Pediatrics 1

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Pediatrics 1
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Pediatrics 1
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  1. Newborn medical history
    • family history, prior and current pregnancies, and events of labor and delivery
    • A history of previous premature birth, intrauterine fetal death, multiple gestation, IUGR, congenital malformation, explained or unexplained neonatal death (e.g., group B streptococcal sepsis), birth trauma, preeclampsia, gestational diabetes, grand multipara status (five or more pregnancies), or cesarean section is associated with additional risk in subsequent pregnancies.
    • Pregnancy complications
    • Maternal medical complications
    • Obstetric complications (placenta previa, placental abruption, oligo- or polyhydramnios, hydrops, PROM or PPROM, preeclampsia, eclampsia)
  2. Components of the Perinatal History
    • Demographic Social Information: Age, Race, STIs, hepatitis, AIDS, Illicit drugs, cigarettes, ethanol, cocaine, Immune status (syphilis, rubella, hepatitis B, blood group), Occupational exposure
    • Past Medical Diseases: Chronic HTN, Heart disease, DM, Thyroid disorders, Hematologic/malignancy, Collagen-vascular disease (SLE), Genetic history-inborn errors of metabolism, bleeding, jaundice, Drug therapy
    • Prior Pregnancy: Abortion, Intrauterine fetal demise, Congenital malformation, Incompetent cervix, Birth weight, Prematurity, Twins, Blood group sensitization/neonatal jaundice, Hydrops, Infertility
    • Present Pregnancy: Current gestational age, Method of assessing gestational age, Fetal surveillance (OCT, NST, biophysical profile), Ultrasonography (anomalies, hydrops), Amniotic fluid analysis (L/S ratio), Oligohydramnios-polyhydramnios, Vaginal bleeding, Preterm labor, Premature (prolonged) rupture of membranes (duration), Preeclampsia, UTIs, Colonization status (herpes simplex, group B streptococcus), Medications/drugs, Acute medical illness/exposure to infectious agents, Fetal therapy
    • Labor And Delivery: Duration of labor, Presentation-vertex, breech, Vaginal versus cesarean section, Spontaneous labor versus augmented or induced with oxytocin (Pitocin), Forceps delivery, Presence of meconium-stained fluid, Maternal fever/amnionitis, Fetal heart rate patterns (distress), Scalp pH, Maternal analgesia, anesthesia, Nuchal cord, Apgar score/methods of resuscitation, Gestational age assessment, Growth status (AGA, LGA, SGA)
  3. Neonatology
    Care given until d/c from nursery
  4. Pediatrics
    Care from d/c until college physical
  5. Newborn period
    1st 28 days of life
  6. AGA (appropriate gestational age)
    Plotting of birth weight and gestational age appropriate
  7. SGA (small for gestational age)
    Symmetrical (head, length, and weight < 10th percentile) versus asymmetrical (only weight <10th Percentile)
  8. LGA (large for gestational age)
    nfants of diabetic mothers
  9. APGAR
    • HR: none (0), <100/min (1), >100/min (2)
    • Resp: None (0), Weak cry (1), Vigorous cry (2)
    • Muscle Tone: None (0), Some (1), Well flexed (2)
    • Reflex Irritability: None (0), Some (1), Cry/Withdrawal (2)
    • Color: Blue (0), Pink body blue extremities (1), Pink all over (2)
  10. Initial Evaluation and Care of the Newborn
    • Observation: activity, skin color
    • APGAR @ 1 & 5 min. 10 min score in depressed infants
    • Skeletal survey: obvious deformity; syndactyly, polydactyly, birth trauma, i.e. fx clavicle, Erb’s palsy
    • Umbilical cord: 2 arteries / 1 vein. 1% have 2 vessel cord; carries slight risk of vascular abnormalities
    • Placenta
    • Initial Care: Eye prophylaxis to prevent GC (erythromycin ointment within 1 hr of birth). Vitamin K 1mg IM within 4 hrs of birth, Blood glucose, Hepatitis B vaccination, Hearing screen, Cord blood (type, Coombs test), Newborn screen
    • Then to nursery: Skin, Auscultation (lungs & heart), Palpate abdomen, HEENT, Genitalia, Hips, Neurologic (tone, reflexes, symmetry of movements)
    • Discharge: 24 – 36 hrs safe for normal newborns, Feeds & voids well, Yellow stool, <10% weight loss, Bili level stable, F/U visit at 48-72 hrs must be insured
    • Severe cardiac defects & infection present in 6hr
    • Infants born to GBS+ mothers should be observed for 48 hrs
  11. Newborn Physical Exam: Skin
    • Bruising, petechiae
    • Meconium staining
    • Acrocyanosis
    • Pallor: anemia
    • Vernix caseosa: ↓ term
    • Lanugo: ↑ in pre-term
    • Peeling skin: post term
    • Hemangiomas
    • Nevus simplex (salmon patch)
    • Mongolian spot
    • LS spine hair tufts
    • Milia
    • Erythema toxicum
    • Seborrhea
    • Neonatal acne
  12. Newborn Physical Exam: Head
    • Cephalohematoma: contained in suture lines
    • Caput succedaneum: crosses suture lines
    • Fontanelles: anterior closes 4-24 mo; average is 1 year. posterior closes 2-4 mo.
    • Craniosynostosis: premature fusion of the sutures
    • Facial nerve palsy
  13. Newborn Physical Exam: Eyes
    • Sees light, shapes, and movement at 8 to 15”.
    • Subconjunctival hemorrhage.
    • Red reflex should be symmetric
    • Leukocoria: Cloudy cornea from cataracts or glaucoma.
    • White eye, cat eye: retinoblastoma
    • Nasolacrimal duct stenosis
    • Observe for ocular malalignment: intermittent strabismus is normal up to 6 months
  14. Newborn Physical Exam: Ears/ Nose
    • Malformed or mal-positioned ears
    • Hearing fully developed by 1 month
    • Examine nose for size and shape
    • Obligate nose breathers: check for patency
    • Choanal atresia
    • Newborn congestion
  15. Newborn Physical Exam: Mouth
    • Epstein’s pearls
    • Natal teeth
    • Thrush
    • Cleft lip / palate
    • Micrognathia: FAS, Pierre Robin syndrome
    • Macroglossia: Trisomy 21, Beckwith-Wiedemann
  16. Newborn Physical Exam: Neck
    • Common masses: branchial cleft cyst, anterior to SCM; thyroglossal duct cyst, midline; cystic hygroma, posterior to SCM
    • Congenital torticollis: identified by head tilt, shortened SCM, positioning, birth trauma
  17. Newborn Physical Exam: Lungs
    • Check breath sounds
    • Rales are not clinically significant in first hours of life
    • Signs of respiratory distress: tachypnea (>60), retractions, grunting
    • Periodic breathing: normal crescendo breathing followed by a brief apneic period
    • Common causes of respiratory distress in the newborn: Aspiration and TTN
    • Aspiration syndromes: meconium or blood (less common), increasing oxygen need, fetal distress, coarse breath sounds, suctioning of trachea and visualizing cords (severe cases)
    • Transient tachypnea of the newborn (TTN): retained secretions, usually resolves in 24-36 hrs
  18. Newborn Physical Exam: Heart
    • Murmurs commonly present in first few days of life
    • usually transient and due to closure of ductus, pulmonary artery stenosis or small VSD
    • Congenital heart disease (CHD) present in 0.8% of infants
    • presentations are cyanotic or acyanotic
    • Irregular rate (due to PACs) not uncommon in first few days of life
  19. Newborn Physical Exam: Abdomen
    • Check for softness, distention, bowel sounds
    • Attempt to palpate kidneys
    • Liver and spleen usually palpable
    • Common abnormalities: esophageal atresia, tracheoesophageal fistula, obstruction, abdominal wall defects, umbilical hernia, GERD
    • Tracheoesophageal fistula: newborn has excessive drooling and choking with attempted feeding, respiratory distress may also be common. Diagnosis made with CXR after placement of nasogastric tube. Surgical treatment required
    • Obstruction
    • Volvulus
    • Hirschsprung disease: Congenital absence of intramural colonic ganglion cells in rectosigmoid. Inability of bowel complex to relax causes functional bowel obstruction. Presents in 1st 24-48 hrs with failure to pass meconium, abdominal distention, and bilious vomiting. Diagnosis requires rectal biopsy
    • Omphalocele: liver & stomach covered by peritoneum at the umbilical orifice.
    • Gastroschisis: abdominal wall defect to right of umbilicus. Intestines/stomach/bladder/liver are outside the peritoneal cavity
    • Umbilical hernia: Incomplete closure of fascial umbilical ring. Found in up to 40% of black infants. Defects < 1. 5 cm usually close by age 5, Defects > 1. 5 cm at 2 years of age, or signs of incarceration surgically closed. Check frequently for easy reduction. coin taping does not help
  20. Newborn Physical Exam: Genitalia
    • Labial adhesion
    • Vaginal discharge: blood may also be present
    • Testicles descended
    • Hydrocele
    • Hypospadias
    • Circumcision
  21. Newborn Physical Exam: Musculoskeletal
    • Clavicle fracture
    • Erb’s palsy
    • Congenital hip dislocation
    • Talipes equinovarus, metatarsus adductus
    • Tibial torsion
    • Syndactyly, polydactyly
    • Tests for Developmental Dysplasia of the Hip (DDH)
    • Barlow: attempts to dislocate an unstable hip. Infant’s thigh is adducted with gentle, downward pressure.
    • Ortolani: will reduce a dislocated hip. Infant’s hip is abducted while anterior pressure is applied to posterior thigh
  22. Newborn Physical Exam: Neurologic
    • Normal flexion of extremities
    • Look for symmetry and spontaneous recoil
    • Character of cry
    • Reflexes: Rooting, Sucking, Palmar grasp (up to 4 mo), Moro or startle reflex (up to 3-6 mo), Babinski (upgoing toes normal until age 2 yrs)
  23. Newborn Vital Signs
    • HR: 120-160
    • RR: 30-60
    • BP: 50-70 systolic
    • Record & plot Ht, Wt, HC
    • BW ↓ 8-10% in 1st 24 hr
    • Regain BW by 2 weeks
  24. Common Abnormalities in Newborns
    • 4 days after birth, tremors at rest signal CNS disease from various possible causes (asphyxia, drug withdrawal)
    • Asymmetric movements of arms or legs: central or peripheral neurological deficits, birth injury (fractured clavicle or brachial plexus injury), or congenital anomalies
    • Visual or hearing deficit
    • Small head
    • Large head
    • Failure to thrive is inadequate weight gain for age.
    • Fever
    • Tachypnea and increased respiratory effort in an infant are signs of possible pneumonia
    • Midline hair tufts over the lumbosacral spine region suggest a spinal cord defect.
    • Jaundice
    • Significant edema of the hands and feet of a newborn girl may be suggestive of Turner's syndrome.
    • Dehydration is a common problem in infants. Usual causes are insufficient intake or excess loss of fluids from diarrhea.
    • Macroglossia
  25. Neonatal jaundice
    • 65% develop jaundice in 1st week
    • jaundice in 1st 24 hrs is not normal: sepsis, hemolytic anemia
    • jaundice that appears on days 2-3 and disappears by day 5 is physiologic; breast fed infants at increased risk
    • Clinical jaundice c/w bilirubin > 5 mg/dL
    • Most caused by unconjugated bilirubin
    • Starts at head and moves down
    • Neurotoxicity: kernicterus at levels > 25mg/dL
    • Sx: lethargy, hypotonia, poor suck, high pitch cry
    • ↑ conjugated bilirubin: think biliary atresia
  26. Hypoglycemia
    • Defined as glucose < 35 – 40 mg/dL
    • By age 3 hr glucose should be 50 – 80 mg/dL
    • Risks: IDM (infants of diabetic mothers), IUGR, infection, prematurity
    • Sx: lethargy, poor feeding, irritability, jitteriness (also seen with hypocalcemia), seizures
    • Rx: IV glucose D10W @ 2ml/kg
  27. Infections
    • transplacental
    • ascending (after rupture of membranes)
    • passage through infected birth canal
    • Bacterial infections: sepsis, pneumonia, meningitis, UTIs, omphalitis
    • Congenital infections: CMV, rubella, varicella, toxoplasmosis, syphilis, TB
    • Perinatal viral infections: HSV, hepatitis B, C
  28. Neonatal Hyperbilirubinemia
    • Unconjugated hyperbilirubinemia
    • Physiologic: Unknown and/or multiple causes
    • risks for physiologic jaundice: Asian>white>black infants, prematurity, sibling with hyperbilirubinemia, breast feeding, breast milk jaundice (rare), breast feeding-associated jaundice (common)
    • treatment: phototherapy, Unconjugated bilirubin in skin converted to water soluble isomers that are excreted without conjugation
    • Pathologic: Increased Production, results from increase in RBC destruction -antibody mediated hemolysis (Coombs +), ABO incompatibility (fairly common), Rh isoimmunization (uncommon)
  29. Term
    38 – 42 weeks
  30. Perinatal mortality:
    20 wk gestation to 7 days after birth
  31. Neonatal mortality:
    Infant death from birth until 28th day
  32. Post natal period:
    28th day to end of 1st yr
  33. Infant mortality rate:
    Neonatal + postnatal
  34. Infant Weight
    • Weight loss in first few days: 5-10% of birth weight
    • Return to birth weight: 7-10 days of age
    • Double birth weight: 4-5 months
    • Triple birth weight: 1 year
    • Quadruple birth weight: 2 year
  35. Average weights:
    • 3.5 kg at birth
    • 10 kg at 1 year
    • 20 kg at 5 years
    • 30 kg and 10 years
  36. Daily weight gain
    • 20-30 g for first 3-4 months
    • 15-20 g for rest of first year
  37. Average annual weight gain:
    5 lbs between 2 years and puberty (spurts and plateaus may occur)
  38. Height
    • Average length: 20 in at birth, 30 in at 1 year
    • A child’s growth velocity slows significantly around the first birthday.
