Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
The 4th Annual Metropolitan New York/New Jersey Pediatric Board Review Course General Pediatrics Andrew D. Racine, M.D., Ph.D. May 16, 2009 Outline Update on immunizations Breastfeeding Nutrition Injury Prevention Development Anticipatory Guidance Child Abuse Update on Immunizations Case #1 Question 1 A 12 year old girl presents to your office for a regular checkup for school entry. She is a recent immigrant from Mexico. Her mother states that she does not have an immunization record. She denies any significant past medical history. There is no history of allergies. Physical exam reveals no abnormalities. Which immunizations would you give at this time? A. Td, IPV, MMR, Varicella, Hep B, MCV4 B. Td, IPV, MMR, Varicella, Hep B, MPSV4, Influenza C. Td, IPV, MMR, Varicella, Hep B, Hep A, HPV D. Tdap, IPV, MMR, Varicella, Hep B, MPSV4 E. Tdap, IPV, MMR, Varicella, Hep B, MCV4, Hep A, HPV, Influenza Pertussis Vaccine (Tdap) Two tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines were approved by the FDA in 2005 and are now recommended for: Adolescents aged 11-12 years who completed their primary series of DTP/DTaP and have not received a Td booster dose Adolescents 13-18 years who missed the 11-12 year Td/Tdap booster and completed their primary series Adolescents who have not received DTP/DTaP/Td/Tdap vaccination (or have no documentation) For wound management in adolescents who have not received Tdap before Meningococcal Vaccine (MCV4) Another change introduced into the schedule in 2005 is the meningococcal conjugate vaccine which is also recommended in Adolescents 11-12 years Unvaccinated adolescents at school entry College freshmen living in dormitories Certain high risk groups Hepatitis A Vaccine In May of 2006 the ACIP broadened its recommendations for the use of Hep A vaccine to include all children between 1-2 years of age. The use of Hep A vaccine is also recommended for high risk groups including: Travelers to endemic areas, MSM, drug users, persons with chronic liver disease, those with clotting factor disorders Influenza Vaccine Influenza vaccine risk factors now include children with compromised respiratory function or handling of respiratory secretions and also children that have an increased risk of aspiration. In August 2008, ACIP issued a recommendation expanding routine influenza vaccination beyond children 6 – 59 months and their household contacts to include all children 6 months to 18 years of age beginning in the 2008-09 flu season. Previously unvaccinated children should receive 2 doses this vaccine. Human Papillomavirus Vaccine Licensed in June 2006, the ACIP recommends routine immunization of females from 9 years of age up to 26 years of age with a three-dose series where the second and third doses are administered at 2 months and 6 months after the first dose. Based on the catch up schedule and the requirements for a patient this age the patient should receive: A. Td, IPV, MMR, Varicella, Hep B, MCV4 B. Td, IPV, MMR, Varicella, Hep B, MPSV4, Influenza C. Td, IPV, MMR, Varicella, Hep B, Hep A, HPV D. Tdap, IPV, MMR, Varicella, Hep B, MPSV4 E. Tdap, IPV, MMR, Varicella, Hep B, MCV4, HEP A, HPV, Influenza Pertussis Pertussis remains endemic despite universal immunization with DTaP. There are 2 peaks of incidence. One is in children under the age of 6 months who are not vaccinated or incompletely vaccinated. The other is in adolescent 11-18 years whose immunity has waned. The morbidity in adolescents is significant. In 2004, 25,827 cases of pertussis were reported in USA. 34% were in children 11-18 years. Licensed Tdap Vaccines BOOSTRIX GlaxoSmithkline Biologicals 10-64 years of age, same t, d, p antigens as INFANRIX but in smaller concentrations ADACEL sanofi pasteur 11-64 years of age, same t, d, p antigens as DAPTACEL but in smaller concentrations Side Effects of Tdap Vaccination Pain Erythema Swelling Headache Fatigue Fever GI events Local Reactions Systemic Reactions Immediate Reactions including dizziness, syncope and vasovagal reactions were reported with ADACEL Case #1 Question 2 Before you give the Tdap vaccine to the patient you ask your attending what is a true contraindication for the vaccine. Your attending responds that: A. Temperature greater than 105 F within 48 hours of a previous DTP/DTaP B. Collapse or shock like state within 48 hours of a previous DTP/DTaP C. History of encephalopathy within 7 days of previous DTP/DTaP D. Latex Allergy E. Pregnancy Contraindications of Tdap Anaphylaxis to any components of the vaccine History of encephalopathy (coma or prolonged seizure) within 7 days of administration of a pertussis vaccine that cannot be