AMBULATORY The Student should become familiar with and be able to discuss the management of the following pediatric problems: 1. Care of the healthy infant and his minor ills. a) well-baby care A healthy infant usually sees the doctor when his newborn, 1 week post- discharge, 1, 2, 4, 6, 9, 12, 15, 18, and 24 months. This evaluation involves the physician, the parents, and the child. Historical information is often taken from the parents, and it is not until children reach later developmental stages that they can more actively contribute information about symptoms. The types of information gathered at these appointments are: Pregnancy and neonatal history; Feeding habits and changes to the diet has the infant grows; Immunization (see b); Developmental assessment; Growth, energy, appetite, sleep and review of systems; Past medical history, medications, allergies, family history and social history. The examination must include: Growth parameters: serial height, weight, and head circumference; Head, eye, nose and throat (HEENT): looking for dysmorphic features, fontanelles closure (anterior closure between 9-18 months, posterior between 2-4 months), vision, red reflex, verify for strabismus, hearing, tympanic membranes, palate CVS: auscultation, peripheral pulses (including femorals), blood pressure only if indicated before the age of 3 (after 3 yearly). Respiratory, abdomen, genitourinary, dermatology (as in adults) MSK: hip (Barlow and Ortolani tests), scoliosis, lumbosacral spine (look for hairy patch, pigmentation, sinus tract) Neurological: primitive reflex in newborns and in early infancy. Finally there is time for counseling/anticipatory guidance regarding nutrition, syndromes like sudden infant death syndrome and injury prevention study. Reference: Behrman: Nelson Textbook of Pediatrics, 17th ed. and MCCQE 2002 b) immunization National Advisory Committee on Immunization (NACI) Recommended Immunization Schedule for Infants, Children and Youth March 16, 2005 Age at DTaP Pneu- Men- Hib MMR Var Hep B dTap Flu vaccination -IPV C C Birth Infancy 2 months 3 doses 4 months 6 months or 6-23 months if not 12 months or 12-15 yet 1-2 months given doses 18 months Pre- or teen/ 4-6 years teen 2-3 doses if not if not 14-16 years yet yet given given DTaP- Diphtheria, Tetanus, acellular Pertussis, and inactivated IPV Polio virus vaccine Hib Haemophilus influenzae type b conjugate vaccine MMR Measles, Mumps and Rubella vaccine Var Varicella vaccine Hep B Hepatitis B vaccine Pneu-C Pneumococcal conjugate vaccine Men-C Meningococcal C conjugate vaccine Diphtheria, Tetanus, acellular Pertussis vaccine (adult dTap formulation) Flu Influenza Vaccine Diphtheria, Tetanus, acellular Pertussis and inactivated Polio virus vaccine (DTaP-IPV): DTaP-IPV vaccine is the preferred vaccine for all doses in the vaccination series, including completion of the series in children who have received ≥ 1 dose of DPT (whole cell) vaccine (e.g., recent immigrants). Haemophilus influenzae type b conjugate vaccine (Hib): Hib schedule shown is for the haemophilus b capsular polysaccharide – PRP conjugated to tetatus toxoid (Act-HIBTM) or the Haemophilus b oligosaccharide conjugate - HbOC (HibTITERTM) vaccines. Measles, Mumps and Rubella vaccine (MMR): A second dose of MMR is recommended, at least 1 month after the first dose for the purpose of better measles protection. For convenience, options include giving it with the next scheduled vaccination at 18 months of age or at school entry (4-6 years) (depending on the provincial/territorial policy), or at any intervening age that is practical. The need for a second dose of mumps and rubella vaccine is not established but may benefit (given for convenience as MMR). The second dose of MMR should be given at the same visit as DTaP-IPV (± Hib) to ensure high uptake rates. Varicella vaccine (Var): Children aged 12 months to 12 years should receive one dose of varicella vaccine. Individuals ≥ 13 years of age should receive two doses at least 28 days apart. Hepatitis B vaccine (Hep B): Hepatitis B vaccine can be routinely given to infants or preadolescents, depending on the provincial/territorial policy. For infants born to chronic carrier mothers, the first dose should be given at birth (with hepatitis B immunoglobulin), otherwise the first dose can be given at 2 months of age to fit more conveniently with other routine infant immunization visits. The second dose should be administered at least 1 month after the first dose, and the third at least 2 months after the second dose, but again may fit more conveniently into the 4 and 6 month immunization visits. A two-dose schedule for adolescents is an option (see chapter on hepatitis B vaccine). Pneumococcal conjugate vaccine - 7-valent (Pneu-C): Recommended schedule, number of doses and subsequent use of 23 valent polysaccharide pneumococcal vaccine depend on the age of the child when vaccination is begun (see chapter on pneumococcal vaccines). Meningococcal C conjugate vaccine (Men-C): Recommended schedule and number of doses of meningococcal vaccine depends on the age of the child (see chapter on meningococcal vaccines). If the provincial/territorial policy is to give Men-C after 12 months of age, 1 dose is sufficient. Diphtheria, Tetanus, acellular Pertussis vaccine - adult/adolescent formulation (dTap): a combined adsorbed "adult type" preparation for use in people ≥ 7 years of age, contains less diphtheria toxoid and pertussis antigens than preparations given to younger children and is less likely to cause reactions in older people. Influenza vaccine (Flu): Previously unvaccinated children in the 6-23 month age group require 2 doses with an interval of at least 4 weeks. The second dose is not required if the child has received one or more doses of influenza vaccine during the previous immunization season (see chapter on influenza vaccine). Reference: Public Health Agency of Canada c) colic How to tell your infant has colic, rule of 3’s: unexplained paroxysms of irritability and crying for more than 3 hour/day and more than 3 day/week for more than 3 weeks in an otherwise healthy, well fed baby. It occurs in 10% of infants. The infant age span is 10 days to 3 months (peak 6-8 weeks). Etiology: Generally regarded as a lag in the development of normal peristaltic movement in GI tract; Other theories suggest a lack of self-soothing mechanisms. Sing: infant cries, pulls up legs and passes gas soon after feeding. Ddx: Wet diaper; Hunger or gas pains; Too hot or too cold; Overstimulated; Need to suck or be held. Management: Parental relief, rest and reassurance. Hold baby, soother, car ride, music, vacuum, check diaper. Possible medications: Ovol drops, gripe water. But they are of no proven benefits. If breast feeding, elimination of cow’s milk proteins in the mother’s diet (effective in a very small percentage of cases). Try casein hydrosylates formula (Neutramigen) Reference: MCCQE 2002 d) night-time Eliminating Nighttime Crying (Trained Night Crier) (For babies over 4 crying months old) When should my baby be able to sleep through the night? From birth to the age of 2 months, most babies awaken twice each night for feedings. Between the ages of 2 and 3 months, most babies need one feeding in the middle of the night. By 4 months of age, most bottle-fed babies sleep more than 7 hours without feeding. Most breast-fed babies can sleep through the night by 5 months of age. Normal children of this age do not need calories during the night and are capable of sleeping through the night without being rocked or held in the middle of the night. Why does my baby wake up crying at night? Some common reasons babies over 4 months old wake up crying at night include: • Holding or rocking your baby until asleep. All children normally wake up 4 or 5 times each night after dreams. Because they usually do not wake up fully at these times, most children can get back to sleep by themselves. However, children who have not learned how to comfort and quiet themselves cry for a parent. If your custom at naps and bedtime is to hold, rock, or lie down with your baby until asleep, your child will not learn how to go back to sleep without your help. Babies who are not usually placed in their cribs while they are still awake expect their mothers to help them go back to sleep when they wake up at night. Because they usually fall asleep away from their cribs, they don't learn to associate the crib and mattress with sleep. This is called poor sleep-onset association. • Providing entertainment during the night. Children may awaken and cry more frequently if they realize they gain from it; for example, if they are walked, rocked, or played with, or enjoy other lengthy contact with their parents. Being brought to the parents' bed makes the problem far worse. Crying at night can also begin after situations that required the parents to give more nighttime attention to their baby for a while. Examples of such problems are colds, discomfort during hot summer nights, or traveling. Many babies quickly settle back into their previous sleep patterns after such situations. However, some enjoy the nighttime contact so much that they begin to demand it. • Believing any crying is harmful. All young children cry when confronted with a change in their schedule or environment (called normal protest crying). Crying is their only way to communicate before they are able to talk. Crying for brief periods is not physically or psychologically harmful. The thousands of hours of attention and affection you have given your child will easily offset any unhappiness that may result from changing a bad sleep pattern. How long does it last? If you try the following recommendations, your child's behavior will probably improve in 2 weeks. The older your child is, the harder it will be to change your child's habits. Children over 1 year old will fight sleep even when they are tired. They will vigorously protest any change and may cry for hours. However, if you don't take these steps, your child won't start sleeping through the night until 3 or 4 years of age, when busy daytime schedules finally exhaust your child. How can I help my child sleep? Try the following suggestions if your baby is over 4 months old and wakes up crying one or more times in the night. 