Pediatrics tornto

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Pediatrics tornto

  1. 1. p Pediatrics Rachel Markin, Babak Rashidi, Tamar Rubin and Elizabeth Yeboah, chapter editors Christophel Kitamura and Michelle Lam, associate editors Janine Hutson, EBM editor Dr. Stacey Bernstein and Dr. Michael WeiDstein, staff editors With contributions from Dr. Perla Lansang Pediatric Quick Reference Values .......... 3 Precocious Puberty Delayed Puberty Primary Care Pediatrics . . . . . . . . . . . . . . . . . . 3 Short Stature Regular Visits Growth Hormone (GH) Deficiency Developmental Milestones Tall Stature Routine Immunization Other Vaccines Gastroenterology ••••••••••.••••••.•••• 36 Nutrition Vomiting Normal Physical Growth Vomiting in the Newborn Period Dentition Vomiting After the Newborn Period Failure to Thrive (FTT) Acute Diarrhea Obesity Chronic Diarrhea Infantile Colic Chronic Diarrhea Without Failure to Thrive Milk Caries Chronic Diarrhea With Failure to Thrive Injury Prevention Counselling Constipation Sudden Infant Death Syndrome (SIDS) Acute Abdominal Pain Circumcision Chronic Abdominal Pain Toilet Training Abdominal Mass Upper Gastrointestinal Bleeding Abnormal Child Behaviours .............. 12 Lower Gastrointestinal Bleeding Elimination Disorders Sleep Disturbances Genetics, Dyamorphisms, and Metabolism ••• 43 Breath-Holding Spells Approach to the Dysmorphic Child Approach to the Crying/Fussing Child Genetic Syndromes Dermatology Muscular Dystrophy (MD) Associations Child Abuse and Neglect ................ 15 Metabolic Disease Phenylketonuria (PKU) Adolescent Medicine . . . . . . . . . . . . . . . . . . . 17 Galactosemia Normal Sexual Development Normal Variation in Puberty Hematology •••••••••••••••.••••••.•••• 48 Physiologic Anemia Cardiology ............................ 18 Iron Deficiency Anemia Heart Murmurs Anemia of Chronic Disease Congenital Heart Disease (CHD) Hemoglobinopathies Acyanotic Congenital Heart Disease Bleeding Disorders Cyanotic Congenital Heart Disease Immune Thrombocytopenic Purpura (ITP) Congestive Heart Failure (CHF) Hemophilia Infective Endocarditis von Willebrands Disease Dysrhythmias Infectious Diseases . . . . . . . . . . . . . . . . . . . . . 52 Development •••••.••••••.•••••••••••.• 26 Fever Developmental Delay Acute Otitis Media (AOM) Intellectual Disability Meningitis Language Delay Urinary Tract Infection (UTI) Learning Disorders Pharyngitis and Tonsillitis Fetal Alcohol Spectrum Disorder (FASD) Streptococcal (GAS) Pharyngitis Infectious Mononucleosis Endocrinology ......................... 29 Pertussis Diabetes Mellitus (DM) Varicella (Chickenpox) Diabetes Insipidus (DI) Roseola Syndrome of Inappropriate Antidiuretic Measles Hormone (SIADH) Mumps Hypercalemia/Hypocalcemia/Rickets Rubella Hypothyroidism Erythema lnfectiosum Hyperthyroidism Reye Syndrome Ambiguous Genitalia HIV Infection Congenital Adrenal Hyperplasia (CAH) Toronto Notes 2011 Pediatrics PI
  2. 2. p Pediatrics Neonatology .......................... 62 Legg-Ca lve-Perthes Disease Normal Baby at Term Slipped Capital Femoral Epiphysis Gestational Age (GA) and Size Congenital Talipes Equinovarus Routine Neonatal Care Scoliosis Approach to the Depressed Newborn Neonatal Resuscitation Otolaryngology ........................ OT Sepsis in the Neonate Acute Otitis Media (AOM) Cyanosis Otitis Media with Effusion (OME) Persistent Pulmonary Hypertension of the Acute Tonsillitis Newborn (PPHN) Tonsillectomy Apnea Airway Problems Respiratory Distress in the Newborn Signs of Airway Obstruction Respiratory Distress Syndrome (RDS) Acute Laryngotracheobronchitis (Croup) Transient Tachypnea of the Newborn (TTN) Acute Epiglottitis Meconium Aspiration Syndrome (MAS) Subglottic Stenosis Pneumonia Laryngomalacia Diaphragmatic Hernia Foreign Body Bronchopulmonary Dysplasia (BPD) Hypoglycemia Plastic Surgery . . . . . . . . . . . . . . . . . . . . . . . . PL Jaundice Cleft Lip Bleeding Disorders in Neonates Cleft Palate Necrotizing Enterocolitis (NEC) Syndactyly Intraventricular Hemorrhage (IVH) Polydactyly Retinopathy of Prematurity (ROP) Hemangioma Common Neonatal Skin Conditions Psychiatry ............................ PS Nephrology ........................... 76 Autism Spectrum Dehydration Asperger Fluid and Electrolyte Therapy Attention Deficit and Hyperactivity Disorder Hematuria Schizophrenia Proteinuria Mood Disorders Hemolytic Uremic Syndrome (HUS) Anxiety Disorders Nephritic Syndrome Eating Disorders Nephrotic Syndrome Hypertension in Childhood Respirology •.••••••.•••••••••••.•••.•• 90 Approach to Dyspnea Neurology ............................ 81 Upper Respiratory Tract Diseases Seizure Disorders Croup Febrile Seizures Bacterial Tracheitis Recurrent Headache Epiglottitis Hypotonia Lower Respiratory Tract Diseases Cerebral Palsy (CP) Pneumonia Neurocutaneous Syndromes Bronchiolitis Acute Disseminated Encelphalomyelitis (ADEM) Asthma Cystic Fibrosis (CF) Neurosurgery ••.•••.•••••••••••••••••• NS Neural Tube Defects Rheumatology ......................... 95 Intraventricular Hemorrhage (IVH) Evaluation of Limb Pain Hydrocepha Ius Septic Arthritis Brain Tumours Growing Pains Dandy-Walker Cyst Transient Synovitis Chiari Malformation Juvenile Idiopathic Arthritis (JIA) Craniosynostosis Systemic Lupus Erythematosus (SLE) Reactive Arthritis Oncology ............................. 87 Lyme Arthritis Leukemia Vasculitides Lymphoma Henoch-Schonlein Purpura (HSP) Brain Tumours Kawasaki Disease Wilms Tumour (Nephroblastoma) Neuroblastoma Urology ............................... U Rhabdomyosarcoma Urinary Tract Obstruction Lymphadenopathy Vesicoureteral Reflux (VUR) Genital Abnormalities Orthopaedics .......................... OR Fractures in Children Common Medications •••••••••••.•••.•• 99 Epiphyseal Injury Pulled Elbow References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Developmental Dysplasia of the Hip P2 Pediatrlc:a Toronto Notes 2011
  3. 3. Toronto Notes 2011 Pediatric Quick Reference Values/Primary Care Pediatrics Pediatrica P3 Pediatric Quick Reference ValuesTable 1. Average V"ltals at Various AgesAge Paisa (bpm) Resp. Rile (br/min) sBP (mmllg)N•nllll 90-170 40-60 70-90S-12 months 80-165 30-55 80-1001-2J11n 80-125 25-45 90-100:1-11 , ... 70-115 18-30 100-1101Z..15YR" 60-100 12-18 110-130 Primary Care Pediatrics Regular Visits• usual schedule: newborn, within 1 week post-discharge, 1, 2, 4, 6, 9, 12, 15, 18, 24 months • yearly until age 6, then every other year until yearly again after age 11• history• physical exam• immunization (see Immunization, P4)• counselling/anticipatory guidance (see Nutrition P6, Colic PIO, Sudden Infant Death Syndrome (SIDS) Pll, and Injury Prevention Counselling Pll sections) Developmental MilestonesTable 2. Developmental MilestonesAge Gro•MIIIIIr Fine Mlllllr Sp-=h and Llng111111 AdaptiV111nd Social Skills G)&weeb Prone: lilb chin SDCilll smie intermittently PUJ.trlc o-lapmantaiiiiiiiiiiDn• , year:2 montlls Prone: IIIIlS extEnded Pulls at clathes Coos RecDgnizes parents - Single words forward 2 years: - 2word sentances4 11111111111 Prone: raises head + Reach and grasp, objects Responds to voice, - Understands 2 stEp commands chest. rolls IMII, no head to mouth laughs 3 years: lag - 3word combes - Rapeats 3&montlls Prone: weight on hends, Ulmr grasp, tnnsfen Begins to babble, Stlanger anxisty beginning - Ridn1ricyc- 1ripodsit objects from hand to hand responds to name of object pennenence • years: - Draws squall9 montlls Pulls to sllrld, crawls Finger-thumb grasp "Mama, dada" - Plays games, - Counb 4 object$ appropriate, imitates peek-a-boo, separation! 