Ch. 1 Pediatric Heath Supervision Flashcards
(24 cards)
Normal Growth
Rules of Thumb for Expected Increase in Weight
Rules of Thumb for Expected Increase in Height
Growth Disturbances = growth outside usual pattern
Two common types & their causes:
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Failure to thrive (FTT) = growth rate of less than expected for a child
- Concerning with child’s weight crosses two major isobars on National Health Statistics charts
- May involve all growth parameters (weight*, height, head circumference [until 2 y/o], sexual maturity)
- Order of affected: weight, length, head circumference
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Most common cause of FTT:
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Inorganic FTT (i.e., disturbed parent-child bond that results in inadequate caloric intake/retention)
- Poor formula preparation, poor feeding techniques, child abuse, maternal depression, alcohol/drug use, mental illness, family violence, poverty, isolation from support systems
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Organic etiologies: underlying organ system pathology, infection, chromosomal disorders, systemic illness
- Determine timing of FTT (i.e., prenatal onset [intrauterine growth retardation] vs. postnatal onset of inadequate weight gain)
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Inorganic FTT (i.e., disturbed parent-child bond that results in inadequate caloric intake/retention)
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Head Growth Abnormalities = Microcephaly, craniosynostosis, macrocephaly
- General concepts:
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Almost all head growth occurs prenatally and during first 2 years of life
- Head circumference at birth is 25% of normal adult head size and increases to 75% of normal adult head size by 1 year of age
- Scalp edema (cephalohematoma) [subperiosteal hemorrhage of newborn cranium after traumatic delivery] may interfere with accurate head circumference measurements
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Almost all head growth occurs prenatally and during first 2 years of life
- General concepts:
Head Growth Abnormalities:
Microcephaly
Craniosynostosis
Plagiocephaly
Macrocephaly
Microcephaly
- Head circumference is 2-3 SDs below mean for age
- Incidence is 1-2/1000 children (0.01%)
- Etiologies:
- Congenital: abnormal induction and migration of brain tissue
- TORCH (Toxoplasmosis, other-syphilis, rubella, CMV, HSV)
- In utero exposure to drugs and toxins
- Chromosomal abnormalities
- Acquired: cerebral insult in late 3rd trimester, perinatal period, or 1 y/o
- Congenital: abnormal induction and migration of brain tissue
- Clinical Features:
- Because head size generally reflects brain size, microcephaly is always associated with a small brain –> developmental delay + intellectual impairment
- May be associated with: cerebral palsy/seizures
Craniosynostosis
- Premature closure of one or more of the cranial sutures
- Etiology: unknown (80-90% cases = sporadic)
- Risk factors:
- Intrauterine constraint
- Crowding
- Metabolic abnormalities
- Hyperthyroidism
- Hypercalcemia
- Clinical Features:
- Cranial sutures remain open until cessation of brain growth, which is 90% completed by age 2 and complete by age 5
- Diagnosis is made by physical exam of head –> usually noted by 6 mo of age / confirmed by skull radiographs and head CT scan
- Mgmt = surgical repair
Plagiocephaly = “flat head syndrome”
- Asymmetry of the infant head shape usually not associated with premature suture closure
- Most common type: positional plagiocephaly –> associated with flattening of the occiput and prominence of ipsilateral frontal area (viewed from the top, the skull is shaped like a parallelogram)
- May be associated with congenital muscular torticollis
- Mgmt: ROM exercises for associated torticollis, repositioning the head during sleep, helmet therapy, “tummy time”
Macrocephaly
- Head circumference > 95% for age
- Unlike microcephaly, size of head in patients with macrocephaly does not necessarily reflect brain size
- Etiologies:
- Familial
- Overgrowth syndromes (e.g., Sotos syndrome), in which all growth parameters are enlarged
- Metabolic storage disorders (e.g., Canavan syndrome, gangliosidoses)
- Neurofibromatosis
- Achondroplasia
- Hydrocephalus
- Space-occupying lesions
- Evaluation:
- Measure parenteral head circumferences and observe for split cranial sutures, bulging anterior fontanelle, irritability, vomiting (suggestive of inc. ICP)
- Head U/S or CT scan to r/o hydrocephalus
- Genetic eval if genetic syndrome suspected
Types of Immunizations
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Active immunization
- Live vaccines:
- Long-lasting immunity, but carry risk of vaccine-associated disease in recipient
- Avoid in pts with compromised immunity (e.g., cancer, congenital or drug-induced immunodeficiencies)
- Examples: OPV; varicella; MMR
- Long-lasting immunity, but carry risk of vaccine-associated disease in recipient
- Non-live vaccines:
- Not infectious –> induce immunity for shorter periods –> thus, require boosters
- Examples: DTaP; hep A & B; inactivated polio (IPV); HIB; influenza; pneumococcal and meningococcal vaccines
- Live vaccines:
-
Passive immunization
- Delivery of preformed antibodies 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 infectious agent
- Examples:
- VZIG for immunocompromised pts who have been exposed to varicella and are high risk for severe varicella infection;
- Newborns born to hep B+ mothers receive hep B IG at birth;
- Visitors to high-risk areas receive hep A immune globulin before travel
Specific Immunizations:
Hep B Vaccine
Type?
