Pediatric Board Study Guide: A Last Minute Review

© Springer International Publishing Switzerland 2015

Osama Naga (ed.)Pediatric Board Study Guide10.1007/978-3-319-10115-6_1

General Pediatrics

Osama Naga¹  

(1)

Pediatric Department, Paul L Foster School of Medicine, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, Tx 79905, USA

Osama Naga

Email: [email protected]

Keywords

GrowthMacrocephalyMicrocephalyPlagiocephalyImmunizationNewborn screeningWell child visitBreast feedingFormula feedingInfantile colicLanguage developmentLimb pain

Growth

Background

Growth is affected by maternal nutrition and uterine size .

Genetic growth potential is inherited from parents and also depends on nutrition throughout childhood.

Growth is affected by growth hormone (GH), thyroid hormone, insulin, and sex hormones, all of which have varying influence at different stages of growth.

Deviation from normal expected patterns of growth often can be the first indication of an underlying disorder.

Carefully documented growth charts serve as powerful tools for monitoring the overall health and well-being of patients.

Key to diagnosing abnormal growth is the understanding of normal growth, which can be classified into four primary areas: fetal, postnatal/infant, childhood, and pubertal.

Weight

Healthy term infants may lose up to 10 % of birth weight within the first 10 days after birth.

Newborns quickly regain this weight by 2 weeks of age.

Infants gain 20–30 g/day for the first 3 postnatal months.

Birth weight doubles at 4 months.

Birth weight triples by 1 year of age.

Height

Height of a newborn increases by 50 % within 1 year.

Height of a newborn doubles within 3–4 years.

After 2 years the height increases by average 5 cm/year.

Measurements

Length or supine height should be measured in infants and toddlers < 2 years.

Standing heights should be used if age > 2 years.

Plot gestational age for preterm infants rather than chronological age.

Specific growth charts are available for special populations, e.g., Trisomy 21, Turner syndrome , Klinefelter syndrome , and achondroplasia .

Growth curve reading

Shifts across two or more percentile lines may indicate an abnormality in growth.

Shifts on the growth curve toward a child’s genetic potential between 6 and 18 months of age are common.

Small infants born to a tall parents begin catch-up growth around 6 months of age.

Weight is affected first in malnourished cases, chronic disease, and malabsorption, or neglect.

Primary linear growth problems often have some congenital, genetic, or endocrine abnormality (see chapter Endocrine Disorders) .

Macrocephaly

Definition

Head circumference (HC) 2 standard deviations above the mean

Causes

Hydrocephalus

Enlargement of subarachnoid space (familial with autosomal dominant inheritance)

Achondroplasia (skeletal dysplasia)

Sotos syndrome Cerebral Gigantism

Alexander’s disease

Canavan’s disease

Gangliosidosis

Glutaric aciduria type I

Neurofibromatosis type I

Familial macrocephaly

It is a benign cause of macrocephaly.

It is autosomal dominant and usually seen in the father.

Infants are usually born with a large head but within normal range at birth.

The head circumference as the infants grow usually exceeds or is parallel to 98th percentile.

Head computed tomography (CT) usually shows enlarged subarachnoid space.

Head CT may show minimal increase in the ventricles, widening in sulci, and sylvian fissure.

Genetic megalocephaly

Similar to familial macrocephaly except the CT is normal

Diagnosis

Head ultrasound is the study of choice.

Head CT scan.

Management

Hydrocephalus and macrocephaly present with enlargement of head circumference; careful attention should be given specially to the preterm babies who may have hydrocephalus.

Plot the gestational age on growth chart for preterm babies instead of chronological age.

Infants born with microcephaly usually have their head circumference (HC) catch up faster than length and weight; abnormal growth pattern may indicate hydrocephalus.

Microcephaly

Definition

Head circumference 2 standard deviation below the mean .

Causes

Trisomy 13, 18 (Edward syndrome) and 21 (Down syndrome)

Cornelia de Lange

Rubinstein–Taybi

Smith–Lemli–Opitz

Prader–Willi syndrome

Teratogen exposure

Fetal alcohol syndrome

Radiation exposure in utero ( 15 weeks gestation)

Fetal hydantoin

TORCH: Toxoplasmosis, Other infections, Rubella, Cytomegalovirus, Herpes simplex virus congenital infection

Meningitis or encephalitis

Gestational diabetes

Maternal hyperphenylalaninemia

Hypoxic-ischemic encephalopathy

Diagnosis

Maternal phenylalanine level

Karyotype of child for suspected congenital abnormality

Head imaging (Head ultrasound, Head CT, or Head MRI)

Amino acid analysis (plasma and urine)

TORCH virus serum titers (mother and child)

Urine culture for cytomegalovirus

Plagiocephaly

Background

Deformational flattening from lack of changes in head positions is the most common cause of asymmetric head shape .

Causes

Positional or supine sleeping is the most common cause of plagiocephaly.

Craniosynostosis .

Craniosynostosis

If one suture is involved, it is usually isolated, and sagittal suture involvement is the most common.

If more than one suture is involved, it is usually associated with genetic disorders.

Posterior plagiocephaly (positional) (Table  1 )

Table 1

Difference between deformational plagiocephaly and unilambdoid synostosis

Anterior displacement of the occiput and the frontal region on the same side (Parallelogram).

Ear position is more anterior on the side of flattening in positional plagiocephaly.

Diagnosis

Plain film or CT scan if craniosynostosis is suspected

Treatment

Observation; usually resolve in 2–4 months.

Keep the wakeful baby in prone position.

Helmet may be beneficial in severe cases of posterior plagiocephaly. It requires 22 h/day and gives best result if used before 6 months.

Treatment of synostosis with surgery between 6 and 12 months .

Developmental Milestones

Newborn

Able to fixate face on light

Visual preference for human face

Regarding a face (shortly after birth)

Responds to visual threats by blinking and visually fixes

Visual acuity is 20/400

Moro, stepping, placing, and grasp reflexes are all active

1 month

Chin up in prone position

Head lifted momentarily to plane of body on ventral suspension

Hands fisted near face

Watches a person

Follows objects momentarily

Startles to voice/sound

Begins to smile

2 months

Chest up in prone position

Holds head steady while sitting

Hands unfisted 50 %

Follows moving object 180°

Able to fixate on face and follow it briefly

Stares momentarily at spot where object disappeared

Listens to voice and coos

Smiles on social contact (reciprocal smiling)

3 months

Props on forearm in prone position

Rolls to side

Brings hands together in midline and to mouth (self discovery of hands)

Follows object in circle in supine position

Regards speaker

Chuckles and vocalizes when talked to

4 months

Sits with trunk support

No head lag when pulled to sit

Rolls from front to back

Lifts head and chest

When held erect pushes with feet

Reaches toward object and waves at toy

Grasps an object and brings to mouth

Plays with rattle

Laughs out loudly

Excited at sight of food

Smiles spontaneously at pleasurable sight/sound

May show displeasure if social contact is broken

Asymmetric tonic reflex gone

Palmar grasp gone

6 months

Sits momentarily propped on hands

Turns from back to the front

Transfers hand-hand

Bangs and shakes toys

Rakes pellets

Removes cloth on face

Stranger anxiety (familiar versus unfamiliar people)

