Pocket.pediatrics

N OT E B OO K

The MassGeneral Hospital fo r Childreir

Handbook o f Pediatrics

jWolters Kluwer Lippincott

P O C K E T

N O T E B O O K

I A T R I C S

Second Edition

E d ite d by

P a r it o s h P r a s a d ,

MD, DTM&H

The MassGeneral Hospital

fo r

Childrerr

Handbook

o f

Pediatrics

0 , Wolters Kluwer I Lippincott W illiam s & W ilkins

Philadelphia • Baltimore • York • Landon Buenos Aires • Hcng Kong • Sydney • Tokyo

A B B R E V IA T IO N S

A A - abdom inal a o rta A b - a ntib od y abd — abdom en A B G - a rte ria l b loo d gas abn - abnorm al A b s o rp - a bso rp tlon A b x - a ntlb io tics accel - accelerate accum - accum ulation

ACEI - anglotensin co nve rtin g enzyme in h ib lto rs A cq - acqulred adenoCa - adenocarclnom a adj - adjacent adol - adolescent adolesc - adolescent A fib - a trial fib rllla tio n A flu tte r - a tria l flu tte r A g - antlgen

a lk phos - alkaline phosphatase A m p - a m plltude o r am plcillin depending

on c o n te x t a m t - a m o un t A m y - amylase

A N A - a nti-nu cle ar antib od y A N C - actlvated n e u tro p h il co u n t anom - anomalous antag - antagonlst a n te r - a n te rio r a ntlchol - a ntlcholinerglc A R - a o rtic re g u rg ita ro n ARB - anglotensin re c e p to r b locke r AS - a o rtic stenosis

A SA - asplrln A S D - a tria l septal defect assoc - associated asym - asym m etric avg - average A z ith ro - azithrom ycln bact - bacterial BB - beta b locke r b/c - because bld - blood

BNP - braln natu eretic peptlde BP - b lo o d pressure bpm — beats p e r m inute brady - bradycardia b tw - between B U N - b lo o d urea nitrogen bx - blopsy carbs — carbohydrates cath - ca th e te rizatlo n C B C - co m p lete bloo d co u n t c/b - co m plicated by C C B - calclum channel b lo cke r C D H - congenital diaphragm atlc hernia CF - cystlc fibrosis

C H D - congenital h e a rt dlsease chem o - chem otherapy C H F - congestive h e a rt fallure c h o rio - ch orioa m n lo nltis

c h ro m o - chro m oso m e ch ro no - chronological C lp ro - ciprofloxacln circ - circum clslon C K D - ch ro nlc kldney disease clinda - cllndam ydn C M V - cytom egalovlrus coags - coagulatlon studies co a rct - co arcta tlo n co lo - coloscopy com m unic - co m m unication compens - com pensation conc - co nce ntratio n congen - congenital conj - conjugated constip - c o n stip a ro n consump - co nsum ption C o r t - c o rtic o s te ro ld C r - creatinine C rC I - cre a tinin e clearance cres-decres - crescendo-decrescendo c r lt - c rlte rla

C TA - clear to auscu ltaron C T D - connective tissue dlsease C T X - chest x-ray o r ce ftrlaxo n e ex - cultures C X R - chest x-ray d/c - discontinué D C M - dilated cardiomyopachy D d x - differential diagnosis dec - decrease decom p - decom pression degen — degenerative dehyd - dehydratlon deliv - delivery depol - depolarized d ep rlv - dep rlva tio n D e rm - d erm ato lo gy desc - descending dev - developm ent D e x - dexamechasone d iff - differential d¡g - dlgoxin discrep - dlscrepancy dlssem - disseminated D M - diabetes m ellitus d /o - d lso rd e r D O L - day o f Ufe d s D N A - double-stranded D N A D T R - deep ten d ón re fle x dx - diagnosis dysfxn - dysfuncclon dz - disease

EBV - E pste in -B a rr virus ED - emergeney d ep a rtm e n t EMG - e le c tro myelograph eos - eosinophils epi - epinephrine epo - epo etin alfa E ry th ro - e ryth ro m ycin esoph - esophageal

esp - especially

ESR - e ry th ro c y te sedim entation rate essent - essential E tO H - alcohol eval - evaluation evid - evidence exacerb - exacérbate exp - e x p ira to ry explan - explanatlon e x t - e x tre m ity FB - foreign body FH x - fam ily h is to ry

FMF - fam illal M e d lterranean fever func - fun ctlo n

f/u - fo llo w up

fx - fra ctu re o r fun ctlo n depending fxn - fun ctio n

GAS - g ro up A S treptococcus G astro - g astro e nte ritis G ER D - gastro-esophageal re flu x

disease gest — gestatlon gluc - glucose

G V H D - g ra ft versus h ost dlsease Gyn - gynecology

H A - headache H c t — h e m a to c rit

H lb - Haem ophllus Influenza B H IV — human ¡m m unodeficlency virus H o N a - hyponatrem ia

H o T N - hypotension H&P - h is to ry and physical HR - h ea rt rate HSM - hepacosplenomegaly H T N - hypertension H x - h isto ry hyperaldo — hyperaldosteronlsm H yp erC a - hypercalcemia hypercoag - hypercoagulabillty h ype rK - hyperkalemia H yp erN a - hypernatrem la hyperphos - hyperphosphatem la h ype rve nt - h ype rventllatlon H ypoC a - hypocalcemia H yp o N a - hyponatrem ia hypophos - hypophosphatem ia hypoplast - hypoplastic Ig - im m unoglobulin

im m un o com p - ¡m m unocom prom ised im p e rf - ¡m perforate

¡m prov - ¡m provem ent ¡nadeq - ¡nadequace inc - ¡ncrease ¡ncld - ¡ncidence ¡ncomp - ¡n co m patlbllity ¡nflamm - ¡n flam m atory in fxn - in fection ing - ingestión ¡nhib - ¡n h lb ito r in no m in - innom inate inpts - ¡npatients inslg - ¡nsignlficant ¡nsp - ¡nsp lra to ry Insuff - insufficient in tra card — incracardlac ¡ntravag - ¡ntravaglnal inv - inverted ¡rreg - irreg u lar IVF - intravenous flulds IVIG — Intravenous im m unoglobulin jn ts - jo in ts

JVD - jugular venous distensión JVP - jugular venous pressure L A - le ft arm

L A D - lym phadenopathy Leuks - leukocytes Levo - Levofloxacin LFT - live r fun ctio n tests LL - le ft leg

LLSB - le ft lo w e r sternal b o rd e r LN - lym ph nodes

L O C - loss o f consclousness LUSB - le ft upp er sternal b o rd e r LV - le ft ve ntrlcle

LVH - le ft v e n trlc u la r h ype rtro ph y ly m p b o p ro llf - lym ph op ro life ra tive m a in t - malntenance Malfxn - m alfunction maiig - malignancy/malignant m a ln ut - m a ln u trltio n m a t - maternal m ax - m áxim um M . cat - Moraxella catorrhalis mee - m econium mech - mechanism meds - m edicatlons m g m t - management MI - m yocardial ¡nfarction M in e ra lo c o rt - m ln e ra lo c o rtic o id M ito c - m ito ch on drla l m od - m o dérate monic - m o n ito r MR - m itra l re g u rg ita ro n MS - m itra l stenosls m u ltl - m ú ltiple muse - muscular m u t - m u tatlon MV — m itra l valve m vm t - m o vem ent MVP — m itra l valve prolapse nec — necrotizlng

N E C - n ecrotizin g e n te ro co litis neonat - neonatal

N H L - N o n -H o d g ld n lym phom a N IC U - neonatal ¡ntenslve care u n it N K C s - natural k llle r cells nm l - norm al

N. mening - Neisseria meningitidis

n on typ - nontypeable n orep i - n orepinephrine

N S A ID - non -ste roida l a ntl-infla m m ato ry drug

o b s t - o b stru ctio n occ - occasionally O C P - o ra l co ntra ce ptive pills o p th o - ophchalm ology O T C - o v e r the c o u n te r o u tp t - o u tp a tie n t PA - p ulm on a ry a rte ry palp’s - palpitations

PALS - p ed ia tric advanced life supporc Pancr - pancreatic

parasymp - parasympachetic P CN - penicillin

PCR - polym erase chain reacción PDA - p ate nt ductus a rteriosus PE - p ulm on a ry em bolism peds - pediatrics periph - peripheral PFT - pulm on a ry fun ctio n te st Phenobarb - phenobarbital pheo - p he och ro m o cytom a p H T N - p ulm on a ry hypercension Plts - platelecs

