The 4 th Annual Metropolitan New York/New Jersey Pediatric Board Review Course General Pediatrics...

The 4The 4thth Annual Metropolitan Annual MetropolitanNew York/New Jersey New York/New Jersey

Pediatric Board Review Pediatric Board Review CourseCourse

General PediatricsGeneral Pediatrics

Andrew D. Racine, M.D., Ph.D.Andrew D. Racine, M.D., Ph.D.May 16, 2009May 16, 2009

OutlineOutline

Update on immunizationsUpdate on immunizations BreastfeedingBreastfeeding NutritionNutrition Injury PreventionInjury Prevention DevelopmentDevelopment Anticipatory GuidanceAnticipatory Guidance Child AbuseChild Abuse

Update on ImmunizationsUpdate on Immunizations

Case #1Case #1

Question 1Question 1

A 12 year old girl presents to your office for a A 12 year old girl presents to your office for a regular checkup for school entry. She is a regular checkup for school entry. She is a recent immigrant from Mexico. Her mother recent immigrant from Mexico. Her mother states that she does not have an states that she does not have an immunization record. She denies any immunization record. She denies any significant past medical history. There is no significant past medical history. There is no history of allergies. Physical exam reveals history of allergies. Physical exam reveals no abnormalities.no abnormalities.

Which immunizations would you give at this Which immunizations would you give at this time?time?

A. Td, IPV, MMR, Varicella, Hep B, MCV4A. Td, IPV, MMR, Varicella, Hep B, MCV4

B. Td, IPV, MMR, Varicella, Hep B, MPSV4, B. Td, IPV, MMR, Varicella, Hep B, MPSV4, InfluenzaInfluenza

C. Td, IPV, MMR, Varicella, Hep B, Hep A, C. Td, IPV, MMR, Varicella, Hep B, Hep A, HPVHPV

D. Tdap, IPV, MMR, Varicella, Hep B, MPSV4D. Tdap, IPV, MMR, Varicella, Hep B, MPSV4

E. Tdap, IPV, MMR, Varicella, Hep B, MCV4, E. Tdap, IPV, MMR, Varicella, Hep B, MCV4, Hep A, HPV, InfluenzaHep A, HPV, Influenza

Pertussis Vaccine (Tdap)Pertussis Vaccine (Tdap) Two tetanus toxoid, reduced diphtheria toxoid and Two tetanus toxoid, reduced diphtheria toxoid and

acellular pertussis vaccines were approved by the acellular pertussis vaccines were approved by the FDA in 2005 and are now recommended for:FDA in 2005 and are now recommended for:

Adolescents aged 11-12 years who completed Adolescents aged 11-12 years who completed their primary series of DTP/DTaP and have not their primary series of DTP/DTaP and have not received a Td booster dosereceived a Td booster dose

Adolescents 13-18 years who missed the 11-12 Adolescents 13-18 years who missed the 11-12 year Td/Tdap booster and completed their year Td/Tdap booster and completed their primary seriesprimary series

Adolescents who have not received Adolescents who have not received DTP/DTaP/Td/Tdap vaccination (or have no DTP/DTaP/Td/Tdap vaccination (or have no documentation)documentation)

For wound management in adolescents who have For wound management in adolescents who have not received Tdap beforenot received Tdap before

Meningococcal Vaccine Meningococcal Vaccine (MCV4)(MCV4)

Another change introduced into the Another change introduced into the schedule in 2005 is the meningococcal schedule in 2005 is the meningococcal conjugate vaccine which is also conjugate vaccine which is also recommended in recommended in

Adolescents 11-12 yearsAdolescents 11-12 years Unvaccinated adolescents at school Unvaccinated adolescents at school

entryentry College freshmen living in dormitoriesCollege freshmen living in dormitories Certain high risk groupsCertain high risk groups

Hepatitis A VaccineHepatitis A Vaccine

In May of 2006 the ACIP broadened its In May of 2006 the ACIP broadened its recommendations for the use of Hep A recommendations for the use of Hep A vaccine to include all children between 1-2 vaccine to include all children between 1-2 years of age. The use of Hep A vaccine is years of age. The use of Hep A vaccine is also recommended for high risk groups also recommended for high risk groups including:including:

Travelers to endemic areas, MSM, drug Travelers to endemic areas, MSM, drug users, persons with chronic liver disease, users, persons with chronic liver disease, those with clotting factor disordersthose with clotting factor disorders

Influenza VaccineInfluenza Vaccine Influenza vaccine risk factors now include Influenza vaccine risk factors now include

children with compromised respiratory function children with compromised respiratory function or handling of respiratory secretions and also or handling of respiratory secretions and also children that have an increased risk of aspiration.children that have an increased risk of aspiration.

In August 2008, ACIP issued a recommendation In August 2008, ACIP issued a recommendation expanding routine influenza vaccination beyond expanding routine influenza vaccination beyond children 6 – 59 months and their household children 6 – 59 months and their household contacts to include contacts to include all children 6 months to 18 all children 6 months to 18 years of ageyears of age beginning in the 2008-09 flu season. beginning in the 2008-09 flu season. Previously unvaccinated children should receive Previously unvaccinated children should receive 2 doses this vaccine.2 doses this vaccine.

Human Papillomavirus Human Papillomavirus VaccineVaccine

Licensed in June 2006, the ACIP Licensed in June 2006, the ACIP recommends routine immunization of recommends routine immunization of females from 9 years of age up to 26 females from 9 years of age up to 26 years of age with a three-dose series years of age with a three-dose series where the second and third doses are where the second and third doses are administered at 2 months and 6 administered at 2 months and 6 months after the first dose.months after the first dose.

Based on the catch up schedule and the Based on the catch up schedule and the requirements for a patient this age the requirements for a patient this age the patient should receive:patient should receive:

A. Td, IPV, MMR, Varicella, Hep B, MCV4A. Td, IPV, MMR, Varicella, Hep B, MCV4 B. Td, IPV, MMR, Varicella, Hep B, MPSV4, B. Td, IPV, MMR, Varicella, Hep B, MPSV4,

InfluenzaInfluenza C. Td, IPV, MMR, Varicella, Hep B, Hep A, C. Td, IPV, MMR, Varicella, Hep B, Hep A,

HPVHPV D. Tdap, IPV, MMR, Varicella, Hep B, D. Tdap, IPV, MMR, Varicella, Hep B,

MPSV4MPSV4

E. Tdap, IPV, MMR, Varicella, Hep E. Tdap, IPV, MMR, Varicella, Hep B, MCV4, HEP A, HPV, InfluenzaB, MCV4, HEP A, HPV, Influenza

PertussisPertussis

Pertussis remains endemic despite universal Pertussis remains endemic despite universal immunization with DTaP. There are 2 immunization with DTaP. There are 2 peaks of incidence. One is in children peaks of incidence. One is in children under the age of 6 months who are not under the age of 6 months who are not vaccinated or incompletely vaccinated. vaccinated or incompletely vaccinated. The other is in adolescent 11-18 years The other is in adolescent 11-18 years whose immunity has waned.whose immunity has waned.

The morbidity in adolescents is significant. The morbidity in adolescents is significant. In 2004, 25,827 cases of pertussis were In 2004, 25,827 cases of pertussis were reported in USA. 34% were in children 11-reported in USA. 34% were in children 11-18 years.18 years.

