PREVENTIVE PEDIATRICS

August 23rd, 2012

Test QuestionWhat topic should we do for next month’s

board review?A. GeneticsB. Development

Screening!

Blood Pressure Screening Hypertension affects 1 out of 4 adults Poorly controlled HTN is the leading

cause of death globally High BP in childhood is a risk factor for

hypertension in adulthood Hence the need for frequent pediatric

blood pressure screening

Blood Pressure Screening Children > 3 yrs old: screened at

every health care encounter

Blood Pressure Screening Preferred method of BP screening is auscultation

If elevated BP detected with oscillometric device, confirm with auscultation

Correct measurement requires appropriate cuff (bladder) size for the child’s right upper arm Width is ≥ 40% of the circumference of the arm Length is 80-100% of the circumference of the arm BP measurements are overestimated to a greater

degree with a cuff that is too small than they are underestimated by a cuff that is too large

Blood Pressure Screening Normal range of blood pressure is

based on sex, age, and height

Lead Screening

Lead Screening Lead toxicities have been well documented

throughout history Used by ancient Egyptians for homicidal purposes Common cause of morbidity and mortality in

shipbuilders, wine drinkers, potters Lead-based paints, gasoline, and food

containers resulted in profound contamination in the early 20th century

In the 1970’s close to 90% of children had blood lead levels (BLLs) greater than 10mcg/dL

Lead Screening Banning of lead in gasoline and paints

as well as wide-spread screening have lead to decreased average BLLs over the past several decades

However, there are still some potential exposures

Question #1All of the following are potential lead

exposure sources, EXCEPTA. Playing with antique, imported toys or

makeup from IndiaB. Drinking bottled waterC. Jumping into dad’s arms after he comes

home from a long day of automobile repairs and soldering

D. Living in a house built in 1948E. Eating dirt next to an old gasoline refinery

Lead Screening For all Medicaid patients:

Universal screening at ages 1 and 2 For other types of insurance:

Based on local state/city health department guidelines Typically at age 2; and at age 12 months for high risk

population ALL children should have at least one BLL

between the ages of 36-72 months At any time for high risk or concern:

Living in high-risk environment where more than 12% of children have elevated BLLs, siblings with elevated BLLs, recent immigrants, parental concern about exposure

Question #2You receive a lab report from a screening

fingerstick blood lead level. The level is 18mcg/dL. What is the best next step?A. Repeat the BLL with a venous sampleB. Administer oral succimer (DMSA) at 10mg/kg

orally every 8 hrs for 5 days followed by every 12 hrs for 14 days

C. Reassure the parents and schedule routine follow up in 6 months

D. Hospitalize the patient for parenteral chelationE. Contact the health department for an

immediate transfer to a lead-free enviornment

**Now < 5mcg/dL**5

Question #3All of the following are reasons why

children are at an increased risk of lead toxicity compared to adults, EXCEPT:A. Increased hand-to-mouth behaviorB. Increased lead absorptionC. Preferential deposition of lead into bones

as opposed to soft tissuesD. Immature blood-brain barrier leading to

greater neurotoxicityE. More common concomitant iron deficiency

anemia

Lead: Clinical Manifestations Affects multiple organ systems, however

most children are ASYMPTOMATIC Greatest concern: neurotoxic potential Even LOW BLLs can have toxic effects

School failure, cognitive loss, hyperactivity, aggression, inattention, distractibility, delinquent behaviors

Decline in IQ scores However, rate of decline in IQ score may be

HIGHER at levels LESS than 10mcg/dL Lead-sensitive pathways that are rapidly saturated at

levels below 10mcg/dL Chronic mildly increased BLLs may have higher risk

Lead: Clinical Manifestations Abdominal colic Constipation Growth failure Hearing loss Renal disease Seizures Encephalopathy Microcytic anemia

Depressed T-cell function

Altered cartilage mineralization

Osteopenia/decreased bone growth

Miscarriage, preterm births

CVD, HTN in adulthood

Lead: Prognosis No RCTs that show that chelation therapy affects

outcomes Cannot reverse any neurologic deficits Treatment based on clinical experience and judgment

