Pediatric Primary Care PNCB 1

The mother of a 3 year old with a peanut allergy asks when he will outgrow the allergy. The BEST response is: "Most children with peanut allergy outgrow it." "Since it started at a young age he'll outgrow it soon." "About 20% of children outgrow an allergy to peanuts." "About 80% of children outgrow an allergy to peanuts by 5 years of age."

"About 20% of children outgrow an allergy to peanuts." The most common foods causing food allergy are milk, egg, peanut, wheat, soy, tree nuts, fish, and shellfish. The natural history of food allergy varies by the type of food and age of child. Of children who develop an allergy to cow's milk during the first year of life, 80% will outgrow the sensitivity by 5 years. Peanut, tree nuts, shellfish and fish allergies are less likely to remit with only about 20% of people reported to outgrow a peanut allergy.

When counseling parents whose children have had food-induced anaphylaxis, which teaching point is the MOST important? Children with asthma tend to have more severe food-induced allergic reactions. Exercise can be a co-factor in food induced anaphylaxis. The severity of previous reactions cannot predict the severity of future reactions. Timely administration of epinephrine is the standard of care.

- Timely administration of epinephrine is the standard of care. Parents should be aware of the fact that food-induced allergic reactions can occur during or soon after exercise, and food allergies and asthma often co-exist. Children with asthma tend to have more severe food-induced reactions and the intensity of previous allergic reactions to foods cannot predict the severity of subsequent reactions. Ultimately, in a child with a history of food-induced anaphylaxis, it is MOST important that parents understand that only epinephrine can stop a food-induced allergic reaction and it should be administered immediately when symptoms occur. Reinforcing that epinephrine should always be carried and immediately available is another important teaching point.

Which diagnostic study warrants the MOST attention when evaluating a child with autism? audiologic evaluation electroencephalogram state-mandated metabolic screening brain imaging

- audiologic evaluation While autism is a diagnosis based upon behavioral criteria reflected in screening tools, there is a remaining need to perform a medical evaluation for the presence of comorbid diagnoses. Communication difficulties are common in children with hearing impairment and children with autism. Deafness is part of the differential diagnosis of autism, and hearing impairment and autism may co-exist. Audiologic and speech evaluations provide baseline information important in developing a treatment plan. Although there is an increased incidence of epilepsy in children with autism, no benefit is derived from performing an EEG on children who do not have a history suggestive of seizures. Newborn metabolic screening programs test for some but not all metabolic diseases, and the diseases tested for vary by state. Cases may also be missed due to false-negatives or because a child is lost to the system. While metabolic testing is not recommended for all children with possible autism, it should be considered in children with a history or physical suggestive of metabolic disease. There is no evidence that brain imaging is of diagnostic value in identifying children with autism.

The MOST common presentation of mild fluorosis is gray discoloration of deciduous teeth. pitting of deciduous teeth. chalky white lines on permanent teeth. dark staining of permanent teeth.

- chalky white lines on permanent teeth. Fluoride prevents dental caries primarily through its topical effect on teeth, and secondarily by the incorporation of systemic fluoride into the enamel of developing teeth. Most children whose water supply is fluoridated require no additional dietary supplementation of fluoride. Breast fed infants generally require fluoride supplementation from 6 months of age until they are taking adequate amounts of fluoride in drinking water. The American Dental Association has developed an algorithm indicating recommended fluoride supplement dosing for infants and children with reference to the level of fluoride in the child's drinking water. Water may be analyzed by most local health departments for fluoride content. Fluoride is also ingested by children taking fluoride supplements, drinking some kinds of bottled waters and juices, and swallowing fluoride toothpaste. Excessive fluoride intake interferes with enamel formation, causing fluorosis. Mild fluorosis presents as chalky white lines on the cutting edges of front permanent teeth. More severe fluorosis causes dark staining and pitting of permanent teeth. Evidence of fluorosis is not usually seen in deciduous teeth. Graying of teeth is usually the result of antibiotic therapy such as tetracycline.

A 1 week old has a papular rash, with some clustered lesions, which was first noticed by the caregiver three days ago. A few areas are vesicular. The infant is otherwise healthy. What is the MOST likely diagnosis? neonatal pustular melanosis milia erythema toxicum neonatal acne

- erythema toxicum Erythema toxicum is a common condition in the newborn period which is described as a papular rash, often evolving into vesicles. It occurs in neonates in the first few days of life up to 2 - 3 weeks of age. Lesions may be clustered, and can recur, but do clear without intervention. Milia is a common lesion in newborns which involves white to yellow papules, usually on the upper body and face and can last for several months. Neonatal acne can be present at birth and involves open and closed comedones. Neonatal pustular melanosis is a rare condition, usually occurring in infants with darker skin tones and is a vesicular rash, involving 2 - 5 mm pustules with a hyperpigmented, nonerythematous base. All of these conditions require no treatment.

The Clinical Laboratory and Improvement Amendments (CLIA) of 1988 sets performance standards and: blood-borne pathogens protection HIPPA regulations licensing requirements Universal (Standard) Precautions

- licensing requirements The Clinical Laboratory and Improvement Amendments (CLIA) of 1988 set performance standards and licensing requirements for hospital and physician-office laboratories based on the complexity of the tests being performed. CLIA standards focus on personnel qualifications of laboratory staff, quality control, quality assurance, and proficiency testing. The primary purpose of the privacy section of HIPPA is to protect the rights of patients. HIPPA regulations define how providers must treat protected health information. The Occupational Safety and Health Administration is a division of the Department of Labor and regulates health and safety in the workplace. Medical offices are required to meet safety standards regarding Universal (Standard) precautions, blood-borne pathogens, and tuberculosis.

The late preterm infant has which of the following risks? excessive wakefulness poor sucking strength tachycardia colic

- poor sucking strength The term "late preterm birth" or "late preterm infant" includes infants born between 34 weeks and 36 6/7 weeks. This late preterm infant has few wakeful periods so time awake should be used for feeding. These infants can also have significant difficulty in developing a coordinated suck, swallow and breathing pattern. At birth, the late preterm infant has an increased potential to develop apnea, bradycardia, hypoglycemia, and sepsis. Infants in this gestational age group are not more likely to develop colic or have tachycardia.

The caregivers of an 18 month old are both overweight. When counseling them about prevention of overweight in their child, suggestions should include measurement of the BMI every 6 months. rewards of candy for playing actively. thirty minutes of structured play each day. stringent parental food controls.

- thirty minutes of structured play each day. Adopting an active lifestyle is as important as a healthy diet in prevention of childhood obesity. Toddlers should be encouraged to engage in at least 30 minutes of structured play and at least 60 minutes per day of unstructured play, preferably outside where play tends to be more physically active. The measurement of the BMI is preferred for children over two years of age. Parents and caregivers should avoid using candy or high fat food as rewards for good behavior. They should instead use stickers, verbal praise, or a fun activity. Stringent controls restricting access to high fat snacks or junk food promotes a child's attention to and intake of restricted foods when they become available, even if the child is not hungry.

Which of the following topical corticosteroids is MOST appropriate for treating an inflammatory rash on the face of a toddler? fluticasone 0.005 % ointment (Cutivate) hydrocortisone valerate 0.2% cream (Westcort) fluocinonide 0.05% gel (Lidex) triamcinolone acetonide 0.025% lotion (Kenalog)

- triamcinolone acetonide 0.025% lotion (Kenalog) When selecting topical steroid medications, practitioners need to be aware of the effect of the potency and vehicle selected on the site to be treated. Ointments are best used on scaly lesions. Creams also provide moisturizing effects and provide a more pleasing cosmetic effect. The scalp, face, and genital area are more absorbent of topical corticosteroids than other regions of the body so a lower potency treatment is preferred. Children are more susceptible to the adverse effects of topical steroids; therefore, a lower potency medication and shorter duration of treatment are warranted. High potency steroids such as fluocinonide 0.05% gel (Lidex) are not recommended for use on the face. Triamcinolone acetonide 0.025% lotion (Kenalog) is the lowest potency steroid listed and the most appropriate for use on the face of a child.