Stops momentarily to no

Gestures for up

Begins to make babbling

Listens then vocalizes when adult stops

Imitates sounds

Smiles/Vocalizes to mirror

7 months

Sits without support steadily

Puts arms out to side for balance

Radial palmar grasp

Refuses excess food

Explores different aspects of toy and observe cube in each hand

Finds partial hidden objects

Looks from object to parents and back when wanting help

Looks toward familiar object when named

Attends to music

Prefers mother

9 months

Stands on feet and hands

Begins creeping

Pulls to stand

Bears walks

Radial-digital grasps of cube

Bangs two cubes together

Bites, chews cookie

Inspects and rings bell

Pulls string to obtain ring

Uses sound to get attention

Separation anxiety

Follows a point oh look at…

Orients to name well

Says mama nonspecific

12 months

Stands well with arms high, leg splayed

Independent steps

Scribbles after demonstration

Fine pincer grasp of pellet

Cooperates with dressing

Lifts box lid and finds toy

Shows parents object to share interest

Says mama and dada

Follows one-step command with gesture

Points to get desired object (proto-imperative pointing) and to share interest

14 months

Walks well

Stands without pulling

Imitates back and forth scribbling

Puts round pig in and out of hole

Can remove hat and socks

Puts spoon in mouth (turn over)

Follows one step commands without gesture

Functional vocabulary of 4–5 words in addition to mama and dada

15 months

Stoops to pick up a toy

Runs stiff-legged

Builds three- to four-cube tower

Climbs on furniture

Drinks from a cup

Releases pellet into bottle

Uses spoon with some spilling

Turns pages in book

Points to one body part

Hugs adult in reciprocation

Gets object from another room upon demand

Uses 3–5 words

Mature jargoning with real words

18 months

Runs well

Creeps downstairs

Throws a ball while standing

Makes four-cube tower

Able to remove loose garments

Matches pairs of objects

Passes M-CHAT

Begins to show shame (when they do wrong)

Points to two of three objects when named and three body parts

Understands mine

Points to familiar people with name

Uses 10–25 words

Uses giant words (all gone; stop that)

Imitates animal sounds

24 months

Walks down stairs holding rail, both feet on each step

Kicks ball without demonstration

Throws a ball overhead

Takes off clothes without button

Imitates circle

Imitates horizontal line

Builds a tower of four cubes

Opens door using knob

Follows two-step command

Points to 5–10 pictures

Uses two-word sentence

Uses 50 + words

50 % language intelligibility

3 years

Balances on one foot for 3 s

Goes upstairs alternating feet, no rails

Pedals tricycle

Copies circle

Puts on shoes without laces

Draws a two- to three-part person

Knows own gender and age

Matchs letter/numeral

Uses 200 + words

Uses three-word sentences

75 % language intelligibility

4 years

Balances on one foot for 4–8 s

Hops on one foot 2–3 times

Copies square

Goes to toilet alone

Wipes after bowel movement

Draws a four- to six-part person

Group play

Follows three-step commands

Tells stories

Speaks clearly in sentences

Says four to five-word sentences

Understands four prepositions

100 % intelligibility

5 years

Walks down stairs with rail, alternating feet

Skipping

Balances one foot for > 8 s

Walks backward heel-toe

Copies triangle

Cuts with scissors

Builds stairs from model

Draws eight- to ten-part person

Names ten color and count to ten

Plays board or card games

Apologizes for mistakes

Knows right and left on self

Repeats six- to eight-word sentence

Responds to why questions

6 years

Tandem walk

Builds stairs from memory

Can draw a diamond shape

Writes first and last name

Combs hair

Looks both ways at street

Draws 12- to 14-part person

Have best friend of same sex

Asks what unfamiliar word means

Repeats eight- to ten-word sentences

Knows days of the week

10,000 word vocabulary

7 years

Ability to repeat five digits

Can repeat three digits backward

Can draw a person that has 18–22 parts

Key Points to Developmental Milestones

Reflexes

Moro is absent around 3–4 months of age

Palmar grasp absent around 2–3 months of age

Parachute starts around 6–9 months of age

Following objects

1 month: follows to midline

2 months: follows past midline

3 months: follows 180°

4 months: circular tracking 360°

Speech intelligibility

50 % intelligible at 2 years

75 % intelligible at 3 years

100 % intelligible at 4 years

Language: receptive

Newborn

Alerts to sound

4 months

Orients head to direction of a voice

8 months

Responds to come here

9 months

Enjoys gesture game

10 months

Enjoys Peek-a-boo

12 months

Follows one-step command with a gesture

15 months

Follows one-step command without a gesture

Language: expressive

Coos

2 months (2–4 months)

Laughs out loud

4 months

Babbles

6 months

Mama or dada nonspecific

9 months

Mama and dada specific

12 months

Vocabulary of 10–25 words

18 months

Two-word sentences

2 years (18–24 months)

Three-word sentences

3 years (2–3 years)

Four-word sentences

4 years (3–4 years)

Drawing

Scribbles

15 months

Circle

3 years

Cross

4 years

Square

4.5 years

Triangle

5 years

Diamond

6 years

Social skills

Reciprocal smiling

2 months

Follows person who is moving across the room

3 months

Smiles spontaneously at pleasurable sight/sound

4 months

Recognizes caregiver socially

5 months

Stranger anxiety

6 months

Separation anxiety and follows point oh look at

9 months

Waves bye-bye back

10 months

Shows objects to parents to share interests

12 months

Parallel play

2 years

Reduction in separation anxiety

28 months

Cooperative play

3–4 years

Ties shoelaces

5 years

Distinguishes fantasy from reality

6 years

Blocks

Passes cubes

More than 6 months

Bangs cubes

9 months

Block in a cup

12 months

Tower three blocks

15 months

Tower four blocks

18 months

Tower six blocks

24 months

Bridge from blocks

3 years

Gate from blocks

4 years

Steps from blocks

5 years

Catching objects

Rakes

5–6 months

Radial-palmar grasp

7–8 months

Inferior pincer

10 months

Fine pincer

12 months

Walking and running

Independent steps

12 months

Walks well

14 months

Runs stiff-legged

15 months

Walks backwards

16 months

Runs well

18 months

Kicks ball without demonstration

2 years

Skips and walks backward heel-toe

5 years

Climbing stairs

Creeps up stairs

15 months

Creeps down stairs

18 months

Walks down stairs holding rail, both feet on each step

2 years

Goes up stairs alternating feet, no rail

3 years

Walks down stairs with rail alternating feet

5 years

Red flags at 2 months of age

Does not respond to loud sounds

Does not watch things as they move

Does not smile at people

Does not bring hands to mouth

Cannot hold head up when pushing up when on tummy

Red flags at 4 months of age

Does not watch things as they move

Does not smile at people

Cannot hold head steady

Does not coo or make sounds

Does not bring things to mouth

Does not push down with legs when feet are placed on a hard surface

Has trouble moving one or both eyes in all directions

Red flags at 6 months of age

Does not try to get things that are in reach

Shows no affection for caregivers

Does not respond to sounds around them

Has difficulty getting things to mouth

Does not make vowel sounds (ah, eh, oh)

Does not roll over in either direction

Does not laugh or make squealing sounds

Seems very stiff, with tight muscles

Seems very floppy, like a rag doll

Red flags at 9 months of age

Does not bear weight on legs with support

Does not sit with help

Does not babble (mama, baba, dada).