Neurodevelopmental lags may not be evident immediately for a patient with elevated BLLs Delays may not be apparent until more challenging

school activities bring them out Neurodevelopmental surveillance should continue

throughout schooling A nurturing and stimulating social environment

can help to ameliorate the toxic effects of lead on the brain

Vision Screening

Vision Vision problems are very common in

children 5-10% of all preschoolers have a vision

problem 5-7% have major refractive errors requiring

correction 4% have strabismus

Of those, 40% have amblyopia 0.1% have cataracts

Screening and early detection improve visual acuity

What do these terms mean?! Refractive error: focusing problem

Myopia (nearsightedness) Hyperopia (farsightedness) Astigmatism

Strabismus: misalignment of the eyes “tropia”: full time misalignment “phoria: tendency to become misaligned “eso” adducting (inward) “exo” abducting (outward)

Amblyopia: loss of visual acuity due to active cortical suppression of vision in that eye Strabismus, anisometropic, deprivational

Cataract: opacification of the lens

Question #4A mother brings her newborn infant in to

your clinic. She asks if the baby can see her. What is your BEST response?A. Infants cannot see colors until 6 months of

ageB. Her baby’s vision is most likely 20/40C. Newborns have no light perception and

gradually develop it over timeD. Infants do not have conjugate gazeE. Newborns can fixate momentarily on a

human face or high-contrast object

Newborn visual acuity Approximated to be 20/400 at 1 month

of age Some sources say 20/200 Improves to 20/30 by 1 year of age

Newborns focus best on a facial construct 12-24 inches from face

Vision Function Age

Visual fixation present

Birth

Fixation well developed

6-9 weeks

Visual following 3 months

Accommodation 4 months

Stereopsis 4 months

Pediatrician Screening Tools Red reflex

Look for bilateral equal color and brightness Should fill entire pupil Use ophthalmoscope set to “O” diopters Defect could indicate: cataract, refractive error,

retinoblastoma Any concern refer to ophthalmology

Fundoscopic exam Requires more cooperation; difficult prior to age 3 Evaluate anterior structures with plus lenses (black

or green numbers) Posterior structures with minus lenses (red

numbers) Can help diagnose ROP (dilated disc vessels)

Pediatrician Screening Tools Visual acuity testing

Varies based on age Variations of Snellen chart (with cartoons,

etc) Difference of two lines between the eyes or

vision less than 20/40 in either eye refer to ophthalmology

Corneal reflex testing Using a penlight to distinguish strabismus

from pseudostrabismus Cover testing

To identify tropias and phorias

Question #5What is the diagnosis?

A. Left AmblyopiaB. Right EsotropiaC. Right ExotropiaD. Left EsotropiaE. Left Exotropia

Strabismus vs Pseudostrabismus

Asymmetry of the amount of white visible on either side of the eye can raise concern

Pseudostrabismus: appearance of misalignment when there is no strabismus present

Use corneal reflex (penlight) test to distinguish

Tropias (manifest strabismus)

Misalignment of the eye that is always present

Large angle deviations are obvious

Small angle deviations can be detected with the Cover-Uncover test UNCOVERED affected

eye will move

Phorias (latent strabismus)

Misalignment that occurs some of the time When

synchronization between the eyes is broken

Can be detected with the Cross-Cover test

Hearing Loss in Children

Hearing Loss in Children Childhood hearing loss can be a debilitating condition that affects 1-6/1000 newborns

The first 36 months after birth represent a critical period in cognitive and linguistic development

Early identification and intervention are CRITICAL Allows deaf and hearing-impaired children to

approach their peers in language skills and academics

Those identified late often won’t reach the same level

Question #6You are on your Well Baby rotation and asked by

some well-educated, new parents what a hearing screen on their baby will involve. The nursery is currently using auditory brainstem response tests (ABR) because the OAE machine is broken. You tell them that

A. It’s simple…you put the baby in a room and see if he looks in the direction of different sounds.

B. You have an ENT doctor come and check out the ear anatomy to make sure it looks good!

C. Sounds are delivered through earphones, and electroencephalogram probes (EEG) records the results.

D. There is a probe in the ear that sends sounds in and then detects sounds being created by the inner ear during transmission.

Hearing Screening The AAP recommends that congenital

hearing loss be detected by 1 month, diagnosed definitively by 3 months, and receive intervention by 6 month of age.

