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Flashcards in Case 4 Deck (71):
1

What is on the differential diagnosis for a child with school failure?

Sensory impairment, Sleep disorder, Mood disorder, Learning disability, Conduct disorder

2

What is the epidemiology of obesity in children?

Prevalence of childhood overweight and obesity in US has doubled in past 20 yrs. Currently, 15 percent of 19 yo are greater than 95th percentile for BMI based on reference data from the 1970s; higher rates in minority and economically disadvantaged children.

3

What is the probability of childhood obesity persisting into adulthood?

20 percent at 4 yrs. Approximately 80 percent in adolescence. Comorbidities will likely persist into adulthood.

4

What are genetic risk factors for obesity?

Prader-Willi syndrome
Barred-Biedl syndrome
Cohen syndrome

5

What are birth history risk factors for obesity?

High birth weight
Maternal diabetes

6

What are family history risk factors for obesity?

For young children, if one parent is obese, odds ratio is about 3 that child will be obese in adulthood. If both parents are obese odds ratio is greater than 10. Before age 3 yr, parental obesity is a stronger predictor of obesity in adulthood than child's own weight status.

7

What are the critical periods of excessive weight gain?

Infancy: Extent and duration of breastfeeding inversely associated with risk of obesity in later childhood (possibly due to physiologic factors in human milk, feeding/parenting patterns)
Adolescence: Normal tendency during early puberty for insulin resistance; early menarche; risk of obesity persisting into adulthood higher among obese adolescents than among younger children.

8

What are environmental risk factors for obesity?

Family/parental dynamics, Lack of safe places for physical activity, Inconsistent access to healthful food choices, low cognitive stimulation in home, low socioeconomic status.

9

What CV sequelae can obesity cause?

Hypertension. Found to occur up to nine times more frequently in overweight children. Approximately 1/3 of children with a BMI greater than 95th percentile are hypertensive.

10

What sleep sequelae can obesity cause?

Obstructive sleep apnea

11

What syndrome sequelae can obesity cause?

Pickwickian syndrome - obesity hypoventilation syndrome

12

What are pulmonary sequelae of obesity?

Morbid obesity may directly cause restrictive lung disease, but is not causally linked with reactive airway disease (RAD). (Conversely, poorly controlled RAD, which in turn impairs exercise tolerance, may contribute to obesity.)

13

What are the endocrine sequelae of obesity?

Insulin resistance (may correlate with acanthosis nigricans on exam), Hyperinsulinism, Type 2 DM, Obesity typically advances bone age and leads to early puberty.

14

What are the gastrointestinal sequelae of obesity?

Nonalcoholic steatohepatitis, Gallbladder disease

15

What are the orthopedic sequelae of obesity?

Blount disease, Slipped capital femoral epiphysis (SCFE): Involves displacement of the femoral head from femoral neck through physeal plate. Most commonly occurs at the onset of puberty in obese patients with delayed sexual maturation. Typical sx include an antalgic gait due to pain referred to the hip, thigh, and/or knee, with limited range of motion (esp. internal rotation) on examination of the hip. SCFE can be diagnosed on plain X-rays of the pelvis which shows widening of the physis.

16

How do you diagnose ADHD in children?

No laboratory test. Diagnosis based on a set of characteristic clinical findings. Core symptoms include inattention, hyperactivity and impulsivity.

17

What is the epidemiology of ADHD?

Est. prevalence in the US is about 8-10 percent, making ADHD the most common neurobehavioral disorder of childhood and among the most common chronic health conditions in schooled children. Not all children with ADHD have obvious behavioral problems, esp. those with predominantly inattentive not hyperactive type.

18

What is notable about girls with ADHD?

Girls who more often get the inattentive type, may be significantly impaired socially and academically, yet go unrecognized.

19

What is the etiology of diabetes in children?

Type 1 DM is characterized by insulin deficiency, typically due to autoimmune destruction of pancreatic beta cells. Type 2 CM is more heterogenous, but typically involves insulin resistance.

20

How does DM present in children?

