on 05-Feb-2017 (Sun)

1. NUTRITION

• Infant feeding (30cc/1oz): breast (20kcal/oz, 0.67kcal/cc), AVG need (100kcal/kg/d)

• For a 9mo, select which foods can be introduced at this age? What are the normal feeding stages for a child?

• 0-6mo: breast milk or formula, 2-4oz (60-120ml) per feed, 8-12 feeds/day, 20-25min per feed
• 6-8mo: solid food introduction – do not delay beyond 9 mo
  • 2 to 3 new foods/wk with few days in between (monitoring allergies)
  • Suggested order: meat/alternatives/iron enriched cereal (rice cereal is least allergenic)àpureed vegetablesàfruit
  • Breast milk/formula (6-8oz, 3-5/day) + infant cereal/biscuit/vege/fruit/meat/beans
• 8-12 mo: finger foods and switch to homogenized (3%) milk (9-12mo); breast/formula (6-8oz, 3-4/day) + cheese/yogurt, bread/pasta, infant cereal, veg/fruit, meat/beans
  • Foods to avoid: honey (risk of botulism), added sugar/salt, juice (not nutritious, too much sugar), anything that is a choking hazard (chunks, round foods like grapes)
• >12mo: avoid excessive milk (i.e. <16 oz/d)
• Wt often falters before length (if length ↓, chr)
• Feeding milestones
  • 0-4mo: root, suck, swallow
  • 6mo: holds bottle/cup
  • 8-12mo: finger feed, chew
  • 12-18mo: uses cup, spoon
  • 18-24mo: likes eating w/ hands
  • 2-5y: food jags (fixated on few foods)
  • 4-5y: knife, fork, good self-eater
    
    Composition of Human Milk
    • Colostrum
    o Energy value
    o Increased sodium, potassium, chloride
    o Increased protein, fat‐soluble vitamins, minerals
    o High level of antibodies
    o Facilitates passage of meconium and establishment of Lactobacillus
    bifidus flora in infant’s gut
    • Mature Milk
    o Energy value (0.67 kcal/mL)
    o Fat (mainly triglycerides)
    o Carbohydrates (mainly lactose)
    o Protein (Whey>Casein)
    o Vitamins/Minerals (except Vitamin D)

Benefits of Breastfeeding
• Infants
o Maternal‐infant bonding
o Composition – digestible macronutrients
o Protection against infections (AOM, RSV infection, diarrhea)
o Passive immunity (macrophages, lymphocytes (IgA), lactoferrin,
lysozyme)
o Decreased incidence of SIDS
o Decreased allergies/atopy
• Maternal
o Decreased postpartum bleeding & faster uterine involution
o Lactational amenorrhea and delayed resumption of ovulation
o Earlier return to pre‐pregnancy weight
o Improved bone remineralization postpartum (and decreased hip
fracture in postmenopausal period)
o Decreased cost
o Ready availability without prep time

Contraindications to Breastfeeding
• Medical Disorders
o Baby: Galactosemia
‐ Absent liver enzyme galactose‐1‐phosphate uridyltransferase
‐ Unable to metabolize galactose, lactose (glucose + galactose)
‐ Without galactose restriction, leads to liver failure and mental
retardation
• Infections
o Mom: HIV, Human lymphotrophic virus (HTLV‐1 or HTLV‐2),
herpetic lesions on breast, active untreated TB
• Medications (www.motherrisk.org)
o Chemotherapy, immunosuppressants, lithium, ergot alkaloids,
radiopharmaceuticals, bromocriptine, iodides

Supplements Required When Breastfeeding
• Vitamin D
o Supplemental dosage: 400 IU/d
o Side effects w/out supplementation: Rickets/hypocalcemic seizure
37
Markers of Successful Breastfeeding
• ≤7% weight loss i...

1. GROWTH
   1. Failure to Thrive: cross 2 %-tiles, wt <3%-tile, <80% ideal body wt

• A 14yo ♂ with 1y Hx of FTT. He is pale and has diffuse abdominal pain. What are possible causes? What are 5 tests you would do to narrow your differential?

• DDx: non-organic, celiac, IBD, CF, T1DM, haematologic, malignancy, liver disease, obstructive uropathy
• Ix: CBC/Fe, celiac screen (tTGT), lytes, urea, Cr, TSH, U/A, Ca²⁺, Vit ADE

• 14yo at 3^rd %ile weight + 10^th %ile height is not eating well. What are 3 possible causes?

• See above

• A full term baby presents with an eating disorder (i.e. FTT). What is your DDx?

• ↓intake: non-organic, GERD, structural, CNS, genetic
• ↓absorption: CF, CMPA, short gut, biliary atresia, GI
• ↑loss: gastroenteritis
• ↑demand: cardiac, ↑THY, infection, respiratory
• Ineffective use: inborn error of metabolism
  2. Obesity

• 14yo ♂ with weight of 67 kg, height 150cm.

• Calculate BMI: 29.8 kg/m²
• 4 complications of obesity: HTN, dyslipidemia, OSA, SCFE, nonEtOH fatty liver
• 3 tests to perform for obesity: lipids, GLUC, HbA1c, ALT/AST, liver U/S

Newborn Growth Parameters
Weight
• At birth = 3.0‐3.5kg (avg)
• Normal to lose up to 10% of birth weight in first 4‐7 days
o BUT should return to birth weight no later than 10‐14 days
• Doubles birth weight by 4‐6 months; triples birth weight by 1 year
• Quadruples birth weight by 2 years
Head Circumference
• At birth = 35cm (avg)
o <32cm 􀃆 small head = small brain until proven otherwise
• May be inaccurate at birth due to caput succedaneum, molding
• 0‐3mths = +2cm/mth
• 3‐6mths =+1cm/mth
• 6‐12mths = +0.5cm/mth
Height
• At birth = 50cm (avg)
• Doubles height by 4 years
• Measure recumbent length until 2 years, then standing height

Normal Growth Velocity


Growth Charts
• Critical to use gender and age appropriate growth charts
• In 2010, the CPS, RCFPC and the Dieticians of Canada, recommended
the use of the 2006 WHO Growth Standards and Reference charts
• WHO Growth Standards based on longitudinal data from solely breast
fed for first six months, healthy children from diverse ethnic and
geographic backgrounds; use BMI after age 10.
• Growth charts are also available for premature infants and certain
syndromes
• Use corrected age up to 2 years for plotting premature infants

Failure to Thrive
Definition
• Weight < 3%ile (the further below the curve the more likely to be
pathologic in origin)
• Weight falls across major %ile lines
• Weight < 80% of ideal body weight*
* use appropriate growth charts for gender and certain genetic conditions
Factors Affecting Physical Growth
• Genetics
• Intrauterine factors
• "Internal time clock"
• Nutrition
• Endocrine hormones
• Chronic infections/diseases
• Psychosocial factors
Etiology
• Inadequate intake: insufficient provision of food, vomiting, oro‐motor
dysfunction
• Inadequate absorption: pancreatic insufficiency, celiac disease
• Increased utilization: chronic diseases, hyperthyroidism
• Ineffective utilization: chromosomal disorders
• Increased losses: chronic diarrhea, urinary losses
Differential Diagnosis
Nonorganic/
Psychosocial
Most common cause of FTT, often seen in conjunction with organic FTT
Specific ...

1. DEVELOPMENT [See chart]
   1. NORMAL

• Case on child not toilet training: what is the likely reason?

• Not yet interested in learning how, i.e. few signs present (requires physiologic, communication, psychologic)

• 5yo has been developing normally, but his father has been concerned he's been showing poor speech. What's the first Ix to do?

• MCQ: audiology testing, NOT genetic testing

• Developmental milestones for 6mo.

• Normal: tripod sits, pivots in prone position, reaches/grasps objects, brings toy to mouth, babbles, squeals when excited, grunts in anger, stranger anxiety starts

• Lists developmental progress for a 12mo, what type of delay does this child have - language, fine motor, gross motor, or global delay?

