Principles and Concepts in Family Medicine PDF

Principals and concepts in family medicine Principles and concepts in family medicine By the end of the lecture the student will be able to: 1. Define family medicine 2. Understand the role of the primary care in the health system 3. Explain the characteristics and functi...

Principals and concepts in family medicine Principles and concepts in family medicine By the end of the lecture the student will be able to: 1. Define family medicine 2. Understand the role of the primary care in the health system 3. Explain the characteristics and function of family physician 4. Identify the patient center care 5. Understand how to Interact with Special Patients 6. Identify the method of giving counseling to the smoker, uncontrolled diabetic patient and depressed patient Definition of Family medicine: (Text book of family medicine 9th edition, part 1 page 1-16) Family medicine is the medical specialty that provides continuing and comprehensive health care for the individual and the family. The scope of family medicine encompasses all ages, both genders, each organ system, and every disease entity. Definition of family physician (Text book of family medicine 9th edition, part 1 page 1-16) Family physicians provide continuing and comprehensive medical care, health maintenance, and preventive services to each member of a family regardless of gender, age, or type of problem (i.e., biologic, behavioral, or social). Primary care (Text book of family medicine 9th edition, part 1 page 1-16) It is provided by physicians specifically trained for and skilled in comprehensive first-contact and continuing care for ill persons or those with an undiagnosed sign, symptom, or health concern (i.e., the “undifferentiated” patient) and is not limited by problem origin (i.e., biologic, behavioral, or social), organ system, or gender. 1  Principals and concepts in family medicine Functions of primary care: (Text book of family medicine 9th edition, part 1 page 1-16) 1. It is first-contact care, serving as a point of entry for the patient into the health care system. 2. It includes continuity by virtue of caring for patients in sickness and in health over some period. 3. It is comprehensive care, drawing from all the traditional major disciplines for its functional content. 4. It serves a coordinative function for all the health care needs of the patient. 5. It assumes continuing responsibility for individual patient follow-up and community health problems. 6. It is a highly personalized type of care Characteristics and Functions of the Family Physician: (Text book of family medicine 9th edition, part 1 page 1-16) 1. Continuing responsibility 2. Comprehensive Care 3. Interpersonal Skills 4. Accessibility 5. Diagnostic skills: undifferentiated problems 6. The family physician as coordinator 1. Continuing responsibility: The family physician’s commitment to patients does not cease at the end of illness but is a continuing responsibility, regardless of the patient’s state of health or the disease process. This longitudinal relationship between physician and patient characterized by trust, loyalty, and a sense of responsibility and improves quality of care especially for those with chronic conditions such as asthma and diabetes. Families receiving continuing comprehensive care have a decreased incidence of hospitalization, fewer operations, and fewer physician visits for illnesses compared with those having no regular physician. This results from the physician’s knowledge of the patients, seeing them earlier for acute problems and therefore preventing complications that would require hospitalization. 2  Principals and concepts in family medicine 2. Comprehensive Care: The term comprehensive medical care requires an awareness of all the factors that may aid or hinder an individual’s recovery from illness. This approach requires consideration of religious beliefs; social, economic, or cultural problems; personal expectations; and heredity. An outstanding clinician recognizes the effects that spiritual, intellectual, emotional, social, and economic factors have on a patient’s illness. The early identification of disease while it is in its undifferentiated stage requires specific training. 3. Interpersonal Skills: One of the foremost skills of family physicians is the ability to use effectively the knowledge of interpersonal relations in the management of patients. 4. Accessibility: The feeling of security that the patient gains just by knowing he or she can “touch” the physician, in person or by phone, is therapeutic and has a comforting and calming influence. 5. Diagnostic skills: undifferentiated problems: The family physician must be an outstanding diagnostician. Skills in this area must be honed to perfection because problems are usually seen in their early, undifferentiated state and without the degree of resolution that is usually present. by the time patients are referred to consulting specialists. This is a unique feature of family medicine because symptoms seen at this stage are often vague and nondescript, with signs being minimal or absent. 6. The family physician as a coordinator: As medicine becomes more specialized and complex, the family physician’s role as the integrator of health services becomes increasingly important. The family physician facilitates the patient’s access to the whole health care system and interprets the activities of this system to the patient. 3  Principals and concepts in family medicine Family doctor patient relationship (The patient centered care) It is important that you are able to effectively communicate with patients to best help them. Essential to communication is being able to quickly establish rapport with your patients. The following steps will strengthen your patient communication skills: American Academy of Family Physicians Division of Medical Education 1. Seek to minimize distractions and interruptions: When visiting with your patients. Put your phone on silent mode during your visit. Close a door if outside noise is a distraction. (However, ask your patient’s permission first. 2. Engage in active listening: Concentrate on what the patient is communicating verbally (by paraphrasing and restatement) and nonverbally (by head nodding) Take into account both facts and emotions. 3. Be deliberate about the nonverbal cues you send: Lean forward, maintain eye contact, nod appropriately, and don’t cross your arms. 4. Offer concrete feedback: When you summarize what you’ve heard, frame your responses by saying “Let me see if I have this right…” Seek to identify or clarify the patient’s feelings by saying “Tell me how you’re feeling about this” or “I have the sense that… 5. Allow the patient to correct or add to your responses: Until he or she confirms your understanding — “Did I miss anything?” According to several sources, the effective use of empathy promotes diagnostic accuracy, therapeutic adherence and patient satisfaction. 4  Principals and concepts in family medicine How to interact with special patients 1- The anxious patient: (FIRST AID for the USMEL Step 2CS Fifth Edition P 40-63) Encourage the patient to talk about his feelings. Ask about the things that are causing the anxiety. Offer reasonable reassurance. You can also validate the patient’s response by saying, “Any patient in your situation might react in this way, but I want you to know that I will do my best to address your concerns.” 2- The angry patient: (FIRST AID for the USMEL Step 2CS Fifth Edition P 40-63) Stay calm and don’t be frightened. Remember that the patient is not really angry; he is just acting angry to test your response. Let the patient express his feelings, and inquire about the reason for his anger. You should also address the patient’s anger in a reasonable way. For example, if the patient is complaining that he has been waiting for a long time, you can validate his feelings by saying, “I can understand why anyone in your situation might become angry under the same circumstances. I am sorry I am late. The clinic is crowded, and many patients had appointments before yours.” 3- The patient who is in pain: (FIRST AID for the USMEL Step 2CS Fifth Edition P 40-63) Show compassion for the patient’s pain. Say something like “I know that you are in pain.” Offer help by asking, “Is there anything I can do for you to help you feel more comfortable?” Do not repeat painful maneuvers. If the patient does not allow you to touch his abdomen because of the severe pain he is experiencing, tell him, “I know that you are in pain, and I want to help you. I need to examine you, though, to be able to locate the source of your pain and give you the right treatment.” Reassure the patient by saying, “I will be as quick and gentle as possible. 