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ACUTE OTITIS MEDIA 3 Criteria Required for Diagnosis: 1.

) History of acute onset of signs and symptoms of middle ear inflammation and effusion 2.) Presence of middle ear effusion (MEE) which is indicated by: a. Bulging of tympanic membrane (highest PPV) b. Limited or absent mobility of TM c. Air fluid level behind TM d. Otorrhea 3.) Signs of symptoms of middle-ear inflammation indicated by: a. Distinct erythema of TM b. Distinct otalgia (pain that interferes with normal activity or sleep) *MEE is most often confirmed with pneumatic otoscopy but can also be confirmed by tympanometry or acoustic reflectometry *Opacification or cloudiness is also a consistent finding for edema of TM *Redness due to inflammation must be distinguished from erythematous flushing due to crying or high fever Clinical Presentation: children often present with non-specific symptoms such as irritability in infants or toddlers and fever with accompanying cough, nasal discharge, stuffiness. More specific symptoms include otalgia and otorrhea. What AOM isnt 1.) Otitis media with effusion (OME): OME is fluid in the middle ear without the presence of inflammation and pain that accompany AOM. OME is often a complication of AOM that persists after the infection is cleared. Chronic OME may require a tympanostomy tube in order to decrease the risk of language delay and hearing loss. 2.) Myringitis: myringitis in inflammation of the ear drum with normal mobility without effusion 3.) Otitis Externa: inflammation of the external ear which causes pain that is exacerbated by manipulation of the external ear Predisposing/Risk Factors: **most of the following are predisposing factors because they increase the retrograde movement of upper respiratory flora into the middle ear 1.) Being a child (most common at 6-24 mos.) due to a. Decreased angle of entry of the Eustachian tube b. Short length of ET c. Decreased tone of ET 2.) viral URI (edema creates a vacuum) 3.) pacifier use 4.) supine bottle feeding

5.) second-hand tobacco smoke **breastfeeding until at least 6 mos. seems to be protective ETIOLOGY: 20% viral 80% bacterial S. pneumoniae (50%) Nontypeable H. influenzae (25%) Moraxella catarrhalis (12%) HOW TO TREAT: Pain Management: the physician should always assess and treat pain if present regardless of whether or not antibiotics will be prescribed! 1.) Acetaminophen, Ibuprofen: mild to moderate pain, mainstay of treatment 2.) Benzocaine (topical agent): additional but brief benefit 3.) Narcotic analgesia: moderate to severe pain Infection: Often AOM is not immediately treated with antibiotics because a lot of children recover on their own within 48 to 72 hours. Not prescribing antibiotics right away not only decreases the rate of resistant bacteria but also eliminates side effects and the cost of the antibiotics. Placebo-controlled studies have shown that children who recover without antibiotics do not have an increased risk of adverse sequelae, including mastoiditis. This treatment method is known as the observation option Observation Option: deferring the use of antibacterials of selected children for 48 to 72h based on diagnostic certainty, age, illness severity and assurance of follow-up. The following guidelines are used to determine when TO and when NOT to use antibiotics. Children <6mo.: always use antibacterial therapy Children 6mo-2yr: certain diagnosis antibacterial therapy uncertain diagnosis antibacterial therapy only if severe Children >2yr: certain diagnosis antibacterial therapy only if severe uncertain diagnosis observation Antibiotic Treatment: amoxicillin @ 80-90 mg/kg/day is the first-line therapy for most children and most cases of AOM. At this dose amoxicillin is affective against susceptible and intermediate resistant pneumococci. If the patient has severe illness and/or blactamase positive H. flu or M. catarrhalis is suspected clavulanate should be added to the amoxicillin (Augmentin). These are the general rules for antibiotic choice, but it becomes a little more complicated when considering penicillin allergies and failure of treatment after 48-72h. A cephalosporin is usually the second line choice unless the allergy is anaphylactic. If this is the case azithromycin or clarithromycin are usually used. (see table in the AOM packet if you are interested in more details) THE END you are now an AOM expert GOOD LUCK!

Pharyngitis/Tonsillitis in Children (info summarized from handout and Nelsons pg488-491) Variation with age groups Presentation and etiologic agents tend to differ between age groups Most common etiology in any age group is viral Less than 3 yrs old o Adenovirus and enteroviruses o Grp A strep can occur, but rarely. If is occurs, tends to present as rhinitis or otitis media Four to seven yrs old is peak incidence of grp A strep; at 15 yrs incidence is 15% and by 18 grp A strep causes 5% of pharyngitis. Viral vs strep pharyngitis Viral o Gradual onset, early fever, malaise, anorexia, moderate throat pain and possible diarrhea. Throat symptoms peak around 2nd or 3rd day. Systemic symptoms eg. Fever usu mild or absent. o May also have conjunctivitis, hoarsness, cough and rhinitis o If two or more of these is present with a pharyngitis, viral etiology likely. Group A Strep o Peak in winter and spring o Acute onset fever, dysphagia, headache. o May have abdominal pain, vomiting, bad breath, ear pain on swallowing, muffled voice, petechia of the soft palate. o Some develop scarlet fever: circumoral pallor, strawberry tongue and fine, diffuse erythematous maculopapular rash. o One third have enlarged exudative tonsils and pharyngeal erythema. o Two thirds have mild pharyngeal erythema and painful anterior cervical adenopathy o Other clues to a strep infection: scarlintiniform rash, paronychia, vaginitis, impetigo, perianal cellulitis or desquamation Lab Tests o Gold standard: Throat culture obtained from tonsillar pillars or posterior pharynx o Rapid strep screens 70-95% sensitive so negative ones should be followed by culture Differential Diagnosis o Rhinovirus: common cold - pharnygitis not as prominent as the cough and rhinorrhea o Coronavirus: common cold o Adenovirus: bilateral, nonpurulent conjunctivitis, pharyngitis a prominent symptom

o HSV-1 (predominately, can get type 2) gingivostomatitis, usu age 1-5. High fever, poor feeding, malaise, stinging mouth pain, drooling, oropharyngeal (tongue, gums, lips, oral mucosa, soft and hard palate) vesicular lesions and lymphadenopathy. Recurrent illness generally milder and limited to the vermilion (herpes labialis). o Parainfluenza virus: spring and fall, common cold and croup o Influenzae: winter months, influenza o Enterovirus: late summer, early fall o Herpangina: pinpoint vesiculoulcerative lesions on anterior tonsillar pillars and soft palate, uvula and tongue. Acute onset high fever, vomiting, headache, sore throat, conjunctivitis, dysphagia (enterovirus) o Infectious mono (EBV): exudative tonsillitis, generalized lymphadenopathy, hepatosplenomegaly, indolent onset or prolonged duration. Elevated atypical lymphocytes on CBC. o Pneumococcal or H.influenzae: purulent nasal discharge, pharngitis, fever o Diptheria: gray exudates on tonsils and uvula o Mycoplasma: hoarseness, cough, nasal congestion in adolescent or older child. o Nasal obstruction, smoking, inadequately humidified air Treatment Treatment is for symptomatic relief and prevention of complications Generally treatment should be withheld until diagnosis confirmed (there is debate in the literature about whether this is harmful or helpful!)EXCEPT: o Acutely ill or toxic appearing child in the face of known strep exposure or outbreak o Scarlet fever rash in association with pharyngitis o Symptomatic pharyngitis and one of the following: past hx of rheumatic fever or recent hx of rheumatic fever in a family member, or in an area with epidemic rheumatic fever of poststrp glomerulonephritis DOC for strep pharyngitis: o Oral penicillin VK for 10 days or o IM benzathine PCN or benzathine and procaine penicillin injection Penicillin allergic patients: erythromycin, clindamycin or 1st gen cephalosporin Should have a clinical response in 24 to 36 hours Group A Strep Carriers Carriers: grp A strep in the respiratory tract, but no serologic response. Most studies suggest not to treat with a second course of antibiotic unless they are symptomatic, have a family history of acute rheumatic fever, undue parental anxiety despite reassurance, outbreak of strep in a closed or semi-closed community or tonsillectomy for chronic carrier state is being considered. Low risk for transmission and complications

Treatment: o Penicillin VK x 10days and rifampin for the last 4days o Amoxicillin-clavulanate o One dose IM penicillin with 4 days rifampin o Clindamycin x 10days