1. Place your baby in the crib drowsy but awake for naps and bedtime. It's good to hold babies and to provide pleasant bedtime rituals. However, when your baby starts to look drowsy, place him in the crib. Your child's last waking memory needs to be of the crib and mattress, not of you. If your baby is very fussy, rock him until he settles down or is almost asleep, but stop before he's fully asleep. He needs to learn to put himself to sleep. Your baby needs to develop this skill so he can put himself back to sleep when he normally wakes up at night. 2. If your baby is crying at bedtime or naptime, visit your baby briefly every 5 to 15 minutes. Visit your baby before she becomes too upset. You may need to check younger or more sensitive babies every 5 minutes. You be the judge. Gradually lengthen the time between your visits. Babies cannot learn how to comfort themselves without some crying. This crying is not harmful. If your child is fearful, hold him until he calms down. Then temporarily sit or lie down in his bedroom until he settles down. Try to leave before he falls asleep. 3. Make the visits brief and boring but supportive. Don't stay in your child's room longer than 1 minute. Don't turn on the lights. Keep the visit supportive and reassuring. Act sleepy. Whisper, "Shhh, everyone's sleeping." Add something positive, such as "You're a wonderful baby," or "You're almost asleep." Never show your anger or punish your baby during these visits. If you hug him, he probably won't let go. Touch your baby gently and help him find his security object, such as a doll, stuffed animal, or blanket. 4. Do not remove your child from the crib. Once you put your child in the crib, do not remove him. Do not rock or play with your baby or bring her to your bed. Brief contact will not reward your baby enough for her to want to continue the behavior. Most young babies cry 30 to 90 minutes and then fall asleep. 5. For crying during the middle of the night, temporarily hold your baby until he is asleep. Until your child learns how to put himself to sleep at naps and bedtime, make the middle-of-the-night awakenings as easy as possible for everyone. If he doesn't fuss for more than 5 or 10 minutes, respond as you do at bedtime. Otherwise, take your crying child out of the crib and hold him until he is asleep. Don't turn on the lights or take him out of the room. Try not to talk to him very much. Often this goes better if Dad goes in. 6. Help your child attach to a security object. A security (transitional) object is something that helps a waking child go to sleep. It comforts your child and helps your child separate from you. A cuddly stuffed animal, doll, other soft toy, or blanket can be a good security object. Sometimes covering a stuffed animal with one of the mother's T-shirts helps a child accept it. Include the security object whenever you cuddle or rock your child during the day. Also include it in your ritual before bedtime by weaving it into your storytelling. Tuck it into the crib next to your child. Eventually, your child will hold and cuddle the stuffed animal or doll at bedtime in place of you. 7. Later, phase out the nighttime holding. Phase out nighttime holding only after your child has learned to quiet herself and put herself to sleep for naps and at bedtime. Then you can expect her to put herself back to sleep during normal middle-of-the-night awakenings. Go to her every 15 minutes while she is crying, but make your visits brief and boring. After your child learns to put herself to sleep at bedtime, awakening with crying usually stops in a few nights. 8. Other helpful hints for sleep problems. • Move the crib to another room. If the crib is in your bedroom, move it to a separate room. If this is impossible, cover one of the side rails with a blanket so your baby can't see you when he wakes up. • Avoid long naps during the day. If your baby has napped for more than 2 hours, wake her up. If she has the habit of taking three naps during the day, try to change her habit to two naps each day. • Don’t changes wet diapers during the night. Change the diaper only if it is soiled or you are treating a bad diaper rash. If you must change your child's diaper, use as little light as possible (for example, a flashlight), do it quickly, and don't provide any entertainment. • Leave your child standing in the crib, if necessary. If your child is standing up in the crib at bedtime, try to get your child to settle down and lie down. If he refuses or pulls himself back up, leave him that way. He can lie down without your help. Encouraging your child to lie down can soon become a game. 9. Keep a sleep diary. Keep a record of when your baby is awake and asleep. Bring it with you to your office follow-up visit. Reference: MDConsult 2. Gastrointestinal system and nutrition a) vomiting and Causes of vomiting in newborns: regurgitation Tracheoesophageal fistula (TEF) o Clinical features: vary with type of fistula. May have hx of maternal polyhydramnios Vomiting, coughing and gagging Cyanosis with feeds, respiratory distress Frothy bubbles of mucus in mouth and nose that return after suctioning Associated anomalies in 50%; VACTERL (Vertebral anomalies; imperforate Anus, Cardiac abnormalities, TracheoEsophageal fistula, Radial and Renal dysplasia and Limb deformity) o Management: Investigate for other congenital anomalies Early repair to prevent lung damage and maintain nutrition. Duodenal Atresia: o Clinical features: Bile-stained vomiting if atresia distal to bile duct Peristaltic waves; no abd. distention Dehydration Associated with Down Syndrome or hx of maternal polyhydramnios o Tx: Decompression with NG tube Correction of metabolic abnormalities Surgical correction Pyloric stenosis: o Clinical features: Non-bilious projectile vomiting that occurs after feeding Usually starts at 2-6 weeks of age Infant hungry and alert, will re-feed FTT (failure to thrive), wasting Dehydration, may lead to prolonged jaundice Gastric peristalsis goes from left upper quadrant (LUQ) to epigastrium Olive sign: olive shaped mass at margin of right rectus absominis muscle Hypochloremic metabolic alkalosis o Tx: Surgical (pyloromyotomy) Malrotation of the intestine: o 3 presentations: Recurrent vomiting (bilious intermittently) FTT with vomiting Sudden onset abdominal pain and then shock (if vomiting with bilious material, malrotation with volvulus until proven otherwise) o Clinical features: Distended abd Vomiting due to volvulus and bands across duodenum o Tx: Surgical Vomiting after newborn: Infections: gastroenteritis, peritonitis, appendicits, hepatitis, ulcers, pancreatitis (all GI). UTI, otitis media, CNS infection (all non-GI). Anatomic: obstructions (intussusception, foreign body, GER) Gastroesophageal reflux: o Clinical features: FTT, recurrent cough, pneumonia or bronchospasm, GI blood loss. o Management: Conservative: thickened feeds, elevate bed to 45o Medical: short-terme enteral feeding to enhance weight gain Dugs: Ranitidin, Omeprazole: to decrease gastric acidity, devrease esophageal irritation or esophagitis. Domperidone: to improve gastric emptying and GI mobility Surgical: indicated for failure of medical therapy (Nissen fundoplication) CNS: o Increased intracranial pressure (ICP) (hydrocephalus, neoplasm) o Drugs/intoxicants o Migraine, meningitis, encephalitis Other: o Metabolic/endocrine: DKA, inborn errors of metabolism, liver failure o Poisons/drugs: lead, digoxin, erythromycin, theophylline o Psychogenic: rumination syndrome, anorexia/bulimia, cyclic vomiting o Food allergy or overfeeding Hx: age of onset, duration, severity quality: bilious, bloody, regurgitation associated sx (fever, abd pain, bowel movements, headaches) effect on growth and development, concurrent disease Physical Exam: tenderness, abdominal distention, masses assess hydration Investigations based on hx and physical exam: bloody emesis: investigate for causes of upper GI bleed bilious emesis: rule out obstruction (upper GI series, U/S) regurgitation: evaluate for reflux (barium swallow with fluoroscopy, 24 hours esophageal pH probe) CBC, lytes, BUN, creatinine, ESR, venous blood gases Urine, blood, and stool culture and sensitivity Amylase, lipase Abd x-ray, U/S, contrast radiology, endoscopy Management: Treat underlying cause and rehydration Reference: MCCQE b) diarrhea Acute diarrhea: Causes: Viral infection: Rotavirus o Slight fever, malaise, vomiting, vague abd pain o Resolves in 3-7 days Bacterial infection: Salmonella, Campylobacter, Shigella, pathogenic E. coli., Yersinia. o More severe abd pain, high fever, bloody diarrhea Parasitic infection: Giardia lamblia, Eentameoba histolytica. Toxin-induced: staphylococcal food poisoning, C. difficile toxin. Allergic: food intolerance Antibiotic induced Non-specific: associated with any non-GI infection, generalized sepsis or shock. Investigations: Hx and physical exam critical to determine degree of dehydration Rectal exam for fecal consistency and for microscopy (leukocytes) Stool for culture and sensitivity, ova and parasites, electron microscopy for viruses If severe: routine blood work, blood and urine cultures. Management: Prevention and treatment of dehydration is most important Replacement of fluid deficits + maintenance + ongoing losses Antibiotic therapy when indicated Oral rehydration therapy with frequent small volumes of pediatric oral rehydration solutions IV may be required for severe dehydration Early refeeding advisable Antidiarrheal medications not indicated. Chronic diarrhea (diarrhea more than 14 days): Without failure to thrive: Infections: bacterial, antibiotic-induced, parasitic, post-infectious (secondary lactase deficiency) Toddler’s diarrhea: most common cause o Dx of exclusion o Onset between 6-36 months of age, ceases spontaneously between 2-4 years o Diet hx: too much juice overwhelms small bowel resulting in disaccharide malabsorption o Stool may contain undigested food particules, 4-6 bowel movements per day o Excoriated diaper rash o Management: reassurance, self-limiting and 4 F’s (adequate fiber, normal fluid intake, 35-40% fat, discourage excess fruit juice) Lactase deficiency (lactose intolerance) o Clinical features Chronic watery diarrhea Abd pain, bloating, borborygmi o 2 scenarios: Primary lactose intolerance: crampy abd pain with loose stools Secondary lactose intolerance: older infant, persistent diarrhea. o Dx: Clinical trial off milk, or lactose free milk Watery stool, acid