1word stranger anxiety12 monthl Walks with support Pincer grasp, throws 2words. follows 1-step Drinks with cup. waves command bye-bye15 monthl Walks without support Draws a line Jal!lon Points to needs11 monthl Climbs up steps with help Tower of 3 cubes. scribbling 10 words, follows Uses spoon, points ID body Dnelopmental Red Flip sirJ1lle commands parts Grcn motor: Not walking at 18 mos Fi1111 IIIIIIDr: Handednass at < 10 masZ4 monthl Climbs up 2feet/step, Tower of 6 cubes, word ptoses, Parallel play, helps ID dress Spnch: <3 words at 18 mos nns. kicks ball, walks undresses uses "I, me. you", Social: Not smiling at 3 mos 50% intelligible Cogmift: No peek-a-boo at 9mcs up and down steps3YNIS Tricycle. climbs up 1 foot/ Copies a circle and across, Prepositions, plurals, llresllunchss fully except step, down 2fesVrtep, IM8 on shoes counts ID 10,75% buttons, knows •ax. age sbrlds on one foot, jumps intelligible4yelll Hops on 1 foot. down Copie& a squarv, u&e& TBII& story, know& Coopntive toilst 1 foot/step scisson 4 coloun, speech trained, buttons dathes, intelligible, uses past knows names of body liln&e parts Skips. rides bicycle Copies atriangle, prilts Auent speech, future name, ties shoelacas lllnse, alphebat
  4. 4. P4 Pediatrica Primary Care Pediatrica Toronto Notes 2011 ..... , Primitive Reflexes • reflexes seen in normal newborns R.nexn • may indicate abnormality (e.g. cerebral palsy) if persist after 4-6 months • Rooting rdlx: infant pu!1U8s llllctile • Moro reflex stimuli n- the mouth • infant is placed semi-upright, head supported by examiners hand, sudden withdrawal of • Puachulll nrftex: tilting the infant to 1he side while in a sitting position supported head with immediate resupport elicits reflex results in ipsilateral arm extension • reflex consists of abduction and extension ofthe arms, opening of the hands, followed by (appears by 1>-8 montha) flexion and adduction of arms • Upgalng plant.r rwlleua • absence of Moro suggests CNS injury; asymmetry suggests focal motor lesions (e.g. brachial aign): is normal in iniBnb (i.e. <2 yra) plexus injury} • Galant reflex • infant is held in ventral suspension and one side of the back is stroked along paravertebral line; the pelvis will move in the direction of stimulated side • grasp reflex: flexion of infants fingers with the placement of a finger in the infants palm • asymmetric tonic neck reflex: turning the head results in the ·fencing" posture (extension of ipsilateral leg and arm and flexion of contralateral leg) • placing and stepping reflex ("primitive walking"): infant places foot on a surface when it is brought into contact with it Routine Immunization Tabla 3. Routine Immunization Schadula V.C:dne Schale Route Reac:tion Canlnlinlklllians 2, 4, 6, 18 mos IM At24-48hll Previous anaphylactic reaction to 4-6yrs Minor: local radness, swelling. vaccine, evolvilg unstable neurologic irritability dis111se, hypcnsponsiWi11ypotonic Major: prolonged crying (1%), following previous vaccine, hypotonic urresponsiw slli1e reaction to neomycin or (1 :1750), seizure (1 :1 950) on day streplllmycin of vaccine Prophylaxis: acetaminophen 10-1 5 mllllqj given 4 hrs prior to injection and q4h Hib 2, 4, 6, 18 mos IM Minor: feve& local redness, swelling. irritability ..... , ...----------------. Pneu-C 2, 4, 6, 15 mos IM Minor: fava& local radnass, swelling. irritability MMR• 12. 18 mos sc At7-14 days Pregnancy, immunocomiJllmised S.r.ty of MMR Vaccine Fawr, measle-lib rash, infanb (except HIV positive Acconling to 1he CDC, 1he weight of lymphadenopa1hy, artlnlgia, chilcnn), anaphylactic reaction to cUIIWI!Iy availabllscilntilic IVidence arthritis, (RR) gelatin does not support 1he hypo1hesis lhllt MMR vaccine causes aithar autism Man-e 2,4,6 mos IM Redn""swellilg (<50%), fewr or lBO. OR 12mos (9%), irritability (<811%), rash (0. 1%) The lll1d11111rk paper linking autism V.r• 15 mos sc Mild local reaction (211% but higher in Pregnant or to get pregnant to 1ha MMR vaccine {Lanl:llt 1998; within next 3 mon1hs, anaphylactic 351(9103):637-41)was relm:led due to Mild papules or vesicles reaction to gelatin false claims in 1he article (Lines! 201 0; (5%) 375(9713):445). Low-grade fever (15%) HepB 3 doses: 0, 1, 6 mos; IM Local redness, swelling Anaphylactic reaction to Bakers yeast given in SDIIII provinces in grade 7 (given at birth if at increased risk i.e. from endemic country, given with HBig mother HBsAg +ve) dlap S1art at 14-16 yrs IM Anali!ylaxis (very rare) Pregnancy (1st trinester) Td Adultyrs, q10yrs IM Local erythema and swelling (711%) Flu•• Start a& 6-23 mas, awry IM Local tendBIIIIss at injection site, Anaphylactic reaction to Bggs, autumn fever, malaise, myalgia. rash, febrile <6 moso!Bge seizures Hypersensitivity reactions
  5. 5. Toronto Notes 2011 Primary Care Pediatrics Pediatrics PSTable 3. Routine Immunization Schedule (continued)Vaccine Schedule Route Reaction ContraindicationsHPV 3 doses: 0, 2, 6 IM Local tenderness, redness, itching, mos for females swelling at injection site, fever between 9-26 Given in some provinces in grade 7 or 8OTaP-IPV - d iptheria, tetanus, acellular pertussis, inactivated polio vaccine (for children under 7yrs)MMR - measles, mumps, rubella vaccine Pneu-C- pneumococcal 7-valent conjugate vaccineH - Hemophilus inftuenzae type bconjugate vaccine Var - varicella vaccine tbMcn-C - meningococcal Ccoojugate vaccine dTap - diphtheria. tetanus, acellular pertussis vaccine fl)(mulationlH B- H ep epatitis Bvaccine Td- tetanus and diphtheria adult type formulationflu- influenza vaccine HPV - human papilloma virus vaccine Hvaricelavaccine and MMR vaccinenot g during the same visit, they must beadministered a least 28 days apart iven t"*For children withsevere or chronic d isease, e.g. cardiac disease. ptjmonary disease, renal d isease. sickleeel disease, diabetes. endOCiine disorders, HIV,immunosuppressed ,long·tenn aspirin therapy, or those who visit residents of clvonic care facaitiesAda from: National Advisi)(V C pted OIMlittee on Immunizatio Recommended Immunization Schedule (Of Infants, Children and Youth (updated March 2005) n.Administration of Vaccines• injection site • infant (<12 months old): anterolateral thigh • children: deltoid• DTaP+IPV+Hib (Pentacel", Pentavax" ): 5 vaccines given as one IM injection• two live vaccines (varicella, MMR) must be given subcutaneously either at the same visit or separated by 4 weeks or moreContraindications to Any Vaccine• moderate to severe illness ± fever (no need to delay vaccination for mild URTI)• allergy to vaccine componentPossible Adverse Reactions• any vaccine • local: induration or tenderness (MMR is especially painful!) • systemic: fever, rash • allergic: urticaria, rhinitis, anaphylaxis• specific vaccine reactions (see Table 3) Other VaccinesHepatitis A inactivated monovalent hepatitis A vaccine (Havrix8 , Vaqta", Avaxim.., Epaxal Berna") given as a series of 2 vaccinations 4-6 months apart recommended as pre-exposure prophylaxis for individuals at increased ri sk of infection (travel to endemic countries, residents of communities with high endemic rates, IV drug use) can also be given as a combination vaccine with Hep B (Twinrix") inmmnoglobulin can be used for short-term protection in infants and immunocompromised patientsBCG Vaccine• infants of parents with infectious TB at time of delivery• groups/communities with high rates of disease/infection (offered to aboriginal children on reserves) , health care workers at risk• only given if patient has a negative TB skin test• side effects: erythema, papule formation 3-6 week after intradermal injection, enlargement of regional lymph nodesTB Skin Test (Mantoux)• screen high risk population only (family history, HIV, immigrants from countries with increased incidence, substance abu e in family, homeless, aboriginal)• intradermal injection of tuberculous antigen, read result at 48-72 hrs• TB test should be postponed for 4-6 weeks after administration of live BCG vaccine due to risk of false positive result• te t interpretation • check area of raised INDVRATIO (not just area of erythema) at 48-72 hours • positive re ult if: • > 15 mm: children >4 years with no risk factor • > lO mm: children <4 years, or at risk for environmental exposure • >5 mm: children with close TB contact, immunosuppressed• BCG hi tory irrelevant- does not usually give po itive response (unles <6 weeks previou ly)• positive reaction means active disease or previous contact with TB
  6. 6. P6 Pediatrica Primary Care Pediatrica Toronto Notes 2011 Wwly -.llliclcyofu......_.v.r:cm. Quadrivalent Meningococcal Vaccine (Menactra•) • • r..nllotalhiGrrnr•«s • given in some provinces in Grade 9 NfJM 2006; 354:11-22 • protects against Neisseria meningitidis strains A, C, W-135, andY llldr. Rlndomillld, ibJbl&bind. phue 31rill • in Canada, currently recommended for patients with asplenia, travelers to endemic areas (such 111111111: 63,225 haiM!1y inllllts from Latin Amarica and Finllnd• as the Hajj in Mecca), laboratory workers, and military recruits ...........: Twucnl d-aiHIIVIIIICCinevs. Epiladls al gllllrolnllriti 11111 -r, Rotavirus Vaccine (RotaTeq®) .....: Thlwccilw il Mllfficaciaus lglillll • oral vaccine given in 3 doses with first at age 6-12 weeks -.JO!airusa---11111 hotpD!i!Dons • shown to reduce viral gastroenteritis in infants llsoc:iiQd Mill 11m • not currently covered in Canada lfbcious l!llllinst mllll IMll oastroentmis. Nutrition Breastfeeding • colostrum for first few days = clear fluid with nutrients (high protein, low fat) and immunoglobulins • full milk production by 3-7 days; mature milk by 15-45 days • support for mothers who want to breast feed should start while in hospital • signs of inadequate intake: <6 wet diapers per day after first week, sleepy or lethargic, <7 feeds per day, sleeping throughout the night <6 weeks, weight loss >10% of birth weight, jaundice • rule of thumb: -1 stool/day of age for first week • feeding schedule (newborn baby needs 120 kcal/kg/day) • premature infants: q2-3 hours • term infants: q3.5-4 hours, q5 hours at night until about 2-3 months of age • breast-fed babies require the following supplements • vitamin K (given IM at birth) • vitamin D (Ddrops•) 400 IU/day, 800 IU/day in northern communities • fluoride (after 6 months if not sufficient in water supply) • iron: from 4 months to 12 months (iron fortified cereals or ferrous sulphate solution) Contraindication• to Breastfeeding • mother receiving chemotherapy or radioactive compounds lhllntlhwllllld . . . . . . . . AIRI:illlll • mother with HIVI AIDS, active untreated TB, herpes in breast region wit3MIIIIIIIIC.mpnd . . IM. . • mother using >0.5 g/kg/day alcohol and/or illicit drugs (decrease milk production and/or bd............ directly toxic to baby) 111eAnllri:81 Joimll d Clini:ll Nulrililn 2003; • mother taking certain medications e.g. antimetabolites, bromocriptine, chloramphenicol, high 78:291-295 diflarancn in growth 11111 dose diazepam, ergots, gold, metronidazole, tetracycline, lithium, cyclophosphamide belli! in irin excklsivelr hreaslled lor31ftls • Note: oral contraceptive pills (OCP) not a contraindication to breastfeeding (estrogen may 61110111b1. decrease lactation but is not dangerous to infant) llldy:lllsemtiOOII t:Ohmt study IWII3483111m II8WixirM Advantages of Breastfeeding .....:11111111 itactions -•igricdy llducad in lila graup al itlllll • "Breast is Best" - exclusive breastfeeding during the first 4 months oflife is recommended by wila WIIIIXCUsivllf hlwlfld for 6 months. Health Canada, the Dietitians of Canada, and the Canadian Pediatric Society This findlna- Died 111111e period between • breast milk is easily digested and has a low renal solute load 3 111:1 61111111111s {ldjullld Ill 0.35 {951 • immunologic Cl: 0.13, 0.96). The brelstfed babies were • IgA, macrophages, active lymphocytes, lysozymes, lactoferrin (lactoferrin inhibits E. coli 11111111 116111111111111 bullflllll-1111 cillamlt in growth in intestine) gruwlll w-llle two P4)S IJ; 12111Gl&. No liQfurtllsoc:iltion-llllld . . _ • protection is greatest during early months, but is cumulative with increased duration of lniiiiiMdina 11111 lila 1111 ai1C3111 0118111i11101Y breastfeeding ill1clilns. • lower allergenicity (decreased cows milk protein allergy and eczema) c:.cuan.: Thill is .. -ciltian *- • lower pH promotes growth of lactobacillus in the gastrointestinal tract (protective against brelllleldina 11111 •ilwlr incidence a1 pathogenic intestinal bacteria) gallnlilllltilal irilctilns in 111m innlt. • parent-child bonding, economical, convenient Complications of Braastfaading • mother • sore/cracked nipples: treat with warm compresses, massage, frequent feeds, soothing barrier creams (Desitin•, Vaseline•), proper latching technique • breast engorgement (usually in first week): continue breastfeeding and/or pumping • mastitis (usually due to S. aureus): treat with cold compresses between feeds, cloxacillin for mother, continue nursing, ± incision and drainage • infant • breastfeeding jaundice (first 1-2 weeks): due to lack of milk production and subsequent dehydration (see Jaundice, P70) • breast milk jaundice: rare (0.5% of newborns, persists up to 4-6 months); not fully understood, thought to be due to substances in breast milk that inhibit conjugation of bilirubin or increased enterohepatic circulation ofbilirubin • poor weight gain: consider dehydration or failure to thrive • oral candidiasis (thrush): check babys mouth for white cheesy material that does not scrape off; treat baby with antifungal such as nystatin (Mycostatin•) (treat mother topically to prevent transmission)
