Lect 1 Well Child

anticipatory guidance

Guidelines explaining what to expect and what to pay attention to during middle childhood; part of well-child visits.

4 months: Begins ___________________. Baby can now laugh. Reaches for and brings objects to mouth. hint: this time I say Dr.Hipp , this time he just "Rolls" to reach for an object kick me and Laughed hard.

Rolling Dtap, Hib, Polio. PCV13, rotavirus

Mid-parental height hint: Lili's is her dad+her mom height - 13 cm then divide by 2 for me just +13

(dad's height+mom's height+ 5 inches(13cm) for males)/2 (dad's height+mom's height - 5 inches for females)/2

*Example growth charts hint: Key word Lili "REMEASURE" if lower by 2 lines then failure to thrive. 1st: Weight [indicate failure to thrive lili is not feeding him. 2nd: length 3rd: HC

*Example growth charts -1st thing to do is REMEASURE! -Growth charts can be a great indicator of something going awry. -In infants with Failure to Thrive: 1st to go is Weight, the length, then HC. -Concerning when begins to drop by 2 lines. -Normal drop in weight when child becomes more active. -Alternate curve for premies -HC, Craniosynostosis

11-16 years old vaccine

11 years · 11 year old brother of Lili who has Wart, which he try to remove it using "Nail"[tetanus] but almost die of Meningococcal at 11 & 16 y.o o 11 : wart ink[HPV]; Nail= DTAP and Meningo coccal 11y.o o 16y.o Meningo coccal

Additional Development

15mo- walks alone. 18mo- Says 4-20 words. Begins 2 word phrases. Scribbles spontaneously. 24mo- Speaks in short phrases, 2-3 words. Uses pronouns. 50% of speech understandable. Walks up and down stairs. Runs. 36mo- Knows first/last name, age, and gender. Dresses self. Speaks in sentences. Rides a tricycle. 4yr- Names colors, draws person with 3 parts. 5yr- Prints letters and numbers. Knows right and left hand. 6yr- Reads several one-syllable printed words. (My, dog, boy) 7yr- ties shoelaces (important to keep in mind for dental health) *Continued on page 76 in textbook.

Additional vaccines hint: Age 4-6 is Very DIM Police varicella DiTp M=MMR Pol= polio

15month vaccine - Dtap 18 month vaccine - Hep A Age 4 - MMR, Varicella, Dtap, Polio

Additional Feeding Guidelines 9mon and 12 mon kids eat like adult don't worry. hint: 4mon: peanut [PB2 brand] lol why????? 6mon-9: fruit , vegi , meat, 9mon- finger foods like coctail , meat raps, 12 month- family dish, swithc to Gold 3 which is full whole milk/cow milk not to exceed 30 Oz or one coke meal.120ml=30 oz hint:

4mo: Introduce "peanuts". Usually given in the form of PB2. 6mo: Step 1s- fruits and veggies. 6mo-9mo: Step 2s, meats and water. 9mo: Slowly introduce finger foods. 12mo: Eating mostly what family eats- switch to whole milk. No more than 30oz a day.

4th month is identical but Hep B is not given. So DR. HiPP

4th month is identical but Hep B is not given. So DR. HiPP

Neonate Blood Pressure

60-90/20-60

Cholesterol Screening

AAP recommends universal screening for all children age 9-11yr of age. ◦May be non-fasting due to minimal change in TC and HDL. ◦non-HDL-C testing is the preferred method for screening for children without risk factors. Universal screening from 12-16yr is not recommended due to normal changes of lipid levels during puberty. Screen at 2yr of age if there are risk factors. (Fasting Lipid Panel) §Parent has total cholesterol >240 mg/dL §Parents or grandparents @ < 55yr (male) <65yr (female): atherosclerosis, MI, angina, stroke, sudden cardiac death, peripheral vascular disease

Cholesterol Screening: [LDL fasting is my preference] Only DUbye in Grade 3-5 [9-11y.o] failed LDH screening test [called Non HDL-c test! - Grade6-10 no LDH test because we are in Puberty and our testetsterone and estro is up for false posetive; -Dubye said he was screened at 2years [Non-HDL-c] [don't require fasting for ped;] because his father like Biruk school bus driver "has risk factor " of AS causing Stroke@brain; MI@heart and PVD@Leg before 55 his father and 65 his mother. or Parent >200 LDL

AAP recommends universal screening for all children age 9-11yr of age. ◦May be non-fasting due to minimal change in TC and HDL. ◦non-HDL-C testing is the preferred method for screening for children without risk factors. Universal screening from 12-16yr is not recommended due to normal changes of lipid levels during puberty. Screen at 2yr of age if there are risk factors. (Fasting Lipid Panel) §Parent has total cholesterol >240 mg/dL §Parents or grandparents @ < 55yr (male) <65yr (female): atherosclerosis, MI, angina, stroke, sudden cardiac death, peripheral vascular disease

Meningococcal meningitis is prevented by which? A. PCV[pneumococcal conjucated vaccine] B. Menigococcal vaccine

ANswer B.