Objective newborn hearing test by 1 month!!! Hearing-impaired infants still reach early

milestones on time (cooing, smiling, babbling, gesturing)

OAE or ABR in newborn nursery 2-stage screen where ABR confirms abnormal

OAE yields lowest # of false positives!

Hearing Screening

Any infant that fails screen = full audiology evaluation by 3 months!!

OUR responsibility to make sure it happens.

Minimally affected by outer and inner ear debris; screens for auditory

neuropathy

Hearing Screening Hearing loss can also be

acquired PCPs should assess risk

factors at each visit and audiology referral if warranted

Screening with conventional audiometry starting at age 4

Question #7The parents of a 4-year old girl bring her to

see your for difficulty paying attention, frequent temper tantrums, problems at preschool. Her only PMH is frequent ear infections. Your in-office screen suggests hearing loss that you suspect is caused by… A. Sensorineural hearing lossB. Conductive hearing lossC. She can hear just fine but probably has ADHD

and couldn’t pay attention for the screen.D. Central hearing loss

The Ear Conductive loss results

from problems with mechanical transmission External canal Tympanic membrane Middle ear ossicles

Sensorineural hearing loss Failure to transduce

vibrations in cochlea to neural impulse

Failure to transmit to vestibulocochlear nerve

Central hearing loss Defects in brainstem or

higher centers

Conductive Hearing Loss Congenital Malformations of the external

ear Abnormal ossicular chain

Acquired Otitis media with effusion is

most common cause Fluid in middle ear from altered

Eustachian tube fx Fluid restricts TM mobility

Cerumen impaction, otitis externa, foreign body

Cholesteatoma

OME: No antibiotics needed; observe for 3mo then referral for hearing test and possible ENT referral; sooner referral if developmental delay or

hearing loss obvious

Question #8You are seeing a newborn with sensorineural

hearing loss on her newborn hearing screen. Mom’s reports prenatal history as unremarkable. On exam, the baby has microcephaly and hepatomegaly with NO other obvious physical abnormalities. The MOST likely cause of the hearing loss isA. Congenital cytomegalovirus infectionB. Alport syndromeC. Middle ear effusionD. Prenatal rubella exposureE. Usher syndrome

SAFETY

Unintentional Injuries in Peds Leading cause of morbidity and mortality among children in the U.S.

Understandable, predictable, and preventable

Risk factors Young children and teenagers Males twice the risk

Greater exposure to activities that result in injury Patterns of risk-taking and rougher play

Substance abuse, especially alcohol Provide age-appropriate home safety

information at every visit

Motor Vehicle Injuries Leading cause of injury death

and disability in all age groups More than 1/3 of children fatally

injured were with drunk drivers Child safety seats reduce the

risk of death by 50-70% Teenagers are at higher risk

Newly licensed and distractible Often speed and use alcohol*

*Talk to parents about a safe ride agreement if alcohol is involved

Major cause of head injury

Question #9A mom is talking to you about her son.

He is always getting upset with her because she wants to hold his hand when they cross the street. At what age should a child be allowed to cross the street independently?A. 15 yearsB. 5 yearsC. 8 yearsD. 13 yearsE. 10 years

Other Injuries Young children are at risk for

pedestrian injuries Not aware of traffic threats Should not be allowed to cross the

street independently until age 10! Bicycles

All parents should be counseled about importance of bicycle helmets Reduce pediatric head injury by

85% 75% of all bicycle-related fatalities

can be prevented with helmet Snell or ANSI approved and proper

fit

Poisons Annually, more than 1 million kids <6

experience toxic exposures, and 90% of these occur at home!

The proper storage of poisonous substances should be discussed at the 6mo visit

Most likely agents in pediatrics Cosmetics and personal care products Cleaning substances Analgesics Cough and cold preparations Plants Pharmaceutical products

Poisons Pediatricians should emphasize the

importance of contacting the poison control center IMMEDIATELY upon suspicion of toxic ingestion by a child

1-800-222-1222 Pediatric poisoning deaths have declined

substantially over the past 30 years…childproof caps has helped with this!!