The child at highest risk for having an elevated blood lead level is a: 3 month old exclusively breastfed infant 6 month old who lives in a home built after 1970 2 year old with iron deficiency anemia 2 year old who is a picky eater D.

2 year old with iron deficiency anemia The amount of lead absorbed from the gut is increased in children with nutritional deficiencies such as iron deficiency anemia (IDA). Iron deficiency anemia is often a comorbidity of lead poisoning. The hand-to-mouth behavior of infants and young children increases their lead exposure. However, living in a home built after 1970 reduces the risk since residential paint used in that era should not have been lead based. Infants more than 4 months of age exclusively breast fed without supplemental iron are at increased risk of IDA. A child who is a picky eater may or may not be at high risk for IDA, depending on foods actually eaten.Which laboratory assessment is the BEST indicator of vitamin D deficiency?

Which laboratory assessment is the BEST indicator of vitamin D deficiency? 25(OH)-D (cholecalciferol) 1,25(OH)2-D (calcitriol) PTH (parathyroid hormone) 25(OH)-D (cholecalciferol)

25(OH)-D (cholecalciferol) The best diagnostic study of vitamin D deficiency is the level of 25(OH)-D (cholecalciferol). 1,25(OH)2-D (calcitriol) is the active metabolite of 25(OH)-D, but due to its short half-life it is not a good indicator of vitamin D sufficiency. The parathyroid hormone releases calcium from bone. Rachitic changes can be seen at growth plates and decreased calcification leads to thickening of the growth plate. Serum calcium and phosphorous are initial screening tests but not the best indicator of vitamin D deficiency.

A 10-month-old male is irritable and refuses to walk. Which of the following infant characteristics would prompt screening for rickets? breastfeeding with 17 oz formula intake per day African American ethnicity recent relocation from Texas to Wisconsin living below 40 degrees latitude

African American ethnicity Rickets is not a disease of the past nor is it limited to developing countries. Children of darker-skinned ethnicity are at increased risk for rickets as melanin decreases UV-B penetration, so they require longer exposure to sunlight to achieve adequate vitamin D levels. Dark-skinned infants who are exclusively breast fed and infants born to mothers who were vitamin D deficient through pregnancy are at higher risk for developing rickets. The American Academy of Pediatrics (AAP) recommends that breast fed infants receive 400 IU of vitamin D as a supplement until they are receiving at least 1000 mL/day of formula or milk. Although rickets may occur in children living at lower latitudes, it is more common in children in the northern United States, above 40 degrees latitude.

The caregiver of a 2 week old states that even though the infant was fed Enfamil LIPIL with iron in the hospital, he is now receiving ProSobee LIPIL formula due to a concern about allergies in an older child. Which is the BEST response? The infant should be switched back to the Enfamil because the ProSobee does not contain an adequate amount of iron. The infant should be maintained on Enfamil until there are obvious signs of allergy such as vomiting and bloody diarrhea. Both formulas contain equal amounts of nutrients including iron. Both formulas contain carbohydrates in the form of lactose.

Both formulas contain equal amounts of nutrients including iron. For the most part, formulas contain equal nutritional value as long as they are designated for infant feeding. The difference between ProSobee and Enfamil is in the carbohydrate content which is milk-based in the latter. ProSobee contains carbohydrates in the form of corn syrup solids instead of lactose, which is sometimes responsible for allergic type reactions, though rare in newborns.

Which test is the MOST sensitive EARLY indicator for musculoskeletal inflammatory disorders? complete blood count with differential (CBC) C-reactive protein (CRP) erythrocyte sedimentation rate (ESR) anti-nuclear antibodies (ANA)

C-reactive protein (CRP) The C-reactive protein (CRP) is an acute phase reactant serum protein which rises rapidly under an inflammatory stimulus. The ESR also documents inflammation and assists in following the course of some chronic rheumatic disorders. The ESR can be falsely low in some illnesses, and the results are affected by prolonged storage of the blood or tilting of the calibrated tube. The CRP has an advantage over the ESR in that it may be performed on freeze-dried specimens, and is most sensitive for early infections and inflammatory processes. The CBC with differential may indicate infection, but is not always elevated in the presence of inflammation. ANA is often present in individuals with pauciarticular disease and fairly common in late-onset rheumatoid disease, but is not an early indicator.

In a 2 month old with visible rib fractures on radiograph, the NEXT most critical evaluation to obtain is a: CT scan of the head long bone series coagulation profile retinal ophthalmologic exam

CT scan of the head Posterior rib fractures associated with accidental trauma are rare. Posterior fractures can be seen in infants who have been shaken as the perpetrator hands are typically wrapped around the infant's thorax during the shaking, with the vertebrae acting as a fulcrum. These findings should alert the provider to consider shaken baby syndrome (SBS). Subdural and subarachnoid hemorrhages are the most common acute intracranial injuries seen in SBS and are associated with high rates of morbidity and mortality. Thus, the most important study to do next is a CT scan. Studies have shown that nearly one third of confirmed abusive head trauma cases were missed on initial presentation, and many infants then sustain additional brain injury along with poorer neurologic outcomes because of the delay in diagnosis. Long bone studies will be needed as part of a thorough work-up of non-accidental trauma, but the skull would be the most critical area to image first. Coagulation studies are done to rule out any coagulation problem associated with injury to the brain and are important for medico-legal reasons, but again, brain studies take precedence. A thorough ophthalmologic exam is needed in suspected cases of SBS—preferably done by a pediatric ophthalmologist.

A 3 year old, who attends daycare, has diarrhea that began with three days of low grade fever and foul smelling watery stools. One month later, he continues to have loose stools and now has abdominal distention. The MOST probable causative organism is: rotavirus Shigella toxicum Giardia lamblia Staphylococcal enterococcus

Giardia lamblia Giardia lamblia is a flagellate protozoan found in contaminated water sources and food. It is the most common parasitic infection in the United States and is commonly transmitted in daycare centers. Symptoms can include abdominal cramps, flatulence, bloating, and watery, greasy foul smelling stools. A large majority of children remain asymptomatic or have intermittent symptoms. Stool culture will identify the organism and the treatment of choice is albendazole or metronidazole for 7 - 10 days.

A mildly ill 4 year old with a recent positive rapid strep test returns with abdominal pain and erythematous nonblanching lesions on the legs. What is the MOST likely diagnosis? scarlet fever Henoch-Schönlein purpura (HSP) systemic lupus erythematosus immune thrombocytopenia purpura

Henoch-Schönlein purpura (HSP) Henoch-Schönlein purpura (HSP) is the most common small vessel vasculitis found in young children. The triad of non-thrombocytopenic palpable purpura, colicky abdominal pain, and arthritis is the most common presentation. It appears more commonly in the spring and fall, and is seen more frequently in males ages two to seven. Group A streptococcus is a common trigger for the development of HSP. Gastrointestinal symptoms usually follow the rash and can range from a colicky abdominal pain to profuse bleeding or perforations. When the gastrointestinal symptoms occur first, the diagnosis of HSP can be missed. Signs and symptoms of scarlet fever include sore throat, with erythematous palate and uvula, palatial petechiae, and a fine, papular exanthema which begins in the axilla, groin and neck and spreads within twenty four hours. These lesions blanch with applied pressure. Systemic lupus erythematosus (SLE) is a chronic illness which involves many systems, but has different presentations. The rash is typically a malar or "butterfly" rash which usually begins on the face and extends to the chest and extremities. The rash of Immune thrombocytopenia purpura is petechial in nature and does not usually include fever as a symptom.

In addition to hypoglycemia, the MOST common complications found in infants born to mothers with diabetes or gestational diabetes include: LGA, neural tube defects, anemia, and renal vein thrombosis SGA, cardiomegaly, polycythemia, and hyperthermia LGA, cardiomegaly, renal vein thrombosis, and polycythemia SGA, hepatosplenomegaly, hypotonia, and anemia

LGA, cardiomegaly, renal vein thrombosis, and polycythemia Infants born to mothers with diabetes or gestational diabetes are generally large for gestational age (LGA) and predisposed to many anomalies and metabolic disorders related to diabetic control during the first trimester and throughout the pregnancy. Hypoglycemia develops in about 25 - 50% of these infants, with only a small percentage actually demonstrating symptoms of jitteriness, hyperexcitability and poor feeding. Cardiomegaly is common in infants of diabetic mothers, occurring about 30% of the time and associated with many different congenital anomalies including asymmetrical septal hypertrophy, subaortic stenosis, atrial septal defect, transposition, and others. Additional anomalies include neural tube defects, and defects of the GI tract and kidneys. These infants have a higher risk of tachypnea for many reasons, and an increased incidence of hyperbilirubinemia, renal vein thrombosis, and polycythemia.

