NURS 643 Study Guide Exam One PDF

NURS 643 Study Guide Exam One Pediatric Health Maintenance Exam Pearls Bright Future Guidelines:  preventative services, communication w/fam & providers, integrate community-based health education, health outcomes o Recommendations for pediatric prevention (print out)...

NURS 643 Study Guide Exam One Pediatric Health Maintenance Exam Pearls Bright Future Guidelines:  preventative services, communication w/fam & providers, integrate community-based health education, health outcomes o Recommendations for pediatric prevention (print out) https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf Immunizations o Discussion: on time, + language, know misconceptions, vaccine refusal form (cover provider), CDC schedule & catch up o https://www.cdc.gov/vaccines/hcp/imz-schedules/child-adolescent-age.html# (Print out vaccine schedule: well child, catch up, medical indications) *CDC vaccine Schedule App instead of print* o Misconceptions: https://www.who.int/news-room/questions-and- answers/item/vaccines-and-immunization-myths-and-misconceptions 1. Diseases already  before vaccines, r/t  hygiene & sanitation 2. Majority of people who get disease have been vaccinated 3. Vaccines cause harmful side effects possible long-term effects we don't even know about → SE muscle soreness & fever 4. Vaccine-preventable diseases have been eliminated from my country, so there is no need for my child to be vaccinated. 5. Multiple vaccines for different diseases at the same time  the risk of SE – kids are exposed to several antigens everyday 6. Additional- Mercury (removed 1979), autism (MD falsified data → prison), arsenic ( levels in dust & breast milk), Aluminum, formalin/formaldehyde, fetal tissue (not killing babies) General Immunization guidelines o Preemie vaccines at chronological age (not gestational) o Live vaccines precautions (MMR, no pregnancies, Immunocompromised) TIPs: Do not ask just do, examine in parent lap, use comfort item DEVELOPMENTAl RED FLAGS o 3m: no head raise prone o 6m: no sit w/support o 9m: no respond to name o 12m: no pull to stand o 16m: no words o 18m: not walking o 2y: no 2-word phrase o 3y: speech not understandable o 4y: not able to dress self o 5y: unable to draw person w/body Newborn  Healthy People 2030:  health and safety of infants o  quality of care during pregnancy (screening), safe sleep, car seat o  breastfeeding, promote vaccines, developmental screening Maternal hx: health hx, OB hx, 3 gen family hx o Pregnancy hx: maternal age, prenatal care, meds (IVF), infection (GBS), substance use, complications (glucose, DM, HTN,  or  amniotic fl) o Vag vs c section, duration of labor/ROM, stained meconium Social Hx: who lives in home (ages, pets, smoking) o Home location & age: well vs city water, smoke detectors, guns o Education/occupation of parents: reading level o $ and emotional support, pregnancy planned, emotional stressors, partner involvement PCP Visits: establish PCP prior to discharge, In pt, 3-5 days, & 1 mo o Health visit: interim hx, unclothed physical exam, weight/length/head, Vit K for developmental surveillance clotting as gut is sterile w/ o In Hospital: Eye prophylaxis, vit K, Screen for disorders (>50, needs to be > 24hrs production after birth r/t establishment of own metabolism) Hep B vaccine (mom hep B + → IVIG), bili screening, establish feeding plan o 3-5 days: review delivery & discharge summary, assess bonding, repeat bili, evaluate mom for PPD Head: o Circumference: micro (FAS, infection) or macro (hydroceph, genetic) o Fontanels: anterior 2-3cm, post 1 cm o Caput succedaneum: superficial swelling that crosses suture lines r/t long labor →  tx, self resolves o Cephalohematoma: deep collection of blood, does not cross suture lines r/t forceps/vacuum during birth, resolves wks-mo, calcify, risk of hyperbilirubinemia, ICU 2wks- 3mo HEENT: *symmetry* o Face: facial nerve paralysis (resolves), cleft lip/palate o Eyes: angle of palpebral fissures, deconjugate gaze (norm), subconjunctival hemorrhage (norm), red reflex (cataract, opthy, & assess TORCH), Conjunctivitis (STDs) o Ears: size, shape, position, skin tag, pits, canal patency, universal hearing test (hospital), kidney eval if abnormalities (develop same time) o Nose: patency, choanal atresia o Mouth: lips, palate, tongue, ankyloglossia (should be able to stick tongue past lip), tied maxillary frenulum Chest & respiratory: RR 30-60 o Thorax: shape (round), size (2 cm < head circumference), ▪ Nipples: white discharge, supernumerary, inverted – ALL NORM o Lung sounds: cough & rales first 12 hrs → clear o Cyanosis: acro (peripheral, first wks, norm), central (not norm)  Cardiac: HR 100-190, inspect perfusion, o Palpation: PMI 4th LICS ( there → dextrocardia) o Auscultate: murmur (birth – days r/t PFO) o Pulses: compare bilaterally, brachial compared to femoral o BP: not in primary care in those 4mo Neuro: Tone, movement, symmetry, reflexes → Skin findings: o Milia: white cysts, resolve spontaneously o Erythema toxicum: red rash, resolves 2wks-4 months o Sebaceous hyperplasia: white/yellow papules, resolves a few weeks o Nevus simplex (salmon patch): fades o Mongolian spots o Port-wine stain:  fade, ophthalmology referral if near eye o Café-au-lait spots: benign o Hemangioma: over airway or fontanel needs referral, resolves up to 4 yrs o Cutis marmorata: mottling r/t cold PCP visit: delivery and DC summary, W/L/head circumference o Assess: hydration, feeding, stool & urination o Maternal-infant bonding  o Home, screening or labs, PPD, 3-5 days weight loss of 5-10% of birth weight → regained by 2wk, 0.5 – 1lb per day Anticipatory guidance o When to call: temp > 100 (99.5 if mom GBS +),  wet diapers (8-10/day), poor feeding, irritability w/ resolve, difficult breathing, Chemoprophylaxis- vitamin D (400IU/day breast fed babies) o Bathing: Sponge until healed umbilicus, mild cleansers,  powder o Stools will vary: breast fed maybe multiple/day, formula 1/day o Safety: Car seat, safe sleep, baby handling o Umbilical care: air dry, place diaper below, separates 10-14 days, call if foul smelling or redness o Circumcision: Clean w/wet cotton ball, petroleum jelly, after healed → pull back loose skin and clean o Uncircumcised: do not retract, gentle cleaning 1 – 12 months Growth o Weight: 0-6 mo: 1 oz/day; 6-12 mo: 0.5 oz/day ▪ Birth