Syrup of ipecac is no longer recommended for the home management of pediatric poisonings

Question #10During the prenatal visit with new parents, a

father expresses concern about regulating the temperature of the bath water for the new baby. You tell them that standards regarding hot water heaters have been determined. Of the following, the temperature that is most appropriate isA. 110ºFB. 120ºFC. 130ºFD. 140ºFE. 150ºF

Burns Most pediatric burns happen at home and

are largely preventable Children 4 and younger

Scald burns from hot foods or liquids in the kitchen

Burns from bath water

A key preventative measure is to set water heater temperatures no higher than 120ºF**

Burns

Water Temperat

ure

Time to 3rd

degree burn

150°F 2 seconds

140°F 6 seconds

130°F 30 seconds

120°F 5 minutes!

Burns Smoke detectors in the home help reduce deaths Per AAP, families should be counseled to attend public

firework displays rather than purchase fireworks for home use Other safety tips: Never allow young child to hold fireworks,

adult supervision at all times, and keep bucket of water nearby Preschool children have the motor skills to strike a match or

lighter…but don’t comprehend the danger! Counsel parents. Use electrical outlet covers in the home to prevent electric

burns.

Drowning Epidemiology In 2005, drowning killed 1100 children in the US 4x this received emergency care for nonfatal

drowning High lifetime health and economic impact Affected children are often neurologically devastated

and require prolonged medical/rehab care African Americans with 1.7x rate Bimodal distribution: peak in toddlers and

adolescents < 1 year old: bathtubs, buckets, toilets 1-4 years old: swimming pools when poorly supervised 15-24 years old: natural bodies of water

Question #11Your best friend is thinking about getting a swimming pool

because the kids would LOVE it! Which picture represents the best pool layout??A

D

C

B

Drowning Prevention Measures to prevent drowning at home include

Draining water from bathtubs and buckets Securing toilet seats Swim with child at arm’s length away (NO MORE)

Swimming pool fences have reduced the incidence of drowning by 50-80% Must be enclosed on ALL 4 SIDES by a fence Minimum of 4 feet tall Self-latching gate

NOT PROVEN Swimming lessons Pool covers and alarms!!

Question #12You are seeing 16-year old twin brothers for

health supervision visits. They tell you that they plan to spend most of the summer boating and fishing at their camp. Of the following, the advice that is MOST likely to decrease their risk of boating-related fatality is toA. Conduct regular engine maintenance on the boatB. Have both boys take swimming lessons before

summerC. Install a carbon monoxide detector on the boatD. Post the phone # to the US Coast Guard on the

boatE. Wear life jackets at all times while on the boat

More Water Safety Boating

Current legislation requires all children age 6-14yo to wear life vests when in small boats

All patients should be counseled to do this, regardless of age

Adult supervision at ALL times Adolescents MUST be informed about water

safety and the dangers of intoxication while in/around water

Firearms More than 33% of households admit to having

firearms, and almost 70% of parents admit that guns are unlocked

Most accidental shootings result from having a gun in the home

Children Strong enough to fire most guns Very curious and want to play with novelty items

In one study of children previously educated about gun safety 75% of kids who found a gun played with it Of those, 50% pulled the trigger

Firearms Removing guns from the home is the only

action that can ensure decreased rates of accidental gun deaths

Parents need to be counseled at every visit about hazards of having a gun in the home

If gun present… Unloaded gun locked away Ammunition kept locked in separate cabinets www.projectchildsafe.org will provide gun safety kits

at no cost

Question #13What is the # 1 cause of mortality for

children younger than 1 year of age?

A. Motor vehicle accidentsB. FallsC. SuffocationD. DrowningE. Fires/burns

Suffocation #1 cause of mortality of children <1 year

Food, coins, and toys are the primary causes of choking-related injury and death

Foods to avoid Peanuts Popcorn Hot dogs Whole grapes, raisins, apple bites, and carrots Candy

Counsel parents to eliminate small items from environment

Dangling cords, dry cleaning bags, other consumer products

Falls Leading cause of nonfatal injuries

Major cause of head injury; mortality rates increase at falls > 15ft

Children <3yo are less likely to have serious injury from falling Falls from windows, roofs, and balconies occur more in

urban areas Openings in windows or railings should be less than 4 inches Double hung windows should be opened from the top

Playgrounds or a frequent site of falls for school-age kids Upper extremity fractures are most common Frequent safety inspections Adult supervision at ALL times is important!

