1. August 23 rd, 2012

2. What topic should we do for next months board review? A. Genetics B. Development

4. Hypertension affects 1 out of 4 adults Poorly controlled HTN is the leading cause of death globally High BP in childhood is a risk factor for hypertension in adulthood Hence the need for frequent pediatric blood pressure screening

5. Children > 3 yrs old: screened at every health care encounter

6. Preferred method of BP screening is auscultation If elevated BP detected with oscillometric device, confirm with auscultation Correct measurement requires appropriate cuff (bladder) size for the childs right upper arm Width is 40% of the circumference of the arm Length is 80-100% of the circumference of the arm BP measurements are overestimated to a greater degree with a cuff that is too small than they are underestimated by a cuff that is too large

7. Normal range of blood pressure is based on sex, age, and height

10. Lead toxicities have been well documented throughout history Used by ancient Egyptians for homicidal purposes Common cause of morbidity and mortality in shipbuilders, wine drinkers, potters Lead-based paints, gasoline, and food containers resulted in profound contamination in the early 20 th century In the 1970s close to 90% of children had blood lead levels (BLLs) greater than 10mcg/dL

11. Banning of lead in gasoline and paints as well as wide-spread screening have lead to decreased average BLLs over the past several decades However, there are still some potential exposures

12. All of the following are potential lead exposure sources, EXCEPT A.Playing with antique, imported toys or makeup from India B.Drinking bottled water C.Jumping into dads arms after he comes home from a long day of automobile repairs and soldering D.Living in a house built in 1948 E.Eating dirt next to an old gasoline refinery

14. For all Medicaid patients: Universal screening at ages 1 and 2 For other types of insurance: Based on local state/city health department guidelines Typically at age 2; and at age 12 months for high risk population ALL children should have at least one BLL between the ages of 36-72 months At any time for high risk or concern: Living in high-risk environment where more than 12% of children have elevated BLLs, siblings with elevated BLLs, recent immigrants, parental concern about exposure

15. You receive a lab report from a screening fingerstick blood lead level. The level is 18mcg/dL. What is the best next step? A.Repeat the BLL with a venous sample B.Administer oral succimer (DMSA) at 10mg/kg orally every 8 hrs for 5 days followed by every 12 hrs for 14 days C.Reassure the parents and schedule routine follow up in 6 months D.Hospitalize the patient for parenteral chelation E.Contact the health department for an immediate transfer to a lead-free enviornment

16. **Now < 5mcg/dL** 5

18. All of the following are reasons why children are at an increased risk of lead toxicity compared to adults, EXCEPT: A.Increased hand-to-mouth behavior B.Increased lead absorption C.Preferential deposition of lead into bones as opposed to soft tissues D.Immature blood-brain barrier leading to greater neurotoxicity E.More common concomitant iron deficiency anemia

19. Affects multiple organ systems, however most children are ASYMPTOMATIC Greatest concern: neurotoxic potential Even LOW BLLs can have toxic effects School failure, cognitive loss, hyperactivity, aggression, inattention, distractibility, delinquent behaviors Decline in IQ scores However, rate of decline in IQ score may be HIGHER at levels LESS than 10mcg/dL Lead-sensitive pathways that are rapidly saturated at levels below 10mcg/dL Chronic mildly increased BLLs may have higher risk

20. Abdominal colic Constipation Growth failure Hearing loss Renal disease Seizures Encephalopathy Microcytic anemia Depressed T-cell function Altered cartilage mineralization Osteopenia/decreased bone growth Miscarriage, preterm births CVD, HTN in adulthood

21. No RCTs that show that chelation therapy affects outcomes Cannot reverse any neurologic deficits Treatment based on clinical experience and judgment Neurodevelopmental lags may not be evident immediately for a patient with elevated BLLs Delays may not be apparent until more challenging school activities bring them out Neurodevelopmental surveillance should continue throughout schooling A nurturing and stimulating social environment can help to ameliorate the toxic effects of lead on the brain

