CONTENT OUTLINE by mikeholy

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									T HE A MERICAN B OARD      OF   P EDIATRICS ®
CONTENT OUTLINE



       General Pediatrics



   Maintenance of Certification Examination




                                                i
                                          INTRODUCTION

This document was prepared by the American Board of Pediatrics for the purpose of developing
maintenance of certification examinations for general pediatricians. The outline defines the body of
knowledge from which the examination is sampled. The content specifications were developed by a
committee of pediatric practitioners and educators.


The same list of content specifications is used by the American Academy of Pediatrics in developing its
PREP educational materials.


If you have comments or questions about these content specifications, or about how they are used,
please e-mail at MOC@abpeds.org.




                                                                                                       ii
Maintenance of Certification Examination in General Pediatrics
                                                       Exam Percentage List
                                                                        Approximate Percent in Examinations                           Page

      I.   Growth and Developmental milestones ............................... 5.0 ................................... 1
     II.   Nutrition and Nutritional Disorders ..................................... 4.0 ................................... 6
    III.   Preventive Pediatrics ............................................................ 5.0 ................................. 12
    IV.    Poisoning and Environmental Exposure
              to Hazardous Substances ................................................. 2.0 ................................. 20
     V.    Fetus and Newborn Infant .................................................... 3.5 ................................. 24
    VI.    Fluid and Electrolyte Metabolism ........................................ 2.5 ................................. 34
   VII.    Genetics and Dysmorphology .............................................. 2.5 ................................. 39
   VIII.   Allergic and Immunologic Disorders ................................... 3.5 ................................. 44
    IX.    Infectious Diseases ............................................................... 4.5 ................................. 49
     X.    Metabolic Disorders ............................................................. 1.5 ................................. 73
    XI.    Endocrine Disorders ............................................................. 3.5 ................................. 76
   XII.    Gastrointestinal Disorders .................................................... 3.5 ................................. 83
   XIII.   Respiratory Disorders........................................................... 4.0 ................................. 92
  XIV.     Cardiovascular Disorders ..................................................... 3.0 ............................... 103
   XV.     Blood and Neoplastic Disorders........................................... 2.5 ............................... 108
  XVI.     Renal Disorders .................................................................... 2.5 ............................... 120
  XVII.    Genital System Disorders..................................................... 1.5 ............................... 130
 XVIII.    Neurologic Disorders ........................................................... 3.0 ............................... 134
  XIX.     Musculoskeletal Disorders ................................................... 3.0 ............................... 146
   XX.     Skin Disorders ...................................................................... 3.5 ............................... 152
  XXI.     Collagen Vascular and Other Multisystem Disorders.......... 1.5 ............................... 157
  XXII.    Disorders of the Eye ............................................................. 1.0 ............................... 162
 XXIII.    Ear, Nose and Throat Disorders ........................................... 4.0 ............................... 165
 XXIV.     Adolescent Medicine and Gynecology ................................ 4.0 ............................... 177
 XXV.      Sports Medicine and Physical Fitness.................................. 2.5 ............................... 190
 XXVI.     Substance Abuse .................................................................. 1.5 ............................... 194
XXVII.     Disorders of Cognition, Language, and Attention ............... 3.5 ............................... 200
XXVIII.    Behavioral and Mental Health Issues................................... 4.0 ............................... 209
 XXIX.     Psychosocial Issues and Problems ....................................... 3.0 ............................... 220
 XXX.      Critical Care ......................................................................... 2.0 ............................... 232
 XXXI.     Emergency Care ................................................................... 3.0 ............................... 235
XXXII.     Pharmacology....................................................................... 2.0 ............................... 239
XXXIII.    Research and Statistics ......................................................... 1.5 ............................... 242
XXXIV.     Ethics for Primary Pediatricians........................................... 1.0 ............................... 243
XXXV.      Patient Safety and Quality Improvement ............................. 1.5 ............................... 249



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I.   Growth and Development Milestones

     A.    Growth

           1.    Normal growth

                 a.    Measurement

                       Know the meaning, uses, and limitations of bone age

                       Recognize the types of anthropometric measurements used in assessing
                       nutritional status and their value

                       Be familiar with techniques to obtain accurate measurements of growth

                       Understand the role of body mass index in monitoring growth

                 b.    Linear growth and weight gain

                       Know that length at birth doubles by 3 to 4 years of age

                       Distinguish between normal growth and abnormal growth by
                       evaluating plots on a growth chart

                       Know that most full-term infants will regain their birth
                       weight within two weeks

                       Know that full-term infants will triple their birth weight
                       by 1 year of age

                 c.    Head growth

                       Know the normal head circumference of a full-term infant
                       at birth

                       Recognize the growth pattern of acquired microcephaly

                       Distinguish between hydrocephaly and macrocephaly

                       Recognize normal and abnormal variations in head shape

                       Recognize the growth pattern of familial macrocephaly

           2.    Atypical growth

                       Know that failure to thrive is a physical sign of under-nutrition
                       in the majority of patients

                       Understand that extensive laboratory evaluation of failure
                       to thrive should be deferred until out-patient dietary management has

                                                                                               1
                  been tried

                  Recognize the observational clues to failure to thrive,
                  eg, oromotor dysfunction, mother-infant interaction

                  Recognize poor feeding technique and inappropriate formula
                  preparation as causes of failure to thrive

                  Recognize that inadequate intake is the most common cause of failure
                  to thrive

                  Recognize the long-term consequences of failure to thrive in infancy

                  Know that failure to thrive may be an expression of parental neglect/
                  inadequacy

                  Formulate the differential diagnosis for an infant with failure to
                  thrive

B.   Surveillance and screening

                  Recognize the importance of regular, periodic standardized
                  developmental and behavioral screening for the well-child population

                  Know the commonly used developmental screening tests and their
                  limitations

                  Know the methods of developmental and behavioral screening

                  Identify the normal developmental sequence for motor, adaptive,
                  language, and social skills development from birth through 6 years
                  of age

                  Recognize significant developmental delay in motor, adaptive,
                  language, and social development from birth through 6 years of age

                  Distinguish among isolated, global, and atypical developmental delay

                  Understand the variations in the developmental sequence that are
                  associated with prematurity

                  Understand the variations in the developmental sequence that are
                  associated with congenital visual impairment

                  Understand the variations in the developmental sequence that are
                  associated with congenital hearing impairment

C.   Developmental milestones

     1.    Milestones for infants and young children

           a.     Neonatal period (first four weeks after birth)
                                                                                          2
     Recognize the normal developmental milestones for the neonatal
     period (eg, alerts to sound (bell or voice); demonstrates visual
     preference for human face)
b.   Two months

     Recognize the normal motor developmental milestones for 2 months of
     age (eg, regards object; follows 180 degrees; lifts head and
     shoulders off bed in the prone position)

     Recognize the normal cognitive/behavioral developmental milestones
     for 2 months of age (eg, smiles socially; coos; makes reciprocal
     vocalizations)

     Know that lack of visual fixation by 2 months of age is abnormal

c.   Four months

     Recognize the normal motor developmental milestones for 4 months of
     age (eg, steady head control while sitting; holds head up; bears
     weight on forearms in the prone position; pushes with feet when in
     standing position; reaches for objects)

     Recognize the normal cognitive/behavioral developmental milestones
     for 4 months of age (eg, laughs out loud, squeals; initiates social
     interaction)

     Know that lack of visual tracking by 4 months of age is abnormal

     Know that lack of steady head control while sitting by 4 months of
     age is abnormal

d.   Six months

     Recognize the normal motor developmental milestones for 6 months of
     age (eg, transfers object from one hand to the other; rolls over in
     both directions; sits with support)

     Recognize the normal cognitive/behavioral developmental milestones
     for 6 months of age (eg, turns directly to sound and voice; babbles
     consonant sounds; imitates speech sounds)

     Know that failure to turn to sound or voice by 6 months of age is
     abnormal

e.   Nine months

     Recognize the normal motor developmental milestones for 9 months of
     age (eg, feeds self with fingers; plays gesture games (pat-a-cake);
     bangs two objects together; holds two objects at one time; grasps
     pellet-like object with immature pincer; sits without support


                                                                           3
     Recognize the normal cognitive/behavioral developmental milestones
     for 9 months of age (eg, says "mama" and "dada" as nonspecific
     sounds (eg, repetitive consonants); understands his/her own name;
     recognizes common objects (eg, bottle) or people (eg, daddy)

     Know that inability to sit by 9 months of age is abnormal

     Know that lack of babbling consonant sounds by 9 months of age is
     abnormal

f.   Twelve months

     Recognize the normal motor developmental milestones for 12 months of
     age (eg, pulls to a stand and cruises; takes a few independent steps;
     neat pincer grasp of raisin or pellet)

     Recognize the normal cognitive/behavioral developmental milestones
     for 12 months of age (eg, says "mama" and "dada" with specific
     meaning; says at least one specific word in addition to "mama" and
     "dada")

g.   Fifteen months

     Recognize the gross normal motor developmental milestones for 15
     months of age (eg, plays ball with examiner; gives and takes a toy;
     drinks from a cup; makes a line with a crayon; makes two-cube tower;
     walks independently; stoops to floor/recovers to standing position)

     Recognize the normal cognitive/behavioral developmental milestones
     for 15 months of age (eg, says three to six specific words; follows
     simple commands; uses jargon; indicates some desires or needs by
     pointing)

h.   Eighteen months

     Recognize the normal motor developmental milestones for 18 months of
     age (eg, feeds self with spoon; stacks tower of three cubes; runs;
     walks up steps with hand held)

     Recognize the normal cognitive/behavioral developmental milestones
     for 18 months of age (eg, imitates household tasks; says 7 to 10
     words; uses words for wants or needs; identifies one or more body
     parts)

     Know that inability to walk independently by 18 months of age is
     abnormal

i.   Twenty-four months

     Recognize the normal motor developmental milestones for 24 months of
     age (eg, washes and dries hands; removes clothing; stacks tower of
     four to six cubes; feeds self with spoon and fork; runs well; kicks

                                                                             4
     ball; jumps with two feet off floor; throws big ball overhand)

     Recognize the normal cognitive/behavioral developmental milestones
     for 24 months of age (eg, combines words into two- or three-word
     phrases; points to pictures named; uses vocabulary of 50+ words;
     uses "I," "me," and "mine" in speech)
     Know that failure to use single words by 24 months of age is abnormal

j.   Thirty-six months

     Recognize the normal motor developmental milestones for 36 months of
     age (eg, helps in dressing (unbuttons clothing, puts on shoes);
     stacks tower of 10 cubes; copies a circle; broad jumps; stands
     momentarily on one foot; pedals tricycle)

     Recognize the normal cognitive/behavioral developmental milestones
     for 36 months of age (eg, speech is 75% intelligible; speaks in
     sentences of five to eight words; knows meaning of simple adjectives
     (eg, tired, hungry, thirsty); knows age and gender)

     Know that failure to speak in three-word sentences by 36 months of
     age is abnormal

k.   Four years

     Recognize the normal motor developmental milestones for 4 years of
     age (eg, copies cross; draws simple figure of a person (head plus
     one other body part); balances on one foot for 3 seconds)

     Recognize the normal cognitive/behavioral developmental milestones
     for 4 years of age (eg, pretend play; speech fully intelligible;
     asks questions (eg, when?, why?, how?); tells a story; counts four
     objects accurately)

l.   Five years

     Recognize the normal motor developmental milestones for 5 years of
     age (eg, dresses and undresses; draws a person with 6 body parts;
     skips, alternating feet)

     Recognize the normal cognitive/behavioral developmental milestones
     for 5 years of age (eg, plays board or card games; asks questions
     about meaning of words; names four colors)

m.   Six years

     Recognize the normal motor developmental milestones for 6 years of
     age (finishing kindergarten) (eg, rides a bicycle without training
     wheels)

     Recognize the normal cognitive/behavioral developmental milestones
     for 6 years of age (finishing kindergarten) (eg, writes name; knows

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                          right from left across the midline ("Touch your right ear with your
                          left hand); knows color names; identifies letters and numbers)

            2.     Milestones for kindergarten readiness

                          Know the indications of social readiness to attend school (eg,
                          ability to separate from parents for several hours at a time; plays
                          well with other children; takes turns; able to follow directions in
                          a group activity; able to relate personal experiences; tells stories)

II.   Nutrition and Nutritional Disorders

      A.    Normal nutritional requirements

            1.     General

                          Recognize problems associated with the early feeding of solid foods

                          Know age-related changes in the ability to absorb and digest
                          different nutrients relevant to infant feeding

                          Understand the potential nutritional deficiencies in adolescents

                          Understand the impact of adolescence and sports participation on
                          nutritional needs

                          Identify what dietary practices place infants at risk for nutritional
                          deficiency (eg, goat milk, vegetarian, single nutritional source)

                          Recognize that many family and cultural determinants influence
                          dietary intake that can affect growth

            2.     Minerals

                          Recognize that full-term neonates have adequate iron
                          stores

                          Know that iron deficiency anemia is the major nutritional deficit of
                          American youths, and identify the signs and symptoms associated
                          with this disorder

                          Judge the nutritional adequacy of infant formulas in relation to
                          mineral content

                          Know the problems associated with inadequate and excessive amounts of
                          phosphorus in the diet of a premature infant

                          Understand the rationales for the use of iron-fortified formulas and
                          recognize the misuse of low-iron formulas

                          Understand the necessity of adequate calcium and phosphorus intake
                          in children and adolescents

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     3.    Vitamins

                  Know that breast milk is deficient in vitamin D

                  Know the absorption, storage, and metabolism of fat-soluble
                  vitamins (A, D, E, K)

                  Understand the necessity of adequate vitamin D intake in children
                  and adolescents

                  Know the absorption and metabolism of water-soluble vitamins
                  (B complex, C)

     4.    Fat

                  Recognize the importance of the quality of fat content in preterm
                  and full-term infants formulas

                  Recognize the difference in preterm and full-term infant's ability
                  to digest fat and absorb fat soluble vitamins

     5.    Protein

                  Know the protein requirements for premature and full-term infants

                  Understand the appropriate age at which cow milk should be
                  introduced into the diet

     6.    Calories

                  Know the caloric requirements for infants, children, and
                  adolescents

                  Know the various circumstances in which the caloric requirements for
                  premature infants vary

B.   Infant feeding

     1.    Breast-feeding

                  Recognize that human and cow milk proteins differ in quality and
                  quantity

                  Know that human milk contains antibodies against certain bacteria and
                  viruses, including high concentrations of secretory IgA antibodies

                  Know that ingested antibodies from human colostrum and milk provide
                  local gastrointestinal immunity against organisms entering the body
                  via this route

                  Understand that the low vitamin K content of human milk may

                                                                                          7
                   contribute to hemorrhagic disease of the newborn infant

                   Know the drugs that are contraindicated in breast-feeding

                   Know that maternal ingestion of drugs with sedative properties has
                   the potential to cause sedation in breast-feeding infants

                   Understand the qualitative and quantitative differences between
                   human milk and infant formulas
                   Know that there is a lower incidence of gastrointestinal infections
                   in infants fed human milk

                   Know the disorders of the breast that may interfere with
                   breast-feeding

     2.     Formula-feeding

                   Know which infant formulas contain lactose

                   Recognize that infants fed goat milk exclusively are prone to
                   megaloblastic anemia due to folate deficiency

                   Know the indications for the use of protein hydrolysate formulas

                   Recognize the signs and symptoms of milk protein allergy

                   Recognize soy as a potential allergen in gastrointestinal protein
                   allergy

                   Understand the nutritional supplements that can be used to increase
                   caloric density of formulas and their risks

                   Understand the difference between milk protein allergy and
                   lactose intolerance

                   Know the indications for the use of soy formula

     3.     Introduction of solid food

                   Know the appropriate age for initiating solid food and the
                   appropriate sequence

                   Understand the consequences of initiating solid food prematurely

C.   Deficiency states and hypervitaminosis (including rickets)

     1.     Vitamin deficiency states

                   Know that rickets may develop in rapidly growing
                   premature infants with low intake of either calcium or
                   phosphorus


                                                                                         8
            Recognize the effects of vitamin D deficiency in children of various
            ages, including breast-fed infants and older children

            Recognize the clinical manifestations of vitamin K deficiency

            Recognize the presenting signs and symptoms of rickets, and manage
            appropriately

            Recognize that a child with a resected terminal ileum and ileal
            inflammation requires appropriate vitamin B12 supplementation, and
            plan the regimen

            Know that folate deficiency may develop in children with
            malabsorption syndrome

            Know the laboratory and radiologic findings in vitamin D deficiency
            rickets

            Know the signs, symptoms, and causes of vitamin E deficiency

            Know the nutritional complications associated with a strict
            vegan diet

            Recognize the signs, symptoms, and causes of vitamin B12 deficiency

            Recognize the signs, symptoms, and causes of vitamin C deficiency

            Recognize the signs, symptoms, and causes of vitamin A deficiency

            Recognize the signs, symptoms, and causes of folate deficiency

2.   Mineral deficiency states

            Know the diseases that are associated with trace mineral deficiency
            (zinc, copper, magnesium, chromium)

3.   Protein, calorie deficiency states

            Recognize the clinical manifestations of protein deficiency,
            including edema and malnutrition

            Recognize that marasmus is caused by inadequate caloric intake

            Know the causes of protein-losing enteropathy

            Know how to diagnose protein-losing enteropathy

4.   Hypervitaminosis

            Recognize the signs and symptoms of hypervitaminosis D

            Recognize the signs and symptoms of hypervitaminosis A

                                                                                   9
D.   Principles of nutritional support

     1.     General

                   Understand the differences among categories of formula used for
                   special nutritional support and the indications for their use

     2.     Tube feeding, enteral nutrition

                   Know the complications of tube feeding
                   Know the advantages of enteral nutrition over parenteral nutrition

                   Understand the indications for providing enteral nutritional support

                   Know the indications for intermittent (bolus) feeding as compared
                   with continuous tube feeding

     3.     Parenteral nutrition

                   Know the indications for total and peripheral alimentation

                   Know the complications of and understand how to monitor
                   parenteral nutrition

E.   Nutritional problems associated with specific diseases,

     conditions

     1.     Gastrointestinal disorders

                   Recognize that secondary lactose intolerance may be caused by
                   acute gastroenteritis

                   Understand the importance of early refeeding on the nutritional
                   status of a child with gastroenteritis

                   Know the particular nutritional deficiencies associated with
                   Crohn disease

     2.     Renal disease

                   Recognize the importance of adequate nutrition on growth in children
                   with renal insufficiency

                   Recognize the nutritional deficiencies that may occur with renal
                   disease

     3.     Hepatic disease

                   Understand the causes of growth failure in patients with chronic
                   cholestatic disease

                                                                                          10
              Know the general dietary recommendations in hepatic disease

              Understand the consequences of hepatic disease on nutrient digestion
              and absorption

              Understand the mechanism of rickets in children with hepatic disease

4.    Cardiac disease

              Know the importance of increasing caloric intake in patients with
              fluid-restricted diets (eg, in cardiac disease)
              Understand the recommendations of the National Cholesterol Education
              Program for Children

5.    Cystic fibrosis

              Recognize the specific nutritional problems in children with cystic
              fibrosis

6.    Hematologic-oncologic disease

              Recognize the importance of adequate nutritional intake in children
              with chronic diseases, including malignancies

7.    Neurologically handicapped children

              Understand and plan management for the different caloric requirements
              of neurologically impaired children

8.    Burns

              Recognize nutritional problems in children with burns

9.    Allergies

              Recognize the effects of a restricted diet for multiple food
              allergies on the nutritional adequacy of a patient's diet

10.   Athletes

              Know the indications for and the adverse effects of ingesting
              sports energy drinks and protein supplements in student athletes

              Know the nutritional complications in pediatric athletes
              (including cheerleaders and dancers)

11.   Vegetarians

              Understand which nutrients need to be supplemented in individuals
              who ingest vegetarian and vegan diets


                                                                                      11
       F.    Obesity

                           Know that patients with moderate exogenous obesity are generally
                           tall for age and that patients with endocrine causes of obesity are
                           small for age

                           Understand the genetic risk factors for obesity

                           Know the complications of obesity (eg, hypertension, type 2 diabetes,
                           metabolic syndrome, polycystic ovary syndrome, dyslipidemia)

                           Understand the differential diagnosis of obesity

                           Know how to monitor and manage obesity and understand the importance
                           of early intervention

                           Know that obesity in adolescence and parental obesity are strong
                           predictors of obesity in adulthood, and understand the associated
                           morbidity

                           Know which interventions have been effective and ineffective in
                           managing adolescent obesity

                           Understand the lifestyle choices that may contribute to obesity,
                           including inadequate physical activity and excessive "screen" time,
                           (TV, computer)

                           Understand the importance of body mass index (BMI) in identifying
                           obesity

                           Understand the definitions of overweight and obesity in terms of
                           body mass index (BMI)

                           Identify the environmental risk factors for obesity

                           Counsel a family with regard to obesity prevention and treatment

                           Understand lifestyle choices that may contribute to obesity

                           Calculate the body mass index (BMI)

                           Understand which adolescents should receive in-depth medical
                           assessments for the sequelae of obesity (eg, BMI > 95th percentile,
                           BMI between 85th and 95th percentile with additional risk factors)

       G.    Weight loss

                           Recognize the possible adverse effects of "fad" weight loss diets

III.   Preventive Pediatrics

       A.    Immunizations
                                                                                                   12
1.   Indications and schedules

           Know the immunization schedules for children

           Know that preterm infants should be immunized at the same
           postnatal age as full-term infants

           Know the indications and the schedule for hepatitis B vaccine

           Know the indications and the schedule for the inactivated
           and live attenuated influenza vaccines

           Know the indications and the schedule for the pneumococcal vaccines
           Know the indications and the schedule for the tetanus vaccine
           (eg, need for routine booster and at the time of injury)

           Know the indications and the schedules for diphtheria, tetanus,
           and pertussis vaccines

           Know the indications and schedule for the mumps vaccine

           Know the contraindications of the (live virus) rubella vaccine

           Know the indications and the schedule for the rubella vaccine

           Know the indications and the schedule for the
           poliovirus vaccine

           Know the indications and the schedule for H. influenzae
           type b vaccine

           Know how to obtain information on immunizations for patients and
           families traveling to foreign countries

           Know the indications and the schedule for varicella
           vaccine

           Know the indications and the schedule for hepatitis A vaccine

           Know the indications and the schedule for the meningococcal vaccines

           Know the recommendations and schedule for the rotavirus vaccine

           Know the recommendations and schedule for the human papillomavirus
           vaccine

           Know the indications and the schedule for the MMR vaccine

           Know the contraindications for the rotavirus vaccine

           Know which serotypes are contained in the human papillomavirus vaccine

                                                                                    13
2.   General contraindications

     a.    Immune deficiency

           Understand which immune-deficient patients should not
           receive a live-virus vaccine

           Plan an immunization schedule for an immune-
           deficient patient

     b.    Egg allergy

           Understand that not all egg-based vaccines are contraindicated for
           children after an anaphylactic reaction to eggs
           Know when it is appropriate to administer measles vaccine to a
           patient with egg allergy

           Know that patients with a history of anaphylactic reaction to eggs
           should generally not receive inactivated influenza vaccine

3.   Prevention by active immunization

     a.    Influenza vaccine

           Know that the influenza vaccine should be administered yearly because
           of changes in antigens, especially to children with certain chronic
           diseases (eg, congenital heart disease, cystic fibrosis, BPD),
           and to immunosuppressed patients after transplant

           Know that the influenza vaccine contains antigens for influenza A and
           B and that the constituency may change annually

           Know the safety of the inactivated influenza vaccine (eg, lack of
           significant neurologic complications, noncommunicability)

           Know the safety of and contraindications for the live attenuated
           influenza vaccine

     b.    Meningococcal vaccine

           Know which serotypes are contained in the meningococcal vaccine

     c.    Pneumococcal vaccine

           Know that pneumococcal vaccines are either conjugated or nonconjugated
           and that each is multivalent

           Know that the immunogenicity of the polysaccharide pneumococcal
           vaccine is limited in children younger than 24 months of age

           Know the benefits for the use of the pneumococcal conjugate vaccine

                                                                                    14
     (prevention of pneumococcal pneumonia and pneumococcal meningitis,
     less effective in prevention of otitis media)

     Understand that the pneumococcal conjugate vaccine is protective
     only against the serotypes included in the vaccine

d.   Hepatitis vaccines

     Know which newborn infants are at greatest risk for infection
     with hepatitis B and the potential consequences of such infection

     Know that the hepatitis B vaccine is composed of recombinant DNA-
     produced HBsAg

     Know the recommended use of hepatitis B vaccine in premature infants

e.   Tetanus vaccine

     Know that the tetanus vaccine is a toxoid

     Know that permanent immunity does not result from C. tetani
     infections treated with antitoxin

     Know the adverse effects of excessive tetanus immunization

f.   Diphtheria-tetanus combination

     Know the difference between DT and dT

     Know the appropriate ages for the use of DT and dT

g.   Pertussis vaccines (cellular and acellular)

     Know the composition of pertussis vaccines

     Know the efficacy and possible complications of pertussis vaccines

     Know the contraindications of pertussis vaccines (eg, unstable or
     active CNS disease, immediate anaphylaxis, encephalopathy within
     seven days)

     Know in which conditions use of the pertussis vaccine is not
     contraindicated (eg, stable CNS disease, family history of seizures,
     SIDS in a sibling, low-grade fever)

h.   DTaP and Tdap vaccines

     Know that administering decreased volumes of the DTaP vaccine because
     of prior reactions is inappropriate

i.   Measles vaccine


                                                                             15
            Know the appropriate use of the measles vaccine during an outbreak

            Know that infants who were immunized for measles when younger than 12
            months of age may not be protected

            Know the contraindications of the (live virus) measles vaccine

            Know the recommendations regarding measles revaccination

            Recognize the importance of the second dose of measles vaccine

     j.     Rubella vaccine

            Realize that although the rubella vaccine is not recommended for use
            in pregnant women, there has never been a reported case of the
            congenital rubella syndrome caused by the vaccine virus

     k.     Poliovirus vaccine

            Know the efficacy of the poliovirus vaccine

            Know the safety of the poliovirus vaccine

            Know that poliovirus infection is transmissible by the fecal-oral
            route

            Know the importance of asking the parents whether everyone in the
            home has been immunized against poliovirus

     l.     Hemophilus influenzae type b vaccine

            Know the composition and use of the H. influenzae type b vaccines

            Recognize the changes of epidemiology of H. influenzae infection
            secondary to widespread use of the vaccine

     m.     Varicella vaccine

            Know the indications for the use of varicella vaccine after
            exposure

4.   Catch-up immunizations

            Plan an immunization schedule for a patient born
            three months prematurely

            Plan an immunization schedule for children or adolescents who begin
            their immunizations late or whose immunizations are delayed

5.   Live vs killed vaccines

            Know which vaccines are live and which are killed

                                                                                    16
B.   Screening

     1.    Principles of screening tests

     2.    Blood pressure

                    Know when to screen for elevated blood pressure and how to
                    interpret the results

                    Know that a single elevated blood pressure reading requires repeat
                    evaluation

                    Know that blood pressure cuff size should be appropriate for patient
                    size

     3.    Hematocrit

                    Know that there may be a difference between a centrally
                    and a peripherally drawn hematocrit

     4.    Lead

                    Know the screening tests available for blood lead concentration

                    Understand that a screening examination for lead can be incorporated
                    into early periodic screening

                    Recognize that children may have multiple nondietary
                    sources of exposure to lead

                    Understand that lead poisoning may be a cause of
                    cognitive difficulty

                    Know the effects of chronic mildly increased blood lead
                    concentrations

                    Know how to manage an increased blood lead concentration

     5.    Hearing

                    Understand that conductive hearing loss results from
                    interference with the mechanical transmission of sound
                    in the outer ear, tympanic membrane, or middle ear

                    Know the natural history of conductive hearing loss

                    Understand that brain stem evoked response audiometry
                    involves electroencephalographic response to auditory
                    stimulus

     6.    Vision
                                                                                           17
                    Know the visual abilities of normal newborn infants

                    Know which conditions may be detected by periodic
                    ophthalmoscopic examinations (eg, cataracts, retrolental
                    fibroplasia, retinoblastoma)

                    Know how to identify ocular tropias and phorias using a
                    cover test

     7.    Hypercholesterolemia/hyperlipidemia

                    Know how to evaluate hypercholesterolemia/hyperlipidemia and its
                    clinical manifestations

                    Know the risk factors for hypercholesterolemia/hyperlipidemia

C.   Disease prevention

     1.    Heart disease

                    Know the risk factors associated with coronary artery disease

     2.    Osteoporosis

                    Counsel families regarding the effects of diet, exercise, and smoking
                    on the natural history of osteoporosis

     3.    Respiratory disease (eg, smoking)

                    Know that passive exposure to cigarette smoke in the home increases
                    the chances, frequency, and duration of lower respiratory tract
                    illness in children

                    Know that common indoor exposures can produce respiratory symptoms:
                    wood fires and stoves, cooking spray, hair spray, animal dander,
                    cigarette smoke

D.   Anticipatory guidance

     1.    Safety

           a.       General

                    Know ways of preventing head injury

                    Provide age-appropriate home safety information

           b.       Automobiles

                    Recommend appropriate car restraint systems based on age and weight
                    of the infant or child

                                                                                            18
             Know the qualities of an adequate car seat

             Know that drunk driving is a major cause of automotive fatalities
             among young drivers

             Know the problems associated with the use of infant car seats for
             premature infants

             Be aware of the significance of non-crash automobile accidents for
             young children

     c.      Stairways

             Know the dangers of infant walkers and stairs

     d.      Bicycles

             Counsel parents regarding bicycle safety

     e.      Rollerblades, skateboards

             Counsel parents and children regarding the use of safety
             equipment with rollerblades and/or skateboards

2.   Poison prevention

             Know that the storage of poisonous substances should be discussed at
             the six-month well-child visit

             Know the value of childproof caps

3.   Burns

             Counsel parents regarding prevention of burns
             (matches, electrical burns, fireworks)

             Know how to counsel parents regarding hot water heaters

4.   Bites and stings

             Instruct families regarding the acute management of sting anaphylaxis
             at home

             Advise a parent on the appropriate method to remove a tick from their
             child

             Counsel the parents of an infant or child regarding the prevention of
             animal bites

5.   Water safety


                                                                                     19
                          Know the facts about drowning deaths (eg, epidemiology, location)

                          Plan safety measures for a home pool

                          Know how to counsel families regarding safe boat use (eg, flotation
                          devices, supervision)

            6.     Sun exposure

                          Counsel parents regarding sunscreens and exposure to sun

            7.     Firearms

                          Counsel parents regarding the risks of having firearms in the home

                          Know the epidemiology of firearms in US households

                          Identify components of an injury prevention plan for firearms in a
                          household (locked, unloaded, discarded)

            8.     Personal safety (eg, strangers)
            9.     "Screen" time (eg, TV, computer)

                          Counsel parents regarding appropriate limits in their children's
                          "screen" (eg, TV, computer) time

            10.    Sleep (eg, SIDS, obstructive sleep apnea, normal patterns)

                          Counsel parents regarding bedtime routines for their children

IV.   Poisoning and Environmental Exposure to Hazardous Substances

      A.    General

            1.     Prevention and risks

            2.     Poison control centers, online resources

                          Understand the data available from poison control centers
                          (eg, signs and symptoms of toxicity, management)

            3.     Therapeutic options for poisoning

                          Understand the management of childhood poisonings

            4.     Recognition of ingestion of unknown substance(s)

                          Understand the management of poisonings by an unknown agent or
                          by multiple agents

      B.    Specific acute poisonings, ingestions, and exposures


                                                                                                20
1.   Nonsteroidal analgesics

            Recognize the signs and symptoms of acetaminophen toxicity

            Understand the management of a suspected or confirmed
            acetaminophen overdose

2.   Opiates

            Recognize the signs and symptoms of an opiate overdose

            Understand the management of an opiate overdose

3.   Anticholinergic substances

            Recognize the signs and symptoms of anticholinergic drug use

4.   Salicylates

            Recognize the signs and symptoms of salicylate toxicity

            Understand the management of salicylate toxicity
5.   Antihypertensives

            Recognize the signs and symptoms of ingestion of medications that
            produce hypotension

6.   Tricyclic antidepressants

            Understand that a danger of tricyclic antidepressant treatment
            is accidental ingestion by siblings

            Understand that cardiac dysrhythmias may occur late after ingestion
            of tricyclic antidepressants

            Recognize the signs and symptoms of tricyclic antidepressant toxicity

            Understand the initial management of tricyclic antidepressant toxicity

7.   Ethanol

            Know that ethanol intoxication may cause hypoglycemia

            Know that ethanol intoxication may mask toxicities from other
            drugs

            Be aware of potentially harmful additives in over-the-counter
            medications (eg, ethanol in mouthwash, salicylate in antidiarrheal
            products)

            Understand the evaluation and management of a possible methanol
            ingestion

                                                                                     21
8.    Hydrocarbons

               Know how to manage a child who has ingested a substance
               containing a hydrocarbon

9.    Organophosphates

               Recognize the signs and symptoms of organophosphate poisoning

               Understand the management of organophosphate poisoning

10.   Carbon monoxide

               Recognize the signs and symptoms of carbon monoxide poisoning,
               and manage appropriately

11.   Acids, alkali, and alkaloids

               Know the common household sources of acids and alkali

               Recognize that gastric lavage is contraindicated in a caustic
               ingestion
               Recognize that corrosive material such as hydrochloric and
               sulfuric acids can be transported to the stomach with few or
               no esophageal burns, causing severe gastritis, perforation, or
               late stricture formation

               Recognize the role of endoscopy after a corrosive ingestion

12.   Button batteries

               Know how to manage a child who has ingested a button battery

13.   Coins

               Know how to manage a child who has ingested a coin

14.   Iron

               Understand how to manage a child with iron ingestion

15.   Ethylene glycol

               Understand the evaluation and management of a possible ethylene
               glycol ingestion

16.   Plants

               Recognize the signs and symptoms following ingestion of a potentially
               toxic plant


                                                                                       22
     17.   Complementary-alternative medicines

                  Understand the importance of asking about the use of
                  complementary/alternative medicines, especially in children with
                  complex conditions such as autism spectrum disorder

     18.   Over-the-counter medicines (eg, cold remedies)

                  Recognize that over-the-counter cough and cold preparations have
                  not been adequately studied in children younger than 6 years of age
                  and that they are not recommended for use for the common cold

                  Know the active ingredients and the common adverse effects and
                  toxicities of over-the-counter cough and cold preparations (eg,
                  dextromethorphan, antihistamines, pseudoephedrine/phenylephrine,
                  guaifenesin)

C.   Exposure to toxic substances in the environment

     1.    Age-related risk and impact of exposure

                  Understand why infants are at greater risk than adults from toxic
                  substances in the environment

     2.    Obtaining an exposure history

                  Know how to obtain a history of exposure to toxic substances in the
                  environment

     3.    Contaminants in drinking water

                  Know the contaminants potentially found in drinking
                  water (eg, E. coli, Cryptosporidium, trichloroethylene,
                  perchloroethylene)

     4.    Contaminants in food

                  Know the toxic substances that may contaminate food sources (eg,
                  mercury, E. coli)

     5.    Chemical hazards in the community

                  Recognize the toxic substances that may contaminate the environment
                  and affect the health of children (eg, pesticides, industrial waste)

     6.    Chemical exposures in the home

                  Know the potential occupational exposures that directly or indirectly
                  affect the health of children

                  Recognize the common exposures and health problems that are
                  associated with house renovation and repair

                                                                                          23
           7.    Exposures from terrorism (eg, anthrax, smallpox)

                        Recognize the characteristic skin lesions of anthrax

                        Differentiate the skin lesions of varicella from those of smallpox

V.   Fetus and Newborn Infant

     A.    Normal newborn infants

           1.    Delivery room management

                 a.     Temperature control

                        Know that a newborn infant is prone to heat loss because of a high
                        surface area-to-body mass ratio

                        Know that a newborn infant who is cold stressed rapidly
                        depletes essential stores of fat and glycogen

                        Know that heat loss in the delivery room can be reduced
                        by the use of a radiant warmer, drying, and swaddling

                        Recognize the hazards and benefits associated with the use of radiant
                        warmers for neonates

                 b.     Assessment

                        Know that a normal newborn infant can fixate

                        Know the components of the Apgar score

                        Understand the significance of the one- and five-minute
                        Apgar scores

           2.    Fetal assessment

                 a.     Non-stress test

                        Know that the non-stress test monitors fetal heart rate
                        reactivity in response to fetal activity

                 b.     Stress test

                        Recognize that the stress test is used to evaluate
                        uteroplacental insufficiency

                 c.     Biophysical profile

                        Know the factors used by obstetricians in evaluating fetal
                        well-being (eg, fetal activity, amount of amniotic fluid,

                                                                                                24
           heart rate)

           Understand the significance and plan the management of fetal
           dysrhythmias

3.   Maternal screening (see IX.I.30)

4.   Transition

     a.    Maturational assessment

           (1).     AGA, LGA, SGA

           Recognize the need to plot anthropomorphic
           measurements against gestational age on a graph

           (2).     Preterm, term, postterm

           Know the physical and behavioral characteristics of a preterm
           infant

           Distinguish between small-for-gestational age and preterm gestation
           in low-birth-weight infants

           Know the physical and behavioral characteristics of a full-term
           infant
           Know the physical and behavioral characteristics of a post-term
           infant

5.   Routine care

     a.    General

           Plan appropriate evaluation of an infant with physiologic breast
           hypertrophy

     b.    Vitamin K

           Know that prophylactic administration of vitamin K will
           prevent classic hemorrhagic disease of the newborn

           Recognize the presenting signs and symptoms of classic
           hemorrhagic disease of the newborn

           Recognize that maternal exposure to drugs that may affect
           coagulation can result in early hemorrhagic disease of
           the newborn

     c.    Eye prophylaxis

           Know that prophylaxis of ocular gonorrheal infection in a newborn
           infant should include silver nitrate solution in single-dose ampules

                                                                                  25
     or single-use tubes of ophthalmic ointment containing
     erythromycin or tetracycline

     Recognize that silver nitrate solution is not adequate
     prophylaxis for neonatal chlamydial conjunctivitis

d.   Feeding requirements

     (1).     Calories

     Recognize that the caloric requirement per kilogram for adequate
     growth is greater for preterm infants than
     for full-term infants

     (2).     Fluid

     Recognize that preterm infants have a greater daily
     fluid requirement per kilogram of body weight than
     full-term infants

     Recognize that insensible water loss is increased
     with prematurity and the use of radiant warmers

e.   Screening

     (1).     General

     (2).     Glucose

     Recognize that the rapid assessment of whole blood
     glucose concentrations (eg, glucose oxidase test strips)
     may yield falsely high or low values

     (3).     Hematocrit

     Know the normal range of the hematocrit value for a newborn infant

     Recognize that preterm infants have lower
     hematocrit values than full-term infants

     Distinguish between the timing of physiologic anemia
     of the full-term infant and of the preterm infant

     (4).     Serologic test for syphilis

     Recognize the presenting signs and symptoms of
     congenital syphilis

     (5).     Expanded metabolic screening

              (a).     Thyroid function


                                                                          26
     Know the possible causes of a decreased serum thyroxine concentration
     in a neonate

     Distinguish between the possible causes of a decreased serum
     thyroxine concentration in a term and preterm neonate with or
     without illness

              (b).     Phenylketonuria

     Know the utility and limitations of PKU screening

     (6).     Hearing

     Understand the use of otoacoustic emission (OAE) devices for neonatal
     hearing screening

f.   Cord care

     Know the recommended methods of umbilical cord care

g.   Physiologic events

     (1).     Stool

     Recognize that the delayed or absent passage of
     meconium is associated with colonic obstruction
     (eg, meconium plug syndrome, Hirschsprung
     disease, imperforate anus)
     Know the difference between bottle-fed infants and
     breast-fed infants as related to stool frequency
     and frequency of feeding

     (2).     Urination

     Know that a newborn infant who does not urinate by
     24 hours of age warrants evaluation

     Plan the evaluation of an anuric infant

     (3).     Vital signs

     Know that blood pressure values vary directly with
     gestational age

     (4).     Spitting vs vomiting

     Recognize that bilious vomiting is a common finding
     in infants with small bowel obstruction

     (5).     Jaundice

     Understand bilirubin synthesis, transport, and metabolism

                                                                             27
                 Distinguish between physiologic jaundice in a full-
                 term infant and physiologic jaundice in a preterm
                 infant

     6.    Discharge plans

                 Know the qualifications for consideration of early discharge of a
                 newborn infant

                 Know the benefits and complications of early discharge of
                 a newborn infant

                 Know the importance of follow-up after early discharge of
                 a newborn infant

     7.    Home birth

B.   Abnormal newborn infants

     1.    General

                 Know the management of any neonatal abstinence syndrome

                 Formulate a differential diagnosis of lethargy and coma in a neonate

     2.    Resuscitation

           a.    Ventilation
                 Know that a normal newborn infant has established
                 regular respirations by 1 minute of age

                 Recognize that a newborn infant who has a slow heart rate and
                 impaired ventilatory effort requires immediate positive-pressure
                 ventilation

                 Recognize the need to establish a patent airway before
                 applying positive-pressure ventilation

                 Know that the initial lung inflation may require increased
                 pressure for the first breath

           b.    Suctioning

                 Recognize a newborn infant's larynx needs to be visualized and
                 the trachea suctioned if thick or particulate meconium is present
                 in the amniotic fluid and the infant is not vigorous

           c.    Perfusion

                 Recognize the indications for external cardiac massage of a newborn
                 infant during resuscitation (eg, if the heart rate does not

                                                                                        28
           increase above 60 beats/min after effective ventilation with oxygen
           has been established)

           Know the proper technique for external cardiac massage
           in a newborn infant

           Recognize the metabolic consequences of continued poor perfusion
           in a newborn infant

3.   Very-low-birth-weight infant

           Recognize that very-low-birth-weight infants often cannot
           achieve an Apgar score greater than 6 because they are
           neurologically immature (eg, hypotonic, blunted response
           to noxious stimuli)

           Plan the initial care of very-low-birth-weight infants
           (eg, administration of a parenteral glucose solution,
           maintenance of a thermoneutral environment)

           Recognize that initial care of a very-low-birth-weight
           infant includes monitoring of blood glucose and arterial
           oxygen concentrations

           Recognize that initial care of the very-low-birth-weight
           infant includes evaluation for sepsis if appropriate

           Understand the prognostic factors for very-low-birth-weight infants

4.   Conditions, diseases
     a.    Hypoxia, ischemia

           Know that hypoxic-ischemic encephalopathy is the most frequent cause
           of neonatal seizure in a full-term infant

           Recognize that neonatal seizures secondary to hypoxic-ischemic
           encephalopathy characteristically occur within 24 hours of birth

           Recognize that the majority of full-term newborn infants who
           have neonatal seizures secondary to hypoxic-ischemic encephalopathy
           do not manifest long-term neurodevelopmental sequelae

           Recognize that intrapartum asphyxiation can cause injury
           to multiple organ systems (eg, kidney, lung, intestine, liver,
           brain, heart)

     b.    Polycythemia, hyperviscosity

           Recognize that newborn infants with polycythemia are at risk for
           hypoglycemia and hyperbilirubinemia, and manage appropriately

           Know that the treatment for symptomatic polycythemia is

                                                                                  29
     a partial exchange transfusion

c.   Nonphysiologic jaundice

     Plan the management of a patient with hyperbilirubinemia

     Recognize the clinical manifestations of acute bilirubin
     encephalopathy

     Recognize the permanent clinical sequelae of bilirubin toxicity
     (kernicterus)

     Understand the strategies for prevention of severe
     hyperbilirubinemia in newborn infants (eg, increasing frequency of
     breast-feeding, screening prior to hospital discharge)

d.   Intracranial hemorrhage

     Plan the evaluation and management of a neonate with intracranial
     hemorrhage

     Recognize the clinical and laboratory findings associated with
     intracranial hemorrhage in a neonate

e.   Small-for-gestational age

     Recognize that small-for-gestational-age infants have
     a higher neonatal mortality rate than appropriate-for-gestational
     age infants

     Know that small-for-gestational-age infants are prone
     to fasting hypoglycemia, polycythemia, and temperature
     instability, and manage appropriately

     Know that perinatal asphyxia is a frequent complication
     of intrauterine growth restriction

f.   Respiratory distress

     (1).     General

     Know the normal arterial blood gas values for a newborn
     infant (pO2 60 to 90 mm Hg, pCO2 35 to 45 mm Hg)

