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Flashcards in Pediatric Health Supervision Deck (123)
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1
Q

<p>What are the 7 steps of the <strong>well child visit</strong>?</p>

A
<ol>
	<li>History</li>
	<li>Developmental surveillance</li>
	<li>Observation of parent-child interaction</li>
	<li>Physical examination</li>
	<li>Additional screening tests</li>
	<li>Immunizations</li>
	<li>Anticipatory guidance</li>
</ol>
2
Q

<p>What are the 6 components of <strong>well child care</strong>?</p>

A

<ul>
<li>Anticipatory guidance (diet, healthy lifestyle promotion)</li>
<li>Specific preventative measures (immunizations)</li>
<li>Screening tests to detect a symptomatic diseases (vision, hearing, newborn metabolic screening, tuberculosis screening)</li>
<li>Early detection and treatment of symptomatic acute illness to prevent complications</li>
<li>Prevention of disability in chronic disease</li>
<li>Assessment of growth and development</li>
</ul>

3
Q

<p>What is routinely monitored for normal growth?</p>

A
<ul>
	<li>Weight</li>
	<li>Height</li>
	<li>Head circumference (until age 2)</li>
	<li>Sexual maturity</li>
</ul>
4
Q

<p>Standardized Growth Curves</p>

A

<ul>
<li>Represent normal values for age for 95% of children</li>
<li>Used to plot weight, height, BMI, head circumference</li>
<li>Special growth curves exist for children w/ particular genetic conditions (Down syndrome, achondroplasia)</li>
</ul>

5
Q

<p><strong>Growth disturbances</strong></p>

<p>Definition</p>

<p>Types</p>

A
<ul>
	<li>Growth outside of the usual pattern</li>
	<li>Types
	<ul>
		<li>Failure to thrive</li>
		<li>Head growth abnormalities</li>
	</ul>
	</li>
</ul>
6
Q

<p><strong>Failure to Thrive</strong></p>

<p>definition</p>

<p>growth parameters</p>

<p>weight vs. length</p>

A

<ul>
<li>Growth rate of less than expected for a child</li>
<li>Concerning when child's weight crosses 2 major %ile isobars</li>
<li>May involve all growth parameters, but <strong>WEIGHT GAIN</strong> is the most abnormal</li>
<li><u>Weight</u> affected before <u>length</u> before <u>head circumference</u></li>
</ul>

7
Q

<p><strong>Rules of Thumb for Expected Increase in Weight </strong></p>

<ul>
	<li>Birth-3 mo</li>
	<li>3-6 mo</li>
	<li>6-12 mo</li>
	<li>1-2 yrs</li>
	<li>2 yrs-adolescence</li>
</ul>
A

<ul>
<li>Birth-3 mo: 30 g/day (regain birth weight by 2 wks)</li>
<li>3-6 mo: 20 g/day (double birth weight by 4-6 mo)</li>
<li>6-12 mo: 10 g/day (triple birth weight by 12 mo)</li>
<li>1-2 yrs: 250 g/mo</li>
<li>2 yrs-adolescence: 2.3 kg/yr</li>
</ul>

8
Q

<p><strong>Rules of Thumb for Expected Increase in Height </strong></p>

<ul>
	<li>0-12 mo</li>
	<li>13-24 mo</li>
	<li>2 yrs-adolescence</li>
</ul>
A
<ul>
	<li>0-12 mo: 25 cm/yr
	<ul>
		<li>birth length increases by 50% at 12 mo</li>
	</ul>
	</li>
	<li>12-24 mo: 12.5 cm/yr</li>
	<li>2 yrs-adolescence: 6.25 cm/yr
	<ul>
		<li>birth length doubles by age 4</li>
		<li>birth length triples by age 13</li>
	</ul>
	</li>
</ul>
9
Q

<p>What are the 2 etiologies of failure to thrive?</p>

<p>Which is the most common?</p>

A

<ul>
<li><strong>Inorganic FTT</strong>

~~~
<ul>
<li><strong>​</strong>a disturbed parent-child bond that results in inadequate caloric intake or retention (most common)</li>
</ul>
</li>
<li><strong>Organic FTT</strong>
<ul>
<li>suggest underlying organ system pathology, infection, chromosomal disorders or systemic illness</li>
</ul>
</li>
</ul>

~~~

10
Q

<p>How do you evaluate <strong>FTT</strong>?</p>

A

<ul>
<li>Careful history &amp; physical</li>
<li>Complete dietary history</li>
<li>Observation of parent-child interaction</li>
<li>Routine screening tests usually not useful</li>
<li>Evaluation of organic etiology directed at timing/onset</li>
</ul>

11
Q

<p>What are the 4 main <strong>head growth </strong>abnormalities?</p>

A
<ul>
	<li>Microcephaly</li>
	<li>Craniosynostosis</li>
	<li>Deformational plagiocephaly</li>
	<li>Macrocephaly</li>
</ul>
12
Q

Almost all head growth occurs prenatally & during the first ____ years of life.
Head circumference at birth is __% of the normal adult head size, and it increases to __% of the normal adult head size by 1 yr of age.

A

2 years

25%, 75%

13
Q

<p>What is a <strong>cephalohematoma</strong>?</p>

A

<ul>
<li>Subperiosteal hemorrhage of the newborn cranium after a traumatic delivery</li>
<li>May interfere w/ accurate head circumference measurement (as well as scalp edema)</li>
</ul>

14
Q

<p><strong>Rules of Thumb for Expected Increase in Head Circumference </strong></p>

<ul>
	<li>0-2 mo</li>
	<li>2-6 mo</li>
	<li>By 12 mo</li>
</ul>
A
<ul>
	<li>0-2 mo: 0.5 cm/wk</li>
	<li>2-6 mo: 0.25 cm/wk</li>
	<li>By 12 mo: total increase = 12 cm since birth</li>
</ul>
15
Q

<p>What are the <strong>inorganic</strong> causes of failure to thrive?</p>

A
<ul>
	<li>Poor formula preparation</li>
	<li>Poor feeding techniques</li>
	<li>Child abuse &amp; neglect</li>
	<li>Parental immaturity</li>
	<li>Maternal depression</li>
	<li>Alcohol or drug use</li>
	<li>Marital discord</li>
	<li>Mental illness</li>
	<li>Family violence</li>
	<li>Poverty</li>
	<li>Isolation from support systems</li>
</ul>
16
Q

