Pediatrics 2 Flashcards
(181 cards)
1
Q
____ in the early 1900s was the first person to closely observe infants and establish developmental norms
A
Gesell
2
Q
By mid-century, theories that stressed the importance of nurture began to prevail by ___, ___, and ___
A
Pavlov
Watson
Skinner
3
Q
Prior to the 1900s, most people thought infants were a _____
A
blank tablet
because they coudln’t tell us what they’re thinking, we assumed they were devoid of intelligence
4
Q
____ was the first to describe the infant as having intelligence (in the second half of the century)
A
Piaget
he said that children actually have the ability to learn, they actively explore the environment and learn how the world works this way
5
Q
Infant development occurs in an ___ and ___ manner
A
orderly
predictable
6
Q
infant development occurs from ____ to ____ and ____ to _____
A
cephalic to caudal
proximal to distal
7
Q
responses to stimuli proceed from general reflexes involving ____ to discreet voluntary actions under _____
A
entire body
cortical control
8
Q
Why is development important? early development lays the foundation for ___ and ___
A
learning ability
mental health
9
Q
early language skill predicts
A
later language complexity
10
Q
growing evidence suggests that early signs of autism can be identified ___.
A
before the first birthday
11
Q
early temperament predicts
A
later disruptive behavior disorders
12
Q
> _____% of adults with mental health disorders had Sx in early childhood
A
50%
13
Q
MC concern presented to PCPs:
A
developmental and/or mental health concerns
14
Q
formal developmental screening is now recommended by the AAP at ___, ____, and ____ month well child visits and developmental surveillance at the other visits
A
9, 18, 24-30
15
Q
What major problems should we be looking for in time of development? (9)
A
cerebral palsy speech/language impairment hearing impairment visual impairment ADHD intellectual disability autism learning disabilities social-emotional or behavioral disorders
16
Q
why is screening important?
A
Early intervention has proven success
17
Q
4 early intervention options
A
- early child hood intervention (ECI) at 0-3 years old.. most important.. includes PT, OT, speech therapy, etc
- head start program at 2-5 years old
- preschool programs for children with disabilities at age 3-5 years
- special education programs through the local school district at age 5-21 years old
18
Q
when screening development, look for at the 5 major areas of development:
A
- physical growth
- gross motor
- visual perception and fine motor skills
- language
- social-emotional
19
Q
normal weight patterns: birthweight is... regained by \_\_\_\_ doubled by \_\_\_\_ tripled by \_\_\_\_ quadrupled by \_\_\_\_
A
2 weeks
5 months
12 months
24 months
20
Q
head growth is measured by ___
A
FOC
21
Q
head growth during the first 5-6 months is due to ____.
A
neuronal cell division
22
Q
later head growth is due to ____ and _____.
A
neuronal cell growth
support tissue proliferation
23
Q
head is approximately adult-sized by how old?
A
5 years
24
Q
4 physical growth RED FLAGS
A
- short stature or poor weight gain
- small head or microcephaly (almost always reflects cerebral pathology with cognitive implications)
- large head or macrocephaly (50% is familial and benign, but WATCH OUT FOR HYDROCEPHALUS)
- dysmorphisms: minor variations or abnormalities on PE
25
> ___ dysmorphisms is highly associated with genetic syndromes
3
26
most dysmorphisms are ____.
non-consequential and normal
27
gross motor skills proceed from a sequence of ____ to _____ and then through a _____ sequence
prone milestones
sitting
standing/ambulating
28
gross motor skills must always be considered in context of a ______
neurological exam
29
It's important to look at ____ and ____ in addition to a regular neurological exam
postural reactions
| primitive reflexes
30
What's the tonic labyrinthine reflex?
when you flex the head and neck >> UE go into flexion too
when you extend the head and neck >> UE go into extension too
31
What's the asymmetrical tonic neck reflex?
when you turn the head to the side, that side goes into extension and the other side flexes
32
What's the positive support reflex?
put a little pressure on their feet and they'll push against the ground
33
Name 3 primitive reflexes. These go away at what age?