  7. 7. Toronto Notes 2011 Primary Care Pecliatrlcs Pediatrica P7Alternatives to BreastfeedingTable 4. Infant Nutrition SourceType ul Nutrition lndic:rionl•l Canlllnt leamPin=d to brent nilklBllllt nilk Most babies 70:30 whey: casein ratio Fat tom distary butiBrfat Carbohydnrte fnrn lactuseCows milk buad Premature babies Plant fats inmd a! diellly butterfat(Enfamilill, Sinilaclt] Lower whey:cesein ratio Contnlindication to breartleedingForlifilld farmull Low birth weight More calories Premature babies Higher amounts of vitamins A, C, D. K May only be used in hospital due to risk a! fat-soluble vitamin toxicitySoy prollin Galactosemia Com syrup solids or sucrose instead of lactusellsomii®, ProsobeeiliJ Lactose intoleralcePartially hvdrolyzad prollins Dulayud gi151ric emptying Protein is 100% whay no casein(Good StartiliJ Risk of cows milk allergyProllin hvdrolysate Malabsorption Protein is 100% casein no whey(Nutramigenlll, Alimentwnlll, Food allergy Com syrup solids, sucrose, OR tapioca starchPregestimil®, Portagen®J instead of lactose ExpensiveAmino acid Food allergy No proteins, ju&t he amino acids(Neocate®J Short gut Com syrup solids in&tead a! lactose Very expensiwMelilbolic lrtom el1tll1i a! mstaboli&m Various different compositions for children galactosemia. propionic acidemia, etc.Mostlomlllu con1Bin 670 Clbias per litre. Theha6{11nn inflntNCJJiiM -100 callqd fGI 0.6 mos and -IOC&Vqd fal&-12 mos."Friild fonnulas falpnmnnbabillllll conllil more CllarifliS. RlmU•IIlll also be IIIPPiemented v.ilh !Ide nutrillnts ill billies v.ilh mallblorplion True llcloM irloi81111C8 islllmnll;" 1n ill cliklr111 und• 1111Infant FeedingTabla 5. Dietary Schadula Foad0 18 4-6 monlhs Breast millr. formula Iron enriched cereals Rice cereals first because less allergenic ..... 4 18 9 montlis Restriction of a08fllllllic foods (e.g. egg Pureed vegetables Yellow/orange vegetables first and green whillls and 1M$ I in the first year of life is controversial. There is a last (more bulky) recent tr1lnd tnWllllll alll1y irtroduction Avoid vegetables high nitrite content ofthiHfoodl. (beets, spinach, turnips) Introduce vegetables before yallow and graen wgstables daily] • Pureed fruits Avoid juices I M-1• CIIDidnglluarU up ta tile Ate Df 4: Pureed meats, fish, poLJtty, egg yolk 1. Hot dogs (uncutl 2. GrapH (uncutl!181211111111111 Finger foods, peuled fruit, cheese and No honey until > 12 monlhs (risk a! 3. CllltiWolher IIIW vegetables cooked vege1llbles, homo milk botulism] 4.Nuts No peanuts or raw, hard vegetables Llllil 5. Fish with bones age 3to 4 years &.Popcorn 7 Hard candies 0 No added sugar, salt. fat or seasonings B. Gum• do not delay introduction of solid foods beyond 9 months• introduce 2-3 new foods per week (easier to identify adverse reactions) and allow a few days between each introduction• avoid excessive milk/juice intake when >1 year
  8. 8. P8 Pediatrica Primary Care Pediatrica Toronto Notes 2011 ...... , •t-----------------, Normal Physical Growth ScoliOiil Screening lle8pil8 man school scrvening • newborn size influenced by maternal factors (placenta, in utero environment) implernan!rld in parb of1hl USA 111d • premature infants (<37 weeks): use c:orrected gestational age until2 years Canada in the 1970&-901, the Canadian • not linear: most rapid growth during first two years and growth spurt at puberty {1994) and American {2004) Task • dllferent tissue growth at different times Fonces on Preventive Carv do NOT cur111ntly rvcommlllld routine • first two years: CNS screening using the Forward Bend Test • mid-clrlldhood: lymphoid tissue {FBn. Cohort studies indicate that the • puberty: gonadal maturation (testes, breast tissue) forward bend test hu poor sensitivity • body proportions: upper/lower segment ratio - midpoint is symphysis pubis for iderrtifyW1g pathological {Kar.chalias et al. 1999, Yawn et al. • newborn 1.7; adult male 0.97; adult female 1.0 1999, Pruijs st al. 1996). Furthermora, • poor correlation between birth weight and adult weight there is no evidence to suggest that screening and incruased bracing ielld to T1ble 6. Aver1ge Growth Par1meters batter autcorn.s. Nonnal Commants ...... , BirthWaight 3.25 kg (71bs) 2 x birth wt by 4-5 mas 3 X birth wt by 1 y&lll Weight loss isnonnal 1II% of birth wt) in first 7days of oowbf---am sh_ould ga_in ZB-_30 g}_da_y.---, __ __ __ __ 4 X birth wt by 2y&llll Neonate should 11gain birth weijlt by -10 days of age Lcngthllllliglrt 50 em (20 in) 25 em in 1st yaar Measure supine length unti12 yaan of age, then 12 em in 2m year measure slllnding height 8 em in 3rd year then 4-7 ern/year until puberty 1/2 adult hsight at 2yea11 Hllll 35em (14 in) 2crnfmonlhfor1st3 mos Measure around occipital, pariellll, and frontal 1crnfmonlh at 3-6 mas prominancas to obtain the glllllt8st circumference 0.5 em/month at 6-12 mas liNd Circlllllflnnce Remnlll• 3, 9, and Muldpllls llf 5: Dentition Newborn IS em 3mos 40cm • primary dentition (20 teeth) 9mos 45cm • first tooth at 5-9 months (lower incisor), then 1 per month until20 teeth 3yrs50cm 9yrs 55cm • 6-8 central teeth by I year • seoondary dentition (32 teeth) • first adult tooth is 1st molar at 6 years, then lower incisors • 2nd molars at 12 years, 3nl molars at 18 years Failure to Thrive (FTT) T1bla 7. Failure to Thrive Patterns Suggative Abnunnality ..... ,, •.t-----------------, GIIIWth Pirillllrten Decreased WI Nonnal HI Normal HC Caloric insufficiency Hypennelabolic state Decreased intake Increased IOS$e$ En•gy Requinlmtnts Decreased WI Decreased HI Normal HC Strut111ral dystrophies Constitutionai!JDWih delay • 0-10 ku: 100 cal/kWday • 1-ZO kQ: 1,000 cal+ 50 calllqVday Emocrine disorder Ftmilial short slalure for llch ku >10 • +ZO kg: 1,500 cal+ 20 callkGday Decreased WI Decreased HI Decreased HC lntralllerine insult Genetic abnonnality for llch ku > 20 HC = held cin:unferm:e; Ht = he9rt; WI = weight ..... ,, Definition •.t-----------------, • weight <3rd percentile, or falls across two major percentile curves, or <80% of expec:ted weight Upper tu L.aw. [U/LI Sqment Retia for height and age is". • inadequate caloric intake most oommon factor in poor weight gain lncrRIId in achondroplasia, short • may have other nutritional deficiencies (e.g. protein, iron, vitamin D) limb syndromn, hypothyroid, starega ·history diseases. • duration of problem and growth history Decrulld in Marian, Klinefultur, Kallman. testosterone deficiency. • detailed dietary and feeding history, appetite, behaviour before and after feeds, bowel habits • pregnarn;y, birth, and postpartum history; developmental and medkal history (including ..... ,...-----------------, , medic:ations); social and family history (parental height, weight, growth pattern) • assess 4 areas of func:tioning: childs temperament, c:hild-parent interac:tion, feeding behaviour and parental psyc:hosocial stressors Calcalating Up,_.tD (IIIli • physical exam SqmentRIItio • height (Ht), weight (Wt), head circumference (HC), arm span, upper-to-lower (U/L) Upper Top of haed to pubic symphysis. segment ratio .._.segment: symphysis to • assessment of nutritional status, dysmorphism, Tanner stage, evidence of c:hronic disease floor. • observation of a feeding session and parent-clrlld interac:tion 11/1.: upper • signs of abuse or neglect