• Normal: gets into sitting position without help, stands without support, walks while holding on, neat pincer grasp, places cubes in cup with release, releases ball with throw, says 2-3 words, understand simple requests and questions, uses facial expressions/actions/sounds to make needs known, responds to own name, separation anxiety begins

• 3 yo development milestone (circle 8): I guess the biggest lesson I took away with me from this exam is from the key features section and this question in particular: listen to what your predecessors have to say about the exam in the past exams you see in this email account! When I saw, in one of the previous peds exam, that one is required to pick things out of a list of 20 development milestones, none of which appears in Toronto Notes, I did not take the warning seriously, and I'm forced to pay for my irreverence. I randomly circled 8 things and would be lucky if I can walk away with half the marks. So the lesson is that not only should you remember the short list of developmental milestones from Toronto Notes or the Peds handbook you got from year 2 for the short answers part, but you should also remember a longer, more exhaustive list of milestones from some other source for the key features version of the development milestonesànot true in 2015

• Normal: walks upstairs using handrail, stands on one foot, rides tricycles, stacks 10 blocks, twists lid off jars, copies a circle, combines 5 or more words in a sentence, understands 2-3 step commands, recognizes colours, shares willingly some of the time, make-believe games, plays with others, listens to music or stories for 5-10 minutes, jumping on one foot, washes and dries own hands, dresses self independently except shoe laces, knows own sex, tells detailed stories, knows primary colours, speaks with plurals

• Pick developmental milestones from a list (I think for a 3yo and another one for a 4yo?)

• See above

• Developmental Milestones achieved by 15 mo? 18mo? What about 6-10 yrs? 16 wks?

See chart

Developmental Milestones
There are four main areas of developement – gross motor, fine motor, language and social. All areas should be explored when exploring a
developmental history. The milestones cited are, on average, those at the 50th percentile for age.




Developmental Problems
...

DOCUMENTATION
Admission Note (Template)
Paediatric History and Physical Examination (as previous), and:
INVESTIGATIONS
• Blood work: CBC, electrolytes, glucose, renal function, liver function
• Microbiology: blood, urine, CSF, nasal, stool cultures
• Imaging: x‐ray, ultrasounds, CT, MRI
• Pathology: if relevant
IMPRESSION/ASSESSMENT (IMP)
This is a (year old) (sex) [who is previously healthy] or [with a history of
XYZ] presenting with (brief summary of pertinent positive/ negative
symptoms on history, signs on physical examination and relevant
investigations) with a most likely diagnosis of _____________.
DIFFERENTIAL DIAGNOSIS (DDX)
May chose to use broad categories by system or process when considering
specific diagnoses (i.e., use of VITAMINS ACD acronym)
Vascular, Infectious/Inflammatory, Traumatic/Toxin, Autoimmune/
Acquired, Metabolic/Medication, Iatrogenic/Idiopathic, Neoplastic, Social,
Allergic, Congenital, Degenerative, Endocrine
MANAGEMENT PLAN/ADMISSION ORDERS (PLAN)
• Admit: Admit to (your service) under (your consultant today).
• Diagnosis: This is what you suspect they have. (e.g., Asthma)
• Diet: DAT (diet as tolerated) NPO (nothing per os/by mouth; if going
for surgery or procedures), Breast feed ad lib, Formula, Tube feeds
(NG‐tube, G‐tube, GJ‐tube)
• Activity: AAT (Activity as Tolerated), bedrest
• Vital Signs: VS (Vital Signs q8‐12h = HR, RR, BP, O2 sat, Temp), VS
q4h (if particularly sick patient requiring more frequent vitals),
Special parameters (e.g., Neurological vitals)
• Monitoring: ECG, oxygen saturation, Ins & Outs, daily weights
• Investigations
o Bloodwork (Hematology, Biochemistry)
o Microbiology
o Imaging
o Consults
• Drugs
o Past: Medication Reconciliation – all regular medications (may not
need all; e.g., no need for previous PO antibiotics if starting IV)
o Present: what does patient need now
o Future: anticipate what patient may need; e.g., fever, nausea, pain,
stools

Progress Note (Template)
(Service) Progress Note
Date, Time
ID
Age, sex with a history of (non‐active/chronic issues) admitted with (list
active/acute issues for why the patient is admitted). Could also include a
list of recent events that occurred since the most recent note.
SUBJECTIVE
• How was patient overnight, how they feel that day, any new concerns
from the patient/parent
• What has changed since the previous note? Does the patient have any
new symptoms? Any pain? How is the patient coping with the active
symptoms, progression, better/worse.
• Ask the parents and patient’s nurse: behaviour, activity, sleep,
appetite, in and outs.
OBJECTIVE
Vitals: HR, BP, RR, SaO2, Temp, daily weight, pain
I/O: Inputs (Diet, IVF), Output (U/O, BM/Diarrhea, Vx, Drains), fluid
balance
General: what the patient is doing, appearance, behaviour, cognition,
cooperation, disposition
P/E: focused physical exam of system involved plus CVS, RESP, ABDO as it
is common for hospitalized patients to develop problems in these regions.
INVESTIGATIONS
New lab results, imaging or diagnostic tests/ interventions and relevant
results still pending
MEDS
Reviewed daily regarding changes such as new/held/discontinued/
restarted (e.g. Ampicillin day 2/10)
IMPRESSION/ASSESSMENT (IMP)
Summarize what the new findings mean, what progress is being made.
Stable vs. Unstable? Improved vs. Worsened? Waiting investigations/
consult? Differential diagnosis if anything has been ruled in/out?
PLAN (P)
1. Issue (1) 􀃆 plan (e.g., UTI on Day 2 of Empiric Abx, likely 14 day
course required, await urine C&S)
2. Issue (2) 􀃆 plan
3. Issue (3) 􀃆 plan
4. Disposition – plans for home, transfer

Discharge Summary (Template)
Check patient’s name, medical record n...

Identifying Data (ID)
• Name, age (years + months), sex, race
• Individuals accompanying the patient and their relationship to patient
• Previously healthy or any known major diagnoses
Chief Complaint (CC)/Reason for Referral (RFR)
• In patient’s or parent’s words (include duration of symptoms)
History of Present Illness (HPI)
• Open‐ended question, allow parents or child to express their concerns
• Select key symptoms and expand (OPQRSTUVW+ARC):
o Onset (“When was your child last well?”), frequency, duration,
timing (intermittent vs. constant),
o Progression of illness over time (“What happened next?”)
o Quality of symptoms (description, character)
o Relieving and aggravating factors
o Severity of symptoms (quantity, visual analog scale)
o Timing and treatments sought out thus far
o U – “How is this illness affecting U?” (school, work, activities
missed)
o V – Déjà Vu: “Has this happened to you before”, similar past
episodes and treatment, outcome, complications
o What do you think is going on or what are you worried about?
o Associated Symptoms (e.g., if CC is vomiting, ask about abdominal
pain, diarrhea, fever etc.)
o Risk Factors (e.g., if CC is cough, ask about personal and family
history of asthma, eczema, atopy, allergies, exposure to smoking)
o Complications (e.g., if CC is sickle cell crisis, ask about transfusions,
chest crises, ICU admissions, major infections etc.)
• For any infectious disease symptoms always ask: recent exposures to
sick contacts (family, daycare, school), recent travel, recent antibiotic
use, animal or pet exposure
• Current hospital management: What has happened so far since you
arrived at the hospital? Treatments received, investigations, your
understanding of the plan for admission
Past Medical History (PMHx)
• Significant past or ongoing medical problems including:
o Acute illnesses requiring ER visits, antibiotics, hospitalization
o Chronic illnesses (e.g. asthma, diabetes, congenital heart disease)
o Surgeries
o Accidents or injuries
o Community resources/services involved or referrals in place (e.g.
speech and language, occupational therapy)
o Other physicians or specialists involved in care
Prenatal/Pregnancy History (Preg)
• Mother’s age
• Obstetrical history – GTPAL
• Current pregnancy – “How was your pregnancy?” Any complications?”
o Screening: blood group, Rh, DAT, HBsAg, Rubella, Syphilis, HIV, GBS
o Genetic screening: MSS, FTS, IPS, amniocentesis, special tests
o Ultrasounds
o Complications: illnesses, infections, bleeding, gestational diabetes
(GDM), gestational hypertension (GHTN),
• Medications, vitamins, iron, smoking, drinking, drug use
Labour and Delivery or Birth History (L&D)
• Gestational age at birth, birth weight
• Labour complications: prolonged rupture of membranes, maternal
temperature, fetal tachycardia, meconium
• Spontaneous vaginal delivery (SVD), interventions required: forceps,
vacuum, caesarian section (C/S) and why
• Resuscitation: APGAR score, routine care, need for resuscitation, NICU
admission, duration
Newborn or Neonatal History (Neonatal)
• Common problems: jaundice, poor feeding, difficulty breathing,
cyanosis, seizures
Medications (MEDS)
• Current medications, purpose, start date, dose, duration, recent
changes and compliance
• Past medications taken for an extended period of time
• Over the counter (OTC), complementary and alternative products
(CAM), vitamins
Allergies
• Commonly no known drug allergies (NKDA)
• Medications, type of reaction (If anaphylactic then Medic alert, epipen)
• Environmental, seasonal, food
Immunizations
• Check if immunizations up to date (IUTD), any additional vaccines
given
• Ask to see immunization record
Developmental History
• Hav...