- tonic labyrinthine reflex
- asymmetrical tonic neck reflex
- positive support
4-6 months
34
what are 2 postural reactions?
- parachute response
| - righting postural reflex (put arm out if get off balance when sitting)
35
5 gross motor RED FLAGS
- persistent fisting beyond 3 months
- spontaneous postures (frog-legging is low tone, scissoring is high tone)
- delays in postural reactions
- abnormal movement patterns
- hand dominance prior to 18 months
36
What are some abnormal movement patterns that would be a red flag for gross motor development (5)
- persistent head lag/floppy baby
- pulling directly to a stand at 4 months (hypertonicity)
- W-sitting (low tone)
- walking without ever crawling
- persistent toe walking (hypertonicity)
37
what happens as balance improves in the sitting position and as the infant begins to walk?
the hands become more available for manipulation of objects
38
In the first year of life, fine motor development is highlighted by what?
the evolution of the pincer grasp and learning to grasp and explore objects
39
In the second year of life, fine motor development is highlighted by what?
the hands using objects as tools
40
visual perception and fine motor skills in the first year of life allow the infant to _____ through _____.
problem solve
| sensory-motor play
41
What are the three elements of "learning to manipulate"?
- visual inspection
- reaching, grasping, mouthing
- refinement of the pincer grasp for closer inspection
42
When does object permanence occur?
9 months
43
Visual perception and fine motor skills in the first year is described as:
in the second year it is described as:
learning to manipulate
manipulating to learn
44
what are the two elements of "manipulating to learn"?
- recognition of objects and their use through imitative and symbolic play
- matching and categorizing objects
45
5 visual perception and fine motor RED FLAGS
- failure to alert to environmental stimuli may indicate sensory impairment
- failure to reach for objects may indicate motor, visual, or cognitive deficit
- persistent mouthing past ~12 months
- lack of imitation by 16 months (AUTISM!)
- absent symbolic play by 24 months (AUTISM!)
46
MC type of delay in development
language
47
what is the best indicator of future intelligence?
language
48
____ is the most difficult to screen in the office and relies heavily on history
language
49
what are the 2 domains of language?
expressive: Broca's
receptive: Wernicke's
50
what are the 3 periods of language development during infancy?
1. prespeech period (0-10 months)
2. naming period (10-18 months)
3. word combination period (18-24 months)
51
What 3 things occur in the pre-speech period (0-10 months)??
- sound localization
- cooing
- babbling
52
What 5 things occur in the naming period (10-18 months)?
- the infant realizes that people and objects have labels
- word counts are important to measure expressive language
- receptive language reflected in understanding simple commands
- pointing (protoimperitive and protodeclarative)
- jargoning
53
protoimperitive vs protodeclarative pointing
protoimperitive= help getting what I want (12 months)
protodeclarative= joint attention (15 months)
54
T/F: autistic kids don't use many gestures
true
55
What 4 things occur in the word combination period (18-24 months)?
- kids typically begin to combine words 6-8 months after they say their first word
- giant words: "let's go" "gimme" "thank you" "stop it" (18-21 months)
- holophrases.. Ex: point to keys and say "mama" to communicate that those are mom's keys (18-21 months)
- word combinations, need an expressive vocab of at least 50 words at 24 months
56
5 language development RED FLAGS
- inability to localize sound by 4-6 months
- absent babbling or consonant production by 6-8 months
- lack of pointing by 12-18 months (AUTISM!)
- low word counts at 18-24 months
- advanced, non-communicative speech (AUTISM!)
