ACUTE OTITIS MEDIA

3 Criteria Required for Diagnosis:

1.) History of acute onset of signs and symptoms of middle ear inflammation and
effusion
2.) Presence of middle ear effusion (MEE) which is indicated by:
a. Bulging of tympanic membrane (highest PPV)
b. Limited or absent mobility of TM
c. Air fluid level behind TM
d. Otorrhea
3.) Signs of symptoms of middle-ear inflammation indicated by:
a. Distinct erythema of TM
b. Distinct otalgia (pain that interferes with normal activity or sleep)
*MEE is most often confirmed with pneumatic otoscopy but can also be confirmed by
tympanometry or acoustic reflectometry
*Opacification or cloudiness is also a consistent finding for edema of TM
*Redness due to inflammation must be distinguished from erythematous flushing due to
crying or high fever

Clinical Presentation: children often present with non-specific symptoms such as

irritability in infants or toddlers and fever with accompanying cough, nasal discharge,
stuffiness. More specific symptoms include otalgia and otorrhea.

What AOM isnt

1.) Otitis media with effusion (OME): OME is fluid in the middle ear without the
presence of inflammation and pain that accompany AOM. OME is often a
complication of AOM that persists after the infection is cleared. Chronic OME
may require a tympanostomy tube in order to decrease the risk of language delay
and hearing loss.
2.) Myringitis: myringitis in inflammation of the ear drum with normal mobility
without effusion
3.) Otitis Externa: inflammation of the external ear which causes pain that is
exacerbated by manipulation of the external ear

Predisposing/Risk Factors:
**most of the following are predisposing factors because they increase the retrograde
movement of upper respiratory flora into the middle ear
1.) Being a child (most common at 6-24 mos.) due to
a. Decreased angle of entry of the Eustachian tube
b. Short length of ET
c. Decreased tone of ET
2.) viral URI (edema creates a vacuum)
3.) pacifier use
4.) supine bottle feeding
 5.) second-hand tobacco smoke
**breastfeeding until at least 6 mos. seems to be protective

ETIOLOGY:
20% viral
80% bacterial
S. pneumoniae (50%)
Nontypeable H. influenzae (25%)
Moraxella catarrhalis (12%)

HOW TO TREAT:
Pain Management: the physician should always assess and treat pain if present regardless
of whether or not antibiotics will be prescribed!
1.) Acetaminophen, Ibuprofen: mild to moderate pain, mainstay of treatment
2.) Benzocaine (topical agent): additional but brief benefit
3.) Narcotic analgesia: moderate to severe pain

Infection: Often AOM is not immediately treated with antibiotics because a lot of
children recover on their own within 48 to 72 hours. Not prescribing antibiotics right
away not only decreases the rate of resistant bacteria but also eliminates side effects and
the cost of the antibiotics. Placebo-controlled studies have shown that children who
recover without antibiotics do not have an increased risk of adverse sequelae, including
mastoiditis. This treatment method is known as the observation option

Observation Option: deferring the use of antibacterials of selected children for 48 to

72h based on diagnostic certainty, age, illness severity and assurance of follow-up. The
following guidelines are used to determine when TO and when NOT to use antibiotics.
Children <6mo.: always use antibacterial therapy
Children 6mo-2yr: certain diagnosis antibacterial therapy
uncertain diagnosis antibacterial therapy only if severe
Children >2yr: certain diagnosis antibacterial therapy only if severe
uncertain diagnosis observation

Antibiotic Treatment: amoxicillin @ 80-90 mg/kg/day is the first-line therapy for most
children and most cases of AOM. At this dose amoxicillin is affective against susceptible
and intermediate resistant pneumococci. If the patient has severe illness and/or b-
lactamase positive H. flu or M. catarrhalis is suspected clavulanate should be added to
the amoxicillin (Augmentin). These are the general rules for antibiotic choice, but it
becomes a little more complicated when considering penicillin allergies and failure of
treatment after 48-72h. A cephalosporin is usually the second line choice unless the
allergy is anaphylactic. If this is the case azithromycin or clarithromycin are usually
used. (see table in the AOM packet if you are interested in more details)

THE END you are now an AOM expert

GOOD LUCK!
 Pharyngitis/Tonsillitis in Children
(info summarized from handout and Nelsons pg488-491)

Variation with age groups

Presentation and etiologic agents tend to differ between age groups
Most common etiology in any age group is viral
Less than 3 yrs old
o Adenovirus and enteroviruses
o Grp A strep can occur, but rarely. If is occurs, tends to present as rhinitis or
otitis media
Four to seven yrs old is peak incidence of grp A strep; at 15 yrs incidence is 15%
and by 18 grp A strep causes 5% of pharyngitis.

Viral vs strep pharyngitis

Viral
o Gradual onset, early fever, malaise, anorexia, moderate throat pain and
possible diarrhea. Throat symptoms peak around 2nd or 3rd day. Systemic
symptoms eg. Fever usu mild or absent.
o May also have conjunctivitis, hoarsness, cough and rhinitis
o If two or more of these is present with a pharyngitis, viral etiology likely.
Group A Strep
o Peak in winter and spring
o Acute onset fever, dysphagia, headache.
o May have abdominal pain, vomiting, bad breath, ear pain on swallowing,
muffled voice, petechia of the soft palate.
o Some develop scarlet fever: circumoral pallor, strawberry tongue and fine,
diffuse erythematous maculopapular rash.
o One third have enlarged exudative tonsils and pharyngeal erythema.
o Two thirds have mild pharyngeal erythema and painful anterior cervical
adenopathy
o Other clues to a strep infection: scarlintiniform rash, paronychia, vaginitis,
impetigo, perianal cellulitis or desquamation
Lab Tests
o Gold standard: Throat culture obtained from tonsillar pillars or posterior
pharynx
o Rapid strep screens 70-95% sensitive so negative ones should be followed
by culture
Differential Diagnosis
o Rhinovirus: common cold - pharnygitis not as prominent as the cough and
rhinorrhea
o Coronavirus: common cold
o Adenovirus: bilateral, nonpurulent conjunctivitis, pharyngitis a prominent
symptom
 o HSV-1 (predominately, can get type 2) gingivostomatitis, usu age 1-5.
High fever, poor feeding, malaise, stinging mouth pain, drooling,
oropharyngeal (tongue, gums, lips, oral mucosa, soft and hard palate)
vesicular lesions and lymphadenopathy. Recurrent illness generally
milder and limited to the vermilion (herpes labialis).
o Parainfluenza virus: spring and fall, common cold and croup
o Influenzae: winter months, influenza
o Enterovirus: late summer, early fall
o Herpangina: pinpoint vesiculoulcerative lesions on anterior tonsillar pillars
and soft palate, uvula and tongue. Acute onset high fever, vomiting,
headache, sore throat, conjunctivitis, dysphagia (enterovirus)
o Infectious mono (EBV): exudative tonsillitis, generalized
lymphadenopathy, hepatosplenomegaly, indolent onset or prolonged
duration. Elevated atypical lymphocytes on CBC.
o Pneumococcal or H.influenzae: purulent nasal discharge, pharngitis, fever
o Diptheria: gray exudates on tonsils and uvula
o Mycoplasma: hoarseness, cough, nasal congestion in adolescent or older
child.
o Nasal obstruction, smoking, inadequately humidified air

Treatment
Treatment is for symptomatic relief and prevention of complications
Generally treatment should be withheld until diagnosis confirmed (there is debate
in the literature about whether this is harmful or helpful!)EXCEPT:
o Acutely ill or toxic appearing child in the face of known strep exposure or
outbreak
o Scarlet fever rash in association with pharyngitis
o Symptomatic pharyngitis and one of the following: past hx of rheumatic
fever or recent hx of rheumatic fever in a family member, or in an area
with epidemic rheumatic fever of poststrp glomerulonephritis
DOC for strep pharyngitis:
o Oral penicillin VK for 10 days or
o IM benzathine PCN or benzathine and procaine penicillin injection
Penicillin allergic patients: erythromycin, clindamycin or 1st gen cephalosporin
Should have a clinical response in 24 to 36 hours