     (2).     Respiratory distress syndrome

     Understand the effects of surfactant administration in an infant with
     respiratory distress syndrome

     Recognize the characteristic clinical and radiographic appearance
     of respiratory distress syndrome


                                                                             30
     Know appropriate treatments for respiratory distress syndrome

     (3).     Pneumothorax

     Recognize that pulmonary air leaks are common in newborn
     infants who are treated with assisted ventilation

     Recognize the characteristic clinical and radiographic appearance
     of a pneumothorax in a newborn infant

     (4).     Meconium aspiration syndrome

     Recognize the characteristic clinical and radiographic appearance
     of meconium aspiration syndrome

     (5).     Congenital pneumonia

     Recognize that neonatal pneumonia can mimic respiratory distress
     syndrome

     (6).     Transient tachypnea of the newborn

     Identify and manage transient tachypnea of the newborn

g.   Cyanosis (nonrespiratory)

     Know that peripheral cyanosis is a common finding in
     healthy full-term newborn infants

     Know that it is difficult to distinguish between
     persistent pulmonary hypertension without meconium
     aspiration and cyanotic congenital heart disease
     Recognize the clinical presentation of a neonate with persistent
     pulmonary hypertension following meconium aspiration

h.   Bronchopulmonary dysplasia (see XIII.E.1)

i.   Sepsis

     Know the appropriate antibiotic treatment for suspected sepsis in
     the immediate newborn period

     Know the significance for infection of prolonged premature rupture
     of the membranes

     Understand the risk of sepsis from the use of intravascular
     catheters

j.   TORCH infections, including HIV

     Recognize that perinatal infection with cytomegalovirus
     may be acquired in utero, during delivery, or in the

                                                                          31
     neonatal period (eg, breast milk, blood transfusion)

     Recognize the signs and symptoms of symptomatic congenital
     cytomegalovirus disease

     Recognize that the majority of newborn infants with
     congenital toxoplasmosis are asymptomatic in the neonatal
     period

     Recognize the clinical manifestations of congenital cytomegalovirus
     infection, including congenital hearing loss and mental retardation

k.   Recognition and stabilization of surgical emergencies

     Plan the evaluation of a full-term infant who has severe
     respiratory failure at birth that does not respond to
     intubation and assisted ventilation

l.   Necrotizing enterocolitis

     Know the usual presentation of necrotizing enterocolitis, and plan
     initial management

     Know that the radiographic finding of pneumatosis
     intestinalis is the hallmark of necrotizing enterocolitis

     Recognize that intestinal stricture formation is a late
     complication of necrotizing enterocolitis

m.   Intestinal obstruction

     Recognize the clinical signs and symptoms of congenital bowel
     obstruction
     Know the treatment of abdominal distention caused by a congenital
     small bowel obstruction

     Know the etiology, diagnostic evaluation, and treatment of
     meconium ileus

n.   Tracheoesophageal fistula

     Recognize the signs and symptoms of esophageal atresia
     with tracheoesophageal fistula

     Know how to evaluate an infant with a tracheoesophageal
     fistula

o.   Abdominal-intestinal wall defect

p.   Infants affected by maternal disorders (eg, diabetes,

     SLE)
                                                                           32
     Recognize that an infant of a diabetic mother is at risk
     for hypoglycemia, hypocalcemia, polycythemia, and neonatal
     small left colon syndrome

     Understand the pathogenesis of hypoglycemia in an infant
     of a diabetic mother

     Recognize that congenital anomalies are more frequent
     among infants of diabetic mothers than among normal
     control infants

     Understand the management of a newborn whose mother has
     type 1 diabetes

q.   Infants affected by maternal medications

     Recognize that the use of some anticonvulsants during pregnancy is
     associated with an increased risk of fetal anomalies

     Know that isotretinoin is a potent teratogen

     Understand the effects of drugs given to the mother during labor
     (eg, opiates, beta-adrenergic tocolytic agents) on the fetus/neonate

     Know the effect on a fetus of lithium use during pregnancy

     Know the effect on a fetus of warfarin use during pregnancy

r.   Infants affected by maternal substance use

     Know that fetal alcohol syndrome is a frequently
     documented cause of mental retardation

     Recognize the physical features of fetal alcohol syndrome, and
     manage appropriately

     Know the association between the maternal use of alcohol and any
     fetal abnormalities and/or neonatal withdrawal syndrome

     Know the association between the maternal use of marijuana and any
     fetal abnormalities and/or neonatal withdrawal syndrome

     Know the association between the maternal use of tobacco and any
     fetal abnormalities and/or neonatal withdrawal syndrome

     Know the association between the maternal use of opiates and any
     fetal abnormalities and/or neonatal withdrawal syndrome

     Know the association between the maternal use of amphetamines and
     any fetal abnormalities and/or neonatal withdrawal syndrome


                                                                            33
                          Know the association between the maternal use of barbiturates and
                          any fetal abnormalities and/or neonatal withdrawal syndrome

                          Know the association between the maternal use of cocaine and any
                          fetal abnormalities and/or neonatal withdrawal syndrome

                          Know the effect of maternal smoking on a fetus

                          Know the impact of maternal drugs of abuse on a fetus

                   s.     Multiple congenital anomalies (See VII)

                   t.     Oligohydramnios

                          Know that any infant with features of the oligohydramnios
                          tetrad (Potter facies) warrants a detailed evaluation of the
                          genitourinary system

                   u.     Deformations

                          (1).     Amniotic bands

                          Know that amniotic bands can become adherent to any part of
                          the fetal body, thereby causing a variety of disruptions
                          (eg, ring-like constrictions of limbs, amputation of digits,
                          disruptive clefts of the face)

                          (2).     Positional deformations (eg, hip dysplasia)

                          Be able to recognize newborn deformations due to fetal constraints
                          in utero

                          Know the difference in how the development of congenital anomalies
                          occurs in fetal deformation and/or malformation

VI.   Fluid and Electrolyte Metabolism

      A.    Composition of body fluids

            1.     Intracellular, extracellular

                          Recognize that a decrease in protein concentration may lead to
                          a reduction in plasma volume and an increase in interstitial
                          volume

                          Know that equilibrium between extracellular fluid and intracellular
                          fluid is maintained by the movement of water in response to
                          alteration of osmolality of either compartment

                          Know the clinical relevance of estimating plasma osmolality from
                          serum electrolytes, blood urea nitrogen, and blood glucose
                          concentrations

                                                                                                34
                  Know that chronic sodium depletion may result in intravascular
                  volume depletion

     2.    Electrolytes (sodium, potassium, chloride)

                  Know the physiologic requirements for sodium and potassium

                  Recognize that serum sodium concentration does not reflect total body
                  sodium content

                  Recognize that serum potassium concentration does not reflect total
                  body potassium content

     3.    Protein

                  Understand that hypoproteinemia causes generalized edema

B.   Acid-base physiology

     1.    Normal mechanisms and regulation

                  Understand the pulmonary mechanism for regulating acid-base
                  physiology

                  Know how to calculate the anion gap

     2.    Acidosis, alkalosis

                  Recognize the clinical and laboratory presentation of metabolic
                  acidosis

                  Recognize the serum findings in clinical disturbances of acid-
                  base balance in the simple disorders, evaluating pH, PCO2, and
                  bicarbonate

                  Plan initial therapy for severe acidosis (metabolic)

                  Know the differential diagnosis of acidosis associated with a high
                  anion gap

                  Know that chronic volume contraction can lead to alkalosis

                  Know the pulmonary compensatory changes seen in primary metabolic
                  alkalosis

                  Know the pulmonary compensatory changes seen in primary metabolic
                  acidosis

                  Know the renal compensatory changes seen in primary respiratory
                  acidosis


                                                                                          35
                  Know the renal compensatory changes seen in primary respiratory
                  alkalosis

                  Know which diuretics produce metabolic alkalosis

                  Know which diuretics produce metabolic acidosis

                  Formulate a differential diagnosis of acidosis with a normal anion gap

C.   Electrolyte abnormalities

     1.    Sodium

           a.     Hypernatremia

                  Know that extracellular fluid volume is relatively spared in
                  hypernatremia

                  Know the symptoms of hypernatremia

           b.     Hyponatremia

                  Recognize diseases associated with hyponatremia and
                  increased sodium in the urine

                  Know the causes of factitious hyponatremia

                  Recognize the importance of urinary sodium concentration and urinary
                  osmolality in the differential diagnosis of hyponatremia

                  Know that chronic diuretic therapy can produce hyponatremia

                  Recognize the importance of estimation of sodium intake and output
                  in evaluating patients with hyponatremia

                  Distinguish between dilutional hyponatremia and a total body deficit
                  of sodium
     2.    Potassium

           a.     Hyperkalemia

                  Know the emergency treatment of hyperkalemia

                  Recognize that severe cardiac rhythm changes may begin abruptly in
                  patients with hyperkalemia

                  Know the signs of hyperkalemia

                  Plan the treatment for a patient with hyperkalemia

           b.     Hypokalemia


                                                                                           36
                    Recognize the development of hypokalemia in a patient with
                    gastroenteritis

                    Recognize the electrocardiographic rhythm abnormalities in patients
                    with hypokalemia

                    Know the emergency treatment of hypokalemia

                    Know the symptoms of hypokalemia

     3.     Chloride

                    Recognize the association of chloride and acidosis in the
                    differential diagnosis of metabolic acidosis

                    Recognize the need for a urinary screening examination for diuretics
                    in the evaluation of hypochloremia

D.   Disease states, specific therapy

     1.     Pyloric stenosis

                    Recognize that the differential diagnosis of metabolic alkalosis
                    includes pyloric stenosis

                    Recognize the acid-base changes seen in pyloric stenosis, and
                    manage appropriately

     2.     Gastroenteritis

                    Plan the management of acute gastroenteritis

     3.     Acute renal failure

                    Know the changing fluid requirements in patients with severe oliguria

                    Know that coexisting volume depletion should be corrected in patients
                    with acute renal failure
     4.     Shock

                    Recognize the clinical signs of shock due to fluid loss

                    Know the type of fluids to be administered in the treatment of shock

                    Recognize that frequent clinical assessment is required in the
                    treatment of shock

                    Recognize that immediate fluid resuscitation of infants in shock may
                    require more than 20 mL/kg of fluid to improve their clinical
                    conditions

     5.     SIADH
                                                                                            37
            Recognize the serum and urine abnormalities in SIADH

            Recognize the clinical abnormalities associated with SIADH

            Know the treatment of SIADH

            Know that plasma volume is increased in SIADH

            Recognize how to differentiate SIADH from hyponatremic dehydration

            Recognize disease conditions and medications associated with SIADH

            Understand the importance of fluid restriction in the management
            of SIADH

            Understand that head trauma can lead to diabetes insipidus or SIADH

6.   Cystic fibrosis

            Recognize the hypochloremic/hyponatremic dehydration seen in cystic
            fibrosis

7.   Dehydration

            Recognize the clinical and laboratory abnormalities of
            hyponatremic dehydration

            Recognize the clinical and laboratory abnormalities of
            hypernatremic dehydration

            Recognize the laboratory abnormalities of isotonic dehydration

            Know how to manage hypernatremic dehydration

            Know how to manage hyponatremic dehydration

            Know how to manage isotonic dehydration

            Understand the effectiveness of oral rehydration solutions in
            treating acute diarrheal dehydration

            Understand the differences between and rationale for the composition
            of oral rehydration solutions

            Know that hypotension is a very late sign of dehydration

            Know that the signs and symptoms of dehydration are related to
            changes in extracellular fluid volume

            Know that intracranial hemorrhage may occur during the development
            of hypernatremic dehydration

                                                                                   38
                         Recognize the possibility of seizures in an infant with chronic
                         hypernatremia who is being rapidly rehydrated

                         Understand how to differentiate diabetes insipidus from hypernatremic
                         dehydration (ie, urine specific gravity, urine and serum osmolalities)

             8.    Hyperosmolar non-ketotic coma

                         Plan appropriate fluid therapy for a patient with hyperosmolar
                         non-ketotic coma to prevent the development of cerebral edema

VII.   Genetics and Dysmorphology

       A.    General

             1.    Mendelian inheritance

                   a.    Autosomal dominant

                         (1).     Incomplete penetrance

                         Recognize the inheritance pattern associated with an autosomal
                         dominant disorder with incomplete penetrance

                         (2).     Variable expressivity

                   b.    Autosomal recessive

                         Recognize the clinical and laboratory features associated with an
                         autosomal recessive disorder

                   c.    X-linked recessive (see also XXVII)

                         Know that Factor VIII and IX deficiencies can be
                         diagnosed prenatally

                         Recognize that fragile X syndrome is associated with X-linked
                         mental retardation

                         Recognize the clinical features associated with an X-linked recessive
                         disorder

                         Recognize the inheritance patterns of X-linked recessive disorders

                   d.    X-linked with incomplete penetrance

                         Understand that the identification of the genetic defect in Rett
                         syndrome has greatly expanded the understanding of its clinical
                         spectrum

                   e.    X-linked dominant
                                                                                                  39
                   Recognize the clinical features associated with an X-linked dominant
                   disorder

     2.     Multifactorial inheritance

     3.     Mitochondrial inheritance

B.   Diagnostic testing

     1.     Prenatal

            a.     Invasive

                   (1).     Preimplantation genetic diagnosis

                   (2).     Chorionic villus sampling

                   Know that sickle cell disease can be diagnosed prenatally
                   (eg, chorionic villus sampling, amniocentesis, fetal erythrocytes)

                   (3).     Amniocentesis

                   Know the appropriate tests for predicting the absence of neonatal
                   respiratory distress syndrome

                   (4).     Prenatal umbilical blood sampling

            b.     Noninvasive

                   (1).     Ultrasonography

                   Know that serial growth can be assessed by ultrasonography
                   of the fetus

                   Know that small-for-gestational-age fetuses are seen in
                   women with chronic systemic illnesses

                   Recognize that prenatal ultrasonography can detect major fetal
                   anomalies (eg, hydro- or anencephalus, myelomeningocele,
                   congenital heart defects, gastrointestinal or genitourinary
                   abnormalities) as early as 16 weeks' gestation

                   (2).     Maternal blood screening

                   Know the significance of abnormal maternal serum
                   alpha-fetoprotein concentrations

                   Know that the measurement of maternal serum alpha-
                   fetoprotein concentration is a useful screening test for
                   the diagnosis of open neural tube defects in a fetus


                                                                                          40
     2.    Postnatal

           a.    Karyotyping

           b.    Fluorescent in situ hybridization

                 Know the common gene defects that can be diagnosed with
                 fluorescent in situ hybridization

           c.    Comparative genomic hybridization

                 Understand that comparative genomic hybridization has replaced
                 high-resolution chromosome analysis to screen patients suspected
                 of having a chromosome abnormality

           d.    Molecular analysis

           e.    Metabolic analysis

           f.    Newborn screening (see also V.A.5.e and XI)

C.   Chromosomal abnormalities

     1.    Autosomal

           a.    Trisomy

                 Recognize the prominent features of trisomy 21 in a newborn
                 infant

                 Know the associated medical problems in children with Down syndrome

                 Recognize the prominent features of trisomy 13 in a newborn infant

                 Recognize the prominent features of trisomy 18 in a newborn infant

           b.    Deletions

                 Understand that a single base pair substitution or deletion can
                 lead to a gene defect with major consequences

           c.    Translocations
                 Recognize that the risk of having another child with Down
                 syndrome is greater for a young woman who is a balanced translocation
                 carrier than for a middle-age woman

                 Recognize that the finding of a structural chromosomal
                 abnormality in an infant (eg, unbalanced translocation) necessitates
                 chromosomal analysis of both parents if future children are planned
                 or possible

                 Understand the risk factors associated with subsequent pregnancies

                                                                                         41
                  when an infant is born with a chromosome abnormality

           d.     Duplications

           e.     Inversions

           f.     Contiguous gene syndromes

                  Recognize contiguous gene syndromes, including Prader-Willi, Angelman,
                  Beckwith-Wiedemann, and DiGeorge, and manage appropriately

                  Recognize the signs of DiGeorge syndrome

                  Appreciate that contiguous gene syndromes (deletion or alteration
                  of multiple gene pairs that are adjacent to one another) can cause
                  syndromes with multiple apparent unconnected defects (eg, Angelman,
                  Prader-Willi)

                  Understand the cause(s) of contiguous gene syndromes

     2.    Sex chromosomes

           a.     Turner syndrome

                  Recognize the features of the Turner phenotype in a
                  newborn infant

                  Know that gonadal dysgenesis is uniformly present in Turner
                  syndrome

                  Know that a definitive diagnosis of Turner syndrome
                  requires chromosomal analysis

                  Recognize that growth hormone may be an effective treatment for
                  Turner syndrome

                  Recognize that growth retardation may be the only clinical
                  manifestation of Turner syndrome

           b.     Klinefelter syndrome

                  Know the major clinical manifestations of
                  Klinefelter syndrome
     3.    47,XYY

     4.    47,XXX

D.   Gene abnormalities

     1.    Short stature (see also XI.B.1)

     2.    Overgrowth syndromes
                                                                                           42
     3.    Neuromuscular disorders (see also XVIII)

                  Know that neurofibromatosis is an autosomal dominant disease with
                  extremely variable expression that produces tumors (including CNS
                  tumors and leukemias)

                  Recognize that neurofibromatosis is inherited as an autosomal-
                  dominant trait with a high spontaneous mutation rate

                  Know the clinical features of neurofibromatosis

     4.    Facial and limb abnormalities

                  Know that upper airway obstruction caused by glossoptosis may cause
                  cor pulmonale in infants with Pierre-Robin sequence

                  Know the clinical features of Treacher Collins syndrome and that
                  it is due to a single gene defect

                  Know that the features of Pierre-Robin sequence are secondary to
                  micrognathia

     5.    Osteochondrodysplasia (see also XIX.A.1.b)

     6.    Craniosynostosis

                  Recognize the clinical findings of premature closure of a cranial
                  suture

                  Distinguish between the closure of cranial sutures secondary to
                  failure of brain growth (small, normally shaped head) and
                  premature closure of a single cranial suture

                  Plan appropriate management for a patient with craniosynostosis

     7.    Storage disorders (see also X.A.1.b)

     8.    Connective tissue disorders (see also XXI.G)

     9.    Hamartoses

E.   Miscellaneous

     1.    Pharmacogenetics

     2.    Trinucleotide expansion

     3.    Imprinting

     4.    Anticipation


                                                                                        43
              5.     Associations

                            Recognize the clinical manifestations of genetic associations
                            (eg, CHARGE, VACTERL, VATER)

              6.     Sequences

              7.     Genetic counseling

VIII.   Allergic and Immunologic Disorders

        A.    General

              1.     Epidemiology

              2.     Prevention by dietary restriction

                            Know that breast-feeding for the first six months after birth
                            with supplementation with a complete, nutritionally balanced
                            hypoallergenic formula will decrease the severity and delay
                            the onset of allergic disease

              3.     Relation to environmental exposure

                            Know that indoor pets may contribute to allergic disease

                            Know that passive exposure to cigarette smoke may exacerbate asthma
                            and allergic rhinitis

                            Know that early exposure to tobacco smoke, especially the mother's,
                            increases the frequency of asthma in children

              4.     Influence of genetics on development of allergy

                            Recognize the factors that influence the incidence of atopy in
                            infants

                            Know that children with one component of atopy syndrome (allergic
                            rhinitis, asthma, eczema) have a threefold greater risk of developing
                            a second component

        B.    Allergic rhinitis (see also XXIII.B.3.b.)

                            Recognize the common characteristics of allergic rhinitis (sneezing,
                            nasal itching)
                            Recognize the association between allergic rhinitis and sinusitis
                            and/or otitis media

                            Recognize that perennial allergic rhinitis is usually caused by
                            indoor allergens such as dust mites and animal danders

                            Know that the treatment of allergic rhinitis includes allergen

                                                                                                    44
                 avoidance, antihistamines, and intranasal corticosteroids

C.   Asthma

     1.   Etiology, epidemiology, natural history

                 Recognize the characteristics of exercise-induced asthma (coughing
                 and wheezing after 5 to 6 minutes of exercise, gradual improvement
                 after 20 to 30 minutes of rest)

                 Know that smog increases the severity of exercise-induced asthma

                 Know that asthmatic patients may have exaggerated obstructive
                 responses to exercise, viral URI, allergen exposure, weather changes,
                 smoke pollutants and other irritants, aspirin, and beta adrenergic
                 blocking drugs

                 Know that children with early-onset asthma (< 3 years of age)
                 who have a parental history of asthma, a confirmed diagnosis of
                 atopic dermatitis, or sensitization to aeroallergens are least
                 likely to outgrow asthma

                 Know that asthmatic patients have bronchial hyperresponsiveness, with
                 exaggerated bronchial obstructive response to environmental changes

                 Know that IgE-mediated allergen challenge induces immediate
                 obstruction, which resolves and is followed in 4-12 hours by
                 persistent late-phase obstruction

                 Know that bronchial hyperresponsiveness increases with late-phase
                 asthmatic responses to allergen exposure and with viral respiratory
                 infections

                 Recognize the frequency of recurrent wheezing in infants with
                 RSV bronchiolitis

                 Develop a discharge plan for a hospitalized asthmatic child that
                 includes assessment of potential asthma triggers in the home,
                 school, and neighborhood

     2.   Diagnosis

                 Know that atelectasis associated with an acute exacerbation of asthma
                 does not usually require bronchoscopy, antibiotics, or chest
                 physiotherapy

                 Recognize the signs of severe obstruction in an acute exacerbation of
                 asthma (severe retractions, inability to speak whole phrases,
                 cyanosis, quite breath sounds in presence of other signs of
                 obstruction, peak expiratory flow rates less that 30% of predicted)

                 Know that the majority of asthmatic school-age children have positive

                                                                                         45
          immediate type allergy skin tests

          Know the classifications of asthma severity and their definitions

3.   Treatment

     a.   Acute

          Know that exercised-induced asthma may be a sign of poorly
          controlled asthma

          Plan the most appropriate treatment for a patient with an acute
          exacerbation of asthma (ie, inhaled adrenergic agonists)

          Plan the most appropriate treatment for a patient with an acute
          exacerbation of asthma that is severe and unresponsive to adrenergic
          agonist therapy (ie, systemic corticosteroids)

          Know that corticosteroids in an acute exacerbation of asthma can
          increase adrenergic response, improve FEV1, and improve oxygenation

          Recognize the clinical manifestations of toxicity to adrenergic
          agonists (muscular tremor, tachycardia, hypokalemia)

          Understand the risks and benefits of inhaled corticosteroids

     b.   Outpatient

          Recognize the characteristics of a child at increased risk of ICU
          hospitalization because of asthma (eg, one or more life-threatening
          episodes, severe asthma requiring chronic steroids, poor control of
          daily symptoms, abnormal FEV1, poor adherence, depression/stress)

          Know the kinetics of short- and long-acting inhaled beta-adrenergic
          agonists

          Plan appropriate outpatient treatment of mild, moderate, or severe
          persistent asthma to include daily anti-inflammatory drugs

          Know that excessive daily use of beta adrenergic agonists has been
          associated with increased mortality and with diminished symptom
          control in asthma

          Know that corticosteroids interfere with the late-phase but not the
          immediate response to allergen exposure

          Know that long-term treatment with inhaled corticosteroids decreases
          bronchial inflammation and bronchial hyperresponsiveness

          Know the role of leukotriene antagonists in the management of asthma

          Know the importance of medical and self-assessment in a patient

                                                                                 46
                   with asthma

                   Know the importance of patient education in asthma management

                   Know that routine pulmonary function testing is recommended for
                   children with persistent asthma

D.   Atopic dermatitis (see XX.B)

E.   Urticaria, angioedema, anaphylaxis

                   Know the etiologic agents that commonly cause urticaria/angioedema/
                   anaphylaxis

                   Plan effective treatment of chronic urticaria

                   Know the signs and symptoms of anaphylaxis

                   Plan effective treatment for anaphylaxis

                   Recognize that chronic urticaria does not warrant allergy testing

F.   Adverse reactions to substances

     1.    Food

                   Know that common foods causing allergic reactions include
                   milk, soy, eggs, peanuts, seafood, wheat, and tree nuts

                   Distinguish between anaphylaxis and food poisoning

                   Know that some patients with moderate or severe eczema have positive
                   skin tests to food, may or may not have acute symptoms on ingesting
                   these foods, and experience improvement in their eczema after
                   eliminating these foods

                   Understand the relationship of eczema and food allergies, and how to
                   evaluate a patient with both

                   Know that more than 90% of food-allergic individuals demonstrate
                   clinical responses to only 1 or 2 foods

                   Know that most milk, egg, and soy allergies are outgrown by 5 years
                   of age

                   Know that most allergies to peanuts, tree nuts, and seafood are
                   not outgrown

     2.    Drugs

     3.    Contrast media


                                                                                          47
                   Know that reactions to contrast media are not IgE mediated and can be
                   prevented by pre-treatment with corticosteroids and antihistamines

G.   Issues in diagnosis and treatment of allergic disease

     1.     Skin testing

                   Know the indications for immediate-type skin testing

                   Know that antihistamines are the most commonly used medicines that
                   alter the results of allergy skin testing

     2.     In vitro testing

                   Know that RAST testing correlates closely with results of skin tests

                   Know that in vitro testing is indicated when antihistamines cannot be
                   stopped, when dermatographism is present, or when severe anaphylaxis
                   has occurred to the agent to be tested

     3.     Immunotherapy

                   Know that immunotherapy is most effective in treating allergic
                   rhinitis

                   Recognize and manage the side effects of immunotherapy injections

     4.     Avoidance education

H.   Immunodeficiency disorders

     1.     Presenting signs and symptoms of potential immunodeficiency

                   Recognize clinical characteristics of antibody deficiency syndromes
                   after 4 to 6 months of age (severe first infections and/or chronic
                   and recurrent bacterial infections in more than one anatomic site)

                   Recognize clinical characteristics of cellular immunodeficiency
                   present in the first few months after birth (failure to
                   thrive, chronic diarrhea, overwhelming infections with viral,
                   bacterial, and/or opportunistic infections)

                   Recognize the clinical characteristics of phagocytic disorders

                   Know that some medications used for transplantation may induce
                   immunodeficiency

     2.     Screening tests

                   Plan the laboratory evaluation of antibody function (quantitative
                   immunoglobulin concentrations, specific antibody to responses to
                   both protein and polysaccharide vaccines)

                                                                                           48
                            Plan the laboratory evaluation of cell-mediated immunity (lymphocyte
                            counts and lymphocyte function)

IX.   Infectious Diseases

      A.     Public health considerations: prevention of infectious diseases

             1.     In child-care centers

                            Be familiar with the risk of acquiring infections transmitted in
                            child-care centers

                            Know the child-care exclusion criteria for infections in children

                            Understand for which illnesses child-care exclusion is not indicated

                            Recognize that hand hygiene is the most important measure to prevent
                            transmission of pathogens in child-care centers

             2.     Hospital and office infection control

                            Know the recommendations for standard precautions

                            Know the recommendations for airborne precautions and how these
                            differ from standard precautions

                            Identify when airborne precautions are required

                            Know the recommendations for droplet precautions and how these
                            differ from standard precautions

                            Identify when droplet precautions are required

                            Know the recommendations for contact precautions and how these
                            differ from standard precautions

                            Identify when contact precautions are required

                            Understand that office and hospital staff should receive an
                            annual influenza immunization

             3.     Through breast-feeding

                            Judge for which maternal breast infections breast-feeding should
                            be interrupted

                            Know for which maternal chronic viral infections breast-feeding
                            is not recommended

                            Understand that human milk provides protection against many
                            gastrointestinal and respiratory infections

                                                                                                   49
     4.     Medical evaluation of internationally adopted children

                   Know the recommendations for screening for infectious diseases
                   in internationally adopted children

                   Recognize that antibody tests to some vaccines are available to
                   assist in the evaluation of immunization status of an inter-
                   nationally adopted child who has a history of questionable medical
                   care

                   Know how to assess the validity of an immunization record of an
                   internationally adopted child

     5.     Prevention of vector-borne diseases

                   Know the measures to prevent tick-borne infections

                   Know the measures to prevent mosquito-borne infections

                   Recognize the precautions for application of topical insect
                   repellants in children

     6.     Prevention of infection associated with recreational water

            use

                   Recognize which pathogens can be transmitted by contaminated
                   recreational water

                   Know that certain pathogens are relatively resistant to chlorination
                   and may cause pool-associated outbreaks of acute gastroenteritis

                   Know the precautions to prevent infections associated with
                   recreational water use

B.   Antibiotics

     1.     Aminoglycosides

                   Be aware of the major toxicity of aminoglycosides (auditory/
                   vestibular damage, nephrotoxicity)

                   Know how to modify aminoglycoside doses when peak or trough
                   concentrations are too high

                   Know the appropriate use of aminoglycosides (ie, serious aerobic
                   gram-negative infections)

     2.     Beta-lactam antibiotics

                   Know the mechanism of action of penicillin and other beta-lactam

                                                                                          50
           antibiotics

           Know that third-generation cephalosporins provide a broad spectrum
           of coverage and have excellent penetration into the cerebrospinal
           fluid

           Understand the advantages of third-generation cephalosporins
           over aminoglycosides (eg, greater activity in deep-tissue
           infections, less toxicity, avoidance of need to monitor renal
           function and drug concentrations)

           Know the appropriate use of penicillinase-resistant penicillins

           Know the appropriate use of ampicillin and amoxicillin

           Know the appropriate use of second-generation cephalosporins

           Know that first-generation cephalosporins do not penetrate well
           into the cerebrospinal fluid

           Know the appropriate use of penicillin

           Recognize the problems that have resulted from the widespread
           use of broad-spectrum cephalosporins (eg, antibiotic resistance,
           Clostridium difficile enterocolitis)

3.   Clindamycin

           Recognize the adverse reactions to clindamycin (eg, diarrhea,
           including Clostridium difficile enterocolitis)

           Know the appropriate use of clindamycin

4.   Macrolides

           Know the appropriate use of erythromycin

           Identify the major adverse effects of the macrolide antibiotics

           Know the appropriate use of clarithromycin and azithromycin

5.   Rifampin

           Know the appropriate use of rifampin

6.   Quinolones

           Know the appropriate use of quinolones in children

7.   Tetracyclines

           Know the appropriate use of tetracycline/doxycycline

                                                                                51
     8.     Trimethoprim with sulfamethoxazole

                  Know the appropriate use of trimethoprim with sulfamethoxazole

                  Know that the major adverse effects of trimethoprim with
                  sulfamethoxazole are rash, neutropenia, and Stevens-Johnson syndrome

     9.     Vancomycin

                  Know the appropriate use of vancomycin

                  Know the most common side effect of vancomycin (ie, reddening of
                  the skin resulting from histamine release)

                  Know the significance of misusing vancomycin (ie, development of
                  resistance, especially of enterococci, S. aureus)

C.   Antivirals

                  Know the appropriate use of acyclovir

                  Know the major adverse effects of acyclovir

                  Know the appropriate use of oseltamivir and zanamivir

D.   Antiparasitics

                  Know the appropriate use of metronidazole

                  Know the appropriate use of mebendazole

                  Know the appropriate use of permethrin

                  Know the appropriate use of malathion

                  Know the appropriate use of chloroquine

                  Know the potential adverse effects of chloroquine

                  Know the appropriate use of mefloquine

                  Know the appropriate use of atovaquone/proguanil

E.   Antimicrobial resistance

                  Recognize that excessive antibiotic use has contributed to the
                  development of antibiotic resistance in the community

                  Understand that extensive use of cephalosporins has contributed to
                  broad-spectrum antibiotic resistance in nosocomial pathogens

                  Recognize that children treated with antibiotics are at increased

                                                                                         52
                   risk of becoming carriers of resistant bacteria
                   Know for which illnesses antimicrobial treatment is generally not
                   indicated: bronchitis, middle ear effusion of short duration, most
                   cases of pharyngitis (unless group A streptococcus), mucopurulent
                   rhinitis of short duration

F.   Antifungals

     1.    Amphotericin B

                   Know the appropriate use of amphotericin B

                   Know that the adverse effects of amphotericin B include hypokalemia
                   and multisystem toxicity, especially to the kidneys

     2.    Fluconazole

                   Know the appropriate use of fluconazole

     3.    Griseofulvin

                   Know the appropriate use of griseofulvin

                   Recognize the adverse effects of griseofulvin therapy and
                   when monitoring of liver function is indicated

G.   Infections in immunocompromised hosts

     1.    Malnutrition

                   Understand the association of infections with malnutrition

     2.    Central nervous system disease

                   Be aware that neonates and children with diseases of the central
                   nervous system may not manifest fever because the
                   thermoregulatory center of the hypothalamus may be
                   immature/abnormal

     3.    Asplenia

                   Know that children with asplenia are susceptible to increased
                   morbidity and mortality from infection with encapsulated
                   organisms

     4.    Malignancy

                   Know that an accepted antibiotic regimen for a patient with
                   cancer who has fever and neutropenia should be effective against
                   Pseudomonas aeruginosa and staphylococci

                   Know that the diagnosis of pneumonia in an immunocompromised host

                                                                                         53
                   may require aggressive procedures, including bronchoscopy

                   Recognize the major infections seen in patients with cancer

     5.     HIV and AIDS

                   Recognize the major opportunistic infections seen in patients
                   with HIV/AIDS

     6.     Burn injury

                   Know the major infections seen in patients with a burn injury

     7.     Indwelling catheters

                   Know the pathogens commonly associated with central catheter
                   infections

                   Plan the treatment of a patient with a central catheter infection

H.   Specific viral pathogens

     1.     Cytomegalovirus

                   Know the diagnostic tests for congenital or acquired cytomegalovirus
                   infection

                   Know that CMV-seropositive individuals are chronic carriers of the
                   virus and may shed the virus in urine, saliva, and genital secretions

                   Know that the cytomegalovirus may cause severe disease in an immuno-
                   compromised host

                   Identify the clinical manifestations of postnatally-acquired
                   cytomegalovirus infection in normal hosts, while recognizing
                   that most infections are asymptomatic

                   Recognize how cytomegalovirus is spread: horizontally (person-to-
                   person transmission through virus-containing secretions), vertically
                   (mother to infant), and through transfusions and transplantations

                   Understand that the definitive diagnosis of congenital
                   cytomegalovirus infection requires isolation of the virus within
                   3 weeks of birth

     2.     Epstein-Barr virus

                   Understand that host factors are important in the outcome of
                   Epstein-Barr virus infection (eg, self-limited infectious
                   mononucleosis in normal hosts and lymphoma in immunocompromised
                   patients)


                                                                                           54
           Know the indications for the use of corticosteroids in
           the treatment of acute infectious mononucleosis (upper airway
           obstruction)
           Know the significance of a high frequency of rash following
           ampicillin therapy in patients with infectious mononucleosis

           Know the epidemiology of Epstein-Barr virus: mode of transmission,
           incubation period, period of communicability

           Know the range of clinical manifestations of Epstein-Barr virus
           infection in children of various ages

           Distinguish (by serologic tests) between acute and past
           Epstein-Barr virus infections

           Plan the management of a patient with uncomplicated infectious
           mononucleosis

           Recognize the potential central nervous system and hematologic
           complications of Epstein-Barr virus infection in a normal host

           Recognize the implications of a negative heterophile antibody
           test for Epstein-Barr virus infection early in the illness and
           in children younger than 4 years of age

3.   Herpes simplex virus (see also XVII.D.4.)

           Know that newborn infants of mothers with primary herpes
           infections are more likely to be infected than infants
           born to mothers with recurrent genital herpes simplex
           infections

           Know the appropriate tests for the diagnosis of herpes simplex
           infection: isolation of the organism, antigen detection,
           nucleic acid amplification, serology

           Plan the appropriate management of a neonatal herpes simplex
           infection, including timing (ie, immediately, even before test
           results are available)

           Recognize that herpes simplex virus can be transmitted from a person
           with a primary or recurrent infection regardless of whether any
           symptoms are present

           Recognize the clinical manifestations of herpes simplex virus
           infection in the neonatal period, and that skin lesions are not
           always present

           Recognize the clinical manifestations of herpes simplex virus
           infection in infants beyond the neonatal period, children, and
           adolescents


                                                                                  55
4.   Varicella-zoster virus

            Understand why varicella-zoster immune globulin is not
            recommended for normal infants over 2 days of age who are
            exposed to chickenpox

            Understand the relationship between varicella and herpes zoster, and
            know that both are caused by the same virus

            Know that varicella-zoster immune globulin should be given within
            96 hours after exposure to varicella

            Know the epidemiology of varicella and herpes zoster: mode of
            transmission, incubation period, period of communicability of
            varicella

            Know the clinical manifestations of varicella and herpes zoster

            Know the control measures for varicella and herpes zoster

            Know the manifestations of varicella infections acquired in
            utero

            Know that varicella in an immunocompromised host may result in
            severe disease

            Know the indications for the use of varicella-zoster immune globulin
            and varicella vaccine in patients exposed to varicella

            Know the indications for antiviral treatment of varicella zoster
            infections in normal and immunocompromised hosts

5.   Measles virus

            Know that intramuscular immune globulin should be given to
            immunocompromised patients and infants who are closely exposed to
            measles but have not been immunized

            Identify the complications of measles

            Know the route and ease of transmission of measles

            Recognize the clinical manifestations of measles

            Know the control measures for measles: isolation (airborne pre-
            cautions), care of exposed personnel, immunization

6.   Mumps virus

            Recognize the common (parotitis) and uncommon (pancreatitis,
            orchitis, meningoencephalitis) manifestations of mumps


                                                                                   56
7.    Rabies virus

            Know that postexposure rabies prophylaxis should consist of
            both passive and active immunizations

            Know the wild and domestic animals that can actively transmit
            rabies to humans

            Know the immunization recommendations after a potential
            bat exposure

8.    Rubella virus

            Know the epidemiology of the rubella virus: mode of transmission,
            incubation period, period of communicability

            Know the clinical manifestations of rubella, both the congenital
            rubella syndrome and postnatally acquired disease

            Know the control measures for rubella: care of exposed personnel

            Recognize that some women of child-bearing age are susceptible to
            rubella despite widespread use of the rubella vaccine

9.    Parvovirus B19 (erythema infectiosum, fifth disease)

            Recognize the clinical manifestations of erythema infectiosum (fifth
            disease)

            Know the complications of parvovirus B19 infection: aplastic
            crisis in children with hemolytic anemia, severe anemia in
            children with HIV/AIDS, fetal hydrops

10.   Human herpesvirus type 6 (roseola)

            Recognize the clinical manifestations of roseola

            Recognize that human herpesvirus type 6 is a common cause of
            febrile seizures

11.   Human immunodeficiency virus

            Know the effect of a mother's HIV-positive status on her infant's
            HIV test

            Recognize that the spread of AIDS occurs by sexual contact or
            contact with infected blood

            Know that abstinence and the use of a condom are the best forms of
            preventing sexual transmission of AIDS

            Know the epidemiology of human immunodeficiency virus infection:

                                                                                   57
             mode of transmission, incubation period, period of communicability

             Know the clinical manifestations of human immunodeficiency virus
             infection and AIDS in neonates compared with older children

             Know the most appropriate screening test (ie, HIV antibody
             titer) for HIV infection in children older than 18 months of age

             Know that cesarean delivery and treatment of an HIV-positive
             mother with antiretroviral drugs decreases the risk of transmission
             of virus to her infant

             Know the means of maternal transmission of HIV to her infant
             (eg, vaginal delivery, through breast-feeding, transplacentally,
             intrapartum)

             Know the preferred method of diagnosis of HIV infection in infancy
             (ie, nucleic acid amplification test)

             Plan the management of an infant whose mother's HIV status is
             unknown

12.   Enteroviruses (echo-, coxsackie-, numbered entero-,

      poliomyelitis)

             Know the epidemiology of the enteroviruses (echo-, coxsackie-,
             entero-, polio-):mode of transmission, peak season

             Know the clinical manifestations of echo- and coxsackievirus
             infections in neonates compared with older children

             Know the diagnostic tests for enteroviruses: culture, nucleic
             acid amplification

13.   Influenza virus

             Know the epidemiology of influenza virus: mode of transmission, peak
             season, incubation period

             Recognize the clinical manifestations of influenza

             Know the laboratory tests for the diagnosis of influenza virus
             infection

             Know the indications for the use of antiviral medications for the
             treatment of influenza, while recognizing that some strains of
             the virus are resistant to antiviral medications

             Recognize the complications of influenza: encephalitis, secondary
             bacterial infections


                                                                                    58
            Understand the factors related to increased rates of complications and
            hospitalizations for influenza: young age (especially younger than 2
            years), asthma, BPD, cystic fibrosis, hemoglobinopathy, malignancy,
            diabetes, congenital heart disease, chronic kidney disease

14.   Parainfluenza virus

            Recognize the clinical manifestations of parainfluenza virus
            infection

15.   Adenovirus (respiratory)

            Know the epidemiology of adenovirus: mode of transmission,
            incubation period, peak season

            Recognize the clinical manifestations of adenovirus infection

16.   Respiratory syncytial virus

            Know the epidemiology of respiratory syncytial virus: mode of
            transmission, incubation period, period of communicability, age
            of onset, peak season

            Recognize the clinical manifestations of respiratory syncytial virus
            infection

            Know the laboratory tests for the diagnosis of respiratory syncytial
            virus: culture, antigen detection

            Plan the management of respiratory syncytial virus infection

            Know the control measures for respiratory syncytial virus infection:
            isolation of hospitalized patients, hand washing

            Identify patients at high risk for morbidity and mortality from
            respiratory syncytial virus infection (eg, those with congenital
            heart disease, bronchopulmonary dysplasia, prematurity/low birth
            weight) and those who may benefit from prophylaxis

            Know that respiratory syncytial virus is the most common cause of
            lower respiratory infections in infancy

17.   Rotavirus

            Know the epidemiology of rotavirus: mode of transmission, incubation
            period, age of onset, peak season

            Know that the best test for the diagnosis of rotavirus infection is
            antigen testing, but that a specific diagnosis is not necessary
            for management

            Recognize the clinical manifestations of rotavirus infection

                                                                                     59
18.   Miscellaneous enteric viruses (adenovirus, norovirus)

             Understand that enteric adenovirus and norovirus cause diarrheal
             disease in infants and children

19.   Arbovirus

             Know the epidemiology of arboviruses in the US: mode of transmission,
             peak season, geography

             Know that arboviruses can cause encephalitis

             Know that the incidence of dengue fever is increasing in many tropical
             countries, and that this diagnosis should be considered in patients
             with an acute febrile illness who have a recent travel history
             in endemic areas

             Recognize the clinical manifestations of West Nile virus infection

             Know the epidemiology of West Nile virus

20.   Hepatitis A virus

             Know the indications for the use of intramuscular immune globulin
             and hepatitis A vaccine for postexposure prophylaxis against
             hepatitis A infection

             Know the epidemiology of hepatitis A: mode of transmission,
             incubation period, period of communicability

             Recognize the clinical manifestations of hepatitis A infection
             in infants and older children

             Know that the best test for the diagnosis of hepatitis A is serology:
             HAV IgM for acute infection, HAV IgG for immunity

21.   Hepatitis B virus

             Plan the treatment of an infant born to a woman who is a hepatitis B
             carrier (eg, combination of hepatitis vaccine and hepatitis B immune
             globulin (HBIG) at birth)

             Know the epidemiology of hepatitis B virus: mode of transmission,
             incubation period, period of communicability

             Recognize the clinical manifestations of hepatitis B infection

             Plan the appropriate screening test for the diagnosis of hepatitis B
             infection (ie, serology)

             Identify groups at high risk for acquiring hepatitis B infection

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                  Know that perinatally-acquired hepatitis B infections are more
                  likely to cause chronic infections than infections acquired
                  later in life

                  Understand that children with chronic hepatitis B infection should
                  be screened periodically for hepatic complications, and that
                  treatment regimens are available

     22.   Hepatitis C virus

                  Know the risk factors for acquiring hepatitis C infection: blood
                  transfusion, IV drug abuse, multiple sexual partners, homosexual
                  activity, infant whose mother has hepatitis C

                  Know the long-term outcome of hepatitis C infection: chronic carriers,
                  chronic hepatitis, cirrhosis, hepatocellular carcinoma

                  Know the appropriate diagnostic tests for hepatitis C infection
                  (nucleic acid amplification, serology), and the appropriate
                  timing of these tests for exposed individuals

