Transcript Case # 2

th
8
The
Annual Metropolitan
New York/New Jersey
Pediatric Board Review Course
General Pediatrics
Andrew D. Racine, M.D., Ph.D.
North Shore University Hospital
Sunday, May 18, 2014
Outline
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Screening
Immunizations
Breastfeeding and nutrition
Anticipatory Guidance
Psycho-social issues
Ethics and Professionalism in primary care
Patient Safety and Quality Improvement
Screening
Case #1
A 9 month old female is brought to your office for
her regular health care maintenance visit. The
components of developmental surveillance that
you perform include all the following except:
A. Eliciting and attending to parental concerns
B. Obtaining relevant developmental history
C. Administering a validated instrument to identify
developmental delays
D. Accurately observing the child/parent
interaction in the examination room
Surveillance
• Surveillance is, “… a flexible continuous process
whereby knowledgeable professionals perform
skilled observations of children during the
performance of health care.”
• It includes attending to parental concerns,
obtaining a history, making accurate and
informed observations, and sharing opinions and
concerns with other relevant professionals.
• It does not involve the application of validated
tools – that is the definition of screening.
Source: AAP Committee on Children with Disabilities, Pediatrics; 2001
Screening
Appropriate criteria for a useful screening tool
include all of the following except:
A. It is valid, i.e. it is sensitive and specific
B. It is reliable
C. It is inexpensive to administer
D. The condition being screened for is prevalent
E. The tool is acceptable to screened subjects
F. There are effective interventions available for
conditions identified by the tool
Screening
• Screening tools should be valid and reliable
meaning that they accurately identify the
condition of interest and that in repeated
applications they give the same result. The tools
should be inexpensive to administer in times of
time and other costs, they should be acceptable to
patients and the conditions identified should be
amenable to intervention.
• We screen for rare as well as prevalent conditions
You and your colleagues are thinking of adding routine
developmental screening to you office practice. In
looking into this possibility you have discovered that:
A. Developmental surveillance should occur at the 9,
B.
C.
D.
E.
18, and 30 month visits.
The goal of developmental screening is to arrive at
a diagnosis and a treatment plan.
The diagnosis of a specific developmental disorder
is necessary to make an EI referral.
Sensitivity and specificity rates of 70%-80% are
acceptable for developmental screening tests.
Subsequent screening is not necessary after a child
passes two screening tests.
Screening
The correct answer is D sensitivity and specificity rates
of 70%-80% are acceptable for developmental
screening tests.
A variety of screening tools with different psychometric
properties are available for screening purposes but,
in general, they have lower sensitivity and specificity
than medical screening tests because of the
underlying variability of the construct being
measured and the absence of specific curative
treatments for some conditions.
Screening
The American Academy of Pediatrics, in its 2006
policy statement on Identifying Infants and
Young Children With Developmental Disorders
recommends surveillance at every preventive
care visit and the use of a standardized tool to
screen low risk children at the 9, 18, and/or 30
month visits.
Screening
• Early Intervention services are valuable for
children identified at high risk. They can
provide evaluation services, developmental
therapies, service coordination, transportation
support, etc.
• The diagnosis of a specific developmental
disorder is not necessary to refer a child
deemed at risk to receive EI services.
Summary
• Surveillance is the process of recognizing
children who may be at risk for developmental
delays and should take place at every well child
visit;
• Screening is the use of a standardized tool to
identify and refine the recognized risk;
• Evaluation is a complex problem to identify a
specific developmental disorder in a child.
Update on Immunizations
A 12 year old girl presents to your office for a regular checkup for
school entry in September. She is a recent immigrant from
Mexico. Her mother states that she does not have an
immunization record. She denies any significant past medical
history. There is no history of allergies. Physical exam reveals no
abnormalities.
Which immunizations would you give at this time?