ASQ-SE Ages and Stages Questionnaires-Social Emotional hint: Areas screened: self-regulation, compliance, social-communication, adaptive functioning, autonomy, affect, and interaction with people

ASQ-SE Ages and Stages Questionnaires-Social Emotional Health- Edition 2 https://agesandstages.com/products-pricing/asqse-2/ Ability to screen ages 1-72mo Areas screened: self-regulation, compliance, social-communication, adaptive functioning, autonomy, affect, and interaction with people Validity is 84%. Test-retest reliability is 89%. Sensitivity, or the ability of the screening tool to identify those children with social-emotional disabilities, 78% at 2 months to 84% at 24 months, with 81% overall sensitivity. Specificity, or the ability of the screening tool to correctly identify those children without social-emotional delays, ranged from 76% at 18 months to 98% at 60 months with 83% overall specificity.

ASQ-3 = Age and Stage Questioner screen developmental progress from 1mont-6month lili. hint: ASQ result by Parents from observation; "it take a PA to 2-3 minute to score it.

Ages and Stages Questionnaires- 3rd Edition Screens developmental progress from age 1mo-66mo Categories: Communication, gross motor, fine motor, problem solving, and personal-social Validity is .82 to .88, test-retest reliability is .91, and inter-rater reliability is .92 The sensitivity* of ASQ-3, or the ability of ASQ-3 to correctly identify those children with delays, ranged from 75% for the 6-month questionnaire to 100% for the 4-month, 14-month, 54-month, and 60-month questionnaires, with 86% overall agreement. The specificity* of ASQ-3, or the ability of ASQ-3 to correctly identify typically developing children, ranged from 70% for the 14-month questionnaire to 100% for the 2-month, 16-month, and 54-month questionnaires, with 85% overall agreement. Multiple Languages available Parents complete in 10-15min, Takes 2-3min to score. Refer when abnormalities identified.

Discuss how parent is feeding baby hint: lili milk don't come 3 days "feed formula until then" but never mix formula and breast milk. "if breaast milk not enought, then add forumula by it self" with out intermixing; - to increase supply for later, pump and store.

Discuss how parent is feeding baby. Milk can take a few days to come in. Pumping to increase milk supply. Adding in formula when breastfeeding alone is not enough. Not mixing breastmilk and formula If still FTT- REFER!

Asad was Bought " M-CHAT" to chat with his friends to improve social starting "before 2years of age to get hime at low risk[0-2 year]; 3-7 = medium risk ; >8 high risk as me and dustyn know Autism regressing after later age is high risk. Lool : I was thinking about the age but the RIsk levels refer to the result form M-CHAT 0-2 no need to follow up ; 3-7; medium risk si early dx and intervention; >8 score is highrisk -bypass follow up and immediate intervention.

Everything should be yes except for 2, 5, and 12

Breastfeeding: Hint: Fe present in breast milk is protected by Lacto-Ferrin [the word means Lact or milk and Ferrin=Fe] so Fe binds to Lactoferrin becoming unavailable for bacteria. -Lysozome- bactericidal; and milk lipid anti viral effec. - antibody for passive immunity from mother

Exclusive breastfeeding is recommended by WHO and AAP for the first 6mo of life. Breast is best. Lactoferrin: binds to Fe, thus making it unavailable to pathogenic bacteria. Lysozyme: enhances sIgA bactericidal activity against Gram-negative organisms Oligosaccharides: intercept bacteria and form harmless compounds that the baby excretes Milk lipids: damage membranes of enveloped viruses Mucins: adhere to bacteria and viruses and help eliminate them from the body.

AG- Newborn & Infants [0-1y] hint: hi babe is sleeping well, i cut nails, you change #diapers, ublicus care

Extensive AG! §Early signs of illness §Safe sleep §# of wet diapers §Diaper changing/ circ care §Umbilicus care §Skin/nail care §Sleeping patterns §

Sensititivty= is sensitive to detect all true posetives [ so magbesbes silehone anything similar is wrongly marked posetive=false posetive error] specific= is specific enought to detect ONLY true posetives [ due to it high rigidity might miss "some diagnsosis" and called False Negative. if 100% sensitive or specific , no missed ---------- [opposite of above words. eg. sensitive detect true posetive,so no missed FALSE NEGATIVE.