Licensed Tdap VaccinesLicensed Tdap Vaccines

BOOSTRIX BOOSTRIX GlaxoSmithkline Biologicals GlaxoSmithkline Biologicals 10-64 years of age, same t, d, p 10-64 years of age, same t, d, p antigens as INFANRIX but in smaller antigens as INFANRIX but in smaller concentrationsconcentrations

ADACELADACEL sanofi pasteur sanofi pasteur 11-64 years of age, same t, d, p 11-64 years of age, same t, d, p

antigens as DAPTACEL but in smaller antigens as DAPTACEL but in smaller concentrationsconcentrations

Side Effects of Side Effects of TdapTdap VaccinationVaccination

Local ReactionsLocal Reactions PainPain ErythemaErythema SwellingSwelling

Systemic ReactionsSystemic Reactions HeadacheHeadache FatigueFatigue FeverFever GI eventsGI events

Immediate Reactions including dizziness, syncope Immediate Reactions including dizziness, syncope and vasovagal reactions were reported with and vasovagal reactions were reported with ADACELADACEL

Case #1Case #1


Before you give the Tdap vaccine to the Before you give the Tdap vaccine to the patient you ask your attending what is patient you ask your attending what is a a truetrue contraindication for the vaccine. contraindication for the vaccine.

Your attending responds that:Your attending responds that:

A. Temperature greater than 105 F within A. Temperature greater than 105 F within 48 hours of a previous DTP/DTaP48 hours of a previous DTP/DTaP

B. Collapse or shock like state within 48 B. Collapse or shock like state within 48 hours of a previous DTP/DTaPhours of a previous DTP/DTaP

C. History of encephalopathy within 7 C. History of encephalopathy within 7 days of previous DTP/DTaPdays of previous DTP/DTaP

D. Latex AllergyD. Latex Allergy

E. PregnancyE. Pregnancy

Contraindications of Contraindications of TdapTdap

Anaphylaxis to any components of Anaphylaxis to any components of the vaccinethe vaccine

History of encephalopathy (coma or History of encephalopathy (coma or prolonged seizure) within 7 days of prolonged seizure) within 7 days of administration of a pertussis vaccine administration of a pertussis vaccine that cannot be attributed to a that cannot be attributed to a different causedifferent cause

Precautions of Precautions of TdapTdap History of an Arthus-type reaction following a History of an Arthus-type reaction following a

previous dose of tetanus- or diphtheria-previous dose of tetanus- or diphtheria-containing vaccinecontaining vaccine

Progressive neurological disorder, uncontrolled Progressive neurological disorder, uncontrolled epilepsy, or progressive encephalopathyepilepsy, or progressive encephalopathy

History of Guillain-Barre syndrome (GBS) History of Guillain-Barre syndrome (GBS) within 6 weeks after a previous dose of within 6 weeks after a previous dose of tetanus toxoid-containing vaccinetetanus toxoid-containing vaccine

Moderate or severe acute illnessModerate or severe acute illness

Not ContraindicationsNot Contraindications Temperature > 105F within 48 hrs of Temperature > 105F within 48 hrs of

DTP/DTaPDTP/DTaP Collapse or shock-like state within 48 hrs Collapse or shock-like state within 48 hrs

of DTP/DTaPof DTP/DTaP Persistent crying for 3 hrs or longer within Persistent crying for 3 hrs or longer within

48 hrs of DTP/DTaP48 hrs of DTP/DTaP Convulsions with or without fever within 3 Convulsions with or without fever within 3

days of DTP/DTaPdays of DTP/DTaP History of entire or extensive limb swelling History of entire or extensive limb swelling

after DTP/DTaP/Tdafter DTP/DTaP/Td Stable neurological disorderStable neurological disorder

Not ContraindicationsNot Contraindications

Brachial neuritisBrachial neuritis Latex allergy other than anaphylaxis-Latex allergy other than anaphylaxis-

BOOSTRIX single dose and ADACEL are BOOSTRIX single dose and ADACEL are latex freelatex free

Pregnancy and breastfeedingPregnancy and breastfeeding ImmunosuppressionImmunosuppression Intercurrent minor illnessIntercurrent minor illness Antibiotic useAntibiotic use

The only true contraindication of the The only true contraindication of the alternatives listed would be:alternatives listed would be:

A.A. Temperature greater than 105 F Temperature greater than 105 F within 48 hours of a previous within 48 hours of a previous DTP/DTaPDTP/DTaP

B. Collapse or shock like state within 48 B. Collapse or shock like state within 48 hours of a previous DTP/DTaPhours of a previous DTP/DTaP

C.C. History of encephalopathy within 7 History of encephalopathy within 7 days of previous DTP/DTaPdays of previous DTP/DTaP

D. Latex AllergyD. Latex Allergy

E. PregnancyE. Pregnancy

Meningococcal DiseaseMeningococcal Disease

American Academy Of Pediatrics. Committee on Infectious Diseases. Prevention and Control of Meningococcal Disease: Recommendations for Use of Meningococcal Vaccines in Pediatric Patients. Pediatrics. 2005:116(2):496-505.

Epidemiology of Epidemiology of MeningococcemiaMeningococcemia

Children < 1 year of ageChildren < 1 year of age

Adolescents 15-18 years of ageAdolescents 15-18 years of age

College freshmen living in dormitoriesCollege freshmen living in dormitories

C5-C9 or C3 deficiencyC5-C9 or C3 deficiency

Functional aspleniaFunctional asplenia

Licensed Meningococcal Licensed Meningococcal VaccinesVaccines

MENOIMUNEMENOIMUNE

Meningococcal polysaccharide vaccine MPSV4Meningococcal polysaccharide vaccine MPSV4

Purified capsular polysaccharides A/C/Y/W-Purified capsular polysaccharides A/C/Y/W-135135

Licensed in 1981Licensed in 1981

MENACTRAMENACTRA

Meningococcal conjugate vaccine MCV4Meningococcal conjugate vaccine MCV4

Purified capsular polysaccharides A/C/Y/W-Purified capsular polysaccharides A/C/Y/W-135 conjugated to diphtheria toxoid.135 conjugated to diphtheria toxoid.

Licensed in 2005Licensed in 2005

Case #1Case #1


Your attending asks you what are the Your attending asks you what are the advantages of the new advantages of the new meningococcal conjugate vaccine vs. meningococcal conjugate vaccine vs. the old polysaccharide vaccine. You the old polysaccharide vaccine. You answer that all of the following are answer that all of the following are true except:true except:

A. The conjugate vaccine produces an A. The conjugate vaccine produces an antibody response which lasts longer antibody response which lasts longer

B. The conjugate vaccine stimulates a B. The conjugate vaccine stimulates a booster responsebooster response

C. The conjugate vaccine promotes herd C. The conjugate vaccine promotes herd immunityimmunity

D. The conjugate vaccine has less side D. The conjugate vaccine has less side effectseffects

E. The conjugate vaccine reduces E. The conjugate vaccine reduces nasopharyngeal carriagenasopharyngeal carriage

MPSV4 antigens induce a T cell independent MPSV4 antigens induce a T cell independent antibody response. As a result there isantibody response. As a result there is

A short lived responseA short lived response No anamnestic or booster response with No anamnestic or booster response with

subsequent challengesubsequent challenge No reduction in nasopharyngeal carriageNo reduction in nasopharyngeal carriage MCV4 antigens are conjugated to diphtheria toxoid MCV4 antigens are conjugated to diphtheria toxoid

so they induce a T cell dependent response so they induce a T cell dependent response resulting inresulting in

A long lasting memoryA long lasting memory Booster response and Booster response and eradication of nasopharyngeal carriage which eradication of nasopharyngeal carriage which

contributes to herd immunity.contributes to herd immunity.