attributed to a different cause Precautions of Tdap History of an Arthus-type reaction following a previous dose of tetanus- or diphtheriacontaining vaccine Progressive neurological disorder, uncontrolled epilepsy, or progressive encephalopathy History of Guillain-Barre syndrome (GBS) within 6 weeks after a previous dose of tetanus toxoidcontaining vaccine Moderate or severe acute illness Not Contraindications Temperature > 105F within 48 hrs of DTP/DTaP Collapse or shock-like state within 48 hrs of DTP/DTaP Persistent crying for 3 hrs or longer within 48 hrs of DTP/DTaP Convulsions with or without fever within 3 days of DTP/DTaP History of entire or extensive limb swelling after DTP/DTaP/Td Stable neurological disorder Not Contraindications Brachial neuritis Latex allergy other than anaphylaxis-BOOSTRIX single dose and ADACEL are latex free Pregnancy and breastfeeding Immunosuppression Intercurrent minor illness Antibiotic use The only true contraindication of the alternatives listed would be: A. Temperature greater than 105 F within 48 hours of a previous DTP/DTaP B. Collapse or shock like state within 48 hours of a previous DTP/DTaP C. History of encephalopathy within 7 days of previous DTP/DTaP D. Latex Allergy E. Pregnancy Meningococcal Disease American Academy Of Pediatrics. Committee on Infectious Diseases. Prevention and Control of Meningococcal Disease: Recommendations for Use of Meningococcal Vaccines in Pediatric Patients. Pediatrics. 2005:116(2):496-505. Epidemiology of Meningococcemia Children < 1 year of age Adolescents 15-18 years of age College freshmen living in dormitories C5-C9 or C3 deficiency Functional asplenia Licensed Meningococcal Vaccines MENOIMUNE Meningococcal polysaccharide vaccine MPSV4 Purified capsular polysaccharides A/C/Y/W-135 Licensed in 1981 MENACTRA Meningococcal conjugate vaccine MCV4 Purified capsular polysaccharides A/C/Y/W-135 conjugated to diphtheria toxoid. Licensed in 2005 Case #1 Question 3 Your attending asks you what are the advantages of the new meningococcal conjugate vaccine vs. the old polysaccharide vaccine. You answer that all of the following are true except: A. The conjugate vaccine produces an antibody response which lasts longer B. The conjugate vaccine stimulates a booster response C. The conjugate vaccine promotes herd immunity D. The conjugate vaccine has less side effects E. The conjugate vaccine reduces nasopharyngeal carriage MPSV4 vs. MCV4 MPSV4 antigens induce a T cell independent antibody response. As a result there is A short lived response No anamnestic or booster response with subsequent challenge No reduction in nasopharyngeal carriage MCV4 antigens are conjugated to diphtheria toxoid so they induce a T cell dependent response resulting in A long lasting memory Booster response and eradication of nasopharyngeal carriage which contributes to herd immunity. Advantages of MCV include all of the following except: A. The conjugate vaccine produces an antibody response which lasts longer B. The conjugate vaccine stimulates a booster response C. The conjugate vaccine promotes herd immunity D. The conjugate vaccine has less side effects E. The conjugate vaccine reduces nasopharyngeal carriage MCV4 Side effects include: Erythema, swelling and induration Guillain-Barre – 17 reported cases from March 2005 – September 2006. GBS incidence estimated at 0.20 per 100,000 person months after vaccine compared to 0.11 per 100,000 person months among 11-19 year olds generally. Human Papillomavirus The most common sexually transmitted infection in the United States (6.2 million new cases annually). HPVs are non-enveloped double stranded DNA viruses of over 100 types including several (16,18,31,33,35, and others) detected in 99% of cervical cancer cases. Risk of HPV associated with number of sexual partners, partner sexual behavior, and immune status. Human Papillomavirus Most infections are transient, asymptomatic and clear within 1-2 years Of the 6.2 million new cases per year, about 74% occur in women 15-24 Acquisition occurs soon after sexual debut Prevalence of HPV 16 may be as high as 40% Consistent condom use may help prevent acquisition HPV Vaccine Quadravalent HPV vaccine (Gardasil®) targets HPV types 6, 11, 16 and 18 HPV types 16 and 18 cause approximately 70% of cervical cancers and types 6 and 11 cause approximately 90% of genital warts Administered in 3 doses with second and third doses given 2 and 6 months after the first dose Combined protocols indicate an efficacy of 98100% in the prevention of CIN 2/3, AIS or genital warts caused by HPV 6, 11, 16 and 18. Case #1 Question 4 You explain to your attending your intention to administer the Gardasil® vaccine and he responds, “Are