pH, positive reducing sugars Positive breath hydrogen test if over 6 years o Management: Lactose-free diet, soy formula Lacteeze, lactaid tabs/drops With failure to thrive: Intestinal causes: Celiac disease: o Clinical features: Presents at any age, usually 6-18 months FTT with poor appetite, irritability, apathy Anorexia, nausea, vomiting, edema Wasted muscles, distended abd and flat buttocks Anemia, bleeding, rickets, clubbing of fingers o Dx: Fat malabsorption studies, small bowel biopsy Antigliadin, antiendomysial antibodies, low D- xylose absorption o Tx: Gluten-free diet for life Avoid BROW (barley, rye, oats, wheat) Milk protein allergy: o Can be associated with anemia, hypoalbuminemia, edema o Often in atopic individuals o 2 scenarios: Enterocolitis – vomiting, diarrhea, anemia, hematochezia Enteropathy – chronic diarrhea, hypoalbuminemia o Tx: casein hydrosylate formula. Inflammatory bowel disease (same as in adults) Other: o Specific enzyme, deficiencies o Liver disease, biliary atresia o α-β-lipoproteinemia o Short gut toxic or immunologic reaction o Bind loop syndrome o Giardia lamblia Pancreatic insufficiency: Cystic fibrosis. Schwachman-Diamond syndrome: o Pancreatic insufficiency, cyclic neutropenia, and anemia o Skeletal abnormalities o Recurrent pyogenic infections (acute otitis media, pneumonia, osteomyelitis) Others: Diets rich in sorbitol, fructose (poorly absorbed carbohydrates) Metabolic/endocrine: o Thyrotoxicosis, Addison disease o Galactosemia Immune defects: IgA deficiency, hypogammaglobulinemia, severe combined immunodeficiency (SCID), AIDS Neoplastic: o Pheochromocytoma o Lymphoma of small bowel Food allergy. Reference: MCCQE c) abdominal Acute abd pain: pain and constipation Important hx: accurate description of pain and its characteristics (lmnopqrst) is there vomiting before pain (gastroenteritis) is there vomiting after pain (surgical condition) Physical exam: rebound tenderness, bowel sounds, rectal exam Investigation: labs: CBC and differential urinalysis to rule out UTI Ddx: gastroenteritis incarcerated hernia UTI Appendicitis o Most common bowel disorder after the age of 5 year old o Clinical features: Low grade fever Anorexia Nausea/vomiting (after onset of pain) Abd pain (periumbilical – RLQ), peritoneal signs Generalized peritonitis is a common presentation in infants/young children o Tx: Surgical Intussusception o 50% between 3 – 12 months, 75% before 2 years of age. o Telescoping of segment of bowel into distal segment – causing ischemia and necrosis o Usual site – ileocecal junction o Clinical features: Classic triad = abd pain, palpable sausage-shaped mass (upper to mid abd), ans red currant jelly stools (only 10 – 15% of patients) Sudden onset of recurrent, paroxysmal, severe periumbilical pain Pain-free remissions Later vomiting and rectal bleeding Shock and dehydration o Dx and Tx: U/S Air enema we see the reverse E sign and it reduces the intussusception. Reduction under hydrostatic pressure Surgery rarely needed. Malrotation Volvulus Henoch-Schönlein Purpura (HSP) Sickle cell crisis Pneumonia DKA Mesenteric adenitis Meckle’s diverticulum Chronic abd pain: Definition = 3 episodes of pain severe enough to affect activities, occurring in a child less than 3 years of age over a period of 3 months. Important hx: Weight loss, appetite, energy, fever Associated vomiting, diarrhea, constipation Characteristics of pain Psychosocial issues Physical exam: Abnormalities suggesting a organic nature vs non organic. Red flags for organic: < 5 years old, pain away from midline, localized pain awakens child at night, prominent vomiting & diarrhea, joint pain, rectal bleed, fever, anemia, travel history, weight loss or failure to gain weight, rash Organic causes (less than 10%): Chronic infection Gastrointestinal o Constipation o IBD, esophagitis, peptic ulcer disease, lactose intolerance o Anatomic anomalies, masses o Pancreatic, hepatobiliary Genitourinary disease Gynecological Cardiovascular Neoplastic Functional/Recurrent abd pain (90%): School age, peak 8-10 yrs Characteristics: Vague, crampy periumbilical or epigastric pain, vivid imagery to describe pain, clustering of episodes. Seldom awakens child from sleep Aggravated by exercise, alleviated by rest School avoidance Psychological factors related to onset and/or maintenance of pain Absence of organic illness. Psychiatric comorbidity: Anxiety, somatoform disorder, elimination disorder, mood, learning disorder, sexual abuse, eating disorder Dx: Exclude organic disorder Consider school phobia Tx: Continue attending school Manage any emotional or family problem Trial of high fiber diet, trial of lactose-free diet Reassurance Constipation -20% of children less than 5 yo., most often diet-related with no specific disease. Hx: Age of onset, dietary hx Associated symptoms (abd pain, encopresis, overflow diarrhea) Physical exam: Examine lower back for evidence of occult cord lesion (neural tube defect), Abd exam, rectal exam. Functional constipation: 99% of cases of constipation There is a lack of bulk or fiber in diet or change in diet. There can also be poor fluid intake. In infants it often occurs when introducing cow’s milk after breast milk. In toddlers and older children it can occur during toilet training, or due to pain on defecation, stool withholding. Complication: Pain retention cycle: anal fissures and pain → withholding passing stool → chronic dilatation and overflow incontinence (encopresis) Tx: Adequate fluid intake (if < 6 months, 150 ml/kg/day) Adequate dietary fiber, mineral oil, laxatives Appropriate toilet training technique. Hirschsprung’s disease: congenital aganglionic megacolon, located in the rectosigmoid area in 75% of cases. This condition is associated with Down syndrome. Clinical features: Severity depends on length of colon involved No meconium within first 24 hours Palpable stool on abd exam with empty rectum on digital rectal exam (DRE) Intermittent diarrhea, BM only with rectal stimulation Constipation, abd distention, vomiting, FTT Dx: Barium enema: proximal dilatation due to functional obstruction, empty rectum Manometric studies: may have false positives Rectal biopsy: definitive diagnosis Tx: Non surgical if short segment Surgical: colostomy and re-anastomosis. Other organic disorders: Intestinal obstruction Endocrine: Hypothyroidism, Diabetes mellitus (DM), Hypercalcemia Neurogenic bowel Anal fissure/stricture/stenosis Collagen vascular disease Drugs: lead, chemotherapy, opioids Reference: MCCQE d) obesity Obesity is a weight that is › 20% greater than expected for age and height. Hx: Diet Activity Family heights and weights Growth curves. Physical exam: May suggest secondary causes (Cushing syndrome) Caliper determination of fat is more sensitive than weight Organic causes are rare (<5%): Genetic: Prader-Willi, Carpenter, Turner syndrome Endocrine: Cushing syndrome, Hypothyroidism Complications: Low correlation between obese children and obese adults Some association with: hypertension, increased LDL, slipped capital femoral epiphysis, type 2 diabetes. Boys: gynecomastia Girls: polycystic ovarian disease, early menarche Psychological: discrimination, teasing, decreased self-esteem. Management: Encouragement and reassurance Diet: qualitative changes; do not encourage weight loss but allow for linear growth to catch up with weight Evidence against very low calorie diets for preadolescents Behavior modification: increase activity, change meal patterns Insufficient evidence for or against exercise, family programs for obese children Education: multidisciplinary approach, dietitian, counseling. Reference: MCCQE e) wasting and Risk factors for wasting and stunting were examined in a stunting longitudinal study of 18 544 children younger than 30mo in Metro Cebu, Philippines. Measures of household demographic and socioeconomic characteristics, maternal characteristics and behavior, and child biological variables were analyzed cross-sectionally in six child age-residence strata by using logistic regression. Our results support biological and epidemiologic evidence that wasting and stunting represent different processes of malnutrition. They also indicate that the principal risk factors for stunting and wasting in infants < 6 mo of age were either maternal behaviors or child biological characteristics under maternal control, eg, breast- feeding status and birth weight. After 6 mo of age, household socioeconomic characteristics emerged with behavioral and biological variables as important determinants of malnutrition. Reference: This information was taken from an article in the American Journal of Clinical Nutrition. Risk factors for wasting and stunting among children in Metro Cebu, Philippines1-3, Judith A Ricci and Stan Becker http://www.ajcn.org/cgi/reprint/63/6/966.pdf#search =%22wasting %20and%20stunting%20in%20pediatrics%22 The World Health Organization defines malnutrition as "the cellular imbalance between supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions." Protein- energy malnutrition (PEM), first described in the 1920s, is observed most frequently in developing countries but has been described with increasing frequency in hospitalized and chronically ill children in the United States. Children may be affected by micronutrient deficiencies, which also have a detrimental effect on growth and development. The most common and clinically significant micronutrient deficiencies in children and childbearing women throughout the world include deficiencies of iron, iodine, zinc, and vitamin A. Hx Clinical signs and symptoms of protein-energy malnutrition (PEM) include the following: o Poor weight gain (wasting) o Slowing of linear growth (stunting) o Behavioral changes - Irritability, apathy, decreased social responsiveness, anxiety, and attention deficits Clinical signs and symptoms of micronutrient deficiencies: Some of the clinical signs and symptoms of specific micronutrient deficiencies may closely resemble those observed in PEM. Deficiencies of micronutrients, including vitamins, minerals, and trace elements have been well described. The most common and clinically significant deficiencies include the following: o Iron - Fatigue, anemia, decreased cognitive function, headache, glossitis, and nail changes o Iodine - Goiter, developmental delay, and mental retardation o Vitamin D - Poor growth, rickets, and