Eye-opener for parents. *Given the complexity of measuring child development, the American Academy of Pediatrics considers high quality developmental screening tests to have sensitivities and specificities of 70% to 80%. Sensitivity is the ability of a test to detect all true positives, whereas specificity is the ability of a test to detect only true positives. If a test is 100% sensitive, there will be nofalse negatives (no missed true positives). If a test is 100% specific, there will be no false positives (no missed true negatives).

STIs- AAP Recommendations hint: HIV- according to AAP they reduce by 15-two. 13 to 64 <25 years old women for GC,Syphilis or if >25y.o with risk factor GC,SYphilis; Lili I know you have no risk factor , but because you are pregnant I will test HIV@blood,Hep B@liver; syphilis, GC [Gonorrhea if risk mostly -GC no clear catch because it is from discharge not urine]

HIV Screening: This screening should be done for EVERYONE ages 13-64. Screenings for Adolescents and Young Adults Under 25 Years of Age: §Annual chlamydia and gonorrhea screenings should be done for women under age 25 as well as older women who are at risk. Screening for syphilis, HIV, chlamydia, and Hepatitis B should be given to all pregnant women, and gonorrhea screening for pregnant women at risk. §Gonorrhea/Chlamydia testing can be done via urine sample- does not have to be a clean catch. Men Who Have Sex With Men (MSM): §These men have higher rates of STIs, such as HIV and syphilis and should be tested for these as well as chlamydia and gonorrhea.

Hearing Screen in Older Children. hint: Lili said at school "he was tested and he failed whisper test" out of all the tests. relax: Acute otitis media[fluid buldging in middle ear] or cerumen impaction is fulll[ you don't clean it Lili mom]?

Hearing Screen in Older Children Mostly gross hearing tested in office. (Whisper Test) ◦Many schools have formal hearing test programs. ◦They fail and then present to your office. ◦ ◦Determine possible benign causes for failed test ◦AOM? Cerumen Impaction? ◦Treat and then have child tested again.

Lili born a Bear ear bb hint: BAER ear test fro abnromal auditory test BAER = Brainstem Auditory Evoked Eesponse carl center here in moutn pleasant.

Hearing evaluation ◦Done before hospital discharge after birth ◦If abnormal » refer for BAER testing ◦Brainstem auditory evoked response

Anticipatory Guidance- General hint: roof: "smoke/CO detector; Optimal sun exposure"; imunizations: Lockers "GUn safety; Medicie control Self esteem

Hint: §Smoke and carbon monoxide detectors §Car restraints §Sun exposure §Smoke exposure §Immunizations §Gun safety §5210 §Poison control §Self-esteem §

1month: Regards the human ____________. Holds head erect and lifts head. Upper extremities with more __________________. Imms and Screening Tests: ______________________________________________________________________________

Human face. Extension. HepB (repeat hearing screen if failed at NB)

We notice correlation with poor behavior, concerns with discipline. Kids who do not watch as much tv seem to be better behaved.

I agree.

infants: 20/40 3 y.o when I was at Etye debritu I read "abogida" from far 40m 20/30 4-5y.o - when I was at "grade 1" I read from 30 students back 20/20 -6-7 when I was Grade 3[ i love Grade 3 but I don't know why!]

Infants- Does the baby track faces/objects? Concern for strabismus (cross-eyed), or amblyopia (lazy eye)? ◦Hirschberg test [corneal reflex test ] - shows strabisumus or ambylopia[lazy eye] Photo Screening Devices [to see symmetrical reflexion] Snellen Eye Chart Normal findings: ◦3 y/o 20/40 ◦4-5 y/o 20/30 ◦6-7 y/o 20/20

Oral Health: Dental Care hint: mainly strippers in teethes so "do apply flouride varnish when they come for Lili take your child to Nazreth every 3-6 month until you see the first teeth(6month); then every 6month to Nazreth for varnish after 1st teeth

Inspect teeth routinely! ◦YOU may be first to note problem ◦Many children have no dental care Instruct on cleaning teeth- Brush twice daily ◦Caregivers oral hygiene (cavities are contagious!) ◦Fluoride recommended for all. ◦Small smear for those <3yr. (size of a grain of rice) ◦Pea sized amount if >3yr Educate on preventing decay ◦NO bottle in bed; limit to no juice. ◦Fluoride varnish applied q3-6mo Dental visit recommended 6mo after 1st tooth

Prof Notes

LDL in non-fasting test are unreliable due to the nature of the assay. TG must be fasting to be reliable. Heavily influenced by recent food intake. Non-HDL-C is the difference between the TC and HDL-C. Non-HDL-C includes all cholesterol present in lipoprotein particles that are considered atherogenic, including LDL-C, lipoprotein(a), intermediate-density lipoprotein, and very-low-density lipoprotein (VLDL). TC and HDL-C can be measured accurately in plasma from nonfasting individuals, making it a more practical screening test for pediatric patients than a fasting lipid profile.