23. Vision problems are very common in children 5-10% of all preschoolers have a vision problem 5-7% have major refractive errors requiring correction 4% have strabismus Of those, 40% have amblyopia 0.1% have cataracts Screening and early detection improve visual acuity

24. Refractive error: focusing problem Myopia (nearsightedness) Hyperopia (farsightedness) Astigmatism Strabismus: misalignment of the eyes tropia: full time misalignment phoria: tendency to become misaligned eso adducting (inward) exo abducting (outward) Amblyopia: loss of visual acuity due to active cortical suppression of vision in that eye Strabismus, anisometropic, deprivational Cataract: opacification of the lens

25. A mother brings her newborn infant in to your clinic. She asks if the baby can see her. What is your BEST response? A.Infants cannot see colors until 6 months of age B.Her babys vision is most likely 20/40 C.Newborns have no light perception and gradually develop it over time D.Infants do not have conjugate gaze E.Newborns can fixate momentarily on a human face or high-contrast object

26. Approximated to be 20/400 at 1 month of age Some sources say 20/200 Improves to 20/30 by 1 year of age Newborns focus best on a facial construct 12-24 inches from face Vision FunctionAge Visual fixation presentBirth Fixation well developed6-9 weeks Visual following3 months Accommodation4 months Stereopsis4 months

27. Red reflex Look for bilateral equal color and brightness Should fill entire pupil Use ophthalmoscope set to O diopters Defect could indicate: cataract, refractive error, retinoblastoma Any concern refer to ophthalmology Fundoscopic exam Requires more cooperation; difficult prior to age 3 Evaluate anterior structures with plus lenses (black or green numbers) Posterior structures with minus lenses (red numbers) Can help diagnose ROP (dilated disc vessels)

28. Visual acuity testing Varies based on age Variations of Snellen chart (with cartoons, etc) Difference of two lines between the eyes or vision less than 20/40 in either eye refer to ophthalmology Corneal reflex testing Using a penlight to distinguish strabismus from pseudostrabismus Cover testing To identify tropias and phorias

29. What is the diagnosis? A.Left Amblyopia B.Right Esotropia C.Right Exotropia D.Left Esotropia E.Left Exotropia

30. Asymmetry of the amount of white visible on either side of the eye can raise concern Pseudostrabismus: appearance of misalignment when there is no strabismus present Use corneal reflex (penlight) test to distinguish

31. Misalignment of the eye that is always present Large angle deviations are obvious Small angle deviations can be detected with the Cover-Uncover test UNCOVERED affected eye will move

32. Misalignment that occurs some of the time When synchronization between the eyes is broken Can be detected with the Cross-Cover test

34. Childhood hearing loss can be a debilitating condition that affects 1-6/1000 newborns The first 36 months after birth represent a critical period in cognitive and linguistic development Early identification and intervention are CRITICAL Allows deaf and hearing-impaired children to approach their peers in language skills and academics Those identified late often wont reach the same level

35. You are on your Well Baby rotation and asked by some well-educated, new parents what a hearing screen on their baby will involve. The nursery is currently using auditory brainstem response tests (ABR) because the OAE machine is broken. You tell them that A.Its simple…you put the baby in a room and see if he looks in the direction of different sounds. B.You have an ENT doctor come and check out the ear anatomy to make sure it looks good! C.Sounds are delivered through earphones, and electroencephalogram probes (EEG) records the results. D.There is a probe in the ear that sends sounds in and then detects sounds being created by the inner ear during transmission.

36. The AAP recommends that congenital hearing loss be detected by 1 month, diagnosed definitively by 3 months, and receive intervention by 6 month of age. Objective newborn hearing test by 1 month!!! Hearing-impaired infants still reach early milestones on time (cooing, smiling, babbling, gesturing) OAE or ABR in newborn nursery 2-stage screen where ABR confirms abnormal OAE yields lowest # of false positives!