Does not play any games involving back-and-forth play

Does not respond to own name

Does not seem to recognize familiar people

Does not look where you point

Does not transfer toys from one hand to the other

Red flags at 1 year of age

Does not crawl

Cannot stand when supported

Does not search for things that they see you hide

Does not say single words like mama or dada

Does not learn gestures like waving or shaking head

Does not point to things

Lose skills they once had

Red flags at 18 months of age

Does not point to show things to others

Cannot walk

Does not know what familiar things are for

Does not copy others

Does not gain new words

Does not have at least six words

Does not notice or mind when a caregiver leaves or returns

Loses skills they once had

Red flags at 2 years of age

Does not use two-word phrases (e.g., drink milk)

Does not know what to do with common things, like a brush, phone, fork, spoon

Does not copy actions and words

Does not follow simple instructions

Does not walk steadily

Loses skills they once had

Red flags at 3 years of age

Falls down a lot or have trouble with stairs

Drools or have very unclear speech

Cannot work simple toys (such as peg boards, simple puzzles, turning handle)

Does not speak in sentences

Does not understand simple instructions

Does not play, pretend, or make-believe

Does not want to play with other children or with toys

Does not make eye contact

Loses skills they once had

Red flags at 4 years of age

Cannot jump in place

Has trouble scribbling

Shows no interest in interactive games or make-believe

Ignores other children or do not respond to people outside the family

Resist dressing, sleeping, and using the toilet

Cannot retell a favorite story

Does not follow three-part commands

Does not understand same and different

Does not use me and you correctly

Speaks unclearly

Loses skills they once had

Red flags at 5 years of age

Does not show a wide range of emotions

Shows extreme behavior (unusually fearful, aggressive, shy, or sad)

Unusually withdrawn and not active

Is easily distracted, has trouble focusing on one activity for more than 5 min

Does not respond to people, or responds only superficially

Cannot tell what is real and what is make-believe

Does not play a variety of games and activities

Cannot give first and last name

Does not use plurals or past tense properly

Does not talk about daily activities or experiences

Does not draw pictures

Cannot brush teeth, wash and dry hands, or get undressed without help

Loses skills they once had

Language Development

Background

It is critical for pediatrician to know language development and possible causes of language delay (Table 2)

Table 2

Cognitive red flags

Cause of language developmental delay

Hearing impairment

Intellectual disability

Autism

Specific language disorders

Dysarthria

Dyspraxia

Maturation delay

Neglect

Immunizations

Table 3

Immunization schedule

a Hib dose at 6 months is not required if using PedvaxHib or COMVAX

bDose at 6 months is not required if using Rotarix,

c Influenza every year beginning at 6 months

Hepatitis B Vaccine

Hepatitis B vaccine (HepB) at birth

Administer to all newborn before hospital discharge .

If mother is hepatitis B surface antigen positive (HBsAg)-positive, administer HepB and 0.5 mL of hepatitis B immunoglobulin (HBIG) within 12 h of birth.

If mother’s HBsAg status is unknown, administer HepB within 12 h of birth and determine mother’s HBsAg status as soon as possible and if HBsAg-positive, administer HBIG (not later than 1 week).

Infant born to HBsAg-positive mother should be tested for HBsAg and antibodies to HBsAg 1 to 2 months after completing the three doses of HepB series (on the next well-visit).

Doses following birth dose (Table 3)

Administer the second dose 1-2 months after the first dose (minimum interval of 4 weeks).

Administration of 4 doses of HepB is permissible if combination is used after birth dose.

The final third or fourth dose in HepB series should not be administered before 6 months of age.

Catch-up vaccination

Unvaccinated person should complete a three-dose series.

Rotavirus Vaccine

Minimum age is 6 weeks

If Rotarix is used administer a 2-dose series at 2 and 4 months of age.

If RotaTeq is used, administer a 3-dose series at age 2, 4, and 6 months.

Catch-up vaccination

The maximum age for the first dose in the series is 14 weeks, 6 days; vaccination should not be initiated in infants of age 15 weeks, 0 days or older.

The maximum age for the final dose is 8 months, 0 days.

DTaP/Tdap Vaccine

DTaP

Composition: Diphtheria toxoid, tetanus toxoid, and acellular pertussis

Administration

DTaP given to children of more than 6 weeks and less than 7 years of age.

Five-dose series DTaP vaccine at age 2, 4, 6, 15 through 18 months, and 4 through 6 years.

The fourth dose may be administered as early as 12 months, provided at least 6 months from the third dose.

Catch-up vaccination

The fifth dose of DTaP vaccine is not necessary if the fourth dose was administered at age 4 years or older.

Tdap

Composition

Similar to DTaP but contain smaller amount of pertussis antigen

Administration

Administer one dose of Tdap vaccine to all adolescents aged 11 through 12 years. Administer one dose of Tdap to pregnant adolescents during each pregnancy (preferred during 27 through 36 weeks gestation) regardless of time since prior Td or Tdap vaccination.

Catch-up vaccination (Fig. 2)

Person aged 7 years and older who are not fully immunized with DTaP vaccine should receive Tdap vaccine as one dose in the catch-up series; if additional doses needed, use Td.

For those children between 7 and 10 years who receive a dose of Tdap as part of catch-up series, an adolescent Tdap vaccine dose at age 11 through 12 years should NOT be administered. Td should be administered instead 10 years after Tdap dose.

Absolute contraindication

History of encephalopathy within 7 days of dosing

Relative contraindication

History of fever > 40.5 °C (105 °F) within 48 h after prior dose

Seizure within 3 days

Shock like condition within 2 days

Persistent crying for more than 3 h within 2 days

Vaccination may be administered under these conditions

Fever of < 105 °F (< 40.5 °C), fussiness, or mild drowsiness after a previous dose of DTaP

Family history of seizures

Family history of sudden infant death syndrome

Family history of an adverse event after DTaP administration

Stable neurologic conditions (e.g., cerebral palsy , well-controlled seizures, or developmental delay)

Haemophilus Influenzae Type b Conjugate Vaccine (Hib)

Background

Hib vaccine prevent invasive bacterial infections usually caused by H. influenzae type b.

Before the advent of an effective type b conjugate vaccine in 1988, H. influenzae type b was a major cause of

serious disease among children in all countries, e.g., meningitis, epiglottitis.

Routine vaccination of HIB (Fig. 1)

Administer a 2- or 3-dose Hib vaccine primary series and a booster dose (dose 3 or 4 depending on vaccine used in primary series) at age 12 through 15 months to complete a full Hib vaccine series.