Pierre Robin Syndrome HINT: PERRIES ARSENAL WITH SMALL LOWER JAW

LOWER JAW SMALL;

MSM [Men who have sex with Men] hint; 90% have sti so screen ofr all STI's

Men Who Have Sex With Men (MSM): §These men have higher rates of STIs, such as HIV and syphilis and should be tested for these as well as chlamydia and gonorrhea.

New Born screen. [See image first on answer flash card] Heel Stick & Metabolic screening done on 1st day. -All 50 States require- but tests vary by state. Done after 1st day of life. Many tests are performed including: ◦Sickle cell, amino acid and organic acid disorders (including PKU), congenital adrenal hyperplasia, thyroid disorders, biotinidase deficiency, galactosemia, carnitine deficiency, CF...

New Born screen. Image

Key point on vaccine schedule

Newborn- Hep B 1mo-2mo- Hep B 2mo- DTaP, Hib, RV, IPV (Polio), PCV13 4mo- DTaP, Hib, RV, IPV (Polio), PCV13 6mo- DTaP, Hib, RV, IPV (Polio), PCV13 Hep B AND 1st Influenza. Booster required in 30 days. *Annually thereafter. 12mo- MMR, Varicella, HepA 4yr- DTaP, IPV, MMR, Varicella 11yr- TDaP, HPV, Meningococcal (ACWY) 16yr- Meningococcal (ACWY), *MenB *MenB not required yet by CDC.

Lili "do i give water? hint: 1.No water, our formula has 80% water. water alone is malnutrition. 2. food as i used to wonder >/= 4months "especially Fe fortified" to avoid anemia devil okay. Rice, cereal, oatmeal are baby meals ... introduce 6-7 gm food/week; very small is like a protein content in infant milk [my Lentils 285gram lol]; peneat? do allergy test first.

No water before 6mo of age. Breastmilk is 80% water. Giving water alone can cause malnutrition. WHO and AAP recommends breastmilk exclusively until 6mo. Reduces future obesity, helps mom to maintain supply. May introduce foods at 4mo if breastmilk is not supporting good weight gain, or GERD. 4mo can also do iron-fortified cereals. Rice cereal. Oatmeal. High risk for peanut allergy - eczema, egg allergy Recommend allergy test before introducing peanut. Introduce 6-7gm 3 times in a week. If high risk, should be medically supervised

Galant Reflex

Onset age: 32 wks gestation Integration age: 2 months Stimulus: Hold infant in prone suspension, gently scratch or tap alongside the spine with finger, from shoulder to buttocks. Response: Lateral trunk flexion and wrinkling of the skin on the stimulated side. Relevance: Facilitates lateral trunk movements necessary for trunk stabilization.

anticipatory guidance [AG]

Optimize child's growth and development. Help parents know what to expect and provide appropriate environment for child. Highly revolved around safety of the child. Best to do both written and verbal communication.

Immunization hint: good news premature <36 or more vaccinated same schedule, don't wait for your physical "if behind " bring him in for vaccine , it is serious lili.

Premature infants are vaccinated at the same chronological age and schedule as full-term infants ◦May hold 1st HBV until 1 month if Mom HBsAG neg Injection site: ◦Anterolateral thigh-infants /toddlers ◦Deltoid- children/ adolescents Vaccines are not just for physicals anymore! ◦Catch up at other visits if behind schedule

immunization hint:

Premature infants are vaccinated at the same chronological age and schedule as full-term infants ◦May hold 1st HBV until 1 month if Mom HBsAG neg Injection site: ◦Anterolateral thigh-infants /toddlers ◦Deltoid- children/ adolescents Vaccines are not just for physicals anymore! ◦Catch up at other visits if behind schedule

infant formula hint: could be: partially hydrolyzed protein: digestible soy for cow allergy; -extensively hydrolyzed lyptomil for hypoallergenic Liptomil; -amino acid based formula expenseive but no allergy because no crude protein.