<p><strong>Microcephaly</strong></p>

<p>definition</p>

<p>incidence</p>

A

<ul>
<li>Head circumference 2-3 standard deviations below the mean for age</li>
<li>1-2/1,000 children</li>
</ul>

17
Q

<p>What are the etiologies of <strong>microcephaly</strong>?</p>

A

<ul>
<li><strong>Congenital</strong>

<ul>
<li>associated w/ abnormal induction &amp; migration of brain tissue</li>
</ul>
</li>
<li><strong>Acquired</strong>
<ul>
<li>caused by a cerebral insult in the late 3rd trimester, perinatal period, or 1st yr of life</li>
<li>affected children are born w/ a normal head circumference that does not growth after the cerebral insult</li>
</ul>
</li>
</ul>

18
Q

<p>What are the clinical features of <strong>microcephaly</strong>?</p>

A
<ul>
	<li>Small brain</li>
	<li>Developmental delay</li>
	<li>Intellectual impairment</li>
	<li>Cerebral palsy or seizures</li>
</ul>
19
Q

<p><strong>Craniosynostosis</strong></p>

<p>definition</p>

<p>etiology</p>

A
<ul>
	<li>Premature closure of one or more of the cranial sutures</li>
	<li>Unknown etiology
	<ul>
		<li>80-90% sporadic </li>
		<li>10-20% familial or part of a genetic syndrome (Crouzon, Apert)</li>
	</ul>
	</li>
</ul>
20
Q

<p>Risk factors for <strong>craniosynostosis</strong></p>

A
<ul>
	<li>Intrauterine constraint or crowding</li>
	<li>Metabolic abnormalities
	<ul>
		<li>hyperthyroidism, hypercalcemia</li>
	</ul>
	</li>
</ul>
21
Q

<p>What are the clinical features of craniosynostosis? What is the most common form?</p>

A
<ul>
	<li>Cranial sutures remain open until cessation of brain growth
	<ul>
		<li>90% completed by age 2</li>
		<li>complete by age 5</li>
	</ul>
	</li>
	<li>Head shape is based on which suture closes prematurely</li>
</ul>
22
Q

<p>5 <strong>congenital</strong> causes of microcephaly</p>

A

<ul>
<li>Early prenatal infection (HIV, TORCH)</li>
<li>Maternal exposure to drugs &amp; toxins (fetal alcohol syndrome)</li>
<li>Chromosomal abnormality (trisomy 13, 18, 21)</li>
<li>Familial microcephaly (autosomal dominant or autosomal recessive)</li>
<li>Maternal PKU</li>
</ul>

23
Q

<p>4 <strong>acquired</strong> causes of microcephaly</p>

A

<ul>
<li>Late 3rd trimester or perinatal infections</li>
<li>Meningitis or meningoencephalitis during 1st yr of life</li>
<li>Hypoxic or ischemic cerebral insult</li>
<li>Metabolic derangements (hypothyroidism, inborn errors of metabolism)</li>
</ul>

24
Q

<p>What is dolichocephaly or scaphocephaly?</p>

A

<ul>
<li>Premature closure of the sagittal suture</li>
<li>Results in an elongated skull</li>
<li>Most common form of craniosynostosis</li>
</ul>

25
Q

<p>What is brachycephaly?</p>

A

<ul>
<li>Premature closure of the coronal suture</li>
<li>Results in a shortened skull</li>
<li>More common in boys</li>
<li>May be associated w/ neurological complications (optic nerve atrophy)</li>
</ul>

26
Q

<p>What is trigonocephaly?</p>

A

<ul>
<li>Premature closure of the metopic suture</li>
<li>Leads to a triangular-shaped head</li>
</ul>

27
Q

<p>What happens with premature closure of MULTIPLE sutures?</p>

A

<ul>
<li>Rare</li>
<li>Associated w/ severe neurologic compromise</li>
</ul>

28
Q

<p><strong>Craniosynostosis</strong></p>

<p>diagnosis</p>

<p>treatment</p>

A

<ul>
<li>Physical exam of the head</li>
<li>Note by 6 mo of age</li>
<li>Confirmation by skull radiographs &amp; head CT</li>
<li>Surgical repair (esp when significant cosmetic concerns)</li>
</ul>

29
Q

<p>What is the definition of plagiocephaly?</p>

A

<p>Asymmetry of the infant head shape NOT associated with premature suture closure</p>

30
Q

<p>What is the most common type of plagiocephaly?</p>

A

<p>Positional plagiocephaly</p>

<p>Flattening of the occiput</p>

<p>Prominence of the ipsilateral frontal area</p>

<p>Viewed from the top, skull shaped like parallelogram</p>

31
Q

<p><strong>Plagiocephaly</strong></p>

<p>associations</p>

<p>incidence</p>

A

<ul>
<li>Association w/ congenital muscular torticollis</li>
<li>Increased incidence, more infants sleep on back to prevent SIDS</li>
</ul>

32
Q

<p>Management of plagiocephaly</p>

A

<ul>
<li>ROM exercises for associated torticollis</li>
<li>Repositioning the head during sleep</li>
<li>Helmet therapy</li>
<li>Increased time in the prone position when awake ("tummy time")</li>
</ul>

33
Q

<p>GI causes of FTT</p>

A
<ul>
	<li>Craniofacial problems</li>
	<li>TE fistula</li>
	<li>GERD</li>
	<li>GI obstruction
	<ul>
		<li>Pyloric stenosis, malrotation, Hirschsprung's disease</li>
	</ul>
	</li>
	<li>Acute/chronic diarrhea</li>
	<li>Inflammatory bowel disease</li>
	<li>Celiac disease</li>
	<li>Cystic fibrosis</li>
</ul>
34
Q

<p>Cardiac causes of FTT</p>

<p>Pulmonary causes of FTT</p>

<p>Heme-Onc causes of FTT</p>

A
<ul>
	<li>Cardiac
	<ul>
		<li>Congenital heart disease</li>
	</ul>
	</li>
	<li>Pulmonary
	<ul>
		<li>Bronchopulmonary dysplasia</li>
		<li>Cystic fibrosis</li>
	</ul>
	</li>
	<li>Heme-Onc
	<ul>
		<li>Iron deficiency anemia</li>
		<li>Malignancy</li>
	</ul>
	</li>
</ul>
35
Q

