Transcript PPT

Intensive Family Medicine Board
Review. PCOM Med net
February 25 2017
Pediatrics
Christine Black-Langenau, DO
Osteopathic Residency Program Director, Byrn Mawr
Hospital
Case 1. Newborn
4-day-old 39 wks. 7lbs 2oz
newborn. NSVD
without complications.
Breastfeeding every 2
hours. Discharged from
nursery day 2. (TcB=8.6
at that time) Follow up
in office at 4 days of life,
appears jaundiced.
Case 1. Newborn
What would be the best
next step for this
jaundiced 4 day old?
a) Stop breastfeeding and
give formula
b) Admit to hospital for
photo therapy
c) Observe bilirubin was
normal at 48 hours.
No further evaluation
needed
d) Venous bilirubin
measurement ASAP.
Case #1 Newborn with Jaundice
 Answer: d
Case 1. Newborn
 Promote and support successful






breastfeeding
Measure TSB or TcB if
jaundiced in the first 24 hours
Interpret bilirubin levels
according to the infant’s age in
hours
Perform risk assessment prior
to discharge
Give parents written and oral
information .
Provide appropriate follow-up
based on time of discharge and
risk assessment.
Treat newborns, when
indicated, with phototherapy or
exchange transfusion.
Nomo gram for designation of risk in 2840 well newborns at 36 or more weeks’ gestational
age with birth weight of 2000 g or more or 35 or more weeks’ gestational age and birth weight
of 2500 g or more based on the hour-specific serum bilirubin values.
Subcommittee on Hyperbilirubinemia et al. Pediatrics
2004;114:297-316
©2004 by American Academy of Pediatrics
Risk Factors for hyperbilirubinemia




Prematurity
Breastfeeding
Asian ethnicity
Metabolic disorder


Hypothyroidism
Glactosemia
 Maternal Diabetes
 Infection
 UTI
 Sepsis
 Drugs
 Increased Bilirubin
Production



Hemolytic Disease
Birth trauma
Polycythemia
 Impaired Bilirubin
Conjugation


Gilbert
Milk jaundice
 Biliary Obstruction
References



American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management
of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics.
2004;114(1):297-316.
Lauer BJ, Spector ND. Hyperbilirubinemia in the newborn.Pediatr Rev. 2011
Aug;32(8):341-9. doi: 10.1542/pir.32-8-341.
Moerschel,S. Cianiaruso, L. A Practical Approach to Neonatal Jaundice. American
Family Physician. number 9. May 2008. Vol 77,
Case #2
5 day old brought by mother because concerned about
rash. States that she noticed on 3rd day of life.
Looks like chicken pox on face and chest. Baby had
normal pregnancy and nursery stay. Breastfeeding
well and had regained birth weight. No sick contacts.
Case #2
What is the rash on this
newborn?
a) Erythma toxicum
neonatorum
b) Transient neonatal
pustular Melanosis
c) Acne neonatorum
d) Seborrheic Dermatitis
e) Milia
Case #2
 Answer: a
Erythma Toxicum
Most common pustular
eruption (40-70%)
Erythmatous macules 2-3 mm.
Evolve into pustules.
Lesions found on head & face,
trunk and proximal extremities
involved
Surrounding erythma
No treatment needed
Transient Neonatal Pustular Melanosis
 Vesiculopapular rash
 Lack of surrounding
erythma
 Pustules rupture and
leave a hyper
pigmented macule
lasting for 3-4 wks.
Acne Neonatorum
 20% newborns
 Closed come domes on




forehead, nose and cheeks
Inflammatory papules and
pustules may develop
Acne develops from
hormonal stimulation
Resolves spontaneously in
2-4 months
Can use benzyl 2.5 % if
severe or persistent.
Seborrhea Dermatitis
 Erythma and greasy scales.