Group A Strep Carriers

Carriers: grp A strep in the respiratory tract, but no serologic response.
Most studies suggest not to treat with a second course of antibiotic unless they are
symptomatic, have a family history of acute rheumatic fever, undue parental
anxiety despite reassurance, outbreak of strep in a closed or semi-closed
community or tonsillectomy for chronic carrier state is being considered.
Low risk for transmission and complications
 Treatment:
o Penicillin VK x 10days and rifampin for the last 4days
o Amoxicillin-clavulanate
o One dose IM penicillin with 4 days rifampin
o Clindamycin x 10days

Complications of Grp A Strep Pharyngitis

Suppurative
o Reflect extension of the infection from the nasopharynx and may result in
sinusitis, otitis media, mastoiditis, cervical adenitis, retro or
parapharyngeal abcess or bronchopneumonia
Nonsuppurative
o Rheumatic fever
Systemic, most frequently involves joints then heart, less
frequently, the CNS, skin and subcutaneous tissue
Can recur
Not all patients have a history of a preceding URI and only ~10%
have positive Strep cultures on diagnosis
Does not occur in infancy and unusual <5yrs of age; peak
incidence between 5-15yrs
Higher incidence in those with a positive family history
Diagnosis based on jones criteria. Must have 2 major or 1 major
and 2 minor manifestations with supporting evidence of preceding
strep infection (ASO titier or Strep antibody, positive throat
culture or recent scarlet fever)
Major: Joints<Carditis<Chorea<Erythema
marginatum<subcutaneous nodules
Minor: Fever, arthralgias, previous rheumatic fever or heart
disease, lab findings of acute phase reaction (sed rate, CRP,
leukocytosis) or prolonged QT on ECG
Treatment depends on affected system but usually includes
penicillin during the acute phase and as prophylaxis for those
diagnosed with rheumatic fever
Early treatment of a strep infection may prevent acute rheumatic
fever.
o Acute post-streptococcal glomerulonephritis (PSGN)
Can occur after strep infection of the skin, throat, or nephritogenic
strains of group A Strep.
Usually occurs within 1-2 weeks of strep infection. Latency is
usually longer following a skin infection than strep pharyngitis.
Present with acute nephritic syndrome
Sudden onset gross hematuria, edema, hypertension, renal
insufficiency
 Early systemic treatment of throat and skin infections may reduce
but not eliminate risk of PSGN
Treatment: Supportive care for renal failure and 10 day course of
systemic antibiotics
Complete recovery in >95% of cases and recurrence is rare.

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

Normal Growth
The Health Maintenance Visit
Allow for physical exam as well as discussion of proper nutrition, behavior,
development, and safety
Monitor normal growth and development
May show disease process or abuse
Growth = inc. in body size; development = inc. function of processes related
to body and mind
AAP recommends health maintenance visits at:
1st week of life (depending on nursery discharge)
2nd week of life
2, 4, 6, 9, 12, 15, and 18 months
1x per year from 2-6 years of life
every other year until adolescence is complete
Normal Growth
Deviation from normal growth patterns may indicate serious or chronic disease
Accurate measurements should be taken at visits, including:
Height
Weight
Head circumference
Some rules of thumb for growth:
Weight:
Changes in weight:
Lose 5-10% of birth weight in 1st few days
Return to normal birth weight at 7-10 days of age
Double weight at 4-5 months
Triple weight at 1 yr
Quadruple weight 2 yr
Avg. weights:
Birth = 3.5 kg
 1 yr = 10 kg
5 yr = 20 kg
10 yr = 30 kg
Daily weight gains:
20-30 grams for 1st 3-4 months
15-20 grams for remainder of 1st year
Annual weight gains:
5 lb. between 2 years and puberty (spurts and plateaus may occur)
Height:
Avg. length or height:
20 inches at birth
30 inches at 1 yr
3 ft at 3 years
40 inches at 4 years (double birth length)
Annual avg. height inc. is 2-3 inches between 4 yr. and puberty
Head Circumference:
Average is 35 cm (13.5 inches) at birth
Growth:
1 cm/month for 1st year (2 cm/month for 1st 3 months, then slower
growth)
10 cm for rest of life
Plot measurements on growth charts b/c they allow you to see deviations in a
kids particular pattern
This shows change even if measurement falls in normal limits (defined as 3rd
to 97th percentile)
What is on CDC Growth Charts published in 2000 (which are based on nationally
representative data)?
Ages 0-36 month chart:
Weight for age
Length for age
HC for age
Weight for length
Ages 2-20 year old chart:
Weight for age
Height for age
BMI for age *BMI = weight(kg) / height (m) squared
If BMI units are pounds and inches squared, multiply by correction
factor of 703 to obtain proper BMI
BMI over 95th percentile means overweight; between 85-95th
percentile means at risk for becoming overweight
Remember that normal child growth patterns include spurts and plateaus
 Growth is not along a smooth line, as the growth chart would have your
think
Large shifts in percentiles or major discrepancies in size should be looked
into, however
When caloric intake is inadequate, weight percentile falls first, then height, and
HC last
Reasons for inadequate caloric intake:
non organic failure to thrive means parents not feeding enough, or not
giving adequate attention
Increased caloric needs:
Chronic illness
Malabsorption issue
What does increasing weight percentile in the face of decreasing height percentile
mean?
Answer: Hypothyroidism
Some words about Head Circumference
HC may be disproportionately large in certain instances including:
Familial macrocephaly (knowing parental head size is crucial)
Hydrocephalus
catch up growth in a neurologically normal premature infant
microcephaly is considered HC below 3rd percentile, even if other
measurements are proportionately low
serial HC measurement is crucial during infancy, when the brain is rapidly
growing, and should be plotted regularly until the age of 3

Disorders of Growth

Deviant growth measurements

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

Table 6-1. Specific Growth Patterns Requiring Further Evaluation

Pattern Representative Further Evaluation
 Diagnoses to Consider
Weight, length, head circumference all Familial short stature Mid-parental heights
<5th percentile
Constitutional short Evaluation of pubertal
stature development
Intrauterine insult Examination of
prenatal records
Genetic abnormality Chromosome analysis
Discrepant percentiles (e.g., weight 5th, Normal variant Mid-parental heights
length 5th, head circumference 50th, or (familial or
other discrepancies) constitutional)
Evaluation of pubertal
development
Endocrine growth Thyroid hormone
failure
Caloric insufficiency Growth factors,
provocative GH
testing
Declining percentiles "Catch-down" growth Complete history and
physical examination
Dietary and social
history
Failure to thrive
evaluation

The role of parental heights in assessing growth problems

Mid-parental height is an approximation of how big the kid will be
For a girl, its: {in inches} (dads height + moms height - 2.5)/2
For a boy, its: {in inches} (dads height + moms height + 2.5)/2
Familial short stature
Growth pattern shows small weight, length , and head circumference
Constitutional short stature
A child who is preadolescent or adolescent by age and starts puberty later than
others (normal variant)
This growth pattern must be examined closely to rule out abnormalities of
pubertal development
Girls are considered normal if secondary sex characteristics (breast buds) are
present by 14, and menarche by 16
If menstruation does not begin until 16, the girl was likely smaller than her
peers when she was 12-13
Catch-down Growth
growth moves to lower percentiles during 1st year of life
 mother had excellent prenatal care and provided appropriate nurturing, so baby
started out on a high growth percentile
Between 6-18 months, baby drops percentiles until they match their genetic
predisposition and then grow along that lower growth percentile
Will have normal developmental, behavioral, and physical exams
must be followed closely to rule out any pathology
Catch-up growth
infants who were born small for gestational age or premature ingest more breast
milk or formula
counsel family that baby needs lots of food until they catch up
baby should get as much as they want, unless throwing up ( not just spitting
up)
unless there are complications that require extra calories, baby will usually catch
up in growth in first year of life
some of these small infants can benefit from a high calorie formula
Distinctive patterns of proportional growth rates correlate with function
Nervous systems most rapid growth is in 1st 2 years, with increasing physical,
emotional, behavioral, and cognitive development