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Td, IPV, MMR, Varicella, Hep
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Td, IPV, MMR, Varicella, Hep
B, MPSV4, Influenza
Td, IPV, MMR, Varicella, Hep
B, Hep A, HPV
Tdap, IPV, MMR, Varicella,
Hep B, MPSV4
Tdap, IPV, MMR, Varicella,
Hep B, MCV4, Hep A, HPV,
Influenza
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The correct answer is 5
1. Td, IPV, MMR, Varicella, Hep B, MCV4
2. Td, IPV, MMR, Varicella, Hep B, MPSV4,
Influenza
3. Td, IPV, MMR, Varicella, Hep B, Hep A, HPV
4. Tdap, IPV, MMR, Varicella, Hep B, MPSV4
5. Tdap, IPV, MMR, Varicella, Hep B, MCV4,
Hep A, HPV, Influenza
Recommended Immunization Schedule, 2014
Pertussis Vaccine (Tdap)
Two tetanus toxoid, reduced diphtheria toxoid and acellular
pertussis vaccines are approved by the FDA for:
• Adolescents aged 11-18 years who completed their primary
series of DTP/DTaP and have not received a Td booster dose
• Adolescents who have not received DTP/DTaP/Td/Tdap
vaccination (or have no documentation)
• For wound management in adolescents who have not
received Tdap before
• Children 7-10 with undocumented immunization status
Before you give the Tdap vaccine to the patient you ask
your attending what is a true contraindication for the
vaccine. Your attending responds that:
1.
2.
3.
4.
5.
Temperature greater than
105 F within 48 hours of a
previous DTP/DTaP
Collapse or shock like state
within 48 hours of a
previous DTP/DTaP
History of encephalopathy
within 7 days of previous
DTP/DTaP
Latex Allergy
Pregnancy
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Contraindications of Tdap
• Anaphylaxis to any components of the vaccine
• History of encephalopathy (coma or prolonged
seizure) within 7 days of administration of a
pertussis vaccine that cannot be attributed to
a different cause
Precautions of Tdap
• History of an Arthus-type reaction following a
previous dose of tetanus- or diphtheria-containing
vaccine
• Progressive neurological disorder, uncontrolled
epilepsy, or progressive encephalopathy
• History of Guillain-Barre syndrome (GBS) within 6
weeks after a previous dose of tetanus toxoidcontaining vaccine
• Moderate or severe acute illness
Not Contraindications
• Temperature > 105F within 48 hrs of DTP/DTaP
• Collapse or shock-like state within 48 hrs of
DTP/DTaP
• Persistent crying for 3 hrs or longer within 48 hrs of
DTP/DTaP
• Convulsions with or without fever within 3 days of
DTP/DTaP
• History of entire or extensive limb swelling after
DTP/DTaP/Td
• Stable neurological disorder
Not Contraindications
• Brachial neuritis
• Latex allergy other than anaphylaxis-BOOSTRIX
single dose and ADACEL are latex free
• Pregnancy and breastfeeding
• Immunosuppression
• Intercurrent minor illness
• Antibiotic use
Meningococcal Vaccine (MCV4)
•
•
•
•
•
Introduced in 2005 the
meningococcal conjugate
vaccine is recommended in
Adolescents 11-12 years
Unvaccinated adolescents
at school entry
College freshmen living in
dormitories
Certain high risk groups
Booster dose
recommended at age 16 (as
of January, 2011)
FIGURE. Annual incidence of meningococcal disease by
age , United States, 1999-2008
MCV4
Side effects include:
Erythema, swelling and induration
Guillain-Barre – 17 reported cases from March
2005 – September 2006. GBS incidence
estimated at 0.20 per 100,000 person months
after vaccine compared to 0.11 per 100,000
person months among 11-19 year olds
generally.
Source: MMWR, 55(41):1120-24, October 2006
Human Papillomavirus
• The most common sexually transmitted infection in
the United States (6.2 million new cases annually).
• 20 million infected Americans – half are teens or
young adults 15-24.
• HPVs are non-enveloped double stranded DNA
viruses of over 100 types including several
(16,18,31,33,35, and others) detected in 99% of
cervical cancer cases.
• Risk of HPV associated with number of sexual
partners, partner sexual behavior, and immune
status.