On scalp, “cradle cap”
Can affect face ears, and
neck.
Erythma in folds
Occurs in first few months of
life
Not itchy
Treatment with tar shampoo
Ketoconazole or cortisone
cream both shown some
benefits if persistent.
References
 O'Connor NR, McLaughlin MR, Ham P.
Physician. Newborn skin: Part I Common
Rashes. Am Family Physician. 2008 Jan
1;77(1):47-52.
Case # 2 b
 5 day old brought by mother because
concerned about rash. After diagnosing the
rash you do a physical exam and notice a
clunk when pressing upwards and abducting
the left hip. What is the next step?
 a) ultrasound of hip
 b) x ray of hips
 c) Referral for Palvik harness
 d) Observe repeat exam in 2 weeks.
Case 2-b
 Answer: d
 Hip dislocation common in the first 2 weeks of
life. If found at birth should observe, and
schedule repeat exam in 2 weeks.
 Reference:

Storer SK, Skaggs DL Developmental dysplasia of the hip. Am Fam Physician. 2006 Oct
15;74(8):1310-6.
Hip Dysplasia
Screened by hip exam as
infant (Barlow, Ortolani)
 Risk factors:

Female, breech, family
history
 What imaging
techniques are used to
evaluate the condition?


4-6 months of age:
sonogram
After 4 months: x ray

Tests commonly used to assess hip stability. (A)
Ortolani maneuver. A gentle upward force is
applied while the hip is abducted.(B) Barlow
maneuver. A gentle downward force is applied
while the hip is adducted

.
Figure from www.aafp.org Hip Dysplasia fromOctober 15, 2006
◆ Volume 74, Number 8 www.aafp.org/afp American Family
Physician 1311
4 month old
 4 months old
brought in for
vaccines and well
visit. Mother
mentions that she is
happy he is sleeping
longer and ask
about changing his
sleeping
arrangement. What
is recommended?
Safest sleep for 4 month old?
a
Cardboard box on floor of parents
room
b
Naps with parent for whole nap
d
c
Naps in kitchen while making dinner
Breastfeeding and sleeps with mom
Safe Sleep =answer A
 Approximately 3,500
infants die annually
in the United States
from sleep-related
deaths, including
sudden infant death
syndrome (SIDS);
ill-defined deaths;
and accidental
suffocation and
strangulation.
 Recently, AAP
recommended baby
sleeps in parents
room for at least 6
months.
Case #3
12 month old male for routine visit. Mother
concerned about development. What
expected at this visit?
 a) Lead screening and hematocrit
 b) blood pressure measurement
 c) developmental screening for speech
skills, asking if putting 2 words together
 d)Anticipatory guidance,
recommendation for child remain in
backwards facing car seat.
Case #3
 Answers: A & D
Health screening for12 month old
 Lead screening and hematocrit.

Lead screening






Geography
Medicaid or Medicare enrolled
House older than 1950’s
Recent renovation in house older than 1978
Sibling or friend with elevated lead level
Recent immigrant to US
Screening in 12 month old
 Low Hematocrit DDX
 Iron deficiency anemia most common
 Inadequate dietary intake and chronic occult loss
 Concurrent infection
 Blood loss
 Hgb disorders, thalassemia, sickle cell
 RBC enzyme defects,G6PD or Pyruvate Kinase
deficiency
 Lead poisoning
 Other- Leukemia, hemylosis Drug induced, HUS
Blood pressure screening
 Screening recommended at 3 years of age




BP readings need to be looked at in regard to
age, sex or height.
Prehypertension =90-95th % or 120/80
Stage I 95th-99th plus 5mm Hg
Stage 2 99th plus 5mm Hg
Hypertension in children- 20% from secondary
causes
Renal disease or coarctation of aorta.
Speech development
Car seat Recommendations
http://www.safekids.org/
Unintentional injury in Children
 Motor Vehicle accident is most common
cause of unintentional cause of death in
children.
 Motor Vehicle 58%
 Drowning
 Poisoning
10.9%
7.7%
Lead screening
 Risk Factors
 Geographic area
 Lives in house built before
1978
 Recent renovations to older
house
 Medicare or Medicaid
enrolled
 Sibling or playmate with
elevated lead level
Case # 4
 4 year old female for
routine visit. Patient
was up to date at last
visit. Mother
concerned about
safety of multiple
vaccines at one visit.
Case #4
 What vaccines are due at
a)
b)
c)
d)
this visit?
MMR and Varicella
DTap and IPV
DTap, IPV, Influenza,
MMR and Varicella
Influenza only
Case #4
 Answer: c
 Recommended Vaccine schedule
should be followed.
 No evidence that vaccines need to be
split up to be more effective or safer.
Aciap.org
Case #5
 11 year old male for
a)
b)
c)
d)
e)
routine visit. Parents
concerned with
decreasing grades and
lack of energy. What
should be covered in
this visit?
School and friends
Smoking and drugs
ADHD evaluation
Vaccines
All of the above
Case #5
Answer: e – all of the above
Case #5
 School and friends