hypocalcemia o Vitamin A - Night blindness, xerophthalmia, poor growth, and hair changes o Folate - Glossitis, anemia (megaloblastic), and NTDs (in fetuses of women without folate supplementation) o Zinc - Anemia, dwarfism, hepatosplenomegaly, hyperpigmentation and hypogonadism, acrodermatitis enteropathica, diminished immune response, poor wound healing Physical exam: Physical findings that are associated with PEM include the following: Decreased subcutaneous tissue: Areas that are most affected are the legs, arms, buttocks, and face. Edema: Areas that are most affected are the distal extremities and anasarca [generalized edema]. Oral changes o Cheilosis, angular stomatitis, papillar atrophy Abdominal findings o Abdominal distension secondary to poor abdominal musculature o Hepatomegaly secondary to fatty infiltration Skin changes o Dry peeling skin with raw exposed areas o Hyperpigmented plaques over areas of trauma Nail changes: Nails become fissured or ridged. Hair changes: Hair is thin, sparse, brittle, and can be easily pulled out, and turns a dull brown or reddish color. Causes: Inadequate food intake is the most common cause of malnutrition worldwide. In developing countries, inadequate food intake is secondary to insufficient or inappropriate food supplies or early cessation of breastfeeding. In some areas, cultural and religious food customs may play a role. Inadequate sanitation further endangers children by increasing the risk of infectious diseases that increase nutritional losses and alters metabolic demands. In developed countries, inadequate food intake is a less common cause of malnutrition. Instead, diseases and, in particular, chronic illnesses play an important role in the etiology of malnutrition. Children with chronic illness are at risk for nutritional problems for several reasons, including the following: o Children with chronic illnesses frequently have anorexia, which leads to inadequate food intake. o Increased inflammatory burden and increased metabolic demands can increase caloric need. o Any chronic illness that involves the liver or small bowel affects nutrition adversely by impairing digestive and absorptive functions. Chronic illnesses that commonly are associated with nutritional deficiencies include the following: o Cystic fibrosis, chronic renal failure, childhood malignancies, congenital heart disease, neuromuscular diseases, chronic inflammatory bowel diseases In addition, the following conditions place children at significant risk for the development of nutritional deficiencies: o Prematurity, developmental delay, in utero toxin exposure (ie, fetal alcohol exposure) Lab Studies: The most helpful laboratory studies in assessing the nutritional status of a child are hematological studies and laboratory studies evaluating protein status. o Complete blood count (CBC) with red blood cell indices and a peripheral smear. This could also help exclude anemia from nutritional deficiencies such as iron, folate, and vitamin B-12 deficiencies. o Measures of protein nutritional status include serum albumin, retinol-binding protein, prealbumin, transferrin, creatinine, and BUN levels. Retinol-binding protein, prealbumin, and transferrin determinations are much better short-term indicators of protein status than albumin. However, in the field, a better measure of long-term malnutrition is serum albumin b/c of its longer half-life. Additional diagnostic evaluation o In children who have a history of adequate food intake and signs/symptoms of malnutrition, focus on identifying the cause of malnutrition. Perform laboratory studies based on information from a complete history and physical examination. o Initial diagnostic laboratory studies include a CBC, sedimentation rate, serum electrolytes, and urinalysis and culture. Stool specimens should be obtained if the child has a history of abnormal stools or stooling patterns or if the family uses an unreliable or questionable source of water. o Additional studies may focus on thyroid functions or sweat chloride tests, particularly if height velocity is abnormal. Further diagnostic studies should be determined as dictated by the history and physical examination. For example, lab tests evaluating renal function, such as phosphorus and calcium, should be obtained in the presence of renal symptoms. Children with suspected liver disease should have triglyceride and vitamin levels obtained, while zinc levels should be obtained in patients with chronic diarrhea. o Celiac serology is a useful screening test and should be considered, especially if there is a family history of celiac disease or if other autoimmune diseases, such as type I diabetes mellitus, are present. Other Tests: Practical nutritional assessment o Complete history, including a detailed dietary history o Growth measurements, including weight and length/height; head circumference in children younger than 3 years o Complete physical examination Sensitive measures of nutritional status o Height-for-age or weight-for-height measurements greater than 2 standard deviations below the mean for age o Height-for-age or weight-for-height measurements more than 2 standard deviations less than the mean for age Height-for-age measurements less than 95% of expected value o Weight-for-height measurements less than 90% of expected value o Less than 5 cm/y of growth in children older than 2 years o Body mass index (BMI) (although not established by the CDC as a criteria for failure to thrive) Medical Care: Following evaluation of the child's nutritional status and identification of the underlying etiology of the malnutrition, dietary intervention in collaboration with a dietitian or other nutritional professionals should be initiated. Children with edema must be assessed carefully for actual nutritional status because edema may mask the severity of malnutrition. Children with chronic malnutrition may require caloric intakes more than 120- 150 kcal/kg/d to achieve appropriate weight gain. The formula for determining adequate caloric intake is: o kcal/kg = (RDA for age X ideal weight)/actual weight Additionally, any micronutrient deficiencies must be corrected for the child to attain appropriate growth and development. Most children with mild malnutrition respond to increased oral caloric intake and supplementation with vitamin, iron, and folate supplements. The requirement for increased protein is met typically by increasing the food intake, which, in turn, increases both protein and caloric intake. Adequacy of intake is determined by monitoring weight gain. In mild-to-moderate cases of malnutrition, initial assessment and nutritional intervention may be done in the outpatient setting. A patient with malnutrition may require hospitalization based on the severity and instability of the clinical situation. Hospitalization of patients with suspected malnutrition secondary to neglect allows observation of the interactions between parent/caregiver and child and documentation of actual intake and feeding difficulties. It may also be warranted in cases where dehydration and acidosis complicate the clinical picture. In moderate-to-severe cases of malnutrition, enteral supplementation via tube feedings may be necessary. Children with chronic malnutrition may require caloric intakes in excess of 120-150 kcal/kg/d to achieve appropriate weight gain. The diet must include adequate amounts of protein and other macronutrients Reference: eMedicine 3. Respiratory a. cough and stridor b. coryza and nasal obstruction c. lymphoid hyperplasia including cervical adenitis, tonsils and adenoids d. apnea and wheezing e. otalgia and otorrhea f. hearing problems 4. Major symptoms a. fever b. convulsion c. headaches including migraine d. enuresis e. encopresis 5. Psychological and emotional a) child protection & -A child suspected of being abused or neglected (upon reasonable b) physical sexual grounds) needs to be reported immediately to CAS. Duty to report abuse overrides patient confidentiality. -Obtain history from child and caregiver separately if possible. Perform a complete physical examination + assess emotional state & development. Document and/or photograph all injuries. STI workup + skeletal survey + CT/MRI. -Hospitalize if indicated or if concerns about further or ongoing abuse. -Request emergency visit of CAS to home if imminent risk to child or siblings is suspected Reference: Behrman: Nelson Textbook of Pediatrics, 17th ed., Toronto Notes 2006. c) learning disability Diagnosis: -assess using achievement tests in reading, math or written expression (WISC III, WRAT). Individual scores significantly below that expected for age, education & IQ. -interferes with academic achievements or ADLs that require reading, math or writing skills. -can include psychiatric comorbidity (10-25%). Complications: -low self esteem, poor social skills, school drop-out. Management: -provide helpful advice and counseling in dealing with the stresses associated with learning challenges. Because children with learning disabilities represent an extremely heterogeneous group, no two children require the same management plan, nor is it possible to predict with certainty at age 7 the needs of a youngster when he or she is 14 yr old. Consequently, affected children and their families require vigilant follow-up and individualized objective advice throughout their academic careers. Reference: Behrman: Nelson Textbook of Pediatrics, 17th ed., Toronto Notes 2006. d) ADD Look for: A annoying T temperamental E energetic N noisy T task incompletion I inattentive O oppositional N negativism Diagnosis: -≥ 6 symptoms of inattention and/or hyperactivity-impulsivity persisting for ≥ 6 months -onset before age 7 -symptoms present in at least 2 settings (i.e. at home, and at school or work) -interferes with academic, family, and social functioning -does not occur exclusively during the course of PDD, schizophrenia, or other psychotic disorders, and is not better accounted for by another mental disorder (e.g. mood, anxiety, dissociative, personality disorder) Management: (1) non-pharmacological • parent management, anger control strategies, positive reinforcement, social skills training, individual/family therapy, resource room, tutors, classroom intervention, exercise routines, extracurricular activities. (2) pharmacological • standard treatment = psychostimulants (Ritalin, Concerta, dextromethamphetamine, Stattera) • for comorbid symptoms = antidepressants, neuroleptics, clonidine, anticonvulsants, β-agonists. Reference: Toronto Notes 2006. e) the non-compliant Conduct disorder child Diagnosis: • persistent behavioural pattern in which others’ basic rights / societal norms are violated • categories of violation include: - aggression to people / animals - property destruction - deceitfulness / theft - serious rule violation • the disturbance causes clinically significant impairment in social, academic, or occupational functioning. • childhood onset – ODD (oppositional defiant disorder), aggressive, impulsive, poor prognosis • adolescent onset - less aggressive, gang-related delinquency, better prognosis • 50% of CD children become adult ASPD (anti-social personality disorder) Treatment: • early intervention necessary and more effective • parent management training, anger replacement training, CBT, family therapy, education / employment programs, social skills training, medications for aggressiveness or comorbid disorders Oppositional defiant disorder Diagnosis: - a pattern of negativistic, hostile, defiant, disobedient behaviour towards parental / authority figures over a 6 month period (i.e. loses temper often, violates minor rules, argumentative, etc.) - behaviour causes significant impairment in social, academic or occupational functioning - behaviours do not occur exclusively during the course of a psychotic or mood disorder - criteria not met for CD Differentiating ODD from transient developmental stage: - onset < 8 years old - chronic duration (> 6 months) - frequent intrusive behaviour Course: may progress to conduct disorder Treatment (goal is to establish generational boundary): parent management training, individual/family psychotherapy Reference: Toronto Notes 2006 & 2002. CHC General Objectives: a. For the student to perfect the clinical skills of history taking and physical examination. b. For the student to see and become familiar with common acute pediatric non-life- threatening pediatric problems c. For the student to become aware of the management of common acute non life- threatening pediatric problems. Specific Objectives: a. For the student to be able to recognize and diagnose: Reference: Toronto Notes 2006, Behrman: Nelson Textbook of Pediatrics, 17th ed., The HSC Handbook of Pediatric, 10th ed. o acute otitis media Clinical presentation: Classic triad: otalgia, fever, hearing loss – usually abrupt onset. Pain over mastoid, otorrhea, irritability, vomiting, diarrhea, anorexia, URI symptoms and ear tugging also common. Tinnitus, vertigo and facial nerve paralysis are rare. Physical examination: Hyperemia, bulging of tympanic membrane, middle ear effusion (loss of visible landmarks). Age group: 18 mo – 6 yr Peak incidence: January - April Complications: Tympanic perforation, chronic otitis, ossicular necrosis, cholesteatoma, meningitis, brain abscess, facial nerve paralysis, mastoiditis, labyrinthitis. o the causes of fever in infants and young children for whom there is no apparent cause of fever. By definition, a documented rectal fever > 38.3°C for ≥ 3 weeks of undetermined etiology after investigation (3days in hospital or 3 outpatient visits). Most fevers of unknown or unrecognized origin result from atypical presentations of common diseases. The principal causes in children are infections and rheumatologic (connective tissue or autoimmune) diseases. Neoplastic disorders should also be seriously considered, although most children with malignancies do not have fever alone. The possibility of drug fever should be considered if the patient is receiving any drug. Infectious causes: Localized Generalized In a traveller UTI TB Malaria Endocarditis Histoplasmosis Typhoid fever Abscess Typhoid Hep. A Osteomyelitis CMV Dengue Empyema EBV HIV Rickettsia Neoplastic causes (lymphoma, leukemia). Collagen vascular diseases (vasculitis). Drug fever (eg. antibiotics). Other causes (IBD, factitious fever, diabetes insipidus). o common gastrointestinal problems such as gastroenteritis, colic, and vomiting and regurgitation. Gastroenteritis Clinical presentation: Acute diarrhea (bloody if bacterial cause), abdominal cramps, vomiting, malaise. Abdominal pain (vague if viral, severe if bacterial). Fever mainly if inflammatory process (mild if viral, high if bacterial). Can be associated with URI. Physical examination: Signs of dehydration. Colic Clinical presentation: Unexplained paroxysms of irritability, crying for > 3 hr/day and > 3 days/wk for > 3 wks in an otherwise healthy, well-fed baby. Child passes gas soon after feeding. Age group: Infancy. Onset 10 days – 3 mo (peak 6-8 wks). Vomiting / regurgitation (a) Tracheoesophageal fistula Clinical presentation: Vomiting, coughing, gagging, cyanosis with feeds, respiratory distress, recurrent pneumonia. Physical examination: Frothy bubbles of mucus in mouth that return after suctioning. Complications: Pneumonia, sepsis, reactive airways disease. (b) Duodenal atresia Clinical presentation: Bilious vomiting if atresia is distal to bile duct. Physical examination & investigations: No abdominal distention. Signs of dehydration. Double bubble sign on CXR. (c) Pyloric stenosis Clinical presentation: Non-bilious projectile vomiting following feeding. Infant hungry. Constipation, failure to thrive. Physical examination & investigations: Abdominal mass (olive sign), visible peristaltis. Signs of dehydration, wasting. Hypochloremic metabolic alkalosis. Age group: Onset at 2-4 wks of age. (d) Malrotation of intestine Clinical presentation: Recurrent intermittently bilious vomiting. Failure to thrive. Sudden onset of abdominal pain and shock. Physical examination: Abdominal distention. Age group: Onset in first 2 mo of life. Complications: Bloody stools, perforation, peritonitis. (e) GER Clinical presentation: Non-bilious vomiting soon after feeding (small volume). Age group: Infancy. Complications: Esophagitis, strictures, Barrett’s esophagus, failure to thrive, aspiration. o common respiratory problems URI Clinical presentation: Inspiratory stridor, hoarseness, suprasternal retractions. (a) laryngotracheobronchitis (Croup) Clinical presentation: Prodrome of rhinorrhea, pharyngitis, low-grade fever & mild cough. Inspiratory stridor at rest, hoarse voice, barking cough. Symptoms worse at night. Physical examination and investigation: Steeple sign (subglottic narrowing) on AP CXR. Age group: 6 mo – 4 yr Peak incidence: Late fall, early winter. (b) epiglottitis Clinical presentation: Dysphagia + dysphonia + drooling + distress. Tripod positioning. Fever, dyspnea, irritability, lethargy. Physical examination and investigation: Erythema and edema of supraglottic structures. Thumb sign (thickened epiglottitis) on lateral neck film. Age group: 2-6 yr Peak incidence: Winter, spring. LRI Clinical presentation: Wheezing (expiratory sounds). (a) pneumonia Bacterial Viral Mycoplasma Temperature ≥ 39°C < 39°C < 38°C Onset Abrupt, may follow Gradually Gradually worsening URI. worsening URI. cough Signs & Respiratory Myalgia, rash, Headache, sore symptoms distress, pleuritic conjunctivitis, throat, myalgia. chest pain. pharyngitis, Rash, conjunctivitis, diarrhea. myringitis, enanthem, hacking paroxysmal cough. CXR Lobar infiltrate. Interstitial Lobar or diffuse infiltrate. infiltrate. (b) bronchiolitis Clinical presentation: Prodome of URI ± fever, poor feeding & irritability. Fever, dehydration, wheezing, crackles, dyspnea, tachypnea, intercostals indrawing & accessory muscle use. Physical examination and investigation: Hyperinflation, peribronchial thickening, ↑ linear markings, areas of atelectasis on CXR. b. For the student to become familiar with the management of the above conditions COMMUNITY PEDIATRICS General: Acquire basis knowledge of growth and development, knowledge of common acute and chronic illnesses and the well baby visit. Develop communication skills, competency in the physical examination, problem solving skills and strategies for health promotion. Skills: Interviewing: • important history for well baby care • respect confidentiality when dealing with adolescents Physical Examination: • Recognize that the age of the child influences the areas included in the exam as well as the order the examination and the approach to the patient. • Accurately measure head circumference, height and weight • Identify Tanner stage. Pubertal & Tanner Staging: Tanner staging is a system to identify the stages of puberty which occur in a predictable series as follows: Boys: Development of External Genitalia: Stage 1 = Prepubertal Stage 2 = Enlargement of scrotum & testes; scrotum skin reddens & changes in texture Stage 3 = Enlargement of penis (length at first); further growth of testes Stage 4 = increased size of penis with growth in breadth & development of glans; testes & scrotum appear larger, scrotum skin is darker Stage 5 = Adult genitalia Girls: Breast Development: Stage 1: Prepubertal Stage 2: Breast bud stage with elevation of breast & papilla; enlargement of areola Stage 3: Further enlargement of breast & areola; no separation of their contour Stage 4: Areola & papilla forma secondary mound above the level of the breast Stage 5: Mature stage: projection of the papilla only, related to recession of areola Boys & Girls – Pubic Hair: Stage 1: Prepubertal Stage 2: Sparse growth of long, slightly pigmented hair, straight or curled, at base of penis or along labia Stage 3: Darker, coarser & more curled hair, spreading sparsely over junction of pubes Stage 4: Hair adult in type, but covering smaller area than in adult; no spread to medial surface of thighs Stage 5: Adult in type & quantity, with horizontal distribution (“feminine”) Reference: Up To Date Article: “Normal Puberty” & endocrinology lectures Clinical Problem-Solving Skills: • Develop a problem list and differential diagnosis for each problem. • Formulate an initial diagnostic & therapeutic plan. Procedures: A) Throat swab Reference: Up To Date: “Throat cultures and other tests for the diagnosis of pharyngitis” Generally performed on a person with symptoms of sore throat & possibly fever if a GAS (group A streptococcus) infection is suspected. The specimen should be obtained prior to the start of any antimicrobial therapy since even a single dose of antibiotics can render the culture negative. Swabs are