Preparation and Content - Variations ◦Infant formulas come in powder, liquid concentrate, and ready-to-feed forms ◦Cow's milk formula is the "typical" most commonly used (Similac, Enfamil) ◦Soy protein based formulas are frequently used for infants allergic to cow's milk (Isomil, Prosobee) ◦Partially hydrolyzed formulas (reduced protein) are marketed as having improved digestibility (Good Start, Gentlease brands) ◦Extensively hydrolyzed formulas (Alimentum, Nutramigen, Pregestimil) are considered "hypoallergenic". One study reported that 90% of children with cow's milk allergies will tolerate them. ◦Amino acid based formulas (Neocate, EleCare and Nutramigen AA) are move expensive, but are reported least likely to cause allergic reactions. ◦ ◦

colostrum=>transitional milk =>vol increase after delivery. Prolactin inhibit GnRH = its frequency of production increase new milk after new milk.

Production, production. After delivery, production increases starting with colostrum. Transitional milk "comes in" with a rapid increase in volume within ~ 2-5 days of delivery. The volume of milk produced appears to be a function of frequency of removal rather than serum levels of prolactin. Inhibitory factors in the milk provide negative feedback to decrease milk production when the breast is not emptied. Mechanical pressure from engorgement may also decrease production.

Vaccination Quick pearl and Mnemonics

Quick tips · At Birth only Hep B ; after >1 y.o add · Avoid living vaccine in immune compromised and Pregnant woman o Vicious Memihir Doro[Chicken/varicella] sniffed Nasal Flu mist near Shintbet ROTO metach car he , got a Yellow fever § Vicious = Viable vaccines § Memihir = MMR § Doro/chicken= Varicela § Sniffed Nasal flu mist= Nasal Flu vaccine is LAIV [Live Attenueted influenza vaccine] · Contraindicated <2 y.o. and immune compromised/old · Just do 2-49y.o § Shint bet ROTO = Rotavirus vaccine [ for diarrhea shint bet metach] § Yellow fever vaccine= live vaccine. o IM flu vaccine is EGG BASED § Avoid in egg allergy, gelatin, latex allergy high risk of ANAPHYLACTIC

additional info on vaccine

RV has to start before 3mo and completed by 8mo Hepatitis A for ALL children ◦1st dose @ 12-23 months ◦2nd dose in 6 months Meningococcal conjugate (MCWY) vaccine ◦1 dose given @ 11-12 years of age ◦2nd dose given at 16yr HPV recommended for males and females ◦1st dose given at 11yr (if first dose given <15yr, 2nd dose in 6mo) ◦If 1st dose given after 15yr then 3 doses required (0, 1, and 6mo)

Hint:

Responds to _______________ and ________________. Upper extremities rest in the ________________ position. Reflexes (Handout) ◦Moro ◦Startle ◦Babinski ◦Sucking ◦Rooting ◦Palmar Grasp ◦Tonic Neck ◦Galant

6 months: [picmonic was right at this age add influenza _____________ alone. Transfers objects from ________________ to ________________. Babbles. Begins to ___________________________________________. Uses _________________ motion to pick up objects. hint: I called hime "Be Dr. HIPPi " ; He sits and babbles(excited to hit me again) this time " He rake objects transferring hand to hand" ; i asked strangers to cover me.

Sits Hand to hand Recognize strangers. Raking Dtap, hib, polio, PCV13, rota, hep b Influenza (needs 2 ½ doses the first year)

2months: hint: vaccine I said to the baby 2 month old "Be Dr. HIPP" "the child smiles first then coo & Cries for diffrent needs of becoming. _______________ responsively. Begins _________________. Different _____c_______________ for different ________________.

Smiles Cooing Cries for difrrent ..... needs.... Combination Vaccine. Dtap, Hib, Polio. PCV13, rotavirus

9months. §Crawling §Pulls to ___________________. §_____________________ along furniture. §Picks up cheerio with ______________________________. (Pincer Grasp) §Non-specific "mama, dada, baba". hint: Now I just looked at hime, he don't like me. so he Crawled & saying Mama,Dada, pull the dress to stand and he cruise around the 9 furnitures, grab the Pencil and poke me PooP .

Stand. Cruising Thumb and index finger

Anemia Screening hint: Lili your african american child needs screening for SICKLE CELL ANEMIA; G6PD; mm is not common but part of CRAB pee's child THalesemia alpha-thal ;

Test once (minimum) ◦At 1yr of age, or sooner if concerns. ◦Classically CBC- New Hemocue. ◦As needed based on risk.