ADDD EFFIL MOOPPPS

Acetaminophen:
- Blocks pain impulse
generation, inhibits
hypothalamic heatregulating
center to
produce antipyresis
-Pain, Fever
-May cause
hepatotoxicity at high
doses. Caution use in
patients with hepatic
impairment

Dimenhydrinate
(Gravol®)
-Blocks chemoreceptor
trigger zone, diminishes
vestibular stimulation
-Nausea,
Vomiting
-May cause sedation

Diphenhydramine
(Benadryl®)
-Competes with
histamine for H1
receptor sites on
effector cells in GIT,
respiratory tract, blood
vessels
-Pruritis
-May cause sedation

Dexamethasone:
- Anti‐inflammatory;
better taste, lower
volume than prednisone
-Asthma
Croup
-Immunosuppression
Weight gain
Hyperglycaemia
Hypertension

Epinephrine
Inhaled:
-Stimulates α, β1 and β2
adrenergic receptors to
relax smooth muscles of
bronchial tree
-Bronchiolitis,
Croup
-Can cause tachycardia

Iron (ferrous
fumerate,
ferrous
sulphate)
-Replaces iron
-Iron deficiency
-Can cause constipation,
black stools

Fluticasone
-Inhaled steroid, minimal
systemic absorption
-Asthma
(inhaled)
Allergic
Rhinitis
(intranasal)
-Ask patients to have a
drink or gargle after
inhaled use to clear
from back of throat.

Ibuprofen
-Reversibly inhibits COX
1 and 2 to decrease
prostaglandin
formation.
-Pain, Fever
-Can cause GI irritation.
Caution use in renal
impairment

Lorazepam
-Benzodiazepine. Binds
to GABA Rc complex and
enhances affinity of
GABA for its Rc site on
the same complex.
-Seizure
Anxiety
disorder
Severe nausea
-Anterograde amnesia,
risk of paradoxical
effects. Risk of CNS
depression and
excessive sedation.

Morphine
-Binds to opiate
receptors in the CNS to
inhibit pain pathways.
-Pain
-May cause CNS
depression

Omeprazole
-Inhibits parietal cell
H+/K+ ATP pump to
suppress basal and
stimulated acid
secretion
-GERD
-Fairly well tolerated.
Can cause headache, GI
side effects (abdominal
pain, diarrhea, nausea)

Ondansetron
-Selective 5‐HT3‐
receptor antagonist,
blocking serotonin, both
peripherally on vagal
nerve terminals and
centrally in the
chemoreceptor trigger
zone
-Post‐operative
nausea &
vomiting,
gastroenteritis,
cyclic vomiting
-Can cause QTc
prolongation. Caution
use in patients with
known QT
prolongation or in
patients on other QTc
prolonging agents.

Phenobarbital
-Long acting barbiturate
with sedative, hypnotic
and anticonvulsant
properties
-Seizures
-Can cause CNS
depression

Polyethylene
Glycol 3350
-Osmotic agent. Causes
water retention in stool
to increase stool
frequency
-Constipation
-Can cause abdominal
bloating, cramping,
nausea and diarrhea

Prednisone
-Decreases neutrophil
migration and reverses
capillary permeability
to prevent or control
inflammation
-Asthma
-Immunosuppression,
weight gain,
hyperglycemia,
hypertension

Salbutamol
-Acts on β2 receptors to
relax bronchial smooth
muscles
-Asthma
-Tachycardia,
hypokalemia,
restlessness

PEDIATRIC PHYSICAL EXAM

General (GEN)

• Appearance: Distressed? Sick? Toxic?

• Behaviour: Co‐operative, agitated, level of activity (sedate, listless, alert, active, playful), communication (interactive, shy, non‐verbal), interaction with caregivers and interviewer

• Development: “pulling up to stand in crib”, “running around”

• Dysmorphic features and body habitus: look at face, ears, hands, feet, genitalia, height, weight, body fat

• Colour: cyanotic, gray, mottled, pale, pink, jaundice

• Nutritional Status: malnourished, well‐nourished, overweight, obese

• Hydration Status: Mucous membranes, tears, skin turgor, fontanelle, sunken eyes, in addition to appropriateness of vital signs. Classify: mild, moderate, severe dehydration

• Circulation: Signs of poor circulation? (e.g., cool extremities; weak, rapid pulse; poor capillary refill; cyanotic, gray, or mottled colour)

• Respiratory: Work of breathing

Normal Pediatric Vital Signs

AGE HR SYSTOLIC BP RR Newborn (<1 week) 90‐160 60‐70 30‐60 Neonate (<1 month) 90‐140 75‐90 30‐60 Infant (<1 year) 100‐190 75‐120 24‐40 Toddler (1‐2years) 90‐150 75‐120 22‐34 Preschool (3‐5years) 90‐120 75‐125 18‐30 Child (6‐12 years) 60‐120 83‐120 16‐24 Adolescent (>12 years) 70‐100 90‐130 12‐18 Adult (>18 years) 60‐100 90‐130 12‐18

• Blood pressure averages vary significantly based on age and height

• A general rule for average blood pressure in children and adolescents is: o Systolic BP 50th percentile (sBP) = 90 + 2 X age o Diastolic BP (dBP) = 2/3 X sBP

Normal Temperature Ranges Syllabus: Leduc et al. Temperature measurement in paediatrcs. Canadian Paediatric Society. 2015.

ROUTE NORMAL TEMPERATURE RANGE Rectal 36.6°C to 38°C (97.9°F to 100.4°F) Ear 35.8°C to 38°C (96.4°F to 100.4°F) Oral 35.5°C to 37.5°C (95.9°F to 99.5°F) Axillary 34.7°C to 37.3°C (94.5°F to 99.1°F)

12

Temperature Measurement Techniques

AGE SUGGESTED TECHNIQUE

Birth to 2 years

1. Rectal (definitive) 2. Axillary (screening low risk children)

Over 2 years to 5 years

1. Rectal (definitive) 2. Axillary, Tympanic (or Temporal Artery if in hospital) (screening)

Older than 5 years

1. Oral (definitive) 2. Axillary, Tympanic (or Temporal Artery if in hospital) (screening)

Anthropometrics

• Weight (Wt, kg)

• Height (Ht, cm) o Supine length to 2 years, then standing height

• Head Circumference (HC, cm) o Generally do from birth to 2 years. >2 yrs, if have specific concerns

• BMI

HEENT (Triple S: size, shape, symmetry)

• Head: shape and symmetry of skull/fontanelles, dysmorphic, sutures

• Eyes: red reflex in infants, strabismus, pupillary response, fundoscopy, lids, conjunctivitis, acuity (>3 years)

• Ears: otoscope, tympanic membranes (TM x 2): clear, erythematous, bulging, effusion, retracted, ear shape, hearing

• Mouth: lips (lesions, colour), mucous membranes including gingiva, tongue, hard/soft palate

• Dentition: presence of teeth, tooth decay

• Pharynx: tonsils, erythema, exudates

• Neck: lymphadenopathy, masses, thyroid, webbing (Noonan, Turner syndrome), torticollis, nuchal rigidity

...

Abstract

Although immunization has decreased the incidence of bacterial pneumonia in vaccinated children, pneumonia remains common in healthy children. Symptoms of bacterial pneumonia frequently overlap those present with viral infections or reactive airway disease. Optimally, the diagnosis of bacterial pneumonia should be supported by a chest radiograph before starting antimicrobials. Factors such as age, vital signs and other measures of illness severity are critical when deciding whether to admit a patient to hospital. Because Streptococcus pneumoniae continues to be the most common cause of bacterial pneumonia in children, prescribing amoxicillin or ampicillin for seven to 10 days remains the mainstay of empirical therapy for nonsevere pneumonia .If improvement does not occur, consideration should be given to searching for complications (empyema or lung abscess). Routine chest radiographs at the end of therapy are not recommended unless clinically indicated.