<p>Renal causes of FTT</p>

A
<ul>
	<li>Chronic renal failure</li>
	<li>Renal tubular acidosis</li>
	<li>Recurrent UTI</li>
	<li>Fanconic syndrome</li>
</ul>
36
Q

<p>Neurologic causes of FTT</p>

A
<ul>
	<li>Hydrocephalus</li>
	<li>Intracranial tumors</li>
	<li>Generalized muscle weakness</li>
	<li>Increased/decreased tone</li>
</ul>
37
Q

<p>Genetic, congenital &amp; metabolic causes of FTT</p>

A

<ul>
<li>Fetal alcohol syndrome</li>
<li>Inborn errors of metabolism</li>
</ul>

38
Q

<p>Immunologic causes of FTT</p>

<p>Infectious causes of FTT</p>

<p>Endocrine causes of FTT</p>

<p>Toxin causes of FTT</p>

A
<ul>
	<li>Immuno
	<ul>
		<li>Immunodeficiency status</li>
	</ul>
	</li>
	<li>Infectious
	<ul>
		<li>TB, HIV, Hepatitis</li>
	</ul>
	</li>
	<li>Endocrine
	<ul>
		<li>Hypothyroidism, Rickets</li>
	</ul>
	</li>
	<li>Toxin
	<ul>
		<li>Lead poisoning</li>
	</ul>
	</li>
</ul>
39
Q

<p>What is macrocephaly?</p>

A

<ul>
<li>Head circumference >95% for age</li>
<li>Unlike microcephaly, the size of the head in patients w/ macrocephaly <u>does not</u> necessarily reflect brain size</li>
</ul>

40
Q

<p>What are the <strong>etiologies</strong> of Macrocephaly?</p>

A
<ul>
	<li>Familial</li>
	<li>Overgrowth syndromes (Sotos syndrome)</li>
	<li>Metabolic storage disorders
	<ul>
		<li>Canavan syndrome, gangliosidoses</li>
	</ul>
	</li>
	<li>Neurofibromatosis</li>
	<li>Achondroplasia</li>
	<li>Hydrocephalus</li>
	<li>Space-occupying lesions</li>
</ul>
41
Q

<p>What are the steps in evaluating macrocephaly?</p>

A

<ul>
<li>Measurement of parental head circumferences</li>
<li>Careful physical examination
<ul>
<li>Observation for split cranial sutures</li>
<li>Bulging anterior fontanelle</li>
<li>Irritability</li>
<li>Vomiting</li>
<li>Indications of <strong>elevated ICP</strong></li>
</ul>
</li>
<li>Head US or CT to rule out hydrocephalus</li>
<li>Genetic evaluation (if suspected)</li>
</ul>

42
Q

<p>\_\_\_\_\_\_\_\_\_\_\_\_ are on of the most important components of well child care &amp; are the cornerstone of pediatric preventative care.</p>

A

<p><strong>Immunizations</strong></p>

43
Q

<p>What is <strong>active</strong> immunization?</p>

A

<p>Induction of long-term immunity through exposure to live attenuated or killed (inactivated) infectious agents</p>

44
Q

<p>What is <strong>passive</strong> immunization?</p>

A

<p>Delivery of preformed ab to individuals who have no active immunity against a particular disease but who have either been exposed to or are at high risk for exposure to the infectious agent.</p>

45
Q

<p><strong>Live vaccines</strong></p>

<p>type of immunity</p>

<p>who should avoid them</p>

<p>examples</p>

A

<ul>
<li><strong>Long-lasting immunity</strong></li>
<li>Risk of vaccine-associated disease in the recipient or secondary host</li>
<li>Avoid in patients w/ <strong>compromised immunity</strong>
<ul>
<li>cancer, congenital/drug-induced immunodeficiencies</li>
</ul>
</li>
<li>Oral polio (OPV), varicella, measles mumps rubella (MMR)</li>
</ul>

46
Q

<p><strong>Non-live vaccines</strong></p>

<p>type of immunity</p>

<p>examples</p>

A

<ul>
<li>Not infectious</li>
<li>Induced immunity for shorter periods</li>
<li>Require <strong>booster immunizations</strong></li>
<li>Diphtheria, tetanus, acellular pertussis (DTaP), Hepatitis A &amp; B, inactivated polio (IPV), H. influenzae type B (HIB), pneumococcal &amp; meningococcal vaccines</li>
</ul>

47
Q

<p>What are some examples of passive immunization?</p>

A

<ul>
<li>Varicella zoster immune globulin (<strong>VZIG</strong>) for immunocompromised patients who have been exposed to varicella &amp; are at high risk for severe varicella infection</li>
<li>Newborns born to Hepatitis B+ mothers receive <strong>Hepatitis B immune globulin</strong> at birth</li>
<li>Visitors to high-risk areas may receive <strong>Hepatitis A immune globulin</strong> before travel</li>
</ul>

48
Q

<p><strong>Hepatitis B vaccine (HBV)</strong></p>

<p>rationale</p>

<p>type</p>

<p>timing</p>

A

<ul>
<li>Hepatitis B infects 300 million worldwide</li>
<li><strong>Recombinant</strong> vaccine w/ particles of HepB surface antigen (HBsAg)</li>
<li>Given as a 3-shot series w/i the <strong>1st year of life</strong></li>
</ul>

49
Q

<p>What is the <strong>rationale</strong> for the DTaP vaccine?</p>

<p></p>

A

<p>Diphtheria, tetanus &amp; pertussis all may cause series disease, especially in young infants</p>

50
Q

<p>What <strong>type</strong> of vaccine is DTaP?</p>

A

<ul>
<li>Inactivated</li>
<li>Historical: DTP w/ <strong>whole-cell killed</strong> <em>Bordetella pertussis</em>, high rate of side effects</li>
<li>Current: DTaP w/ <strong>purified acellular</strong> <em>B. pertussis</em>, lower rates of vaccine associated fever, seizures, local rxns</li>
</ul>