Patients with Type 2 DM typically have a more indolent presentation than patients with Type 1 DM. In Type 2 DM, weight loss is less common, and DKA is rare, although 25 percent of pts. with Type 2 DM will have ketonuria at dx. "Accidental" diagnosis by routine laboratory screening, especially urinalysis, occurs in up to one third of patients with Type 2 DM; this presentation is rare in Type 1 DM.

21

What is the epidemiology of DM?

Type 1 DM is more likely to present in early childhood. Age is not generally helpful in differentiating between Type 1 and Type 2 DM in adolescence. The CDC reports that type 2 DM (previously "non-insulin dependent" or "adult-onset" DM) represented 19 percent of all DM cases in children between 2002 and 2005. Though most of these patients are adolescents, rare cases have been reported in children as young as 5 yo. The trend is clearly rising.

22

How do you diagnose DM in children?

Sx of DM (polyuria, polydipsia, polyphagia or weight loss), plus random blood glucose level greater than 200 mg/dL (greater than 11.1 mmol/L). OR Fasting serum glucose greater than 126 mg/dL (greater than 7.0 mmol/L) Or, 2-hour serum glucose greater than 200 mg/dL (greater than 11.1 mmol/L) during oral glucose tolerance test.

23

What is the criteria for ADA Guidelines for testing for Type 2 DM in children and adolescents?

Overweight. BMI greater than 85th percentile. Weight:height greater than 85th percentile. Weight greater than 120 percent ideal for height plus any two of the following risk factors: (1) family hx of type 2 DM in 1st or 2nd deg relatives (2) Race/ethnicity (AI, AA, Hispanic, Asian/Pacific islander), signs of insulin resistance (acanthosis nigricans, polycystic ovary syndrome, HTN, dyslipidemia)

24

What is the timing for ADA Guidelines for testing for Type 2 DM in children and adolescents?

Start screening at age 10 years or at onset of puberty, whichever is earlier.

25

What is the frequency for ADA Guidelines for testing for Type 2 DM in children and adolescents?

Every 2 years.

26

What is the preferred test for ADA Guidelines for testing for Type 2 DM in children and adolescents?

Fasting serum glucose.

27

How should you screen for HTN in children?

Measure bp yearly starting at age 3 yrs as part of routine health maintenance visits.

28

What is the normal bp for a child?

Less than 90th percentile for age, gender, height and weight.

29

What is preHTN for a child?

Between 90th and 95th percentile for age, gender, height and weight.

30

What is Stage 1 HTN in a child?

Between 95th and 99th percentile for age, gender, height and weight plus 5 mmHg

31

What is Stage 2 HTN in a child?

Greater than 99th percentile for age, gender, height and weight plus 5 mmHg

32

What is the etiology of most blood pressure elevation in children greater than 6 yo and in adolescents?

Most due to primary HTN, for which obesity has been found to be an important correlate.

33

What are secondary causes of HTN in children?

Renal parenchymal disease and coarctation of the aorta. These are more important to consider in young patients who have substantial elevation in bp (often above the 99th percentile) and have little family history of HTN, but they can also occur in older children and adolescents. Secondary causes also include: Placement of umbilical arterial or venous line as neonate might predispose to renal vascular disease. Renal scarring due to childhood UTI. Catecholamine excess (eg pheochromocytoma or neuroblastoma)

34

What is the protocol for administering influenza vaccine for children less than 9 yr of age?

The first yr of immunization with either the killed injected or live intranasal vaccine, children less than 9 yo need 2 doses one month apart. Thereafter, annual single dose of vaccine.

35

What is the protocol for administering Hepatitis A vaccine?

Recc. for children less than 23 mo who live in areas where vaccination programs target older children, who are at increased risk for infection or for whom immunity against hepatitis A is desire. Now its routinely reach at 12 and 18 mo.

36

What are important factors to consider while taking a history of an obese child?

(1) Reproductive system (menstrual irregularity). Early menarche, not delayed puberty, has been associated with a BMI greater than 85th percentile. (2) Psychiatric concerns (depression, low self esteem)

37

How is BMI calculated and why is it better?

Wt in kg/height in meters2. BMI better reflects the amy of body fat compared with weight from muscle or bone than weight for height measurements.

38

What BMI defines Obese in children?

BMI greater than 95th percentile for age.

39

What BMI defines Overweight in children?