used for specimen collection. Some physicians use a dual swab technique, in order to collect specimens for direct antigen detection & for culture at the same time. The specimen for culture will be sent to the lab only if the office-based rapid antigen detection test (RADT) is negative. Ask the patient to be cultured to open their mouth widely & say a long “ah”. The tongue is gently depressed with a sterile tongue blade. The swab is then gently passed over the tongue & into the posterior pharynx. The mucosa behind the uvula & between the tonsils should then be gently swabbed with a back & forth motion. The specimen is obtained by vigorous swabbing of both tonsils (or tonsillar fossae) & the posterior pharynx. The tongue, buccal mucosa & hard palate are not good sites & should be avoided. The organism is viable on the swab (dry) for 48-72 hours; but if processing will be delayed beyond this, it is recommended the swab be placed in medium (eg. Stuart or Amies). Possible complications (other than being slightly uncomfortable) is that kids might sometimes gag or even vomit from having the back of their throat touched. B) Vaccine Reference: The Hospital for Sick Children (HSC) Handbook of Pediatrics – pg. 417 Premature Infants: follow normal schedule based on postnatal age Schedule Interruptions: no need to restart from the beginning Site of Injection: Infants = anterolateral thigh; all others are in the deltoid area IM Injections: use long needles (eg. >2cm) Acetaminophen 15mg/kg at 0 & 4h post-vaccination & then q4h to decrease fever & fussiness - Routine vaccines can be given safely & effectively at same time using different sites - If possible, monitor children for 15min post-vaccination for hypersensitivity reaction - Report any significant adverse reactions to the local medical officer of health Live vaccines are contra-indicated in pregnancy & immunocompromized patients Reference: Publicly Funded Routine Immunization Schedule for Children Beginning Immunization in Early Infancy (http://www.health.gov.on.ca/english/public/pub/immun/immunization.html) Measles Pneumo- Chicken Age at mumps Men-C Hepatitis Diptheria Pertussis Tetanus Polio HIB coccal pox vaccination rubella conjugate B conjugate (Varicella) (MMR)* 2 months 4 months 6 months 12 months 15 months† 18 months 4-6 years ** 12 years (grade 7) ‡ 14-16 years * MMR = measles, mumps and rubella vaccine must be given after the first birthday. If your child has not had chicken pox or the vaccine he/she can receive the chicken pox vaccine at 5 years ** of age. † These vaccines can be given as early as 12 months of age. Contraindications: Symptom or Condition Vaccine Anaphylactic Reaction to: Previous Dose of Vaccine Vaccine that caused the anaphylactic reaction Neomycin IPV, DTaP-IPV-Hib, Pentacel, MMR, Varicella Gelatin Varicella & MMR Baker’s Yeast HBV Vaccine Eggs Influenza Streptomycin IPV Immunodeficient State in Recipient Congenital Immunodeficiency MMR, Varicella, OPV, BCG OPV, BCG, Precautions with MMR & Varicella Pregnancy MMR, Varicella, OPV, BCG Immunosuppression MMR, Varicella, OPV, BCG Immunodeficient State in Household Contact Congenital Immuodeficiency OPV HIV OPV High Dose Systemic Steroids Defer MMR, Varicella, BCG, OPV Note: IPV is the inactivated poliovirus (SC) & OPV is the live virus (give PO) Knowledge: Health Supervision • describe the contents and demonstrate ability to provide a health supervions visit to include anticipatory guidance about nutrition, behavior, immunization, injury prevention and healthy life style for teenagers. History: • Ensure privacy & confirm confidentiality • Review vaccine status – esp. rubella & risk factors for hepatitis B, HIV & hep. C • Review HEADS: o H = home – relationship w/ parents, siblings, family support, stress & responsibility & independence o E = education – present & past, school performance, career goals, likes & dislikes o A = activities – hobbies/interests, friends, job, dating & antisocial behaviour – truancy, violence & problems with the law o D = drugs – smoking, alcohol, prescription & street drugs, dieting o S = sexuality – activity, birth control, STDs & sexual orientation; also suicide & depression screen • describe the different types of immunizations, their indications and side effects in childhood. Reference: The Hospital for Sick Children (HSC) Handbook of Pediatrics – pg. 417 See vaccination schedule for timing (aka indication) Adverse Effects of Vaccines: Diphtheria = DTaP Vaccine local irritation (20%), fever (5%), transient nodule might develop @ injection site, may last a few weeks. Booster redness & swelling (70%) Pertussis = IM, inactivated bacteria & acellular neurologic sequelae w/ whole cell vaccine, reactions with acellular vaccine are rare Tetanus Immune Globulin (TIG) = toxoid, IM injection anaphylaxis (rarely), peripheral neuropathy (rare); adult booster local erythema & swelling which increases w/ age Poliovirus = inactivated (sub-cutaneous) local discomfort or inflammation (5%); oral, live virus paralytic poliomyelitis (1 in 2.4 million) Measles = live virus (sub-cutaneous) discomfort, local inflammation, fever, non- infectious rash, encephalitis (1 in 1 million), transient thrombocytopenia (1 in 24000), disseminated disease & death in immunocompromised patients Mumps = live virus (sub-cutaneous) fever, mild skin rash, parotitis (1%), aseptic meningitis (1 in 3 million) Rubella = live virus (sub-cutaneous) discomfort, local inflammation, fever (10%), lymphadenopathy, stiff neck or arthralgias (5%), noninfectious rash (1%), transient arthralgias (common in postpubertal females) Pneumococcal Vaccines: Pneumococcal Polysaccharide (Pneumovax) (IM/SC for strep pneumo) for kids >2years of age with one of the following conditions: • Anatomic or functional asplenia • Sickle cell disease • Nephritic syndrome • Chronic CSF leak • HIV or immunosuppression • Organ transplantation Heptavalent Pneumococcal Conjugate (Prevnar) (IM for pneumococcal capsular antigens) redness (10-14%), swelling (10-12%), fever (15-24%), irritability (44-59%), rash (0.5-1.5%) – follow routine schedule. Meningococcal Vaccines: Meningococcal Polysaccharide (SC against Neisseria meningitidis groups A, C, Y, W-135; not routine) for use in contacts of cases with diseases of the mentioned serogroups & in patients >2years with asplenia or complement or factor D deficiency – might be recommended in: • Military recruits • Lab workers handling meningococcus • Travelers to Mecca, Saudi Arabia or other endemic areas Meningococcal Conjugate (IM against Meningococcal C capsular antigen) single dose in kids >12 months or multiple doses if <12 months. Side effects include redness/swelling (<50%), fever (9%), irritability (<80%), rash (0.1%) Varicella (live virus, SC) injection site reaction (20%), rash elsewhere (3-5%), low grade fever (15%) Influenza (polyvalent, killed strains; IM) – recommended for pretty much everyone these days… RSV Prophylaxis (RSV IGIV) recommended for kids <24 months w/ bronchopulmonary dysplasia (BPD) who required medical treatment within 6 months preceding RSV season & for infants born <32 weeks gestation +/- BPD who are <6 months at the start of RSV season. It is also for kids who are hospitalized & at risk for other viral infections; for infants receiving IVIG for immunodeficient states & infants unable to receive IM injections. NOTE: it may interfere with the patient’s response to vaccines (ie. MMR should be given at least 9 months after the last dose of RSV IGIV) Rabies (Active (HDCV, human cell vaccine) or Passive (RIG, human rabies immune globulin)) – IM injection, for the general treatment of animal bites (dogs & cats that have signs of rabies or suspected rabies & for skunk, bat, fox, coyote, raccoon & other carnivores). Side effects: HDCV pain, erythema, swelling, headache, nausea, abdominal pain, myalgias, dizziness, serum sickness-like reactions following boosters (all common reactions); RIG local pain & low-grade fever. Growth: • If possible, recognize and investigate appropriately short stature, failure to thrive, obesity, abnormal head size. Reference: Essentials of Pediatrics Nelsons, 5th edition Growth is assessed by plotting accurate measurement on growth charts and comparing each set of measurements with previous measurements. Charts presently available are: For 0-36 months For ages 2-20 - weight for age o weight for age - length for age o height for age - head circumference by age o Body Mass Index (BMI) for age* - weight for length * BMI = body weight (kg)/height2 (m2); index for classifying adiposity Rules of thumb for growth Weight 1. Weight loss in first few days: 5-10% of birth weight 2. Return to birth weight: 7-10 days of age Double birth weight: 4-5months Triple birth weight: 1yr Quadruple birth weight: 2 yr 3. Average weights: 3.5kg at birth 10 kg at 1 yr 20 kg at 5 yr 30kg at 10yr 4. Daily weight gain: 20-30g for first 3-4 months 15-20g for rest of the first year 5. Average annual weight gain: 5 lb between 2 yr and puberty (spurts and plateaus may occur) Height 1. Average length: 20 inches at birth, 30 inches at 1 yr 2. at 3 year, the average height is 3 ft tall 3. At 4 yr, the average child is 40m tall (double birth length) 4. Average annual height increase: 2-3 inches between 4 yr and puberty Head Circumference (HC) 1. Average HC: 35 cm at birth (13.5 inches) 2. HC increases: 1cm/mo for first yr (2cm/mo for first 3mo, then slower); 10 cm for rest of life Specific Growth Patterns Requiring Further Evaluation Pattern Representative Diagnosis Further Evaluation to Consider Weight, length, HC all <5th Familial Short Stature Mid-parental heights percentile Constitutional Short Stature Bone Age Intrauterine Insult Evaluation of pubertal Genetic Abnormality development Examination of prenatal records Chromosome analysis Discrepant percentiles (e.g. Normal variant (familial or Mid-parental heights weight 5th, length 5th, HC constitutional) Evaluation of pubertal 50th, or other discrepancies) Endocrine growth failure development Caloric Insufficiency Thyroid hormone Growth factors, provocative growth hormone testing Declining percentiles “Catch-down growth” Complete history and physical exam Dietary and social history Failure to thrive evaluation Mid-Parental Height Calculations -For a girl: [paternal height (inches) + maternal height (inches) -2.5] / 2 -For a boy: [paternal height (inches) + maternal height (inches) + 2.5} / 2 -Mid parental height is a gross approximation of child’s future height. Catch-down growth -growth moves to lower percentiles during first year of life -infants start at high percentiles due to excellent prenatal care -between 16-18 months, they assume a lower percentile until they match their genetic “programming”, then begin to grow along new lower percentiles -they usually do not decrease more than 2 major percentiles Failure to thrive Is diagnosed by weight that falls or remains below the 3rd percentile for age, that decreases crossing two major percentile lines on the growth chart overtime, or that is less than 80% of the median weight for the height of the child. Causes of Failure to Thrive (investigations based on clinical suspicions of cause) Environmental GI Congenital/Anatomic Infections (common) Cystic Fibrosis and Chromosomal HIV Emotional other causes of Abnormalities, genetic TB deprivation pancreatic syndromes Hepatitis Rumination insufficiency Congenital heart Urinary tract Child maltreatment Celiac Disease disease infection Maternal Other Malabsorption GI abnormalities Chronic sinusitis depression syndromes Vascular rings Parasitic Poverty Gastrointestinal Upper airway infection Poor feeding reflux obstruction techniques Dental caries Improper formula Congenital preparation immunodeficiency Improper mealtime syndromes environment Unusual parental nutritional beliefs Metabolic Neurologic Renal Hematologic Thyroid disease Cerebral Palsy Chronic renal failure Sickle cell Adrenal or Hypothalamic and Renal tubular acidosis disease pituitary disease other CNS tumours Urinary tract infections Iron deficiency Aminoaciduria, Hypotonia syndromes anemia organic aciduria Neuromuscular Galactosemia diseases Degenerative and storage diseases Obesity -Child (age 2-20y) is overweight or obese if BMI is above 95th percentile for age -Child (age 2-20y) is at risk of being overweight if BMI between the 85th and 95th percentile for age For children younger than 2 years old, weight for length greater than 95th percentile may indicate overweight or obesity and warrants further assessment. Assessment o anthropometric data- weight, height, BMI o Dietary and physical activity history o Physical examination- BP, adiposity distribution, markers of co morbidities (acanthosis nigricans, hirsutism, hepatomegaly, orthopedic abnormalities) and physical stigmata of genetic syndrome (Prader-Willi syndrome). o Lab studies- for children with BMI >95th percentile or with evidence of co morbidities: fasting lipid profile, fasting insulin and glucose levels, liver function tests and thyroid function tests. Other studies guided by findings in history and physical. Head Circumference Megalocephaly – HC may be disproportionately large when there is familial megalocephaly (knowing size of parents heads is essential), hydrocephalus, or merely “catch up” growth in a neurologically normal infant. Microcephalic- when the child’s HC is at less than 3rd percentile, even if length and weight measurements are proportionately low. Catch-up growth o infants who were born small for gestational age or premature ingest more breast milk or formula and usually catch up within the first year. • If possible, recognize normal variants of growth, such as familial short stature and constitutional delay Normal Variants of Growth Familial Short Stature Constitutional Short Stature - normal growth velocity - normal growth velocity - normal bone age - delayed adolescence - short stature in childhood and - may have family history of delayed puberty adulthood - may require short term therapy with androgens/estrogens - delayed bone age - eventual achievement of normal adult stature Behavior • describe the typical presentation of common behavioral problems, e.g. sleep, temper tantrums, toilet training, eating, colic, enuresis, attention deficit disorder, risk taking and defiance. Reference: Essentials of Pediatrics Nelsons, 5th edition Normal Sleep - Full term infants sleep 2/3 of the day - 1 year olds sleep 15 hours/day (2-3 hours in the day, the remainder at night) - 12 years of age, adolescence require 9 hours of sleep/day Common Sleep Disorders - Obstructive sleep apnea: snoring and breathing pauses during sleep - Adolescent insomnia - Parasomnias: night talking most common, sleep walking, night terrors (kids have no recollection of night terrors, child may scream and may not recognize parents during an episode) - Children with ADHD and fetal alcohol syndrome are more likely to suffer from disordered sleep Temper Tantrums - Out of control behavior including screaming, stomping, hitting, head banging, falling down, and other violent displays of frustration. - In extreme can include breath holding, vomiting, conjunctival hemorrhages, and serious aggression, including biting. - Normal behavior in 1-3 year old children, when the temper tantrum period is of short duration (2-5 minutes) and the tantrums are not manipulative in nature - If the behavior is present frequently after the age of 3, the possibility of family stress or conditions that reinforce the tantrum behavior should be considered. Toilet Training - Toilet training usually begins after the 2nd birthday and is mastered by age 3 in middle class white US populations - Toilet training between 12-18 months continues to be accepted in lower income families - Prerequisites include the child’s ability to recognize the sensation of urination and defecation, get to the toilet, maintain adequate attention span to sit for the necessary time, take pride in achievement or parental pleasure, understand the sequence of tasks required, and avoid oppositional behavior Eating General guidelines for children older than 2 years old - consume 3 regular meals daily with healthful snacks according to appetite, activity and growth needs - include a variety of foods with abundant vegetables and fruits Eating Disorders - Eating disorders are common chronic diseases in adolescents, especially females - Often triggered by normal developmental milestones of adolescence - Patient has an unrealistic body image and feels too fat despite appearing excessively thin Crying Can be a sign of distress, pain, hunger or tiredness and it is often difficult to interpret the meaning of an infants cry. Normal Development 0 - 2 weeks = crying minimal 2 - 6 weeks = daily crying duration increases from an average of 2 hr/day to 3 hr/day 12 weeks = average daily crying 1 hour/day Colic • crying more than 3 hours/day for more than 3 days per week for more than 3 weeks • often described as paroxysmal, and can be characterized by facial grimacing, drawing up legs and passing flatus • less than 5% of infants evaluated for chronic crying have an organic etiology • Lab and imaging studies are reserved for infants in whom there are history or physical examination findings suggesting an organic cause for excessive crying Enuresis - Urinary incontinence in a child who is considered adequately mature to have achieved continence - Classified as diurnal (daytime) or nocturnal (nighttime) - Daytime dryness is expected by 4 years of age - Nighttime dryness is expected by age 6 years - Child may present with primary enuresis (a child who has never achieved dryness) or secondary enuresis (a child who has been dry for at least 6 months) Attention Deficit/Hyperactivity Disorder - neurobehavioural disorder defined by symptoms of inattention, hyperactivity, and impulsivity - children must have symptoms in at least 2 environments and functional impairment in addition to the symptoms of the disorder diagnosis - Diagnosis is made by history - Higher prevalence in boys than girls (2-3:1) - Comorbid conditions commonly occur with ADHD, including speech language delay and learning disabilities - Psychiatric conditions, such as conduct disorder, depression and anxiety disorder also are more common in children with ADHD then in the general population Risk Taking Adolescence- on history be sure to ask about - Home/Friends, Education/Employment, Alcohol, Drugs, Diet, Sex, Suicide/Depression, Spirituality - Issues that can not be kept confidential- suicide intent, a positive HIV test (a duty to warn third parties) and disclosure of sexual or physical abuse. • identify behavioral and psychosocial problems Context of Behavioral Problems Child Factors Health (past and current) Developmental Status Temperament (e.g. difficult, slow to warm up) Coping Mechanisms Parental Factors Misinterpretation of stage-related behaviors Mismatch of parental expectations and characteristics of child Parental characteristics (e.g. depression, lack of interest, rejection, over protectiveness) Coping Mechanisms Environmental Factors Stress (e.g. marital discord, unemployment, personal loss) Support (e.g. emotional, material, informational, childcare) Parent-Child Interactions The common pathway through which the listed factors interact to influence the development of a behavior problem. The key to resolving the behavior problem. Nutrition • describe the caloric, vitamin, and mineral needs and routine sequence of food introuction for infants and small children. Human milk (breast milk) is the recommended primary source of nutrients for healthy term infants during the first year of life. Iron fortified infant formulas are acceptable substitutes when mother's milk is not available. Vitamin D supplements should be included for the first year of life. Solid foods are added between four and six months of age as neuromuscular development and coordination allow safe swallowing of pureed foods. By 12 months the infant should be eating a variety of foods from all four food groups. Start with iron containing foods such as iron fortified infant cereal or meat. Cow’s milk (homo milk 3.5-4.0% fat) can be introduced at 9-12 months. Partly skimmed or 2% fat is not recommended in first 2 years. Do not feed an infant honey in the first 12 months due to the risk of botulism! Reference: www.uptodateonline.com • identify the major differences between human milk and commonly available formulas Reference: www.uptodateonline.com • describe the advantages of breast feeding and list the common difficulties experienced by breast-feeding mothers DIRECT INFANT BENEFITS: the direct benefits of human milk include improvement in gastrointestinal function and host defense, and prevention of acute illnesses