PMI - p o in t o f m axlm al impulse PMNs - p o lym orph o nu cle ar cells P N A - pneumonía

PO — p e r oral p o lya rtic - p olya rticu la r p op - p opulation poss - possible p o st - p o s te rio r PPI - p ro to n pum p ¡n h ib ito r pRBCs - packed red bloo d cells p re do m - p re do m in a nt Preg - pregnancy pres - pressure prev — previous PRN - p e r requested need p rog - prognosis progest - progestin p ro ph y/pp x - prophylaxis p r o t - p ro te in p ro x - proxim al PS - pulm on ic stenosis p t - p atient PTX - p ne um oth orax pulm - pulm on a ry

PVM - pulm on a ry venous markings PVR - p ulm on a ry vascular resistance p /w - presents w ith

pyelo - p yelonephritis RA - rig h t arm

R A D - reactive a irw ay disease RAE - rig h t a tria l enlargem ent RBBB - rig h t bundle branch b lock RCT - random ized c o n tro lle d tria l rec - re co m m endation re fra c - re fra c to ry regurg - re g u rg ita ro n renovase - renovascular req - required resp - response resusc - resuscitation resxn - resección re tic - re ticu locyte

RF - rh e um a toid fa c to r rhabdo - rhabdom yolysis r p t - repeat

RSV - re sp ira to ry syncytial virus RV - rig h t vencricle

RVH - rig h t v e n tricu la r h yp e rtro p h y RVOT - rig h t v e n tricu la r o u tflo w tra c t Rx - tre a tm e n t

rxn - reaction sat - saturation

SBI - spontaneous bacterial infección SBP - systolic blood pressure SEN - systolic ejectio n m u rm u r sens - se nsitivity

sev - severe sign - significan! signif - significant sinopulm - sin op u lm o na ry SOB - shortness o f breath spec - specificity

S. pneumo - Streptococcus pneumoniae sp o n t - spontaneous

SSRI - selective se ro to n in reuptake ¡n h ib ito r

Staph/S. aureus - Staphylococcus oureus

std - standard

STI - sexually tra n sm itte d in fection subclav - subclavian

subseq - subsequent suff - sufficient sugg - suggests suppl - supplem entation supravent - su praventricular Surg - surgery

SVR - system ic vascular resistance SVT - su pra-ve n tricu lar tachycardia sx - sym ptom s

symp - sym pathetic syn - syndrom e sz - seizure szr - seizure tachy - tachycardia TB - tuberculosis thal - thalassemia col - toleran ce to x - to x ic ity TR - tricu sp id re g u rg ita ro n TS - tricu sp id stenosis T V - tricu sp id valve u ncirc - uncircum cised U n com p - uncom plicated univ - universal u nk - unknow n

URI - upp er re s p ira to ry infección U ro - uro log y

US - ultrasound U/S - ultrasound UTI - u rin a ry tra c t in fection Vaneo - vancomycin v e n tric - v e n trid e V fib - v e n tricu la r fib rilla tio n V it - vitam in A b b re vi a t io n s

vol - volum e

VSD - ventriculo se pta l defect V T - v e n tric u la r tachycardia Vz/vac - vaccine V Z V - varicella zo s te r virus w / - w ith w /i - w ith in w /o - w ith o u t w n l - w ith in n orm al lim its

W P W - W o lf-P a rk in s o n -W h ite w /u - w o rk up x fe r - tra nsfe r xfusion - transfusión xp la n t - transplant X R T - radiation therapy yo - years oíd

CONTENTS

Contributors

iii

Foreword

v

Preface

vi

Abbreviotions

vii

PRIMARY CARE A N D A DO LESCENT MEDICINE

Meredith Eicken, Aura Obando, andYoung-HoYoon

V ital Signs b y A g e

1-1

D eve lo pm e n ta l M ilestones

1-1

H ealthcare M aintenance

1-3

Im m unizations

1-5

O ve rV ie w o f G ro w th

1-6

Failure to T h r iv e

1-7

O v e rw e ig h t and O b e s ity

1-8

Breast-Feeding

1 -9

Sudden Infant D eath S yndrom e (SIDS)

1 -10

Skull D e fo rm itie s

1-11

N eo n a ta l Jaundice

1 -12

A u tis m Spectrum D is o rd e r (A S D )

1-15

Lead Screening and T o x ic ity

1 -17

C o n tra c e p tio n

1-19

G ynecologic Exam

1-20

Eating D is o rd e rs

1 -20

EMERGENCY DEPARTMENT

Sylvia Romm, Nina L. Gluchowski, Hasan S. Merali, and Linda T. Wang

Rapid Evaluation and M anagem ent o f C o m m o n

P ediatric Emergencies

2-1

S trid o r

2-4

A naphylaxis

2-5

A p p a re n t Life-T hre a te n in g Event (ALTE)

2-6

Fever W ith o u t an Identified Source in Infants and C h ild re n

2-8

A p p e n d icitis

2-11

Intussusception

2 -1 2

Burns

2 -12

C a rb ó n M o n o xid e Inhalation

2 -1 4

Traum a O ve rV iew

2 -14

Head Trauma

2-15

Foreign Bodies A s p ira tio n and Ingestión

2 -17

T h e C ry in g Infant

2-18

T o xico lo g y

2-19

Facial Trauma

2-22

ALLERGY A N D IM M U N O LO G Y

Dominica P. Donnal and Elizabeth C. TePas

Food A lle rg y

3-1

A to p ic D e rm a titis (A D )

3-2

D ru g A lle rg y

3-3

U rtic a ria

3-4

C O N T E N T S X ¡¡

B-C ell D eficie n cy (H u m o ra l Im m u n ity)

3-6

T-C ell D eficiencies (C e llu la r Im m u n ity)

3-8

C o m b in e d Im m une D eficiencies

3-8

C o m p le m e n t D eficiencies

3-9

Phagocytic D is o rd e rs

3 -10

C A R D IO LO G Y

Elena K. Grant, M atan Setton, Deepak Palakshappa, and Ana María Rosales

EKG In te rp re ta ro n

4-1

H e a rt M u rm u rs

4 -2

Syncope

4-3

C he st Pain

4-4

C ya n o tic C h ild

4-5

C on g e nita l H e a rt Disease

4 -7

Essential H y p e rte n s io n

4-9

P ediatric D ysrhythm ia s

4 -11

P e rica rd itis and Pericardial Effusion

4-13

C ard io m yo p a th ie s (C M )

4 -1 4

C ongestive H e a rt Failure

4 -15

E N D O C R IN O L O G Y

Sarabeth Broder-Fingert, Julia Elisabeth von Oettingen, Manasi Sinha,and

Lynne L. Levitsky

D iabetes M e llitu s

5-1

D iabetes M e llitu s Type 1

5-1

D iabetes M e llitu s Type 2

5-3

D ia b e tic Ketoacidosis

5-3

H ypoglycem ia

5-5

T h y ro id Function Testing

5-6

H y p e rth y ro id is m

5-6

H y p o th y ro id is m

5-7

A d ren a l Insufficiency (A l)

5-8

H y p o p itu ita ris m

5 -1 0

A m b ig u o us G e nitalia

5 - 1 1

Precocious P u b e rty

5 - 1 1

Delayed P u b e rty

5 -12

S h o rt S tature

5 -12

A m e n o rrh e a

5-13

Polycystic O varían Syndrom e (PC O S)

5 -14

FLUIDS A N D ELECTROLYTES

David A. Lyczkowski and Avram Traum

Body and P arenteral Fluids

6-1

D e h yd ra tio n and R eh yd ra tion

6-1

H y p o n a tre m ia

6-3

H y p e rn a tre m ia

6-5

H ypo ka lem ia

6-7

H ype rka le m ia

6-8

H ypocalcem ia

6-11

H ypercalcem ia

6 -12

H yperm agnesem ia/H ypom agnesem ia

6 -14

A cid -B a se D is o rd e rs

6 -16

M e ta b olic A cido sis

6 -16

M e ta b olic A lkalosis

6 -19

R e sp ira to ry A cido sis and A lkalosis

6-20

GASTROENTEROLOG Y

Pañtosh Prasad and Jeffrey A. Biller

A c u te A b d o m in a l Pain

7-1

Peptic U lc e r Disease (P U D )

7-1

V o m itin g

7-2

G astroesophageal R eflux Disease (G ER D )