Timing of vaccination?
Recombinant vaccine with particles of hep B surface antigen (HBsAg)
Timing: three-shot series within ~first year of life
- 1st dose HBV: Birth (within 12 hrs)
- 2nd dose: 1-2 mo.
- 3rd dose: 6-18 mo.
Specific Immunizations:
Diphtheria, tetanus, and acellular pertussis vaccine (DTaP)
Type?
Timing of vaccination?
DTaP vs. dT
Type? Inactivated
Timing?
- 3 dose primary series:
- 1st dose: 2 mo
- 2nd dose: 4 mo
- 3rd dose: 6 mo
- 2 dose secondary series:
- Booster 1: 12-18 mo
- Booster 2: 4-6 yr
dT (diphtheria and tetanus combined) contains 1/10th the dose of diphtheria toxoid and is recommended at age 11-12 and every 10 years thereafter
- Note that dT rather than DTaP is given to children > 7 y/o
Specific Immunizations:
Oral and inactivated polio vaccines (OPV/IPV)
Advantages? Disadvantages?
Timing?
-
Live attenuated (OPV), administered orally
- Advantage:
- Induction of both host immunity and secondary immunity b/c it is excreted in the stool of recipient and may infect, and thus immunize, close contacts (i.e., herd immunity)
- Disadvantage:
- Possibility of vaccine-related polio
- Advantage:
-
Non-live or inactivated (IPV), administered subcutaneously or IM
- Advantage:
- No vaccine-related polio
- Disadvantage:
- Does not induce secondary immunity
- Advantage:
Timing: In the U.S., only IPV is now recommended
- 1st dose: 2 mo.
- 2nd dose: 4 mo.
- Booster 1: 6-18 mo.
- Booster 2: 4-6 y/o.
Specific Immunizations:
HIB
Type of vaccine?
Timing of vaccination?
Type: conjugate vaccine with H. flu polysaccharide linked to various protein antigens, including diphtheria or tetanus toxoids, to augment immunogenicity
Timing of vaccination:
- Dose 1: 2 mo.
- Dose 2: 4 mo.
- Dose 3: 6 mo.
- Booster: 12-15 mo.
Specific Immunizations:
MMR
Type of vaccine?
Timing of vaccination?
- Measles: severe illness with complications that include pneumonia associated with significant mortality
- Mumps: commonly associated with parotitis but may also cause meningoencephalitis and orchitis
- Rubella: causes mild viral syndrome in children but may cause severe birth defects in offspring of susceptible women infected during pregnancy (TORCHeS)
Type of vaccine: live attenuated
Timing of vaccination: MMR recommended at 12-15 mo with a booster at either 4-6 years or 11-12 years of age
Specific immunizations:
Varicella vaccine
Type of vaccine?
Timing of vaccination?