MPSV4 vs. MCV4

Advantages of MCV include all of the Advantages of MCV include all of the following except:following except:

A. The conjugate vaccine produces an A. The conjugate vaccine produces an antibody response which lasts longer antibody response which lasts longer

B. The conjugate vaccine stimulates a B. The conjugate vaccine stimulates a booster responsebooster response

C. The conjugate vaccine promotes herd C. The conjugate vaccine promotes herd immunityimmunity

D. The conjugate vaccine has less side D. The conjugate vaccine has less side effectseffects

E. The conjugate vaccine reduces E. The conjugate vaccine reduces nasopharyngeal carriagenasopharyngeal carriage

MCV4MCV4

Side effects include:Side effects include: Erythema, swelling and indurationErythema, swelling and induration Guillain-Barre – 17 reported cases Guillain-Barre – 17 reported cases

from March 2005 – September 2006. from March 2005 – September 2006. GBS incidence estimated at 0.20 per GBS incidence estimated at 0.20 per 100,000 person months after vaccine 100,000 person months after vaccine compared to 0.11 per 100,000 person compared to 0.11 per 100,000 person months among 11-19 year olds months among 11-19 year olds generally.generally.

Human PapillomavirusHuman Papillomavirus The most common sexually transmitted The most common sexually transmitted

infection in the United States (6.2 million infection in the United States (6.2 million new cases annually).new cases annually).

HPVs are non-enveloped double stranded HPVs are non-enveloped double stranded DNA viruses of over 100 types including DNA viruses of over 100 types including several (16,18,31,33,35, and others) several (16,18,31,33,35, and others) detected in 99% of cervical cancer cases.detected in 99% of cervical cancer cases.

Risk of HPV associated with number of Risk of HPV associated with number of sexual partners, partner sexual behavior, sexual partners, partner sexual behavior, and immune status.and immune status.

Human PapillomavirusHuman Papillomavirus

Most infections are transient, Most infections are transient, asymptomatic and clear within 1-2 yearsasymptomatic and clear within 1-2 years

Of the 6.2 million new cases per year, Of the 6.2 million new cases per year, about 74% occur in women 15-24about 74% occur in women 15-24

Acquisition occurs soon after sexual debutAcquisition occurs soon after sexual debut Prevalence of HPV 16 may be as high as Prevalence of HPV 16 may be as high as

40%40% Consistent condom use may help prevent Consistent condom use may help prevent

acquisitionacquisition

HPV VaccineHPV Vaccine

Quadravalent Quadravalent HPV vaccineHPV vaccine ( (GardasilGardasil®®) targets ) targets HPV types 6, 11, 16 and 18HPV types 6, 11, 16 and 18

HPV types 16 and 18 cause approximately HPV types 16 and 18 cause approximately 70% of cervical cancers and types 6 and 11 70% of cervical cancers and types 6 and 11 cause approximately 90% of genital wartscause approximately 90% of genital warts

Administered in 3 doses with second and third Administered in 3 doses with second and third doses given 2 and 6 months after the first doses given 2 and 6 months after the first dosedose

Combined protocols indicate an efficacy of 98-Combined protocols indicate an efficacy of 98-100% in the prevention of CIN 2/3, AIS or 100% in the prevention of CIN 2/3, AIS or genital warts caused by HPV 6, 11, 16 and 18.genital warts caused by HPV 6, 11, 16 and 18.

Case #1Case #1


You explain to your attending your You explain to your attending your intention to administer the intention to administer the GardasilGardasil®® vaccine and he responds, “Are you vaccine and he responds, “Are you nuts? That vaccine costs a gazillion nuts? That vaccine costs a gazillion dollars!! What are you a Merck dollars!! What are you a Merck shareholder or something?” You shareholder or something?” You calmly reply that:calmly reply that:

A.A. The vaccine only costs $50 per doseThe vaccine only costs $50 per dose

B.B. The treatment of genital warts and The treatment of genital warts and cervical cancer costs more than $8 cervical cancer costs more than $8 billion a year in the U.S.billion a year in the U.S.

C.C. Depending upon how long you Depending upon how long you assume immunity lasts and what assume immunity lasts and what percent of girls get the vaccine, percent of girls get the vaccine, immunizing all 12 year old girls will immunizing all 12 year old girls will cost only $3,000 to $25,000 per QALY.cost only $3,000 to $25,000 per QALY.

D.D. Vaccinating will save the future costs Vaccinating will save the future costs of having to screen for cervical cancer of having to screen for cervical cancer in these patientsin these patients

HPV Costs and BenefitsHPV Costs and Benefits

Management of warts and cervical cancer costs Management of warts and cervical cancer costs about $4 billion per year in the U.S.about $4 billion per year in the U.S.

Vaccine for Children’s program (VFC) will cover Vaccine for Children’s program (VFC) will cover costs of Gardasil for eligible patientscosts of Gardasil for eligible patients

Several cost/benefit analyses estimate the cost Several cost/benefit analyses estimate the cost of a QALY to be between $3,000 and $25,000 of a QALY to be between $3,000 and $25,000 depending upon underlying assumptionsdepending upon underlying assumptions

Factors to consider: duration of vaccine Factors to consider: duration of vaccine protection, duration of natural immunity, protection, duration of natural immunity, frequency of cancer screening, vaccine frequency of cancer screening, vaccine coveragecoverage

A.A. The vaccine only costs $50 per doseThe vaccine only costs $50 per dose

B.B. The treatment of genital warts and The treatment of genital warts and cervical cancer costs more than $8 cervical cancer costs more than $8 billion a year in the U.S.billion a year in the U.S.

C.C. Depending upon how long you Depending upon how long you assume immunity lasts and what assume immunity lasts and what percent of girls get the vaccine, percent of girls get the vaccine, immunizing all 12 year old girls will immunizing all 12 year old girls will cost only $3,000 to $25,000 per QALY.cost only $3,000 to $25,000 per QALY.

D.D. Vaccinating will save the future costs Vaccinating will save the future costs of having to screen for cervical cancer of having to screen for cervical cancer in these patientsin these patients

Case #1Case #1


You ask your 12 year old patient to You ask your 12 year old patient to return in 4 weeks to continue the return in 4 weeks to continue the catch up schedule of vaccination you catch up schedule of vaccination you started.started.

At that visit you will administer:At that visit you will administer:

A. Td,IPV,MMR,Hep BA. Td,IPV,MMR,Hep B

B. Td,IPV,MMR,Varicella,Hep BB. Td,IPV,MMR,Varicella,Hep B

C. Tdap,IPV,MMR,Hep B,MCV4C. Tdap,IPV,MMR,Hep B,MCV4

D. Tdap,IPV,MMR,Varicella,Hep BD. Tdap,IPV,MMR,Varicella,Hep B

E. Tdap,IPV,MMR,Varicella,Hep E. Tdap,IPV,MMR,Varicella,Hep B,MCV4B,MCV4

Catch-up ScheduleCatch-up Schedule Tdap is licensed for only one dose. Tdap is licensed for only one dose.

According to the AAP, the patient in this According to the AAP, the patient in this case should receive 3 tetanus/diphtheria case should receive 3 tetanus/diphtheria toxoid vaccines and only one of them toxoid vaccines and only one of them should also contain pertussis, preferably should also contain pertussis, preferably the first dose.the first dose.

Varicella- Varicella- Two dosesTwo doses are now are now recommended. A 2recommended. A 2ndnd dose is given in 4 dose is given in 4 weeks for those over 13 and in 3 months weeks for those over 13 and in 3 months for those less than 13.for those less than 13.