7-4

P yloric Stenosis

7-5

G a stro in te stin a l Bleeding

7-5

A c u te D ia rrh ea

7-7

C h ro n ic D ia rrh e a

7-9

C eliac Disease

7 -10

In fla m m a to ry Bow el Disease (IB D )

7-11

Jaundice

7 -14

A b n o rm a l L ive r Function Tests

7 -14

H ep a titis

7-15

B iliary T ra ct Disease

7 -18

A c u te Pancreatitis

7 -19

C h ro n ic Pancreatitis

7-20

HEM ATOLOGY

Fei J. Dy and Eric F. Grabowski

A n e m ia

8-1

H em o g lo b in o p a th ie s

8-2

P latelet D is o rd e rs

8-6

C oa g u la tio n

8-7

Bone M a rro w Failure

8 -12

O N C O L O G Y

Olga Rose and Alison Friedmann

Lym phadenopathy in th e P ediatric Patient

9-1

P ediatric O n c o lo g ic Emergencies

9-1

N e u tro p e n ia in th e P ediatric Patient

9-4

A c u te Lym phoblastic Leukem ia

9-5

A c u te M yelogenous Leukemia

9-5

H od g kin Lym phom a

9-6

N o n -H o d g k in Lym phom a

9-7

Transfusions

9-8

P ediatric B ra in T u m o rs

9 -1 0

N e u ro b la sto m a

9-11

O steo sa rco m a

9 -1 2

O th e r C h ild h o o d Tu m o rs

9 -13

C he m o -A sso cia te d N ausea/V om iting

9 -1 4

C h e m o th e ra p y A d ve rse Effects

9-15

C O N T E N T S X ÍV

IN FEC TIO US DISEASE

Rebecca Cook, Emily 8. Rubín, Sophia Delano, and Chadí M. El Saleeby

Fever o f U n kn o w n O rig in

10-1

In fectious M eningitis

10-1

P e rio rb ita l (Preseptal) and O rb ita l C e llu litis

10-3

A c u te O titis M edia

10-4

Lym phadenitis

10-5

Lyme Disease

10-6

U T I/P ye lo n e p h ritis

10-7

C e llu litis

10-8

Septic A r th r itis and O s te o m ye litis

10-9

Sexually T ra n sm itte d Infections

10-11

Tuberculosis

10-1 6

H IV

10-1 7

Pediatric Pneumonía

10-19

GENETIC A N D METABOLISM

Paritosh Prasad

In b o rn E rro rs o f M e tabolism

11-1

Emergencies

1 1-2

H ypoglycem ia

1 1-2

H yp e ra m m on e m ia

11-3

A b n o rm a l N e w b o rn Screen

11-3

Galactosem ia

11-3

Phenylketonuria/Phenylalaninem ia

11-4

M anagem ent o f K n o w n In b o rn E rro rs o f M etabolism

1 1-4

P o stm o rte m Labs

1 1-6

T risom y 13

11-6

T risom y 18

11-6

T riso m y 21

1 1-6

T u rn e r S yndrom e

1 1-7

Fragile X

1 1-8

K lin e fe lte r

1 1-8

Vacterl

1 1-9

Lysosomal Storage Diseases

1 1-9

M ito c h o n d ria l D efects

1 1-1 0

E h le rs-D a n lo s Syndrom e

11-11

Marfan Disease

1 1-1 2

NEURO LOGY

Kristen A. Lindgren, N\axy Zelime Ward, Casey Olm-Shipman, and

Verne S. Caviness

Febrile Seizures

12-1

F irst N o n fe b rile Seizure in C h ild re n

12-1

Epilepsy

12-2

Status Epilepticus (SE)

12-4

D yskin esias/M ovem ent D is o rd e rs

12-5

Tics & T o u re tte S yndrom e (TS)

12-5

A b n o rm a l G a it/A ta xia

12-6

W eakness/P eripheral N e u ro p a th ie s

12-7

C e re b ra l Palsy

12-13

Headache (H A )

12-14

N e u ro cu ta n e o u s Syndrom es

12-15

A D H D

12-17

PULMONARY

Harmony Catón, Anna Tien Labowsky, Sze Man Tse, LaeIYonker, and

Natan Noviski

Q u ic k Reference f o r R e sp ira to ry Signs

13-1

Tachypnea

13-2

S trid o r

13-2

C ough

13-3

W h e e z e

13-5

H em o p tysis

13-8

P le u ritic C he st Pain

13-9

A P N E A

13-11

D ia g n ostic Studies

1 3-1 2

RENAL

Melissa A. Watker and Avram Traum

U rinalysis

14-1

A c u te Kidney In ju ry (A K I)

14-1

C h ro n ic K idn e y Disease

14-3

S econdary H yp e rte n sio n

14-4

H e m a tu ria , N e p h ritic Syndrom es

14-4

U rin a ry T ra ct C alculi

14-5

N e p h ro tic S yndrom e

14-6

Renal Tubular A cido sis

14-6

V e sico u re te ral R eflux

14-7

C on g e nita l Renal M a lfo rm a tio n s

14-8

RHEUM ATOLOGY

Paritosh Prasad and Holly Rothermel

Juvenile Id io p a th ic A r th r itis (JIA)

15-1

Reactive (E n th e sitis-re lated ) A r th r itis

15-2

Systemic Lupus E rythem atosus

15-3

V asculitides

15-5

D erm a to m yo sitis/P o lym yo sitis

15-9

N IC U

Ashley A. Ferullo and Joseph H. Chou

D e liv e ry R oom M anagem ent

16-1

Basic N IC U M anagem ent

16-4

P u lm o n a ry/R e sp ira to ry

16-7

C ard iova scu lar

16-9

G a s tro e n te ro lo g y

16-10

Infectious Disease

16-13

H e m a to lo g y

16-16

N e u ro lo g y

16-17

C O N T E N T S x v i

PICU

Abigail R. Woodhead and Brian M. Cummings

Prophylaxis ¡n C ritic a l lllness

Pain C o n tro l and Sedation

R e sp ira to ry Failure

Mechanical V e n tila tio n

P ediatric EC M O /EC LS

V entilator-associated Pneumonía (VAP)

A c u te R e sp ira to ry D istress S yndrom e (ARDS)

Septic Shock

In o tro p e s, C h ro n o tro p e s , and Vasopressors

Increased Intracranial Pressure

Rapid Sequence In tu b a tio n

1

C LIN IC A L IMAGES IN PEDIATRIC

DERMATOLOGY

V I T A L SIGNS BY AGE

i

H e a r t Rate R e s p ira to ry Rate BP (S B P /D B P ) P re m a tu re 120-170 40-70 75-55/45-35 0 -3 m o 100-150 35-55 85-65/55-45 3 -6 m o 9 0-120 30-45 90-70/65-50 6 -1 2 m o 80-120 25-40 100-80/65-55 1 -3 y r 70-110 20-30 105-90/70-55 3 -6 y r 65-110 20-25 1 1 0 -9 5 /7 5 -6 0 6 -1 2 y r 60-95 14-22 120-100/75-60 124-y r 55-85 12-18 135-110/85-65

Repro du ced fro m N dson Tcxlbook o f Pediatrics. 1 8 th ed. Saunders; 20 07 :7 0 -7 4 , 67 7,2 4 3 4 .