Type of vaccine: live attenuated vaccine
Timing of vaccination:
- 1st dose: recommended at 12-18 mo
- 2nd dose: 4-6 yo
Specific Immunizations:
Hep A
Type of vaccine:
Timing of vaccination and recommendations:
Hep A
Type of vaccine: inactivated
Timing of vaccination and recommendations: 2 y/o + booster 6 mo. later for the following groups:
- Susceptible children living in communities with high hepatitis A rates & those traveling to endemic areas
- Individuals in other groups with high hep A rates: chronic liver disease, homosexual, bisexual men, drug users, pts with clotting factor disorders receiving blood products, pts at high risk for occupational exposure
Specific Immunizations:
Pneumococcal vaccines (Pneumovax and Prevnar)
Pneumovax: composed of polysaccharide capsular antigens from 23 pneumococcal serotypes
- Major advantage:
- Vaccine contains antigens from pneumococcal strains causing almost all cases of bacteremia and meningitis during childhood
- Major disadvantage:
- Vaccine has little immunogenicity in children younger than 2 y/o
- Indications:
- Vaccine is used primarily for older children and adults at high risk for pneumococcal disease (e.g., patients with sickle cell anemia who are functionally asplenic, immunodeficiency, chronic liver disease, and nephrotic syndrome)
Prevnar is composed of seven pneumococcal serotypes
- Major advantage:
- Immunogenicity and efficacy in preventing meningitis, pneumonia, bacteremia, and otitis media from the most common pneumococcal strains in children < 2 y/o
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Major disadvantage:
- Does not confer broad coverage against pneumococcal strains as Pneumovax
- Indications:
- Vaccine recommended for all children younger than 2 y/o and for selected children older than 2 y/o who are at high risk for pneumococcal disease
- Prevnar is recommended at 2, 4, and 6 mo. with booster at 12-15 mo.
Adverse effects of immunization:
MMR and varicella
Both are live attenuated vaccines –> fever and rash may occur 1-2 weeks after immunization (i.e., after the incubation period of the virus)
Contraindications and precautions to immunization:
a. ____________ to a vaccine or its constituents
b. _____________ within 7 days after DTaP vaccine
c. _____________ patients should not receive OPV, MMR, and varicella vaccines.
d. _____________ patients should not receive live vaccines.
a. Anaphylaxis to a vaccine or its constituents
b. Encephalopathy within 7 days after DTaP vaccine
c. Immunodeficient patients should not receive OPV, MMR, and varicella vaccines.
d. Pregnant patients should not receive live vaccines.
Well Child Screening includes (8):
- Complete history and physical exam
- Growth measurements
- Blood pressure measurements
- Strabismus screening
- Vision screening for ophthalmologic disoders
- Hearing screening
- TB screening
- Laboratory screening
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Neonatal Metabolic (State) Screening:
- congenital hypothyroidism
- PKU
- galactosemia (all can lead to irreversible brain injury)
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Cholesterol and Lipid Screening:
- Recommended for children > age 2 with family hx of hypercholesterolemia, hyperlipidemia, or early MI
- Children with elevated cholesterol levels (75th-90th percentile) should have fasting lipid panel that includes total cholesterol, TGs, HDL, LDL
- Iron Deficiency Anemia Screening
- Urinalysis Screening
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Lead Screening
- Children < 6 y/o most susceptible to effects of lead
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Neonatal Metabolic (State) Screening:
Circumcision:
10% of uncircumcised males ultimately require circumcision for any of the following conditions:
Phimosis
Paraphimosis
Balanitis
- Phimosis
- Inability to retract foreskin (normal up to age 6 but is always abnormal if ballooning of the foreskin occurs during urination)
- Paraphimosis
- When retracted foreskin cannot be returned to its normal position and acts as tourniquet –> obstruction to lymphatic flow and edema –> emergent surgery for venous return
- Balanitis
- Inflammation of the glans of penis
- May be associated with Candida spp. or Gram-negative infections in infants and STis in adults
Contraindications to circumcision
- Penile abnormalities (e.g., hypospadias)
- Prematurity
- Bleeding diatheses
Pediatric Dental Care
Tooth Eruption:
Range of eruption?
What is the first tooth?
How many primary teeth and when established by?
How many secondary teeth and when established by?