Human Papillomavirus
• Most infections are transient, asymptomatic
and clear within 1-2 years
• Of the 6.2 million new cases per year, about
74% occur in women 15-24
• Acquisition occurs soon after sexual debut
• Prevalence of HPV 16 may be as high as 40%
• Consistent condom use may help prevent
acquisition
Human Papillomavirus Vaccine
Two HPV vaccines have been licensed by the FDA
for use in girls:
• A quadrivalent vaccine was approved in June
2006 (HPV4, Gardasil, Merke and Co.), and
• A bivalent vaccine was approved in 2009 (HPV2,
Cervarix, GlaxoSmithKlein).
As of 2011, the quadrivalent vaccine is now
recommended for boys as well
HPV Vaccine
• Quadrivalent HPV vaccine (Gardasil®) targets HPV types
6, 11, 16 and 18
• Bivalent HPV vaccine (Cervarix®) targets HPV 16 and 18.
• HPV types 16 and 18 cause approximately 70% of
cervical cancers and types 6 and 11 cause approximately
90% of genital warts
• Both vaccines are administered in 3 doses with 2nd and
3rd doses given 2 and 6 months after the first dose
• Combined protocols indicate an efficacy of 98-100% in
the prevention of CIN 2/3, AIS or genital warts caused by
HPV 6, 11, 16 and 18.
Case # 2
In December of last year a mother comes into
your office with her 4 month old infant
daughter who is due for her health care
maintenance visit. She brings along her 3 year
old son as well. He has not yet received his flu
vaccine for this year but did receive it last
year. You advise this mother that:
Influenza Vaccine
A. Both children should receive seasonal flu vaccines;
B. Neither child should receive seasonal flu vaccine;
C. The three year old should receive seasonal flu
vaccine but the four month old should not;
D. The 4 month old infant should receive seasonal flu
vaccine but if the three year old gets a rash from
eggs he should not receive it this year;
E. The three year old needs two doses of the seasonal
flu vaccine because he is less than 9 years old.
Influenza Vaccine
• Influenza vaccine risk factors now include children with compromised
respiratory function or children that have an increased risk of
aspiration.
• ACIP recommends immunizing all children 6 months to 18 years of
age. Previously unvaccinated children 6 months to 8 years of age
should receive 2 doses of this vaccine.
• Available as Trivalent inactivated vaccine (IIV3), Quadrivalent
inactivated vaccine (IIV4), Recombinant Trivalent vaccine (RIV3), or
Live Attenuated Quadrivalent Influenza Vaccine (LAIV4)
• Those with reported egg allergy may receive the vaccine unless they
have had severe reactions (anaphylaxis)
Source: ACIP, 2013 http://www.cdc.gov/flu/professionals/acip/2013-interim-recommendations.htm
Breastfeeding
Case # 1
A female infant presents for her two week
check-up. She was born after a 38 week
uncomplicated pregnancy via spontaneous
vaginal delivery at a birth weight of 3 kg. Her
mother is breastfeeding and asks whether
breast milk alone is sufficient for her baby.
What advice should you give her?
True or False?
1. The baby should receive oral iron supplements
for the first 6 months of life.
2. The baby does not need vitamin K after birth
so long as the mother is taking oral Vitamin K.
3. Starting shortly after birth, the baby will need
400 IU of vitamin D daily while she is
exclusively breastfed.
True or False?
1. The baby should receive oral iron supplements
for the first 6 months of life.
2. The baby does not need vitamin K after birth
so long as the mother is taking oral Vitamin K.
3. Starting shortly after birth, the baby will need
400 IU of vitamin D daily while she is
exclusively breastfed.
Question # 1
False
Iron
• Iron stores at birth are proportional to birth
weight or size.
• Iron stores for term infants are sufficient to
meet needs for the first 4-6 months of life.
• Breast milk contains <0.1 mg/100cc of iron
but it is in a highly bio-available form (50%
of it is absorbed compared to 4% of iron in
iron-fortified formulas).
• Infants’ adequate intake of iron is
approximately 0.27 mg/day for the first 4-6
months of life.
True or False?
1. The baby should receive oral iron supplements for the
first 6 months of life.
2. The baby does not need vitamin K after birth so long
as the mother is taking oral Vitamin K.