• A recent systematic review o f 69 observational studies suggests tha t previously published reference ranges fo r HR & RR may require updating.These centile charcs & an interactive calculator available at http://madox.org/tools-and-resources (Lancet 2011:377:1011)

A b o v e : R e spira to ry ra te centiles fo r children fro m b irth to 18 y r

D E V E L O P M E N T A L M ILE S TO N E S

('ñrigbí Fuíures Gwcteiines for Health Super/ision ofín/ants, Children, and Adolescerrs. 3rd ec. 2008:39: Pediatr Rev 2010:31:267: Pediatr Rev 2010:31:364; Pbdiatr Rev 2011:32533)

rIT AL S lG N S BY AG E 1 -l |

C o g n itio n and S o c ia l- E m o tio n a l A g e G ro ss M o to r Fine M o to r C o m m u n ic a tio n & S e lí-h e lp

1 mo • Lifts chin when • Hands cightly • Throaty noises • F ixa te s on prone fisted • Startles to faces (sh o u ld • Turns head • Hands to sounds do by 2 m o )

when supine mouth • Discriminates parent’s voice

2 mo • Lifts chin when • T ra cks p ast • Coos • S ocial s m ile prone m id lin e (by • Alerts to voice (b y 6 m o ) • Head bobs if 4 m o ) & sounds • Recognizes

held sitting • Hands unfisted V2 of time, holds hands together

parent 4 mo • Props on • Tracks to 180° • O rie n ts to • Laughs o u t loud

wrists when • Shakes rattle voice (by 6 m o ) • Enjoys looking prone • Mouths objects • A lt vocalization a round • N o head lag • Reaching fo r w/ speaker;

“ converses"

• Smiles w h e n p u lle d objeccs spontaneously to s it • Repeacs actions

• Rolls fronc to if results are back interesting

6 mo • S its • Reaches w / • Babbles “ dada” • Recognizes u n s u p p o rte d one hand • L iste n s, th e n strangers (b y 9 m o ) • Transfers hand vo ca lize s w h e n

• Commando to hand sp e a k e r stop s crawis (8 mo) • Rakinggrasp (b y 9 m o )

9 mo • Pulís to stand • Pincer grasp • Babbles • Waves “ bye-bye” • Cruises (9 -1 2 mo) “ m a m a ” (by • Reciprocates • Crawis • Bangs blocks 1 2 m o ) gestures (by

together • Imitates sounds • Responds to

ñam e (by

12 m o )

12 m o ) • Uses sound to get

attention • Stranger anxiety

12 mo • Stands alone • Primitive marks • 1 word • Proto-imperative • W a lk s fe w on paper • Immature jargon pointing

ste p s alon e • Finger feeds • Pat-a-cake (b y 18 m o ) part o f meal • Imitates

• Follows 1-step command w•! gesture 15 mo • Walks carrying • Scribbles in • 3 -6 w o rd s (by • Follows

single-objects imita tion 24 m o ) step command • Stoops & • Stacks 3 -4 • Says no correctly w/o gesture

recovers cubes • P ro to -• Climbs on • Turns pages d e c la ra tiv e

furniture * Uses spoon, cup p o in tin g 18 mo • Walks up ♦ Scribbles • 10-25 words • Helps in house

steps with spontaneously • Points to people • Removes hand held • 4-cube tow er and 3 body parts clothing • Runs well when named • Im a g in a tiv e • Throws ball • Spoken

languagel gesture com bos

play

2 yr • Walks down • Lines cubes up • >50 words 50% • Follows series of steps using rail as train intelligible 2 independent • Throws ball * Imitates circle • 2-w o rd commands

overhand, and/or line phrases * Takes o ff clothing kicks ball • Parallel play 2.5 yr ♦ Jumps • Turns paper • Uses pronouns • Washes & dries

• Walks on toes pages in book • Recites parts o f hands • Alternates feet • 8-cube tow er known books • Puts on clothing

going up stairs • Imitates adult accivities

3 yr • Balance on • Copies a cirde • >200 words • Brushes teeth w/ each fo o t for * Strings beads • 3 -w o rd help 3 sec • Unbuttons se nte nce s • Ñames friends • Pedáis tricyd e clothes • Speech 75% • Imaginativo play • H eel-toe walk intelligible • Begins sharlng • Catches ball • Uses plurals • Knows ñame,

age,sex • Toilet trained 4 yr • Hops on one • Copies a cross • Follows 3-step • Tells tall tales foot and square commands • Interactive play • Gallops • Draws 4 -6- • 100% intelligible (elabórate

part person • Knows colors fantasy) • Buttons • Has memorized

songs • Understands

adjectives

• Group play • 1 cióse friend S y r • Skips * Copies a * Identifies most • Has group o f

triangle letters, numbers friends • Cuts w / o ut o f order • Apologizes fo r

scissors • Counts to 10 mistakes • W rites first • Future tense

ñame • Reads 25 words

6 yr * Tándem walk • Ties shoes • 8 -1 0 word • Same-sex best • Draws diamond sentences friend • W rites first & • Knows days of • Distinguishes

last ñames, the week fantasy from short sentences ♦ Reads 250 words reality Bolded milestones are red flogs if missed by age specified in parentheses.

R e d Flags

• Missed m ilestones (p a rticularly bolded ones) o r loss o f previously acquired m ilestones should prom pc fu r th e r developm ental & medical assessmenc

• Persistent fisting a t 3 m o may re present e arlie st indicación o f n e u ro m o to r dysfxn • Rolling <3 mo, pulling d ire ctly to stand (ra tlie r than sit) a t 4 m o,W -sitting, bunny hopping,

and toe-w alking may indícate spasticity

• P rim itive reflexes (M o ro , asym m etric to n ic neck) disappear b tw 4 - 6 m o; persistence a t 9 m o may indícate n e u ro m o to r dysfxn

• P ro te ctive postural reflexes (righting, p ro te c tio n , equ ilib rium ) appear b tw 6 -9 m o; if n o t present, w ill lead to d ifficu lty sittin g and standing

• Due to Back to Sleep campaign, tu m m y tim e im p o rta n t fo r reaching milestones • Hand dom inance b efore 18 m o may indícate co ntra la te ra l weakness • Failure to a le rt to e nvironm ental stim u li may indicace visual o r a u d ito ry déficits

H E A L T H C A R E MAINTENANCE

(Bright Futures Guidelines for Health Supervisión o f Infants, Children, and Adolescents. 3rd ec.:

2008:39; Pocket G uide)

A ge A n tic ip a to r y G u id a n ce S cre e n in g N e w - • Weight gain, feeding • Newborn genetic b o rn • Crib safety (own crib in parents' room, narrow slats screen

w ith sides up, back to bed, no loose bedding) • Hearing (if not • Rear-facing car seat in back seat1 done in hospital) • Home safecy (smoke detectors, w ater cemp <120°, no • Postpartum

smoking) depression • Emergency phone numbers, CPR • Vision, BP (if risk

factorslconcerns)

1 m o • Start supervised "tummy tim e” • Maternal

• Develop routines, recognizing cues postpartum • Calm baby by rocking, talking, swaddling, never shake depression • Toy safety (caution w / loops, strings, cords) • 78 (if risk factors)

H e a lt h M a in t e n 1 -:

2 m o 4 m o 6 m o 9 m o 12 m o 15 m o 18 m o 2 y r 2.5 y r 3 y r 4 y r 5 -6 y r

Strategies fo r ¡ncreased fussiness Plan for return to school/work Keep small objects, plástic bags ouc o f reach Always supervise when on high place o r in tub Put to bed when awake but drowsy. can sleep in crib in own room (low er mattress before begins sitting) Introduce cereal if child ready

Avoid bottle in bed

Support increases in language and cognitive development, read aloud

Introduce single-ingredient soft foods if ready; lim it juice Clean teeth with washcloth/soít brush & water Home safety (block stairs, cleaning produces, heaters, o utle t covers, window guards; lock weapons; avoid infant walkers)

Discipline (+ reinforcement, distracción, lim it use o f “ no") Anticipace changing sleep pattern

Be aware o f new social skills & separation anxiety Lim it o r avoid TV, videos, computers

Provide 3 meáis, 2 -3 snacks/d; T texture & variety of cable foods, introduce cup

W a ter safety (always be w /i arm’s length) Discipline (time out, praise, distracción) Est. bedtime roucine w/reading, 1 nap/d Supervise tooth brushing bid w / fluoride, only bottled water

Encourage self-feeding (avoid small, hard food; choking)

Lock medicacions, know poison control num Maintain consistent routine. Present child w ith options. speak in simple dear language Avoid bótele in bed

Pire safety (lock macches, lighters) Support independence but set limlts Daily playeime, read, sing Anticípate anxiecy in new situations

Toilet training (when dry fo r 2 hr at a time, knows wet/dry/bow el movement, pulís pants up/down) Switch to forward-facing car seat w / harness'1

Help child express feelings Encourage play w / others

Teach personal hygiene, to ile t training (above) Encourage active play: Use bike helmec, supervise outdoor play, cross Street w / adult

Switch to fat-free m¡lkb Repeat speech with correct grammar Establish family routine including exercise Encourage storytelling, imaginative play

Lim it media exposure to <2 hr/d, no TV in bedroomb Move furniture away from Windows

Consider structured learning programs (pre-school, museum crips), encourage reading

Teach safety around adults (abuse prev) Answer ?'s about body parts using appropriate cerms Discuss school experiences

Eat breakfast, fruits, and vegetables

2 cups low-fat milk/dairy per d

60 min mod to vigorous physical activicy per db Begin flossing daily

W ater safety, swimming lessons Use safety equipment w ith sports

• Verify hearing screening and rescreen if needed • Anemia (if preterm/

LBW, not on iron- fortified formula)