Normal Development Physical Assessment

Newborn period
Primitive neonatal reflexes are unique in the newborn, due to continued CNS
development after birth
Delay in the expected disappearance of these reflexes warrants further
investigation
Most important reflexes to assess are as follows:
Moro reflex
Elicit by lifting infant just barely off mattress and letting drop; you will
see abduction and upward movement of the arms, followed by adduction
and flexion
Should disappear by 4-6 months
Rooting reflex
Touch corner of infants mouth, resulting in lowering of the lower lip on
the same side with tongue movement toward stimulus; face may also turn
Disappears at 4-6 months
Sucking reflex
Vigorous sucking when almost any object is placed in the infants mouth
Later replaced by voluntary sucking only
Grasp reflex
 Occurs when placing object in palm (palmar grasp) or sole (plantar grasp);
infant will flex fingers or curl toes
Palmar grasp disappears at 3-4 months; plantar grasp disappears at 6-8
months
Asymmetric tonic neck reflex
Place infant in supine position, and turn head to side; this placement
results in ipsilateral extension of the arm and the leg into a fencing
position; contralateral side flexes
Disappears at 2-3 months
Later infancy
As kids develop fine motor skills, they are first able to control posture, then
proximal muscles, then distal muscles
At this time, parents may notice orthopedic deformities
If deformity is able to be manually put into the proper position by the
examiner, it has a high likelihood of resolving with progression of fine
motor skills
Fixed deformities warrant immediate pediatric consultation
Visual and ocular movements should be continuously evaluated to prevent
strabismus
Cover test and light reflex should be done at every visit
Late school age / Early adolescent
If participate in sports, need comprehensive sports physical, including
Cardiovascular exam
Hx of heart disease or murmurs, dyspnea or chest pain on exertion, irregular
heart rate, syncope, or seizure should be referred to Peds cardiologist
Family hx of heart disease or disease of the vasculature before age 50, or
unexplained death at any age requires addition assessment
This applies to immediate family or immediate familys immediate family
Contact sports require special vulnerabilities to be assessed
Hx of renal disease, such as having only 1 kidney
Vision should be assessed
Adolescent
These kids need comprehensive health assessment to ensure that there are no
major problems with passage through puberty
Other issues of physical development include:
Scoliosis - most is only mild and requires only observation
obesity
trauma
Monitor kids sexual maturity, which will provide an ongoing evaluation of
puberty
It is about 2 years from breast buds until menarche
Girls must be assessed as to their menstrual cycles, especially dysmenorrhea
(painful period) or menometrorrhagia (irregular or excessive bleeding during
period or between periods)
 Boys must be assessed for gynecomastia
Developmental milestones (well established through the age of 6)
A behavior is the response of the neuromuscular system to a specific situation
By observing specific behaviors (or asking parents about them), we can
compare a childs behavior with that of normal kids, whose behaviors evolve
in a uniform sequence within specific age ranges
Our assessment covers many areas of development:
Gross motor
Fine motor
Language
Some areas that are missed in this assessment include social and emotional
development
After 6 years, development is assessed by things like school performance,
intelligence tests, personality profile, etc

Normal Development Psychosocial Assessment

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

Table 7-1. Evaluating School Readiness

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

Early Adolescence
Attention is focused on the present and the peer group
Normality is typically sought
Exploratory, undifferentiated sexual behavior resulting in physical contact with
same sex partners is normal; heterosexual interest may also develop
Difficult to interview these patients, b/c they usually respond with short answers,
and have little insight
Middle Adolescence
More abstract thinking is now performed
Focus on identity, not limited only to the physical aspects of themselves
Explore their parents and societys value system, sometimes by expressing the
contrary side of dominant values
Challenge authority, seek independence
Many high risk behaviors engaged
Unprotected sex
Drugs
Dangerous driving
At higher risk for morbidity or mortality from accidents, homicide, and
suicide
Late adolescence
Think more about the future
More committed to sexual partners than earlier
Unresolved separation anxiety from previous developmental stages may emerge at
this time
Modifying psychosocial behaviors
 Operant conditioning involves manipulation of environmental antecedents and
consequences of actions to modify maladaptive behavior and to increase desirable
behavior
Four major methods of operant conditioning include:
Positive reinforcement following good behavior with a favorable event
Negative reinforcement follow good behavior with removal, cessation,
or avoidance of unpleasant event
Extinction occurs when there is a decrease in the frequency of a
previously reinforced behavior because the reinforcement is withheld
Punishment decreases behavior through unpleasant consequences
Positive reinforcement has been proved to be more effective than punishment
Temperament (behavioral style)
Three common constellations of temperamental characteristics:
Easy Child (40% of kids)
Regular biologic functions (eating, sleeping, elimination)
Positive mood and approach to new stimuli
High adaptability to change
Mild to moderate intensity of responses
Difficult Child (10% of kids)
Irregular biologic functions
Negative mood and negative withdrawal from new stimuli
Poor adaptability
Intense responses
Slow to Warm Up Child (15% of kids)
low activity level
withdrawal from new stimuli
slow adaptability
mild intensity responses
somewhat negative mood
the remaining children have more mixed temperaments

Disorders of Development

Developmental surveillance and screening

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

Table 8-1. Developmental Milestones

Fine Motor- Personal-
Age Gross Motor Adaptive Social Language Other Cognitive
2 Moves head Regards face Alerts to bell
wk side to side
2 Lifts shoulder Tracks past Smiles Cooing
mo while prone midline responsively
Searches for sound
with eyes
4 Lifts up on Reaches for Looks at hand Laughs and
mo hands object squeals
Rolls front to Raking Begins to work
back grasp toward toy
If pulled to sit
from supine,
no head lag
6 Sits alone Transfers Feeds self Babbles
mo object hand
to hand
Holds bottle
9 Pulls to stand Starting to Waves bye-bye Says Dada and
mo pincer grasp Mama, but
nonspecific
Gets into Bangs 2 Plays pat-a- 2-syllable sounds
sitting position blocks cake
together
12 Walks Puts block in Drinks from a Says Mama and
mo cup
cup Dada, specific
Stoops and Imitates others Says 1-2 other
stands words
15 Walks Scribbles Uses spoon and Says 3-6 words
mo backward fork
Stacks 2 Helps in Follows
blocks housework commands
18 Runs Stacks four Removes Says at least 6
mo blocks garment words
Kicks a ball "Feeds" doll
2 yr Walks up and Stacks 6 Washes and Puts 2 words Understands
 down stairs blocks dries hands together concept of "today"
Throws Copies line Brushes teeth Points to pictures
overhand
Puts on clothes Knows body parts
3 yr Walks steps Stacks 8 Uses spoon Names pictures Understands
alternating feet blocks well, spilling concepts of
little "tomorrow" and
"yesterday"
Broad jump Wiggles Puts on t-shirt Speech
thumb understandable to
stranger 75%
Says 3-word
sentences
4 yr Balances well Copies O, Brushes teeth Names colors
on each foot maybe + without help
Hops on one Draws Dresses Understands
foot person with without help adjectives
3 parts
5 yr Skips Copies Counts
Heal-to-toe Understands
walks opposites
6 yr Balances on Copies Defines words Begins to
each foot 6 sec understand "right"
and "left"
Draws
person with
6 parts

Because of the variability of childhood development, standards for abnormality in

developmental/behavioral screens are set lower than what is usually accepted for
other medical screens
Sensitivity and Specificity are both between 70-80%
Denver Developmental Screening Test II is commonly used
Assesses kids from birth to 6 years in four domains:
Personal-social
Fine motor-adaptive
Language
Gross motor
Parent reported screens have good validity compared to office visits
Language screening
See table 8-2 for rules of thumb
Table 8-2. Rules of Thumb for Speech Screening
Articulation (Amount of
Age Speech Understood by a Following
(yr) Speech Production Stranger) Commands
1 1-3 words One-step
commands
2 2- to 3-word phrases Two-step
commands
3 Routine use of sentences
4 Routine use of sentence sequences; Almost all
conversational give-and-take
5 Complex sentences; extensive use Almost all
of modifiers, pronouns, and
prepositions