5  Principals and concepts in family medicine Counseling Counseling patients on lifestyle modification and psychosocial problems is a fundamental competency for family physicians. Approximately 40% of primary care office visits are for chronic illness in which psychosocial factors play a major role in etiology and disease progression. Counseling patients about health risk behaviors and health education is a core component of 18% of all primary care office visits. (American Family Physician, Counseling Patients in Primary Care: Evidence-Based Strategies) Although these behaviors may or may not be relevant to your primary diagnosis, it is important that they be addressed in a rapid yet caring manner. The Five A’s: (American Family Physician, Counseling Patients in Primary Care: Evidence-Based Strategies) Definition: The five A’s (ask, advise, assess, assist, arrange;) protocol for primary care physicians to efficiently assess and counsel patients about smoking cessation, alcohol intake, and weight loss. Whenever possible, advising and assessing should link the patient’s presenting problem (e.g., gastrointestinal distress, knee pain with a body mass index above 30 kg per m2) to objective, factual standards (e.g., safe vs. unsafe levels of alcohol use, recommended daily caloric intake). Patients are likely to respond more favorably to “I” statements (“I recommend…”) rather than “You” statements (“You should…”) An example of using the 5 A’s is: The recommended guidelines to help patients quit smoking: (FIRST AID for the USMEL Step 2CS Fifth Edition P 40-63) 1. Ask the patient about tobacco use: Do you smoke cigarettes? 2. Advise him or her to quit: I strongly recommend that you quit smoking 6  Principals and concepts in family medicine 3. Assess the patient’s willingness to make an attempt to quit: Ask two questions in relation to “importance” and “self-efficacy”: 1. “Would you like to be a nontobacco user?” 2. “Do you think you have a chance of quitting successfully? 4. Assist in the quit attempt: Help the patient to develop a quit plan Recommend the use of approved medication if needed 5. Arrange for follow-up: Arrange a follow-up contact with your patient either in person or by telephone. Refer the patient to specialist support if needed. 7  Clinical Assessment of newborn Clinical assessment of newborn Specific learning Objectives ILOs: By the end of the lecture the student will be able to: 1. Identify items of Apgar score 2. Apply the care of newborn 3. Differentiate between normal and abnormal finding in neonatal assessment 4. Demonstrate understanding of newborn screening Contents: 1. Apgar score 2. Newborn Care 3. Common Birth injuries 4. Physical examination: normal and abnormal findings 5. Newborn screening 1  Clinical Assessment of newborn Case 1 As a family physician you deliver a woman in 42 weeks’ pregnancy in the primary health care normal vaginal delivery. For assessment of the baby 1. What are the immediate care for the newborn you should do? Wipe the newborn's mouth and nose to clear airway secretions, usesuction only if necessary. Dry and stimulate the newborn. Provide warmth. Skin-to-skin contact with mother and initiation of breastfeeding Clamp and cut the umbilical cord Vitamin K ( IM): to prevent Hemorrhagic disease of the newborn (bleedingdisorder due to vitamin K deficiency Newborn Prophylaxis: Eye Erythromycin or tetracycline ointment prevents gonococcal and chlamydial conjunctivitis. Hepatitis B: Children born to mothers with HbsAg should receive hepatitis B immune globulin (HBIC) and HBV vaccine in the first 12 hours of life. 2. What is the Apgar score and how to calculate? o The Apgar score is a practical method of systematically assessing newborn infants immediately after birth. o There are 5 signs evaluated, and each is given a score of 0, 1, or 2. A total score of 10 indicates an infant in the best possible condition. An infant with a score of 0-3 requires immediate resuscitation. o Apgar scores are routinely assessed at 1 and 5 minutes, and every 5 minutes thereafter as long as resuscitation is continuing. o The 1-minute score gives an idea of what was going on during labor and delivery. o The 5-minute score gives an idea of response to therapy (resuscitation). o In general, the Apgar score is not predictive of outcome; however, infants with score 0−3 at ≥5 minutes compared to infants with score 7−10 have worse neurologic outcome 2  Clinical Assessment of newborn 3. What are the normal finding in physical examination in newborn? Measurements (Amboss) o Normal range (10th to 90th percentile at 40 weeks gestation) o Length: ∼ 50 cm (48– 53 cm) o Weight: ∼ (2.9–3.9 kg)) ▪ Boys: (2.9–3.9 kg) ▪ Girls: (2.8–3.8 kg) o Head circumference: ∼ 35 cm (33–37 cm) Vital signs (Amboss) o Respiratory rate: 40–60 breaths per minute o Heart rate: 120–160 beats per minute NB First passage of urine within 24 hours of birth First passage of meconium (a black-green, tarry substance that forms the newborn's feces) within 48 hours after birth 3  Clinical Assessment of newborn 4. When you examine the baby you find a Pale, pink vascular macules; found in his eyelids what is this and what are the differential diagnosis? Salmon patch (nevus simplex) Differential diagnosis: Cutis marmorata: Lacy, reticulated vascular pattern over most of body when baby is cooled; improves over first month; abnormal if persists. Mongolian spots: Blue to slate-gray macules; seen on presacral, back, posterior thighs; more in nonwhite infants; arrested melanocytes; usually fade over first few years; differential: child abuse. 4  Clinical Assessment of newborn Erythema toxicum, neonatorum: Firm, yellow-white papules/pustules with erythematous base; peaks on second day of life; contain eosinophils; benign Hemangioma: Superficial: bright red, protuberant, sharply demarcated; most often appear in first 2 months; most on face, scalp, back, anterior chest; rapid expansion, then stationary, then involution (most by 5–9 years of age); treated by: beta blockers, embolization; Deeper: bluish hue, firm, cystic, less likely to regress; treated by: (steroids, pulsed laser) only if large and interfering with function. 5. What are possible abnormal findings you may find in the head? 1.Preauricular tags/pits: Look for hearing loss and genitourinary anomalies. 2.Coloboma of iris: Cleft at “six o’clock” position; most with other eye abnormalities. 5  Clinical Assessment of newborn 3.Aniridia: Hypoplasia of iris; defect may go through to retina; association with Wilms tumor 6. What are the common congenital anomalies in extremities you should search for? Polydactly >5 number of fingers or toes. No treatment needed if good blood supply. Upper extremities: decrease movement and asymmetric Moro reflex may indicate a brachial plexus injury. Lower extremities: Most flexible deformities result from intrauterine posture and usually resolve spontaneously. 7. A mother of 2 days’ infant comes to your clinic in the primary health care to show you a swelling in her infant scalp on examination you found Diffuse edematous swelling of soft tissues of scalp; crosses suture lines what is your diagnosis? Caput succedaneum 6  Clinical Assessment of newborn 8. What are the differential diagnosis of this condition? Cephalohematoma Subperiosteal hemorrhage: does not cross suture line which May have underlying linear fracture; resolve in 2 weeks to 3 months and may calcify or cause jaundice. Skull fractures: In utero from pressure against bones or forceps; linear: most common. Outcome: Linear: no symptoms and no treatment needed Depressed: elevate to prevent cortical injury. 