PEDI PEARLS

by Dr. Rick Cortes

PHYSICAL EXAM
TECHNIQUE
Physical Exam
• You are the conductor of the orchestra…..tell the parents
what you want them to do
Physical Exam
• Examine kids in their parent’s lap when they feel
threatened
Physical Exam
• Progress from least to most invasive, so listen to the heart
and lungs first and then progress from head to toe
Heart and Lung Exam
• Listen anteriorly and posteriorly
Fontanelle Exam
• The fontanelles close by 18mo old
Ear Exam Technique
Throat Exam Tips
• To examine the child’s throat the parents need to hold the
hands and forehead
Throat Exam Tips
• If the pt is kicking with teeth clenched then parents will
also hold the legs with their legs, slide the tongue
depressor past the last molar, move to the midline and
then press down on posterior tongue
Physical Exam Tips
• Make sure to examine anterior mouth in addition to the
oropharynx
Abdominal Exam Tips
• 2 handed technique on exam table – bottom hand feels
and the top hand pushes
• Distract the pt while examining them and watch their
eyes…..if they wince or guard then they are tender
NORMAL GROWTH AND
DEVELOPMENT
Normal Weight Gain
• BW 3kg
• Regain BW by 10 days old
• Gain 1oz / day x 3 mos (2lbs / month, 1kg / mo)
• Double BW by 6mos old
• Triple BW by 1yr old
Normal Weight Gain

Age (yrs) Weight (kg)

1 10
3 15
5 20
7 25
9 30
11 35
13 45
15 55
17 65
Normal Height Growth Velocity
Age (yrs) Height (inches)
0 20
1 30 (10in of growth in 1y)
2 35 (5in of growth in 1y)
3 38 (3in of growth in 1y)
4 2.5 in / yr till pubertal growth spurt
Pubertal growth spurt Achieve adult height
Normal Development
• 2wks: baby can see well and should start social
smiling with parents
• 4mo: good head control
• 7-8mo: sit up without support
• 9mo: crawl
• 1yr: walk and talk
• 17mo: 17 word vocabulary
• 2yrs: 2 word sentences
• 4yrs: speech should be understood by strangers
WELL CHILD CARE
Checkups
• Always asses the child’s growth chart: weight, height,
head circumference up until 3yrs old, BMI
• Ask family if they have any questions or concerns about
their child
Blood Pressure
• Do annually starting at 3yrs old
Vision and Hearing Screen
• Vision screening starting at 3yrs old but realistically not
effectively done until 4yrs old for most kids
• Hearing screening done at birth and again starting at age
4yrs old
Vision, Hearing or Speech Concerns
• Refer for parental concerns regarding vision, hearing or
speech (most times)
Autism Spectrum Screening Questionnaire
• Questionnaire about speech and behavior development
given to families at times of checkups between 1-4 yrs old
Modified Checklist for Autism
• Autism screening questionnaire for toddlers around 18m
old (MCHAT) prompting parents about the child’s speech
and behavior development
 Depression Screening
• >12y old and older
• Establish confidentiality
• HEADSS (Home, Education/Employment, Activities,
Drugs, Sexuality, Suicide/Depression)
VACCINATIONS
Vaccine Nuances
• Pediarix = DTaP / IPV / HBV
• Pentacel = DTaP / IPV / Hib
• Rotateq = Rotavirus vaccine (<8mo old)
• Prevnar 13 = 13 serotypes of PCV (Pneumococcal conjugate
vaccine) (<5yrs old)
• Hib (<5yrs old)
• Proquad = MMRV (1, 4 yrs old)
• Kinrix = DTaP / IPV (4yrs old)
• Menactra = MCV4 = A,C,Y, & W-135 strains of Meningococcus
(11, 16yrs old)
• Bexsero = MCV-B (16yrs old and 1mo later)
• HPV9 = >9yrs old for boys and girls; <15y: 2doses 6mo apart;
>15y old 3doses given on day1, 2mo later and then 4m later
Checkup Schedule
• Birth HBV
• 1-2d old: Newborn screen blood test #1
• 2-3d after d/c from newborn nursery: 1st checkup
• 2wks old: Newborn screen blood test #2
• 6-8wks: DTaP, IPV, Hib, PCV, Rota, HBV
• 4mo: DTaP, IPV, Hib, PCV, Rota
• 6mo: DTaP, IPV, Hib, PCV, Rota, HBV
• 9mo:
• 1y: Hib, PCV, HepA, MMRV, Hgb/Pb, Dentist, Kid routine, ASSQ
• 15m: DTaP ASSQ
• 18m: HepA ASSQ or MCHAT
• 2y: Pb ASSQ
• 30m: ASSQ
• 3y: ASSQ
• 4y: DTaP, IPV MMRV ASSQ
Checkup Schedule
• 5y
• 6y
• 7y
• 8y
• 9y HPV—6mo!HPV#2, Cholesterol
• 10y
• 11y TdaP, MCV4
• 12y HEADSS
• 13y HEADSS
• 14y HEADSS
• 15y HPV—2mo!HPV#2—4mo!HPV#3 HEADSS
• 16y MCV4, MCV-B—1mo!MCV-B#2 HEADSS
• 17y HEADSS
• 18y Cholesterol, HIV HEADSS
Flu Shots
• Recommended for kids with Asthma, chronic diseases,
and premies
• Start vaccinating by October
• 6m – 8y: 2 doses 1mo apart for 1st flu shot only and 1
dose for all future flu seasons
• >8y: 1 dose only
Synagis (RSV)

