unrestrained) -*All infants and toddlers should ride in rear facing car seat until 2 years* or until they reach weight/height limits for car seats -After 2 yo, they can ride in forward facing car seat w/ harness until they reach 4'9 and is between 8-12 yo -*All kids under 13 should ride in rear seats* BICYCLE: -Honestly? This is an objective? Wear a f*#$ing helmet FIREARM: -*A gun in home double likelihood of lethal suicide attempt* -Adolescents w/ history of depression or violence are at higher risk w/ gun in home -Lock up your guns. It's not rocket science people.

OJC other interesting information regarding vaccines and important websites

Measles is one of the most easily spread diseases in the world https://wwwnc.cdc.gov/travel https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html

List and describe the common problems in the newborn infant: BIRTH TRAUMA

Most common injuries: - soft tissue bruising - *fractures --> immobilization for 8-10 days* - cervical plexus palsy *MC C5-C6 --> Erb-Duchenne palsy* Other: - facial palsy --> usually resolves in a few weeks - *Subgaleal hemorrhage --> EMERGENCY!* -->replace blood and clotting factors

Recognize the clinical manifestations, assessment, diagnosis and the management of disorders of the nose and sinuses to include *viral rhinitis*, allergic rhinitis, acute and chronic sinusitis, nasal infection and nasal trauma.

Most common pediatric infectious disease *Clinical Manifestations* - Clear or mucoid rhinorrhea - Sneezing, congestion, sore throat - Possible fever *Assessment/Diagnosis* - Clinical signs and symptoms *Management* - Symptomatic control. - Acetaminophen or NSAIDs for fever and pain - Humidification, nasal saline drops.

Recognize the clinical manifestations, assessment, diagnosis and the management of *orbital cellulitis*.

NOTE: Preseptal cellulitis usually forms from exogenous source. The eyelids are painful, red and swollen and there can be a mild fever, but vision and eye movements are unchanged. If untreated, this can progress to orbital cellulitis, passing beyond the orbital septum. *Clinical Manifestations* ● Erythematous and edematous eyelids, pain, fever ● Decreased vision, restricted eye movements, afferent pupillary defect, pain with eye movement ● May see proptosis (protruding eye) *Assessment/Diagnosis* CT or MRI *Management* ● Systemic antibiotics ● May require surgical drainage in conjunction with antibiotics ● Drainage of infected sinuses

Define routine exam time points from birth to childhood.

Newborn, 2 wks, 1 mo., 2 mo., 4 mo., 6 mo., 9 mo., 12 mo., 15 mo., 18 mo.,2 yrs, 30 mo, 3 yrs., annual well-exams thereafter 9 mos, 18 mos, and 30 mos- do ASQ developmental screening 15 mos do MCHAT (autism screening)

5b. Understand disorders of mucous clearance: cystic fibrosis and *bronchiectasis*.

Not covered in lecture, from book: *Bronchiectasis* is the permanent dilation of bronchi resulting from airway obstruction by retained mucus secretions or inflammation in response to chronic or repeated infection. It occurs either as a consequence of a preceding illness (severe pneumonia or foreign body aspiration) or as a manifestation of an underlying systemic disorder (like CF) *Clinical Presentation* -Chronic cough, purulent sputum, fever, and weight loss. -Recurrent respiratory infections and dyspnea on exertion are also common. -On physical examination, finger clubbing may be seen. -Rales, *rhonchi*, *wheezes* and decreased air entry are often noted over the bronchiectatic areas. *Diagnosis* -High resolution CT -Bronchiectasis has numerous causes. The most common bacteria detected in cultures from the lower respiratory tract include S pneumoniae, S aureus, nontypeable H influenzae, and P aeruginosa. *Treatment* Aggressive antibiotic therapy during pulmonary exacerbations and routine airway clearance are mainstays of treatment.

List and describe common problems in the newborn infant: Respiratory Distress Syndrome

Note: *RDS = Hyaline Membrane Disease (HMD)* - Lungs lack surfactant (keeps the alveoli from collapsing) - Symptoms: hypoxemia, tachypnea, apnea, cyanosis Diagnosis: ABG (decreased aO2, low pH) and *ground glass on chest x-ray* Treatment: 1. *give surfactant* through endotracheal tube 2. breathing support- ventilator, O2, CPAP, ECMO For any infant respiratory problem, give oxygen! *Goal: O2 sat of 92-96%*

Estimate gestational age and fetal growth including assessment of fetal well-being.

