Lecture 1 Flashcards
(52 cards)
Age ranges
o Newborn – under one month of age o Infant – under one year of age o Toddler – 12-36 months o Pre-schooler – 2-5 years o School age – 5 to 12 years o Adolescent – 13-18 years
Pediatrics
Our population is generally 0-18yo.
Children are not little adults! Their metabolism, anatomy and developmental changes require specialized care.
Interventions are often anticipatory, including prophylactic screening, vaccination, and systematic parental education.
Pediatrics
Pediatric population
74.2 million children (ages 0-18) in 2010*
4 million births per year
2.8 million first generation immigrants**
Peds cause of death
o Causes of death
1) unintentional injuries
2) assault (homicide)
3) cancer
4) suicide
5) congenital malformations
o 1638 children died and 214,000 were injured in 2004 in auto accidents
o 2/3 of child passengers who die in an automobile are linked to a drunk driver
o 66% of Americans are overweight
o 32% of children 2 to 19 years old are overweight
o 18% of American children were obese in 2009-2010
anticipatory guidance and screening
o birth – state screen, hearing screen, heart screen, jaundice
o infancy – developmental screening, growth monitoring
o toddler - Hgb & lead screening, vaccines, social & language development
o preschool & school age - vision/hearing, behavioral growth, school performance
o school age to adolescence – safe behaviors, counseling (HEADSSS assessment)
Peds transitions
o There is a schedule of well child checks to follow development and catch issues.
Newborns
Infants - 2 months, 4 month, 6 month, 9 month, 12 month
Toddlers - 15 month, 18 month, 24 month, 30 month
Pre-School Age - 2 year, 3 year, 4 year
School Age
Adolescents - Early, Middle, Late
peds ethics
Goal: to seek a beneficial balance between values when making medical decisions
-four ethical principles non-maleficence - “first do no harm” beneficence – doing good autonomy – patient empowerment justice – equally distributing benefits and burdens
-examples: • chemotherapy at end of life • informed consent • confidentiality • conflicts of interest
Peds consent
-decisions for children are made by third-party caregivers
not exclusive to pediatrics
transition to decision-making by patient occurs in limited fashion in adolescents
decisions of deeper consequence for adolescents become controversial if patient and caregiver disagree
state law guides care of teens in some circumstances
-informed consent
includes discussion of treatment, its benefits and risks, and alternatives
adolescents ethics
o the age of consent varies with the clinical circumstance
CA Minor Consent Rules (see .pdf in Blackboard)
o examples of limited confidentiality include pregnancy, sexually transmitted diseases, suicidality and threats
Extreme prematurity ethics
o despite medical advances in the past 50 years, viability without devastating debility is very difficult to avoid around 22-24 weeks gestational age and younger
24 weeks is what we consider to be generally viable
o current practice is to provide comfort care and not resuscitation for the fetus delivered before 22-24 weeks’ gestation
o decision to withhold invasive therapy from patients of or over 24 weeks’ gestation rests between judgment of parents and assessment by practitioner
differs from similar decision for term newborn or older child
immunizations
-beneficence
individual disease prevention
public health benefit (“herd immunity”)
-non-maleficence
transient pain
rare serious side effects
-autonomy
patient refusal often overridden by parent
parent refusal often reflects misinformation or recognition of risks without a congruent recognition of benefits
refusal can be a grasp for greater parent autonomy when other avenues for autonomy in medical care or child care seem scarce
“distributive justice” is the concept that all members of society share in both its burdens (risk of immunization) and benefits (herd immunity) to have a just society
end-of-life care
o The directive of palliative care is to maintain, improve and support the quality of life at their most effective level of functioning until the time of death
o curative care and palliative care can co-exist
o goals
representing the best interest of the child
revisit the goals of continued medical treatment
revisit benefits and burdens of current treatment
delineating limits of therapy (AND orders)
o palliative care is incomplete without attention to cultural and spiritual norms observed by the patient and their family
o parents often ask for the clinician’s guidance in communicating difficult issues with the child