  9. 9. Toronto Notes 2011 Primary Care Pecliatrlcs Pediatrica P9• investigations (as indicated by clinical presentation) • CBC, blood smear, dectrolytes, urea, ESR, T4, TSH, urinalysis • bone age x-ray (left wrist- compared to standardized wrist x-rays) • karyotype in all short girls and in short boys where appropriate • any other tests indicated from history and physical exam: renal or liver function tests, venous blood gases, ferritin, immunoglobulins, sweat chloride, fecal fatOrganic FTT (10%)• inability to feed • insufficient breast milk production • poor retention (GERD, vomiting) Clinlul Signs of FTT • CNS, neuromuscular, mechanical problems with swallowing and sucking SMAI1111D • anorexia (associated with chronic disease) Subcuteneous fat 1011• inadequate absorption (see Pediatric Gastroenterology. P39) Muscle atrophy • malabsorption: celiac disease, cystic fibrosis (CF), pancreatic insufficiency Alopecia • loss from the GI tract: chronic diarrhea, vomiting Lethargy Lagging behind nonnal• inappropriate utilization of nutrients Kwashiorkor • renal loss: e.g. tubular disorders Infection (recunent) • inborn errors of metabolism Dennlllitis • endocrine: type 1 diabetes, diabetes insipidus (DI), hypopituitarism, congenital hypothyroidism• increased energy requirements • pulmonary disease: CF • cardiac disease • endocrine: hyperthyroidism, Dl, hypopituitarism • malignancies • chronic infections • inflammatory: systemic lupus erythematosus (SLE)• decreased growth potential • specific syndromes, chromosomal abnormalities, GH deficiency • intrauterine insults: fetal alcohol syndrome (FAS), TORCH infections• treatment: cause-specificNon-Organic FTT (90%)• often due to malnutrition, inadequate nutrition, poor feeding technique, errors in making formula• these children may present as picky eaters, with poor emotional support at home or poor temperamental "fit" with caregiver• may have delayed psychomotor, language, and personal/social development• emotional deprivation, poor parent-child interaction, dysfunctional home• child abuse and/or neglect• parental psychosocial stress, personal history of suffering abuse or neglect• treatment: most are managed as outpatients with multidisciplinary approach • primary care physician, dietitian, psychologist, social work, child protection services Obesity• a quarter of Canaadian children ages 2-17 are overweight or obese, 8% are obese (2004)Definition• BMI >95th percentile for age and height• caused by a chronically positive energy balance (intake exceeds expenditure)Risk Factors• genetic predisposition: • if 1 parent is obese - 40% chance of obese child • if both parents are obese - 80% chance of obese child• genetic heritability accounts for 25-40% of juvenile obesityClinical Presentation• history: diet, activity, family heights and weights, growth curves• body mass index (BMI) tends not to be used by pediatricians prior to adolescence• physical examination: may suggest secondary cause, e.g. Cushing syndrome• organic causes are rare (<5%) • genetic: e.g. Prader-Willi, Carpenter, Thmer syndromes • endocrine: e.g. Cushing syndrome, hypothyroidism
  10. 10. P10 Pediatrics Primary Care Pecliatria Toronto Notes 2011 • complications . . . . -.. ...,._ .. llnlwliF! c-111 CIMII • childhood obesity is an unreliable predictor of adult obesity 11(51:16&-73 • unless > 180% of ideal body weight ..,....Todlnnaii80IIflllli;lf1d • however, 70% of obese adolescents become obese adults demopilic millill ilfle IJIMience ri • association with: hypertension, dyslipidemia, slipped capital femoral epiphysis, type 2 -ightCndl111 cliililn. SlUr. Assessl11lll al Ire!* ill BMIIIIiG dl1il diabetes, asthma, obstructive sleep apnea mlill 1181 Cntill FilnM &.wy 1111 1111 • boys: gynecomastia 1H6 Nllionlll LDI9Uhl SIMi al Clildrell • girls: polycystic ovarian disease, early menarche, irregular menses 111dYoulh. • psychological: teasing, decreased self-esteem, unhealthy coping mechanisms, depression lllil a..-: Thepi"MIInCiaf a.vniglt- obel8 chih 11U1J7 Ill 13 ,_., IIICUWirundi • management from 118110 1996 I)AlYillCI, nd provilcilll • encouragement and reassurance; engagement of entire family lllilliollll!!adjuslilgfol lf1d • diet: qualitative changes; do not encourage weight loss but allow for linear growth to catch cllmopilic ch-mrilllcs. up with weight; special diets used by adults are not encouraged . . . .:i1199&,33alllcJwslllldMalan W8l1l dU8iiad •• CIW!Mi;d. end 1 ol boys O!i • evidence against very low calorie diets for preadolescents 111d "al gils- ciB1iieiiiS ollese. The odds • behaviour modification: increase activity, change eating habits/meal patterns llllioeaDI:ilbld wilh 1111 1111 111 1116 c:llngl • education: multidisciplinary approach, dietitian, counselling il1111prMilncefl cliitirn IIIII l24 {1!11. 2n.JJOI f1lr Canida• • Mole. • surgery and pharmacotherapy are not used in children Thera 111 cll•llgionll wilh b II A*llic c-dl more iketf1D be IMIWeiQit •d lrliil cliimn lin lily. Thill Infantile Colic nol dcielllly eiXUIIBd far II dlllnnces il socioeconomic ci!unlllalces. pleUIIelce al childllood *tily • rule of 3s: unexplained paroxysms of irritability and crying for >3 hours/day and >3 days/week is iiiCIII!ilg i l l l - al t.ID. lilhlllgh 11111111 for >3 weeks in an otherwise healthy, well-fed baby • in Allrict.lldL • occurs in 10% of infants • etiology: generally regarded as a lag in the development of normal peristaltic movement in gastrointestinal tract; other theories suggest a lack of self-soothing mechanisms • other reasons why babies cry: wet, hunger or gas pains, too hot or cold, overstimulated, need to suck or be held • timing: onset 10 days to 3 months of age; peak 6-8 weeks • child cries, pulls up legs and passes gas soon after feeding • management • parental relief; rest and reassurance • hold baby, soother, car ride, music, vacuum, check diaper • medications (Oval• drops, gripe water) of no proven benefit • ifbreastfeeding, elimination of cows milk protein from mothers diet (effective in very small percentage of cases) • try casein hydrosylates formula (Nutramigen•) Milk Caries • decay of superior front teeth and back molars in first 4 years of life • often occur in children put to bed with a bottle of milk or juice • can also be caused by breastfeeding (especially prolonged night feeds) • prevention • no bottle at bedtime (unless plain water} • use water as thirst quenchers during the day, do not sweeten pacifier (> 1 year) • can clean teeth with soft damp cloth or toothbrush and water • avoid fluoridated toothpaste until able to spit (>3 years) due to fluorosis risk (stains teeth) • Canadian Dental Association recommends assessment by dentist 6 months after eruption of first tooth, or by 1 year of age