Five weeks after joining the cross-country team, a 15 year old complains of pain in the front of his left shin that intensifies 15 minutes into each practice run. Plain radiographs of the left leg are normal. Which subsequent test would be MOST appropriate for diagnosis? bone scan MRI of left leg repeat plain films in 1 week repeat plain films in 2 weeks

MRI of left leg Tibial stress fractures are common in runners. An adolescent who complains of pain in the front of the shin which intensifies 15 minutes into running has symptoms consistent with an anterior tibial stress fracture. It is important to diagnosis this quickly and to make the appropriate orthopedic referral. A bone scan would be positive in this type of stress fracture, but it remains positive for the subsequent 1-2 years. Therefore, it is not useful for assessing healing or ability to return to play. MRI has replaced bone scans as the most sensitive tool for diagnosing stress fractures in long bones. Repeating plain films in 2 weeks can demonstrate periosteal reaction if a stress fracture is present. There is no reason to wait 1-2 weeks for a diagnosis and delay treatment.

The parents of a 2 year old are concerned that their child is having temper tantrums in public settings. Which is the BEST response? The temper tantrum is an indication that the child is tired and needs to go home. Make sure to ensure safety while ignoring the child's display of behavior. You can pick the child up and take him to a quiet place for a time out. In a public place, it is okay to give into the child's desires to maintain peace.

Make sure to ensure safety while ignoring the child's display of behavior. Temper tantrums are common in children between the ages of 12 months and four years of age and may occur as often as once a week in this age group. A temper tantrum is often the sign that a child is frustrated and trying to achieve autonomy, yet is still immature in the reactions to the outcome of the situation. Appropriate responses and interventions by the parents can assist the child in attaining developmental mastery. Some suggestions include trying to prevent a tantrum by offering the child achievable choices, maintaining an environment that provides positive reinforcement for desired behavior, and fighting only those battles which need to be won. If a child does exhibit a tantrum, provide a safe environment and do not over-react to the behavior. Stay nearby the child during the temper tantrum and provide positive reinforcement when the behavior improves. A two year old is too young to understand the ramifications of a time out, so removing the child from the scene may not be helpful. The child may need to be restrained if in danger from the environment, so holding the child may be appropriate. Giving in to the child reinforces the behavior, despite where the tantrum occurs.

A school-age child with 4 days of viral respiratory symptoms now has a fever of 103° F (39.4° C), tachypnea, decreased breath sounds to auscultation and a white blood cell count of 17,000/microliter. The MOST likely organism is: Streptococcus pneumoniae Group B streptococci Mycoplasma pneumoniae Pneumocystis carinii

Streptococcus pneumoniae Ninety percent of childhood bacterial pneumonia is caused by Strep pneumoniae. While Mycoplasma pneumoniae is also a common cause of pneumonia in school- age children, this scenario is suggestive of secondary bacterial infection following a viral infection. With bacterial pneumonia, a chest radiograph usually demonstrates lobar consolidation. Group B streptococci and Chlamydial pneumoniae are organisms more often associated with pneumonia affecting infants. Pneumocystis carinii occurs most often in immunocompromised individuals, not healthy school-age children.

Which scenario BEST represents an example of child ASSENT in health care research? a 5 year old who passively shrugs when asked for permission to participate in a clinical trial a 6 year old who is shown pictures of the research opportunity and agrees with a nodding of the head a 9 year old who verbally refuses then consents to participate the following day a 10 year old who is asked by the parents to participate and is silent when approached

a 9 year old who verbally refuses then consents to participate the following day Assent or the child's permission to participate is influenced not only by the child's chronological age but perceived developmental understanding. Thus, the capacity to engage in assent is best described as on a continuum, with a positive assent dependent upon the child's developmental level and capability. The younger child, due to developmental limitations, cannot be viewed as an independent decision maker despite informational methods used. Additionally, assent should be an affirmative choice and not simply silence or passive resignation. When seeking child assent, the child's choices should be taken seriously. Therefore, the child's dissent should also be respected.

A medical office that serves all pediatric age groups should keep medical records until the age of majority. a minimum of 7 years past the age of majority. until the patient is 21 years of age. for 1 year after the child is no longer a patient in that office.

a minimum of 7 years past the age of majority. Medical records should be kept in an office practice which has children as patients a minimum of 7 years past age of majority. Storage of the records is an issue especially for larger practices and those using paper charts. Optical scanners and electronic file cabinets can help handle storage issues.

Completion of drug screening on an adolescent at the request of a parent is considered a risk to the patient-practitioner relationship. a reliable method of determining recent use of a substance such as marijuana. an acceptable measure to assist with patient referral for therapy. unreliable because of the long half-life of most drugs of abuse.

a risk to the patient-practitioner relationship. Although practitioners should complete substance use screening at every adolescent well visit, performing drug screens at the request of parents should be avoided because of the risk of interference with a trusting patient-provider relationship. The testing of urine for drugs of abuse is not always reliable since the accuracy of results can be affected by factors such as the specific gravity and creatinine concentration of the urine. Except in the case of marijuana, most drugs of abuse also have relatively short half-lives, so urine testing only reflects use within the past 48 hours. Overall, laboratory testing should not be performed without the knowledge and consent of the competent adolescent.

An 11 year old presents with a 3 day history of a cough at night, tachypnea, and upper respiratory infection (URI) symptoms. Exam reveals loud inspiratory and expiratory wheezing. Which should be the FIRST course of action? administer inhaled albuterol oxygen by mask obtain a chest radiograph administer oral steroids

administer inhaled albuterol Coughing, wheezing, shortness of breath, and tachypnea, along with URI symptoms indicate a reactive airway process and a possible diagnosis of asthma. The first course of action should be to administer an albuterol nebulizer treatment to manage the airway. Steroids could be considered if wheezing persists after the albuterol therapy. Without signs of respiratory distress, oxygen is not required. A chest radiograph can be done after the albuterol treatment, if reactive airway problems or asthma is not thought to be the cause of the wheezing.

Which of the following is the foundation of treatment for cyclic vomiting syndrome? aggressive hydration biofeedback dietary management oral sumatriptan

aggressive hydration Cyclic vomiting syndrome (CVS) is characterized by recurrent episodic attacks of vomiting, and between episodes are periods that are completely symptom free. Attacks are associated with pallor, lethargy, abdominal pain, intense nausea, and unremitting vomiting. The mainstay of treatment for CVS is aggressive hydration, antiemetics, sedatives, and analgesics. Abortive therapy should be administered as early as possible. In children older than 12 years of age with infrequent and/or mild episodes, treatment with Triptans are one option. Sumatriptan administered intranasally at onset is contraindicated if a basilar artery migraine is present. Biofeedback and dietary management are important treatments for many types of migraine, but hydration remains the mainstay for CVS.

Which of the following statements regarding alternating doses of ibuprofen and acetaminophen for fever is MOST accurate? alternating drugs increases the risk of dosage errors and toxicity alternating allows for lower total dosage of both drugs alternating drugs results in more rapid resolution of the fever than using either drug alone is appropriate only for children over the age of six months

alternating drugs increases the risk of dosage errors and toxicity Alternating doses of ibuprofen and acetaminophen for fever is a common practice of parents. Despite the lack of data to support this practice and the potential for harm, some health care providers continue to endorse this practice for their patients. Both acetaminophen and ibuprofen do block prostaglandin synthesis and have the same efficacy. There is no evidence that alternating doses has an additive effect, allowing lower amounts to be given. There is also no data to support the belief that fever will be reduced more rapidly. The use of ibuprofen is generally not recommended for infants younger than 6 months; however there is also no evidence to support alternating drugs for any age group. Acetaminophen should be given no more than five times in a 24 hour period, and ibuprofen should be given only every six to eight hours. There is a serious risk of overmedication and possible toxicity with the practice of alternating these medications, and there have been no demonstrable benefits. Therefore, the practice should be discouraged.