Note: Newborn = first 28 days of life *Date of the last menstrual period* - best indicator of gestational age *Early fetal ultrasound* (within 12 weeks) provides supporting information - accurate within *6 days* Postnatal estimate - *Ballard method* - Assign points for neonatal physical characteristics - Assign points for neuromuscular signs - *Higher score = older gestational age* - Accurate within *~2 weeks* From the book: If physical examination indicates a gestational age within 2 weeks of that predicted by the obstetric dates (LMP), the gestational age is as assigned by the obstetric date. *AGA* - appropriate size for gestational age *SGA* - small for gestational age *IUGR* - intrauterine growth restriction (SGA) *LGA* - large for gestational age

Occurs deep in skin, at the bottom of the follicle or an apocrine gland *Clinical Manifestations/Diagnosis* ○ Erythematous, firm, acutely tender nodule with ill-defined borders ○ Staphylococci→ most common organism *Complications* - Cellulitis *Treatment* ○ I&D, may require adjuvant systemic antibiotics

Recognize the clinical manifestations, diagnosis and management of *mastoiditis*.

Suppurative infection of the mastoid air cells → destruction of the thin bony septae between air cells → the formation of abscess cavities and the dissection of pus into adjacent areas. Now not that common, but used to be 1 in 5 before abxs. *Clinical Manifestations* ● Ear pain, fever, postauricular tenderness, erythema, edema, fluctuance, displacement of the auricle ● Mastoid area appears indurated and red ● Severe tenderness of mastoid palpation ● Acute otitis media is almost always present ● Late finding → ear protrusion *Diagnosis* ● Clinical ● If imaging needed, CT scan *Management* ● IV antibiotics: Culture directed (taken after TM tube placement) ● If no improvement within 24-48 hours of IV antibiotics (needs to cross BBB) or abscess develops → surgery ● Tympanostomy tube insertion, I&D, myringotomy, mastoidectomy Image: erosion of the outer cortex of the mastoid

Recognize the clinical manifestations, diagnosis and management of *acute otitis externa. AOE*

Otitis externa (OE) is a cellulitis of the soft tissues of the EAC. Humidity, heat, and moisture and localized trauma contribute. *Clinical Manifestations* • Sx: acute onset of pain, aural fullness, decreased hearing, and sometimes itching in the ear. • Possible discharge (clear or purulent) • Symptoms tend to peak within 3 days *Diagnosis* • -Pain with manipulation of pinna or tragus • -Ear canal is swollen and narrowed (esp consider if you can't get the otoscope in the ear) • -Debris in the ear canal • Hard to see TM 2/2 canal edema *Management* • Most common organism: Staphylococcus aureus and Pseudomonas aeruginosa. • Pain control, removal of debris • Topical antimicrobial: 1st line FQ ear drops (Ciprodex) 7-10 days • If no systemic symptoms, eardrops only. No oral abx • Keep the ear dry, avoid swimming, if TM intact, use ethyl alcohol and white vinegar 1:1 mixture after swimming to keep the ear dry. (If TM intact) *IF EAR TOO SWOLLEN TO GET DROPS IN CANAL: Use an ear wick* (expandable tube sponge you thread into the hole, drops on one end come out the other end, will fall out on its own when swelling goes down) *Complication* • Untreated could lead to facial cellulitis • Immunocompromised can develop osteomyelitis in the skull base (life threatening emergency)

11. Understand pathophysiology, presentation, and management of common pediatric GI problems: GERD, pyloric stenosis, *constipation*, acute diarrhea, volvulus, intussusception, and Hirschsprung disease.

Pathophysiology *Presentation* -Children >4yo must have 2 or more of the following for 2 months: -->Less than 3 bowel movements per week -->More than 1 episode of encopresis per week (encopresis = fecal incontinence that occurs when impacted stool fills the colon and fluid leads out) -->Impaction of the rectum with stool -Passage of stool so large it obstructs the toilet -->Retentive posturing with fecal withholding -->Pain with defecation ^Children <4y/o must have 2 or more for at least 1 month. *Functional constipation* usually starts during toilet training when the child is unwilling to defecate on the toilet. Retained stool becomes large and painful to pass. This is *voluntary* withholding of stool. (Other causes: drugs, dietary, structural defects, smooth muscle dz...) *Warning signs*: onset at <1 month of age, delayed passage of meconium, family history of Hirschprung, ribbon stools, blood in stool, FTT, fever, bilious emesis, abnormal thyroid gland, severe abd distension, perianal fistual, abnormal position of anus, absent anal reflex, decreased lower extremity strength/reflex, tuft of hair on spine, sacral dimple, gluteal cleft deviation, anal scars, extreme fear during anal inspection *Prognosis/treatment* -Increase water intake and foods with fiber (bran, fruit, vegetables) -Toilet training/demystification -If dietary changes are ineffective, may try MiraLax (second line include lactulose, MOM and mineral oil) -Treat for at least 2 mo and until all sx have been resolved for at least 1 mo to allow bowel to return to normal -Tx should be decreased gradually -If encopresis recurs, may consider psych or emotion abuse -If persistent problem, consider referral to GI