51
Q

<p>What is the <strong>timing</strong> of the DTaP vaccination?</p>

A

<ul>
<li>DTaP recommended at 2, 4, &amp; 6 mo w/ boosters at 12-18 mo &amp; 4-6 yrs</li>
<li>dT (diphtheria &amp; tetanus) contains 1/10 diphtheria toxoid &amp; is recommended at age 11-12 and every 10 yrs thereafter</li>
<li>Note that dT rather than DTaP is given to children<u>></u>7 yrs of age</li>
</ul>

52
Q

<p>What is the <strong>rationale</strong> for the oral &amp; inactivated polio vaccines(OPV/IPV)?</p>

A

<ul>
<li>Poliovirus is an <strong>enterovirus</strong> w/ propensity for the CNS, causing transient or permanent paresis of the extremities &amp; meningoencephalitis</li>
<li>Eradicated from the Western hemisphere &amp; South Pacific but <strong>remains</strong> in isolated pockets throughout the world</li>
</ul>

53
Q

<p><strong>Live attentuated OPV</strong></p>

<p>advantages</p>

<p>disadvantages</p>

A

<ul>
<li><u>Advantages</u>: induction of both host immunity &amp; secondary immunity b/c it is excreted in the stool of the recipient &amp; may infect (immunize) close contacts (<strong>herd immunity</strong>)</li>
<li><u>Disadvantages</u>: possibility of <strong>vaccine-related polio</strong>; in recent years, the only cases of polio in the USA have been associated w/ OPV</li>
</ul>

54
Q

<p><strong>Non-live (inactivated) IPV</strong></p>

<p>advantages/disadvantages</p>

<p>timing</p>

A
<ul>
	<li>SubQ or IM</li>
	<li><u>Advantage</u>: no vaccine-related polio</li>
	<li><u>Disadvantage</u>: no secondary immunity</li>
	<li>Timing (USA)
	<ul>
		<li>Only IPV is now recommended</li>
		<li>Given at 2 &amp; 4 mo</li>
		<li>Boosters at 6-18 mo &amp; 4-6 yrs</li>
	</ul>
	</li>
</ul>
55
Q

<p>What is the <strong>rationale</strong> for the Haemophilus influenzae type b vaccine (HIB)?</p>

<p></p>

A

<ul>
<li><em>H. influenzae</em> type b was a serious cause of <strong>invasive bacterial infection </strong>before vaccine licensure in 1985

~~~
<ul>
<li>Meningitis, epiglottitis, sepsis</li>
</ul>
</li>
<li>Now more rare since vaccine</li>
</ul>

~~~

56
Q

<p>What <strong>type</strong> of vaccine is HIB?</p>

A

<ul>
<li><strong>Conjugate vaccine</strong></li>
<li><em>H. influenzae</em> polysaccharide linked to various protein antigens (diphtheria or tetanus toxoids) to augment immunogenicity</li>
</ul>

57
Q

<p>What is the <strong>timing</strong> of the HIB vaccine?</p>

A

<ul>
<li>Recommended either at 2, 4, &amp; 6 mo w/ booster at 12-15 mo or at 2, 4, &amp; 12 mo</li>
<li>Depends on type of vaccine conjugate</li>
</ul>

58
Q

<p>What is the <strong>rationale</strong> for the MMR vaccine?</p>

A

<ul>
<li><strong>Measles</strong>

<ul>
<li><strong>​</strong>severe illness w/ complications that include pneumonia associated w/ significant mortality</li>
</ul>
</li>
<li><strong>Mumps</strong>
<ul>
<li>Commonly associated w/ parotitis</li>
<li>Meningoencephalitis &amp; orchitis</li>
</ul>
</li>
<li><strong>Rubella</strong>
<ul>
<li>Mild viral syndrome in children</li>
<li>Severe birth defects in offspring of susceptible women infected during pregnancy</li>
</ul>
</li>
</ul>

59
Q

<p><strong>MMR vaccine</strong></p>

<p>type of vaccine</p>

<p>timing</p>

A

<ul>
<li><strong>Live attenuated vaccine</strong></li>
<li>12-15 mo w/ a booster either at 4-6 yrs or 11-12 yrs</li>
</ul>

60
Q

<p><strong>Varicella vaccine</strong></p>

<p>rationale</p>

<p>type</p>

<p>timing</p>

A

<ul>
<li>Virus responsible for chicken pox &amp; zoster</li>
<li>Uncomplicated illness but severe disease in very young &amp; older patients</li>
<li><strong>Live attenuated vaccine</strong></li>
<li>12-18 mo</li>
</ul>

61
Q

<p>What is the <strong>rationale</strong> for the Hepatitis A vaccine?</p>

A

<ul>
<li>Hepatitis A is the <strong>most common viral cause of hepatitis</strong> worldwide</li>
<li>Asymptomatic in up to 70% of infected children younger than 6 yrs of age</li>
<li>Most severe disease in older children &amp; adults, but rarely associated w/ fulminant hepatitis</li>
</ul>

62
Q

<p><strong>Hepatitis A vaccine</strong></p>

<p>type</p>

<p>timing</p>

A

<ul>
<li><strong>Inactivated vaccine</strong></li>
<li>2 yrs of age or older, with a booster 6 mo later for the following:
<ul>
<li><strong>susceptible children</strong> living in communities w/ high hepatitis A rates (2x national rate) &amp; those traveling to endemic areas</li>
<li>individuals in <strong>other groups </strong>w/ high hepatitis A rates, including those w/ chronic liver disease, homosexual &amp; bisexual men, users of illicit drugs, patients w/ clotting factor disorders receiving blood products, &amp; patients at high risk for occupational exposure</li>
</ul>
</li>
</ul>

63
Q

<p>What is the <strong>composition</strong> &amp;<strong>rationale</strong> for the Pneumococcal vaccines (Pneumovax/Prevnar)?</p>

A

<ul>
<li>Composed of polysaccharide capsular antigens from 23 pneumococal serotypes</li>
<li>Pneumococcus (<em>Strep pneumoniae</em>)</li>
<li>Most common cause of <strong>acute otitis media</strong> &amp; <strong>invasive bacterial infections </strong>in children younger than 3 yrs of age</li>
</ul>

