2. A mother brings her one year old male child to clinic for a well child exam and reports that she is unable to fully retract her son’s foreskin. What action is required? Reassurance Full reduction of foreskin in the office Urology referral

4.  Reassure  At birth 4% of the foreskin is retractable  At 6 months 15%  1 year 50%  3 years 80%  6 years 90%

5.  Define phimosis, paraphimosis, balanitis and posthitis

10.  Phimosis refers to the inability to retract the foreskin.  Paraphimosis occurs when retracted foreskin acts as a tourniquet in the midshaft of the penis.  Balanitis is inflammation of the glans.  Posthitis is inflammation of the foreskin.

11.  In the newborn nursery you notice that a female baby has 2 hymenal skin tags.  What advice will you give the parents?

13.  Hymenal skin tag is smooth pink tissue projecting up to ½ inch  Occurs in 10% of newborn girls  Slowly resolves over course of 2-4 weeks

14.  At the 2 month well baby visit a mother reports that her son has frequent erections, “what causes this”?

15.  Frequently caused by full bladder

16.  How long after exposure to chicken pox can a child expect to come down with the disease?

18.  Lesions will appear 14-16 days after exposure  Average child gets 500 sores  Usually takes 6-7 days for lesions to crust  2 nd person in same household usually has more lesions than the first person exposed

19.  When can a child diagnosed with: a) Influenza; b) Mononucleosis; c) Roseola; d) Scarlet fever e) UTI; return to school?

20.  Influenza › Incubation period is 24-36 hours › May return to school after fever resolves  Mononucleosis › Incubation period is 4-7 weeks › Most contagious while febrile › Carried in the saliva for 6 months  Roseola › Incubation period is 12 days › Human herpes virus #6 › Will see high fever 2-4 days after exposure › Fever followed in 24 hours by pink macular rash › Contagious while rash is present, 1-2 days › May return to school when rash resolves

21.  Scarlet fever › Group A beta strep infection › Must stay home at least 24 hours after initiation of antibiotic therapy  UTI › Must stay home at least 24 hours after antibiotic therapy is initiated

22.  What are the “5 red rashes”?

28. 1. Scarlet fever 2. Measles 3. Rubella 4. Roseola 5. Erythema Infectiosum

29.  After exposure to erythema infectiosum, when will symptoms appear and how long will a child be contagious?

30.  Human Parvovirus B-19  Incubation period 10-14 days  Initial pink/red rash on cheeks lasting 1-3 days  Followed by reticular rash on extremities lasting 1-3 weeks  Contagious one week prior to initial rash  Absence of fever or low grade fever (< 101)  May see rhinorhea, pharyngitis, anemia

31.  Parents notice that their 1 month old girl is losing her hair daily. Is this normal? What advice do you give?

32.  Shedding of hair in first month of life is normal  Permanent hair will usually appear by 6 months

33.  At the 2 month visit a mother reports that her baby’s hips are tight. Her other son now 2 years of age was much more flexible. Upon physical exam you are able to rotate the legs outward approximately 60 degrees. You decide to: › Refer to Ortho › Order an ultrasound › Reassure the parents

34.  Reassure the parents  Less than 50% of newborns are able to have 90 degree outward spread (frog leg position)  Greater than 60 degrees is normal as long as it’s symmetrical

35.  Parents call your office concerned that their 1 week old has firm thickened lumps of skin on both cheeks. You recall that this child was a forceps delivery and discharged home as a healthy baby after 36 hours. What advice do you give the parents?

37.  Fat necrosis secondary to birth trauma  May see bruising on day 1-2 of life but fat tissue injury isn’t usually apparent until day 5-10 of life  Usually resolves in 3-4 weeks

38.  At the prenatal visit parents ask when it would be appropriate to take their healthy newborn: a) Outside b) On a camping trip c) On an airplane

39.  Newborns can go outside at any time  Avoid close contact with groups of people for the first month of life  Limit sun exposure to 10 to 15 minutes at a time  Best sun exposure protection is clothing first then very limited amounts of sunscreen usually better used after 6 months of life

40.  In what order will baby teeth erupt?

41. 1. Two lower incisors 2. Four upper incisors 3. Four first molars and two lower incisors 4. Four canines 5. Four second molars

42.  What is the difference between breast feeding jaundice and breast milk jaundice?

43.  Breast feeding jaundice occurs in 5-10% of babies secondary to insufficient intake of fluid and calories. Treatment is to increase frequency of feeds to every 1 ½ to 2 ½ hours and no more than 4 hours without a feed at night.  Breast milk jaundice occurs in 1-2% of babies due to an enzyme in the milk that increases the resorption of bilirubin from the gut. Starts by day 4-7 and may last 3 to 10 weeks. Treat by increasing the feeds. If bilirubin doesn’t decrease may have to supplement with formula and alternate with breast milk for 2 to 3 days.