Risks for Pre-term and Post-term infants

Pre-term infant (<37 weeks) Risks: - Resp. distress syndrome - surfactant deficiency - Necrotizing enterocolitis - Patent ductus arteriosis - Apnea - Hypoglycemia - Jaundice Post-term infant (>42 weeks) Risks: - Meconium aspiration (meconium = neonate poop) - Trisomies and other syndromes

• Identify and describe the laws and the reporting procedure pertaining to child abuse and neglect.

REPORTING: -Entry through Florida Abuse Hotline report (1-800-96-ABUSE) or law enforcement -*Child Protection Teams (CPT) provide medically lead multidisciplinary assessments for children suspected of being abused or neglected* -CPT services supplement the child protective investigation activities of DCF and LE *WHEN IS IT MANDATORY TO REPORT TO CPT:* -Injuries to the head, bruises to neck or head, burns, fractures in a child of any age -Bruises anywhere on a child < 5 years -Sexual abuse allegations -Any STI in a pre‐pubertal child -Malnutrition/FTT -Medical Neglect -Mental Injury -Siblings of a child dead in home or hospital or later died as a result of suspected abuse

Risks for LGA and SGA newborns

SGA (small for gestational age): *Symmetrical growth restriction* --> event of early pregnancy: - chromosomal abnormality - drug or alcohol use - congenital viral infections *Asymmetrical growth restriction* - brain growth has been spared - *better chance for normal growth/development LGA (large for gestational age): Increased risk of *birth trauma* LGA infants of diabetic mothers - increased risk of: - hypoglycemia - polycythemia - congenital anomalies - cardiomyopathy - hyperbilirubinemia - hypocalcemia

Assessment and Management of Developmental Delay

Screening Tools to be used at 9, 18, & 30 mos: Denver, Bayley, Ages and Stages Questionnaire (ASQ) <3 y/o: Early Intervention >3 y/o: VPK (early preschool) Individual Therapy: PT/OT/Speech Therapy

List and describe common problems in the newborn infant: DRUG ADDICTED

Symptoms: neonatal abstinence syndrome (NAS) - problems with feeding and sleep - fever - increased tone - tremors and seizures Supportive treatment: - swaddling the infant - quiet, dimly lit environment - minimize procedures and disturbances *Oral morphine or methadone* - common meds

2. Understand the concept of inborn errors of metabolism and specifically the clinical presentation, diagnosis, and management of the following specific disorder: *galactosemia* aka GALT

So, dietary lactose is broken down by lactase into glucose and galactose and then in a 3 step process, galactose is converted to glucose. This metabolic pathway is important for the newborn whose main carb source is lactose. -*Autosomal recessive* disorder of galactose metabolism, 1/50,000 live births in US *Clinical presentation* -Lethargy, poor feeding, jaundice, *cataracts* (w/i 2mo if not treated and usually reverse w/ tx), hepatomegaly -> after being fed milk -Infants may die in 1st week (book says month and often from E. Coli Sepsis) *Diagnosis* -Newborn screening measures GALT activity and/or Galactose and Galactose-1-phosphate (Florida just measures GALT) -Will have a false negative ONLY if baby is transfused before sample collected. -F/U testing for (+) screening: Urinary reducing substances (positive w/o galactosemia, negative if they switched to soy), whole blood or erythrocyte GALT activity and erythrocye red cell galactose-1-phosphate *Management* -Strict dietary lactose restriction, monitored by following galactose-1-phosphate levels in red blood cells (also give Ca+ replacement) -Goal is for therapy to be initiated within first few days after birth to have the best chance of precluding the development of speech and learning problems. -If unrecognized, this disorder can lead to early death or a chronic course characterized by cirrhosis, cataracts, seizures and mental retardation. -Long term prognosis (even with treatment): Mild growth failure, learning disabilities, ataxia, tremor and verbal dyspraxia -Ovarian failure, probable infertility in males

Recognize the clinical manifestations, assessment, diagnosis and the management of *Viral pharyngitis*.