                  Recognize that children with chronic hepatitis C infection should
                  undergo periodic screening tests for hepatic complications, and
                  that treatment regiments are available

     23.   Human papillomavirus

                  Identify the clinical manifestations of human papillomavirus
                  infection

                  Know the epidemiology of human papillomavirus: prevalence, risk
                  factors, mode of transmission

                  Recognize that specific human papillomavirus strains are
                  associated with cervical cancer and others with genital warts

     24.   Human metapneumovirus

                  Recognize that human metapneumovirus is a common cause of
                  bronchiolitis and that it may be indistinguishable from RSV
                  bronchiolitis

I.   Bacterial pathogens

     1.    Anaerobes

                  Recognize the common clinical manifestations of anaerobic infections

     2.    Arcanobacterium haemolyticum

                  Understand that the clinical manifestations of infection caused

                                                                                           61
            by Arcanobacterium haemolyticum may be indistinguishable from that
            caused by group A streptococcus

3.   Brucella (brucellosis)

            Know that brucellosis should be considered in the differential
            diagnosis of fever of unknown origin

4.   Campylobacter species

            Plan the treatment of a Campylobacter infection

            Recognize the clinical manifestations of a Campylobacter infection

            Know the epidemiology of Campylobacter infections (eg, in the
            GI tract of domestic and wild poultry, dogs, cats)

5.   Bartonella henselae (cat-scratch disease)

            Recognize the clinical manifestations of cat-scratch disease,
            including fever of unknown origin

            Formulate a differential diagnosis in a patient with suspected
            cat-scratch disease, (eg, nontuberculous mycobacterial infection,
            tuberculosis, sarcoidosis)

            Know how to diagnose cat-scratch disease

            Know the epidemiology of cat-scratch disease (ie, recent contact
            with cats, often kittens)

6.   Chlamydia and Chlamydophila (chlamydial infections)

            Identify the clinical manifestations of Chlamydia trachomatis in a
            neonate (eg, neonatal conjunctivitis)

            Know the mode of transmission of Chlamydia trachomatis
            (eg, vertically from mother to infant, sexually)

            Know the appropriate diagnostic tests for different sites of
            Chlamydia trachomatis infection (eg, culture, nucleic acid ampli-
            fication, DNA probe, direct fluorescent antibody titer; C.
            trachomatis-specific IgM for diagnosis of pneumonia)

            Know the treatment of a chlamydial infection (eg, conjunctivitis,
            pneumonia, genital tract)

            Know the clinical manifestations of Chlamydia trachomatis pneumonia
            in young infants

            Know that Chlamydophila pneumoniae can cause illness that resembles
            Mycoplasma pneumoniae infection both clinically and epidemiologically

                                                                                    62
             Recognize the clinical manifestations of genital tract infections
             caused by Chlamydia trachomatis (eg, vaginitis, urethritis,
             cervicitis, epididymitis, endometritis, chronic pelvic inflammatory
             disease leading to infertility)

7.    Clostridium botulinum (botulism)

             Know the epidemiology of botulism (foodborne, wounds)

             Recognize the clinical manifestations of botulism
             Plan the laboratory diagnosis of infant botulism: detection of
             Clostridium botulinum toxin and/or organisms in stool

8.    Clostridium difficile

             Understand the significance of finding Clostridium difficile toxin
             in the stool at different ages (neonate versus 4-year-old child)

             Recognize the clinical manifestations of Clostridium difficile
             infection (eg, diarrhea, pseudomembranous enterocolitis)

             Know how to diagnose a Clostridium difficile infection

             Plan the treatment of a Clostridium difficile infection

             Know the infection control measures for Clostridium difficile
             infection

9.    Corynebacterium diphtheriae (diphtheria) (See also III.A.)

             Recognize the clinical manifestations of diphtheria

10.   Enterococcus

             Know the treatment of enterococcal infections: drug(s) of choice,
             alternative drugs, ineffective drugs

             Know the clinical syndromes usually associated with enterococci:
             urinary tract infection, bacteremia with and without endocarditis,
             meningitis, peritonitis

11.   Escherichia coli

             Know the association of enterohemorrhagic Escherichia coli
             with hemolytic-uremic syndrome

             Recognize the clinical manifestations of Escherichia coli
             infection in children of various ages

12.   Neisseria gonorrhoeae (gonococcal infections)


                                                                                   63
            Know the major clinical manifestations of Neisseria gonorrhoeae
            infection: disseminated gonococcal infection, neonatal
            conjunctivitis, pharyngitis, urethritis, cervicitis, salpingitis,
            pelvic inflammatory disease

            Know the laboratory tests for Neisseria gonorrhoeae: isolation,
            nucleic acid amplification tests

            Know the treatment of the major clinical diseases caused by
            Neisseria gonorrhoeae infection

            Know the infection control measures for gonococcal infections:
            prevention of neonatal ophthalmia, infants born to mothers with
            gonococcal infection, management of sexual partner(s)

13.   Hemophilus influenzae

            Know the indications for the use of prophylactic antibiotics for
            control of diseases that spread from person to person (eg,
            H. influenzae infections)

            Recognize the clinical manifestations of Hemophilus influenzae type b
            infection

            Plan the treatment of a nontypable Hemophilus influenzae infection

14.   Helicobacter pylori

            Plan the treatment of a Helicobacter pylori infection

            Identify risk factors for Helicobacter pylori infection: residence
            in a developing country, lower socioeconomic group

            Understand the Helicobacter pylori infection may be asymptomatic
            in children, and that chronic active gastritis as a result of the
            infection increases the risk of duodenal and gastric ulcers

15.   Kingella kingae

            Know the most common infections associated with Kingella kingae
            (eg, pyogenic arthritis, osteomyelitis)

16.   Listeria monocytogenes

            Recognize Listeria monocytogenes as a cause of neonatal sepsis

            Know the mode of transmission of Listeria monocytogenes

17.   Borrelia burgdorferi (Lyme disease)

            Know that Lyme disease causes fever and arthritis that may
            be confused with juvenile rheumatoid (idiopathic) arthritis

                                                                                    64
            Know the mode of transmission of Lyme disease

            Know the clinical manifestations of Lyme disease

            Know how to diagnose Lyme disease clinically (erythema migrans) and
            by laboratory findings (serum antibody titers after first few weeks)

            Know the treatment of Borrelia burgdorferi (Lyme disease): drug(s)
            of choice, alternative drugs, ineffective drugs

            Know that there is a high rate of false positive results for
            Lyme disease with the screening test for serum antibodies
            (EIA or IFA)

18.   Neisseria meningitidis (meningococcal infections)

            Recognize that vaccines are not available against N.
            meningitidis serogroup B

            Know that certain close contacts of patients with N. meningitidis
            meningitis require chemoprophylaxis

            Know what to recommend to a parent when it is reported
            that a child has been exposed to meningitis in school

            Know the major clinical syndromes of Neisseria meningitidis
            (meningococcemia, meningitis)

            Know the diagnostic tests for invasive meningococcal disease
            (ie, Gram stain, isolation, antigen detection, polymerase chain
            reaction)

            Recognize that Neisseria meningitidis is the leading cause of
            bacterial meningitis in young children in the US

            Understand which patients are at increased risk of invasive
            and recurrent meningococcal disease (eg, asplenia, terminal
            complement component)

            Know the epidemiology of Neisseria meningitidis infection

            Plan the treatment of a Neisseria meningitidis infection

19.   Mycobacterium tuberculosis

            Know how to identify and interpret a positive tuberculin skin test

            Understand that an x-ray study of the chest is indicated when a
            tuberculin skin test is positive

            Understand the effect of the BCG vaccine on the tuberculin skin test

                                                                                   65
            Know the management of tuberculosis in a health-care worker

            Know the reasons for false-positive and false-negative tuberculin
            skin test results

            Know the mode of transmission of Mycobacterium tuberculosis

            Know the major clinical manifestations of Mycobacterium tuberculosis:
            pneumonia, lymphadenitis, arthritis, meningitis, osteomyelitis,
            gastrointestinal and renal disease

            Plan the management of a child who has an adult household contact
            with active tuberculosis
            Know the indications for isolating a hospitalized patient with
            tuberculosis: disease state, duration

            Differentiate between a latent tuberculosis infection and
            tuberculosis disease

            Know which populations and age groups are at high risk for a
            latent tuberculosis infection and tuberculosis disease

            Know the major components of the treatment of tuberculosis disease
            (eg, multiple medications, regimen dependent on type of disease
            and resistance pattern of organism)

20.   Mycoplasma pneumoniae

            Know the age-related clinical manifestations of Mycoplasma infections

            Know the laboratory tests for Mycoplasma pneumoniae: isolation,
            serology, polymerase chain reaction

            Plan the treatment of Mycoplasma pneumoniae infection

            Recognize that Mycoplasma pneumoniae is a leading cause of
            pneumonia in school-age children and young adults

            Identify the extrapulmonary manifestations (eg, pharyngitis, rash,
            Stevens-Johnson syndrome, hemolytic anemia, arthritis, CNS disease)
            of a Mycoplasma infection

            Know the epidemiology of Mycoplasma pneumoniae: long incubation
            period; community epidemics; outbreaks in hospitals, colleagues,
            military bases

21.   Nontuberculous mycobacteria

            Understand the diagnosis and treatment of cervical adenitis secondary
            to nontuberculous mycobacteria


                                                                                    66
             Know the major clinical manifestations of nontuberculous mycobacteria
             in immunocompetent children

22.   Pasteurella multocida

             Know the mode of transmission of Pasteurella multocida

             Know the most common clinical manifestation of a Pasteurella
             multocida infection (ie, cellulitis at the site of an animal bite
             that develops within 24 hours of injury)

             Know the treatment of Pasteurella multocida infection

23.   Bordetella pertussis (pertussis)

             Know that adolescents and adults are important sources of
             pertussis in infants and children

             Know that immunity to pertussis is not life-long

             Plan the use of chemoprophylaxis for the contacts of patients who
             have pertussis

             Know the mode of transmission of pertussis

             Recognize the clinical manifestations of pertussis in neonates,
             children, and adolescents

             Know the diagnostic tests available for pertussis: isolation,
             polymerase chain reaction, serology, direct fluorescent antibody

             Plan the management of a patient with pertussis

             Recognize that antibiotic treatment does not alter the clinical
             course of pertussis in the paroxysmal phase

             Understand the importance of pertussis immunization for family
             members of newborn infants

24.   Pseudomonas species

             Know the risk factors for development of severe pseudomonas
             infections: cystic fibrosis, cancer patients with neutropenia,
             hospitalized patients receiving broad-spectrum antibiotic therapy

             Know which antibiotics are generally effective against
             Pseudomonas infections

25.   Rickettsial diseases (Rocky Mountain spotted fever,

      ehrlichiosis)


                                                                                     67
             Identify the clinical manifestations of Rocky Mountain spotted fever

             Know that therapy should be initiated when Rocky Mountain
             spotted fever is suspected, even before the diagnosis is confirmed

             Know the mode of transmission of Rocky Mountain spotted fever

             Plan the treatment of Rocky Mountain spotted fever

             Know that human ehrlichiosis is similar clinically to Rocky
             Mountain spotted fever

             Understand the geographical distribution of Rocky Mountain
             spotted fever

26.   Salmonella species
             Know the mode of transmission of Salmonella species

             Know the clinical manifestations of typhoid fever

             Plan the treatment of an invasive Salmonella infection

             Know that otherwise healthy patients with uncomplicated Salmonella
             gastroenteritis should not receive antimicrobial therapy

             Know the mode of transmission of non-typhoidal Salmonella infection

             Recognize the clinical manifestations of non-typhoidal Salmonella
             gastroenteritis (eg, fever; increased leukocyte count; diarrhea;
             blood, mucus, neutrophils in stool)

             Understand that otherwise healthy patients with uncomplicated
             Salmonella gastroenteritis should not receive antimicrobial therapy

             Recognize the clinical manifestations of non-typhoidal Salmonella
             infection (eg, bacteremia, osteomyelitis, meningitis, brain abscess)

             Identify patients at high risk of invasive Salmonella infection
             (eg, young infants, patients with immunocompromise or
             hemoglobinopathy)

27.   Shigella species (shigellosis)

             Know the mode of transmission of Shigella species

             Know the major clinical manifestations of Shigella species: fever;
             seizures; diarrhea; blood, mucous, and neutrophils in stool

             Plan the treatment of Shigella infection

28.   Staphylococcus aureus


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            Know that Staphylococcus aureus is distinguished from other
            staphylococci by its production of coagulase

            Recognize the major clinical syndromes of Staphylococcus aureus:
            cellulitis, osteomyelitis, pyogenic arthritis, furunculosis,
            scalded skin syndrome, toxic shock syndrome, pneumonia, endocarditis

            Know that isolation and susceptibility testing are important when
            Staphylococcus aureus infection is suspected

            Know the treatment of methicillin-sensitive and methicillin
            resistant Staphylococcus aureus infection

            Understand the management of a patient with staphylococcal
            toxic shock syndrome

            Know that methicillin-resistant Staphylococcus aureus (MRSA) is
            a common cause of skin and soft tissue infections

            Know the most important component of therapy (ie, incision and
            drainage) for methicillin-resistant Staphylococcus aureus
            furunculosis

            Understand the management of staphylococcal toxic shock syndrome:
            aggressive drainage of accessible site(s) of infection; therapy
            with both a bacterial cell wall inhibitor (eg, oxacillin, vancomycin)
            and a protein synthesis inhibitor (eg, clindamycin)

29.   Staphylococcus, coagulase-negative

            Understand that coagulase-negative staphylococcal infections are
            usually associated with intravascular or urinary catheters,
            CSF shunts, and other foreign bodies

            Know that many coagulase-negative staphylococcal isolates
            represent contamination of the culture material

30.   Streptococcus agalactiae (group B streptococcus)

            Know the mode of transmission of group B streptococcus

            Recognize the major clinical manifestations of group B
            streptococcal infection: early onset septicemia and pneumonia;
            late onset bacteremia, pneumonia, meningitis, pyogenic arthritis,
            osteomyelitis

            Know the treatment of group B streptococcus infection

            Understand the importance of maternal screening for group B
            streptococcus and the appropriate treatment of women with positive
            results


                                                                                    69
            Know the recommendations for evaluation of an infant whose mother
            is colonized with group B streptococcus, and how the administration
            of intrapartum antibiotic therapy affects the evaluation

31.   Streptococcus pneumoniae (pneumococcal infections)

            Know the major clinical manifestations of Streptococcus pneumoniae
            infection: otitis, sinusitis, bacteremia, pneumonia,
            meningitis

            Know that the treatment of Streptococcus pneumoniae infection
            depends on antibiotic susceptibility testing and that the type of
            infection (eg, meningitis, otitis, pneumonia, bacteremia) affects
            antibiotic choice

            Recognize the population in which invasive pneumococcal disease
            is more common: children with sickle cell disease, asplenia,
            HIV/AIDS, cochlear implants
            Understand the impact of routine heptavalent pneumococcal
            immunization on pneumococcal infections in children

32.   Streptococcus pyogenes (group A streptococcus)

            Know the mode of transmission of group A streptococcus

            Recognize the clinical manifestations of group A streptococcal
            infection: pharyngitis, impetigo, cellulitis, toxic shock syndrome,
            necrotizing fasciitis

            Recognize the complications of poststreptococcal infection:
            rheumatic fever, glomerulonephritis

            Know the laboratory tests for group A streptococcal infection:
            isolation, antigen detection; ASO and anti-DNAse B for rheumatic
            fever

            Plan the treatment of group A streptococcal infection

            Recognize the association between invasive group A streptococcal
            infection and varicella

33.   Treponema pallidum (syphilis)

            Know the mode of transmission of Treponema pallidum

            Recognize the clinical manifestations of congenital and acquired
            syphilis

            Plan the laboratory diagnosis of congenital and acquired syphilis

            Know the treatment of congenital syphilis (ie, penicillin), and that
            CNS involvement must always be considered when planning the treatment

                                                                                    70
                  regimen

     34.   Yersinia enterocolitica

                  Recognize the clinical manifestations of Yersinia enterocolitica
                  infection

                  Know the indications for the treatment of Yersinia enterocolitica
                  infection: drugs(s) of choice, alternative drugs

J.   Fungal pathogens

     1.    Candida species

                  Be aware of factors that predispose a patient to the development of
                  candidiasis (eg, repeated use of antibiotics, immunosuppression,
                  burns, indwelling catheters, and total parenteral nutrition)

                  Know the various conditions that predispose to persistent or
                  recurrent candidiasis of the oral cavity in an infant younger than
                  6 months of age: maternal breast colonization, contaminated vitamin
                  dropper, antibiotic use, pacifier use

                  Know the various conditions that predispose to persistent or
                  recurrent candidiasis of the oral cavity in children older than 6
                  months of age: immune deficiency, AIDS, antibiotic use

                  Plan treatment for a patient with a Candida infection

     2.    Coccidioides

     3.    Aspergillus, Histoplasma, Sporothrix

                  Recognize that aspergillosis is a fungal infection usually of the
                  lungs, and occurs almost exclusively in patients with impaired host
                  responses

K.   Parasitic pathogens (protozoa, metazoa)

     1.    Giardia lamblia (giardiasis)

                  Know the epidemiology of Giardia lamblia infection (giardiasis):
                  mode of transmission, common reservoirs, risk factors

                  Plan appropriate laboratory tests for Giardia lamblia infection
                  (giardiasis):stool examination; duodenal aspirate or biopsy

                  Know the treatment of symptomatic Giardia lamblia (giardiasis)
                  infection (ie, drug(s) of choice, alternative drugs, ineffective
                  drugs) and that treatment of asymptomatic carriers is not
                  recommended


                                                                                        71
            Identify the clinical manifestations of Giardia lamblia infection

2.   Toxoplasma gondii (toxoplasmosis)

            Know the clinical manifestations of congenital toxoplasmosis
            and the importance of prompt treatment

            Identify the clinical manifestations of Toxoplasma gondii
            infections acquired after birth

            Know the epidemiology of toxoplasmosis: hosts, intermediate
            hosts, modes of transmission (vertical transmission from mother
            to infant, ingestion of cysts from contaminated food or soil)

3.   Trichomonas vaginalis (trichomoniasis)

            Know the treatment of Trichomonas vaginalis, and that the
            partner should also be treated

            Recognize the clinical manifestations of Trichomonas vaginalis
            infection

            Know the epidemiology of Trichomonas vaginalis

            Know the tests needed for diagnosis of Trichomas vaginalis
            infection: examination of a wet-mount preparation of vaginal
            secretions, antigen and nucleic acid detection

4.   Pneumocystis jiroveci (carinii)

            Recognize the clinical manifestations of Pneumocystis jiroveci
            (carinii) infection

            Know that trimethoprim with sulfamethoxazole is effective for the
            prophylaxis of a Pneumocystis jiroveci (carinii) infection

            Know that pneumonia caused by Pneumocystis jiroveci (carinii)
            occurs almost exclusively in immunocompromised patients

5.   Enterobius vermicularis (pinworms)

            Diagnose and treat infections caused by Enterobius
            vermicularis

6.   Plasmodium species (malaria)

            Know that malaria parasites have developed resistance to many
            drugs, and that prophylactic regimens are determined by the
            resistance patterns in the country of destination

            Know that malaria should be considered as a possible diagnosis in a
            febrile patient who has traveled to an endemic region

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                           Know that prompt diagnosis of Plasmodium falciparum infection is
                           essential because it is life-threatening

           7.     Ascaris (ascariasis)

                           Recognize the clinical manifestations of ascariasis

           8.     Entamoeba histolytica (amebiasis)

                           Recognize the clinical manifestations of amebiasis

           9.     Necator americanus (hookworm)

                           Know the geographic distribution of hookworm infestation (eg,
                           prevalent worldwide in tropical and subtropical areas), and that
                           it is a common cause of hypochromic microcytic anemia

           10.    Taenia solium, Taenia saginata, Taenia asiatica

                           Recognize that cysticercosis is a major cause of seizures in
                           countries where Taenia solium is endemic

           11.    Toxocara

     L.    Emerging infectious diseases

           1.     SARS-associated coronavirus infection

                           Know the epidemiology of severe acute respiratory syndrome (SARS)
                           caused by coronavirus

                           Recognize the clinical manifestations of severe acute respiratory
                           syndrome (SARS) caused by coronavirus

           2.     Avian influenza

                           Know the epidemiology of avian influenza H5N1

                           Recognize the clinical manifestations of avian influenza A
                           infection

X.   Metabolic Disorders

     A.    Diagnosis

           1.     General

                  a.       Screening

                  b.       Genetics (see also VII.D.7)


                                                                                               73
     Know when genetic counseling is appropriate for the family
     of a child with a metabolic disease

c.   Recognition by signs and symptoms

     Recognize the signs and symptoms of inborn errors of carbohydrate
     metabolism

     Recognize the signs and symptoms of hyperinsulinism

     Recognize lipoprotein disorders

     Recognize Gaucher disease and lipid storage disease

     Recognize urea cycle defects

     Recognize organic acidemias

     Recognize glycogen storage disease

     Recognize the signs and symptoms of Tay-Sachs disease

     Know how to evaluate patients with suspected metabolic disease who
     are comatose

     Know how to evaluate patients with suspected metabolic disease who
     are hypoglycemic

     Know how to evaluate patients with suspected metabolic disease who
     are acidotic

     Recognize the clinical features of disorders of fatty acid and
     carnitine metabolism

     Recognize the clinical findings of a disorder of amino acid
     metabolism

     Recognize the signs and symptoms of the mucopolysaccharidoses,
     including Hurler syndrome

     Recognize the signs and symptoms of mitochondrial diseases

d.   Recognition by laboratory results

     Recognize the laboratory findings in a patient who has a disorder
     of fatty acid metabolism

     Recognize the laboratory findings in a patient who has a disorder
     of carnitine metabolism

     Recognize the laboratory findings in a patient who has
     mucopolysaccharidosis

                                                                          74
                 Know which laboratory studies should be obtained in a child
                 suspected of having a metabolic disorder before treatment is
                 initiated

B.   Treatment

     1.   General

                 Know the natural history of treated and untreated phenylketonuria

                 Plan the appropriate initial response to a positive neonatal
                 screening test for metabolic diseases

     2.   Diet

     3.   Medication

                 Know how to manage carbohydrate metabolic disorders (eg, glycogen
                 storage diseases type I)

                 Know how to treat hypoglycemia

     4.   Prognosis and long-term care

                 Be familiar with the long-term prognosis of phenylketonuria
                 and the effects of dietary adherence to outcome

                 Be familiar with the long-term prognosis and chronic management
                 of galactosemia

                 Be familiar with the long-term prognosis and chronic management
                 of lipid storage disease, including Gaucher disease

                 Be familiar with the long-term prognosis and chronic management
                 of urea cycle defects

                 Be familiar with the long-term prognosis and chronic management
                 of organic acidemias

                 Be familiar with the long-term prognosis and chronic management
                 of the mucopolysaccharidoses, including Hurler syndrome

                 Be familiar with the long-term prognosis and chronic management
                 of Tay-Sachs disease

                 Be familiar with the long-term prognosis and chronic management
                 of hyperinsulinism

                 Be familiar with the long-term prognosis and chronic management
                 of lipid disorders


                                                                                     75
                            Be familiar with the long-term prognosis and chronic management
                            of glycogen storage disease

XI.   Endocrine Disorders

      A.    Sex differentiation

            1.     Normal development

            2.     Ambiguous genitalia

                   a.       Congenital adrenal hyperplasia

                            Recognize the signs and symptoms of congenital adrenal
                            hyperplasia

                            Know the laboratory evaluation of congenital adrenal
                            hyperplasia

                            Know that congenital adrenal hyperplasia can be diagnosed prenatally

                            Plan the treatment for an adrenal crisis in a patient with congenital
                            adrenal hyperplasia

                            Understand the value of neonatal screening for salt-losing
                            congenital adrenal hyperplasia in male infants with normal
                            genitalia

                   b.       Other intersex disorders

                            Understand that maternal exposure to androgens or progestins can
                            cause virilization in female infants

      B.    Growth

            1.     Short stature (see also VII.D.1)

                   a.       General

                            Know the most common causes of short stature

                            Plan the evaluation of children whose height has decreased from
                            the 20th to the 5th percentile

                            Understand that growth velocity may be decreased in children with
                            chronic disease

                            Distinguish among constitutional short stature, genetic (familial)
                            short stature, and growth hormone or thyroid deficiencies by
                            growth chart evaluation

                   b.       Familial
                                                                                                    76
                  Know how to distinguish between familial short stature and other
                  conditions

                  Know the natural history of familial short stature

           c.     Constitutional growth delay

                  Know how to use laboratory tests effectively to
                  distinguish between constitutional growth delay and other
                  conditions

                  Know the natural history of constitutional growth delay

                  Know how to use growth charts to evaluate constitutional
                  growth delay

           d.     Growth hormone deficiency

                  Recognize the signs and symptoms of acquired and congenital growth
                  hormone deficiency (eg, micropenis)

     2.    Tall stature

                  Differentiate among the causes of tall stature
C.   Puberty

     1.    Normal

                  Distinguish between the variations of normal (eg, thelarche,
                  pubarche) and precocious puberty

                  Know the pathophysiology and differentiating features of normal
                  vs abnormal gynecomastia in males

                  Understand the significance of a breast mass in an adolescent girl

     2.    Precocious puberty

                  Recognize the signs and symptoms of precocious puberty

                  Know the differential diagnosis of precocious puberty

                  Know that premature thelarche occurs without other signs of
                  puberty, is most common among those 1 to 4 years of age, and
                  often regresses spontaneously

                  Recognize the importance of obtaining a history of medication use,
                  including phytoestrogens and estrogen-based creams, when
                  evaluating a child with premature breast development

                  Recognize the tumors that may produce precocious puberty (eg,

                                                                                       77
                  in liver, CNS, ovary, testes, adrenal glands)

                  Know how to use laboratory tests effectively to distinguish an
                  adrenal etiology of precocious puberty

                  Recognize that testosterone creams used by parents can cause
                  virilization in male or female children

                  Know the causes of precocious puberty

     3.    Delayed puberty

           a.     General

                  Recognize the signs and symptoms of delayed puberty

                  Know the causes of delayed puberty

           b.     Primary gonadal (gonadal dysgenesis/Turner syndrome)

                  Recognize the signs and symptoms of gonadal dysgenesis
                  (Turner syndrome)

                  Know the diagnostic tests for gonadal dysgenesis (Turner syndrome),
                  including karyotype, and serum concentrations of luteinizing
                  hormone, follicle-stimulating hormone, and estradiol
                  Understand the importance of evaluating for cardiac and renal
                  disorders in gonadal dysgenesis (Turner syndrome)

           c.     Constitutional

                  Understand the familial influences on the onset of puberty

                  Know how to interpret the growth chart and bone age x-ray when
                  evaluating constitutional delayed puberty

                  Know the natural history of constitutional delayed puberty

                  Know when treatment for constitutional delayed puberty
                  is indicated and understand the therapeutic options

D.   Thyroid disorders

     1.    Hashimoto thyroiditis

                  Recognize the signs and symptoms of Hashimoto thyroiditis

                  Know the laboratory studies that distinguish among Hashimoto
                  thyroiditis, other causes of thyroid enlargement, and
                  hypothyroidism

                  Know the natural history of Hashimoto thyroiditis

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                  Know that Hashimoto thyroiditis is the most common cause of
                  goiter in adolescents

                  Know that Hashimoto thyroiditis may be associated with other
                  autoimmune disorders

     2.    Cyst, tumor, nodule

                  Recognize the signs and symptoms of a thyroid cyst/tumor

                  Understand the importance of referral in a child with a thyroid
                  mass/nodule

                  Know the significance of a previous history of irradiation to the
                  head and neck in a patient with a thyroid mass/nodule

                  Know that a solitary thyroid nodule may be a sign of thyroid cancer

                  Recognize a thyroglossal duct cyst

     3.    Hypothyroidism

                  Know the consequences of untreated hypothyroidism in the neonate

                  Recognize the signs and symptoms of congenital and acquired
                  hypothyroidism
                  Know the varying causes of congenital and acquired hypothyroidism

                  Know how to manage and treat congenital and acquired
                  hypothyroidism and the use of thyroid-stimulating hormone to
                  guide treatment

                  Know the prognosis for a patient with congenital or acquired
                  hypothyroidism

                  Know how to recognize and diagnose thyroid-binding globulin (TBG)
                  deficiency

     4.    Hyperthyroidism

                  Recognize the signs and symptoms of hyperthyroidism

                  Know how to use history, physical examination, and laboratory
                  tests effectively to diagnose hyperthyroidism

                  Be aware of various modalities for treatment of hyperthyroidism

                  Recognize the signs and symptoms of neonatal hyperthyroidism

E.   Parathyroid disorders


                                                                                        79
                  Recognize the typical laboratory findings associated with
                  hypoparathyroidism

                  Know that DiGeorge syndrome (22q-) can be a cause of hypopara-
                  thyroidism

                  Understand that hypercalcemia with hypophosphatemia suggests
                  hyperparathyroidism

F.   Adrenal gland disorders

     1.    General

     2.    Addison disease

                  Recognize the signs and symptoms of Addison disease

                  Know how to use laboratory tests effectively for the diagnosis of
                  Addison disease

                  Plan the treatment of an adrenal crisis in a patient with Addison
                  disease

                  Recognize that Addison disease is usually an autoimmune disorder

                  Recognize the signs and symptoms of adrenal insufficiency after
                  discontinuation of exogenous corticosteroid therapy

                  Know the complications of sudden withdrawal of corticosteroids
                  in pharmacologic doses in patients with adrenal insufficiency

     3.    Cushing syndrome

                  Recognize the signs and symptoms of Cushing syndrome

                  Recognize that exogenous corticosteroids, including topical and
                  inhaled preparations, can cause signs of Cushing syndrome

                  Plan the laboratory evaluation of Cushing syndrome

G.   Pituitary gland disorders

                  Recognize the clinical manifestations of hypopituitarism

                  Recognize the clinical manifestations of craniopharyngioma

                  Recognize the clinical manifestations and laboratory findings
                  associated with diabetes insipidus

H.   Diabetes

     1.    General
                                                                                      80
            Recognize the signs and symptoms of type 1 diabetes

            Know how to treat type 1 diabetes effectively to achieve
            good control: insulin, diet, exercise, and psychologic
            acceptance of the disease

            Know the natural history of type 1 diabetes (eg, "honeymoon" period)

            Counsel patients on the self-management of type 1 diabetes
            (hyperglycemia, sick days)

            Know how to manage sick days in diabetic patients

            Know the long-term complications of type 1 diabetes

            Know the importance of blood glucose control in the prevention of
            long-term complications of type 1 diabetes

            Recognize the association between type 1 diabetes and other
            autoimmune disorders, including celiac disease

            Understand how to manage hypoglycemia in diabetic patients,
            including those with celiac disease and Hashimoto thyroiditis

            Recognize that ketotic hypoglycemia is the most common type of
            hypoglycemia presenting in early childhood

            Recognize the typical presentation of ketotic hypoglycemia in a
            young child

2.   Diabetic ketoacidosis

            Know the complications of type 1 diabetes, particularly
            diabetic ketoacidosis and its pathophysiology, treatment, and
            complications (hypokalemia, hypoglycemia, cerebral edema, shock)

            Recognize cerebral edema as a complication of the treatment of
            diabetic ketoacidosis

            Understand the risks of using bicarbonate in diabetic ketoacidosis

            Know that noncompliance is a major cause of recurrent diabetic
            ketoacidosis

            Plan the management of a child who has mild to moderate diabetic
            ketoacidosis

3.   Type 2 diabetes

            Understand the difference between type 1 diabetes and type 2
            diabetes

                                                                                   81
                  Know that acanthosis nigricans is a marker for insulin resistance

                  Formulate the treatment approaches to type 2 diabetes

                  Plan appropriate screening tests for type 2 diabetes

                  Recognize the long-term complications of type 2 diabetes

                  Recognize that complications of type 2 diabetes may be present
                  at diagnosis

I.   Metabolic syndrome

                  Plan appropriate screening tests for metabolic syndrome

                  Identify the risk factors that necessitate screening tests for
                  metabolic syndrome

                  Plan appropriate initial management of a patient with metabolic
                  syndrome (eg, lifestyle modification with diet and physical
                  activity)

                  Understand the significance of metabolic syndrome (cardio-
                  vascular risk factors)

J.   Disorders of PTH, calcium, and phosphate metabolism (see II.C.)

     1.    Hypocalcemia

                  Recognize the signs and symptoms of hypocalcemia

                  Know the causes of hypocalcemia in a neonate

                  Know that hypocalcemia with hypophosphatemia suggests vitamin D
                  deficiency

     2.    Hypercalcemia

                  Recognize the signs and symptoms of hypercalcemia

                  Recognize the possibility of hypercalcemia and its complications
                  following prolonged immobilization

     3.    Hypophosphatemia

                  Recognize the typical clinical and laboratory findings associated
                  with familial hypophosphatemic rickets

                  Plan the treatment of a child with familial hypophosphatemic rickets

     4.    Rickets (see II.C)
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XII.   Gastrointestinal Disorders

       A.    Abdominal pain

             1.     Acute

                    a.      General

                            Know the patterns of referred visceral pain

                            Know the evaluation of a patient with acute abdominal pain

                            Formulate an age-appropriate differential diagnosis of the acute
                            onset of abdominal pain in a pediatric patient

                            Understand the mechanism of injury by which nonsteroidal
                            anti-inflammatory drugs may produce gastrointestinal symptoms

                    b.      Appendicitis

                            Recognize appendicitis as a cause of acute abdominal pain

                            Know the laboratory evaluation of appendicitis

                    c.      Cholecystitis, cholelithiasis

                            Recognize the presence of cholecystitis in children

                            Know the risk factor associated with the development of
                            cholelithiasis
                    d.      Pancreatitis

                            Recognize the signs, symptoms, and laboratory findings of acute
                            pancreatitis in children

                            Formulate a differential diagnosis for chronic or recurrent
                            pancreatitis in children

                    e.      Intussusception, volvulus, malrotation

                            Recognize the presence of intussusception

                            Recognize the presence of malrotation

                            Recognize the presence of volvulus

                    f.      Trauma

                            Recognize the likely sites of injury following blunt abdominal trauma

                    g.      Obstruction
                                                                                                    83
                Formulate a management plan for a patient with postoperative
                intestinal obstruction

     2.   Chronic

          a.    Functional

                Know the differential diagnosis of recurrent abdominal pain in an
                11-year-old girl

                Recognize the clinical manifestations of chronic recurrent
                abdominal pain

                Plan the management of patients with chronic recurrent abdominal
                pain

                Plan the evaluation of a patient with chronic recurrent abdominal
                pain

          b.    Irritable bowel syndrome

                Know how to recognize and manage irritable bowel syndrome

          c.    Acid-peptic disorder

                Know the clinical presentations and role of acid-peptic disorders
                in recurrent abdominal pain in pediatric patients

          d.    Other

                Recognize the role of lactose intolerance in recurrent abdominal
                pain

                Recognize the clinical presentation of abdominal migraine

B.   Abdominal mass

                Formulate an age-appropriate differential diagnosis for an
                abdominal mass in a pediatric patient

C.   Vomiting

     1.   Gastrointestinal and nongastrointestinal causes of vomiting

                Understand the age-related differential diagnosis of vomiting

                Understand the significance of bilious vomiting

                Know the management of a newborn infant with bilious vomiting

                Know the evaluation and management of a 3-week-old infant with

                                                                                    84
                  projectile vomiting

                  Know the role of serotonin receptor antagonists in preventing and
                  treating vomiting

     2.    Vomiting from infectious and noninfectious causes

                  Understand that vomiting may be a symptom of a systemic illness

                  Recognize the role of vomiting in the clinical presentation of
                  acute gastroenteritis

     3.    Structural causes of vomiting

                  Recognize the clinical findings of pyloric stenosis

                  Know the clinical situations in which duodenal atresia may occur

                  Know the evaluation and management of a 2-year-old child with the
                  acute onset of vomiting with obstruction

                  Plan the initial management of an infant with duodenal atresia

     4.    Disorders associated with chronic vomiting

                  Plan the evaluation of a child with recurrent cyclic vomiting

D.   Esophageal disorders

     1.    Motility

                  Recognize that regurgitation is physiologic in a significant number
                  of infants
                  Recognize the differences between rumination and regurgitation

     2.    Trauma

           a.     General

                  Recognize the signs and symptoms of esophageal trauma

           b.     Caustic ingestion

                  Understand that corrosive esophageal burns after alkali ingestion can
                  occur in the absence of mouth burns

           c.     Foreign body

                  Know the symptoms of an esophageal foreign body

                  Know the treatment of an esophageal foreign body


                                                                                          85
     3.    Gastroesophageal reflux

                 Recognize the symptoms of complications of gastroesophageal reflux
                 (eg, poor growth, pain, anemia, dystonic movements)

                 Know how to evaluate a patient who has gastroesophageal reflux

                 Know the treatment for gastroesophageal reflux

                 Know the prognosis of gastroesophageal reflux

                 Recognize the association between gastroesophageal reflux and
                 respiratory symptoms

E.   Diarrhea

     1.    Diarrhea caused by infectious mechanisms

                 Know the common etiologic agents of infectious diarrhea in children

                 Recognize the signs and symptoms of enteropathogenic Escherichia coli
                 infection

                 Recognize the signs and symptoms of Campylobacter diarrhea

                 Distinguish between Salmonella and Shigella with regard to
                 pathophysiology and symptomatology

                 Recognize that Cryptosporidium can be a cause of chronic diarrhea in a
                 nonimmunocompromised host

                 Understand that pseudomembranous colitis can be a complication of
                 antibiotic therapy

                 Know the clinical manifestations of Giardia lamblia (giardiasis)

                 Plan treatment for a patient with Escherichia coli diarrhea

                 Recognize the clinical signs and laboratory findings associated
                 with Escherichia coli 0157:H7 infection

                 Know that antidiarrheal medications are not recommended for children

     2.    Diarrhea caused by noninfectious mechanisms

                 Understand the mechanism and management of lactose intolerance

                 Recognize the incidence of lactase and sucrase isomaltase deficiency
                 in different ethnic groups

                 Recognize the symptoms, available tests, and treatment of
                 milk-protein intolerance

                                                                                          86
                    Recognize that colitis in a breast-fed infant is a possible
                    manifestation of food allergy secondary to allergens in the mother's
                    diet

                    Know the differential diagnosis of noninfectious intractable
                    diarrhea in infancy

     3.    Chronic nonspecific diarrhea

                    Understand the diagnosis and prognosis of chronic nonspecific
                    diarrhea of early childhood (toddler's diarrhea)

                    Recognize that poor growth, fever, and melena are incompatible with
                    the diagnosis of chronic nonspecific diarrhea

                    Understand that extremely low fat diets, sorbitol, fruit juices, and
                    excessive water consumption may produce chronic nonspecific diarrhea

     4.    Protracted diarrhea

                    Know that malnutrition, chronic infection, systemic disease, and
                    immunodeficiency are predisposing factors to the development
                    of diarrhea

                    Plan the initial evaluation of an infant with protracted diarrhea

                    Understand the importance of providing enteral nutrition in treating
                    protracted diarrhea

F.   Constipation

                    Know the complications of Hirschsprung disease

                    Know how to distinguish between simple constipation and
                    Hirschsprung disease in the newborn period

                    Know the clinical manifestations of Hirschsprung disease

                    Recognize the signs and symptoms of fecal overflow incontinence

                    Know the action of laxatives, stool softeners, and lubricants

                    Formulate a differential diagnosis for constipation in a young child

                    Recognize the role of rectal biopsy in an infant with suspected
                    Hirschsprung disease

G.   Jaundice

     1.    Neonatal and infancy


                                                                                           87
     a.    Bilirubin metabolism

           Recognize that diagnostic studies to detect hemolytic diseases
           are necessary in a full-term infant who becomes clinically icteric
           during the first day after birth

           Know the appropriate diagnostic tests to establish the
           cause of unconjugated hyperbilirubinemia

           Know how to evaluate a 2-day-old infant with jaundice

           Understand the age-related differences in bilirubin metabolism
           (increased erythrocyte turnover and decreased intracellular
           metabolism and excretion in the newborn infant)

           Recognize the clinical presentation of a child with Gilbert syndrome

     b.    Breast-milk jaundice

           Recognize that breast-feeding is the most frequent cause of
           exaggerated unconjugated hyperbilirubinemia in the neonatal period

           Know that breast-feeding does not cause conjugated hyperbilirubinemia

           Know the management of the infant with breast-milk jaundice

           Recognize that sepsis, galactosemia, and endocrine disorders can be
           readily diagnosed in the neonate with conjugated hyperbilirubinemia

     c.    Infectious and noninfectious causes of jaundice

           Recognize cholecystitis in children

           Recognize the signs and symptoms of biliary atresia

           Know the diagnostic tests for biliary atresia
           Know the management of biliary atresia

           Know the metabolic diseases that can lead to conjugated
           hyperbilirubinemia in the neonatal period

           Recognize the signs and symptoms of a choledochal cyst

           Formulate a differential diagnosis of infectious causes of
           jaundice in an infant

           Plan the initial management of a patient who has obstructive
           jaundice

2.   Children and adolescents

     a.    Infectious and noninfectious causes of jaundice
                                                                                   88
                  Know how to evaluate a child with conjugated hyperbilirubinemia

                  Know the laboratory evaluation of hepatitis

                  Know the immediate and long-term complications of hepatitis

                  Recognize the signs and symptoms of Wilson disease

                  Recognize the signs and symptoms of infectious hepatitis

                  Recognize the signs and symptoms of chronic hepatitis

                  Know the multiple etiologies of chronic hepatitis in an older child

                  Recognize the signs and symptoms of liver disease due to alpha-1
                  antitrypsin deficiency

           b.     Obstructive jaundice

                  Recognize signs and symptoms of cholelithiasis and
                  choledocholithiasis

H.   Gastrointestinal bleeding

     1.    Upper versus lower gastrointestinal bleeding

                  Recognize that esophageal varices may first present with upper
                  gastrointestinal bleeding

                  Know how to evaluate a patient with upper gastrointestinal bleeding

                  Plan the appropriate evaluation for a patient who has blood in
                  vomitus and/or stool

                  Recognize the importance of alcohol-induced gastritis in adolescents,
                  and manage appropriately
                  Know the age-related differential diagnosis for rectal bleeding

                  Know the differential diagnosis of vomiting bright red blood

                  Distinguish among the etiologies of occult blood and bright red blood
                  per the rectum

                  Know the importance of anal examination in the evaluation of rectal
                  bleeding

                  Know the differential diagnosis of vomiting coffee-ground material

                  Know the differential diagnosis of vomitus that tests positive for
                  occult blood


                                                                                          89
                     Understand the importance of the use of a nasogastric tube in
                     establishing the source of gastrointestinal bleeding

                     Plan the evaluation of a young child with melena and hemodynamically
                     significant blood loss

     2.    Polyps

                     Recognize that a solitary juvenile polyp is not associated with
                     adenocarcinoma of the colon

                     Know the signs and symptoms of inherited polyposis syndromes
                     that carry a risk of colon cancer

                     Recognize the signs and symptoms of juvenile polyposis

     3.    Meckel diverticulum

                     Know the signs and symptoms of Meckel diverticulum

                     Plan the management of Meckel diverticulum

I.   Ulcer disease

                     Know the evaluation of a child with suspected ulcer disease

                     Understand the mechanisms of action and indications for H2
                     receptor antagonists and proton pump inhibitors in ulcer disease

                     Know that gastritis is a clinical manifestation of Helicobacter pylori
                     infection

                     Recognize the risk factors for ulcer disease in childhood

                     Understand the methods for diagnosing Helicobacter pylori infection

                     Recognize the symptoms of dyspepsia in a child with recurrent
                     abdominal pain
J.   Hepatomegaly

                     Know the significance of simultaneous splenomegaly and hepatomegaly

                     Know the significance of hepatomegaly in a 1-month-old infant

                     Recognize age-related changes during physical examination of the
                     liver

                     Know how to evaluate a child with hepatomegaly

                     Know the signs, symptoms, and laboratory findings associated with
                     portal hypertension


                                                                                              90
K.   Malabsorption

     1.    General

                  Know the appropriate laboratory tests for malabsorption

                  Know the differential diagnosis for malabsorption at various ages

                  Know the clinical conditions associated with a rectal prolapse

     2.    Mucosal disease (celiac disease)

                  Know that the diagnosis of celiac disease depends on characteristic
                  small intestinal histopathologic findings and response to a gluten-
                  free diet