weight doubled 6m & tripled 1yr o Length: 0-6 mo: 2.5cm (1 inch)/mo 6-12 mo: 1.25cm (0.5 inch)/mo o Head circ: 0-6 mo: 1.5cm (0.6in)/mo; 6-12 mo: 0.5cm (0.2in)/month o Fontanel closure: Posterior 6-8 weeks, Anterior 12-18 mo o Charts: age, gender, conditions, premature adjusted up to 2 yrs, child should follow curve through growth 1 Month: H&P like newborn o Development: turn head side to side, focus on face (8-10in away), console when talked to o Sleep: 15-17hr w/established nap pattern, review safe sleep, place drowsy (not sleeping) infant to bed o Nutrition: feed 8-10x, breast feed 10 min each side, 2-4oz every 3-4hrs, BM 1x/day or w/every feed, non-nutritive sucking o Skills/Care: verbal interactions, tummy time o Immunization: hep B if not done @ birth 2 month: o Development: lift head & chest prone, vocalize > cry, turn head to sound, smile spontaneously o Sleep: longer at night, 3-4 naps o Skills/Care: coping cry period (can’t be consoled), cow milk protein allergy, high contrast & squeak/rattle toys o Immunization: DTaP, IPV, Hib, PCV, HBV, rotavirus o Nutrition: BF 8-10x/day, 10min/breast Formula: 3-5oz 6-8x/day ▪ Formula: Neuro-Pro (Enfamil), Advance (Similac) ▪ Lactose sensitivity: Sensitive (Enfamil & Similac) ▪ Gas/spit-up/fussy: Gentlease (Enfamil), Total Comfort (Similac)  ▪ Reflux: Added Rice (Enfamil & Similac) ▪ Constipation: Reguline (Enfamil) ▪ CMPA- Nutramigen (Enfamil), Alimentum (Similac) 4 month: o Development: Roll over front to back, head midline, minimal to no head lag, aware of hands, reaches for items, vocalize & laugh, home safety, no use of walkers o Sleep: may sleep w/out feeding, learning to self-soothe, baby rolls over in sleep  roll them back, move to crib once rolling o Tooth abruption (up to 1yr): drooling,  solid foods, readiness for solids (good head control,  tongue protrusion) introduce allergen (Peanut butter), BF babies need multi vit & iron o Immunization: DTaP, IPV, HiB, PCV, rotavirus 6 month: H&P, weight 3-5oz/wk, height 0.5 in/mo o Development: Sit unsupported, transfer object hand to hand, pincer grasp, bear weight on feet, tooth eruptions (irritable, drool, low grade fever, caine meds, iced teethers) fluoride supplement o Social: stranger anxiety Play: imitates,  screen time o Sleep: Fall asleep alone, do not pick up let self soothe o Nutrition: 8-12hrs at night w/out feeding, sold food, feed in highchair, drink from cup (NO JUICE, H2O only) o Immunizations: DTaP, HiB, PCV, IPV, HepB, influenza 9 month: o Development: pull to stand & cruise, simple commands, comfort item, language (mama & dada), discipline is distractions, play (books & blocks) o Safety: lower crib mattress, drowning prevention o Nutrition: table food cut into swallowable sizes, choking hazards (grapes, hotdogs), can hold spoon o Screening: anemia for high risk, lead, TB if risk 1 year: H&P, triple birth weight, height 50% longer, AF starts closing o Development: walking (safety), mama & dada specific, begin to explore away from parent o Sleep: 8-11hr, 1-2 naps o Nutrition: wean to whole milk (16-24oz), 3 meals, 2-3 snacks o Immunizations: MMR, varicella, hep A, HiB, PCV (can wait 15m), flu RED FLAGS: page 115 in book Early Childhood 1-4 yrs 15 months: Temper & behavior towards others o Development: walk forward & back, climb up stairs, 3-5 words, hold utensils, notice body o Sleep: preparation routine  o Nutrition: Self-feeding, 3 meals, 2 snacks o Guidance:  screen time, reinforce + behavior, allow choices, safety o Immunizations: first boosters 18 months: developmental screening (autism – MCHAT) o Developmental: run, aims while throwing, scribbles, stack 4-6 blocks, 15-20 words, point to body parts o Guidance: sleep, nutrition, behavior o Immunizations: Hep A #2 (must be 6mo from the 1st dose) 2 years: H&P switch to CDC growth charts, calculate BMI (on CDC website) o Underweight 97%ile o Development: kick ball forward, throw overhand, unbutton & unzip, walk upstairs, combine words, parallel play (egocentric) o Guidance: new issues, screen time (1 hr educational) o Screening: lead, lipid if risk, dental visit o Toilet training readiness: stays dry 2 hrs ▪ Assists in dressing self, recognizes urge, able to follow directions, wants to be clean & dry, parent readiness ▪ Talk and read books about toilet, assist w/use, praise 30 Months: o Development: jump both feet, imitate draw circle, attempt to use fork, recognizes colors, takes turns, speech 50% understandable, 2–3 word sentences, help tell stories o Continue discussions of potty training, nutrition, sleep, safety 3 year: Primary teeth complete, start BP readings o Normal 95%ile o Repeat BP on more than one occasion to determine HTN o Screen: hearing, vision o Development: catches ball, ride tricycle, uses scissors, pus on shoes & socks, speech understandable, concept of justice, preschool readiness 4 year: o Development: stand on one foot 5 seconds, dresses self, string beads, three step commands, ask “how” & “why” o Screen: vison normal 20/40, hearing o Immunizations: MMR, Varicella, DTaP, IPV Middle Childhood 5-10 years Physical Development: Height 2-3 in/yr, Weight 5-7lb/yr o Head circum  measured (not after age 3), Vison: 20/20, Primary teeth shed, RR 18 – 30, HR-60-100, atherosclerosis (age 7) Puberty: body change, girl after age 8, boys after age 9  o Chart tanner stages at every visit Motor Development: o Gross motor: strength & coordination, run, hop, jump, skip, bike, swim, skate, competitive, skills refined o Fine motor: dexterity, drawing recognizable, technology, self-care (tie-shoes, comb hair, brush teeth), Late hand-eye (play instruments) Social: o independence from home & family, sense of self in community, friendships, sleep overs, ACE, family traditions Emotional: o self-regulation, control impulse & emotion, concrete thinking (right & wrong), entry in school, anxiety, depression, self-esteem, caregiver relationship o Guidance: model emotions, help child express emotions Communication & Language: stuttering resolved o 6-7yrs: strong receptive language (jokes don’t make sense) ▪ Difficulty following complex directions, make L & Th sounds o 8-9yrs: comparatives, tells jokes & stories, pronouns o 10-12yrs: multiple meaning of words, express emotions, understands metaphors o Assess school performances, guidance in reading & writing Cognitive: concrete