Everything should be yes except for 2, 5, and 12

The Modified Checklist for Autism in Toddlers (M-CHAT) is a validated developmental screening tool for toddlers between 16 and 30 months of age. It is designed to identify children who may benefit from a more thorough developmental and autism evaluation. §Recommended by AAP to be administered at 18mo and 24mo of age. §LOW-RISK: Total Score is 0-2. §Rescreen at 24mo. §MEDIUM-RISK: Total Score is 3-7. §Rescreen at 24mo and if score is >2, Refer. §HIGH-RISK: Total Score is 8-20. §Refer Immediately.

Responds to _______________ and ________________. Upper extremities rest in the ________________ position. Hint: " call his name, and touch he will respond.; and his hands on his mouth so flexed always. Hint: do all of reflexes in 24 hours of lili birth. "lili what are you doing,checking reflex" Reflexes (Handout) ◦Moro ◦Startle ◦Babinski [after 24 hours] ◦Sucking ◦Rooting ◦Palmar Grasp ◦Tonic Neck ◦Galant

Touch and sound. Flexed Imms and screenings done at hospital. Heel prick. Done after 24 hours.

validity "if a test method is valid to test what it pertains" reliable is "repitiion" if always same result then reliabl.e

Validity is described as the degree to which a research study measures what it intends to measure. Test-Retest Reliability (sometimes called retest reliability) measures test consistency — the reliability of a test measured over time. In other words, give the same test twice to the same people at different times to see if the scores are the same. For example, test on a Monday, then again the following Monday. The two scores are then correlated.

12 month hint: Stands alone. Begins to _________________. Waves bye-bye. Specific "Mama, Dada". May say _________________ other words. Searches for hidden toys. (Object permanence) Knows his/her own ____________. Comes when called. _______________ at desired objects. Hint: When his name called Baby lili he waves at his mama "Mama, i will go in"[more than 2 words], he kew it and stand and walkin by him self. The Dr Hide, but "object permanence"[find hidden toys] ; I know you there and starting pointing at him[points at objects]. Imms and Screening Tests: MMR, Varicella, HepA. Hib, PCV13 CBC/Lead.___________________________________ Important Extras: Switch from bottle to sippy cup. Switch to whole milk.

Walk. 1 or 2 Name. Points In Michigan, need 2 lead tests by age 6; usually done at age 1 and age 2

Hint: this todays world expose chidlren to risk factors such as poverty/toxic stress.

With the typical ups and downs of young children's emotions and behavior, delays or problems can be easily missed. And today, as more children are increasingly exposed to risk factors such as poverty or toxic stress, the likelihood of depression, anxiety, and anti-social behavior increases. There is tremendous opportunity during the first few years of a child's life to identify and address potential social-emotional concerns. Video until 1:18

PKU (phenylketonuria) hint: Phonex with ketone key cause "mentally retarded hyp pigmentation.

a condition that makes it impossible for babies to metabolize certain proteins

PHQ-9

assessment that evaluates degree of depression

Vit K also given as newborn •Pediarix, which combines DTaP, Hep B, and IPV (polio) • ProQuad, which combines MMR and varicella (chickenpox) • Kinrix, which combines DTaP and IPV (polio) • Pentacel, which combines DTaP, IPV (polio), and Hib

combination.

4-6 Years Very DIM Police

· Very= Varicella · Di= DTaP · M= MMR · Police= Polio virus.

12-18 Month "Very MAD HIPP"

· Very= Varicella · M= MMR · A= Hep A [2wice at @12 & @18 month ] · D= DTaP @15month [unique ] · Hi = Hib · P = PCV [pneumococcal conjugated vaccine ] · P= Polio

Lili: how would i know hungry?defar he will put fist hand on hist tummy/chest, suckle on everything... flex arm/hand saying give it to me. hint your new boar eats every 2 - 3 hour! like 8 -12 times per day hint: if full sleep, turn out not rooting.

f

FLP [fasting lipid panel] hint: repeat in 1-3 month after your life style change

fasting lipid panel

hirschberg test (corneal light reflex) hint: Initial Screening test for strabismus. Checking for symmetrical corneal light reflections with pen light

hold penlight 12 inches from both eyes, light reflection should be symmetric. asymmetry could indicate weakness of extraoccular movements.

Vaccinations schedules [ premature and mature are same schedule ] o 2&6Month Bee Dr.HIPP; 4month Dr HIPP o 12-18 month : Very MAD HIPP - 4-6 years: Very DiM Police at 4-6PM

o 2&6Month Bee Dr.HIPP; 4month Dr HIPP [ Hep B o 12-18 month : Very MAD HIPP - 4-6 years: Very DiM Police at 4-6PM

Moro reflex (startle reflex)

occurs when a baby is startled by a loud noise, a sudden movement, or the head falling back. The arms are thrown apart. The legs extend and then flex. A brief cry is common

Craniosynostosis hint: cranio setano mesay = become fusing and big scull bone increasing head circumfrance.

the premature fusing of the skull bones

PKU and Congenital Hypothyroidism tested for in ALL states. Both result in severe mental retardation, but can be easily treated if identified. Before 24 hours it may be too early to recognize certain diseases. Hint: Phonex with ketone key cause "mentally retarded[same us hypothyroidism] hyp pigmentation

treated by avoiding Phenylalenin; for hypothyroidism= give thryoid.