Key Words: Antimicrobial therapy; Bacterial pneumonia; Viral pneumonia

Most physicians who care for children and youth have had experience with managing acute pneumonia. The incidence of pneumonia due to any etiology is lower in the developed areas of the world compared with less developed areas because immunization coverage rates may be lower in developing areas.[1] Pneumococcal conjugate vaccines have been shown to decrease radiologically proven pneumonia admission rates in children younger than five years of age by an average of 27%.[2][3]

The present practice point focuses on the current diagnosis and management of uncomplicated, acute, community-acquired pneumonia in healthy immunized children with no underlying pulmonary pathology aside from mild reactive airways disease. The present practice point does not apply to persistent (chronic) pneumonia syndromes (with symptoms for >2 weeks), aspiration pneumonia or recurrent pneumonias, or to pneumonia associated with chronic medical problems such as immunodeficiency, because these pneumonias may be caused by different pathogens or require more extensive investigation. The present practice point replaces a previous document published in 2011.[4]

Definition and host risk factors

Pneumonia is an acute inflammation of the parenchyma of the lower respiratory tract caused by a microbial pathogen. Bacterial infections are usually primary but, occasionally, viral respiratory tract infections such as influenza are followed by bacterial pneumonias.[5] Uncomplicated pneumonias may be accompanied by small parapneumonic effusions. Evidence of empyema (pus in the pleural space), a lung abscess or a necrotic portion of lung parenchyma implies the development of a complicated pneumonia.

Etiology

The most common causes of pneumonia in infants and preschool children are viruses that usually, but not exclusively, circulate in winter (eg, respiratory syncytial virus, influenza, parainfluenza virus and human metapneumovirus). Viruses as a sole cause of pneumonia are less common in older children, with the exception of influenza.

Among bacteria, Streptococcus pneumoniae continues to be the most common bacterial pathogen causing pneumonia in children of all ages. Group A streptococcal pneumonia is much less common. Although Staphylococcus aureus

...

viral:
more assc sx's, high/low lymphocytes

bact:
higher T, just cough &amp; fever, really high/low WBCs (neutrophils), ESR higher

1) • Identification: • Name • Date • Supine or erect

2) quality: rotation, penetration (intervertebral spaces through the heart shadow), Inspiration (when the 8-9th posterior rib is visible or 6th anterior rib)
-Hyperinflation – > 9 posterior ribs
-Poor inspiration – < 8 posterior ribs

3) white:
-soft tissue
-bones
-heart (size, shape, position)

4) black structures
-Trachea and bronchi
-Lungs – Size – Compare 3 lung fields – Hilum and vascular structure (» Size » Shape » Density)
- Stomach bell

5) Other structures
– Diaphragm
– Costrophrenic angles and pleura
– Mediastinal structures

One of the fi rst tasks as an emergency
physician is to put the patient at ease. Talk
to the child as well as the parents. For
older children, introduce yourself to them
fi rst before the parents and sit down on
the bed or chair as to not tower over them.
Try to facilitate the relationship and open
up communication by noticing something
cool about them (i.e. light-up shoes, Dora
T-shirt or fun toy).

While doing the actual physical exam, try
to use the parent’s lap as much as possible
as the child is most comfortable there. To
distract and calm them, consider telling
them a story throughout the exam or try
to make the physical exam a game – play
with the instruments.

Finally, consider
having something fun in your pocket such
as stickers or a bubble-blowing pen to
make the experience more enjoyable.

observation is the best initial diagnostic
tool. The degree of alertness and
interaction, responsiveness to parents and
respiratory status are all valuable measures
of illness that may either suggest or
eliminate concerns of toxicity.

After observation, it is important to begin
the exam with auscultation of the heart
and lungs as this is usually when the child
is calm, quiet and most cooperative. Do
not forget that a negative lung auscultation
is not suffi cient to rule out signifi cant
pulmonary disease; the appearance of the
patient (tachypnea, respiratory distress) is
much more predictive.

The last items to perform in the physical
exam should always be those things that
are most threatening to the child, including
looking in the ears and mouth.

Newborn
Case 1: A 3-week-old male presented to the
emergency department for congestion and
cough. Mom stated that the infant was not
eating as well, but had normal wet diapers.
No fever noted at home or on exam.
As mentioned above, it is important to
observe the newborn. One of the best tips
is to undress and hold the baby. Holding
allows the clinician to assess multiple
things at once, including level of alertness,
respiratory status and tone. This initial
assessment gives the clinician a good
sense of “sick or not sick.”
It is also important to have the baby
undressed to do a careful examination,
looking for rashes, bruises, hair
tourniquets, etc. During the exam, this
newborn was observed to have an apneic
episode. The patient was admitted for
an evaluation that ultimately revealed a
diagnosis of pertussis.
Infant

Infant
Case 2: A 5-month-old male presented
with fever and fussiness. The patient
was seen fi ve days earlier with fever and
URI, diagnosed with otitis media and
discharged home with amoxicillin. Prior to
arrival, the patient had multiple episodes
of vomiting and decreased urine output.
Initial assessment revealed an illappearing,
febrile infant. While observing
the infant and beginning the physical
exam, it is important to place your hand on
the infant’s head and assess the fontanelle.
A fontanelle is measured as full, fl at, or
depressed. Cup your palm on the back of
the baby’s head and then move forward.
The curve of your palm should touch the
fontanelle if it is normal. If the fontanelle
doesn’t touch, it is depressed; if it pushes
your hand up, it is full.
In young infants, a bulging fontanelle may
be seen with meningitis, but meningismus
is rare before one year of age. Another
possible exam fi nding in infants with
meningitis is a paradoxical response
to consoling maneuvers like cuddling.
When a caregiver “cuddles” an infant,
the meninges are stretched and irritated
making the infant more fussy. By contrast,
the same infant will calm when laid fl at.
This infant’s fontanelle was full and
tense. Throughout the exam, the patient
was irritable and diffi cult to console. The
infant was appropriately resuscitated and
underwent a full septic work-up, revealing
pneumococcal meningitis.

Toddler
Case 3: An 18-month-old male presents
with complaint of seizure witnessed at
home 20 minutes prior to arrival.
Many pediatric patients will present to
the emergency department after a seizure.
When evaluating this patient, it is crucial to
do a good neurological exam. The biggest
tip for the pediatric neurological exam is
to stop, look and listen. You will learn the
most from the child’s spontaneous activity,
including mental status, cranial nerves,
coordination, and motor status.
Assess patients based on developmental
milestones for their age group. If
age appropriate, make sure to watch
them walk. Also, watch the child sit
unsupported as truncal instability may be a
clue to vertiginous symptoms or cerebellar
pathology. Try to carry one thing that
could fake for a toy or draw a face on a
tongue depressor to help attract the child’s
attention.
Upon examination of this patient, he had
right-sided weakness which resolved
within an hour. The patient was diagnosed
with Todd’s paralysis and new-onset
seizure disorder.

Preschooler
Case 4: A 3-year-old female presents
with abdominal pain and fever over the
past day. Patient has some vomiting
and diarrhea. Emesis is nonbilious
and nonbloody. Diarrhea is watery
and yellow. The patient has also had
decreased oral intake and urine output. On
exam, the patient is febrile and appears
uncomfortable.
Performing a good abdominal exam is
critical for the assessment of this patient,
but can often be challenging. Children
cannot developmentally pinpoint the
location of abdominal pain until they are at
least four years old, and perhaps not even
then. With symptoms and an exam that are
nonspecifi c, abdominal pathology can be
very diffi cult to diagnose in this age group.
Attempt to calm and distract the patient as
much as possible.
For infants, make sure to have a pacifi er
available during the abdominal exam.
Another option for the crying infant is to use
sucrose to calm them during auscultation
and palpation. Flexing the hips will also
facilitate relaxation and a better exam. For
patients that are ticklish, you can have the
child place their hand on yours and push
down as if they are doing the exam.
For children with abdominal pain, make sure
to always undress the patient and evaluate for
rashes to assure that diseases like HenochSchönlein
Purpura (HSP) are not missed.
Also, referred pain is very common, and
pneumonia or strep throat may present with
abdominal pain of any location with focal or
diffuse pain on exam.
Using the above techniques, the patient
in the case was found to have signifi cant
tenderness without rebound. Upon further
evaluation, the patient was found to have
acute appendicitis.
The above tips and tricks should allow
for a smoother encounter with the pediatric
patient. If the tactics are not working,
do your physical exam in stages. Start
quickly with the most essential, then return
frequently to perform each additional
layer. Always remember that a graceful
approach will go a long way with assessing
children. „

Figure 1: Additional Tips & Tricks
General
Always undress.
Eyes
If trying to get a newborn to open their eyes, holding the infant’s head and dipping it down will cause
them to open their eyes.
Never try to pry a baby’s eyes open when they are crying as you will not be able to over power them and
will just anger them more.
Infants should fi x and follow a moving object with both eyes by 3 months of age. Use bright objects or
noises to help assess extraocular movements.
Ears
If having a hard time looking in the ears, hold arms above head.
If unable to turn their head, wiggle the otoscope light in front of their eyes and then move it to the
opposite side of the ear you want to look in. The child will often track with the light and turn their head
so their ear is then right in front of you.
Have parent stabilize the head. Use one hand to grab the pinna while holding the otoscope with the
thumb and index fi nger and using the little fi nger and heel of the hand to stabilize the otoscope against
the side of the face (See Figure 2).2
Mouth/Throat
Wetting the tongue depressor makes it taste better.
Have the child pant like a dog when doing a throat swab as it helps prevent gagging.
Heart
If worried about murmurs, gently and briefl y blow in the face of a neonate which slows down their heart
rate momentarily so that you can better ausculate for murmurs.
Lungs
If you want them to take a deep breath, can have them blow out the light on the otoscope or can ask
them to pretend to blow out the birthday candles.