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

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

Dysfluency (stuttering) is common in 3-4 year olds

Unless the dysfluency is severe, is accompanied by tics or unusual
posturing, or occurs after 4 years old, parents should be counseled that it is
normal and transient
Other issues in assessing development and behavior
Table 8-4 lists some contextual factors that should be considered in the etiology of
a childs behavioral or developmental problem
Table 8-4. Context of Behavioral Problems
Child Factors
Health (past and current)
Developmental status
Temperament (e.g., difficult, slow to warm up)
Coping mechanisms
Parental Factors
Misinterpretations of stage-related behaviors
Mismatch of parental expectations and characteristics of child
Parental characteristics (e.g., depression, lack of interest, rejection, overprotectiveness)
Coping mechanisms
Environmental Factors
Stress (e.g., marital discord, unemployment, personal loss)
Support (e.g., emotional, material, informational, child care)
Parent-Child Interactions
The common pathway through which the listed factors interact to influence the
development of a behavior problem
The key to resolving the behavior problem

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

Appendix: The Denver II Scale

I copied the explanation of the Denver and how to use it from the book, in case someone
hasnt used it yet. Here it is:
The Denver Developmental Screening Test II is commonly used by general
pediatricians (Figs. 8-1 and 8-2). The Denver II assesses the development of children
from birth to 6 years in four domains: (1) personal-social, (2) fine motor-adaptive, (3)
language, and (4) gross motor. Items on the Denver II are carefully selected for their
reliability and consistency of norms across subgroups and cultures. The Denver II is a
useful screening instrument, but it cannot assess adequately the complexities of
socioemotional development. Children with "suspect" or "untestable" scores must be
followed carefully.
The pediatrician asks questions (items labeled with an "R" may be asked of parents to
document the task "by report") or directly observes behaviors. On the scoring sheet, a line
is drawn at the child's chronologic age. All tasks that are entirely to the left of the line that
the child has not accomplished are considered delayed (at least 90% of the population
accomplished the task). If the test instructions are not followed accurately or if items are
omitted, the validity of the test becomes much poorer. To assist physicians in using the
Denver II, the scoring sheet also features a table to document confounding behaviors,
such as interest, fearfulness, or apparent short attention span. Repeat screening at
subsequent health maintenance visits often detects abnormalities that a single screen was
unable to detect.
Instructions for the Denver II. Numbers are coded to scoring form (see Fig. 8-1).
"Abnormal" is defined as two or more delays (failure of an item passed by 90% at that
age) in two or more categories or two or more delays in one category with one other
category having one delay and an age line that does not intersect one item that is passed.
(From Frankenburg WK: Denver II Developmental Screening Test, 2nd ed. Denver,
Denver Developmental Materials, 1990.)

SPECIAL NEEDS CHILD EVALUATION

1. Mental Retardation: significant subnormal intellect for developmental stage+

decreased adaptive behaviors (home living, communication, social interaction)
2 std. dev below, or ~3rd percentile IQ score
Stanford Binet IQ Test: MR if < 67
Weschler Intelligence Scale (WSC III): MR if <70
Of greater importance is areas of defecit
DDx (descending frequency):
Alterations in embryonic devel: chromosomal changes, prenatal influence
Idiopathic (~1/3 do not have identifiable reasons for disability!)
Env/Social: deprivation, neglect, toxins (e.g. lead)
Pregnancy/ perinatal complications
Hereditary: e.g. Fragile X
Acquired: infection, trauma, toxin (e.g. lead)
Socioeconomic status ~ mild MRnot profound MR
Px: the earlier the cognitive defecit is noticeable, the more severe it is likely to be

2. Vision Impairment- can delays in perception, imitative behavior (smiling),

motor, bonding
Partial vision: 20/70- 20/200; very common (1/500 school kids)
 Legal blindness: 20/200 in better eye or visual field angle < 20deg
Mild/Moderate visual impairment- usually refractive errors
a. Myopia (mc): near sighted
b. Hyperopia: far-sighted
c. Astigmatism: abnl. shaped cornea
Refractive errors in kids <6y can still amblyopia: pathological alterations
in visual system that decr. acuity
Severe visual impairment: usually diagnosed @ 4-8m following parental concerns
&/or findings on PE (fixation, visual tracking, persistant nystagmus)
* note: binocular vision not expected in neonatal period, assess
vision with electric impulses/electrodes along optic path
DDx:
a. Retinopathy of prematurity: mc, usually bilateral
- oxygen toxicity to premature blood vessels of retina,
causes vasoconstriction obliteration, fibrovascular proliferation
b. Congenital cataracts: amblyopia
c. Optic atrophy
d. Retinal degeneration/retinitis pigmentosa
e. RB
f. Congenital glaucoma

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

4. Speech/Language Impairment
 Concerning signs are any dysfluency, repetitions, blocks, struggles (grimacing,
blinking, excessive gestures) or:
Birth
} no startle, attendance to voice, babbling
6m
10m- no response to name, only shrieks/grunts
12m- only vowel sounds
15m- no response to no, bye-bye, bottle
18m- <6 words
21m- no resonse to give me, sit, come
23m- no 2-word phrases (thank you, all gone)
24m- most speech still incomprehensible
no pointing to body parts, no word combos
30m- no short sentences, prepositions, questions
36m- no understanding by unfamiliar listeners
DDx speech delay:
MR
Hearing impairment
Social deprivation
Autism
Oral-motor abnormality
SPEECH disorder (d/o) vs. LANGUAGE d/o
- articulation d/o: sounds, syllables - receptive: cant understand
- fluency d/o: stoppage, stutter, prolonged sounds - expressive: cant put words
resonance d/o: pitch, volume, quality together, impaired vocab,
social
inappropriateness
Tx: speech therapy- best outcome if begun before 3y
5. Cerebral Palsy: group of nonporgressive motor impairment syndromes
Motor impairment: hemiparesis/hemiplegia, diplegia (usu. legs),
quadriplegia..all impairment rated for severity I-V
Secondary to anomalies/lesions of immature brain
~ 2-2.5/1000, higher in premature, twins
Causes:
o Perinatal asphyxia
o Kernicterus
o Occult infections/inflammation
Risk factors:
o Maternal thyroid or seizure d/o
o FHx of MR
o Low SES
o Hormone tx
o Pregnancy/perinatal complication (asphyxia, ischemia)
o Bilirubin encephalopathy
 Types:
a. Spastic- mc; injury of UMNs incr. tone/hyperreflexive
b. Dyskinetic- abnormal, involuntary movements
c. Ataxic- cerebellar injury abnl posture, loss of coordination
d. Choreoathetotic- due to kernicterus stormy movements, decr. Tone
e. Mixed- more complications with this type
Co morbid conditions include epilepsy, learning disability, behavior challenges,
sensory impairments
Tx: PT/OT, for spasticity: botulinum toxin or baclofen, plus management of
seizueres, sensory impairments

WELL CHILD EVALUATION

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

Well child Screening

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

2) Vision- until 3y, visual screen inferred from gross motor development, subjective
reports, and eye exam; after 3y use Snellen card (with objects or letters)

3) Anemia- screen at ages of highest risk for Fe-defic. Anemia:

 9 m- high incidence of
Fe-deficiency! 11y 21y

@ birth if Childhood
premature screening in high- Routine screening resumes in
or VLBW risk or present sx. adolescence; once for boys,
annually for girls

4) Urinalysis- blood, signs of infection, renal function etc.

5) Lead- can irreversible devel/behavioral abnormality!