The primary series with ActHIB, MenHibrix, or Pentacel consists of 3 doses and should be administered at 2, 4, and 6 months of age.

The primary series with PedvaxHib or COMVAX consists of 2 doses and should be administered at 2 and 4 months of age; a dose at age 6 months is not indicated.

One booster dose (dose 3 or 4 depending on vaccine used in primary series) of any Hib vaccine should be administered at age 12 through 15 months.

An exception is Hiberix vaccine. Hiberix should only be used for the booster (final) dose in children aged 12 months through 4 years who have received at least one prior dose of Hib-containing vaccine.

Catch-up vaccination

If dose 1 was administered at ages 12 through 14 months, administer a second (final) dose at least 8 weeks after dose 1, regardless of Hib vaccine used in the primary series.

If the first 2 doses were PRP-OMP (PedvaxHIB or COMVAX), and were administered at age 11 months or younger, the third (and final) dose should be administered at age 12 through 15 months and at least 8 weeks after the second dose.

If the first dose was administered at age 7 through 11 months, administer the second dose at least 4 weeks later and a third (and final) dose at age 12 through 15 months or 8 weeks after second dose, whichever is later, regardless of Hib vaccine used for first dose.

If first dose is administered at younger than 12 months of age and second dose is given between 12 through 14 months of age, a third (and final) dose should be given 8 weeks later.

For unvaccinated children aged 15 months or older, administer only 1 dose.

Important to know

Do not immunize immunocompetent children > 5 years of age even if they never had HIB vaccine.

Vaccinate children with functional/anatomical asplenia, e.g., patient with sickle cell anemia or AIDS at any age even if > 5 years old.

Vaccinate children < 24 months of age who have had invasive H. influenzae because they may fail to develop natural immunity following natural infection.

Pneumococcal Vaccine

Routine vaccination with PCV13

Administer a 4-dose series of PCV13 vaccine at ages 2, 4, and 6 months and at age 12 through 15 months.

For children of ages 14 through 59 months who have received an age-appropriate series of 7-valent PCV (PCV7), administer a single supplemental dose of 13-valent PCV (PCV13).

Minimum age is 6 weeks

Minimum age for pneumococcal polysaccharide vaccine (PPSV23) is 2 years

PCV is recommended for all children younger than 5 years

Catch-up vaccination with PCV13

Administer 1 dose of PCV13 to all healthy children aged 24 through 59 months who are not completely vaccinated for their age.

Vaccination of persons with high-risk conditions with PCV13 and PPSV23

All recommended PCV13 doses should be administered prior to PPSV23 vaccination if possible.

For children 2 through 5 years of age with conditions such as: chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including asthma if treated with high dose oral corticosteroid therapy); diabetes mellitus, anatomic, or functional asplenia; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated with treatment with immunosuppressive drugs or radiation therapy, e.g., malignant neoplasms and leukemias.

For children aged 6 through 18 years who have, e.g., cerebrospinal fluid leak; cochlear implant; sickle cell disease and other hemoglobinopathies; anatomic or functional asplenia.

Inactivated Poliovirus Vaccine (IPV)

Routine vaccination

Administer a 4-dose series of IPV at ages 2, 4, 6 through 18 months, and 4 through 6 years.

The final dose in the series should be administered on or after the fourth birthday and at least 6 months after the previous dose.

Catch-up vaccination

Minimum age: 6 weeks

In the first 6 months of life, minimum age and minimum intervals are only recommended if the person is at risk for imminent exposure to circulating poliovirus (i.e., travel to a polio-endemic region or during an outbreak).

If 4 or more doses are administered before age 4 years, an additional dose should be administered at age 4 through 6 years and at least 6 months after the previous dose.

A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6 months after the previous dose.

If both OPV and IPV were administered as part of a series, a total of four doses should be administered, regardless of the child’s current age. IPV is not routinely recommended for the USA residents aged 18 years or older.

Oral Poliovirus Vaccine

Background

It is a live oral vaccine (Table 4).

Not used in the USA anymore.

Contraindication

Children with immunodeficiency

Children who live with adult HIV-infected or immunocompromised

Measles, Mumps, and Rubella (MMR) Vaccine

Background

MMR is a combination of three attenuated live viruses.

It is not contraindicated in children with egg allergy.

Routine vaccination

Administer a 2-dose series of MMR vaccine at ages 12 through 15 months and 4 through 6 years. The second dose may be administered before age 4 years, provided at least 4 weeks have elapsed since the first dose.

Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the USA for international travel. These children should be revaccinated with 2 doses of MMR vaccine, the first at age 12 through 15 months (12 months if the child remains in an area where disease risk is high), and the second dose at least 4 weeks later.

Administer 2 doses of MMR vaccine to children aged 12 months and older before departure from the USA for international travel. The first dose should be administered on or after age 12 months and the second dose at least 4 weeks later.

Catch-up vaccination

Ensure that all school-aged children and adolescents have had 2 doses of MMR vaccine; the minimum interval between the 2 doses is 4 weeks.

Contraindication

Anaphylactic reaction to neomycin or gelatin

Pregnancy however, it is not an indication for abortion

Immunodeficiency, e.g., AIDS, however HIV infected children can receive MMR

Vaccination may be administered under these conditions

Positive tuberculin skin test

Simultaneous tuberculin skin testing

Breastfeeding

Pregnancy of recipient’s mother or other close or household contact

Recipient is female of childbearing age

Immunodeficient family member or household contact

Asymptomatic or mildly symptomatic HIV infection

Allergy to eggs

Varicella

Background

Live attenuated virus vaccine contain small amount of neomycin and gelatin.

Two doses are recommended.

Minimum age is 12 months, second dose at 4–6 years.

Combination with MMR vaccine is now available.

Routine vaccination

Administer a 2-dose series of VAR vaccine at ages 12 through 15 months and 4 through 6 years.

The second dose may be administered before age 4 years, provided at least 3 months have elapsed since the first dose.

If the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid.

Contraindication

Immunocompromised children

Pregnant women

Vaccination may be administered under these conditions

Pregnancy of recipient’s mother or other close or household contact.

Immunodeficient family member or household contact.

Asymptomatic or mildly symptomatic HIV infection.

Humoral immunodeficiency (e.g., agammaglobulinemia).

Children with HIV, or who live with immune compromised adult can take the vaccine.

Vaccine can be given to children who live with pregnant women.

Hepatitis A (HepA) Vaccine

Routine vaccination

Initiate the 2-dose Hep A vaccine series at 12 through 23 months; separate the 2 doses by 6–18 months .

Children who have received 1 dose of Hep A vaccine before age 24 months should receive a second dose 6–18 months after the first dose.

For any person aged 2 years and older who has not already received the HepA vaccine series, 2 doses of HepA vaccine separated by 6–18 months may be administered if immunity against hepatitis A virus infection is desired.

Catch-up vaccination

The minimum interval between the two doses is 6 months.