64
Q

<p><strong>Pneumovax</strong></p>

<p>advantage</p>

<p>disadvantage</p>

<p></p>

A

<ul>
<li><u>Advantage</u>: vaccine contains <strong>antigens</strong> from pneumococcal strains causing almost all cases of bacteremia &amp; meningitis during childhood</li>
<li><u>Disadvantage</u>: vaccine has <strong>little immunogenicity </strong>in children <2 YO</li>
</ul>

65
Q

<p>What are the <strong>indications</strong> for the Pneumovax vaccine?</p>

A
<ul>
	<li><strong>Older children &amp; adults at high risk for pneumococcal disease</strong></li>
	<li>Patients w/ sickle cell anemia who are functionally asplenic</li>
	<li>Immunodeficiency</li>
	<li>Chronic liver disease</li>
	<li>Nephrotic syndrome</li>
	<li>Patients w/ anatomic asplenia</li>
</ul>
66
Q

<p><strong>Prevnar vaccine</strong></p>

<p>advantages</p>

<p>disadvantage</p>

A

<ul>
<li>7 pneumococcal serotypes</li>
<li><u>Advantages</u>: immunogenicity &amp; efficacy in preventing meningitis, pneumonia, bacteremia &amp; otitis media from the most common pneumococcal strains in children <2 YO</li>
<li><u>Disadvantage</u>: does not confer as broad coverage against pneumococcal strains as Pneumovax</li>
</ul>

67
Q

<p>What are the <strong>indications</strong> for the Prevnar vaccine?</p>

A

<ul>
<li><strong>All children <2 YO</strong></li>
<li>Selected children >2 YO who are at high risk for pneumococcal disease</li>
<li>Prevnar recommended at 2, 4, &amp; 6 mo w/ a booster at 12-15 mo</li>
</ul>

68
Q

<p>What are some <strong>adverse effects</strong> of immunization?</p>

A

<ul>
<li>Most mild-moderate, w/i first 24 hrs
<ul>
<li><strong>Local inflammation, low-grade fever</strong></li>
</ul>
</li>
<li><strong>MMR &amp; varicella </strong>are live attenuated vaccines
<ul>
<li>Fever &amp; rash 1-2 wks after immunization</li>
<li>After the incubation period of the virus</li>
</ul>
</li>
<li>Serious side effects that may result in permanent disability or be life-threatening are rare
<ul>
<li>Vaccine-related polio after OPV</li>
</ul>
</li>
</ul>

69
Q

<p>What are some <strong>contraindications</strong> to immunization?</p>

A

<ul>
<li><strong>Anaphylaxis</strong> to a vaccine or its constituents</li>
<li><strong>Encephalopathy</strong> w/i 7 days after DTaP vaccine</li>
<li>Patients w/ progressive <strong>neurologic disorders </strong>(uncontrolled epilepsy) should not receive DTaP vaccine until neuro status is stabilized</li>
<li><strong>Immunodeficient</strong> patients should not receive OPV, MMR &amp; varicella vaccines. Household contacts shouldn't receive OPV as it is shed in the stool</li>
<li><strong>Pregnant</strong> patients should not receive live vaccines</li>
</ul>

70
Q

<p>What are some <strong>precautions</strong> for all vaccines?</p>

A

<ul>
<li>Moderate to severe illness (w/ or w/o fever)</li>
<li>Mild illnesses, including febrile illnesses, are <strong>not</strong> contraindications to immunization</li>
</ul>

71
Q

<p>What are some <strong>precautions</strong> fro the DTaP vaccine?</p>

A

<ul>
<li>Temp of 40.5oC w/i 48 hrs after prior vaccination</li>
<li>Collapse or shocklike state w/i 48 hrs after prior vaccination</li>
<li>Seizures w/i 3 days after prior vaccination</li>
<li>Persistent, inconsolable crying lasting<u>></u>3 hrs occuring w/i 48 hrs after prior vaccination</li>
</ul>

72
Q

<p>What are some <strong>precautions</strong> for MMR &amp; varicella vaccines?</p>

A

<ul>
<li>Immunoglobulin (<strong>IVIG</strong>) administration w/i the preceding 3-11 mo, which might interfere w/ the patient's immune response to these vaccines</li>
</ul>

73
Q

<p>What is the focus of each well child visit?</p>

A

<p>To <strong>identify</strong> undetected problems &amp;the <strong>risks</strong> of such problems</p>

74
Q

<p>What are some examples of screening assessments?</p>

A

<ul>
<li>Complete history &amp; physical examination</li>
<li>Growth measurements</li>
<li>Blood pressure measurements</li>
<li>Strabismus &amp; vision screening</li>
<li>Hearing screening</li>
<li>Tuberculosis screening</li>
<li>Laboratory screening</li>
<li>*Vision screening for ophthalmologic disorders begins after birth</li>
</ul>

75
Q

<p>Hearing screening recommendations</p>

A

<ul>
<li><strong>Universal newborn hearing screening </strong>(before hospital discharge) is now recommended</li>
<li>Evidence that moderate-to-profound hearing loss in early infancy is associated w/ <strong>impaired language development</strong></li>
<li>Early detection &amp; intervention for hearing loss may improve speech &amp; language acquisition</li>
</ul>

76
Q

<p>What types of <strong>audiometric tests</strong> are used for hearing screening?</p>

A

<ul>
<li>Brainstem auditory evoked response (BAER)</li>
<li>Evoked otoacoustic emission (EOE)</li>
</ul>

<p>Most effective screening is to use <strong>both</strong> of the above tests in combination</p>

77
Q

<p>What is the brainstem auditory evoked response (<strong>BAER</strong>) test?</p>

A

<ul>
<li>Measures the <strong>EEG</strong> waves generated in response to clicks via electrodes pasted to the infant's scalp</li>
<li>The <strong>most accurate test</strong>, but requires costly equipment &amp; trained operators</li>
</ul>

78
Q

<p>What is the evoked otoacoustic emission (<strong>EOE</strong>) test?</p>

A

<ul>
<li>Measures sounds generated by <strong>normal cochlear hair cells</strong> that are detected by a microphone placed into the external auditory canal</li>
<li>EOE accuracy may be affected by debris or fluid w/i the external or middle ear</li>
<li>It <strong>requires less</strong> expensive equipment &amp; less operator training</li>
</ul>