                  Recognize the clinical manifestations of celiac disease

                  Understand the mechanism of malabsorption in patients with cystic
                  fibrosis compared with the mechanism of malabsorption in patients
                  with celiac disease

                  Know the foods in which gluten can be found

     3.    Pancreatic insufficiency (cystic fibrosis, Shwachman

           syndrome)

                  Understand the role of pancreatic enzymes in the treatment of
                  pancreatic exocrine insufficiency

                  Know the age-related gastrointestinal signs and symptoms of cystic
                  fibrosis

                  Understand the association of hepatobiliary disease with
                  cystic fibrosis

                  Recognize that Shwachman syndrome is a cause of pancreatic
                  insufficiency
                  Recognize the adverse effects of chemotherapeutic drugs on intestinal
                  function

                  Recognize symptoms of malabsorption as a result of pancreatic
                  insufficiency

     4.    Enzyme deficiency (lactase, sucrase-isomaltase)

                  Recognize the symptoms of a carbohydrate malabsorption disorder

     5.    Short-gut syndrome, including bacterial overgrowth

                  Recognize the clinical situations in which bacterial overgrowth

                                                                                          91
                            may play a role in malabsorption

              6.     Fat malabsorption and chronic liver disease (biliary

                     atresia, CF)

                            Understand the rationale for the use of medium-chain triglyceride oil
                            in the management of fat malabsorption

        L.    Inflammatory bowel disease

                            Know the reasons for growth failure in patients with
                            inflammatory bowel disease

                            Know the clinical manifestations of Crohn disease

                            Understand that chronic perianal lesions can be an early sign
                            of Crohn disease

                            Know that patients with Crohn disease may have growth failure
                            secondary to decreased caloric intake

                            Distinguish the clinical manifestations of Crohn disease from those
                            of ulcerative colitis

                            Plan the initial evaluation of a patient with suspected inflammatory
                            bowel disease

                            Understand that isolated growth failure can be a presentation of
                            Crohn disease

                            Recognize that recurrent aphthous oral lesions can be a
                            manifestation of Crohn disease

                            Plan the management of a patient with severe colitis (fever,
                            hypoalbuminemia, and anemia)

                            Know the differential diagnosis of acute colitis in an adolescent

        M.    Refeeding syndrome
                            Recognize the signs and symptoms and laboratory abnormalities
                            associated with refeeding syndrome

XIII.   Respiratory Disorders

        A.    General signs and symptoms

              1.     Stridor

                            Know the differential diagnosis of congenital stridor

                            Know the different etiologies of stridor in children of

                                                                                                    92
             different ages

             Know that endoscopy is the diagnostic tool of choice for
             laryngeal and vocal cord disorders

             Understand the appropriate approach to the evaluation of congenital
             stridor

             Know that vocal cord dysfunction may mimic asthma

2.   Respiratory failure

             Know the parameters of respiratory failure

             Know the manifestations of chronic hypoxemia: polycythemia,
             pulmonary hypertension, cor pulmonale

             Know the clinical manifestations of acute hypercapnia: flushing,
             agitation, confusion, tachycardia, headache

             Recognize the combination of arterial blood gas values that indicate
             chronic carbon dioxide retention (increased PCO2, normal pH, increased
             serum bicarbonate concentration, increased base excess)

             Know the potential risks and benefits of administering oxygen to
             children with chronic respiratory failure

             Know when to intubate and when to provide oxygen therapy in patients
             with respiratory failure of various etiologies

3.   Cough

             Know the differential diagnosis of chronic cough in
             children of different ages

             Distinguish between the clinical manifestations of psychogenic
             cough and those of cough caused by organic etiology

             Recognize cough as a major and at times singular manifestation
             of asthma

             Understand the limited indications for cough suppressants

             Know that the initial screening evaluation of a chronic cough should
             include x-ray study of the chest, a sweat test, tuberculin skin test,
             and pulmonary function tests before resorting to other tests

             Know which conditions that occur in childhood impair the
             effectiveness of cough: cerebral palsy, muscle weakness, vocal
             cord dysfunction, CNS disease, thoracic deformities, pain

4.   Exercise intolerance
                                                                                      93
             Know that exercise intolerance may reflect etiologies other
             than pulmonary disease: anemia, muscle weakness, deconditioning,
             cardiac disease, psychogenic causes

             Know that exercise intolerance may be a presenting symptom of chronic
             lung diseases (eg, asthma, interstitial lung disease) or vocal
             cord dysfunction

5.   Apnea

             Distinguish between apnea and periodic breathing

             Know the difference between central and obstructive apnea

             Know the testing procedures used to evaluate the presence and
             degree of obstructive apnea in older children

             Know the differential diagnosis of central apnea in infancy

             Know the treatment of idiopathic recurrent apnea in premature infants

             Understand the association between apnea and anemia in premature
             infants

6.   Wheezing

             Know the differential diagnosis of recurrent wheezing

             Know to consider a foreign body in the differential diagnosis of
             wheezing

7.   Tachypnea

             Know that respiratory rates vary with age, and that normal
             variations occur with sleep, eating, and activity in normal children

             Recognize that tachypnea is a sensitive indicator of respiratory
             disease

8.   Hemoptysis

             Know the differential diagnosis of hemoptysis in children

             Know the initial management of hemoptysis in children and adolescents

9.   Cyanosis

             Know that cyanosis is not a sensitive indicator of oxyhemoglobin
             desaturation

             Know the common extrapulmonary causes of cyanosis: right-to-left

                                                                                     94
                    shunt, methemoglobinemia

                    Know how to validate and quantitate a clinical observation of
                    cyanosis: arterial blood gases, oxyhemoglobin saturation

     10.   Clubbing

                    Recognize disorders commonly associated with digital clubbing

B.   Upper airway

     1.    General

                    Know that upper respiratory tract infection and airway obstruction in
                    young infants lead to respiratory distress

     2.    Croup

                    Distinguish between viral and noninfectious croup

                    Know the appropriate management of croup

                    Know the clinical manifestations of laryngotracheobronchitis (croup)

     3.    Epiglottitis

                    Know how to treat a child with epiglottitis

                    Differentiate the clinical and radiographic findings of viral croup
                    from those of epiglottitis and bacterial tracheitis

                    Know the risks of examination of patients with suspected epiglottitis

C.   Lower airway

     1.    Vascular anomalies

                    Recognize the variable presentation of vascular anomalies
                    affecting the airway

                    Know the diagnostic modalities that facilitate identification
                    of vascular anomalies obstructing the airway

     2.    Congenital malformations

                    Recognize that congenital malformations of the lung
                    (eg, hypoplastic lung, cystic adenomatoid malformation)
                    may cause respiratory signs and symptoms

     3.    Bronchiolitis

                    Recognize the clinical manifestations of bronchiolitis

                                                                                            95
           Know the indicators for hospital admission for a child with
           bronchiolitis

           Know the appropriate management of a child with bronchiolitis

4.   Aspiration syndromes

           Recognize the signs and symptoms of foreign body aspiration

           Know how to evaluate for suspected foreign body aspiration

           Know the long-term complications of foreign body aspiration

           Know that there is often no history of foreign body aspiration

           Know the pulmonary complications of gastroesophageal reflux

           Know the possible radiographic manifestations of foreign body
           aspiration

           Know that recurrent aspiration can recur with swallowing disorders
           independent of gastroesophageal reflux

           Plan the management of a patient with aspiration of a foreign body

           Understand that hydrocarbon pneumonitis may cause acute and chronic
           lung disease

           Know that aspiration can occur despite the presence of a
           tracheostomy

           Plan the management of hydrocarbon pneumonitis

5.   Bronchiectasis

           Know the differential diagnosis of bronchiectasis

           Know that high-resolution CT of the chest is useful to diagnose
           bronchiectasis in a child

6.   Tracheomalacia

           Know that tracheomalacia can occur as a complication of chronic
           mechanical ventilation in children

           Know that tracheoesophageal fistula may result in tracheomalacia

           Know the clinical manifestations of tracheomalacia and
           laryngomalacia

7.   Tracheitis
                                                                                 96
                   Recognize the signs and symptoms of bacterial tracheitis

                   Know the typical clinical course of bacterial tracheitis, including
                   biphasic illness, precipitous worsening, requirement for intubation,
                   and relatively prolonged intubation

                   Know the treatment of bacterial tracheitis

                   Know the microbiology of bacterial tracheitis

     8.   Hemosiderosis

                   Know that hemosiderosis is associated with hemoptysis

D.   Parenchymal

     1.   Pneumonias

                   Plan the appropriate therapy for different types of pneumonia

                   Know the etiologies of pneumonia in children of different ages

                   Know the major acute and chronic complications of pneumonia,
                   including empyema, sepsis, pneumothorax, bronchopleural fistula,
                   and pneumatoceles

                   Know the clinical manifestations of pneumonias with different
                   etiologies

                   Know the laboratory tests for pneumonia, including x-ray study of the
                   chest, blood culture, complete blood count, urine antigen detection
                   studies, serology for Mycoplasma, sputum culture

                   Know the sequelae of pneumonia, and manage appropriately

                   Know the methods of prevention and/or control of pneumonia

                   Know which organisms are likely to cause the pleural and parenchymal
                   complications of pneumonia

                   Know that invasive studies (eg, bronchoscopy, lung aspiration,
                   open lung biopsy) may be indicated in patients with acute pneumonia

                   Know the differential diagnosis of recurrent pneumonia
                   Know that congenital lesions of the lung may mimic pneumonia

                   Know the significance of pneumonia in a child with neuromuscular
                   disease

                   Know the treatment of pneumonia in a child with neuromuscular
                   disease

                                                                                           97
     2.    Diaphragmatic hernia

                 Recognize the clinical manifestations of a diaphragmatic hernia

                 Know the appropriate initial therapy for a diaphragmatic hernia

                 Know the initial stabilization maneuvers for a newborn infant with a
                 diaphragmatic hernia

                 Know that diaphragmatic hernia is associated with persistent
                 pulmonary hypertension and subsequent abnormalities including
                 poor growth, tracheomalacia, and developmental delay

     3.    Trauma

                 Know how to evaluate a child with respiratory symptoms
                 following chest wall trauma

                 Know how to stabilize a child with respiratory symptoms following
                 chest wall trauma

     4.    Drowning, near drowning, acute respiratory distress syndrome

                 Know the clinical manifestations of acute respiratory distress
                 syndrome

                 Know the natural history of acute respiratory distress syndrome

                 Know the pulmonary sequelae of acute respiratory distress syndrome

                 Know that acute respiratory distress syndrome has multiple etiologies

                 Know that a patient with minimal symptoms following a near drowning
                 may later develop symptoms that require hospitalization

                 Know that acute respiratory distress syndrome may result from a near-
                 drowning after a period of initial recovery

                 Know the major causes of death in children with acute respiratory
                 distress syndrome: sepsis, extrapulmonary multiorgan failure, air
                 leaks

E.   Newborn infants

     1.    Bronchopulmonary dysplasia (chronic lung disease of infancy)
                 Recognize that bronchopulmonary dysplasia can develop in a newborn
                 infant, regardless of gestational age, who has been treated with
                 artificial ventilation and an enriched oxygen concentration

                 Recognize that infants with bronchopulmonary dysplasia are prone to
                 cor pulmonale and recurrent wheezing with infections

                                                                                         98
                   Recognize that failure to thrive and severe respiratory infections
                   are common in infants with bronchopulmonary dysplasia

                   Recognize that infants with bronchopulmonary dysplasia may require
                   home oxygen therapy

                   Recognize that gastroesophageal reflux is a common association in
                   children with bronchopulmonary dysplasia and that it may aggravate
                   their respiratory status

                   Recognize that aversive oral motor behavior is associated with
                   bronchopulmonary dysplasia, thereby limiting ways to feed such infants

                   Recognize that poor growth may be a sign of insufficient
                   oxygenation in a child with bronchopulmonary dysplasia

                   Know that children with bronchopulmonary dysplasia often
                   require greater than 100% of the recommended dietary allowance for
                   calories in order to grow

     2.     Other - not BPD

                   Know the specific radiographic findings in idiopathic neonatal
                   respiratory distress syndrome

                   Differentiate between the normal results of a newborn chest
                   x-ray and the radiographic patterns that reflect meconium
                   aspiration

                   Differentiate between the normal results of a newborn chest
                   x-ray and the radiographic patterns that reflect pneumonia

                   Recognize subglottic stenosis as a complication of endotracheal
                   intubation

                   Know how to distinguish between pulmonary disease and cyanotic
                   congenital heart disease as a cause of hypoxemia and metabolic
                   acidosis in a neonate

                   Recognize that chronic lung disease may result from meconium
                   aspiration

F.   Asthma (see VIII.C)

G.   Cystic fibrosis

                   Know the common microbial pathogens involved in the pulmonary
                   complications of cystic fibrosis

                   Know the extrapulmonary complications of cystic fibrosis


                                                                                            99
                  Know the indications for aggressive management with antimicrobial
                  therapy for cystic fibrosis

                  Understand the inheritance of cystic fibrosis

                  Know how to diagnose cystic fibrosis

                  Know the association of rectal prolapse and cystic fibrosis

                  Know the neonatal non-pulmonary manifestations of cystic fibrosis:
                  meconium ileus, meconium peritonitis, prolonged jaundice

                  Understand the need for supplemental calories, pancreatic enzymes,
                  and fat-soluble vitamins in patients with cystic fibrosis

                  Know the manifestations of cystic fibrosis in infancy:
                  hypoproteinemia, anemia, steatorrhea, recurrent pulmonary symptoms,
                  hypochloremic alkalosis

                  Recognize and diagnose exocrine pancreatic insufficiency in infants

                  Recognize the importance of planning for survival into adulthood
                  for patients with cystic fibrosis

                  Know that hemoptysis and pneumothorax can be potentially life-
                  threatening complications of cystic fibrosis

                  Understand the management of pulmonary disease (eg, inhaled
                  antibiotics, DNase) in patients with cystic fibrosis

                  Plan appropriate management of a patient with extrapulmonary
                  complications of cystic fibrosis

H.   Primary ciliary dyskinesia (dysmotile cilia syndrome)

                  Know that otitis media, dextrocardia, and/or bronchiectasis may be
                  due to primary ciliary dyskinesia

                  Know that ciliary biopsy is required to diagnose primary ciliary
                  dyskinesia

I.   Extrapulmonary

     1.    Pleural fluid

                  Diagnose the presence of pleural disease with an imaging study of
                  the chest

                  Understand the etiologies of pleural fluid accumulations

                  Describe the characteristics of pleural fluid associated with
                  empyema

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                  Know the characteristics of pleural fluid due to chylothorax

                  Understand the importance of draining an empyema

     2.    Pneumothorax, pneumomediastinum

                  Know the signs and symptoms of pneumothorax

                  Know the appropriate therapy for a child with pneumothorax

                  Know that spontaneous pneumothoraces occur and may recur in young
                  asthenic boys

                  Know that asthma may be associated with pneumothorax and/or
                  pneumomediastinum

                  Recognize that pneumothorax may be a complication of resuscitation
                  and mechanical ventilation

     3.    Thoracic deformities

                  Recognize the association between scoliosis and restrictive pulmonary
                  disease

                  Recognize that severe progressive neuromuscular disease of any
                  etiology can produce serious restrictive pulmonary disease

                  Recognize that pectus excavatum is not usually associated with
                  pulmonary disease or exercise limitation

J.   Pulmonary hypertension and cor pulmonale

                  Know that oxygenation may decrease during abnormal sleep, which may
                  cause pulmonary hypertension or exacerbate existing cor pulmonale

                  Know that pulmonary hypertension is potentially reversible

                  Know the situations in which pulmonary hypertension and
                  cor pulmonale may occur

K.   Sleep disorders

                  Know the respiratory and non-respiratory conditions that may cause
                  sleep disorders

                  Understand the symptoms that reflect poor sleep quality in children

                  Know the indications for surgery in adenoid/tonsillar hypertrophy
                  causing obstructive sleep apnea

                  Know the appropriate evaluation of suspected obstructive sleep

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                   apnea in children

                   Know the differential diagnosis of obstructive sleep apnea in
                   children

                   Know that children with severe obstructive apnea due to upper
                   airway obstruction are at significant risk for respiratory distress
                   postoperatively (eg, due to postoperative airway swelling,
                   postoperative obstructive pulmonary edema)

                   Differentiate night terrors from nightmares

                   Know common causes of somnolence in adolescents

                   Recognize that narcolepsy can be present in adolescents

                   Understand that prescribed and over-the-counter medications may
                   affect sleep

L.   Sudden infant death syndrome

                   Recognize a child with an apparent life-threatening event (ALTE)

                   Know the appropriate management of a child with an apparent
                   life-threatening event (ALTE)

                   Know the risk factors for sudden infant death syndrome

                   Know the relationship between apnea and sudden infant death
                   syndrome

                   Know that the differential diagnosis of apparent life-threatening
                   events (ALTE) in infancy includes infection, metabolic abnormality,
                   gastroesophageal reflux, aspiration, cardiac dysrhythmia, seizures,
                   nonaccidental trauma, apnea of infancy

                   Recognize the limitations of cardiorespiratory ("apnea") monitors
                   in following infants with apparent life-threatening events (ALTE)

M.   Diagnostic testing

     1.     Pulmonary function testing

                   Know what spirometry measures

     2.     Oximetry

                   Know the correlation between PaO2 and oxyhemoglobin saturation

                   Understand the value and limitations of pulse oximetry in caring
                   for children with acute pulmonary disease


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                           Know the common causes of inaccurate measurement of SpO2

             3.     Blood gas analysis

                           Recognize the limitations of capillary blood gas testing

                           Recognize arterial blood gas findings in a patient who has acute
                           respiratory failure (or opiate overdose)

             4.     Imaging

                           Recognize intrathoracic airway obstruction by x-ray study of
                           the chest

                           Recognize atelectasis by x-ray study of the chest

       N.    Environmental tobacco smoke exposure

                           Recognize the possible side effects of environmental tobacco
                           smoke exposure

                           Recognize that household fumes (eg, from cooking) may be
                           harmful to children

XIV.   Cardiovascular Disorders

       A.    General aspects

             1.     Blood pressure (see III.B.2)

                           Recognize prescription, over-the-counter, and illicit drugs
                           likely to elevate the blood pressure

                           Understand the treatment of hypertension in children

                           Know that coarctation of the aorta causes upper extremity
                           hypertension

             2.     Chest pain

                           Know that chest pain in healthy children is generally not
                           cardiopulmonary in origin

                           Recognize the cardiovascular causes of chest pain

             3.     Syncope

                           Understand that the description of a syncopal episode usually directs
                           the evaluation

                           Know the importance of cardiovascular evaluation in patients with
                           syncopal or pre-syncopal episodes with exercise

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                  Recognize the cardiac causes of syncope

     4.    Murmur

                  Recognize the qualities of innocent heart murmurs and provide
                  appropriate counseling

                  Recognize that a child with an innocent murmur requires no further
                  evaluation

B.   Congestive heart failure

     1.    Diagnosis

                  Recognize irritability, dyspnea during feeding, and decreased volume
                  with each feeding as symptoms of congestive heart failure in infants

                  Identify early fatigue, exercise intolerance, anorexia, and cough as
                  symptoms of congestive heart failure in older children

                  Recognize the signs and symptoms of congestive heart failure

                  Identify the important physical findings (eg, edema, hepatomegaly,
                  jugular vein distention, cardiomegaly, gallop rhythm) in congestive
                  heart failure in older children

                  Know how an imaging study of the chest may help diagnose congestive
                  heart failure

                  Understand the association between systemic arteriovenous
                  malformation and congestive heart failure in a newborn infant

                  Recognize the common causes of congestive heart failure in infants and
                  children

                  Understand the role of the pulmonary vascular bed in the presentation
                  of congestive heart failure in infants with large volume left-to-
                  right shunts

     2.    Management

                  Plan the treatment of congestive heart failure

C.   Congenital heart disease

     1.    General

                  Recognize the increased risk and plan appropriate evaluation of
                  congenital heart disease in a newborn infant with congenital
                  anomalies (eg, trisomy 21, trisomy 18, fetal alcohol syndrome,
                  22q11 microdeletion, 45,XO)

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2.   Cardiogenic shock

           Know that an electrocardiogram and echocardiography should be part of
           the evaluation of a patient with possible cardiogenic shock

           Know that cardiogenic shock may be the initial finding in a newborn
           infant with congenital heart disease

           Recognize the findings of cardiogenic shock in the newborn infant

           Know the treatment of cardiogenic shock in the newborn infant

           Know what important lesions are associated with the shock-like
           presentation in a newborn infant

3.   Cyanotic disease

     a.    Diagnosis

           Distinguish between central cyanosis and acrocyanosis

           Identify the clinical characteristics of a tetralogy spell

           Know the cardiac causes of cyanosis in the newborn infant

           Recognize that the absence of improvement in arterial oxygen content
           with 100% oxygen in comparison with room air is compatible with the
           diagnosis of cyanotic congenital heart disease

           Recognize the clinical features of transposition of the great
           arteries

     b.    Management

           Know the complications of polycythemia in a patient with cyanotic
           congenital heart disease

           Understand the prognosis for a patient with tetralogy of Fallot

           Understand the prognosis for cognitive development in patients with
           cyanotic congenital heart disease

           Know that a relative anemia can be associated with a stroke in a
           patient with cyanotic congenital heart disease

           Know the immediate management of a child with a hypoxic episode

           Understand the role of ductus arteriosus in cyanotic congenital heart
           disease and the use of prostaglandin E1 in treatment

4.   Acyanotic disease


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            a.     Diagnosis
                   Recognize the major clinical findings in patients with cardiac
                   anomalies such as ventricular septal defect, atrial septal defect,
                   patent ductus arteriosus, aortic stenosis, or pulmonic stenosis

                   Know the importance of patent ductus arteriosus in the presentation
                   of hypoplastic left heart syndrome and in coarctation of the aorta

            b.     Management

                   Plan the initial management of a premature infant with patent
                   ductus arteriosus

                   Understand the immediate (eg, referral) and long-term (eg, frequent
                   BP measurements) management in a patient with coarctation of the
                   aorta

                   Know the expected natural history of ventricular septal defect

                   Know the expected natural history of a bicuspid aortic valve

                   Understand the management of severe pulmonary valve stenosis

                   Understand the risks for pulmonary vascular obstructive disease
                   (Eisenmenger) in patients with untreated large left-to-right shunt
                   lesions with pulmonary hypertension (eg, large VSD, AV septal defect,
                   large PDA)

D.   Infectious and postinfectious diseases

     1.     Infective endocarditis

                   Know the indications for antibiotic prophylaxis in children with
                   congenital heart lesions

                   Know the drugs of choice for the prophylaxis of infective endocarditis

                   Know the clinical manifestations of infective endocarditis

                   Know the management of infective endocarditis

                   Know the microbiology of infective endocarditis

                   Know the epidemiology of infective endocarditis, including risk
                   factors

                   Know that a blood culture is the most important test for the
                   diagnosis of infective endocarditis

     2.     Rheumatic fever

                   Identify the clinical manifestations of rheumatic fever

                                                                                            106
                  Know the laboratory findings of rheumatic fever
                  Identify the murmurs of mitral insufficiency and aortic
                  insufficiency as the most common murmurs in rheumatic fever

                  Know the major and minor criteria for the diagnosis of rheumatic
                  fever

                  Know the epidemiology of rheumatic fever

                  Know that echocardiography should be done in a patient with rheumatic
                  fever

                  Plan the initial management of acute rheumatic fever

     3.    Myocarditis

                  Identify the clinical manifestations of myocarditis

                  Know the laboratory evaluation of myocarditis

                  Know the microbiology of myocarditis

     4.    Pericarditis

                  Know the etiologies and clinical manifestations of pericarditis

                  Know the laboratory evaluation of pericarditis

                  Know the microbiology of pericarditis

                  Know the pathogenesis of pericarditis

                  Know the treatment of pericarditis, including the importance of
                  surgical drainage

     5.    Kawasaki disease (see also XXI.B.2.)

                  Understand the proper use of echocardiography in the
                  evaluation and management of patients with Kawasaki disease

                  Identify the cardiac complications of Kawasaki disease and the
                  timing of onset; understand their prevention and treatment and the
                  importance of follow-up evaluation

E.   Rate and rhythm disorders, ischemia

                  Identify the clinical manifestations of common cardiac arrhythmias

                  Understand the clinical significance of a prolonged corrected QT
                  interval


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                          Using electrocardiographic patterns, identify premature atrial
                          contractions, premature ventricular contractions, supraventricular
                          tachycardia, and ventricular tachycardia
                          Understand the treatment of supraventricular tachycardia

      F.    Systemic diseases affecting the heart

                          Know that hyperthyroidism should be considered in the evaluation of
                          a patient with persistent sinus tachycardia

                          Recognize that patients with Marfan syndrome may have associated
                          cardiac disease that precludes participation in sports

                          Know the cardiovascular conditions associated with Turner syndrome

                          Recognize the signs and symptoms of superior vena cava syndrome

                          Know the importance of cardiovascular evaluation when there is a
                          family history of hypertrophic cardiomyopathy, muscular dystrophy,
                          or Marfan syndrome

                          Understand the importance of a family history of cardiovascular
                          disease and familial hyperlipidemia and hypercholesterolemia in
                          children and evaluate appropriately

                          Identify the cardiovascular risk factors in children, and evaluate
                          appropriately

                          Plan the initial management of a child with a positive family history
                          of hyperlipidemia

XV.   Blood and Neoplastic Disorders

      A.    General aspects

            1.     Recognition by history

                          Know that jaundice, dark urine, and a sudden change in exercise
                          tolerance may indicate a hemolytic anemia

                          Recognize recurrent bacterial infections as a manifestation
                          of quantitative or qualitative leukocyte disorders

                          Know that children with severe neutropenia may become infected
                          with their own skin and bowel flora

                          Recognize that children with a family history of hematologic
                          disorders (eg, hemophilia, bleeding complications, hemoglobinopathy,
                          hemolytic disease) may also be at risk and require screening or
                          evaluation

                          Recognize that children with a family history of excessive cancers

                                                                                                  108
            may also be at risk and require screening or evaluation

2.   Recognition by physical examination

            Recognize mucosal ulcerations as a sign of neutropenia

            Distinguish between bruising due to thrombocytopenia
            and normal bruising in an active child

            Recognize that child abuse may be a cause of bruising in a
            child with a normal platelet count

            Recognize that vasculitic disorders may be a cause of bruising
            or purpura in a child with a normal (or increased) platelet
            count

            Know that thrombocytopenia or functional platelet disorders may
            cause bruising, petechiae, epistaxis, or gastrointestinal bleeding
            but rarely cause deep muscle or joint bleeding

            Recognize palpable bruises or bruises in areas not
            exposed to trauma as distinctly abnormal

            Formulate the differential diagnosis of a patient with a purpuric
            rash

            Recognize that children with hemihypertrophy and somatic overgrowth
            syndromes should be periodically evaluated for the development of
            associated embryonal tumors

3.   Interpretation of laboratory results

            Recognize the physiologic anemia of infancy and understand that
            further laboratory evaluation is unnecessary

            Know that iron deficiency and thalassemia minor are the most
            common causes of a microcytic anemia

            Know that the reticulocyte count usually distinguishes between
            disorders of erythrocyte production and those of erythrocyte
            destruction

            Know that a total leukocyte count and a leukocyte
            differential count are needed to diagnose neutropenia

            Know that neutropenia is usually defined as a neutrophil count
            <1000/mm3

            Recognize that bleeding time is a test of platelet and blood
            vessel function

            Recognize that thrombocytopenia is defined as a platelet count

                                                                                  109
                  <150,000/mm3

                  Recognize that a bone marrow aspirate is necessary in the
                  evaluation of a child with multiple pancytopenias

                  Understand the normal variation in hemoglobin concentration and mean
                  corpuscular volume during childhood

B.   Erythrocyte disorders

     1.    Nutritional anemias

           a.     Iron deficiency

                  Understand that iron deficiency causes nonhematologic
                  effects such as behavior and learning disturbances

                  Know that dietary deficiency is the most common cause
                  of iron deficiency anemia in young children

                  Know that cow milk contains very little bio-available iron and that
                  an infant with iron deficiency often drinks large
                  amounts of cow milk

                  Understand the need to look for bleeding as a cause of
                  iron deficiency in the child with a normal diet

                  Know how to diagnose iron deficiency anemia

                  Know that treatment of iron deficiency with ferrous sulfate should
                  continue after the hemoglobin concentration has returned to normal

                  Know that intramuscular iron injections or erythrocyte infusions are
                  not appropriate for the child with routine nutritional iron
                  deficiency

           b.     Vitamin B12, folic acid deficiency

                  Recognize vitamin B12 or folate deficiency as a cause of
                  macrocytic anemia

                  Document the diagnosis of B12 or folate deficiency with specific
                  measurement of serum B12 concentration or serum or erythrocyte
                  folic acid concentrations before beginning replacement therapy

                  Know that B12 deficiency may occur following small bowel
                  resection or as a result of a maternal vegan diet in a child
                  who is breast-fed exclusively

                  Know that ingestion of fresh goat milk as a principal source of
                  nutrition in infancy is a cause of folate deficiency


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2.   Hemolytic anemias

     a.    Membrane disorders

           Recognize jaundice and splenomegaly as findings of
           hereditary spherocytosis
           Know that increasing pallor in a child with hereditary
           spherocytosis may be a sign of an aplastic crisis that
           warrants monitoring of the hemoglobin concentration and
           reticulocyte count

           Know that a sudden increase in jaundice in a child with
           hereditary spherocytosis may be a sign of increasing
           hemolysis, that warrants monitoring of the hemoglobin concentration

           Know that a child with hereditary spherocytosis or other erythrocyte
           membrane disorders should receive pneumococcal, meningococcal, and
           Hemophilus influenzae vaccines before splenectomy and prophylactic
           penicillin after splenectomy

           Recognize that parvovirus B19 is the most common cause of an aplastic
           crisis in patients with hereditary spherocytosis

     b.    Enzyme abnormalities

           Know that G6PD deficiency is a common X-linked
           disorder

           Know that the sudden onset of pallor and anemia may be
           a manifestation of G6PD deficiency

           Know the causes of hemolysis in patients with G6PD deficiency,
           and manage appropriately

           Be aware of the clinical differences in the form of G6PD deficiency
           seen in patients of different ethnic backgrounds

     c.    Hemoglobinopathies

           Understand that sickle cell disease can be diagnosed at
           birth

           Know that children with sickle cell disease are particularly
           susceptible to death from overwhelming bacterial sepsis and require
           early evaluation and treatment when febrile

           Recognize the findings of an enlarged spleen and
           worsening anemia as indicative of a sequestration crisis
           in sickle cell disease

           Understand that immediate intervention with intravenous
           fluids and/or blood is the treatment for acute

                                                                                   111
           sequestration crises

           Recognize painful swelling of the hands and/or feet as
           a manifestation of sickle cell disease in young children

           Understand the use of prophylactic penicillin in children with
           sickle cell disease
           Recognize increasing pallor, decreased hemoglobin concentration, and
           a decreased reticulocyte count as findings in an aplastic
           crisis in sickle cell disease

           Know that acute chest syndrome and painful crises are
           common manifestations of sickle cell disease

           Know that thalassemia major usually presents as a severe
           hypochromic, microcytic anemia with enlargement of the
           liver and/or spleen

           Recognize association of cholelithiasis in a patient with sickle
           cell disease

           Know that priapism is a common manifestation of sickle cell disease

           Understand the presenting signs and diagnostic evaluation for
           suspected thalassemia

     d.    Immune-mediated anemias

           Recognize pallor, jaundice, and splenomegaly as signs of
           autoimmune hemolytic anemia in children, and manage appropriately

           Understand that direct and indirect Coombs tests are a necessary part
           of the evaluation of a child with acute-onset anemia

           Understand the complications of an erythrocyte transfusion in a
           child with autoimmune hemolytic anemia

           Know that corticosteroids are useful in treating
           autoimmune hemolytic anemia

           Know that ABO incompatibility may cause anemia in a first-
           born child, but Rh incompatibility rarely does

           Know that progressive and severe anemia may occur at 4
           to 8 weeks of age in infants with ABO or Rh incompatibility

3.   Aplastic and hypoplastic erythrocyte disorders

     a.    Diamond-Blackfan syndrome

           Distinguish between the clinical characteristics of Diamond-Blackfan
           syndrome and transient erythroblastopenia of childhood

                                                                                   112
           b.     Transient erythroblastopenia of childhood

                  Know the signs, symptoms, and laboratory findings of
                  transient erythroblastopenia of childhood

                  Understand the role of erythrocyte transfusions in transient
                  erythroblastopenia of childhood
     4.    Therapeutic approaches

                  Understand the risk of transmitting infectious diseases during
                  blood transfusion(s)

                  Recognize that erythrocyte transfusions may be associated with
                  hemolytic, febrile, and urticarial reactions

                  Understand the role of erythrocyte transfusions in the management
                  of anemia

                  Understand the role of erythropoietin in the management of anemia of
                  renal failure and chronic inflammatory disease

C.   Leukocyte disorders

     1.    Quantitative leukocyte disorders

           a.     Congenital and immune-mediated neutropenia

                  Recognize that congenital neutropenia may be persistent
                  or cyclical, and manage appropriately

           b.     Acquired, nonimmune neutropenia

                  (1).     Sepsis

                  Recognize neutropenia as a sign of overwhelming
                  bacterial sepsis

                  (2).     Drugs

                  Understand that neutropenia may be drug-induced
                  and, if so, should lead to discontinuation of the
                  drug

                  Recognize that common viral infections may cause
                  transient neutropenia that does not require
                  specific treatment

     2.    Qualitative leukocyte disorders

                  Recognize that a child with recurrent bacterial infections
                  and a normal neutrophil count may have abnormal neutrophil

                                                                                         113
                   function

                   Recognize clinical signs of abnormal leukocyte function (eg,
                   periodontal disease, perirectal ulceration, delayed umbilical
                   cord separation)

     3.     Therapeutic approaches

                   Understand the role of growth factors in the treatment of
                   neutropenia

D.   Platelet disorders

     1.     Quantitative platelet disorders

            a.     Decreased platelet production

                   Know that thrombocytopenia in a newborn infant may be
                   a sign of bacterial sepsis and, in an ill child, should
                   lead to appropriate culture and antibiotic therapy

                   Recognize that a history of medications should be part
                   of the evaluation of a child with thrombocytopenia

                   Recognize that the presence of thrombocytopenia in a
                   newborn infant with microcephaly or other congenital
                   abnormalities may be due to a congenital viral infection
                   such as CMV

            b.     Increased platelet destruction

                   (1).       Congenital

                   Recognize thrombocytopenia, eczematoid rash and
                   recurrent infections as signs of Wiskott-Aldrich
                   syndrome

                   Know that a rapidly enlarging hemangioma should
                   lead to a platelet count to check for
                   thrombocytopenia

                   Manage the thrombocytopenia associated with TAR syndrome

                   (2).       Acquired

                   Know that ITP is characterized by a low platelet count and normal
                   or increased platelet production in the bone marrow

                   Understand that most children with ITP will recover
                   in less than one year without treatment

                   Know that the common presenting symptom of ITP is

                                                                                       114
                    increased bruising

                    Know that corticosteroids and intravenous immune globulin
                    usually increase the platelet count in children with ITP but do not
                    alter the natural course (ie, length of disease)

                    Understand that aspirin or other drugs that
                    interfere with platelet function should not be
                    given to children with ITP or other quantitative
                    or qualitative platelet disorders
                    Recognize persistent or severe headache as a symptom of
                    intracranial hemorrhage in ITP

                    Know that splenectomy is not an appropriate therapy
                    at the onset of ITP in a child who is not having
                    major bleeding problems

                    Know that a mother with ITP may have an infant with
                    thrombocytopenia, and know how to manage the infant

                    Recognize that multiple siblings with neonatal
                    thrombocytopenia suggests isoimmune
                    thrombocytopenia

                    Know that thrombocytopenia due to maternal ITP or
                    isoimmune thrombocytopenia usually resolves within
                    six to 12 weeks

                    Plan the appropriate management of a patient with ITP

     2.    Qualitative platelet disorders

     3.    Therapeutic approaches

E.   Pancytopenia

     1.    Decreased production

           a.       Congenital (Fanconi anemia)

           b.       Acquired aplastic anemia

                    Understand that aplastic anemia and childhood leukemia
                    may both present with purpura, pallor, and fever

                    Know that the absence of blasts in the peripheral blood
                    of a patient with pancytopenia does not rule out the
                    diagnosis of leukemia

     2.    Increased destruction

                    Know that pancytopenia may result from autoimmune destruction of

                                                                                          115
                  erythrocytes, leukocytes, and platelets (Evans syndrome), and
                  manage accordingly

     3.    Therapeutic approaches

F.   Coagulation disorders

     1.    Congenital bleeding and thrombotic disorders

                  Know that excessive bleeding after circumcision may be the
                  first sign of a congenital coagulation factor deficiency
                  Identify prothrombin time and partial thromboplastin time as
                  important parts of the evaluation a patient with increased bruising

                  Know that a child born to the daughter of a person with
                  hemophilia should be tested for that particular bleeding
                  disorder

                  Know that for a woman who is a carrier of hemophilia, there
                  is a 50% chance that a male offspring will have that bleeding
                  disorder

                  Know that headache is an important symptom of intracranial
                  bleeding and requires early assessment and treatment

                  Understand that serious head trauma in a person with hemophilia
                  requires careful assessment and early replacement therapy even
                  in the absence of neurologic abnormalities

                  Recognize bleeding in the forearm of a person with hemophilia
                  as an emergency because of the danger of nerve compression

                  Know that femoral or jugular venipunctures should be avoided
                  in the person with hemophilia who has not received replacement
                  treatment

                  Know that some children with hemophilia have a negative family
                  history for bleeding disorders

                  Recognize that partial thromboplastin time is often normal in patients
                  with von Willebrand disease, but the bleeding time is commonly
                  prolonged

                  Recognize that the first manifestation of von Willebrand
                  disease in girls may be heavy menstrual bleeding

                  Recognize that a strong family history of pulmonary emboli or
                  deep vein thrombosis may suggest a congenital hypercoagulable
                  disorder

                  Understand the usefulness of DDAVP in the treatment of a patient with
                  hemophilia or von Willebrand disease

                                                                                           116
                  Recognize von Willebrand disease as a common inherited bleeding
                  disorder, and evaluate and manage appropriately

     2.    Acquired bleeding and thrombotic disorders

                  Identify the need for measuring prothrombin time, partial thrombo-
                  plastin time, and platelet count as part of the evaluation for
                  disseminated intravascular coagulation in a child with sepsis and
                  purpura

                  Recognize purpura as an indication of bacterial sepsis in a
                  febrile child

     3.    Therapeutic approaches

                  Understand the role of coagulation factor replacement for hemophilia

                  Understand the role of fresh frozen plasma and cryoprecipitate
                  in the management of bleeding diatheses

                  Understand the role of thrombolysis and anticoagulation in the
                  management of thrombotic disorders

G.   Neoplastic disorders

     1.    Hematologic malignancies

           a.     Leukemias

                  Recognize bone pain as a symptom of leukemia

                  Understand that most patients with acute lymphoblastic leukemia
                  will be cured of their disease using current treatment strategies

                  Identify the central nervous system and testes as
                  important sites of relapse of acute lymphoblastic
                  leukemia

                  Identify Down syndrome as a disease with an increased
                  risk of leukemia

                  Understand that different childhood leukemias (ALL, AML, chronic
                  leukemias) have distinct therapies and outcomes

           b.     Lymphomas

                  Recognize the need for evaluation of supraclavicular lymph node
                  enlargement

                  Identify the chest x-ray as an important part of the initial
                  evaluation of the patient with an unexplained lymphadenopathy

                                                                                         117
           Know that overwhelming sepsis is a serious complication in
           patients with Hodgkin disease who have undergone splenectomy,
           and know that such patients should be evaluated thoroughly if
           fever develops

           Recognize that renal function and serum electrolytes should be
           assessed in patients who have suspected leukemia or lymphoma
           to exclude tumor lysis syndrome

2.   Solid tumors

     a.    Neuroblastoma
           Understand that a neuroblastoma usually presents as a nontender
           abdominal mass

           Understand that urinary catecholamine excretion is increased
           in most patients with a neuroblastoma and that tests of urine for
           VMA and VHA are appropriate screening tests for the tumor

     b.    Wilms tumor

           Know that Wilms tumor is associated with hemihypertrophy and
           aniridia, somatic overgrowth, and/or genitourinary abnormalities

           Understand that Wilms tumor usually presents as an abdominal
           mass and may cause hypertension and/or hematuria

           Understand the prognosis of Wilms tumor

     c.    Brain tumors

           Recognize the signs and symptoms of craniopharyngioma

           Recognize the presenting signs of brain tumor (eg, headache,
           deteriorating school performance, ataxia, emesis)

     d.    Bone and soft tissue tumors

           Know that the presenting symptom of osteosarcoma is usually
           bone pain or swelling

           Identify the clinical and laboratory features of osteoid osteoma

           Understand that Ewing sarcoma and osteosarcoma are the most
           common malignant bone tumors in children, and that both may
           metastasize to the lungs

           Recognize that the biopsy of a malignant bone tumor should be
           done at a pediatric oncology center with attention to subsequent
           safe tumor resection


                                                                               118
     e.    Histiocytosis syndromes of childhood

           Recognize the clinical manifestations of the histiocytosis syndromes
           of childhood

     f.    Other tumors (eg, germ cell, liver, retinoblastoma)

           Understand that serum alpha-fetoprotein and beta-human chorionic
           gonadotropin may be markers of germ cell tumor and hepatoblastoma

           Know that hereditary retinoblastoma frequently involves both
           eyes and presents at a younger age than sporadic retinoblastoma

           Understand the genetics of retinoblastoma and the importance of
           frequent ocular examinations in children with a positive family
           history

3.   Oncologic emergencies

     a.    Spinal cord compression

           Differentiate the clinical manifestations of spinal cord compression
           (eg, from a tumor) from those of other myelopathies, and evaluate
           appropriately

           Recognize the need for immediate evaluation of children complaining
           of back pain, lower extremity weakness, and/or bowel and bladder
           dysfunction to evaluate for spinal cord compression

     b.    Mediastinal mass

     c.    Infection and sepsis

           Identify varicella as a life-threatening illness in a patient
           receiving chemotherapy, and know that varicella-zoster immune
           globulin should be given immediately after exposure to varicella

           Recognize the need for immediate evaluation of a febrile child who
           is neutropenic as a result of chemotherapy

           Recognize wheezing, positional dyspnea, and a chest mass as an
           indication for immediate evaluation and management due to the risk
           of acute respiratory failure

           Know that children receiving chemotherapy require prophylaxis
           against Pneumocystis jiroveci (carinii) pneumonia

4.   Therapeutic considerations

           Understand that live-virus vaccines should not be given during
           chemotherapy


                                                                                  119
                          Understand the gonadal effects associated with the use of
                          chemotherapeutic drugs

                          Understand the effects of cranial irradiation on growth hormone
                          secretion

                          Be familiar with the late sequelae of cancer and cancer therapy

                          Understand that most vaccinations (even inactivated) are withheld
                          during chemotherapy since adequate immune response is compromised

XVI.   Renal Disorders

       A.    General

             1.     Normal function

                          Know age-related changes in glomerular filtration rate and the
                          impact on the serum creatinine concentration

                          Recognize the limitations of 24-hour urine collections in pediatric
                          patients

             2.     Proteinuria

                          Plan the appropriate evaluation of a child with proteinuria

                          Recognize that fever and exercise are causes of transient proteinuria

                          Recognize that a dipstick examination of an alkaline urine might
                          yield a false-positive result for proteinuria

             3.     Hematuria

                          Know the differential diagnosis of a child with gross hematuria

                    a.    Persistent microscopic hematuria

                          Plan the appropriate evaluation and management of a child with
                          microscopic hematuria

                          Recognize the differential diagnosis and prognosis of patients with
                          persistent microscopic hematuria with and without persistent
                          proteinuria

                          Recognize the importance of the family history in a child with
                          persistent microscopic hematuria

                          Know that structural abnormalities should be ruled out in patients
                          with gross hematuria

                          Know that myoglobin can yield false-positive results for hematuria on

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           urinalysis

     b.    Causes of gross and microscopic hematuria

           Plan the evaluation of hematuria in a child with sickle cell trait
           or disease

