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					         The 3rd Annual
     New York/New Jersey
 Pediatric Board Review Course

                General Pediatrics



Andrew D. Racine, M.D., Ph.D.
May 18, 2008
                  Outline

   Update on immunizations
   Breastfeeding
   Injury Prevention
   Anticipatory Guidance
   Dermatology review
   Child Abuse
Update on Immunizations
                   Case #1
Question 1
A 12 year old girl presents to your office for a
  regular checkup for school entry. She is a
  recent immigrant from Mexico. Her mother
  states that she does not have an immunization
  record. She denies any significant past medical
  history. There is no history of allergies.
  Physical exam reveals no abnormalities.
Which immunizations would you give at this
 time?
   A. Td, IPV, MMR, Varicella, Hep B, MCV4

   B. Td, IPV, MMR, Varicella, Hep B, MPSV4

   C. Td, IPV, MMR, Varicella, Hep B, Hep A, HPV

   D. Tdap, IPV, MMR, Varicella, Hep B, MPSV4

   E. Tdap, IPV, MMR, Varicella, Hep B, MCV4,
    Hep A, HPV
            Pertussis Vaccine (Tdap)
    Two new tetanus toxoid, reduced diphtheria toxoid
    and acellular pertussis vaccines were approved by the
    FDA in 2005 and are now recommended for:
   Adolescents aged 11-12 years who completed their
    primary series of DTP/DTaP and have not received a
    Td booster dose
   Adolescents 13-18 years who missed the 11-12 year
    Td/Tdap booster and completed their primary series
   Adolescents who have not received
    DTP/DTaP/Td/Tdap vaccination (or have no
    documentation)
   For wound management in adolescents who have not
    received Tdap before
    Meningococcal Vaccine (MCV4)
    Another change introduced into the
    schedule in 2005 is the meningococcal
    conjugate vaccine which is also
    recommended in
   Adolescents 11-12 years
   Unvaccinated adolescents at school entry
   College freshmen living in dormitories
   Certain high risk groups
          Hepatitis A Vaccine
In May of 2006 the ACIP broadened its
  recommendations for the use of Hep A vaccine
  to include all children between 1-2 years of age.
  The use of Hep A vaccine is also recommended
  for high risk groups including:
 Travelers to endemic areas, MSM, drug users,
  persons with chronic liver disease, those with
  clotting factor disorders
  Human Papillomavirus Vaccine

Licensed in June 2006, the ACIP recommends
  routine immunization of females from 9
  years of age up to 26 years of age with a
  three-dose series where the second and third
  doses are administered at 2 months and 6
  months after the first dose.
Based on the catch up schedule and the
 requirements for a patient this age the patient
 should receive:

   A. Td, IPV, MMR, Varicella, Hep B, MCV4
   B. Td, IPV, MMR, Varicella, Hep B, MPSV4
   C. Td, IPV, MMR, Varicella, Hep B, Hep A, HPV
   D. Tdap, IPV, MMR, Varicella, Hep B, MPSV4

 E.  Tdap, IPV, MMR, Varicella, Hep B,
    MCV4, HEP A, HPV
                  Pertussis
Pertussis remains endemic despite universal
  immunization with DTaP. There are 2 peaks of
  incidence. One is in children under the age of 6
  months who are not vaccinated or incompletely
  vaccinated. The other is in adolescent 11-18
  years whose immunity has waned.
The morbidity in adolescents is significant. In
  2004, 25,827 cases of pertussis were reported in
  USA. 34% were in children 11-18 years.
        Licensed Tdap Vaccines
   BOOSTRIX GlaxoSmithkline Biologicals
    10-18 years of age, same t, d, p antigens
    as INFANRIX but in smaller concentrations

   ADACEL sanofi pasteur
    11-64 years of age, same t, d, p antigens
    as DAPTACEL but in smaller
    concentrations
Side Effects of Tdap Vaccination
                    Local Reactions
   Pain
   Erythema
   Swelling
                  Systemic Reactions
   Headache
   Fatigue
   Fever
   GI events

Immediate Reactions including dizziness, syncope and
  vasovagal reactions were reported with ADACEL
                Case #1

Question 2

Before you give the Tdap vaccine to the
 patient you ask your attending what is a
 true contraindication for the vaccine.

Your attending responds that:
A. Temperature greater than 105 F within 48
   hours of a previous DTP/DTaP
B. Collapse or shock like state within 48 hours
   of a previous DTP/DTaP
C. History of encephalopathy within 7 days of
   previous DTP/DTaP
D. Latex Allergy
E. Pregnancy
       Contraindications of Tdap

   Anaphylaxis to any components of the
    vaccine

   History of encephalopathy (coma or
    prolonged seizure) within 7 days of
    administration of a pertussis vaccine that
    cannot be attributed to a different cause
           Precautions of Tdap
   History of an Arthus-type reaction following a
    previous dose of tetanus- or diphtheria-
    containing vaccine

   Progressive neurological disorder, uncontrolled
    epilepsy, or progressive encephalopathy

   History of Guillain-Barre syndrome (GBS) within
    6 weeks after a previous dose of tetanus toxoid-
    containing vaccine