9. What are the screening tests you should do for this infant? Every newborn is screened before discharge or day 4 of life. It is more reliable if done after 48 hours of oral feedings (substrates for metabolic diseases). Phenylketonuria, tyrosinemia type I, 21-hydroxylase deficiency, classic galactosemia HbS/β-thal, Hb SS, HbS/HbC Congenital hypothyroidism Cystic fibrosis 7  Clinical Assessment of newborn 1-Phenylketonuria Phenylalanine hydroxylase; accumulation of PHE in body fluids and central nervous system o Presentation Normal at birth; gradual MR over first few months Intellectual disability, vomiting, growth retardation, purposeless movements, athetosis, seizures o Associations: Fair hair, fair skin, blue eyes, tooth abnormalities, microcephaly o Treatment: Low PHE diet for life 2- Classic Galatosemia Galactose-1-phosphate uridyl transferase deficiency; accumulation of Gal-1-P with injury to kidney, liver, and brain Presentation: Jaundice (often direct), hepatomegaly, vomiting, hypoglycemia, cataracts, seizures, poor feeding, poor weight gain, intellectual disability Associations: Predisposition to E. coli sepsis; developmental delay, speech disorders, learning disabilities May begin prenatally transplacental galactose from mother Treatment: No lactose reverses growth failure, kidney and liver abnormalities and cataracts, but not neurodevelopmental problems 8  Clinical Assessment of newborn Phenylketonuria (PKU) Classic Galactosemia 9  Clinical Assessment of newborn 3-Hearing loss Pediatric hearing loss is more prevalent than diabetes mellitus and all childhood cancers. A universal newborn hearing screening is recommended prior to newborn discharge, with the goal of evaluating all hearing loss by age 3 months. Usually the otoacoustic emissions test (OAE) is used, where a small earphone/microphone is placed in the ear and sounds are played. i. If hearing is normal: an echo is reflected back into the ear canal and is measured by the microphone. ii. If hearing is not normal: (patient does not pass), newborns are given theauditory brainstem response test (ABR) (most accurate hearing measure through age 6 months). Sounds are presented through a small earphone, measured with head electrodes, and analyzed by a computer. Normal OAE: intact hearing through the cochlea Normal ABR: also establishesthe integrity of the auditory nerve iii. Causes of hearing loss: - Up to 60% prelingual is genetic, >500 syndromes with hearing loss); - 70-80% is autosomal recessive, with 50% having defect in connexin 26 (a gap junction protein). - Up to 25% are non-genetic and up to 25% are idiopathic. Examples include CMV (most common congenital cause; then other congenital infections); otitis media with effusion (OME) (most common childhood cause); bacterial meningitis, especially pneumococcus (occurs early and in >30%); trauma, especially to temporal bone. 10  Vaccination program in primary health care Vaccination program in primary health care (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020 (p150-176) Specific learning Objectives ILOs: By the end of the lecture the student will be able to: Identify the Vaccination Rules. Describe Precautions, contraindication of vaccination and misconceptions. Describe vaccination in specific situations in family medicine practice (proper use of live vaccines in immune status, active immunization after disease exposure) Identify the classification of vaccines & describe specific vaccines (Routine vaccination) Identify the vaccination program in Egypt Contents: Definition of vaccine, vaccination and immunization. Vaccination Rules. Precautions, contraindication and misconceptions of vaccination Vaccination in specific situations in family medicine practice (proper use of live vaccines in immune status, active immunization after disease exposure) Classification of vaccines & Specific vaccines (Routine vaccination) Vaccination program in Egypt 1  Vaccination program in primary health care Definitions: (AMBOSS: Medical Knowledge platform for doctors and students) Vaccine: Ø A product (e.g., dead or weakened organism) that provides immunity from a disease Ø May be administered through injection, orally, or nasally Vaccination: Ø Administration of a vaccine that induces an active immune reaction in form of cellular and/or humoral response, providing immunity against a pathogen. Immunization: Ø The process by which a person becomes protected from a disease Ø Vaccines and recovering from some infections cause immunization. § Passive immunization: Injection of preformed antibodies induces a rapid humoral response against a specific pathogen § Active immunization (Live attenuated vaccines): Modified functioning virus or bacterium that can replicate in the patient's body but does not cause disease. Vaccine Rules: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) For stimulation of an adequate and persisting antibody response, 2 or more doses are usually required. In general, vaccines from different manufacturers are interchangeable. - Most vaccines can be safely and effectively administered simultaneously. - A lapse in schedule does not require reinstitution of the entire series. - Unknown or uncertain immunization status: Ø When in doubt, the child should be considered to be disease- susceptible, and appropriate immunizations should be initiated without delay. Ø To be counted, the vaccine(s) must be documented on a formal immunization record, regardless of country. 2  Vaccination program in primary health care Dose: No reduced dose or divided dose should be administered, including to babies born prematurely or at low birth weight (except: first dose hepatitis B). Active immunization of people who recently received gamma globulin Ø Live virus vaccine may have diminished immunogenicity when given shortly before or during the several months after receipt of immunoglobulin (Ig) so live vaccine is delayed (3–11 months). Precautions and contraindications of vaccination: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) Minor illness, with or without a fever, does not contraindicate immunization. Fever, per se, is not a contraindication. Ø Guidelines for administration are based on the physician’s assessment of illness and on specific vaccines the child is scheduled to receive. Ø If fever or other problems suggest moderate or serious illness, the child should not be immunized until recovered. Documented egg allergy is not a contraindication to the MMR. MMR is derived from chick embryo fibroblast tissue cultures but does not contain significant amounts of egg cross-reacting proteins. Influenza vaccine contains egg protein, but studies have shown that, like reactions secondary to any component in any vaccine, there are only rare instances of severe reaction in people who truly have an egg protein allergy. As a result, the American Academy of Pediatrics states that children with egg allergy can receive influenza vaccine with no additional precautions than those considered for any vaccine. This means that for any vaccine administration, the patient should be observed post-administration and any severe allergic manifestations should be anticipated and treated appropriately with medication should they occur. Misconceptions of vaccination: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) The following are not contraindications to immunizations: A reaction to a previous DTaP of temperature 12 months as soon as possible and VZIG to all immunocompromised and susceptible pregnant women. No vaccine or VZIG for healthy infants age 0-12 months. - VZIG also for susceptible pregnant women, newborn whose mother had the onset of chickenpox within 5 days before delivery to 48 hours after delivery, and certain hospitalized premature infants. Hepatitis: Hepatitis B: after exposure in nonimmune patient, give hepatitis B Ig plus vaccine; repeat vaccine at 1 and 6 months. Hepatitis A: if patient is not vaccinated, give 1 dose of vaccine as soon as possible but within 2 weeks of exposure. Mumps and Rubella: Not protected by postexposure administration of live vaccine Recommended for exposed adults who were born in the United States in or since 1957 and who have not previously had or been immunized against either; except pregnancy. Classification of vaccines & specific vaccines (Routine vaccination): (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) 5  Vaccination program in primary health care v SPECIFIC VACCINES (ROUTINE VACCINATION) in USA: (Just to know) (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) Centre of disease control (CDC). 6  Vaccination program in primary health care Hepatitis B: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) First dose should be given soon after birth, before hospital discharge, with a total of 3 doses by age 18 months if mother is HBsAg negative. The infant born to a hepatitis B surface antigen (HBsAg)-positive mother should receive the first dose of hepatitis B virus (HBV) plus hepatitis B Ig at 2 different sites within 12 hours of birth; all 3 doses should be given by age 6 months (treat same as exposure). All children and adolescents who have not been immunized should begin the series during any visit to the physician DTAP: Triple vaccine (Diphtheria toxoid – Tetanus toxoid – Killed acellular pertussis): (World Health Organization,2004) Route: IM Side effects: – Local reactions (generally erythema and induration with or without tenderness) are common – Mild systemic reactions such as fever, drowsiness, and anorexia occur frequently. – Neurological complications (convulsion – encephalopathy) (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) All DTaP vaccines for the United States currently contain acellular pertussis. The rates of local reactions, fever, and other common systemic reactions are substantially lower with acellular pertussis vaccines than with whole-cell vaccine (but may still occur). Use DT if there has been a serious reaction. No full dose pertussis or diphtheria after age 7 years, 0 days. Total of 5 doses is recommended before school entry, with the final given at preschool age, 4–6 years. 