you nuts? That vaccine costs a gazillion dollars!! What are you a Merck shareholder or something?” You calmly reply that: A. The vaccine only costs $50 per dose B. The treatment of genital warts and cervical cancer costs more than $8 billion a year in the U.S. C. Depending upon how long you assume immunity lasts and what percent of girls get the vaccine, immunizing all 12 year old girls will cost only $3,000 to $25,000 per QALY. D. Vaccinating will save the future costs of having to screen for cervical cancer in these patients HPV Costs and Benefits Management of warts and cervical cancer costs about $4 billion per year in the U.S. Vaccine for Children’s program (VFC) will cover costs of Gardasil for eligible patients Several cost/benefit analyses estimate the cost of a QALY to be between $3,000 and $25,000 depending upon underlying assumptions Factors to consider: duration of vaccine protection, duration of natural immunity, frequency of cancer screening, vaccine coverage A. The vaccine only costs $50 per dose B. The treatment of genital warts and cervical cancer costs more than $8 billion a year in the U.S. C. Depending upon how long you assume immunity lasts and what percent of girls get the vaccine, immunizing all 12 year old girls will cost only $3,000 to $25,000 per QALY. D. Vaccinating will save the future costs of having to screen for cervical cancer in these patients Case #1 Question 5 You ask your 12 year old patient to return in 4 weeks to continue the catch up schedule of vaccination you started. At that visit you will administer: A. Td,IPV,MMR,Hep B B. Td,IPV,MMR,Varicella,Hep B C. Tdap,IPV,MMR,Hep B,MCV4 D. Tdap,IPV,MMR,Varicella,Hep B E. Tdap,IPV,MMR,Varicella,Hep B,MCV4 Catch-up Schedule Tdap is licensed for only one dose. According to the AAP, the patient in this case should receive 3 tetanus/diphtheria toxoid vaccines and only one of them should also contain pertussis, preferably the first dose. Varicella- Two doses are now recommended. A 2nd dose is given in 4 weeks for those over 13 and in 3 months for those less than 13. MCV4 only one dose is required. Return Visit should include: A. Td,IPV,MMR,Hep B B. Td,IPV,MMR,Varicella,Hep B C. Tdap,IPV,MMR,Hep B,MCV4 D. Tdap,IPV,MMR,Varicella,Hep B E. Tdap,IPV,MMR,Varicella,Hep B,MCV4 Hepatitis A Vaqta and Havrix are both licensed for children 1 year of age and older and they are now recommended as part of the routine immunization schedule to be given to all children at the age of 1 year. Children who are not vaccinated by 2 years should be vaccinated at subsequent visits. 2 doses are recommended 6 months apart. Rotavirus Rotavirus is the leading cause of severe gastroenteritis worldwide resulting in more than 500,000 deaths/year. In the USA it is a major disease burden with 3.2 million episodes of diarrhea, 60,000 hospitalizations and 2060 deaths /year. Additional problems include Shedding of the virus before sxs develop and up to 21 days after onset of the disease Children developing insufficient immunity after one infection and therefore experiencing it more than once Major cause of day-care center acquired gastroenteritis Rotavirus vaccines All rotavirus vaccines are oral, live attenuated, containing glycoprotein (VP7) and protease-cleaved proteins (VP4) of Group A rotavirus, the most prevalent type found in humans. ROTASHIELD –licensed in 1998, tetravalent rhesushuman reassortment, withdrawn from the market due to cases of intussusception. ROTATEQ – FDA approved in 2006, pentavalent bovinehuman reassortment, no intussusception reported in large trial of 70,000 doses (3 dose regimen). ROTARIX – Live attenuated human monovalent vaccine approved for use in April, 2008 (2 dose regimen). Rotavirus Vaccine Characteristic RotaTeq Rotarix No. of doses 3 2 2, 4, 6 mo. 2, 4 mo. Recommended ages Minimum age for 1st dose 6 wks Maximum age for 1st dose 14 weeks and 6 days Minimum interval Maximum age for last dose 4 weeks 8 months 0 days Breastfeeding Case # 1 A female infant presents for her two week check-up. She was born after a 38 week uncomplicated pregnancy via spontaneous vaginal delivery at a birth weight of 3 kg. Her mother is breastfeeding and asks whether breast milk alone is sufficient for her baby. What advice should you give her? True or False? 1. The baby should receive oral iron supplements for the first 6 months of life. 2. The baby does not need vitamin K after birth so long as the mother is taking oral Vitamin K. 3. Starting shortly after birth, the baby will need 400 IU of vitamin D daily while she is exclusively breastfed. True or False? 