MCV4 only one dose is required.MCV4 only one dose is required.

A. Td,IPV,MMR,Hep BA. Td,IPV,MMR,Hep B

B. Td,IPV,MMR,Varicella,Hep BB. Td,IPV,MMR,Varicella,Hep B

C. Tdap,IPV,MMR,Hep B,MCV4C. Tdap,IPV,MMR,Hep B,MCV4

D. Tdap,IPV,MMR,Varicella,Hep BD. Tdap,IPV,MMR,Varicella,Hep B

E. Tdap,IPV,MMR,Varicella,Hep E. Tdap,IPV,MMR,Varicella,Hep B,MCV4B,MCV4

Return Visit should include:Return Visit should include:

Hepatitis AHepatitis A

Vaqta and Havrix are both licensed for Vaqta and Havrix are both licensed for children 1 year of age and older and children 1 year of age and older and they are now recommended as part of they are now recommended as part of the routine immunization schedule to the routine immunization schedule to be given to all children at the age of 1 be given to all children at the age of 1 year. Children who are not vaccinated year. Children who are not vaccinated by 2 years should be vaccinated at by 2 years should be vaccinated at subsequent visits. 2 doses are subsequent visits. 2 doses are recommended 6 months apart.recommended 6 months apart.

RotavirusRotavirusRotavirus is the leading cause of severe Rotavirus is the leading cause of severe

gastroenteritis worldwide resulting in more than gastroenteritis worldwide resulting in more than 500,000 deaths/year.500,000 deaths/year.

In the USA it is a major disease burden with 3.2 In the USA it is a major disease burden with 3.2 million episodes of diarrhea, 60,000 million episodes of diarrhea, 60,000 hospitalizations and 20-60 deaths /year.hospitalizations and 20-60 deaths /year.

Additional problems includeAdditional problems include Shedding of the virus before sxs develop and up Shedding of the virus before sxs develop and up

to 21 days after onset of the diseaseto 21 days after onset of the disease Children developing insufficient immunity after Children developing insufficient immunity after

one infection and therefore experiencing it more one infection and therefore experiencing it more than oncethan once

Major cause of day-care center acquired Major cause of day-care center acquired gastroenteritisgastroenteritis

Rotavirus vaccinesRotavirus vaccinesAll rotavirus vaccines are oral, live attenuated, All rotavirus vaccines are oral, live attenuated,

containing glycoprotein (VP7) and protease-containing glycoprotein (VP7) and protease-cleaved proteins (VP4) of Group A rotavirus, the cleaved proteins (VP4) of Group A rotavirus, the most prevalent type found in humans.most prevalent type found in humans.

ROTASHIELDROTASHIELD –licensed in 1998, tetravalent rhesus- –licensed in 1998, tetravalent rhesus-human reassortment, withdrawn from the market human reassortment, withdrawn from the market due to cases of intussusception.due to cases of intussusception.

ROTATEQ – ROTATEQ – FDA approved in 2006, pentavalent FDA approved in 2006, pentavalent bovine-human reassortment, no intussusception bovine-human reassortment, no intussusception reported in large trial of 70,000 doses (3 dose reported in large trial of 70,000 doses (3 dose regimen).regimen).

ROTARIX – ROTARIX – Live attenuated human monovalent Live attenuated human monovalent vaccine approved for use in April, 2008 (2 dose vaccine approved for use in April, 2008 (2 dose regimen).regimen).

Rotavirus Vaccine

Characteristic RotaTeq Rotarix

No. of doses 3 2

Recommended ages 2, 4, 6 mo.

2, 4 mo.

Minimum age for 1st dose

6 wks

Maximum age for 1st dose

14 weeks and 6 days

Minimum interval 4 weeks

Maximum age for last dose

8 months 0 days

BreastfeedingBreastfeeding

Case # 1Case # 1

A female infant presents for her two A female infant presents for her two week check-up. She was born after a week check-up. She was born after a 38 week uncomplicated pregnancy 38 week uncomplicated pregnancy via spontaneous vaginal delivery at a via spontaneous vaginal delivery at a birth weight of 3 kg. Her mother is birth weight of 3 kg. Her mother is breastfeeding and asks whether breastfeeding and asks whether breast milk alone is sufficient for her breast milk alone is sufficient for her baby. What advice should you give baby. What advice should you give her?her?

True or False?True or False?

1.1. The baby should receive oral iron The baby should receive oral iron supplements for the first 6 months of life.supplements for the first 6 months of life.

2.2. The baby does not need vitamin K after The baby does not need vitamin K after birth so long as the mother is taking oral birth so long as the mother is taking oral Vitamin K.Vitamin K.

3.3. Starting shortly after birth, the baby will Starting shortly after birth, the baby will need 400 IU of vitamin D daily while she is need 400 IU of vitamin D daily while she is exclusively breastfed.exclusively breastfed.





Question # 1Question # 1

FalseFalse

IronIron Iron stores at birth are proportional to birth Iron stores at birth are proportional to birth

weight or size. weight or size. Iron stores for term infants are sufficient to Iron stores for term infants are sufficient to

meet needs for the first 4-6 months of life.meet needs for the first 4-6 months of life. Breast milk contains <0.1 mg/100cc of iron Breast milk contains <0.1 mg/100cc of iron

but it is in a highly bio-available form (50% but it is in a highly bio-available form (50% of it is absorbed compared to 4% of iron in of it is absorbed compared to 4% of iron in iron-fortified formulas).iron-fortified formulas).

Infants’ adequate intake of iron is Infants’ adequate intake of iron is approximately 0.27 mg/day for the first 4-6 approximately 0.27 mg/day for the first 4-6 months of life.months of life.






FalseFalse

Vitamin KVitamin KVitamin K is a fat soluble vitamin necessary Vitamin K is a fat soluble vitamin necessary

for the posttranslational carboxylation of for the posttranslational carboxylation of glutamic acid residues of coagulation glutamic acid residues of coagulation proteins Factors II, VII, IX and X.proteins Factors II, VII, IX and X.

lpi.oregonstate.edu/infocenter/vitamins/vitamink/kcycle.html

Vitamin KVitamin K

Breast milk has inadequate amounts of Breast milk has inadequate amounts of vitamin K to satisfy infant vitamin K to satisfy infant requirements.requirements.

All breastfed infants should receive 0.5 All breastfed infants should receive 0.5 - 1.0 mg of vitamin K IM after the first - 1.0 mg of vitamin K IM after the first feeding and within the first 6 hrs of life.feeding and within the first 6 hrs of life.

Oral vitamin K may not provide the Oral vitamin K may not provide the stores necessary to prevent stores necessary to prevent hemorrhage in later infancy and is not hemorrhage in later infancy and is not recommended at this timerecommended at this time..






TrueTrue

Vitamin DVitamin D

Vitamin D (calciferol) is available Vitamin D (calciferol) is available from certain dietary sources and can from certain dietary sources and can be synthesized in skin upon exposure be synthesized in skin upon exposure to UV light.to UV light.

Adequate intake of vitamin D for Adequate intake of vitamin D for infants is 400 IU per day as per infants is 400 IU per day as per recent AAP guidelines (2008).recent AAP guidelines (2008).

Vitamin D content of human milk is Vitamin D content of human milk is low (22 IU/L).low (22 IU/L).

Vitamin DVitamin D

Breastfed infants should receive Breastfed infants should receive supplements of 400 IU of vitamin D supplements of 400 IU of vitamin D per day so long as the daily per day so long as the daily consumption of vitamin D-fortified consumption of vitamin D-fortified formula or milk is below 1,000 ml.formula or milk is below 1,000 ml.