• Oral health risk assessment • Lead (if risk factors)

• TB (if risk factors)

Structured developmental screen Oral health risk assessment • Anemia, lead Structured developmental screen Autism-specific screen Autism screen Lead screen

Dyslipidemia (if risk factors) • Developmental screen (structured) • Visual acuity measurement • Visual acuity measurement • A udiom etry • Visual acuity measurement • A udiom etry (6 yr)

7 -8 y r • Once 4/9'/, can stop using booster seat ¡n car; must use lap and shoulder belta

• Ask ceacher fo r evaluation if any concerns • Encourage¡ndependence

• Discuss rules and consequences • Note and discuss early pubertal changes • Supervise Computer use

9 -1 0 • Encourage self-responsibility, assign chores y r • Know child's friends and ensure adequate supervisión,

discuss bullying • Puberty. body image • Counsel about sexual activity • Counsel about avoiding tob, alcohol, drugs • Lim it non-academic screen tim e to 2 hr/d 1 1 -1 4 * Begin speaking w / child alone at clinic visits y r • 3+ servings low fat milk/daily per d

• Coping w ith stress, mood changes, non-violent conflict resolution

• Secure alcohol and prescription medicatlons • 13 yo may sit in fro n t seat o f car • Caution with drivers using any alcohol/drugs 1 5 -1 7 • Driving safety; Lim it night driving, teen driving; always y r wear seac belt

• Encourage responsibility, comm involvement • Violence prev, sexual activity, substance use 1 8-21 • Planning fo r the future

y r • Continué discussions regarding violence prevention, sexual activity, substance use_______________________

Snellen tese (8 yr) A udiom etry (8 yr)

Snellen test {10 yr) A udiom etry (10 yr) Universal lipid screening Snellen (once during tim e period)

STI screening (if sexually active)

Substance use

Lipid screening (if abn btw 9 -1 1 yo or

new risk factors) Snellen (once during tim e period) Screening Snellen (once during tim e period) Fasting lipid profile ■'Car Safety Seats:A Guide for Families 2012,AAR

bPediatrics 2011; 128:S213. B a s ic C o n c e p ts

• Assess p a re n t-ch ild in te ra ctio n during visits

• Review age-appropriace vital signs and g ro w th curves a t each visit

• U n in te n tion a l in juries are the p rim a ry cause o f death in children o v e r age 1 yr, so focus should be placed on in ju ry p revention during H C M visits.A A P has policy updates regarding specific re com m endations (Pediatrics 2 0 0 7 ;1 19:202) A t t e n t i o n D é f ic it H y p e r a c t iv i ty D is o r d e r

(Pediatrics 2011:128:1007: Pediatr Rev ,2003:24:92)'

• A A P recom m ends eval in pts 4 -1 8 yo w / hyperactivity, in atte ntio n, im pulsivity, & academic o r behavior concerns

• D x requires m eeting DSM -IV c rite ria & requires o b se rva d o r fro m caregivers o r teachers regarding duración & severity o f sym ptom s & degree o f ¡m pairm ent • A D H D rating scales can be helpful in making che diagnosis

• Should assess fo r co m o rb id p sychiatric o r medical co nditions

• Rx varies based upon age & severity. May need re ferra l to additional specialists C h o le s te r o l S c re e n in g (Pediatrics 2011:128:5213)

• Evidence su pp orts early ¡dentification & Rx o f dyslipidemia to reduce C V D risk • O bta in fasting lipid panel (FLP) tw ice b tw 2 -8 y r & avg results if+ F H fo r early C V D

(m en <55 yo, w o m e n <65 ye), parents w / dyslipidemia, o r child w / o th e r risk facto rs o r high-risk condición (Table 9-5 in G uideline)

• Universal lipid screening between 9 -1 1 y r (FLP o r non-fasting n o n -H D L chol) • Ages 1 2 -1 7 yo, recheck FLP tw ic e if new risk factors

• Repeat universal lipid screening b tw 18-21 y r as lipid levels 2 10 -2 0% w / p ub e rty • Manage p e r algorithm s if abnormal

IMMUNIZATIONS

B a sics

• G uide fo r parents: h ttp ://w w w .cdc.gov/vaccines/parents/index.htm l • VISs are available at: http://ww w.cdc.gov/vaccines/pubs/vis/default.htm

I v e r v ie w o f G r o w th 1-1

L

’ Vaccine A dve rse Event R e po rtin g System (VAERS): http://wvAv.vaers.hhs.gov • U nexpected o r clinically signiflcant event a fte r vaccine adm in should be docum ented

¡n medical re co rd and VAERS fo rm should be com pleted

• R eportable adverse events: Anaphylaxis, anaphylactic shock, brachial neuritis, encephalopathy o r encephalitis, ch ro nic a rthritis,T T P , vaccine-strain measles viral ¡nfxn, p aralytic polio, intussusception, death, o r any adverse reaction th a t w o u ld be co ntra in dicatio n to fu tu re adm inistratio n

• National Vaccine Injury C om pensation Program: Provides compensation fo r people w h o have suffered in ju ry 2/2 a covered vaccine: www.hrsa.gov/vaccinecom pensation T h im e r o s a l (N Engi J M ed 2007:357:1281: Pediatrics 2004:114:793) • M e rcu ry-co n ta in in g preservative w / a ntibacterial and antifungal p ro p e rtie s • A ll ro u tin e ly recom m ended vaccines are thim e rosa l-free e xce p t some m u lti-dose vial

flu vaccines and antivenom s

• IVIG and Rho ¡mmune g lobulin do n o t contain thim erosal

• M u lti studies do n o t s u p p o rt assoc b tw thim e rosa l exposure and neuro-psych déficits C o n t r a in d ic a t io n s fl A lle rg y Clin Irriiriuno! 2004:114:1010)

• To any vaccine:Anaphylaxis a fte r a previous vaccine dose o r co m p on en t • Live attenuated vaccines should be adm inistered to g e th e r o r a t least 28 d apart • D T a p , T d a p : Encephalopathy w /i 7 d o f adm in o f previous dose

* D e fer vaccine in pts w / progressive neurologic d isorde r (infantile spasm s.uncontrolled epilepsy, encephalopathy) until neurologic status clarified

* Freq b oo sters may re su lt in A rth u s -lik e rxn ; painful swelling sh ou ld er to e lbo w • H e p a t it is B v a c c in e : C aution in pts w / severe yeast a llergy,allergic rxn ra re ly o c c u r • In flu e n z a ( liv e - a t t e n u a t e d ) : Pregnancy, k n ow n severe im munodeficiency, certain

medical co nd itio ns, anaphylactic allergy to eggs • In flu e n z a ( in a c t iv a t e d ) : Anaphylactic allergy to eggs

• IP V : C ontains tra ce am ounts o f stre pto m ycin , neomycin, and polym yxin-B • M M R : Pregnancy, kn ow n severe im m unodeficiency; contains tra ce a m t neomycin • V a r ic e lla : Pregnancy, know n severe im m unodeficiency; contains tra ce a m t neomycin,

precaución if received antib od y-co n ta in in g p ro d u c t w /i 1 1 m o • R o ta v ir u s : SCID

• Z o s te r : Suppression o f ce llu lar im m unity, pregnancy N O T C o n t r a in d ic a t io n s t o V a c c in a tio n s

• M ild acute o r convalescent illness w ith low -grade fever in an o th e rw ise well child • O n a ntim icro bia l therapy

• N o nspecific allergies o r relatives w ith vaccine allergies

• P rio r rx n to vaccine th a t ¡neluded soreness, redness, o r swelling a t the in je ction site • P re m a tu rity - vaccines should be given according to b irth age, n o t c o rre cte d age • Im m unosuppression o f household co n ta ct (inactivated flu vaccine pre fe rred ) • Pregnancy in a household c o n ta ct o r if breast-feeding

• FHx o f seizures, SIDS, o r o f an adverse event fo llo w in g vaccination

O V E R V I E W 0 F G R 0 W T H

(Nelson Textbook o f Pediatrics. 1 Sth ed. Saunders; 2007:70-71. 677,2434:

Pediatr Rev 2006;27:e1; Pediatr Rev 2011:32:404) • Term infants lose up to 10% o f BW, then regaln by 2 w k