operations, empathy, reading o Assess: use of school resources, IEP or 504 plan, need for referral to educational psychologist o Guidance: parent involvement in school, regular homework time School readiness: kindergarten @ age 5 o Perform self-care, interact w/new people, act w/responsibility, separate from family, predictor (attention, behavior self-regulation) School refusal: staying home w/parental knowledge o Physical complaints: improve during the day, disappear on weekends o Social/emotional: anxiety, self-esteem, isolation o Parent feelings, assess physical care, MH referral Nutrition: 3 meals & snacks  o Proteins, vit D, eating habits (vegan, fast food), disordered eating o Multivit for those w/picky diets Oral Health: brushing & flossing, dental care, limit sugar, protective gear Sleep: 9-12 hrs, sleep routine, limit screen time before bed (1 hr), avoid scary Safety: Car seat/booster (age 8 or 4’9”), bike safety, sport safety o Sunscreen (30 spf or >), digital/social media Screening: o Anemia (iron w/meat), BP, BMI, development, vison (6,8,10,12), hearing, dyslipidemia (lipoprotein 1x age 9-11), psychosocial/behavior RED FLAGS (do not need to memorize, just know general) pg 152 Adolescent Health Growth & development Female (tanner stages above) o Ovary size ,Thelarche 8-13 yrs, Peak height velocity stage 2 to 3, Pubarche: 11yrs, Menarche: 9-15yrs, Breast asymmetry, Early development risk Growth & development Male, can grow to age 20-21 o Testicular & penis enlargement, Pubarche, Spermarche: stage 3-5, Height velocity: stage 3-4, Voice change, Hair change (pubic, axillary, facial, body),  Muscle mass, Gynecomastia Early adolescent (11-14yrs): tanner stage 2-4 o Cognitive: daydreaming, goals change, personal values o Social: lonely, wide mood swings, body conscious, privacy & friends o Guidance: physical changes, emotional coping, sexual responsibility o Immunizations: TDaP, MCV4, HPV (2 injections 6 mo apart) Middle adolescent (15-17yrs): interest in attractiveness → diet, muscle build o School & friend focused (family ), sexual drive, parental conflict, o Screening: school performance, depression, driving, STI o Guidance: nutrition (iron, Ca), technology use, sleep (8-9hr), sex o Immunizations: MCV4, meningitis B Late adolescent (18-21yrs): o adult reasoning, understand consequences, future planning o Screening: STI, cervical CA (pap age 21), high risk behaviors, menstrual hx (anemia) o Immunizations: seasonal flu & catch up Risk Assessment: o SSHADES Strength-based psychosocial history, CRAFFT (drugs & etoh), PHQ-9 (depression), GAD-7 (anxiety) RED FLAGS pg 159 Sexuality and Gender Identity Infancy: sexual reflexes, body exploration, parent-infant bonding Early childhood: confuse gender, self-pleasuring, lack of personal space o Start teaching “private parts” Preschool: exploration of body, question where babies come from  o Uses appropriate words for body parts, explain gender differences, potty training, hygiene (female: front → back) Content children should know by age 5 o Understand male vs female, use appropriate words for body parts o their bodies are theirs (say “no”, only parents for cleaning and providers w/parents for physical) o know where babies come from and how they get “in” and “out” o be able to talk about body parts w/out feeling “naughty” o be able to ask trusted adults about sexuality o “sex talk” is private for home Middle Childhood: curiosity, gender permeance understood, sexual development o Exploration games, “potty language” o NOT NORMAL: not age appropriate, prolonged behavior, child anxious or extremely aroused, child forced, knows more about sexual acts Content Children should know by 6-9 o Aware that all grow and reproduce o Aware sexuality is important at all ages (parents, grandparents) o Know and use proper words for body parts (own and opposite sex) o Understand that there are many kind of caring family types o Aware that sexual identity includes orientation (LBGTQ+) o Understand the basic facts about how you get HIV/AIDs o Take an active role in managing their body’s health and safety Early adolescence: menarche (discuss before start) & spermarche o Sexual pleasure, body image, same sex friends, intimacy limited, sex education Content children should know 9-13 Pg 79 Middle adolescence: test ability to attract a partner o Exploration of sexual identity, moral significance of sexuality Late adolescence: expression w/sexual expressions, responsibility Approaches to teaching about sex: book page 78 Individuals w/intellectual & physical development disabilities o Same physical development, vulnerable to abuse, less sex education LBGTQ+: safe healthcare environment o Confidentiality, correct pronouns, nonjudgmental language, available resources, risks ( risk of suicide), U of M gender clinic RED FLAGS Pg 77 Prescribing Medications In Pediatrics Considerations: resist pressures from parents (Abx when viral) o Know OTC (what they are taking and help w/dosing), renal & hepatic maturations (Preemie), use clinical guidelines (insurance coverage), ID drug interactions & SE, check interactions Prescribing o Absorption: SQ & IM, GI, topical (infant  absorption)  o Distribution: weight, bone & teeth (stain perm teeth), preemie ( absorption into CSF), protein binding, breastfeeding (what’s mom taking) o Metabolism: liver Elimination: kidney Adherence: o  length of tx, medical condition,  doses/day, palatability ( concentration), pill swallowing, expense, belief system (dye free), family/social (multiple household) Script needs: medication name, amount in ml (not mg), how often, route, duration, and how many pills/ml to dispense ADHD DSM-5: https://www.cdc.gov/adhd/diagnosis/?CDC_AAref_Val=https://www.cdc.gov/ncbddd/a dhd/diagnosis.html o Criteria 1: inattention, 6 or more symptoms of inattention up to age 16 or 5 or > age 17 years and adults; symptoms have been present for at least 6 mo, and they are inappropriate for developmental level o Criteria 2: hyperactivity - impulsivity, 6 or more symptoms to age 16 years, or five or more for adolescents age 17 years and adults; symptoms present for at least 6 mo to an extent that is disruptive and inappropriate for the person’s developmental level o Conditions: ▪ Several symptoms present before age 12 years ▪ Several symptoms present in 2 or more settings, (such as at home, school) ▪ Clear evidence that the symptoms interfere with, or  the quality of, social, school, or work functioning ▪ Symptoms not better explained by another mental disorder ▪ Symptoms do not happen only during the course of schizophrenia or another psychotic disorder o Presentations: combined (most common), predominately inattentive, predominately hyperactive-impulsive Prevalence: 11.4% of population, boys > girls o Co-dx w/behavioral disorders (conduct, anxiety, autism, Tourette) Etiology: exact cause/risk unknown o Genetics, fetal/neonatal exposure (etoh & smoking), prematurity & low birth weight, exposures (lead), brain injury, ACE’s Potential complications  o Learning, social relationships, self-esteem, employment, traffic violations & MVA (distracted driving), family discord, substance use, depression, anxiety Assessment o Hx: why is ADHD a concern?, HPI, birth hx, family & environment, medical, developmental (delays), behavioral, attention (DMS-5), academic (performance, problems, fighting) o ADL: feeding (sit through meal), elimination, sleeping (r/o sleeping disorder, falling/staying asleep), activity, family relationships, MH, coping, stress, tolerance, school & teacher hx o Distinguish between MHD vs behavioral issues o Physical Exam: VS (BMI may be low when unable to sit through meal), vison & hearing, behavior observation, dysmorphic stigmata, skin (abuse, café o lait spots), ENT (FAS), Neuro, screen (iron, lead, thyroid) o Multiple assessment scales available Management o Initial meeting with family: education of disorder to family and child (neurotransmitter issue), establish goals (max academic achievement) o Family support: routines, family meetings & therapy, support groups o Both parents and/or households need to be consistent o Home: environment, homework (plan), exercise (before homework), fun, technology (organize), nutrition (- dyes), sleep (OSA) o Classroom: IEP or 504 plan – need official dx and referral o Medication: best when used w/behavioral therapy ▪ Age, severity, comorbid conditions, insurance coverage ▪ Preschool: meds not recommended, ▪ School-ages: meds & therapy ▪ Stimulant: first line therapy, know what to monitor for and how they work,  w/drawal symptoms → wear off every night, monitor linear growth @ each visit (weight), SE = GI upset w/ appetite,  BP/CP/Tachy arrythmia, insomnia ▪ Non-stimulant ▪ Start low and go slow, follow-up on month when starting or changing (every three months following) Autism & Behavior Disorders Autism spectrum disorder (ASD): 1/59 children o DSM-5 Criteria: must have two from second bullet ▪ Deficit in social communication & interaction across contexts (Social- emotional reciprocity, Non-verbal, poor eye contact,  friends), lack of facial expressions ▪ Restricted, repetitive, patterns of behavior, interest, or activities (motor movements, use of objects, or speech), Insistence on sameness; Highly restricted, fixed interests with abnormal intensity or focus, Hyper/hypo reactivity to sensory input  ▪ Present in infancy & early childhood, functional impairment, not related to intellectual disability or developmental delay o Screening: MCHAT for all age 18mo-24mo old (not for older children) ▪ May be negative at 18mo but + at 24 o Management: Goal is to gain greatest potential of patient ▪ Refer to developmental pediatrician/psychiatrist ▪ Applied behavioral analysis → strategies for disruptive behavior ▪ Dietician (picky eaters w/textures), speech & OT, school IEP, GI (diet, constipation, PICA), neuro (seizures), dentistry ( teeth brushing r/t sensation) o Aggression ▪ Irritability, emotional dysregulation (“big emotions”), impulsivity, overt (physical, common in males), covert (threat, “mean girls”, common in females) ▪ Risks: neurodivergent, stress, genetic maltreatment, inconsistent/harsh discipline, bullying, parental rejection ▪ Management: screening (suicide, homicide ideation, behavioral disorders, abuse, substance use), r/o differential dx (conduct disorder, oppositional defiant disorder), Positive parenting education & behavioral health specialist Conduct Disorder (CD): violation of rights of others and societal norms o Cause: chronic negative circumstances o Manifestations: aggressive behavior w/threats and/or physical harm to others and animals, nonaggressive behavior that causes property damage, lying or stealing, serious violation of rules or laws o Management: + parenting, social-cognitive skill training, teacher classroom management strategies, group & family therapy, CPS (abuse) Oppositional Defiant Disorder (ODD): negative, defiant, hostile, disobedient o Easily annoyed, do not see that they have a problem o Manage: refer for behavioral therapy, + parenting, consistent healthy discipline, school collab Disruptive mood dysregulation disorder (DMDD) o Irritability w/verbal/physical outburst, onset < 10yo (2 different settings, 3x/wk for > 1yr) o Manage: refer to behavioral therapy, parent skills, socioemotional skills Behavioral Health Disorders Anxiety: 7% of youth, apprehension w/unknown stimuli, normal development o Inappropriate daily function & social interactions o Peds anxiety disorder triad: 1. Separation, 2. Generalized, 3. Social o Risks: Genetics, shy behavior, social/life environment (trauma), comorbid (ADHD, learning & eating disorders, OCD, substance use) o Separation: most common in pediatrics, abnormal reaction  ▪ Clinical findings: developmentally inappropriate, worry about harm to self or loved ones, reluctant to sleep alone or away from home, persistent avoidance of being alone, nightmares o Generalized: cognitive and obsessive → no focus ▪ Clinical findings: worry r/t future events, overwhelmed, poor sleep, fatigue, irritability, difficult concentration ▪ Manage: CBT (fam involved), play therapy, mindfulness, psychodynamic therapy, meds (learn in MH) OCD: obsession (persistent), Compulsion (repetitive behavior) o Severe distress, time consuming, interfere w/function o PANDAS (Ped autoimmune neuropsych disorder assoc w/strep) ▪ OCD and/or TIC, age 3 – puberty, abrupt onset & episodic, group A beta- hemolytic strep infection, remission w/abx ▪ Manage: neurologist (that supports dx), abx, ID o Differential dx: autism, eating disorder, social phobia, neuro o Quick screening: intrusive thoughts, do these problems bother you? ▪ Washing hands or clean more than