7  Vaccination program in primary health care Pertussis booster (Tdap) vaccine is now recommended during adolescence, regardless of immunization status; is also recommended even if one has already had pertussis disease. Tdap (childhood tetanus) is given at age 11–12, and then Td (adult tetanus) every 10 years; may be given any time after 7th birthday if needed because it contains only partial doses of diphtheria and pertussis. Contraindications for DTAP vaccine: (World Health Organization,2004) - Sever febrile illness - During polio epidemics - History of sever adverse reaction (convulsions – encephalopathy – anaphylaxis) and give only DT - Children with progressive neurologic disease - After 6 years of age use only DT. Tetanus: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) - Tetanus Prophylaxis in Wound Management. 8  Vaccination program in primary health care Poliomyelitis virus vaccine: 1) Sabin vaccine (trivalent): (World Health Organization,2004) – Given orally – Life-long immunity – Herd immunity – Induce systemic and local intestinal immunity. – Fragile and need proper storage. 2) Salk vaccine (monovalent)(IPV): (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) - Used in developed countries, and is now the only poliovirus vaccine available in the United States. - Given I.M. - Expensive - Inactivated virus - Give only systemic immunity Four doses of IPV, with the last at preschool age, 4–6 years Any child up to 18 years of age should receive all doses, if behind. Any child who has received OPV from another country should complete schedule in United States with IPV. HIB conjugated vaccine: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) Does not cover nontypeable Haemophilus. Depending on the vaccine brand, the recommended primary series consists of 3 or 4 doses. After the primary series, an additional booster dose is recommended at 12–15 months of age, regardless of which regimen was used for the primary series. If immunization is not initiated (i.e., child is behind) until age 15–59 months, then there is catch-up (1 dose), but not given after age 5 years in normal children Invasive disease does not confirm immunity; patients still require vaccines if age appropriate, i.e., age < 5 years. 9  Vaccination program in primary health care Pneumococcal vaccines: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) Pneumococcal conjugate vaccine (PCV13) Purified polysaccharides of 13 serotypes conjugated to diphtheria protein Routine administration as a 4-dose series for all children age 15 months and younger If no dose given yet between age 15–59 months, then there are catch-up doses 23-valent pneumococcal polysaccharide vaccine (PS23)—given as additional protection to the PCV13 in some high-risk children (e.g., functional/anatomic asplenia) age >2 years Age ≥65 years (PPSV-23) Varicella: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) Recommended at age 12 months or older for healthy people who have not had varicella illness, with second dose at age 4–6 years Catch-up dosing: both doses should be given for proper immunity May still have breakthrough varicella; milder than unimmunized, rarely spreads Has been associated with the development of herpes zoster after immunization (rare) Most people age >18 years, even without a reliable history of varicella infection, will still be immune. MMR: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) Live attenuated vaccine: issues as above for varicella First dose given at age 12–15 months Second dose given at preschool age, 4–6 years Catch-up with 2 doses Hepatitis A vaccine: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) Recommended for all children age >1 year (12–23 months) Two doses, 6 months apart 10  Vaccination program in primary health care Also recommended routinely for chronic liver disease patients, homosexual and bisexual men, users of illegal drugs, patients with clotting-factor disorders, and those at risk of occupational exposure Can give with other vaccines. Meningococcal conjugate vaccine (MCV4): (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) Administer MCV4 to: All children at the age 11–12 visit and booster at age 16 All college freshmen living in dormitories, if not vaccinated There is now a vaccine for serotype B for high risk patients and during outbreaks (status post concurrent type B outbreaks at Princeton and UC Santa Barbara) Meningococcal B vaccine is recommended only for those at increased risk for meningococcal B disease—persistent complement component deficiencies (C3, C5- C9, properdin, factor D, factor H); anatomic or functional asplenia, including sickle cell disease; and those residing in a community with a serogroup B meningococcal disease outbreak per the local health department on the basis of CDC criteria (college students not considered at increased risk since the incidence is not greater than that of the same-aged general population). N.B: MPSV4 is the older, pure polysacharide vaccine, while MCV4 is the newer, conjugated vaccine. Influenza vaccine: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) Inactivated influenza vaccine (typical flu shot) - Administered intramuscularly - Inactivated influenza vaccine has been deemed safe in egg-allergic patients - Given annually during flu season for children age >6 months (A strains, B strains, and H1N1). 11  Vaccination program in primary health care Live influenza vaccine - Live attenuated vaccine has recently had only 3% effectiveness so has not been used in last 2 seasons: the AAP has stated that it may be used in 2019 season, but the preferred vaccine is the quadrivalent inactivated vaccine. Rotavirus vaccine: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) Oral live attenuated vaccine Given at ages 2, 4, 6 months Essentially no catch-up if behind (no dose after age 8 months) Safe, highly effective (no intussusception; M and M from disease reduced significantly) Human Papilloma virus (HPV) vaccine: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) Quadrivalent vaccine (6, 11, 16, 18) or bivalent vaccine (16, 18) to girls at the age 11-12 visit (through age 26) for cervical cancer prevention Quadrivalent vaccine (6, 11, 16, 18) to boys age 11–12; for genital warts caused by HPV 6,11. Can be given in both males and females as early as age 9. 3 doses: Now 9-valent in both girls (9-26) and boys (9-15): 6, 11 (genital warts), 16, 18, 31, 33, 45, 52, 58 (cervical cancer prevention) Precancerous lesions (all 9) including anal intraepithelial neoplasia Anal cancer (16, 18, 31, 33, 45, 52, 58) - Doses 2 and 3: give at 2 months and then 6 months after first 12  Vaccination program in primary health care Vaccination program in Egypt: 13  Vaccination program in primary health care Age Dose Vaccine Disease Dose Route First 24h Birth Hepatitis-B Hepatitis B 0.5 IM cm² At birth 0 Dose Oral Polio (Sabine) Poliomyelitis 2 drops Oral TB BCG Tuberculosis (TB) 0.5 ID cm² Oral Polio (Sabine Poliomyelitis 2 drops Oral 1st Dose vaccine) Penta Vaccine Diphtheria- Pertusis- 0.5 IM (DPT-Hepatitis B- Tetanus- Hepatitis B- cm² Hib) Haemophilus 2 months influenza) Polio (Salk Poliomyelitis 0.5 IM vaccine) cm² Oral Polio (Sabine Poliomyelitis 2 drops Oral 2nd Dose vaccine) Penta Vaccine Diphtheria- Pertusis- 0.5 IM (DPT-Hepatitis B- Tetanus- Hepatitis B- cm² Hib) Haemophilus 4 months influenza) Polio (Salk Poliomyelitis 0.5 IM vaccine) cm² Oral Polio (Sabine Poliomyelitis 2 drops Oral rd 3 Dose vaccine) Penta Vaccine Diphtheria- Pertusis- 0.5 IM (DPT- Hepatitis B- Tetanus- Hepatitis B- cm² Hib) Haemophilus 6 months influenza) Polio (Salk Poliomyelitis 0.5 IM vaccine) cm² 9 months 4th Dose Oral Polio (Sabine Poliomyelitis 2 drops Oral vaccine) 12 5th Dose Oral Polio (Sabine Poliomyelitis 2 drops Oral vaccine) months MMR Measles -Mumps- 0.5 SC Rubella cm² Oral Polio (Sabine Poliomyelitis 2 drops Oral Booster vaccine) 18 Dose MMR Measles -Mumps- 0.5 SC months Rubella cm² DPT Diphtheria-Pertusis - 0.5 IM Tetanus cm² 14  Vaccination program in primary health care BCG vaccine: (World Health Organization,2004) Live attenuated vaccine Given in the first 3 months Intradermal Side effects: –Axillary lymphadenopathy – disseminated TB. 15  Nutrition in infants and Toddlers Nutrition in infants and Toddlers (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020 (p119-125) & (First Aid for the pediatrics clerkship) Specific learning Objectives ILOs: By the end of the lecture the student will be able to: Apply explanatory model for optimal nutrition during fetal and child development and describe the concept of the nutrition in the first 1,000 days of life. Apply principles of health education to the mothers about the benefits of breastfeeding for her and