• A vg infant B W doubles by 4 m o and trip le s by 1 y r; height doubles by age 3^4 • Exclusively breast-fed infants gain w t faste r than form ula-fed f o r firs t few mo, then

m o re slo w ly a fte r 3 mo; resolves by 1 y r

• G ro w th d uring p u b e rty accounts f o r nearly 1/5 o f height. G irls achieve peak height a t Sexual M a tu rity Rating 2 -3 com pared w ith boys a t Rating 3 -4

• A n t e r i o r f o n ta n e lle : N o rm a l size 20 ± 10 mm; closes a t 9 -1 8 m o • P o s t e r io r f o n ta n e lle : Closes by 2 mo

• Excessively large fontanelle: IUGR, hypo thyroid , p re m atu rity,T risom y 13/1 8/2 1, hydro- cephalus, a ch o nd ro p lasia.A pe rt syndrom e, cleidocranial dysostosis, cong. rubella, H a lle rm a n n -S tre iff syndrom e, hypophos, Kenny syndrom e, osteogenesis im perfecta, pyknodysostosis, R ussell-Silver s y n d ro m e ,V it D def rickets

• Excessively small fontanelles: M icrocephaly, craniosynostosis, hype rth yroidism • Average g ro w th and ca lorlc re q uirem en ts (A dapted fro m Nelson Textbook o f Pediatrics)

A g e A ve ra g e W e ig h t G ain (g /d ) L e n g th (c m /m o ) H e ad C irc u m fe re n c e (c m /m o ) D a ily C a lo ric A llo w a n c e (k c a l/k g /d ) B ir th - 3 m o 25-30 3.5 2 115 3 -6 m o 20 2 1 110 6 -9 m o 15 1.5 0.5 100 9 -1 2 m o 12 1.2 0.5 100 1-3 y r 8 1 0.25 100 4 -6 y r 6 3 cm/yr 1 cm/yr 90-100 M id p a r e n ta l H e ig h t

• Boys: (Paternal height in in. i m aternal height in in. i 5)12 i■/- 3 in. • G irls: (Parental height in in. + m aternal height in in. - 5)/2 +1- 3 in. G r o w t h C h a r t s (A m Fam Physician 2003:68:879) (G ro w th charts at www .cdc.gov/grow lhcharts)

• C D C recom m ends using W H O charts fo r ages 0 - 2 y r and C D C charts a fte r 2 y r (M M W R Recom m Rep 2 01 0;59(RR-9): 1 -1 5 )

• W H O charts developed based on predominantly breast-feeding children in environments supporting optim al g ro w th and are considered “ ideal" g ro w th charts compared w ith C D C charts representing “ actual" g ro w d i patterns

• Length should be measured via length-board (<2 yo); height measured via stad io m e ter • Head circ measured ju st above e yeb ro w and ears, across m o st p ro m in e n t p a rt o ccipu t • Special g ro w th curves available fo r:T riso m y 21, P ra d e r-W illi,W illia m s syndrom e,

C o rn e lia de Lange syn drom e ,T u rne r syndrom e, Rubinstein-Taybi syndrom e, Marfan syndrom e, achondroplasia, and lo w and v e ry lo w B W p re te rm infants <1,500 g (use Infant Health and D evelopm ental Program [IH D P ] g ro w th curves)

F A I L U R E T 0 T H R I V E

(Pediatr Rev 2000:21:257: A m Fam Physician 2003:68:879: Clin Fam Pr 2003:5:293: Pediatr Rev 2006;27:e1: Pediatr Rev 2011:32:100)

I n t r o d u c t io n

• N o standard d x c rite ria exist; failure to th riv e (FTT) m o st co m m o nly defined as decel g ro w th across 2 m a jo r p ercen tile lines, o r w e ig ht fo r age less than 5 th p ercen tile • Challenging to in te rp re c Crossing 2 m ajor percentile curves (either t o r i ) found to be

com m on b tw b irth to 6 m o o f age (32-39% o f C alifornian infants), less com m on b tw 6 -2 4 m o (6-15% ), & léase com m on b tw 2 4 -6 0 m o (1-10% ). Shifts in weight-for-height occurred nearly tw ice as frequently (Pediatrics 2004;113:e617)

• 1 ° e tio lo g y is m a ln u tritio n , 2/2 m uid medical, behavioral, psychosocial. & e nviron causes • M a ln ou rish m e n t 1 st decreases weight, then height, then head circum ference • Decreased height g ro w th suggests congenital, genetic, o r end ocrin e abn orm a lity • P ro po rtio na l decrease in height and weight suggests underlying chronic medical condition E tio lo g y

• In a d e q u a te c a lo r ic in ta k e

• Inco rrect form ula prep o r breast-feeding challenges.difficulty transitioning to table food, excessive juice intake

• Mech feeding d iff (anatom ic, o ra l lesions), m o to r d iff (o ro m o to r dysfxn, C N S dz) • Familial dysfxn, d isturbe d p a re n t-ch ild relationship (neglect o r hypervigilance) • P overty and fo o d insecurity

• In a d e q u a te a b s o r p tio n

• M ilk p ro te in allergy, GERD, v it o r m ineral (a cro de rm atitis enteropathica, scurvy) • CF, Celiac disease, IBD, b ilia ry atresia, o r live r disease

• C h ro n ic to d d le r diarrhea, infectious diarrhea • N e cro tizin g e n te ro c o litis o r s h o rt-g u t syndrom e • In c r e a s e d m e t a b o lic d e m a n d

• H yp erthyro id ism , g ro w th h orm on e deficiency, hype rco rtiso lism , p itu ita ry insufficiency, diencephalic syndrom e, insulin resistance (IUG R)

• H ypoxem ia (congenital h e a rt disease, ch ro nic lung disease, consillar hypercrophy) • C h ro n ic in fectio n (T O R C H , HIV.TB, im m unodeficiency)

• Malignancy o r renal disease

• G enetic abn (Trisom y 21, 18, 13, Russell-Silver, P ra d e r-W illi, C o rn elia de Lange) • M etabolic disorde rs (storage diseases, am ino acid d isorders)

C lin ic a l M a n ife s ta tio n s

• P lot weight, height, and head circum ference a t every visit; assess tre nd • D etailed h isto ry: D ie t, types o f foods, & eating behaviors

• PMH: B irth h is to ry (p re m a ture , SGA, IUGR, s h o rt gut), n ew b o rn genetic screen • FHx: S tature o f fam ily m em bers, FTT, mental illness, eating disorders, resp o r Gl dz • SHx: Caregivers, fam ily su p p o rt, stressors (econom ic, intrafam ilial, m a jo r life events),

substance abuse, child p ro te ctive Service ¡nvolvem ent

• PE: D ysm orp h ic features, evid. o f underlying dz, signs o f abuse/neglect • Assess severity o f m a ln u tritio n

• O bse rve in teractio ns betw een p arent and child, especially during feeding D ia g n o s tic S tu d ie s

• Review 3 d fo o d diary

• C o nside r referrals (Gl, n u tritio n , feeding eval, OT, PT, SW, psych, genetics) • N o ro u tin e lab tests are indicated, unless suggested by the hiscory o r physical exam • G eneral tests to consider include CB C, Chem 20, U /A , fecal fat, s to o l guaiac, sweat

ch lorid e test, celiac testing (to ta l IgA .TissueTransglutaminase (T T G ) IgA) M a n a g e m e n t

• O u tp a tie n t: D epe n de n t upon e tiolo g y o f FTT

• Feeding behavior m od w / high-calorie d ie t (catch-up g ro w th ) • 12 0 kcal/kg x (median w e ig ht in k g /cu rre n t w e ig h t in kg) = kcal needed • Usually 1 .5 -2 x re co m daily ca lo ric intake; catch-up w e ig ht precedes height • Suppl cals w / conc. form ulas, high-cal m ilk d rin ks (PediaSure), ca lorie -rich foods • MVI w / ¡ron and zinc

• S tructu re m ealtim e

• Inpatient: Pts w / severe m a ln u tritio n (w eight <60% o f ideal, hypotherm ia, bradycardia, o r H o T N ), e le ctro lyte abn, dehydration, failure to achieve catch-up g ro w th w / o u tp t m gmt, o r if concern fo r child safety

• M o st ch ildren resume g ro w th w / in te rve n tio n w ith in wks to mos, may re q uire supplemental enteral feeds to increase ra p id ity o f g ro w th

O V E R W E I G H T AND O B E S I T Y

(Pediatrics 20C-7;120:5164: Pediatrics 2007:120:5193; Pediatrics 2007:120:5229; Pediatrics 2007:120:S254)

