7420 Final Exam Study Guide PDF

Sleep: 1. What counseling would you provide parents whose children experience nightmares? Nightmares occur during REM sleep 75% of children have nightmares that occur in the last 3rd of the night 2. After fully assessing the situation, what suggestions might you have for families of a toddl...

Sleep: 1. What counseling would you provide parents whose children experience nightmares? Nightmares occur during REM sleep 75% of children have nightmares that occur in the last 3rd of the night 2. After fully assessing the situation, what suggestions might you have for families of a toddler with sleep refusal? Parent education/prevention Extinction (you have a bedtime routine 4-5 consistent quiet activities 20-30 min in length, use a mantra like “good night I love you,” then walk out of the room) ○ Takes about 4 days to sleep train night 2/3 the baby’s cry increases in duration ○ Used to teach the child how to fall asleep independently and eventually to sleeping through the night Graduated extinction ○ Lengthening out the time of crying takes about 4-7 days to carried out completely Schedule awakening Positive routines/faded bedtime with response cost (bedtime pass trade in with prizes at around 3 yrs of age) Replace physical parental presence with new sleep onset associations that will be present when the child wake at night Parents should leave the room before the child falls asleep If the child cries, frequent checks, and reassurance, but with increasing intervals If the child comes out of the room, take the child right back and tuck back in without unnecessary conversation, arguing, etc. Child is not allowed to sleep with parents Takes about 4 days to sleep train night 2/3 the baby’s cry increases in duration 3. What are possible causes of sudden unexpected infant death associated with sleep environments? Not placing the infant in back to sleep Having anything except the correct mattress and fitted sheet in the crib ○ ex. -blanket  -pillow -crib liners -hats -toys Having anything hanging over the crib such as a mobile Co-sleeping Suffocation Asphyxia Entrapment Infection Ingestions Metabolic diseases Arrhythmia associated cardiac issues Trauma (accidental or non accidental) Nutrition & Food Scarcity: 1.What is the appropriate age to introduce complementary foods during infancy? What are common methods of complementary (solid) food introduction? When and how should potentially allergenic foods be introduced? The appropriate age to introduce complementary foods during infancy is 6 months of age and no earlier than 4 months of age as this can increase the risk for food allergies The common methods of complementary (solid) food introduction are as follows: ○ There is no evidence that any one food group should be introduced first, apart from foods with high allergenic potential Peanuts Tree nuts Eggs Dairy Shellfish ○ Offer 1 new food at a time over at least 3 days, watching for signs of allergies  ○ Feed soft purees via spoon with infant secured/supported in a highchair with straps ○ Include iron rich foods in the diet daily Animal protein Green leafy vegetables Fortified cereal ○ Offer new foods with high allergenic potential at home, one new ingredient at a time ○ CONTINUE to offer human milk (or formula, when milk is not available) along with solids through 12 mo Allergenic foods should be introduced once a few complementary foods considered to be low allergenic risk have been introduced (ie meats, infant cereals, vegetable or fruits), foods with higher allergy potential (peanuts, tree nuts, dairy, eggs, shellfish) may be introduced one at a time in SMALL amounts at home ○ Never introduce at a daycare or restaurant ○ In children with a strong family history of atopy (sibling or parent with food allergy) but no personal history of atopy you can introduce high allergen foods in the above manner ○ EXCEPTION-for infants with a personal history of moderate-severe atopic dermatitis or history of immediate or severe reaction to ANY previously introduced food/human milk exposure to food Refer to allergist for evaluation +/- testing prior to home introduction of highly allergenic foods 2. What is the recommended daily intake of Vitamin D in infants? Preschool aged children? School aged children? How is this best obtained by patients at each age (dietary sources vs. need for supplementation)? If the child is under one years old and is weaned from human milk and taking at least 1 liter (32oz) per day of Vitamin D containing infant formula For the breastfed infant parents can do one of two things: ○ Infant supplementation of 400 IU PO everyday ○ Lactating parent supplementation