The MOST APPROPRIATE management of an infant or young child with recurrent wheezing is montelukast (Singulair) budesonide (Pulmicort) ipratropium (Atrovent) albuterol (Proventil HFA

budesonide (Pulmicort) Studies have consistently demonstrated that inhaled corticosteroids are the preferred initial controller therapy for all infants and toddlers with persistent asthma. Montelukast, a leukotriene-modifying agent, has demonstrated some bronchopulmonary protection that is independent of concurrent steroid use. It may be a useful adjuvant to therapy for some young children with asthma, but it is not approved for use in children less than 12 months of age. Ipratropium provides additive benefit to short-acting beta agonists during moderate-to-severe asthma exacerbations, and is used most often in the emergency or inpatient setting. Ipratropium is not indicated for first-line or maintenance therapy. Inhaled bronchodilators do not alter the chronic course of this common pediatric illness.

While awaiting culture results, which of the following is the BEST empiric treatment for a febrile child with urine positive for nitrites and leukocytes in a geographical area with highly resistant E. coli? amoxicillin cefixime nitrofurantoin TMP/SMX

cefixime Early therapy for children with urinary tract infections (UTIs) is considered optimal for reducing illness severity, and the likelihood of long-term renal injury. Children with a urinalysis or microscopic urine evaluation suggesting UTI should be given empiric antibiotic therapy until culture results are available. Resistance to amoxicillin is approaching 35% and to TMP/SMX is approaching 20%. Cefixime is the recommended therapy unless resistance has been shown in the local community. Nitrofurantoin is not recommended for use in children with febrile evidence of UTI because it does not concentrate well in the kidneys.

Which is the MOST APPROPRIATE management for a 14-year-old sexually active adolescent who tests positive for Neisseria gonorrhea and Chlamydia trachomatis? azithromycin, 1 g orally, single dose ceftriaxone 250 mg IM, + azithromycin 1 g orally, single dose ofloxacin 400 mg orally, single dose, to both the adolescent and partner metronidazole 2 g, single dose and doxycycline 100 mg BID x 7 days

ceftriaxone 250 mg IM, + azithromycin 1 g orally, single dose Infection with N. gonorrhoeae is a major cause of pelvic inflammatory disease, ectopic pregnancy and infertility, and can facilitate HIV transmission. To treat uncomplicated genital gonorrheal infections, the most recent Centers for Disease Control and Prevention (CDC) update recommends a single IM injection of ceftriaxone plus azithromycin or doxycycline in specific doses. Because of a progressive rise in resistance to penicillin, tetracycline, and quinolones, the CDC advises against using these antibiotic classes to treat gonorrhea. To treat trichomoniasis, administer metronidazole (Flagyl) to both partners. Use a seven-day course of Flagyl to treat bacterial vaginosis (BV).

A 10 year old presents with a 0.2 - 0.3 inch swollen mass centrally located on his left upper eyelid. There is mild erythema and no pain. The MOST likely diagnosis is: external hordeolum coloboma of the eyelid blepharitis chalazion

chalazion A chalazion is a chronic, sterile, granulomatous inflammation around the meibomian gland. It is usually centrally located along the lid. Although an internal hordeolum (stye) may be located in the same area of the eyelid, clinical findings of the hordeolum include a tender, swollen red furuncle. In contrast, the course of a chalazion includes mild erythema and slight swelling of the lid. After a few days, the inflammation resolves and a painless mass remains. An external hordeolum or stye is found closer to the lid margin. A coloboma of the eyelid is a cleft-like deformity of the eyelid, not a mass. Blepharitis is inflammation of the eyelid margins, and does not present with a mass.

A child weighing 45 kg has a positive rapid strep test and is started on amoxicillin. Two days later the mother calls and reports the child has developed an itchy, raised rash over his trunk, but no other symptoms. Which of the following is the BEST management strategy? change to minocycline 75 mg twice daily for 10 days with meals acknowledge penicillin allergy and add an antihistamine to the current regimen continue the amoxicillin as the rash is a response to a toxin from the strep bacteria change to clindamycin 300 mg every 8 hours for the next 8-10 days

change to clindamycin 300 mg every 8 hours for the next 8-10 days The itchy, raised rash suggests the child may have an allergic sensitivity to penicillin. For penicillin-allergic individuals, acceptable alternatives include a narrow-spectrum oral cephalosporin, oral clindamycin, or various oral macrolides or azalides. Minocycline is used to treat susceptible gram negative and gram positive infections involving the respiratory or urinary tracts in children over 8 years of age. The oral formulation of clindamycin is prepared as 75 mg/5 ml, and the recommended dose for children with streptococcal pharyngitis is 20 mg/kg/day divided every 8 hours.

A 6 day old presents with tachypnea, grunting, tachycardia and hepatomegaly. Which of the following conditions is MOST likely the cause? coarctation of the aorta hypertrophic subaortic stenosis large atrial septal defect small ventricular septal defect

coarctation of the aorta Coarctation of the aorta may cause heart failure in the first post-natal week as the patent ductus arteriosus closes. A large atrial septal defect causes right-sided volume loading. However, the compliant right ventricle accepts large volumes. The maladaptive cardiac hypertrophy from volume overload leading to heart failure develops only after several years. Hypertrophic subaortic stenosis is seldom associated with pediatric heart failure. Large ventricular septal defects (not usually small ones) can cause cardiac failure in infants.

Watching infant TV shows or videos before 3 years of age has been associated with advanced neurological development. cognitive problems at school. increased language skills. obesity in toddlerhood.

cognitive problems at school. Watching TV before the age of 3 years is associated with attention and cognitive problems at school, as well as delayed language acquisition. Increased television watching has been implicated in increased caloric intake in children, and there is no evidence that advanced neurological development occurs as a result of watching television or videos.

A nurse practitioner is considering a position with a pediatric pulmonologist in a clinic which specializes in the treatment of cystic fibrosis. There are patients in the practice who are over the age 21. Which would be the BEST action to take? decline the job offer for one in which only pediatric patients will be seen contact the state board of nursing regarding regulations related to patient populations agree to take the job since cystic fibrosis is a pediatric illness regardless of the patient's chronological age contact the certification agency to determine their rulings regarding patients over the age of 21

contact the state board of nursing regarding regulations related to patient populations Pediatric nurse practitioners (PNP) must base practice decisions on national and state legislation, which is usually guided by recommendations from organizations such as the American Academy of Pediatrics (AAP) and the National Association of Pediatric Nurse Practitioners (NAPNAP). Practice standards and competencies exist for this purpose. Ultimately, though, individual states determine licensure regulations and the PNP must be familiar with these rulings in order to practice under a state's jurisdiction. Most states require some type of physician collaborative agreement which can spell out specifics such as the age of patients being seen. The AAP and NAPNAP both offer support in the care of older patients with specific pediatric problems. Before taking any position, it is important for the PNP to examine state guidelines and be familiar with practice recommendations from all recognized organizations.

Which of the following BEST demonstrates the oral behavior of a 12 month old in relation to readiness for feeding? begins chewing meat with rotary mouth movements controls bite of soft cookie controls liquid taken from cup sucks in anticipation of the spoon

controls bite of soft cookie Oral development progresses for both eating and language. Between ages 4 and 6 months children begin sucking movements in anticipation of the spoon. Children between 10 and 12 months of age can control bites of soft cookie, and begin to use rotary chewing movements, but have not accomplished this task with meat. By ages 16-18 months the mouth is able to control liquid taken from a cup, and by 19-24 months the child can chew meat with rotary movements.

Which is the INITIAL approach for a healthy 5 year old with a BMI of 30 and a fasting low density lipoprotein (LDL) of 120 mg/dL? counseling regarding nutrition and physical exercise obtaining annual blood pressure measurements obtaining biannual fasting lipid profiles prescribing a bile acid sequestrant

counseling regarding nutrition and physical exercise This child's BMI of 30 equates to a body mass index-for-age percentile of greater than 95%. The most appropriate approach for a child who is obese and has a borderline elevated LDL level is to encourage a healthy diet and increased physical exercise. A bile sequestrant, such as cholestyramine, is associated with poor compliance due to palatability and GI complaints. Fasting lipid profile screening and blood pressure measurement should occur in the context of annual well-child and health maintenance visits.

