BRS Peds Notes - Summary BRS Pediatrics PDF

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Comprehensive notes of BRS Pediatrics...

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Chapter 1: Pediatric Health Supervision Weight  Rules of Thumb o Birth – 3mo: gains 30g/day; regains birth weight by 2 weeks o 3 – 6mo: 20g/day; doubles birthweight by 6 months o 6 – 12mo: 10g/day; triples birthweight by 12 months o 1 – 2yr: 250g/mo (8.3g/day) o 2yr – adolescence: 2300g/yr (6.3g/day)  Failure to Thrive – growth below what’s expected in a child; may involve all three growth parameters o Weight 1st affected  height/length  head circumference o Inorganic causes – inadequate food intake (most common; poor formula prep/feeding technique, abuse, parental immaturity, maternal depression, alcohol/drug abuse, etc.) o Organic causes – often due to some malformation of an organ system, chronic hereditary problem, metabolic disorder, or infectious/poisonous etiology o Diagnosed with careful history & physical with further evaluation directed as suspected underlying cause. Height (Length)  Rules of Thumb o 0 – 12mo: 25cm/yr; length should increase by 50% by 12mo o 13 – 24mo: 12.5cm/yr o 2yr – adolescence: 6.25cm/yr (birth length doubles by age 4; triples by age 13) Head Circumference  Rules of Thumb o 0 – 2mo: 0.5cm/wk (head is 25% final circumference at birth) o 2 – 6mo: 0.25cm/wk o By 12mo: increased by 12cm in total (head is at 75% final circumference at 1yr) o Cephalohematoma is bleeding between the skull and periosteum, often occurring during birth trauma. It requires no intervention and will go away on it’s own. May rarely cause jaundice or anemia if severe. It does alter head circumference when present.  Microcephaly – circumference >2SD below normal. Congenital (abnormal brain development) or acquired (cerebral insult in late 3rd trimester or 1st year of life; often head is normal for age initially, but does not grow after insult) o Associated with small brain, intellectual impairment, cerebral palsy, & seizures  Craniosynostosis – premature closure of fontanelle(s); often sporatic o Normally sutures are 90% closed by age 2 & completely closed by age 5 o Sagittal suture = elongated skull (scaphocephaly; most common form) o Coronal suture = shortened skull (brachycephaly; associated with neurologic complications) o Frontal (metopic) suture = triangular-shaped head (trigonocephaly) o Premature closure of multiple sutures is rare and associated with severe neurologic problems  Plagiocephaly – asymmetric head shape that doesn’t involve premature closure of sutures o Most commonly flattening of the occiput (back of head) due to lying on back o “Tummy time” is a common practice to have baby on belly during the day for a certain amount of time to prevent plagiocephaly  Macrocephaly – head circumference >95% for age (does NOT reflect brain size) o May be familial/metabolic/overgrowth syndrome/intracranial lesion/achondroplasia o Evaluation includes careful measurement of head circumference of parents, evaluation of elevated ICP (bulging fontanelle, vomiting, irritability), Head CT (rule out hydrocephalus), or genetic evaluation if concern for genetic disorder as cause

Immunizations from Age 0-18yr Immunization Dose 1 Hepatitis B Birth Rotavirus 2 months DTaP 2 months H.flu (Hib) 2 months Pneumonia 2 months (PCV13) Polio (Inactivated) 2 months Influenza Start at 6 months (annual Vaccine) MMR 12-15 months Varicella 12-15 months Hepatitis A 12-23 months Meningococcal 11-12 yr TDap 11-12 yr HPV >11yr Meningococcus B 16-18yr Pneumonia PPSV23 High-risk only