Informed Consent (c.f. assent): 1) appropriate info 2) decision-making capacity 3) voluntariness (←the 3 hallmarks of informed consent)

Confidentiality

• Age not a factor
• Unless teen is
  • Suicidal, homicidal, has thoughts of self-harm/harming others
  • <16yo w/ hx of current/past abuse
  • Disclosure of abuse & children <16yo in home

Capacity & consent

• Capable if
  • Able to UNDERSTAND info relevant to making decision re: tx
    • Eg I’ll lose my leg if I don’t manage my DM
  • And able to APPRECIATE consequences of a decision
    • Eg of no appreciation: That’s in the future so I don’t care if I’ll lose my leg, I want to live my life now
• Assume everyone’s capable.
  • Don’t assume incapability b/c
    • Age, Refusal/Disagreement w/ tx, Request for alt tx, Psych/neuro dx, Disability
• Healthcare decisions for ped pts should be made jointly by health care team, parents, & child/adoles to varying deg

Assent = children given info they understand & some appropriate choice in tx

Sexual consent (Ontario): 12-13yo ± 2, 14-15yo ± 5, 16yo (no porn, prostitution, authority)

Best interests of child: looking at their interests broadly & not focusing exclusively on biomed facts; value judgment; harm-benefit balance

Family centered-care: triadic model of therapeutic relationship; child’s best interest trumps FCC

(list of 6? principles that the professor asked us to memorize for the exam)
BEST INTERESTS OF THE CHILD: survival, harms/benefits, Tx, QoL
DEVELOPING CHILD AUTONOMY
FAMILY CENTRED CARE
TRUTH TELLING/DISCLOSURE
CONFIDENTIALITY: exceptions (harm, self-harm, abuse <16y)

Failure to Thrive: cross 2 %-tiles, wt <3%-tile, <80% ideal body wt

• A 14yo ♂ with 1y Hx of FTT. He is pale and has diffuse abdominal pain. What are possible causes? What are 5 tests you would do to narrow your differential?

• DDx: non-organic, celiac, IBD, CF, T1DM, haematologic, malignancy, liver disease, obstructive uropathy
• Ix: CBC/Fe, celiac screen (tTGT), lytes, urea, Cr, TSH, U/A, Ca²⁺, Vit ADE

• A full term baby presents with an eating disorder (i.e. FTT). What is your DDx?

• ↓intake: non-organic , GERD, structural, CNS, genetic
• ↓absorption: CF, CMPA, short gut, biliary atresia, GI
• ↑loss: gastroenteritis
• ↑demand: cardiac, ↑THY, infection, respiratory
• Ineffective use: inborn error of metabolism

• 14yo ♂ with weight of 67 kg, height 150cm.

• Calculate BMI: 29.8 kg/m²

4 complications of obesity: HTN, dyslipidemia, OSA, SCFE, nonEtOH fatty liver3 tests to perform for obesity: lipids, GLUC, HbA1c, ALT/AST, liver U/S

Newborn Growth Parameters
Weight
• At birth = 3.0‐3.5kg (avg)
• Normal to lose up to 10% of birth weight in first 4‐7 days
o BUT should return to birth weight no later than 10‐14 days
• Doubles birth weight by 4‐6 months; triples birth weight by 1 year
• Quadruples birth weight by 2 years

Head Circumference
• At birth = 35cm (avg)
o <32cm 􀃆 small head = small brain until proven otherwise
• May be inaccurate at birth due to caput succedaneum, molding
• 0‐3mths = +2cm/mth
• 3‐6mths =+1cm/mth
• 6‐12mths = +0.5cm/mth

Height
• At birth = 50cm (avg)
• Doubles height by 4 years
• Measure recumbent length until 2 years, then standing height

Normal Growth Velocity

use BMI after age 10.

Failure to Thrive
Definition
• Weight < 3%ile (the further below the curve the more likely to be
pathologic in origin)
• Weight falls across major %ile lines
• Weight < 80% of ideal body weight*
* use appropriate growth charts for gender and certain genetic conditions

Factors Affecting Physical Growth
• Genetics
• Intrauterine factors
• "Internal time clock"
• Nutrition
• Endocrine hormones
• Chronic infections/diseases
• Psychosocial factors

Etiology of FTT
• Inadequate intake: insufficient provision of food, vomiting, oro‐motor
dysfunction
• Inadequate absorption: pancreatic insufficiency, celiac disease
• Increased utilization: chronic diseases, hyperthyroidism
• Ineffective utilization: chromosomal disorders
• Increased losses: chronic diarrhea, urinary losses

Differential Diagnosis:
Nonorganic/Psychosocial
-Most common cause of FTT, often seen in conjunction with organic FTT

Specific Organic Diseases
• Genetic: Turner/Downs/Russell Silver Syndrome, FAS, TORCH
• Cardiac: Chronic cardiac failure
• Pulmonary: Recurrent or chronic infections, Cystic Fibrosis
• GI: GERD, vomiting, IBD, chronic liver disease, malabsorption
syndromes (Celiac Disease, CF, Schwachman Diamond syndrome)
• Renal: Chronic renal failure, obstructive uropathies
• Endocrine: Hyperthyroidism, hypopituitarism, DM‐1, DI
• CNS: Difficulty coordinating swallow, MR, CP, Diencephalic Syndrome
• Haematology: Chronic hematologic disorders, malignancies
• Inflammatory/Immune: SLE, immunodeficiencies

Risk Factors
Child Factors
• Premature, low birth weight
• Feeding, sleep or elimination problems
• Recurrent illness
• Developmental delay
Parental Factors
• Parents abused or neglected as children
• Unwanted, unplanned pregnancy
• Marital problems, single parent
• Drugs/alcohol
• Young inexperienced parents
• Unwell/stressed parent
• Poor follow‐up, uncooperative parents
• Misconceptions of eating habits and nutrition
Child and Parental Factors
• Difficulty feeding, refusal to feed
• Colic, sleep problems
• Behavioural issues
• Parent not able to recognize child’s needs and respond to child’s cues
Environmental Factors
• Low SES, unemployment
• Lack of support, social isolation
• Lack of access to consistent medical care

FTT History
• Duration of problem, detailed dietary and feeding history, appetite,
behavior before and after feeds, BM history, vomiting
• Pregnancy, birth, birth weight, postpartum history, developmental
history, growth patterns
• Family patterns of growth including parental heights and age of
puberty
• Current illnesses, symptoms, past medical history
• Family relationships, detailed social history
• Assess child’s temperament, child‐parent interaction, feeding
behaviour, parental psychosocial issues
Physical Exam
• Ht/Wt/HC‐ plot on growth chart; compare to prior values
• HR, RR, BP
• Complete general physical examination

FTT Investigations/Imaging
• Use your history and physical exam to guide your choice of
investigations
• Consider investigations to look for etiology and investigations to assess
for other deficiencies
• CBC, lytes, urea, creatinine, TSH, T4, U/A, celiac screen, vitamin A,D,E,
ferritin, calcium
• Consider karyotype, microarray, bone age (AP x‐ray of L hand and
wrist) if also short stature
Management
• Treat underlying cause
• Provide education about age‐appropriate foods, mealtime scheduling
and behaviour
• Caloric fortification of food
• May need referral to dietitian, social work

• Case on child not toilet training: what is the likely reason?

• Not yet interested in learning how, i.e. few signs present (requires physiologic, communication, psychologic)

• 5yo has been developing normally, but his father has been concerned he's been showing poor speech. What's the first Ix to do?