Special populations

Administer 2 doses of Hep A vaccine at least 6 months apart to previously unvaccinated persons who live in areas where vaccination programs target older children, or who are at increased risk for infection, e.g., persons traveling to or working in countries that have high or intermediate endemicity of infection; men having sex with men; users of injection and non injection illicit drugs; persons who work with HAV-infected primates or with HAV in a research laboratory

Meningococcal Conjugate Vaccines

Background

Called MVC4 or meningococcal conjugate vaccine, quadrivalent

Indications

All children 11–12 years of age routinely

Routine vaccination:

Administer a single dose of Menactra or Menveo vaccine at age 11 through 12 years, with a booster dose at age 16 years.

Adolescents aged 11 through 18 years with human immunodeficiency virus (HIV) infection should receive a 2-dose primary series of Menactra or Menveo with at least 8 weeks between doses.

For children aged 2 months through 18 years with high-risk conditions, see below.

Catch-up vaccination

Administer Menactra or Menveo vaccine at age 13 through 18 years if not previously vaccinated.

If the first dose is administered at age 13 through 15 years, a booster dose should be administered at age 16 through 18 years with a minimum interval of at least 8 weeks between doses.

If the first dose is administered at age 16 years or older, a booster dose is not needed.

Vaccination of persons with high-risk conditions and other persons at increased risk of disease

Children with anatomic or functional asplenia (including sickle cell disease):

For children younger than 19 months of age, administer a 4-dose infant series of MenHibrix or Menveo at 2, 4, 6, and 12 through 15 months of age.

For children aged 19 through 23 months who have not completed a series of MenHibrix or Menveo, administer 2 primary doses of Menveo at least 3 months apart.

For children aged 24 months and older who have not received a complete series of MenHibrix or Menveo or Menactra, administer 2 primary doses of either Menactra or Menveo at least 2 months apart. If Menactra is administered to a child with asplenia (including sickle cell disease), do not administer Menactra until 2 years of age and at least 4 weeks after the completion of all PCV13 doses.

Children with persistent complement component deficiency

For children younger than 19 months of age, administer a 4-dose infant series of either MenHibrix or Menveo at 2, 4, 6, and 12 through 15 months of age.

For children 7 through 23 months who have not initiated vaccination, two options exist depending on age and vaccine brand:

For children who initiate vaccination with Menveo at 7 months through 23 months of age, a 2-dose series should be administered with the second dose after 12 months of age and at least 3 months after the first dose.

For children aged 24 months and older who have not received a complete series of MenHibrix, Menveo, or Menactra, administer 2 primary doses of either Menactra or Menveo at least 2 months apart.

For children who initiate vaccination with Menactra at 9 months through 23 months of age, a 2-dose series of Menactra should be administered at least 3 months apart.

For children who travel to or reside in countries in which meningococcal disease is hyperendemic or epidemic, including countries in the African meningitis belt or the Hajj, administer an age-appropriate formulation and series of Menactra or Menveo for protection against serogroups A and W meningococcal disease. Prior receipt of MenHibrix is not sufficient for children traveling to the meningitis belt or the Hajj because it does not contain serogroups A or W.

For children at risk during a community outbreak attributable to a vaccine serogroup, administer or complete an age- and formulation-appropriate series of MenHibrix, Menactra, or Menveo.

Catch-up recommendations for persons with high-risk conditions

If MenHibrix is administered to achieve protection against meningococcal disease, a complete age-appropriate series of MenHibrix should be administered.

If the first dose of MenHibrix is given at or after 12 months of age, a total of 2 doses should be given at least 8 weeks apart to ensure protection against serogroups C and Y meningococcal disease.

For children who initiate vaccination with Menveo at 7 months through 9 months of age, a 2-dose series should be administered with the second dose after 12 months of age and at least 3 months after the first dose.

Human Papillomavirus (HPV) Vaccines

Background

Prevent cervical cancer, precancerous genital lesions, and genital wart due to HPV type 6, 11, 16, and 18

Routine vaccination

Administer a 3-dose series of HPV vaccine on a schedule of 0, 1–2, and 6 months to all adolescents aged 11 through 12 years. Either HPV4 or HPV2 may be used for females, and only HPV4 may be used for males.

The vaccine series may be started at age 9 years.

Administer the second dose 1–2 months after the first dose (minimum interval of 4 weeks), administer the third dose 24 weeks after the first dose and 16 weeks after the second dose (minimum interval of 12 weeks).

Catch-up vaccination

Administer the vaccine series to females (either HPV2 or HPV4) and males (HPV4) at age 13 through 18 years if not previously vaccinated.

Use recommended routine dosing intervals (see above) for vaccine series catch-up.

Table 4

Methods of vaccine administration

Anaphylaxis and Vaccinations

Egg: Influenza and yellow fever vaccines

Egg allergy is no longer a contraindication to influenza vaccine.

Most egg allergic patients can safely receive influenza.

Individuals with a history of severe (life threatening) allergy to eating eggs should consult with a specialist with expertise in allergy prior to receiving influenza vaccine . Egg anaphylaxis is a contraindication to give influenza vaccine

Gelatin: MMR, varicella

Streptomycin, neomycin: IPV and OPV

Neomycin: MMR, varicella

Common Adverse Reaction of Vaccines

Low grade fever

Local reaction and tenderness

General Conditions Commonly Misperceived as a Contraindications (i.e., Vaccination May Be Administered Under These Conditions)

Mild acute illness with or without fever

Mild-to-moderate local reaction (i.e., swelling, redness, soreness); low-grade or moderate fever after previous dose

Lack of previous physical examination in well-appearing person

Current antimicrobial therapy

Convalescent phase of illness

Preterm birth (hepatitis B vaccine is an exception in certain circumstances)

Recent exposure to an infectious disease

History of penicillin allergy, other non vaccine allergies, relatives with allergies, or receiving allergen extract immunotherapy

Positive PPD test

Active tuberculosis

Special Considerations

If PPD not given with MMR at the same day, PPD test should wait for 4–6 weeks (MMR may alter result if not done on the same day)

Fig. 1

Recommended immunization schedule for persons aged 0 through 18 years—USA, 2014

Fig. 2

Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are more than 1 month behind—USA, 2014

Screening

Newborn Screening

All states screen for:

Congenital hypothyroidism

Phenylketonuria

Other state added more diseases, e.g., metabolic and hemoglobinopathies

Vision Screening

Background

Early detection of ocular conditions can allow for assessment and treatment of a vision-threatening or life-threatening condition.

Any parental concern raised by suspicion of a white pupil reflex should be referred urgently.

If there is ever any concern regarding a child’s red reflex status, the most prudent action is to refer the patient for a complete ocular examination.

The neonate can have intermittent strabismus with either an eso- or exodeviation of the eyes (eyes turned in or out), which should resolve by 2–4 months.