BMI between 85-95th percentile for age.

40

What does a too large or too small bp cuff do?

Too large will give a falsely low bp measurement. Too small will give a falsely elevated bp.

41

How should a bp cuff fit?

A cuff should cover 2/3 of the upper arm and the internal bladder should encircle 80-100 percent of the arm circumference.

42

What is white coat HTN and how do you control for it?

It is a common cause of elevated BP measurements. Taking several bp readings in succession may reveal a steady decline in the bp toward the normal range in such cases.

43

What can be a valuable asset in obtaining serial bp readings over time?

A school nurse can do this in a less threatening environment.

44

How should a patient having their bp taken be seated?

Seated, in a relaxed state, with arm held at heart level. Holding the arm down at the side may elevate the systolic bp as much as 20-30 mmHg in an adolescent.

45

What is motivational interviewing?

Technique used to discover the patient's motivation for changing his or her behavior.

46

How do you do motivational interviewing?

(1) Ask pt or caregiver to state reasons they want to change. This sets tone that this is something they are working on because they want to, not just because you said so. (2) Set an attainable goal. Make sure that you and the patient agree upon the goal. Your patient may have the best sense of what is attainable at this time. (3) Use external motivators. (star charts and other reward programs may be especially important motivation for young children who have a limited understanding of more esoteric goals such as good health). (4) Empower patient and family to manage change themselves.

47

What are signs and symptoms than can mimic ADHD behaviors?

Sensory impairment, sleep problems, mood disorder, learning disability, oppositional defiant disorder (ODD)

48

How can sensory impairment be confused with ADHD?

Hearing or vision impairment can mimic inattention.

49

How can sleep problems be confused with ADHD?

Inadequate sleep due to obstructive sleep apnea, narcolepsy or poor sleep hygiene may adversely affect school performance. Pts. with ADHD often have poor sleep hygiene, but typically do not seem overtired.

50

How can mood disorders be confused with ADHD?

Prevalence of mood disorders increases with age. Depression affects an est. 1-2 percent of elementary school age children and 5 percent of adolescents. Depressive sx may mimic inattention. Childhood depression has a high rate of conversion to bipolar disorder, which may look like hyperactivity. Children with ADHD have a higher rate of mood disorders than control populations. These disorders may mimic or accompany ADHD.

51

How can learning disabilities be confused with ADHD?

A disorder of cognition that manifests itself as a problem involving academic skills. Most states require documentation of a discrepancy between intelligence quotient (IQ) and academic achievement for the diagnosis of a learning disability. Learning disabilities clearly impair academic performance but may also lead to behavioral or attention problems, particularly at school. Poor school performance frequently prompt the evaluation for ADHD. Inattention may stem from an inappropriate classroom assignment (applies to gifted students as well). Comorbidity between learning disabilities and ADHD is common; many experts feel that one diagnosis should not be made without evaluating for the other. An educational assessment should be part of the evaluation for any child with behavioral problems and poor school performance.

52

How can oppositional defiant disorder (ODD) be confused with ADHD?

Its characterized by a pattern of negativistic, hostile and defiant behavior. Conduct disorder (CD) is a more severe disorder of habitual rule breaking, characterized by a pattern of aggression, destruction, lying, stealing and/or truancy. ODD and CD have high comorbidity rates with ADHD.

53

What is the cause of most hypertension in children?

Most bp elevation in children older than 6 yrs is due to primary HTN and obesity is an important correlate. Consider secondary causes of HTN such as renal parenchymal disease and coarctation of the aorta in young patients with substantial blood pressure elevation and with little family history of HTN.

54

What should you test for in a child with obesity?

Hypercholesterolemia, hypertriglyceridemia, hyperinsulinism.

55

What should you know about hypercholesterolemia and hypertriglyceridemia?

Hypertriglyceridemia and low HDL cholesterol are strongly correlated with metabolic syndrome, which occurs almost exclusively as a consequence of obesity. Several studies have shown that dyslipidemia may improve with weight reduction.

56

What tests should be done to evaluate hyperinsulinism in an overweight child?