3. Starting shortly after birth, the baby will need 400 IU
of vitamin D daily while she is exclusively breastfed.
Question # 2
False
Vitamin K
Vitamin K is a fat soluble vitamin necessary for the
posttranslational carboxylation of glutamic acid
residues of coagulation proteins Factors II, VII, IX and
X.
lpi.oregonstate.edu/infocenter/vitamins/vitamink/kcycle.html
Vitamin K
• Breast milk has inadequate amounts of
Vitamin K to satisfy infant requirements.
• All breastfed infants should receive 0.5 - 1.0
mg of Vitamin K IM after the first feeding
and within the first 6 hrs of life.
• Oral Vitamin K may not provide the stores
necessary to prevent hemorrhage in later
infancy and is not recommended at this
time.
True or False?
1. The baby should receive oral iron supplements
for the first 6 months of life.
2. The baby does not need vitamin K after birth
so long as the mother is taking oral Vitamin K.
3. Starting shortly after birth, the baby will need
400 IU of vitamin D daily while she is
exclusively breastfed.
Question # 3
True
Vitamin D
• Vitamin D (calciferol) is available from certain
dietary sources and can be synthesized in skin
upon exposure to UV light.
• Adequate intake of vitamin D for infants is 400
IU per day as per recent AAP guidelines
(2008).
• Vitamin D content of human milk is low (22
IU/L).
Vitamin D
• Breastfed infants should receive supplements
of 400 IU of vitamin D per day so long as the
daily consumption of vitamin D-fortified
formula or milk is below 1,000 ml.
• The recommended routine use of sunscreen in
infancy decreases vitamin D production in
skin.
Case # 1 (cont’d)
On further review of the mother’s history you
discover that she is CMV positive, is taking
anti-hypertensive medications, and has
resumed her half-pack per day cigarette
consumption since the baby was delivered.
When asked whether any of these factors
present a problem for her continuing to
breastfeed, what should you advise her?
Breastfeeding and viruses
Viruses can be transmitted into human milk but
only the presence of certain viruses in the
mother are contraindications to breastfeeding
in the United States. These include:
HIV-1, HIV-2, HTLV-1, HTLV-2 and HSV if there are
lesions present on the nipple.
Hepatitis B, Hepatitis C, CMV, and rubella are not
contraindications for breastfeeding.
Breastfeeding and medications
Like viruses almost all medications taken by the
mother are excreted into breast milk but only a
very few are contraindications to breastfeeding.
These include:
Radioisotopes, anti-metabolites or
immunosuppressive agents, lithium,
chloramphenicol, iodides, bromocriptine, and
ergot alkaloids.
Breastfeeding and smoking
Tobacco is not a contraindication to
breastfeeding but nursing mothers should be
advised not to smoke in the vicinity of the
newborn and should be sensitively counseled
to seriously consider abandoning this filthy,
expensive, debilitating habit.
Nutrition
Current recommendations are to delay the
introduction of cow’s milk until 12 months of age.
The rationale for this recommendation includes all
of the following except:
Cow milk has a higher renal solute load delivered
to the kidney than human milk;
B. The iron content of cow milk is inadequate to
prevent iron deficiency;
C. Cow milk induces gastroesophageal reflux;
D. Cow milk may cause increased fecal blood loss in
some infants;
E. The caloric content of cow milk is sufficient for
infant growth by 12 months of age.
A.
Nutrition
The correct answer is C. Cow milk does not
induce GE reflux. It only contains 0.5mg/L of
iron of which 10% is absorbed making it
insufficient to prevent iron deficiency. It can
induce fecal blood loss in some infants and it
has higher concentrations of sodium and
potassium than human milk or formula. It’s
caloric content is sufficient for growth at 1
year.
You are rounding in the newborn nursery with a group
of residents. In describing the choices of infant
nutrition that might optimize growth and development
you are MOST likely to tell them:
A. Preterm and term infants generally require
between 100-120 kcal/kg/day of energy to grow;
B. Preterm infants generally require less caloric intake
per kilogram to grow than do term infants;
C. Term infants generally require between 60-80
kcal/kg/day to grow;
D. Term infants generally require between 30-50
mL/kg/day of fluid intake;
E. Term infants with BW > 2,500 gms require more
energy per kilogram to grow than those infants
with BW less than 2,500 gm.