of 4,000 IU PO everyday  For the breastfed infant parents can do one of two things until over age 1 that are weaned and drinking up to 1 liter of Vitamin D fortified cow’s milk every day plus dietary sources of Vitamin D such as eggs, fortified dairy, salmon Children 1-3yo: 600 IU of vitamin D daily Children 4-8yo: 600 IU of vitamin D daily 3. Discuss iron deficiency and the health risks associated. List common ages for initial presentation, risk factors for the condition and dietary sources rich in iron. *Adequate iron stores are necessary for optimal neurodevelopment* Iron Deficiency and the Health Risks Associated: ○ Iron is necessary for critical functions such as neuronal function, metabolism of neurotransmitters and myelination Studies have documented long term cognitive deficits associated with iron deficiency in infancy and early childhood ○ Iron deficiency increases risk for lead related health issues Patients who are iron deficient exhibit increased intestinal absorption of lead when exposed and have reduced response to lead chelation therapy Prevention of iron deficiency anemia seen as an effective, low-cost primary lead poisoning prevention measure Common Ages for Initial Presentation: ○ Infants 9-24 months of age Risk Factors for Iron Deficiency Anemia: ○ Babies who are born prematurely ○ Low birth weight babies ○ Babies who drink cow/goat milk before age 1 ○ Breastfed babies who aren’t given complementary foods containing iron after 6 months Dietary Sources Rich in Iron: ○ Red meats ○ Poultry ○ Fatty fish  ○ Dark, leafy greens (spinach) ○ Tofu ○ Lentils/beans ○ Fortified cereals ○ Prunes *When paired with foods rich in vitamin C such as citrus, tomato’s, sweet potatoes, and dark leafy greens dietary absorption of iron increases 4. What is food insecurity? List risk factors for food insecurity. Discuss how living in a food insecure household places children at risk for nutrient deficiencies and health/mental health issues. Food insecurity- the limited or uncertain availability of nutritional adequate and safe foods or limited or uncertain ability to acquire quality, high nutrition foods in socially acceptable ways Risk factors for food insecurity: ○ Low income ○ Unemployment ○ Race/ethnicity ○ Disability Impact of Food Insecurity: ○ At risk for developing cardiovascular disease, hyperlipidemia, diabetes ○ At risk for developing Vitamin D, Calcium, and Iron deficiencies because children are unable to obtain sufficient nutrients from fresh fruits, vegetables, dairy products, meats, and poultry ○ Associated with increased rates of asthma, increased lifetime rates of depression, decreased outpatient/preventive care and increase in emergency department utilization rates these become risk factors because being worried about food is considered an adverse childhood event along with families experiencing the above risk factors for food insecurity as they are also adverse childhood events. 5. Name five adverse health outcomes associated with elevated BMI in children.  Type II diabetes Fatty liver disease Dyslipidemia Sleep apnea Hypertension 6. Discuss how social determinants of health impact rates of obesity in childhood. Social Determinants of Health: ○ Economic stability ○ Education access and quality ○ Health care access and quality ○ Neighborhood and built environment ○ Social and community context ○ Enough money to buy food ○ Adequate health insurance to attend yearly physical to provide an opportunity to screen for obesity and educate on prevention ○ Adequate health insurance to attend yearly physical to re-qualify for WIC ○ Safe place to play outside 7. How would you approach the finding of elevated BMI at a healthcare visit? Discuss the use of a body positive, patient centered approach to discussing overweight and obesity with pediatric patients and families in the outpatient setting, with focus on prevention of comorbid conditions. Patient centered-approach to addressing adiposity/obesity in childhood MUST BE PATIENT CENTERED at all times Positive-ALWAYS keep positive body image at the forefront of the conversation and foster patient autonomy and positive self-esteem Identify-IDENTIFY that BMI > 95% carries increased lifetime risk of preventable diseases and that goal of identifying elevated BMI in primary care is to promote health-looking at calculations that convey risk, not body shape or size Discuss-DISCUSS physical exam findings of concern (ie acanthosis nigricans) and WHY they are of concern-because they represent  increased risk of health complications both in the immediate future and throughout the lifetime-NOT because of body shape or size Recognize- RECOGNIZE the role