    • At age 3 year: average child is 3 ft tall
    • Age 4 years: average child 40 in tall (double birth length)
    • Average annual height increase: 2-3 in between age 4 yr and puberty
    • Small growth spurts are common
  39. Head Circumference
    • Average HC: 35 cm at birth
    • HC increases: 1 cm/ mo for first year (2 cm/ mo for first 3 mo, then slower); 10 cm for rest of life
  40. Caloric needs:
    • During the first 6 months of life, infants require 110–120 kcal/kg/day for growth.
    • By 1 year of age, daily caloric needs decrease to ~100 kcal/kg.
  41. Rule of Three:
    3 yrs, 3 ft, 33 lbs.
  42. Motor Milestones
    • 2 months: able to lift head up on his own
    • 3 months: can roll over
    • 4 months: can sit propped up without falling over
    • 6 months: is able to sit up without support
    • 7 months: begins to stand while holding on to things for support
    • 9 months: can begin to walk, still using support
    • 10 months: is able to momentarily stand on her own without support
    • 11 months: can stand alone with more confidence
    • 12 months: begin walking alone without support
    • 14 months: can walk backward without support
    • 17 months: can walk up steps with little or no support
    • 18 months: able to manipulate objects with feet while walking, such as kicking a ball
  43. Language
    • 3 months: markedly less crying than at 8 weeks; when talked to and nodded at, smiles, followed by squealing-gurgling sounds, usually called cooing, which is vowel-like in character and pitch-modulated; sustains cooling for 15-20 seconds
    • 4 months: responds to human sounds more definitely; turns head; eyes seem to search for speaker; occasionally some chuckling sounds
    • 5 months: the vowel-like cooing sounds begin to be interspersed with more consonantal sounds… acoustically, all vocalizations are very different from the sounds of the mature language of the environment
    • 6 months: cooing changes into babbling resembling one-syllable utterances; neither vowels nor consonants have very fixed recurrences; most common utterances sound somewhat like ma, mu, da, di
    • 8 months: reduplication for more continuous repetition becomes frequent; intonation patterns become distinct; utterances can signal emphasis and emotions
    • 10 months: Vocalizations are mixed with sound-play such as gurgling or bubble-blowing appears to wish to imitate sounds, but the imitations are never quite successful; beginning to differentiate between words heard by making differential adjustments
    • 12 months: identical sound sequences are replicated with higher relative frequency of occurrence and words (mama or dada) are emerging; definite signs of understanding some words and simple commands (show me your eyes)
    • 18 months: has a definite repertoire of words—more than three, but less than 50; still much babbling but now of several syllables with intricate intonation patterns; no attempt at communicating information and no frustration for not being understood; words may include items such as “thank you” or “come here,” but there is little ability to join any of the lexical items into spontaneous two-item phrases; understanding is progressing rapidly
    • 24 months: vocabulary of more than 50 items (some children seem to be able to name everything in the environment); begins spontaneously to join vocabulary items into two-word phrases; all phrases appear to be own creations; definite increase in communicative behavior and interest in language
    • 30 months: fastest increase in vocabulary with many new additions every day; no babbling at all; utterances have communicative intent; frustrated if not understood by adults; utterances consist of at least 2 words; many have 3 or even 5 words; sentences and phrases have characteristic child grammar; that is, they are rarely verbatim repetitions of an adult utterance; intelligibility is not very good yet, though there is great variation among children; seems to understand everything that is said to him
  44. Piaget’s Theory of Cognitive Development
    • Sensorimotor (0-2 years): The infant explores the world through direct sensory and motor contact. Object permanence and separation anxiety develop during this stage.
    • Preoperational (2-6 years): the child uses symbols (words and images) to represent objects but does not reason logically. The child also has the ability to pretend. During this stage, the child is egocentric.
    • Concrete operational (7-12 years): The child can think logically about concrete objects and can thus add and subtract. The child also understands conservation.
    • Formal operational (12 years- adults): The adolescent can reason abstractly and think in hypothetical terms.
  45. Cognitive: Assimilation
    • fit practice to theory
    • Complex but familiar external objects are simplified to fit pre-existent categories in your head
  46. Cognitive: Accommodation
    • fit theory to practice
    • You have to change the ideas in your head to fit the realities of external objects
  47. Stages of Play
    • Solitary play: alone and unaware of other children
    • Onlooker play: watch other children
    • Parallel play: alongside, but don’t interact with other children
    • Associative play: interact and share, but not playing the same game
    • Cooperative play: play together, help, take turns, games with rules
  48. Developmental surveillance
    informal process done at every office visit comparing skill levels to lists of mile-stones
  49. Developmental screening:
    • American Academy of Peds recommends screening at 9 months, 18 months, and 30 months
    • General screening tests: cover all behavioral domains
    • Targeted screens: focus on one area of development
    • Denver Developmental Screening Test II: assesses development of children from birth- 6 yrs in 4 domains (Personal-social, Fine motor-adaptive, Language, Gross motor)
    • Autism Screening Questionnaire: Modified Checklist for Autism in Toddlers (M-CHAT)
    • Language Screening: correlates best with cognitive development in the early years
    • Parent: Ages and Stages Questionnaires, Child Development Inventories, Parents’ Evaluations of Developmental Status
  50. Thomas and Chess studied nine behaviors in children in order to understand temperament.
    • Activity: the amount of physical activity present during the day
    • Rhythmicity: the extent to which patterns of eating, sleeping, and elimination are consistent or inconsistent from day to day
    • Approach or withdrawal: reaction to novel situations
    • Adaptability: the ease of changing behavior in a socially desirable direction
    • Threshold of responsiveness: the degree to which the person response to light, sound, etc. How much does it take to get you to respond.
    • Intensity of reaction: the amount of energy exhibited an emotional reactions. How big is your reaction.
    • Quality of mood: the quality of emotional expression either positive or negative
    • Distractibility: the ease of being interrupted by sounds, light, or unrelated behavior
    • Attention span and persistence: the extent of continuation of behavior without interruption
  51. Temperament Types
    • Easy (40%): regular, positive approach to new things, adaptable, mild to moderate mood intensity, mainly positive mood, usually a joy
    • Difficult (10%): irregular, negative withdrawal, non-adaptable, intense moods that are often negative
    • Slow to Warm Up ( 15%): mildly intense negative responses, slow adaptability
  52. Colic and Crying
    • Less than 5% of infants evaluated for excessive crying have an organic etiology.
    • Girls and boys are affected equally.
    • The family should be asked first to describe the crying, including duration, frequency, intensity, and modifiability.
    • Does the infant have associated symptoms, such as pulling up of the legs, facial grimacing, vomiting, or back arching?
    • When did the crying first begin?
    • Has the crying changed?
    • Does anything relieve the crying?
    • Does anything exacerbate the crying?
    • Is there a diurnal pattern to the crying?
    • A review of systems is essential because crying in an infant is a systemic symptom that can herald disease in any organ system.
    • Past medical history also is important because infants with perinatal problems are at increased risk for neurologic causes of crying.
    • Attention to the feeding history is crucial because some causes of crying are related to feeding problems, including hunger, air swallowing (worsened by crying), gastroesophageal reflux, and food intolerance.
    • Questions concerning the family's ability to handle the stress of the infant's crying and their knowledge of infant soothing strategies assist the clinician in assessing risk for mental health comorbidities and developing an intervention plan suitable for the family.
    • Babies spend a lot of time fussing and crying, but it gradually decreases
    • 6 to 8 week old babies have a fussy period toward the end of the day that gradually disappears by 12 weeks
    • Babies need to develop their own means of comforting themselves and need help to do this- thumbs, pacifiers, “lovey”, positioning
    • Advise parents to do what they can for the baby then soothe or leave the baby alone.
    • Crying is an important form of infant communication
    • Over stimulating a baby or too much handling can prolong fussing
    • Crying after the first year of age to demand attention is a red flag for behavior problems in the future
    • Diagnosed using rule of threes—crying for more than 3 hours per day, for more than 3 days per week, for more than 3 weeks
  53. Feeding disorders
    • A child’s desire to become more independent during early toddlerhood frequently leads to struggles with parents at mealtime. Many children are more interested in playing and exploring their environment than with eating, which may lead to parental concern that their child’s consumption is insufficient.
    • Many parents complain that their children are “picky eaters.” For most children, this is normal. Few toddlers eat well at all meals, yet most will consume an appropriate variety of foods over time.
    • Young children frequently cycle through favorite foods, eating them almost exclusively before tiring of them. Parents should be counseled that most children will again accept these foods if reintroduced at a later time.
    • Parents should offer three meals and two to three snacks each day, making sure to offer a variety of developmentally appropriate foods.
    • At least 2 hours should pass between feedings. If children are allowed to “graze,” or snack more frequently, they often are not hungry at meal time.
    • Children should sit at the table in a high chair or a chair with a booster seat.
    • Parents should eat at the table with their children to provide models for good eating behavior.
    • Finger foods and child-sized utensils are ideal.
    • Young children are often messy eaters. They enjoy touching and playing with their food. Some families may prefer to place a plastic drop cloth under their children’s high chairs to expedite cleaning. Parents should be encouraged to wait until after dinner to bathe their children.
    • Parents must avoid nagging their children to eat. If they engage in battles with their children over food, they will lose.
    • Do not use desserts or sweets as a reward for eating other foods.
    • Televisions and videotapes should be turned off to minimize distractions.
  54. Feeding RED FLAGS
    • Toddlers who are not eating foods with complex textures, such as meats or stews, should be referred to a speech therapist for an oromotor assessment. Some children with very specific food preferences may also exhibit other behaviors suggesting a pervasive developmental disorder; thus, a complete developmental screening is indicated.
    • Children with pica are at high risk of iron-deficiency anemia and lead toxicity.
    • Although young children typically prefer a more limited variety of foods than adults, healthcare providers must ensure that a child’s food choice is not excessively limited.
  55. Brazelton’s States of Consciousness in Babies
    • Deep sleep
    • Light or REM sleep
    • Indeterminate state- rousing and returning to sleep
    • Wide awake, alert state
    • Fussy, alert state
    • Crying
  56. Childhood Sleep Patterns
    • Newborns: 16 hours per day, 2 to 4 hours at a time
    • 3 to 4 month olds: 4 to 8 hours at a time
    • 6 to 8 month olds: 8 to 12 hours at night and two 2-hour naps
    • 12 month olds: about 14 hours per day, still napping
    • The transition to only an afternoon nap happens around 15 months of age
    • Two-year-olds: 11-12 hours at night and two 2-hour naps
    • Most children nap until three years of age and most stop by five years of age
    • Five-year-olds: 11 hours at night
    • Preadolescents: 10 hours a night
    • Adolescents: Try to get adolescents to sleep 6 to 8 hours if you can. They need about 9 hrs but get 6-7 hrs which builds up sleep deprivation. Burn out melatonin as they get older. Need to get bright lights off (cell phones, etc).
  57. Sleeping Through the Night
    • 70% by three months of age
    • 83% by six months of age
    • 90% by 12 months of age
  58. Ways to Help with Sleep
    • Teach self-comforting
    • Bedtime routines
    • Prevent the child from getting too tired
    • Be firm
    • Try not to be part of the child’s process of going to sleep
  59. Sleep Problems of Older Children
    • Resistance to going to sleep
    • Restlessness
    • Nightmares
    • Sleepwalking
    • Sleep talking
    • Night terrors
    • Insomnia
    • Increased sleeping
  60. Parasomnias
    • Parasomnias include night terrors, sleepwalking, and sleep talk and involve movement from stage 3 or 4 sleep into REM.
    • Night terrors are common, occur in preschool children, and are likely to resolve with time and developmental maturation.
    • Night terrors are differentiated from nightmares, which occur later in the night and result from arousal from REM or dreaming sleep.
    • Children typically remember their nightmares, but have no recollection of night terrors.
    • Parents often report distress at their child's night terrors because the child may scream and not recognize them during the episode.
    • Night terrors are best managed by minimal intervention. The child can be laid down and quietly comforted.
  61. Circadian Rhythm Disorder
    • Circadian rhythm disorder in adolescence is caused by irregularities in sleep hygiene and leads to delayed sleep phase syndrome.
    • Many adolescents stay up late and sleep 7 hours or less a night during the week with attempts to recoup lost sleep on the weekend.
    • This schedule disrupts the biologic clock.
    • Teens then develop bedtime insomnia and difficulty maintaining sleep during the night with inability to arouse in the morning.
    • Sleep deprivation leads to cognitive problems and problems of emotional regulation.
    • Circadian rhythm disorder in adolescents can be treated by meticulous attention to sleep hygiene and gradual resetting of the biologic clock.
    • Melatonin (dose 2.5 to 10 mg) has soporific properties useful in treating delayed sleep phase syndrome. Developmentally normal and developmentally delayed children have been treated successfully with melatonin for difficulty falling asleep.
  62. Temper Tantrums
    • Most common in 2 to 4-year-olds and most outgrow it
    • A problem if it becomes the child’s favorite means of problem-solving
    • The evaluation of a child who is having temper tantrums requires a complete history, including perinatal and developmental information.
    • Describing behavioral patterns can aid in the identification of a genetic disorder.
    • Careful attention to the child's daily routines may reveal problems associated with hunger, fatigue, inadequate physical activity, or overstimulation.
    • A social history is important because family stress can exacerbate or prolong what begins as a normal developmental phase.
    • When this normal behavior is frequent or occurs beyond age 3, the possibility of family stress or conditions that reinforce the tantrum behavior should be considered.
    • Some children may be exposed to violence in the home and may be exhibiting learned behavior.
    • The coexistence of other behavioral problems, such as sleep problems, learning problems, and social problems, suggests the possibility of a more serious mental health disorder.
  63. Temper Tantrum Differential Diagnoses
    • Most children who have temper tantrums have no underlying medical problem.
    • In rare instances, seizures may mimic a tantrum.