Falls Infant walkers

Delay normal motor and mental development Are dangerous!

Falls are overwhelmingly common, often down stairs (75-96% of cases)

AAP recommends walkers (with wheels) are banned! Rollerblades and skateboards

AAP recommends full protective gear (helmet, wrist guards, knee pads, and elbow pads)

Parents must be counseled to set an example for their kids

Car Safety

Question #14I am an 11month old infant who weighs

20lbs. According to the AAP, which type of car restraint system should my mommy put me in?A. B.

C.

Newborn Rear facing Infant-only car seat Convertible car

safety seat Rear middle seat is

safest How long can I use

this seat? Until 2 yrs Reach seats height

and weight maximum Usually 35 lbs.

Infant-only Car Seat Infants weighing up to 22-30lbs Rear-facing only Shoulder harnesses at or just below the

infants’ shoulders

Infants up to 40-65lbs Can be rear-facing or front-facing Used as long as the child fits

Child’s ears below the seat back and shoulders below the seat strap slots

Convertible Car Safety Seat

Toddlers If > 2 yrs or have

outgrown rear-facing car seat…

Forward-facing car safety seat Convertible or

Combination How long can I use

this seat? As long as possible Up to weight or height

maximum 65 to 80 lbs

Combination Seat

Child Weight or height

above the forward-facing limit

A belt-positioning booster seat

How long can I use this seat? Until vehicle lap-

and shoulder seat belt fits properly 4 feet 9 inches 8 to 12 years old

Belt Positioning Booster Purpose to raise the child up to provide appropriate

positioning of the car seat belt Shoulder belt should rest across the chest without touching the

neck or face Lap belt should lie over the upper thighs (not the abdomen)

High-back variety preferred

“When can I sit in the front seat??”

13 years oldBack seat safest until 16yrs!

Question #15 Which is the following is NOT a feature of an

adequate car seat?A. A booster seat that positions the car seat belt across

the chest and over the upper thighsB. A rear-facing, infant-only car seat with the retainer clip

of the harness at the level of the axillaC. A convertible seat that when secured to the car moves

only 2 inches to either sideD. A forward-facing car seat with hooks at the base

attached to anchors in the crease of the rear seats and a hook at the top attached to an anchor on the high rear panel of the vehicle (LATCH system)

E. A five-point restraint that buckles between the legs, with two straps across the shoulders and two straps across the hips

Good Car Seats 5-point-restraint LATCH system

(lower anchors and tethers for children)

When safely secured, the car seat should not move 1 inch to either side

Special Case: Premature Babies 24% of preterm babies do

not fit into infant car seats Risks of car seats

Apeas Bradycardias Desats

Car seat challenge Preterm infants (<37WGA)

AND term infants with respiratory issues

No straightforward recommendations if they fail

Position as best you can Recommend observing

infant closely during travel and limiting travel time

Louisiana Law Rear facing car seat until 1 year or 20

lbs Forward facing car seat until 4 years or

40 lbs Booster seat until 6 years or 60 lbs

Unless car has lap belt, then may use lap belt only

MORE CONTENT SPECS!

Screen Time “Screen time” includes TV, video games,

computer, etc. Limited to 2 hours per day for all children NO televisions in child’s bedroom Parents should also be made aware of link with

obesity and decreased academic performance

The Sun Most recognized preventable factor for skin

cancer is exposure to ultraviolet light One blistering sunburn can increase the

risk of melanoma Protection

Avoidance of prolonged sun exposure, especially from 10am-4pm

Protective hats and clothing if outside for long periods of time (infants and young children)

Sunscreen (for older children) SPF is a measure of UVB protection (linked to skin

CA), need SPF15 or higher To prevent UVA damage, need broad spectrum

sunscreen (1-4 stars) Reapply every 2 hours Children <6 months can wear sunscreen, but

usually small amounts only on exposed surfaces.