- Range of eruption? B/w 3-16 mo., with avg of 6 mo.
- What is the first tooth? Lower central incisor (mandibular)
- How many primary teeth and when established by? 20… usually by 2 y/o
- How many secondary teeth and when established by? 32… usually by 6-8 y/o
In dental trauma, prognosis is highest if the avulsed tooth is stored how?
In liquids, esp. milk
A 4 week old boy is evaluated for macrocephaly. In addition to a head circumference > 95%, his coronal and sagittal sutures are split 1 cm and his fontanelle is bulging. Both of his parents’ head circumferences are > 95%. Which one of the following is the most likely explanation for the infant’s macrocephaly?
A. Familial
B. Achondroplasia
C. Hydrocephalus
D. Metabolic storage disorder
E. Neurofibromatosis
C. Hydrocephalus
This pt has signs of increased ICP, which includes split sutures and a bulging fontanelle. Other symptoms of ICP include irritability and vomiting. Hydrocephalus is the only option that is associated with increased ICP. Metabolic storage disorders, NF, achondroplasia, and familial macrocephaly are associated with enlarged head circumference but are not associated with increased ICP in a patient of this age.
A 9-mo girl is diagnosed with iron-deficiency anemia. Her past medical hx includes an uncomplicated delivery at 38 weeks. The infant was fed with formula until 6 mo, at which time she was switched to baby foods and whole milk. Which one of the following is correct regarding her iron-deficiency anemia?
A. Her age is atypical for px of IDA.
B. Her early birth at 38 weeks gestation has led to the anemia.
C. Early introduction of cow’s milk is the likely cause of her anemia.
D. Insufficient dieatry intake of iron is the likely cause of her anemia.
E. The pt’s early introduction of solids is the likely cause of her anemia.
C. Early introduction of cow’s milk is the likely cause of her anemia.
Introduction of cow’s milk should occur only after 9 mo of age… early introduction = known risk factor for IDA… this is b/c cow’s milk offers less bioavailable iron and may also result in stool blood loss
Prematurity (<37 w/o) may result in lower iron stores with resultant anemia
A 1 y/o child living in an apt with old chipping paint is suspected of being at high risk for lead intoxication. Which of the following findings on a routine health maintenance visit would support this diagnosis?
A. FTT
B. Anemia
C. Fluorosis
D. Microcephaly
E. Impaired hearing
B. Anemia
Lead intoxication may cause a variety of clinical manifestations, including neurocognitive impairment, lethargy, anemia, vomiting, and irritability. Most patients exposed to lead, however, are asymptomatic. Fluorosis is not associated with lead exposure, and lead exposure has not been known to result in microcephaly, FTT, or hearing impairment.
On a routine health maintenance visit, a 9 mo infant is noted to have normal growth and development, and an unremarkable physical exam. Which of the following should be included in your counseling of the parents at this time?
A. Vitamin D supplementation should be initiated if the pt has minimal exposure to sunlight.
B. The patient should be encouraged to begin using a walker to stimulate gross motor development.
C. The infant should now be placed in a forward-facing car seat.
D. Toilet training should be initiated.
E. Eggs and fish may now be introduced into the infant’s diet.
A. Vitamin D supplementation should be initiated if the pt has minimal exposure to sunlight.
^ will prevent development of rickets in first year of life
Infant walkers are not recommended b/c of risk of injury associated with their use.
Infants should be placed in a rear-facing car seat until they are 12 mo and weigh 20 lbs.
Toilet training generally initiated between 1-2 y/o.
B/c of risk of allergy, fish, egg whites, wheat, citrus fruits, nuts, chocolate avoided until at least 1 y/o.
An HIV+ patient presents 24 hrs after being exposed to varicella, with no prior hx of chicken pox, nor any record of having received the varicella vaccine.
What is the most appropriate type of immunization indicated at this time?
Passive immunization is indicated.
An immunocomproised pt, such as a child with HIV, exposed to varicella, would be at high risk for acquiring a severe varicella infection and should therefore receive VZIG (an example of passive immunization), ideally within 96 hrs of exposure to the disease.