    • Hearing loss and language delay are associated with temper tantrums.
    • Children with brain injury and other brain disorders are at increased risk for prolonged temper tantrum behavior (in terms of actual tantrum duration and continued manifestation after the normal tantrum age).
    • These children include former premature infants and children with autism, traumatic brain injury, cognitive impairment, and Prader-Willi and Smith-Magenis syndromes.
    • Children with rare conditions, such as congenital adrenal hyperplasia and precocious puberty, also may present with severe and persistent tantrums.
  64. Stages of a Tantrum
    • Grumbly, grouchy, tense, moody: a slight provocation leads to an outburst
    • No! No! No!: tantrum runs down at this point
    • Leave me alone!
    • “Hangover”: child looks tired, but returns to “normal”
  65. Prevention of Tantrums
    • Parental example of good anger management
    • Warn child about looking angry
    • Help child relax
    • Attend to physiological needs (hungry, tired)
    • Teach other ways to vent or express anger
    • Regular routines for sleeping, eating, and physical activity in a childproofed home (or daycare center) provided by well-rested and psychologically healthy parents (or caregivers) usually result in a quick transition through this challenging period.
  66. What to do During a Tantrum
    • IGNORE!
    • Separate from the child
    • Avoid rewarding the tantrum
    • Reward calm behavior
  67. Toilet Training
    • Most children are toilet trained between the ages of two and three
    • Tends to go more smoothly if parents wait until the child is ready
    • Signs of readiness: discomfort with the dirty diaper, staying dry for two hours straight, showing interest in the toilet
    • Toileting problems: daytime enuresis, nocturnal enuresis, encopresis
    • Prerequisites for achieving elimination in the toilet 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.
    • The entire process of toilet training can take 6 months and need not be hurried.
  68. Daytime Enuresis
    • Two types- physiological and psychological
    • First evaluate for a physiological problem (urinary tract infection, bladder problem, etc.)
    • If no physiological problem is present, wetting may be part of a larger behavior problem
  69. Nocturnal Enuresis
    • Fairly common until four or five years of age
    • 75% of four-year-olds are dry at night
    • 1% to 2% of adolescents and adults are not dry at night
    • Most bedwetting will stop no matter what is done
    • Most are deep sleepers
    • Treatment can include medication and alarm training
  70. Encopresis
    • Encopresis is the regular, voluntary or involuntary passage of feces into a place other than the toilet after 4 years of age.
    • Encopresis without constipation is uncommon and may be a symptom of oppositional defiant disorder or other psychiatric illness.
    • Soiling is the involuntary passage of stool and often is associated with fecal impaction.
    • The normal frequency of bowel movements declines between birth and 4 years of age, beginning with greater than four stools per day to approximately one per day.
    • Most is not caused by psychiatric problems
    • Most commonly begins with an episode of constipation followed by a blockage of stool in the colon
    • Blockage in the colon leads to the death of nerve cells in the bowel and loss of sensation
    • Loss of sensation can lead to leakage and accidents
    • Important to avoid negative consequences that could lead the child to hide evidence of accidents
    • Treatment involves: clean out, use of diet and laxatives to prevent further constipation
    • The child may require a program of scheduled times to sit on the toilet and rewards for doing so
    • Treatment usually results in slow but steady improvement
  71. 3 Kinds of Disobedience
    • Passive resistance: pouting, whining, delaying
    • Defiance: arguing, tantrums
    • Spiteful: does the opposite
  72. Causes of Disobedience
    • Inappropriate, lax, or inconsistent discipline
    • Parental stress
    • Negative parental attitude toward authority
    • Child is tired, hungry, or upset- “arsenic hour”
  73. Prevention of Disobedience
    • Clear, fair expectations and swift consequences
    • Give appropriate choices
    • Use rewards for compliance
    • Have a strong relationship with the child
    • Know how to use time-out appropriately
    • Ignore misbehavior when possible
  74. Moral Development
    • Obedience and punishment (might makes right): obey to avoid punishment
    • Instrumental orientation: okay to get rewards
    • Good boy/nice girl: conform to seek approval
    • Law and order: conform blindly to social conventions and rules
    • Social contract: individual rights. Laws are social contract and people can agree to change them
    • Universal ethical principles: decisions based on personal beliefs and abstract principles. Conform to avoid self-condemnation
  75. Methods to Establish and Maintain Breast Milk Supply
    • Baby to breast within 1-2 hours post birth
    • babies are awake and alert and searching for the breast
    • skin-to-skin: important
    • deep sleep state – may last 24 hrs
    • encourage feeding 8-12 times/24 hrs
    • cluster feeding may occur
    • deep latch/listen for swallows
    • Average feeding is 20-40 minutes of active sucking and swallowing
    • Frequent feedings stimulate the body to transition colostrum to milk by day #3-4
    • Family education, support, and encouragement is key
  76. Foremilk:
    • high in volume, low in fat
    • As feeding progresses, fat content of milk rises steadily
  77. Hindmilk
    • end of feeding; low in volume but high in fat
    • Allow infant to finish first breast before switching to second breast
  78. Advantages of Breast Feeding
    • Infant: Decreases incidence or severity of diarrhea, respiratory illnesses, OM, bacteremia, bacterial meningitis, and necrotizing enterocolitis
    • Mothers experience decreased risk of postpartum hemorrhage, longer period of amenorrhea, reduced risk of ovarian and premenopausal breast cancers, and possibly reduced risk of osteoporosis
    • Societal advantages: reduced health care costs b/c of lower incidence of illness in breastfed infants and reduced employee absenteeism for care attributable to infant illness
    • May reduce incidence of food allergies and eczema
    • Contains protective bacterial and viral Abs (secretory IgA) and nonspecific immune factors, including macrophages and nucleotides, which help limit infections
  79. Breast Engorgement: Onset may be gradual, immediately post-partum, Bilateral, Generalized heat and swelling, Generalized pain, Maternal temperature : <38.4 (101 F )
    Treatment: heat prior to feeding, breastfeed, or pump, ice post feeding, cabbage leaves
  80. Sore Nipples
    • Some nipple tenderness may be normal
    • Persistent nipple soreness and pain not normal
    • Positioning
    • Correct latch
    • Begin feed on least sore side
    • Hydrogel dressings / breast shells
  81. Plugged Ducts
    • Onset gradual
    • Unilateral
    • May be little or no heat; swelling may shift
    • Pain is mild, but localized
    • Maternal temperature: < 38.4 C
    • Treatment: heat/massage/nurse
  82. Mastitis
    • Onset: sudden or gradual – after 10 days
    • Unilateral
    • Localized edema, heat, erythema
    • Pain: intense but localized
    • Maternal temperature: >38.4
    • Flu-like systems
    • Treatment: breastfeed/pump/rest/fluids/antibiotics (Dicloxicillanm, Oxacillin, First-generation cephalosporin, Erythromycin)
  83. Yeast Infection
    • Nipples that are persistently sore
    • Unresponsive to position changes, sucking corrections, or nipple creams
    • Pinkish-red appearance with shiny nipples/areola; White plaques on nipples
    • Treatment: Mother and baby should be treated simultaneously. Antifungal preparations – miconazole, clotrimazole, nystatin, gentian violet. Diflucan
  84. Adequacy of Milk Supply Assessed By Voiding and Stooling Patterns Of Infant
    • well-hydrated infant voids 6-8x daily
    • each voiding should soak (not just moisten) diaper and urine should be colorless
    • by 5-7 days, loose yellow stools should be passed at least 4x daily
    • Rate of weight gain provides most objective indicator of adequate milk intake
    • Total weight loss after birth should not exceed 7%, and birth weight should be regained by 10 days
    • Mean feeding frequency during early weeks postpartum: 8-12x daily
  85. Supplemental Feeding: “Complementary Foods”
    • By approx 6 months, complementary feeding of semisolid foods is suggested
    • By this age, an exclusively breastfed infant requires additional sources of several nutrients: protein, iron, zinc
    • If introduction of solid foods is delayed, nutritional deficiencies can develop, and oral sensory issues may occur
    • General signs of readiness include ability to hold head up and sit unassisted, bringing objects to mouth, showing interest in foods, and ability to track spoon and open mouth
    • Relatively high-fat and calorically dense diet is needed to deliver adequate calories
    • Can use vitamin-fortified and iron-fortified dry cereals for calories and micronutrients (esp. iron)
    • Single-grain cereals (rice, oatmeal, barley) are recommended as starting cereals to help ID allergies or food intolerances; new foods every week
    • Can also introduce pureed fruits, veggies, and meats
  86. Weaning
    • American Academy of Pediatrics recommends breastfeeding for at least 1 year (solely breast milk till 6 months, then start breast milk + complementary foods)
    • Proceed slowly, regardless of the age of your child.
    • Experts advise that you not abruptly withhold your breast, which can be traumatic.
    • Skip a feeding. Skip a feeding and see what happens. Offer a cup or bottle of milk instead. As a substitute you can use your own pumped milk, formula, or cows' milk (if your child is at least a year old). If you reduce feedings one at a time over a period of weeks your child will have time to adjust to the changes. Your milk supply will also diminish, without leaving your breasts engorged or giving you mastitis, a breast infection.
    • Shorten nursing time. Start by cutting the length of time your child is actually on the breast. If he usually nurses for five minutes, try three. Depending on his age, follow the feeding with a healthy snack such as unsweetened applesauce or a cup of milk or formula. (Note, however, that babies younger than 6 months may not be ready for solids.) Bedtime feedings may be harder to curb — they're usually the last to go.
    • Postpone and distract. Try postponing feedings if you're only nursing a couple of times a day. This method works well if you have an older child you can reason with. If your child asks for the breast, say you'll feed him later and distract him. Instead of nursing in the early evening, you could tell him to wait until bedtime.
  87. Breast Anatomy
    • Glandular Tissue: makes/transports milk
    • Connective Tissue: supports breast
    • Blood: nourishes breast
    • Lymph: waste removal
    • Nerves: makes breast sensitive to touch/stimulates release of hormones triggering let-down/milk-ejection reflex
    • Adipose: protection from injury
  88. Hormonal Influences on the Breast
    • Estrogen: stimulates ductal system to grow levels drop at delivery
    • Progesterone: Increase in pregnancy: growth and size of alveoli/lobes; drop at delivery/triggers milk
    • Human Placental Lactogen: instrumental in breast/nipple/areolar growth before birth
    • Prolactin: Increase contributes to accelerated growth of alveoli
    • Oxytocin: contracts smooth muscle layer of cells surrounding the alveoli to squeeze milk into ductal system
  89. Colostrum:
    • precursor to milk
    • protein and antibody rich
    • 5-10 milliliters/feeding
  90. Milk:
    • transitions in between 2-4 days pp
    • volume increases quickly
    • 750ml – 1000ml/24 hrs by 10-14 days pp
  91. Near-term / Pre-term infant : 34-38 weeks
    • 34-37 weeks: full-term nursery or ICN
    • Effective breastfeeding may not occur or is inconsistent
    • Supplementation at breast or with alternative feeding method
    • Support and encouragement
    • Feedings improve as infant matures developmentally
  92. ICN/PICU/SCN: mom is pumping to provide milk
    • Pre-term breast milk uniquely suited for preterm baby
    • Initiate pumping within 6-8 hours after delivery
    • Pump every 3 hours around the clock while establishing supply
    • Collaboration with pediatric team, support services, individualized feeding plan once going to the breast
  93. Ineffective/non-nutritive breastfeeding
    • Mom does not feel strong tug on nipple
    • Immature suck pattern
    • No audible swallows when feeding
    • Baby falls asleep at breast after 5-10 minutes
    • Lactation consult / feeding plan
  94. Breast Reduction
    • May impact ability to breastfeed
    • Counseling related to potential impact
    • Different options: individualized
    • Supplementation may be necessary
    • Close follow-up
    • Engorgement may be an issue
  95. Breast Augmentation
    • Breast augmentation done for variety of reasons
    • Lactation success will depend on surgical technique used
    • Potential for nerve disruption and pressure from implant
    • Close follow-up needed; observe for engorgement
  96. Pediatric Growth
    • Plot at each visit (BMI ≥ 2 years)
    • HC until 2 years
    • Consider family Hx
    • Growth delay: thyroid, renal, anemia, infection, malabsorption, growth hormone, collagen vascular disease, leukemia
  97. Pediatric Development
    • Evaluate at each visit; screen at selected visits
    • Medicaid requires for periodic/annual visits up to age 6
    • Observation; in older children ask about school performance, future aspirations
    • Parental reports of milestones
  98. Screen for obesity by measuring BMI
    • USPSTF recommends in children >6
    • AAP recommends annually
    • Children with BMI≥ 95th percentile should receive intensive counseling, behavioral therapy
  99. Vitamin D
    Children should receive 400 IU of vitamin D daily
  100. Fluoride
    Children living in areas with inadequate fluoride in their water supply (<0.6ppm) should take a daily fluoride supplement
  101. Immunizations
    • Age-appropriate immunizations (including catch-up immunizations if applicable) should be given
    • 97% of children immunized by school entry
  102. Testicular exams and scoliosis screening
    No longer recommended.
  103. Autism
    AAP recommends autism screening at 18 months
  104. Anticipatory Guidance: Safety
    • The Injury Prevention Program: TIPP
    • #1 cause of death > 1y
    • Bicycle helmet
    • Firearms
    • Drowning
    • Choking: BLS
    • Poison
    • Burns, water temp 120
    • Car seats
  105. Car seats:
    • < 20#: rear facing seat
    • 20-40#: front facing
    • 40-60# booster seat
    • > 60# lap belt
    • 4’: regular shoulder/lap belt
  106. Anemia
    • done at least once between 12 & 24 months
    • screen adolescents after onset of menses
    • Iron deficiency is the most common cause
    • Risk: LBW, cow’s milk, anemic mother
    • Sx: Developmental & behavior deficits
    • Prevention: Fe fortified cereal/formula, limit cow’s milk to less than 24oz/d, & only after 1y/o
    • Minimum screen @ 12-24 months, 4-6 y/o, and menstruating females
    • Rx: Fe 4mg/kg/d
    • SE: taste, constipation
  107. Lead
    • done at least once between 12 & 24 months
    • questionnaire
    • Infants at high risk for exposure
    • Source: lead based paint and gas
    • Medical emergency lead> 70µg/dL
    • Lead > 55 µg/dL: colic, nausea, myalgia, seizures, HA, anemia
    • Lead >10µg/dL: decreased IQ; academic difficulties
    • Acceptable level < 10
    • Consider chelation >25
    • Screen between 12 and 24 months
  108. Lipids
    • AAP recommends screening at 6 and 8 years of age and then annually beginning at 10 years.