57
4 parent-completed tests for cognitive, language, motor development:
- Ages and stages questionaire (ASQ-3)
- Parent's evaluation of developmental status (PEDS)
- Child development inventory (CDI)
- Survey of wellbeing of young children (SWYC)
58
2 parent- completed tests for social-emotional behavior:
- Ages and stages questionnaire (ASQ-SE)
| - Pediatric symptom checklist (PSC)
59
A parent-completed tests for autism:
Modified checklist for autism in toddlers (M-CHAT)
60
What are the AAP recommendations for M-CHAT?
do at the 15-18 month visit and the 24-30 month visit
61
6 clinician-administered screening/eval test for cognitive and language development
- Denver developmental screening test (DDST-2)
- Battelle developmental inventory screening tool
- Gesell
- Bayley infant developmental screen (BINS)
- Cognitive adaptive test (CAT)
- Clinical linguistic auditory milestone scale (CLAMS)
62
T/F: we should watch for red flags of development and make referrals early rather than employ "watchful waiting"
true
63
the 3 types of abuse are:
```
neglect (70%)
physical abuse (20%)
sexual abuse (10%)
```
64
what age group has the highest rate of victimization?
<1 year
65
most fatalities of abuse happen to what age group?
< 3 years
66
what percentage of abuse cases are due to parents?
80%
67
how many children die per year from maltreatment/
1,720
68
ethical consideration:
| parents have an ethical and legal responsibility to...
protect the life and health of their kids
69
ethical consideration:
| the legal responsibility is spelled out in the...
legal codes of states
70
ethical consideration:
when there is variance between parental action and stated legal responsibility to protect their minor children, the state is empowered to...
take action to restore health and safety to the child
71
ethical consideration:
| al healthcare personnel have moral and legal professional responsibilities and expectations to...
protect the well being of their patients
this is stated in professional codes of ethics and in licensing regulations put forth by licensing and credentialing bodies as a condition of practice
72
ethical consideration:
| it is ethically and legally the responsibility of professionals to...
protect their patients
73
ethical consideration:
| pediatric PC provides a unique opportunity to...
tackle child abuse and neglect
74
ethical consideration: pediatricians, at their core, are essentially ____ for children
advocates
75
ethical consideration:
| many practitioners identify a concern about what may happen to children after a CPS report is made as a reason for...
choosing not to report suspected maltreatment
76
ethical consideration:
AAP states, "HIPAA permits disclosure of information without legal guardian authorization in matters that affect ____ and ____ the child and intervention and investigation of matters that relate to abuse or neglect, public health, and safety."
treatment of and medical intervention for
77
according to the law: professionals have ___ hours to make a report
48
78
according to the law:
| reports about child abuse are confidential or not?
confidential
79
according to the law:
| reporting child abuse does or does not breach patient confidentiality?
does not
80
according to the law:
| you are ____ from criminal and civil liability
immune
81
according to the law:
| it is a _____ for failure to report suspected abuse
class B misdemeanor
82
according to the law:
| it is a _____ for failure to stop or report sexual assault of a child
class A misdemeanor
83
"professional" means an individual who is _____ or who is an employee of a facility licensed, certified, or operated by the state and who, in the normal course of official duties or duties for which a license or certification is required, has direct contact with children.
licensed or certified by the state
84
5 reasons to report suspected or child abuse
1. to prevent further injury or death of a child
2. maltreatment is linked to life-long health consequences
3. healthcare staff have a moral and legal responsibility to ensure the safety and well-being of patients
4. legal obligation to report child maltreatment
5. consequences for not taking action may include criminal and civil actions against the professional and/or license and institution
85
What's a sentinel injury?
commonly missed, minor injuries that should pique your suspicion for abuse.
ex: bruises, subconjunctival hemorrhages
86
What is meant by "escalation of injury"?
when sentinel injuries are missed, the patient then comes back with more serious injuries later
87
what kind of family does child abuse occur in?