most people? ▪ Feel the need to check or double check things often? ▪ Have thoughts that bother you that you would like to get rid of? ▪ Spend time doing things (brush teeth, get dressed) in order? ▪ Bother you when things are not in line/order? o Manage: individual, developmental, CBT, meds – SSRI Tic Disorders: sudden, repetitive, unconscious, Motor or vocal, male > female o Tourette’s multiple motor w/1 verbal before age 18, last 1 yr o Findings: motor (blinking, shrugging, twitch), vocal (sniff, grunt, words) o Manage: comprehensive intervention = extinguish tic,  awareness of behavior, teach another behavior (snapping rubber band), + reinforcement, meds = alpha adrenergic Depression: Major (2 wks), persistent (>2 yrs), adjustment (w/in 3mo of life stressor) o Risk factors: → o Scales: ▪ Child behavior checklist: 1.5-5 and 6-18 yo ▪ Children’s depression rating scale revised: 6- 12 yo  ▪ Children’s depression inventory: 6-18 yo ▪ Center for epidemiologic studies-depression scale: adolescents ▪ Depression self-rating scale: adolescents ▪ Pediatric symptom checklist: 4yo-adolescent ▪ PHQ-9 and modified for teens: 6-10yo and 11yo to adolescents o Findings:  mood, loss of interest, ∆ in appetite/sleep, suicidal thoughts o Differentials: Medical cause, substance use (meds, toxins), infection lead, anemia, eating disorder, PMS, neuro, testing (CBC, CMP, vit D, B12, folate, pregnancy, EBV titers, thyroid, LFT, CRP/ESR, UA, drug screen) o Manage: Establish safety (guns, knives, meds), follow-up, community resources, family emergency plan RED FLAGS: SUICIDE WARNING SIGNS (ER for suicidal ideation) pg 428 Child Maltreatment Types: Neglect (most common), physical abuse, sexual abuse, medical neglect Risk factors o Child: prematurity, irritable baby, unplanned pregnancy, developmental delay, chronic health condition, behavioral difficulties, physical disability, multiple gestation o Caregiver: Etoh & substance use, criminal hx, MH issue, lack of interest in child’s needs, hx of child abuse/neglect, young age,  education o Home: family/intimate partner violence, nonbiological/transient caregivers in the home, single-parent home, previous CPS involvement o Community: poverty, social isolation, or lack of social support Protective factors o Child: high self-esteem, impulse control o Caregiver: resilience, higher education, sense of competency o Community: access to health, education & social services, caring adult in school, involved in extracurriculars & religious community Neglect: o Fail to provide: Physical (nutrition, hygiene, shelter, clothing), emotional (ignore child), Medical/dental ( care, delay in screening/care), educational (miss 25 or more days,  enroll child in school, inattentive to special ed) o Fail to supervise: fail to ensure a child’s safety, inadequate supervision (unsafe activities, exposed to hazards, left alone), exposed to violence o Manage: Did action of lack of action result in harm to child?  ▪ Yes → CPS (gets resources fast) no → referral for services ▪ Hx: growth, poverty etc. Physical abuse: intentional force → injury o History ?s: When (date and time), where did it occur, was it witnessed, what was done after the injury (when did they seek care), specific details of injury, what remedies were tried o RED FLAGS: ∆ providers frequently, story ∆s, inconsistency among caregivers, describe the injury to be less than it is, story doesn’t match injury,  hx of trauma offered, described as self-inflicted o Bruising: multiple stages of healing & areas of body, non- ambulatory child, patterned marks (grab, slap) o Fractures: ANY in non-ambulatory infant w/out clear accident, multiple, bilateral, different stages of healing, multiple & complex skull w/simple story o Burns: clear shape of hot item, spare flexed areas, spill  consistent w/story, cigarette, peri burns o Head trauma: movements in 1 hr of sleep (sleep study), ferritin/iron levels o Tx: avoid nicotine & caffeine, iron replacement, ∆ meds Sleep disordered breathing: o Risks: African decent, craniofacial anomalies, Downs, neuromuscular disease, choanal atresia, obesity, tonsillar hypertrophy, GERD o S&S: snoring, gasping, apnea, paradox respirations, neck hyperextension, night sweats, tachycardia, parasomnia, cognitive behavioral issues o Dx: PSG (apnea, hypopnea >1.5x/hr) o Tx: mandibular distraction, CPAP, nasal steroids, Montelukast Infectious Disease in Children Disease Hx: HPI, fam hx (autoimmune), Social (daycare/school) o Birth history, Meds (abx use?), immunizations (lack of), exposure (known illness/travel, smoke/mold), ROS, diet (PICA) Physical Exam: VSS (fever,  RR, BP), irritability & lethargy o Disease focused: neck pain/stiffness (meningitis), murmur (endocarditis), refusal to walk, skin & mucous membrane ∆ Management: prevent spread, abx use w/caution, immunization  Exanthem (widespread rash) Types  Hand, Foot, & mouth: Coxsackievirus (most common), enterovirus o Spread: Fecal oral, summer-early fall, incubation 3-6 days o Lives on surfaces long time = whole day care getting it o Macular lesions in mouth, hands, feet, butt, genitalia ▪ Turn to eroded vesicles w/erythematous halo o Fever 1-2 days, rash 1-2 wks, supportive tx (Fls, antipyretic, pain, educate that the skin will peel) Poliovirus: enterovirus, fecal oral & respiratory o Unimmunized (oral polio vaccine), viral culture stool & throat o DD: flaccid muscle weakness/paralytic disorders (GB) o Tx: supportive,  skeletal deformity, activity Roseola Infantum: human herpesvirus (HHV-6), age 7m-24m o Incubation 9-10 days, high fever 3-5 days, →  fever and rash o Maculopapular rash, not contagious after rash, Tx supportive Varicella: Airborne respiratory particles or contact w/lesion o Incubation 10-21 days, Contagious 1-2 days before lesions and until lesions are crusted over, can get from shingles exposure o Low-grade fever 1-2 days → rash w/pruritis, HA< malaise, anorexia, cough, sore throat o Stages of rash: red macule→papule→vesicular→pustular→crusted ▪ *Lesions all at different stages* o Complications: ▪ PNA: 3-4 days after rash,  response to antivirals, led to death ▪ Secondary bacterial infection: group A strep, S. aureus (cellulitis, septicemia, nec fasc, meningitis)  ▪ Post infection cerebellar ataxia: sudden onset 2-3wks after that persists for 2 mo ▪ Encephalitis (5-20% mortality): lethargy, drowsy, confused, seizures ▪ Herpes zoster, otitis media, retinitis o Tx: supportive (fls, antipyretic, diphenhydramine for itch) ▪ Skin care: warm/oat bath, trim nails short ▪ Antiviral: 24hr after rash appearance ▪ VZIG: post exposure prophylaxis w/in 4 days (immunocompromised, newborn of infected mother, infant 40C (104F) Cause: Infectious (viral mostly), non-infectious (autoimmune), neonate (HSV) Ask parent for max temp, tx, fear of fever Assessment: o Rectal: 3yo) o Tympanic: tip needs to fit in canal, infrared heat by temporal arteries DD: Virus (most common), bacteria, immunizations, CA, meds (penicillin), o autoimmune & inflammatory (Crohns), congenital infection Hx: onset/duration, current meds, sick contacts, immunization status o Immunodeficiency, prenatal course INFECTION RED FLAGS: Age 3 sec), dehydration (fontanels) o Meningitis: seizure, petechiae, bulging fontanel o Unreliable caregivers Labs: UA, WBC & ANC, BC, stool culture, CRP, procal (sepsis), lumbar puncture o CXR (100.4 o Reoccurrence rx: than 1 occurrence o H&P: description, relationship between fever and seizure, neuro symptoms, fam hx, maternal smoking ( risk), prematurity, neuro exam, Diagnostics (EEG, MRI, LP) o Tx: seizure first aid, time them, >5 min → 911, *airway* ▪ Antipyretics, abatement meds (not normally needed) ▪ Simple = primary care. complex = referral to neurologist HEENT: Ear Otitis Externa: inflammation external auditory canal and/or auricle o Acute diffuse OE: “swimmers ear” most common o Acute localized, Eczematous: > 6 wks, otomycosis (fungal) o Necrotizing (malignant): immunocompromised o Causes: Obstruction & H2O retention,  wax (overcleaning), trauma (q-tips), alteration in pH, bacteria (pseudomonas & staph), fungal (aspergillus & candida) o Risks: previous hx, swimming/diving, earplugs, hearing aids, hot humid weather, eczema, allergic rhinitis asthma, DM, AIDS, leukopenia, malnut o S&S: Ear pain that  w/stimulation over 1-2 days,  hearing, tinnitus, fever, pruritic, discharge, unilateral, erythema, edema o Tx: remove debris (only w/intake TM), ear wick,  swim (2-5 days) ▪ Meds topical: hydrocortisone/neomycin/polymyxin B (cortisporin) 3gtt q6-8 for 5-10 days, oflaxacin, ciproflaxin) ▪ Antifungal: clotrimazole 1% otic 4gtt QID for 7 days o Prevention:  trauma,  frequent washing ears,  swim in bad water, empty ears of water after swim, prophylactic gtts ▪ Isopropyl alcohol and acetic acid in a 2:1 ratio Otitis media: behind ear drum o AOM: 3wk progression of middle ear acute inflammation ▪ Severe: pain and fever >39 Non-severe: temp 3mo o AOM: Eustachian tube obstruction/dysfunction, inflammation ▪ Viral RSV ▪ Bacterial (more common): strep pneumoniae, h. influenza, Moraxella catarrhalis, strep pyrogens ▪ Neonatal (not common): E.coli, GBS, enterococcus ▪  in kids r/t flat E tubes, neonate  risk meningitis ▪ Risk: 2 mild uni/bilateral, shared decision making (call in abx just in case) Amoxicillin, Augmentin (amoxicillin in the last 30 days, cefdinir (penicillin allergy) ▪ Referal: Emergent = intracranial complications, semi-urgent (2-3 days) fail of abx, non-urgent perforation w/persistent otorrhea Recurrent, co-existing illness, colonization w/MR bacteria ▪ Prevention: immunizations (flu), xyitol, nasal inflammation, ear tubes, hearing test w/OME for >3mo, language delay, learning issues or significant loss of hearing Tympanogram: ear canal volume,  5 yr 5-10mg Loratadine (Claritin): 2-5 5 mg, >6 10mg Fexofeadine (allegra): 2-12 30mg BID, >12 180mg ▪ Leukotriene receptor antagonist: Montelukast (singular) 2-15yr 5mg chew tab PO daily, > 15yr 10mg normal tab ▪  neo-synephrine w/kids, also causes rebound inflammation ▪ Nasal steroid: Flonase: >4yr 1-2 sprays a day, >12yr 2 sprays Qnasal: 4-11 1 spray, >12 2 sprays o Complications: bacterial sinusitis, eustachian tube dysfunction, OM, malocclusion, High palate Foreign body: unilateral purulent drainage, odor, epistaxis, obstruction o DDx: polyp, rhinitis, rhinosinusitis, nasal tumor o Tx: suction secretions, currete, alligator forceps Epistaxis: recurrent (5 or more/yr) o Cause: mucosal irritation, systemic (coags), environmental (dry heat) o Hx: recent trauma, allergies, URI, bleeding/tarry stools, anticoagulants, topical nasal sprays, cocaine use, fam hx of bleeding disorders o Dx: CBC, Coags o Tx: sit up/lean forward w/pressure for 5 min, cool mist humidifier (nasal saline), topical Abx, neo-synephrine, nasal packing w/urgent referral, prevent w/humidification & nasal corticosteroids Throat Pharyngitis: infection or irritation of the pharynx or tonsils o Viral (most common): rhinovirus, adenovirus o Bacterial (GAS): mycoplasma and chlamydia pneumonia o Allergy, trauma, toxins, and neoplasia o Hx: ▪ GAS: 4-7yo, sudden onset, sick contact, HA, vomiting , hx rheumatic fever  ▪ Viral: cough/rhinorrhea, vomiting (more likely GAS), sore throat ▪ Other bacterial: hx recent orogenital contact GAS o DX: Centor Criteria, - strep gets sent for cx in kids o PE: airway patency, temp, hydration status (eat/drink, UO) ▪ HEENT: *know differences* Conjunctivitis: adenovirus Scleral icterus: mono Rhinorrhea: viral Tonsillopharygenal/ palate petechiae: GAS & mono Tonsillopharyngeal exudate, Oropharyngeal vesicular lesion, lymphadenopathy ▪ CV: murmurs (RF) ▪ R: pharyngitis and LRI (M. pneumoniae) ▪ Abd: hepatosplenomegaly (mono) ▪ Skin: Sandpaper rash (scarlet fever), maculopapular rash o Tx: amoxicillin (50mg/kg BID for 10 days), cephalexin (25-50mg/kg q 12hr for 10days max of 500 mg q 12hr), Macrolide (high resistance rate), ∆ toothbrush ▪ Tonsillectomy: ENT consult, 3 infections a year for 3 yrs or 5 infections a year for 2 yrs, or 7 infections in 1 year Mono: pharyngitis w/fatigue, HA, nausea, abd pain o S&S: petechiae, lymphadenopathy (systemic, tender, mobile), hepatosplenomegaly, fever (worse in after no one), CBC (lymphocytes), EBV, LFTs o Tx: Supportive w/antipyretics, fls, BR 1-2 wks for fatigue ▪ Malaise 2-3 months,  contact sports or heavy lifting for at least 2-3 wks and avoiding splenic trauma for 2 mo Tonsillolith (tonsil stones): white or yellow concretions in tonsillar crypts that originate as a result of microorganisms and cellular debris retention o S&S: halitosis (bad breath) o Tx: manual extraction, tonsillectomy w/airway concerns Peritonsillar abscess: suppurative infection of the tissues between the