  11. 11. Toronto Notes 2011 Primary Care Pecliatrlcs Pediatrics Pll Injury Prevention Counselling• injuries are the leading cause of death in children >1 year of age• main causes: motor vehicle crashes, burns, drowning, falls, choking, infanticideTabla 8. Injury Pnwantion Counsalling0-6 months li-1 2 monthsDo not IB11V8 alone on bad, on Instal stair barriers Never IBIMI unattended Bicycle halmatchange table or in tub Discourage use of walkers Keep pot handles turned to Never leave unsupervised atKeep crib rails up back of stove home, driveway or pool Avoid play areas sharp·Check WliiBr tBfll) before bathing edged tabiBS and comars No nuts, lliW caiiDIB, Teach bib safety, stranger etc. due to choking hazard safety, and street safetyDo nat hold hat liquid and infant at Caver electrical outletsthe s1111e tine Unplug appliances when nat No running while eating Swimming lessons, sunscreen, tllddler seals in the car, fencesTurn dawn hat watar heater in use around pools. dentist by age 3Check mile temp before feedilg Keep small objects. plastic bags, cleaning products, andHave appropriate car seats - medications out of reach before aiiOMd to leawhospital Supervise during feeding• <9 kg: rear-facing• 10.18 kg: front-facing• 18-36.4 kg: booster seat• always have Poison Control number by telephone• have smoke and carbon monoxide detectors in the house and check yearlyPoison Prevention• keep all types of medicines, vitamins, and chemicals locked up in a secure container• potentially dangerous: drugs, drain cleaners, furniture polish, insecticides, cosmetics, nail polish remover, automotive products• do not store any chemicals in juice, soft drink. or water bottles• keep alcoholic beverages out of reach: 3 oz hard liquor can kill a 2-year-old• always read label before administering medicine to ensure correct drug and dose Sudden Infant Death Syndrome (SIDS)Definition• sudden and unexpected death of an infant <12 months of age in which the cause of death cannot ..... , be found by history, examination or a thorough postmortem and death scene investigation Appilrut Uflt.Threat.ning EvwmEpidemiology (ALT&I• 0.5/1,000 (leading cause of death between 1-12 months of age}; M:F = 3:2 A group of conditions often milked by an epilode of apnea. cy•nosil,• more common in children placed in prone position change in tc1111, or in 1111111111• in full term infants, peak incidence is 2-4 months, 95% of cases occur by 6 months llatul occurring in • cllild. whn an• increase in deaths during peak respiratory syncytial virus (RSV) season obsamrfears the child may ba dying.• most deaths occur between midnight and 8 AM It is unclear whether or not there is 1 conn action lmwNn ALTEs and SIDS, and 1 thorough workup should be doneRisk Factors looking for 1 cause oftha ALTE (e.g.• more common in prematurity, if smoking in household, minorities (higher incidence in infection, cardiac, neurologicl aboriginals and African Americans}, socially disadvantaged• risk of SIDS is increased 3-5 times in siblings of infants who have died of SIDSPrevention - •aack to Sleep, Front to Play•• place infant on back, NOT in prone position when sleeping• allow supervised play time daily in prone position• alarms/other monitors not recommended- increase anxiety and do not prevent life-threatening events• avoid overheating and overdressing• appropriate infant bedding (firm mattress, avoid loose bedding and crib bumper pads)• nosmoking• pacifiers appear to have a protective effect; do not reinsert if falls out
  12. 12. P12 Pediatrics Primary Care PediatricaJAbnonoal Chllcl Behaviours Toronto Notes 2011 Circumcision • elective procedure to be performed only in healthy, stable infants • contraindicated when genital abnormalities present (e.g. hypospadias) or known bleeding disorder • usually performed for social or religious reasons (in Ontario, not covered by OHIP) • complications (<1%): local infection, bleeding, urethral injury • medical benefits include prevention of phimosis, slightly reduced incidence of UTI, balanitis, cancer of the penis • 2 recent RCTs (Lancet 369, Feb 2007) suggested that routine circumcision significantly reduced HIV transmission (studies conducted in high endemic areas, i.e. Africa); circumcision also appears to reduce HPV transmission • routine circumcision is not currently recommended by the CPS or AAP Toilet Training • 90% of kids attain bowel control before bladder control • generally females train earlier than males • 25% by 2 years old (in North America), 98% by 3 years old have daytime bladder control • signs of toilet readiness: • ambulating independently, stable on potty, desire to be independent or to please caregivers (i.e. motivation), sufficient expressive and receptive language skills (2-step command level), can stay dry for several hours (large enough bladder) Abnormal Child Behaviours Elimination Disorders ENURESIS • involuntary urinary incontinence by day and/or night (typically by 5-6 years old) • wetting at least twice a week for at least 3 consecutive months or causing significant distress to the child • treatment should not be considered until6 years of age; high rate of spontaneous cure • should be evaluated if >6 years old; dysuria; change in gross colour, odour, stream; secondary or diurnal Primary Nocturnal Enuresis • wet only at night during sleep, can be normal up to age 6 • prevalence: 10% of 6-year olds, 3% of 12-year olds, 1% of 18-year olds • developmental disorder or maturational lag in bladder control while asleep • more common in boys, family history common • treatment: • time and reassurance (-20% resolve spontaneously each year), behaviour modification (limiting nighttime fluids, voiding prior to sleep), engage child with rewards, bladder retention exercises, scheduled toileting • conditioning: "wet" alarm wakes child upon voiding (70% success rate) • medications (considered second line therapy): DDAVP by nasal spray or oral tablets (high relapse rate, costly), oxybutynin (Ditropan•), imipramine (Tofranil•) (rarely used, lethal if overdose, cholinergic side effects) Secondary Enuresis • develops after child has sustained period of bladder control (6 months or more) • nonspecific regression in the face of stress or anxiety (e.g. birth of sibling, significant loss, family discord) • may also be secondary to urinary tract infection (UTI), diabetes mellitus (DM), diabetes insipidus (DI), neurogenic bladder, cerebral palsy (CP), sickle cell disease, seizures, pinworms • may occur if engrossed in other activities • treatment depends on cause Diurnal Enuresis • daytime wetting (60-80% also wet at night) • timid, shy, temperament problems • most common cause: micturition deferral (holding urine until last minute) • may also result from psychosocial stressors, rule out structural anomalies (e.g. ectopic ureteral site, neurogenic bladder), UTI, constipation, CNS disorders • treatment: depends on cause; behavioural (scheduled toileting, double voiding, good bowel program), pharmacotherapy