of genetics/epigenetics-some individuals have higher propensity for increased body mass. RECOGNIZE the role of societal structures in creating unequal risk for elevated BMI (access to healthy foods, targeted marketing) Screen- SCREEN with recommended measures to assess for co-morbidities-and focus on the TEST RESULT numbers, less on the numbers on the scale 8. State the recommended screening tests for patients ages 10+ with BMI > 95% and the frequency at which these tests are to be administered. Tests ○ Fasting blood glucose and/or HgA1c ○ Fasting lipid panel/non-fasting if not feasible ○ ALT, AST, consider GGT ○ Consider 25 OH Vitamin D ○ Consider sleep study ○ Consider liver ultrasound ○ Consider uric acid ○ Consider fasting serum insulin ○ Consider urine microalbumin/creatinine ratio ○ Consider C-peptide, hs-CRP Timing ○ Every two years Dental: 1. What factors are associated with an increased incidence of tooth enamel defects in young children? Some tooth surfaces are more prone to decay: ○ Newly erupted teeth (immature enamel) ○ Those with enamel defects Enamel cells very sensitive to systematic insults Enamel disruption can cause macro/microscopic defects  Increased incidence of enamel defects are associated with: ○ Lower SES ○ Children born prematurely ○ Children with certain congenital and genetic diseases and other children with special needs, such as children with cerebral palsy and intellectual disabilities 2. When does the American Academy of Pediatrics recommend that a child’s first visit to a dentist occur? Why? AAP recommends that a child’s first visit to the dentist should occur within 6 mo of eruption of the first tooth, and no later than 12 mo of age They recommend this to establish a risk assessment for developing caries, providing anticipatory guidance, and parental education 3. What are the routine recommendations regarding juice intake in infants and toddlers? Do not routinely give fruit juice to infants younger than 12 mo since it offers NO nutritional benefit at this age 1-3 y.o.: ○ Limit fruit juice to a maximum of 4oz (½ cup), do not allow child to carry a cup or box of juice throughout the day From 4 to 6 years old, fruit juice is limited to 4-6 ounces, or half to ¾ cup per day From 7 to 18 years old, limit juice to 1 cup, or 8 ounces, per day 4. Why is it best to do a comprehensive assessment when determining the need for fluoride supplementation in young children? Because the need for fluoride could be due to the child’s water supply source, or because of SEVERE risk for increased caries, and/or both of the aspects noted above Topical Effect: ○ Inhibiting tooth demineralization ○ Enhancing remineralization ○ Inhibiting bacterial metabolism Available forms: ○ Toothpaste  ○ Varnish (professional application) ○ Mouth rinses Systemic effect: ○ Not as effective as topical ○ Reducing enamel solubility through incorporation into its structure during tooth development ○ Available forms: Water Supplements Fluoride supplementation: ○ Optimal water fluoridation level is 0.7ppm ○ City water may be fluoridated ○ Bottled water may have naturally occurring fluoride depending on source ○ Water filters- Most filters are charcoal based and do not remove fluoride Only reverse osmosis water filters (very costly to install) remove fluoride ○ Fluoride levels of well water are variable so testing is available ○ Dietary fluoride supplementation by prescription for children at HIGH caries risk who do not have access to optimally fluoridated water is recommended by the AAPD ant the CDC Important to prescribe sugar free preparation Oral Examination: ○ Positioning the patient-knee to knee best for young children ○ Lift the lip ○ Look at all the teeth-front, back, and sides ○ Note plaque (rough white buildup), white spots, cavities, abscesses, and damaged teeth ○ Examine the soft tissues-including the tongue, lips, gums, and cheeks Injury Prevention: 1. What safety counseling would you provide regarding the care of a newborn? A toddler? A school age child? A pre-adolescent? Newborn: Highest risk: falls, SIDS, unintentional injuries Constant supervision required Safe sleep environment with passive supervision/proximity to the infant while asleep ○ Back to sleep/safe to sleep Back and side-sleeping = 8x higher risk for SIDS If child can roll, as long as you put them to sleep on their back it’s okay if they roll onto their side or back (able to roll back if they need to) Firm mattress Crib with fixed sides (no drop rails) Tight fitting crib sheet No pillows or blankets No bumpers Pacifier for sleep initiation ○ Safe alternatives to bed sharing ○ Room sharing (without bed sharing) is protective