• MCQ: audiology testing, NOT genetic testing

• Developmental milestones for 6mo.

• Normal: tripod sits, pivots in prone position, reaches/grasps objects, brings toy to mouth, babbles, squeals when excited, grunts in anger, stranger anxiety starts

• Lists developmental progress for a 12mo, what type of delay does this child have - language, fine motor, gross motor, or global delay?

• Normal: gets into sitting position without help, stands without support, walks while holding on, neat pincer grasp, places cubes in cup with release, releases ball with throw, says 2-3 words, understand simple requests and questions, uses facial expressions/actions/sounds to make needs known, responds to own name, separation anxiety begins

• 3 yo development milestone (circle 8):

• Normal: walks upstairs using handrail, stands on one foot, rides tricycles, stacks 10 blocks, twists lid off jars, copies a circle, combines 5 or more words in a sentence, understands 2-3 step commands, recognizes colours, shares willingly some of the time, make-believe games, plays with others, listens to music or stories for 5-10 minutes, jumping on one foot, washes and dries own hands, dresses self independently except shoe laces, knows own sex, tells detailed stories, knows primary colours, speaks with plurals

There are four main areas of developement – gross motor, fine motor, language and social.

The milestones cited are, on average, those at the 50th percentile for age.

8. 6-day-old with jaundice - Meghan

February 1, 2017 1:39:29 PM EST

Knowledge

Jaundice

Jaundice is the physical finding associated with hyperbilirubinemia and may result from both unconjugated and conjugated forms of bilirubin.

Unconjugated hyperbilirubinemia can have serious consequences.

Kernicterus

Definition

Kernicterus is the pathological term used to describe staining of the basal ganglia and cranial nerve nuclei by bilirubin. Kernicterus also describes the clinical condition that results from the toxic effects of high levels of unconjugated bilirubin.

Sequelae

Severely affected newborn infants may:

lose the suck reflex become lethargic develop hyperirritability and seizures, and ultimately die

Infants who survive may develop:

opisthotonus (abnormal posturing that involves rigidity and severe arching of the back, with the head thrown backward) rigidity oculomotor paralysis tremors

Cho Sooyoung - sooyoung.cho@mail.utoronto.ca 1/22

hearing loss, and ataxia

Screening and Treatment

In the past, kernicterus among full-term newborn infants primarily resulted from the hemolysis and subsequent unconjugated hyperbilirubinemia that was caused by Rh incompatibility (erythroblastosis fetalis). These infants typically were severely anemic, in shock and acidotic, and had total bilirubin levels well above 25 mg/dL (428 μmol/L). Screening for Rh incompatibility and the use of anti-Rh immunoglobulin (RhoGAM®) have markedly reduced Rh-induced hemolysis and the incidence of kernicterus. In addition, treatment of unconjugated hyperbilirubinemia with phototherapy has had an important impact on management of hyperbilirubinemia.

See the associated reference ranges in conventional and SI units. (http://www.med- u.org/virtual_patient_cases/labreferences)

Newborn Bilirubin Physiology

Most (~75%) of the bilirubin produced in the healthy newborn comes from physiological breakdown of red blood cells.

Pathway

The hemoglobin released from the red cells is converted to unconjugated bilirubin that is insoluble in aqueous solutions and binds to albumin in the blood stream. In the liver the bilirubin is extracted by the hepatocytes where it binds to cytosolic proteins and is then conjugated with glucuronide by uridine diphosphate glucuronyl transferase (UDPGT, also known as glucuronosyl transferase). The conjugated bilirubin is water-soluble and is excreted into the bile and then into the intestine.

In adults, most of the bile is metabolized by the intestinal flora to urobilin and excreted in the stool. The newborn infant, however, lacks the gastrointestinal flora to metabolize bile, which allows the β-glucuronidase present in the meconium to hydrolyze the conjugated bilirubin back to its unconjugated form.

The unconjugated bilirubin is then reabsorbed into the blood stream where it binds to albumin. Newborns absorb significant quantities of bilirubin through this process, known as enterohepatic circulation.

Etiologies of Jaundice

2/22

Physiologic Jaundice

This is defined as a total bilirubin level ≤ 15 mg/dL (≤ 257 μmol/L) in full-term infants who are otherwise healthy and have no other demonstrable cause for elevated bilirubin.

Almost all newborn infants have hyperbilirubinemia, but it is benign and self- limited.

Physiologic jaundice i

...

developmental problems Differential Diagnosis
• Motor
o Problems with CNS (e.g., Cerebral palsy)
o Problems with PNS (e.g., Muscular dystrophy)
o Metabolic conditions (e.g., Hypothyroidism)
o Genetic syndromes (e.g., Down Syndrome)
• Language
o Structural/functional abnormalities of oromotor anatomy
o Hearing impairment
o Pure language disorders
o Pervasive developmental disorders (e.g., Autism Spectrum
Disorder)
• Cognitive
o Global developmental delay due to:
- Genetic conditions (e.g., Fragile X)
- Deprived environment
- Prenatal/perinatal events leading to brain anoxia/ischemia
(rare)
- Prenatal exposures (e.g., Fetal Alcohol Spectrum Disorders)
• Emotional/Social
o Pervasive developmental disorders (e.g., Autism Spectrum
Disorder)
o Deprived environment

developmental problem Management
• Motor
o Educate parents about poor correlation between motor delays and
intelligence
o Refer to Physiotherapy and Occupational therapy
o Educate parents on developmental targets and techniques for
helping achieve specific milestones
- e.g. adequate ‘Tummy Time’ to facilitate development of head
control, rolling over, etc.
• Language
o Audiology assessment
o Referral to local early intervention services
o Speech and language (SLP) evaluation
o Enroll child in nursery school
o Educate parents regarding language facilitation techniques
- make noises or sing and repeat sounds the child says
- ask questions/make comments that lead to a response
- label objects and emphasize action words
- read to the child
- use simple, slow language
• Cognitive
o Thorough history:
- Pregnancy (obstetrical history, exposures, complications)
- Birth (gestational age, complications, delivery, resuscitation)
- Family History (parents, siblings, consanguinity)
- Social History (identify deprived environments)
o Physical exam including head growth, dysmorphic features,
neurologic exam
o Hearing/vision assessment
o Other tests as indicated: karyotype, blood lead levels, metabolic
screen, TSH, CT/MRI
o Find appropriate schooling/community living
o Help family find support groups, funding, respite
• Emotional/Social
o Early intervention with early intervention therapists
o Provide opportunities for increased contact with other children e.g.,
play groups, structured daycare
o Refer to specific therapeutic groups
o If applicable, remove child from deprived environment with help of
children’s aid society

Enhanced 18Month
WellBaby
Visit
Syllabus: Canadian Task Force on Preventative Health Care. Recommendations on
screening for developmental delay. CMAJ. 2016; 188(8):579.
• Important time to review child’s developmental domains and
achievement of milestones
• Visit should incorporate use of Rourke Baby Record, screening for
parental morbidities (mental health, physical illness), promotion of
literacy activities (reading, singing), and information about resources
• Standard developmental screening tools (eg: Nipissing) no longer
recommended for children whose parents or clinicians have no
concerns regarding delay
• Screening still appropriate in children presenting with
signs/symptoms, or parental concerns of delay.