Complications of Grp A Strep Pharyngitis Suppurative o Reflect extension of the infection from the nasopharynx and may result in sinusitis, otitis media, mastoiditis, cervical adenitis, retro or parapharyngeal abcess or bronchopneumonia Nonsuppurative o Rheumatic fever Systemic, most frequently involves joints then heart, less frequently, the CNS, skin and subcutaneous tissue Can recur Not all patients have a history of a preceding URI and only ~10% have positive Strep cultures on diagnosis Does not occur in infancy and unusual <5yrs of age; peak incidence between 5-15yrs Higher incidence in those with a positive family history Diagnosis based on jones criteria. Must have 2 major or 1 major and 2 minor manifestations with supporting evidence of preceding strep infection (ASO titier or Strep antibody, positive throat culture or recent scarlet fever) Major: Joints<Carditis<Chorea<Erythema marginatum<subcutaneous nodules Minor: Fever, arthralgias, previous rheumatic fever or heart disease, lab findings of acute phase reaction (sed rate, CRP, leukocytosis) or prolonged QT on ECG Treatment depends on affected system but usually includes penicillin during the acute phase and as prophylaxis for those diagnosed with rheumatic fever Early treatment of a strep infection may prevent acute rheumatic fever. o Acute post-streptococcal glomerulonephritis (PSGN) Can occur after strep infection of the skin, throat, or nephritogenic strains of group A Strep. Usually occurs within 1-2 weeks of strep infection. Latency is usually longer following a skin infection than strep pharyngitis. Present with acute nephritic syndrome Sudden onset gross hematuria, edema, hypertension, renal insufficiency

Early systemic treatment of throat and skin infections may reduce but not eliminate risk of PSGN Treatment: Supportive care for renal failure and 10 day course of systemic antibiotics Complete recovery in >95% of cases and recurrence is rare.

Nelsons p 488-491 has a section on pharyngitis. Most info was the same as that in the handout. There was so more information on some less common causes of pharyngitis under differential diagnosis that I did not include above: Vincent infection, Noma, Ludwig angina, and periodic fever, aphthous somatitis, pharyngitis and cervical adenitis (PFAPA).

Normal Growth
The Health Maintenance Visit Allow for physical exam as well as discussion of proper nutrition, behavior, development, and safety Monitor normal growth and development May show disease process or abuse Growth = inc. in body size; development = inc. function of processes related to body and mind AAP recommends health maintenance visits at: 1st week of life (depending on nursery discharge) 2nd week of life 2, 4, 6, 9, 12, 15, and 18 months 1x per year from 2-6 years of life every other year until adolescence is complete Normal Growth Deviation from normal growth patterns may indicate serious or chronic disease Accurate measurements should be taken at visits, including: Height Weight Head circumference Some rules of thumb for growth: Weight: Changes in weight: Lose 5-10% of birth weight in 1st few days Return to normal birth weight at 7-10 days of age Double weight at 4-5 months Triple weight at 1 yr Quadruple weight 2 yr Avg. weights: Birth = 3.5 kg

1 yr = 10 kg 5 yr = 20 kg 10 yr = 30 kg Daily weight gains: 20-30 grams for 1st 3-4 months 15-20 grams for remainder of 1st year Annual weight gains: 5 lb. between 2 years and puberty (spurts and plateaus may occur) Height: Avg. length or height: 20 inches at birth 30 inches at 1 yr 3 ft at 3 years 40 inches at 4 years (double birth length) Annual avg. height inc. is 2-3 inches between 4 yr. and puberty Head Circumference: Average is 35 cm (13.5 inches) at birth Growth: 1 cm/month for 1st year (2 cm/month for 1st 3 months, then slower growth) 10 cm for rest of life Plot measurements on growth charts b/c they allow you to see deviations in a kids particular pattern This shows change even if measurement falls in normal limits (defined as 3rd to 97th percentile) What is on CDC Growth Charts published in 2000 (which are based on nationally representative data)? Ages 0-36 month chart: Weight for age Length for age HC for age Weight for length Ages 2-20 year old chart: Weight for age Height for age BMI for age *BMI = weight(kg) / height (m) squared If BMI units are pounds and inches squared, multiply by correction factor of 703 to obtain proper BMI BMI over 95th percentile means overweight; between 85-95th percentile means at risk for becoming overweight Remember that normal child growth patterns include spurts and plateaus

Growth is not along a smooth line, as the growth chart would have your think Large shifts in percentiles or major discrepancies in size should be looked into, however When caloric intake is inadequate, weight percentile falls first, then height, and HC last Reasons for inadequate caloric intake: non organic failure to thrive means parents not feeding enough, or not giving adequate attention Increased caloric needs: Chronic illness Malabsorption issue What does increasing weight percentile in the face of decreasing height percentile mean? Answer: Hypothyroidism Some words about Head Circumference HC may be disproportionately large in certain instances including: Familial macrocephaly (knowing parental head size is crucial) Hydrocephalus catch up growth in a neurologically normal premature infant microcephaly is considered HC below 3rd percentile, even if other measurements are proportionately low serial HC measurement is crucial during infancy, when the brain is rapidly growing, and should be plotted regularly until the age of 3

Disorders of Growth
Deviant growth measurements Most common cause is technical (faulty equipment and human error) 1st step in workup is repeat measurement separate growth charts are available for very low birth weight babies, Turners, Downs, achondroplasia, and other dysmorphology syndromes Variability in body proportion Kids heads are really big compared to body size Wearing hats reduces heat loss Variability in Body form Often follows familial patterns Patterns of growth requiring further evaluation are included in table 6-1 Table 6-1. Specific Growth Patterns Requiring Further Evaluation Pattern Representative Further Evaluation

Weight, length, head circumference all <5th percentile

Diagnoses to Consider Familial short stature Mid-parental heights Constitutional short stature Intrauterine insult Evaluation of pubertal development Examination of prenatal records Chromosome analysis Mid-parental heights Evaluation of pubertal development Thyroid hormone Growth factors, provocative GH testing Complete history and physical examination Dietary and social history Failure to thrive evaluation

Genetic abnormality Discrepant percentiles (e.g., weight 5th, Normal variant length 5th, head circumference 50th, or (familial or other discrepancies) constitutional)

Endocrine growth failure Caloric insufficiency Declining percentiles "Catch-down" growth

The role of parental heights in assessing growth problems Mid-parental height is an approximation of how big the kid will be For a girl, its: {in inches} (dads height + moms height - 2.5)/2 For a boy, its: {in inches} (dads height + moms height + 2.5)/2 Familial short stature Growth pattern shows small weight, length , and head circumference Constitutional short stature A child who is preadolescent or adolescent by age and starts puberty later than others (normal variant) This growth pattern must be examined closely to rule out abnormalities of pubertal development Girls are considered normal if secondary sex characteristics (breast buds) are present by 14, and menarche by 16 If menstruation does not begin until 16, the girl was likely smaller than her peers when she was 12-13 Catch-down Growth growth moves to lower percentiles during 1st year of life

mother had excellent prenatal care and provided appropriate nurturing, so baby started out on a high growth percentile Between 6-18 months, baby drops percentiles until they match their genetic predisposition and then grow along that lower growth percentile Will have normal developmental, behavioral, and physical exams must be followed closely to rule out any pathology Catch-up growth infants who were born small for gestational age or premature ingest more breast milk or formula counsel family that baby needs lots of food until they catch up baby should get as much as they want, unless throwing up ( not just spitting up) unless there are complications that require extra calories, baby will usually catch up in growth in first year of life some of these small infants can benefit from a high calorie formula Distinctive patterns of proportional growth rates correlate with function Nervous systems most rapid growth is in 1st 2 years, with increasing physical, emotional, behavioral, and cognitive development

Normal Development Physical Assessment

Newborn period Primitive neonatal reflexes are unique in the newborn, due to continued CNS development after birth Delay in the expected disappearance of these reflexes warrants further investigation Most important reflexes to assess are as follows: Moro reflex Elicit by lifting infant just barely off mattress and letting drop; you will see abduction and upward movement of the arms, followed by adduction and flexion Should disappear by 4-6 months Rooting reflex Touch corner of infants mouth, resulting in lowering of the lower lip on the same side with tongue movement toward stimulus; face may also turn Disappears at 4-6 months Sucking reflex Vigorous sucking when almost any object is placed in the infants mouth Later replaced by voluntary sucking only Grasp reflex