Safety measures for safe transportation Water safety: ○ Supervision around ANY water ○ High risk sites: swimming pools, bathtubs, standing water Remember: fall accounts for 50% of injury-related ED visits in infants in the US Toddler: Highest risk: drowning, falls, ingestion/choking, MVA, bites or other injuries from pets/animals ○ Prevention: high levels of supervision Childproofing daily environment, home, car ○ Car seat safety: 2 AND 30: Must remain in rear facing until 2 yo and 30 lbs  ○ Water safety: Supervision around ANY water High risk sites: swimming pools, bathtubs, standing water Swimming lesson for children over the age of 1yr Childproofing meals—reduce choking hazards (no tube-shaped foods, popcorn, raw carrots, nut butters) Child proof tantrums/aggression ○ Help child calm down ○ State consequence of actions ○ Redirect behaviors into more socially acceptable means School age: Never leave home alone! Car seat safety: ○ 5 AND 40: Must remain in 5-point harness until 5yo and 40lbs ○ 8 AND 60: Must remain in lap positioning booster seat until 8yo and 60lbs Water safety: ○ Supervision around any water ○ Swimming pools, bathtubs, standing water Play dates: ○ Is there going to be a parent home? ○ What is in the home? Guns? Are guns locked up? US is world leader in gun injuries among youth Easy access to firearms = increased intentional and unintentional firearm injuries in youth Sports ○ Appropriate equipment Helmets ○ What moves are allowed? Heading ball? Address “appropriate touch” Peer pressure- Know child’s friends Know the influence of violence- video games, community, etc. Pre-adolescent:  Car seat safety: ○ Should be 13 years old before sitting in front passenger seat Water safety: ○ Natural bodies of water 2. Regarding safety, what are examples of primary prevention initiatives? Secondary prevention? Primary prevention: advising about safe storage of cleaning chemicals, as well as the storage of cleaning chemicals high out of children’s reach Secondary prevention: use of properly installed rear-facing car seat; installation of smoke detectors and sprinkler systems 3. What are key considerations when determining whether an infant is properly secured in a car seat? Always read car seat and vehicle manuals when installing/using car seat or booster seat 2 AND 30: must be in rear-facing car seat until 2yo AND 30lbs ○ *INFANT* should be rear-facing ○ Never wear puffy clothes/jacket under car seat ○ Place the harnesses in rear-facing seat in slots that are at or below the infant’s shoulders ○ Ensure harness is snug and chest clip is at center of chest even with child’s armpits ○ Make sure car seat is installed tightly in vehicle with either lower ankle or locked seat belt ○ Never place rear-facing seat in front seat of a vehicle with active front passenger airbag ○ Make sure seat is at proper angle so child’s head doesn’t flop forward 5 AND 40: must be in 5-point harness until 5yo AND 40lbs 8 AND 60: must be in booster seat until 8yo AND 60lbs 4. What resources would you share with parents regarding safe installation of car seats and proper use of car seats/booster seats at a given age/weight?  Speak with certified CPST AAP Car Seats: Information for Families site 5. Discuss key water safety measures aimed at reducing drowning events. Swimming lesson for children 1yo and older Swimming proficiency Recognize situations that could reduce swimming ability in local environment (rip tides, currents, extreme cold) Recognizing one’s own limitations in and around water Knowledge of proper use of survival floatation devices Recognition of other swimmers in distress and how to safely assist them, including CPR Environmental barriers: pool gates with locks, fencing, lifeguards 6. What are key factors known to be associated with increased rates of unintentional firearm injuries in minors? How does the presence of a firearm in the home relate to incidences of youth suicide? 1.7 million children live in homes with unlocked, loaded guns ¾ first and second graders know where their parents keep their firearms and 1/3 of them admit to touching them without parent knowledge Fatal unintentional gunshot injuries are usually inflicted by a sibling or a peer Easy access = increased intentional AND unintentional firearm injuries in youth Death rates higher in states with greater gun availability than those with strong restrictions limiting availability Suicide rate 4x higher for children living in homes with guns 7. List three social determinants associated with gun violence. Income inequality Residential economic and racial segregation Intergenerational social mobility  Individual’s level of trust in institutions (police, mental health care systems, etc) Economic opportunity Public welfare spending Elimination: 1) Discuss cross-cultural differences in approaches to toilet training. What are the perceived benefits of initiating toilet training in infancy? In the older toddler? Cross Cultural Differences: ○ Western countries generally initiate toilet training later than in many developing nations ○ Majority of parents in the developing countries reported start/completion of toilet training between 7-12 mo ○ European pediatricians surveyed recommended toilet training starting at 24 mo and advised a longer duration for skill mastery ○ In European nations surveyed, diapers are viewed as a potty-training tool for children Perceived Benefits of Initiating Toilet Training in Infancy: ○ In Sri Lanka, potty training is seen to reduce infections, contaminations, and diaper rash ○ In Ghana, seen as a positive way to help a child become more independent ○ In Asia, South American and African nations surveyed diaper is seen as an aid for parents Perceived Benefits of Initiating Toilet Training in the Older Toddler: ○ In Belgium and the Netherlands, preschool readiness is the main motivating factor for potty training 2) What practice suggestions might you offer to a family that is struggling with toilet training their toddler? Introduce the young toddler to toilet use by allowing them to observe parent Give the child the language for their bodily functions as well as the anatomical terms for the body parts involved in toileting  Read books about toilet training Be sensitive to the child’s fears, it is common to be fearful of the “loud” flushing sounds or of using an unfamiliar bathroom Feet on the floor! A low to the ground potty allows for foot support If using a toilet ring, offer a footstool to support feet Keep the diet fiber rich Constipation can lead to painful defecation, which leads to withholding stool leading to more constipation Use positive reinforcement and EXPECT voiding/BM accidents DO NOT start training in times of stress (a move, birth of new sibling, family crisis such as illness or death) 3) Developmentally, what are common time periods for constipation to occur? Infants at weaning Toddlers acquiring toilet skills (shame vs doubt) School age 4) What are the initial approaches for evaluating a child with constipation in the primary care setting? A child with enuresis? Evaluating a child with constipation: ○ Assess what the patient’s baseline bowel patterns were and how current symptoms deviate from this ○ Was there any change in diet (introduction of solids in late infancy, picky eating/low fiber diet, dietary restrictions) ○ Any medications (iron supplements, narcotic pain medications given post-op, use of laxatives for symptoms) ○ Any change in voiding patterns (frequent UTIs, enuresis) ○ Any “diarrhea” or inability to get to the bathroom on time for BMs Encopresis is the passage of stool (intentionally or involuntary) into clothing in a child with the developmental age of less than or equal to 4 years Often misinterpreted by parent or patient as diarrhea or as poor hygiene/poor toileting skills  Often labeled by caregivers as due to laziness or as a deliberate effort when, in the majority of cases, the soiling is involuntary (retentive encopresis) Requires aggressive constipation “clean out” and maintenance treatment to alleviate underlying constipation Constipation red flags: ○ Passage of meconium after 48 hours of birth in a full-term infant ○ Constipation starting within the first year of life ○ Family history of Hirschsprung’s disease ○ Ribbon stools ○ Blood in the stools in the absences of anal fissures ○ Failure to thrive ○ Bilious vomiting ○ Severe abdominal distention ○ Abnormal thyroid gland ○ Abnormal position of the anus ○ Absent anal or cremasteric reflex ○ Decreased lower extremity strength/tone/reflex ○ Sacral dimple ○ Tuft of hair on spine ○ Gluteal cleft deviation ○ Anal scares ○ Extreme fear during rectal examination Evaluating a Child with Enuresis: ○ Once a family has indicated that a child is struggling with enuresis, it’s important to take a thorough history ○ Make sure to assess for 3 major contributors: CONSTIPATION, SNORING, and STRESSORS ○ Constipation and detrusor overactivity are strongly interrelated Constipation leads to a distended rectum which leads to compression of the bladder with decreased bladder capacity and increased post-void residual urine in the bladder which increases detrusor instability ultimately leading to the INVOLUNTARY PASSAGE OF URINE  ○ In obstructive sleep apnea syndrome (OSAS), patients experience apnea which lead to hypoxic episodes