Dose 2 1-2 months 4 months 4 months 4 months 4 months

Dose 3 6-18 months

Dose 4

6 months 12-15 months 6 months

15 month + 4-6yr 12-15 months 12-15 months

4 months

6-18 months

4-6yr

4-6yr 4-6yr 12-23 months

>11yr

>11yr

Vaccinations By age:  0mo – Hep B  2mo – HepB, Rota, DTaP, H.flu, PCV13, Polio  4mo – Rota, DTaP, H.flu, PCV13, Polio  6mo – Hep B, DtaP, PCV13, polio, Flu  12mo – H.flu, PCV13, MMR, Varicella, HepA  6yr – DtaP, MMR, Varicella  12yr – Meningococcal, TDaP, HPV  18yr – Meningococcus B Problems with Vaccination  Vaccination reactions o Low-grade fever/inflammation at vaccine site o Fever/rash 1-2wk after any live vaccine (reaction to virus post-incubation period) o Very rarely life-threatening reactions  Contraindications – anaphylaxis, encephalopathy 40.5/collapse or shock/seizure/inconsolable crying 48-72hr following vaccination Well Child Screening  Neonatal screening – congenital hypothyroidism (cretinism), phenylketonuria (PKU), galactosemia, sickle cell anemia, hemoglobinopathies, cystic fibrosis, and sometimes metabolic disorders  Vision screening – begins at birth and continues onward till pt leaves your practice  Hearing screening – either through brainstem evoked potential (BAER) or evoked otoacoustic emission (EOE); should be done at each visit to ensure proper functioning  Cholesterol/Lipid screening – not recommended unless family history for hypercholesterolemia, hyperlipidemia, or elevated cholesterol >75th percentile

Iron deficiency anemia screening – usually done between 9-15mo, often alongside universal screening of hemoglobin levels  TB screening – Mantoux test recommended once per year, especially in patients at high-risk exposure  Lead screening – all children (esp. high risk) between 9mo – 6yr of age. Should be tested any time lead exposure or signs of intoxication are present Circumcision  Not recommended routinely by the AAP for medical reasons  Some reduced rate of penile cancer and possible decreased UTI risk at 4.5 o Whiff test (+; fishy) o Microscopic slide: increased WBCs, decreased lactobacilli, clue cells present  Dx: 3 out of 4 present: Abnormal grey discharge, pH >4.5, (+) whiff test, or clue cells or Gram stain (+)  Tx: metronidazole (oral or intravaginal) or clindamycin (oral or intravaginal) o Treatment of sexual partners does NOT help prevent recurrence Vaginal Candidiasis (“yeast infection”)  Overgrowth of Candida spp. typically from air-born sources; requires estrogenized tissue  Presentation: increased thick/white/”cottage-cheese like” discharge with itching and burning that often “cannot be reached”; normal vaginal pH; o Whiff test (-) o Microscopic slide: hyphae/buds present  Dx: Visualization (+) on slide or culture (+); clinical evaluation is not reliable o Latex agglutination testing is useful for non-C.albicans Candida as they do not show hyphae  Tx: intravaginal nystatin or oral fluconazole (150mg) o Intravaginal botic acid capsules or gentian violet will treat C.Glabrata as it resists azoles o Sexual partners are NOT treated, as it is not considered an STD Trichomoniasis  Growth of a protozoan that only lives within the human urogenital tract  Presentation: increased yellow-green/grey/frothy/sticky discharge with dysuria, dyspareunia, itching/burning; pH >4.5; strawberry cervix with punctate hemorrhages o Whiff test (+/-; fishy) o Microscopic slide: normal epithelial cells, increased WBCs, motile Trichomonads  Dx: visualization on microscopic slide  Tx: metronidazole (oral; don’t forget disulfiram-like rxns) or tinidazole (oral) o Screening for other STDs should be undertaken with women infected o Sexual partners also need to be treated Atrophic Vaginitis may also present with similar complaints (itching, burning, dyspareunia) typically occuring in older women; usually does NOT involve vaginal discharge; pH often >4.2; improved with vaginal lubricant  Urinary tract may have similar changes causing increased urinary frequency/increased UTIs  Tx: vaginal lubricant and topic/oral estrogen replacement therapy Desquamative inflammatory Vulvo-vaginitis typically occurs in post-menopausal women with purulent discharge, exfoliation of epithelium, vulvar burning/erythema, few lactobacilli.  Often caused by overgrowth of Gram (+) bugs affecting both vaginal and vulva  Tx: clincamycin cream (2%) for 14 days

STI Screening  When one STD is present, other should be tested for. Because the patient is engaging in risky enough sexual activity to contract one, they can likely contract more than one.  Regular Screening based on age should be part of a normal visit o Sexually active...