Nutrition
The correct answer is A, preterm and term
infants require 100-120 kcal/kg/day to grow.
Determinants of energy requirements for
infants include gestational age, illness, a history
of surgery or wound healing, local environment
and other factors.
Your are seeing a 10 year old girl in your office who
comes in for health care maintenance. On exam she is
noted to have a BMI of 28 putting her over the 95%ile
for her age in girls. You recall that BMI, as a measure of
adiposity has been shown to be associated with all of
the following except:
A. Socio-economic status
B. Gender
C. Birthweight
D. Race
E. Pubertal status
Nutrition
• The correct answer is C. A distinct socioeconomic gradient in obesity has been
demonstrated in national data sets as have
differences by race and ethnicity. Girls have
higher rates of obesity than do boys and
obesity increases with the onset of puberty.
Birthweight per se is not highly correlated
with later measures of adiposity (although
SGA babies may be at greater risk).
Nutrition
After leaving the exam room with your medical
student, a discussion about trends in obesity
takes place. You point out to your trainee
that, with respect to the epidemiology of
obesity all of the following statements are
true except:
Nutrition
A. The prevalence of obesity and overweight has doubled
B.
C.
D.
E.
in the U.S. in the past 20 years;
Each extra hour per day of TV watching among 12-17
year olds increases the prevalence of obesity by 2%;
The concordance rate of obesity among monozygotic
twins is between 0.7 and 0.9;
The increase in obesity has occurred despite the fact
that the majority of school-aged children still report 4
hours of vigorous activity per week;
By 19–24 months of age, French fries are the most
commonly consumed vegetable in the U.S.
Nutrition
• The correct answer is D. Obesity rates have
doubled in the past 2 decades. One extra
hour of TV watching does is associated with an
increase in the prevalence of obesity by 2%.
Obesity is highly heritable and French fries are
the most commonly eaten vegetable by 19-24
months. School children average less than 2
hours of vigorous exercise per week according
to national data.
Anticipatory Guidance
“There are things that’ll knock you
down you don’t even see coming”
Injury Prevention
A 6 month old boy is at your office with his
father for a routine health care maintenance
visit. In discussing injury prevention for his
infant, the father wants to know what he
should be most concerned about with respect
to his infant’s safety. What should you tell
him?
Leading Causes of Death by
Age Group 2009
1
2
3
< 1 yr
1-4 yrs
5-9 yrs
10-14 yrs
Congenital
Anomalies
5,319
Short
Gestation
4,538
SIDS
2,030
Unintentional
Injury
1,466
Congenital
Anomalies
464
Homicide
376
Unintentional
Injury
773
Malignant
Neoplasms
477
Congenital
anomalies
195
Unintentional
Injury
916
Malignant
Neoplasms
419
Suicide
259
National Vital Statistics Reports, 61, October 2012
Leading Causes of Injury Deaths
by Age Group 2009
100%
80%
Other
Firearms
Burn
Drown
Motor Veh
60%
40%
20%
0%
1-4 Years
5-9 Years
10-14 Yrs
Deaths Due to Injury
in Childhood
• SIDS is the leading preventable cause of death in
children less than 1 year of age.
• Unintentional injury is the leading cause of death
in children from 1 to 15 years of age.
• Motor vehicle incidents, drowning and deaths
from burns taken together account for over 75%
of all deaths from injury in children between 1
and 15 years of age.
Water Safety
The father of a 4 year old boy asks you about
keeping the child safe from injury around the
family pool. When counseling him about the
epidemiology of childhood drowning, a TRUE
statement is:
A. Drowning is the leading cause of
death due to injury
B. For every one drowning victim there
are 5 near drownings
C. Pool alarms have eliminated the need
for fencing
D. Residential pools are the most
common drowning sites
E. The ratio of male-to-female drowning
deaths is 1:1
Water Safety
Residential pools are the most common site of
drowning for children younger than 5. Infants
drown in bathtubs most often and adolescents
in fresh water lakes and rivers.