Sleep Plays a vital role in the growth and

development of children Sleep behaviors and problems change as a

child progresses from infancy to adolescence Insufficient and poor quality of sleep may

manifest as Change in mood, behavior, memory, and attention Hyperactivity and poor impulse control (younger

children)

Sleep Pediatrician should stress the importance of a

bedtime routine when counseling parents Age-appropriate bedtime Dark, quiet, cool bedroom Put the child to bed drowsy but awake No sleeping in the parents’ bed

Pediatricians need to screen for childhood sleep disorders in both healthy children and specific vulnerable populations (behavioral and developmental conditions, genetic disorders, chronic medical problems)

Sleep

Bites and Stings Acute management of sting anaphylaxis

at home Recognize signs and symptoms of

anaphylaxis Epinephrine…counsel on use!!!

Epipen Jr. (0.15mg) Epipen (0.3mg)

Antihistamines haven’t shown any immediate benefit

Proper tick removal Within 24-72 hours Fine mosquito tweezers close to skin surface

Pull upward with steady, even pressure Don’t twist or jerk the tick Clean area and your hands after removal

NO “painting” or heating tick for removal

Coronary Artery Disease Risk factors

Male sex, older age, post-menopausal Family history of heart disease

Higher if father or brother developed heart disease before 55 Higher if mother or sister developed heart disease before 65

Race African Americans, American Indians, and Mexican

Americans are more likely to have heart disease than caucasians

Smoking High LDL (bad cholesterol) and low HDL (good) Uncontrolled HTN or diabetes Physical inactivity Obesity Uncontrolled stress and anger

Respiratory Disease Passive exposure to cigarette smoke in the

home increases the chance, frequency, and duration of lower respiratory tract illness in children

Common indoor exposures can produce respiratory symptoms Wood fires and stoves Cooking sprays Hairsprays Animal dander

Osteoporosis A systemic skeletal disease

characterized by low bone mass and micro-architectural deterioration of bone tissue, with increase in bone fragility and fracture susceptibility

Failure to achieve peak bone mass represents a preventable risk factor for osteoporosis in later years

Counsel families on effects of… Diet: rich in Ca and VitD (400IU/day);

supplement important if not adequate Exercise: weight bearing forces on

the skeleton have a positive effect of bone size and mineralization

Smoking: decreases bone mineral density

Iron deficiency screening Universal screening for anemia at 12 months

Fingerstick Hgb concentration Assessment of risk factors

Low socioeconomic status, history of prematurity or low birth weight, lead exposure, exclusive breastfeeding beyond 4 months of age without supplemental iron, and weaning to whole milk or complementary foods that do not include iron-fortified cereals or foods rich in iron

For infants and toddlers (1–3 years of age), additional screening can be performed at any time if there is a risk of iron deficiency

Hematocrit In the newborn period, hemoglobin and

hematocrit measurements usually are drawn peripherally (heelstick)

Hemoglobin and hematocrit values from capillary samples may be as much as 15% higher than those from venous samples** Particularly if the peripheral blood flow is

diminished due to prematurity, sepsis, congenital heart disease, etc

Repeat heelstick with venous sample

Hypercholesterolemia Dyslipidemia: imbalance in the levels of low-

density lipoprotein (LDL) cholesterol, HDL cholesterol, and triglycerides

Strong risk factor for adult CVD Children with elevated cholesterol levels

continue to have elevated cholesterol into adulthood

Treating childhood dyslipidemia may help prevent or reduce the risk of adult CVD and reduce the atherosclerotic burden later in life

Dyslipidemia is largely asymptomatic in childhood

Hypercholesterolemia Previous recommendation: Screening based

only on family history of early CVD Missed 30-60% of children with dyslipidemias

New recommendation (2011): Universal screening Non-fasting non-HDL cholesterol Children 9 to 11 years old (prior to onset of

puberty) and again at 17 to 21 years If non-HDL ≥ 145 mg/dL , obtain fasting lipid panel

Hypercholesterolemia Targeted screening with two fasting lipid profiles

at ages 2 to 8 years old and 12 to 16 years old for patients with risk factors for hyperlipidemia: 1. Patient with moderate-high risk medical condition

Kawasaki with current or regressed aneurysm, CKD/ESRD, post renal or orthotoptic heart transplant, nephrotic syndrome, HIV, SLE, JRA

2. Patient with diabetes, HTN, BMI ≥ 95th %, smoker 3. Family history of early CVD

Parent/grandparent: age <55 for males, age <65 for females MI, sudden death, coronary artery disease, PVD, stroke

Parent with total cholesterol ≥ 240mg/dL or known dyslipidemia

THE END!!