  13. 13. Toronto Notes 2011 Abnormal Chlld Behaviours Pediatrics P13ENCOPRESIS• fecal incontinence in a child >4 years old, at least once per month for 3 months• prevalence: 1-1.596 of school-aged children (rare in adolescence); M:F = 6:1 in school-aged children• usually associated with chronic constipation• must exclude medical causes (e.g. Hirschsprung disease, hypothyroidism, hypercalcemia, spinal cord lesions, anorectal malformations)Retentive Encopresis• causes • physical: anal fissure (painful stooling) • emotional: disturbed parent-child relationship. coercive toilet training. social stressors• history • child withholds bowel movement, develops constipation, leading to fecal impaction and seepage of soft or liquid stool (overflow incontinence) • crosses legs or stands on toes to resist urge to defecate • distressed by symptoms, soiling of clothes • toilet training coercive or lacking in motivation • may show oppositional behaviour• physical exam • digital rectal exam: large fecal mass in rectal vault • anal fissures (result from passage of hard stools)• treatment • complete clean-out ofbowel • enemas and suppositories • maintenance of regular bowel movements - compliance is crucial • stool softeners (e.g. Colace•, Lactulose•, Lansoyl•, mineral oil regularly) • diet modification (see Pediatric Gastroenterology. P40) • toilet schedule and positive reinforcement • assessment and guidance regarding psychosocial stressors • behavioural modification• complications: continuing cycle, toxic megacolon (requires >3-12 months to treat), bowel perforation Sleep DisturbancesTypes of Sleep Disturbances• insufficient sleep quantity _._______________ .... 1 • di.fficulty falling asleep (e.g. Limit Setting Sleep Disorder) Daily Sleep llel(uir-nt • preschool and older children • < 6 morrlh5 16 • bedtime resistance • 6 months 14.5 holliS • due to caregivers inability to set consistent bedtime rules and routines • 12 months 13.5 holliS • 2 yeat1 13 • often exacerbated by childs oppositional behaviours • 4 yHI1 11.5 holliS• poor sleep quality • 6 yeat1 9.5 hours • frequent arousals (e.g. Sleep Onset Association Disorder) • 12 yem 8.5 hours • infants and toddlers • 18 yean a hours • child learns to fall asleep only under certain conditions or associations (with parent, with lbplldtlma light on, in front oftelevision) • 2/8v at 1 year • 1/day at 2 years: 2-3 hours • child loses ability to self soothe • 0.5/day Ill 5 (81rs: 1.7 hours • during the normal brief arousal periods of sleep (q90-120 min), child cannot fall back asleep because same conditions are not present• parasomnias • episodic nocturnal behaviours • often involves cognitive disorientation and autonomic/skeletal muscle disturbance • e.g. sleep walking, sleep terrors, nightmaresManagement of Sleep Disturbances• set strict bedtimes and "wind-down" routines• do not send child to bed hungry• always sleep in bed, in a dark, quiet and comfortable room, without "associations"• do not use bedroom for timeouts• systematic ignoring and gradual extinction for sleep onset association disorder• positive reinforcement for limit setting sleep disorderNightmares• prevalence: common in boys, 4-7 years old• associated with REM sleep (anytime during night)• upon awakening. child is alert and clearly recalls frightening dream• may be associated with daytime stress/anxiety• treatment: reassurance
  14. 14. P14 Pediatrics Abnormal Child Behaviours Toronto Notes 2011 Night Terrors • prevalence: 15% of children have occasional episodes • abrupt sitting up, eyes open, screaming • panic and signs of autonomic arousal • occurs in early hours of sleep, non- REM. stage 4 of sleep • no memory of event, parents unable to calm child • stress/anxiety can aggravate them • course: remits spontaneously at puberty • treatment: reassurance for parents Breath-Holding Spells • occur in 0.1-5% ofhealthy children 6 months-4 years of age • spells usually start during first year of life • 2 types • cyanotic (more common), usually associated with anger/frustration • pallid, usually associated with pain/surprise • child is provoked (usually by anger, injury or fear), starts to cry and then becomes silent • spell resolves spontaneously or the child may lose consciousness; rarely progresses to seizures • treatment: behavioural- help child control response to frustration and avoid drawing attention to spell; avoid being too permissive in fear of precipitating a spell Approach to the Crying/Fussing Child - - - - - - History • description of infants baseline feeding, sleeping, crying patterns • infectious symptoms - fever, tachypnea, rhinorrhea, ill contacts • feeding intolerance - gastroesophageal reflux with esophagitis • nausea, vomiting, diarrhea, constipation • trauma • recent immunizations (vaccine reaction) or medications (drug reactions), including maternal drugs taken during pregnancy (neonatal withdrawal syndrome), and drugs that may be transferred via breast milk • inconsistent history, pattern of numerous emergency department (ED) visits, high-risk social situations all raise concern of abuse Physical Examination • perform a thorough head-to-toe exam with the child completely undressed Table 9. The Physical Examination of the Crying/Fussing Child Organ System Exlminl1ian Findinp Poaibla Oilgnlllil HEENT Bulging fontanelle Meningitis, shaken baby syndrome Blepharospasm. tearing Comeal abrasion Retnal hemorrhage Shaken baby syndrome Oropharyng•l infections Thruah, gingivostDITllltitis, harp11ngina. otitis media Neuralogictl lrrilllbility or lelhiiQV Meningitis, shaken baby syndrome C.nliavllcullr Poor perfusion Sepsis, anomalous coronary artery, meningitis, myocarditis, congestive heart faiure (CHF) Tachycanlia Supravenbiculartachycardia RaiiPilltory Tachypnea Pnewnonia, CHF Grunting Respiratory disease, response to pain AIHiami111l Mass, empty RLQ Intussusception Genitourillry Scrollll swelling Incarcerated hernia, testicular torsion Penile/clitoral swelling Hair tourniquet Anal fissure Constipation or diarrflea Hamoccutt positive stool Intussusception, nacrotizi-4j enterocolitis, volvulus Point tenderness or decreased movement Fracture, syphilis, osteomyelitis, toll/finger hair tourniquet