ALL KINDS OF FAMILIES
88
4 common characteristics of missed abuse:
- young infants
- caucasian children
- 2 parent households
- children without seizures or respiratory problems
89
for every Dx of child abuse that's made, ___ are missed
2
90
When ___ in the family increases, there is a decrease in the caretaker's ability to _____
stress
| cope
91
maternal ___ is another big factor in cases of child maltreatment
depression
92
2/3 of children in the child welfare system in the US have ______ as a contributing factor
substance abuse
93
(abuse) things to remember when taking a history from a parent
- remain non-judgemental
- obtain a detailed Hx
- use open ended questions
- ask about other children in the home
- speak to the parent WITHOUT the child
94
(abuse) things to remember when taking a history from a child
- use age-appropriate language
- do not suggest persons or actions or probe
- use open ended questions
- document the child's words
- speak to the patient WITHOUT the parent
95
Definition of physical abuse
```
a non-accidental physical injury that leaves:
bruises
burns
cuts
broken bones
other injuries
```
96
Bruises and lacerations that raise abuse suspicion (5 things)
- on a non-mobile infant (usually <6 months)
- on central or fleshy areas
- patterned or unusually distributed
- of different stages of healing
- frenulum laceration is almost always due to abuse (a commonly missed sentinel injury)
97
TEN-4 rule for bruising:
```
T: torso
E: ears
N: neck
4:
- bruising in TEN regions if < 4 years old
- any bruising if <4 months old
- >4 bruises in general
```
98
How do you tell the age of a bruise by looking at it?
YOU CAN'T
only way to tell is if you know when the incident happened
99
What's the most common presentation of abuse?
bruising
100
what percentage of kids < 6 months have non-abuse bruises?
<1%
101
bruising is a precursor to
AHT
102
bruising is missed in ____% of fatal or near-fatal cases of abuse
39%
103
if an infant has facial bruising, they will most likely return with ___.
abusive head trauma
104
2 types of burns common in child abuse:
- forced immersion scald
| - patterned contact burns
105
____ burns are less likely to be abusive
splatter
106
forced immersion burns are
- usually seen during ____.
- pattern includes: (3 things)
toilet training;
- zebra striping
- doughnut sparing
- stocking feet
107
intra-abdominal injury S/Sx
- abdominal pain, tenderness
- abdominal abrasions or bruising
- palpitation of hematoma
- blood in urine
- decreased hematocrit on CBC
- elevated transaminase
- abnormal vitals (SBP <90, RR <10 or >29)
108
____ is the MC thing to cause presentation
skeletal fracture
109
children with abusive Fx are often too young to ____.
provide history
110
the history for skeletal fractures due to abuse may be ____ or ____.
lacking
| intentionally misleading
111
missed abusive Fx can result in ____.
repeated abuse, sometimes with devastating consequences
112
misidentifying an accidental fracture as abuse can have detrimental effects for ___.
patient and family
113
incidence of skeletal fractures due to abuse decreases as ___ increases
age
114
3 things to Dx abuse in skeletal Fx patient
- skeletal survey
- bone chemistries
- history
115
When would you do a skeletal survey in a 0-24 month old, 2-5 year old, and 5+ year old?
0-24 months: anytime there is concern for abuse
2-5 years: when abuse is strongly suspected or the child is unable to communicate
5+ years: radiographs of individual sites of injury suspected on clinical grounds
116
high specificity radiologic findings for abuse
```
CMLs
rib fx, esp posteromedial
scapular fx
spinous process fx
sternal fx
```
117
greater proportion of children with NAT have multiple fractures as compared to children with accidental fractures.
as the number of fractures _____, the likelihood of NAT _____.
increased
| increased
118
MC type of fracture seen at TCH
skull fx
119
____ skull fractures should raise suspicion for abuse
complex
120
complex vs simple skull fractures
simple/linear:
single fracture line
usually don't cross suture lines
< 3 mm separation
```
complex:
linear, crossing suture lines
branching, stellate
depressed
comminuted
```
121
suspicion of abuse should arise whenever a caregiver gives an explanation of an injury that: (2 things)
- seems unlikely due to the child's developmental abilities
| - changes or is implausable
122
2 other red flags for abuse...