Sore Throat *Clinical Manifestations* Conjunctivitis, hoarseness, symptoms of URI, anterior stomatitis, ulcerative lesions, viral rash and diarrhea *Assessment/Diagnosis* - *Infectious Mononucleosis*: Exudative tonsillitis, cervical adenitis, fever, splenomegaly, EBV. *Amoxicillin* is contraindicated, will often give the patient a *rash* (See photo) - *Herpangina*: Ulcers surrounded by halo in mouth, caused by Coxsackie A - *Hand, Foot, Mouth*: Ulcers in mouth, vesicles on palms soles, buttocks - *Pharyngoconjunctival Fever*: exudative tonsillitis, conjunctivitis, lymphadenopathy, fever *Management* Treatment → supportive

Recognize the clinical manifestations, assessment, diagnosis and the management of *Bacterial pharyngitis*.

Sore Throat *Clinical Manifestations* Sudden onset sore throat, fever, tender cervical adenopathy, palatal petechia, beefy-red uvula, and a tonsillar exudate suggests a streptococcal infection, headache, stomachache, N/V *Assessment/Diagnosis* -Diagnosis: throat culture or rapid antigen test *CENTOR Criteria* *C*ough absent *E*xudate on tonsils *N*odes *T*empurature *OR* old or young modifier *Management* -Penicillin V or Benzathine PCN, or Amoxicillin PCN allergy? → Cephalexin, Azithromycin, Clinda

• Understand the components involved in a comprehensive well child examination to include appropriate methods and indications for the measurement of blood pressure, pulse, respiratory rate and temperature in children age 2-20 years.

THE PEDS EXAM IS AGE BASED: -Newborn/Infant (0-12 months) -Early Childhood (1-4 yrs) -Middle Childhood (5-10 yrs) -Adolescent/Young Adult (11-21 yrs) Blood Pressure: *Begin at age 3 years in normotensive kids. Do several repeat measurements to insure accuracy.* Cuff width = 50-60% limb circumference *Diagnosis of HTN based on norms for age* Always take: *Pulse, respiratory rate, and temperature.* Vision Screen: *Yearly starting at age 3yrs.* Hearing Screen: *Yearly starting at age 3 yrs* WELL CHILD CHECK EXAMS: Undress for the exam & plot on growth charts 0-30 mos: *Temp, Wt (lbs/kg), Length (in/cm), Head Circumference* (in/cm) 3-21 yrs: *Temp, Wt (lbs/kg), Ht (inches/cm), BP, BMI*

Recognize the clinical manifestations, assessment, diagnosis and the management of *Acute sinusitis*.

Technically sinusitis is now called Rhinosinusitis because it also involves the nose. *Clinical Manifestations* Nasal congestion, nasal drainage, post-nasal drip, anosmia, HA, fever, facial pain/pressure, ear pressure *Assessment/Diagnosis* - URI symptoms are present 10+ days beyond onset, or symptoms worsen within 10 days after an initial period of treatment - Cold does not improve by 10-14 days and worsens after 5-7 days *Management* Amoxicillin: first line therapy - Augmentin for severe symptoms, in day care or recently on antibiotics - PCN allergic patients → cephalosporins - Macrolides → patients with an anaphylactic reaction to PCN - IV antibiotics are indicated if there is failure of improvement

List and describe the clinical manifestations, complications and treatment of common pediatric skin diseases, including *atopic dermatitis*.

The itch that rashes. Chronic relapsing inflammation of the skin due to faulty epidermal barrier (faults in Filaggrin gene) *Clinical Manifestations/Diagnosis* • Dry skin • Presence of eczema • Onset before 2 years of age *3 Phases:* 1. Infantile Eczema: cheeks and scalp first, then trunk and extremities. 2 m - 2 yrs 2. Childhood/Flexural eczema (1/3 progress): antecubital and popliteal fossae. 2yrs to adolescent 3. Adolescent eczema (1/3 progress): same as above, adds hand/foot dermatitis *Complications* - Cracks in barriers can become infected. S. Aureas or Strep or HSV (eczema herpeticum) *Treatment* *ACUTE:* wet dressings and topical corticosteroids *CHRONIC:* 1. Goal: avoid irritants and restore hydrations -Use mild soaps/shampoos, avoid rough clothing, limit baths and use warm (not hot) water, occlusive emollient should be applied just after bathing, wet dressings for flare ups MILD ● Topical steroids - low potency steroids twice a day < 2 weeks. Ex: Hydrocortisone, desonide MODERATE Medium potency topical steroids for moderated cases BID. Ex: Triamcinolone, mometasone **Only low potency steroids on face, axilla, groin, and intertriginous areas ONCE daily** MODERATE TO SEVERE ● Oral Antihistamines, especially with Atopic triad treatment (allergies, asthma, atopic dermatitis) ● Topical calcineurin inhibitors -Not for use in children < 2 years -Example: tacrolimus, pimecrolimus

• Understand anticipatory guidance measures for discussion with parents in the prevention of violence in infants and children.