for the child & contraindication of breast feeding Describe the common problems of breastfeeding. Apply principles of health education to the mothers about the basic principles of complementary feeding Contents: Optimal nutrition during fetal and child development and the nutrition in the first 1,000 days of life. Benefits of breastfeeding for mother and for the child Contraindication of breast feeding Common problems of breastfeeding Formula feeding Basic principles of complementary feeding 1  Nutrition in infants and Toddlers The first 1000 days of life: Refers to the period beginning right from a baby’s conception through to two years of age and it is a critical period in their development. - It’s a period of time when children are growing and developing both physically and emotionally at a faster rate than at any other time in their life (UNICEF, 2017) Optimal nutrition in infants and Toddlers: 1.Breast feeding 2.Formula feeding 3. Basic principles of complementary feeding 4. Vitamin and Mineral Supplements 1.Breast feeding: (First Aid for the pediatrics clerkship) Newborn Feeding Tips: - For term newborns, caloric requirement is 100–120 kcal/kg/day (as compared to 1-year-old, 75 kcal/kg/day). - Newborns grow at a rate of about 30 g/day. - Newborns should be breast- or formula-fed every 3–4 hours thereafter. - Supply = demand, the more often the baby breast-feeds, the more milk will be produced. - If the child has stopped losing weight by 5–7 days and begins to gain weight by 12–14 days, then feeding is adequate. - Hunger is not the only reason for that the infants cry. They don’t need to be fed every time they cry. ` - Human milk is ideal for a term infant in first year of life. - Whole cow’s milk is not suitable for infants because the higher intake of sodium, potassium, and protein ↑ renal solute load. - Cow’s milk (whole milk until age 2) can be introduced after the first birthday. - Optimal protein requirement of term infant is 2.2 g/kg body weight per day. 2  Nutrition in infants and Toddlers Other important tips: (For your knowledge) (World health organization, UNICEF) Suckling: Is the drawing of milk into the mouth from the nipple out of a mammary gland (breast), suckling is also referred to as nursing or breastfeeding. Suckling is the method by which newborn are nourished. Steps to a good position and good suckling: - Tickle your baby's lips with your nipple, will help baby open mouth wide. - Aim your nipple just above your baby's top lip. Make sure your baby's chin isn't tucked into their chest. - Aim your baby's lower lip away from the base of your nipple. Baby's lips should be turned outward like a fish. Your baby should lead into the breast chin first and then latch onto your breast. Your baby's tongue should be extended, and your breast should fill your baby's mouth. Signs of a good suckling: - The latch is comfortable and pain free. - Your baby's chest and stomach rest against your body, so that baby's head is straight, not turned to the side. - Your baby's chin touches your breast. - Your baby's mouth opens wide around your breast, not just the nipple. - Your baby's lips turn out. - Your baby's tongue cups under your breast. - You hear or see swallowing. - Your baby's ears move slightly. Burping: Babies usually need to burp when they take in air while eating, which makes them feel full too fast. This happens more often with bottle-fed babies, who tend to eat faster but breastfed babies swallow some air as well, especially if the mother has a lot of milk or has a fast letdown, or if the baby is very hungry and wants to eat fast. - The different positions for burping that are comfortable for the baby: 1- Sit upright and hold the baby against chest. Baby's chin should rest on your shoulder. With the other hand, gently pat your baby's back. Sitting in a rocking chair and gently rocking with your baby may also help. 2- Hold your baby sitting up, in your lap or across your knee. Support your baby's chest and head with one hand by cradling your baby's chin in the palm of your hand. Rest the heel of your hand on your baby's chest, but be careful to grip your baby's chin, not the throat. Pat the baby's back with the other hand. 3- Lay your baby on your lap on his or her belly. Support your baby's head and make sure it's higher than his or her chest. Gently pat your baby's back. 3  Nutrition in infants and Toddlers Stages of breast milk: 1) First stage: Colostrum: (First Aid for the pediatrics clerkship) - The first milk produced after birth until 3–4 days postpartum. - Usually a deep lemon color. - Helps to clear bilirubin from the gut, produced from the high red blood cell turnover during blood volume contraction in the first weeks of life, which helps prevent jaundice. - High in protein, minerals, immunologic factors, and antimicrobial peptides such as lactoferrin and lactoperoxidase; low in carbohydrates and fat. 2) Second stage: Transitional Milk: - Transition milk replaces Colostrum. - It’s creamy and has high level of proteins, vitamins, fat and lactose. - The color of the milk slowly changes from yellow to white. - As the breast starts to stimulate you might feel fuller, firmer and a bit of discomfort. Regular feeding can ease any discomfort during this stage. 3) Third stage: Mature milk: (AMBOSS: Medical Knowledge platform for doctors and students) - After few weeks, breast milk reaches its mature form. It is lighter in color and stays consistent Mature milk is composed of: - Proteins, lactose and oligosaccharides, fats, minerals, trace elements, and vitamins - Proteins and cells that provide passive immunity in neonates - Immunoglobulins (secretory IgA), lactoferrin, lysozymes - Lymphocytes, macrophages - Common probiotic strains such as Lactobacillus and Bifidobacterium. They play a significant role in the development of a baby’s immune system, working to protect against infection and create a healthy gut microbiome. Ø Fore milk: - Milk that flows at the starting of the feed is Fore milk. - Its watery and quenches baby thirst. Ø Hind Milk: - The milk that flows as the breast empties is Hind milk. - Its higher in fat, calories and quenches baby’s hungry 4  Nutrition in infants and Toddlers Benefits of breastfeeding for mother and for the child: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) Psychological/emotional: maternal-infant bonding Premixed; right temperature and concentration Immunity: protective effects against enteric and other pathogens; less diarrhea, intestinal bleeding, spitting up, early unexplained infant crying, atopic dermatitis, allergy, and chronic illnesses later in life; passive transfer of T-cell immunity. Decreased allergies compared to formula fed Maternal: weight loss and faster return to preconceptional uterine size Contraindications: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) HIV; HBV; CMV; HSV (if lesions on breast); acute maternal disease if infant has no disease eg, tuberculosis, sepsis; breast cancer; substance abuse Drugs: (absolute contraindications): antineoplastics, radiopharmaceuticals, ergot alkaloids, iodide/ mercurials, atropine, lithium, chloramphenicol, cyclosporin, nicotine, alcohol Drugs (relative contraindications) neuroleptics, sedatives, tranquilizers, metronidazole, tetracycline, sulfonamides, steroids No contraindication with mastitis N.B: Mothers with HBV infection are free to breastfeed after the neonate has received the appropriate recommended vaccinations against HBV. The Ten Steps to Successful Breastfeeding: (National implementation of the Baby-friendly Hospital Initiative 2017,WHO) 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 5  Nutrition in infants and Toddlers 4. Help mothers initiate breastfeeding within one half-hour of birth. 5. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breastmilk, unless medically indicated. 7. Practice rooming in – that is, allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. Common problems of breastfeeding: (First Aid for the pediatrics clerkship) 1. Soreness of nipples: Not due to prolonged feeding––due to improper positioning and poor removal. 2. Engorgement: Unpleasant/painful swelling of the breasts when feeding cycle is ↓ suddenly (relieved by ↑ feeding on affected breast). 3. Maternal fatigue, stress, and anxiety: Affects hormones needed for lactation. 4. Fear of inadequate milk production, → formula milk supplementation. As the infant begins to feed less often, less milk is naturally produced. This often causes mother to misconceive that she is not producing enough milk to nourish the baby. Because of this, mother will frequently begin supplementing her milk with bottle milk, beginning a cycle of longer intervals between feeding, which causes less and less milk to actually be produced. 