Occurs when placing object in palm (palmar grasp) or sole (plantar grasp); infant will flex fingers or curl toes Palmar grasp disappears at 3-4 months; plantar grasp disappears at 6-8 months Asymmetric tonic neck reflex Place infant in supine position, and turn head to side; this placement results in ipsilateral extension of the arm and the leg into a fencing position; contralateral side flexes Disappears at 2-3 months Later infancy As kids develop fine motor skills, they are first able to control posture, then proximal muscles, then distal muscles At this time, parents may notice orthopedic deformities If deformity is able to be manually put into the proper position by the examiner, it has a high likelihood of resolving with progression of fine motor skills Fixed deformities warrant immediate pediatric consultation Visual and ocular movements should be continuously evaluated to prevent strabismus Cover test and light reflex should be done at every visit Late school age / Early adolescent If participate in sports, need comprehensive sports physical, including Cardiovascular exam Hx of heart disease or murmurs, dyspnea or chest pain on exertion, irregular heart rate, syncope, or seizure should be referred to Peds cardiologist Family hx of heart disease or disease of the vasculature before age 50, or unexplained death at any age requires addition assessment This applies to immediate family or immediate familys immediate family Contact sports require special vulnerabilities to be assessed Hx of renal disease, such as having only 1 kidney Vision should be assessed Adolescent These kids need comprehensive health assessment to ensure that there are no major problems with passage through puberty Other issues of physical development include: Scoliosis - most is only mild and requires only observation obesity trauma Monitor kids sexual maturity, which will provide an ongoing evaluation of puberty It is about 2 years from breast buds until menarche Girls must be assessed as to their menstrual cycles, especially dysmenorrhea (painful period) or menometrorrhagia (irregular or excessive bleeding during period or between periods)

Boys must be assessed for gynecomastia Developmental milestones (well established through the age of 6) A behavior is the response of the neuromuscular system to a specific situation By observing specific behaviors (or asking parents about them), we can compare a childs behavior with that of normal kids, whose behaviors evolve in a uniform sequence within specific age ranges Our assessment covers many areas of development: Gross motor Fine motor Language Some areas that are missed in this assessment include social and emotional development After 6 years, development is assessed by things like school performance, intelligence tests, personality profile, etc

Normal Development Psychosocial Assessment

Bonding and Attachment in infancy Bonding occurs after birth and reflects the feelings of the parents toward the newborn (unidirectional) Attachment involves reciprocal feelings between the parent and the infant that develops gradually over the first year Stranger anxiety begins between 9-18 months, when infant is insecure about separation from primary caregiver Developing autonomy in early childhood Toddlers will still cling to their parents in times of stress, but in normal activity may actively separate themselves Limit setting at this time is essential to balance the childs emerging independence School readiness Should be assessed when a toddler has reached autonomy and independence Preschool aids in acquiring socialization and language skills, as well as learning Children often due better in kindergarten if their 5th birthday is at least 4-6 months before the beginning of the school year Also, girls are generally more ready than boys Speech therapy, occupational therapy, and physical therapy are federally mandated to children who need them in school Table 7-1. Evaluating School Readiness Physician Observations (Behaviors Observed in the Office) Ease of separation of the child from the parent Speech development and articulation

Understanding of and ability to follow complex directions Specific preacademic skills Knowledge of colors Counts to 10 Knows age, first and last name, address, and phone number Ability to copy shapes Motor skills Stand on one foot, skip, and catch a bounced ball Dress and undress without assistance Parent Observations (Questions Answered by History) Does the child play well with other children? Does the child separate well, such as a child playing in the backyard alone with occasional monitoring by the parent? Does the child show interest in books, letters, and numbers? Can the child sustain attention to quiet activities? How frequent are toilet-training "accidents"?

Early Adolescence Attention is focused on the present and the peer group Normality is typically sought Exploratory, undifferentiated sexual behavior resulting in physical contact with same sex partners is normal; heterosexual interest may also develop Difficult to interview these patients, b/c they usually respond with short answers, and have little insight Middle Adolescence More abstract thinking is now performed Focus on identity, not limited only to the physical aspects of themselves Explore their parents and societys value system, sometimes by expressing the contrary side of dominant values Challenge authority, seek independence Many high risk behaviors engaged Unprotected sex Drugs Dangerous driving At higher risk for morbidity or mortality from accidents, homicide, and suicide Late adolescence Think more about the future More committed to sexual partners than earlier Unresolved separation anxiety from previous developmental stages may emerge at this time Modifying psychosocial behaviors

Operant conditioning involves manipulation of environmental antecedents and consequences of actions to modify maladaptive behavior and to increase desirable behavior Four major methods of operant conditioning include: Positive reinforcement following good behavior with a favorable event Negative reinforcement follow good behavior with removal, cessation, or avoidance of unpleasant event Extinction occurs when there is a decrease in the frequency of a previously reinforced behavior because the reinforcement is withheld Punishment decreases behavior through unpleasant consequences Positive reinforcement has been proved to be more effective than punishment Temperament (behavioral style) Three common constellations of temperamental characteristics: Easy Child (40% of kids) Regular biologic functions (eating, sleeping, elimination) Positive mood and approach to new stimuli High adaptability to change Mild to moderate intensity of responses Difficult Child (10% of kids) Irregular biologic functions Negative mood and negative withdrawal from new stimuli Poor adaptability Intense responses Slow to Warm Up Child (15% of kids) low activity level withdrawal from new stimuli slow adaptability mild intensity responses somewhat negative mood the remaining children have more mixed temperaments

Disorders of Development
Developmental surveillance and screening About 15-18% of kids in US have developmental or behavioral disabilities Parents will often not bring these issues to the attention of the pediatrician, so it is important to ask about them at every visit After 6 years old, development is mostly screened through school performance Developmental screening is a brief evaluation comparing the developmental skills of a particular child with skills of a population of children to identify children with suspected delays who require further diagnostic assessment

These involve standardized screening tests AAP recommends the use of standardized screening tools at every visit

Table 8-1. Developmental Milestones Fine Motor- PersonalAge Gross Motor Adaptive Social 2 Moves head Regards face wk side to side 2 Lifts shoulder Tracks past Smiles mo while prone midline responsively

Language Alerts to bell Cooing

Other Cognitive

4 Lifts up on mo hands Rolls front to back If pulled to sit from supine, no head lag 6 Sits alone Transfers Feeds self Babbles mo object hand to hand Holds bottle 9 Pulls to stand Starting to Waves bye-bye Says Dada and mo pincer grasp Mama, but nonspecific Gets into Bangs 2 Plays pat-a2-syllable sounds sitting position blocks cake together 12 Walks Puts block in Drinks from a Says Mama and mo cup cup Dada, specific Stoops and Imitates others Says 1-2 other stands words 15 Walks Scribbles Uses spoon and Says 3-6 words mo backward fork Stacks 2 Helps in Follows blocks housework commands 18 Runs Stacks four Removes Says at least 6 mo blocks garment words Kicks a ball "Feeds" doll 2 yr Walks up and Stacks 6 Washes and Puts 2 words Understands

Searches for sound with eyes Reaches for Looks at hand Laughs and object squeals Raking Begins to work grasp toward toy

down stairs Throws overhand

blocks dries hands Copies line Brushes teeth

together concept of "today" Points to pictures

Puts on clothes Knows body parts Uses spoon Names pictures Understands well, spilling concepts of little "tomorrow" and "yesterday" Broad jump Wiggles Puts on t-shirt Speech thumb understandable to stranger 75% Says 3-word sentences 4 yr Balances well Copies O, Brushes teeth Names colors on each foot maybe + without help Hops on one Draws Dresses Understands foot person with without help adjectives 3 parts 5 yr Skips Copies Counts Heal-to-toe Understands walks opposites 6 yr Balances on Copies Defines words Begins to each foot 6 sec understand "right" and "left" Draws person with 6 parts 3 yr Walks steps Stacks 8 alternating feet blocks

Because of the variability of childhood development, standards for abnormality in developmental/behavioral screens are set lower than what is usually accepted for other medical screens Sensitivity and Specificity are both between 70-80% Denver Developmental Screening Test II is commonly used Assesses kids from birth to 6 years in four domains: Personal-social Fine motor-adaptive Language Gross motor Parent reported screens have good validity compared to office visits Language screening See table 8-2 for rules of thumb

Table 8-2. Rules of Thumb for Speech Screening Articulation (Amount of Age Speech Understood by a (yr) Speech Production Stranger) 1 1-3 words 2 3 4 5 2- to 3-word phrases

Following Commands One-step commands Two-step commands

Routine use of sentences Routine use of sentence sequences; Almost all conversational give-and-take Complex sentences; extensive use Almost all of modifiers, pronouns, and prepositions

In the first 2 years of life, the most dramatic changes in language occur in receptive language If there is a language delay, a hearing deficit must be considered Table 8-3 lists some high risk situations for hearing loss