- screen for risk factors: old home/buildings? Industrial exposure
(auto radiator repair, battery recycling)? traditional remedies (Mexican),
hobbies (pottery glaze)?
- state requires lead measurements @ 9-12mo &/or 2y
- sample must be from venous blood (cap blood:
false +)

6) Tuberculosis- assess @ 1y since child TB usually systemic (miliary)

- PPD test: evaluation 48-72h; positive based on size:
- + if 10 mm or 5 mm with HIV, immunocomp.,
previous TB

7) Cholesterol- screen in high risk pts: obese, smoker, DM or FHx of high

cholesterol, heart disease, MI
- if random total cholesterol 200 mg/dL, follow with fasting
analysis

8) STDs- screen any child with any history of any form of sexual intercourse at
least annually; in girls: screen for HPV with Pap smear 3y after sexual
intercourse or age 21

Immunizations- very impt. Component of WCC, see Chases

outline!
Dental- recommendation is visit to hygienist ea. 6months, dental
exam ea. 1year - look for evidence of milk-bottle caries!never let child
sleep with milk bottle!
Nutrition- growth curves!!- see Leigh Annes outline!
Anticipatory Guidance
i. Injury prevention
Car safety- crashes are mcCOD in 1m-1y!
 - should not d/c pt w/o good car seat
- seat laws: required until 4y or 40 lbs
- 1y: rear facing, 1y: front facing
- 4-8 y: booster seat
- 12y: back seat only!
Sleep safety- 6m: back to sleep to prevent SIDS
ii. Violence prevention
iii. Nutrition
iv. Development/Behavior (see Table 9-5 p 40-41 in Nelson for complete guideline)
Discipline- goal is to teach self control, not just punish- more important
to reinforce good behavior- common techniques are:
a. scolding: less effective over time, caution against derogatory
statements, encourage parents: good child who does bad occasionally
b. physical punishment: can escalate to abuse or teach child to hit
c. threats: never threaten to leave child!- loss of privileges is best
- recommend balance of freedom and limits: limits should be clearly
explained and enforcement should be firm, brief, consistently linked to
undesired behavior
i. Extinction: ignoring frequent, annoying behavior (tantrums); good
for toddlers too young to understand timeout- always follow w/
praise!
ii. Timeout- immediately following behavior, recc: 1 min/ year age

Nutrition Sources: Infant Feeding Article, Nelsons, First Aid

Questions- Leigh Anne @ lahosk2@uky.edu
Infants
Breastfeeding:
- Superior because of benefits to infant and mom:
o For newborn, anti-infective properties lower risk of diarrhea, resp illnesses, OM,
bacteremia, bacterial meningitis, necrotizing enterocolitis, maybe food allergies,
eczema, asthma, Crohns, DM; also may provide cognitive benefits, although
other factors may be involved.
o For mom, lowers risk of post-partum hemorrhage, ovarian/breast cancer,
osteoporosis, lengthens amenorrhea, provides mother-baby bonding, and lowers
health care costs.
- Problems/Contraindications
o Engorgement ~3rd postpartum day; treat by enhancing milk flow
o Mastitis: fever, chills, malaise, tx: frequent emptying of breast and abx
o Breast abscess may progress from mastitis; tx: incision and draining, abx, regular
emptying. CAN nurse with affected breast if comfort allows.
o Jaundice: more common in breastfed than formula-fed
Breastfeeding: insufficient milk intake, poor wt gain, high unconj. bili
2 to high enteropathic circulation. Tx: increase milk production/intake
Breast Milk: (older infants) prolonged elevated serum bili d/t unknown
factor in milk that increases bilirubin absorption. Dx of exclusion, rare.
o DO NOT breast-feed Herpes breast lesions, HIV (in Africa, benefits>risks),
infant galactosemia, w/ TB, syphilis, varicella - can restart breastfeeding after tx
 initiated; Maternal drug use absolutely contraindicated: radioactive compounds,
anti-metabolites, lithium, anti-thyroid; warn mother against etOH, nicotine,
caffeine, etc
- Human Milk Content: ~20 kcal/oz
o Protein - 70%whey and 30%casein, many proteins that boost immune system
o Lipids (50% of energy content)- includes essential FA and long-chain FA
(including arachidonic and docosahexaenoic acids that are NOT in bovine
milk or in formulas may be important to neuro/retinal development)
o Carbohydrate: Lactose; Lactase appears late, so some lactose may enter distal
small bowel and ferment, allowing proliferation of lactobacilli; these produce an
acid medium that suppresses other pathogenic organisms and promotes
absorption of Ca and PO4
o Adequate Vitamins and Minerals, low Na+ and solute concentrations.
o Must supplement at 4-6 months:
Fe (1 mg/kg/day) through Fe-fortified cereal.
VitD (400IU/day) for dark-skinned or those not exposed to sun-light
Fluoride if water supply contains <0.3ppm fluoride
o Should NOT supplement with water, glucose water, or formula in healthy babies
- In the early weeks, infant should feed 8-12x/day; assess adequacy through voiding and
stool patterns and rate of wt gain:
o Voiding: nL 6-8 soaked diapers/day; Stools @5-7 days, loose yellow seedy
4x/day, more than formula-fed; after 6-8 weeks, breastfed infants may go several
days w/o stool
o Weight: <7% loss after birth, and should regain birth wt by day 10, then infants
should gain approximately 25-30g/day or 5-7 oz/week
o Rates of growth slower in breastfed than formula-fed
Formula Feeding:
- Indications for formula use: mothers who do or can not provide human milk, certain
inborn errors of metabolism causing intolerance, mothers with infn known to transmit in
breast milk HIV, some CMV, HSV, mom on chemotherapy, radioactive compounds,
anti-thyroid meds, or Lithium, or FTT after encouragement / breastfeeding therapy
- Newborns require ~110-120 kcal/kg/day.
- Formula-fed infants have more rapid wt-gain than breastfed- discrepancies do not
persist past age 2 years; may be greater risk of obesity in formula-fed.
Types of Formulas:
- Cows Milk-based
o Content:
20kcal/oz (similar to human milk), AAP recommends Fe-fortified!
Protein: 1.4-1.6g/dL (about 40% greater than that in human milk).
Contains different ratios of whey to casein proteins with different amino
acid patterns.
Fat: also 50% of caloric content; butterfat of cow milk replaced with
vegetable oils to enhance digestibility and absorption. Essential fatty
acids (linoleic and alpha-linoleic acids) added; debate of whether AA and
DHA should be added (they are NOT added currently).
Carbohydrate: Lactose. Lactose intolerance rare in 1st year, but
nonlactose-containing formulas are increasingly given to infants w/
nonspecific GI symptoms; should be reserved for pts with galactosemia
and lactase deficiency.
 Iron: 12 mg/L. Although AAP recommends all infants take Fe, low-Fe
containing formulas are still made, because of a perception that Fe causes
constipation.
Mineral and Vitamin content adequate for first year, except for Fluoride
should be added at 6 months if water has <0.3ppm
- Soy Formulas:
o for galactosemia, lactose intolerance, vegetarian families, and when allergic to
cows milk proteins (but often child will be allergic to both)
o Supplemented with methionine, glucose oligomers as carbohydrate source, fats
similar to cows milk-based formulas. Do not prevent later allergies.
o The use of soy formulas and lactose-free cows milk formulas greatly exceeds the
incidence of cow milk protein allergy and lactose intolerance.
- Therapeutic Formulas:
o Protein hydrosylate formulas: for infants intolerant/allergic to intact milk protein;
some hydrosylated protein formulas also contain medium-chain TGs to facilitate
fat absorption and are lactose-free, good for pts with malabsorption problems
CF, short gut syndrome, biliary atresia, lactase deficiency, etc.
o Low-solute formulas: for pts with renal, CV dysfxn require careful use and
follow-up.
o Special Amino-acid based formulas: for specific inborn errors of metabolism.
o Toddler formulas: with higher protein, fat, and carbohydrate contents for
nutritional supplements for young children with FTT from variable etiologies.
- Lead Exposure: still common in US; older homes with lead pipes. Moms instructed to use
only cold water, run water for 2 minutes, and avoid boiling it.

Nutritional Needs of Preterm Infants:

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

Introducing Complimentary Solid Feedings: usually occurs at 4-6 mos.