Many parents question whether or not this means that their baby is teething, but a first tooth usually appears around 6 months old. Typically, the first teeth to come in are almost always the lower front teeth (the lower central incisors), and most children will usually have all of their baby teeth by age 3.

true

HPV if not given before 15 year like if not given by 11 as it is suppposed to then requires 3 shot 0,1,6month.

true.

tonic neck reflex

turning the head to one side, extending the arm and leg on that side, and flexing the limbs on the opposite side

Television viewing hint: TV is allowed >/= 2 years old AAP woww!

§Average US child watches 3 hrs /day §Does not include other "screens" §Tvs in bedrooms increase time watched §Kids < 2 yrs : NO TV TIME per AAP §Excessive tv viewing associated with ◦Negative effects related to violence, sexuality, substance abuse, nutrition, body self-image ◦More recent data suggests that excessive tv viewing may have long lasting negative effect on cognitive development and academic achievement

Blood Pressure hint: Eye Debre at our class 3 yr old "bring a hand cuff blood press" as we think of punishment to class ; so when they pump it hard it was painful. hint; too narrow BP cuff= over estimate too wide= under estimate.

§Begin screening at 3yr §Size of cuff is important §Width of inflatable portion should be 50% of the circumference of the limb. §Cuffs that are too narrow will __________________________ reading. §Cuffs that are too wide will __________________________ reading. §(If renal or cardiovascular abnormality should obtain BP reading at every visit regardless of age) §Cannot diagnose hypertension based on automated BP readings.

AG- Elementary Children [6-12 [grade 2-grade 6] hint: Bullying [grade 4], I remember homework friend(mike), - Micky cousin "road pediatstrian safety

§Bullying §Extracurriculars §Friends §Homework §Positive role model §Encourage independence §Praise strengths §Helmet/safety pads §Pedestrian safety

Lead Screening hint: I said very MaDD Hippi @12-18 month [one of the D is for lead] at 1year!; is your home 1950's , fire bullet, fishing etc. Lead >10 is diagnosis Lead >45 is CHELATING [dmsa-DI MercaptoSuccinic acid] Hey lili "I am going to report you and your house " If elevated report to local Health Dept- they begin investigation.

§Children at increased risk due to propensity for everything to go in their mouth. §Venous Blood Sample is preferred- fingerstick option available. §Lead Levels as low as 10ug/dL can cause behavioral problems and learning disabilities. §Chelation therapy indicated if >45ug/dL §Universal Screening at 1yr of age. ◦Medicaid requires a second screening at 2yr of age. §Lead Risk Questionnaire ◦Was your home built prior to 1950? (Lead paint) ◦Does anyone in the home have a job/hobby with exposure to lead? ◦Batteries, copper/brass foundry, firing range, auto repair shop, fishing, pottery making

Toddler/preschool (3 to 5 yrs) hint: I remember when we cry doro , abarosh before sunflower - eating habit, decipliline, falls, diall 911[i remember calling tele];

§Eating habits §Falls §Fire plan §Dialing 911 §Learning parents' names §Good touch/Bad touch §Discipline

Obesity hint:

§Epidemic across all aspects of medicine. §BMI >95th percentile §Emphasize healthy food choices, food pyramid. §Include whole family §Parents lead by example. §Parents do the grocery shopping. §5-2-1-0 Obesity Initiative §

AG- preteens/teens [12-18 grade 6-12] hint: feven Liya remember so "hide computer for no prono, ; sexual safety when sissay,elias and haregewoin. peer refusal skills [ wooow ] -

§Expected body changes §Computer/Phone safety §Sexual safety §Peer refusal skills §Future plans § § § §

continued... hint: when he wake up "feed him" ; play for interaction but never shake baby ;" in bath room avoid drown, hot water

§Feeding §Illness prevention §Parent-infant interaction §Accept help §Hot water temp §Drowning prevention §Falls from rolling over §Never shake baby

Composition of human milk hint: fore milk is "Low in fat" hence why when milk just start coming out it is thin watery...but rich in aminoacid. the fat increase over several minute as child bresast feeds so 'fat will not be wasted'. -passive immunity,macrophages, GI flora .