79
Q

<p><strong>Neonatal metabolic state screenings</strong></p>

<p>diseases</p>

<p>reasoning</p>

A

<ul>
<li>Treatable, prevention of irreversible brain injury
<ul>
<li><strong>Congenital hypothyroidism</strong></li>
<li><strong>Phenylketonuria</strong></li>
<li><strong>Galactosemia</strong></li>
</ul>
</li>
<li>Early intervention (penicillin prophylaxis) significantly decreases morbidity &amp; mortality
<ul>
<li><strong>Sickle cell anemia</strong></li>
<li>Other hemoglobinopathies</li>
</ul>
</li>
</ul>

80
Q

<p>Routine screening of <strong>cholesterol &amp; lipid</strong> panels (are/aren't) recommended because.....</p>

A

<ul>
<li>Are <strong>NOT</strong> recommended</li>
<li>Lack of information about the risks &amp; benefits of treating hyperlipidemia during childhood</li>
<li>Costs &amp; limitations of currently available screening tests</li>
</ul>

81
Q

<p>When is cholesterol &amp; lipid screening <strong>recommended</strong>?</p>

A

<ul>
<li>Children <strong>>2 YO</strong> w/ fahx of hypercholesterolemia, hyperlipidemia or early MI</li>
<li>Protocol
<ul>
<li>Screening cholesterol if either parent has a hx of hypercholesterolemia</li>
<li>Screening fasting lipid panel if either parents or grandparents have a hx of CVD or sudden death</li>
</ul>
</li>
</ul>

82
Q

<p>If a child has elevated cholesterol levels (75th-90th percentile), what <strong>lab test</strong> should they have?</p>

A

<ul>
<li><strong>Fasting lipid panel</strong>

~~~
<ul>
<li>Total cholesterol</li>
<li>TGs</li>
<li>HDL</li>
<li>LDL</li>
</ul>
</li>
</ul>

~~~

83
Q

<p>At what age is <strong>iron deficiency anemia</strong> most common?</p>

A

<ul>
<li>Children <6 YO</li>
<li>Peaking btwn 9-15 mo</li>
</ul>

84
Q

<p>What are the <strong>risk factors </strong>for iron deficiency anemia?</p>

A

<ul>
<li>Prematurity</li>
<li>Low birth weight</li>
<li>Early introduction of cow's milk (<9 mo)</li>
<li>Insufficiency dietary intake of iron</li>
<li>Low SES</li>
</ul>

85
Q

<p>Universal screening of hemoglobin levels is recommended........</p>

A

<p>btwn 9-15 mo</p>

<p>btwn 4-6 years</p>

86
Q

<p>When is <strong>urinalysis</strong> warranted in a child?</p>

A

<ul>
<li><strong>Little evidence</strong> that routine surveillance of urinalysis or routine urine cultures are efficacious or cost effective</li>
<li>Urine studies are recommended only when clinically warranted or when required for school entry or by local health departments</li>
</ul>

87
Q

<p>How is <strong>Tuberculosis</strong> screened?</p>

<p>Who should receive it?</p>

A

<ul>
<li>Intradermal injection of purified protein derivative
<ul>
<li><strong>PPD, Mantoux skin test</strong></li>
</ul>
</li>
<li>Skins tests analyzed at 48-72 hrs after placement &amp; interpreted on the basis of the level of risk for TB in the particular child</li>
<li>Recommended for children at <u>risk</u> for TB</li>
</ul>

88
Q

<p>What types of children are at <strong>risk for TB</strong>?</p>

A

<ul>
<li><strong>Contacts</strong> of persons w/ confirmed or suspected infectious tuberculosis</li>
<li>Children in contact w/ high-risk groups
<ul>
<li>Adults <strong>incarcerated</strong> or institutionalized during the preceding 5 yrs</li>
<li><strong>HIV</strong>-infected household members</li>
<li><strong>Homeless</strong> persons</li>
<li>Users of illicit <strong>drugs</strong></li>
<li>Migrant <strong>farm</strong> workers</li>
</ul>
</li>
<li>Children w/ <strong>radiographic or clinical findings </strong>suggestive of tuberculosis</li>
<li>Children who have <strong>immigrated</strong> from endemic areas, those w/ hx of travel to endemic areas, or those w/ significant contact w/ indigenous persons from endemic areas (Asia, Africa, Middel East, Latin America)</li>
<li>Children w/ <strong>HIV</strong></li>
<li>Children w/o specific risk factors who reside in <strong>high prevalence areas</strong></li>
</ul>

89
Q

<p>How common is lead intoxication (<strong>plumbism</strong>)?</p>

A

<ul>
<li>Public health risk among children <5 YO</li>
<li>Up to <strong>4%</strong> of all children in the US have evidence of increased lead absorption, including up to <strong>20%</strong> of inner city children</li>
</ul>

90
Q

<p>What are the <strong>risk</strong> factors of lead intoxication?</p>

A

<ul>
<li>Ingestion of lead-containing paint or putty from <strong>homes built before 1978</strong></li>
<li>Drinking water from lead<strong> pipes</strong> or pipes w/ lead-containing solder</li>
<li>Exposure to lead smelters or lead-painted commercial structures during <strong>demolition</strong></li>
<li>Use of lead-glazed <strong>pottery</strong> in food preparation</li>
<li>Use of lead-containing <strong>folk remedies</strong></li>
</ul>

91
Q

<p>At what age are children most susceptible to lead intoxication?</p>

A

Children

92
Q

<p>Describe <strong>acute</strong> lead intoxication</p>

A
<ul>
	<li>Anorexia</li>
	<li>Apathy</li>
	<li>Lethargy</li>
	<li>Anemia</li>
	<li>Irritability</li>
	<li>Vomiting</li>
	<li>May progress to encephalopathy</li>
</ul>
93
Q

<p>Describe <strong>chronic</strong> lead intoxication</p>

A
<ul>
	<li>Most commonly <strong>asymptomatic</strong></li>
	<li>Neurologic sequelae
	<ul>
		<li>Developmental delay</li>
		<li>Learning problems</li>
		<li>Mental retardation</li>
	</ul>
	</li>
</ul>
94
Q