Table 8-3. Conditions Considered High Risk for Associated Hearing Deficit Congenital hearing loss in first cousin or closer relative Bilirubin level of 20 mg/dL Congenital rubella or other nonbacterial intrauterine infection Defects in the ear, nose, or throat Birth weight of 1500 g Multiple apneic episodes Exchange transfusion Meningitis 5-min Apgar score of 5 Persistent fetal circulation (primary pulmonary hypertension) Treatment with ototoxic drugs (e.g., aminoglycosides and loop diuretics)

Dysfluency (stuttering) is common in 3-4 year olds Unless the dysfluency is severe, is accompanied by tics or unusual posturing, or occurs after 4 years old, parents should be counseled that it is normal and transient Other issues in assessing development and behavior Table 8-4 lists some contextual factors that should be considered in the etiology of a childs behavioral or developmental problem

Table 8-4. Context of Behavioral Problems Child Factors Health (past and current) Developmental status Temperament (e.g., difficult, slow to warm up) Coping mechanisms Parental Factors Misinterpretations of stage-related behaviors Mismatch of parental expectations and characteristics of child Parental characteristics (e.g., depression, lack of interest, rejection, overprotectiveness) Coping mechanisms Environmental Factors Stress (e.g., marital discord, unemployment, personal loss) Support (e.g., emotional, material, informational, child care) Parent-Child Interactions The common pathway through which the listed factors interact to influence the development of a behavior problem The key to resolving the behavior problem

Good rapport with kid and parent is essential in obtaining the right information Dont ignore the kid Talk to adolescents, and establish a relationship with them that is distinct from their parents, but dont exclude the parents State laws vary as to consent and confidentiality, so learn your states laws Serial visits and interviewing Use open ended questions to help guide the interview Request clarification or more detail when needed Recapitulate information at frequent intervals to ensure proper understanding Use respect and empathy

Appendix: The Denver II Scale

I copied the explanation of the Denver and how to use it from the book, in case someone hasnt used it yet. Here it is: The Denver Developmental Screening Test II is commonly used by general pediatricians (Figs. 8-1 and 8-2). The Denver II assesses the development of children

from birth to 6 years in four domains: (1) personal-social, (2) fine motor-adaptive, (3) language, and (4) gross motor. Items on the Denver II are carefully selected for their reliability and consistency of norms across subgroups and cultures. The Denver II is a useful screening instrument, but it cannot assess adequately the complexities of socioemotional development. Children with "suspect" or "untestable" scores must be followed carefully. The pediatrician asks questions (items labeled with an "R" may be asked of parents to document the task "by report") or directly observes behaviors. On the scoring sheet, a line is drawn at the child's chronologic age. All tasks that are entirely to the left of the line that the child has not accomplished are considered delayed (at least 90% of the population accomplished the task). If the test instructions are not followed accurately or if items are omitted, the validity of the test becomes much poorer. To assist physicians in using the Denver II, the scoring sheet also features a table to document confounding behaviors, such as interest, fearfulness, or apparent short attention span. Repeat screening at subsequent health maintenance visits often detects abnormalities that a single screen was unable to detect. Instructions for the Denver II. Numbers are coded to scoring form (see Fig. 8-1). "Abnormal" is defined as two or more delays (failure of an item passed by 90% at that age) in two or more categories or two or more delays in one category with one other category having one delay and an age line that does not intersect one item that is passed. (From Frankenburg WK: Denver II Developmental Screening Test, 2nd ed. Denver, Denver Developmental Materials, 1990.) SPECIAL NEEDS CHILD EVALUATION 1. Mental Retardation: significant subnormal intellect for developmental stage+ decreased adaptive behaviors (home living, communication, social interaction) 2 std. dev below, or ~3rd percentile IQ score Stanford Binet IQ Test: MR if < 67 Weschler Intelligence Scale (WSC III): MR if <70 Of greater importance is areas of defecit DDx (descending frequency): Alterations in embryonic devel: chromosomal changes, prenatal influence Idiopathic (~1/3 do not have identifiable reasons for disability!) Env/Social: deprivation, neglect, toxins (e.g. lead) Pregnancy/ perinatal complications Hereditary: e.g. Fragile X Acquired: infection, trauma, toxin (e.g. lead) Socioeconomic status ~ mild MRnot profound MR Px: the earlier the cognitive defecit is noticeable, the more severe it is likely to be 2. Vision Impairment- can delays in perception, imitative behavior (smiling), motor, bonding Partial vision: 20/70- 20/200; very common (1/500 school kids)

Legal blindness: 20/200 in better eye or visual field angle < 20deg Mild/Moderate visual impairment- usually refractive errors a. Myopia (mc): near sighted b. Hyperopia: far-sighted c. Astigmatism: abnl. shaped cornea Refractive errors in kids <6y can still amblyopia: pathological alterations in visual system that decr. acuity Severe visual impairment: usually diagnosed @ 4-8m following parental concerns &/or findings on PE (fixation, visual tracking, persistant nystagmus) * note: binocular vision not expected in neonatal period, assess vision with electric impulses/electrodes along optic path DDx: a. Retinopathy of prematurity: mc, usually bilateral - oxygen toxicity to premature blood vessels of retina, causes vasoconstriction obliteration, fibrovascular proliferation b. Congenital cataracts: amblyopia c. Optic atrophy d. Retinal degeneration/retinitis pigmentosa e. RB f. Congenital glaucoma

3. Hearing Impairment Mild hearing loss is usually conductive: mcc of loss is acquired middle ear disease (some conditions predispose to middle ear disease, e.g. Downs Syndrome) Severe hearing loss is usually sensineuronal: i. Congenital infection (rubella, CMV) ii. Meningitis iii. Asphyxia iv. Kernicterus v. Ototoxis drugs (aminoglycosides) vi. Tumors/chemotherapy Surveillance is NOT adequate to prevent/catch hearing impairment: a. Auditory Brain Stem Response screen : electrodes, meausures response to tones b. Otoacoustic emissions: uses tiny probe to measure sound waves produced by inner ear Tx: -conductive hear loss from middle ear dz can be minimized using ear tubes - sensineuronal hearing loss and permanent conductive hearing loss can be managed with amplification aids, lip reading, sign language, speech therapy. Pts with profound sensineuronal hearing loss can consider cochlear implant 4. Speech/Language Impairment

Concerning signs are any dysfluency, repetitions, blocks, struggles (grimacing, blinking, excessive gestures) or: Birth } no startle, attendance to voice, babbling 6m 10m- no response to name, only shrieks/grunts 12m- only vowel sounds 15m- no response to no, bye-bye, bottle 18m- <6 words 21m- no resonse to give me, sit, come 23m- no 2-word phrases (thank you, all gone) 24m- most speech still incomprehensible no pointing to body parts, no word combos 30m- no short sentences, prepositions, questions 36m- no understanding by unfamiliar listeners DDx speech delay: MR Hearing impairment Social deprivation Autism Oral-motor abnormality SPEECH disorder (d/o) vs. LANGUAGE d/o - articulation d/o: sounds, syllables - receptive: cant understand - fluency d/o: stoppage, stutter, prolonged sounds - expressive: cant put words resonance d/o: pitch, volume, quality together, impaired vocab, social inappropriateness Tx: speech therapy- best outcome if begun before 3y 5. Cerebral Palsy: group of nonporgressive motor impairment syndromes Motor impairment: hemiparesis/hemiplegia, diplegia (usu. legs), quadriplegia..all impairment rated for severity I-V Secondary to anomalies/lesions of immature brain ~ 2-2.5/1000, higher in premature, twins Causes: o Perinatal asphyxia o Kernicterus o Occult infections/inflammation Risk factors: o Maternal thyroid or seizure d/o o FHx of MR o Low SES o Hormone tx o Pregnancy/perinatal complication (asphyxia, ischemia) o Bilirubin encephalopathy

Types: a. Spastic- mc; injury of UMNs incr. tone/hyperreflexive b. Dyskinetic- abnormal, involuntary movements c. Ataxic- cerebellar injury abnl posture, loss of coordination d. Choreoathetotic- due to kernicterus stormy movements, decr. Tone e. Mixed- more complications with this type Co morbid conditions include epilepsy, learning disability, behavior challenges, sensory impairments Tx: PT/OT, for spasticity: botulinum toxin or baclofen, plus management of seizueres, sensory impairments WELL CHILD EVALUATION

Interview overview:
CHILD - concerns - follow-ups - routines (eating, sleeping, bowels) - development - behavior ENVIRONMENT - Family: who cares for child? interactions with others? stresses? Supports? - Community: outside care, peers, school - Physical: stimulation, safety

Well child Screening

1) Newborn a. Metabolic- ex: PKU, glactosemia, congenital hypothyroid, MSUD - these are serious diseases of low prevalence but good px with early detection b. Hemoglobin- electrophoresis for hemoglobinopathies ( SS, thalassemia) - these diseases have incr. risk of anemia, infection - if + Sickle cell (SS): prophylactic penicillin since sepsis is the major cause of mortality in these kids! c. Hearing- infant: hearing impairments speech/language/cognitive delay - use headphones + head electrodes to measure impulses - if abnl: further evaluate with evoked response EEG - older infants: until 3y ask parents about child response to sound, speech development; after 3y additional objective hearing screen with standard recordings 2) Vision- until 3y, visual screen inferred from gross motor development, subjective reports, and eye exam; after 3y use Snellen card (with objects or letters) 3) Anemia- screen at ages of highest risk for Fe-defic. Anemia:

9 m- high incidence of Fe-deficiency! @ birth if premature or VLBW Childhood screening in highrisk or present sx.