   Moderate or severe acute illness
          Not Contraindications
   Temperature > 105F within 48 hrs of DTP/DTaP
   Collapse or shock-like state within 48 hrs of
    DTP/DTaP
   Persistent crying for 3 hrs or longer within 48
    hrs of DTP/DTaP
   Convulsions with or without fever within 3 days
    of DTP/DTaP
   History of entire or extensive limb swelling after
    DTP/DTaP/Td
   Stable neurological disorder
           Not Contraindications

   Brachial neuritis
   Latex allergy other than anaphylaxis-BOOSTRIX
    single dose and ADACEL are latex free
   Pregnancy and breastfeeding
   Immunosuppression
   Intercurrent minor illness
   Antibiotic use
The only true contraindication of the
   alternatives listed would be:
A. Temperature greater than 105 F within 48
   hours of a previous DTP/DTaP
B. Collapse or shock like state within 48 hours
   of a previous DTP/DTaP
C. History of encephalopathy within 7 days of
   previous DTP/DTaP
D. Latex Allergy
E. Pregnancy
                       Meningococcal Disease




American Academy Of Pediatrics. Committee on Infectious Diseases. Prevention and Control of Meningococcal Disease:
Recommendations for Use of Meningococcal Vaccines in Pediatric Patients. Pediatrics. 2005:116(2):496-505.
    Epidemiology of Meningococcemia

   Children < 1 year of age

   Adolescents 15-18 years of age

   College freshmen living in dormitories

   C5-C9 or C3 deficiency

   Functional asplenia
    Licensed Meningococcal Vaccines
MENOIMUNE
Meningococcal polysaccharide vaccine MPSV4
 Purified capsular polysaccharides A/C/Y/W-135
 Licensed in 1981
MENACTRA
Meningococcal conjugate vaccine MCV4
 Purified capsular polysaccharides A/C/Y/W-135
 conjugated to diphtheria toxoid.
 Licensed in 2005
               Case #1

Question 3

Your attending asks you what are the
 advantages of the new meningococcal
 conjugate vaccine vs. the old
 polysaccharide vaccine. You answer that
 all of the following are true except:
A. The conjugate vaccine produces an antibody
   response which lasts longer
B. The conjugate vaccine stimulates a booster
   response
C. The conjugate vaccine promotes herd
   immunity
D. The conjugate vaccine has less side effects
E. The conjugate vaccine reduces
   nasopharyngeal carriage
             MPSV4 vs. MCV4
MPSV4 antigens induce a T cell independent antibody
  response. As a result there is
 A short lived response

 No anamnestic or booster response with
  subsequent challenge
 No reduction in nasopharyngeal carriage



MCV4 antigens are conjugated to diphtheria toxoid so
  they induce a T cell dependent response resulting in
 A long lasting memory

 Booster response and

 eradication of nasopharyngeal carriage which
  contributes to herd immunity.
Advantages of MCV include all of the following
   except:
A. The conjugate vaccine produces an antibody
   response which lasts longer
B. The conjugate vaccine stimulates a booster
   response
C. The conjugate vaccine promotes herd
   immunity
D. The conjugate vaccine has less side effects
E. The conjugate vaccine reduces
   nasopharyngeal carriage
                MCV4


Side effects include:
  Erythema, swelling and induration
  Guillain-Barre – 17 reported cases from
  March 2005 – September 2006. GBS
  incidence estimated at 0.20 per 100,000
  person months after vaccine compared to
  0.11 per 100,000 person months among
  11-19 year olds generally.
         Human Papillomavirus
   The most common sexually transmitted infection
    in the United States (6.2 million new cases
    annually).
   HPVs are non-enveloped double stranded DNA
    viruses of over 100 types including several
    (16,18,31,33,35, and others) detected in 99% of
    cervical cancer cases.
   Risk of HPV associated with number of sexual
    partners, partner sexual behavior, and immune
    status.
         Human Papillomavirus
   Most infections are transient,
    asymptomatic and clear within 1-2 years
   Of the 6.2 million new cases per year,
    about 74% occur in women 15-24
   Acquisition occurs soon after sexual debut
   Prevalence of HPV 16 may be as high as
    40%
   Consistent condom use may help prevent
    acquisition
                 HPV Vaccine
   Quadravalent HPV vaccine (Gardasil®) targets
    HPV types 6, 11, 16 and 18
   HPV types 16 and 18 cause approximately 70%
    of cervical cancers and types 6 and 11 cause
    approximately 90% of genital warts
   Administered in 3 doses with second and third
    doses given 2 and 6 months after the first dose
   Combined protocols indicate an efficacy of 98-
    100% in the prevention of CIN 2/3, AIS or
    genital warts caused by HPV 6, 11, 16 and 18.
                Case #1
Question 4