           Know the association between hypercalciuria and microscopic hematuria,
           and evaluate appropriately

     c.    Nonhematogenous etiology of red urine

           Determine by history and laboratory evaluation the etiology of red
           urine

4.   Dysuria
           Recognize that the etiology of dysuria may be age-related and
           that numerous other etiologies include vaginitis, chemical irritation,
           and trauma

           Understand the importance of taking a history regarding
           sexual activity when considering the differential
           diagnosis of abdominal pain and dysuria

           Recognize the importance of perineal inspection in girls with dysuria

5.   Incontinence

     a.    Nocturnal

           Know that some children with enuresis may have a functionally reduced
           bladder capacity and/or frequent uninhibited bladder contractions

           Recognize that children with secondary nocturnal enuresis rarely have
           serious underlying disease

     b.    Organic

           Know that an ectopic urethral opening can cause incontinence
           in females

           Know the organic etiologic factors of nocturnal incontinence: urinary
           tract infection or anomaly, lumbosacral anomaly, diabetes, epilepsy

           Know the importance of skin abnormalities in the sacral area when
           evaluating patients with primary enuresis

     c.    Functional, daytime incontinence

           Evaluate and manage a child with daytime incontinence

           Know that constipation contributes to urinary incontinence

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                  Know that incontinence may be related to infrequent voiding

           d.     Voiding dysfunction

                  Recognize voiding dysfunction in children with urinary frequency
                  and negative urine cultures

B.   Congenital

     1.    Renal dysplasia

           a.     Unilateral multicystic dysplastic kidney

                  Recognize that multicystic dysplastic kidney frequently
                  presents as a unilateral flank mass in neonates/infants

           b.     Autosomal-dominant polycystic kidney disease

                  Know that children with autosomal-dominant polycystic kidney
                  disease may have hypertension

                  Know that autosomal-dominant polycystic kidney disease may be
                  associated with intracranial aneurysms

                  Know that abdominal ultrasonography is the preferred diagnostic
                  procedure in children suspected of having autosomal-dominant
                  polycystic kidney disease

           c.     Autosomal-recessive polycystic kidney disease

                  Know the clinical presentation of autosomal-recessive
                  polycystic kidney disease in neonates, infants, and children
                  with congenital hepatic fibrosis

           d.     Renal agenesis

                  Recognize the association of bilateral renal aplasia or severe
                  dysplasia with pulmonary hypoplasia (Potter syndrome)

     2.    Abnormalities of the collecting system, kidney, and bladder

           a.     General

                  Know the differential diagnosis of urinary tract obstruction

                  Plan the evaluation of an infant with anuria more than 48 hours after
                  birth

           b.     Hydronephrosis

                  Know that hydronephrosis is one of the causes of abdominal masses in

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                  infants

          c.      Hydroureter and megaureter

                  Know the urologic findings associated with prune-belly (Eagle-Barrett)
                  syndrome

          d.      Ureterocele

                  Know that a ureterocele may lead to urinary tract obstruction

          e.      Vesicoureteral reflux

                  Know the natural history (eg, etiology, familial association,
                  outcome) of vesicoureteral reflux

     3.    Abnormalities of the urethra

          a.      Posterior urethral valves

                  Recognize that a palpably distended bladder and a weak
                  urinary stream in a newborn or infant boy are suggestive of posterior
                  urethral valves

                  Recognize that renal failure may develop in boys with posterior
                  urethral valves despite repair of the valves

                  Recognize the necessity for long-term evaluation of renal and
                  bladder function in patients with posterior urethral valves

          b.      Urethral stricture

                  Know that urethral strictures in boys almost always
                  result from urethral trauma (iatrogenic or accidental)

                  Know that a girl with a narrow urethra needs no treatment

     4.    Hereditary nephropathy (eg, familial nephritis)

                  Know that deafness is bilateral and sensorineural in Alport syndrome

C.   Acquired

     1.    Infection of the urinary tract

          a.      Pyelonephritis

                  Know the predominant organisms causing urinary tract
                  infection in children

                  Recognize that children with reflux nephropathy are often
                  asymptomatic

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           Evaluate a child who is not toilet-trained following an initial
           upper urinary tract infection

           Know the indication for long-term antibiotic prophylaxis against
           urinary tract infection

           Know the appropriate initial antimicrobial drugs for acute
           pyelonephritis before urine culture results are available

           Recognize the association between vesicoureteral reflux and
           hypertension

           Recognize the association of urinary tract infection and unexplained
           fever in infants

           Know the importance of antibiotic sensitivity testing in the
           treatment of acute pyelonephritis

           Know the epidemiology of urinary tract infection: age of onset,
           gender

           Know that urinalysis alone is insufficient to diagnose a urinary
           tract infection

           Recognize the association between urinary tract infection and
           constipation

     b.    Cystitis

           Know the appropriate antibiotic treatment for and follow-up
           management of acute cystitis

           Understand the importance of a history of sexual activity in a
           patient who has cystitis

           Plan the treatment for cystitis in a sexually active patient

           Plan the management of recurrent cystitis

           Know that secondary enuresis may be a sign of cystitis

2.   Acute glomerulonephritis

           Know the laboratory evaluation of acute post-streptococcal nephritis

           Understand that acute post-streptococcal nephritis rarely progresses
           to chronic renal failure

           Recognize the immediate complications (eg, hypertension, fluid
           overload) of post-streptococcal nephritis


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           Know the time sequence of resolution of hypocomplementemia,
           hematuria, and proteinuria in post-streptococcal glomerulonephritis

           Plan the initial management of acute post-streptococcal
           glomerulonephritis

           Differentiate acute post-streptococcal glomerulonephritis from
           other forms of glomerulonephritis

3.   Nephrotic syndrome

           Know the presenting signs and symptoms of minimal-change nephrotic
           syndrome

           Recognize the laboratory findings in children with minimal-
           change nephrotic syndrome

           Plan the initial treatment for a child with an initial episode of
           nephrotic syndrome

           Know the differential diagnosis of nephrotic syndrome with and
           without hematuria

           Understand that minimal-change nephrotic syndrome is a relapsing
           disease

           Understand the complications of diuretic therapy in a child with
           nephrotic syndrome

           Understand the etiology of hyponatremia in nephrotic syndrome

           Recognize the complications of nephrotic syndrome (eg, peritonitis,
           thromboses)

           Know the factors (eg, hypertension) that predict the prognosis of
           nephrotic syndrome

           Recognize that response to therapy is one of the best indicators
           of the prognosis in nephrotic syndrome

           Recognize that the prognostic significance of a decreased serum C3
           concentration in a patient with nephrotic syndrome is an indication
           of a diagnosis other than minimal change disease

4.   Hemolytic-uremic syndrome

           Know the diagnostic laboratory findings in children with hemolytic-
           uremic syndrome (eg, thrombocytopenia, microangiopathic hemolytic
           anemia, uremia)

           Know the appropriate initial management of a child with hemolytic-
           uremic syndrome

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                  Recognize the signs and symptoms and diarrheal prodrome of
                  hemolytic-uremic syndrome

                  Know the association between enterohemorrhagic E. coli O157:H7 and
                  hemolytic-uremic syndrome

                  Understand the risk of antibiotic therapy in a patient who has an
                  enterohemorrhagic E. coli O157:H7 urinary tract infection

     5.    Henoch-Schoenlein purpura

                  Recognize the renal manifestations of Henoch-Schoenlein purpura

                  Know that nephrotic syndrome in association with Henoch-Schoenlein
                  purpura is a poor prognostic sign

                  Understand that Henoch-Schoenlein nephritis rarely progresses to
                  chronic renal failure

     6.    IgA nephropathy
                  Recognize the signs and symptoms of IgA nephropathy

D.   Other renal conditions

     1.    Renal failure

           a.     Acute renal failure

                  Plan the initial treatment for a child with acute renal
                  failure

                  Recognize the utility of the urinary sodium concentration and the
                  fractional excretion of sodium in children with oliguria

                  Recognizes the causes of acute renal failure in infants and
                  children

           b.     Intrinsic renal failure

                  Understand the principles of the initial treatment of a child
                  with acute renal failure: fluid administration,
                  correction of hyperkalemia and acidosis

                  Know the transient effect of bicarbonate, glucose, insulin,
                  and calcium on hyperkalemia associated with renal failure

                  Recognize the complications of acute renal failure

                  Know that drug dosages must be modified in acute renal failure

                  Know the importance of nutrition in a child with acute renal failure

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              Recognize that the risk of tetany is increased during bicarbonate
              therapy when serum calcium concentration is decreased

2.   Chronic kidney disease (chronic renal failure)

              Understand the major complications of chronic kidney disease

              Recognize that volume and salt depletion may develop in an infant
              with renal dysplasia or hydronephrosis

              Know that growth failure is common in children with chronic kidney
              disease, and that growth hormone therapy may be useful in those
              with growth failure

              Know that acidosis contributes to growth failure in chronic kidney
              disease

              Understand the alterations in calcium, vitamin D, and phosphorus
              metabolism seen in chronic kidney disease

3.   End-stage kidney disease and transplantation
              Recognize the possibility of renal transplantation and the improving
              prognosis for infants born with chronic kidney disease

              Recognize that immunizations should be given to patients prior
              to renal transplantation

              Recognize that patients with end-stage kidney disease need to
              attend school or be home-schooled

4.   Trauma

     a.       Renal injuries

              Evaluate a child with blunt abdominal trauma with and
              without hematuria

     b.       Urethral injury

              Understand that gross urethral bleeding is a
              contraindication to catheterization following acute
              trauma

5.   Toxins

              Know the drug classes that can cause renal toxicity (eg, antibiotics,
              NSAIDs, chemotherapeutic agents, cyclosporine, tacrolimus)

6.   Urinary tract stones

              Recognize the symptoms of urinary tract stones in children

                                                                                      127
                    Plan the evaluation of a child with urinary tract stones

                    Recognize the association of nephrocalcinosis and furosemide therapy
                    in neonates

                    Know the value of increasing fluid intake in children with urinary
                    tract stones

                    Recognize the difference in calcium excretion resulting from thiazide
                    vs loop diuretic therapy

                    Recognize the association of hypercalciuria and the formation of
                    urinary tract stones

                    Recognize the role of chronic infection and urine stasis in the
                    formation of urinary tract stones

     7.    Renal tubular acidosis

                    Know that growth failure is a common presentation of renal tubular
                    acidosis

                    Formulate a differential diagnosis of renal tubular acidosis,
                    including the association with other tubular defects

E.   Hereditary conditions with renal manifestations (eg, nephrogenic

     DI)

                    Recognize the signs and symptoms of diabetes insipidus in
                    children

                    Know how to interpret urine and serum osmolality values in a
                    child with diabetes insipidus

                    Recognize the association between cranial injury/surgery and
                    diabetes insipidus, and that it is an inherited disorder

F.   Hypertension

     1.    General

                    Identify stupor, seizures, and vomiting as symptoms of
                    hypertensive encephalopathy

                    Know the initial evaluation of hypertension

                    Know that most children with hypertension are asymptomatic at
                    presentation

                    Formulate a differential diagnosis of hypertension in children

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             and adolescents

             Recognize the different mechanisms of action of different classes of
             antihypertensive drugs

             Recognize the causes of false blood pressure measurements in
             relation to age and size

             Understand the value of repeated blood pressure measurements for
             "white coat" hypertension

2.   Renal

             Know the causes of renal hypertension

3.   Vascular

             Recognize that hypertension is associated with neurofibromatosis

             Recognize the association of renal artery stenosis with
             Williams syndrome

4.   Adrenal

     a.      Pheochromocytoma

             Recognize the signs and symptoms of hypertension in children with
             pheochromocytoma

             Recognize that pheochromocytoma may be associated with complications
             of prolonged corticosteroid use

             Recognize that pheochromocytoma may be associated with other
             diseases (von Hippel Lindau, neurofibromatosis, multiple endocrine
             neoplasia)

     b.      Cushing syndrome

             Know that hypertension in a short, obese child may be due to Cushing
             syndrome

5.   Miscellaneous causes

     a.      Essential hypertension

             Understand the differential diagnosis of essential hypertension

             Understand the treatment of essential hypertension

     b.      Administration of drugs

             Know that certain drugs can cause hypertension in children (eg,

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                            albuterol, contraceptives, corticosteroids, decongestants, illicit
                            drugs)

XVII.   Genital System Disorders

        A.    General

              1.     Pain

                     a.     Infection

                            Recognize that pelvic inflammatory disease may be a cause
                            of right upper quadrant pain in an adolescent girl
                            (Fitz-Hugh-Curtis syndrome)

                            Understand the importance of screening all patients with pelvic
                            inflammatory disease for other sexually transmitted diseases

                            Recognize and manage of a patient with pelvic inflammatory disease

                            Interpret slides of wet preparations of vaginal discharge (eg,
                            clue cells, leukocytes, trichomonads)

                     b.     Trauma (accidental or self-induced)

                            Consider instrumentation of the penis or insertion
                            of a foreign body into the vagina as a cause of
                            genital pain and malodorous discharge

              2.     Abnormal masses

                     a.     Hydrocele, inguinal hernia

                            Know the differential diagnosis of a mass in the inguinal
                            area in an infant: hydrocele, inguinal hernia, trauma,
                            tumor

                            Know how to diagnose an inguinal hernia

                            Know how to diagnose a hydrocele

                            Plan the evaluation of a patient with a mass in the inguinal area

                     b.     Bartholin gland cyst

                     c.     Varicocele

                            Diagnose and manage a varicocele

                            Understand how to examine an adolescent for a varicocele

              3.     Discharge
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           a.    Vaginal

                 Recognize the influence of maternal estrogens on an infant
                 during the first three weeks of life

                 Evaluate and recognize the cause of a vaginal discharge in a
                 preadolescent girl

           b.    Urethral

                 Know that Gram-negative intracellular diplococci in urethral discharge
                 supports the diagnosis of gonococcal disease in males

     4.    Bleeding

           a.    Vaginal

                 Know the causes of vaginal bleeding in a preadolescent girl

           b.    Uterine

                 Recognize estrogen withdrawal as an etiology of uterine
                 bleeding in a newborn infant

B.   Male
     1.   Congenital abnormalities

           a.    Hypospadias

                 Recognize that first-degree hypospadias is rarely associated with
                 renal anomalies

                 Know that surgical correction should be done within the first year
                 after birth for patients with first-degree hypospadias

                 Know that circumcision should be delayed in patients with hypospadias

           b.    Cryptorchidism

                 Know the pathophysiology and natural history of cryptorchidism

                 Distinguish between undescended testes and retractile
                 testes

                 Know the complications of undescended testes: infertility
                 and increased incidence of testicular tumors

                 Plan the appropriate management of a patient with undescended testes

                 Know that hypospadias with bilateral cryptorchidism is an indication
                 to evaluate for intersex disorders

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     c.    Micropenis

           Know the significance of hypoglycemia in a patient with micropenis

           Know how to diagnose micropenis by measurement in a newborn boy

           Understand the significance of the suprapubic fat pad in evaluating
           penile size

     d.    Phimosis

           Recognize that the accumulation of smegma beneath
           the infantile prepuce is not pathologic

           Recognize phimosis and paraphimosis

2.   Acquired abnormalities

     a.    Testicular torsion

           Recognize the signs and symptoms of testicular torsion, and that it
           can be bilateral

           Recognize the importance of prompt referral for surgical
           exploration of testicular torsion

           Recognize the importance of early ultrasonography with Doppler flow
           in the diagnosis of testicular torsion

     b.    Infection

           (1).     Orchitis

           Diagnose orchitis based on signs and symptoms

           Identify the common causes of orchitis

           (2).     Epididymitis

           Know the signs and symptoms of epididymitis

           Know the most common cause of epididymitis in adolescents

           (3).     Urethritis

           Know the signs and symptoms of urethritis

           Know the treatment of urethritis

           Know that an important cause of urethritis in adolescents is
           chlamydial infection

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                Understand the alternative non-culture methods for identifying
                urethritis

          c.    Trauma

                Know that urethral stricture can be a complication of bladder
                catheterization

                Know that hematuria can result from bladder catheterization

          d.    Testicular masses

                Know the methods of evaluation for testicular masses

                Know the risks for testicular cancer

C.   Female

     1.   Congenital abnormalities

          a.    Imperforate hymen

                Know the signs and symptoms of an imperforate hymen

                Recognize the clinical manifestations of hydrometrocolpos

          b.    Labial adhesions
                Recognize labial adhesions

                Know the natural history of labial adhesions and the appropriate
                therapy

     2.   Acquired abnormalities

          a.    Ovarian torsion

                Know the signs and symptoms of ovarian torsion

          b.    Ovarian cyst

                Plan an appropriate diagnostic evaluation for a patient with an
                ovarian cyst

                Recognize that small ovarian cysts are part of normal development

          c.    Vulvovaginitis

                Know the differential diagnosis of vulvovaginitis:
                nonspecific vulvovaginitis, herpes simplex infection,
                trichomoniasis, candidiasis, pinworm infestation, and a
                foreign body

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         D.    Dermatologic disorders

               1.     Contact dermatitis

                              Recognize causative agents of perineal contact dermatitis in
                              various age groups: clothes, diapers, topical powders or
                              ointments in younger children; perfumes, leotards, sprays,
                              tampons, and douches in adolescents

               2.     Parasites

                              Recognize the signs and symptoms of pediculosis pubis

                              Know the treatment regimens for pediculosis pubis

               3.     Warts

                              Recognize the signs and symptoms of condylomata acuminata

                              Know that the presence of condylomata acuminata in a prepubertal
                              child raises the suspicion of sexual abuse

                              Know the treatment regimen for condylomata acuminata

                              Know the implications of condylomata acuminata in an adolescent

                              Know that the majority of venereal warts in children under 2 years
                              of age are acquired by nonsexual transmission
               4.     Herpes simplex (see also IX.H.3)

                              Know how to diagnose a genital herpes simplex virus infection

                              Know how to manage a genital herpes simplex virus infection

XVIII.   Neurologic Disorders

         A.    Signs and symptoms of neurologic dysfunction

               1.     Headache

                      a.      Differentiation

                              Recognize the physical characteristics of a headache
                              due to increased intracranial pressure

                              Know the elements of history that characterize a migraine

                              Be aware of neurologic defects that can be associated
                              with a migraine

                              Know the elements of history that characterize a

                                                                                                   134
              headache due to stress/tension/emotion

              Know that a headache can be caused by depression

              Know the elements of history that characterize a
              headache due to increased intracranial pressure

     b.       Evaluation

              Know the signs and symptoms of a headache that indicate a need
              for follow-up with magnetic resonance imaging or CT scan

              Know the values and limitations of ancillary neurodiagnostic tests in
              the evaluation of a headache

     c.       Treatment

              Plan the abortive treatment of an acute migraine

              Plan the treatment of a headache due to stress/tension/emotion

              Recognize the potential complications of using narcotics, sedatives,
              and nonsteroidal anti-inflammatory drugs to treat a chronic or
              recurrent headache

              Plan prophylactic treatment for recurrent migraine

2.   Altered level of consciousness

     a.       General
              Know to measure ammonia concentration and organic acid
              concentrations in neonatal coma

              Know the common causes of an altered level of consciousness

              Plan the initial phase of evaluation for an altered level of
              consciousness

              Recognize that disorders of metabolism, liver, kidneys, lungs or
              heart can be manifested as encephalopathy

     b.       Ingestions and intoxications

              Know which ingestions are likely to result in neurologic toxicity

     c.       Child abuse

              Know which historic and physical findings should lead to
              consideration of child abuse as a cause of an altered level of
              consciousness

3.   Ataxia
                                                                                      135
           Know the common causes of acute ataxia

           Know the common causes of vertigo

           Know how to evaluate a child with ataxia

           Know the prognosis of childhood acute cerebellar ataxia

4.   Movement disorders (involuntary, paroxysmal)

           Know the etiology, clinical features, prognosis, and treatment of
           Sydenham chorea

           Know which drugs reverse the symptoms of drug-induced
           movement disorders

           Differentiate between tic disorder and Tourette syndrome

           Know that tics and Tourette syndrome can be worsened by certain
           drugs

           Know the drugs useful in the treatment of Tourette syndrome

           Distinguish between tics and other involuntary movements

           Know the common causes of chorea

           Know which drugs can cause movement disorders

           Know that Tourette syndrome is associated with behavioral
           difficulties, learning disabilities, and attention deficit disorder

5.   Increased intracranial pressure

           Know to exclude a mass lesion by brain imaging in the presence
           of increased intracranial pressure

           Know the common causes of pseudotumor cerebri

           Recognize the need to measure the opening pressure at lumbar
           puncture

           Know the signs and symptoms of increased intracranial pressure in
           infants

           Know the signs and symptoms of increased intracranial pressure in
           children

           Know the contraindications of immediate examination of the
           cerebrospinal fluid


                                                                                 136
                  Plan the medical management of a patient who has increased
                  intracranial pressure

     6.     Weakness and hypotonia

                  Distinguish among acute and chronic causes of weakness

                  Know the benefits and limitations of ancillary neurodiagnostic tests
                  in the evaluation of weakness (eg, serum creatine kinase activity,
                  electromyography)

                  Distinguish between central and peripheral nervous system causes of
                  hypotonia

                  Know the differential diagnosis of hypotonia in infants

                  Know how to evaluate hypotonia in infants

B.   Infection

     1.     Meningitis

            a.    Pathophysiology

                  Know the common acute complications of meningitis

                  Know the etiologies of neonatal meningitis

                  Know the etiologies of meningitis in children

                  Know the causes of meningitis when no bacteria are isolated (eg,
                  partially treated, parameningeal focus, Borrelia, spirochete,
                  M. tuberculosis)

            b.    Diagnosis

                  Distinguish among cerebrospinal fluid findings in
                  bacterial, fungal, and viral meningitis

                  Know the clinical manifestations of bacterial meningitis

                  Know the differential diagnosis of fever and petechiae/purpura in
                  bacterial meningitis

                  Know the clinical manifestations of aseptic meningitis

                  Know the laboratory diagnosis of aseptic meningitis

            c.    Management

                  Know how to manage subdural effusion associated with
                  bacterial meningitis

                                                                                         137
           Know the acceptable treatments of meningitis

           Know the management of cerebral edema in meningitis

           Know the importance of monitoring fluid balance and electrolyte
           concentrations in meningitis

           Know the indications for diagnostic imaging in patients with
           meningitis

           Recognize the need for auditory testing following meningitis

           Know the potential long-term sequelae of meningitis

2.   Encephalitis

     a.    Pathophysiology

           Know the common causes of encephalitis

     b.    Diagnosis

           Recognize the signs and symptoms of herpes encephalitis

           Recognize the cerebrospinal fluid findings in herpes
           encephalitis

           Know the clinical symptoms of encephalitis

           Know the role of neurodiagnostic testing in the evaluation of a child
           with encephalitis

           Know the appropriate microbiologic, serologic, and molecular
           diagnostic tests in a child with encephalitis

     c.    Management

           Know how to manage encephalitis

           Know the common sequelae of encephalitis

3.   Abscess

     a.    Signs and symptoms

           Know the clinical manifestations of brain abscess

     b.    Pathophysiology

           Know that many brain abscesses contain multiple organisms, including
           anaerobes

                                                                                   138
           c.     Diagnosis

                  Know that neuroimaging studies should be done before examination
                  of the cerebrospinal fluid in suspected brain abscess

                  Understand the imaging techniques for diagnosing brain abscess

           d.     Management

                  Understand the treatment of brain abscess

                  Know the propensity for brain abscess to complicate cyanotic heart
                  disease, sinusitis, and pulmonary disease

     4.    Myelitis

           a.     Signs and symptoms

                  Recognize the clinical manifestations of myelitis

           b.     Diagnosis

                  Plan the evaluation of a patient in whom post-infectious myelitis
                  is suspected

C.   Degenerative conditions

     1.    Signs and symptoms

                  Recognize the historical features indicative of a
                  degenerative CNS disorder

                  Recognize the signs and symptoms of degenerative CNS disorders
                  Know the clinical presentation and course of Rett syndrome

     2.    Diagnosis

                  Understand the initial evaluation of a patient with suspected CNS
                  degenerative disease

D.   Developmental malformation, static neurologic deficit

     1.    Malformations

           a.     Spinal dysraphism

                  Know that a myelomeningocele is usually associated with hydrocephalus

                  Recognize the most common orthopedic problems associated with
                  a myelomeningocele and their relative significance


                                                                                          139
                 Understand the evaluation and fundamental long-term management of
                 neurogenic bladder

                 Know the fundamental long-term management of a neurogenic bowel

                 Know the clinical and radiographic features and prognosis of spina
                 bifida occulta

                 Know the differential diagnosis of acute neurologic deterioration in
                 a child with myelomeningocele

                 Identify the clinical manifestations and plan the diagnostic
                 evaluation of spinal dysraphism

                 Recognize the importance of folic acid supplementation in
                 the prevention of neural tube defects

           b.    Head size and shape

                 Recognize the clinical features of hydrocephalus

                 Recognize the signs and symptoms of shunt malfunction in
                 hydrocephalus

                 Know the differential diagnosis of microcephaly

                 Know the differential diagnosis of macrocephaly

                 Know the causes and management of abnormal head shape

     2.    Cerebral palsy

                 Recognize the clinical features of cerebral palsy, including
                 classifications

                 Know the risk factors associated with cerebral palsy

                 Know the disabilities associated with cerebral palsy: cognitive,
                 visual, communication, auditory, motor, seizure activity,
                 behavioral, oral function, nutrition

                 Know the principles of management for children with cerebral palsy
                 (eg, feeding, spasticity, mobility, activities of daily living,
                 education)

E.   Seizures

     1.    General

           a.    Pathophysiology

                 Recognize the metabolic causes of seizures

                                                                                        140
     Know which drugs may precipitate or exacerbate seizures

     Know the most common causes of acute seizures

b.   Diagnosis

     Distinguish among epileptic seizures and paroxysmal non-epileptic
     events (eg, breath-holding spells, tics, self-stimulation, syncope,
     gastroesophageal reflux, psychogenic seizures, sleep disturbances)

     Recognize the factors associated with an increased risk of
     seizure disorder

     Know the etiologic and therapeutic implications of partial versus
     generalized seizures

     Know how to manage a child following a first seizure

     Know how to manage a child with recurring seizures

     Formulate a management plan for a patient with psychogenic seizures

c.   Treatment

     Know that drug selection is based on seizure type

     Understand the indications for discontinuing anticonvulsant therapy

     Know the indications for initiating anticonvulsant therapy

     Know the relationship between etiology and prognosis in seizures

     Know the side effects and toxicities of anticonvulsants

     Know the value, limitations, and timing of serum drug concentration
     determinations during the management of seizures

     Know the laboratory abnormalities caused by anticonvulsants

     Know the interactions of anticonvulsants with other drugs,
     including other anticonvulsants

     Understand the cognitive/behavioral consequences of treatment
     with anticonvulsants

     Understand the cognitive/behavioral problems associated with seizure
     disorders

d.   Management and monitoring

     Provide appropriate counseling regarding activities and behavior of a

                                                                             141
            child with a seizure disorder (eg, athletics, school, driving,
            medications)

            Understand the psychosocial effects of epilepsy

            Know the effects of epilepsy and anticonvulsant therapy on
            reproductive health (eg, contraception) and the fetus

2.   Neonatal

            Know the differential diagnosis of neonatal seizures

            Know the clinical manifestations of neonatal seizures

            Know the prognosis following neonatal seizures

3.   Febrile

     a.     General

            Know the natural history of febrile seizures

            Know the risk factors associated with febrile seizures
            related to later epilepsy

            Know the diagnostic criteria for a febrile seizure

     b.     Diagnosis

            Know the appropriate evaluation of a child with febrile seizures

     c.     Treatment

            Know the management of febrile seizures

4.   Infantile spasms

     a.     Signs and symptoms

            Recognize the characteristic clinical features of infantile spasms

     b.     Pathophysiology

     c.     Treatment

            Know the prognosis for children with infantile spasms

5.   Absence epilepsies (petit mal)

            Understand the drugs used to treat absence epilepsy

            Recognize the characteristics of absence epilepsy

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     6.    Complex partial seizures

                    Recognize the clinical features of complex partial epilepsy

                    Understand the drugs used to treat complex partial seizures

     7.    Status epilepticus

                    Know to measure serum glucose, electrolyte, calcium, and magnesium
                    concentrations in a patient with status epilepticus

                    Know the medications that can be administered rectally to treat
                    status epilepticus

                    Know the possible etiologies of status epilepticus: infection,
                    toxin, electrolyte imbalance, drug withdrawal

     8.    Epilepsy syndromes

                    Identify the clinical manifestations of rolandic epilepsy

                    Recognize the clinical manifestations of juvenile myoclonic epilepsy

                    Understand the appropriate treatment of rolandic epilepsy

     9.    Tuberous sclerosis

                    Recognize the clinical manifestations of tuberous sclerosis, and
                    manage appropriately

F.   Cerebrovascular disease

     1.    Stroke

           a.       Signs and symptoms

                    Identify the clinical features of childhood stroke
           b.       Pathophysiology

                    Know the causes of stroke in children

     2.    Vascular anomalies

                    Identify the clinical features of arteriovenous malformations
                    of childhood

G.   Spinal cord disease

     1.    Signs and symptoms

                    Recognize the clinical manifestations of an acute spinal cord

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                  lesion

                  Know the association between atlantoaxial instability in Down
                  syndrome and potential neurologic complications

                  Recognize the significance of bladder and bowel dysfunction in spinal
                  cord disease

     2.    Diagnosis

                  Plan the initial neurodiagnostic evaluation in a patient with acute
                  spinal cord dysfunction

H.   Peripheral nerve and nerve roots

     1.    Guillain-Barre syndrome

           a.     Signs and symptoms

                  Know the presenting signs and symptoms of Guillain-Barre syndrome

                  Know that respiratory compromise may occur rapidly in
                  Guillain-Barre syndrome

                  Know the risk factors that are associated with Guillain-Barre syndrome
                  (eg, recent immunization, varicella infection)

           b.     Diagnosis

                  Know the differential diagnosis of Guillain-Barre syndrome

                  Know the expected results of laboratory procedures such as
                  examination of the cerebrospinal fluid, nerve conduction studies,
                  and electromyography in Guillain-Barre syndrome

                  Know that cranial nerves may be affected in Guillain-Barre syndrome

                  Know that autonomic dysfunction in Guillain-Barre syndrome may be
                  prominent and dangerous
           c.     Treatment

                  Understand the treatment of Guillain-Barre syndrome (eg, IVIG,
                  plasmapheresis)

     2.    Neuropathy

                  Recognize the clinical manifestations of childhood peripheral
                  neuropathy

                  Know the common causes of peripheral neuropathy in childhood
                  (eg, hereditary sensory and motor neuropathy)


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                  Recognize the signs and symptoms of and plan treatment for
                  Bell palsy

     3.    Brachial plexus injuries at birth

                  Recognize the clinical manifestations of neonatal brachial plexus
                  injuries

                  Know the management and prognosis of neonatal brachial plexus
                  injuries

I.   Neuromuscular junction

                  Recognize that ticks may cause paralysis

                  Know the signs and symptoms of myasthenia gravis

                  Understand the laboratory and electrophysiologic studies to evaluate
                  children with myasthenia gravis

                  Understand the appropriate management for a patient with myasthenia
                  gravis

J.   Muscle diseases

     1.    Signs and symptoms

                  Know the clinical features of dystrophinopathy (Duchenne/Becker
                  muscular dystrophy)

                  Know that a Gowers sign indicates proximal muscle weakness

                  Know the natural history and late complications of the muscular
                  dystrophies

                  Formulate a differential diagnosis for a patient who has weakness
                  and an increased serum creatine kinase activity

     2.    Pathophysiology

                  Know the genetics of dystrophinopathy (Duchenne/Becker muscular
                  dystrophy)

                  Formulate a differential diagnosis for a patient who has an
                  acquired muscle disorder (eg, inflammatory, infectious, toxic)

     3.    Diagnosis

                  Understand the laboratory studies available to diagnose muscle disease
                  of childhood

K.   Central nervous system trauma
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             1.     Pathophysiology

                          Know that the outcome of a head injury is related to the duration and
                          degree of coma

                          Know that a linear skull fracture in an infant younger than 1 year of
                          age is a sign of possible child abuse

                          Know the signs and symptoms of spinal trauma

                          Recognize the clinical features of epidural hematoma

                          Recognize the clinical features of subdural hematoma

             2.     Management

                          Know the long-term neurologic and behavioral consequences of head
                          trauma

                          Recognize the neuroendocrine complications of a head injury

                          Recognize that cerebral edema is a consequence of head trauma

                          Understand the clinical course and management of epidural hematoma

                          Recognize the association of cervical cord injury with head trauma

                          Recognize that intracranial hematomas can occur in the absence of a
                          skull fracture

                          Understand the clinical course and management of subdural hematoma

                          Know the role of pharmacologic therapy in acute spinal cord or
                          craniocerebral trauma

       L.    Neurodiagnostic testing

                          Know the value and limitations of neurodiagnostic techniques such as
                          magnetic resonance imaging, computed tomography, and ultrasonography

                          Understand the value and limitations of neurodiagnostic techniques
                          such as evoked potentials, electromyography, and electroencephalo-
                          graphy

XIX.   Musculoskeletal Disorders

       A.    Congenital

             1.     General body

                    a.    Osteogenesis imperfecta
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            Know the clinical features osteogenesis imperfecta

            Recognize the association of deafness with osteogenesis
            imperfecta

     b.     Chondrodysplasias (see also VII.D.5)

            Recognize the inheritance pattern of achondroplasia

            Recognize the clinical features and complications of achondroplasia

            Recognize the significance of apnea in a patient with achondroplasia

     c.     Arthrogryposis

            Recognize the clinical features of arthrogryposis

2.   Head and neck

     a.     Torticollis

            Understand the etiology of congenital torticollis

            Understand that physical therapy (stretching) of the neck
            by a pediatric physical therapist and/or a parent may be successful
            treatment for torticollis

            Recognize that the differential diagnosis of torticollis includes
            head tilt secondary to malformation of the cervical spine, visual
            disturbance, posterior fossa tumor, etc.

            Differentiate between congenital and paroxysmal torticollis

     b.     Klippel-Feil syndrome

            Know the clinical and radiologic features of Klippel-Feil syndrome

3.   Trunk and spine (eg, tethered cord, occult spina bifida)

            Know that congenital scoliosis is associated with other
            congenital abnormalities
4.   Lower extremities

     a.     Clubfoot

            Recognize that the treatment for talipes equinovarus is
            casting or splinting of the affected foot

            Know that the most common component of clubfoot is equinovarus
            deformity


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                  Be aware that early treatment of clubfoot is critical

          b.      Metatarsus valgus, varus

                  Understand that if the forefoot can be abducted past the midline,
                  massage and exercise are usually sufficient to treat metatarsus
                  valgus/varus

          c.      Coxa valgus, vara

                  Know the physical findings of coxa valgus/varus

          d.      Plano valgus

                  Know that no treatment for plano valgus is required in
                  childhood

                  Know that a longitudinal arch support may be helpful if
                  plano valgus is painful for adolescents

          e.      Femoral anteversion, tibial torsion

                  Know that the natural history of femoral anteversion is
                  self-correction

                  Know that x-ray studies are not necessary for the diagnosis
                  of femoral anteversion

                  Know how to evaluate a child with femoral anteversion

                  Know that toe-walking may be a normal stage in gait development or
                  may reflect underlying pathologic conditions such as neuromuscular
                  disease

          f.      Polydactyly

                  Plan appropriate management of polydactyly

          g.      Leg length discrepancy

                  Recognize that leg length discrepancy may be associated with abnormal
                  abduction of the hip

B.   Acquired

     1.    Infections

          a.      Osteomyelitis

                  Know that osteomyelitis usually begins with an episode of bacteremia

                  Know that the most common bacterial cause of

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     osteomyelitis is Staphylococcus aureus

     Understand that osteomyelitis generally occurs by
     hematogenous spread but may continue to spread by
     local extension

     Be aware of the early clinical findings (localized
     tenderness over the metaphysis and pain on weight
     bearing) in osteomyelitis

     Understand that osteomyelitis is most directly confirmed by
     aspiration of the metaphysis for culture and sensitivity

     Be aware that indicative x-ray findings in osteomyelitis do
     not generally appear until 10 to 14 days after
     infection

     Know the role of bone scanning and magnetic resonance imaging
     in osteomyelitis

     Understand the management of osteomyelitis

     Know the age-related microbiology of osteomyelitis

     Know the appropriate antibiotic management of osteomyelitis

     Recognize the clinical manifestations and laboratory findings in a
     patient with osteomyelitis of the pelvis

b.   Arthritis

     Recognize the most common organisms that
     cause pyogenic arthritis

     Know that a common cause of pyogenic arthritis
     is spread from an adjacent osteomyelitis

     Distinguish between pyogenic arthritis and toxic synovitis

     Know the clinical manifestations of pyogenic arthritis in neonates
     compared with those in older children

     Know the best laboratory tests for pyogenic arthritis: joint
     aspiration, fluid analysis
     Know the importance of drainage of purulent fluid in pyogenic
     arthritis, particularly surgical drainage of hip and shoulder
     arthritis

     Know the appropriate antibiotic management of pyogenic arthritis

     Distinguish between arthritis and arthralgia


                                                                          149
          Know the characteristics of arthritis associated
          with rheumatic fever

          Recognize the viral causes of acute arthritis

     c.   Synovitis

          Know that toxic synovitis is a disorder of
          exclusion

          Know that the differential diagnosis of a painful hip varies
          according to patient age and gender

2.   Trauma

     a.   Dislocations (see also XXXI.D.5.)

          Recognize the historical and clinical manifestations of subluxation
          of the patella

          Know that rigorous quadriceps rehabilitation should be
          instituted to prevent recurrence of dislocation of the
          patella

          Know the epidemiology of shoulder dislocation

     b.   Ligamentous (sprains, strains)

          Understand that the presence or character of pain may be the dominant
          indicator of type and severity of ligament injuries

          Know the acute management of sprains

          Understand that severe sprains require protection against
          another insult during their healing phase

          Know the appropriate use of ice packs in soft tissue injury

          Know the clinical manifestations of various sprains

          Recognize that an ankle injury in a prepubertal adolescent may
          be a growth plate fracture rather than an ankle sprain

     c.   Bone (see also XXXI.D.5.)