  15. 15. Toronto Notes 2011 Abnormal Chlld BehaviousJChild Abuae and Neglect Pediatric. PIS DermatologyTabla 1D. Common Paediatric RashesType of Rnh Diffli...UI Appearanc:1Diaper Dennatiti1 lnitant ctrrtact Shiny, red macule$1plltches. no flexural nwlvement Sebonheic d81111atitis Yellow, greasy rnacuiBB/plaquas on erythema. scales Candida! Eiythematous macerated papule$1plaques. satelite lesionsDlh• Dlllnlllitis Atopic dermatitis Eiythematous papule!liplaques, oozilg. excoriation. lichenification. classic areas of involvement NuiTIITillar dermatitis Amular erythematuus plaques. oozing. crustilg Allergic contact dermatitis Red papuleWplaques/Vasici&BIbullae, in area of allergen lnitant ctrrtact Morphology depends on irritant Dyshidrotic dermatitis Papulovesicular, craclcin{llfissuring. hands and feet ("Tapioca pudding1 Sebonheic d81111atitis See above, sellaceous areas such as nasolabial folds and scalpPlp!Hsquamous Enlptions Psoriasis Eiythematous plaques silvery scales, nail pittinw onycholysis Pityriasis rosea Salmon11ink plaques, herald patch with smaler papules rchristmes tree" pattern) Scabies Polymorphic (red IIIICOriilllld papulas/nodules, burrows), in well spaces,lfulds, very pruritic lmpatigo crusts or superficial Tinea corporis Round erythematous plaques. central clearing and scaly borderExlnlllems (HI DIQD!!Iqlcm. D40)Dnlg llaldions (HI QlrD!Itp!ggy. D22)Acne (HI Dei!Dilplpgy, D1Z) Child Abuse and NeglectDefinition• an act of commission (abuse- physical, sexual, or psychological) or omission (neglect) by a caregiver that harms a childLegal Duty to Report• upon reasonable grounds to suspect abuse and/or neglect, physicians are required by law to contact the Childrens Aid Society (CAS) personally to disclose all information• duty to report overrides patient confidentiality; physician is protected against liability• ongoing duty to report: ifthere are additional reasonable grounds to suspect abuse and/or neglect, a further report to the CAS must be madeRisk Factors• environmental factors • social isolation • poverty • domestic violence• caregiver factors • parents were abused as children • psychiatric illness • substance abuse • single parent family • poor social and vocational skills, below average intelligence• child factors • difficult temperament • disability, special needs (e.g. developmental delay) • premature
  16. 16. Pl6 Pediatrics Child Abuse and Neglect Toronto Notes 2011 Presentation of Physical Abusel·r • history inconsistent with physical findings, or history not reproducible no cruising, no bruising." • delay in seeking medical attention • injuries of varied ages, recurrent or multiple injuries • distinctive marks: belt buckle, cigarette burns, hand prints • patterns of injury: bruises on the face, abdomen, buttocks, genitalia. upper back; posterior rib fractures; immersion burns (e.g. hot water) INunlmion af Negl.at • altered mental status: head injury, poisoning • Failure to thrive, developmental delay • lnadequat& or dirty clothing. poor • physical findings not consistent with any underlying medical condition hygiene • shaken baby syndrome • Child uxhibits poor attachment to • violent shaking of infant resulting in intracranial hemorrhages, retinal hemorrhages, and peran11, no anxifiy posterior rib fractures • head trauma is the leading cause of death in child maltreatment Sexual Abuse • prevalence: 1 in 4 females, 1 in 10 males • peak ages at 2-6 and 12-16 years • most perpetrators are male and known to child • in decreasing order: family member, non-relative known to victim, stranger • presentation • disclosure: diagnosis usually depends on child telling someone • psychosocial: specific or generalized fears, depression, nightmares, social withdrawal, lack of trust, low self-esteem. school failure, sexually aggressive behaviour, advanced sexual knowledge, sexual preoccupation or play • physical signs: recurrent UTis, pregnancy, STis, vaginitis, vaginal bleeding, pain, genital injury, enuresis • investigations depend on presentation, age, sex, and maturity of child • sexual assault examination kit within 24 hours if prepubertal, within 72 hours ifpubertal • rule out STI, un, pregnancy (consider STI prophylaxis or morning after pill) • rule out other injuries (vaginal/anal/oral penetration, fractures, head trauma) Management of Child Abuse and Neglect • history • from child and each caregiver separately (if possible) • physical exam • head to toe (do not force) • emotional state • development • document and/or photograph all injuries: type, location, size, shape, colour, pattern • be aware of"red herrings• (e.g. Mongolian blue spots vs. bruises) • investigations • blood tests to rule out medical causes (e.g. thrombocytopenia or coagulopathy) • STI work-up • skeletal survey/bone scan • CT/MRI • fundoscopy to rule out retinal hemorrhage • report all suspicions to CAS; request emergency visit if imminent risk to child or any siblings in the home • acute medical care: hospitalize if indicated or if concerns about further or ongoing abuse • arrange consultation to social work and appropriate follow-up • may need to discharge child directly to CAS or to responsible guardian under CAS supervision
  17. 17. IbroDlo Nota 2011 Adolescent Medidne PecUatrica Pl7 Adolescent Medicine Normal Sexual Development• puberty occurs with the maturation of the hypothalamh:-pituitary-gonadal W&o increases In the pulsatile release of gonadotropin hormone (GnRH) -+ increased release of LH and FSH -+ maturation ofgonads and release of sex steroids -+ secondary sexual characterlatl.cs Ad.._...lqdi_clll Allt.ellllt• also requires adrenal production of androgens IIEEADIIS llomefem•les EducetiarVEmpoyment• occurs between age 8-13 years (may start early as 6 yean in African-American girls) Eating• usual sequence Aetivitiel Drugs • thelarche: breast budding (breast asymmetry may occur as one breast may grow faster than the other; becomes less noticeable as maturation continues) • adrenarche: uillary hair, body odour, mUd acne • growth spurt ..., lexulllity luili:laandd...,....ian • menarche: mean age 13 years; occurs 2 years after breast development and indicates that growth spurt is almost complete (Thnner Stage 4)• early puberty is common and often constitutional, late puberty is rareM•lea• occurs between age 9-14 years (starts 1 years later than In girls)o usual sequence • testicular enlargement • penile enlargement occurs at Tanner Stage 4 • adrenarcbe: axillary and facial hair, body odour, mild acne • growth spurt: OCCillS later in boys (Tanner Stage 4)• early puberty is uncommon (need to rule out organic disease) but late puberty is common and often constitutional FEMALE BIEAST Step 1: llq1l 2: Bl..t IDI St.g. 3: of llqll4: Anlala IDI St.gll 5c Millin, niptlla en., papi1IIIIMil8d 11 s11111 11111111, na papil1 fllnn S8Candily projiiCis, na _,.,., mound, 1111largemllll af contour •pa!Biion mound mcun:l noll FEMALE GENITAL Stlp Z: Small amount Stap 3: Derbr, COIIIIII, Stlp 4: Adl.ft-type hair, Stlglli: M111ura of larc. 81rlight cr Cllted. curlier her diltrtutld na IIC!nion tD medial liltrilution widleiiMd lllilirtlv Pill111111111d hair IPII"Iv DYa plbia thiWII tD mdal thp lllangllllbillllllj!D. MAlE GENITAL (r Step 1: No hei; PQPI.tlerbll Stlp Z: Small amount af larc.ltnlight cr Cllted, lllilirtlv pigmanbld hair liang bile of panis. Stap 3: DeJtar; conar, Stlp 4: JWt.type hlir, curliar hllirdiatltlulal •pa!Hy DYa pUNa. t.ngtherilg of p.ril, I na IIC!Inaion tD medial thir#IL lnciiiiiU in paris liciiTiflra1CI and langth. Stlglli: M111ura liltrilution widlslft8d tD mdal thir#IL AdUt siza &Wgamlllllll1llltll furtlw eniiiiiiiJllnt Df dlvelop11111nt rl .nd IICIUium, lllddrilg """ and KIUUn blh..-enlaiJIIIrtr/1 111111111•nd KIUU!l, of acrallll - dlrkwiing GIICIU!IIIIIkil Cl Dlllt Acconl ZD11Figun 1. TaiDar Stagiag

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