You explain to your attending your intention
 to administer the Gardasil® vaccine and he
 responds, “Are you nuts? That vaccine
 costs a gazillion dollars!! What are you a
 Merck shareholder or something?” You
 calmly reply that:
A. The vaccine only costs $50 per dose
B. The treatment of genital warts and
  cervical cancer costs more than $8 billion a
  year in the U.S.
C. Depending upon how long you assume
  immunity lasts and what percent of girls get
  the vaccine, immunizing all 12 year old girls
  will cost only $3,000 to $25,000 per QALY.
D. Vaccinating will save the future costs of
  having to screen for cervical cancer in these
  patients
        HPV Costs and Benefits
   Management of warts and cervical cancer costs
    about $4 billion per year in the U.S.
   Vaccine for Children’s program (VFC) will cover
    costs of Gardasil for eligible patients
   Several cost/benefit analyses estimate the cost
    of a QALY to be between $3,000 and $25,000
    depending upon underlying assumptions
   Factors to consider: duration of vaccine
    protection, duration of natural immunity,
    frequency of cancer screening, vaccine coverage
A. The vaccine only costs $50 per dose
B. The treatment of genital warts and
  cervical cancer costs more than $8 billion a
  year in the U.S.
C. Depending upon how long you assume
  immunity lasts and what percent of girls get
  the vaccine, immunizing all 12 year old girls
  will cost only $3,000 to $25,000 per QALY.
D. Vaccinating will save the future costs of
  having to screen for cervical cancer in these
  patients
                 Case #1

Question 5

You ask your 12 year old patient to return in
 4 weeks to continue the catch up schedule
 of vaccination you started.

At that visit you will administer:
A. Td,IPV,MMR,Hep B
B. Td,IPV,MMR,Varicella,Hep B
C. Tdap,IPV,MMR,Hep B,MCV4
D. Tdap,IPV,MMR,Varicella,Hep B
E. Tdap,IPV,MMR,Varicella,Hep B,MCV4
             Catch-up Schedule
   Tdap is licensed for only one dose.
    According to the AAP, the patient in this case
    should receive 3 tetanus/diphtheria toxoid
    vaccines and only one of them should also
    contain pertussis, preferably the first dose.
   Varicella- Two doses are now recommended.
    A 2nd dose is given in 4 weeks for those over
    13 and in 3 months for those less than 13.
   MCV4 only one dose is required.
    Return Visit should include:
A. Td,IPV,MMR,Hep B
B. Td,IPV,MMR,Varicella,Hep B
C. Tdap,IPV,MMR,Hep B,MCV4
D. Tdap,IPV,MMR,Varicella,Hep B
E. Tdap,IPV,MMR,Varicella,Hep B,MCV4
              Hepatitis A
Vaqta and Havrix are both licensed for
 children 1 year of age and older and they
 are now recommended as part of the
 routine immunization schedule to be given
 to all children at the age of 1 year.
 Children who are not vaccinated by 2
 years should be vaccinated at subsequent
 visits. 2 doses are recommended 6
 months apart.
                   Influenza
   Influenza vaccine risk factors now include
    children with compromised respiratory function
    or handling of respiratory secretions and also
    children that have an increased risk of
    aspiration.
   In July 2007, ACIP issued a recommendation
    expanding routine influenza vaccination to
    children 6 – 59 months and their household
    contacts. Previously unvaccinated children
    should receive 2 doses this vaccine.
                    Rotavirus
Rotavirus is the leading cause of severe gastroenteritis
  worldwide resulting in more than 500,000
  deaths/year.
In the USA it is a major disease burden with 3.2 million
  episodes of diarrhea, 60,000 hospitalizations and 20-
  60 deaths /year.
Additional problems include
 Shedding of the virus before sxs develop and up to 21
  days after onset of the disease
 Children developing insufficient immunity after one
  infection and therefore experiencing it more than once
 Major cause of day-care center acquired
  gastroenteritis
             Rotavirus vaccines
All rotavirus vaccines are oral, live attenuated,
   containing glycoprotein (VP7) and protease-cleaved
   proteins (VP4) of Group A rotavirus, the most
   prevalent type found in humans.
ROTASHIELD –licensed in 1998, tetravalent rhesus-
   human reassortment, withdrawn from the market due
   to cases of intussusception.
ROTATEQ – FDA approved in 2006, pentavalent bovine-
   human reassortment, no intussusception reported in
   large trial of 70,000 doses.
ROTARIX – licensed in 30 countries but not in USA yet,
   divalent human vaccine, also well tolerated.
Breastfeeding
                Case # 1
A female infant presents for her two week
  check-up. She was born after a 38 week
  uncomplicated pregnancy via spontaneous
  vaginal delivery at a birth weight of 3 kg.
  Her mother is breastfeeding and asks
  whether breast milk alone is sufficient for
  her baby. What advice should you give
  her?
              True or False?
1. The baby should receive oral iron supplements
   for the first 6 months of life.
2. The baby does not need vitamin K after birth so
   long as the mother is taking oral Vitamin K.
3. Starting before 2 months of age the baby will
   need 200 IU of vitamin D daily while she is
   exclusively breastfed.
Question # 1



   False
                       Iron
   Iron stores at birth are proportional to birth
    weight or size.
   Iron stores for term infants are sufficient to
    meet needs for the first 4-6 months of life.
   Breast milk contains <0.1 mg/100cc of iron
    but it is in a highly bio-available form (50% of
    it is absorbed compared to 4% of iron in iron-
    fortified formulas).
   Infants’ adequate intake of iron is
    approximately 0.27 mg/day for the first 4-6
    months of life.
Question # 2



   False
                  Vitamin K
Vitamin K is a fat soluble vitamin necessary for the
  posttranslational carboxylation of glutamic acid
  residues of coagulation proteins Factors II, VII,
  IX and X.