          Know the significance of the compartment
          syndrome

          Understand that occult fractures can cause gait disturbances in
          young children

          Understand the importance of growth plate fractures and injuries

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3.   Miscellaneous

     a.    Scoliosis

           Know the etiology and natural history of scoliosis

           Know how and when to examine for scoliosis

           Know the therapies for scoliosis

     b.    Kyphosis

           Know the presenting symptoms of kyphosis

           Know the treatment objectives for kyphosis: pain relief, prevention
           of neurologic deficit, achievement of acceptable appearance, good
           follow-up evaluation

     c.    Avascular necrosis (Legg-Calve-Perthes disease)

           Know that Legg-Calve-Perthes disease commonly
           occurs between 3 and 10 years of age

           Know that boys are more likely to have Legg-Calve-Perthes
           disease than girls

           Know that Legg-Calve-Perthes disease should be considered in the
           differential diagnosis of a child with a limp

     d.    Apophysitis

           Understand the etiology of Osgood-Schlatter disease

           Know the clinical manifestations and clinical course of
           Osgood-Schlatter disease

           Understand the etiology and clinical management of Sever disease

     e.    Slipped capital femoral epiphysis

           Know the presenting symptoms of a slipped capital
           femoral epiphysis

     f.    Myositis

           Plan the evaluation and management of a patient with myositis

           Know the etiology of myositis

     g.    Back pain


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                           Formulate a differential diagnosis for back pain in children
                           and adolescents

                           Plan the evaluation of a patient with back pain

                           Formulate a management plan for a patient with spondylolisthesis

                   h.      Developmental dysplasia, subluxation of the hips

                           Know that ultrasonography is the most precise imaging modality for
                           confirmation of the diagnosis of developmental dysplasia of the
                           hip(s) in young infants

                           Recognize asymmetry of the gluteal and thigh folds as
                           a sign of possible subluxation of the hip

                           Know that initially there may be no abnormal signs of
                           subluxation of the hip in developmental dysplasia of the hip(s)

                           Know that developmental dysplasia of the hips is more likely in
                           girls and in infants who are born by breech presentation

                           Know that isolated hip clicks are unlikely indicators of dysplasia

                   i.      Bone cysts

                           Know the natural history and differential diagnosis of bone cysts

XX.   Skin Disorders

      A.    Newborn skin

            1.     Pigmentary and vascular lesions

                           Know that the distribution of a port wine stain is
                           important in determining whether it will be associated
                           with a leptomeningeal angiomatosis (Sturge-Weber
                           syndrome)

                           Know that a tunable dye laser offers effective cosmetic
                           palliation of port wine stains

            2.     Pustular lesions

                   a.      Erythema toxicum

                           Recognize erythema toxicum
                           Know that the lesions of erythema toxicum are filled with
                           eosinophils

                   b.      Transient neonatal pustular melanosis


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                   Recognize the lesions of transient neonatal pustular
                   melanosis

                   Know that a Gram stain will help distinguish between
                   transient neonatal pustular melanosis and staphylococcal
                   pustules

            c.     Neonatal impetigo

B.   Atopic dermatitis

                   Plan appropriate treatment of eczema (emollients, corticosteroids,
                   antibiotics, and allergen elimination when appropriate)

                   Identify factors that worsen eczema (drying, chemical irritants, heat,
                   and physical trauma)

                   Identify the characteristic features of atopic dermatitis:
                   pruritus, morphology and distribution, and chronic relapsing
                   course

                   Recognize that children with atopic dermatitis are prone to
                   recurrent infections, particularly with S. aureus and herpes simplex

C.   Infectious rashes and infestations

     1.     Bacterial infections

            a.     General

                   Know the microbiology of skin infections, and how etiology is
                   influenced by age, site, and history of trauma or wound

                   Know the clinical manifestations of skin infections: impetigo,
                   ecthyma, cellulitis, abscess

                   Know the treatment of skin infections associated with wounds

                   Know the sequelae of streptococcal skin infections

            b.     Impetigo

                   Know that S. aureus is the primary cause of both bullous and pustular
                   impetigo

            c.     Staphylococcal scalded skin syndrome

                   Recognize the appearance of the staphylococcal scalded skin
                   syndrome

                   Know that staphylococcal scalded skin syndrome is mediated by a
                   toxin released by certain strains of staphylococci

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            d.     Methicillin-resistant Staphylococcus aureus infection

                   Recognize the dermatologic manifestations of MRSA infection

     2.     Papular urticaria

                   Recognize papular urticaria

                   Understand that papular urticaria represents a hypersensitivity
                   reaction to insect bites

     3.     Scabies

                   Recognize the lesions of scabies

                   Know that all contacts and family members of a child with
                   scabies will require treatment even if they have no rash

                   Understand the treatment for scabies

     4.     Fungal infections

                   Distinguish between tinea corporis and granuloma annulare

                   Distinguish between tinea pedis and atopic dermatitis

                   Recognize the appearance of tinea versicolor

     5.     Molluscum contagiosum

                   Recognize molluscum contagiosum

                   Know the management options for molluscum contagiosum

     6.     Warts-condyloma acuminatum (see XVII.D.3)

     7.     Pediculosis

                   Recognize the life cycle of human lice

                   Plan the treatment for a patient with pediculosis

     8.     Cellulitis (see also XXII.A.3)

                   Plan treatment for various forms of cellulitis

     9.     Necrotizing fasciitis

D.   Hair loss

     1.     Alopecia areata
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                  Recognize the classic features of alopecia areata

     2.    Trichotillomania

                  Recognize that trichotillomania is characterized by the presence
                  of hair shafts of different lengths in the area of alopecia

     3.    Tinea capitis

                  Know that the clinical appearance of tinea capitis is variable

                  Recognize and understand the etiology of a kerion

                  Know that systemic therapy (eg, griseofulvin, itraconazole) is
                  necessary to eradicate tinea capitis

                  Know that griseofulvin therapy is safe and does not require
                  routine laboratory studies to monitor its toxicity

     4.    Telogen effluvium

E.   Neurocutaneous syndromes

     1.    General

     2.    Neurofibromatosis

                  Know that six or more cafe au lait spots > 0.5 cm in diameter
                  suggests the diagnosis of neurofibromatosis

                  Be aware that neurofibromas usually do not appear until after puberty

     3.    Tuberous sclerosis

                  Know that the earliest sign of tuberous sclerosis may be
                  hypopigmented macules

     4.    Sturge-Weber syndrome

F.   Pigmented lesions

     1.    Hyperpigmentation

                  Understand that a helpful diagnostic sign in urticaria pigmentosa is
                  pigmented lesions that flare after being rubbed

                  Recognize the early warning signs of malignant melanoma

     2.   Hypopigmentation
G.   Acne


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                   Know that angiofibroma may be mistaken for acne

                   Plan for the treatment of acne vulgaris with first-line topical
                   medications, retinoic acid, and benzoyl peroxide

                   Recognize that in teenagers receiving corticosteroids, a
                   characteristic form of acne may develop

                   Know when to prescribe systemic antibiotics for acne and which
                   antibiotics to use

H.   Other

     1.      Hemangiomas

             a.    Natural history

                   Know the typical course of strawberry hemangiomas

             b.    Therapeutic options

                   Know the indications for therapy for hemangiomas

     2.      Erythema multiforme, Stevens-Johnson syndrome

                   Recognize that the spectrum of severity of erythema multiforme ranges
                   from targetoid lesions to Stevens-Johnson syndrome

     3.      Contact dermatitis

                   Know that rhus dermatitis (eg, poison ivy) is not spread by fluid
                   contained in the vesicular or bullous lesions

                   Recognize that contact dermatitis is characterized by linear
                   vesicles and papules

     4.      Short- and long-term effects of sun exposure

                   Know that sun damage to the skin is additive and leads to aging
                   of the skin as well as an increased incidence of skin cancers

     5.      Ectodermal dysplasia

     6.      Sebaceous nevus

     7.      Dermoids

     8.      Ichthyosis

                   Recognize ichthyosis vulgaris

                   Know that ichthyosis commonly occurs in children with atopic

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                           dermatitis

                           Understand that keratolytic agents (eg, lactic acid, citric acid)
                           are effective therapies in the management of ichthyosis vulgaris

             9.     Psoriasis

                           Identify psoriasis

             10.    Pityriasis rosea

                           Identify the rash of pityriasis rosea

                           Recognize the clinical manifestations of pityriasis rosea, including
                           its course

                           Recognize that secondary lues may mimic pityriasis rosea

             11.    Seborrheic dermatitis

             12.    Cutaneous manifestations - endocrine, metabolic, nutritional

                    disorders

                           Recognize the distribution of the rash of acrodermatitis
                           enteropathica

                           Know that acrodermatitis enteropathica is a manifestation of
                           zinc deficiency

                           Recognize acanthosis nigricans

                           Understand the association of acanthosis nigricans with insulin
                           resistance

XXI.   Collagen Vascular and Other Multisystem Disorders

       A.    Systemic lupus erythematosus

             1.     Clinical manifestations

                    a.     Usual

                           Recognize the clinical manifestations of systemic lupus
                           erythematosus

                           Distinguish between rheumatic fever and symptoms of systemic lupus
                           erythematosus

                    b.     Unusual

             2.     Laboratory evaluation
                                                                                                  157
     a.    Antinuclear antibody testing

           Know that a positive ANA test is the usual finding in
           systemic lupus erythematosus

           Recognize that a low-titer ANA may be seen in unaffected
           individuals and family members

           Recognize that a positive ANA occurs in many conditions other than
           lupus erythematosus

     b.    Anti-DNA determination

           Understand the value of anti-double-stranded DNA in establishing
           a diagnosis of systemic lupus erythematosus

     c.    Complement concentrations

     d.    Hematologic evaluation

           Know the hematologic manifestations of systemic lupus
           erythematosus

3.   Course and complications

           Understand that infection is a major cause of mortality in systemic
           lupus erythematosus

           Recognize central nervous system lupus

           Recognize a serious infection in a patient with systemic
           lupus erythematosus receiving immunosuppressive therapy

           Understand that renal disease is a common complication of
           systemic lupus erythematosus

           Recognize the significance of multiorgan involvement in systemic
           lupus erythematosus

4.   Therapy

           Recognize the major complications of corticosteroid therapy
           in systemic lupus erythematosus

           Know which drugs are useful in the treatment of systemic
           lupus erythematosus

           Know that anti-DNA and serum complement determinations are
           helpful in guiding treatment in a patient with systemic lupus
           erythematosus

5.   Neonatal lupus syndrome
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                   Identify the clinical picture of neonatal lupus, including heart
                   block

                   Know which tests are useful in evaluating neonatal lupus

B.   Vasculitis syndromes

     1.     Henoch-Schoenlein purpura

            a.     Clinical manifestations

                   Recognize the typical and atypical presentations of Henoch-Schoenlein
                   purpura syndrome

                   Recognize that Henoch-Schoenlein purpura may present with
                   initial abdominal pain or joint complaints, and manage appropriately

            b.     Diagnosis

                   Know the typical laboratory findings in Henoch-
                   Schoenlein purpura

     2.     Kawasaki disease (see also XIV.D.5.)

            a.     Clinical manifestations

                   Know the clinical manifestations of Kawasaki disease

                   Know the differential diagnosis of Kawasaki disease

            b.     Laboratory abnormalities

                   Know the laboratory abnormalities seen in Kawasaki disease

            c.     Management

                   Recognize the value of high-dose intravenous immune globulin
                   and aspirin therapy in the treatment of Kawasaki disease

C.   Juvenile rheumatoid (idiopathic) arthritis

     1.     Clinical presentations

                   Recognize the major presentations of juvenile rheumatoid (idiopathic)
                   arthritis

                   Identify the patient with systemic juvenile rheumatoid (idiopathic)
                   arthritis and serositis, lymphadenopathy, increased leukocyte
                   count, and anemia

                   Identify the typical patient with pauciarticular juvenile

                                                                                           159
            rheumatoid arthritis

            Recognize that rheumatoid factor is usually negative in
            juvenile rheumatoid (idiopathic) arthritis

2.   Clinical course and prognosis

     a.     Eye disease

            Know the ocular complications of juvenile rheumatoid (idiopathic)
            arthritis

            Identify ANA as a marker for eye disease in juvenile
            rheumatoid (idiopathic) arthritis

     b.     Cardiac disease

            Identify a patient with cardiac complications of systemic juvenile
            rheumatoid (idiopathic) arthritis

3.   Differential diagnosis

            Understand that juvenile rheumatoid (idiopathic) arthritis is often
            a disease of exclusion, and know the differential diagnosis

            Recognize the value of the examination of joint aspirate to
            distinguish between juvenile rheumatoid (idiopathic) arthritis
            and septic arthritis

            Recognize Lyme disease as a mimic of pauciarticular juvenile
            rheumatoid arthritis

            Distinguish between juvenile rheumatoid (idiopathic) arthritis and
            rheumatic fever

4.   Therapy

     a.     Pharmacologic agents

            Understand the pharmacologic treatment of juvenile rheumatoid
            (idiopathic) arthritis

            Recognize the complications of and nonsteroidal anti-inflammatory
            drug therapy in juvenile rheumatoid (idiopathic) arthritis:
            bleeding, gastritis, abnormal liver function test results,
            encephalopathy

     b.     Other therapies

            Recognize the need for a comprehensive program (including physical
            therapy) for the management of juvenile rheumatoid (idiopathic)
            arthritis

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D.   Other rheumatic disorders

     1.    Dermatomyositis

           a.     Clinical presentation

                  Recognize the classic picture of dermatomyositis: pain, weakness,
                  rash

           b.     Diagnosis

                  Know the appropriate laboratory evaluation of dermatomyositis

     2.    Scleroderma

                  Recognize the clinical manifestations of localized scleroderma
                  (morphea and linear scleroderma)

                  Recognize that localized scleroderma is much more common than
                  systemic sclerosis and has a better outcome

     3.    Sarcoidosis

                  Recognize the common manifestations of sarcoidosis in childhood

E.   Ankylosing spondylitis

                  Recognize the clinical and laboratory findings in a patient with
                  ankylosing spondylitis

F.   Other arthritis and arthralgia syndromes

     1.    Arthritis of inflammatory bowel disease

                  Recognize that arthritis may occur in patients with inflammatory
                  bowel disease

     2.    Postinfectious arthritis

                  Recognize a patient with postinfectious arthritis

                  Identify the common illnesses associated with postinfectious
                  arthritis

                  Plan the management of a patient with postinfectious arthritis

     3.    Reactive arthritis

                  Know the clinical manifestations of reactive arthritis

     4.    Hypermobility syndrome
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                               Know that the treatment of hypermobility syndrome is by
                               explanation (ie, counsel the patient to avoid excessive
                               movement)
                               Understand the relationship between hypermobility and joint
                               complaints

                               Know the physical findings in hypermobility syndrome

              5.     Functional joint complaints

                               Recognize a patient with functional joint complaints

                               Plan the management of a patient with growing pains

        G.    Inherited disorders of connective tissues (see also VII.D.8)

              1.     Marfan syndrome

                               Know the clinical and laboratory findings of Marfan syndrome

              2.     Ehlers-Danlos syndrome

                               Recognize the clinical manifestations of Ehlers-Danlos syndrome

XXII.   Disorders of the Eye

        A.    External disorders

              1.     Alignment and movement disorders

                     a.        Strabismus

                               Recognize the importance of the early detection of
                               strabismus to prevent amblyopia

                               Distinguish between pseudostrabismus and true strabismus

                     b.        Nystagmus

                               Recognize that nystagmus may signify important eye or central
                               nervous system pathology

              2.     Conjunctivitis

                               Distinguish between allergic and infectious
                               conjunctivitis

                               Understand that a patient with conjunctivitis may have a systemic
                               disease, such as uveitis

                               Know the microbiology of conjunctivitis in neonates and older

                                                                                                   162
            children

            Know the clinical manifestations of conjunctivitis (influence of age)

            Know the treatment of conjunctivitis
            Know the methods of prevention of conjunctivitis: neonatal
            prophylaxis, hand washing

3.   Orbital and periorbital (preseptal) cellulitis

            Recognize the difference between preseptal and orbital
            cellulitis

            Know the role that ethmoid sinus infections play in
            periorbital and orbital cellulitis

            Know the microbiology of orbital cellulitis

            Know the pathogenesis of orbital cellulitis

            Know the clinical manifestations of orbital cellulitis

            Know the laboratory tests for orbital cellulitis

            Know the treatment of orbital cellulitis

            Know the acute complications of orbital cellulitis

            Know the microbiology of periorbital (preseptal) cellulitis

            Know the pathogenesis of periorbital (preseptal) cellulitis

            Know the clinical manifestations of periorbital (preseptal)
            cellulitis

            Know the diagnostic approach for periorbital (preseptal) cellulitis

            Know the treatment of periorbital (preseptal) cellulitis

            Understand the role of imaging in distinguishing preseptal
            cellulitis from orbital cellulitis

4.   Stye, chalazion

            Recognize the difference between a stye and a chalazion

            Know the appropriate management of a stye and a chalazion

5.   Nasolacrimal duct obstruction

            Recognize the typical presentation of a blocked nasolacrimal
            duct

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                    Know the appropriate management of a blocked nasolacrimal duct

     6.    Ptosis

                    Know the importance of differentiating congenital from acquired
                    ptosis

B.   Internal disorders

     1.    Congenital glaucoma

                    Recognize the signs and symptoms of congenital glaucoma

                    Know that congenital glaucoma may be associated with port wine stains
                    involving the upper and lower eyelids

     2.    The white pupil

           a.       Cataracts

                    Know that congenital cataracts may be associated with
                    congenital infections, inherited conditions, radiation, and
                    corticosteroid use

                    Understand that an abnormal pupil may be a sign of congenital
                    cataract

                    Understand the risk factors for the development of cataracts

           b.       Retinoblastoma

                    Recognize the presenting signs of retinoblastoma

                    Know that retinoblastoma may be inherited

     3.    Papilledema, papillitis

                    Know the importance of decreased vision in papilledema

                    Recognize the significance of papilledema

     4.    Retinopathy of prematurity

                    Recognize that preterm infants who have been treated with
                    oxygen require a first retinal examination at 4 to 6 weeks of
                    age to identify those who have retinopathy of prematurity

                    Know the groups of infants who should be screened for retinopathy of
                    prematurity

C.   Miscellaneous
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               1.     General

                             Plan the evaluation of a red, painful eye

               2.     Amblyopia

                             Recognize conditions that may lead to amblyopia

               3.     Foreign bodies, corneal abrasions

                             Recognize the clinical presentations of corneal abrasion
                             including irritability in young infants

                             Know the appropriate management and follow-up evaluation
                             of corneal abrasions

                             Know the appropriate examination for a suspected foreign body in
                             the eye

               4.     Trauma to the eye

                             Be able to evaluate trauma to the eye; including hyphema

                             Recognize the clinical signs of a blow-out fracture of the orbit

               5.     Tumor or hemangioma affecting vision

                             Recognize the visual consequences of tumors in the periorbital area

XXIII.   Ear, Nose, and Throat Disorders

         A.    Ears

               1.     Congenital malformations

                             Recognize that malformed external and middle ears may be
                             associated with renal anomalies, craniofacial malformations,
                             and inner ear malformations

               2.     External ear

                             Know the appropriate prophylaxis for children with recurring otitis
                             externa who swim frequently

                             Know the treatment of "swimmer's ear"

                             Know the differential diagnosis of otitis externa

                             Know the pathogenesis of otitis externa

                             Know the microbiology of otitis externa

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           Recognize the presentation of a foreign body in the external ear
           canal (eg, otorrhea)

           Know the diagnosis and treatment of a hematoma of the external ear

3.   Middle ear

     a.    Acute otitis media

           (1).     Etiology, epidemiology

           Recognize that otitis media is more common in infants fed with propped
           bottles

           Know the microbiology of acute otitis media, including
           the prevalence of beta-lactamase-producing bacteria

           Know the pathogenesis of acute otitis media (ie, the proposed
           primary role of eustachian tube dysfunction in causing middle ear
           disease)

           Know the epidemiology of acute otitis media: age of onset, peak
           season

           Know that the initial occurrence of otitis media at a young age places
           on infant at increased risk of recurrent or chronic middle ear
           disease

           Know that nontypeable Hemophilus influenzae continues to be an
           important cause of acute otitis media in older children

           Know the microbiology of acute otitis media in the first six weeks
           after birth, and that the most common pathogens causing otitis media
           in this age-group are the same as in older children

           Know that the bacteriology of bullous myringitis is the same as
           acute otitis media

           (2).     Diagnosis

           Know that acute otitis media in the first six weeks after birth
           requires careful evaluation and follow-up

           Know that pneumatic otoscopy is the preferred generally available
           method of diagnosing middle ear effusion because diminished tympanic
           membrane mobility usually accompanies middle ear effusion

           Recognize the clinical manifestations of acute otitis media:
           fever may or may not be present, otalgia, nonspecific symptoms
           (eg, irritability)


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     (3).     Therapeutic options

     Recognize the indications for drainage procedures(tympanocentesis
     and/or myringotomy) during acute otitis media: unsatisfactory
     response to therapy, immunocompromised, seriously ill, suppurative
     complications

     Recognize the potential complications of tympanocentesis
     and myringotomy
     Know the current standard antimicrobial treatment for acute otitis
     media as well as alternative and ineffective drugs

     Recognize that the use of antihistamines and
     decongestants as a treatment for acute otitis media has no
     proven value

     Know the common indications for changing antibiotic therapy during
     acute otitis media: persistent or recurrent ear pain or fever or
     both after two to three days of therapy; the development of a
     suppurative complication

     Know that effusion may persist for 2 to 3 months or longer following
     acute otitis media

     Know that acute otitis media may resolve without antibiotic therapy

b.   Otitis media with effusion (secretory otitis media)

     (1).     Diagnosis

     Know the predisposing factors for otitis media with effusion
     in children

     Know the etiologies of diminished tympanic membrane mobility and that
     middle ear effusion is the most frequent cause

     Know the underlying conditions associated with otitis media with
     effusion: craniofacial abnormalities, chronic sinusitis

     Know the importance of a hearing assessment in children with otitis
     media with effusion lasting longer than 3 months or recurrent otitis
     media

     (2).     Therapeutic options

     Know the management of otitis media with effusion and the importance
     of follow-up evaluation

     Know that antihistamines and decongestants have no value in the
     resolution of effusion in infants and children with
     otitis media with effusion


                                                                             167
     Know the management of otitis media with effusion, including the
     concept that treatment later with an antimicrobial drug effective
     against beta-lactamase-producing bacteria may be helpful after an
     initial course of amoxicillin has failed

     Plan the appropriate management of a child with otitis media with
     effusion

     Know that otitis media with effusion may not require antibiotic
     therapy
     (3).     Complications

     Recognize that cholesteatoma may be a complication of otitis media

     Know that otitis media with effusion is often asymptomatic but may
     include hearing loss, discomfort, and behavior changes

     Know that hearing loss in young children with otitis media with
     effusion may be associated with delayed speech and language
     development, at least in the short term

c.   Chronic suppurative otitis media

     Know that hearing amplification is available for children of all ages

     Distinguish between the bacteriology of chronic suppurative otitis
     media (Pseudomonas, Staphylococcus) and acute otitis media

     Plan the management of chronic suppurative otitis media

d.   Recurrent otitis media

     Know the management of exacerbation of a recently treated episode
     of acute otitis media

     Know that recurrent otitis media may be associated with underlying
     conditions (eg, sinus disease, immunodeficiency, primary ciliary
     dyskinesia, dysmotile cilia syndrome, cleft palate)

     Know the role of follow-up visits for an episode of otitis media
     to document middle ear status (eg, the presence of recurrent or
     chronic middle ear disease or both)

     Know the role of antimicrobial prophylaxis in the management of
     recurrent otitis media: indications for, antibiotics of choice,
     antibiotics not recommended

e.   Other (not otitis media)

     Recognize the sources of nonotogenous (referred) pain
     to the ear: temporomandibular joint dysfunction, teeth,
     pharyngitis

                                                                             168
           Know the causes of ear drainage in a child with a perforated
           tympanic membrane or a tympanostomy tube

           Know the intratemporal complications of middle ear disease (eg,
           perforation of the tympanic membrane, acquired cholesteatoma,
           tympanomastoiditis, petrositis tympanosclerosis)

           Know why infection and otorrhea occur when a ventilation tube
           is in place

           Know the central nervous system complications of middle ear disease

     f.    Otorrhea

           Know that persistent watery otorrhea may represent cerebrospinal
           fluid leakage

           Know the etiologies of purulent ear drainage

           Know the etiologies of bloody ear drainage

4.   Inner ear

           Know the clinical presentation of benign paroxysmal vertigo

           Know the differential diagnosis of balance disturbance in children

           Know that the inner ear may be affected by viral or bacterial
           infections (eg, rubella, cytomegalovirus, mumps)

5.   Hearing loss

     a.    Etiologies

           Recognize the conditions that contribute to a conductive
           hearing loss in children

           Recognize that a moderate to severe conductive
           hearing loss after trauma may represent ossicular
           disruption

           Know which commonly used pediatric drugs might
           produce sensorineural hearing loss

           Recognize that acoustic trauma produces high-
           frequency hearing loss

           Know that a mild conductive hearing loss may be subtle and may
           present as ignoring behavior, increasing the television volume, etc.

           Know the neonatal risk factors for a sensorineural hearing

                                                                                  169
                 impairment: hyperbilirubinemia, infection, craniofacial deformities,
                 family history, neonatal depression, low birth weight, prolonged
                 ventilation, ototoxic drugs, certain syndromes (eg, Waardenburg)

           b.    Diagnostic techniques

                 Understand tympanometry and the various functions
                 it measures

                 Know the techniques for hearing evaluation at different
                 ages

                 Know that evaluation of the auditory system is available for
                 children of all ages

                 Understand that tympanometry can be a useful clinical adjunct (eg,
                 detection of perforation, assessment of patency of tympanostomy tubes)

                 Know the limitations of screening audiometry

                 Know that tympanometric findings may be normal in the presence of a
                 sensorineural hearing loss and other pathology

           c.    Therapeutic options

                 Recognize the frequency and importance of hearing loss in children
                 with bacterial meningitis and the need for follow-up

                 Know that Alport syndrome is an inherited condition that may be
                 associated with progressive sensorineural hearing loss, progressive
                 nephritis, and, in some cases, eye abnormalities

     6.    Mastoiditis

                 Know that mastoiditis can represent a complication of otitis media

                 Know the microbiology of mastoiditis

                 Recognize the clinical manifestations of acute mastoiditis

                 Plan appropriate therapy for mastoiditis, including surgery, if
                 required

                 Know that the laboratory evaluation of mastoiditis includes imaging
                 and culture of the middle ear effusion or possible surgical drainage

B.   Nose and nasopharynx

     1.    Choanal atresia

                 Recognize the signs and symptoms of choanal atresia


                                                                                          170
              Know how to evaluate a child with suspected choanal atresia

              Understand the association of choanal atresia and other congenital
              anomalies

2.   Epistaxis

              Understand the evaluation of a child with severe
              recurrent epistaxis

              Know the differential diagnosis of epistaxis

3.   Rhinitis
     a.     General

              Know that nasal congestion in adolescents may be associated with
              use of illicit inhaled drugs

              Understand the complications of using topical decongestants in
              children, including the fact that the local effects of topical
              decongestants in infants under 6 months of age can be
              life-threatening

              Know that most neonates are predominantly nasal breathers

              Formulate a differential diagnosis for a patient who has chronic
              rhinitis: allergy, sinusitis, polyps, cystic fibrosis, foreign body

     b.       Allergic rhinitis (see also VIII.B.)

              Distinguish between allergic rhinitis and nonallergic rhinitis
              by history and physical examination

              Understand the treatment of allergic rhinitis

     c.       Infectious rhinitis

              Know that group A streptococcal infection can present as protracted
              nasopharyngitis in infants and younger children

              Recognize the systemic effects of oral decongestants and
              antihistamines in infants and young children

4.   Polyps

              Recognize that nasal polyps occur in children

              Know the conditions associated with nasal polyps in children: cystic
              fibrosis, asthma, chronic allergic rhinitis, chronic sinusitis

              Know that the diagnosis of nasal polyps is an indication for a sweat
              test, even in the absence of failure to thrive

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     5.    Common cold

                  Understand the epidemiology of the common cold

                  Know the microbiology of the common cold (viral etiology)

                  Know that common colds are a frequent trigger for asthma in
                  children

     6.    Trauma

                  Recognize the significance of a hematoma of the nasal septum

                  Recognize the physical findings and know the management of a hematoma
                  of the nasal septum

     7.    Foreign body

                  Know the clinical presentation of a nasal foreign body

     8.    Adenoids (see XXIII.G.1.)

C.   Sinuses

     1.    Acute sinusitis

                  Recognize the limitations of imaging studies in diagnosing
                  acute sinusitis in young children

                  Know the common clinical presentations of acute sinusitis in children

                  Know the microbiology of acute maxillary sinusitis

                  Know that acute sinusitis unresponsive to conventional therapy may
                  require surgical referral

                  Know the treatment of acute sinusitis: drug(s) of choice,
                  alternative drugs, ineffective drugs

                  Know the intraorbital complications that may occur with ethmoid
                  sinusitis

                  Recognize that intraorbital and intracranial complications (brain
                  abscess) may occur with frontal sinusitis

                  Know at what ages the various sinuses develop

                  Know that sinusitis should be in the differential diagnosis of
                  toothache, sore throat, persistent cough, and poorly controlled
                  asthma


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                     Know that nasal swab cultures and throat cultures may not
                     correlate well with cultures of sinus aspirates

                     Know that orally administered decongestants and antihistamines
                     are of unproven benefit in the treatment of acute sinusitis

     2.       Chronic sinusitis

                     Know the predisposing factors for chronic sinusitis in children:
                     allergy, immune deficiency, primary ciliary dyskinesis (immotile
                     cilia syndrome), cystic fibrosis

     3.       Trauma

                     Know that trauma involving fracture of the frontal sinus requires
                     surgical repair and that delay may lead to later CNS infection

D.   Throat

     1.       Infections

              a.     Viral (see also IX.H.)

                     Recognize that viral infections are the most common
                     cause of acute pharyngitis in infants and preschool children

              b.     Bacterial

                     (1).     Peritonsillar abscess

                     Recognize the signs and symptoms of peritonsillar
                     abscess in children

                     Know the laboratory tests for peritonsillar abscess: imaging
                     studies, culture

                     Know the treatments of peritonsillar abscess: drug(s) of choice,
                     alternative drugs, ineffective drugs, surgical drainage

                     Know the microbiology of peritonsillar abscess

                     (2).     Tonsillitis, pharyngitis

                     Know when and why antibiotic therapy is indicated
                     for pharyngitis and the duration of such therapy

                     Know that the usefulness of routine throat cultures in the diagnosis
                     of pharyngitis is limited to group A streptococci and N. gonorrhoeae

                     Know that routine throat and nasopharyngeal cultures are of no value
                     in predicting the etiology of otitis media, sinusitis, pneumonia, or
                     meningitis

                                                                                            173
                 Know the differential diagnosis of exudative tonsillopharyngitis

                 Know that a child with a persistent positive throat culture for group
                 A streptococcus who is still symptomatic following a complete course
                 of therapy for proven group A streptococcal pharyngitis deserves
                 culture and further management

                 (3).     Retropharyngeal abscess

                 Know how to treat retropharyngeal abscess: drug(s) of choice,
                 alternative drugs, ineffective drugs, surgical drainage

                 Know the microbiology of retropharyngeal abscess in children

                 Recognize the clinical manifestations of retropharyngeal abscess
                 in children

                 Recognize that imaging studies may aid in the diagnosis of retro-
                 pharyngeal abscess in children

E.   Mouth and oropharynx

     1.   Tongue, oral cavity, uvula, salivary glands

                 Distinguish clinically between hand-foot-and-mouth disease,
                 herpangina, acute herpetic gingivostomatitis, and aphthous ulceration

                 Know that most children with a short lingual frenulum require no
                 therapy

                 Know important causes of parotitis: viral, bacterial,
                 sialolithiasis, recurrent idiopathic

                 Know the differential diagnosis of preauricular swelling: parotitis,
                 lymphadenitis, tumor, lymphosarcoma

                 Recognize the clinical presentation of cold panniculitis

                 Know that a bifid uvula is associated with submucous cleft
                 palate and middle ear effusion

     2.   Cleft lip, cleft palate

                 Understand how to feed a newborn infant with a cleft palate

                 Recognize the clinical problems other than nutrition associated with
                 cleft palate in children: speech, dental, hearing, middle ear disease

                 Know that middle ear effusion is almost universally present in
                 children with cleft palate


                                                                                         174
                    Recognize submucous cleft and that recurrent or chronic otitis media
                    can be associated

                    Recognize the association and management of mandibular hypoplasia
                    with upper airway obstruction (eg, Pierre Robin syndrome)

                    Know that cleft palate deformities may be associated with chromosomal
                    disorders and other abnormalities (eg, skeletal, craniofacial, eye)

     3.     Teeth

            a.      Normal development

                    Know the definition and causes of delayed dental eruption:
                    hypothyroidism, hypopituitarism, ectodermal dysplasia, rickets

                    Know how to counsel parents regarding their child's dental care
                    Recognize the relationship of dietary intake and feeding habits to
                    dental health

            b.      Trauma

                    Know the therapeutic options for an avulsed tooth

            c.      Cavities

                    Know the recommendations for fluoride use

                    Know the usual clinical picture of "nursing bottle" caries

            d.      Infection

                    Recognize the varied clinical manifestations of dental infections:
                    swelling below the jaw with a mandibular dental abscess,
                    periorbital swelling with a maxillary dental abscess

                    Know the association between an anaerobic infection and dental and
                    periodontal disease

F.   Neck

     1.     Cervical adenitis

                    Know how to evaluate a child with an acute cervical
                    lymphadenopathy

                    Know the management of acute or chronic cervical lymphadenopathy

                    Know the etiology and evaluation of a chronic cervical
                    lymphadenopathy

                    Know the microbiology of acute cervical lymphadenitis and the

                                                                                            175
                  influence of age on etiology

                  Know that S. aureus is an important cause of acute cervical
                  lymphadenitis in infants, and that surgical drainage may be
                  necessary

                  Know the differential diagnosis of cervical lymphadenopathy as
                  regarding location, the presence or absence of generalized
                  lymphadenopathy, the presence or absence of systemic symptoms

     2.    Laryngitis, hoarseness

                  Know that hoarseness may follow endotracheal extubation in
                  children

                  Know the differential diagnosis of hoarseness

                  Plan an appropriate evaluation of a patient with hoarseness
     3.    Neck masses

                  Know the differential diagnosis of neck masses: lymphoma, cystic
                  hygroma, thyroglossal duct cyst, branchial cleft abnormalities

G.   Surgical intervention; chronic airway obstruction

     1.    Tonsillectomy and adenoidectomy

                  Know the indications for a tonsillectomy

                  Know the complications of a tonsillectomy and adenoidectomy

                  Know the indications for an adenoidectomy

                  Recognize the serious outcomes that may be associated with tonsillar
                  or adenoidal hypertrophy or both: obstructive sleep apnea, fatigue
                  associated with sleep deprivation, cor pulmonale, failure to thrive
                  associated with poor feeding or obstructive breathing

                  Know the importance of the proper evaluation of velopharyngeal
                  insufficiency in a child being considered for a tonsillectomy or
                  adenoidectomy or both

     2.    Myringotomy and tympanostomy tube placement

                  Know the indications for inserting tympanostomy tubes in
                  children with acute otitis media

                  Know the potential short-term and long-term complications of the use
                  of tympanostomy tubes

                  Recognize the indications for inserting tympanostomy tubes in
                  children with otitis media with effusion

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XXIV.   Adolescent Medicine and Gynecology

        A.    Adolescent development

              1.    Physiologic

                    a.     Pubertal staging (sexual maturity rating)

                           (1).     General

                           Recognize the stages of sexual development

                           Know the range of age of the onset of puberty among boys
                           and girls in the U.S.

                           Know that peak height velocity in girls occurs earlier in pubertal
                           staging (and chronologically) than in boys

                           Understand that an individual adolescent's bone age (skeletal
                           maturity) and chronologic age may be disparate by as much as two
                           years and still be within normal limits

                           Know that there is a genetic influence on the timing of puberty
                           (including age at menarche)

                           Know that pubertal progression from sexual maturity rating
                           stage 2 to stage 5 can require 2.5 to five years to complete

                           Understand the impact of relatively early or late puberty on final
                           adult height

                           Understand the changes in gonadotropin secretion during puberty

                           Know that the upper body segment-to-lower body segment ratio is
                           lower in teens during their growth spurt than in adults

                           (2).     Male

                           Know that most boys achieve a genital sexual maturity rating (Tanner)
                           of stage 4 prior to the attainment of peak height velocity

                           Know the sequence of development of secondary sexual characteristics
                           in boys (testicular growth, pubarche, penile growth, peak height
                           velocity)

                           Know that testicular enlargement is the earliest sign of puberty in
                           boys

                           Know the etiology and management of gynecomastia in boys

                           Recognize that pubertal gynecomastia as well as breast development

                                                                                                   177
     can be asymmetric and that neither indicates pathology

     Know that a testicular volume of < 4 mL is prepubertal

     (3).     Female

     Know the average age and range at which menarche occurs in American
     adolescents

     Know the sequence of development of secondary sexual characteristics
     in girls (breast budding, pubarche, peak height velocity, menarche)

     Know that girls' heights will typically increase 6 to 8 cm
     after menarche has occurred

     Know that vaginal bleeding in a girl with a sexual maturity rating
     at stage 2 for breast development is not likely to represent
     menarche (menarche usually occurs in stage 4)

     Recognize that physiologic leukorrhea commonly precedes menses
     by three to six months

b.   Increase in height and weight with growth spurt

     Know that the adolescent peak height velocity is more closely
     correlated with sexual maturity rating stage than with
     chronologic age

     Understand the concept of bone age or skeletal maturity and how it is
     determined for clinical purposes (x-ray of the wrist and hand)

     Know the average prepubertal height velocity (5 to 6 cm/year) and the
     accelerated rate (9 to 10 cm/year) in the peak adolescent growth spurt
     and that completion of the pubertal growth spurt takes two to four
     years

     Recognize the methods for assessing the relationship of parental
     stature to an individual adolescent's stature

c.   Changing laboratory parameters

     Know that the hematocrit value increases in adolescent males when the
     growth spurt begins

     Know that increased alkaline phosphatase activity (osteogenic
     fraction) in an adolescent may be attributed to a growth spurt rather
     than to a dysfunction

     Know that cholesterol concentrations begin to increase gradually
     during adolescence

     Know that after puberty, the normal hemoglobin concentration in males

                                                                              178
           is 14 to 18 g/dL

           Know that blood pressure in adolescence is closely related to
           height and age

           Recognize the upper 95th percentile of blood pressure as a criterion
           for separating normal patients from those meriting evaluation for
           hypertension

     d.    Failures and variations in adult growth and development

                    (see XI)

           Understand the limitations of knowing height and weight at only one
           point in time in assessing a short adolescent (ie, it is helpful to
           know growth velocity)

           Understand the concept of constitutional delay in maturation

           Know that the absence of any signs of puberty after the age of about
           13 years in a girl or about 14 years in a boy merits investigation
           Know that most delayed puberty in boys is constitutional

           Know that in constitutionally delayed puberty, the bone age
           (skeletal maturity) is less than the chronologic age and typically
           corresponds to the height age

           Know that Turner syndrome can present for the first time as
           pubertal delay

           Know that hormones that accelerate the rate of growth also
           accelerate epiphyseal closure and have the ultimate effect of
           limiting growth potential

           Know that the premature arrest of previously normal growth rate in
           an adolescent demands thorough evaluation

           Understand the definition, diagnosis, and management
           of precocious puberty in boys

           Know the psychosocial risks for boys and girls with delayed puberty

           Know the psychosocial risks for girls and boys with precocious
           puberty

2.   Psychologic growth and development

     a.    Development of a self-identity

           Know that an adolescent "loner" who does not identify with any
           peers may have psychologic difficulties


                                                                                  179
     Understand the effect of rapid body changes on an adolescent's sense
     of self

     Know that experimenting or trying out various styles of dress or
     behavior is part of an adolescent's search for identity

     Know that some degree of rebellion against the family's image of the
     adolescent is part of the adolescent's search for identity

     Know that the rate of emotional and cognitive development does not
     parallel the rate of physical maturation

b.   Psychologic separation from the family

     Recognize that parental acceptance of an adolescent's separation from
     the family often enables the adolescent to psychologically return to
     the family later

     Know that for the young adolescent, the peer group is an important
     means of beginning separation from the family

c.   Relationship to the peer group
     Know that for the young adolescent, the peer group usually consists
     of those of the same sex with similar dress, grooming, and behavioral
     standards

     Understand that the peer group has a powerful influence on the
     adolescent's healthy and unhealthy behaviors: smoking, alcohol,
     drugs, sex, risk-taking, school attitudes

d.   Consequences of the emergence of a poor self-image

     Know that a poor self-image correlates with many adolescent problems:
     adjustment (family and peer relationships, depression/suicide);
     school (underachievement, truancy); health (substance abuse, sexual
     acting out/pregnancy, risk-taking behavior)

     Recognize the importance of encouraging parents/family to foster
     a positive self-image in an adolescent by praise and acceptance

e.   Family influence

     Recognize the importance in any emotional/psychiatric
     assessment (or routine health history) of understanding
     family dynamics and the potential impact such dynamics
     may have on symptomatology

     Recognize the importance of the family in modeling
     behaviors of smoking (cigarettes), drinking (alcohol),
     conflict resolution, and violence (intergenerational
     abuse)


                                                                             180
           Understand that the process of pubertal maturation
           requires role readjustments among and between family
           members, often resulting in increased stress and conflict

           Know the importance of identifying not only sources of stress within
           within families but predominant modes of coping with stress

     f.    Media influence

           Know that exposure to pro-tobacco media and marketing promote
           positive attitudes about tobacco use in teens

           Recognize that frequent exposure to television violence at an early
           age is a risk factor for aggressive behavior in adolescents

3.   Sexuality

           Know that homosexual and heterosexual experimentation
           is common in early adolescence

           Know the elements involved in counseling parents about their
           adolescents' emerging sexuality

           Know an adolescent's most common sources of information about
           sexuality: peers, the media, and rarely parents, doctors, or teachers

           Know the patterns of sexual behavior in adolescents in the US

4.   Cognitive

     a.    Chronology of cognitive development

           Know that concrete thinking characterizes the early adolescent,
           whereas abstract reasoning is seen in the maturing adolescent

           Know that experience and environment can substantially influence
           cognitive development

     b.    Consequences of concrete thinking for adolescent behavior

           Know that an adolescent with concrete thinking deals largely with
           physically present or real objects in problem-solving

           Recognize the limited ability of the early adolescent to imagine
           the consequences of risky behavior

           Recognize the limited ability of an early adolescent to link cause
           and effect in regard to health behavior (eg, smoking, overeating,
           alcohol, drugs, reckless driving)

           Recognize the limited ability of an early adolescent to have a
           concept of long-range health risks (eg, cholesterol in diet,

                                                                                   181
                   sedentary life-style)

            c.     Implications of cognitive development re physician-pt

                   communication

                   Know that advice or an explanation by a physician will be more
                   effective if it is adapted to the cognitive developmental level
                   of the adolescent receiving it

     5.     Social development

            a.     General

                   Recognize that "crushes" on adults are not uncommon in early and
                   mid-adolescent social development

                   Recognize that risk-taking and testing of limits are part of
                   achieving independence and self-identify for the adolescent

                   Recognize that the capacity for a mature type of intimacy is a task
                   of late adolescence

                   Recognize that transient homosexual experimentation is not uncommon
                   in early and mid-adolescent social development

            b.     Health related

                   Know that any chronic illness may adversely affect an adolescent's
                   achievement of independence and a positive self-image

                   Know that any health issue affecting the appearance of an adolescent
                   may interfere with achieving a positive self-image (eg, acne or
                   deformity)

                   Know that adolescents with nonvisible health conditions (diabetes,
                   epilepsy, learning disability) may have emotional problems similar
                   to those associated with visible conditions

                   Recognize that rejection of authority and risk-taking tendencies of
                   an adolescent may include rejection of medical advice and medical
                   treatment previously accepted

B.   Health issues of adolescence

     1.     Preventive healthcare

                   Understand the importance of routinely reviewing behavioral risk
                   factors, including school performance, proper nutrition and
                   exercise, extracurricular activities, substance use, sexuality
                   issues, and sleep when evaluating adolescents


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2.   Gynecology

     a.   General

          Know the value of a pelvic examination in the diagnosis of sexually
          transmitted diseases

          Recognize the gynecologic etiologies for both acute and
          chronic abdominal pain

          Know that genital tract obstruction in adolescent girls may be
          characterized by abdominal pain, constipation, urinary retention,
          and an abdominal mass

          Know that infrequent menstrual periods within the first two years
          after menarche do not warrant laboratory investigation under most
          circumstances

          Identify the noncontraceptive advantages of oral contraceptive pills
          (ie, treating dysmenorrhea, decreased risk of pelvic inflammatory
          disease, decreased benign breast disease)

          Know the indications for a pelvic examination in adolescents

     b.   Vaginal discharge
          Know the management for a physiologic vaginal discharge (leukorrhea)

          Know that most pathologic vaginal discharges of adolescence
          are generally linked to sexual activity

          Know the appropriate management of the
          uncomplicated pathologic vaginal discharges

     c.   Dysfunctional uterine bleeding

          Know that a working differential diagnosis for dysfunctional uterine
          bleeding includes threatened abortion, tubal pregnancy, pelvic
          inflammatory disease, endocrinopathies such as hyperthyroidism, and
          coagulopathies

          Know that ovarian failure is a risk factor for osteoporosis

          Know that polycystic ovary syndrome may produce dysfunctional uterine
          bleeding

          Know the preferred treatment of dysfunctional uterine bleeding in
          adolescence and that surgical intervention is rarely necessary

          Know that the evaluation of dysfunctional uterine bleeding must
          include the possibility of iron deficiency

          Know that dysfunctional uterine bleeding indicates anovulation

                                                                                  183
     Know that menstrual bleeding that persists beyond 10 days is not
     physiologic

     Know the most common causes of menometrorrhagia

d.   Amenorrhea

     Know that primary amenorrhea is defined clinically as
     the lack of menses by the age of 16 years or by two years
     after sexual maturation

     Know that the differential diagnosis of primary amenorrhea
     includes anatomic variants of the genital tract, pregnancy, ovarian
     pathology, adrenal disease, and hypothalamic/pituitary disorders

     Know that secondary amenorrhea is defined as the cessation of menses
     after menarche

     Know the etiologies of secondary amenorrhea and their respective
     treatments

     Understand exercise-induced amenorrhea

     Know that polycystic ovary syndrome is a common cause of secondary
     amenorrhea in adolescents
     Know the characteristics of adolescents with polycystic ovary
     syndrome

     Know that secondary amenorrhea may precede significant weight loss
     in anorexia nervosa

     Know that menstrual irregularity is not a diagnostic criterion for
     bulimia

     Understand the management of exercise-induced amenorrhea

e.   Dysmenorrhea

     Know the differential diagnosis of dysmenorrhea, including primary
     dysmenorrhea (without organic disease) and secondary dysmenorrhea
     (with organic etiologies such as an intrauterine device, pelvic
     inflammatory disease, and endometriosis)

     Recognize the role of prostaglandin inhibitors in the
     treatment of primary dysmenorrhea

     Know the costs and benefits of the various treatment options for
     primary dysmenorrhea

     Know that exercise, acetaminophen, a healthy diet, and rest are
     relatively ineffective in the treatment of primary dysmenorrhea

                                                                            184
          Know that primary dysmenorrhea is a common cause of episodic school
          absence in adolescent girls

          Know the pathophysiology of primary dysmenorrhea

3.   Pregnancy

     a.   Medical considerations

          Know that with good prenatal care and nutrition, the physiologic
          outcomes for young adolescent mothers can be significantly improved

          Understand that the younger a pregnant teen is, the greater the
          risk of pregnancy complications for the teen and fetus

     b.   Emotional, social, economic issues

          Recognize the social, economic, and educational problems associated
          with teenage pregnancy

     c.   Prevention

          (1).     Contraceptive technology

          Know the forms of contraception available to adolescents

          Know the complications of the various forms of contraception for
          adolescents

          Identify the theoretic contraceptive effectiveness
          of the various methods of birth control for adolescents

          Know the relative and absolute contraindications to the use of
          oral contraceptives

          (2).     Abstinence education

          Recognize that adolescents who participate in abstinence-only
          programs or who take abstinence pledges are just as likely to
          participate in sexual activity as those adolescents who do not
          participate in such programs

          (3).     Social, emotional aspects

          Understand the obstacles to the effective use of contraceptives in
          adolescence

          Recognize that many adolescents are sexually active before
          consulting a physician about birth control and many are using
          some inadequate method of birth control


                                                                                185
           Understand the most common reasons that adolescent girls and boys do
           not use contraceptives

           Understand the importance of peer or partner pressure and cognitive
           maturation in an adolescent's failure to use contraception

           Know adolescents' most commonly held misconceptions about effective
           use of contraceptives

           Know that many adolescents are poorly compliant with oral
           contraception

           Know that compliance with a contraceptive method is positively
           associated with a perceived lack of side effects, older age of the
           user, satisfaction with the selection of the contraceptive method,
           and desire to avoid pregnancy

           Recognize that pediatricians are likely to see many children who are
           not yet sexually active and thus have a unique opportunity and
           responsibility to intervene early and prevent consequences of
           unprotected sexual activity

4.   Consequences of sexual behavior (except pregnancy)

     a.    Sexually transmitted infections

           Know that Gardnerella vaginalis is a normal vaginal flora but is
           seen more commonly in sexually active youth
           Know that the most common microbiology of pelvic inflammatory disease
           is Neisseria gonorrhoeae and Chlamydia trachomatis, but anaerobes
           and gram-negative rods may also be implicated

           Know the clinical manifestations of pelvic inflammatory disease

           Know the laboratory tests for pelvic inflammatory disease

           Know the relationship between contraceptive choice and the prevention
           of sexually transmitted diseases, including HIV/AIDS

           Know that trichomoniasis and genital warts are often asymptomatic in
           boys

           Know that gonorrhea and chlamydial infections can cause
           menometrorrhagia

           Know that gonorrhea and chlamydial infections produce cervicitis, not
           vaginitis, in adolescents

           Know the clinical characteristics of bacterial vaginosis that would
           suggest the diagnosis