Drowning is the 2nd leading cause of death in
this age group (remember earlier) with peak
incidence in the summer months and highest
rates in the west and the south.
Water Safety
Four sided fences 5 ft high with self-closing self-locking
gates are the most effective enclosures for residential
pools.
Pool alarms, pool covers, swimming lessons for young
children and floatation devices are not as effective as
proper enclosures in preventing drowning deaths.
Male to female ratio is 3:1 and 50% of submersion
victims are declared dead at the site (drowning to
near drowning ratio of 1:1).
Fire
A 4 year old rescued from a house fire is brought
in by paramedics having been found
unconscious at the scene. She is difficult to
arouse, in no respiratory distress with clear
breath sounds, no external burns but soot
around her nares. Her temperature is 37.0° C,
HR 130 bpm, RR 24 and oxygen saturation
97% on 100% O2 administered via nonrebreather.
The MOST likely cause of her depressed mental
status is:
Fire
A.
B.
C.
D.
E.
Acute respiratory distress syndrome
Airway edema
Carbon monoxide exposure
Methemoglobinemia
shock
Fire
The correct answer is C suggested by her altered
level of consciousness. She is tachycardic but
without evidence of respiratory embarrassment
or impaired perfusion ARDS, airway edema or
shock are unlikely. Methemoglobinemia can be
congenital or acquired (from exposure to certain
drugs, foods, or chemicals) and usually presents
with cyanosis and respiratory distress in
children.
Fire
Carbon monoxide poisoning is common causing
over 500 fatalities in the U.S. each year. It initially
causes nausea, fatigue, confusion, and headache
but the tissue hypoxia resulting from impaired O2
transport can lead to somnolence, seizures,
myocardia depression, dysrhythmias and death.
Pulse oximetry cannot distinguish
carboxyhemoglobin from oxyhemoglobin and is
therefore an unreliable test.
Anticipatory Guidance:
Development
A six month old breast fed male infant is at your office
for a well child check-up. He has been previously well
and on exam babbles, reaches for your stethoscope and
pulls to a sitting position without head lag. He can also:
A.
B.
C.
D.
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Finger feed himself
Imitate sounds
Pull to stand
Transfer objects from
one hand to the other
E. Use a scissors grasp to
obtain a piece of
cereal
Development
Correct answer is 4, transfer objects.
As part of his normal development this infant probably
began to hold a rattle briefly at 2 months, reached for
objects and and lifted himself onto extended elbows at
4 months. He probably also began to roll over at 4
months and could roll both ways by 6 months. He
likely began to coo at 2 months, to laugh out loud at 4
months, and to begin to babble at 6 months. Pulling
to stand usually begins around 8 months. Finger
feeding and imitating sounds usually starts at 9
months.
A young boy arrives for a health supervision visit. His
mother reports that he says “mama,” “dada,” “bye,”
“up,” and “ball.” While playing on the floor he points to
a toy truck on the shelf. His mother asks him to bring
her the truck which he does. These developmental
milestones suggest the child is CLOSEST to:
of
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21
12 months of age
15 months of age
18 months of age
21 months of age
24 months of age
12
A.
B.
C.
D.
E.
Development
The correct answer is B. 15 months of age.
At this age infants generally have a vocabulary of about 6
words, can follow simple commands, point to parts of
their bodies and use gestures and jargon to express
themselves. 18 month olds have a vocabulary of about
10-15 words and 21 month olds know 30 to 50 words.
Two year olds are beginning to put two word phrases
together and generally know about 100 words. They
can follow complex commands.
Development
Familiarity with expected language milestones is important
for the calculation of the language developmental
quotient according the formula:
LQ = language age/chronological age X 100
A child with an LQ of less than 70 should be referred for
further evaluation.
Psycho-social Issues
Case #1
You are seeing a set of parents with their 8 year
old boy for a health care maintenance visit.
The mother asks you whether allowing her
son to watch TV when he comes home from
school is a bad idea.
The MOST accurate statement you can make to
her about the influence of television viewing
on children is:
Media
A. Most adolescents have difficulty discriminating
between what they see on TV and what is real.
