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AMBULATORY

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					  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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