- delay in seeking treatment
| - frequent changes in healthcare facilities
123
3 things to help date fractures
- resolution of soft tissue swelling
- loss of fracture definition
- callus formation
124
most kids with inflicted fractures have ____ bruises
ZERO
125
7 things that are not abuse
- birth injury
- accidents
- children with weak bones (bedridden)
- prematurity (osteopenia)
- nutritional (scurvy, rickets)
- infection (osteomyelitis)
- metabolic (osteogenesis imperfecta)
126
______ is one of the leading child maltreatment-related fatalities
AHT
127
____% of head trauma-related deaths in the USA in children <2 years old result from abuse
50-80%
128
the majority of abusive head trauma victims are ____ old
<2 years
129
peak incidence of AHT:
3 months
130
put AHT in the DDx anytime an infant has ____
vomiting without illness
131
2 common findings in shaken baby syndrome
- retinal hemorrhages
| - skeletal Fx
132
AHT does not propose a ____
MOI
133
non-specific Sx of AHT
```
vomiting or poor feeding
extreme irritability
breathing problems
seizures
lethargy
```
134
specific signs of AHT
subdural hematoma
retinal hemorrhages
skeletal fractures
135
AHT is often mis-diagnosed as
reflux/colic
| viral infection
136
AHT: physical signs of subdural hemorrhage, subarachnoid hemorrhage, parenchymal injury (contusion), and/or DAI in the context of ____
an absent or implausible history
137
comment on 3 things when examining retinal hemorrhages:
1. description
2. distribution
3. extent
138
____% of children with AHT DO NOT have retinal hemorrhages. When they do have them, ____% are unilateral
20%
| 15%
139
____ is defined as "act of omission or commission which constitutes a failure to provide conditions that are essential for the healthy physical and emotional development of a child."
neglect
140
6 types of neglect
```
physical
medical
dental
supervisional
emotional
educational
```
141
consider the following studies in neglect cases:
```
radiographic skeletal survey
CT scan
bleeding eval: CBC, PT, PTT
toxicology screens
urinalysis
transaminases
```
142
new name for Munchausen by Proxy
medical child abuse
143
definition of medical child abuse
fabrication, exaggeration, or induction of Sx resulting in the child receiving harmful or potentially harmful medical Tx at the instigation of the caregiver
144
IMPORTANT in determining MEDICAL CHILD ABUSE
RESOLUTION OF SX WHEN SEPARATION OCCURS
145
general concepts of MCA presentation:
- no typical presentation
- all organ systems are targets
- Sx presentation is limited only by the perpetrator's medical knowledge, sophistication and imagination
146
Sx in MOA can be:
- ______ of existing problem
- ______ of Sx/disorder, lab reports/specimens
- ____
- ____
- ____
```
exaggeration
fabrication
persuasion
simulation
induction
```
147
Dx of MCA
- multidisciplinary approach
- child's safety is most important
- separate caregiver and child to confirm
- meticulous documentation!!
- maintain chain of custody with lab specimens
148
prognosis for MCA
can run the entire spectrum of physical and psychiatric sequelae
149
secondary gains in MCA
```
attention
financial gain
involve an absent parent/reconnect
fascination with all things medical
sympathy from the community
```
150
definition of sexual abuse
sexual activity with a child by an adult or an older youth
151
non-touching sexual abuse:
- exposure to porn
- indecent exposure
- photographing a child in sexual poses
- making a child watch or hear sexual acts
- voyeurism
- online sexual solicitation
152
touching sexual abuse:
- touching a child's genitals, anus, or breasts for sexual pleasure
- making a child touch someone's genitals
- playing sexual games
- putting objects or body parts inside the vulva, vagina, mouth, or anus of a child
153
worrisome behaviors for sexual abuse:
- new words for private body parts
- sexual behavior inappropriate for age or adult-like
- simulating sexual activities with toys
- excessive masturbation
- persistent and/or aggressive sexual play with other children
- refusing to talk about a secret, esp one with an adult friend
- prominent genitals in drawings
154
non-specific symptoms of sexual abuse
- genital discharge
- anogenital redness
- urinary pain/itching
- enuresis
- encopresis
- chronic abdominal pain
- asymptomatic
155
signs that are specific for trauma
genital/anal bleeding
| anogenital bruising
156
signs that are specific for sexual abuse
STIs
| pregnancy
157
____ of physical exams of children suspected of being physically abused are without definitive findings
3/4ths
158
why aren't there usually definitive findings of abuse?