1. The baby should receive oral iron supplements for the first 6 months of life. 2. The baby does not need vitamin K after birth so long as the mother is taking oral Vitamin K. 3. Starting shortly after birth, the baby will need 400 IU of vitamin D daily while she is exclusively breastfed. Question # 1 False Iron Iron stores at birth are proportional to birth weight or size. Iron stores for term infants are sufficient to meet needs for the first 4-6 months of life. Breast milk contains <0.1 mg/100cc of iron but it is in a highly bio-available form (50% of it is absorbed compared to 4% of iron in ironfortified formulas). Infants’ adequate intake of iron is approximately 0.27 mg/day for the first 4-6 months of life. True or False? 1. The baby should receive oral iron supplements for the first 6 months of life. 2. The baby does not need vitamin K after birth so long as the mother is taking oral Vitamin K. 3. Starting shortly after birth, the baby will need 400 IU of vitamin D daily while she is exclusively breastfed. Question # 2 False Vitamin K Vitamin K is a fat soluble vitamin necessary for the posttranslational carboxylation of glutamic acid residues of coagulation proteins Factors II, VII, IX and X. lpi.oregonstate.edu/infocenter/vitamins/vitamink/kcycle.html Vitamin K Breast milk has inadequate amounts of vitamin K to satisfy infant requirements. All breastfed infants should receive 0.5 - 1.0 mg of vitamin K IM after the first feeding and within the first 6 hrs of life. Oral vitamin K may not provide the stores necessary to prevent hemorrhage in later infancy and is not recommended at this time. True or False? 1. The baby should receive oral iron supplements for the first 6 months of life. 2. The baby does not need vitamin K after birth so long as the mother is taking oral Vitamin K. 3. Starting shortly after birth, the baby will need 400 IU of vitamin D daily while she is exclusively breastfed. Question # 3 True Vitamin D Vitamin D (calciferol) is available from certain dietary sources and can be synthesized in skin upon exposure to UV light. Adequate intake of vitamin D for infants is 400 IU per day as per recent AAP guidelines (2008). Vitamin D content of human milk is low (22 IU/L). Vitamin D Breastfed infants should receive supplements of 400 IU of vitamin D per day so long as the daily consumption of vitamin D-fortified formula or milk is below 1,000 ml. The recommended routine use of sunscreen in infancy decreases vitamin D production in skin. Case # 1 On further review of the mother’s history you discover that she is CMV positive, is taking anti-hypertensive medications, and has resumed her half-pack per day cigarette consumption since the baby was delivered. When asked whether any of these factors present a problem for her continuing to breastfeed, what should you advise her? Breastfeeding and viruses Viruses can be transmitted into human milk but only the presence of certain viruses in the mother are contraindications to breasteeding in the United States. These include: HIV-1, HIV-2, HTLV-1, HTLV-2 and HSV if there are lesions present on the nipple. Hepatitis B, Hepatitis C, CMV, and rubella are not contraindications for breastfeeding. Breastfeeding and medications Like viruses almost all medications taken by the mother are excreted into breast milk but only a very few are contraindications to breastfeeding. These include: Radioisotopes, anti-metabolites or immunosuppressive agents, lithium, chloramphenicol, iodides, bromocriptine, and ergot alkaloids. Breastfeeding and smoking Tobacco is not a contraindication to breastfeeding but nursing mothers should be advised not to smoke in the vicinity of the newborn and should be sensitively counseled to seriously consider abandoning this filthy, expensive, debilitating habit. More on Breastfeeding Regarding the physiology of lactation, which of the following statements is true: 1. 2. 3. 4. After delivery, prolactin concentration drops leading to increased milk synthesis. Lactation does not occur if pregnancy does not progress beyond 20 weeks. Obesity does not interfere with lactogenesis. Oxytocin causes the milk ejection or let-down reflex. More on Breastfeeding Regarding the physiology of lactation, which of the following statements is true: 1. 2. 3. 