37. Any infant that fails screen = full audiology evaluation by 3 months!! OUR responsibility to make sure it happens. Minimally affected by outer and inner ear debris; screens for auditory neuropathy

38. Hearing loss can also be acquired PCPs should assess risk factors at each visit and audiology referral if warranted Screening with conventional audiometry starting at age 4

39. The parents of a 4-year old girl bring her to see your for difficulty paying attention, frequent temper tantrums, problems at preschool. Her only PMH is frequent ear infections. Your in-office screen suggests hearing loss that you suspect is caused by… A.Sensorineural hearing loss B.Conductive hearing loss C.She can hear just fine but probably has ADHD and couldnt pay attention for the screen. D.Central hearing loss

40. Conductive loss results from problems with mechanical transmission External canal Tympanic membrane Middle ear ossicles Sensorineural hearing loss Failure to transduce vibrations in cochlea to neural impulse Failure to transmit to vestibulocochlear nerve Central hearing loss Defects in brainstem or higher centers

41. Congenital Malformations of the external ear A bnormal ossicular chain Acquired Otitis media with effusion is most common cause Fluid in middle ear from altered Eustachian tube fx Fluid restricts TM mobility Cerumen impaction, otitis externa, foreign body Cholesteatoma OME: No antibiotics needed; observe for 3mo then referral for hearing test and possible ENT referral; sooner referral if developmental delay or hearing loss obvious

42. You are seeing a newborn with sensorineural hearing loss on her newborn hearing screen. Moms reports prenatal history as unremarkable. On exam, the baby has microcephaly and hepatomegaly with NO other obvious physical abnormalities. The MOST likely cause of the hearing loss is A.Congenital cytomegalovirus infection B.Alport syndrome C.Middle ear effusion D.Prenatal rubella exposure E.Usher syndrome

45. Leading cause of morbidity and mortality among children in the U.S. Understandable, predictable, and preventable Risk factors Young children and teenagers Males twice the risk Greater exposure to activities that result in injury Patterns of risk-taking and rougher play Substance abuse, especially alcohol Provide age-appropriate home safety information at every visit

46. Leading cause of injury death and disability in all age groups More than 1/3 of children fatally injured were with drunk drivers Child safety seats reduce the risk of death by 50-70% Teenagers are at higher risk Newly licensed and distractible Often speed and use alcohol* *Talk to parents about a safe ride agreement if alcohol is involved Major cause of head injury

47. A mom is talking to you about her son. He is always getting upset with her because she wants to hold his hand when they cross the street. At what age should a child be allowed to cross the street independently? A.15 years B.5 years C.8 years D.13 years E.10 years

48. Young children are at risk for pedestrian injuries Not aware of traffic threats Should not be allowed to cross the street independently until age 10! Bicycles All parents should be counseled about importance of bicycle helmets Reduce pediatric head injury by 85% 75% of all bicycle-related fatalities can be prevented with helmet Snell or ANSI approved and proper fit

49. Annually, more than 1 million kids <6 experience toxic exposures, and 90% of these occur at home! The proper storage of poisonous substances should be discussed at the 6mo visit Most likely agents in pediatrics Cosmetics and personal care products Cleaning substances Analgesics Cough and cold preparations Plants Pharmaceutical products

50. Pediatricians should emphasize the importance of contacting the poison control center IMMEDIATELY upon suspicion of toxic ingestion by a child 1-800-222-1222 Pediatric poisoning deaths have declined substantially over the past 30 years…childproof caps has helped with this!! Syrup of ipecac is no longer recommended for the home management of pediatric poisonings

51. During the prenatal visit with new parents, a father expresses concern about regulating the temperature of the bath water for the new baby. You tell them that standards regarding hot water heaters have been determined. Of the following, the temperature that is most appropriate is A.110ºF B.120ºF C.130ºF D.140ºF E.150ºF