    • USPSTF and AAFP: “insufficient evidence” to support routine screening in pediatric patients
    • Children & adolescents with a family history of CAD and/or dyslipidemia warrant screening
    • Children with a personal history of obesity, hypertension and/or diabetes should be screened as well
  109. TB
    • Assess risk for exposure
    • Screen based on high risk status
    • Risk: direct contact with TB +, HIV +, prisoner, birth in endemic area
    • Mantoux is only recommended test and can be done as early as 3 months
    • BCG vaccination is not a contraindication to TB skin testing
  110. Eye Exam
    • Red reflex
    • Pupillary reflex
    • 1 mo. old should fixate on face
    • Acuity: minimal acceptability
    • 3 -4y/o = 20/40
    • 4 y/o and older = 20/30
    • Strabismus: ocular malalignment
    • pseudostrabismus
    • Amblyopia: loss of vision d/t disuse
    • Corneal light reflex equal
    • Cover test
    • Vision Screening: Part of every health supervision exam
    • Ask parents if they notice abnormalities
    • Birth-3 months: evaluate for fixation, alignment, eye disease.
    • AAP recommends routine vision testing at 5, 6, 8,10 &12 years using an “age-appropriate” test. Refer children for acuity 20/40 or greater.
    • USPSTF recommends vision screening for children younger than 5 years but has no recommendations for older children.
    • Medicaid requires annual screening beginning at 3 yrs
  111. Hearing Screening
    • Universal newborn hearing screening program (UNHSP)
    • ABR (auditory brainstem response)
    • EOAE (evoked otoacoustic emissions)
    • Screen before hospital D/C
    • Ask parents about hearing at visits
    • AAP recommends assessment with pure tone audiometry at 5,6, 8 and 10 years of age; USPSTF makes no recommendations after infancy
    • Medicaid requires annual screening beginning at 4 years
  112. Describe the prevalence of child abuse.
    • Each year in the United States, 3 million reports of suspected maltreatment are made to child welfare agencies.
    • Approximately 1 million of these reports are substantiated after investigation by Child Protective Services (CPS).
    • These reports represent only a small portion of the children who suffer from maltreatment.
    • Child abuse and neglect are often considered in broad categories that include physical abuse, sexual abuse, emotional abuse, and neglect.
    • Neglect is the most common, accounting for approximately half of the reports made to child welfare agencies.
  113. Child neglect
    Defined by omissions that prevent a child's basic needs from being met. These needs include adequate food, clothing, supervision, housing, health care, education, and nurturance.
  114. Physical Abuse:
    Parent, guardian, custodian, or caretaker inflicts or allows serious physical injury by nonaccidental means
  115. Sexual Abuse
    Involvement of children in sexual activities that they cannot understand, for which they are developmentally unprepared and cannot give consent to, and that violates societal taboos. Most perpetrators are adults or adolescents who are known to the child and who have real or perceived power over the child.
  116. Emotional Abuse
    • Parent, guardian, or caretaker creates or allows serious emotional damage; OR parent, guardian, or caretaker encourages, directs or approves delinquent acts including moral turpitude committed by the juvenile
    • Evidence of emotional damage: severe anxiety, depression/ withdrawal, aggression towards himself or others
  117. Physical Abuse: Yellow Flags
    • Multiple ER or Clinic Visits for trivial complaints in an apparently well child
    • Question of apnea
    • Failure to thrive
    • Multiple injuries in the past
    • Doctor-shopping
    • Non-specific family in crisis
  118. Physical Abuse: Red Flags
    • Incongruous history for an injury
    • Little knowledge of how an injury occurred
    • Little desire to know how an injury occurred
    • Blame the child – “accident prone”
    • Unreasonable expectations for developmental age
    • Delay in seeking care
    • Dead on arrival (DOA)
  119. Clues to the Diagnosis of Physical Abuse
    • A child presents for medical care with significant injuries, and a history of trauma is denied, especially if the child is an infant or toddler
    • The history provided by the caregiver does not explain the injuries identified
    • The history of the injury changes significantly over time
    • A history of self-inflicted trauma does not correlate with the child's developmental abilities
    • There is an unexpected or unexplained delay in seeking medical care
    • Multiple organ systems are injured, including injuries of various ages
  120. Bruising
    • Common in healthy, active children once cruising/walking is achieved
    • 35% of children develop bruising at least every other week
    • Higher incidence in 2-5 year olds
    • Most common over bony prominences
    • Variable Appearance
    • Complexion/skin color
    • Depth and force of impact
    • Vascularity of impacted skin
    • Connective tissue density
    • Time/age of injury
    • **There is no way to accurately date bruises
  121. Inflicted/ Intentional Bruising
    • Question ALL bruising in neonates and young infants
    • Question extensive bruising in all infants and children
    • Question bruising in protected skin sites
    • Question pattern-type or geometric shape bruising
  122. DDx for bruising
    • Unintentional: accidents, dye tattoos
    • Misdiagnosis: mongolian spots
    • Infection: impetigo, staph, strep
    • Immunologic: vasculitis, contact derm
    • Dermatologic: eczema, psoriasis
    • Vascular: hemangioma
    • Hematologic: ITP, hemophilia
    • Congenital: Ehlers-Danlos
    • Phyto/photodermatitis
    • Folk-healing: coining, cupping
  123. Burns
    • Most burns occur at home
    • 10-25% of burns in children occur from abuse
    • Most burns in children occur between ages 1 to 5 years old
    • There is a high mortality associated with inflicted burns
    • Scalds are the most common type of inflicted burns
  124. Burn Types
    • Scald burns: hot liquid or oil, steam, immersion
    • Flame burns
    • Contact burns: stoves, heaters, irons, curling irons, light bulbs
    • Electrical and microwave burns
    • Chemical burns
  125. Full thickness burns: water temp and time
    • 120 degrees F = 10 min.
    • 122 degrees F = 5 min.
    • 127 degrees F = 1 min.
    • 130 degrees F = 30 sec.
    • 150 degrees F = 2 sec.
    • 158 degrees F = 1 sec.
  126. Head and Intra-cranial Trauma
    • Scalp contusions/lacerations/ edema, subgalial hemorrhage
    • Skull fractures
    • Extra-axial hemorrhages (EDH, SDH, SAH)
    • Brain contusions, shearing, edema, infarction, ischemia
    • Intra-ventricular hemorrhage
    • Ocular injuries
    • Leading cause of fatal child abuse
    • Non-specific symptoms: Irritability, Lethargy, Vomiting, Apnea, Seizures, Poor feeding, Limpness, Stiffness
    • Acute SDH is suspicious, not diagnostic
    • Develop thorough differential diagnoses to determine labs/studies
    • Head CT for acute assessment
    • Brain MRI for on-going assessment
    • Skeletal survey and ophthalmology exam routinely in infants < 1 year old, and strongly consider in 1-2 year olds
  127. DDx Head Trauma
    • Birth trauma: IVH, germinal matrix bleed
    • Accidental trauma
    • Inflicted trauma
    • Metabolic disorder: glutaric aciduria, severe rickets, Menke’s kinky hair, OI (?)
    • Infection: meningitis, DIC
    • Hematologic disorder: ITP, Vit. K deficiency
    • Vascular Malformation: aneurysm, AVM
    • Neoplasm
  128. Retinal hemorrhages
    • Uncommon in accidental head trauma: 0-2% versus 38-61% in abusive head trauma
    • In Shaken Baby Syndrome: Usually associated with SDH and brain injury. Usually numerous, in all 4 quadrants and extend to the anterior ora serrata. Usually in multiple layers of the retina. Can be unilateral or bilateral. Skeletal injuries frequently found
    • In children, RHs are unlikely to result from increased ICP alone
    • Severe impact trauma to the head may be associated with small numbers of RHs in the posterior pole or no RHs
    • Severe compressive chest trauma may be associated with RHs
    • Normal newborns may have small numbers of superficial RHs which usually resolve within 2-3 weeks
    • RHs can result from ECMO, coagulopathies, vasculitis, SBE, meningitis, severe HTN
  129. Skeletal Injuries
    • Occurs in 10-50% of abused children
    • Skeletal injury is most specific in infants
    • Diaphyseal fxts are the most common
    • Skeletal survey is the gold standard for bone evaluation (long bones, hands, feet, axial skeleton, skull). Not as useful over 5 years old. Most sensitive in < 2 years old
    • Bone scan may detect subtle fxts
    • May need to repeat in 2 weeks for callous formation
    • High Specificity: metaphyseal fxts, posterior rib fxts, scapular fxts, spinous process fxts, sternal fxts
    • Moderate Specificity: multiple fxts (esp. bilateral), fxts of different ages, epiphyseal separations, vertebral body fxts/subluxations, digital fxts, complex skull fxts
    • Low Specificity: subperiosteal new bone, clavicular fxts, long bone shaft fxts (unless in infant), linear skull fxts
  130. DDx for fractures
    • Birth Trauma: clavicle, humerus, femur
    • Prematurity: multifactorial
    • Metabolic disorders: rickets (Vit D), scurvy (Vit C), copper deficiency, Menke’s kinky hair
    • Genetic disorders: congenital pain indifference, Caffey’s disease, Osteogenesis imperfecta Types I & IV (rare heritable disorder of connective tissue resulting from abnormal collagen synthesis. Causes fragile bones, frequent fractures, easy bruising, blue sclera)
    • Infections: osteomyelitis, congenital syphilis (long-bone periosteal reaction, metaphyseal irregularity), TB (vertebral involvement, spondylitis/Potts disease)
    • Drug effects: chemotherapy, vitamins, anticonvulsants, diuretics, hyperalimentation
  131. Sexual
    • Thorough medical exam
    • Give child choices when possible
    • Never forcibly restrain child for exam
    • Help child become comfortable with the room and equipment
  132. Sexual Abuse: Are There Behavioral Symptoms?
    • Sexual Acting Out
    • Excessive Masturbation
    • Self-injurious Behavior
    • Eating/Sleeping Changes
    • Promiscuity
    • Substance Abuse
    • Fears
    • Depression
    • Aggression
    • Anxiety
    • Suicide
  133. Sexual Abuse: Are There Physical Symptoms/Signs?
    • Chronic Medical Complaints.
    • Gastrointestinal Complaints (stomachaches, anal pain, constipation, encopresis, bleeding, anal discharge).
    • Genitourinary Complaints (dysuria, hematuria, frequency, enuresis, discharge, bleeding, itching, rash, lesions, pain, amenorrhea, pregnancy).
    • Dermatologic Complaints (bruises, lesions, ulcers, pustules, vesicles, petechiae, rashes, swelling).
  134. AHA recommended cardiac history for sports participation
    • During or after exercise (or family)
    • Chest pain? SOB?
    • Passed out? Dizzy? Lightheaded?
    • Tired quicker than friends?
    • Racing heart / skipped beats?
    • Hx HTN, high cholesterol, murmur, heart problems?
    • Family die “sudden death” or heart-related issues before age 50?
    • Family h/o heart trouble?
    • Unexplained fainting?