4. After delivery, prolactin concentration drops leading to increased milk synthesis. Lactation does not occur if pregnancy does not progress beyond 20 weeks. Obesity does not interfere with lactogenesis. Oxytocin causes the milk ejection or let-down reflex. More on Breastfeeding The delivery of the placenta results in a fall in estrogen and progesterone concentrations which no longer exert their negative feedback influence on pituitary prolactin release. As a result, prolactin levels rise. Lactation begins usually around 16 weeks of pregnancy. Conditions that can interfere with or delay lactation include PCOS, diabetes, obesity and stress. More on Breastfeeding Oxytocin is released by the posterior pituitary in response to infant suckling. This then causes a contraction of the myeloepithelial cells around the alveoli in the breast resulting in the milkejection reflex or let-down. More on Breastfeeding Compared to the weight gain of formula fed infants in the first year of life, the weight gain of breast fed infants: A. Is less rapid during the first 3-4 months but then catches up B. Is more rapid during the first 3-4 months but then slows down C. Generally results in a slightly heavier infant by 12 months of age D. Does not differ at all More on Breastfeeding Compared to the weight gain of formula fed infants in the first year of life, the weight gain of breast fed infants: A. Is less rapid during the first 3-4 months but then catches up B. Is more rapid during the first 3-4 months but then slows down C. Generally results in a slightly heavier infant by 12 months of age D. Does not differ at all More on Breastfeeding Breast fed infants tend to gain more weight than do formula fed infants in the first 3-4 months of life. It is acceptable for their weight gain to cross one or two percentiles downward in the period after 4 months so long as they maintain their length and head circumference. More on Breastfeeding By the end of the first year of life, breast fed infants who had solids introduced at 4-6 months of age tend to be slightly leaner than formula fed infants. Term infants require between 100 to 120 kcal/kg per day in order to grow. Nutrition Nutrition Current recommendations are to delay the introduction of cow’s milk until 12 months of age. The rationale for this recommendation includes all of the following except: Nutrition A. B. C. D. E. Cow milk has a higher renal solute load delivered to the kidney than human milk; The iron content of cow milk is inadequate to prevent iron deficiency; Cow milk induces gastroesophageal reflux; Cow milk may cause increased fecal blood loss in some infants; The caloric content of cow milk is sufficient for infant growth by 12 months of age. Nutrition The correct answer is C. Cow milk does not induce GE reflux. It only contains 0.5mg/L of iron of which 10% is absorbed making it insufficient to prevent iron deficiency. It can induce fecal blood loss in some infants and it has higher concentrations of sodium and potassium than human milk or formula. It’s caloric content is sufficient for growth at 1 year. Nutrition You are rounding in the newborn nursery with a group of residents. In describing the choices of infant nutrition that might optimize growth and development you are MOST likely to tell them: Nutrition A. Preterm and term infants both require 100-120 kcal/kg/day of energy to grow; B. Preterm infants require less caloric intake per kilogram to grow than do term infants; C. Term infants require 60-80 kcal/kg/day to grow; D. Term infants require 30-50 mL/kg/day of fluid intake; E. Term infants with BW > 2,500 gms require more energy per kilogram to grow than those infants with BW less than 2,500 gm. Nutrition The correct answer is A, preterm and term infants require 100-120 kcal/kg/day to grow. Determinants of energy requirements for infants include gestational age, illness, a history of surgery or wound healing, local environment and other factors. Nutrition Energy requirements can be thought of as divided into the following needs Correct fluid requirements for infants are 60-100 cc/kg/day. Category RMR Activity Temp. reg Growth Storage Loss Total Kcal/kg/d 50-60 0-10 0-10 10-15 20-30 10-15 90-140 Nutrition Your are seeing a 10 year old girl in your office who comes in for health care maintenance. On exam she is noted to have a BMI of 28 putting her over the 95%ile for her age in girls. You recall that BMI, as a measure of adiposity has been shown to be associated with all of the following except: Nutrition A. Socio-economic status B. Gender C. Birthweight D. Race E. Pubertal status Nutrition The correct answer is C. A distinct socioeconomic gradient in obesity has been demonstrated in national data sets. Girls and African Americans have higher rates of obesity than others and obesity increases with the onset of puberty. Birthweight per se is not highly correlated with later measures of adiposity (although SGA babies may be at greater risk). Nutrition After leaving the exam room with your medical student, a discussion about trends in obesity takes place. You point out to your trainee that, with respect to the epidemiology of obesity all of the following statements are true except: Nutrition A. The prevalence of obesity and overweight has B. C. D. E. doubled