           Know the current recommended treatment regimens for pelvic

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            inflammatory disease

            Know the acceptable treatment alternatives for genital warts

            Know the differential diagnosis and etiology of urethritis in
            adolescent boys

            Know the appropriate treatment of urethritis in adolescent boys

            Know the indications for and limitations of oral acyclovir treatment
            for genital herpes

            Know the indications for the hospitalization of an adolescent with
            pelvic inflammatory disease

            Recognize the association in girls of perihepatitis with both
            gonococcal and chlamydial infections

            Know that pelvic inflammatory disease is a risk factor for
            subsequent ectopic pregnancy and infertility

            Know the causative organisms of sexually transmitted infections in
            adolescence: trichomoniasis, chlamydial infection, gonorrhea,
            herpes, syphilis, HIV, human papillomavirus

            Understand the importance of counseling adolescents about the
            necessity of condom use during anal as well as vaginal intercourse

            Recognize the bacterial causes of vaginitis (eg, Peptostreptococcus,
            Bacteroides, Gardnerella)

     b.     Noninfectious consequences

            Know that the mortality associated with pregnancy and delivery
            exceeds the mortality associated with any contraceptive methods

            Know the indications for a Papanicolaou smear in adolescence

            Understand that all sexually active adolescents should be screened
            yearly for Chlamydia trachomatis and, depending on local rates of
            infection, for Neisseria gonorrhoeae

            Recognize that higher-risk adolescents (eg, those with multiple
            sexual partners or histories of prior sexually transmitted
            sexual infections) should be screened for Chlamydia trachomatis
            and Neisseria gonorrhoeae every 6 months

5.   Chronic illness

     a.     Adjustment

            Understand the relationship between chronic illness and

                                                                                   187
           psychopathology in adolescence

     b.    Adherence

           Realize that adherence to medical regimens can be improved in
           chronically ill youths when it is discussed rather than dictated

           Recognize the barriers to adherence in chronically ill patients,
           including time and financial costs, pain, inconvenience,
           embarrassment, and/or the acknowledgment of personal vulnerability

           Know that when establishing a treatment plan, the most
           difficult part of achieving adherence is changing established
           behaviors

     c.    Transition to adulthood

           Understand the psychologic issues of life transition for an
           adolescent with a chronic illness or disability

           Know that for youths with chronic illness and disability,
           transition to adult health care needs to be planned to
           avoid any significant disruption of services

           Recognize that parents of chronically ill adolescents may have
           difficulty allowing their children to take control of their own
           healthcare management

6.   Eating disorders

           Know that amenorrhea is an early warning sign of anorexia
           nervosa

           Know the characteristics of anorexia nervosa and the criteria for
           diagnosis

           Know the characteristics of bulimia and the criteria for
           diagnosis

           Know the differential diagnosis of anorexia nervosa and bulimia

           Understand the treatment approaches to anorexia nervosa

           Understand the treatment approaches to bulimia

           Recognize that inflammatory bowel disease and achalasia can appear
           to be eating disorders

           Recognize that obesity or an obsession about thinness can be a
           predecessor of eating disorders such as anorexia nervosa or bulimia

           Know the indications for the hospitalization of adolescents with

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           anorexia nervosa

           Know the indications for the hospitalization of adolescents with
           bulimia

           Know the factors affecting the prognosis for adolescents with
           anorexia nervosa

           Know the factors affecting the prognosis for adolescents with bulimia

7.   Behavioral health issues

     a.    Delinquency

           Recognize the factors that predispose to the development of adolescent
           delinquent behavior: parental psychiatric illness, ADHD, learning
           disability, serious behavioral problems (eg, setting fires, cruelty
           to animals) before 5 years of age, serious head trauma

           Know the categories of health problems that are particularly common
           among delinquent youths: injuries, sexually transmitted infections,
           dental problems, cigarette use, alcohol and drug use/abuse

           Know that parental involvement with their adolescent's school
           and extracurricular activities and knowledge about their child's
           friends are protective factors for delinquency

     b.    Adherence

           Know that parents' involvement with adolescents' health-related
           activities is associated with improved adherence
           Identify the features of an illness or a treatment regimen that tend
           to worsen a patient's adherence to treatment: lack of symptoms,
           more than one treatment, side effects of treatment, multiple daily
           medication doses, lack of perceived seriousness of the illness

           Know the behavioral techniques that may enhance patient adherence:
           medicine calendar, dosing in synchrony with a patient's regular
           activity

     c.    Risk-taking

           Know the leading causes of death and serious injury among adolescents
           in the United States

     d.     Violence

           Know the options for postcoital contraception for the female rape
           victim and recognize when they should be used

           Recognize the features of post-traumatic stress disorder as
           associated with rape

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                  Know the nonviolent strategies for conflict resolution (negotiation,
                  mediation) that are appropriate for adolescents

                  Know that firearms are a leading cause of death in adolescents

                  Identify the various roles that teens play regarding school
                  violence: perpetrator, victim, encouraging bystander, nonviolent
                  conflict resolver

           e.     Stress

                  Recognize that stress may present clinically with
                  vague, generalized somatic complaints

C.   General management issues

     1.    Consent, confidentiality, privacy

           a.     The law

                  Know which circumstances (eg, marriage, parenthood, military service,
                  living on one's own, supporting one's self) legally emancipate
                  minors and give them adult status for accepting or rejecting
                  medical treatment

                  Understand when parents must be advised of a child's condition
                  (eg, serious suicidal or homicidal ideation, other potentially
                  lethal behaviors)

           b.     Special considerations for intellectually challenged

                  patients

                  Understand the state and federal statutes that govern the care of
                  intellectually challenged persons

     2.    Office practice in adolescent medicine

                  Know that age alone does not dictate whether parents accompany
                  adolescents during the physical examination and history

                  Understand that assessment of the functional status of an adolescent
                  (peer relationships, school, work, family relationships) is a
                  specific task of the adolescent visit

                  Understand the pediatrician's different strategies to facilitate
                  the parent-child exchange of information about sexuality

                  Know that anticipatory guidance topics relevant to accident
                  prevention for adolescents include drinking and driving, the
                  use of seat belts and bicycle helmets, and firearm safety

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                           Understand the importance of interviewing an adolescent without
                           the parents present

                           Understand the importance of obtaining a confidential sexual and
                           substance use history during a health care visit for an adolescent

XXV.   Sports Medicine and Physical Fitness

       A.    Injury prevention

                           Know that trauma sustained by juvenile athletes is frequently
                           due to incomplete healing of a previous injury

                           Understand the factors that influence participation in contact
                           sports by healthy children and adolescents

                           Identify risks in a conditioning program for junior high school
                           athletes at the beginning of the sports season

       B.    Evaluation for sports participation

                           Know the guidelines for children with Down syndrome concerning
                           participation in sports

                           Know what limitations an acute febrile illness places on
                           sports participation

                           Know the conditions that should be evaluated by a cardiologist prior
                           to sports participation

                           Know how to advise a patient with a seizure disorder regarding
                           participation in sports
                           Differentiate among cardiovascular conditions as a reason for
                           disqualification from sports

                           Know how to advise a patient with type 1 diabetes
                           regarding participation in sports

                           Understand the importance of assessing and documenting neurocognitive
                           function in a preparticipation sports examination (ie, for
                           comparative purposes in sideline evaluation of an athlete with a
                           head injury)

                           Know that if a physician disqualifies an athlete from one sport, he
                           or she should attempt to direct them to another sport

       C.    Sports injury and treatment

             1.     General

                    a.     Bruises, hematomas
                                                                                                   191
            Know that a considerable amount of blood can be lost with a
            deep hematoma of the thigh

            Know how to treat bruises and hematomas: ice packs, compression

     b.     Heat illness

            Know the symptoms of heat illness

            Know the complications of heat stroke

            Plan optimal replacement for fluid losses associated with athletic
            activity

            Plan the evaluation and management of an athlete with heat illness

            Know that children have less tolerance to exercise than adults when
            air temperature is greater than body temperature

            Understand the mechanisms of heat-related illness

     c.     Return to play criteria

            Know the criteria for return to play in sports after a head injury

            Know that the criteria for return to play following an eye injury
            includes ophthalmologic evaluation

            Know the criteria for return to play following various injuries:
            shoulder, knee, ankle, stress fracture, shin splints

            Know that the criteria for return to play after a neck injury
            includes an appropriate medical evaluation
            Plan the appropriate management of a player with an acute
            neck injury

     d.     Overuse syndromes

            Plan the management of an athlete with an overuse injury

            Know the most common type of overuse injuries in athletes

2.   Head

            Know the sports most commonly associated with a head injury

3.   Eye and ear

            Know the indications for the use of goggles for eye protection in
            sports activities


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             Plan the acute management of an eye injury

             Recognize the signs of hyphema, and that immediate ophthalmologic
             referral is mandatory

4.   Mouth

             Know the indications for the use of mouth guards in athletics

5.   Neck

             Understand that water sports are an important cause of cervical
             injuries

             Know that improper handling of a neck injury will increase the
             neurologic deficiency

6.   Shoulder

             Plan the appropriate initial management of a shoulder dislocation

7.   Elbow

             Recognize and plan the appropriate initial management of
             complications of a dislocation of the elbow

             Recognize and plan the appropriate initial management of elbow
             pain in an athlete

8.   Wrist

             Recognize that a distal radial epiphyseal injury is common in young
             gymnasts

             Recognize that a scaphoid fracture is associated with a poor
             prognosis

9.   Knee

             Identify the physical findings that support the diagnosis of
             patellofemoral dysfunction

             Understand the risk factors for patellofemoral dysfunction

             Recognize the physical examination findings that are consistent
             with internal derangement of the knee

             Plan appropriate management of a patient with patellofemoral
             dysfunction

             Know the criteria for orthopedic consultation for a knee injury


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                             Recognize prepatellar bursitis in an athlete, and manage
                             appropriately (eg, treatment, referral)

              10.    Ankle

                             Plan the treatment of uncomplicated ankle injuries

                             Recognize the possibility of an epiphyseal injury in an apparent
                             ankle sprain in a child whose growth plates have not closed

                             Know when to treat or refer an athlete with an uncomplicated ankle
                             injury

        D.    Nutritional requirements

              1.     Hydration and rehydration

                             Know that for the juvenile athlete, fluids should not be
                             restricted during an athletic event or practice

              2.     Weight gain and loss

                             Understand the role of fluids in weight control for athletes

                             Know the appropriate amount of weight loss per week for athletes who
                             participate in sports with weight categories

                             Know that many athletes who participate in sports with weight
                             categories practice weight control that may be pathogenic and
                             pathologic

        E.    Performance-enhancing drugs

                             Recognize the signs and symptoms of the use of performance-enhancing
                             drugs

                             Know how to diagnose the use of performance-enhancing drugs
                             by data collection (history, physical examination, and laboratory
                             evaluation)

                             Know the side effects of anabolic steroids and other performance-
                             enhancing drugs (eg, creatine, androstenedione)

        F.    Physical fitness

                             Understand the importance of regular exercise to promote good
                             general health

                             Understand the importance of skeletal maturity in dictating the
                             appropriate type of physical training

XXVI.   Substance Abuse
                                                                                                    194
A.   Epidemiology

     1.    Current data

                    Know that the use/abuse of multiple drugs is far more common than the
                    use/abuse of any single drug

                    Understand the general trends in substance use and abuse (for alcohol,
                    marijuana, and tobacco, in the US among children and adolescents

     2.    Developmental patterns

                    Know the approximate initial age for experimentation with the major
                    drugs of use/abuse

                    Know that earlier exposure to drugs of use/abuse is associated with a
                    higher probability of dependence

B.   Risk factors

     1.    Genetic

                    Know that there appears to be a genetic predisposition to
                    alcoholism

     2.    Familial

                    Understand that familial issues such as parental drug use/abuse,
                    child abuse, family disruption, and family tolerance of alcohol use
                    are associated with adolescent substance abuse

     3.    Peer group

                    Understand that the extent of drug use among close friends is an
                    excellent predictor of drug use/abuse in an adolescent

     4.    School

                    Understand that early academic failure predisposes to adolescent
                    behavioral dysfunction, including substance use/abuse

                    Understand that feelings of connectedness to school, family, and
                    community are protective against substance use/abuse in youths

C.   Laboratory evaluation

     1.    Ethical and practical

                    Understand the role of urine screening in caring for a patient
                    with a known drug use problem


                                                                                             195
                  Understand the potential adverse effect on the doctor-patient
                  relationship that might arise from urine screening for drugs
                  without the knowledge and/or consent of the teenager

                  Know the requisites for collecting a reliable urine sample for
                  drug screening: collection under observation, prevention
                  of adulteration

     2.    Applicability and limitations

                  Know the approximate duration of positivity of urine screening
                  varies by drug, dose, and frequency of use

                  Know that false-positive and false-negative results are common
                  in urine drug testing, and the reasons for this

D.   Role of primary care practitioner

     1.    Evaluation by interview

           a.     Recognition of drug-related dysfunction

                  Recognize the need to evaluate for drug use/abuse as a possible
                  etiology for or concomitance to a wide range of adolescent
                  dysfunction (eg, delinquency, school failure, promiscuity, running
                  away from home, family conflict, depression, suicide attempts)

                  Know that psychiatric symptoms are common among adolescents with
                  substance abuse disorders

           b.     Obtaining a history

                  Understand the need to know not only which drugs are being used/abused
                  by youth, but also how often, in what circumstances, and with
                  what risks

                  Understand the requisites for privacy and confidentiality in
                  eliciting a drug history from a child
                  Understand the necessity of obtaining information from parents
                  about their own drug use/abuse and any concerns about their child's
                  drug use/abuse

           c.     Collateral contacts

                  Understand the potential value of information gathered from school or
                  police authorities in evaluating drug use/abuse

     2.    Coordinating role

                  Understand the physician's role in coordinating management of drug
                  abuse treatment in youths across service systems (eg, school,
                  mental health facilities, drug and alcohol treatment centers)

                                                                                           196
     3.    Anticipatory guidance

                  Understand the physician's role in counseling youth and their parents
                  about the dangers of drug/alcohol use/abuse and methods to minimize
                  those dangers (eg, avoidance of drinking and driving, surreptitious
                  drug use, peer group behaviors, appropriate parental monitoring)

                  Understand the physician's role in conversations with parents
                  regarding parental drug/alcohol use/abuse patterns, their
                  perception, and their potential influence on adolescent behavior

     4.    Office counseling

                  Know the stages of drug/alcohol use and the importance of office-
                  based counseling for experimentation and regular drug use by youths

     5.    Evaluating and preparing for referral

                  Understand the role of the primary care practitioner in preparing an
                  adolescent and a family for referral for drug/alcohol use/abuse
                  treatment

     6.    Opportunities for community initiatives

                  Understand the value of the primary care practitioner's involvement
                  in drug/alcohol use/abuse education within the schools and
                  general community

                  Know the potential advantages of community-based initiatives
                  such as Safe Rides and Students Against Driving Drunk (SADD)

     7.    Referring for treatment

                  Understand the obligation of the primary care practitioner to
                  periodically reassess the progress of a patient referred for
                  substance use/abuse treatment

                  Know that the potential for relapse is lifelong for those who use/
                  abuse drugs/alcohol

E.   Specific substances

     1.    Overview

                  Understand that street drugs are often adulterated and that an
                  overdose may be secondary to either a combination of drugs or a drug
                  other than the one alleged to have been taken by the overdose victim

     2.    Alcohol

                  Know the major physiologic consequences (somatic consequences)

                                                                                          197
           attributable to alcohol use/abuse, including the potential for
           physiologic addiction

           Know the major behavioral consequences of alcohol use/abuse

           Know the signs and symptoms of an acute alcohol overdose

           Understand the management of acute alcohol overdose

3.   Marijuana

           Know the major physiologic consequences (somatic consequences)
           attributable to marijuana use/abuse

           Know the major behavioral consequences of marijuana use/abuse,
           including whether there is a known potential for physiologic
           addiction

4.   Tobacco

           Know the major physiologic consequences (somatic consequences)
           attributable to smoking tobacco

           Know the major behavioral consequences of tobacco use/abuse,
           including whether there is a known potential for physiologic
           addiction

           Know the major physiologic consequences (somatic consequences)
           attributable to chewing tobacco

           Know the role that pharmacologic and non-pharmacologic treatment
           may play in tobacco cessation

5.   Opiates

           Know the major physiologic consequences (somatic consequences)
           attributable to the use of opiates or the method of opiate
           administration

           Know the major behavioral consequences of opiate use/abuse, including
           whether there is a known potential for physiologic addiction

           Recognize the signs and symptoms of an acute opiate overdose

           Understand the management of an acute opiate overdose

6.   Amphetamines

           Know the major physiologic consequences (somatic consequences)
           attributable to amphetamines or the method of amphetamine
           administration (oral, intravenous, smoking)


                                                                                   198
            Know the major behavioral consequences of amphetamine use/abuse,
            including whether there is a known potential for physiologic
            addiction

            Know the signs and symptoms of an acute amphetamine overdose

            Understand the management of an acute amphetamine overdose

7.    Hallucinogens

            Know the major physiologic consequences (somatic consequences)
            attributable to hallucinogens or the method of hallucinogen
            administration

            Know the major behavioral consequences of hallucinogen use/abuse,
            including whether there is a known potential for physiologic
            addiction

            Know the signs and symptoms of acute hallucinogen intoxication

            Understand the management of acute hallucinogen intoxication

8.    Cocaine

            Know the major physiologic consequences (somatic consequences)
            attributable to cocaine or the method of cocaine administration

            Know the major behavioral consequences of cocaine use/abuse,
            including whether there is a known potential for physiologic
            addiction

            Know the signs and symptoms of an acute cocaine overdose

9.    Inhalants

            Know the physiologic consequences of the use/abuse of inhalants

            Know the variety of agents used as inhalants (eg, organic solvents,
            fuels, toluene, paint thinner, glues, spray paint, gasoline, Freon,
            propane)

            Know the signs and symptoms of an acute inhalant overdose

            Know that cardiac dysrhythmias are the major cause of death from
            inhalant overdose

            Understand the management of an acute inhalant overdose

10.   Anabolic steroids

            Know the physiologic consequences of the use/abuse of anabolic
            steroids

                                                                                  199
                             Know the major behavioral consequences of the use/abuse of
                             anabolic steroids

               11.    Over-the-counter medicines

                             Recognize the risk of abuse of over-the-counter cough and cold
                             preparations (eg, pseudoephedrine, dextromethorphan)

XXVII. Disorders of Cognition, Language, and Learning

        A.     Developmental delay, intellectual disabilities

               1.     Clinical features, presentation

                             Understand that language development in infancy
                             and early childhood is a better predictor of
                             cognitive function than motor development

                             Recognize the definition of intellectual disabilities

                             Recognize the clinical presentations of intellectual disabilities

                             Understand that the age of presentation varies with the severity of
                             intellectual disabilities (ie, more severe cases allow for earlier
                             recognition)

                             Know that the majority of children with intellectual disabilities
                             are in the middle range of impairment

                             Know that mild intellectual disabilities and borderline
                             intelligence may not be recognized until the child enters school
                             (ie, in kindergarten, or first or second grade

                             Distinguish between mild and moderate intellectual disabilities with
                             regard to the potential for educational and independence/vocational
                             achievement

                             Understand the factors that determine independence and productivity
                             in a child with intellectual disabilities

                             Understand the range of intellectual deficit in most common genetic
                             syndromes (eg, fragile X, trisomy 21, fetal alcohol)

                             Know the associated deficits in intellectual disabilities (eg, speech,
                             language, and hearing disorders; seizures; cerebral palsy;
                             visual disorders)

                             Know the progression of speech intelligibility, and that deviation
                             from that progression is abnormal (eg, 0% of intelligibility to
                             strangers is 2/4 at 2 years, 3/4 at 3 years, 4/4 at 4 years)


                                                                                                      200
     2.    Etiologies (see also VII)

                  Recognize the importance of obtaining a family history in each
                  instance of intellectual disability

                  Know the perinatal causes of intellectual disabilities

                  Know the postnatal (acquired) causes of intellectual disabilities

                  Recognize the physical stigmata of the most common genetic
                  syndromes (eg, fragile X, fetal alcohol, trisomy 21, Williams)

                  Know the common metabolic causes of intellectual disabilities

                  Know the common chromosomal causes of intellectual disabilities

                  Know the common inheritance patterns of intellectual disabilities

                  Know the common infectious causes of intellectual disabilities

                  Know the common teratogenic causes of intellectual disabilities

     3.    Screening and diagnostic evaluation

                  Know the indications for specific genetic tests in children
                  with intellectual disabilities

                  Understand the indications for imaging tools (eg, cranial
                  ultrasonography, CT scan, MRI) in establishing a specific diagnosis
                  in evaluating intellectual disabilities

                  Know the indications for obtaining metabolic tests in children
                  with intellectual disabilities

     4.    Therapeutic options

                  Understand that children with intellectual disabilities and/or
                  autism spectrum disorder who have symptoms of hyperactivity
                  and short attention span may respond to medication

B.   Autism spectrum disorder

     1.    Clinical features, presentation
                  Know the clinical features of the autism spectrum disorders

                  Distinguish between a child with autism spectrum disorder and a
                  child with isolated speech and language delay

                  Distinguish between a child with an autism spectrum disorder and a
                  child with intellectual disabilities

                  Know the association of intellectual disabilities with

                                                                                        201
                  autism spectrum disorder

                  Distinguish between a child with autism spectrum disorder and a
                  child with profound hearing loss

                  Recognize atypical developmental patterns that may be indicators
                  of autistic spectrum disorder

     2.    Etiologies

                  Know the biologic basis for autistic behavior

     3.    Screening and diagnostic evaluation

                  Understand the diagnostic criteria for the autism spectrum
                  disorders

                  Understand the screening for the autism spectrum disorders in the
                  medical home should be completed at 18, 24, and 30 months of age

     4.    Therapeutic options

                  Know the role of medications in the autism spectrum disorders

C.   Speech and language disorders

     1.    Presentation

                  Recognize that normal disfluency of childhood occurs in preschool
                  children during the attainment of language skills (age 2 to 3 years)
                  and that stuttering represents a clinical disorder after 5 years
                  of age

                  Know which circumstances influence language development in a
                  typically developing child

                  Know that articulation of all consonant sounds is not complete
                  until 6 years of age

     2.    Etiologies

                  Know the causes of delayed language development

                  Understand the importance of family history in the diagnosis
                  language disorders

                  Know that children with delayed language should have an audiologic
                  evaluation

     3.    Screening and diagnostic evaluation

                  Plan the diagnostic evaluation of an 18- to 20-month-old boy who

                                                                                         202
                  does not say any words

                  Know the indications for referral of a child to a speech pathologist
                  for evaluation of stuttering

                  Know the indications for referral for language evaluation during
                  different age groups, including < 2 years, preschool, and school
                  age years

                  Understand the role of rating scales and questionnaires for
                  assessment of language disorders

                  Recognize the ages at which language screening should be included
                  in a developmental evaluation

     4.    Therapeutic options

                  Recognize the available evidence-based treatments for speech
                  and language disorders

D.   Learning disorders

     1.    Clinical features, presentation

                  Distinguish between learning and intellectual disabilities

                  Recognize that cognitive abilities and academic skills develop
                  at different rates for individual children

                  Recognize that children with above average intelligence may
                  have academic failure and learning disabilities

                  Understand that disorders of learning may present throughout
                  a school career

                  Know that reversals (b and d) in writing can be normal for children
                  through 7 years of age

                  Recognize that learning disabilities are usually not outgrown

                  Recognize that problems encountered in content classes (eg, social
                  studies, history) may reflect reduced reading comprehension, impaired
                  short-term memory, or a slow reading rate

                  Know the presenting complaints of children with learning
                  disabilities

                  Recognize the consequences of learning disabilities

                  Identify the indicators of learning difficulties (eg, preschool delay
                  in speech and language, failure to learn letters and numbers by the
                  end of kindergarten, failure to learn to read simple words by the

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            end of first grade)

            Formulate a differential diagnosis in a child who presents with
            academic difficulties

            Understand that learning disabilities may present as an attention
            difficulty

            Know the range of learning disabilities (eg, reading, written
            expression, mathematics)

2.   Etiologies

            Recognize that the causes of school-related difficulties are usually
            multifactorial (eg, learning difficulties, attention, social,
            environmental)

            Know the importance of family history in the evaluation of a child
            with learning difficulties

            Recognize that patients who have CNS-based chronic conditions
            (eg, epilepsy, myelomeningocele) have an increased incidence of
            learning disabilities

            Recognize that temporary learning problems are associated with
            post-concussive syndrome

3.   Screening and diagnostic evaluation

            Know the indications for psychological, educational, and medical
            evaluation of a child with poor school performance

            Recognize factors that affect prognosis in a learning-disabled child

            Know the indications for and limitations of psychoeducational and/or
            neuropsychologic tests for learning disabilities

            Know the indications for and limitations of neuroimaging studies
            (eg, SPECT, PET, fMRI) in a patient who has a learning disability

            Recognize diagnostic testing patterns consistent with common
            specific learning disabilities

4.   Therapeutic options

            Recognize that the educational criteria for placement in special
            classes are different in different communities

            Know the process by which schools determine eligibility for
            special education services

            Understand the basic tenets of the Individuals with Disabilities

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                   Education Act (IDEA)

                   Understand the difference between a 504 Plan and an Individualized
                   Education Plan

     5.     Other factors influencing learning and performance

            a.     General

                   Recognize the factors other than intellectual and learning
                   disabilities that can cause academic underachievement (eg, emotional
                   factors, chronic illness, truancy, drug usage)

            b.     Temperament

            c.     Family factors

                   Recognize how family environment (eg, socioeconomic class, parental
                   educational status, culture, family structures) affects school
                   performance and behavior

            d.     Physical impairments and chronic illness

                   Recognize the medical problems that may present as complaints about
                   school performance or behavior (eg, complex partial or absence
                   seizures, Tourette syndrome, visual problems, mild conductive hearing
                   loss)

                   Recognize that chronic illnesses (eg, inflammatory bowel disease,
                   asthma, malignancy, epilepsy, diabetes, arthritis, hemophilia,
                   human immunodeficiency virus infection, cystic fibrosis)
                   and their treatments affect school performance

            e.     Medications

                   Know the medications that may alter school performance (eg,
                   antihistamines, anticonvulsants)

            f.     Emotional disturbances (eg, anxiety, depression)

                   Recognize that emotional disorders can manifest
                   as academic or behavioral problems

                   Recognize that chronic school failure can lead to depression,
                   anxiety, substance use, other risky behaviors, reduced motivation
                   for school work, juvenile delinquency, and school drop-out

                   Recognize that students with learning disabilities are at increased
                   risk for behavioral/mental health disorders

E.   Special sensory deficits


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1.   Hearing impairment

     a.    Clinical features, presentation

           Know that hearing impairment that begins after the age
           of 5 years has less of an impact on language development
           than an earlier onset of hearing impairment

           Understand the relationship between the various levels of
           hearing impairment (mild, moderate, severe, profound)
           and language development

           Know the presenting complaints in infants and preschool children with
           hearing impairment

           Know that infants with a congenital hearing impairment achieve the
           normal prelinguistic language milestones (smiling, cooing, babbling,
           gesture games) at the normal time

           Recognize that some hearing loss may not be detected by newborn
           hearing screening examinations

           Know that deafness is associated with an increased risk of
           learning disabilities and a resultant low reading level

     b.    Etiologies

           Know the common causes of congenital deafness

           Know the association between meningitis and hearing loss in infants
           and preschool children

     c.    Screening and diagnostic evaluation

           Know the indications for brain stem evoked auditory response testing
           in the neonatal period

           Know how to evaluate an infant with a severe hearing loss

           Know the causes of an acquired hearing impairment

     d.    Therapeutic options

           Know the major approaches to the education of deaf children

2.   Visual impairment

     a.    Clinical features, presentation
     b.    Screening and diagnostic evaluation

           Know the common visual acuity screening tests for preschool and
           school-age children and the age range for which they are appropriate

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                  Recognize the developmental sequelae of congenital infections, eg
                  visual impairment

           c.     Etiologies

                  Know the contribution of ophthalmologic problems (eg, strabismus
                  amblyopia, nystagmus, visual acuity defects, blindness) to reading
                  or academic problems

           d.     Therapeutic options

                  Know the indications for referral for vision evaluation at
                  different ages

                  Know the major approaches to the education of visually impaired
                  children

F.   Diagnostic evaluation and community-based treatment

     1.    Diagnostic assessment instruments

           a.     Cognition, intelligence, and adaptive behavior

                  Understand that as the discrepancy between verbal and
                  performance IQ scores increases, so does the likelihood
                  of learning/performance dysfunction in the child

                  Recognize that both achievement tests and a test of
                  intelligence are valuable in the evaluation of children with
                  school learning problems

                  Know the definition of IQ and the normal range

                  Recognize that subnormal scores on achievement
                  tests with normal overall intelligence may indicate
                  a specific learning disability

                  Know the value and limitations of various hearing tests (eg,
                  tympanogram, behavioral audiometry, pure tone audiometry, brain
                  stem evoked auditory response, and otoacoustic emissions)

                  Understand that the predictive validity of intelligence testing
                  increases with the age of the child

                  Know the factors that may influence performance on intelligence tests

                  Recognize that the full subtest profile of scores on standardized
                  IQ tests is more useful than the full-scale IQ score alone
                  Know the IQ ranges for each category of intellectual function on
                  standardized IQ tests


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           Know the components of an adaptive behavior assessment and the
           ranges from normal to impaired

     b.    Academic achievement

           Understand how to interpret the scores on standardized
           achievement tests

2.   Educational and developmental programs

           Know the indications for and the value of language, occupational,
           and physical therapy

           Recognize the importance of extracurricular activities for the
           self-esteem of learning-disabled children

           Recognize the availability of alternative strategies to help
           learning-disabled students circumvent weaknesses (eg, texts on tape,
           oral testing, use of word processors, spell check)

           Understand the general goals of early intervention programs for
           infants and preschool children with disabilities

           Understand the educational settings for children with learning
           disorders and disabilities (eg, self-contained classrooms, resource
           rooms, public or private tutoring)

           Know the provisions of current legislation (Individuals with
           Disabilities Education Act, Rehabilitation Act) for infants,
           toddlers, and preschool and school-age children with disabilities

           Know the advantages and disadvantages of educational inclusion
           for children and youth with disabilities

           Know the advantages and disadvantages of grade retention

3.   Behavioral interventions

           Understand the utility of behavior modification approaches in the
           overall management of children with learning, developmental, and
           behavioral problems

4.   Counseling

           Know the common stress points (or times) for parents in the life
           of their child with a developmental disability

5.   Use of community resources

           Know the types of community service available to the family
           with a child with a developmental, learning, and/or behavioral/
           mental health disorder

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               6.    Complementary and alternative therapies

                            Evaluate the research data regarding dietary intervention
                            (eg, Feingold diet, sugar restriction, megavitamins, food allergy)
                            for children with learning and behavioral problems, and provide
                            appropriate guidance

                            Evaluate the research data regarding controversial
                            perceptual/therapeutic interventions (eg, patterning, visual
                            training exercises, sensory integration) for children with
                            developmental disabilities, and provide appropriate guidance

                            Understand the forces that drive parents of children with develop-
                            mental disabilities to nonstandard treatments (eg, striving for rapid
                            solutions, frustration with medical/educational systems, family
                            pressure, finances, lack of community programs, guilt/remorse)

XXVIII. Behavioral and Mental Health Issues

        A.     Developmental stages

               1.    Pregnancy, birth, first days after birth

                     a.     Prenatal care

                            Understand the importance of advising a mother about the
                            environmental effects on her fetus of alcohol, cigarette
                            smoking, drug use, and nutrition

                            Recognize the importance of identifying resources for maternal/
                            familial support during the perinatal period and early infancy

                            Recognize the content and goals of a prenatal visit or class

                     b.     High-risk pregnancy

                            Understand the spectrum of reactions of parents to a malformed
                            infant when diagnosed at birth or in utero

                     c.     Parent-infant attachment

                            Recognize the benefit of nursing policies that allow
                            early and frequent contact between mother and infant

                            Recognize that attachment may occur even if an infant is lost through
                            stillbirth, neonatal death, or adoption, and recognize that physical
                            contact may alleviate grief reactions in these situations

                            Recognize that a mother and father may attach differently to
                            a newborn infant, particularly with a multiple birth if one
                            infant is hospitalized

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           Recognize the implications of adolescent fatherhood in the
           establishment of the family unit: immaturity, poor parenting skills,
           inconsistent involvement, low income

           Know that seeking proximity to a parent during times of stress to
           re-establish a sense of well being is consistent with healthy
           parent-infant attachment

2.   Infancy

     a.    Colic

           Know the frequency of crying at various ages (eg, up
           to three hours a day at 6 weeks of age)

           Understand the importance of history in the diagnosis
           of colic, whereas a physical examination and laboratory tests
           usually are not helpful

           Plan a therapeutic program to manage colic and be aware that there
           are useless and dangerous therapies for colic: repeated formula
           changes, megavitamins, drugs

     b.    Feeding

           Distinguish normal variations in feeding from patterns that reflect
           poor parenting practices (eg, feeding to quiet the infant,
           propping the bottle)

     c.    Rocking movements

           Know that normal individuals may demonstrate repetitive
           movements

           Differentiate between normal and abnormal repetitive movements

           Know that repetitive movements may represent self-stimulation in a
           neglectful environment

     d.    Temperament

           Identify the types of temperament in infants

           Recognize that parental counseling should address the temperamental
           characteristics of infants

3.   Toddler and preschool

     a.    Toilet training

           Know that the appropriate age for toilet training is related

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     to cultural influences, neurophysiologic readiness, and
     the child's motivation

     Recognize the signs of a neurophysiologic readiness for toilet
     training

     Know the usual age that boys and girls attain control
     of bowel and bladder functions

     Develop a therapeutic plan for delayed toilet training

b.   Habits

     (1).     Thumb sucking

     Know the natural history of thumb sucking: onset
     in utero or in the first few months after birth, peak at 18 to
     21 months of age, resolution by 4 years of age

     Know the benefits and risks of various approaches to dealing with
     prolonged thumb sucking

     Know the problems of prolonged thumb sucking

     (2).     Masturbation

     Know the clinical features and natural history of self-exploration
     and masturbation

     Know that masturbation in public suggests poor
     awareness of social reality

     Know that masturbation seldom produces self-induced injury in
     childhood

     Know the differential diagnosis of and appropriate counseling for
     excessive masturbation: sexual overstimulation, environmental
     deprivation, genital disease (itching)

c.   Anticipatory guidance

     Know that a knowledge of milestones allows the physician
     to reassure parents regarding normal development and
     prevents overanxious behavior

     Know the relation of accident proneness to family stress,
     disorganization, and hazardous environments

     Know how to appropriately counsel parents about setting limits for
     toddlers

d.   Temper tantrums, breath-holding
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           Understand that frustration, anger, and the fear and pain associated
           with minor injuries are etiologies for breath holding

           Design a therapeutic program for the management of breath holding

           Design a therapeutic program for the management of temper tantrums

           Develop a plan for managing aggressive behavior (eg, hitting, biting)

     e.    Head banging

           Recognize that head banging does not indicate a sensory
           deficit

4.   Middle childhood

     a.    Fears and phobias

           Distinguish between fears and phobias

           Develop a plan for managing fears

     b.    Lying and stealing

           Know when lying and stealing indicate severe psychiatric disturbance

     c.    Anticipatory guidance

           Know the importance of guidance during middle childhood regarding
           discipline

           Know the appropriate elements involved in counseling parents about
           sex education for their middle school-age children

           Understand the issues involved in counseling parents about the
           involvement of their children in middle school in extracurricular
           activities such as music and sports: underinvolvement, over-
           competitiveness, socialization

5.   Adolescence

     a.    Anticipatory guidance

           Recognize that some aggressive negative behavior may be
           adolescent rebellion: contrast frequency, severity,
           duration of symptoms

           Identify the behavioral changes common with the onset of early
           adolescence: fatigue, increased sleeping, irritability,
           secretiveness, easy embarrassment


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B.   Externalizing behaviors and conditions

     1.    Aggressive behaviors (eg, aggression, ODD, CD, antisocial

           behaviors)

           a.     Clinical features, presentation

                  Differentiate aggressive behavior from normal variants (eg,
                  aggressive oppositional variant)

           b.     Etiologies

                  Recognize the environmental and biological contributors to the
                  development and maintenance of aggressive behaviors

                  Understand the factors related to biting at various stages
                  of development

                  Understand the influences of exposure to violence in the media
                  on aggressive behavior in children and adolescents

                  Understand the association between child maltreatment and later
                  aggressive behavior

                  Understand the association between corporal punishment and
                  aggression in children, adolescents, and adults

           c.     Screening and diagnostic evaluation

                  Plan the evaluation of a child with aggressive behavior (eg, school-
                  family information, developmental milestones, child interview,
                  rating scales for ADHD, ODD/CD)

                  Understand the role of rating scales and questionnaires in the
                  assessment of a child with aggressive behavior

           d.     Therapeutic options

                  Understand the management of aggressive behavior at different ages

                  Know how to advise families on the management of aggressive, biting,
                  or bullying behavior

                  Know how to advise a school or child-care center on the management
                  of aggressive, biting, or bullying behavior

     2.    Disruptive behaviors (eg, oppositionality, ODD, CD)

           a.     Clinical features, presentation

                  Understand that starting fires and cruelty to animals may indicate an

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           underlying psychiatric disturbance

           Understand the stages of development typically associated with
           oppositional behaviors (eg, tantrum in toddler, adolescence)

           Recognize the natural history of oppositional defiant or conduct
           disorder based on the developmental stage

           Recognize the behavioral and functional characteristics of
           oppositional defiant or conduct disorder and the variations
           in presentation

           Distinguish between oppositional defiant or conduct disorder and
           temperamental variations

           Understand the range of prognoses for children with oppositional
           defiant or conduct disorder

     b.    Etiologies

           Recognize the environmental (eg, family systems, community) and
           biological (eg, genetics, co-existing conditions) contributors to
           oppositional and defiant behaviors

     c.    Screening and diagnostic evaluation

           Recognize the common conditions occurring in concert with
           oppositional defiant or conduct disorder (eg, ADHD, learning
           difficulties)

           Understand how to evaluate a child with defiant, oppositional, or
           delinquent behavior (eg, school-family information, developmental
           milestones, child/adolescent interview, rating scales)

           Know the criteria for referral of a child with defiant, oppositional,
           or delinquent behavior

           Understand the role of rating scales and questionnaires in the
           assessment of disruptive behaviors (eg, Vanderbilt, Conners)

     d.    Therapeutic options

           Know the role of behavioral modification strategies in the
           management of disruptive behaviors

3.   Antisocial behaviors, delinquency

     a.    Clinical features, presentation

           Know the associated signs of antisocial behavior: poor
           school performance, truancy, poor self-esteem, low
           frustration tolerance

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           b.     Etiologies

                  Know that antisocial behavior may be indicative of other
                  disorders: depression, anxiety, psychosis

                  Recognize the environmental and biological contributions to the
                  development and maintenance of antisocial behaviors

           c.     Screening and diagnostic evaluation

                  Know how to evaluate a child with antisocial behavior

                  Know the criteria for referral of a child with antisocial behavior

                  Understand the role of rating scales and questionnaires in the
                  assessment of antisocial behaviors

           d.     Therapeutic options

                  Be aware of the therapeutic options available for managing antisocial
                  behavior in an adolescent

C.   Internalizing behaviors and conditions

     1.    Anxiety

           a.     Clinical features, presentation

                  Recognize the manifestations of childhood anxiety disorders,
                  (eg, generalized, situational) and manage appropriately

                  Understand the epidemiology of anxiety disorders in children and
                  adolescents (eg, age-based differences, gender-based differences)

                  Understand the relationship between temperamental characteristics
                  and anxiety

                  Differentiate worries from anxiety disorders

                  Recognize the signs and symptoms of phobias and anxiety disorders
                  and the range of common presentations

                  Recognize the signs and symptoms of post-traumatic stress disorder
                  in children and adolescents and the range of common presentations
                  (eg, sleep problems, agitation/anxiety)

                  Recognize the importance of active outreach and screening for
                  post-traumatic stress disorder in children and adolescents after
                  a traumatic event (eg, school shooting, environmental calamity)

                  Recognize that post-traumatic stress disorder may have a delayed

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           onset following a traumatic event

           Recognize the signs and symptoms of obsessive-compulsive disorder

     b.    Etiologies
           Recognize the behavioral situations that contribute to or
           exacerbate anxious and fearful behaviors

           Understand the environmental and biological contributions to the
           etiology of phobias and anxiety disorders

           Understand the environmental and biological contributions to the
           etiology of obsessive-compulsive disorder

     c.    Screening and diagnostic evaluation

           Recognize the common co-existing conditions associated with
           anxiety disorders

           Understand the role of rating scales and questionnaires in the
           assessment of anxiety behaviors (eg, SCARED, MASC)

     d.    Therapeutic options

           Understand the pharmacologic and non-pharmacologic management of
           phobias and anxiety disorders

           Understand the pharmacologic and non-pharmacologic management of
           post-traumatic stress disorder

           Understand the pharmacologic and non-pharmacologic management of
           obsessive-compulsive disorder

2.   Mood and affect disorders

     a.    Clinical features, presentation

           Understand that depressive disorders may present a variety of
           symptoms (eg, fatigue, somatic complaints, school problems, acting
           out, irritability)

           Understand the depressive mood swings of a normal adolescent

           Recognize the biologic correlates (eg, sleep issues, change in
           appetite) of depression

           Understand the epidemiology of depression in children and
           adolescents (eg, gender-based differences, age-based differences)

           Understand the variability in the presentation of childhood
           bipolar disorder


                                                                                216
                  Recognize that acting out and oppositional behaviors rather than
                  vegetative symptoms can be seen in youth with depression

           b.     Etiologies

                  Understand the association of depression with complex illness
                  Understand the association between depression and substance use/abuse

                  Recognize that anxiety disorders often coexist with depressive
                  disorders

                  Understand the association between anger/hostility and anxiety and
                  depression in adolescents

                  Understand that depression and substance abuse are more common
                  in teens with sexual orientation issues (eg, gay, bisexual,
                  transgender)

                  Recognize the environmental and biological (eg, genetic)
                  contributors to the development of depressive disorders

                  Recognize the common co-existing conditions of depressive disorders

                  Recognize the environmental and biological (eg, genetic)
                  contributors to the development of childhood bipolar disorders

           c.     Screening and diagnostic evaluation

                  Distinguish between a major depressive disorder, dysthymia, and
                  brief grief reactions, and adjustment disorder with depressed mood

                  Understand the role of rating scales and questionnaires for the
                  assessment of depressive behaviors (eg, PHQ-9, Columbia Teen
                  Screen, Beck Depression Inventory)

           d.     Therapeutic options

                  Understand the pharmacologic and non-pharmacologic treatment
                  approaches to depression

D.   Suicidal behavior

                  Understand that self-poisoning after 6 years of age is not likely
                  to be accidental

                  Understand that asking a child or adolescent about suicidal thoughts
                  or actions will not "put such ideas into his/her head"

                  Understand the warnings signs of suicide (eg, isolation from
                  friends, giving things away)

                  Understand that self-inflicted harm, even in children, may be a sign

                                                                                          217
                  of an attempted suicide

                  Know that publicity regarding suicide may prompt other adolescents to
                  attempt suicide

                  Know the epidemiology of suicide attempts

                  Know the epidemiology of mortality due to suicide

                  Recognize that the psychologic intent does not always correlate
                  with the seriousness of the physical suicide attempt (suicidal
                  gestures must be taken seriously)

                  Identify the features of a child's or adolescent's suicide
                  attempt that indicate a more or less serious situation

                  Understand that homosexual adolescents are at risk for suicide

                  Know the risk factors associated with suicidal behavior in
                  children and adolescents

                  Know the risk factors associated with a poor prognosis for
                  children and adolescents who have attempted suicide

                  Know how to assess a child or adolescent with suicidal ideation

                  Know the indications for hospitalization of a child or adolescent
                  at risk of suicide

                  Recognize the factors that are protective against suicidal
                  behavior (eg, religion, school engagement, family connectedness,
                  coping strategies, reduction of firearms in the home)

                  Recognize the impact of suicide on peers and members of the family

                  Understand the management of a child or adolescent with suicidal
                  ideation or behavior