The purpose of administering acidophilus while taking antibiotics is to decrease pH in the gastrointestinal tract. enhance the absorption of the antibiotic in the colon. treat diarrheal illnesses caused by Clostridium difficile. decrease diarrhea by adding additional fiber.

decrease pH in the gastrointestinal tract. Lactobacillus acidophilus is often recommended for children on long term antibiotic therapy. It is a probiotic, found in yogurt and manufactured as a supplement, which assists in re-establishing the acidic environment in the gastrointestinal tract, thereby reducing the production of bacteria, fungus, or yeasts. It is helpful in the treatment or prevention of antibiotic-induced diarrhea and vaginal or diaper candidal infections. While it does not destroy bacteria, such as Clostridium difficile, it creates an unfavorable environment for continued growth of the bacteria.

Caregivers have been giving dextromethorphan at night to a 3 year old with a three day history of upper respiratory illness. Which of the following is the BEST advice? add a decongestant during the day discontinue the antitussive medication add an antihistamine to improve symptoms continue the dextromethorphan at night

discontinue the antitussive medication Parents and caregivers should be advised that the use of decongestants, antihistamines, and cough medicine is not indicated for children younger than 4 years old, and should be used with caution in children younger than 6 years old. The child should receive symptomatic relief for fever, pain, and nasal congestion using an antipyretic and normal saline.

It is important to address and provide adequate control for ADHD symptoms in adolescence, especially when the adolescent is: dating engaged in advanced placement courses driving involved in competitive sports

driving The 2011 Clinical Practice Guideline for ADHD in children and adolescents, published by the American Academy of Pediatrics, updates two previous guidelines from 2000 and 2001. One area of particular note in the update is an expanded age range to include both preschool-age children and adolescents. Clinicians prescribing medication for adolescents with ADHD should assess for symptoms of substance abuse, and also prescribe medication with the assent of the adolescent. When young children are diagnosed with attention deficit / hyperactivity disorder (ADHD), the primary concern is often academic success. However, those concerns are compounded with safety risks as the adolescent with ADHD begins to become more independent. In addition to the inherent risks of driving, there is also an increased risk of distractibility in an adolescent with untreated ADHD which could lead to motor vehicle collisions. Special concern should be taken to provide medication coverage for symptom control while driving. Longer acting medications or short acting medications taken in the late afternoon might be helpful.

In addition to a developmental evaluation, which baseline studies should be included for an infant diagnosed with 22q11 deletion syndrome? echocardiogram, thyroid function, and renal ultrasound calcium levels, abdominal ultrasound, and immunologic screening echocardiogram, renal ultrasound, and immunologic screening thyroid function, calcium levels, and abdominal ultrasound

echocardiogram, renal ultrasound, and immunologic screening The 22q11 deletion syndrome, also known as DiGeorge syndrome or thymic hypoplasia, is one of the most common genetic syndromes affecting 1 in 4000 infants. The most prevalent clinical findings include congenital heart defects, usually tetralogy of Fallot or truncal defects, characteristic facial features, especially palatal abnormalities, immune deficiencies, hypocalcemia, speech and developmental delays, feeding problems, and renal anomalies. Development and speech are major concerns in children with 22q11 deletion, so early intervention is extremely important. Baseline screening should include echocardiography, renal ultrasound, and immunologic evaluation, including T and B cell flow cytometry and quantitative IG and calcium levels. Abdominal ultrasound is not indicated and hypocalcemia is the result of hypoparathyroidism, not hypothyroidism, so thyroid levels are not indicated initially.

A toddler is unable to use the right arm normally after the caregiver pulled her arm to prevent the child from falling. Which finding would confirm the diagnosis of subluxation of the radial head? severe swelling and bruising of the elbow elbow flexed with pronated forearm point tenderness at ulnar aspect of elbow obvious deformity of the forearm

elbow flexed with pronated forearm Subluxation of the radial head, also called nursemaid's elbow, must be differentiated from a fracture prior to reducing the annular ligament of the elbow. Radiographic examination is not necessary if the child's physical findings and history are consistent with subluxation. The typical presentation of this injury includes the following: age 2-5 years; history of a longitudinal traction injury, possible "pop" and immediate pain, inability to use the arm normally, and arm splinted against the side. On examination the elbow appears normal, is flexed with a pronated forearm against the body, is tender laterally over the radial head, and has limited flexion with no supination. If the child fell on his/her elbow or there is no history of a traction injury, suspect a fracture and order the appropriate radiograp

The MOST common barrier related to transitioning health care for an adolescent with special needs or chronic illness is finding an adult health care provider for transition. resistance of the family and adolescent to transition of care. lack of health care provider time to plan for transition of care. difficulty in talking with patients about transitioning care.

finding an adult health care provider for transition. Finding an adult health care provider, one who is qualified to care for young adults with special health care needs, is the most commonly perceived barrier to the successful transition of health care as identified by family and young adults, pediatric health care providers, and adult internists. Transitioning of care requires time and communication with the parents and adolescents involved. Many families may be hesitant to leave the nurturing environment of pediatric care, and may perceive differences in adult practices as a difficult adjustment. Internists may lack the training and qualifications to address many of the complicated health care needs of adolescents with chronic illnesses. Because of the delicate nature of such conversations, some pediatric providers may not be comfortable in dealing with the complexities of transitioning care.

A 5 year old complains of a painful left eye after being accidentally scratched by a sibling two hours ago. Fluorescein exam shows a small central corneal abrasion. The MOST appropriate management during the first 24 hours is frequent application of topical antibiotic. observation of the injured eye. frequent application of topical nonsteroidal anti-inflammatory drops. occlusive patching of the injured eye.

frequent application of topical antibiotic. Accidental abrasion of the corneal epithelium causes pain, tearing, and photophobia and is a common eye injury in children. An abrasion can be detected by examining the eye with a Wood's lamp after instillation of fluorescein dye. The one time use of a topical ophthalmic anesthetic may be useful in gaining cooperation for an adequate eye exam. The goal of treatment is rapid healing of the abrasion. Until such healing occurs, the eye should be protected from infection by the use of a topical ophthalmic antibiotic every 4-6 hours for a few days. The repeated use of a topical anesthetic is not recommended, as these medications can cause corneal toxicity and inhibit the blinking reflex. Topical steroids are not recommended as they lower the eye's resistance to infection. Oral acetaminophen or ibuprofen and intermittent cool compresses may manage discomfort. Narcotics are not recommended because of frequent side effects. The use of topical nonsteroidal anti-inflammatory drops is being studied in the treatment of some sterile corneal abrasions, such as those acquired during laser treatment of refractive errors in adults, but are not recommended in management of traumatic corneal abrasions in children. Patching is no longer recommended for most corneal abrasions, as it does not reduce discomfort or speed healing and makes instillation of antibiotic medication more difficult. Most corneal abrasions heal steadily over the first 24-48 hours. Persistent or increasing pain or discomfort after the first 24 hours indicates the need for further ophthalmologic evaluation.

A school-age male athlete presents with a recurrent episode of hematuria. A urinalysis shows: nitrite and leukocyte esterase negative; greater than 50 RBC per high power field; and protein greater than 100 mg/L. The MOST likely diagnosis is: myoglobinuria glomerulonephritis drug/medication use urinary tract infection

glomerulonephritis Glomerulonephritis is a noninfectious process characterized by findings of hematuria and proteinuria. Myoglobinuria is ruled out by the number of red blood cells present, and the negative nitrite and leukocyte esterase make a urinary tract infection unlikely. Although drug/medication use can discolor urine, the findings of blood and protein in the urinalysis suggest another etiology.