52. Most pediatric burns happen at home and are largely preventable Children 4 and younger Scald burns from hot foods or liquids in the kitchen Burns from bath water A key preventative measure is to set water heater temperatures no higher than 120ºF**

53. Water Temperature Time to 3 rd degree burn 150°F2 seconds 140°F6 seconds 130°F30 seconds 120°F5 minutes!

54. Smoke detectors in the home help reduce deaths Per AAP, families should be counseled to attend public firework displays rather than purchase fireworks for home use Other safety tips: Never allow young child to hold fireworks, adult supervision at all times, and keep bucket of water nearby Preschool children have the motor skills to strike a match or lighter…but dont comprehend the danger! Counsel parents. Use electrical outlet covers in the home to prevent electric burns.

55. In 2005, drowning killed 1100 children in the US 4x this received emergency care for nonfatal drowning High lifetime health and economic impact Affected children are often neurologically devastated and require prolonged medical/rehab care African Americans with 1.7x rate Bimodal distribution: peak in toddlers and adolescents < 1 year old: bathtubs, buckets, toilets 1-4 years old: swimming pools when poorly supervised 15-24 years old: natural bodies of water

56. Your best friend is thinking about getting a swimming pool because the kids would LOVE it! Which picture represents the best pool layout?? A D C B

57. Measures to prevent drowning at home include Draining water from bathtubs and buckets Securing toilet seats Swim with child at arms length away (NO MORE) Swimming pool fences have reduced the incidence of drowning by 50-80% Must be enclosed on ALL 4 SIDES by a fence Minimum of 4 feet tall Self-latching gate NOT PROVEN Swimming lessons Pool covers and alarms!!

58. You are seeing 16-year old twin brothers for health supervision visits. They tell you that they plan to spend most of the summer boating and fishing at their camp. Of the following, the advice that is MOST likely to decrease their risk of boating- related fatality is to A.Conduct regular engine maintenance on the boat B.Have both boys take swimming lessons before summer C.Install a carbon monoxide detector on the boat D.Post the phone # to the US Coast Guard on the boat E.Wear life jackets at all times while on the boat

59. Boating Current legislation requires all children age 6-14yo to wear life vests when in small boats All patients should be counseled to do this, regardless of age Adult supervision at ALL times Adolescents MUST be informed about water safety and the dangers of intoxication while in/around water

60. More than 33% of households admit to having firearms, and almost 70% of parents admit that guns are unlocked Most accidental shootings result from having a gun in the home Children Strong enough to fire most guns Very curious and want to play with novelty items In one study of children previously educated about gun safety 75% of kids who found a gun played with it Of those, 50% pulled the trigger

61. Removing guns from the home is the only action that can ensure decreased rates of accidental gun deaths Parents need to be counseled at every visit about hazards of having a gun in the home If gun present … Unloaded gun locked away Ammunition kept locked in separate cabinets www.projectchildsafe.org will provide gun safety kits at no cost www.projectchildsafe.org

62. What is the # 1 cause of mortality for children younger than 1 year of age? A.Motor vehicle accidents B.Falls C.Suffocation D.Drowning E.Fires/burns

63. #1 cause of mortality of children <1 year Food, coins, and toys are the primary causes of choking-related injury and death Foods to avoid Peanuts Popcorn Hot dogs Whole grapes, raisins, apple bites, and carrots Candy Counsel parents to eliminate small items from environment Dangling cords, dry cleaning bags, other consumer products

64. Leading cause of nonfatal injuries Major cause of head injury; mortality rates increase at falls > 15ft Children <3yo are less likely to have serious injury from falling Falls from windows, roofs, and balconies occur more in urban areas Openings in windows or railings should be less than 4 inches Double hung windows should be opened from the top Playgrounds or a frequent site of falls for school-age kids Upper extremity fractures are most common Frequent safety inspections Adult supervision at ALL times is important!