There was one slide on this that was super vague. Im going to ask Mrs. Cole if this is important.

Describe the vision screening and evaluation in infants and children.

VISION: -*Beginning at birth and throughout childhood during well child visit* (from powerpoint) Usually start with red-reflex then get more comprehensive as the kid ages and can comply. -*Get ocular history at every visit!* -Amblyopia has a "window period" for treatment in early childhood. -*Amblyopia "lazy eye" can lead to functional blindness.* In the first 4 decades of life amblyopia causes more vision loss than all other ocular diseases combined! *Amblyopia*: Unilateral or bilateral decrease of visual acuity caused by form vision deprivation. When nerve pathways between the brain and an eye aren't properly stimulated, the brain favors the other eye. We can screen for this and fix this if we get this early enough. *Strabismus*: Ocular misalignment (Look at the picture for details) *Myopia*: Nearsightedness (Far away objects are blurry) Image is focused in front of the eye. *Hyperopia*: Farsightedness (nearby objects are blurry) Image is focused behind the eye. AAP STANDARDS FOR VISUAL ACUITY: (don't memorize) Birth (term): fixation, intermittent strabismus, visual acuity 20/400-600 One Month: horizontal following to midline, visual acuity 20/300 Two Months: improving alignment, visual acuity 20/200 Six months: visual acuity 20/30-40 20/20 for > 8 year old

• Describe the screening, primary prevention, and risk factors for iron deficiency anemia.

WHAT: -*Its the most common anemia and nutritional deficiency* -20% of children will have anemia (most common amongst toddlers) -*Most anemic children are asymptomatic* -*Adversely affects motor & cognitive development* SCREENING: -Age 6 months to 3 years (rapid growth & inadequate intake of dietary iron) -Premature, SGA, or infants with IUGR Infants fed cow's milk < 1 year (may result in GI blood loss) -Breastfed infants > 6 months not receiving iron rich foods -Children 1- 5 years who consume > 24 ounces of milk -*We also screen hemoglobin at 12 months* RISK FACTORS: -Children with special health needs (chronic infections or restricted diets) -2x higher risk among non-Hispanic blacks & Mexican-American (22%) females vs. white (10%) TREATMENT: -Prevent with adequate dietary means -*Iron dosing, (3-6 mg/kg of elemental iron)*

• Describe the screening, primary prevention, and risk factors for lead toxicity.

WHY WE DO IT: -Elevated BLLs in children are a major preventable health problem that *affects children's mental and physical health* -The higher a child's BLL and the longer it persists, the greater the chance that the child will be affected. -Elevated blood lead levels can result in learning disabilities, behavioral problems, mental retardation & at extremely high levels (70 µg/dL or higher), seizures, coma, and even death. PREVENTION: Keep your kids away from... -Lead paint -Lead in untreated water -Lead in soil -Glazed pottery (lead is everywhere, its an inescapable fate coming for us all) SCREENING: -*Lead screening at 6 months- 6 years* -*Perform testing at 1 and 2 years (targeted screening for older kids living in communities w/ high % of old housing, or high % of kids with elevated blood lead levels) *How do we screen* -Finger stick (capillary samples) -Venous blood lead is most accurate & should confirm level > 5 mcg/dL -Home inspection for persistent elevated levels 14 mcg/dL + evaluate cognitive development 45 mcg/dL + chelation of lead required High blood levels are > 70 mcg/dL = urgent!

• Describe the screening, evaluation and management of hyperlipidemia in infants and children.