- the child generally knows the perpetrator and physical force is not often used
- disclosure of abuse is usually delayed
- mucous membranes heal quickly often without scarring
159
5 elements of medical exam
- STI/HIV testing
- photographic documentation with colposcope
- rape kit if under 96 hours since assault
- blue maxx light for evidence collection in acute cases
- health care facilities must be able to handle emergency care for sexual assault and provide survivors with emergency contraception info
160
signs of domestic violence
- facial bruising
- injuries inconsistent with Hx
- depression/anxiety
- reluctant to explain discipline in the home
- repeatedly misses apts
- frequently asks for medical advice not related to child's medical needs
161
what to do in domestic violence cases:
- use ____ screening regularly
- speak with the ____ alone
- reinforce _____
- discretely provide info on _____
- inform mother of ____
```
RADAR
mother
confidentiality
community resources
precautionary measures to take to avoid injury to her or her child
```
162
what is RADAR screening?
```
R: routinely screen mothers
A: ask direct ??
D: document findings
A: assess her safety
R: respond
```
163
behavioral effects of parental substance abuse on child
- delayed in development as result of neglect
- may blame themselves for parent's use
- may be reluctant to bring friends home
164
psychiatric effects of parental substance abuse on child
increased incidence of depression, anxiety, ED, suicide attempts
165
educational effects of parental substance abuse on child
- inability to concentrate at school or home
| - may be tired due to chaos at home and inability to sleep or lack of structure for nutrition and rest
166
emotional effects of parental substance abuse on child
exhibit mistrust, guilt, shame, ambivalence, fear
167
____ and ____ account for most of the top drugs abused by 12th graders in the past year
marijuana, prescription and OTC meds
168
after several years of decline, current and past year use of ____ has risen among 8th and 10th graders
ecstasy
169
alcohol use has continued to ____ among high school seniors
decline
170
screening for teen substance use:
CRAFFT
C: have you ever ridden in a CAR driven by someone (including self) that was high or drunk?
R: do you ever use alcohol or drugs to RELAX, feel better about yourself, etc
A: do you ever use alcohol/drugs while by yourself, ALONE
F: do you ever FORGET things you did while using alcohol or drugs
F: do your family or FRIENDS ever tell you that you should cut down on your drinking/drug use?
T: have you gotten into TROUBLE while you were using alcohol, drugs?
171
physical warning signs of teen alcohol/drug use
fatigue
repeated health complaints
red and glazed eyes
lasting cough
172
emotional warning signs of teen alcohol/drug use
```
personality change
sudden mood changes
irritability
irresponsible behavior
low self-esteem
poor judgement
depression
general lack of interest
```
173
family warning signs of teen alcohol/drug use
starting arguments
breaking rules
withdrawing from the fam
174
school warning signs of teen alcohol/drug use
```
decreased interest
negative attitude
drop in grades
many absences
truancy
discipline problems
```
175
RF for child abuse/neglect
```
parental depression
substance abuse
intimate partner violence
parent stress
harsh punishment
food security
```
176
3 protective factors for abuse/neglect
social support
self-efficacy
parenting competence
177
2 challenging behaviors and developmental issues that ay increase the risk for child maltreatment:
infant crying
| toilet training
178
help parents become more skilled communication about sexuality and sexual abuse in order to ___
prevent sexual abuse
179
2 things to do with resources
- understand their availability and effectiveness
| - advocate for implementation and sustaining of community-based services to help families prevent maltreatment
180
the law does not require health care professionals to be certain that abuse has occurred before they report, but merely "____."
have a cause to believe
181
3 services offered by CPS
investigation
placement assessment
court approves permanency for child