Concerning conditions

Corneal opacities

Cataracts

Glaucoma

Persistent fetal vasculature

Retinoblastoma

Congenital ptosis

Capillary hemangiomas causing mechanical ptosis

Strabismus

Refractive errors such as high hyperopia (farsightedness)

High myopia (nearsightedness)

Astigmatism

Anisometropia (significant difference between the refractive errors between the eyes)

Cover and uncover test

Child should be looking at an object 10 ft away

Movement in the uncovered eye when the opposite is covered or uncovered suggest potential strabismus

Patient should referred if strabismus or amblyopia is suspected

Vision assessment

Allen figures, HOTV letters, tumbling Es, or Snellen chart

Evaluation

History

Examine outer structure of the eye and red reflex before the newborn leaves the nursery

Vision assessment; e.g., fix and follow

Ocular motility

Pupil examination

Ophthalmoscopic and red reflex evaluation

Indication for referral of newborn

Abnormal red reflex requires urgent referral

History of retinoblastoma in parents or sibling

Persistent strabismus

Indication for referral (1 month to 3 years)

Poor tracking by 3 months

Persistent eye deviation or strabismus at any time

Occasional strabismus or eye deviation beyond 4 months of age

Abnormal red reflex at any time

Chronic tearing or discharge

Indication for referral (3–5 year)

Strabismus

Chronic tearing or discharge

Fail vision screen; cannot read 20/40 with one eye or both or two line difference between eyes

Uncooperative after two attempt

Fail photo-screening

Indication for referral > 5 years of age

Cannot read at least 20/30 with one eye or both eyes or two line difference between eyes

Fail photo-screening

Not reading at grade level

Indication for referral children at any age

Retinopathy of prematurity

Family history of retinoblastoma

Congenital glaucoma

Congenital cataracts

Systemic diseases with eye disorders, e.g., retinal dystrophies/degeneration, uveitis, glaucoma

Nystagmus

Neurodevelopmental delays

Hearing Screening (See ENT Chapter for More Details)

Background

AAP recommended 100 % screening of infants by age of 3 months

AAP recommended formal hearing screening to ALL children at 3, 4, and 5 years then every 2–3 years until adolescence

Method of screening, e.g.,

Auditory brainstem response testing (ABR)

Goal of screening

Identify hearing loss of 35 dB or greater in 500–4000 Hz range

Indication for hearing screening in special situations

Parent express concern of hearing problem, language, or developmental delay.

History of bacterial meningitis.

Neonatal CMV infection.

Head trauma .

Syndrome associated with hearing loss, e.g., Alport syndrome.

Exposure to ototoxic medication.

Blood Pressure Screening

Indication

All children on yearly basis starting at 3 years of age

Coexisting medical conditions associated with hypertension

Pediatric cuff size

Minimum cuff width

Width 2/3 length of upper arm

Width > 40 % of arm circumference

Minimum cuff length

Bladder nearly encircles arm

Bladder length 80–100 % of circumference

Normal blood pressure

< 90th percentile for age and sex

Blood pressure > 95th percentile should be confirmed over a period of days to weeks

Lead Screening

The American Academy of Pediatrics and the CDC developed new recommendations

All Medicaid-eligible children and those whose families receive any governmental assistance must be screened at age 1 and 2 years.

Children living in high-risk environments, e.g. > 12% of children have elevated blood lead levels (BLL).

Other children should be screened based on their state/city health departments’ targeted screening guidelines.

Children who have siblings with elevated BLLs above 10 mcg/dL.

Recent immigrants.

Immigrant children, refugees, or international adoptees should be screened upon entering the USA.

Measurement of lead

Venous lead levels are more accurate than fingerstick measurements due to higher contamination from skin surfaces.

An elevated capillary BLL should be confirmed with a venous sample.

Lead interventional threshold has been lowered to levels 5 mcg/dL.

Risk factors for lead poisoning

Living in or regularly visiting a house built before 1950 or remodeling before 1978.

Other sibling or family member with high lead level.

Immigrant or adopted children.

Using folk remedies.

Environment with high or unknown lead level.

Children in Medicaid are at high risk.

Effect of lead intoxication

A decline of 2–3 points in children’s intelligence quotient (IQ) scores for each rise above 10 mcg/dL.

Concomitant iron deficiency anemia; increased lead absorption.

Neurotoxicity.

Abdominal colic.

Constipation .

Growth failure.

Hearing loss.

Microcytic anemia.

Dental caries.

Spontaneous abortions.

Renal disease.

Seizures.

Encephalopathy.

Death.

Iron Deficiency Screening

Definition of anemia

Hemoglobin 2 standard deviation below the mean for age and sex

Screening age

AAP bright future recommends Hemoglobin/Hematocrit screening at 1 year of age.

Screening of high risk children

Prematurity

Low birth weight

Early introduction of cow’s milk

Strict vegans

Poverty

Limited access to food

Associated medical conditions

Urinalysis Screening

No routine UA screening is recommended by AAP bright future at this time.

APP bright future recommend urine dipstick testing in sexually active male and females between age 11–21 years of age.

Tuberculosis (TB) Screening

Routine screening for TB is no longer recommended.

Method of screening

The intradermal Mantoux tuberculin skin test (TST) is the most reliable diagnostic for TB.

The test consists of 0.1 mL of purified protein derivative (PPD) injected intradermally on the volar aspect of the forearm.

Forming a 6- to 10-mm wheal.

The area is inspected at 48–72 h; induration, not erythema.

It is measured transversely to the long axis of the forearm and the results recorded in millimeters.

The test is considered to be positive at specific sizes of the area of induration, depending on associated features.

Indication for initial TB screening

If active disease is suspected

Contacts of individuals who have confirmed or suspected active TB

Children who have clinical or radiographic findings suggestive of TB

Children emigrating from countries where TB is endemic, who visit these countries frequently, or who have frequent visitors from these countries

All children who will begin immunosuppressive therapy

Children infected with HIV

Incarcerated adolescents

Positive TST interpretation depends on the size of induration and associated risk factors (see infectious disease chapter)

Critical to know

Positive TST result in a child or adolescent should be regarded as a marker for active disease within that community and should serve as a call to investigate contacts and to find and treat cases of latent TB.

Autism Screening

AAP bright future recommend Autism screening at 18 months of age.

Repeat specific screening at 24 months visit or whenever parental concern raised.

DSM-IV criteria to children younger than 3 years of age:

Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by lack of showing, bringing, or pointing out objects of interest)

Lack of social and emotional reciprocity

Marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction

Delay in or total lack of the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)

Oral Health Screening

Tooth care

Once tooth erupts, it should be brushed twice daily with plain water.

Once the child reaches 2 years of age, brush teeth twice daily with a pea sized amount of fluoride toothpaste.

Daily flossing.

Prevention of bacterial transmission ( Streptococcus mutans or Streptococcus sobrinus)

Practice good oral hygiene and seek dental care.

Do not share utensils, cups, spoons, or toothbrushes with the infant.

Do not clean a pacifier in the mouth before giving it to the infant.