Which of the following signs or symptoms is MOST often associated with anorexia nervosa? salivary gland enlargement hypothermia hypertension elevated erythrocyte sedimentation rate

hypothermia Disordered or dysfunctional eating occurs along a spectrum. Both anorexia nervosa and bulimia nervosa are characterized by a distortion of body perception, often accompanied by depression. Anorexia nervosa's physical signs and symptoms are related to chronic malnutrition; hence amenorrhea, hypothermia, hypotension, and bradycardia are often seen. Bulimia nervosa involves episodes of binge eating and compensatory behavior to prevent weight gain, often purging. If the purging behavior is vomiting, salivary gland enlargement can be present.

Which is the BEST initial treatment for a 10 year old who presents with a six month history of headaches twice a month described as frontal, pounding, lasting for most of the day, and accompanied by nausea and light sensitivity? diphenhydramine (Benadryl) ibuprofen (Advil) promethazine (Phenergan) sumatriptan (Imitrex)

ibuprofen (Advil) Migraine without aura is the most common form of migraine headache in children. It is characterized as intense frontal or temporal headache lasting from 1 to 48 hours, accompanied by nausea, vomiting, and sensitivity to light and sound. Acetaminophen has faster onset of action than ibuprofen, but ibuprofen has shown greater headache resolution. Sumatriptan is approved for use in adolescents. Daily antidepressants such as amitriptyline are widely used in preventive treatment in migraine management. Promethazine has indications as an adjunct medication for postoperative nausea and vomiting in children older than 2 years.

Which of the following activities would be beneficial to a child with stage 1 hypertension? inline skating rock wall climbing weight lifting horseback riding

inline skating All children and adolescents should be encouraged to participate in regular exercise because of its cardiovascular, pulmonary, and weight maintenance or reduction benefits. In children with hypertension, regular exercise has been shown to reduce both systolic and diastolic pressure. Those with stage 1 hypertension are encouraged to participate in most types of exercise, but caution is needed when recommending exercise to those with stage 2 hypertension until blood pressure is normalized. Exercise with the lowest cardiac demand would be horseback riding, weight lifting, and rock wall climbing. The highest cardiac demand exercise is skating. Aerobic exercises are also beneficial in reducing blood pressure. Isometric activity is associated with increased blood pressure. Among the listed activities skating is the only aerobic activity.

Which annual testing is recommended for an adolescent with Turner syndrome? CBC, serum glucose, celiac panel celiac panel, CBC, thyroid function CBC, celiac panel, metabolic panel lipid profile, serum glucose, thyroid function

lipid profile, serum glucose, thyroid function Among females with Turner syndrome, there is a high level of undiagnosed lipid and thyroid abnormalities. Glucose intolerance is common, and hypothyroidism occurs frequently in children with Turner syndrome. Therefore, clinical guidelines endorsed by the American Academy of Pediatrics (AAP) include annual fasting lipids and blood glucose, as well as liver and thyroid function tests. Screening for celiac disease is recommended every 2- 5 years in school-age children and only as needed for children older than 10 years if indicated clinically. Renal function, metabolic profile, and cardiology evaluation should be obtained at diagnosis. ENT and audiology assessments should also be done every 1-5 years.

Which clinical or diagnostic finding is MOST significant for pertussis in an adolescent? hyperinflation on chest radiograph persistent night-time cough lymphocytosis on CBC productive cough

lymphocytosis on CBC Pertussis should be considered when the CBC shows extreme lymphocytosis, especially in adolescence since there is waning immunity from childhood vaccines. The cough associated with pertussis in adolescence may not be the typical pertussis, like the cough of younger children, and is not limited to night time occurrence. Hyperinflation on chest radiograph is usually indicative of air trapping as occurs in asthma. To formally diagnose pertussis, PCR detection has replaced culture because of cost, improved sensitivity, and the decreased time to diagnosis.

Which of the following has been identified as a potential cause of bowel perforation if ingested? jewelry beads latex balloons magnets marbles

magnets Ingestion of magnets poses a danger to children, and the number of magnets is thought to be critical. If a single magnet is ingested there is less likelihood of complications. If more than 2 magnets are ingested the magnetic poles are attracted to each other across the bowel wall which cause obstruction, leading to necrosis and intestinal perforation. Latex balloons, marbles and jewelry beads pose choking risks to children.

With which of the following situations in the emergency department would the use of small, titrated doses of narcotics be CONTRAINDICATED? migraine headache minor laceration requiring sutures multisystem trauma suspected appendicitis

minor laceration requiring sutures The pain from minor injuries requiring sutures can usually be controlled with topical anesthetics and distraction techniques such as parental presence and child-life interventions. Although a general belief that giving narcotics to patients with abdominal pain or trauma will hinder the evaluation, several studies have indicated that narcotics do not hinder evaluation. Therefore, the use of small, titrated doses of narcotics is reasonable in these situations.

Which of the following is a protective factor against early childhood caries? breastfeeding to one year living in rural area pacifier use mom's healthy teeth

mom's healthy teeth It is important for health care providers to screen and identify risk factors for the development of dental caries in children. While breastfeeding provides optimal nutrition, breast milk contains sugars that can cause caries in young children if proper dental hygiene is not provided. Fluoride in drinking water is not widely available in rural areas, so fluoride supplementation is important in this population. Pacifier use has not been found to prevent or cause caries. A mother's healthy teeth is a protective factor since she is less likely to harbor the bacteria in her mouth that causes caries and will then be less likely to colonize her baby's mouth.

The MOST common hematological presentation of leukemia in children is anemia accompanied by: neutropenia and thrombocytopenia leukocytosis and monocytosis neutropenia and blast cells on peripheral smear monocytosis and blast cells on peripheral smear

neutropenia and thrombocytopenia The most common hematological presentation for childhood leukemia is neutropenia, anemia, and thrombocytopenia. The triad of leukocytosis, anemia, and hepatomegaly is seen in about 20% of children with high risk acute lymphocytic leukemia (ALL) and can be misdiagnosed as infectious mononucleosis, due to the circulating atypical lymphocytes which can appear very similar to leukemic blast cells. If the white blood cell count is not elevated, blast cells are commonly absent on the peripheral smear.

Parents complain that their child awakens crying and agitated during the last half of night sleep. The child is awake and can be comforted. The parent denies other behaviors. This child is experiencing: sleep terrors nightmares somniloquy sleep starts

nightmares Nightmares typically occur during rapid eye movement (REM) sleep in the latter half to one third of the nighttime sleep cycle. In the event of a nightmare, the child is fully awake and responds to parental or caregiver comforting measures. Night terrors or sleep terrors occur in the first portion of sleep and are manifested by abrupt partial awakenings accompanied by a blood curdling scream, characterized by intense autonomic symptoms such as pupillary dilation, diaphoresis, and tachypnea. With sleep terrors the child cannot be fully aroused or comforted by parental presence. Sleep starts and somniloquy are sleep-wake transition disorders typically occurring during the time of transition from wakefulness to sleeping and vice versa. Sleeps starts are characteristically sudden, muscular jerking of the arms and legs. Somniloquy or sleep talking is common during childhood and associated with sleep terrors. Vocalizations and bodily movements are rare with nightmares.

Education for caregivers whose child has sickle cell disease should include that the majority of pain crises are triggered by which of the following? no identifying cause temperature changes cigarette smoke exposure stressful situations

no identifying cause Sickle cell disease is a common genetic hematologic disorder. Pain is the most common and disabling symptom of sickle cell disease. Environmental temperature and second-hand smoke exposure have been studied as possible precipitating factors, but have not been supported by the research. Negative emotions can facilitate the pain cycle. In general, pain episodes are erratic and unpredictable and occur for various, unknown reasons.

A 6 month old has an excoriated, erythematous rash in the diaper area with pinpoint satellite lesions. Which topical treatment would be MOST appropriate? nystatin ointment 1% hydrocortisone cream mupirocin ointment tacrolimus cream

nystatin ointment Diaper rash consisting of sharply defined erythematous patches with satellite lesions or pustules is consistent with Candida albicans diaper dermatitis. This is best treated with an antifungal topical agent such as nystatin, miconazole, clotrimazole, or ketoconazole. Hydrocortisone may assist in decreasing the inflammation, but is not a treatment. Since this is a fungal rash, mupirocin would not be effective since it is an antibacterial. Tacrolimus is limited to use as a second-line agent for short term and intermittent treatment of moderate to severe atopic dermatitis for non-immunocompromised patients.