  135. Sudden Death of the Athlete
    • 95% SUDDEN DEATH in athletes <30 yo involve cardiovascular system
    • Hypertrophic cardiomyopathy
    • Commotio cordis
    • Coronary artery anomalies
    • Myocarditis (Coxsackie B or viral, Marfan’s, substance abuse)
    • >35 yo - MCC CAD
    • Non-cardiac: heat illness, asthma, anaphylaxis, trauma
  136. Hypertrophic Cardiomyopathy
    • Most common cause of SCD in the young athlete
    • Autosomal Dominant
    • Septum thickening
    • Non-obstructive form predominant
    • NO murmur
    • Absolute thickness >15mm; <12 mm normal
    • S/S: Usually NONE! Dyspnea (90%), CP (25%), Syncope or presyncope (15%), Palpitations, Fatigue, Edema (rare), Asymptomatic
    • Epidemiology: Asymptomatic, young individuals performing moderate to severe exertion, Football and Basketball 70%, Males 90% , High School 60%
  137. HCM Risk Factor
    • Family History- cardiac death <50
    • Palpitations
    • Chest pain with exercise
    • Prior aborted cardiac arrest and sustained Ventricular Tachycardia
  138. HCM Murmur
    • due to hypertrophy & stiffness of left ventricle
    • Systolic crescendo-decrescendo murmur
    • Heard best between at LSB, well after 1st sound
    • Radiates to axilla but not neck
    • Increases with Valsalva (decreased venous return to heart)
    • Decreases with squatting & increases when the patient stands
  139. Perform an appropriate cardiac exam for athletes according to AHA guidelines
    • Complete Physical Exam
    • Height / Weight / BMI
    • Eye: Pupils (document physiologic anisocoria). Acuity <20/40 corrected or legal blindness in one eye MUST wear protective eyewear
    • Skin: rashes, lice
    • CV: BP, pulses, heart sounds (murmurs)
    • Lungs: assess for asthma or other chronic lung disease
    • Abdomen: masses, organomegaly
    • Neurologic
    • MSK: brief screen with focus on any past injured areas
    • Assess for Marfan’s
    • Genitalia: (Males) Testes – single or undescended, masses; Hernia; Teach TSE; Cup support required if solitary testis
    • Female exam - only if indicated
  140. Assess for Marfan’s
    • Tall & thin, long extremities, hands & feet
    • Kyphoscoliosis
    • High-arched palate
    • Pectus excavatum
    • Acrachnodactyly
    • Arm span > height
    • Hyperlaxity
    • Thumb sign
    • Wrist sign
  141. Recommendations for murmurs requiring further evaluation:
    • Grade 3/6 systolic murmur
    • Any diastolic murmur
    • Any murmur that gets louder with provocative testing
  142. Hypertensive athletes
    • Increase in total peripheral resistance
    • Increases in myocardial oxygen consumption
    • Impaired vasodilation with exercise
    • Results in LVH
    • Thickened, stiff, poorly compliant ventricular walls
    • Leads to decrease filling
    • Decreased blood supply to the cardiac muscle
    • Decreased cardiac output during exercise can significantly impair athletic performance
  143. Heat stroke
    • Impaired vasodilatory response
    • Body cannot dissipate heat properly
    • Core temperatures elevate
    • Excessive water loss
    • Hypokalemia
  144. Two Minute Orthopedic Exam
    • Inspect symmetry
    • Neck ROM
    • Resisted shoulder shrug
    • Resisted shoulder abduction
    • Shoulder IR/ER
    • Elbow F/E/S/P
    • Clench and spread fingers
    • Back extension
    • Back flexion (scoliosis screen)
    • Contract quads
    • Duck walk
    • Heal / Toe standing
  145. Concussion
    • S/S: H/A, dizziness, N&V, memory / attention deficit
    • Second impact syndrome: Seen in players not fully recovered from initial concussion
    • Second head injury results in significant brain edema, even if minor
  146. Stingers
    • Stretch or compression injury of brachial plexus (C5-T1)
    • 1st episode: OK to play if there are no neurologic symptoms
    • Recurrent / persistent symptoms: need MRI to R/O spinal stenosis
    • Proper neck strengthening, safe techniques, protective equipment
  147. Asthma 3 Features:
    • Airway obstruction
    • Airway inflammation
    • Airway hyperresponsiveness
  148. Exercise induced asthma
    • Typically occurs 5-10 min post-exercise
    • Attacks resolve spontaneously
    • 40% with allergic rhinitis; 90% with asthma
    • 20% prevalence in high school athletes
  149. Decision to Clear Concussion
    • Does the problem place the athlete at increased risk of injury?
    • Is any other participant at risk of injury because of the problem?
    • Can the athlete safely participate with treatment (medication, rehab, bracing, etc?)
    • Can limited participation be allowed while treatment is being initiated?
    • If clearance is denied only for certain activities, in what activities can the athlete safely participate?
  150. Clearance
    • Cleared for all sports without restriction
    • Cleared for all sports without restriction with recs for further eval or treatment
    • Not cleared: Pending further evaluation, For all sports, For certain types of sports
    • Familiarity with demands of specific sport is essential to making appropriate decisions about clearance
    • Use published guidelines but clinical judgment should also be used when applying them
  151. Athletes’ Heart
    • Heart undergoes changes due to training
    • Difficult to distinguish from HCM
    • Septum = 13 to 15mm “grey zone”
    • EKG usually not helpful – meet criteria LVH with unusual features
    • LV diastolic cavity size
    • <45 mm in most HCM patients
    • >55 mm in athletes
  152. Murmurs
    • Recommendations for murmurs requiring further evaluation
    • Grade 3/6 systolic murmur
    • Any diastolic murmur
    • Any murmur that gets louder with provocative testing
  153. Hypertensive Athletes
    • Increase in total peripheral resistance
    • Increases in myocardial oxygen consumption
    • Impaired vasodilation with exercise
  154. LVH
    • Thickened, stiff, poorly compliant ventricular walls
    • Leads to decrease filling
    • Decreased blood supply to the cardiac muscle
    • Decreased cardiac output during exercise can significantly impair athletic performance
  155. BP elevation
    • BP can get as high as the mid 200’s over the mid 100’s in athletes with hypertension
    • Especially with exercises such as weight lifting
  156. HTN and Heat Stroke
    • Impaired vasodilatory response
    • Body cannot dissipate heat properly
    • Core temperatures elevate
    • Excessive water loss
    • Hypokalemia
  157. BP Recommendations
    • BP should be accurately measured in all individuals who wish to participate in competitive athletics before they begin training
    • Bethesda Guidelines—HTN
    • Thorough H&P and limited laboratory testing
    • Evaluate for secondary causes
    • Ascertain target organ damage
    • Normal (<120/80): No restrictions
    • Pre-HTN (120/80—139/89): Modify lifestyle but no restrictions from physical activity. If LVH pt should start medication and limit participation until BP is normal.
    • Stage 1 HTN (140/90—159/99): If no evidence of end organ damage including LVH; no limitations (Try control with lifestyle modification). CBC, Chem 7, lipid profile, urine analysis and EKG
    • Stage 2 HTN (>160/100: Even with no evidence of LVH or end organ damage the athlete should have participation restricted until BP controlled by medications or life style modification. Above labs plus echocardiogram and therapy.
    • Hypertensive athletes should increase exercise gradually to avoid cardiac catastrophes (MI, Stroke, Sudden cardiac death)
  158. Marfan’s Syndrome
    • Autosomal dominant trait; 1:20,000
    • 39% result from new mutation
    • Affects MSK, CV, and ocular systems
    • Mortality: rupture of thoracic aortic aneurysm
  159. Female Athlete Triad
    • Disordered eating
    • Amenorrhea
    • Osteopenia or Osteoporosis
    • Important History
    • Menstrual history?
    • Stress fx?
    • Dietary practices?
  160. Pediatrics: Oral Exam
    • oral mucosa
    • labial frenum (frenulum)
    • lingual frenum (frenulum)
    • hard palate
    • soft palate
    • tongue
    • erupted teeth
    • gingiva
  161. Eruption
    • process by which teeth emerge into oral cavity
    • usually is bilateral & symmetric
    • mandibular central incisors first to erupt
    • maxillary central incisors erupt next
    • 1° dentition fully erupted by age 30 months
    • variation normal
    • girls sooner than boys
  162. Teething
    • blamed for many symptoms
    • fever is not associated with teething
    • excessive drooling and irritability are associated
    • gingival swelling
    • eruption cysts
    • oral analgesics best
    • topical analgesics may be helpful but use with caution
  163. Exfoliation
    • Process of loss of primary teeth with eruption of permanent teeth
    • usually begins @ age 6 years
    • permanent tooth develops apical to 1° tooth as it migrates through alveolar bone
    • early exfoliation: local causes; systemic causes (cyclic neutropenia, histiocytosis)
    • delayed exfoliation: prolonged retention of 1° teeth
    • Red Flags/ Referrals
    • Early exfoliation
    • Delayed (>6 months) eruption of primary or permanent teeth may be due to genetics, hypothyroidism, hypopituitarism, rickets
    • Complete failure of eruption: associated with variety of rare pediatric syndromes
    • Variations in number of teeth/missing teeth
  164. Caries
    Most common chronic disease of childhood
  165. Risks for Dental Caries
    • Family history
    • active decay or multiple fillings in mother associated with increased level of transmissible cariogenic bacteria
    • maternal dietary habits
    • Socioeconomic status: caries is a disease of poverty
    • Dietary history: diets high in sugar promote tooth decay
    • Bedtime bottles/prolonged use of sippy cups
    • Enamel defects
    • Insufficient cleaning (visible plaque)
    • Liquid medications
    • Exposure to passive tobacco smoke
  166. Early Childhood Caries (ECC)
    • Previously known as nursing bottle caries
    • Definition: presence of 1 or more decayed, missing or filled surfaces in any primary tooth in a child aged 1-6 years
    • Protective: good salivary flow, good oral hygiene, balanced diet, adequate fluoride
    • Children with caries in 1° teeth are 3x more likely to develop caries in their permanent teeth
  167. Infant Oral Hygiene
    • Starts at birth: clean gums with soft cloth
    • Visual screening at HM visits as soon as first teeth erupt
    • lift lip to examine all erupted teeth and oral mucosa closely
    • check for plaque, white spot lesions and/or cavities
    • Teeth should be cleaned with soft brush at least 2x/day
    • parental supervision up to age 6
    • add fluoride toothpaste for children with ECC or those at increases risk of caries
    • Flossing: initiate when space between teeth too small to clean adequately with toothbrush
  168. Caries Pathogenesis
    • Bacterial fermentation of carbohydrates ↓’es pH of dental plaque which leads to demineralization of tooth enamel
    • caries result from complex interaction between dietary carbohydrates and oral flora → biofilm (dental plaque) that adheres to tooth surface
    • >100 microbes play role; S. mutans most commonly associated
    • diets high in carbohydrates create increased proportion of cariogenic bacteria in oral flora
    • white spot lesion: initial carious lesion
    • brown/black lesions: stages of decay
    • disease eventually extends to pulp
    • Bacterial fermentation of carbohydrates ↓’es pH of dental plaque which leads to demineralization of tooth enamel
    • S. mutans & S. sobrinus are responsible for the initiation of cariogenesis
    • S. mutans is transmitted from mother to child resulting in colonization of child’s oral cavity
    • early colonization is associated with ↑’ed risk of caries and ECC
    • L. acidophilus and L.casei are responsible for the progression of caries
  169. Dietary Counseling for Caries
    • Avoid foods with increased cariogenic risk: those that are high in carbohydrates, are slowly cleared from mouth and decrease oral pH
    • limit sugary snacks to post-meal deserts
    • limit grazing on high-carb foods
    • limit fruit juices to 4oz/d; no sodas before 2½ yrs
    • only water or milk between meals
    • avoid sleeping with bottle
    • follow MyPyramid dietary guidelines
  170. fluoride supplementation:
    • Vital part of decreasing dental caries
    • increases resistance to demineralization
    • enhances mineralization
    • inhibits bacterial colonization of plaque
  171. dental care
    • Timing of first visit: controversial
    • previously recommended at age 3 years
    • new AAP guidelines (2003) recommend first visit at age 1 year (or 6 months after first eruption)
    • rationale: early initiation of preventive care, anticipatory guidelines regarding oral hygiene, reduce fear/anxiety associated with dentist
  172. establishment of dental home
    • initial visit at 12-18 months with scheduled monitoring
    • risk assessment
    • comprehensive care
  173. Fluoride Supplements
    • Fluoride supplements should not be used in children < 6 months of age
    • Parents should know fluoride concentration of their child’s 1° source of drinking water
    • Parents should supervise use of fluoridated toothpaste in children < 6 years of age
    • pea-sized amount
    • No fluoride rinses in children <6 years
  174. Fluoride Therapy
    • PAFTs: gels, foams, rinses, varnishes
    • varnishes recommended at HM visits
    • Goal: to reduce the incidence of early childhood caries in North Carolina.
    • If fluoride exposure unknown recommend buying fluoridated bottled water and omit supplements
    • ADA advises mixing infant formula with non-fluoridated water
  175. Fluoride toothpaste
    • <2 years: only in children @ high risk of caries
    • ≥2 years: pea-sized amount
  176. Gingivitis
    • inflammation of gingiva(gum) adjacent to tooth
    • usually occurs secondary to plaque accumulation
    • “universally” present in children and adolescents
    • resolves with improved oral hygiene
  177. Periodontitis
    • More severe
    • Loss of attachment.
    • destruction of bone
    • Juvenile periodontitis: more virulent form of periodontitis around permanent first molars and incisors
    • Polymicrobial etiology
    • Treatment: surgical & non-surgical debridement, antibiotic therapy
  178. Antibiotics for Pediatric Dental Infections
    • Once infection has spread to pulp, classic signs of infection/inflammation develop
    • pain, facial swelling, parulis (“gumboil”)
    • severe complications can develop: sinus infection, cavernous sinus thrombosis, brain abscesses
  179. Antibiotics for odontogenic infections:
    • pen VK 25-50mg/kg/d in divided doses (erythromycin can be used in penicillin allergy)
    • clindamycin
    • Antibiotic therapy followed by root canal therapy or extraction
    • Amoxicillin for SBE prophylaxis: 50mg/kg
  180. Luxation
    • intrusive: require surgical or orthodontic repositioning
    • lateral & extrusive: repositioning and splinting
  181. fracture
    fragments can be rebonded
  182. avulsion
    • seek immediate care; handle tooth by crown only
    • attempt to re-implant and hold with gentle pressure
    • if unable to re-implant do not allow to dry; place in protective solution (Hank’s salt solution, milk, saline)
    • take child to dentist or ED
  183. Causes of Dental Trauma:
    • Falls (especially in infants & toddlers)
    • Sports/Play
    • Altercations (adolescents)
    • MVAs
    • Child abuse
  184. Intrusion injuries of primary maxillary front teeth is most severe
    • intrusions < 3mm have good prognosis
    • severe luxations usually require extraction
    • Mild injuries (concussions/subluxations) usually result in color changes; monitor for ~6 weeks
    • yellow: no intervention needed
    • brown/black: pulp necrotic, will likely need extraction
    • A primary tooth that has been avulsed is usually not re-implanted.
  185. Preventing Dental Trauma: Mouthguard
    • prevent injuries to teeth
    • should be mandatory in contact sports
    • in children with primary and mixed dentition boilable, self-molding types are acceptable and economical
    • Hank’s balanced salt solution should be part of emergency kit in all organized sports/teams
  186. Patient groups that require prophylactic antibiotic coverage prior to invasive dental manipulation.
    • Immunosuppressed children:
    • are at increased risk of infection in oral cavity
    • monitor frequently; encourage vigorous oral hygiene
    • therapies may be toxic to oral mucosa: monitor for mucositis, ulcers
  187. Dental Anatomy and Physiology
    • dental development begins in utero at ~ 6 weeks
    • 20 primary (deciduous) teeth
    • 32 permanent teeth
    • 4 components of teeth: enamel, dentin, pulp, cementum
    • mastication, speech, facial aesthetics
  188. Oral Habits/ Non-nutritive Sucking
    • A normal part of early childhood development
    • self-soothing
    • pacifiers, sucking on digits
    • Frequency decreases as child ages
    • sucking on digits usually lasts longer
    • Stop pacifier by 1yr (AAP) or 3yrs (AAPD)
    • Digit sucking habits should end by age 6yrs
    • may be associated with malocclusion if it persists
  189. Nutrition assessment
    • Medical Hx
    • Anthropometrics: linear growth, weight, head circumference, growth charts, specialty growth charts, BMI
    • Biochemical
    • Clinical
    • Dietary
    • Social
  190. Anthropometrics
    • Provides information about child’s physical growth: linear growth, weight, head circumference, growth charts, specialty growth charts, BMI
    • Measurements may be compared to growth charts.