Routine screening resumes in adolescence; once for boys, annually for girls

4) Urinalysis- blood, signs of infection, renal function etc. 5) Lead- can irreversible devel/behavioral abnormality! - screen for risk factors: old home/buildings? Industrial exposure (auto radiator repair, battery recycling)? traditional remedies (Mexican), hobbies (pottery glaze)? - state requires lead measurements @ 9-12mo &/or 2y - sample must be from venous blood (cap blood: false +) 6) Tuberculosis- assess @ 1y since child TB usually systemic (miliary) - PPD test: evaluation 48-72h; positive based on size: - + if 10 mm or 5 mm with HIV, immunocomp., previous TB 7) Cholesterol- screen in high risk pts: obese, smoker, DM or FHx of high cholesterol, heart disease, MI - if random total cholesterol 200 mg/dL, follow with fasting analysis 8) STDs- screen any child with any history of any form of sexual intercourse at least annually; in girls: screen for HPV with Pap smear 3y after sexual intercourse or age 21 outline!

Immunizations- very impt. Component of WCC, see Chases Dental- recommendation is visit to hygienist ea. 6months, dental
exam ea. 1year sleep with milk bottle! - look for evidence of milk-bottle caries!never let child

Nutrition- growth curves!!- see Leigh Annes outline! Anticipatory Guidance

i. Injury prevention Car safety- crashes are mcCOD in 1m-1y!

- should not d/c pt w/o good car seat - seat laws: required until 4y or 40 lbs - 1y: rear facing, 1y: front facing - 4-8 y: booster seat - 12y: back seat only!

Sleep safety- 6m: back to sleep to prevent SIDS ii. Violence prevention iii. Nutrition iv. Development/Behavior (see Table 9-5 p 40-41 in Nelson for complete guideline) Discipline- goal is to teach self control, not just punish- more important to reinforce good behavior- common techniques are: a. scolding: less effective over time, caution against derogatory statements, encourage parents: good child who does bad occasionally b. physical punishment: can escalate to abuse or teach child to hit c. threats: never threaten to leave child!- loss of privileges is best - recommend balance of freedom and limits: limits should be clearly explained and enforcement should be firm, brief, consistently linked to undesired behavior i. Extinction: ignoring frequent, annoying behavior (tantrums); good for toddlers too young to understand timeout- always follow w/ praise! ii. Timeout- immediately following behavior, recc: 1 min/ year age


Sources: Infant Feeding Article, Nelsons, First Aid Questions- Leigh Anne @

Infants Breastfeeding: - Superior because of benefits to infant and mom: o For newborn, anti-infective properties lower risk of diarrhea, resp illnesses, OM, bacteremia, bacterial meningitis, necrotizing enterocolitis, maybe food allergies, eczema, asthma, Crohns, DM; also may provide cognitive benefits, although other factors may be involved. o For mom, lowers risk of post-partum hemorrhage, ovarian/breast cancer, osteoporosis, lengthens amenorrhea, provides mother-baby bonding, and lowers health care costs. - Problems/Contraindications o Engorgement ~3rd postpartum day; treat by enhancing milk flow o Mastitis: fever, chills, malaise, tx: frequent emptying of breast and abx o Breast abscess may progress from mastitis; tx: incision and draining, abx, regular emptying. CAN nurse with affected breast if comfort allows. o Jaundice: more common in breastfed than formula-fed Breastfeeding: insufficient milk intake, poor wt gain, high unconj. bili 2 to high enteropathic circulation. Tx: increase milk production/intake Breast Milk: (older infants) prolonged elevated serum bili d/t unknown factor in milk that increases bilirubin absorption. Dx of exclusion, rare. o DO NOT breast-feed Herpes breast lesions, HIV (in Africa, benefits>risks), infant galactosemia, w/ TB, syphilis, varicella - can restart breastfeeding after tx

initiated; Maternal drug use absolutely contraindicated: radioactive compounds, anti-metabolites, lithium, anti-thyroid; warn mother against etOH, nicotine, caffeine, etc - Human Milk Content: ~20 kcal/oz o Protein - 70%whey and 30%casein, many proteins that boost immune system o Lipids (50% of energy content)- includes essential FA and long-chain FA (including arachidonic and docosahexaenoic acids that are NOT in bovine milk or in formulas may be important to neuro/retinal development) o Carbohydrate: Lactose; Lactase appears late, so some lactose may enter distal small bowel and ferment, allowing proliferation of lactobacilli; these produce an acid medium that suppresses other pathogenic organisms and promotes absorption of Ca and PO4 o Adequate Vitamins and Minerals, low Na+ and solute concentrations. o Must supplement at 4-6 months: Fe (1 mg/kg/day) through Fe-fortified cereal. VitD (400IU/day) for dark-skinned or those not exposed to sun-light Fluoride if water supply contains <0.3ppm fluoride o Should NOT supplement with water, glucose water, or formula in healthy babies - In the early weeks, infant should feed 8-12x/day; assess adequacy through voiding and stool patterns and rate of wt gain: o Voiding: nL 6-8 soaked diapers/day; Stools @5-7 days, loose yellow seedy 4x/day, more than formula-fed; after 6-8 weeks, breastfed infants may go several days w/o stool o Weight: <7% loss after birth, and should regain birth wt by day 10, then infants should gain approximately 25-30g/day or 5-7 oz/week o Rates of growth slower in breastfed than formula-fed Formula Feeding: - Indications for formula use: mothers who do or can not provide human milk, certain inborn errors of metabolism causing intolerance, mothers with infn known to transmit in breast milk HIV, some CMV, HSV, mom on chemotherapy, radioactive compounds, anti-thyroid meds, or Lithium, or FTT after encouragement / breastfeeding therapy - Newborns require ~110-120 kcal/kg/day. - Formula-fed infants have more rapid wt-gain than breastfed- discrepancies do not persist past age 2 years; may be greater risk of obesity in formula-fed. Types of Formulas: - Cows Milk-based o Content: 20kcal/oz (similar to human milk), AAP recommends Fe-fortified! Protein: 1.4-1.6g/dL (about 40% greater than that in human milk). Contains different ratios of whey to casein proteins with different amino acid patterns. Fat: also 50% of caloric content; butterfat of cow milk replaced with vegetable oils to enhance digestibility and absorption. Essential fatty acids (linoleic and alpha-linoleic acids) added; debate of whether AA and DHA should be added (they are NOT added currently). Carbohydrate: Lactose. Lactose intolerance rare in 1st year, but nonlactose-containing formulas are increasingly given to infants w/ nonspecific GI symptoms; should be reserved for pts with galactosemia and lactase deficiency.

Iron: 12 mg/L. Although AAP recommends all infants take Fe, low-Fe containing formulas are still made, because of a perception that Fe causes constipation. Mineral and Vitamin content adequate for first year, except for Fluoride should be added at 6 months if water has <0.3ppm

Soy Formulas: o for galactosemia, lactose intolerance, vegetarian families, and when allergic to cows milk proteins (but often child will be allergic to both) o Supplemented with methionine, glucose oligomers as carbohydrate source, fats similar to cows milk-based formulas. Do not prevent later allergies. o The use of soy formulas and lactose-free cows milk formulas greatly exceeds the incidence of cow milk protein allergy and lactose intolerance. Therapeutic Formulas: o Protein hydrosylate formulas: for infants intolerant/allergic to intact milk protein; some hydrosylated protein formulas also contain medium-chain TGs to facilitate fat absorption and are lactose-free, good for pts with malabsorption problems CF, short gut syndrome, biliary atresia, lactase deficiency, etc. o Low-solute formulas: for pts with renal, CV dysfxn require careful use and follow-up. o Special Amino-acid based formulas: for specific inborn errors of metabolism. o Toddler formulas: with higher protein, fat, and carbohydrate contents for nutritional supplements for young children with FTT from variable etiologies. Lead Exposure: still common in US; older homes with lead pipes. Moms instructed to use only cold water, run water for 2 minutes, and avoid boiling it.