in the U.S. in the past 20 years; Each extra hour per day of TV watching among 12-17 year olds increases the prevalence of obesity by 2%; The concordance rate of obesity among monozygotic twins is between 0.7 and 0.9; The increase in obesity has occurred despite the fact that the majority of school-aged children still report 4 hours of vigorous activity per week; By 19–24 months of age, French fries are the most commonly consumed vegetable in the U.S. Nutrition The correct answer is D. Obesity rates have doubled in the past 2 decades. One extra hour of TV watching does is associated with an increase in the prevalence of obesity by 2%. Obesity is highly heritable and French fries are the most commonly eaten vegetable by 19-24 months. School children average less than 2 hours of vigorous exercise per week according to national data. Injury Prevention Injury Prevention A 6 month old boy is at your office with his father for a routine health care maintenance visit. In discussing injury prevention for his infant, the father wants to know what he should be most concerned about with respect to his infant’s safety. What should you tell him? Leading Causes of Death by Age Group - 2001 1 2 3 < 1 yr 1-4 yrs 5-9 yrs 10-14 yrs Congenital Anomalies 5,513 Short Gestation 4,410 SIDS 2,234 Unintentional Injury 1,714 Congenital Anomalies 557 Malignant Neoplasms 420 Unintentional Injury 1,283 Malignant Neoplasms 493 Congenital anomalies 182 Unintentional Injury 1,553 Malignant Neoplasms 515 Suicide 272 Leading Causes of Injury Deaths by Age Group 2001 100% 80% Other Firearms Burn Drown Motor Veh 60% 40% 20% 0% 1-4 Years 5-9 Years 10-14 Yrs Deaths Due to Injury in Childhood SIDS is the leading preventable cause of death in children less than 1 year of age. Unintentional injury is the leading cause of death in children from 1 to 15 years of age. Motor vehicle incidents, drowning and deaths from burns taken together account for over 75% of all deaths from injury in children between 1 and 15 years of age. Motor Vehicle Injury Prevention When counseling a parent with respect to infant car seats, all of the following are true except: A. Children should face the rear of the vehicle until they are at least 1 year of age or weigh at least 20 lbs. B. Convertible safety seats positioned upright and facing forward should be used for children beyond 1 year and 20 lbs until they reach 40 lbs. C. A rear facing car safety seat must not be placed in the front passenger seat of any vehicle with an air bag on the front passenger side. Motor Vehicle Injury Prevention Answer A: Children must weigh 20 lbs and be at least 1 year of age before sitting in a forward facing car seat. Many infants reach 20 lbs before their first birthday but should not be turned to face forward before that time. Motor Vehicle Injury Prevention Convertible seats are the safest for children after they reach 1 year and 20 lbs until they are 40 lbs and can use booster seats. Convertible Car Seat (Up to 40 lbs) Booster Car Seat (More than 35-40 lbs) Motor Vehicle Injury Prevention No rear facing seats should be placed in the front passenger seat of a car equipped with air bags; and any child less than 13 should preferentially sit in the rear seat to avoid injury from inflating air bags. Drowning Injury The father of that 6 month old infant also has a 4 year old boy at home. When counseling him about the epidemiology of childhood drowning, a TRUE statement is: A. Drowning is the leading cause of death due to injury B. For every one drowning victim there are 5 near drownings C. Pool alarms have eliminated the need for fencing D. Residential pools are the most common drowning sites E. The ratio of male-to-female drowning deaths is 1:1 Drowning Injury Residential pools are the most common site of drowning for children younger than 5. Infants drown in bathtubs most often and adolescents in fresh water lakes and rivers. Drowning is the 2nd leading cause of death in this age group (remember earlier) with peak incidence in the summer months and highest rates in the west and the south. Drowning Injury Four sided fences 5 ft high with self-closing selflocking gates are the most effective enclosures for residential pools. Pool alarms, pool covers, swimming lessons for young children and floatation devices are not as effective as proper enclosures in preventing drowning deaths. Male to female ratio is 3:1 and 50% of submersion victims are declared dead at the site (drowning to near drowning ratio of 1:1). A. Drowning is the leading cause of death due to injury B. For every one drowning victim there are 5 near drownings C. Pool alarms have eliminated the need for fencing D. Residential pools are the most common