An adolescent presents with an infected pierced naval, revealing moderate swelling, erythema, and exudate. The piercing, kept open with a gold ring, is one month old, and has been maintained with antibacterial soap and water cleansing. The adolescent reports swimming in a lake one week ago. Which of the following is the MOST appropriate? removal of jewelry from naval oral antibiotic therapy topical therapy cleansing with peroxide

oral antibiotic therapy Infections are one of the most common complications following body piercing. Each piercing site has a typical length of time for healing—the naval site being the slowest to heal at 6 months after piercing. While there is no uniform treatment of infected piercing sites, a course of antibiotic therapy which is effective against Staphylococcus aureus is advised, in addition to cleansing and topical antibiotic. Decisions to remove the jewelry should be made only if the removal would facilitate drainage; otherwise, it is better to leave the jewelry in place. If systemic symptoms occur, the adolescent should be admitted to the hospital for incision and drainage of the site and intravenous antibiotics.

An anxious mother is concerned about frequent vomiting in her 4 ½ month old. A thorough history is obtained and the physical exam is unremarkable. Weight gain is appropriate. Which is the FIRST course of action? a proton pump inhibitor, omeprazole (Zegerid), orally at 1 mg/kg/day an H2 blocker, ranitidine (Zantac), orally at 12 mg/kg divided bid thicken the formula with rice cereal parental education and anticipatory guidance

parental education and anticipatory guidance The diagnosis of uncomplicated gastroesophageal reflux (GER) should be made in this scenario. In uncomplicated GER, parental education, guidance, and support are always required and usually sufficient to manage healthy, thriving infants with symptoms likely due to physiologic GER. In formula fed infants, thickened formula reduces the frequency of overt regurgitation and vomiting, but does not result in a measureable decrease in the frequency of esophageal reflux episodes. Thickening formula would be a next step to minimize vomiting episodes. No proton pump inhibitor has been approved for use in infants younger than 1 year of age. The dose for ranitidine (Zantac) is 4-10 mg/kg/day divided twice daily.

Of the following, the MOST effective method to prevent childhood gun injuries and death is parents and caregivers eliminating children's access to guns. educating children with the Eddie the Eagle program. educating children with the STAR Program parents and caregivers making children aware of locked guns in the home.

parents and caregivers eliminating children's access to guns. It is widely believed that teaching gun safety to young children is effective in keeping them from handling guns when found, thus decreasing childhood gun deaths and injury. The most advertised program is the National Rifle Association's Eddie Eagle Gun Safety Program that teaches children when they find a gun to stop, do not touch, leave the area, and tell an adult. The Straight Talk About Risks (STAR) Program developed by the Center to Prevent Handgun Violence emphasizes learning, practicing gun safety skills, role playing, and self-reflection using common coping mechanisms for anger and fear. In a controlled study looking at actual behavior in matched groups, half who had a gun safety program based on the STAR program and half who had no gun safety instruction, no significant differences were found in the percentage of children who handled the gun, left the area, and contacted an adult. No controlled study has been done on the effectiveness of the Eddie Eagle Gun Safety Program. The American Academy of Pediatrics maintains that the most reliable and effective means of preventing gun deaths and injury is the removal of guns from children's homes and communities.

The benefit of fluoride is achieved through which of the following mechanisms? bacteriocidal effect on Streptococcus mutans destruction of milk sugars prevention of plaque adherence remineralization of carious lesions

remineralization of carious lesions It is important for health care providers to screen for dental caries and to identify risk factors for development of decay. Caries occur from the overgrowth of the bacteria Streptococcus mutans, streptococcus sobrinus, and lactobacillus species, which are part of normal human flora. These bacteria adhere well to the tooth surface. Topical fluoride is effective in assisting in the prevention of caries by inhibiting demineralization and aiding in the remineralization of carious lesions. While fluoride does not prevent plaque adherence, it can alter the enamel of teeth making it more resistant to the destructive effects of the bacteria found in the mouth. Milk sugars are a common cause of caries providing a medium for the bacteria to flourish.

Which POST competition guidance promotes best nutrition practices for the pediatric athlete? additional protein consumption is needed for tissue repair protein supplements will increase muscle size if taken after competition fat loading is most important within the first 1-2 hours replacement of carbohydrates should optimally occur within 2 hours

replacement of carbohydrates should optimally occur within 2 hours Young athletes and coaches often look to dietary management to provide a competitive edge and improved performance. While few studies exist, principles of nutrition remain constant. Carbohydrates remain the cornerstone of an athlete's diet. Intermittent sports such as football and soccer rely primarily on glucose for fuel. Endurance sports such as cross country use glycogen stores first and then use fat for energy. Carbohydrate rich meals should be eaten 1-4 hours prior to exercise, reducing the volume closer to exercise time. Carbohydrate loading is helpful only for endurance sports such as cross country and bicycling, which comprises only a small percentage of participation sports. The nutritional demands of non-endurance sports are not much greater that the demands of growth. Greater emphasis should be placed on fluid replacement. Additionally, replacing carbohydrates to replenish glycogen stores should occur in the first 1-2 hours after competition and is an aide in recovery. Additional protein is not necessary for tissue repair. Protein supplements will not increase muscle mass. Lastly, a diet high in fat increases gastric emptying time and is not recommended prior to an athletic event.

The caregiver of a 7 year old is concerned about the child's dislike of school. It is late fall, and the child has now been absent for 20 days. The FIRST challenge for the caregiver is to obtain psychological counseling. send the child to school every day. determine what the physical illness may be. have the child catch up on missed school work.

send the child to school every day. Children with school phobia or school refusal often have other underlying problems including depression, separation anxiety disorder, and other anxiety or fear related issues. The first challenge for parents or caregivers is to send the child to school calmly and to reward each completed day of school. Working with the school system or an outside counselor in determining other underlying problems is also important. Having a complete physical exam is also helpful in ruling out any real physical problems, but having the child return to school is still the primary goal.

A 16 year old has taken pravastatin (Pravachol) for 4 months and has experienced a decrease in her low density lipoprotein level (LDL) from 250 mg/dL to 175 mg/dL. Which of the following would prompt discontinuing this statin? migratory joint pains inadequate response to the statin serum HCG of 600 MIU serum alanine transferase 2.5 times normal

serum HCG of 600 MIU Statins are potent teratogens and are contraindicated during pregnancy. Pravachol is considered a pregnancy risk factor "X," so with an elevated HCG, the medication should be discontinued. Statin use is associated with rare episodes of rhabdomyolysis. Complaints of muscle pain would mandate discontinuing a statin, but migratory joint pains, suggestive of arthritis, would not. An LDL that has decreased from 250 mg/dL to 175 mg/dL represents an adequate response to the statin. This result is well within the 20-50% cholesterol lowering effect predicted for this drug. Mild elevations of liver transaminases are present in <1.2% of patients and require continued monitoring, but not discontinuing the medication.

A 12 month old with no recent medication history presents with bullous impetigo, fever, malaise, and diffuse erythroderma. Mucous membranes are not affected. When the skin is gently rubbed, the epidermis in the area is denuded. These findings are characteristic of: staphylococcal scalded skin syndrome toxic shock syndrome toxic epidermal necrolysis Stevens-Johnson syndrome

staphylococcal scalded skin syndrome Staphylococcal scalded skin syndrome (SSSS) is caused by a toxin released by the bacteria Staphylococcus aureus. A common finding with SSSS is a positive Nikolsky's sign, such that the outer epidermis separates from the basal layer following gentle friction. SSSS may be differentiated from other conditions by lack of exposure to drugs, lack of mucous membrane involvement, and lack of respiratory symptoms. The rash of toxic shock syndrome is widespread blanching erythroderma, and hyperemia of the mucous membranes. Toxic epidermal necrolysis presents with mucous membrane involvement and generalized epidermal sloughing. Stevens-Johnson syndrome presents with upper respiratory symptoms along with target lesions followed by skin denudation of less than 10% of the body surface area. Mucous membranes are almost always involved.