§Fore and hind milk ◦The milk first ingested by the infant (fore milk) has a lower fat content. As the infant continues to breast feed over the next several minutes, the fat content increases. §Specific Enzymes to aid neonatal digestion. §Appropriate amount of protein, fat, carbs, vitamins, and minerals to support healthy development. §Antibodies for passive immune support. §Many macrophages. §Numerous factors that help support intestinal microflora.

infant formula Hint: infant formula is marketed which age? remember number 3 promotion was allowed! So infant formula is <12 month of age [S-26GOld 1 &2 ]

§Is a manufactured food designed and marketed for feeding to babies and infants under 12 mo of age, usually prepared for bottle-feeding or cup feeding from powder (mixed with water) or liquid (with or without additional water). Composition ◦The composition of infant formula is designed to be roughly based on an human mother's milk at approximately 1-3 months postpartum. ◦The most commonly used infant formulas contain purified cow's milk whey and casein as a protein source, a blend of vegetable oils as a fat source, lactose as a carbohydrate source, a vitamin-mineral mix, and other ingredients depending on the manufacturer.

Weigth gain rules? Hint: the first two weeks becaus momy is moody, baby loses 10% of weight which is normal if more , pediatrician. - every month i want to see 1 Ounce weight increase okay after the first mont.

§Lose 5-10% of birthweight after birth §10% or more is abnormal. §Should be back to birthweight by 2wk of age §Need to gain 0.5-1oz daily in first few months of life.

Tuberculosis hint:

§Only screen if risk factors present §Close contact with person with TB §Foreign-born from (or travel to) endemic areas: Asia, Africa, Middle East, Latin America §Contact with prisoner, migrant farm worker, HIV infected individual, illicit drug user, homeless or recently homeless §Screen via Intradermal Test (PPD) §Measure Induration ONLY (not redness) §>10mm = positive §>5mm = positive if HIV or otherwise `````````immunocomprimised

Depression: postpartem depression first two week for Mom; in Edinamol by[ Edinburg postnatal depression scalre PHQ-9 for adolescent screening 12-18 USPSTF.

§Postpartum Depression §Edinburgh Postnatal Depression Scale §1-6mo timeframe of the infant §Adolescent Depression §The USPSTF recommends screening for MDD in adolescents aged 12 to 18 years. §PHQ-9/ PHQ-A §file:///C:/Users/FOX%20USER/Downloads/APA_DSM5_Severity-Measure-For-Depression-Child-Age-11-to-17.pdf

Measurements of Growth hint: first "his head circumfrence[occipt tuberance to frontal tuberence" then height, & weight. Weight and Height until 2 years recumbenent it is easier; and Lordosis is common in child so "height < length of children, so we want to know the length in recumbent. No lili BMI is after 2 years because of false posetive for height before that.

§Weight §Measure infant on scale naked or with dry diaper only. §Length/Height §Length from 0-24mo, measured "recumbent". §Height after 24mo, measured standing. §Child's length is more than child's height because lordosis is common in young children. §Head Circumference §Measured from 0-2yr of age. §Measure around occipital and frontal protuberances. §BMI §Begin measuring at 2yr of age. §BMI= [(wt in Kg) ÷ (ht in m)2] §Screening tool: ◦Obese (>95%) ◦Overweight (85-95%) ◦Underweight (<5%) §Trend of growth chart is most important!

Additional Feeding Guidelines - feed baby whisky size 1.5 OZ first two weeks and double whiskey 3-4 the rest two week to 1 month every 3-4 hurs or 6-10X lol parasite. frequency decrease with age ... - by the time they are 6month = 6 ounces ... hint; whole milk 1-2 years then switch to 1-2 %; health food to support growht spurt

§Whole milk until 2yr of age, then switch to 1-2%. §Children >1yr have rapidly alternating levels of Growth Hormone with growth spurts. §Picking eating common in toddler years. §Avoid food conflicts. §Healthy food choices, food pyramid.

2nd and 6th month are identical; Mnemonic= Be DR. HiPP

· B= Hep B o An infant born to HBsAg +ve mother must receive vaccine within 12 hours [at two sites one HBV vaccine and the other "hep ig for passive immunity"; then at 2month & 6month like any other child · D= DTaP [against Diphteria & Titanus&Pertusis [ci in encephalopathy ]:dose= both Toxoids ] · R=RV [roto yeshint bet memtecha = Diarrhea] · Hi = Hib [Haemophilus influenza · P= Pneumoccoal conjugage vaccine [PCV 13] - capsular organism so given in asplenia[splenectomy] P= Poli [inactivated]