drowning sites E. The ratio of male-to-female drowning deaths is 1:1 Injury Prevention: Burns You are approaching the end of a health care maintenance visit for a 2 year old girl. The mother explains that the family recently moved into a private house having lived previously in an apartment. What four concrete pieces of advice can you give her about how she might make her new home safe from the standpoint of preventing burn injuries to her toddler? Injury Prevention: Burns 1. Don’t smoke in the home. Home fires cause three fourths of all fire deaths and children below the age of 5 are at highest risk. Adults who smoke carelessly or who fall asleep while smoking are responsible for the largest percentage of home fires that kill or injure children. Injury Prevention: Burns 2. Install smoke detectors on each floor in the house and test them every 6 months. Smoke detectors provide the best protection should a home fire begin since: a) most fires start in the early morning hours; b) most fires burn for a long time before discovery; and c) deaths are usually due to CO poisoning so early alerts can help prevent injury and death. Injury Prevention: Burns 3. Prepare emergency escape plans for use in the event of a fire. Even children as young as 3 can be taught how to safely get out of the house in the event of a fire. If fire extinguishers are available in the home (and they should be) children should always be taught to leave the house rather than try to put out a fire themselves. Injury Prevention: Burns 4. Set hot water heaters at no higher than 120o F. Tap water at 160o F can produce a fullthickness scald burn in less than 1 second. At 120o F the scalding time is increased to between 2 and 10 minutes. Development Development A six month old breast fed male infant is at your office for a well child check-up. He has been previously well and on exam babbles, reaches for your stethoscope and pulls to a sitting position without head lag. He can also: 1. 2. 3. 4. 5. Finger feed himself Imitate sounds Pull to stand Transfer objects from one hand to the other Use a scissors grasp to obtain a piece of cereal Development Correct answer is 4, transfer objects. As part of his normal development this infant probably began to hold a rattle briefly at 2 months, reached for objects and and lifted himself onto extended elbows at 4 months. He probably also began to roll over at 4 months and could roll both ways by 6 months. He likely began to coo at 2 months, to laugh out loud at 4 months, and to begin to babble at 6 months. Pulling to stand usually begins around 8 months. Finger feeding and imitating sounds usually starts at 9 months. Development You are examining a young boy during a health supervision visit. His mother reports that he says “mama,” “dada,” “bye,” “up,” and “ball.” While playing on the floor he sees a toy truck on the shelf and points to it. His mother asks him to bring her the truck which he does. These developmental milestones suggest the child is CLOSEST to: A. 12 months of age B. 15 months of age C. 18 months of age D. 21 months of age E. 24 months of age Development The correct answer is B. 15 months of age. At this age infants generally have a vocabulary of about 6 words, can follow simple commands, point to parts of their bodies and use gestures and jargon to express themselves. 18 month olds have a vocabulary of about 10-15 words and 21 month olds know 30 to 50 words. Two year olds are beginning to put two word phrases together and generally know about 100 words. They can follow complex commands. Development Familiarity with expected language milestones is important for the calculation of the language developmental quotient according the formula: LQ = language age/chronological age X 100 A child with an LQ of less than 70 should be referred for further evaluation. Development You and your colleagues are thinking of adding routine developmental screening to you office practice. In looking into this possibility you have discovered that: Development A. Developmental surveillance should occur at the B. C. D. E. 9, 18, and 30 month visits. The goal of developmental screening is to arrive at a diagnosis and a treatment plan. The diagnosis of a specific developmental disorder is necessary to make an EI referral. Sensitivity and specificity rates of 70%-80% are acceptable for developmental screening tests. Subsequent screening is not necessary after a child passes two screening tests. Development The correct answer is D sensitivity and specificity rates of 70%-80% are acceptable for developmental screening tests. A variety of screening tools with different psychometric properties are available for screening purposes but, in general, they