    • Age appropriate growth is the hallmark of adequate nutrition
  191. Linear growth and Weight
    • For infants and children up to 36 months of age, a recumbent measurement is preferred
    • Standing height is used for older children (greater than 3 years of age)
    • For children who cannot stand, an arm span measurement can be used
    • Most full-term infants lose some weight in first few days of life (6%)
    • Infants usually double birth weight between 4-6 months
    • By the first year, birth weight is tripled
    • Length increases by 50-55% and HC by 40% in the first year
    • Between 1-2 years, average growth in stature is 4 3/4 inches
    • Between 1-2 years, average growth in weight is 5.5 - 6.6 pounds
    • During preschool years, growth is slow and steady
    • Differences in growth by gender may be noted from about age six
    • After 9th to 10th year, weight increases at a rate of 4 kg/year
    • Height increases an average of 6 - 8 cm per year until puberty
    • Teen gains about 20% of adult height and 50% of adult weight during adolescence
    • Average peak height velocity = 9.5 to 10.3 cm per year for boys
    • Average peak height velocity = 8.4 to 9.0 cm per year for girls
  192. BMI
    • Ratio of weight to the square of height in meters (BMI = kg/m2)
    • Used as an indicator of weight relative to height
    • BMI correlates with measures of body fatness in children and teens
  193. Biochemical
    • Laboratory values can provide information about a child’s macronutrient and micronutrient stores.
    • For example, serum protein, iron status, and vitamin and electrolyte levels can help determine the nutrition plan
  194. Dietary
    • Usual nutrition intake and dietary habits
    • Botanicals, vitamins and minerals
    • Any recent involuntary weight changes
    • Dentition
    • Food allergies/aversions/intolerances
    • Cultural or religious dietary concerns
  195. Social
    • Family History
    • Number of caregivers
    • Socioeconomic status including use of supplemental food programs
    • Family’s perception of nutritional status of child
    • Religious or cultural beliefs impacting food intake
  196. Breastfeeding
    • the ideal and uniquely superior food for infants for the first year of life and as the sole source of nutrition for the first 6 months
    • Human milk feeding decreases the incidence or severity of diarrhea, respiratory illnesses, otitis media, bacteremia, bacterial meningitis, and necrotizing enterocolitis
    • may reduce the incidence of food allergies and eczema
    • contains protective bacterial and viral antibodies (secretory IgA) and nonspecific immune factors, including macrophages and nucleotides, which also help limit infections
    • several nutritional and non-nutritional advantages over infant formula
    • bioavailable protein content, a generous quantity of essential fatty acids, the presence of long-chain unsaturated fatty acids of the ω-3 series, low sodium and solute load, and highly bioavailable concentrations of calcium, iron, and zinc
  197. Cow’s milk based formulas
    • Standard substitute for breast milk
    • Protein source – cow’s milk protein
    • Vary in the ratio of casein to whey
    • Current requirements – 1.7 -3.4 grams per 100 calories
    • Carbohydrate source– lactose
    • Fat source– vegetable blend similar to breast milk
  198. Soy formulas
    • Protein source – soy protein isolate
    • provide a nutritionally safe alternative to cow's milk-based formulas when intolerance occurs from immune reactions to cow's milk proteins
    • Carbohydrate source – sucrose and/ corn syrup solids
    • Fat source – vegetable blend
    • Calcium & phosphorus levels increased by 20%
    • Soy protein-based formulas are not recommended for babies born prematurely
  199. Hydrolyzed protein formulas
    • Protein source – hydrolyzed casein or whey
    • Sources of carbohydrate and fat vary based on product
    • Not recommended for colic, sleeplessness or irritability
    • Expensive
  200. Amino Acid-Based Formula
    • Indicated for babies with food allergies
    • Protein source – amino acids
    • Carbohydrate source – corn syrup solids
    • Fat source – LCFA and MCT
    • Very expensive
  201. Frequency and volume of feeds
    • Stomach capacity varies with age of child
    • Full term infant can eat up to 20-90 ml per feed
    • Increases to 90-150 ml by 1 month of age
    • Birth to 1 week: 6-10 feeds/day, 30-90 mL/feed
    • 1 wk to 1 mo: 7-8 feeds/day, 60-120 mL/feed
    • 1-3 months: 5-7 feeds/day, 120-180 mL/feed
    • 3-6 months: 4-6 feeds/day, 180-240 mL/feed
    • 6-9 months: 3-4 feeds/day, 210-240 mL/feed
    • 9-12 mnonths: 3 feeds/day, 210-240 mL/feed
  202. Too much feeding
    • If bottle-fed, the baby is consuming more than 4 to 6 ounces (120 to 180 ml) per feeding.
    • She vomits most or all the food after a complete feeding.
    • Her stools are loose and very watery, eight or more times a day.
    • (Keep in mind that breastfed babies normally tend to have much more frequent and looser stools.)
  203. Too little feeding
    • If breastfed, the baby stops feeding after ten minutes or less.
    • She wets fewer than four diapers per day; particularly if she has begun sleeping through the night, she may be feeding inadequately (since most babies feed at least once during the night), and may urinate less often and become mildly dehydrated.
    • She has infrequent or very hard stools in the first month.
    • She appears hungry, searching for something to suck shortly after feedings.
    • She becomes more yellow, instead of less, during the first week
  204. Feeding allergy or digestive disturbance
    • Your baby vomits most or all food after a complete feeding.
    • She produces loose and very watery stools eight or more times a day or has blood in the stools.
    • She has a severe skin rash
  205. Spitting up possible causes
    • Your baby needs to be held more upright during and after feedings.
    • The nipple flow is too fast or slow.
    • Your baby needs more frequent burping.
    • Your baby is sensitive or allergic to an ingredient in the formula you're using.
    • Find out more about formula allergies and sensitivities and choosing formula.
    • Keep in mind that spitting up is very common in babies – and may be unavoidable.
    • About 40 percent of young babies spit up regularly, and the peak age for spitting up is 4 months
  206. Vomiting after feeding possible causes
    • Overfeeding.
    • Formula is improperly stored or handled.
    • Powdered formula isn't mixed with enough water (making it overly concentrated).
    • Your baby is sensitive or allergic to an ingredient in the formula you're using.
  207. Stomach pain possible causes
    • Overfeeding.
    • Your baby is sensitive or allergic to an ingredient in the formula you're using.
  208. Excessive gas possible causes
    • Getting too much air from the bottle.
    • Your baby needs to be held in a different position during feedings.
    • Your baby is sensitive to an ingredient in the formula you're using.
    • Inadequate or infrequent burping.
  209. Seems hungry after a feeding possible cause
    • Underfeeding.
    • Keep in mind that babies have a strong urge to suck, and this can be misinterpreted as hunger.
  210. Fussy and crying at the beginning or end of a feeding possible causes
    • Overfeeding
    • Underfeeding.
    • Your baby is sensitive or allergic to an ingredient in the formula you're using.
    • The bottle nipple is too big for your baby's mouth.
    • The flow of formula is too slow or too fast.
    • Painful gastroesophageal reflux
  211. Colicky behavior possible causes
    • Your baby is sensitive or allergic to an ingredient in the formula you're using.
    • Overfeeding
    • Underfeeding
  212. Isn't gaining weight (after 2 weeks old) possible cause
    • Underfeeding.
    • Be sure to talk to the doctor about your baby's failure to gain weight.
    • It's a serious issue and can indicate other medical problems, like chronic disease, heart disease, and metabolic concerns.
  213. Isn't wetting five to six disposable diapers or six to eight cloth diapers a day possible cause
    • Underfeeding.
    • Your baby may be dehydrated
  214. A rash, hives, or eczema possible cause
    • Your baby is allergic to an ingredient in the formula you're using.
    • A formula allergy is especially likely if your baby's having moderate to severe eczema or full-blown body hives.
    • Of course, there's always the possibility that contact with something else – a skin product, clothing item, or detergent, for example – is causing the problem..
  215. Is gagging or gulping formula possible causes
    • The flow of formula is too fast.
    • Underfeeding.
    • Your baby needs to be held more upright during feedings.
  216. Trouble sucking from the bottle possible causes
    • The bottle nipple is too big for your baby's mouth.
    • The flow of formula is too slow.
  217. Won't take the bottle possible causes
    • Your baby may not be hungry.
    • You're introducing (or reintroducing) the bottle and your baby's not used to it.
    • Breastfed babies often reject the bottle initially, and it may take perseverance and multiple attempts before they accept it.
  218. A red ring around the rectum that doesn't clear up possible cause
    Your baby is sensitive or allergic to an ingredient in the formula you're using.
  219. Constipation, or stools that are unusually hard possible cause
    Your baby is sensitive or allergic to an ingredient in the formula you're using.
  220. Diarrhea, or stools that are loose, watery, or foul smelling possible causes
    • Your baby is sensitive or allergic to an ingredient in the formula you're using.
    • Formula is improperly stored or handled.
  221. Stools that are mucus-like and mixed with blood possible cause
    Your baby is sensitive or allergic to an ingredient in the formula you're using.
  222. What are Cues That Babies are Developmentally Ready for Solid Foods?
    • The American Academy of Pediatrics (AAP) recommends that the introduction of solids be delayed until 4 to 6 months of age.
    • Are able to sit upright with support
    • Open their mouth when they see a spoon coming towards them
    • Can move the food from the spoon and swallow without pushing back out of mouth
    • Make chewing motions
    • They have the ability to reject food: Turning head, Keep mouth tightly closed, Forcing food back out of mouth
  223. Toddler Nutrition
    • Cereals commonly are mixed with breast milk, formula, or water and later with fruits
    • Juice frequently is given to infants, although it is not a necessary "food" for infants. If given, juice should be started only after 6 months of age, be given in a cup (as opposed to a bottle), and limited to 4 oz daily
    • New single-ingredient foods generally can be offered approximately every week
    • Cow's milk ideally is not introduced until approximately 1 year of age to avoid occult intestinal blood loss
  224. Age 2-3 yrs
    • Offer a variety of nutritious foods, including some choice that contain fat such as milk and peanut butter
    • Serve small, nutritious meals and snacks and allow the child to ask for seconds
    • Structure and routine for eating is important for young children.
    • Grazing between meals and snacks should be limited
    • Let the child assume responsibility for how much to eat
  225. Age 3-6 yrs
    • Serve small, nutritious meals and snacks and allow the child to ask for seconds
    • Encourage parents to involve their child in simple food related tasks (e.g., making muffins together) to encourage them to try these foods
  226. Eating disorders can start as early as age 9
    • Girls are predominantly affected
    • 5% are males
  227. Obesity
    • Greater than 90th percentile for weight for height; or
    • Greater than or equal to the 95th percentile body mass index, age and sex specific
    • Obesity in early childhood can lead to adult obesity.
  228. Obesity Prevention
    • Limit television
    • Encourage exercise
    • Limit sugary beverages
    • Watch portion size
    • Make changes in school breakfast and school lunch
  229. diet and eating habits of children 2 and older.
    • Cow's milk ideally is not introduced until approximately 1 year of age to avoid occult intestinal blood loss.
    • Low fat (2%) or whole milk is recommended until 2 years of age, after which fat free milk is recommended
    • Juice intake for toddlers and young children should be limited to 4 to 6 oz/day, and juice intake for children 7 to 18 years of age should be limited to 8 to 12 oz/day
    • By 1 year of age, infants should be eating meals with the family, have a regular schedule of meals and snacks, and be encouraged to self-feed with appropriate finger foods
    • A general rule for the quantity of food to offer is 1 tablespoon of each food provided per meal, with more given if the toddler requests.
    • Prudent Diet for kids > 2 yrs
  230. General Dietary Recommendations
    • Consume 3 regular meals daily with healthful snacks (2-3/day) according to appetite, activity, and growth needs
    • Include a variety of foods with abundant vegetables and fruits
  231. Carbohydrates
    • Complex carbohydrates should provide ≥55%-60% of daily calories;
    • half of all grains should be whole-grain, high-fiber foods.
    • Simple sugars should be limited to <10% daily calories
  232. Fat
    • <30% of total calories should come from dietary fat.
    • Saturated and polyunsaturated fats should make up <10% total calories each.
    • Monounsaturated fats should provide at least 10% total calories.
    • Encourage lean cuts of meat, fish, low-fat dairy products, vegetable oils.
    • Cholesterol intake should approximate 100 mg/1000 kcal/day (maximum of 300 mg/day)
    • Severe fat restriction (≤15%-20% total calories) should be avoided because it may result in growth failure
  233. Sodium
    Limit sodium intake by choosing fresh over highly processed foods
  234. BEHAVIORAL
    Limit grazing behavior, eating while watching television, and regular consumption of high-calorie, low-nutrient foods
  235. Commonly prescribed vitamins and supplements for infants and children.
    Key nutrients – Calories, calcium, iron, zinc, Vitamin B12
  236. Recommended Calcium Intake
    • 1-3 yrs: 500 mg/d
    • 4-8 yrs: 800 mg/d
    • 9-18 yrs: 1300 mg/d
    • How many times a day does your child drink white or flavored milk?
    • How often does your child eat cheese, yogurt, yogurt drinks or other dairy products?