Bullying is common
and should be
asked about.
Bullying most
common in middle
school
 Bully victims have
 Higher level of health
problems
 Higher academic
problems
 Poorer emotional
adjustment
 increased
psychosocial
 Suicide
 Anxiety and
depression
Depression
 2.8% of kids younger than 13.
 More likely to show irritability than sad mood.
Restlessness, separation anxiety or phobias
more common.
ADHD
 2-16% school aged children
 DSM-IV


Inattention- 6 or more symptoms of inattention
and persisted for 6 months and is maladaptive
Impulsivity-6 or more symptoms of
hyperactivity or impulsivity for 6 months and is
maladaptive or inconsistent with
developmental level
ADHD DSM IV
 hyperactive-impulsivity or inattention were
present before 7 years of age
 Impairment are present in two or more
settings
 There is clear evidence of significant
impairment in social, academic, or
occupational functioning
 Symptoms are not part of a psychiatric or
developmental disorder
ADHD coexisting conditions
 Anxiety
 Conduct disorder
 Developmental disorder
 Mood disorder
 Oppositional Defiant Disorder
 Substance abuse
 Tic
25%
10-20%
10-20%
15-75%
35%-65%
20-40%
50%
Rader R, McCauley L, Callen EC . Current strategies in the diagnosis and treatment
of childhood attention-deficit/hyperactivity disorder. Am Fam Physician. 657-65. 2009 Apr
15;79(8):
References

American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of
hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics.
2004;114(1):297-316.

Lauer BJ, Spector ND. Hyperbilirubinemia in the newborn.Pediatr Rev. 2011 Aug;32(8):3419. doi: 10.1542/pir.32-8-341.
Moerschel,S. Cianiaruso, L. A Practical Approach to Neonatal Jaundice. American Family
Physician. number 9. May 2008. Vol 77,


Rader R, McCauley L, Callen EC . Current strategies in the diagnosis and treatment of
childhood attention-deficit/hyperactivity disorder. Am Fam Physician. 657-65. 2009 Apr
15;79(8):

Clark MS, Jansen KL, Cloy JA. Treatment of childhood and adolescent depression. Am
Fam Physician. 2012 Sep 1;86(5):442-8. Review

Storer SK, Skaggs DL. Developmental dysplasia of the hip.Am Fam Physician. 2006 Oct
15;74(8):1310-6. Review

Riley M, Bluhm B. High blood pressure in children and adolescents. Am Fam
Physician. 2012 Apr 1;85(7):693-700. Review.
References
 Theurer WM, Bhavsar AK. 502-9.Prevention of unintentional childhood
injury.
 Am Fam Physician. 2013 Apr 1;87(7):
 Warniment C, Tsang K, Galazka SS, Lead poisoning in children. Am
Fam Physician. 2010 Mar 15;81(6):751-7.
 O'Connor NR, McLaughlin MR, Ham P. Newborn skin: Part I. Common
rashes. Am Fam Physician. 2008 Jan 1;77(1):47-52.
 Riley M, Locke AB, Skye EP. Health maintenance in school-aged
children: Part II. Counseling recommendations.Am Fam Physician.
2011 Mar 15;83(6):689-94
 Caudle,J. and Runyon, M.K. Bullying Among Today’s Youth:The
Important Role of the Primary Care Physician. Osteopathic Family
Physician 2013 Vol5, no4, July/August. 140-146