capsule of the palatine tonsil and pharyngeal muscles  o Unilateral, inadequate tx of bacterial tonsillitis or abscess formed in a group of salivary glands o Hx: recurrent pharygotonsillitis and abscess, snoring/OSA, sore throat/dysphagia, neck swelling & pain (usually 5-7 days   w/abx) o S&S: trismus (pain w/mouth opened wide), fever, pooling of saliva/drooling, tiredness, irritability, muffled voice, referred ear pain o PE: asymmetric swelling lateral and superior to the affected tonsil w/displacement of the affected tonsil medially and anteriorly ▪ Tonsil may be normal or have erythema and exudates ▪ Uvula displaced → contralateral side, Soft palate red &swollen o Tx: ▪ airway compromised: ED IV abx → primaxin, unasyn, Rocephin ▪ Outpt: Augmentin, hydration, analgesics Dermatology Disorders Bacterial Impetigo: strep pyogens, staph aureus, MRSA o Hx: pruritic spread, fever, fatigue, diarrhea o PE: *non-bollous honey colored crust on erythematous base ▪ Bullous: pustular blisters w/thin coating ▪ Regional lymphadenopathy o Tx: topical mupirocin ▪ Abx: cephalexin 40mg/kg/day for 7 -10 days, augmentin 50-90 mg/kg/day for 7-10 days, dicloxacillin 15-50 mg/kg/day, clindamycin 10-25mg/kg/day ▪ Educate: handwashing, no daycare for 24hrs, follow-up if no improvement in 48-72hrs (Cx&S) Staphylococcal scalded skin syndrome: not common, under age 5 o S&S: abrupt, fever, malaise, lethargy, tender erythroderma, nikolsky sign (skin peels) o Tx: hospitalization for IV abx, topical mupirocin Cellulitis: localized, deeper than impetigo o Cause: strep periorbital, staph extremities & perianal, H. influenzae buccal and joint (look at vaccines) o Hx: previous skin damage, recent URI, fever, pain, malaise, anorexia, chills, anal pruritis, stool retention, constipation o PE: erythematous poorly demarcated, tender & warm, reginal lymphadenopathy o Labs: CBC blood cx, wound cx dependent on presentation o Tx: Hospitalization neonate or febrile infant (toxic or periorbital) ▪ Abx: strep = penicillin V 30-60 mg/kg for 10 days (allergy 3rd gen cephalosporin) Staph cephalexin 50-100mg/kg/day TID for 10 days or Bactrim 8-12 mg/kg/day BID for >2mo old ▪ MRSA: clindamycin 10-30mg/kg TID for 10 days ▪ Follow up daily  Folliculitis: superficial bacterial inflammation of hair follicle o Staph aureus, pseudomonas aeruginosa, e coli o Hx: moist environment, contaminated H2O (hot tub, river) o S&S: pruritis, tenderness, discrete 1-2mm papule/pustule on face, scalp, extremities, butt, back o Tx: warm compress, wash w/soap, topical keratolytic, mupirocin, or clindamycin, PO cephalexin 40-50mg/kg/d o Follow-up: 1 wk, 1 day for furuncle or abscess, ID causes Paronychia: finger infection caused by staph, strep, pseudomonas o S&S: around finger or toenail, tender, drainage, erythema, edema, purulent exudate, cuticle broken o Tx: Oral staph coverage, candida nystatin 3-4 wks, loosen nail to allow pus (Cx), warm soaks, nail care (wide toed shoes) Candidiasis: o Hx: recent abx or steroid use, rash in warm moist area o PE: mouth white plaque, red base, diaper red macule/papule, sharp boarder satellite lesions, vulvovaginal thick yellow dc & itchy, nail transverse ridge, loss of cuticle o Tx: oral (refer to mouth section); ▪ Skin: topical nystatin, clotrimazole, ketoconazole, every diaper ∆ until rash gone + 2 days; hydrocortisone 1% 1-2 days only if inflammation severe ▪ Keep cool & dry, mild soap & water, avoid powder, new pacifiers Tinea Capitis: scalp ring worm fungal, common age 2-10, > boys o S&S: hair loss & pruritis, scaling, erythema, crusting, bald or broken hair patches o Cause: trichophyton tonsurans “black dot” (most common), Microsporum canis (dull, fine, gray scale) o Dx: wood lamp (yello/green), hair scraping, KOH prep o Tx: topical agents ineffective r/t poor absorption on scalp ▪ Griseofulvin 10-15mg/kg/day for 6-8wks (take w/fatty food) ▪ Shampoo w/selenium sulfide or ketoconazole ▪ Kerion: oral prednisone 1-2mg/k/d for 5-14 days, abx prevention ▪ Follow up 2 wks, check fam members, CBC, Liver & renal function no longer standard of practice o Pt education:  share hates, combs, etc., SE of Griseofulvin = rash, urticaria, GI upset, photosensitivity, HA; hair growth takes months or may not come back, house cleaning, regular hair shampoo, avoid hair traction, wash pets, Tinea Corporis: direct contact w/human, soil, animals o Trichophyton, miscrosporum and Epidermophyton o Hx: contact sport, daycare, hot/humid, immunosuppression o S&S: flat, scaly, red patch, central clear or solid w/pustules o Tx: topical antifungal 1-4wks, Griseofulvin PRN,  topical steroids (make worse), tx contact, exclude daycare & sports for 24 hrs after tx  o Follow up 2 wks if not clear Tinea cruris “jock itch”: trichophyton rubrum, Epidermophyton floccosum o Risk: male, obesity, sweating, chaffing, hot/humid, athletes foot (putting on pants) o S&S: groin/upper thighs, erythema to bown, sharply demarcated raised plaque, usually bilateral & symmetric o Tx: Topical antifungals 4-6 wks, wear cotton underwear & loos clothing Tinea pedis: sweaty feet, exposure to damp areas o S&S: itching, burning, odor, crack, abrasion, cuts, weight bearing areas and between toes o Tx: topical antifungal 1 cm past (long course of tx), continue 7 days after clearing o Pt Ed: keep dry wash w/water or vinegar, aluminum deodorant to prevent sweating, wash shoes Tinea Versicolor: Malassezia furfur, trunk, pale areas o S&S: dark in winter, not tan in summer, multiple scaling macules or patches, guttate pattern (tear gtt) o Tx: selenium sulfide for 30min 2x/wk for 2-4 wks → monthly for 3 mo ▪ Older adolescent: ketoconazole, clotrimazole ▪ Resistant: oral fluconazole, encourage sweating Herpes simplex: HSV1, primary (days -wks) & recurrent (dormant) o Hx: Primary = fever, malaise, painful vesicles, Recurrent = burn, tingle, itch then outbreak o PE: gingivostomatitis (clustered vesicles), lymphadenopathy, herpes labialis (cluster weepy vesicles), herpetic whitlow (deep vesicles hands) o Dx: viral cx o TX: *underlying skin disorders, immunocompromised, severe gingivitis w/ PO intake* ▪ Burrow’s solution soak TID ▪ Acyclovir 20-40mg/k/dose 5x for 5 days max 1000mg/day >2yrs, severe case ▪ Topical antiviral > age 12yrs, abx for 2ndary infection ▪ Oral anesthetics: rinse and spit: lidocaine, Benadryl ▪ Supportive: antipyretic, fls, oral