                        lpi.oregonstate.edu/infocenter/vitamins/vitamink/kcycle.html
                 Vitamin K
   Breast milk has inadequate amounts of
    vitamin K to satisfy infant requirements.
   All breastfed infants should receive 0.5
    - 1.0 mg of vitamin K IM after the first
    feeding and within the first 6 hrs of life.
   Oral vitamin K may not provide the
    stores necessary to prevent
    hemorrhage in later infancy and is not
    recommended at this time.
Question # 3


   True
                  Vitamin D
   Vitamin D (calciferol) is available from
    certain dietary sources and can be
    synthesized in skin upon exposure to UV
    light.
   Adequate intake of vitamin D for infants is
    200 IU per day.
   Vitamin D content of human milk is low
    (22 IU/L).
                  Vitamin D

   Breastfed infants should receive
    supplements of 200 IU of vitamin D per
    day so long as the daily consumption of
    vitamin D-fortified formula or milk is below
    500 ml.
   The recommended routine use of
    sunscreen in infancy decreases vitamin D
    production in skin.
        More on Breastfeeding
Compared to the weight gain of formula fed
   infants in the first year of life, the weight gain
   of breast fed infants:
A. Is less rapid during the first 3-4 months but
   then catches up
B. Is more rapid during the first 3-4 months but
   then slows down
C. Generally results in a slightly heavier infant by
   12 months of age
D. Does not differ at all
       More on Breastfeeding

Compared to the weight gain of formula fed
   infants in the first year of life, the weight
   gain of breast fed infants:
A. Is less rapid during the first 3-4 months but
   then catches up
B. Is more rapid during the first 3-4 months
   but then slows down
C. Generally results in a slightly heavier infant
   by 12 months of age
D. Does not differ at all
       More on Breastfeeding

Breast fed infants tend to gain more weight
  than do formula fed infants in the first 3-4
  months of life.
It is acceptable for their weight gain to cross
  one or two percentiles downward in the
  period after 4 months so long as they
  maintain their length and head
  circumference.
       More on Breastfeeding

By the end of the first year of life, breast fed
  infants who had solids introduced at 4-6
  months of age tend to be slightly leaner
  than formula fed infants.
Term infants require between 100 to 120
  kcal/kg per day in order to grow.
Injury Prevention
          Injury Prevention

A 6 month old boy is at your office with his
  father for a routine health care
  maintenance visit. In discussing injury
  prevention for his infant, the father wants
  to know what he should be most
  concerned about with respect to his
  infant’s safety. What should you tell him?
Leading Causes of Death by Age
         Group - 2001
     < 1 yr       1-4 yrs         5-9 yrs        10-14 yrs
1   Congenital   Unintentional   Unintentional   Unintentional
    Anomalies       Injury          Injury          Injury
      5,513         1,714           1,283           1,553
2     Short       Congenital      Malignant       Malignant
    Gestation     Anomalies       Neoplasms       Neoplasms
      4,410          557             493             515
3     SIDS        Malignant       Congenital       Suicide
      2,234       Neoplasms       anomalies          272
                     420             182
Leading Causes of Injury Deaths
      by Age Group 2001
 100%

  80%
                                            Other
  60%                                       Firearms
                                            Burn
  40%                                       Drown
                                            Motor Veh
  20%

  0%
        1-4 Years   5-9 Years   10-14 Yrs
         Deaths Due to Injury
             in Childhood
   SIDS is the leading preventable cause of
    death in children less than 1 year of age.
   Unintentional injury is the leading cause of
    death in children from 1 to 15 years of age.
   Motor vehicle incidents, drowning and deaths
    from burns taken together account for over
    75% of all deaths from injury in children
    between 1 and 15 years of age.
 Motor Vehicle Injury Prevention
When counseling a parent with respect to infant car
   seats, all of the following are true except:
A. Children should face the rear of the vehicle until
   they are at least 1 year of age or weigh at least
   20 lbs.
B. Convertible safety seats positioned upright and
   facing forward should be used for children
   beyond 1 year and 20 lbs until they reach 40 lbs.
C. A rear facing car safety seat must not be placed
   in the front passenger seat of any vehicle with
   an air bag on the front passenger side.
Motor Vehicle Injury Prevention
Answer A: Children must weigh 20 lbs and be
  at least 1 year of age before sitting in a
  forward facing car seat. Many infants reach
  20 lbs before their first birthday but should not
  be turned to face forward
 before that time.
     Motor Vehicle Injury Prevention
      Convertible seats are the safest for children
        after they reach 1 year and 20 lbs until they
        are 40 lbs and can use booster seats.