ultimately affecting bladder function and control Surgical correction of airway obstruction/OSAS can be curative for both snoring and nocturnal enuresis ○ When there’s enuresis and behavioral changes, assess for stressors Major life changes, parental discord or abuse can trigger bedwetting Enuresis red flags: ○ Weight loss, decreased rate of linear growth and or nausea → check creatinine and urine protein/urine glucose and physical examination ○ Excessive thirst with a need to drink at night → check urine glucose, complete a fluid intake list, consider creatinine and morning urine osmolality, physical examination ○ Voiding difficulties (weak stream and need to strain to void) → check uroflow and residual urine, physical examination ○ Secondary nocturnal enuresis with recent debut→check urine glucose, physical examination ○ Heavy snoring or sleep apneas → contact ENT, physical examination Hearing & Speech: 1. In identifying children with communication disorders, at what age would you expect the well infant to coo? To babble? An infant should be able to coo at around 2-4 mo An infant should be able to babble about 6 mo 2. What testing methods are used for newborn hearing screening? Otoacoustic Emissions: sounds produced either spontaneously or evoked by the cochlear, specifically the outer hair cells, and measured in the outer ear canal or external ear canal, if there is fluid/meconium sometimes babies will fail this test.  Auditory Brainstem Evoked Response and Auditory Steady State Response: tells us how the cochlea and brain pathways for hearing are working where only loudness level is checked. The infant passes if their brain shows that they are hearing the sound. It is used if the newborn fails the otoacoustic emissions test. Well babies ○ Screened no sooner than 12 hrs post birth, but prior to discharge ○ OAE screen 1st ○ ABR screen is 2nd, if the newborn fails the OAE screen NICU ○ Tested after 34 weeks gestational age ○ No antibiotics ○ No crib conditions ○ No nasal cannula ○ ABR for both 1st and 2nd screen Referred babies are given 1 mo f/u appt for a re-screen ABR 3. What is the primary purpose of universal hearing screening? It is a way to identify hearing-impaired newborns with or without risk factors 4. What problems place infants at risk for hearing loss? - Family history of hearing loss/childhood onset of hearing loss - Prematurity - If in the NICU for over 5 days, premature infants should be re-screened for hearing loss at 6-9 months corrected age - Speech-language delay - History of otitis media - Trauma, especially temporal bone fractures - Parent concerns - Ototoxic medications, especially oncology medications - Families may not be educated on ototoxic risk of oncology medications ahead of starting treatment - Hyperbilirubinemia with exchange, regardless of length of stay - Perinatal asphyxia, potentially from HIE, especially if they required hypothermic treatment  - ECMO = associated with delayed onset of hearing loss, should be monitored for most of their childhood - In-utero infections, including: Herpes, Rubella, Syphilis, Toxoplasmosis, CMV, Zika - Craniofacial malformations - Congenital microcephaly - Congenital or acquired hydrocephalus - Temporal bone abnormalities - Other syndromes associated with atypical hearing thresholds - Bacterial or viral meningitis/encephalitis = may be very rapid loss; monitor closely as profound hearing loss can happen within a day 5. According to AAP recommendations, how should providers respond to parental concerns about hearing loss? Any parental concern about hearing loss should be taken seriously and requires objective hearing screening of the patient. All providers of pediatric health care should be proficient with pneumatic otoscopy and tympanometry. 6. What are indications for referral to audiology for suspected hearing loss? When to refer to speech & language eval: - When the child has a lack of interest in communicating - Child is not following simple directions - Loss of previous milestones - No single words ( by 14 months of age) - Vocabulary of less than 50 words (by age 2) - Less than 50% of unintelligible speech to strangers (by age 3) - Child is not associating spoken words to pictures or objects - Screening tools to use: - Language development survey - ASQ - MacArthur-Bates Communicative Development Inventory (CDI) Needs a hearing eval: - Risk factors of hearing loss (JCIH)-2019 guidelines - Family hx of hearing loss - Pre-maturity (NICU stay >5 days, re-screen 6-9 mo corrected age) - Speech-language delay - Hx of otitis media - Trauma (temporal bone) - Parental concerns - Ototoxic medications (ex. oncology-related medications)