The recommended routine use of The recommended routine use of sunscreen in infancy decreases sunscreen in infancy decreases vitamin D production in skin.vitamin D production in skin.

Case # 1Case # 1

On further review of the mother’s history On further review of the mother’s history you discover that she is CMV positive, is you discover that she is CMV positive, is taking anti-hypertensive medications, taking anti-hypertensive medications, and has resumed her half-pack per day and has resumed her half-pack per day cigarette consumption since the baby cigarette consumption since the baby was delivered. was delivered.

When asked whether any of these factors When asked whether any of these factors present a problem for her continuing to present a problem for her continuing to breastfeed, what should you advise her?breastfeed, what should you advise her?

Breastfeeding and virusesBreastfeeding and viruses

Viruses can be transmitted into human milk Viruses can be transmitted into human milk but only the presence of certain viruses in but only the presence of certain viruses in the mother are contraindications to the mother are contraindications to breasteeding in the United States. These breasteeding in the United States. These include:include:

HIV-1, HIV-2, HTLV-1, HTLV-2 and HSV if HIV-1, HIV-2, HTLV-1, HTLV-2 and HSV if there are lesions present on the nipple.there are lesions present on the nipple.

Hepatitis B, Hepatitis C, CMV, and rubella Hepatitis B, Hepatitis C, CMV, and rubella are not contraindications for are not contraindications for breastfeeding.breastfeeding.

Breastfeeding and Breastfeeding and medicationsmedications

Like viruses almost all medications Like viruses almost all medications taken by the mother are excreted into taken by the mother are excreted into breast milk but only a very few are breast milk but only a very few are contraindications to breastfeeding. contraindications to breastfeeding. These include:These include:

Radioisotopes, anti-metabolites or Radioisotopes, anti-metabolites or immunosuppressive agents, lithium, immunosuppressive agents, lithium, chloramphenicol, iodides, chloramphenicol, iodides, bromocriptine, and ergot alkaloids.bromocriptine, and ergot alkaloids.

Breastfeeding and smokingBreastfeeding and smoking

Tobacco is not a contraindication to Tobacco is not a contraindication to breastfeeding but nursing mothers breastfeeding but nursing mothers should be advised not to smoke in the should be advised not to smoke in the vicinity of the newborn and should be vicinity of the newborn and should be sensitively counseled to seriously sensitively counseled to seriously consider abandoning this filthy, consider abandoning this filthy, expensive, debilitating habit.expensive, debilitating habit.

More on BreastfeedingMore on Breastfeeding

Regarding the physiology of lactation, Regarding the physiology of lactation, which of the following statements is true:which of the following statements is true:

1.1. After delivery, prolactin concentration drops After delivery, prolactin concentration drops leading to increased milk synthesis.leading to increased milk synthesis.

2.2. Lactation does not occur if pregnancy does not Lactation does not occur if pregnancy does not progress beyond 20 weeks.progress beyond 20 weeks.

3.3. Obesity does not interfere with lactogenesis.Obesity does not interfere with lactogenesis.

4.4. Oxytocin causes the milk ejection or let-down Oxytocin causes the milk ejection or let-down reflex.reflex.


Regarding the physiology of lactation, Regarding the physiology of lactation, which of the following statements is true:which of the following statements is true:

1.1. After delivery, prolactin concentration drops After delivery, prolactin concentration drops leading to increased milk synthesis.leading to increased milk synthesis.

2.2. Lactation does not occur if pregnancy does not Lactation does not occur if pregnancy does not progress beyond 20 weeks.progress beyond 20 weeks.

3.3. Obesity does not interfere with lactogenesis.Obesity does not interfere with lactogenesis.

4.4. Oxytocin causes the milk ejection or let-down Oxytocin causes the milk ejection or let-down reflex.reflex.


The delivery of the placenta results in a fall in The delivery of the placenta results in a fall in estrogen and progesterone concentrations estrogen and progesterone concentrations which no longer exert their negative feedback which no longer exert their negative feedback influence on pituitary prolactin release. As a influence on pituitary prolactin release. As a result, prolactin levels rise.result, prolactin levels rise.

Lactation begins usually around 16 weeks of Lactation begins usually around 16 weeks of pregnancy.pregnancy.

Conditions that can interfere with or delay Conditions that can interfere with or delay lactation include PCOS, diabetes, obesity and lactation include PCOS, diabetes, obesity and stress.stress.


Oxytocin is released by the posterior pituitary Oxytocin is released by the posterior pituitary in response to infant suckling. This then in response to infant suckling. This then causes a contraction of the myeloepithelial causes a contraction of the myeloepithelial cells around the alveoli in the breast resulting cells around the alveoli in the breast resulting in the milk-ejection reflex or let-down.in the milk-ejection reflex or let-down.


Compared to the weight gain of formula fed Compared to the weight gain of formula fed infants in the first year of life, the weight infants in the first year of life, the weight gain of breast fed infants:gain of breast fed infants:

A.A. Is less rapid during the first 3-4 months Is less rapid during the first 3-4 months but then catches upbut then catches up

B.B. Is more rapid during the first 3-4 months Is more rapid during the first 3-4 months but then slows downbut then slows down

C.C. Generally results in a slightly heavier Generally results in a slightly heavier infant by 12 months of ageinfant by 12 months of age

D.D. Does not differ at allDoes not differ at all

More on Breastfeeding

Compared to the weight gain of formula Compared to the weight gain of formula fed infants in the first year of life, the fed infants in the first year of life, the weight gain of breast fed infants:weight gain of breast fed infants:

A.A. Is less rapid during the first 3-4 Is less rapid during the first 3-4 months but then catches upmonths but then catches up

B. Is more rapid during the first 3-4 months but then slows down

C.C. Generally results in a slightly heavier Generally results in a slightly heavier infant by 12 months of ageinfant by 12 months of age

D.D. Does not differ at allDoes not differ at all


Breast fed infants tend to gain more Breast fed infants tend to gain more weight than do formula fed infants in weight than do formula fed infants in the first 3-4 months of life.the first 3-4 months of life.

It is acceptable for their weight gain to It is acceptable for their weight gain to cross one or two percentiles cross one or two percentiles downward in the period after 4 downward in the period after 4 months so long as they maintain months so long as they maintain their length and head circumference.their length and head circumference.


By the end of the first year of life, By the end of the first year of life, breast fed infants who had solids breast fed infants who had solids introduced at 4-6 months of age tend introduced at 4-6 months of age tend to be slightly leaner than formula fed to be slightly leaner than formula fed infants.infants.

Term infants require between 100 to Term infants require between 100 to 120 kcal/kg per day in order to grow.120 kcal/kg per day in order to grow.

Nutrition

http://www.photos.com/en/search/close-up?eqvc=79970&oid=2700660

NutritionCurrent recommendations are to delay

the introduction of cow’s milk until 12 months of age. The rationale for this recommendation includes all of the following except:

Nutrition

A. Cow milk has a higher renal solute load delivered to the kidney than human milk;

B. The iron content of cow milk is inadequate to prevent iron deficiency;

C. Cow milk induces gastroesophageal reflux;D. Cow milk may cause increased fecal blood

loss in some infants;E. The caloric content of cow milk is sufficient

for infant growth by 12 months of age.

Nutrition

The correct answer is C. Cow milk does not induce GE reflux. It only contains 0.5mg/L of iron of which 10% is absorbed making it insufficient to prevent iron deficiency. It can induce fecal blood loss in some infants and it has higher concentrations of sodium and potassium than human milk or formula. It’s caloric content is sufficient for growth at 1 year.