44.  Can teething cause low grade fever, sleep problems and/or diarrhea?

45. NO

46.  Are sponge baths an effective means of reducing fever?

47.  Not necessary for fevers less than 104 and responsive to Tylenol or Ibuprofen.  May be useful for fevers greater than 104 and unresponsive to antipyretics  Recommended for emergencies like heat stroke, febrile seizures or any fever greater than 106.  Use warm water at 85-90 degrees  Don’t use alcohol due to absorption through skin or inhalation

48.  Are there any exceptions to the preferred supine sleeping position for newborns?

49.  Premature babies on oxygen and/or with apnea; most can sleep on their backs by the time they go home.  Babies with congenital anomalies involving the upper airways like a large tongue, a small mouth or floppy larynx  Infants with complications from GERD like recurrent pneumonia from aspiration, apnea and frequent choking spells.

50.  Give rehydration advice to the mother of a 9 month old with watery diarrhea.

51.  Oral rehydration solution (Pedialyte) for the first 6-24 hours.  After 24 hours may use full strength formula  If diarrhea still present after 3 days may consider using a partially hydrolyzed formula like progestimel for a few days

52.  How do you remove a tick?

54.  Grasp the tick as close to the skin as possible using tweezers.  Apply constant upward traction until the tick releases its grasp  Don’t twist or jerk as it might cause the tick to regurgitate in the skin or might cause the head to break off.  Smothering with Vaseline or alcohol won’t work because ticks only breath once every few hours

55.  When can a child’s ears be pierced?

56.  Ideally parents should wait until the child is approximately 8 years old so that they can play an active role in the decision  Not recommended that you pierce before 4 years of age or until the child is old enough to know not to fidget with the earring, or take it out and swallow it.

57.  You have diagnosed a chemical urethritis in an eight year old female. Describe treatment and prevention strategy.

58.  Soak bottom in warm water with 4 tablespoons of baking soda for 20 minutes  Repeat this every 4 hours while awake  This removes any residual soap, concentrated urine or other irritants in the genital area  Pain usually clears in 12 to 24 hours  Thereafter, recommend only clear water for cleansing genitals

59.  What’s the difference between Miliaria and Milia?

62.  Milia › Tiny white papules on mainly nose and cheeks › Caused by blocked pores › Resolves in 1 to 2 months › No creams or ointments necessary  Miliaria › Pink papules caused by blocked sweat glands › Also known as heat rash › Treat with cool baths › May use 1% Hydrocortisone cream if papules itch

63.  Give advice to a Mom whose 3 year old was stung by a ‘big ole Bumble Bee’.

66.  Watch for signs of allergic reaction › Respiratory symptoms › Edema › Hives  If visible remove stinger by brushing over skin with a credit card or something similar, otherwise don’t worry about removal  Gently rub site for 20 minutes with a cotton ball soaked in meat tenderizer or aluminum based deodorant. Ice may also relieve pain but apply for 10 minutes.

67.  Parents report seeing nits on their child’s eyelashes. How do you advise the parents? How long will lice live off of the human body?

69.  Apply petroleum jelly to eyelashes twice a day for 8 days  Wash all combs and clothes  Check the head for lice  Lice can live for 72 hours off the human body  Nits can survive for 3 weeks

70.  A parent asks: “how do I deal with my sleepwalking child?”

71.  Gently lead child back to bed, don’t expect child to wake up  Protect from accidents by using safety locks, gates. No bunk beds  Avoid exhaustion as sleepwalking increases in fatigue states  Move bedtime up 15 minutes each night until child self-wakes in am.  Try prompted awakenings to prevent sleepwalking › Observe episodes for few days to understand timing of event › Wake child up 15 minutes prior to expected episode › Keep child awake for 5 minutes › Do this for 7 days  This is an inherited tendency in approximately 15% of kids ages 4- 15.  Usually occurs within 2 hours of bedtime and lasts for 5-20 minutes.

72.  What are night terrors?

73.  Characterized by screaming, crying spells lasting 10 to 30 minutes.  Child has no memory of event  Begins 1-2 hours after sleep  Occurs in 2% of children between ages 1 and 8  Prevention › Wake child up 15 minutes before expected event › Make child wake up quickly and keep them awake for 5 minutes › Do this for 8 days

74.  Permanent iris color will present by what age?

76.  Children who will ultimately have dark colored irises will change by 2 months of age  Children who will ultimately have light colored eyes will change by 6 months

77.  A mom calls you on Sunday night and reports that her 5 year old with a history of intermittent constipation is complaining of rectal pain. What do you advise?

78.  To provide quick relief have child sit in a warm bath. This will relax the anal sphincter  Have parent give a glycerin suppository to stimulate defecation  Gentle rectal stimulation for 10 seconds using a thermometer or with a lubricated finger covered in plastic wrap will also stimulate stooling

79.  Describe breath holding spells and what can be done during an attack

81.  Usually occurs between ages of 6 months to 2 years, typically preceded by an upsetting event  Characterized by 1 to 2 long cries and then child holds breath upon expiration until lips become bluish. 5% will hold breath until they faint  Usually lasts for 1 minute or less  May occur daily but typically 1-2 times per month  Can not be prevented  Treat by having child lay down flat with cool compresses to head