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

Toddlers
- Cows milk: not introduced until 1 year to avoid occult intestinal blood loss, and then
should be limited to avoid reducing intake of other nutritionally important solid foods.
- Juice: for toddlers, <4-6oz/day; for 7-18yo, <8-12oz/day.
- Power struggles are common between parents and children.
- Families in federal assistance programs are significantly either under or overweight.
- @ 2 years, complex carbohydrates 55-60%, simple sugars <10%, fat intake is gradually
increased to ~30% and not less than 20%, Na intake should be limited, Avoid grazing!

Adolescents
- When poor eating habits commonly develop.
- Excessive sugar (soda, fruit juices, coffee) weight gain and tooth decay
- Osteoporosis due to poor dietary calcium or vitamin intake becoming more common

Obesity
- Defined: body weight 10% > that ideal body wt for age, gender height.
- 10% of 4-5 yo obese; 15% of Americans 6-19 overweight; highest in African American
and Mexican populations
- Certain genetic disorders account for <5% of Obesity (examples: Cushings syndrome,
hyperinsulinism, muscular dystrophy, Prader-Willi Syndrome, myelodysplasia,
pseudohypoparathyroidism, Turners Syndrome)
- Obese children Obese adults; risk increases with age, degree of obesity, family hx
- Must screen for complications: psychosocial, growth, CNS, respiratory (apnea), CV,
ortho (SCFE), metabolic (DM); and for conditions/syndromes associated with obesity:
o Obesity makes SHADE: SCFE, Hypertension, Apnea, Diabetes, Embarrassment
- Dx: graph BMI on curve: >85th% at risk for overweight, >95th% overweight/obese.
- Tx: organized program of diet and exercise, behavioral modifications, must maintain
nutrients for growth: for children 2-7 with BMI > 95th%, MAINTAIN wt; if there are 2
complications, LOSE wt
- NO television for children <2 years; and for older children, limit TV time to <2hours.
- Prevention: Breastfeeding, regularly scheduled meals, recognize satiety cues, and never
force children to eat when they are unwilling. After 2 years, switch to 2% or skim milk.

Pediatric Undernutrition
 - Protein-Energy Malnutrition (PEM) a leading cause of death <5 yo worldwide
- Failure to Thrive:
o Defined: wt <3rd % or a fall off the growth chart by 2 lines.
o Prevalence ~5-10%, associated with psychosocial risk factors
o Signs: SMALLKID: Subcutaneous fat loss, Muscle atrophy, Alopecia, Lagging
behind norms, Lethargy, Kwasiorkor/marasmus, Infection, Dermatitis
- Marasmus: severe Protein-Calorie Malnutrition (PCM), wasting.
o Due to low nutritional intake or associated with chronic diseases (CF, TB, cancer,
AIDS, celiac disease).
o Emaciation with wt <70% ideal or <60% of median
o Loss of muscle mass and subcutaneous fat stores
o Bradycardia, hypothermia, hypotension, decreased strength, dry thin skin and
hair, atrophy of filiform papillae, stomatitis, delayed wound healing, impaired
immunity
- Kwashiorkor: hypoalbuminemic, edematous malnutrition, presents with pitting edema
o Inadequate protein intake w/ good caloric intake, normal or slightly low weight
o PE: generalized edema, atrophy of muscle mass but maintenance of adipose
tissue, thin dull hair, skin changes (hyperpigmented hyperkeratosis, pellagroid,
painful desquamation), angular cheilosis, filiform atrophy, moon facies, enlarged
liver, basilar rales
- Tx of malnutrition: initiated and advanced slowly to prevent unmasking micronutrient
deficiencies and intolerance by the previously less-active GIT. IV fluids should be
avoided to avoid resulting CHF or renal failure.
o Calories started at 20% above childs recent intake (or 50-75% nL requirement)
o Avoid Refeeding syndrome: fluid retention, hypoPO 4, hypoMg, hypoK+
o Caloric intake increased 10-20%/day until age-appropriate growth
o For infants/children, provide 100-120kcal/kg based on ideal wt, no added Fe
- Complications: infn, hypoglycemia, hypothermia, bradycardia, micronutrient deficiencies

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

TODDLER DEVELOPMENT
Growth and appearance
-growth slows after infancy
-after 2, toddlers gain ~5# in weight and 2.5/yr
-growth occurs in spurts
-growth occurs primarily from L.E.
-between 2 and 2.5 kid will reach 50% of adult height
Gross motor skills
-motor skills develop rapidly during this time
-most walk w/o assistance by 18 mo.
-@ ~ age 2, gait becomes flexible, steady walking pattern with adult heel-toe
progression
-by 36 mo, can stand on one foot briefly
-often test their skills beyond their abilities
Fine motor skills
-result from refinements in reaching, grasping, and manipulating small objects
 -avg 18 mo old can make a tower of 4 blocks
-1 yr later (2.5) can stack 8 blocks
-18 mo old will hold crayon and scribble spontaneously
-1.5 yr later (3yr) can grasp as adult and make a circle and maybe a stick fig.
Affective development
-new drive for automomy
-begins to test boundries/limits daily
-classic manifestation of struggle for autonomy is the temper tantrum
Impulse control
-begin to develop impulse control
-18 mo old may have minimal impulse control
-2 yo exhibit wide variations in impulse control
-most 3 yr old have mastered some degree of impulse control
-impulse control, improved motor skills, struggle for autonomy are highly evident
during toilet trng
-successful toilet trng usually at end of 3rd yr (just before 3rd b-day)
-consistent daytime dryness @ ~ 2.5 yr old
Attachment
-remains important developmental theme
-refers to the bond that forms between infant and caregiver
-secure bond important for toddler who seeks autonomy
Temperament
-how a child approaches a given situation
-has strong genetic influences
-apparent during earliest infancy
-3 temperamental constellations: easy, hard, slow to warm-up
-approx 10% difficult, 40% easy, 15% slow to warm-up
-difficulties may arise when a toddlers temperament conflicts with caregivers
expectations
Cognitive Development
-transition from sensorimotor to pre-operational
-marked by development of symbolic thinking
-transition form sensorimotor to symbolic thought typically between 18 & 24
months
-ex. Block may serve as a car, a bucket as a hat
-develop object permanence (finding an object despite not seeing it hidden)
-by 3, can draw primitive figures that represent important people
-@ 3 develops elaborate play and imagination
-continues to see world egocentrically
Language
-around age 2, toddlers use language to convey thoughts and needs
-avg 18 mo old has vocab of at least 20 words
-receptive language somewhat more advanced
-in a few months (~20) 50% of language should be intelligible to strangers
-by age 3, voc increases to about 500 words, 75% intelligible to strangers
-begins myriad of why questions
 PRESCHOOL DEVELOPMENT(this handout was terrible, absolutely terrible)
Communicative and motor aspects
-many changes occurring from 2-5
-early developmental guidance should focus on all children to optimize function
-several researchers have noted existence of multiple intelligences rather than just
IQ
-developmental guidance must take into account childs temperament and
parenting style
-guidelines for child health supervision entitled Bright Futures
-these guidelines suggest the use of a process called developmental surveillance,
where emergence of abilities in children over time
-provides specific trigger questions
Conducting Developing Surveillance
Developmental trajectory
-must decide quickly which topics to pursue at the visit
-should generate a developmental trajectory before visit concludes
-develop traj is a hypothesis formed by the interaction among child, parent, and
environment
-trigger questions address all major areas of developmental functioning:
speech/language, cognition, gross/fine motor, personal-social skills, adaptive
skills
Overview of milestone
-development proceeds in spurts and has ranges of ages for attainment
-2,3,4,5 yr old visits are assumed to be conducted w/in 3 months of birthday
-for tasks listed, @ least 50% of children w/in 6 months of visit age could
complete
Specific concerns
Specific Concerns
Communication
-children master most of the syntax by age 6
-2 yr old language consists of more words than jargon even if not understood by
strangers
-150-200 word vocab with 2 word utterances
-use inflexion in asking questions
-2 yr old mimic what others say (echolalia)
-criterion for referral is voc of <50 words or not putting 2 words together at age
~2
 -2 yr old with expressive lang delay with intact receptive lang has better prognosis
-3 yr old speaks in simple well formed sentences
-sentence length increases by 1-2 words per year in preschool period
-5 yr old can use complete sentences and tell jokes
-dysfluency occurs transiently between 2.5 and 4 yrs old
-worsening stuttering beyond age 4 should be taken seriously
-1% of preschool age children dxd with stuttering
-great variation in development of language
-girls more advanced than boys
-children with superior language skills have fewer behavioral probs
Clinicians interview of the child
-should attempt to communicate directly with child
-drawing interview: creates a conversation piece that has childs interest and
attention
Comprehension
-distinguish simple requests from simple instructions without gestured clues
-naming body parts possible response for the 15,18,24 mo visits
-good 2 yr visit is names of 7 body parts
-can pick the larger of 2 lines @ 3 yrs
School readiness
-parents eager and anxious about preschoolers readiness for school
-reading not expected before age 6
Gross motor skills(see prev handout)
-@ 2 bent over while running
-@ 3 more upright
-improving balance, coordination continues
Approach to fever in the child:

Warning****There was no specific packet in our notes that addressed this issue, so as
you study some of the other material (otitis, pharyngitis, etc) think about their own signs
and symptoms and how you might approach those as causes of fever. What follows is the
information I saw constantly as I researched this topic:

History:

1. Age: Fever in infants < 3 months of age should be considered as evidence of serious
bacterial infection until proven otherwise.

2. Duration of fever : Fever lasting for more than 4-7 days is rarely due to self limiting
viral illness and needs investigation. Fever lasting for more than 2 weeks indicates
serious underlying problem and needs thorough investigation.

3. Pattern of fever

4. Contact with similar diseases

5. Past history of similar illness: Recurrent viral infections are common in children
especially in the first year of school. Children between 2 months to 6 years of age are
also susceptible to recurrent viral infections. Malaria may often recur, as the therapy is
merely suppressive.

6. Drugs used in the treatment and its response

7. Progress of fever: Fever due to viral infection peaks over a day or two and gradually
declines in 3-4 days. Bacterial fever worsens if left untreated. Malarial fever develops
suddenly and declines swiftly.

8. Accompanying symptoms: specific symptoms help in localising the site of infection

such as cough/cold in respiratory illness, diarrhea/vomiting in GI infection, dysuria in
UTI, drowsiness or convulsions in meningitis. .

10. Immunization: Does the child have all of their vaccinations? Have they recently
received an immunization that this might be a reaction to?

B. Physical examination:

1. Assess seriousness:

Presence of the following signs suggests the possibility of serious underlying diseases:

a) Respiratory distress

b) Drowsiness / meningeal signs

c) Signs of impending shock

d) Purpuric spots

e) Abdominal guarding / rigidity

2. General examination:

i) General appearance:

ii) Body temperature: Must be quickly judged by merely touching the skin over the
central and peripheral parts of the body. Differential body temperature: warm
chest/abdomen and cool periphery-indicates severe illness.

iii) Pulse rate: With every degree Fahrenheit rise in the fever, pulse rate goes up by 10
beats/min. Disproportionate increase in the pulse rate may suggest early sepsis or
primary cardiac disease.
iv) Respiratory rate : Normal ratio of pulse and respiration in health is 4:1. The ratio is
increased in primary cardiac disease and decreased in respiratory pathology.

v) Skin rash

vi) Lymphadenopathy

vii) ENT examination

3. Systemic examination

i. Respiratory system

ii.Cardiovascular system

iii. Central nervous system

iv. Abdomen

Finally, pay attention to certain diagnosis that depend on fever: i.e.-Kawasakis fever of
five days, Fever of Unknown origin (must be greater than 8 days), etc.

For FUO, the three most common causes are infectious diseases, connective tissue
diseases, and neoplasms

Labs should be based upon the presenting symptoms, but a CBC with diff. is certainly
useful, as are UA in possible pyelonephritis or UTI. Look for signs of recent trauma
that may have caused brain damage (possibly causing thermoregulation insufficiencies).

Treatment should be based upon symptoms, but anti-biotic therapy should never be used
unless a specific diagnosis is present.

I realize that a lot of this is vague, and I apologize, but a kid with a fever isnt the most
specific symptoms to diagnose either. Ultimately, with an appropriate history and
physical (as described above), it should be easier to narrow down a diagnosis, and thus
a set of labs and treatment to take care of it.

General Information
Parental consent must be obtained and documented
Must provide Vaccine Information Statement
General Information
Minor, afebrile illnesses do not contraindicate vaccination
Fever usually contraindicates vaccination, unless associated illness is minor
Febrile illness IS a contraindication for DPaT
General Information
 Vaccinate prematurely born infants at normal intervals at normal doses
NO vaccines for pregnant women except in urgent need for dT
General Information
Documentation of vaccination should include:
Manufacturer
Lot number
Name, address, title of person giving injection
General Information
Most doses in a series must be 4 weeks apart
Multiple vaccines can be given at one time, but in different syringes and different
injection sites
Polio
Site: Subcutaneous or IM
OPV (live, oral) no longer used
All IPV (killed, subcutaneous) schedule now used
Contraindications:
Anaphylaxis to neomycin or streptomycin
MMR
Site: Subcutaneous
Live attenuated
Reactions:
Febrile seizures for 5-12 days post injection
Rash and encephalitis from measles
Encephalitis from mumps
Lymphadenopathy, arthralgia, polyneuropathy from rubella
Contraindicated
Pregnancy (not child of pregnant mother)
Within 3-11 months of receiving certain blood products
Anaphylaxis to neomycin or gelatin
NOT a TB infection (MMR will decrease PPD reactivity for 4-6 weeks)

Varicella
Site: Subcutaneous
Live, attenuated
Prevents varicella in 70-85%
Prevents serious disease in 95%
Reactions
Pain and redness
Fever
Varicella-like rash at injection site or generalized (7%)
Contraindications
Immunocompromised patients (research ongoing for leukemia)
Pregnancy (not child of pregnant mother)
 Anaphylaxis to neomycin or gelatin
Receipt of certain blood products
No contact with immunocompromised people if rash develops
Do not give salicylates (aspirin) within 6 weeks of vaccine to prevent Reyes
Syndrome
Must be stored at 15 degrees C, used within 30 minutes of reconstitution
Rotavirus
Site: Oral
Live
Old RotaShield recalled due to febrile reactions and intussusception
New Rotateq (pentavalent)
Reactions
Diarrhea and vomiting
NOT intussusception
Precautions
Immunodeficiency
GI disease
History of intussusception
Influenza
Site: IM or nasal
Inactivated is IM
Live, attenuated is nasal spray
Contraindication
Egg allergy
Hepatitis A
Site: IM
Inactivated
Reactions
Pain
Contraindications
Allergy to alum or phenoxyethanol
Recommended in endemic areas and international travel
Now recommended for universal use
Hepatitis B
Site: IM
Recombinant Hepatitis B (contains HBsAG)
Reactions
Soreness
Contraindications
Anaphylaxis to bakers yeast
HPV
 Site: IM
Types 6, 11, 16, and 18
6 and 11: 90% of genital warts
16 and 18: 70% of cervical cancer
Female patients age 9-26 years
DPT
Site: IM (anterolateral thigh of infant or deltoid of older child)
Usually given as DTaP
Diphtheria and Tetanus
Toxoids
Having illness does not give immunity
Doses:
DT-pediatric
dT-adult (1/10 to 1/20 amount of diphtheria toxoid due to increased reactivity
with age over 7 years)
Tdap-adolescent
Reaction:
Local pain, redness, swelling, fever
Anaphylaxis
DPT (continued)
Pertussis
Inactivated Bordetella pertussis (now acellular)
Culture-proven illness gives immunity
Small doses are given after age 7 years (Tdap)
Reaction:
Contraindications:
Anaphylaxis--contraindicates use
Encephalopathy--contraindicates use
Cautions:
Convulsions within 3 days
Inconsolable for 3 hours
Collapse or shock
Fever to 105
Defer:
In evolving or unknown neurological disorder.
NOT in known seizure disorder
If delayed, delay whole DPaT