WHY: -Risk factors for the development of atherosclerosis can be identified in childhood SCREENING: -All children screened for cholesterol at least once between ages 9 and 11 years, and again between ages 17 and 21 years. *No screening below 2 years of age* -2−10 years: Selective screening if: -->Family history (+) for early CVD -->Parent with known dyslipidemia -->Child with established Risk Factors -->Child with special risk condition *ALL children should receive cholesterol screening once between 9-11 and again between 17-21* -Non-fasting cholesterol & HDL can be initial screening test, abnormal results should be followed up with a fasting lipid profile -*Consider starting meds at age 10 for those who fail lifestyle changes (try for 6 months)* WHEN TO MANAGEME: -Severe dyslipdemia (LDL > 190 mg/dL), pharmacologic therapy should be considered -160 mg/dL + FH, consider pharmacotherapy -130 mg/dL + diabetes, consider pharmacotherapy

Outline the neurological evaluation and infantile reflexes (see charts Canvas/CMDT)

newborn movements are involuntary & purposeless (immature nervous system) & Primitive Reflexes are present but they should go away. If they persist, early indicator of neuro abnormality (i.e. CP) *reflexes:* 1. *moro*- stimulated by sudden neck extension the shoulders abduct and extend, fingers and elbows extend finally arms flex and adduct. *Stops at 4-6 mos.* 2. *startle*- same result as moro reflex by stimulus is sudden noise or clapping 3. *rooting*- aka the breastfeeding reflex, head turns to side of stimulus and move their mouth to search for nipple stimulated by touching their mouth. *stops at 4 months* 4. *positive supporting*- extension of legs to attempt to support their weight stimulated by light pressure on plantar surface.* stops at 3-5 months* when its . replaced by volitional weight bearing with support 5. *palmar grasp*- hands fist & fingers flex in response to touch on their palms. *stops at 5-6 months* 6. *plantar grasp*- flexion of all toes in response to pressure on sole distal to metatarsals. *stops at 12-14 months* with walking. 7. *asymmetric tonic neck*- extremities extend on face, side, flex on occiput side in response to head turning to site. *stops at 6-7 months* 8. *symmetric tonic neck*- arms flex and legs extend in response to neck flexion. arms extend, legs flex in response to neck extension. *stops at 6-7 months* 9. *automatic neonatal walking*- if you hold them up and touch their feet to ground, they try to start walking. *stops at 3-4 months* 10. *placement/placing*- extremities flex to get over obstacle in response to contact on dorsum of foot/hand. *stops before end of 1st yr.*

Know how to calculate pediatric doses for medications.

o Will have to calculate a dose Lb → Kg (2.2) o Example: Weight: 45 lb → ~20 kg Dose: 10 mg/kg/dose → 200 mg Suspension = 160 mg/ 5 mL Dose is 6.25 mL → round down to 6 mL o Calculated based on patient's weight in kg o Usually mg/kg/day or mg/kg/dose o Dosing should ALWAYS be written in mg o Be sure to check the max dose and always round down o Greater than 30kgs is entering adult dosing so double check. After 40kg is deff adult dose. o Mg → mL 5mL = 1 tsp 15 mL = 1 tbsp 30 mL = 1 oz

Know the three most common pathogens for otitis media and standard antibiotic therapy.

■*Bacterial:* Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis *Treatment*: ■ For pain: ibuprofen or acetaminophen ■ High dose amoxicillin: first line antibiotic ■ If child has taken amoxicillin within the last 30 days, give amoxicillin-clavulanate (augmentin) enhanced strength ■ Oral cephalosporins (cefuroxime, cefpodoxime, cefdinir): more B lactamase stable and a good alternative for children with allergies to amoxicillin ■ *Viral agents 45-70% of AOM;* (most common): RSV, rhinovirus, coronavirus, influenza, parainfluenza, adenovirus, enterovirus

Development- 5 years old

●Language-Tell age (can be "this many" fingers) knows 4 colors, complex sentences ●Personal-social ○Dresses and undresses without assistance, Prints a few letters ●Motor-Skips smoothly, alternating feet, stands on one foot for 10 seconds, catches bounced ball ●Fine motor - Copies *triangle*, draws recognizable person with body, head, etc. with 8 details, Counts 10 objects correctly ●Other-Knows right and left hand, Does simple chores at home ( taking out garbage, drying silverware), Good motor ability but little awareness of dangers (AKA stupid)

Development 6-7

●Language-approx 2560 words, fully intelligible 6-7 word sentences, defines word by function (use) or composition (eg chair to sit in); reads several one-syllable printed words ●Personal/social- ties shoelaces, differentiates morning and afternoon ●Motor-advanced throwing, stands on foot alternately (eyes closed), walks line backward heel to toe ●Adaptive- builds 3 steps w/ blocks, draws person w neck/hands/clothes, counts to 30, adds and subtracts within 5, copies diamond

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