Nutrition

You are rounding in the newborn nursery with a group of residents. In describing the choices of infant nutrition that might optimize growth and development you are MOST likely to tell them:

NutritionA. Preterm and term infants both require 100-

120 kcal/kg/day of energy to grow;B. Preterm infants require less caloric intake per

kilogram to grow than do term infants;C. Term infants require 60-80 kcal/kg/day to

grow;D. Term infants require 30-50 mL/kg/day of fluid

intake;E. Term infants with BW > 2,500 gms require

more energy per kilogram to grow than those infants with BW less than 2,500 gm.

Nutrition

The correct answer is A, preterm and term infants require 100-120 kcal/kg/day to grow. Determinants of energy requirements for infants include gestational age, illness, a history of surgery or wound healing, local environment and other factors.

Nutrition

Energy requirements can be thought of as divided into the following needs

Correct fluid requirements for infants are 60-100 cc/kg/day.

Category Kcal/kg/d

RMR 50-60

Activity 0-10

Temp. reg 0-10

Growth 10-15

Storage 20-30

Loss 10-15

Total 90-140

Nutrition

Your are seeing a 10 year old girl in your office who comes in for health care maintenance. On exam she is noted to have a BMI of 28 putting her over the 95%ile for her age in girls. You recall that BMI, as a measure of adiposity has been shown to be associated with all of the following except:

Nutrition

A. Socio-economic statusB. GenderC. BirthweightD. RaceE. Pubertal status

Nutrition

The correct answer is C. A distinct socio-economic gradient in obesity has been demonstrated in national data sets. Girls and African Americans have higher rates of obesity than others and obesity increases with the onset of puberty. Birthweight per se is not highly correlated with later measures of adiposity (although SGA babies may be at greater risk).

Nutrition

After leaving the exam room with your medical student, a discussion about trends in obesity takes place. You point out to your trainee that, with respect to the epidemiology of obesity all of the following statements are true except:

NutritionA. The prevalence of obesity and overweight has

doubled in the U.S. in the past 20 years;B. Each extra hour per day of TV watching among 12-

17 year olds increases the prevalence of obesity by 2%;

C. The concordance rate of obesity among monozygotic twins is between 0.7 and 0.9;

D. The increase in obesity has occurred despite the fact that the majority of school-aged children still report 4 hours of vigorous activity per week;

E. By 19–24 months of age, French fries are the most commonly consumed vegetable in the U.S.

Nutrition The correct answer is D. Obesity rates

have doubled in the past 2 decades. One extra hour of TV watching does is associated with an increase in the prevalence of obesity by 2%. Obesity is highly heritable and French fries are the most commonly eaten vegetable by 19-24 months. School children average less than 2 hours of vigorous exercise per week according to national data.

Injury PreventionInjury Prevention

Injury PreventionInjury Prevention

A 6 month old boy is at your office with A 6 month old boy is at your office with his father for a routine health care his father for a routine health care maintenance visit. In discussing maintenance visit. In discussing injury prevention for his infant, the injury prevention for his infant, the father wants to know what he should father wants to know what he should be most concerned about with be most concerned about with respect to his infant’s safety. What respect to his infant’s safety. What should you tell him?should you tell him?

Leading Causes of Death by Leading Causes of Death by Age Group - 2001Age Group - 2001

Leading Causes of Death by Leading Causes of Death by Age Group - 2001Age Group - 2001

< 1 yr< 1 yr 1-4 yrs1-4 yrs 5-9 yrs5-9 yrs 10-14 yrs10-14 yrs11 CongenitaCongenita

l l AnomaliesAnomalies

5,5135,513

Unintentional Injury1,714



22 Short Short GestationGestation

4,4104,410

Congenital Congenital AnomaliesAnomalies

557557

Malignant Malignant NeoplasmsNeoplasms

493493

Malignant Malignant NeoplasmsNeoplasms

515515

33 SIDSSIDS

2,2342,234Malignant Malignant NeoplasmsNeoplasms

420420

Congenital Congenital anomaliesanomalies

182182

Suicide Suicide

272272

Leading Causes of Injury Leading Causes of Injury DeathsDeaths

by Age Group 2001by Age Group 2001

0%

20%

40%

60%

80%

100%

1-4 Years 5-9 Years 10-14 Yrs

OtherFirearmsBurnDrownMotor Veh

Deaths Due to Injury Deaths Due to Injury in Childhoodin Childhood

SIDS is the leading preventable cause of SIDS is the leading preventable cause of death in children less than 1 year of age.death in children less than 1 year of age.

Unintentional injury is the leading cause of Unintentional injury is the leading cause of death in children from 1 to 15 years of age.death in children from 1 to 15 years of age.

Motor vehicle incidents, drowning and Motor vehicle incidents, drowning and deaths from burns taken together account deaths from burns taken together account for over 75% of all deaths from injury in for over 75% of all deaths from injury in children between 1 and 15 years of age.children between 1 and 15 years of age.

Motor Vehicle Injury Motor Vehicle Injury PreventionPrevention

When counseling a parent with respect to infant car When counseling a parent with respect to infant car seats, all of the following are true seats, all of the following are true exceptexcept::

A.A. Children should face the rear of the vehicle until Children should face the rear of the vehicle until they are at least 1 year of age or weigh at least they are at least 1 year of age or weigh at least 20 lbs.20 lbs.

B.B. Convertible safety seats positioned upright and Convertible safety seats positioned upright and facing forward should be used for children facing forward should be used for children beyond 1 year and 20 lbs until they reach 40 lbs.beyond 1 year and 20 lbs until they reach 40 lbs.

C.C. A rear facing car safety seat must not be placed A rear facing car safety seat must not be placed in the front passenger seat of any vehicle with in the front passenger seat of any vehicle with an air bag on the front passenger side.an air bag on the front passenger side.


Answer A:Answer A: Children must weigh 20 lbs Children must weigh 20 lbs andand be at be at least 1 year of age before sitting in a forward least 1 year of age before sitting in a forward facing car seat. Many infants reach 20 lbs before facing car seat. Many infants reach 20 lbs before their first birthday but should not be turned to their first birthday but should not be turned to face forwardface forward

before that time.before that time.


Convertible seats are the safest for children Convertible seats are the safest for children after they reach 1 year and 20 lbs until after they reach 1 year and 20 lbs until they are 40 lbs and can use booster seats.they are 40 lbs and can use booster seats.

ConvertibleConvertibleCar SeatCar Seat(Up to 40 (Up to 40 lbs)lbs)

Booster Booster Car SeatCar Seat(More than (More than 35-40 lbs)35-40 lbs)


No rear facing seats should be placed No rear facing seats should be placed in the front passenger seat of a car in the front passenger seat of a car equipped with air bags; and any child equipped with air bags; and any child less than 13 should preferentially sit less than 13 should preferentially sit in the rear seat to avoid injury from in the rear seat to avoid injury from inflating air bagsinflating air bags. .