65. Infant walkers Delay normal motor and mental development Are dangerous! Falls are overwhelmingly common, often down stairs (75-96% of cases) AAP recommends walkers (with wheels) are banned! Rollerblades and skateboards AAP recommends full protective gear (helmet, wrist guards, knee pads, and elbow pads) Parents must be counseled to set an example for their kids

67. I am an 11month old infant who weighs 20lbs. According to the AAP, which type of car restraint system should my mommy put me in? A.B. C.

68. Rear facing Infant-only car seat Convertible car safety seat Rear middle seat is safest How long can I use this seat? Until 2 yrs Reach seats height and weight maximum Usually 35 lbs.

69. Infants weighing up to 22-30lbs Rear-facing only Shoulder harnesses at or just below the infants shoulders Infants up to 40-65lbs Can be rear-facing or front-facing Used as long as the child fits Childs ears below the seat back and shoulders below the seat strap slots

70. If > 2 yrs or have outgrown rear-facing car seat… Forward-facing car safety seat Convertible or Combination How long can I use this seat? As long as possible Up to weight or height maximum 65 to 80 lbs

71. Weight or height above the forward- facing limit A belt-positioning booster seat How long can I use this seat? Until vehicle lap-and shoulder seat belt fits properly 4 feet 9 inches 8 to 12 years old

72. Purpose to raise the child up to provide appropriate positioning of the car seat belt Shoulder belt should rest across the chest without touching the neck or face Lap belt should lie over the upper thighs (not the abdomen) High-back variety preferred

73. 13 years old Back seat safest until 16yrs!

74. Which is the following is NOT a feature of an adequate car seat? A.A booster seat that positions the car seat belt across the chest and over the upper thighs B.A rear-facing, infant-only car seat with the retainer clip of the harness at the level of the axilla C.A convertible seat that when secured to the car moves only 2 inches to either side D.A forward-facing car seat with hooks at the base attached to anchors in the crease of the rear seats and a hook at the top attached to an anchor on the high rear panel of the vehicle (LATCH system) E.A five-point restraint that buckles between the legs, with two straps across the shoulders and two straps across the hips

75. 5-point-restraint LATCH system (lower anchors and tethers for children) When safely secured, the car seat should not move 1 inch to either side

76. 24% of preterm babies do not fit into infant car seats Risks of car seats Apeas Bradycardias Desats Car seat challenge Preterm infants (<37WGA) AND term infants with respiratory issues No straightforward recommendations if they fail Position as best you can Recommend observing infant closely during travel and limiting travel time

77. Rear facing car seat until 1 year or 20 lbs Forward facing car seat until 4 years or 40 lbs Booster seat until 6 years or 60 lbs Unless car has lap belt, then may use lap belt only

79. Screen time includes TV, video games, computer, etc. Limited to 2 hours per day for all children NO televisions in childs bedroom Parents should also be made aware of link with obesity and decreased academic performance

80. Most recognized preventable factor for skin cancer is exposure to ultraviolet light One blistering sunburn can increase the risk of melanoma Protection Avoidance of prolonged sun exposure, especially from 10am-4pm Protective hats and clothing if outside for long periods of time (infants and young children) Sunscreen (for older children) SPF is a measure of UVB protection (linked to skin CA), need SPF15 or higher To prevent UVA damage, need broad spectrum sunscreen (1-4 stars) Reapply every 2 hours Children <6 months can wear sunscreen, but usually small amounts only on exposed surfaces.