Attention Deficit/Hyperactivity Disorder
Syllabus: Floet et al. Attention Deficit/Hyperactivity Disorder. Pediatrics in Review.
2010;31(2):56.
American Academy of Pediatrics. ADHD: Clinical Practice Guideline for the
Diagnosis, Evaluation and Treatment of Attention‐Deficit/Hyperactivty Disorder in
Children and Adolescents. Pediatrics. 2011;128(5):1007.
Introduction
• ADHD is a neurobehavioral disorder defined by symptoms of
inattention, hyperactivity, and impulsivity.
• There is a two‐ to three‐fold higher prevalence in boys than girls with
girls being more likely to be diagnosed with the inattentive‐type ADHD
• Can profoundly effect academic performance, social interactions and
well being
DSM5
Diagnostic Criteria for Attention Deficit/Hyperactivity Disorder
A. A persistent pattern of inattention and/or hyperactivity‐impulsivity
that interferes with functioning or development, as characterized by
(1) and/or (2):
1. Inattention: Six (or more) of the following symptoms have persisted
for at least 6 months to a degree that is inconsistent with
developmental level and that negatively impacts directly on social
and academic/occupational activities:
a. Often fails to give close attention to details or makes careless
mistakes in schoolwork, at work, or during other activities (e.g.,
overlooks or misses details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play
activities (e.g., has difficulty remaining focused during lectures,
conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind
seems elsewhere, even in the absence of any obvious
distraction).
d. Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (e.g., starts tasks
but quickly loses focus and is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty
managing sequential tasks; difficulty keeping materials and
belongings in order; messy, disorganized work; has poor time
management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that
require sustained mental effort (e.g., schoolwork or homework;
for older adolescents, preparing reports, completing forms,
reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school
materials, pencils, books, tools, wallets, keys, paperwork,
eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older
adolescents, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running
errands; for older adolescents, returning calls, paying bills,
keeping appointments).
j. Hyperactivity and impulsivity: Six (or more) of the following
symptoms have persisted for at least 6 months to a degree that
is inconsistent with developmental level and that negatively
impacts directly on social and academic/occupational activities:
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is
expected (e.g., leaves his or her place in the classroom, in the
office or other workplace, or in other situations that require
remaining in place).
c. Often runs about or climbs in situations where it is
inappropriate. (Note: In adolescents, may be limited to feeling
restless.)
d. Often unable to play or engage in leisure activities quietly.
e. Is often "on the go," acting as if "driven by a motor" (e.g., is
unable to be or uncomfortable being still for extended time, as
in restaurants, meetings; may be experienced by others as being
restless or difficult to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before...

Autism Spectrum Disorder
Syllabus: Johnson C et al. Identification and Evaluation of Chidlren with Autism
Spectrum Disorders. Pediatrics. 2007;120(5):1183.
Harrington et al. The Clinician’s Guide to Autism. Pediatrics in Review.
2014;35(2):62.
Simms et al. Autism, Language Disorder, and Social (Pragmatic) Communication
Disorder: DSM‐V and Diferential Diagnosis. Pediatrics in Review. 2015;36(8):355.
Introduction
• The essential features of autism spectrum disorder are persistent
impairment in reciprocal social communication and social interaction,
and restricted, repetitive patterns of behavior, interests, or activities.
• These symptoms are present from early childhood and limit or impair
everyday functioning
• Social skills deficits can be noticed in infancy with aversion to cuddling
and lack of acknowledgement of the caregiver
• Also can involve language delays/deficits, motor signs (e.g.,
stereotypies, toe walking), sensory deficits (e.g., intolerance to sound)
• Cognitive abilities vary; typically difficulties with reasoning/planning,
greater abilities in rote memory
DSM5
Criteria for Autism Spectrum Disorder
A. Persistent deficits in social communication and social interaction
across multiple contexts, as manifested by the following, currently or
by history (examples are illustrative, not exhaustive; see text):
1. Deficits in social‐emotional reciprocity, ranging, for example, from
abnormal social approach and failure of normal back‐and‐forth
conversation; to reduced sharing of interests, emotions, or affect; to
failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social
interaction, ranging, for example, from poorly integrated verbal and
nonverbal communication; to abnormalities in eye contact and
body language or deficits in understanding and use of gestures; to a
total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding
relationships, ranging, for example, from difficulties adjusting
behavior to suit various social contexts; to difficulties in sharing
imaginative play or in making friends; to absence of interest in
peers.
B. Restricted, repetitive patterns of behavior, interests, or activities, as
manifested by at least two of the following, currently or by history
(examples are illustrative, not exhaustive; see text):
1. Stereotyped or repetitive motor movements, use of objects, or
speech (e.g., simple motor stereotypies, lining up toys or flipping
objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or
ritualized patterns of verbal or nonverbal behavior (e.g., extreme
distress at small changes, difficulties with transitions, rigid thinking
patterns, greeting rituals, need to take same route or eat same food
every day).
3. Highly restricted, fixated interests that are abnormal in intensity or
focus (e.g., strong attachment to or preoccupation with unusual
objects, excessively circumscribed or perseverative interests).
4. Hyper‐ or hyporeactivity to sensory input or unusual interest in
sensory aspects of the environment (e.g., apparent indifference to
pain/temperature, adverse response to specific sounds or textures,
excessive smelling or touching of objects, visual fascination with
lights or movement).
C. Symptoms must be present in the early developmental period (but may
not become fully manifest until social demands exceed limited
capacities, or may be masked by learned strategies in later life).
D. Symptoms cause clinically significant impairment in social,
occupational, or other important areas of current functioning.
E. These disturbances are not better explained by intellectual disability
(intellectual developmental disorder) o...

Learning Disorders
Syllabus: Rimrodt et al. Learning Disabilities and School Failure. Pediatrics in
Review. 2011;32(8):315.
Byrd R. School Failure: Assessment, Intervention, and Prevention in Primary Care
Pediatrics. Pediatrics in Review. 2005;26(7):233.
• Represent a disability based on a descrepency between a person’s
intellectual ability and actual academic performance
• Further specificed into the particular area of academic function
affected:
o Mathematics disorder
o Reading disorder
o Disorder of reading expression
• Any child who has school problems and is suspected of having a
learning disability should be referred for a comprehensive
psychoeducational evaluation
• Accomodations can be made at school through the Identification,
Placement, and Review Committee (IPRC). The IPRC will:
o decide whether or not a student should be identified as exceptional
o identify the areas of a student’s exceptionality
o decide an appropriate placement for a student
o review identification and placement at least once per school year
• An IEP (Individual Education Plan) is developed (in consultation with
parents and the student) for each student who has been identified as
exceptional by the IPRC process. An IEP is a written plan that describes
the strengths and needs of the student, services established to meet
that student’s needs, and how these should be delivered

Bullying
Syllabus: Lamb et al. Approach to Bullying and Victimization. Canadian Family
Physician. 2009;55(4):356.
Introduction
• Defined as the use of power or aggression to cause distress or control
of another
• Can be direct (face‐to‐face) or indirect (gossip, exclusion)
• Negative actions can include:
o Physical actions (punching, kicking, biting)
o Verbal actions (threats, name calling, insults)
o Social exclusion (spreading rumours, gossiping, excluding)
• Actions are repeated and the intensity or duration establishes
dominance

History
• When a physician identifies a possible bullying situation, the following
questions can help determine what type of help may be appropriate
o Who do you bully/who bullys you?
o What do you do to others/what do others do to you? (e.g. gossiping,
insults, hitting, etc.)
o When and how often do you bully/are you bullied?
o Where do you bully/where are you bullied?
o Why do you bully others/why do you think you are bullied?
o How do you think the kids feel when you bully them or how do you
feel when you are bullied?
Management
• Comprehensive strategies that encompass the school, family and
community are most likely to be effective
o establish a social school environment that promotes safety
o provide access to health and mental health services
o integrate school, family and community prevention efforts
o provide training to enable school staff to promote safety and
prevent violence effectively

Toilet Training
Syllabus: Clifford et al. Toilet Learning: Anticipatory Guidance with a child‐oriented
approach. Paediatrics and Child Health. 2000;5(6):333.
Feldman. Managing primary nocturnal enuresis. Paediatr Child Health. 2005;
10(10):611.
Bayne et al. Nocturnal enuresis: An approach to assessment and treatment. Peditrics
in review. Pediatrics in Review. 2014; 35(8):327.
Austin et al. Dysfunctional Voiding. Pediatrics in Review. 2000;21(10):336.
Har et al. Encoperesis. Pediatrics in Review. 2010;31(9):368.
Signs of a child’s toilet learning readiness
• Can understand and follow simple instruction
• Diaper is consistently dry for 2 to 3 hours at a time or after naps
• Bowel movements are somewhat regular and predictable
• Seems uncomfortable with soiled diapers and wants to be changed
• Recognizes and tells or shows need to urinate or stool
• Can walk to bathroom and pull pants up and down
• Is stable on potty (good trunk support)
• Interested and motivated to learn how to use the potty
• Shows interest in 'big kid' underwear
- Child does not need to show all of the signs, but at least a few should be
present to indicate the child is ready for toilet training
- Average age for a child to be toilet trained is between 2 to 3 years old
- Advise parents to expect accidents during initial training

Sleep Requirements

Newborns
• Should sleep on back in crib with flat surface, no pillows or soft items
• In parents’ room for first 6 months
Older babies
• Maintain regular daytime and bedtime schedule
• Start consistent bedtime routine
• Avoid putting baby to bed with a bottle