6  Nutrition in infants and Toddlers Signs of insufficient feeding of infant: - Fewer than six wet diapers per day after age 1 week (before that, count one wet diaper per age in days for first week of life). - Continual hunger, crying. - Continually sleepy, lethargic baby. - Fewer than seven feeds per day. - Long intervals between feedings. - Sleeping through the night without feeding. - Loss of >10% of weight. - ↑ jaundice. 5. Jaundice: 6. Possible vitamin deficiencies: A, D, K, B12, thiamine, riboflavin. Infants who are exclusively breast-fed should receive vitamin drops after age 4 months. 7  Nutrition in infants and Toddlers 2. Formula feeding: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) Infant formulas: Formula feeding is used to substitute or supplement breast milk. Supplementation with formula is only recommended if: (AMBOSS: Medical Knowledge platform for doctors and students) o Neonate loses > 7% of birth weight during the first 10 days of life o Neonatal urine output is decreased o Neonatal stool output is decreased (< 3 small stools per day) o Maternal breast milk production is inadequate o Breastfeeding is contraindicated Categories of infant formula: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) Most commercial formulas are cow-milk–based with modifications to approximate breast milk. They contain 20 calories/ounce. Specialty formulas (soy, lactose-free, premature, elemental) are modified to meet specific needs. (First Aid for the pediatrics clerkship) 8  Nutrition in infants and Toddlers (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) 3. Basic principles of complementary feeding: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) - Solid foods should be slowly initiated in infants between 4–6 months of age, with continued breast/formula feeding. - The recommended initial complementary feeding food is rice cereal fortified with iron and are given only at 4-6 months - Stepwise introduction of strained foods (vegetables and fruits), then dairy, meats (6- 9 months), one new food should be introduced per week to allow easy identification of food allergies. - Table foods are given at 9-12 months - No honey in first year of life—infant botulism - Pureed meat, green leafy vegetables, and dried beans are good sources of iron and zinc. - Cow's milk can be introduced into the diet after 1 year of age 9  Nutrition in infants and Toddlers Readiness for Solid Foods: (First Aid for the pediatrics clerkship) (For your knowledge) - Hand-to-mouth coordination. - ↓ tongue protrusion reflex. - Sits with support. - Lack of head lag. - Drooling. - Opens mouth to spoon. 4. Vitamin and Mineral Supplements: (Kaplan: USMLE- STEP 2 CK: PEDIATRICS-Lecture notes 2020) - A normal newborn has sufficient stores of iron to meet requirements for 4–6 months, but iron stores and absorption are variable. - Breast milk has less iron than most formula, but has higher bioavailability. - Formula is supplemented with vitamin D; breastfed infants must be supplemented from birth (400 IU/d) - Vitamin K is routinely given intramuscularly at birth, so no supplementation needed. - Both breast milk and formula are 90% H2O, so no additional H2O needed Others: (First Aid for the pediatrics clerkship) - Fluoride Supplementation after age 6 months if the water is not fluorinated sufficiently (particularly well water). - If mother is a strict vegetarian, supplement thiamine and vitamin B12. - Human milk will have adequate vitamin C only if mother’s intake is sufficient. - Commercial formula is often modified from cow’s milk and fortified with vitamins and minerals so that no additional supplements are needed for the full- term infant. 10  Child growth and development assessment Child growth and development assessment USMLE STEP 2 CK Lecture Notes 2020 Pediatrics chapter 3 (growth and development) page100-112 Specific learning Objectives ILOs: By the end of the lecture the student will be able to: 1.Demonstrate steps in evaluation of growth 2.Understand growth assessment and disorders of growth I height and weight 3.Identify Primitive reflexes and developmental milestones Contents 1. Basic Principles of Growth 2. Assessment of Growth 3. Primitive reflexes and developmental milestones 1  Child growth and development assessment Childhood growth: Basic principles of growth: (USMLE STEP 2 CK Lecture Notes 2020 Pediatrics chapter 3 (growthand development) page100-112  In the first week of life, a newborn typically loses up to 10% of birth weight (BW) due to the elimination of large amounts of extravascular fluid.  By 2 weeks, Body Weight should be regained.  In the first month of life, a neonate should gain ~30 grams perday, which slows to ~20 grams/day at 3–4 months.  By 6 months, an infant typically doubles BW and triples by 1 year  Growth rate slows further between 6 and 12 months and then appetite begins to decline through 18 months of age.  Between 2–5 years: The height and weight increase at a steady rate, but head- circumference rate of growth decreases somewhat  Between age 6 and 12 years: 3–6 growth spurts each year for 8- week periods each; slower brain growth; myelination complete by age 7  Between age 10 and 20 years: acceleration in early adolescence. Boys’ highest growth stops at age 18. Their average peak is 13.5 years (2–3 years later than girls, and continues 2–3 years after girlshave stopped). Girls’ average peak is 11.5 years and it stops at age 16. Assessment of growth: USMLE STEP 2 CK Lecture Notes 2020 Pediatrics chapter 3 (growth and development) page100-112  Weight/height CC  9-12 months HC = CC  After 1 year CC > HC Teething Deciduous(primary) Average age of eruption th Central incisors 6 month th Lateral incisors 9 month th First molars 12 month th Canines 18 month Teething Permanent (secondary Average age of eruption th First molar 6 year th Central incisors 6 year th Lateral incisors 7 year th Canines 10 year th First premolars 10 year th Second premolars 11 year Second molars th th 11 to12 year th Third molar 20 year The teeth in the lower jaw are shed earlier than those in the upper and girl’s teeth earlier than boy’s teeth 4  Child growth and development assessment Growth patterns:  The growth chart is the best tool to determine patterns of growth,with separate charts for boys and girls.  The charts measure weight for age, height for age, head circumference for age, weight for height, and body mass index (BMI). Each chart has multiple curves (either 5–95% or 3–97%) Evaluation of growth: USMLE STEP 2 CK Lecture Notes 2020 Pediatrics chapter 3 (growthand development) page100-112 Growth velocity (GV): yearly increments of growth; should follow agrowth curve  Normal Abnormal Bone age = Ideal  Genetic chronological age Genetic (familial)  Chromosomal short stature Bone age < Constitutional  Chronic systemic chronological age delay disease  Endocrine related Bone age ≥ Obesity (tall)  Precocious puberty chronological age Familial tall  Congenital adrenal stature hyperplasia  Hyperthyroidism Slope = change in height / change in age Chronologic age (CA): actual age Bone age (BA): x-ray of left hand and wrist (non-dominant hand) 5  Child growth and development assessment Familial short stature o Patient is parallel to growth curve o Strong family history of short stature o Chronologic age equals bone age 6  Child growth and development assessment Pathologic short stature  Patient may start out in normal range but then starts crossing growth percentiles.  Differential diagnosis: craniopharyngioma, hypothyroidism, hypopituitarism, nutritional problems, and other chronic illnesses.  Suspect Turner syndrome in females with pathologic short stature. Suspect craniopharyngioma if short stature and vision problems 7  Child growth and development assessment Constitutional delay  BA < CA  The most common cause of short stature and sexual infantilism in adolescents  Delayed onset of puberty o  Late adolescent growth spurt  Delayed bone age  Normal final adult height is reached  Parents are of normal height 8  Child growth and development assessment Development: USMLE STEP 2 CK Lecture Notes 2020 Pediatrics chapter 3 (growthand development) page100-112  Development includes 5 main skill areas: visual-motor, language, motor, social, and adaptive.  