81. Plays a vital role in the growth and development of children Sleep behaviors and problems change as a child progresses from infancy to adolescence Insufficient and poor quality of sleep may manifest as Change in mood, behavior, memory, and attention Hyperactivity and poor impulse control (younger children)

82. Pediatrician should stress the importance of a bedtime routine when counseling parents Age-appropriate bedtime Dark, quiet, cool bedroom Put the child to bed drowsy but awake No sleeping in the parents bed Pediatricians need to screen for childhood sleep disorders in both healthy children and specific vulnerable populations (behavioral and developmental conditions, genetic disorders, chronic medical problems)

84. Acute management of sting anaphylaxis at home Recognize signs and symptoms of anaphylaxis Epinephrine…counsel on use!!! Epipen Jr. (0.15mg) Epipen (0.3mg) Antihistamines havent shown any immediate benefit Proper tick removal Within 24-72 hours Fine mosquito tweezers close to skin surface Pull upward with steady, even pressure Dont twist or jerk the tick Clean area and your hands after removal NO painting or heating tick for removal

85. Risk factors Male sex, older age, post-menopausal Family history of heart disease Higher if father or brother developed heart disease before 55 Higher if mother or sister developed heart disease before 65 Race African Americans, American Indians, and Mexican Americans are more likely to have heart disease than caucasians Smoking High LDL (bad cholesterol) and low HDL (good) Uncontrolled HTN or diabetes Physical inactivity Obesity Uncontrolled stress and anger

86. Passive exposure to cigarette smoke in the home increases the chance, frequency, and duration of lower respiratory tract illness in children Common indoor exposures can produce respiratory symptoms Wood fires and stoves Cooking sprays Hairsprays Animal dander

87. A systemic skeletal disease characterized by low bone mass and micro-architectural deterioration of bone tissue, with increase in bone fragility and fracture susceptibility Failure to achieve peak bone mass represents a preventable risk factor for osteoporosis in later years Counsel families on effects of… Diet: rich in Ca and VitD (400IU/day); supplement important if not adequate Exercise: weight bearing forces on the skeleton have a positive effect of bone size and mineralization Smoking: decreases bone mineral density

88. Universal screening for anemia at 12 months Fingerstick Hgb concentration Assessment of risk factors Low socioeconomic status, history of prematurity or low birth weight, lead exposure, exclusive breastfeeding beyond 4 months of age without supplemental iron, and weaning to whole milk or complementary foods that do not include iron-fortified cereals or foods rich in iron For infants and toddlers (1–3 years of age), additional screening can be performed at any time if there is a risk of iron deficiency

89. In the newborn period, hemoglobin and hematocrit measurements usually are drawn peripherally (heelstick) Hemoglobin and hematocrit values from capillary samples may be as much as 15% higher than those from venous samples** Particularly if the peripheral blood flow is diminished due to prematurity, sepsis, congenital heart disease, etc Repeat heelstick with venous sample

90. Dyslipidemia: imbalance in the levels of low-density lipoprotein (LDL) cholesterol, HDL cholesterol, and triglycerides Strong risk factor for adult CVD Children with elevated cholesterol levels continue to have elevated cholesterol into adulthood Treating childhood dyslipidemia may help prevent or reduce the risk of adult CVD and reduce the atherosclerotic burden later in life Dyslipidemia is largely asymptomatic in childhood

91. Previous recommendation: Screening based only on family history of early CVD Missed 30-60% of children with dyslipidemias New recommendation (2011): Universal screening Non-fasting non-HDL cholesterol Children 9 to 11 years old (prior to onset of puberty) and again at 17 to 21 years If non-HDL 145 mg/dL, obtain fasting lipid panel

92. Targeted screening with two fasting lipid profiles at ages 2 to 8 years old and 12 to 16 years old for patients with risk factors for hyperlipidemia: 1. Patient with moderate-high risk medical condition Kawasaki with current or regressed aneurysm, CKD/ESRD, post renal or orthotoptic heart transplant, nephrotic syndrome, HIV, SLE, JRA 2. Patient with diabetes, HTN, BMI 95 th %, smoker 3. Family history of early CVD Parent/grandparent: age <55 for males, age <65 for females MI, sudden death, coronary artery disease, PVD, stroke Parent with total cholesterol 240mg/dL or known dyslipidemia