Nutritional Needs of Preterm Infants: - Premature (<34-36wks) and LBW (<2000-2500g) infants may have special nutritional needs - VLBW infants (<1500g and < 32 weeks) have extraordinary nutritional needs: o Require fortified human milk or preterm infant formulas ( 24kcal/oz) o >100-120kcal/day to achieve wt gain of 15 g/kg/day o Protein 3.5-4g/kg/day, Fat should constitute 50% of energy intake. o Carbohydrates should constitute 40-50% calories or 10-14 g/kg/day; human milks lactose in the distal bowel may cause fermentive diarrhea, but is generally well-tolerated. Preterm infant formulas contain glucose polymers to avoid osmotic diarrhea. o Higher mineral requirements: Na+ and K+ (2.5-3.5mEq/day); Ca2+, P, Mg2+ needs are inversely related to gestational age, and can be met by preterm formula or by fortifying human milk with liquid or powder milk-fortifiers. Iron in the form of FeSO4 should be provided 2-4mg/kg/day, and greater (6mg/kg/day) if taking erythropoietin. o Powder milk-fortifiers increase caloric content of human milk from ~20 kcal/oz to 24kcal/oz and add minerals, but consequently lower fat absorption, necessitating intakes of 180ml/kg/day (vs. 150ml/kg/day of preterm formulas). Introducing Complimentary Solid Feedings: usually occurs at 4-6 mos.

Recommended for more protein, Fe, Zn. Need high fat and caloric-dense for energy for increasing activity. If introduction delayed, oral-sensory aversion. Timing depends on neuro and GI maturation of infant should be able to sit and coordinate mastication and swallowing, and be capable of digestion and absorption Important to continue breast/formula feeding through first year. Complimentary foods: o Vitamin and Fe-fortified SINGLE-grain cereals to id allergies/intolerances o Introduce single-ingredient foods - 1/week o Single-ingredient meats for Fe/Zn o Juice only after 6 months, in a cup, and <4oz daily. Risk of Dental Caries! o NO sleep w/ bottle of milk/formula/juice to avoid Infant Bottle Tooth Decay o Avoid fish, peanuts, nuts, dairy, eggs foods with high allergicity o Avoid hotdogs, grapes, nuts, etc foods that may obstruct airway o Avoid Honey before 1-2 years infant botulism.

Toddlers - Cows milk: not introduced until 1 year to avoid occult intestinal blood loss, and then should be limited to avoid reducing intake of other nutritionally important solid foods. - Juice: for toddlers, <4-6oz/day; for 7-18yo, <8-12oz/day. - Power struggles are common between parents and children. - Families in federal assistance programs are significantly either under or overweight. - @ 2 years, complex carbohydrates 55-60%, simple sugars <10%, fat intake is gradually increased to ~30% and not less than 20%, Na intake should be limited, Avoid grazing! Adolescents - When poor eating habits commonly develop. - Excessive sugar (soda, fruit juices, coffee) weight gain and tooth decay - Osteoporosis due to poor dietary calcium or vitamin intake becoming more common Obesity - Defined: body weight 10% > that ideal body wt for age, gender height. - 10% of 4-5 yo obese; 15% of Americans 6-19 overweight; highest in African American and Mexican populations - Certain genetic disorders account for <5% of Obesity (examples: Cushings syndrome, hyperinsulinism, muscular dystrophy, Prader-Willi Syndrome, myelodysplasia, pseudohypoparathyroidism, Turners Syndrome) - Obese children Obese adults; risk increases with age, degree of obesity, family hx - Must screen for complications: psychosocial, growth, CNS, respiratory (apnea), CV, ortho (SCFE), metabolic (DM); and for conditions/syndromes associated with obesity: o Obesity makes SHADE: SCFE, Hypertension, Apnea, Diabetes, Embarrassment - Dx: graph BMI on curve: >85th% at risk for overweight, >95th% overweight/obese. - Tx: organized program of diet and exercise, behavioral modifications, must maintain nutrients for growth: for children 2-7 with BMI > 95th%, MAINTAIN wt; if there are 2 complications, LOSE wt - NO television for children <2 years; and for older children, limit TV time to <2hours. - Prevention: Breastfeeding, regularly scheduled meals, recognize satiety cues, and never force children to eat when they are unwilling. After 2 years, switch to 2% or skim milk. Pediatric Undernutrition

Protein-Energy Malnutrition (PEM) a leading cause of death <5 yo worldwide Failure to Thrive: o Defined: wt <3rd % or a fall off the growth chart by 2 lines. o Prevalence ~5-10%, associated with psychosocial risk factors o Signs: SMALLKID: Subcutaneous fat loss, Muscle atrophy, Alopecia, Lagging behind norms, Lethargy, Kwasiorkor/marasmus, Infection, Dermatitis Marasmus: severe Protein-Calorie Malnutrition (PCM), wasting. o Due to low nutritional intake or associated with chronic diseases (CF, TB, cancer, AIDS, celiac disease). o Emaciation with wt <70% ideal or <60% of median o Loss of muscle mass and subcutaneous fat stores o Bradycardia, hypothermia, hypotension, decreased strength, dry thin skin and hair, atrophy of filiform papillae, stomatitis, delayed wound healing, impaired immunity Kwashiorkor: hypoalbuminemic, edematous malnutrition, presents with pitting edema o Inadequate protein intake w/ good caloric intake, normal or slightly low weight o PE: generalized edema, atrophy of muscle mass but maintenance of adipose tissue, thin dull hair, skin changes (hyperpigmented hyperkeratosis, pellagroid, painful desquamation), angular cheilosis, filiform atrophy, moon facies, enlarged liver, basilar rales Tx of malnutrition: initiated and advanced slowly to prevent unmasking micronutrient deficiencies and intolerance by the previously less-active GIT. IV fluids should be avoided to avoid resulting CHF or renal failure. o Calories started at 20% above childs recent intake (or 50-75% nL requirement) o Avoid Refeeding syndrome: fluid retention, hypoPO4, hypoMg, hypoK+ o Caloric intake increased 10-20%/day until age-appropriate growth o For infants/children, provide 100-120kcal/kg based on ideal wt, no added Fe Complications: infn, hypoglycemia, hypothermia, bradycardia, micronutrient deficiencies

**Review Vitamin and Mineral Deficiencies through three tables provided in Nelsons**

TODDLER DEVELOPMENT Growth and appearance -growth slows after infancy -after 2, toddlers gain ~5# in weight and 2.5/yr -growth occurs in spurts -growth occurs primarily from L.E. -between 2 and 2.5 kid will reach 50% of adult height Gross motor skills -motor skills develop rapidly during this time -most walk w/o assistance by 18 mo. -@ ~ age 2, gait becomes flexible, steady walking pattern with adult heel-toe progression -by 36 mo, can stand on one foot briefly -often test their skills beyond their abilities Fine motor skills -result from refinements in reaching, grasping, and manipulating small objects

-avg 18 mo old can make a tower of 4 blocks -1 yr later (2.5) can stack 8 blocks -18 mo old will hold crayon and scribble spontaneously -1.5 yr later (3yr) can grasp as adult and make a circle and maybe a stick fig. Affective development -new drive for automomy -begins to test boundries/limits daily -classic manifestation of struggle for autonomy is the temper tantrum Impulse control -begin to develop impulse control -18 mo old may have minimal impulse control -2 yo exhibit wide variations in impulse control -most 3 yr old have mastered some degree of impulse control -impulse control, improved motor skills, struggle for autonomy are highly evident during toilet trng -successful toilet trng usually at end of 3rd yr (just before 3rd b-day) -consistent daytime dryness @ ~ 2.5 yr old Attachment -remains important developmental theme -refers to the bond that forms between infant and caregiver -secure bond important for toddler who seeks autonomy Temperament -how a child approaches a given situation -has strong genetic influences -apparent during earliest infancy -3 temperamental constellations: easy, hard, slow to warm-up -approx 10% difficult, 40% easy, 15% slow to warm-up -difficulties may arise when a toddlers temperament conflicts with caregivers expectations Cognitive Development -transition from sensorimotor to pre-operational -marked by development of symbolic thinking -transition form sensorimotor to symbolic thought typically between 18 & 24 months -ex. Block may serve as a car, a bucket as a hat -develop object permanence (finding an object despite not seeing it hidden) -by 3, can draw primitive figures that represent important people -@ 3 develops elaborate play and imagination -continues to see world egocentrically Language -around age 2, toddlers use language to convey thoughts and needs -avg 18 mo old has vocab of at least 20 words -receptive language somewhat more advanced -in a few months (~20) 50% of language should be intelligible to strangers -by age 3, voc increases to about 500 words, 75% intelligible to strangers -begins myriad of why questions