have lower sensitivity and specificity than medical screening tests because of the underlying variability of the construct being measured and the absence of specific curative treatments for some conditions. Development Surveillance is the process of recognizing children who may be at risk for developmental delays and should take place at every well child visit; Screening is the use of a standardized tool to identify and refine the recognized risk; Evaluation is a complex problem to identify a specific developmental disorder in a child. Development Early Intervention services are valuable for children identified at high risk. They can provide evaluation services, developmental therapies, service coordination, transportation support, etc. The diagnosis of a specific developmental disorder is not necessary to refer a child deemed at risk to receive EI services. Development The American Academy of Pediatrics, in its 2006 policy statement on Identifying Infants and Young Children With Developmental Disorders recommends surveillance at every preventive care visit and the use of a standardized tool to screen low risk children at the 9, 18, and/or 30 month visits. Anticipatory Guidance You are seeing a set of parents with their 8 year old boy for a health care maintenance visit. The mother asks you whether allowing her son to watch TV when he comes home from school is a bad idea. The MOST accurate statement you can make to her about the influence of television viewing on children is: TV Viewing A. Most adolescents have difficulty discriminating between what they see on TV and what is real. B. Nearly 2/3 of all programming includes violence and children’s programming contains the most violence. C. 50% of 2-7 year olds have a TV in their room. D. A majority of parents report that they always watch TV with their children to monitor the content of what is seen. TV Viewing Although young children and adolescents are vulnerable to the messages conveyed on television, it is predominantly younger children who cannot discriminate between what is real and what they see on TV. In a random survey of parents with children from kindergarten through 6th grade published in 1996, 37% reported that their child had been frightened or upset by a TV program seen during the preceding year. Cantor J, Nathanson AI. Children’s fright reactions to television news. J Commun. 1996;46: 139-152. TV Viewing About one third of parents of 2-7 year olds report that their children have a television in their room. Less than half of all parents state that they always watch television with their children to monitor the content of what is being seen. TV Viewing A recently completed 3 year National Television Violence Study reported that: Nearly 2/3 of all programming contains violence; That children’s shows contain the most violence; That portrayals of violence are usually glamorized; and Perpetrators often go unpunished. Federman J. ed. National Television Violence Study Vol 3. Thousand Oaks, CA: Sage; 1998. TV Viewing A. Most adolescents have difficulty discriminating between what they see on TV and what is real B. Nearly 2/3 of all programming includes violence and children’s programming contains the most violence C. 50% of 2-7 year olds have a TV in their room D. A majority of parents report that they always watch TV with their children to monitor the content of what is seen Child Abuse Case #4 The parents of a 9 month old baby girl who is new to your practice bring her for a regular checkup. There are no complaints. Physical exam reveals the following lesion: dermatlas.com/derm/ The following risks factors may indicate child abuse except: A. Patient is less than 3 years of age B. There is a history of spousal abuse C. Father is an alcoholic D. Mother did not breastfeed the child E. The child is a foster child D. Mother did not breastfeed the child Risk factors for Child Abuse – Parental Past history of abuse or family violence Inability to cope, lack of support, attachment issues Closely spaced pregnancies, financial problems Alcoholism, addiction, psychosis, depression Young parental age, single parent Risk factors for Child Abuse – Child Child is less than 3 years of age Twin, prematurity Chronic illness, mental retardation, learning disability Foster or adopted child Child abuse – Physical signs Bruises, burns, bites, blunt-instrument marks Fractures – bucket handle, posterior rib fractures, multiple fractures at different stages of healing Intracranial hemorrhages Retinal hemorrhages Duodenal hematomas, lacerations of liver and spleen, mesenteric tears Oral lacerations Failure to thrive Multiple posterior rib fractures Bucket handle fracture aafp.org/afp/ 20000515/3057_f7.jpg