Convertible                     Booster
Car Seat                        Car Seat
(Up to 40 lbs)                  (More than
                                35-40 lbs)
Motor Vehicle Injury Prevention
No rear facing seats should be placed in the
 front passenger seat of a car equipped
 with air bags; and any child less than 13
 should preferentially sit in the rear seat to
 avoid injury from inflating air bags.
           Drowning Injury

The father of that 6 month old infant also
   has a 4 year old boy at home. When
   counseling him about the epidemiology of
   childhood drowning, a TRUE statement is:
A. Drowning is the leading cause of
   death due to injury
B. For every one drowning victim there
   are 5 near drownings
C. Pool alarms have eliminated the need
   for fencing
D. Residential pools are the most
   common drowning sites
E. The ratio of male-to-female drowning
   deaths is 1:1
             Drowning Injury
Residential pools are the most common site of
  drowning for children younger than 5. Infants
  drown in bathtubs most often and adolescents in
  fresh water lakes and rivers.
Drowning is the 2nd leading cause of death in this
  age group (remember earlier) with peak
  incidence in the summer months and highest
  rates in the west and the south.
             Drowning Injury
Four sided fences 5 ft high with self-closing self-
  locking gates are the most effective enclosures
  for residential pools.
Pool alarms, pool covers, swimming lessons for
  young children and floatation devices are not as
  effective as proper enclosures in preventing
  drowning deaths.
Male to female ratio is 3:1 and 50% of submersion
 victims are declared dead at the site (drowning
 to near drowning ratio of 1:1).
A. Drowning is the leading cause of
   death due to injury
B. For every one drowning victim there
   are 5 near drownings
C. Pool alarms have eliminated the need
   for fencing
D. Residential pools are the most
   common drowning sites
E. The ratio of male-to-female drowning
   deaths is 1:1
     Injury Prevention: Burns
You are approaching the end of a health
 care maintenance visit for a 2 year old
 girl. The mother explains that the family
 recently moved into a private house
 having lived previously in an apartment.
 What four concrete pieces of advice can
 you give her about how she might make
 her new home safe from the standpoint of
 preventing burn injuries to her toddler?
     Injury Prevention: Burns
1. Don’t smoke in the home.
Home fires cause three fourths of all fire
   deaths and children below the age of 5
   are at highest risk.
Adults who smoke carelessly or who fall
   asleep while smoking are responsible for
   the largest percentage of home fires that
   kill or injure children.
       Injury Prevention: Burns

2. Install smoke detectors on each floor in
   the house and test them every 6 months.
Smoke detectors provide the best protection should
   a home fire begin since: a) most fires start in the
   early morning hours; b) most fires burn for a
   long time before discovery; and c) deaths are
   usually due to CO poisoning so early alerts can
   help prevent injury and death.
      Injury Prevention: Burns

3. Prepare emergency escape plans for use
   in the event of a fire.
Even children as young as 3 can be taught how to
   safely get out of the house in the event of a
   fire. If fire extinguishers are available in the
   home (and they should be) children should
   always be taught to leave the house rather than
   try to put out a fire themselves.
     Injury Prevention: Burns

4. Set hot water heaters at no higher than
   120o F.
Tap water at 160o F can produce a full-
   thickness scald burn in less than 1
   second. At 120o F the scalding time is
   increased to between 2 and 10 minutes.
 Anticipatory Guidance Potpourri
A six month old breast fed male infant is at your
    office for a well child check-up. He has been
    previously well and on exam babbles, reaches
    for your stethoscope and pulls to a sitting
    position without head lag. He can also:
1.   Finger feed himself
2.   Imitate sounds
3.   Pull to stand
4.   Transfer objects from one hand to the other
5.   Use a scissors grasp to obtain a piece of cereal
        Anticipatory Guidance
               Potpourri
Correct answer is 4, transfer objects.
As part of his normal development this infant
  probably began to hold a rattle briefly at 2
  months, reached for objects and and lifted himself
  onto extended elbows at 4 months. He probably
  also began to roll over at 4 months and could roll
  both ways by 6 months. He likely began to coo at
  2 months, to laugh out loud at 4 months, and to
  begin to babble at 6 months. Pulling to stand
  usually begins around 8 months. Finger feeding
  and imitating sounds usually starts at 9 months.
        Anticipatory Guidance
               Potpourri
You are seeing a set of parents with their 8 year
  old boy for a health care maintenance visit. The
  mother asks you whether allowing her son to
  watch TV when he comes home from school is a
  bad idea.
The MOST accurate statement you can make to
  her about the influence of television viewing on
  children is:
                 TV Viewing

A. Most adolescents have difficulty discriminating
   between what they see on TV and what is real.
B. Nearly 2/3 of all programming includes violence
   and children’s programming contains the most
   violence.
C. 50% of 2-7 year olds have a TV in their room.
D. A majority of parents report that they always
   watch TV with their children to monitor the
   content of what is seen.
                                       TV Viewing
Although young children and adolescents are
  vulnerable to the messages conveyed on
  television, it is predominantly younger children
  who cannot discriminate between what is real
  and what they see on TV. In a random survey of
  parents with children from kindergarten through
  6th grade published in 1996, 37% reported that
  their child had been frightened or upset by a TV
  program seen during the preceding year.

Cantor J, Nathanson AI. Children’s fright reactions to television news. J Commun. 1996;46: 139-152.
               TV Viewing

About one third of parents of 2-7 year olds
 report that their children have a television
 in their room.
Less than half of all parents state that they
  always watch television with their children
  to monitor the content of what is being
  seen.
                                    TV Viewing
  A recently completed 3 year National Television
    Violence Study reported that:
   Nearly 2/3 of all programming contains
    violence;
   That children’s shows contain the most
    violence;
   That portrayals of violence are usually
    glamorized; and
   Perpetrators often go unpunished.