<p>What age groups are recommended to have <strong>lead screening</strong>?</p>

A

<ul>
<li>All children 9 mo - 6 yrs of age living in <strong>older, dilapidated housing</strong></li>
<li>All children 9 mo - 6 yrs of age who are siblings, visitors, playmates of children w/ lead <strong>intoxication</strong></li>
<li>All children 9 mo - 6 yrs of age living near lead <strong>smelters</strong> or lead processing plants or whose parents/family have a lead-related <strong>occupation</strong> or hobby</li>
<li>Children of any age living in older housing where <strong>renovation</strong> is occuring</li>
<li>All children of any age living in areas in which the percentage of 1-2 year olds w/ elevated lead levels exceeds <strong>12%</strong></li>
</ul>

95
Q

<p><strong>Blood lead levels</strong> of \_\_\_\_\_\_\_ have been associated w/ effects on cognition in young children.</p>

<p>Management?</p>

A

<ul>
<li><u><</u>10 ug/dL</li>
<li>Based on serum levels after repeat testing
<ul>
<li><strong>Education</strong> to decrease exposure</li>
<li><strong>Chelation</strong> for very high lead levels</li>
</ul>
</li>
</ul>

96
Q

<p>Approximately \_\_\_% of male infants in the US are circumcised.</p>

<p>Circumcision for medical reasons (is/is not) recomended by the American Academy of Pediatrics.</p>

A

<p><strong>60%</strong></p>

<p><strong>is NOT</strong></p>

97
Q

<p>What are the medical <strong>benefits</strong> of circumcision?</p>

A

<ul>
<li>Increased incidence of<strong> penile cancer </strong>in uncircumcised adult men (HPV)</li>
<li>Increased incidence of <strong>cervical cancer</strong> in female sexual partners of uncircumcised men</li>
<li><strong>UTI's</strong> are 10x more common in uncircumcised male infants</li>
</ul>

98
Q

<p>What are the <strong>3 reasons</strong> an uncircumcised male may ultimately require circumcision?</p>

<p></p>

A

<p>*10% of uncircumcised males*</p>

<ul>
	<li>Phimosis</li>
	<li>Paraphimosis</li>
	<li>Balanitis</li>
</ul>
99
Q

<p>define Phimosis</p>

A

<ul>
<li><strong>Inability to retract the foreskin</strong></li>
<li>Normal up to age 6</li>
<li>Always abnormal if ballooning of foreskin occurs during urination</li>
</ul>

100
Q

<p>define Paraphimosis</p>

A

<ul>
<li>When the retracted foreskin can't be returned to its normal position &amp; acts as a <strong>tourniquet</strong>, resulting in obstruction to lymphatic flow &amp; edema</li>
<li>Obstruction of venous return --> emergent surgery</li>
</ul>

101
Q

<p>define Balanitis</p>

A

<ul>
<li><strong>Inflammation of the glans of the penis</strong></li>
<li><u>Infants</u>: <em>Candida</em> spp or gram-neg infections</li>
<li><u>Adults</u>: STIs</li>
</ul>

102
Q

<p>\_\_\_\_\_\_\_ &amp; \_\_\_\_\_\_\_ are strongly recommended during circumcision.</p>

A

<p>Anesthesia &amp; analgesia</p>

103
Q

<p>What are the potential <strong>complications</strong> from a circumcision?</p>

A
<ul>
	<li>Bleeding</li>
	<li>Infection</li>
	<li>Poor cosmesis</li>
	<li>Phimosis (secondary to insufficient foreskin removal)</li>
	<li>Urinary retention</li>
	<li>Injury to</li>
</ul>
104
Q

<p>What are some <strong>contraindications</strong> to circumcision?</p>

A
<ul>
	<li>Penile abnormalities (hypospadias)</li>
	<li>Prematurity</li>
	<li>Bleeding diatheses</li>
</ul>
105
Q

<p><strong>Tooth eruption</strong></p>

<p>age range</p>

<p>first tooth</p>

<p>primary vs. secondary</p>

A
<ul>
	<li>3-16 mo (average 6 mo)</li>
	<li>First tooth: lower central incisor</li>
	<li><strong>Primary teeth</strong>
	<ul>
		<li>20 teeth</li>
		<li>established by 2 yrs of age</li>
	</ul>
	</li>
	<li><strong>Secondary teeth</strong>
	<ul>
		<li>begins w/ lower central incisor</li>
		<li>6-8 yrs of age</li>
		<li>32 secondary ("permanent") teeth</li>
	</ul>
	</li>
</ul>
106
Q

<p><strong>Delayed dental eruption</strong></p>

<p>definition</p>

<p>causes</p>

A
<ul>
	<li>Primary eruption occuring <strong>after 16 mo </strong>of age</li>
	<li>Causes
	<ul>
		<li>Familial</li>
		<li>Hypothyroidism</li>
		<li>Hypopituitarism</li>
		<li>Genetic syndromes
		<ul>
			<li>Down syndrome</li>
			<li>Ectodermal dysplasia
			<ul>
				<li>Conical-shaped teeth</li>
				<li>Dysmorphic facial features</li>
				<li>Decreased sweat glands</li>
				<li>Alopecia</li>
			</ul>
			</li>
		</ul>
		</li>
	</ul>
	</li>
</ul>
107
Q

<p><strong>Early dental eruption</strong></p>

<p>definition</p>

<p>causes</p>

A
<ul>
	<li>Primary eruption <strong>before 3 mo</strong></li>
	<li>Causes
	<ul>
		<li>Familial</li>
		<li>Hyperthyroidism</li>
		<li>Precocious puberty</li>
		<li>Growth hormone excess</li>
	</ul>
	</li>
</ul>
108
Q

<p>When should <strong>tooth brushing</strong> be started?</p>

<p>What can be used?</p>

<p>When can children do it on their own?</p>

A

<ul>
<li>Should begin <strong>as soon as teeth erupt</strong></li>
<li>Moist washcloth or gauze pad initially</li>
<li>Soft toothbrush as early as tolerated</li>
<li><strong>2-3 YO</strong>: able to assist in brushing their own teeth
<ul>
<li>Fluoride toothpaste may be used</li>
</ul>
</li>
</ul>