A 4 month old with congenital nasolacrimal duct obstruction had several episodes of dacryocystitis and is currently hospitalized for cellulitis. Which is the appropriate follow up? continued frequent massage over the lacrimal duct daily use of an ophthalmic antibiotic ointment surgical referral for potential tear duct probing oral antibiotic prophylaxis

surgical referral for potential tear duct probing Congenital nasolacrimal duct obstruction (CNLDO) occurs in about 6% of newborn infants, and resolves spontaneously in most children by 12 months of age. Symptoms include excessive pooling of tears in the eye, overflow of tears onto the lid or cheek, and reflux of mucoid material from the lacrimal sac. Appropriate conservative management of CNLDO includes frequent massage and cleansing of the lids and lashes with warm water. Application of an ophthalmic antibiotic ointment or drops is useful when mucopurulent discharge is present, rather than on a continuous basis, which may be irritating to the cornea. Gentle downward massage over the nasolacrimal duct is helpful in clearing the accumulation of mucoid material, though it is not established as a curative measure. If tearing persists after 12 months of age, or if the younger infant has repeated episodes of dacryocystitis, earlier referral to an ophthalmologist for tear duct probing or other surgical management is recommended.

The MOST appropriate INITIAL management of a toddler with persistent postinfectious diarrhea is to continue with a regular diet. start a high fat, low carbohydrate diet. switch to a lactose-free diet. start a clear liquid diet.

switch to a lactose-free diet. Lactose intolerance can result from intestinal mucosal injury following an acute or subacute diarrheal episode. Postinfectious persistent diarrhea, also known as postinfectious enteropathy, can result in symptoms ranging from mild to severe diarrhea. It is a poorly understood entity that is manifested by continued diarrhea after eradication of the initially offending pathogen. The treatment of mild persistent postinfectious diarrhea for children over one year of age is a lactose-free diet. Diarrhea should improve with the elimination of lactose. Children with severe persistent diarrhea or those who do not respond to a lactose-free diet and for whom no other cause of their persistent diarrhea is found need follow-up evaluation.

Which of the following is the BEST INITIAL counseling for a family of a 5 year old with nocturnal enuresis? wake the child frequently during the night so urination is effective symptoms are often a developmental lag and will be outgrown medication therapy has the best long term response rate an alarm system is the best choice as it is usually covered by health insurance

symptoms are often a developmental lag and will be outgrown Primary nocturnal enuresis is a common problem in children between the ages of 5 and 8. In most cases, the symptoms will be outgrown without treatment. Once any medical or physical problem is ruled out, common sense approaches include limiting fluids after dinner, encouraging urination right before sleep, and holding the urine for longer periods during the day. These procedures do help in many cases and should be the first counseling information given to families. Alarm systems work well, waking the child when the first few drops of urine are sensed, but are not always covered by health care insurance. Medications like DDAVP and imipramine are also effective as long as they are used, but relapses can occur when they are stopped.

Which of the following recommendations applies to a 16-year-old female who has been treated for a sexually transmitted infection? retest for chlamydia and gonorrhea 3 months after treatment retest for syphilis and gonorrhea 6 months after treatment test for cure following treatment of chlamydia and trichomoniasis test for cure following treatment is not indicated

test for cure following treatment is not indicated Except in pregnant women, test-of-cure (i.e., repeat testing 3-4 weeks after completing therapy) is not advised for persons treated for sexually transmitted infections with the recommended or alterative regimens, unless therapeutic compliance is in question, symptoms persist, or reinfection is suspected. Syphilis is easy to cure in its early stages with penicillin. The need to re-test for syphilis after being treated is based on the individual's risk factors.

Which BEST describes the meaning of sun protection factor (SPF) 6 labeled on sunscreen? application of the sun screen will protect the child from UVA rays for 6 hours the sun screen prolongs the time to sun burn by a factor of 6 the sun screen will continue to work for 60 minutes in water application of the sun screen will protect the child from UVB rays for 6 hours

the sun screen prolongs the time to sun burn by a factor of 6 Sunscreens provide a chemical or physical barrier or block to the sun's rays. Most sunscreens include multiple chemicals to provide broad coverage for different types of light, i.e.; UVA and UVB. The SPF is the length of protection as compared to the use of no sun screen, thus a factor of 6 will prolong the time to burn by 6. Children should be protected with a high sun protection factor. Sweat, swimming and wind will affect the longevity of the sunscreen, so it should be reapplied as directed on the package or bottle. A sun resistant sun screen will function for 40 minutes in water and waterproof sunscreens work for 80 minutes in water.

An afebrile 3 year old with no history of trauma presents with a one day history of a limp. Physical exam is negative except for pain with weight bearing. The child has a history of a viral illness one week ago. What is the MOST likely diagnosis? septic arthritis osteomyelitis fracture transient synovitis

transient synovitis Transient synovitis occurs with a sudden onset of a refusal to walk, and is more common in boys. Septic arthritis presents with a fever, along with hip pain and limited range of motion (ROM). Osteomyelitis can present similarly to septic arthritis, but trauma usually precedes it. Signs of a fracture would include inflammation, along with pain.

Which is the BEST next step for an adolescent with scaly patches limited to the torso, palms of hands, and soles of feet? active nonintervention treponemal antibody test topical steroids oral antifungals

treponemal antibody test Non-specific scaly rashes are common in children and adolescents; it is important to differentiate possible causes so that management is appropriate. Scaly patches that involve the torso, palms of the hands, and soles of feet should prompt consideration of secondary syphilis for which the treponemal antibody test is appropriate. Active nonintervention is appropriate for pityriasis rosea, although oral antihistamines may be used for those who have associated itching. While topical steroids are effective for eczematous lesions, eczema is rarely found on the palms of hands and soles of feet. Oral antifungal medications may be used in the treatment of tinea versicolor.

Which of the following should be included in the plan of care for preterm infants? use of a car seat without a shield harness supplemental vitamin D at 4 months for breast fed infants immunizations beginning at 2 months corrected age evaluation of vision at 3 months

use of a car seat without a shield harness Preterm infants eligible to ride in car safety seats should not use the shield harness because it may be too large for a smaller infant. Breastfed infants should be supplemented with vitamin D until they are taking at least 1 liter per day of vitamin D fortified formula or whole milk. Immunizations are administered at the appropriate scheduled times, on the same schedule as full term infant counterparts. Vaccinations with DTaP, IPV, Hib and Rotavirus should occur at two months chronological, not corrected, age. Preterm infants should have vision tested annually beginning at six months.

According to the National Asthma Education and Prevention Program (NAEPP) Expert Panel 3 Update, potential long-term adverse effects of chronic inhaled corticosteroids use in children includes decreased bone mineral density. hypothalamic-pituitary-axis (HPA) suppression. vertical growth delay in the first year of treatment. ocular toxicity.

vertical growth delay in the first year of treatment. There is strong evidence from clinical trials that followed children for up to 6 years indicating that the use of long-term daily inhaled corticosteroids is safe in children. There is no evidence of decreased bone mineral density, HPA suppression or ocular toxicity (cataracts or glaucoma). There is a potential for slight growth delay (1 cm in height in the first year), but this is not sustained in subsequent years of treatment, is not progressive, and may be reversible.

Nutrition assessment of the child on a strict vegan diet should include regular growth monitoring, diet analysis, and laboratory assessment of vitamin B12, zinc and iron status. vitamin B12, calcium, and electrolytes. electrolytes, iron and vitamin B6. vitamin B6, zinc and calcium

vitamin B12, zinc and iron status. Slower growth rates have been reported in infants and children who follow vegan and macrobiotic diets during the first five years of life. However, catch-up growth usually occurs in these children by age 10 years. Strict restriction of dietary fats is not part of a vegan diet, and may provide a clue to serious eating disorders in the adolescent. Iron deficiency anemia is a common complication of vegan diets in adolescents and will not resolve without dietary change and/or iron supplementation. Adolescents who are vegetarian may experience a later onset of menstruation, probably related to a lower percentage of body fat. Strict vegan diets are most lacking in protein and some nutrients. High incidence of deficiencies in vitamin B12, iron and zinc have been identified and ultimately these children have the risk of developmental retardation. Growth monitoring, diet analysis, counseling and laboratory assessment of vitamin B12, iron and zinc should be included in health maintenance visits.