B. Nearly 2/3 of all programming includes
violence and children’s programming contains
the most violence.
C. 50% of 2-7 year olds have a TV in their room.
D. A majority of parents report that they always
watch TV with their children to monitor the
content of what is seen.
Media
Although young children and adolescents are vulnerable
to the messages conveyed on television, it is
predominantly younger children who cannot
discriminate between what is real and what they see
on TV. In a random survey of parents with children
from kindergarten through 6th grade published in
1996, 37% reported that their child had been
frightened or upset by a TV program seen during the
preceding year.
Cantor J, Nathanson AI. Children’s fright reactions to television news. J Commun. 1996;46: 139-152.
Media
About one third of parents of 2-7 year olds
report that their children have a television in
their room.
Less than half of all parents state that they
always watch television with their children to
monitor the content of what is being seen.
Media
A recently completed 3 year National Television
Violence Study reported that:
• Nearly 2/3 of all programming contains
violence;
• Children’s shows contain the most violence;
• Portrayals of violence are usually glamorized;
• Perpetrators of violence often go unpunished.
Federman J. ed. National Television Violence Study Vol 3. Thousand Oaks, CA: Sage; 1998.
The much beloved grandfather of one of the families in your
practice has just died of a heart attack. All five children in the
family are expressing their grief in various ways. Considering the
cognitive and behavioral aspects of the understanding of death,
which of the following correctly matches the age of the child
with their most likely response to their grandfather’s death?
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The 18-month-old feels her
grandfather died because she
was mad at him
B. The 3-year-old wonders if
Grandpa will still be able to
go fishing with him this
summer
C. The 4-year-old worries that
she is going to die soon
D. The 8-year-old asks, “Why not
me?”
E. The 13-year-old develops
separation anxiety
The Correct Answer is B.
A. The 18-month-old feels her grandfather died
because she was mad at him
B. The 3-year-old wonders if Grandpa will still
be able to go fishing with him this summer
C. The 4-year-old worries that she is going to
die soon
D. The 8-year-old asks, “Why not me?”
E. The 13-year-old develops separation anxiety
Coping with Death
• Children less than 2 years of age, in what Piaget
refers to as the sensori-motor stage of
development, have very little concept of death.
They can sense emotional discomfort in those
around them and may withdraw or become
irritable.
• Children between 2 and 6 are in a preoperational
stage of development and may engage in magical
thinking, lacking a sense of the permanence of
death or its causes.
Coping with Death
• Sometime around 6 years of age concrete
operational thinking allows children to develop a
sense of the permanence and irreversibility of
death which leads to morbid fascination with
death, phobias, school avoidance reactions or
separation anxiety.
• It is in adolescence with the formal operational
stage of development and abstract thinking that
the existential implications of death emerge
giving rise to questions like, “Why not me?”
Case #3
Two bleary-eyed yawning parents come to your
office with their smiling two month old infant
girl complaining that the baby ‘never sleeps’.
In counseling them regarding normal sleeping
patterns for infants, you tell them that:
Sleep
A. Most babies can’t distinguish night from day until 4
months of age;
B. In the first 2 – 3 months of life most babies sleep up
to 16 hours per day in 3-4 hour spurts;
C. The best treatment if the baby is not sleeping is to
place her in her crib and let her cry until she falls
asleep;
D. Like adults, 2 month olds cycle through REM and
non-REM sleep every 90 – 110 minutes;
E. Cereal in her bottle may help her sleep at night.
Sleep
• Most babies begin to distinguish day from
night beginning at 2 months of age and by 4
months, many are sleeping through the night.
• Their REM non-REM sleep cycles, however, are
shorter than adults, lasting usually about 50
minutes.
Sleep
• Sleep onset disorders may be forestalled if
young infants and toddlers are put into their
cribs drowsy but awake, providing them the
opportunity to learn how to self-soothe in the
transition to sleep but active “sleep training”
should probably wait until a baby is at least 6
months of age.
• There is no evidence that early introduction of
solid foods hastens good sleep hygiene and
should be avoided.