Risk group infants should be referred to a dentist as early as 6 months of age and no later than 6 months after the first tooth erupts or 12 months of age (whichever comes first) for establishment of a dental home:

Children with special health care needs

Children of mothers with a high caries rates

Children with demonstrable caries, plaque, demineralization, and/or staining

Children who sleep with a bottle or breastfeed throughout the night

Children in families of low socioeconomic status

Well Child Visits

Well Visit Schedule

Infancy

Newborn

3–5 days old

1, 2, 4, 6, and 9 months

Early childhood

12, 15, 18, 24, 30 months, 3 and 4 years

Middle childhood

Yearly from 5 to 10 years

Adolescents

Yearly from 11 to 21 years

Counseling Each Well Visit Is Very Important

Bath safety

Sun exposure

Fluoride supplementation

Nutrition

Immunization

Common cold management

Age Appropriate Anticipatory Guidance, e.g.,

Feeding in newborn

Dental care when first tooth appear

Dental appointment at 12 months if pediatric dentist is available

TV limitations

Reading to the child

Helmet for bicycle

Discussion about drug, sex, depression at age of 10 and up

Environmental Safety Counseling

Motor vehicle crash

Backseat (middle) placement of child

Rear-facing car until age 2 years

Forward-facing car seat until 40 Ib

Booster seat until at least 80 Ib and 57 in

Drowning

Enclose pools completely with at least 4-ft fence and self closing gate

Wear life jackets on boats and when playing near water

Do not leave children unattended in baths

Supervise closely (adults within one arm’s reach of a child in or near water)

Fire and burns

Install smoke detector on every level of the home and near sleeping areas

Reduce water heater temperature to 120 °F

Do not drink hot fluids near children

Never leave the stove unattended

Gun

If parents choose to keep a firearm in the home, the unloaded gun and ammunition must be kept in separate locked cabinets.

Poisoning

Keep all potential poisons in original containers and out of reach .

Keep all medication out of reach.

Place child-resistant caps on medications.

Install carbon monoxide detectors on every level of home.

Keep poison control number near the phone: 1800-222-1222.

Threats to breathing

Remove comforters, pillows, bumpers, and stuffed animals from crib

Avoid nut, carrots, popcorn, and hot dog pieces

Keep coins, batteries, small toys, magnets, and toy arts away from children < 4 year old

Falls

No baby walkers with wheels

Recreation

Ensure helmets are fitted and worn properly

Keep children < 10 years off road

Nutrition

Breast feeding

Milk after birth is normally low in volume and rich in antibodies is called colostrum .

Poor and irregular feeding is normal in the beginning.

Mother should resist the supplementation with formula in the first few weeks.

Baby should feed on demands, usually every 2–3 h for 10–15 min.

Newborn should not go longer than 4–5 h without feed because of risk of hypoglycemia .

Infant may lose 10 % of birth weight before regaining it within 10–14 days after birth.

Best indicator of appropriate feeding is the number of wet diapers.

Formula feeding

Feeding on demand and frequency and interval same as breast feeding .

Most babies can begin weaning bottle to cup between 9 and 12 months.

Bottle on bed to sleep can cause significant problem with dental caries.

Vitamins and minerals

Iron

Term, healthy breastfed infants should be supplemented with 1 mg/kg per day of oral iron beginning at 4 months of age until appropriate iron-containing complementary foods.

Partially breastfed infants (more than half of their daily feedings as human milk) who are not receiving iron-containing complementary foods should also receive 1 mg/kg per day of supplemental iron.

All preterm infants should have an iron intake of at least 2 mg/kg per day through 12 months of age.

Whole milk should not be used before 12 completed months of age (can cause occult blood and worsening anemia).

Standard infant formula contain enough iron, i.e., 12 mg/L. No need for iron supplementation if the infant feeding more than one liter of formula per day.

Vitamin D

Supplementation with 400 IU of vitamin D should be initiated within days of birth for all breastfed infants, and for non breastfed infants and children who do not ingest at least 1 L of vitamin D–fortified milk daily.

Fluoride

No fluoride should be given to infant of less than 6 months.

If the fluoride in water supply < 0.3 PPM begin supplementation at 6 months of age.

If fluoridation in water supply is > 0.6 PPM, no need for taking extra fluoride.

Less than 6 years old should use only pea sized quantity toothpaste for tooth brushing.

Solid food

At 4–6 months.

Better to introduce only one new food at a time.

Avoid food items that cause aspiration , e.g., raw carrots, hard candy, hot dog pieces if less than 3 years of age.

No skim or low fat milk before 2 years of age.

No salt or sugar to be added to infant’s diet.

Discipline

Disciplining the child is not easy, but it is a vital part of good parenting.

The AAP recommends a three-step approach toward effective child discipline.

Establish a positive, supporting, and loving relationship with the child. Without this foundation, the child has no reason, other than fear, to demonstrate good behavior.

Using positive reinforcement to increase desired behavior from the child.

If the parents feel discipline is necessary, AAP recommends to avoid spanking or use other physical punishments. That only teaches aggressive behavior and becomes ineffective if used often.

Using appropriate time outs for young children.

Discipline of older children by temporarily removing favorite privileges, such as sports activities or playing with friends.

Immigrants and Internationally Adopted Children

For children entering US for permanent residency or visas the following diseases are supposed to be excluded

Active tuberculosis, HIV, syphilis, gonorrhea, lymphogranuloma venereum, chancroid, and leprosy

No laboratory testing is required for children <15 years of age

Evaluation of the immigrants

Depending on the country of origin, and living condition, e.g., orphan, refugee camp

Immunization record

Immunization record is acceptable from other countries as long as documenting date, dose, and name of the vaccines

If no immunization record is available or any method of documentation all the required vaccines should be given all over.

Common health problems in high risk immigrants

Infections

Immunization status

TB

Parasites

Hepatitis B

HIV

Syphilis

Malaria

Nutrition

Anemia

Malnutrition

Rickets

Iodine deficiency

Toxins

Lead

Prenatal alcohol

Radioactivity

Growth and development

Estimated age

Vision and hearing

Dental caries

Congenital defects

Developmental delay

Infantile Colic or Crying Infants

Background

Crying by infants with or without colic is mostly observed during evening hours and peaks at the age of 6 weeks .

Infantile colic usually make the babies cry and make parents frustrated.

Usually colic occurs once or twice a day.

Should respond to comforting.

Baby acts happy between bouts of crying.

Normal physical findings

Weight gain: Infants with colic often have accelerated growth; failure to thrive should make one suspicious about the diagnosis of colic

Exclusion of potentially serious diagnoses that may be causing the crying

Demonstrated and suggested causes of colic may include the following

Gastrointestinal causes (e.g., gastroesophageal reflux disease [GERD], over- or underfeeding, milk protein allergy, early introduction of solids)

Inexperienced parents (controversial) or incomplete or no burping after feeding

Exposure to cigarette smoke and its metabolites

Food allergy

Low birth weight

Home care of infantile colic

Hold and comfort, e.g., gentle rocking, dancing with baby, wind-up swing, or vibrating chair

Warm bath

Feed the baby every 2 h if formula or every 1 h and half if breast feeding

Breast feeding mother should avoid caffeine

Oral glucose water may help

Dietary changes may include the following

Elimination of cow’s milk protein in cases of suspected intolerance of the protein.

In infants with suspected cow’s milk allergy, a protein hydrolysate formula is indicated.

Soy-based formulas are not recommended, because many infants who are allergic to cow’s milk protein may also become intolerant of soy protein .

Limb Pain

Background

It is also known as growing pain .

Most common skeletal problem in pediatrics.