hygiene o Referral: newborns (IV acyclovir < 1 mo r/t HSV encephalopathy), immunocompromised, eye or eyelid Molloscum Contagiosum: Pox virus, low health risk, direct contact & surfaces o S&S: pink, discrete papule 1-6mm, umbilicated (pit in center) o Tx: spontaneously disappear 6m-2yr, curette, SA, cantharidin,  topical steroids, secondary infection, do not itch Wart (Verruca): HPV, common flesh colored, scaly papule o Plantar: grow inward o Flat: slightly elevated papule o Condylomata accumulate (genital)  o Tx: resolve 3-5yrs, keratolytic = SA, duct tape, cryo, cantharidin 0.7%, risk of scaring, repeat as often as needed Pediculosis (lice): transmission direct & indirect contact o Live 24hr off of host, like clean hair o Hx: known contact, white substance in hair, pruritis o PE: live visualized, nits, warm areas o Tx: permethrin to damp hair, comb nits, house cleaning (plastic bag for 2 wks), ivermectin for resistant areas Scabies: itching worse at night, mild w/progression o S&S: brown/red/gray burrows, web fingers, flexor surfaces, proximal foot, vesicupustular lesions o Tx: permethrin 5%, diphenhydramine oral or hydrocortisone topical for itching, all family and close contacts (daycare), house cleaning (plastic for 1 wk, wash in hot water) o Pt ed: rash/itching for up to 3 wks, return to school 24 hr after tx Contact dermatitis: dry skin, lip licker, plant, detergent, metal o Tx: id cause, burrow’s solution, cold compress, oatmeal bath, petroleum or lanolin, topical corticosteroids, oral for severe, antihistamines Diaper dermatitis: chemical irritation from urine & feces, poor hygiene o Hx: type of diapers, new care products, recent diarrhea or abx, frequency of diaper change, method of cleansing o Chemical: shiny, peeling, erythema vs mechanical: red, dry, macerated o Inside skin folds (outside skin folds, think candida) o Tx: ▪ Prevention: keep skin clean & dry, protective barrier, large enough diaper, thick absorbent diapers ▪ Tx: sitz bath, air dry, burrow’s soak, hydrocortisone 0.5-1% for 5 days max,  fls (dilute urine), follow-up by phone 1-2 days Seborrheic dermatitis: cradle cap & dandruff o Infant CC: scalp, behind ears, neck or trunk ▪ S&S: erythematous flake/thick crust, yellow, waxy scales ▪ Tx: resolves spontaneously (1yr), mineral oil o Adolescent DD: scalp, forehead, behind ears, eyebrows ▪ Mild flake w/erythema, yellow, greasy scales ▪ Tx: medicated shampoo 2-3x/wk alternated w/prescription strength ketoconazole 2.5% or selenium sulfide 2.5% Urticaria & angioedema: hypersensitivity o Urticaria: idiopathic, rapid onset, food, sting, bite, chemical, latex, caterpillars, infection, drugs, genetic, immune ▪ Annular erythema, pale centers, scattered or confluent, transient, blanch w/pressure o Angioedema: gradual onset, face & eyes, hands & feet, airway edema ▪ ACE inhibitors  o Hx: fam or medical hx, possible atopy, pruritis & scratching, recent food, medication, vaccination, infection, cold, heat, exercise, sun, water, pressure o Tx: diphenhydramine 0.5-1mg/kg/dose every 4-6 hr (max of 50mg/dose) ▪ Epinephrin 1:1000 0.01ml/kg for anaphylaxis ▪ Prednisone 1-2mg/kg/day ▪ Recurrent: CBC, allergy panel, thyroid, EBV, ANA, mycoplasma Pityriasis Rosea: wall appearing adolescent o S&S: herald patch (oval erythema, fine scale), secondary lesions (symmetric macular popular scales, Christmas tree pattern, pruritis) o Tx: calamine, emollient, topical Benadryl, slight sun exposure,  oral steroids, self-limiting, non-contagious, resolves 6-12wks Keratosis pilaris “chicken skin”: small bumps in hair follicles o S&S: appear spontaneously extensor extremities, butt, cheeks, atopy, cold/dry climates, winter, papules w/follicular plugs o Tx: lubricants & emollients, topical keratolytic recurrence, common Neonatal Skin Disorders Erythema Toxicum Neonatorum: 24-48hr after birth w/unknown cause o Discrete erythematous macule or patch w/central papule, vesicle, or pustule; clusters of papules, palms and soles spared o Tx: none, can take wks to resolve Acne o Neonatal: first 2 wks, inflammatory erythematous papules & pustules ▪ Tx: watchful waiting o Infant: 4-6 wks, resolve in 6-12mo, risk of scaring, full range of acne ▪ Tx: topical 2.5% benzayl peroxide or 2% erythromycin of 1% clindamycin 1-2x day Milia: benign keratinous cysts, 1-3mm white/yellow, spontaneously disappear o Epstein pearls: in mouth Miliaria (heat rash): o S&S: rubra erythematous papule on forehead and upper trunk, crystallina (vesicle w/clear fl r/t trapping of sweat), pustulosa (more inflammation) o Tx: prevention, avoid overheating & thick emollients, resolves spontaneously Transient Neonatal pustular melanosis: cause unknown, present @ birth o 5% of African American babies o S&S: pustule w/out surrounding erythema, hyperpigmented macule w/scale o Dx: presentation Tx: spontaneously resolves Café-au-lait macule: 2% all infants, 10% of all AA infants o Tan macule w/well-defined border o Dx: presentation Tx: none o Associated conditions (>6 lesions): neurofibromatosis type 1, McCune-Albright, Cushing’s Mongolian spots: 90% of AA infants  o Dermal melanocytosis, dark gray macule o Dx: clinical presentation (document location), Tx: none Congenital melanocytic nevi: birth – 6 mo o Risk malignancy: 20cm = 4.8% o Dx: larger than acquired nevi, elevated surface and texture ∆ o Tx: small & not ∆ing = observe, Large = refer to plastic sx o CNS involement risk: present on head or midline back → MRI o Refer is ABCDE ∆ Infantile hemangioma: benign, 1-2 wks, vascular, warm o Phases: growth, plateau, spontaneous involution o Superficial: bright red papule/plaques, rubbery o Deep: blue/purple nodules, warm o DX: multiple lesions = risk of liver, GI tract, CNS involvement ▪ Bear lesion: risk airway involement, assess bi-phasic stridor & hoarseness, ENT laryngoscopy ▪ Lumbosacral: underlying spinal, urogenital, anorectal → MRI o Tx: Goals to  pain, prevent long-term deformity, prevent complications,  psych trauma ▪ Local wound care: ulceration, topical abx, compression, non-stick ▪ Topical high dose steroid (watch growth) or timolol ▪ Oral propranolol: slows growth/accelerated involution ▪ Pulse-dye laser: ulcerated lesions ▪ Prognosis: spontaneous involution 5-10 years ▪ Refer: high risk location (periocular, nasal tip, ear, lip, genital/lumbosacral region, airway, hepatic, multiple lesions