Federman J. ed. National Television Violence Study Vol 3. Thousand Oaks, CA: Sage; 1998.
               TV Viewing
A. Most adolescents have difficulty
   discriminating between what they see on
   TV and what is real
B. Nearly 2/3 of all programming includes
   violence and children’s programming
   contains the most violence
C. 50% of 2-7 year olds have a TV in their
   room
D. A majority of parents report that they
   always watch TV with their children to
   monitor the content of what is seen
Dermatology
             Case # 1
     A 2 month old boy experiences the
onset of a salmon-colored confluent scaly
rash on his cheeks, neck, groin and axillae.
The mother points out an erythematous
patch behind the right ear. There is no
history of fever or other systemic symptoms.
The patient seems otherwise well and is not
uncomfortable with the rash. There is no
involvement of his nails.
dermatlas.com/derm/
  The rash is consistent with

A. Atopic Dermatitis
B. Candidal Dermatitis
C. Seborrheic Dermatitis
D. Contact Dermatitis
E. Psoriasis
           C. Seborrheic Dermatitis
   Etiology – unknown
   Epidemiology – seen during infancy and in
    adolescence
   Clinical – symmetric distribution in areas of high
    concentration of sebaceous glands (face, scalp and
    intertriginous areas such as neck, axilla, groin, post
    auricular). Salmon colored and scaly. Non pruritic.
   Treatment – Skin – topical steroids
     Scalp – oil/comb or antiseborrheic shampoo
   Complications – Secondary infection
                      Post inflammatory pigmentary
                      changes
dermatlas.med.jhmi.edu
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
                 Atopic Dermatitis
   Etiology – Unknown. Interplay of genetics and
    environment. Associated with atopy. More than
    50% develop asthma/allergic rhinitis.
   Epidemiology – 10-15% of children, with
    rapidly increasing prevalence.
   Pathogenesis – Keratinocytes induce T cells to
    produce decreased g interferon (a T2 inhibitor)
    thus contributing to eosinophilia and IgE.
   Clinical – Vicious cycle which begins with
    predisposition to dry skin – pruritis - scratching
    - more dryness and erythematous weeping
    crusted rash with indistinct border.
Distribution varies with age:
  Infantile - Starts on cheeks and spreads to
  neck/wrists/hands/abdomen/extensor surfaces.
  Diaper area often spared.
  Childhood – Extensor lesions now become
  flexural. Greater tendency for chronicity.
  Adolescent – Also includes dorsal hands, feet
  and between fingers and toes. May also
  involve eyelids, infra auricular fold and vulva.
Lichenification – thickened, hyperpigmented skin
Atopic pleats – extra groove on lower eyelid
Pallor around nose, mouth and ears
Treatment – “Break vicious cycle” lubrication,
  humidifiers, mild soaps, soft cotton clothing, anti
  pruritics.
 Food elimination – May be considered in children
  under 2 yrs. since it is associated in 40% of cases.
 Topical Steroids – Start with low potency.

 Immune modulators –The FDA after reviewing their
  safety has issued a warning that the use of calcineurin
  inhibitors may be associated with an increased risk of
  cancer. For refractory mod to severe cases.
 Tar, phototherapy and systemic treatment with
  glucocorticoids, cyclosporine and interferon reserved
  for severe cases.
Complications – Secondary infection due to altered cell
  immunity (MRSA, eczema herpeticum).
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
                    Psoriasis
   Etiology – Unknown. Associated with certain
    HLA types. Multifactorial inheritance.
   Epidemiology – Incidence 1-3%. Onset before
    age 20 in 37% of cases. In childhood F:M ratio
    2:1. Adults 1:1.
   Clinical – Round, erythematous, well
    marginated patches covered by a grayish or
    silvery white scale. Individual small lesions
    coalesce to form patches. Distribution – scalp,
    extensor surfaces, lumbosacral, anogenital
    regions. Sometimes flexural.
Special Features
 Auspitz sign – removal of scale results in fine
  punctate bleeding points.
 Koebner phenomenon – skin lesions that occur
  at the site of local injury
 Guttate psoriasis – round or oval lesions appear
  suddenly over a large part of the body after a
  URI, with strep or withdrawal of steroids.
 Pityriasis amianteca – psoriasis on the scalp -
  firmly adherent crusts somewhat resistant to tx.
 Nail involvement – Pitting, discoloration,
  subungal hyperkeratosis, onycholysis.
Pathogenesis – Marked increase in epidermal cell
  turnover.
Treatment – Lubrication, avoid scratching.
 Steroids – use least potent topical that’s
  effective
 Vit D Analogs – calcipotriene stings, takes long
  to work
 Topical Retinoids – syst tox in large quantity

 Tar +/- UV light or PUVA (UV + psoralens)