    • Does your child drink calcium-fortified juices?
    • Does your child eat any of the following a weekly basis: broccoli, beans, greens, tofu, soy beverages?
    • Does your child take calcium supplement?
    • Breastfed or partially breastfed infants drinking less than 1 L (32 oz) formula should receive a daily vitamin D supplement of 400 IU (10 μg)
    • Ascorbic Acid Deficiency
    • Results in the clinical manifestations of scurvy manifested by irritability, bone tenderness with swelling, and pseudoparalysis of the legs may occur if infants are fed unsupplemented cow's milk in the first year of life or if the diet is devoid of fruits and vegetables
  237. Infantile beriberi
    Occurs between 1 and 4 months of age in breastfed infants whose mothers have a thiamine (B1) deficiency (alcoholism), in infants with protein-calorie malnutrition, in infants receiving unsupplemented hyperalimentation fluid, and in infants receiving boiled milk
  238. Pellagra or niacin deficiency disease
    Characterized by weakness, lassitude, dermatitis, photosensitivity, inflammation of mucous membranes, diarrhea, vomiting, dysphagia, and, in severe cases, dementia
  239. Dietary deprivation or malabsorption of vitamin B6
    in children results in hypochromic microcytic anemia, vomiting, diarrhea, failure to thrive, listlessness, hyper-irritability, and seizures
  240. Folate deficiency
    • Characterized by hypersegmented neutrophils, macrocytic anemia, and glossitis, may result from a low dietary intake, malabsorption, or vitamin-drug interactions
    • infants require 10 times as much folate as adults
  241. Vitamin B12
    • Dietary sources are animal products only, and strict vegetarians should take a vitamin B12 supplement
    • Exclusively breastfed infants ingest adequate vitamin B12 unless the mother is a strict vegetarian without supplementation
  242. Vitamin A deficiency
    • Appear as a group of ocular signs termed xerophthalmia.
    • The earliest symptom is night blindness, which is followed by xerosis of the conjunctiva and cornea
  243. Vitamin D deficiency
    • Appears as rickets in children and as osteomalacia in postpubertal adolescents.
    • Inadequate direct sun exposure and vitamin D intake are sufficient causes, but other factors, such as various drugs and malabsorption are also causes
    • Breastfed infants, especially infants with dark-pigmented skin, also are at risk for vitamin D deficiency.
  244. Hemorrhagic disease of the newborn
    • Disease more common among breastfed infants, occurs in the first few weeks of life
    • The AAP recommends that parenteral vitamin K (0.5 to 1 mg) be given to all newborns shortly after birth
  245. Asthma
    • Airway Inflammation
    • Airway hyperreactivity
    • (Reversible) airway obstruction
  246. Epidemiology of asthma
    • Asthma is the most common chronic disease of childhood in industrialized countries, affecting nearly 6 million children younger than 18 years of age in the United States.
    • The 2003 National Health Interview Survey of the Centers for Disease Control and Prevention yielded a lifetime asthma prevalence of 12.5% and current asthma prevalence of 8.5% in children younger than 18 years of age.
    • Between 1996 and 2004, asthma attack rates and asthma prevalence have stabilized when compared with the previous 12 months.
  247. Clinical symptoms of asthma
    • Wheezing
    • Coughing
    • Chest tightness or pain
    • Shortness of breath
  248. Assessing Frequency of Asthma Symptoms
    • Number of hospitalizations / ICU admissions
    • Number of ER or PMD visits
    • Missed days of school or work
    • Days / week with symptoms
  249. Diagnostic Studies Utilized In the Evaluation of Asthma
    • Blood tests: CBC + differential, Immune work up, QIGs; Antibody titers
    • Sweat test
    • Allergy skin testing
    • GER evaluation
    • Pulmonary function: spirometry + lung volumes, methacholine challenge, exercise testing
    • X-rays: chest radiograph
    • CXR indications: Atypical presentation, Asymmetric breath sounds, Suspicion of foreign body, Lack of clinical improvement, Worsening of clinical course, Persistent oxygen requirement
    • CXR findings: Normal, Hyperinflation, Peribronchial thickening, Atelectasis versus infiltrate, Pneumothorax / pneumomediastinum
    • sinus films
    • Bronchoscopy
  250. DDx for asthma
    • Anatomic abnormality
    • Infection
    • Foreign body
    • Cystic fibrosis
    • Gastroesophageal reflux
    • Bronchopulmonary dysplasia
    • Pulmonary edema
    • Laryngeal dysfunction
  251. Asthma Triggers
    • URI’s
    • Exercise
    • Changes in weather
    • Exposure to irritants
    • Emotional states
    • Allergens
    • Cold air
    • Seasons
    • Medications
    • Food additives
  252. Asthma Home monitoring
    • Peak flow meters are very useful for following lung function at home
    • PEFR dips before the patient is symptomatic
    • PEFR correlates well with FEV1
    • PEFR is reproducible
    • Peak flow meters are inexpensive, portable, and highly reliable
  253. Drawbacks to Peak Flow Meters
    • Effort dependent
    • Only 1 variable is measured (versus 5 for spirometry)
    • For maximal benefit, peak flow monitoring should be done on a daily basis
  254. Uses for Peak Flow Meters
    • Monitor daily pulmonary function
    • Measure diurnal variation in pulmonary function
    • Monitor degree of airway obstruction
    • Predict asthma exacerbations before symptomatic
    • Monitor response to asthma therapy
    • Provocational testing (trigger assessment)
    • Assess if symptoms are due to asthma
  255. Candidates for Peak Flow Meters
    • All patients with severe asthma
    • Select patients with moderate asthma
    • Patients with poorly controlled asthma
    • Patients unsure of their asthmatic triggers
    • Patients who underestimate the degree of their illness and extent of their airway obstruction
  256. Establishing Peak Flow Zones
    • Baseline values
    • Personal best
    • Percent predicted
  257. Peak Flow Guidelines
    • Green Zone (> 80%)
    • Yellow Zone (50-80%)
    • Red Zone (< 50%)
  258. Rules for Good Asthma Control
    • If they are on what appears to be a “good” asthma treatment plan but doing poorly, then…
    • Not enough medication
    • Confounding feature being missed: Allergies; gastroesophageal reflux; cystic fibrosis
    • Wrong diagnosis
    • Suboptimal medication delivery
    • Poor technique (not using spacer; cannot use diskus)
    • Poor adherence
  259. When to Refer Asthma
    • Acute life-threatening asthma attack
    • Moderate to severe asthma
    • Steroid-dependent asthma
    • Atypical/complicated asthma
    • Poor response to optimal therapy
    • Confounding variables are present
    • More complicated diagnostic studies required
  260. Ideal Asthma Management
    Daily anti-inflammatory agent PLUS PRN bronchodilator agent
  261. Asthma and Viral upper respiratory tract (RSV, influenza virus)
    • Limit exposure to viral infections (day care with fewer children)
    • Annual influenza immunization for children with persistent asthma
  262. Asthma and Tobacco smoke, wood smoke
    • No smoking around the child or in child's home
    • Help parents and caregivers quit smoking
    • Eliminate use of wood stoves and fireplaces
  263. Asthma and Dust Mites
    • Essential actions: Encase pillow, mattress, and box spring in allergen-impermeable encasement. Wash bedding in hot water weekly
    • Desirable actions: Avoid sleeping or lying on upholstered furniture, Minimize number of stuffed toys in child's bedroom, Reduce indoor humidity to <50%, If possible, remove carpets from bedroom and play areas; if not possible, vacuum frequently
  264. Asthma and Animal Dander
    • Remove the pet from the home or keep outdoors; if removal is not acceptable
    • Keep pet out of bedroom
    • Use a filter on air ducts in child's room
    • Wash pet weekly (the evidence to support this has not been firmly established)
  265. Asthma and Cockroach Allergens
    • Do not leave food or garbage exposed
    • Use boric acid traps
    • Reduce indoor humidity to <50%
    • Fix leaky faucets, pipes
  266. Allergens and Mold
    • Avoid vaporizers
    • Reduce indoor humidity to <50%
    • Fix leaky faucets, pipes
  267. Bronchodilators
    • methylxanthine derivatives: theophylline (Slobid, Theodur, Uniphyl)
    • beta-2 agonists: albuterol (Ventolin, Proventil, Proair), levalbuterol (Xopenex), salmeterol (Serevent)
    • anti-cholinergic agents: atropine, ipratropium (Atrovent)
  268. Anti-inflammatory agents:
    • mast cell stabilizers: cromolyn (Intal), nedocromil (Tilade)
    • inhaled steroids: beclomethasone (Qvar), fluticasone (Flovent), budesonide (Pulmicort), mometasone (Asmanex), ciclesonide (Alvesco), triamcinolone (Azmacort), flunisolide (Aerobid)
    • leukotriene inhibitors: zileuton (Zyflo), zafirlukast (Accolate), montelukast (Singulair)
    • anit-IgE antibodies
  269. Steroid Side effects
    • Topical side effects: oral thrush, change in phonation
    • Systemic side effects: dose dependent, uncommon if total daily dose is < 1200 mcg of beclomethasone / day
  270. Status asthmaticus
    • Acute exacerbation of asthma that does not respond adequately to therapeutic measures and may require hospitalization.
    • Exacerbations may progress over several days or occur suddenly and can range in severity from mild to life-threatening.
    • Significant respiratory distress, dyspnea, wheezing, cough, and a decrease in peak expiratory flow rates characterize deterioration in asthma control.
    • During severe episodes of wheezing, pulse oximetry is helpful in monitoring oxygenation.
    • In status asthmaticus, arterial blood gases may be necessary for measurement of ventilation.
    • As airway obstruction worsens and chest compliance decreases, carbon dioxide retention can occur.
    • In the face of tachypnea, a normal Pco2 (40 mm Hg) indicates impending respiratory arrest.
  271. Asthma Treatment
    • First-line management of asthma exacerbations includes supplemental oxygen, repetitive or continuous administration of short-acting bronchodilators, and oral or intravenous corticosteroids.
    • Administration of anticholinergic agents (ipratropium) with bronchodilators decreases rates of hospitalization and duration of time in the emergency department.
    • Early administration of oral corticosteroids is important in treating the underlying inflammation.
  272. Systemic Steroids
    • Useful to treat acute attacks
    • Usual dose for an asthma flare: 2 mg/kg/day
    • maximum dose of 40 - 60 mg/day
  273. Duration of therapy for an asthma flare:
    • mild to moderate flare: 3-5 days with no taper required
    • moderate to severe flare: 5 days with taper as per clinical course
  274. Short term side effects of Systemic Steroids
    • increased appetite
    • weight gain
    • fluid retention
    • irritability
  275. Long term side effects of Systemic Steroids
    • growth suppression
    • adrenal suppression
    • immunosuppression
    • decreased bone density
    • hypertension
    • diabetes
    • glaucoma
    • cataracts
  276. Musculoskeletal Issues in Infants
    • The newborn's hips are externally rotated.
    • Pes planus and genu varum are common.
    • Infants are usually born with a flexed posture.
    • These contractures usually decrease to neutral within the first 4 to 6 months.
    • The foot is often flat and tucked under at birth; the ankle will be inverted and the forefoot is adducted when compared with the hindfoot.
    • The lateral border of the foot must straighten out, even with dorsiflexion, to be considered secondary to in utero positioning.
  277. The head and neck may also be distorted by in utero positioning.
    • The spine and upper extremities are less likely to be affected.
    • By the age of 3 to 4 years, the effects of in utero positioning have usually resolved.
  278. Musculoskeletal Issues in Toddlers
    • Broad-based gait is usually inconsistent and is characterized by short, rapid steps and does not have the reciprocal arm swing.
    • Gait coordination improves over time and a normal gait is usually achieved by the time a child enters elementary school.
    • An excessively clumsy 3- or 4-year-old should spark concerns for muscular dystrophy.
  279. Cephalohematoma
    • Sub-periosteal swelling
    • Within suture lines
    • 5-20% underlying linear skull fx
    • Skull imaging if depressed fx or neurologic sx
    • Complications: Anemia, hyperbilirubinemia. Elevated calcified ridge
    • Tx: Resorb 2-12 weeks
  280. Caput Succedaneum
    • Extra-periosteal swelling
    • Crosses suture lines often
    • Overlying ecchymosis and pitting
    • Head molding
    • Complications: Hyperbilirubinemia
    • Tx: Observation; Resorb in few days
  281. Torticollis (Wryneck)
    • Found 1st 6-8 weeks of life
    • Keeps head tilted to one side and turned opposite side
    • SCM fibrosis and thickening
    • May have small nontender mass or “tumor” attached to muscle on side of tilting
    • Gradually regresses
    • Gone 4-6 months
    • 10-20% associated with hip dysplasia
    • Sx: Head tilts to affected side; face turns away from affected side. 75% right side
    • Tx: Stretching, Positioning of child to look opposite way. 10% surgery to lengthen muscle.