Assessment is based on acquisition of milestones occurring sequentially and at a specific rate: each skill area has a spectrum ofnormal and abnormal  Abnormal development in one area increases likelihood of abnormality in another area, so careful assessment of all skills isneeded  Developmental diagnosis is a functional description/classificationand does not specify an etiology  Developmental delay is performance significantly below average, i.e. developmental quotient (developmental age/chronologic age × 100) of < 75; may be in ≥1 areas; 2 assessments over time are morepredictive than a single assessment Note: For infants born 36 Months): 2  Approach of a child with fever in primary care Case 1 A mother of an eight days’ infant came to your office with her infant crying and look feverish Rectal temperature >38° C. 1. How to diagnose fever in this age (neonates) and how to manage? (First Aid Family Medicine board third edition page420) (https://www.msdmanuals.com/professional) Neonates (infants < 28 days) are considered functionally immunocompromised because they often fail to contain infection locally and, as a result, are at higher risk of serious invasive bacterial infections most commonly caused by organisms acquired during the perinatal period. The most common perinatal pathogens in neonates are group B streptococci, Escherichia coli (and other gram-negative enteric organisms) and herpes simplex virus. These organisms can cause bacteremia (viremia with herpes simplex), pneumonia, pyelonephritis, meningitis, and/or sepsis. Even well appearing febrile children 38 °C (100.4° F) is considered a fever in this age group. Rectal temperature >38° C (100.4°F) is considered a fever in this age group While viruses are the most likely source, consider late onset of congenitally acquired illnesses, such as rubella and cytomegalovirus, or infections acquired at birth, such as, E coli, and Listeria. Early infection may also be the first sign of a congenital abnormality Diagnosis: Complete blood count with differential, blood culture, urine analysis, urine culture, lumbar puncture. Also consider chest X ray, stool culture, and viral culture. Management: Admit and treat with broad spectrum antibiotics while awaiting culture results. Give ampicillin plus a third generation cephalosporin or gentamicin. Antibiotics may be discontinued at 48 hours if all cultures are negative and the infant is clinically stable 3  Approach of a child with fever in primary care Case 2: A mother come to the family physician with a child aged two months, she said the child is feverish, after measuring rectal temperature, it’s 39° C 1. What are the common cause of fever in Infants (31 -90 days) and how to diagnose and manage? (First Aid Family Medicine board third edition page420) Most febrile children 1 month to 3 months of age without an obvious focus of infection on examination have self-limited viral disease. However, a small number (of such patients are early in the course of a serious infection (eg, bacterial meningitis). Thus, the main concern in a patient is whether occult bacteremia (pathogenic bacteria in the bloodstream without focal symptoms or signs on examination) is present. The most common causative organisms of occult bacteremia are Streptococcus pneumoniae and Haemophilus influenzae. The widespread use of vaccinations against both of these organisms has made occult bacteremia much less common. Diagnosis: if no source is found Urine analysis and urine culture in all infants. CBC with differential and blood culture if urine analysis is negative or if the child is ill appearing. Also consider lumbar puncture if child is ill-appearing or if antibiotics are being started empirically. As indicated: chest x-ray, stool culture, and viral culture. Management: according to the cause. if no cause appeared clinically: Start third-generation cephalosporin (eg, ceftriaxone) after collecting cultures if white blood cells >15 or 20,000/mcL (> 20 × 109/L) should have a chest x-ray. These children should be given parenteral antibiotic therapy (usually using ceftriaxone) targeting the likely pathogens in this age group (S. pneumoniae, Staphylococcus aureus, Neisseria meningitidis, H. influenzae type b) and be admitted to the hospital pending culture results. Management: All toxic appearing children should receive empiric IV or IM antibiotics while awaiting cultures. Unvaccinated children with WBC >15,000 should also receive empiric antibiotics. 5  Approach of a child with fever in primary care Case 4: A mother come to the family medicine center with her child aged 4 years, he is complaining of fever 38 0c and runny nose 1. How to diagnose and manage fever in children more than 36 months? https://www.msdmanuals.com/professional The risk of occult bacteremia is lower in this age group, and a source of fever is generally identifiable and treated as needed. Review of systems should note symptoms suggesting possible causes, including Runny nose and congestion (viral upper respiratory infection) Headache (sinusitis, lyme disease, meningitis), Ear pain or waking in the night with signs of discomfort (otitis media), Cough or wheezing (pneumonia, bronchiolitis), Abdominal pain (pneumonia, strep pharyngitis, gastroenteritis, urinary tract infection, abdominal abscess), Back pain (pyelonephritis), A history of repeated infections (immunodeficiency) or symptoms that suggest a chronic illness, such as poor weight gain or weight loss (tuberculosis, cancer), is identified. Certain symptoms can help direct the evaluation toward noninfectious causes; they include heart palpitations, sweating, and heat intolerance (hyperthyroidism) and recurrent or cyclic symptoms (a rheumatoid, inflammatory, or hereditary disorder). 2. What are the red flags in fever in infants and children? AMBOSS Medical Knowledge platform for doctors and students General Fever lasting > 3 weeks Temperature > 40°C (104°F) Rash (especially petechial) Anemia Neutropenia (see neutropenic fever) Jaundice Lymphadenopathy (if generalized or persisting > 2 weeks) 6  Approach of a child with fever in primary care Localized CNS: neck stiffness, seizures, headache, altered level of consciousness, altered mental status ENT: purulent ear discharge, mastoid pain Chest: hemoptysis, hypoxemia Abdomen: guarding, organomegaly, ascites, melena, hematochezia, persistent vomiting, voluminous diarrhea Musculoskeletal: joint swelling, reduced range of motion. 3. What is the treatment of fever in infant and children? (https://www.msdmanuals.com/professional) Treatment is directed at the underlying disorder. Fever in an otherwise healthy child does not necessarily require treatment. Although antipyretics can provide comfort, they do not change the course of an infection. In fact, fever is an integral part of the inflammatory response to infection and can help the child fight the infection. Antipyretic drugs that are typically used include Acetaminophen Ibuprofen Acetaminophen tends to be preferred because ibuprofen decreases the protective effect of prostaglandins in the stomach and, if used chronically, can lead to gastritis. The dosage of acetaminophen is 10 to 15 mg/kg orally, IV, or rectally every 4 to 6 hours. The dosage of ibuprofen is 10 mg/kg orally every 6 hours. Use of one antipyretic at a time is preferred. Aspirin should be avoided in children because it increases the risk of Reye syndrome if certain viral illnesses such as influenza and varicella are present. Nondrug approaches to fever include putting the child in a warm or tepid bath, using cool compresses, and undressing the child. Caregivers should be cautioned not to use a cold water bath, which is uncomfortable and which, by inducing shivering, may paradoxically elevate body temperature. As long as the temperature of the water is slightly cooler than the temperature of the child, a bath provides temporary relief. 7  Approach of a child with fever in primary care Case 5: A mother of 1 year child come in a hurry to the emergency department said that her child was feverish and is suffering from multiple contractions in his body for 5 mints or less. What is febrile seizure? AMBOSS Medical Knowledge platform for doctors and students Usually presents as a brief (15 minutes. Also includes >1 episode in 24 hours. Differential diagnosis: Includes CNS infection and epileptic seizures. Diagnosis: Usually made clinically, but if the seizures have atypical feature, a neurological work up including labs, MRI and EEG may be indicated. Consider Lumber puncture (LP) in children aged less than 2 months. 8  Approach of a child with fever in primary care 4. How to manage this case and what are the possible complications? AMBOSS Medical Knowledge platform for doctors and students Management: Simple febrile seizures are usually benign and treated with supportive care, airway management, and antipyretic given orally or rectally as needed. In rare cases, when children are prone to febrile seizure, diazepam can be used at seizure onset and repeated as necessary until the fever resolves. Complications: Children with a history of complex febrile seizures have a higher risk of developing epilepsy. 