D e f in itio n

• Calculación o f body mass Índex (BMI) - ([w e ig h t (kg )]/[h e ig h t (m )]J) recom m ended fo r screening d /t ease o f calculación and co rrespondence w ith adu lt measures • A ge- and sex-specific BMI charts established by C D C in 2000 • BMI categories fro m th e 2007 A A P E xpe rt C o m m itte e re p o rt

• <5th percentile: U n derw eight; 5 th -8 4 th percentile: Healthy weight; 8 5 th -9 4 th percentile: O verw e igh t; >95th percentile: Obese; >99th percentile: Severely obese (c u to ff p oints fo r >99th p ercentile available a t Pediatrics 2007;120:S164) P re v a le n c e & E p id e m io lo g y (JAMA 2006:295:1549; Pediatrics 2010:125:361) • 33.6% ch ildren 2 - 1 9 yo o ve rw e ig h t [N H A N E S 2 0 0 3 -2 0 0 4 ] and 12-18 % o f 2 -1 9 yo

pts are obese, a three - to six-fold increase fro m 1970s • Increased risk among A frica n A m e rica n and Hispanic populations S e le c te d C o m p lic a t io n s o f O b e s ity

• R e s p ir a to r y : A sthm a exacerbation, OSA, ca rd iop u lm o na ry deco nd itio n ing • C a rd io v a s c u la r: H T N , dyslipidemia, pulm H T N and c o r pulmonale, inc risk o f co ro na ry

h ea rt disease as adu lt if still overweight/obese (N Engl J Med 2007:357:2329) • G l: GERD, co nstipation, gallbladder disease, n on alcoholic fa tty live r disease • E n d o c rin e : DM 2, PCOS, metabolic syndrome (T waist circ + 2 o f following: T triglycerides,

i HDL, H T N , insulin resistance) (Pediatrics 2005:116:473)

• O r t h o p e d ic : Slipped capital fem oral epiphysis, B lo un t’s disease, musculoskeletal stress • D e r m a t o lo g ic : In te rtrig o , acanthosis nigricans

• N e u r o lo g ic : P seu d otu m or ce re bri (idiopathic in tracranial hypertension) • P s y c h ia tr ic : Depression

• P rem ature death C lin ic A s s e s s m e n t

• USPSTF recom m ends screening all children >6 yo f o r o be sity using BMI • Risk factors: S GA a t b irth , m at gest D M , parencal obesity, FHx o f D M 2 /H L /H T N

• Assess d ie t and physical a ctivity: always check BP • Labs

• F a s tin g lip id s : See H ealthcare Maintenance section

• F a s tin g p la s m a g lu c o s e : (A D A recs [D iabetes C are 2012;34:S 11]) • <10 yo and p re pu be rta l: N o ro u tin e screening

• A t o nse t o f p u b e rty if <10 yo o r sta rtin g at 10 yo: BMI >85th% (o r >85% w t fo r height o r w t >120% ideal fo r height) and any 2 o f follow ing : FHx 0Í T2D M in 1st- o r 2nd-degree relative; Native A m erican, A frican Am erican, Latino, o r Asian/ Pacific Islander ethnicity; signs o f o r risk fo r insulin resistance (acanthosis nigricans, H T N , dyslipidemia, PCOS, b irth w t was SGA), o r m aternal diabetes o r G D M during child’s gestation. Screen q3yr

• T ra n s a m in a s e s : Biannually fo r all pts >95th %¡le fo r BMI o r >85th %¡le w / additional risk factors p e r A A P E xpert C o m m itte e recs (Pediatrics 2007;120:S164),ALT m ore im p o rta n t per Endocrine Society recs (J Clin Endo M e t 2008:93:4576)

P re v e n tio n (A d v N u tr 2012:3:56)

• D ie t: L im it sugar-sweetened drinks, encourage fru its and veg, e at Q D breakfast, lim it eating o u t, lim it p o rtio n size, encourage fam ily meáis

• Physical activity: L im itTV tim e <2 hr/d ,n o T V in bedroom ,U SD A/A AP /C D C recommendation is >60 min m od-vigorous physical activity Q D , i sedentary activities.

T r e a tm e n t

• Stages o f Rx p e r A A P E xp e rt C o m m itte e recs

• S ta g e 1: P revention plus - p rev counseling as above w / qm o f/u 3 -6 m o • S ta g e 2: S tructu re d w e ig h t m g m t - dietitia n re ferra l, fre q m o n ito rin g q 3 -6 m o • S ta g e 3: Com prehensive m ultid iscip lin ary in te rve n tio n — in volvem ent o f behavioral

co un se lo r and exercise specialist; q w k visits fo r 8 - 1 2 w k

• S ta g e 4 : T e rtia ry care in terven tion - very low-cal diets, meds, a nd /or b ariatric surgery fo r adolescents

• USPSTF recom m ends re ferra l to intensive w e ig ht m g m t program (dietary, physical activity, and behavioral in te rve n tio n s) (Pediatrics 2010:125:361)

• Increased cardiovascular risk fro m childhood overweight/obesity is n o t permanent! Data fro m 4 co ho rts dem onstrated tha t non-obese adults w h o w e re overw eight o r obese as children had reduced risks fo r Type 2 D M , H T N , dyslipidemia, and atherosderosis sim ilar to those w h o had been never overw eight o r obese (N Engl J Med 2011:365:1876)

B R E A S T - F E E D I N G

B re a s t- fe e d in g R a te s U n it e d S ta te s , 2001 (C D C National Immunization Survey 8/1/11; accessed January 2012)

• 74,5% in itiate, 44.3% a t 6 mo, 23.8% a t 1 y r o f age

• Goal f o r H ealthy People 2020: 82% in itia te , 60.6% a t 6 mo, 34.1% a t 1 yo In f a n t B e n e fits (Pediatr Rev 2011:32:267; Pedatrics 2012;129:e827)

• C o lo s tru m kn ow n as " fir s t im m un iza tion ” containing high co nce ntratio ns o f antibodies • T im m unity: i A O M , G l infections, hospitalizations fo r lo w e r re sp ira to ry infections, NEC. Effect o f maternal ¡mmunoglobulins in human milk at mucosal level in mouth, nasopharynx, and G l by blocking e n try o f microbes; also has a nti-infla m m ato ry and a nti-oxidant p roperties, and p ro bio tics tha t lim it g ro w th o f intestinal pathogens

• A ll benefits magnified ¡n p re -te rm infants and in th e developing w o rld

• L on g-term benefits: 4 SIDS, fo o d allergies, a to p ic derm atitis, asthma, celiac dz, IBD, obesity, DM II, leukemia, and lym phom a; im proved n eurodevelopm ental outeom es, visual and a u d ito ry acuity, intelligence scores, teachers ratings

M a te r n a l B e n e fits

• i risk o f breast and ovarían C A , D M II (if no h is to ry o f gestational diabetes); cumulative breast-feeding >12 m o: i risk fo r RA, H T N , hyperlipidem ia, C V dz

• May facilítate re tu rn to pre-pregnaney w e ig ht and reduce o steoporosis and postp artu m depression b u t data less clear

• Benefits f o r in fant and m o th e r c o rre la te w ith dose and d ura tio n o f breast-feeding C o n t r a in d ic a t io n s

• Infant w ith elassie galactosemia (galactose 1-phosphate urid yltransferase deficiency), maple syrup u riñ e disease, phenylketonuria

• C e rta in medications: Search fun ctio n available on LactMed: h ttp ://to xne t.n lm .n ih .g o v/ cgi-bin/sis/htm lgen?LACT

• M o the r receiving radioactive isotopes until cleared, antim etabolites o r chem otherapeutic agents, o r those using drugs o f abuse. If stable on methadone maintenance O K to BF • Bacterial m astitis: A llo w f o r m aternal c o m fo rt and 24 h r o f effective a n tib io tic rx • HSV, v a rice lla -zo ste r lesions o f th e breast (m ay use o th e r breast if unaffected),

c onsider anci-viral ppx in infant along w ith anti-viral rx o f m o th e r

• H IV in fectio n in developed w o rld (exclusive BFing may pro vide survival b enefit in places w h ere the re is lack o f clean water, p o o r availability o f form u la, and high rate o f dehydrating illness)

• M o th e r w / HTLV 1 o r 2, active untreated p ulm o n a ryT B (until infant on IN H o r m o th e r tre ate d fo r 2 w k), untreated brucellosis

