August 23rd, 2012
What topic should we do for next month’s board
review?
A. Genetics
B. Development
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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

Children > 3 yrs old: screened at every health
care encounter

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 child’s 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

Normal range of blood pressure is based on sex,
age, and height

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
20th century
In the 1970’s close to 90% of children had blood
lead levels (BLLs) greater than 10mcg/dL


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
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 dad’s 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

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
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
**Now < 5mcg/dL**
5
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


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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

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
Abdominal colic
Constipation
Growth failure
Hearing loss
Renal disease
Seizures
Encephalopathy
Microcytic anemia
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Depressed T-cell
function
Altered cartilage
mineralization
Osteopenia/decreased
bone growth
Miscarriage, preterm
births
CVD, HTN in adulthood

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


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

Refractive error: focusing problem
 Myopia (nearsightedness)
 Hyperopia (farsightedness)
 Astigmatism

Strabismus: misalignment of the eyes
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“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
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 baby’s 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

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 Function
Age
Visual fixation present
Birth
Fixation well developed
6-9 weeks
Visual following
3 months
Accommodation
4 months
Stereopsis
4 months
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Red reflex
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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)

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
What is the diagnosis?
A.
B.
C.
D.
E.
Left Amblyopia
Right Esotropia
Right Exotropia
Left Esotropia
Left Exotropia
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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
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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

Misalignment that
occurs some of the time
 When synchronization
between the eyes is
broken

Can be detected with
the Cross-Cover test
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 won’t reach the same level
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. It’s 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.
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!
Minimally affected by outer and inner
ear debris; screens for auditory
neuropathy
 Any infant that fails screen = full audiology
evaluation by 3 months!!
 OUR responsibility to make sure it happens.

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
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
couldn’t pay attention for the screen.
D. Central hearing loss

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

Congenital
 Malformations of the external ear
 Abnormal ossicular chain

Acquired
OME: No antibiotics needed;
 Otitis media with effusion is most
observe for 3mo then referral for
common cause
hearing test and possible ENT
referral; sooner referral if
 Fluid in middle ear from altered
developmental delay or hearing loss
Eustachian tube fx
obvious
 Fluid restricts TM mobility
 Cerumen impaction, otitis externa,
foreign body
 Cholesteatoma
You are seeing a newborn with sensorineural hearing
loss on her newborn hearing screen. Mom’s 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.
B.
C.
D.
E.
Congenital cytomegalovirus infection
Alport syndrome
Middle ear effusion
Prenatal rubella exposure
Usher syndrome
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

Leading cause of injury death and
disability in all age groups
 More than 1/3 of children fatally
injured were with drunk drivers

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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
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.
B.
C.
D.
E.
15 years
5 years
8 years
13 years
10 years

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
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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
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Cosmetics and personal care products
Cleaning substances
Analgesics
Cough and cold preparations
Plants
Pharmaceutical products

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

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.
B.
C.
D.
E.
110ºF
120ºF
130ºF
140ºF
150ºF
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**
Water
Temperature
Time to 3rd
degree burn
150°F
2 seconds
140°F
6 seconds
130°F
30 seconds
120°F
5 minutes!
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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

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Preschool children have the motor skills to strike a match or
lighter…but don’t comprehend the danger! Counsel parents.
Use electrical outlet covers in the home to prevent electric
burns.
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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
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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
Your best friend is thinking about getting a swimming pool because the
kids would LOVE it! Which picture represents the best pool layout??
A
C
B
D
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Measures to prevent drowning at home include
 Draining water from bathtubs and buckets
 Securing toilet seats
 Swim with child at arm’s 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!!
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 boatingrelated 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

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
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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
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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
What is the # 1 cause of mortality for children
younger than 1 year of age?
A.
B.
C.
D.
E.
Motor vehicle accidents
Falls
Suffocation
Drowning
Fires/burns

#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

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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

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!

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 
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.
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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.
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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
 Child’s ears below the seat
back and shoulders below
the seat strap slots


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



Weight or height
above the forwardfacing 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

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
13 years old
Back seat safest until 16yrs!
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


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


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



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

“Screen time” includes TV, video games, computer, etc.
 Limited to 2 hours per day for all children
 NO televisions in child’s bedroom
 Parents should also be made aware of link with obesity and
decreased academic performance

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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.



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)

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)

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 haven’t shown any immediate
benefit

Proper tick removal
 Within 24-72 hours
 Fine mosquito tweezers close to skin
surface
 Pull upward with steady, even pressure
 Don’t twist or jerk the tick
 Clean area and your hands after removal
 NO “painting” or heating tick for removal

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


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



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

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


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



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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

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

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 ≥ 95th %, 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