during the time of breastfeeding. GI function: breast milk stimulates GI growth (maturation) and motility Host Defense: Increase the rate of gastric emptying, increase lactase activity in young infants, decrease intestinal permeability, host defence of IgA, IgG, lactoferrin, lysozyme, and WBC’s LONG-TERM INFANT BENEFITS: There is increasing evidence that breast milk has potential-long term benefits after the period of breastfeeding. These include possible reduction of acute illnesses (decreased respiratory and GI infections), decreased risk of specific chronic diseases, and improved neurodevelopmental outcome compared to formula-fed infants. Chronic disease — There are reported associations between the duration of breastfeeding and a reduction in incidence of obesity, cancer, adult coronary heart disease, certain allergic conditions, type 1 diabetes mellitus, and inflammatory bowel disease. Improved neurodevelopmental outcome: improved cognition and motor development. There is a positive relationship between the duration of breast feeding and cognition. MATERNAL BENEFIT: As with infants, breastfeeding provides direct clinical benefits to mothers during lactation and long-term benefits beyond the breastfeeding period. Lactation: • Acceleration of recovery from childbirth by oxytocin's action on uterine involution. Oxytocin secretion is stimulated by breastfeeding. • Reduction of maternal response to stress. It has been suggested that the neuroendocrine peptides, oxytocin and prolactin, are important components of the stress axis and have a positive impact on social behaviors including maternal- infant bonding. • Weight loss after pregnancy is enhanced by prolonged breastfeeding. • Prolongation of postpartum anovulation. Although breastfeeding prolongs anovulation, it should not be considered an entirely reliable means of contraception. Long-term benefits: Long-term benefits of breastfeeding for the mother include a decreased risk of developing breast cancer, ovarian cancer, and possibly, osteoporosis. Below is a list of the most common difficulties that many breastfeeding mothers experience. ENGORGEMENT — Engorgement refers to swelling of the breast and can occur early or late in the postpartum period. Early engorgement is secondary to edema, tissue swelling, and accumulated milk, while late engorgement is due solely to accumulated milk. Engorgement can be quite painful for some women, whose breasts become hard and warm to the touch. SORE NIPPLES — Nipple sensitivity increases during pregnancy and peaks on approximately the fourth postpartum day. Normal sensitivity can be distinguished from the pain due to nipple trauma by its time course. Normal sensitivity typically subsides approximately 30 seconds to one minute after suckling begins. In contrast, pain due to trauma persists at the same or an increasing level throughout the nursing episode. PLUGGED DUCTS — Plugged ducts are localized areas of milk stasis with distention of mammary tissue. Symptoms include a palpable lump with tenderness. They are distinguished from mastitis by the absence of signs of systemic infection such as fever >38.3º C, erythema, or myalgia. The etiology of plugged ducts is unknown. MASTITIS — Mastitis is an infection of the breast. It typically presents as a hard, red, tender, swollen area of one breast associated with fever >38.3º C. Other systemic complaints include myalgia, chills, malaise, and flu-like symptoms. Common etiologic agents include Staphylococcus aureus, streptococcus, and Escherichia coli. BREAST ABSCESS —Breast abscess is an uncommon problem in breast feeding women with a reported incidence of 0.1 percent. The presentation of breast abscess is similar to mastitis, with breast pain and systemic symptoms. A fluctuant mass is palpable. BLOODY NIPPLE DISCHARGE — A small percentage of women have bloody nipple discharge in the first few days postpartum, resulting in bright red colostrum (also known as "rusty pipe syndrome"). The condition is related to vascularization of ducts during pregnancy. It typically resolves within a few days. NIPPLE VASOCONSTRICTION — Women who have the Raynaud phenomenon or unusual cold sensitivity may develop cutaneous vasospasm of the nipple. BITING — After eruption of the primary teeth, which normally begins at six to ten months of age, biting during breastfeeding can cause trauma to the nipple. Mothers can usually teach their infants not to bite the nipple by immediately removing the breast from his or her mouth as soon as a bite begins and placing the infant immediately on a safe surface, such as a blanket on the floor. If the mother is consistent, the baby usually learns quickly not to bite. WEANING — Exclusive breastfeeding is recommended for the first six months after birth, and partial breastfeeding for at least 12 months, and thereafter for as long as mutually desired. The World Health Organization advises that partial breast feeding continue for up to two years, and beyond. Reference: www.uptodateonline.com Adolescent Issues • describe strategies for interviewing and counselling adolescents in contraception, STD, and risk taking behaviours. Physicians must proactively address sexuality with their patients. Sexual health “encompasses the absence of sexually transmitted diseases and reproductive disorders, control of fertility, avoidance of unwanted pregnancies, and sexual expression without exploitation, oppression, or abuse” Reference: Margaret, R.H., et al. The Proactive Sexual Health History. American Family Physician 2002, 66(9); 1705-12 -allocate time to discus sexual health during office visits -avoid judgmental attitudes and demonstrate empathy -questions about sexual health should be asked in a sensitive manner -do not make assumptions (ie. sexual orientation) -ensure confidentiality -provide a safe quiet location to talk to the patient -Practice -become comfortable with the topic of sex • if possible, describe pertinent features in the history and physical exam when evaluating a patient with delay in pubertal development. Tanner Stage 1 (Prepubertal) Males Height increases at basal rate: 5-6 cm/year Testes Smaller than 4 ml or long axis <2.5 cm Pubic Hair No coarse, pigmented hair Penis Stage No growth Tanner Stage 2 Height increases at basal rate: 5-6 cm/year Testes Size 4 ml or long axis 2.5 to 3.2 cm Age 11.5 years (age 9.5 to 13.5 years) Pubic Hair Minimal coarse, pigmented hair at base of penis Age 12.0 years (age 9.9 to 14.0 years) Penis Stage Earliest increased length and width Age 11.5 years (age 10.5-14.5 years) Tanner Stage 3 Height increases at accelerated rate: 7-8 cm/year Testes Size 12 ml or long axis 3.6 cm Age 14.0 years (11.5-16.5 years) Pubic Hair Coarse, dark curly hair spread over the pubis Age 13.1 years (11.2-15.0 years) Penis Stage Increased length and width Age 12.4 years (10.1-14.6 years) Other Changes Gynecomastia may occur (age 13.2 years) Voice breaks (age 13.5 years) Muscle mass increases Tanner Stage 4 Height increases at peak rate: 10 cm/year (age 13.8) Pubic Hair Hair of adult quality Not spread to junction of medial thigh with perineum Age 13.9 years (12.0-15.8 years) Penis Continued growth in length and width Age 13.2 years (11.2-15.3 years) Testes Length 4.1 to 4.5 cm Other Changes Axillary hair (age 14.0 years) Voice changes (age 14.1 years) Acne Vulgaris (age 14.3 years) Tanner Stage 5 No further height increases after age 17 years Pubic Hair Adult pubic hair distribution (15.3 years) Pubic hair spreads to medial thigh No hair spread to linea alba Penis Mature genital size by 16.5 years Testes Length >4.5 cm Secondary sexual characteristics Facial hair present on sides Mature male physique Gynecomastia disappears Growth in Boys Peak height velocity: Age 13.5 (11.7-15.3 years) Basal growth occurs up until Tanner Stage 3 Basal Growth rate: 5.0 to 6.0 cm per year Pubertal Growth Boys who mature average time: 9.5 (7.1-11.9) cm/yr Boys who mature early: 10.3 (7.9-12.5) cm/yr Boys who mature late: 8.5 (6.3-10.7) cm/yr Tanner Stage 1 (Prepubertal) Females Height increases at basal rate: 5-6 cm/year Breast Papilla elevation only Pubic Hair Villus hair only No coarse, pigmented hair Tanner Stage 2 Height increases at accelerated rate: 7-8 cm/year Breast Breast buds palpable and areolae enlarge Age 10.9 years (8.9-12.9 years) Pubic Hair Minimal coarse, pigmented hair mainly on labia Age 11.2 years (9.0-13.4 years) Modifications based on increasingly earlier Puberty White: Stage 2 changes may appear one year earlier Black: Stage 2 changes may appear two years earlier Tanner Stage 3 Height increases at peak rate: 8 cm/year (age 12.5) Breast Elevation of breast contour; areolae enlarge Age 11.9 years (9.9-13.9 years) Pubic Hair Dark, coarse, curly hair spreads over mons pubis Age 11.9 years (9.6-14.1 years) Other changes Axillary hair develops (13.1 years) Acne Vulgaris develops (13.2 years) Tanner Stage 4 Height increases at 7 cm/year Breast Areolae forms secondary mound on the breast Age: 12.9 years (10.5-15.3 years) Pubic Hair Hair of adult quality No spread to junction of medial thigh with perineum Age: 12.6 years (10.4-14.8 years) Tanner Stage 5 No further height increases after age 16 years Breast Adult breast contour Areola recesses to general contour of breast Pubic hair Adult distribution of hair Pubic hair spreads to medial thigh Pubic hair does not extend up linea alba Other Milestones Adrenarche: Age 6 to 8 years Menarche: Age 12.7 years (10.8-14.5 years) Delayed >1 year if low body fat (e.g. athlete) Growth in Girls Peak height velocity: 11.5 years (9.7-13.3 years) Basal growth occurs up until Tanner Stage 2 Basal Growth rate: 5.0 to 6.0 cm per year Pubertal Growth Girls who mature average time: 8.3 (6.1-10.4) cm/yr Girls who mature early: 9.0 (7.0-11.0) cm/yr Girls who mature late: 7.5 (5.4-9.6) cm/yr Delayed Adolescence in Phenotypic Male or Female Girls: Delayed breast development No breast development by age 14 years No breast development 5 years after Menarche No Menses by age 16 years (Primary Amenorrhea) Boys: Testicular length under 2.5 cm by age 14 years Genital growth not complete five years from start (Tanner, JM. Journal of Pediatrics 1985; 107(3): 317-29) • recognize psychosocial and mental health problems common in adolescents to include school failure, eating disorders, depression and suicide.
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