• Recommended for kids with extreme prematurity

(<28wks), chronic lung disease, cyanotic heart disease,
neuromuscular weakness
• Passive immunization - monoclonal antibody against RSV
injected monthly during RSV season (October – March)
• Costs $1,000 per shot so each pt has to be qualified for
shot by their insurance
Morbidly Obese Kids (BMI>97%)

• HgbA1C
• Cholesterol
Anticipatory Guidance
• Given to families for kids at specific ages
• My nurse reviews items on the anticipatory guidance for
the respective age of the child with the families at the time
of the vital signs
CARSEATS
Carseats
• Rear facing till 2yrs old
• Forward facing toddler carseat 2-4yrs old
• Booster seat 4 – 8yrs old
• Regular seat belt in the vehicle when the seat belt strikes
the clavicle and not the neck
AUTISM SPECTRUM
DISORDER
Autism Spectrum Disorder
Autism Spectrum Disorder: PDD, Autism, Asperger’s,
Rett Syndrome
Deficits in speech and has repetitive behaviors like hand flapping, rocking
movements, antisocial, odd interests
Autism Spectrum Disorder
• W/U rarely indicated: Chromosomes including Fragile X
screen, Pb level, EEG PRN, MRI
PRN, metabolic testing
• Tx: Applied Behavioral Analysis (OT, ST, Behavioral
Therapy all at one location)
• Meds: Aggressive: Risperdal, Abilify, atypical
neuroleptics
• Anxious or depressed: SSRI’s
• Insomnia: Melatonin
• Music therapy
• Antipsychotics Med Labs: CBC, CMP, cholesterol,
HgbA1C
ADHD
ADHD - Diagnosis
• Inattention and / or hyperactivity that interferes with
school performance
ADHD- Diagnosis
• Diagnosis: Vanderbilt forms for parents and teachers
ADHD – Rules of Thumb
• Start low dose and then titrate the dose to the desired
effect
• Follow up 1 month after making medication changes
ADHD – Treatment Options <6y old
• Short acting medications: CHEAP
• Ritalin
• Focalin
• Methylin (liquid)
• Adderall
• Evekeo
• Procentra (liquid)
• Zenzedi
ADHD – Treatment Options >6y old
• Long acting medications: EXPENSIVE
• Vyvanse – lasts 13hrs, prodrug
• Focalin XR – lasts 8-12 hours
• Concerta – swallow pill only, lasts 12 hrs, fewer side effects
Focalin XR vs. Concerta
ADHD – Treatment Options >6y old
• Adderall XR – lasts 8-12hrs, hyper kids
• Daytrana Patches – med delivered through a patch
• Quillivant XR – liquid 12hr methylphenidate
• Dyanavel XR – extended release liquid amphetamine
• Quillichew ER – only comes in 20,30, & 40mg
• Adzenys XR-ODT – ODT delivery
• Cotempla XR-ODT – 60% of med peaks w/i 1hr and lasts 12hrs
• Aptensio XR – 40% initial release and 60% delayed release at
the end of school, lasts 12hrs
• Jornay PM – give @8pm; helps pts wake up ready for the day;
bead technology; don’t chew or crush; applesauce ok to sprinkle
and swallow without chewing
ADHD - >13yrs old
• Mydayis – Triple bead technology; for rapid metabolizer
ADHD - Insomnia
• Clonidine
• Trazodone
• Remeron
• Klonipin
ADHD – Alternatives or adjuncts
• Intuniv
• Tenex
• Dyslexia can be a comorbid condition
• Consider psychological testing if max doses of
medications not helping to screen for anxiety or
depression
ADHD – Monitoring Medication
• Follow up in 1 month after med changes
• Follow growth chart and reassess med q 6mo once
maintenance dose achieved
• My office policy is to do CBC q 1yr
Kids do the funniest things

The End
The End