PRESCHOOL DEVELOPMENT(this handout was terrible, absolutely terrible) Communicative and motor aspects -many changes occurring from 2-5 -early developmental guidance should focus on all children to optimize function -several researchers have noted existence of multiple intelligences rather than just IQ -developmental guidance must take into account childs temperament and parenting style -guidelines for child health supervision entitled Bright Futures -these guidelines suggest the use of a process called developmental surveillance, where emergence of abilities in children over time -provides specific trigger questions Conducting Developing Surveillance Developmental trajectory -must decide quickly which topics to pursue at the visit -should generate a developmental trajectory before visit concludes -develop traj is a hypothesis formed by the interaction among child, parent, and environment -trigger questions address all major areas of developmental functioning: speech/language, cognition, gross/fine motor, personal-social skills, adaptive skills Overview of milestone -development proceeds in spurts and has ranges of ages for attainment -2,3,4,5 yr old visits are assumed to be conducted w/in 3 months of birthday -for tasks listed, @ least 50% of children w/in 6 months of visit age could complete Specific concerns Specific Concerns Communication -children master most of the syntax by age 6 -2 yr old language consists of more words than jargon even if not understood by strangers -150-200 word vocab with 2 word utterances -use inflexion in asking questions -2 yr old mimic what others say (echolalia) -criterion for referral is voc of <50 words or not putting 2 words together at age ~2

-2 yr old with expressive lang delay with intact receptive lang has better prognosis -3 yr old speaks in simple well formed sentences -sentence length increases by 1-2 words per year in preschool period -5 yr old can use complete sentences and tell jokes -dysfluency occurs transiently between 2.5 and 4 yrs old -worsening stuttering beyond age 4 should be taken seriously -1% of preschool age children dxd with stuttering -great variation in development of language -girls more advanced than boys -children with superior language skills have fewer behavioral probs Clinicians interview of the child -should attempt to communicate directly with child -drawing interview: creates a conversation piece that has childs interest and attention Comprehension -distinguish simple requests from simple instructions without gestured clues -naming body parts possible response for the 15,18,24 mo visits -good 2 yr visit is names of 7 body parts -can pick the larger of 2 lines @ 3 yrs School readiness -parents eager and anxious about preschoolers readiness for school -reading not expected before age 6 Gross motor skills(see prev handout) -@ 2 bent over while running -@ 3 more upright -improving balance, coordination continues Approach to fever in the child: Warning****There was no specific packet in our notes that addressed this issue, so as you study some of the other material (otitis, pharyngitis, etc) think about their own signs and symptoms and how you might approach those as causes of fever. What follows is the information I saw constantly as I researched this topic: History: 1. Age: Fever in infants < 3 months of age should be considered as evidence of serious bacterial infection until proven otherwise. 2. Duration of fever : Fever lasting for more than 4-7 days is rarely due to self limiting viral illness and needs investigation. Fever lasting for more than 2 weeks indicates serious underlying problem and needs thorough investigation. 3. Pattern of fever 4. Contact with similar diseases

5. Past history of similar illness: Recurrent viral infections are common in children especially in the first year of school. Children between 2 months to 6 years of age are also susceptible to recurrent viral infections. Malaria may often recur, as the therapy is merely suppressive. 6. Drugs used in the treatment and its response 7. Progress of fever: Fever due to viral infection peaks over a day or two and gradually declines in 3-4 days. Bacterial fever worsens if left untreated. Malarial fever develops suddenly and declines swiftly. 8. Accompanying symptoms: specific symptoms help in localising the site of infection such as cough/cold in respiratory illness, diarrhea/vomiting in GI infection, dysuria in UTI, drowsiness or convulsions in meningitis. . 10. Immunization: Does the child have all of their vaccinations? Have they recently received an immunization that this might be a reaction to? B. Physical examination: 1. Assess seriousness: Presence of the following signs suggests the possibility of serious underlying diseases: a) Respiratory distress b) Drowsiness / meningeal signs c) Signs of impending shock d) Purpuric spots e) Abdominal guarding / rigidity 2. General examination: i) General appearance: ii) Body temperature: Must be quickly judged by merely touching the skin over the central and peripheral parts of the body. Differential body temperature: warm chest/abdomen and cool periphery-indicates severe illness. iii) Pulse rate: With every degree Fahrenheit rise in the fever, pulse rate goes up by 10 beats/min. Disproportionate increase in the pulse rate may suggest early sepsis or primary cardiac disease.

iv) Respiratory rate : Normal ratio of pulse and respiration in health is 4:1. The ratio is increased in primary cardiac disease and decreased in respiratory pathology. v) Skin rash vi) Lymphadenopathy vii) ENT examination 3. Systemic examination i. Respiratory system ii.Cardiovascular system iii. Central nervous system iv. Abdomen Finally, pay attention to certain diagnosis that depend on fever: i.e.-Kawasakis fever of five days, Fever of Unknown origin (must be greater than 8 days), etc. For FUO, the three most common causes are infectious diseases, connective tissue diseases, and neoplasms Labs should be based upon the presenting symptoms, but a CBC with diff. is certainly useful, as are UA in possible pyelonephritis or UTI. Look for signs of recent trauma that may have caused brain damage (possibly causing thermoregulation insufficiencies). Treatment should be based upon symptoms, but anti-biotic therapy should never be used unless a specific diagnosis is present. I realize that a lot of this is vague, and I apologize, but a kid with a fever isnt the most specific symptoms to diagnose either. Ultimately, with an appropriate history and physical (as described above), it should be easier to narrow down a diagnosis, and thus a set of labs and treatment to take care of it. General Information Parental consent must be obtained and documented

Must provide Vaccine Information Statement General Information Minor, afebrile illnesses do not contraindicate vaccination Fever usually contraindicates vaccination, unless associated illness is minor Febrile illness IS a contraindication for DPaT General Information

Vaccinate prematurely born infants at normal intervals at normal doses

NO vaccines for pregnant women except in urgent need for dT General Information Documentation of vaccination should include: Manufacturer Lot number Name, address, title of person giving injection General Information Most doses in a series must be 4 weeks apart

Multiple vaccines can be given at one time, but in different syringes and different injection sites Polio Site: Subcutaneous or IM


OPV (live, oral) no longer used All IPV (killed, subcutaneous) schedule now used Contraindications: Anaphylaxis to neomycin or streptomycin Site: Subcutaneous Live attenuated Reactions: Febrile seizures for 5-12 days post injection Rash and encephalitis from measles Encephalitis from mumps Lymphadenopathy, arthralgia, polyneuropathy from rubella Contraindicated Pregnancy (not child of pregnant mother) Within 3-11 months of receiving certain blood products Anaphylaxis to neomycin or gelatin NOT a TB infection (MMR will decrease PPD reactivity for 4-6 weeks)

Varicella Site: Subcutaneous Live, attenuated Prevents varicella in 70-85% Prevents serious disease in 95% Reactions Pain and redness Fever Varicella-like rash at injection site or generalized (7%) Contraindications Immunocompromised patients (research ongoing for leukemia) Pregnancy (not child of pregnant mother)

Anaphylaxis to neomycin or gelatin Receipt of certain blood products No contact with immunocompromised people if rash develops Do not give salicylates (aspirin) within 6 weeks of vaccine to prevent Reyes Syndrome Must be stored at 15 degrees C, used within 30 minutes of reconstitution Rotavirus Site: Oral Live Old RotaShield recalled due to febrile reactions and intussusception New Rotateq (pentavalent) Reactions Diarrhea and vomiting NOT intussusception Precautions Immunodeficiency GI disease History of intussusception Influenza Site: IM or nasal

Inactivated is IM Live, attenuated is nasal spray

Contraindication Egg allergy Hepatitis A Site: IM Inactivated Reactions Pain Contraindications Allergy to alum or phenoxyethanol Recommended in endemic areas and international travel Now recommended for universal use Hepatitis B Site: IM