prenatal visit
o An appointment before birth allows
clinician to interview family: family and genetic history, maternal medical and obstetric history, parent concerns and attitudes toward medical care
family to interview clinician: orientation to facility and personnel, familiarization with office practices, discussion of controversial topics
frequently asked questions at prenatal visits
pros vs. cons of: • perinatal interventions (vitamin K, eye ointment, etc.) • breastfeeding • circumcision • pacifiers • immunizations • nutritional supplements who should be present to assist the parents during the first few months of life? home birth genetic screening & testing cord blood storage
maternal medical history
maternal age (advanced is ≥35 years)
illnesses present before pregnancy
complications of previous pregnancies & deliveries
past cesarean delivery (32.8% of all U.S. deliveries in 2010)
level of obstetric care
complications and medications during pregnancy
placental concerns
maternal infections
estimated date of confinement (gestational age estimate)
• 34-36 6/7 late pre-term
• 37-41 6/7 weeks is term
• 42 weeks is post-term
maternal labs
blood type, Rh antibody testing
glucose tolerance test – tells you if mom has DM and if baby is at risk for DM
rubella immunity
hepatitis B surface antigen screening – babies who are infected with hep B from mom don’t clear the virus and it can progress to liver failure
HIV antibody screening (offered in California)
Chlamydia trachomatis and Neisseria gonorrhoeae screening
Streptococcus agalactiae (GBS) rectovaginal culture – every mom is screened for this because it can cause severe infecitons in the kids
syphilis screening (rapid plasma reagin, RPR)
AFP/triple screen – looks for genetic defects like neural defects or down syndrome
possibly amniocentesis or chorionic villus sampling
ultrasound at prenatal visit
congenital anomaly screening
earlier studies more accurate in estimation of gestational age
before birth: birth history
Maternal temperature monitoring – fever might mean that she has an infection and risk for baby
Rupture of membrane time – as soon as the water breaks, the baby is at risk for infection: Anything that is prolonged (16-18 hrs) affects infection risk
Fluid clarity – normal amniotic fluid should be clear, but there may be myconium
Intrapartum medications (antibiotics, magnesium): Magnesium can depress the baby and cause HoTN
Fetal heart rate monitoring: Noninvasive, scalp electrode
after birth: birth history
Apgar scoring
Vital signs and anthropometric data (weight, length, head circumference): The weight is the paramount number that tells you how well the baby is doing
Physical exam incl. confirmation of gestational age
Hypoglycemia monitoring (in select populations) – infants of diabetic mothers, large infants and small infants
Initial skin-to-skin contact and breastfeeding
apgar score
o The most common scores are 8 and 9
o Done at 1 and 5 minutes. If the number is still less than 8, score again at 10 mins
birth weight
o AGA-Appropriate for gestational age.
o LGA- Large for gestational age. Weight that is >90%tile for a particular gestational age. Associated with gestational diabetes. Patients can have low blood sugars.
o SGA- Small for gestational age. Weight that is <10%tile for a particular gestational age. Can be caused by placental problems, maternal hypertension, illicit drug usage.
perinatal complications
o Concerns Fetal asphyxia & acidosis Chorioamnionitis – infections of the placenta Maternal-fetal drug intoxication Hypoglycemia Neonatal hypothermia Respiratory issues– meconium aspiration, TTN, pneumothorax Undiagnosed congenital anomalies
Hemorrhagic disease of the newborn
-really rare
-Vitamin K deficiency causes rare but devastating bleeding – vit K is needed for clotting cascade, synthesized by liver, babies and kids struggle with this
o ***Most important newborn medication.
GI bleed, stroke and intraventricular hemorrhage have high morbidity
Etiology: Poor liver synthesis in the new born - Breast milk is a poor vitamin K source
Treatment: Prophylactic treatment - vitamin K intramuscularly – dramatically reduces bad outcomes of bleeds in kids; Oral Vitamin K regimens are done in other countries and some providers in the US advertise these. However, there is no data to show that it is as effective as IM administration.
eye prophylaxis
o Erythromycin eye ointment
less irritating than previously used silver nitrate
prevents gonococcal ophthalmia
does not prevent chlamydial conjunctivitis
prevents infection by other bacteria than GC and CT