109
Q

<p><strong>Dental floss</strong> to remove plaque from btwn teeth should be initiated when.....</p>

A

<p>tight contact exists btwn teeth</p>

110
Q

<p><strong>Fluoride</strong></p>

<p>benefits</p>

<p>sources</p>

A
<ul>
	<li>Children who consume optimal amts from birth until adolescence have <strong>50-75%</strong> less dental decay than expected</li>
	<li>Sources
	<ul>
		<li>Fluoridated water (not in USA)</li>
		<li>Fluoride supplements</li>
		<li>Fluoride toothpaste</li>
	</ul>
	</li>
</ul>
111
Q

<p>What is <strong>fluorosis</strong>?</p>

<p>What are the effects?</p>

A
<ul>
	<li>Caused by excess fluoride</li>
	<li><strong>Affects permanent teeth</strong></li>
	<li>Leads to abnormalities in dental enamel &amp; dentin</li>
	<li>Effects are <u>cosmetic</u> only
	<ul>
		<li>White streaks</li>
		<li>Pitting</li>
		<li>Gray-brown staining</li>
	</ul>
	</li>
	<li>Most critical time for dental vulnerability to excess fluoride: <strong>2-4 yrs of age</strong></li>
</ul>
112
Q

<p>In what population of children is fluoride supplementation important?</p>

A

<ul>
<li>Exclusively breastfed children <strong>>6 mo</strong>

<ul>
<li>Breast milk has little fluoride</li>
</ul>
</li>
<li>Children who live in areas where tap water contains <strong><0.3 ppm</strong> fluoride</li>
</ul>

113
Q

<p>What are <strong>natal</strong> teeth?</p>

<p>What are <strong>neonatal</strong> teeth?</p>

A

<ul>
<li><strong>Natal teeth</strong>

~~~
<ul>
<li>those that are present at birth</li>
</ul>
</li>
<li><strong>Neonatal teeth</strong>
<ul>
<li>those that emerge during the 1st mo</li>
</ul>
</li>
</ul>

~~~

114
Q

<p>What are the most common teeth that erupt early?</p>

A

<ul>
<li><strong>Mandibular central incisors</strong></li>
<li>>90% primary teeth</li>
<li><10% supernumerary teeth (teeth in excess of usual number)</li>
</ul>

115
Q

<p>What is the <strong>etiology</strong> &amp; <strong>management</strong> of early teeth?</p>

A

<ul>
<li>Etiology often unknown
<ul>
<li>Exposure to environmental toxins</li>
<li>Familial</li>
</ul>
</li>
<li>No intervention unless..
<ul>
<li><strong>Hypermobile teeth</strong></li>
<li><strong>Breastfeeding difficulty</strong></li>
<li><strong>Trauma to infant's lip/tongue</strong></li>
</ul>
</li>
<li><u>Aspiration</u> of natal/neonatal tooth feared but very unlikely</li>
</ul>

116
Q

<p>\_\_\_% of children have<strong> nursing/bottle caries</strong>.</p>

<p>Most often seen at \_\_\_\_ months of age.</p>

A

<p><strong>3-6%</strong></p>

<p><strong>24-30</strong></p>

117
Q

<p>What are the <strong>etiologies</strong> of nursing/bottle caries?</p>

<p>Most common bacterial agent?</p>

A

<ul>
<li>Associations
<ul>
<li>falling asleep w/ nipple (breast or bottle) in the mouth</li>
<li>children who breastfeed excessively or who carry around a bottle as a habit</li>
</ul>
</li>
<li><strong><em>Streptococcus mutans</em></strong>
<ul>
<li>Doesn'tappear in oral cavity until teeth erupt</li>
<li>Acquired from colonized parents/siblings</li>
</ul>
</li>
</ul>

118
Q

<p><strong>Nursing/bottle caries</strong></p>

<p>clinical features</p>

<p>management</p>

A

<ul>
<li><strong>Clinical features</strong>

~~~
<ul>
<li>Maxillary incisors</li>
<li>Canines</li>
<li>Primary 1st molars</li>
<li>Lower teeth spared initially b/c covered by the tongue</li>
</ul>
</li>
<li>Rx: placement of dental crowns or extraction</li>
</ul>

~~~

119
Q

<p>What is<strong> dental trauma</strong>?</p>

<p>What are the prognostic factors?</p>

A

<ul>
<li>A permanent tooth that has been <strong>traumatically avulsed</strong> may be re-implanted if placed into the socket rapidly</li>
<li>Most important factor: <strong>extraoral time</strong></li>
<li>Prognosis highest if avulsed tooth is stored in liquids (especially <strong>milk</strong>)</li>
<li>Dry-stored tooth has poor prognosis, even after 30 minutes</li>
</ul>

120
Q

<p>How is dental trauma managed?</p>

<p>What about primary teeth?</p>

A
<ul>
	<li>Management
	<ul>
		<li>Gentle rinsing of an avulsed tooth w/ saline</li>
		<li>Placement into the socket</li>
		<li>Referral to a dentist</li>
	</ul>
	</li>
	<li>Avulsed primary teeth do not require re-implantation</li>
</ul>
121
Q

<p>What is the timing of <strong>developmental screening</strong>?</p>

A

<ul>
<li>Assessed at each well child visit from infancy through school age</li>
<li>School performance substitutes in developmentally normal children<u> >5-6 YO</u></li>
</ul>

122
Q

<p>What is <strong>anticipatory guidance</strong>?</p>

A

<ul>
<li><strong>Patient &amp; parent education</strong></li>
<li>Provided during each well child visit</li>
<li>Tailored to the child's current developmental level &amp; to anticipated changes in the child's development in the interim before the next scheduled visit</li>
</ul>

123
Q

<p>What are the 9 topics covered by anticipatory guidance?</p>

A

<ol>
<li>Health habits (tobacco, drug, alcohol counseling)</li>
<li>Prevention of illness &amp; injury (safety)</li>
<li>Nutrition</li>
<li>Dental care</li>
<li>Social development &amp; family relationships</li>
<li>Sexuality</li>
<li>Parental health</li>
<li>Self responsibility</li>
<li>School &amp; vocational achievement</li>
</ol>