 Systemic methotrexate, oral retinoids,
  cyclosporine.
Complications – Psoriatic arthritis. No
  relationship between severity of cutaneous
  disease and the development of joint disease.
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
    Contact Dermatitis – non allergic
Irritant Contact Dermatitis – results from direct
  contact with caustic agents which include
  soaps, bleaches, detergents, solvents, bubble
  baths, saliva, urine, feces, etc. resulting in
  changes in the skin which follow the
  distribution of the contact. Classical example is
  diaper dermatitis – Fecal enzymes are activated
  by alkaline urea in the urine. Rash is
  erythematous, scaly, well demarcated and
  distributed along the convex surfaces of the
  perineum, sparing intertriginous areas.
Treatment includes frequent diaper changes,
  gentle cleaning and barrier pastes.
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
        Contact Dermatitis - allergic
Etiology – Type IV delayed type hypersensitivity
   reaction. Agents include poison ivy, oak and sumac,
   nickel, rubber, glue, dye, neomycin, topical
   anesthetics and antihistamines, cosmetics.
Clinical – Erythema, intense pruritis, vesiculation,
   crusting and scaling with distribution following the
   pattern of sensitization.
Initial reaction – 8-12 hours following exposure.
Subsequent reaction – 7 – 10 days following exposure.
Treatment – avoidance, washing skin immediately after
   contact, steroids topical and oral, antihistamines.
              Case #2

The following painful lesion developed in a
5 year old boy who was playing in his
back yard where there were a lot of
mosquitoes.
www.atlas-dermato.org
             The lesion is
A. Impetigo
B. Folliculitis
C. Furuncle
D. Ecthyma
E. Erysipelas
                   D. Ecthyma
   Etiology – beta hemolytic strep, occasionally
    staph and pseudomonas.
   Epidemiology – Poor hygiene, malnutrition,
    trauma, insect bites and other pruritic lesions.
   Clinical – Vesicle with erythematous base and
    crusting erodes into the skin forming an ulcer
    with elevated margins. Lesions are painful,
    slow growing and chronic. Commonly found in
    the lower extremities and the buttocks.
   Treatment – warm compresses, removal of
    crusts, systemic antibiotics
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
                    Impetigo
 Etiology – beta hemolytic strep and staph
 Epidemiology – any age but more common in
  the young, in exposed areas (non bullous), in
  traumatized areas of skin (bullous)
 Clinical – Non bullous – erythematous macules
  -> thin roofed vesicles surrounded by a red
  base –> rupture and release yellow fluid –>
  drying with formation of honey colored crust.
          Bullous – superficial blisters that rupture
  and leave an erythematous, denuded base.
 Autoinoculation contributes to spread.
   Treatment –
    With localized lesions topical mupirocin.
    With disseminated lesions systemic treatment
    with diclox, augmentin, cephalexin,
    clindamycin.
   Complications – Beta strep infections can result
    in acute glomerulonephritis and scarlet fever.
    In addition, both organisms can contribute to
    the development of osteomyelitis, arthritis,
    pneumonia, sepsis, cellulitis, lymphangitis.
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
                     Folliculitis
Superficial or deep infection of hair follicles
 Etiology – S. aureus. Occasionally strep, proteus,
  pseudomonas.
 Epidemiology – Induced by agents that obstruct
  pilosebacious glands such as oils, tars, occlusive
  dressings. Atopic dermatitis and seborrhea predispose
  as well as poor hygiene and excess sweating. Shaving
  can cause sycosis barbae, a deeper form of folliculitis.
  Hot tub dermatitis occurs in areas covered by the
  bathing suit and is caused by pseudomonas 8-12 hrs
  after exposure.
 Clinical – yellow pustule surrounded by red areola
  surrounding a hair shaft. Distributed anywhere on the
  body where there is hair.
 Treatment – avoid offending agent, gentle cleansing,
  topical antibiotics.
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
                     Furuncle
Develops from preceding folliculitis which extended more
   deeply into the skin or from trauma.
Etiology – Staph aureus Group I and II.
Clinical – red, tender, well circumscribed nodule which
   enlarges and then becomes boggy and fluctuant. If
   untreated it will suppurate and release purulent
   discharge. Healing results in scar formation.
Treatment – systemic antibiotics and incision and
   drainage.
Complications – carbuncles which are aggregates of
   interconnected furuncles that drain at multiple points
   on the cutaneous surface. They present with systemic
   symptoms such as fever, malaise and prostration.
   Seen more commonly with obesity, diabetes and
   immunosuppression.
dermatlas.med.jhmi.edu



                         forlag.fadl.dk
                    Erysipelas
Cellulitis with marked lymphatic vessel involvement due
   to Group A beta hemolytic streptococci.
Epidemiology – direct inoculation or hematogenous
   spread.
Clinical – Abrupt onset of systemic symptoms followed
   by an area of erythema which enlarges to reveal a
   tense, hot, painful, shiny, brawny infiltrated plaque
   with a distinct and well marginated border. Most
   commonly on the face and the scalp but can be
   anywhere.
Treatment – Penicillin. If allergic then erythromycin or
   clindamycin. With penicillin resistance nafcillin,
   oxacillin, augmentin, cephalothin, cefazolin
Complications – Patients my become bacteremic,
   especially infants.
              Case #3

A 12 year old female patient is diagnosed
with UTI. Two days after starting
treatment with bactrim she experiences
the acute onset of the following rash:
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
   The rash is most likely to be