Drowning InjuryDrowning Injury

The father of that 6 month old infant The father of that 6 month old infant also has a 4 year old boy at home. also has a 4 year old boy at home. When counseling him about the When counseling him about the epidemiology of childhood drowning, epidemiology of childhood drowning, a TRUE statement is:a TRUE statement is:

A.A. Drowning is the leading cause of Drowning is the leading cause of death due to injurydeath due to injury

B.B. For every one drowning victim For every one drowning victim there are 5 near drowningsthere are 5 near drownings

C.C. Pool alarms have eliminated the Pool alarms have eliminated the need for fencingneed for fencing

D.D. Residential pools are the most Residential pools are the most common drowning sitescommon drowning sites

E.E. The ratio of male-to-female The ratio of male-to-female drowning deaths is 1:1drowning deaths is 1:1


Residential pools are the most common site Residential pools are the most common site of drowning for children younger than 5. of drowning for children younger than 5. Infants drown in bathtubs most often and Infants drown in bathtubs most often and adolescents in fresh water lakes and adolescents in fresh water lakes and rivers.rivers.

Drowning is the 2Drowning is the 2ndnd leading cause of death in leading cause of death in this age group (remember earlier) with this age group (remember earlier) with peak incidence in the summer months and peak incidence in the summer months and highest rates in the west and the south.highest rates in the west and the south.


Four sided fences 5 ft high with self-closing self-Four sided fences 5 ft high with self-closing self-locking gates are the most effective enclosures locking gates are the most effective enclosures for residential pools.for residential pools.

Pool alarms, pool covers, swimming lessons for Pool alarms, pool covers, swimming lessons for young children and floatation devices are not young children and floatation devices are not as effective as proper enclosures in preventing as effective as proper enclosures in preventing drowning deaths.drowning deaths.

Male to female ratio is 3:1 and 50% of Male to female ratio is 3:1 and 50% of submersion victims are declared dead at the submersion victims are declared dead at the site (drowning to near drowning ratio of 1:1).site (drowning to near drowning ratio of 1:1).

A.A. Drowning is the leading cause of Drowning is the leading cause of death due to injurydeath due to injury

B.B. For every one drowning victim For every one drowning victim there are 5 near drowningsthere are 5 near drownings

C.C. Pool alarms have eliminated the Pool alarms have eliminated the need for fencingneed for fencing

D. Residential pools are the most common drowning sites

E.E. The ratio of male-to-female The ratio of male-to-female drowning deaths is 1:1drowning deaths is 1:1

Injury Prevention: BurnsInjury Prevention: Burns

You are approaching the end of a health You are approaching the end of a health care maintenance visit for a 2 year old care maintenance visit for a 2 year old girl. The mother explains that the family girl. The mother explains that the family recently moved into a private house recently moved into a private house having lived previously in an apartment. having lived previously in an apartment. What four concrete pieces of advice can What four concrete pieces of advice can you give her about how she might make you give her about how she might make her new home safe from the standpoint her new home safe from the standpoint of preventingof preventing burn injuries to her burn injuries to her toddler?toddler?


1.1. Don’t smoke in the home.Don’t smoke in the home.

Home fires cause three fourths of all fire Home fires cause three fourths of all fire deaths and children below the age of deaths and children below the age of 5 are at highest risk.5 are at highest risk.

Adults who smoke carelessly or who fall Adults who smoke carelessly or who fall asleep while smoking are responsible asleep while smoking are responsible for the largest percentage of home for the largest percentage of home fires that kill or injure children.fires that kill or injure children.


2.2. Install smoke detectors on each floor in Install smoke detectors on each floor in the house and test them every 6 months.the house and test them every 6 months.

Smoke detectors provide the best protection Smoke detectors provide the best protection should a home fire begin since: a) most fires should a home fire begin since: a) most fires start in the early morning hours; b) most fires start in the early morning hours; b) most fires burn for a long time before discovery; and c) burn for a long time before discovery; and c) deaths are usually due to CO poisoning so deaths are usually due to CO poisoning so early alerts can help prevent injury and death.early alerts can help prevent injury and death.


3.3. Prepare emergency escape plans for Prepare emergency escape plans for use in the event of a fire.use in the event of a fire.

Even children as young as 3 can be taught how Even children as young as 3 can be taught how to safely get out of the house in the event to safely get out of the house in the event of a fire. If fire extinguishers are available of a fire. If fire extinguishers are available in the home (and they should be) children in the home (and they should be) children should always be taught to leave the house should always be taught to leave the house rather than try to put out a fire themselvesrather than try to put out a fire themselves. .


4.4. Set hot water heaters at no higher Set hot water heaters at no higher than 120than 120o o F.F.

Tap water at 160Tap water at 160o o F can produce a full-F can produce a full-thickness scald burn in less than 1 thickness scald burn in less than 1 second. At 120second. At 120o o F the scalding time F the scalding time is increased to between 2 and 10 is increased to between 2 and 10 minutes.minutes.

Development

DevelopmentDevelopment

A six month old breast fed male infant is at your A six month old breast fed male infant is at your office for a well child check-up. He has been office for a well child check-up. He has been previously well and on exam babbles, reaches previously well and on exam babbles, reaches for your stethoscope and pulls to a sitting for your stethoscope and pulls to a sitting position without head lag. He can also:position without head lag. He can also:

1.1. Finger feed himselfFinger feed himself2.2. Imitate soundsImitate sounds3.3. Pull to standPull to stand4.4. Transfer objects from one hand to the otherTransfer objects from one hand to the other5.5. Use a scissors grasp to obtain a piece of cerealUse a scissors grasp to obtain a piece of cereal


Correct answer is 4, transfer objects.Correct answer is 4, transfer objects.As part of his normal development this infant As part of his normal development this infant

probably began to hold a rattle briefly at 2 probably began to hold a rattle briefly at 2 months, reached for objects and and lifted months, reached for objects and and lifted himself onto extended elbows at 4 months. He himself onto extended elbows at 4 months. He probably also began to roll over at 4 months and probably also began to roll over at 4 months and could roll both ways by 6 months. He likely could roll both ways by 6 months. He likely began to coo at 2 months, to laugh out loud at 4 began to coo at 2 months, to laugh out loud at 4 months, and to begin to babble at 6 months. months, and to begin to babble at 6 months. Pulling to stand usually begins around 8 months. Pulling to stand usually begins around 8 months. Finger feeding and imitating sounds usually starts Finger feeding and imitating sounds usually starts at 9 months.at 9 months.


You are examining a young boy during a health You are examining a young boy during a health supervision visit. His mother reports that he says supervision visit. His mother reports that he says “mama,” “dada,” “bye,” “up,” and “ball.” While “mama,” “dada,” “bye,” “up,” and “ball.” While playing on the floor he sees a toy truck on the playing on the floor he sees a toy truck on the shelf and points to it. His mother asks him to shelf and points to it. His mother asks him to bring her the truck which he does. These bring her the truck which he does. These developmental milestones suggest the child is developmental milestones suggest the child is CLOSEST to:CLOSEST to:

A.A. 12 months of age12 months of age D. 21 months of ageD. 21 months of ageB.B. 15 months of age15 months of age E. 24 months of ageE. 24 months of ageC.C. 18 months of age18 months of age


The correct answer is B. 15 months of age. The correct answer is B. 15 months of age.

At this age infants generally have a vocabulary of At this age infants generally have a vocabulary of about 6 words, can follow simple commands, about 6 words, can follow simple commands, point to parts of their bodies and use gestures point to parts of their bodies and use gestures and jargon to express themselves. 18 month and jargon to express themselves. 18 month olds have a vocabulary of about 10-15 words olds have a vocabulary of about 10-15 words and 21 month olds know 30 to 50 words. Two and 21 month olds know 30 to 50 words. Two year olds are beginning to put two word phrases year olds are beginning to put two word phrases together and generally know about 100 words. together and generally know about 100 words. They can follow complex commands.They can follow complex commands.