Pneumococcal
Site: IM
Conjugated capsular polysaccharides
Conjugated with nontoxic diphtheria protein
7 serotypes (cause of 80% of pediatrics pneumococcal bacteremia) in new vaccine
for < 2 years of age
Prevents bacteremia, meningitis, and pneumonia, but NOT otitis media
 23 serotypes in old vaccine for >2 years of age
Reactions
Erythema, swelling, tenderness, fever
Contraindications
Allergy to components, including diphtheria toxoid
Meningococcal
Site: IM
Polysaccharide (Menomune) (MPSV4)
Give to patients in endemic areas, immunodeficient, asplenic, or college freshmen
Age range: >2 years
Revaccinate in 3-5 years
Conjugated (Menactra) (MCV4)
Same patients as above, plus entry to middle or high school
Age range: 11-55 years
No current recommendation for revaccination
Reactions
Pain, fever, headache, malaise
Contraindications
Allergy to vaccine or components
HIB
Site: IM
Conjugated
Having invasive H. influenza type B at age younger than 2 years does not confer
immunity, but contracting the disease over age 2 years will provide immunity
Reactions
Fever or soreness
Contraindications
None specifically
General Rules
Subcutaneous:
MMR
Varicella
Polio (IM or subcutaneous)
Notes
Review the schedule in the Routine Childhood Immunizations handout
Table 4
Table 5

General Feeding Guidelines

Hold the baby
Burp after q 2 ounces\
Supplements:
 Fluoride: 0.25 mg/day, use for non-fluorinated water with formula and in breast
feeding
Vitamin D: use in breast feeding
Iron: use in breast feeding beginning at 4 months
General Feeding Guidelines
At 2 weeks, feed 3 ounces/pound/day at interval of q 3-4 hours
At 2 months, feed 26-32 ounces/day
At 4 months, feed no more than 40 ounces/day and can begin solids
At 6 months, feed 26-32 ounces of formula/day and encourage more solids (fruits,
vegetables), give sip cup
At 10-11 months, introduce meats
At 11-12 months, wean bottle, whole or 2% milk, no more strained food, see
decreased appetite
At 15 months, no bottle, no more than 24 ounces milk, see decreased appetite
At 2 years and up, encourage healthy snacks and all 4 food groups

General Safety Guidelines

Use rear-facing car seat under 20 pounds
Use front-facing car seat over 20 pounds
Use seatbelt and booster seat at 40 pounds and 40 inches (usually age 4)
Set water heater to 120 degrees Fahrenheit
Have fire evacuation plan and change smoke detector batteries q 6 months
Dont smoke, if so, do outside
No toys with small parts
Dont use walkers
Childproof the house (outlets, cords, gates, etc.)
Call poison control
Toddlers may get lost, be careful
Swimming lessons at age 4-5 years
Watch for sex, drugs, and rock-n-roll in adolescents

General Health Guidelines

Position Back to Sleep
Use lubricant for diaper rash
Worry only if fever >101
Tylenol: 10-15 mg/kg q 4 hrs
Motrin: 5-10 mg/kg q 6 hrs
Use karo syrup for constipation (hard/pain)
Teething starts at 4 months, give Tylenol for fever
URI common: no worry fever <101 and good po intake, use vaporizer, bulb
suction, saline nasal drops
Flexible shoes to protect feet at 12 months
Regular bedtime at 12 months
General Health Guidelines (continued)
Gait may be normally bow-legged until 2 years
 Brush teeth at 18 months, all teeth by 2-2.5 years, go to dentist at 3 years
Toilet train at 2.5 to 3 years, enuresis until 5-6 years
Naps until 1st grade (and in medical school)
TV: 1-2 hours/day
Exercise at 4 years
Talk about puberty/body changes and sex/disease/pregnancy and confidentiality to
adolescentsexplain everything, eating habits, seat belts, impaired drivers

General Psychosocial Guidelines

Crying is normal for 2-3 hours/day or 10-15 minutes prior to sleep at 2 weeks old
Colic may last from 2 weeks to 3 months of age, treat with car rides, walking and
bouncing, and quiet environments
Interact more with baby at 2 months
At 4 months, sleep alone, use playpen
At 6 months, child understands no, set limits, stranger anxiety occurs,
encourage sleeping alone
At 11-12 months, encourage independence and language, separation anxiety
occurs
At 15 months, tantrums begin, discipline by distraction, ignoring,
verbal/nonverbal disapproval, time out
At 18 months, says no so do no give too many choices, explores genitalia
General Psychosocial Guidelines (continued)
At 2 years, begins helping with self care, worries about separation
At 3 years, consider daycare qualifications (enough trained staff, health
regulations, etc.), nightmares and night terrors, imaginary friends until 1st grade
At 4 years, better at self care, can share, give a few responsibilities
At preschool, answer questions about sex and anatomy, teach manners
At 6-8 years, pay attention to school and peers
At 11-12 years and adolescents, talk about sex, drugs (including EtOH and
tobacco), and rock-n-roll, friends, and depression

General Screening Guidelines

At 2 weeks, may repeat thyroid function tests, PKU tests, galactosemia tests
Metabolic screen report should be in chart by 2 months
Children 6 months to 6 years should be screened for lead poisoning, especially if
In or around a house built before 1960
Around people who have known lead poisoning
Parents are around lead
Live near plants that release lead
Cholesterol screening for children 2 years of age who have
Parents or grandparents who have CAD or CAD studies, bypass, MI, angina,
PVD, cerebrovascular incident, or sudden cardiac death before age 55
Parents or grandparents with total cholesterol >240
Unobtainable family history
Risk factors such as poor diet, poor exercise, and overweight
Screen for scoliosis at 11-12 years
 Check pubertal changes at 11-12 years
Safety and Injuries
Injuries
45% deaths of 1-4 years
70% deaths of 4-19 years
Motor vehicle crashes (MVC) is number 1 cause of death in all age groups
Education helps
Risk factors for injury
Poorly supervised
Poor environment
Low socioeconomic status
Age
Sex
Safety and Injuries
Infants
Suffocation, abuse, MVC, bath related, falls
Toddlers
Burns, drowning, falls, poisoning
School-age
Pedestrian injuries, bike injuries, MVC, burns, drowning
Teens
MVC, drowning, burns, intentional trauma, and work-related
Safety and MVC
Use of seat restraints reduces death by 70% and serious injury by 65%
Always use shoulder strap or correct size car seat
Car seat no longer needed at ~80 pounds and 4 feet 9 inches
Teens at highest risk for MVC injury
Safety and Bicycles
250 to 300 deaths per year per bike injuries
Helmets reduce brain injury by 80% and reduce middle and upper face injuries
Fit: sits low on forehead, parallel to ground when head is upright, only 2 fingers
under chin strap, does not shift over eyes
Replace after any impact and after 5 years
Safety and Pedestrians
Pedestrian injuries usually occur during day, often in crosswalks
If < 5 years, may dart into traffic
If <10 years, may not be competent at safely crossing street
Do not cross major street alone until over 10 years
Safety and Fire
Risk of fire injuries: first decade of life, low socioeconomic status, mobile homes
Death by asphyxiation
 Cigarettes are cause of 30-40% of fires
Teach stop, drop, roll over 3 years
Safety and Burns
Burn injuries usually involve tap water
40% of pediatric burns require hospitalization
Use caution around stoves, pots/pans, electric cookers with cords
Trivia: Water that is 150 degrees Fahrenheit causes a full thickness burn of adult
skin in about 2 seconds.
Safety and Drowning
Adult supervision prevents drowning
Stay within reach
Learn CPR
Child < 5 years may not realize danger in order to call for help
Pool fences should be 5 feet high, no vertical openings over 4 inches wide
Safety and Firearms
Eliminate firearms from home or restrict access to firearms in the home
85% of unintentional firearm injuries occur in the home
Firearms in home increase risk of adolescent suicide by 10X and adolescent
homicide by 5X