A. Fixed Drug Eruption
B. PLEVA
C. Exanthematous Drug Eruption
D. Urticaria
E. Erythema Multiforme
           E. Erythema Multiforme
Mucocutaneous hypersensitivity syndrome
 Etiology – Viruses (most commonly herpes
  simplex), bacteria (including mycoplasma),
  protozoa, fungi, TB, foods, immunizations,
  sunlight, malignancy, radiotherapy, IBD,
  Polyarteritis Nodosa, Sarcoidosis, Graft vs. Host
  disease.
  Many drugs can cause EM including sulfa,
  penicillin, tetracycline, anticonvulsants,
  allopurinol, barbiturates, salicylates, NSAIDs,
  isoniazid, captopril, etoposide.
   Clinical – Acute onset of a fixed, symmetrical
    eruption consisting of erythematous macules,
    papules, vesicles or bullae with predilection for
    palms, soles, dorsi of hands and feet, extensor
    surface of arms and legs. May extend later to
    trunk, face and neck. The hallmark lesion of
    EM is the target – an erythematous plaque with
    central clearing and a dusky center.
    If an enanthem is present it involves oral
    lesions only.
   Treatment – Supportive.
                         Stevens – Johnson
                                    Severe form of EM.
                                    Characterized by an
                                    abrupt prodrome, same
                                    eruption as EM and
                                    involvement of at least
                                    2 mucous membranes.
                                    Treatment is supportive
                                    and morbidity and
                                    mortality are significant.
dermatlas.med.jhmi.edu
         Pityriasis Lichenoides et
            Varioliformis Acuta
   Also known as Mucha Habermann’s Disease
   Thought to result from immune
    dysregulation prompted by exposure to viral,
    bacterial or other environmental antigen
   Recurrent crops of red papules 2-4 mm with
    central crustingb (looks like chickenpox)
   May treat with oral erythromycin for 1 –2
    months
Zitelli. Atlas of Pediatric Diagnosis. 2nd Edition
                   Urticaria
Experienced by 20%, but most of the time the
  etiology is unknown.
Allergic causes
 Antibiotics –Penicillins/Cephalosporins/Sulfa

Urticaria can occur during or soon after course.
 Bee stings

 Seasonal and contact allergens

 Food – Infants – eggs/milk –may outgrow.

Older children – peanuts/sesame/shellfish/fish ---
  do not outgrow.
Non-allergic Causes
 Cholinergic – heat, exertion, sweating & stress induce
  acetylcholine which in turn induces histamine release
  and urticaria. Starts in adolescence.
 Aquagenic – contact with water or perspiration.

 Solar – with minimal exposure to sunlight.

 Cold – inherited (mild), acquired (severe)

 Viral – EBM, Hep C, Herpes, Coxsackie

 Pressure – tight clothes. Onset 4-6 hrs after pressure.

 Vibratory – working with drills or jackhammers.

 Papular – at the site of insect bites.

 Histamine induced –product induces histamine release
  in non allergic patient (IVP dye, azo dye)
Characteristic rash is composed of erythematous
  wheals that are highly variable, rapidly
  changing and transient with individual lesions
  lasting less than 24-48 hours. Intensely
  pruritic. It may be associated with
  angioedema.
Acute <6 weeks, causes can often be found.
Chronic > 6 weeks, commonly unknown etiology.
May be an important sign of systemic disease
  including malignancy, CV, autoimmune disease.
 Treatment – avoidance, antihistamines (H1
  +H2 may work better than H1), steroids,
  cyproheptadine (cold), leukotriene inhibitors
  (together with H1).
Vanderhooft. Contemporary Pediatrics. 1998. Vol 15(5):118-137
 Exanthematous Drug Eruption
This is the most common drug reaction and
  is responsible for 50% of all drug
  reactions.
It consists of erythematous macules and
  papules which begin on the trunk, then
  spread to the face and extremities and
  may include palms and soles. It is pruritic
  and not associated with fever.
It resembles a viral exanthem and must be
  carefully distinguished.
Child Abuse
             Case #4

The parents of a 9 month old baby
girl who is new to your practice bring
her for a regular checkup. There are
no complaints. Physical exam reveals
the following lesion:
dermatlas.com/derm/
 The following risks factors may
  indicate child abuse except:

A. Patient is less than 3 years of age
B. There is a history of spousal abuse
C. Father is an alcoholic
D. Mother did not breastfeed the child
E. The child is a foster child
 D. Mother did not breastfeed the child
Risk factors for Child Abuse – Parental
 Past history of abuse or family violence

 Inability to cope, lack of support, attachment issues

 Closely spaced pregnancies, financial problems

 Alcoholism, addiction, psychosis, depression

 Young parental age, single parent

Risk factors for Child Abuse – Child
 Child is less than 3 years of age

 Twin, prematurity

 Chronic illness, mental retardation, learning disability

 Foster or adopted child
        Child abuse – Physical signs
   Bruises, burns, bites, blunt-instrument marks
   Fractures – bucket handle, posterior rib
    fractures, multiple fractures at different stages
    of healing
   Intracranial hemorrhages
   Retinal hemorrhages
   Duodenal hematomas, lacerations of liver and
    spleen, mesenteric tears
   Oral lacerations
   Failure to thrive
Multiple posterior rib fractures



                                 Bucket handle fracture




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