If 85 to 95 percentile and no risk factors, obtain fasting lipid profile. If 85-95 percentile with risk factors (family hx or physical) obtain fasting lipid profile plus hepatic transaminases and fasting glucose. If greater than 95 percentile (w/ or w/o risk factors), obtain above plus blood urea nitrogen (BUN) and creatinine.

57

What should the weight management goals be for a patient in 85-95 percentile?

Weight maintenance or slowing of weight gain until BMI is less than 85th percentile.

58

What should the weight management goals be for a patient in greater than 95 percentile?

Weight maintenance or gradual weight loss until BMI in 85th percentile. Not more than one pound per month in preteens.

59

What should the weight loss goals be for teens?

No more than one pound of loss per week in teens. Assess patient/family readiness for change prior to making a treatment plan.

60

How do you assess family and patient readiness for weight loss?

(1) Inquiring whether weight is a concern for the parent or the child and talking about immediate effects (with patient) and long term effects (with parent) are effective strategies. (2) Using BMI as a visual aid to demonstrate that the child is overweight by national standards has been shown to be an effective motivator for changing eating, drinking and exercise habits. (3) Family must be engaged if any health behaviors are to be altered.

61

How often should you follow up with child or adolescent trying to loose weight?

Follow up every 3 to 6 months.

62

How should treatment plans start for children or adolescents looking to loose weight?

Start with general recommendations for dietary changes and physical activity; if not meeting goals, may escalate to therapy to include structured diet and exercise programs, with or without direct supervision of multidisciplinary team.

63

What are some dietary assessments and recommendations for children trying to lose weight?

No sugar-sweetened beverages (eg soda, juice drinks, sports drinks). Limit meals outside the home (esp. fast food restaurants). Eat breakfast daily. Five or more daily servings of fruits and vegetables. Limit consumption of energy-dense foods. Eat diet with balanced macronutrients (fat, protein, carbohydrates)

64

What physical activity assessment and recommendations should you make for a child or adolescent loosing weight?

Limit sedentary activities (screen time, such as TV, video games and computer) to less than 2 hrs a day. At least 60 minutes of moderate physical activity daily.

65

How should you manage preHTN in children?

(1) Implement therapeutic lifestyle changes. (2) Ask school nurse to record weekly BP check. (3) Follow up BP in office in 6 mo. (4) Reserve treatment with pharmacological agents for children: Whose BP is consistency very high. With evidence of target-organ effects, such as left ventricular hypertrophy. Because development of obesity in childhood and adolescence is strongly related to HTN in adult life, encourage patients to control their weight and pursue fitness. Wt. loss and improved CV conditioning have been demonstrated to lower bp in HTN adolescents. Many experts recommend beginning a lower sodium diet as a way to reduce blood pressure.

66

ADHD Medication:

80 percent of children with ADHD respond to stimulant medication. (ex regimen: sustained release methylphenidate 18 mg by mouth once daily in AM, monday through friday). Pts. treated with stimulant medication are at no higher risk for substance abuse than their peers. In fact, some data suggest that a positive response to stimulant medication may reduce a patient's likelihood of substance abuse, as well as other high-risk behaviors.

67

What are adverse effects of ADHD medication?

Appetite suppression is most common effect associated with stimulant use. Weight loss if any is typically minor. Insomnia is a common, dose-related side effect. It is typically worse on the first days of medication.

68

How many children treated with stimulant medication develop tic disorders?

Less than 1 percent. In most cases, the tics resolve when the medication is discontinued.

69

What have studies shown about growth velocity in children on stimulant medications for ADHD?

Studies have shown slight decrease in growth velocity in children on stimulant medication for ADHD, and growth should be closely monitored for children on these meds. This effect appears to stop when medications are stopped.

70

What happened to ADHD drugs in 2006?

An advisory committee recc. that a black box warning be placed on stimulant medication regarding CV risks; the FDA rejected this recc. at least for children, missing a highlighted warning. The CV risks of these medications seems to be (1) primarily limited to children with known heart disease and (2) higher for adults (who account for about 10% of stimulant usage) than children.

71

What are additional recommendations when treating patients with ADHD?

Consider educational achievement testing. Ask parents to observe child for possible side effects of medication: poor appetite, difficulty sleeping, facial twitching. Recommend website/reading material on ADHD to parents.