Characteristic feature of growing or limb pain

Deep aching pain in the muscles of the legs

Most pain occur in the middle of the night or in evening

Usually resolve in the morning

Respond to heat massage and analgesics

No joint involvement

No inflammation present

Diagnosis

Growing pains, a diagnosis of exclusion, requires that symptoms only occur at night and that the patient has no limp or symptoms during the day.

Red flags and possible other causes of a child with limb pain or limping

Fever and chills may suggest septic arthritis, leukemia, Henoch-Schönlein purpura (HSP), and juvenile idiopathic arthritis (JIA), all present with limp and fever

Recent URI may suggest transient synovitis.

Toddlers; Causes of limp in the toddler are infectious/inflammatory (e.g., transient synovitis, septic arthritis, osteomyelitis), trauma (e.g., toddler’s fracture), stress fractures, puncture wounds , lacerations , neoplasm, developmental dysplasia of the hips, neuromuscular disease , cerebral palsy , and congenital hypotonia.

Limping with hip or knee pain; Legg-Calve-Perthes disease (LCPD) common at 4–10 years of age, slipped capital femoral epiphysis specially obese adolescents

Morning stiffness, e.g., JIA, weakness

Nocturnal pain; neoplasm

Back Pain or tenderness, e.g., diskitis. New footwear or a change in the amount of walking may be reported.

Signs of weakness, paresthesias, or incontinence may be detected in acute spinal cord syndromes.

Dark or discolored urine may be reported with myositis.

Easy bruising, weight loss, or bone pain may be seen with neoplastic or other infiltrative disease .

Urethral discharge suggest a genitourinary tract abnormality; vaginal discharge may point toward a diagnosis of pelvic inflammatory disease; testicular pain in males may present as a limp.

Family history may include short stature, vitamin D-resistant rickets, Charcot-Marie-Tooth disease, SLE, RA, or a history of developmental delay (e.g., cerebral palsy)

Management of growing pain

Reassurance

Ibuprofen

Suggested Readings

1.

Feigelman S. The first year. In: Kliegman RM, Stanton BF, St. Geme JW III, Schor NF, Behrman RE, editors. Nelson textbook of pediatrics, 19th ed. Philadelphia: Saunders Elsevier; 2011. p. 26–31.

2.

Keane V. Assessment of growth. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, editors. Nelson textbook of pediatrics, 18th ed. Philadelphia: Saunders Elsevier; 2007. p. 70–4.

3.

Gerber RJ, Wilks T, Erdie-Lalena C. Developmental milestones: motor development. Pediatr Rev. 2010;31:267–77. doi:10.1542/PIR.31-7-267.CrossRefPubMed

4.

American Academy of Pediatrics; Section on Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; American Academy of Ophthalmology; American Association of Certified Orthoptists. Red reflex examination in neonates, infants, and children. Pediatrics. 2008;122:1401–04.CrossRef

5.

Academy of Pediatrics, Committee on Environmental Health. Lead exposure in children: prevention, detection, and management. Pediatrics. 2005;116:1036–46.CrossRef

6.

Canivet CA, Ostergren PO, Jakobsson IL, Dejin-Karlsson E, Hagander BM. Infantile colic, maternal smoking and infant feeding at 5 weeks of age. Scand J Public Health. 2008;36(3):284–91.CrossRefPubMed

© Springer International Publishing Switzerland 2015

Osama Naga (ed.)Pediatric Board Study Guide10.1007/978-3-319-10115-6_2

Behavioral, Mental Health Issues and Neurodevelopmental Disorders

Mohamad Hamdy Ataalla¹  

(1)

Department of Child and Adolescent Psychiatry, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA

Mohamad Hamdy Ataalla

Email: [email protected]

Keywords

Anxiety disordersMood and affect disordersADHDAggressionBreath-holding spellsOppositional defiant disorderConduct disorderSleep medicineSexual behaviorsThumb suckingEnuresis (bed-wetting)Autistic disordersChildhood schizophreniaLearning disabilities

Anxiety Disorders

Background

Common psychiatric disorder in children

Females may report anxiety disorder more than males

Multiple risk factors

Genetics: parents with anxiety disorder

Temperamental style: inhibited

Parenting styles: overprotective, over-controlling, and overly critical

Insecure attachment relationships with caregivers: anxious/resistant attachment

Common developmental fears

Separation anxiety (decrease with age)

Fear of loud noise and strangers (common in infants)

Fear of imaginative creature, and darkness (common in toddler)

Fear of injuries or natural events (e.g., storm)

Worries about school performance, social competence, and health issues (children and adolescents)

Anxiety disorders

Fears and worries become disorder when they are impairing and if they do not resolve with time

Anxious child may present with somatic complaints (headache and stomachache) , or disruptive behaviors (defiance, anger, crying, and irritability) while trying to avoid anxiety provoking stimulus.

Separation anxiety disorder (SAD)

Separation anxiety is developmentally normal: in infants and toddlers until approximate age 3–4 years

Separation anxiety disorder: symptoms usually present after the age of 6 years

Symptoms should present for at least 4 weeks to make the diagnosis

Excess distress due to fear of separation from attachment figure

Excess worrying about own or parent’s safety

Nightmares with themes of separation, somatic complaints, and school refusal

Specific phobia

Marked and persistent fear of a particular object or situation that is avoided or endured with great distress, for example, fear of animal or injections

Generalized anxiety disorders (GAD)

Chronic, excessive worry in a number of areas such as schoolwork, social interactions, family, health/safety, world events, and natural disasters with at least one associated somatic symptom for at least 6 months

Social phobia

Feeling scared or uncomfortable in one or more social settings (discomfort with unfamiliar peers and not just unfamiliar adults), or performance situations

Selective mutism

Persistent failure to speak, read aloud, or sing in specific situations (e.g., school) despite speaking in other situations (e.g., with family)

Panic disorder

Recurrent episodes of intense fear that occur unexpectedly

Associated with at least 4 of 13 autonomic anxiety symptoms such as pounding heart, sweating, shaking, difficulty breathing, and chest pain

Post traumatic stress disorders (PTSD)

Persistent pattern of avoidance behavior, trauma re-experiencing and emotional distress that last after 6 months of exposure to severe distress or trauma

Associated conditions

Depression

Externalizing behaviors disorders, e.g., oppositional defiant disorder (ODD)

Attention deficit hyperactivity disorders (ADHD)

Selective mutism

School refusal

Screening/rating scales

Multidimensional anxiety scale for children: MASC

Child anxiety related disorders: SCARED

Management

Provide education, for example, educate parents that phobias are not unusual but not associated with impairment in most cases

Combined psychotherapy and pharmacological are more effective

Psychotherapy (could be offered alone in mild anxiety cases)

Cognitive behavioral therapy (CBT) (e.g., trauma focused CBT for PTSD)

Parent–child and family intervention

Psychodynamic psychotherapy for selected adolescents cases

Pharmacotherapy: selective serotonin reuptake inhibitors (SSRIs), e.g., fluoxetine and sertraline

School refusal: do not advise school’s leave. Treat underlying anxiety as