9  Common behavioral and psychological disorders affecting children Common Behavioral and Psychological Disorders Affecting the Child (Kaplan USMLE step 2 ck: pediatrics, 2020 Ch.5 P 138) (1st Aid for USMLE Step 2 CK, 6th Edition p 398) Specific learning Objectives ILOs: By the end of this lecture the student will be able to: 1- Enumerate the common behavioral or psychological disorders affecting the child 2- Diagnose the child with behavioral or psychological disorders 3- Manage the common behavioral or psychological disorders affecting the child. Contents: 1) Attention-deficit hyperactivity disorder (ADHD) 2) Autism spectrum disorders 3) Disruptive behavioral disorders 4) Eating disorders 5) Enuresis 6) Encopresis 7) Sleep disorders 1  Common behavioral and psychological disorders affecting children Case 1: K.J. is a 6-year-4-month-old male whose mother reports to his primary care physician that “his teacher is concerned about his ability to focus at school.” he also reports that K.J. is “having difficulty mastering kindergarten material.” 1- What is the possible diagnosis for this child? Attention-Deficit Hyperactivity Disorder (ADHD) Defenition: A persistent pattern of excessive inattention and/or hyperactivity/impulsivity. More common in males; typically presents between ages 3 and 13. Often shows a familial pattern. 2- What are the diagnostic criteria for that disease? Diagnosis requires six or more symptoms from each category listed below for six or more months in at least two settings → significant social and academic impairment. Some symptoms must be present in patients before age seven. 3- Enumerate the different types of ADHD? a) Inattention: Poor attention span in schoolwork/play; poor attention to detail or careless mistakes; does not listen when spoken to; has difficulty following instructions or finishing tasks; loses items needed to complete tasks; forgetful and easily distracted. 2  Common behavioral and psychological disorders affecting children b) Hyperactivity/impulsivity: Fidgets; leaves seat in classroom; runs around inappropriately; cannot play quietly; talks excessively; does not wait turn; interrupts others. 4- How can you treat that disease? Initial treatment may be non-pharmacologic (e.g., behavior modification). Sugar and food additives are not considered etiologic factors. Pharmacologic treatment includes the following: Psychostimulants: Antidepressants (e.g., SSRIs, and α 2-agonists (1st Aid for USMLE Step 2 CK, 6th Edition p 398) Case 2: A mother came to the family physician complaining of delay speech of her 2 year young child that he cannot say any word till now with less interest to contact with the surrounding 1- What is the possible diagnosis for this child case? Mostly Autism Spectrum Disorders More common in males. May be associated with tuberous sclerosis and fragile X syndrome. Symptom severity and IQ vary widely. 3  Common behavioral and psychological disorders affecting children 2- What are the other characteristic features for autism? Characterized by abnormal or impaired social interaction and communication together with restricted activities and interests, evident before age three. Patients fail to develop normal social behaviors (e.g., social smile, eye contact) and lack interest in relationships. The development of spoken language is delayed or absent. Children show stereotyped speech and behavior (e.g., hand flapping) and restricted interests (e.g., preoccupation with parts of objects). 3- How can you treat it? Intensive special education, behavioral management, and symptom- targeted medications (e.g., neuroleptics for aggression; SSRIs for stereotyped behavior). Family support and counseling are crucial. (1st Aid for USMLE Step 2 CK, 6th Edition p 398) 4- What are the possible psychiatric disorder other than Autism and ADHD the child may have and describe them? a) Disruptive Behavioral Disorders: Includes conduct disorder and oppositional defiant disorder. More common among males and in patients with a history of abuse. 4  Common behavioral and psychological disorders affecting children History/Physical examination: 1) Conduct disorder: A repetitive, persistent pattern of violating the basic rights of others or age-appropriate societal norms or rules for one year or more. Behaviors may be aggressive (e.g., rape, robbery, animal cruelty) or nonaggressive (e.g., stealing, lying, deliberately annoying people). May progress to antisocial personality disorder in adulthood. 2) Oppositional defiant disorder: A pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures (e.g., losing temper, arguing) for six or more months. May progress to conduct disorder. Treatment: Individual and family therapy (1st Aid for USMLE Step 2 CK, 6th Edition p 399) 5  Common behavioral and psychological disorders affecting children b) Eating Disorders: Pica: v Definition: Repeated or chronic ingestion of things not considered food, e.g., clay, paper, paint, dirt after year 2, needs investigation. v Predisposing factors: Intellectual disability and lack of parental nurturing Also with family disorganization, poor supervision, and psychological neglect v More common with autism, brain-behavior disorders, and low socioeconomic status v Increased risk for lead poisoning, iron deficiency, and parasitic infections Case 3: A.B., a healthy boy aged 8 years, had never been able to achieve complete nighttime dryness since being potty trained at age 3 years. The boy mentioned that he occasionally recalled experiencing a dry night or two, but it had not been sequential or predictable. 1- What is your provisional diagnosis for this case? Enuresis: Definition: Voluntary or involuntary repeated discharge of urine after a developmental age when bladder control should be present (most by age of 5 years); there are 2 types. 6  Common behavioral and psychological disorders affecting children 2- What are the different types of enuresis and how you can manage them? a) Primary: No significant dry period; most common and usually nocturnal (nocturnal enuresis) Hyposecretion of ADH and/or receptor — dysfunction Relationship of sleep architecture, diminished arousability during sleep, and abnormal bladder function; anatomic malformations Management: Thorough history and physical, (should begin with behavioral treatment; not definitive, varying success rates): Enlist cooperation of child—chart dryness, reward system Child should void before going to sleep Alarm to wake once 2−3 hours after falling asleep; may use alarm that goes off when child wets a special sheet (bell and pad alarm) No punishment or humiliation Psychotherapy for traumatized children or when behavioral therapy has failed Pharmacotherapy for failed behavioral therapy in nocturnal enuresis—oral b) Secondary: After a period of — dryness ≥6 months Causes—psychological, urinary tract infection, constipation, diabetes More common in girls Evaluation—urinalysis Management—treat underlying disorder Children with both diurnal and nocturnal enuresis: Especially with voiding difficulties, more likely to have abnormalities of the urinary tract Ultrasonography or flow studies are indicated in these cases. (Kaplan USMLE step 2 ck: pediatrics, 2020 Ch.5 P 140) 7  Common behavioral and psychological disorders affecting children 3- What is the elimination disorder that may also suffer from? Encopresis: Passage of feces into inappropriate places after a chronologic age of 4 years, or equivalent developmental level May be primary or secondary Causes—psychological (toilet phobia), early toilet training, aggressive management of constipation, painful defecation, fissures 4- What are the types of encopresis and how you can manage it? v Retentive encopresis — most common: ü 2/3 of cases ü Hard stool on rectal examination is sufficient to document, but a negative ü exam requires a plain abdominal x-ray ü Presence of fecal retention is evidence of chronic constipation, and thus treatment will require active constipation management ü May have abnormal anal sphincter function Management v Clear impacted fecal material (with mineral oil or laxative) but avoid long- term laxative use v Concomitant behavioral management v Regular postprandial toilet-sitting v High-fiber diet v Familial support for behavior modification v Group or individual — psychotherapy (Kaplan usmle step 2 ck: pediatrics, 2020 Ch.5 P 141) 8  Common behavioral and psychological disorders affecting children Case 4: A mother came to you with a12-year-old male with a history of sleepwalking and disturbed sleep pattern. 1- What are the sleep disorders you know to help this mother? c) Sleep disorders: Parasomnias: Definition: Parasomnias are episodic nocturnal behaviors that often involve cognitive disorientation and autonomic and skeletal muscle disturbance v Associated with relative CNS immaturity v More common in children than adults; abate with age 2- How can you differentiate between atrial arousal and nightmares? (Kaplan USMLE step 2 ck: pediatrics, 2020 Ch.5 P 138) (Kaplan USMLE step 2 ck: pediatrics, 2020 Ch.5 P 146 9