Familiarity with expected language milestones Familiarity with expected language milestones is important for the calculation of the is important for the calculation of the language developmental quotient according language developmental quotient according the formula:the formula:

LQ = language age/chronological age X 100LQ = language age/chronological age X 100

A child with an LQ of less than 70 should be A child with an LQ of less than 70 should be referred for further evaluation.referred for further evaluation.

Development

You and your colleagues are thinking of adding routine developmental screening to you office practice. In looking into this possibility you have discovered that:

DevelopmentA. Developmental surveillance should occur at

the 9, 18, and 30 month visits.B. The goal of developmental screening is to

arrive at a diagnosis and a treatment plan.C. The diagnosis of a specific developmental

disorder is necessary to make an EI referral.D. Sensitivity and specificity rates of 70%-80%

are acceptable for developmental screening tests.

E. Subsequent screening is not necessary after a child passes two screening tests.

Development

The correct answer is D sensitivity and specificity rates of 70%-80% are acceptable for developmental screening tests.

A variety of screening tools with different psychometric properties are available for screening purposes but, in general, they have lower sensitivity and specificity than medical screening tests because of the underlying variability of the construct being measured and the absence of specific curative treatments for some conditions.

Development

Surveillance is the process of recognizing children who may be at risk for developmental delays and should take place at every well child visit;

Screening is the use of a standardized tool to identify and refine the recognized risk;

Evaluation is a complex problem to identify a specific developmental disorder in a child.

Development

Early Intervention services are valuable for children identified at high risk. They can provide evaluation services, developmental therapies, service coordination, transportation support, etc.

The diagnosis of a specific developmental disorder is not necessary to refer a child deemed at risk to receive EI services.

Development

The American Academy of Pediatrics, in its 2006 policy statement on Identifying Infants and Young Children With Developmental Disorders recommends surveillance at every preventive care visit and the use of a standardized tool to screen low risk children at the 9, 18, and/or 30 month visits.

Anticipatory GuidanceAnticipatory Guidance

You are seeing a set of parents with their 8 You are seeing a set of parents with their 8 year old boy for a health care year old boy for a health care maintenance visit. The mother asks you maintenance visit. The mother asks you whether allowing her son to watch TV whether allowing her son to watch TV when he comes home from school is a bad when he comes home from school is a bad idea.idea.

The MOST accurate statement you can make The MOST accurate statement you can make to her about the influence of television to her about the influence of television viewing on children is:viewing on children is:

TV ViewingTV Viewing

A.A. Most adolescents have difficulty Most adolescents have difficulty discriminating between what they see on TV discriminating between what they see on TV and what is real.and what is real.

B.B. Nearly 2/3 of all programming includes Nearly 2/3 of all programming includes violence and children’s programming violence and children’s programming contains the most violence.contains the most violence.

C.C. 50% of 2-7 year olds have a TV in their room.50% of 2-7 year olds have a TV in their room.D.D. A majority of parents report that they always A majority of parents report that they always

watch TV with their children to monitor the watch TV with their children to monitor the content of what is seen.content of what is seen.


Although young children and adolescents are Although young children and adolescents are vulnerable to the messages conveyed on vulnerable to the messages conveyed on television, it is predominantly younger television, it is predominantly younger children who cannot discriminate between children who cannot discriminate between what is real and what they see on TV. In a what is real and what they see on TV. In a random survey of parents with children from random survey of parents with children from kindergarten through 6kindergarten through 6thth grade published in grade published in 1996, 37% reported that their child had been 1996, 37% reported that their child had been frightened or upset by a TV program seen frightened or upset by a TV program seen during the preceding year.during the preceding year.

Cantor J, Nathanson AI. Children’s fright reactions to television news. J Commun. 1996;46: 139-152.


About one third of parents of 2-7 year About one third of parents of 2-7 year olds report that their children have a olds report that their children have a television in their room.television in their room.

Less than half of all parents state that Less than half of all parents state that they always watch television with they always watch television with their children to monitor the content their children to monitor the content of what is being seen.of what is being seen.


A recently completed 3 year National A recently completed 3 year National Television Violence Study reported that:Television Violence Study reported that:

Nearly 2/3 of all programming contains Nearly 2/3 of all programming contains violence; violence;

That children’s shows contain the most That children’s shows contain the most violence;violence;

That portrayals of violence are usually That portrayals of violence are usually glamorized; andglamorized; and

Perpetrators often go unpunished.Perpetrators often go unpunished.

Federman J. ed. National Television Violence Study Vol 3. Thousand Oaks, CA: Sage; 1998.

TV Viewing

A.A. Most adolescents have difficulty Most adolescents have difficulty discriminating between what they see discriminating between what they see on TV and what is realon TV and what is real

B. Nearly 2/3 of all programming includes violence and children’s programming contains the most violence

C.C. 50% of 2-7 year olds have a TV in 50% of 2-7 year olds have a TV in their roomtheir room

D.D. A majority of parents report that they A majority of parents report that they always watch TV with their children to always watch TV with their children to monitor the content of what is seenmonitor the content of what is seen

Child AbuseChild Abuse

Case #4Case #4

The parents of a 9 month old The parents of a 9 month old baby girl who is new to your baby girl who is new to your practice bring her for a regular practice bring her for a regular checkup. There are no checkup. There are no complaints. Physical exam complaints. Physical exam reveals the following lesion:reveals the following lesion:

dermatlas.com/derm/dermatlas.com/derm/

http://162.129.70.33/images/cigaretteburn_1_030226.jpg

A. Patient is less than 3 years of ageA. Patient is less than 3 years of age

B. There is a history of spousal abuseB. There is a history of spousal abuse

C. Father is an alcoholicC. Father is an alcoholic

D. Mother did not breastfeed the childD. Mother did not breastfeed the child

E. The child is a foster childE. The child is a foster child

The following risks factors The following risks factors may indicate child abuse may indicate child abuse

except:except:

D. Mother did not breastfeed the D. Mother did not breastfeed the childchild

Risk factors for Child AbuseRisk factors for Child Abuse – – ParentalParental Past history of abuse or family violencePast history of abuse or family violence Inability to cope, lack of support, attachment issuesInability to cope, lack of support, attachment issues Closely spaced pregnancies, financial problemsClosely spaced pregnancies, financial problems Alcoholism, addiction, psychosis, depressionAlcoholism, addiction, psychosis, depression Young parental age, single parentYoung parental age, single parent

Risk factors for Child AbuseRisk factors for Child Abuse – – ChildChild Child is less than 3 years of ageChild is less than 3 years of age Twin, prematurityTwin, prematurity Chronic illness, mental retardation, learning Chronic illness, mental retardation, learning

disabilitydisability Foster or adopted childFoster or adopted child

Child abuse – Physical signsChild abuse – Physical signs Bruises, burns, bites, blunt-instrument Bruises, burns, bites, blunt-instrument

marks marks Fractures – bucket handle, posterior rib Fractures – bucket handle, posterior rib

fractures, multiple fractures at different fractures, multiple fractures at different stages of healing stages of healing

Intracranial hemorrhagesIntracranial hemorrhages Retinal hemorrhagesRetinal hemorrhages Duodenal hematomas, lacerations of liver Duodenal hematomas, lacerations of liver

and spleen, mesenteric tearsand spleen, mesenteric tears Oral lacerationsOral lacerations Failure to thriveFailure to thrive

aafp.org/afp/ aafp.org/afp/ 20000515/3057_f7.jpg20000515/3057_f7.jpg

Multiple posterior rib fracturesMultiple posterior rib fractures

Bucket handle fractureBucket handle fracture

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