E.   Psychotic behavior, thought disorders

                  Understand the behaviors suggestive of schizophrenia

F.   Disorders of attention and impulse control

     1.    Clinical features, presentation

                  Recognize that the prevalence rate of ADHD is higher in boys than
                  in girls

                  Know the spectrum of symptoms that can occur with ADHD subtypes
                  (inattention, impulsivity, hyperactivity)


                                                                                          218
            Recognize that anxiety or depression can present as hyperactivity or
            inattention

            Know that ADHD is difficult to accurately diagnose in the early years
            of life

            Know that ADHD-combined type reaches its peak prevalence of
            identification in the early elementary school years, but that
            ADHD-inattentive subtype may not be identified until later in
            the school career

            Know the long-term outcome for children with ADHD as adolescents and
            adults

            Know the differential diagnosis of a child presenting with
            behavior problems in school

            Understand that the manifestations of hyperactivity and
            impulsivity decrease but that challenges with inattention
            remain problematic over time

            Recognize that a large percentage of youth with ADHD will have
            clinically significant impairment in adulthood

            Recognize that the most common presentation of ADHD in preschool
            children is problems with hyperactivity and impulse control

2.   Etiologies

            Know that coexisting conditions (eg, oppositional defiant disorder,
            conduct disorder, anxiety, depression, learning disabilities) are
            frequently seen in children with ADHD

            Know the medical causes of hyperactivity and/or attention
            difficulties

            Know the neurochemical basis of ADHD

3.   Screening and diagnostic evaluation

            Recognize that the diagnosis of ADHD cannot be made by use of a
            specific test

            Recognize that observation of behavior in a physician's office does
            not usually reflect the situation at school

            Understand the role of diagnostic studies in the evaluation
            of disorders of attention, including laboratory, neuroimaging,
            psychoeducational testing, and continuous performance tests

            Understand the reasons for requesting information on symptoms
            and impairment from two or more settings in a patient with

                                                                                    219
                            suspected ADHD

                            Understand that patients with CNS-based chronic conditions
                            (eg, epilepsy, myelomeningocele, lead poisoning) are at
                            increased risk of ADHD

              4.     Therapeutic options

                            Know that stimulant medications improve attention in normal
                            individuals as well as in children with attention deficit hyper-
                            activity disorder

                            Know that medication alone is not sufficient for the
                            treatment of ADHD

                            Recognize the importance of communicating with the teachers of a
                            child with ADHD when medications are used

                            Know the medications used in treating ADHD

                            Know the side effects of medications used to treat ADHD, the
                            contraindications to their use, and the potential for
                            their abuse

                            Know the management strategies for a child with ADHD and its
                            coexisting conditions (eg, behavioral management strategies, special
                            education placement, tutoring, cognitive monitoring strategies,
                            psychotherapy, hypnosis)

                            Know the medical indications for the use of stimulant medications
                            outside of school hours

                            Know that ADHD medications may be useful through adolescence and
                            beyond

                            Know the beneficial effects of ADHD medications

                            Understand that classroom accommodations for children with
                            ADHD may by implemented under Section 504 of the Rehabilitation
                            Act (504 Plan) or under the Individuals with Education Disabilities
                            (IED) Act

XXIX.   Psychosocial Issues and Problems

        A.    Family and environmental issues

              1.     General issues

                            Know the value of anticipatory guidance and the provision
                            of information and support for critical life events

                            Identify regressive behavior and somatic complaints as

                                                                                                   220
            signs of stress

            Understand that parental-focused positive reinforcement is
            critical throughout childhood and adolescence

            Understand how to help families transition their adolescents
            from a pediatric practice to a provider who cares for adults

2.   Critical life events

     a.     Divorce

            Understand that the developmental stage of a child will
            have an effect on the child's response to divorce

            Understand that the developmental stage of a child will have an
            effect on the child's response to a blended family

            Be aware of custodial issues in divorce (eg, joint versus sole
            custody, child's choice, visitation) and their effect on the child

            Recognize that a child's emotional adjustment to divorce may affect
            his/her own subsequent intimate relationships

     b.     Death

            Understand that the developmental stage of a child will
            have an impact on his/her response to a death in the
            family

            Know how to counsel a family and child regarding the death of a loved
            one

            Know the stages of grief and the spectrum of reactions for a child and
            a family when a loved one dies: shock, anger, denial, disbelief,
            sadness

            Recognize the patterns of responses of family members (spouse,
            siblings) to a life-threatening or terminal illness

     c.     Sudden infant death

            Recognize the psychosocial issues surrounding the use of home monitors

            Recognize the importance of physician review of case with parents
            after SIDS has occurred (including risk of SIDS in siblings)

3.   Impact of mass media

            Understand the potential negative effects of TV viewing on children:
            increases aggressive behavior; acceptance of violence; obscures dis-
            tinction between fantasy and reality; trivializes sex and sexuality;

                                                                                     221
           increases passivity, obesity, & perhaps the risk of suicidal behavior

           Know the average time children spend with television relative to
           other activities (school, play, etc)

           Know about limit-setting techniques for TV time, including the
           recommendation that children younger than 2 years of age should not
           watch TV

           Know the relationship of TV viewing to the selection of toys, cereals,
           and so forth
4.   Socioeconomic factors

5.   Adoption

           Understand the physician's role in international adoption

6.   Foster care

           Understand the physician's role in foster care

           Know that children in foster care are by definition children with
           special healthcare needs (eg, high rates of physical, mental,
           dental, developmental/educational needs; substantial psychosocial/
           familial dysfunction)

           Understand that children in foster care need special evaluations (eg,
           screening within 72 hours of placement; comprehensive assessment
           within 30 days of placement, including formal mental health and
           developmental/educational evaluations)

           Understand that children in foster care need a medical home with
           care coordination and case management that may involve biological
           and/or foster parents, caseworkers, and specialists involved
           in care

           Know the basics of how the child welfare and foster care systems
           function (eg, roles of caseworkers, judges, attorneys, biological
           parents; basics of local state laws; consent issues)

           Understand that behavioral problems lead to placement instability
           of children in foster care and that instability in turn can
           create/exacerbate developmental and behavioral problems

           Understand that dealing with behavioral problems of children
           in foster care can improve the placement stability, which, in turn,
           will increase the child's chances for a permanent placement

           Recognize the needs of youth aging out of the foster care system
           (eg, independent living skills, social support)

           Recognize the high risk for homelessness, incarceration, teenage

                                                                                    222
                  pregnancy, and drug/alcohol dependency in youths aging out of the
                  foster care system

     7.    Discipline

                  Know the various forms of effective discipline (eg, time out, time
                  in, "catch 'em when they're good," ignoring certain behaviors)

     8.    Cultural issues in medical care

B.   Specific problems, conditions

     1.    Enuresis

                  Distinguish between primary and secondary enuresis

                  Distinguish between nocturnal and diurnal enuresis

                  Consider the etiologic factors of nocturnal enuresis: genetic,
                  gender, maturational delay, psychosocial, sleep state

                  Know that nocturnal enuresis is common among school-age
                  children

                  Know that regressive bed-wetting is related to a stressful
                  environment or event such as the birth of sibling or moves

                  Understand that diurnal enuresis after continence is achieved
                  should prompt evaluation

                  Recognize the importance of a family history of nocturnal
                  enuresis

                  Know that laboratory studies for enuresis are unlikely to be
                  positive unless additional clinical findings are present

                  Know the various treatment approaches for nocturnal enuresis:
                  counseling, hypnosis, urine alarm, imipramine, no treatment, DDAVP

                  Advise parents about coping with enuresis without causing psychologic
                  problems

                  Recognize other causes of daytime enuresis: incontinence
                  secondary to environmental stress, a "resistant" child, urgency
                  incontinence

                  Know various treatment approaches for daytime enuresis: counseling,
                  hypnosis, bladder-training exercises, no treatment

                  Know the limited efficacy and significant risks of the pharmacologic
                  treatment of enuresis (including imipramine and DDAVP)


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2.   Encopresis

           Know the association of encopresis with a urinary tract
           infection and enuresis

           Understand the physiologic effect of stool retention

           Distinguish between encopresis and Hirschsprung disease

           Understand the medical management of encopresis

           Understand that encopresis is a symptom rather than a
           developmental variation after the age of 4 to 5 years
           Recognize the symptoms of stool withholding during toilet training

           Know the management of stool withholding during toilet training

           Understand the etiologies of encopresis: organic, behavioral,
           environmental (privacy issues)

           Understand the management of the various etiologies of encopresis

           Understand that a combination of medical therapy, behavioral
           modification, and counseling results in the greatest success in the
           treatment of encopresis

           Distinguish between delayed bowel training and encopresis

           Understand that the successful treatment of encopresis varies with
           the age of onset and that relapses are common

3.   Psychosomatic disorders

           Recognize the factors associated with conversion reactions: model,
           symbolism, primary gain, secondary gain, la belle indifference,
           hysterical personality

           Understand the importance of cost-effective investigation of
           psychosomatic disorders

           Understand the association of psychosomatic disorders with
           stress

           Distinguish between primary and secondary gain in regard to
           conversion reactions and psychosomatic complaints

           Know the common symptoms, physical findings, and the course of
           chronic pain syndromes (head, chest, abdomen, and legs)

           Understand the treatment approaches for psychosomatic disorders

           Know the differential diagnosis of conversion symptoms:

                                                                                 224
            psychophysiology, hypochondriasis, malingering, somatic delusions

            Know that school attendance and absenteeism are important to assess
            with every complaint of recurrent pain

            Understand that psychosomatic disorders (chronic pain) may be
            manifestations of parental anxiety and parental pressure for a child
            to perform

4.   Sibling rivalry

            Know that sibling rivalry is common and be able to counsel
            parents appropriately

            Devise a therapeutic plan for an aggressive sibling rivalry

5.   Separation anxiety and school refusal

            Know the relationship of separation anxiety to school phobia
            or school refusal

            Understand that separation anxiety is developmentally appropriate
            in the preschool child and during the first few months of school in
            kindergarten or first grade

            Understand the family dynamics of separation anxiety

            Distinguish between separation anxiety and truancy as a cause of
            school absence

            Develop a therapeutic plan for abnormal separation anxiety

            Understand the impact of maternal depression on childhood behavior

6.   Sleep disorders

            Know the normal developmental progression of sleep patterns

            Know "night-waking" patterns at different ages

            Understand the association of night waking with
            separation anxiety

            Understand the importance of the parental response and
            concern toward sleep disorder in their infant

            Know that sleep disorders are common in childhood

            Distinguish between nightmares and night terrors

            Plan a therapeutic program to assist parents in dealing with an
            infant with frequent night waking, night-day reversal, sleep refusal

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                  Develop a therapeutic plan for managing a child with bedtime refusal
                  or frequent awakening

                  Develop a management plan for a child who has night terrors

     7.    Vulnerable child syndrome

                  Understand the factors that predispose a child to the vulnerable
                  child syndrome

                  Recognize how a health crisis, real or perceived, of a child may
                  affect parenting of the child

                  Know how to provide anticipatory guidance to prevent vulnerable
                  child syndrome

     8.    Rumination and cyclical vomiting

                  Distinguish between nonorganic causes of vomiting (eg, rumination
                  and cyclic vomiting) and organic etiologies

                  Develop a plan of management for rumination

     9.    Pain

                  Recognize that dealing with and tolerance to pain vary with
                  a child's developmental stage

                  Describe different techniques to manage pain/anxiety in children at
                  different developmental stages

     10.   Gifted child

                  Recognize the effect of a gifted child on family function

                  Know how to advise parents about managing a gifted child (home,
                  school, peers, socialization)

C.   Chronic illness and handicapping conditions

                  Recognize a grief reaction in parents with children with handicapping
                  conditions

                  Recognize ineffective treatment methods for handicapping conditions,
                  eg, visual training, megavitamins, patterning

                  Understand the effect of a chronic illness on siblings

                  Recognize increased child abuse among handicapped children

                  Know that psychosocial factors are associated with but do not cause

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                  chronic illness (eg, asthma, seizures, inflammatory bowel disease)

                  Understand the effect of a chronic illness on a marriage and family
                  economics

                  Understand the role of the pediatrician in the facilitation of a
                  normal progression of a chronically ill or handicapped child to adult
                  behavior, including separation from parents and emerging sexuality in
                  spite of chronic illness

                  Understand the psychosocial effects associated with the use of home
                  medical equipment (eg, oxygen monitors, physical therapy,
                  transportation, hygiene)

                  Understand the importance of being supportive and nonthreatening
                  while talking with parents whose children have chronic diseases
                  Know the factors involved in making appropriate ethical decisions
                  relating to children with chronic and handicapping diseases

                  Monitor growth and development in patients following all types of
                  transplantation

                  Recognize psychosocial and family issues associated with all types
                  of transplantation

                  Understand the importance of providing a medical home for
                  children with chronic conditions (eg, registry, medical summary,
                  care plan, transition plan)

D.   Violence

     1.    Family violence

                  Recognize circumstances that may indicate intimate-partner violence:
                  depression, substance use/abuse, physical injuries

                  Know possible effects of intimate-partner violence on children:
                  physical abuse, injury while protecting mother, injury from assault
                  directed at mother, learned aggression, post-traumatic stress
                  disorder, hypervigilance

                  Recognize common characteristics of violent children and adolescents:
                  exposure to corporal punishment and intimate-partner violence,
                  perception that the world is hostile, little awareness of options for
                  conflict resolution, poor peer relations, impulsiveness

                  Know important precipitants of violence by batterers: pregnancy,
                  efforts by women to leave the home, initiation of separation or
                  divorce

     2.    Societal violence


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E.   Abuse and neglect

     1.    Child abuse

           a.     Epidemiology

                  Recognize the possibility of abuse or neglect in failure
                  to thrive

                  Recognize that a related caregiver is the abuser of
                  a child in 90% of child abuse cases

                  Recognize that siblings of abused children are at increased risk of
                  abuse

                  Recognize that other forms of intimate-partner violence frequently
                  accompany child abuse
                  Understand that neglect is the most common form of child abuse

           b.     Etiology

                  Understand the origins of child abuse: child stresses (eg, handicap,
                  hyperactivity), social/situational stresses (eg, poverty, isolation,
                  family discord, multiple births, parent-child conflicts), and parent
                  stress (eg, abused as a child, depression, substance abuse)

                  Know that abusive and neglectful parents often have severely
                  unrealistic expectations for their children's behavior

           c.     Signs and symptoms

                  (1).     Distribution of injuries

                  Know that fractures of ribs, scapulae, and sternum
                  are rarely accidental

                  Distinguish between cutaneous signs of physical abuse and accidental
                  injury

                  Distinguish between the physical findings of inflicted and accidental
                  burns

                  Know the most common fracture locations and types in physically
                  abused children

                  (2).     Bruises

                  Understand the staging of bruises

                  Distinguish between cutaneous signs of physical abuse and of
                  nonabusive skin conditions (eg, Mongolian spot, coining, cupping,
                  urticaria pigmentosa)

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     Recognize injuries in children that are infrequently indicative of
     physical abuse (dislocated elbow, clavicular fracture, toddler
     fracture of the tibia)

     (3).     Burns

     Distinguish between an inflicted burn and skin
     conditions that mimic burns (eg, staphylococcal
     impetigo, herpes, contact dermatitis, and toxic
     epidermal necrolysis)

     (4).     Ingestions

     Recognize that ingestions may be manifestations of child abuse

     (5).     Fractures

     Distinguish between inflicted fractures and
     conditions such as osteogenesis imperfecta,
     hypophosphatasia, infantile cortical hyperostosis,
     and osteoid osteoma

     Recognize the role of a bone survey for fractures in suspected child
     abuse

     Recognize that fractures are present in a minority of physically
     abused children

     Recognize the chip fracture of metaphysis as
     commonly due to wrenching or pulling injuries

     Know that a radionuclide bone scan can reveal subtle areas of
     skeletal trauma that may not be seen on plain-film x-ray studies
     of bones

     (6).     Shaken infant syndrome

     Recognize the need for a skeletal survey in a child
     with a subdural hematoma

     Recognize abuse as the most common cause of serious
     intracranial injuries during the first year after birth

     Recognize shaking as a possible cause of coma in
     the absence of signs of cutaneous trauma

     Recognize the need for a retinal examination to identify retinal
     hemorrhage in suspected head trauma due to shaking

d.   Treatment, legal issues


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           Know that sexual abuse should usually be reported to law enforcement
           and must be reported to a state child protection agency

           Know that under state laws physicians are legally obligated to
           report suspected abuse

           Recognize that an investigation of unsubstantiated cases of child
           abuse produces stress in a family

           Recognize that an unsubstantiated report/finding by a child
           protection agency does not necessarily mean that abuse or neglect did
           not occur

           Recognize that the standard of proof in a civil court is the
           preponderance of evidence (ie, a lesser standard than in criminal
           proceedings re child abuse)

           Recognize the problems associated with foster home placement
           (including the continued risk of child abuse)
           Recognize the need for a team approach in the management of child
           abuse

           Be aware of intervention options for families involved in child abuse

           Understand the role of a child advocate (guardian ad litem) in legal
           proceedings

           Know circumstances that can lead to failure to substantiate child
           abuse: failure to locate child; failure to locate parents; parents'
           refusal to speak to investigators; duplicate reports; child's refusal
           to repeat history; non-English speaking family

           Recognize that many abused and neglected children are not removed
           from their parents or placed in foster care

2.   Neglect

           Understand that neglect of safety and neglect of medical care are
           forms of abuse

           Know that excessive quietness, compliance, or apathy in an infant or
           toddler may be a symptom of neglect or abuse

3.   Factitious disorder (Munchausen syndrome) by proxy

           Recognize the signs of factitious disorder (Munchausen syndrome)
           by proxy: recurrent sepsis from injecting fluids, chronic diarrhea
           from laxatives, false renal stones from pebbles, fever from heating
           thermometer, rashes from trauma, sugar or blood in the urine, etc

           Recognize the features of the parent of a child with factitious
           disorder (Munchausen syndrome) by proxy

                                                                                   230
           Recognize that children with factitious disorder (Munchausen
           syndrome) by proxy may exhibit significant ongoing psychologic
           problems

           Know the components of a management plan for a patient with
           factitious disorder (Munchausen syndrome) by proxy

4.   Sexual abuse

     a.    Epidemiology

           Understand the age and gender distribution of sexual abuse

           Recognize that the absence of a protective parent from the home
           increases the risk of sexual abuse

           Recognize that most perpetrators of sexual abuse are known by the
           child before the abuse occurs

     b.    History

           Know that a complaint of genital pain may infrequently indicate
           sexual abuse

           Understand techniques for obtaining information from a child
           suspected of being sexually abused

           Know which physical complaints can lead to a diagnosis of sexual
           abuse (genital discharge, genital pain)

           Know that in suspected sexual abuse, the first detailed interview of
           a child is diagnostically critical

           Know that an explicit description and imitation of adult sexual
           behavior by children may indicate either victimization or observation
           of sexual acts (not fantasy)

           Know why to avoid repetitive interviewing of an allegedly sexually
           abused child: creates rote quality to responses, increases likelihood
           of leading questions, increases chance of "learned" responses, is un-
           necessarily stressful, increases chances of inconsistency/retraction

           Recognize the advantages/disadvantages of anatomically correct dolls
           for interviewing (advantage: the child who is nonverbal can point;
           disadvantage: risk of overinterpretation)

           Recognize that drawing of genitalia by a child may indicate sexual
           abuse

           Know that when sexual abuse is suspected, the child should be
           interviewed alone

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                            Recognize that verbatim statements by a child may qualify as evidence
                            in a criminal court (re sexual abuse)

                       c.   Physical examination

                            Recognize the physical findings that are consistent with sexual abuse

                            Know that labial adhesions, vulvar erythema, and anal tags are not
                            signs of abuse

                            Know how to conduct a physical examination for suspected sexual abuse

                       d.   Laboratory findings

                            Know that the presence of a sexually transmitted disease may indicate
                            sexual abuse

                            Know that a chlamydial infection may be acquired from the mother at
                            birth and persist

                            Know which microbiologic tests are helpful in documenting
                            suspected sexual abuse

                       e.   Forensic evidence

                            Know that sexually transmitted disease in a prepubertal child
                            is presumptive evidence of sexual abuse

                            Understand the importance of using only "gold standard" tests
                            to diagnose sexually transmitted diseases in children because
                            of the legal issues involved

                            Know that evidence of seminal fluid is infrequently found in sexually
                            abused children

                            Know that seminal fluid is unlikely to be found/persist beyond 72
                            hours in a sexually abused child

                       f.   Management

                            Recognize that sexual abuse can recur even when families are
                            receiving treatment

                            Know the current recommendation for antibiotic prophylaxis for
                            prepubertal and adolescent sexual assault victims

                            Recognize the importance of not assigning blame to the victim in
                            helping families cope with sexual abuse

XXX.   Critical Care


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A.   Recognition of impending systemic failure

     1.    General (vital sign changes)

                   Understand that a normal blood pressure reading does not
                   preclude shock

                   Understand the importance of prolonged capillary refilling time
                   in a sick patient

                   Know that a sign of impending coma is increasing respirations

                   Realize that a temperature greater than 41 C is frequently
                   associated with invasive bacterial infections

                   Recognize the conditions associated with malignant hyperthermia
                   during general anesthesia

                   Know that environmental temperature influences capillary refilling
                   time

     2.    Central nervous system
                   Recognize a unilateral dilated pupil as a sign of uncal herniation

                   Distinguish between tachypnea that is compensatory versus
                   hyperventilation

                   Recognize the criteria for brain death

                   Recognize the role of neurodiagnostic studies in the determination
                   of brain death

     3.    Respiratory

                   Recognize the signs and symptoms of impending respiratory failure

                   Recognize the signs associated with severe airway obstruction

     4.    Cardiac

                   Recognize cardiogenic shock

     5.    Renal

                   Recognize and plan the therapy for a hypertensive emergency

                   Distinguish between prerenal and renal azotemia by clinical
                   and laboratory evaluation

     6.    Hepatic

                   Identify the signs and symptoms of impending hepatic failure

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     7.    Electrolytes

                  Recognize adrenal insufficiency by laboratory and clinical
                  evaluation

                  Distinguish between adrenal insufficiency and the syndrome of
                  inappropriate antidiuretic hormone by laboratory and clinical
                  evaluation

                  Recognize water intoxication in an infant

     8.    Skin

                  Plan initial antibiotic therapy in a child with purpura
                  and possible sepsis

B.   Emergency life support

     1.    General

                  Plan the initial evaluation of an accident victim

     2.    Airway and respiratory

                  Choose the correct ventilatory tube size for children of various ages

                  Know the value of PEEP in a patient with pulmonary edema

     3.    Cardiac and circulatory (shock)

                  Know the correct method for cardiopulmonary resuscitation in
                  children of all ages

                  Choose the correct drug(s) for the initial management of septic
                  versus cardiogenic shock

                  Know the guidelines for the initial therapy of hypovolemic or
                  septic shock

                  Realize the occasional value of a bone marrow needle to
                  administer fluid intraosseously in a patient in shock

C.   Common conditions requiring emergency life support

     1.    Airway, chest

           a.     Upper airway obstruction

                  Distinguish between asthma and foreign body aspiration

           b.     Pneumonia, bronchiolitis
                                                                                          234
                     c.    Burns

                           Recognize airway injury in a patient with an acute burn

                     d.    Near-drowning

                           Know how to treat hypothermia associated with a near drowning

                           Recognize cerebral edema in an asphyxiated patient

                           Understand the factors that predict the prognosis in a patient who
                           has had a near-drowning episode

                     e.    Hemothorax, flail chest

                           Identify a flail chest

                     f.    Respiratory distress

                           Recognize a child with early acute respiratory distress syndrome
                           after shock

             2.      Cardiac and circulatory
                           Recognize cardiac failure

                           Plan the acute treatment of congestive heart failure in a child
                           or adolescent

                           Recognize complete heart block from the findings on electrocardio-
                           graphy and physical examination

                           Plan the initial therapy for paroxysmal atrial tachycardia

                           Recognize pericardial tamponade

                           Recognize prolonged QT syndrome in a patient with syncope

             3.      Abdomen

                           Recognize an acute "surgical abdomen"

                           Know the role of a CT scan in acute abdominal trauma

                           Plan the initial evaluation of a patient with probable splenic
                           rupture

XXXI.   Emergency Care

        A.   Fever

                           Know the differential diagnosis of fever without localizing signs in

                                                                                                  235
                  children of varying ages

                  Understand the correct methods for measuring body temperature

                  Plan the management of children of varying ages with a high fever:
                  local measures, medication, dosage

                  Understand the normal range of body temperature

B.   Seizures

                  Plan the initial therapy for status epilepticus

                  Recognize the correct loading doses for major anticonvulsants

C.   Wounds

     1.    General

                  Recognize the problem with a laceration through the vermilion border
                  of the lip

                  Understand the principles of wound cleansing

                  Evaluate a patient with a swollen foot and a fever after a puncture
                  wound through a sneaker

                  Know when to use immune globulins for tetanus prophylaxis

                  Know the clinical manifestations of puncture wounds (bites,
                  penetrating nail injuries) related to the time since the injury
                  occurred

                  Know the management of puncture wounds (bites, penetrating nail
                  injuries), including the consideration of surgical drainage

                  Know the sequelae of puncture wounds (bites, penetrating nail
                  injuries)

                  Understand the management and complications of lacerations

     2.    Bites and stings (see also III.D.4.)

           a.     Rabies protocol

                  Know what kinds of bites do not require rabies prophylaxis

                  Know what to do with the animal that bites a child

           b.     Dog, cat bite

                  Know the appropriate antibiotic therapy for dog or cat bites

                                                                                         236
          c.    Snake bite

                Plan the management of a snake bite

          d.    Spider bite

                Plan the management of a spider bite

          e.    Human bite

          f.    Insect sting

                Recognize life-threatening reactions to Hymenoptera stings
                (hypotension, wheezing, laryngeal edema)

                Know that immunotherapy with insect venom is 98% effective in
                preventing subsequent reactions

                Know that patients younger than 16 years of age who experience either
                large local reactions or generalized urticaria to insect stings
                do not require skin testing or desensitization to Hymenoptera

D.   Trauma

     1.   Abdominal trauma
     2.   Multisystem trauma

     3.   Head injuries

                Know the immediate life-threatening complications of closed-
                head trauma

                Recognize the usefulness and limitations of computed tomography
                (CT scan) in a patient with a closed-head injury and brief loss of
                consciousness

                Recognize that severe brain injury/trauma may be present in a
                patient who has no external signs of trauma

                Recognize the significance of ecchymoses in the orbital area

                Understand the significance of blood behind the tympanic membrane

                Assess the status of a patient with a head injury

                Recognize the signs of a progressive increase in intracranial
                pressure

                Know that an x-ray study of the skull may be negative in a patient
                with significant intracranial injury and may be positive in a
                patient without a significant intracranial injury

                                                                                        237
             Plan the outpatient management of minor head trauma

             Know that the Battle sign (postauricular bruise) indicates a basilar
             skull fracture

             Understand the value of retinal examination in a patient with seizures
             or in a coma

             Know that papilledema may not be present initially and may develop
             later in the course of intracranial hypertension

             Recognize the association of drug and alcohol use/abuse with head
             injury

             Know that temporal bone fractures are commonly manifested by
             bleeding from the external auditory canal or hemotympanum,
             hearing loss, facial paralysis, and cerebrospinal fluid otorrhea

             Know the signs and symptoms of closed head trauma

             Plan the initial management of a patient with acute CNS trauma

4.   Burns

             Plan outpatient treatment for minor burns

             Know the problems associated with electrical burns

             Distinguish between first-degree burns and more serious burns

             Plan initial therapy for a child with burns over a substantial
             portion of the body surface area

5.   Fractures, dislocations

     a.      Neurovascular states

             Know the bone and joint injuries that commonly affect vasculature,
             eg, supracondylar fracture of humerus

     b.      Specific problems (eg, spiral fracture, "nursemaid's"

             elbow)

             Identify a greenstick fracture

             Recognize the typical patient with subluxation of the radial head
             (nursemaid's elbow)

             Plan the treatment for subluxation of the radial head (nursemaid's
             elbow)

                                                                                      238
                         Recognize fracture of the clavicle and plan treatment

                         Recognize acromioclavicular separation in an athlete

                         Evaluate and stabilize a patient with a possible spinal cord injury

XXXII. Pharmacology

       A.    Pharmacodynamics

             1.   Absorption

                         Recognize which drugs should be taken with food or which should be
                         taken on an empty stomach

                         Recognize factors that influence bioequivalence of drugs (eg, brand
                         name vs generic drugs)

             2.   Hepatic drug metabolism

                         Recognize that certain drugs may alter the elimination and
                         half-life of many other drugs

                         Know that premature infants have slow elimination of caffeine
                         and theophylline, and that levels should be monitored

                         Recognize the drugs that stimulate hepatic drug metabolism
                         (phenobarbital, carbamazepine, phenytoin, rifampin)

                         Recognize the drugs that inhibit hepatic drug metabolism
                         (erythromycin, ciprofloxacin, cimetidine, omeprazole)

             3.   Renal excretion

                         Know that drug elimination rates in sick newborn infants
                         are highly unpredictable

                         Know that dosage requirements of renally excreted drugs such as
                         theophylline, digoxin, and aminoglycosides are highly unpredictable
                         in infants and that monitoring of drug concentrations is indicated

                         Understand the circumstances requiring adjustment of antibiotic
                         doses for newborn infants

                         Recognize that renal function demonstrates an age-dependent increase
                         in glomerular filtration rate, thus leading to the necessity for a
                         different dose of renally excreted drugs (eg, aminoglycosides,
                         penicillins, digoxin) in neonates

             4.   Half-life


                                                                                                239
                  Recognize that a much longer than average half-life for a given drug
                  can accumulate toxic levels at average doses

                  Know that four to five half-lives are required to reach a steady
                  state

     5.    Interpretation of drug concentration

                  Recognize nonadherence as the major factor when drug
                  concentrations or drug actions are highly variable in an adolescent

                  Know the importance of timing drug concentration measurement

                  Recognize the influence of drug metabolism, drug excretion, or route
                  administration on drug pharmacokinetics

     6.    Adverse drug reactions

                  Distinguish between dose-related and idiosyncratic drug effects

                  Know that a drug allergy and rash may be idiosyncratic reactions

                  Understand the role of reporting adverse drug reactions to the FDA

     7.    Drug interactions

                  Know that concomitant administration of certain drugs can alter
                  concentrations of other drugs in the patient's regimen

                  Understand the potential for interactions between drugs and
                  alternative therapies (eg, herbs)

B.   Specific drugs

     1.    Antibiotics

                  Recognize serum sickness reaction to an antibiotic

                  Recognize the risk of hypersensitivity reactions to an antibiotic

                  Recognize the risk of ototoxicity or nephrotoxicity when
                  vancomycin or an aminoglycoside is administered

     2.    Diuretics

                  Recognize ototoxicity and nephrotoxicity as potential adverse
                  dose-related effects of furosemide

                  Understand the long-term complications of furosemide therapy

     3.    Corticosteroids


                                                                                         240
                Know the risks and how to manage a patient who has received long-
                term corticosteroids and requires surgery

                Know the special management needs of chronically corticosteroid-
                dependent children with respect to stress, surgery, and varicella
                infection

                Know the special risks for chronically corticosteroid-dependent
                children (eg, growth retardation, pathologic fractures,
                immunosuppression, cataracts, diabetes)

     4.   Immunosuppressants

                Recognize the long-term risks of chronic immunosuppression

     5.   Antihistamines

     6.   Beta-blocking drugs

                Recognize common side effects of beta-blocking drugs

     7.   Anti-inflammatory drugs

                Recognize the risks associated with the use of aspirin

                Recognize the risks associated with the use of nonsteroidal anti-
                inflammatory drugs

     8.   H2-blocking drugs

     9.   Beta-agonists

C.   Pain management

     1.   Minimal sedation (anxiolytic)

     2.   Moderate sedation

                Understand the definition of procedural sedation as opposed to
                deep sedation and general anesthesia

                Understand what level of observation and monitoring is recommended
                for a patient undergoing procedural sedation

                Recognize side effects and signs and symptoms of an overdosage
                of commonly prescribed sedatives, and manage appropriately

                Understand the indications and contraindications for moderate
                sedation

                Understand there should be an appropriate interval of fasting
                before moderate sedation

                                                                                     241
               3.     Sedative analgesia (eg, opioids, nitrous oxide, ketamine)

               4.     Non-pharmacologic techniques (eg, biofeedback, hypnosis,

                      distraction)

XXXIII. Research and Statistics

        A.     Study design

                               Understand the validity hierarchy for study design and study type

                               Understand the uses and limitations of randomized clinical trials

                               Understand the uses and limitations of controlled clinical trials

                               Understand the uses and limitations of cohort studies

                               Understand the uses and limitations of case-control studies

                               Understand the uses and limitations of cross-sectional and
                               longitudinal studies

                               Understand the uses and limitations of systematic review and
                               meta-analysis

                               Understand the uses and limitations of descriptive epidemiologic
                               studies

                               Understand the uses and limitations of case reports/series and
                               anecdotal evidence

                               Understand how sample size affects the power of a study

                               Understand how sample size may limit the ability to detect adverse
                               events

                               Identify the study design most likely to yield valid information
                               about the accuracy of a diagnostic test

                               Identify the study design most likely to yield valid information
                               about the benefits and/or harms of an intervention

                               Identify the study design most likely to yield valid information
                               about the prognosis of a condition

        B.     Data analysis

                               Understand validity and how it might be compromised

                               Understand reliability and how it might be compromised

                                                                                                    242
                            Understand bias and how it might distort the estimate of the
                            association between exposure and outcome

                            Understand confounding and how to control for it in a study

                            Understand generalizability and how it relates to validity

                            Understand the concept of intention-to treat analysis to maintain
                            the power of a study

                            Understand the concept of number-needed-to-treat when utilized
                            to describe therapeutic interventions

                            Distinguish between type I and type II statistical errors

                            Assess how the data source (eg, diaries, billing data, discharge
                            diagnostic code) may affect study results

        C.     Reading and interpreting results

                            Understand prevalence and incidence

                            Understand pre-test and post-test probability

                            Understand positive and negative predictive values

                            Understand sensitivity and specificity and how to apply them
                            to test results

                            Understand standard deviation in the interpretation of results

                            Understand standard error in the interpretation of results

                            Understand confidence interval in the interpretation of results

                            Understand likelihood ratio and when it might be useful to reach
                            a diagnosis

                            Understand relative risk analysis and odds ratio

                            Distinguish statistical significance from clinical importance

                            Given the need for specific clinical information, identify a clear,
                            structured, searchable clinical question

XXXIV. Ethics for Primary Pediatricians

        A.     Autonomy, beneficence, and rights

               1.    Critical care, end of life, and limitations on medical


                                                                                                  243
     intervention

     a.     Decisions to withdraw/withhold life-sustaining medical

            intervention

            Recognize and apply ethical decision-making when caring for
            critically ill patients

            Recognize and apply ethical principles when involved in end-of-life
            care

            Recognize and apply ethical principles with regard to limitations
            on medical intervention

     b.     Decisions to withdraw/withhold artificial

            hydration/nutrition

            Recognize and apply ethical principles when involved in decisions
            to withdraw/withhold artificial hydration/nutrition

     c.     Cardiopulmonary resuscitation and "do not resuscitate"

            (DNR) orders

            Recognize and apply ethical principles involving cardiopulmonary
            resuscitation and "do not resuscitate" (DNR) orders

     d.     Futility

            Recognize and apply ethical principles regarding the issue of
            medical futility
     e.     Persistent vegetative state

            Recognize and apply ethical principles when caring for a patient
            who is in a persistent vegetative state

     f.     Palliative care and pain management

            Recognize and apply ethical principles involving palliative care
            and pain management

     g.     Physician-assisted suicide and euthanasia

            Recognize and apply ethical principles involving physician-assisted
            suicide and euthanasia

2.   Maternal/fetal conflicts

            Recognize and apply ethical principles when dealing with a
            situation that involves maternal/fetal conflicts

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     3.     Patient-parent-pediatrician relationship

           a.      Obligations: veracity, fidelity, and confidentiality

                   Recognize and apply ethical principles involved in the patient-
                   parent-pediatrician relationship regarding issues of veracity

                   Recognize and apply ethical principles involved in the patient-
                   parent-pediatrician relationship regarding issues of fidelity

                   Recognize and apply ethical principles involved in the patient-
                   parent-pediatrician relationship regarding issues of confidentiality

           b.      Informed consent/dissent/assent

                   Recognize and apply ethical principles involved in the patient-
                   parent-pediatrician relationship regarding issues of informed
                   consent/dissent/assent

                   Understand the difference between informed consent and assent

           c.      Minors as decision-makers

                   Recognize and apply ethical principles involved in the patient-
                   parent-pediatrician relationship regarding minors as decision-makers

                   Understand when it is appropriate to have a minor involved in
                   making decisions about his or her medical care

           d.      Advance care planning/directives

                   Recognize and apply ethical principles involved in the patient-
                   parent-pediatrician relationship regarding advance care planning
                   Understand the use of advance directives in pediatrics

           e.      Religious (philosophical) exemptions

                   Recognize and apply ethical principles involved in the patient-
                   parent-pediatrician relationship regarding religious (philosophical)
                   exemptions for medical treatment/immunizations

B.   Ethics and the use of technology

     1.     New technology

           a.      Genetics

                   Recognize and apply ethical principles involved in use of
                   technology for genetic studies in genetics counseling

           b.      Cochlear implants
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                   Recognize and apply ethical principles involved in use of
                   cochlear implants

            c.     Sex/gender assignment

                   Recognize and apply ethical principles involved in sex/gender
                   assignment

     2.     Imperiled newborn infants

            a.     Delivery room resuscitation issues

                   Recognize and apply ethical principles regarding imperiled newborn
                   infants and delivery room resuscitation issues

            b.     In the neonatal intensive care unit

                   Recognize and apply ethical principles involved in decision making
                   for imperiled newborn infants in the neonatal intensive care unit

     3.     Organ transplantation and donation

                   Recognize and apply ethical principles involved in decisions
                   regarding organ transplantation and donation

     4.     Enhancement therapies

            a.     General considerations

                   Recognize and apply ethical principles involved in deciding when
                   to use enhancement therapies

            b.     Growth hormone

                   Recognize and apply ethical principles involved in determining
                   when the use of growth hormone therapy is appropriate (eg, in
                   consultation with a pediatric endocrinologist)

            c.     Performance enhancement

                   Recognize and apply ethical principles involved in use of
                   technology for performance enhancement therapies

C.   Allocation of health care resources

     1.     Just allocation of health care

                   Recognize and apply ethical principles regarding the just
                   allocation of health care resources

     2.     Managed care issues
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                   Recognize and apply ethical principles involved in managed
                   care issues

D.   Professionalism and institutional ethics

     1.     Cross-cultural issues

                   Recognize and apply ethical principles involved in professionalism
                   and institutional ethics relative to cross-cultural issues

     2.     Institutional ethics committees

                   Recognize and apply ethical principles regarding institutional
                   ethics committees

     3.     Professionalism

            a.     General issues

                   Understand the ethical principles that uphold professionalism
                   and institutional ethics

            b.     Gifts

                   Recognize and apply ethical principles regarding professionalism
                   and institutional ethics in the giving and receiving of gifts

            c.     Errors and malpractice

                   Recognize and apply ethical principles regarding medical errors

                   Recognize and apply ethical principles regarding malpractice

            d.     Conflicts of interest

                   Recognize and apply ethical principles regarding conflicts of
                   interest

            e.     Medical testimony and expert witness

                   Recognize and apply ethical principles regarding medical
                   testimony and being an expert witness

            f.     Physicians who may present a risk to patients

                   Recognize and apply ethical principles regarding physicians who
                   may present a risk to patients

     4.     Research and children

                   Recognize and apply ethical principles regarding research

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                  involving children

E.   Special medical circumstances

     1.    Brain death

                  Recognize and apply ethical principles surrounding the issue of
                  brain death

     2.    Care of patients with disabilities

                  Recognize and apply ethical principles regarding the care of
                  children and adolescents with disabilities

     3.    Children with AIDS/HIV infection

                  Recognize and apply ethical principles regarding the care of
                  children and adolescents with AIDS/HIV infection

     4.    Violence and child abuse

           a.     Intimate-partner violence

                  Recognize and apply ethical principles regarding the issue of
                  intimate-partner violence

                  Recognize and apply ethical principles regarding the issues of
                  physical and mental abuse

           b.     Violence in society

                  Recognize and apply ethical principles regarding violence in
                  society

           c.     Child abuse

                  Recognize and apply ethical principles regarding child abuse
                  (eg, confidentiality, reporting)

     5.    Complementary and alternative medicine

                  Recognize and apply ethical principles regarding the use of
                  complementary and alternative medicine

     6.    Children in foster care

                  Recognize and apply ethical principles regarding children in
                  foster care

F.   Education, training, and evaluation

     1.    Curriculum resources
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                            Identify curriculum resources for professional ethics in education,
                            training, and evaluation

              2.     Evaluation tools

                            Identify evaluation tools for professional ethics with regard to
                            the education, training, and evaluation of pediatric residents

XXXV. Patient Safety and Quality Improvement

        A.    Definitions used in discussions of patient safety

                            Understand and apply the definition of a medical error

                            Understand and apply the definition of a near-miss event

                            Understand and apply the definition of a sentinel event

                            Understand and apply the definition of a preventable adverse event

                            Understand and apply the definition of a non-preventable adverse
                            event

        B.    Epidemiology of medical error and harm

                            Understand the contribution of adverse events to the morbidity
                            and mortality of pediatric patients

                            Understand the contribution of adverse events to the cost of
                            medical care

                            Recognize the common causes of adverse events in pediatric patients

                            Identify situations presenting high risk for adverse events in the
                            management of pediatric patients

        C.    Detecting and reporting adverse events
                            Understand the relationship between the detection of a medical
                            error and the ability to discover and effect improvements
                            6399.CC RC                   Identify barriers to reporting adverse events

                            Apply effective strategies to improve reporting of adverse events

                            Apply voluntary systems for reporting of adverse medical events

                            Recognize the use of National Patient Safety Goals to improve
                            patient safety

        D.    Disclosure of medical errors

                            Use appropriate means to disclose medical errors to patients

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                     Apply appropriate methods of support for patients and their
                     families after an error producing medical harm occurs

                     Use appropriate methods of support for physicians and other health-
                     care providers after an error producing medical harm occurs

E.   Methods to reduce medical adverse events

                     Recognize the relative role of systems and individuals in producing
                     medical error and harm

                     Understand and apply root cause analysis to determine the factors
                     contributing to an error

                     Anticipate system vulnerabilities by applying failure mode
                     effects analysis

                     Understand and apply evidence-based interventions to reduce medical
                     adverse events

                     Use best-practice guidelines to reduce medical adverse events

                     Use effective methods of communication to reduce errors in the
                     health-care setting

                     Recognize what interventions can reduce error in situations (eg,
                     stress, fatigue, distraction) at high risk for medical error

                     Understand and apply methodologies to prevent medication errors

                     Understand the role of ancillary services such as the pharmacy
                     in the prevention of medication errors

                     Understand the role of computerized order entry and dose-range
                     checking in reducing medication errors

                     Understand the impact of product naming and packaging on
                     medication safety
                     Understand the role of medical device design in prevention of
                     medical error

                     Understand the contribution of patient factors to adverse events

                     Understand the role of patients and their families in reducing
                     adverse events

F.   Principles of quality improvement applied to improving patient

     safety

     1.       Key principles of patient safety
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           Understand the importance of leadership in creating a culture of
           safety in the health-care system

           Apply knowledge of human factors in the design of systems and
           processes promoting patient safety

           Promote effective team functioning in the prevention of medical
           error

           Understand the importance of assessment and redesign of health-
           care processes before error occurs

           Understand the importance of creating and maintaining a learning
           environment (eg, morning report, meetings with partners) in
           improving patient safety

2.   Core principles of quality improvement

           Understand what a system is (eg, people, procedures, equipment)
           and how each component of that system affects outcome

           Recognize that analysis of variation in data is critical in
           quality improvement to understand whether the variation is
           actually improvement

           Understand that quality improvement is based on applying a
           scientific method to improving human systems

           Apply the psychology of change (eg, motivating people to improve)
           to improve health-care systems

           Recognize that quality improvement requires looking at data or
           processes (ie, trends) over time

           Identify the components of the Langley Model for Improvement: Plan-
           Do-Study-Act

                                                                              Last Revised July 2010




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