Recombinant Hepatitis B (contains HBsAG) Reactions Soreness Contraindications Anaphylaxis to bakers yeast


Site: IM Types 6, 11, 16, and 18 6 and 11: 90% of genital warts 16 and 18: 70% of cervical cancer Female patients age 9-26 years


Site: IM (anterolateral thigh of infant or deltoid of older child) Usually given as DTaP Diphtheria and Tetanus Toxoids Having illness does not give immunity Doses: DT-pediatric dT-adult (1/10 to 1/20 amount of diphtheria toxoid due to increased reactivity with age over 7 years) Tdap-adolescent Reaction: Local pain, redness, swelling, fever Anaphylaxis DPT (continued) Pertussis Inactivated Bordetella pertussis (now acellular) Culture-proven illness gives immunity Small doses are given after age 7 years (Tdap) Reaction: Contraindications: Anaphylaxis--contraindicates use Encephalopathy--contraindicates use Cautions: Convulsions within 3 days Inconsolable for 3 hours Collapse or shock Fever to 105 Defer: In evolving or unknown neurological disorder. NOT in known seizure disorder If delayed, delay whole DPaT Pneumococcal Site: IM Conjugated capsular polysaccharides Conjugated with nontoxic diphtheria protein 7 serotypes (cause of 80% of pediatrics pneumococcal bacteremia) in new vaccine for < 2 years of age Prevents bacteremia, meningitis, and pneumonia, but NOT otitis media

23 serotypes in old vaccine for >2 years of age Reactions Erythema, swelling, tenderness, fever Contraindications Allergy to components, including diphtheria toxoid Meningococcal Site: IM Polysaccharide (Menomune) (MPSV4) Give to patients in endemic areas, immunodeficient, asplenic, or college freshmen Age range: >2 years Revaccinate in 3-5 years Conjugated (Menactra) (MCV4) Same patients as above, plus entry to middle or high school Age range: 11-55 years No current recommendation for revaccination Reactions Pain, fever, headache, malaise Contraindications Allergy to vaccine or components HIB Site: IM Conjugated Having invasive H. influenza type B at age younger than 2 years does not confer immunity, but contracting the disease over age 2 years will provide immunity Reactions Fever or soreness Contraindications None specifically General Rules Subcutaneous: MMR Varicella Polio (IM or subcutaneous) Notes Review the schedule in the Routine Childhood Immunizations handout Table 4 Table 5 General Feeding Guidelines Hold the baby

Burp after q 2 ounces\ Supplements:


Fluoride: 0.25 mg/day, use for non-fluorinated water with formula and in breast

Vitamin D: use in breast feeding Iron: use in breast feeding beginning at 4 months General Feeding Guidelines At 2 weeks, feed 3 ounces/pound/day at interval of q 3-4 hours At 2 months, feed 26-32 ounces/day At 4 months, feed no more than 40 ounces/day and can begin solids At 6 months, feed 26-32 ounces of formula/day and encourage more solids (fruits, vegetables), give sip cup At 10-11 months, introduce meats At 11-12 months, wean bottle, whole or 2% milk, no more strained food, see decreased appetite At 15 months, no bottle, no more than 24 ounces milk, see decreased appetite At 2 years and up, encourage healthy snacks and all 4 food groups General Safety Guidelines Use rear-facing car seat under 20 pounds Use front-facing car seat over 20 pounds Use seatbelt and booster seat at 40 pounds and 40 inches (usually age 4) Set water heater to 120 degrees Fahrenheit Have fire evacuation plan and change smoke detector batteries q 6 months Dont smoke, if so, do outside No toys with small parts Dont use walkers Childproof the house (outlets, cords, gates, etc.) Call poison control Toddlers may get lost, be careful Swimming lessons at age 4-5 years Watch for sex, drugs, and rock-n-roll in adolescents General Health Guidelines Position Back to Sleep Use lubricant for diaper rash Worry only if fever >101 Tylenol: 10-15 mg/kg q 4 hrs Motrin: 5-10 mg/kg q 6 hrs Use karo syrup for constipation (hard/pain) Teething starts at 4 months, give Tylenol for fever URI common: no worry fever <101 and good po intake, use vaporizer, bulb suction, saline nasal drops Flexible shoes to protect feet at 12 months Regular bedtime at 12 months General Health Guidelines (continued) Gait may be normally bow-legged until 2 years

Brush teeth at 18 months, all teeth by 2-2.5 years, go to dentist at 3 years Toilet train at 2.5 to 3 years, enuresis until 5-6 years Naps until 1st grade (and in medical school) TV: 1-2 hours/day Exercise at 4 years Talk about puberty/body changes and sex/disease/pregnancy and confidentiality to adolescentsexplain everything, eating habits, seat belts, impaired drivers General Psychosocial Guidelines Crying is normal for 2-3 hours/day or 10-15 minutes prior to sleep at 2 weeks old Colic may last from 2 weeks to 3 months of age, treat with car rides, walking and bouncing, and quiet environments Interact more with baby at 2 months At 4 months, sleep alone, use playpen At 6 months, child understands no, set limits, stranger anxiety occurs, encourage sleeping alone At 11-12 months, encourage independence and language, separation anxiety occurs At 15 months, tantrums begin, discipline by distraction, ignoring, verbal/nonverbal disapproval, time out At 18 months, says no so do no give too many choices, explores genitalia General Psychosocial Guidelines (continued) At 2 years, begins helping with self care, worries about separation At 3 years, consider daycare qualifications (enough trained staff, health regulations, etc.), nightmares and night terrors, imaginary friends until 1st grade At 4 years, better at self care, can share, give a few responsibilities At preschool, answer questions about sex and anatomy, teach manners At 6-8 years, pay attention to school and peers At 11-12 years and adolescents, talk about sex, drugs (including EtOH and tobacco), and rock-n-roll, friends, and depression General Screening Guidelines At 2 weeks, may repeat thyroid function tests, PKU tests, galactosemia tests Metabolic screen report should be in chart by 2 months Children 6 months to 6 years should be screened for lead poisoning, especially if In or around a house built before 1960 Around people who have known lead poisoning Parents are around lead Live near plants that release lead Cholesterol screening for children 2 years of age who have Parents or grandparents who have CAD or CAD studies, bypass, MI, angina, PVD, cerebrovascular incident, or sudden cardiac death before age 55 Parents or grandparents with total cholesterol >240 Unobtainable family history Risk factors such as poor diet, poor exercise, and overweight Screen for scoliosis at 11-12 years

Check pubertal changes at 11-12 years Safety and Injuries Injuries 45% deaths of 1-4 years 70% deaths of 4-19 years Motor vehicle crashes (MVC) is number 1 cause of death in all age groups Education helps Risk factors for injury Poorly supervised Poor environment Low socioeconomic status Age Sex Safety and Injuries Infants Suffocation, abuse, MVC, bath related, falls Toddlers Burns, drowning, falls, poisoning School-age Pedestrian injuries, bike injuries, MVC, burns, drowning Teens MVC, drowning, burns, intentional trauma, and work-related Safety and MVC Use of seat restraints reduces death by 70% and serious injury by 65% Always use shoulder strap or correct size car seat Car seat no longer needed at ~80 pounds and 4 feet 9 inches Teens at highest risk for MVC injury Safety and Bicycles 250 to 300 deaths per year per bike injuries

Helmets reduce brain injury by 80% and reduce middle and upper face injuries Fit: sits low on forehead, parallel to ground when head is upright, only 2 fingers under chin strap, does not shift over eyes Replace after any impact and after 5 years Safety and Pedestrians Pedestrian injuries usually occur during day, often in crosswalks

If < 5 years, may dart into traffic If <10 years, may not be competent at safely crossing street

Do not cross major street alone until over 10 years Safety and Fire Risk of fire injuries: first decade of life, low socioeconomic status, mobile homes Death by asphyxiation

Cigarettes are cause of 30-40% of fires

Teach stop, drop, roll over 3 years Safety and Burns Burn injuries usually involve tap water 40% of pediatric burns require hospitalization Use caution around stoves, pots/pans, electric cookers with cords

Trivia: Water that is 150 degrees Fahrenheit causes a full thickness burn of adult skin in about 2 seconds. Safety and Drowning Adult supervision prevents drowning Stay within reach Learn CPR Child < 5 years may not realize danger in order to call for help

Pool fences should be 5 feet high, no vertical openings over 4 inches wide Safety and Firearms Eliminate firearms from home or restrict access to firearms in the home 85% of unintentional firearm injuries occur in the home Firearms in home increase risk of adolescent suicide by 10X and adolescent homicide by 5X