Ethics and
Professionalism
Ethics
The mother of a 12 year old boy who is doing quite
well in school comes to you to ask for a
prescription for Concerta because she believes
that his use of the medication will enhance his
academic performance and maximize his chances
of being accepted to an elite university.
The decision whether or not to accede to this
mother’s request pits which two ethical
principles against one another?
Ethics
A. Autonomy and beneficence
B. Justice and non-malfeasance
C. Altruism and non-discrimination
Ethics
Autonomy:
The right to make decisions and to act on them
freely - specifically the patient’s right to control
what happens to his or her body. In pediatrics this
right is normally invested in the parent or guardian
as pediatric patients are considered to lack
capacity to make such decisions for themselves.
Ethics
Beneficence:
An obligation to act for the benefit of others
which, in a medical context, obligates the
physician to act in the interest of his or her
patient.
When a mother insists on a treatment for her
child that is not in the child’s best interest, the
principles of autonomy and beneficence come
into conflict with one another.
Ethics
Justice and non-malfeasance
Justice refers to the fair distribution of resources
that is not dependent upon social status, race,
ethnicity, gender or other non-relevant
characteristics.
Non-malfeasance is the primary duty of physicians
to, “Do no harm”. Neither principle is at issue in
this case since Concerta is neither in short supply
nor likely to harm the patient if taken.
Ethics
Altruism and non-discrimination
Altruism refers to the unselfish regard or
devotion to the welfare of others.
Non-discrimination is a duty to treat all
patients equally regardless of social class,
religious background, race, ethnicity, gender,
or other features. This mother’s request does
not invoke either of these ethical elements.
A fifteen year old girl comes to your practice concerned
because she has missed three menstrual periods. A
urine pregnancy test confirms that she is pregnant.
She pleads not to have this information disclosed to her
mother. This patient is making an appeal to which
feature of your professionalism?
A.
B.
C.
D.
E.
Honesty and integrity
Reliability and responsibility
Respect for others
Compassion/empathy
Self-awareness and knowledge of limits
Professionalism
Honesty and integrity refers to the ability to
meet commitments and to be intellectually
honest and straightforward in interactions
with peers and with patients. Withholding
information from this patient’s parents at her
request does not represent an appeal to
honesty and integrity on your part.
Professionalism
Reliability and responsibility represent
accountability to patients, families, colleagues,
medical systems and the society, specifically
the willingness to identify and acknowledge
errors and to discuss consequences and
alternatives with any affected party. The
outcome of this clinical scenario is not the
result of a medical error and does not involve
this professional concept.
Professionalism
Respect for others refers to regard for the
individual worth and dignity of all persons
including sensitivity to gender, race, sexual
orientation and other features as well as the
maintenance of patient confidentiality. Your
patient is making a direct appeal to this aspect
of professional conduct by asking you to
refrain from communicating the results of her
test to her mother at the present time.
Professionalism
Compassion/empathy refers to the ability to
understand a patient’s or family’s pain or
discomfort from their point of view rather
than from the point of view of the
pediatrician. Although one might argue that
your patient is appealing to your empathy on
some level here, the central issue is not her
anxiety so much as the duty to maintain her
confidentiality that is at issue.
Professionalism
Self-awareness and knowledge of limits involves
the maturity to recognize when a clinical
problem involves issues beyond the
knowledge or skills of a particular provider
and the willingness to solicit guidance from
others. There is nothing in this scenario that
could be construed to be beyond the
competence of a primary care pediatrician.
Patient Safety and Quality
Improvement
In developing a culture of safety from a
quality improvement perspective, all of the
following elements are critical except:
• Encouragement of reporting
• Ability to be flexible to changing demands and
circumstances
• Emphasis on individual behavior
• Establishment of a non-punitive environment
• Creation of a culture that learns from its mistakes
Correct Answer is C
A well functioning patient safety approach
recognizes human fallibility as an unavoidable
element in high-risk endeavors and focuses on
systems rather than individuals. It encourages
the reporting of mistakes in a non-punitive
environment , maintains an ability to be
flexible and to change with emerging
circumstances by creating a self-sustaining
culture that actively learns from its mistakes.
I think we’re done