• Maternal C M V ¡n p re-term o r L B W infants: Poss assoc w / late onset sepsis-like syndrome; antiviral rx may be indicated

N O T C o n t r a in d ic a t e d

• Maternal Hep B surface antigen positive, Hep C in fection (unless co -infected w / HIV) • Maternal carriage o f C M V fo r te rm Infants, isolated m aternal fever

" Candidal in fection o f breast; tre a t b o th m o th e r and infant and co ntinué BFing S e le c te d A A P B r e a s t- fe e d in g R e c o m m e n d a tio n s

• Baby Friendly Hospital Initiative (b y W H O -U N IC E F ) endorsed byA A R prom otes 10 steps to successful breast-feeding

• V itam in D supplem entation • Begin fro m b irth ; 400 IU daily

• D /c w hen daily consu m p tion o fV ita m in D -fo rtifie d form u la o r m ilk >500 mL • Frequency o f feeding

• 8 - 1 2 tim es daily d uring in itia tio n ; 6 -8 tim es daily when w ell established • N o w a te r needed u nd er 6 m o; no c o w ’s m ilk until age 1 y r

• Intro d uce d co m p lem en tary iro n -rich foods a t 4 -6 m o (A A P recs 6 m o fo r exclusively breast-fed infants), o th e rw ise supplem ent 1 mg/kg/d iro n starting a t 4 m o u n til then • F ollow -up visits

• C h eck w e ig ht and breast-feeding a t 3 -5 d and 1 0 -1 4 d B r e a s t- fe e d in g S u p p o r t

• Lactation co nsu ltan t w w w .ilca.o rg , La Leche League w w w .llli.o rg

C ow ’s

See A lle rg y sectlon.

Re f l u x

See G l section.

SUDDEN INFANT DEATH SYNDROME ( SI DS)

D e f in itio n (Pediatrics 2011:128^1341; Pediatr Rev 2007:28:209)

• Cause assigned to unexplained death o f infant <1 yo a fte r tho ro u gh eval including scene investigation, autopsy, and review o f clinical history. Infant usually previously healthy • C om prises m a jo rity o f SUID (sudden unexpected infant death), w h ich is te rm fo r all

such deaths, w h e th e r cause id entified o r n o t E p id e m io lo g y

• 2,327 infants in 2006 in US: 3:2 - <J:§, Black and A m e rican-lndian infant rates double th a t o f w h ite infants. Asian and Hispanic infants rate half o f w h ite infants

• Rate L fro m 1.2 deaths p e r 1,000 live b irth s in 1992 to 0.57 in 2001, stable since then. A A P issued recs on supine sleeping in 1992, “ Back to Sleep’’ education campaign began in 1994. Changes since 1999 may be related to reclassification o f o th e r causes o f SUID • Similarly, prevalence o f supine sleep p ositio n in g stable since 2001 a t 75% • T h ird leading cause o f death in infancy, to p cause o f death in 1 -1 2 m o -o ld age group R is k F a c to rs

• Prone and side sleeping p ositions (T risk o f re-breathing e xpired gasses),soft bedding, overheating. Risk higher in side sleeping than in p ro ne positio n

• M aternal smoking during pregnancy and e nvironm ental tobáceo smoke • Inadequate prenatal care, young m aternal age, p re m a tu rity o r lo w b irth w e ig ht • Family w ith one SIDS death has 2 -6 % risk o f a second SIDS death

P a th o p h y s io lo g y : P ro p o s e d M e c h a n is m s

• Convergence o f exogenous stressor (i.e„ prone position), critical period o f developm ent (i.e„ im m ature cardio-respiratory/arousal systems), & vulnerable infant (i.e., L B W ) lead to Progressive asphyxla, bradycardia, H o T N , m et acidosis, ineffectual gasping, and death • Re-breathlng theory: Prone infants trap exhaled C O2 around face, 1 arousal. Some SIDS

infants w / brainstem w / SHT-R abn at ventral medulla; l arousal resp to hypercarbla & hypoxia • In ú te ro n icotin e expo sure alters expression o f n lco tin ic acetylcholine re c e p to r ¡n

b rainstem areas th a t c o n tro l a uto no m ic fun ctio n, depresses re co ve ry fro m hypoxia, and Impairs arousal p atterns

• Some SIDS infants w / p olym orphism s in 5 H T tra n s p o n e r gene w / i [S H T ] a t synapse • O th e r genes related to Q T pro lon g atio n and a uto no m ic nervous System developm ent D if f e r e n t ia l D ia g n o s is

• Sepsis, PNA, cardiomyopathy, congenital h eart dz, arrhythm ia, prolonged QT, accidental o r non-accidental trauma, suffocation, and inherited m etabolic disorders

R is k R e d u c tio n

• Supine sleep p ositio n a t all tim es (rem ind 2° caregivers)

• Firm c rib m attress covered w / single fitte d sheet; avoid blankecs b u t if used, should be tucked in on 3 sides, n o t covering the face/head

• Breast-feeding (may reduce risk o f SIDS by 50%)

• A voidance o f tobáceo, sm oke, a lcohol, and illic it drug exposure

• Pacifier use confers p ro te c tio n (5 0 -60 % -l risk). Begin a fte r breastfeeding established • R oom sharing w ith o u t bed sharing (can reduce risk o f SIDS by 50%), N o evidence

th a t in-bed co-sleepers reduce ris k o f SIDS & are n o t recom m ended by AAP. Avoid co-bedding o f tw in s and múltiples

• R outine im m unization (may reduce risk o f SIDS by 50%)

• A void overheating. (R isk o f SIDS may be reduced in w e ll-ven tila te d ro o m s, possibly w ith use o f fan)

S K U L L D E F O R M I T I E S

P o s itio n a l s k u ll d e f o r m it y (Pediatrics 2011:128:136; Clin Pediatr (Phila) 2007:46:292) • E tio lo g y : Lim ited o r selective head ro ta tio n + supine p ositio n + fíat resting surface

+ rapid skull g ro w th + g ravity = p ositional skull d e fo rm ity • B a s ic ty p e s

• Plagiocephaly: From G re ek “ plagios” fo r oblique o r slanting and “ kephalos" fo r head, asym m etric flattening o f o ccipu t w / a n te rio r displacement o f ipsilateral ear, forehead, & cheek; resulting in shape sim ilar to parallelogram; -70% rig h t sided, n o t related to handedness

• Scaphocephaly/dolichocephaly: From G re e k “ skaphe" fo r boat o r skiff, T’d a n te rio r- p o s te rio r relative to biparietal diam eter, o fte n develops in premies

• Brachycephaly: From G re e k “ brakus” f o r sh o rt, t ’d biparietal relative to A P diam eter, can re su lt fro m sym m etric fla tte ning o f o cciput; m o re com m o n in Asia

• E p id e m io lo g y : Depends on c rite ria used, seems to have t ’d significantly since AAP's “ Back to Sleep” campaign starte d , likely b tw 1 3-48% o f infants u nd er 1 yo • R is k fa c to r s

• Assoc w / supine pos, male g ender,firstborn status, m o to r delay o r I tim e on abd, t use o f car seats/carriers, unvaried feed position "head positional preference”

• Skull d e fo rm ity may be p re sen t a t b irth , related to in tra u te rin e c o n stra in t (m últiples, oligohydram nios, breech), fórceps o r vacuum use a t delivery, p re m a tu rity • Can also re su lt fro m o r be exacerbated by to r tic o llis o r visual déficits • C lin ic a l p r e s e n ta tio n

• Vast m a jo rity o f parents re p o rt no flattening o f head a t b irth

• Flattening n oted, w o rse ns betw een 0 -4 m o ;ty p ic a lly stabilizes 4 - 6 m o; becomes less noticeable a fte r 6 m o

• Flattening o f o ccipu t, a n te rio r displacem ent o f ipsilateral ear, forehead, and cheek • Head cakes on a parallelogram shape

• D iffe r e n tia l: Lam bdoid craniosynostosis presents sim ilarly; rare: Incidence 3 in 100,000 • In c o n tra st to DP.ear p o s te rio rly displaced (" if th e ear is near, stee r clear” ,and refer);

head takes on a trapezoidal shape

• Palpable bony ridge a t lam bdoid suture, between o ccipita l and parietal bones • D ia g n o s is , p r e v e n tio n , a n d t r e a t m e n t

• N o te ris k factors, evalúate head shape a t each w e ll visít • Imaging n o t needed; assess fo r to r tic o llis o r visual defeets

¡K U Ll D E F O R M IT IE S M il