    • Refer if not improved in 6 months
  282. Erb’s Palsy
    • Brachial plexus injury at birth (C5-6)
    • Stretch injury usually during difficult delivery, breech or prolonged labor
    • May image to assess bony damage
    • Klumpke’s Paralysis (C7, C8, T1)
    • Sx: Unable to move arm, Affected arm may be smaller
    • Tx: Exercises to keep joints limber and strengthen – may take up to 2 years
    • Sx consult if no improvement first 3-6 months
  283. Nursemaid’s Elbow (Radial Head Subluxation)
    • Usually under 5yo
    • MC orthopedic injury children <2yo
    • M>F, L>R
    • Radial head subluxes due to traction on arm
    • Sx: Crying/screaming of elbow pain. Hold arm flexed and against belly. Refusal to use arm
    • Tx: Reduce with supination and flexion of arm. Feel “pop”. If unable, splint
    • Recurrence high exp if <2yo
    • Rarely sx needed to tighten annular ligament
  284. Polydactyly
    • Supernumerary digits (hands or feet)
    • 1/3 with both
    • Blacks > Whites (@10x)
    • Usually border digits (5th)
    • Tx: Surgical 6-9 months old
  285. Syndactyly
    • Webbed digits
    • Toes – usually between 2nd and 3rd
    • Unless problem with stability, surgery usually cosmetic decision
  286. Kyphosis
    • Congenital: Spinal column does not develop properly. Surgery often needed early
    • Postural: F>M, usually adolescents
    • Scheuermann’s: Usually in teens. MC thoracic. Discs irregular and wedge-shaped in imaging
  287. Spondylolysis
    • Stress fracture of pars interarticularis
    • 95% at L5
    • Gymnasts, football, weight lifting
    • Potentially asymptomatic or similar to lumbar strain
    • Oblique radiographs (Scottie dog)
    • Tx: Conservative
  288. Spondylolisthesis
    • Anterior “slippage” of the vertebra (usually L5) leading to radiating pain to or below knees
    • Usually worse with standing, extension
    • Step-off sometimes seen
    • Lateral radiographs
    • Tx: Conservative first
    • Worsening slippage or lack of response to conservative may require surgery
  289. Scoliosis
    • Idiopathic – MC (also congenital, juvenile)
    • Goal – prevent progression
    • Female more likely to progress
    • Tx: <20° - Monitor (6-12 month xrays) and Exercises. 25°-45 ° - Bracing often used. > 45 ° - Surgery often recommended
  290. Developmental Dysplasia of the Hip
    • Head of femur not firmly in hip socket
    • Risks: Breech, Female, Family history, First born
    • 60% left, 20% right, 20% both
    • Sx: Asymmetry of thigh or gluteal folds, Limb length discrepancy, Restricted abduction
    • Tests: Ortolani, Barlow, Galeazzi
    • Dx: US – study of choice (1st 6 weeks), X-rays useful after 4-6 months
    • Tx: Up to 6 months – Pavlik harness. >6 months – open reduction and hip spica cast
  291. DDx for Limp
    • Trauma: any age, sudden onset, no fever, pain, ± swelling, ± ROM loss
    • Infection: younger age, gradual onset, fever, pain, ± swelling, ± ROM loss
    • Inflammation: >2yo, gradual onset, ± fever, pain, swelling, ROM loss
    • Malignancy: any age, gradual onset, , ± fever, pain, ± swelling, ± ROM loss
    • Legg-Perthes: 4-10yo, gradual onset, no fever, pain, no swelling, ROM loss
    • SCFE: 9-15yo, gradual/sudden onset, no fever, pain, no swelling, ROM loss
    • Congenital Hip Dysplasia: 1-18yo, gradual onset, no fever, ± pain, no swelling, ROM loss
    • Neurologica: any age, gradual onset, no fever, no pain, no swelling, ROM loss
    • Diskitis: any age, gradual onset, ± fever, ± pain, no swelling, no ROM loss
  292. Legg-Calve-Perthes Disease
    • Avascular necrosis femoral head
    • 4-10 yo; M>F by 5x
    • Sx: Gradual pain groin, anterior thigh; worse with movement. Limp. Loss of IR/ER
    • Dx: Xray showing mottled femoral head
    • Tx: Physical therapy, Petrie cast, Occasionally surgery
  293. Slipped Capital Femoral Epiphysis
    • Femoral head displaced from neck through physis
    • Usually idiopathic
    • Obese, hypogonadic adolescent boys (3x)
    • 60% bilateral
    • Sx: limp, affected leg turned out and appear shorter. Loss Flexion, IR, Abduction
    • Tx: Surgical fixation femoral head
  294. Osteochondroma:
    • #1 bone tumor in children
    • Sx: Pain free mass
    • Tx: Excise; Rarely malignant
  295. Osteosarcoma:
    • Pain or mass in long bone
    • 30% five yr survival
    • Mets to lung
    • Tx: chemo/radio/ surgery
  296. Ewing Sarcoma:
    • Sx: Pain, fever, ↑ WBC
    • Tx: chemo/radio/ surgery
    • Poor prognosis in large pelvic lesions
  297. Osteoid Osteoma:
    • Sx: Night pain
    • Tx: Excision
    • Not malignant; recurs
  298. Osgood-Schlatter
    • Tibial tubercle apophysitis
    • Sinding-Larsen-Johansson (distal pole patella)
    • Overuse injury
    • Running, jumping
    • M>F, 10-14yo
    • Sx: Worse with growth spurt or increased activity, Localized pain / swelling; step-off
    • Xray to r/o avulsion
    • Tx: Activity as tolerated, Patellavator, Stretch / Strength / Ice, NSAIDs after activity
    • Self-limiting
  299. Intoeing
    • Feet turned inward instead of straight in walking / running
    • DD: Metatarsus adductus, Tibial torsion, Increased femoral anteversion, Genu varum
  300. Metatarsus Adductus
    • Metatarsus adductus is a foot deformity characterized by a sharp, inward angle of the front half of the foot.
    • It is thought to occur as a result of the infant's position inside the uterus where the feet are bent inward at the instep.
    • Most cases resolve spontaneously and the majority of the remainder can be corrected with simple exercises.
    • Due to “uterine packing”
    • Medial forefoot varus
    • Can be passively corrected
    • Self correcting by 12-18 months
    • Passive stretching
    • Serial casting in persistent cases
  301. Tibial Torsion
    • Internal twisting of the tibia
    • Self corrects by 2 – 4 years
    • Avoid belly sleeping & IR positions
    • Encourage sitting lotus position
    • Usually self-limited
    • Splints and orthotics ineffective
  302. Increased Femoral Anteversion
    • Femur turns inward
    • Most obvious 5-6yo
    • Gait appears clumsy; patellae & feet point inward
    • Child may trip often & tends to sit in “W” position
    • Spontaneous resolution by late childhood
    • Surgery may be considered in severe deformity with functional disability but after 9-10 years old
  303. Genu Varum (Bowed Leg)
    • Distal tibia varus
    • Primarily physiologic
    • DD: Vit D Def – Rickets, Blount’s disease
    • X-ray if increasing after 16 months or with asymmetry
    • Spontaneous correction by 2-3 years if physiologic
    • Brace / Surgery for others
  304. Genus Valgum (Knock Knees)
    • Distal tibia valgus
    • Imaging if valgus > 15-20° or assoc with short stature
    • Rx: Observation
    • Normal alignment by early adolescence
  305. Talipes Equinovarus (Club Foot)
    • Congenital Deformity
    • Fixed ankle plantar flexion
    • Heel inversion
    • Varus forefoot
    • Smaller, shorter than other side
    • 1:1000, M>F slightly
    • May be associated with spinal deformities
    • Treatment (Ponseti): Serial casting, Surgical tendon release, Night brace 2 years
  306. Sever’s
    • Calcaneal apophysitis
    • Common in 7-15 yo
    • Well localized posterior calcaneal pain along Achilles insertion
    • X-ray not indicated
    • Tx: Activity as tolerated, Stretch / Strength / Ice, NSAIDs after activity, Self-limiting, Heel cups?
  307. Salter-Harris Classification
    • (S) Straight
    • (A) Above
    • (L) Lower
    • (T) Though
    • (R) Ram
  308. Obstructive Sleep Apnea Syndrome
    • Partial to complete upper airway obstruction during sleep
    • Associated with O2 desaturations and/or CO2 elevation
    • 1-3% of pediatric population
    • Peak ages: 2 - 7 years old
    • Before puberty: Male = Female
    • After puberty: Male >> Female
  309. Factors that increase the incidence of sleep apnea in pediatrics
    • Enlarged tonsils and/or adenoids
    • Obesity
    • Craniofacial abnormalities
    • Nasal polyps
    • Chronic allergic rhinitis
    • Pharyngeal infections
  310. Sleep Apnea in Children vs Adults
    • Snoring: Children (snoring ± apnea); Adults (snoring + apnea)
    • Sex: Children (M = F); Adults (M >> F)
    • Cause: Children (enlarged T&A); Adults (obesity)
    • PSG: Children (OSA/H; arousals); Adults (OSA)
    • TX: Children (surgery, CPAP, wt loss); Adults (wt loss, CPAP, surgery)
  311. OSA Evaluation
    • Sleeping: Snoring, Observed apnea, Resuscitative gasps, Disturbed or restless sleep, Paradoxical chest wall movements, Observed difficulty breathing, Enuresis
    • Awake: Mouth breathing, Nasal obstruction, Excessive daytime tiredness, Behavioral problems, Hyperactivity, Trouble concentrating
    • PE: Frequently normal, Adenotonsillar hypertrophy, Macroglossia, Retrognathia, Obesity vs. poor growth, Blood pressure, Cardiac examination
    • Complications: Pulmonary HTN, Developmental delay, Growth retardation, Death, Cor pulmonale, Behavioral problems, Failure to thrive
  312. Infants common signs and symptoms of sleep apnea
    • failure to thrive (weight loss or poor weight gain)
    • mouth breathing
    • problems sleeping and restless sleep
    • enlarged tonsils and adenoids
  313. Toddlers common signs and symptoms of sleep apnea
    • mouth breathing
    • problems sleeping and restless sleep
    • enlarged tonsils and adenoids
    • snoring
    • nocturnal snorting, gasping, choking
    • excessive perspiring during sleep
    • frequent URIs
    • developmental problems
    • learning problems
    • severe bedwetting (once old enough)
  314. Adolescents common signs and symptoms of sleep apnea
    • mouth breathing
    • problems sleeping and restless sleep
    • enlarged tonsils and adenoids
    • daytime cognitive and behavior problems, including problems paying attention, aggressive behavior and hyperactivity, which can lead to problems at school
    • morning headaches
    • frequent URIs
    • nocturnal snorting, gasping, choking
    • excessive perspiring during sleep
    • depression
  315. Laboratory Evaluation for Sleep Apnea (not usually helpful)
    • CBC / electrolytes
    • ECG
    • Radiology: chest x-ray, sinus films, lateral neck films
    • Polysomnography
  316. Screening Studies (not usually helpful except for overnight oximetry)
    • Clinical screening tests
    • Home videotaping
    • Wrist band actuator / bed monitor
    • Overnight oximetry
    • Home sleep studies
  317. Polysomnography Components
    • EEG
    • EMG (± limb leads)
    • SaO2
    • Impedance monitoring; chest wall, abdomen, (sum)
    • EOG
    • ECG
    • ETCO2
    • Nasal / oral airflow
    • pH probe
    • Video EEG
    • Esophageal manometry
  318. PSG Variables Assessed
    • Total study time
    • Total sleep time
    • Sleep efficiency
    • Sleep latency
    • REM latency
    • Sleep staging
    • Arousals
    • Oxygenation
    • Ventilation
    • Apneas
    • Hypopneas
    • Periodic breathing
    • Cardiac arrhythmias
    • (Seizure activity)
  319. Obstructive apnea
    • in children: obstructive apneas for 2 or more breaths
    • in adults: obstructive apnea > 10 seconds
  320. Central apnea
    • central apnea > 20 seconds
    • any central apnea associated with an O2 desaturation > 4% and/or bradycardia
  321. Hypopnea
    decrease in measured airflow of ³ 50%
  322. Apnea index:
    • child: > 1 apneas/hour
    • adult: > 5 - 10 apneas/hour
  323. Can (probably) defer obtaining a PSG if:
    • patient > 2 years old
    • history “classic” for OSA
    • excellent underlying health
    • normal physical examination
    • no underlying risk factors
    • low risk for post-operative complications
  324. Indications for PSG
    • Snoring
    • Witnessed apneas
    • Restless sleep
    • Excessive daytime tiredness
    • Neuromuscular diseases with FEV1 < 50%
    • Assessment of alveolar hypoventilation
    • Poorly controlled sickle cell disease
    • Unexplained pulmonary hypertension, cor pulmonale, polycythemia
  325. Maybe/ Not necessarily PSG
    • Sleep disturbances: parasomnias, dyssomnias
    • Insomnia
    • Poor sleep hygiene
    • Seizures
    • Known medical conditions that affect sleep
  326. Surgery Indications
    • Failed CPAP therapy
    • Patient is not a candidate for CPAP therapy
    • Surgically amenable problem
    • The key to successful surgery is correctly identifying the area of obstruction
    • Remember, there may be more than one area of obstruction!
  327. Sites of Obstruction
    • Nasopharynx: turbinate enlargement, deviated septum, nasal polyps
    • Oropharynx: tonsillar hypertrophy, adenohypertophy, macroglossia, adipose tissue
    • Hypopharynx: adipose tissue, macroglossia, mandibular size or structure abnormalities (such as micrognathia or retrognathia)
  328. Adenotonsillectomy
    • most common OSA surgery in children
    • safe; outpatient procedure
    • post-operative swelling can transiently worsen OSA
    • adenoids can “grow back”
    • Indications: OSA due to enlarged adenoids and tonsils, obese patients with OSA and a small oropharynx
    • Advantages: high safety record, very common, outpatient procedure, curative in many cases
    • Disadvantages: pain, dehydration, bleeding, post-operative swelling can transiently worsen OSA, adenoids can “grow back”
  329. Other Surgical Interventions for OSA
    • Uvulopalatopharyngoplasty (UPPP)
    • Laser-assisted uvulopalatoplasty
    • Hyoid suspension and genioglossus advancement
    • Mandibular/maxillary advancement
    • Midline glossectomy
    • Tracheostomy
  330. CPAP Complications
    • nasal / oral dryness
    • epistaxis
    • nasal congestion
    • sneezing
    • rhinorrhea
    • sinusitis
    • claustrophobia
    • mask irritation
    • nasal abrasions
    • aerophagy
    • facial deformities???
    • (decreased cardiac output)
  331. Medications for Sleep Problems
    • oxygen
    • thyroxine
    • theophylline
    • acetazolamide
    • medroxyprogesterone
    • antidepressants: SSRIs (i.e.: fluoxetine), tricyclic (i.e.: imipramine, protriptyline)

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