Sleep Problems
Night terrors
• Parasomnia that occurs in first third of night
• High to extreme autonomic agitation
• High arousal threshold, agitated if awakened
• No daytime sleepiness or recall of event
Nightmares
• Occur in last third of night during REM sleep
• Mild to high autonomic arousal/agitation
• Low arousal threshold, agitated after event
• Can have daytime sleepiness and frequent, vivid recall of event
• Very common
BEARS Screening Tool for Pediatric Sleep Disorders

Sleep associations
• Infant or toddler child has learned to fall asleep only under certain
conditions or has specific sleep associations that require parental
intervention, such as being rocked or fed, which are usually readily
available at bedtime
• During the night, when the infant or toddler awakens, they are not able
to get back to sleep ("self‐soothe") unless those same conditions are
available
90
o The infant then "signals" the caregiver by crying or coming into the
parents' bedroom if the child is no longer in a crib until the
necessary associations are provided
o Ferber method advocates that at bedtime child is put in bed while
they are drowsy, but still awake, to help them learn how to fall
asleep on their own (self‐soothe)

Colic
Syllabus: Cohen et al. Colic. Pediatrics in Review. 2012;33(7):332.
• Infantile colic is defined as
o paroxysms of irritability, fussiness or crying that start and stop
without obvious cause;
o episodes lasting 3 h or more per day and occurring at least three
days per week for at least three weeks; and
o no failure to thrive
• Peaks at 6 weeks of age and typically ends by 3‐4 months
• Crying is most frequent in the late afternoon or evening
• Holding or rocking and offering a pacifier might help
• There is no evidence that medicines really help with colic
• There is no or insufficient evidence to support dietary changes
including probiotics, lactose free diet, soy formulas
• If there is a concern about cow’s milk protein allergy, a time limited
(two week) trial of hypoallergenic formula or elimination of cow’s milk
from the maternal diet can be undertaken

Gotta Find Strong Coffee Soon
•Gross Motor
•Fine Motor
•Speech/ Language
•Cognitive
•Social Emotional, Behaviour
•(Adaptive Skills)

Approach to Developmental History
-History of presenting illness
-Perinatal history (TORCH inf's)
-Past medical history
-Hearing, vision, sleep, feeding
-Developmental history (-start asking from several age groups lower than current age; observe child)
-Family history (developmental delay, learning disabilities
metabolic/genetic conditions
consanguinity)
-Social history (typical day, language spoken at home, other children at home, daycare/preschool, child maltx/CAS, income, etc)

physical exam
•Weight, height and head circumference at 50th percentile (want to know if macro/microcephaly, any dysmoprhic ft's
make sure to undress & look at skin)
•Low, posteriorly rotated ears but no other dysmorphic features or unusual birth marks
•Normal general and neurologic examinations


GLOBAL DEVELOPMENTAL DELAY
Significant delay (at least two standard deviations below the mean with standardized tests) in at least two developmental domains from the following:
Gross or fine motor
Speech/ language
Cognition
Social/ personal
Activities of Daily Living
-Child must be less than 5 years old

Causes of GDD/ID

Pediatric milestones in development
1 year:
-single words
2 years:
-2 word sentences
-understands 2 step commands
3 years:
-3 word combos
-repeats 3 digits
-rides tricycle
4 years:
-draws square
-counts 4objects

Stairs mnemonic. Two at two. One at four.
Two feet on each step at two years. One foot per step at four years.

Birth to 1 Year: Remember that the goal of the first year is to be able to walk (walk at 12 months). At six months you are halfway there (remember “sit at six”). Just with these two milestones you can pretty much fill in everything else. Remember that everything is from head to toe. So 2 months (the first time we really check milestones) you check for head lifting (neck control). You roll at 4 months (at level of shoulders and chest). Then, again, at six you sit. You crawl at 9 months and pull to stand (crawl, pull to stand at 9 months) which makes sense as being between sitting and walking.
In Review:
2 months: lift head 45 degrees
4 months: roll over (front to back first, then back to front, easier if you can push off with hands)
6 months: sit (halfway to goal, halfway through year, “sit at six”)
9 months: crawl, stand (halfway between sitting and goal)
12 months: walk (the goal)

15 months – 5 years: Memorize these milestones in a story as they are harder to associate with particular months like the first year. Using this progression story may help you.
15 months: walks well
18 months: throws objects
24 months/2 years: up and down stairs (one foot at a time); run
3 years: Tricycle (3 wheels, 3 years), jump in place
4 years: up and down stairs alternating feet (2 feet x up/down = 4), balance on 1 foot for 4 seconds (legs look like a 4 when on 1 foot), hop
5 years: skip (5 looks like an “S”kips)
Story: a child on the 1st floor of her house sits up, crawls, cruises, then 1) WALKS to stairs, 1.5) THROWS object up stairs, 2) CLIMBS up the stairs and RUNS to his trike, 3) RIDES a trike upstairs, JUMPS off, 4) RUNS down the stairs, HOPS off the stairs and 5) SKIPS away
3. Once you’ve memorized the months of well child checks and corresponding gross motor milestones, begin to memorize the archetype babies for each age group. These little stories incorporate all the other milestones into a single image which is much easier than trying to memorize many unrelated facts. There are some ways to conceptually link milestones across categories, but they are not frequent enough to be useful for fast recall and the salient milestones and timing which is what happens on tests and during morning report.

Here are all the babies with milestones listed:
2 months: lift head 45 degrees (when laying on face), turns to sound, follows objects past midline, social smile
Parent’s Little Baby: looks up to sound, smiles because he sees both his parents, one on either side of midline

4 months: lift head 90 degrees/raise up to chest, roll over, find midline, reach for objects, puts objects in mouth, coos (these are vowel sounds), and laughs
Fat Happy Baby: baby is rolling and laughing and cooing because he just discovered midline and is reaching for cake that he will cram into his mouth

6 months: sit up with no head lag, raking grasp, transfer objects between hands, babbles (consonants), recognizes familiar faces
Street-Corner Baby: sitting up on sidewalk, transferring a rake from hand to hand while babbling at people he thinks he recognizes

9 months: Crawl, pull to stand, point, specific babbling (mama, dada), stranger anxiety
Watch Dog Baby: crawls to window, pulls to stand to see out, points at stranger in yard and says “mama” to get attention of parents.

12 months: Walk, pincer grasp, 1 word, patacake, bye bye, peekaboo
Playful Zombie Baby: walking at you, snapping pincers, repeating one word over and over (brrraaaaains), and just wants to play patacake and peekaboo before waving bye bye.

15 months: walks well, imitates, controlled release of blocks (can stack 2)
Little Sister Baby: wants to be just like big sister, walks confidently to the blocks and imitates making a 2 block tower

18 months: Throw, scribble, 4 block tower, 1 step command, uses spoon/cup, points to parts of body
Sir Charming Baby: needs to get note to Rapunzel so scribbles note on pape...

Developmental assessment
Primitive reflexes
Mnemonic: MPRAG
M Moro
P Placing reflex
R Rooting
A Atonic neck reflex
G Grasp reflex

Head circumference with age
· Remember 3, 9, and multiples of 5:
Newborn 35 cm
3 mos 40 cm
9 mos 45 cm
3 yrs 50 cm
9 yrs 55cm

Head Circumference

336:633

Infants increase their head circumference by 12 centimeters during the first year of life as they start with an average of 35 centimeters and end up with an average of 47 centimeters. To remember the rates of increase at various months of the first year, we can use the above mnemonic; *It means that during the first three months infants will gain six centimeters increase in OFC (occipitofrontal circumference) which means 2 centimeters per month. *The next three months the rate is three centimeters in three months which means 1 cm per month. *The next six months the rate is three centimeters in six months which means 0.5 cm per month.

Length and height values and acceleration

Although there are a number of formulas that facilitate the estimation of the expected length or height at a given age but this mnemonic is incredibly easy to remember. Just remember multiples of the number 5

Birth

1 Year

4 Years

8 Years

12 Years

50 cm

75 cm

100 cm

125 cm

150 cm

25cm/yr*

10 cm/yr*

5cm/yr*

5cm/yr*

Weights of children with age
Newborn 3 kg
6 mos 6 kg (2x birth wt at 6 mos)
1 yr 10 kg (3x birth wt at 1 yr)
3 yrs 15 kg (odd yrs, add 5 kg until 11 yrs)
5 yrs 20 kg
7 yrs 25 kg
9 yrs 30 kg
11 yrs 35 kg (add 10 kg thereafter)
13 yrs 45 kg
15 yrs 55 kg
17 yrs 65kg

124 124 rule.
1day birth wt (this is the easy one)
2week regain birth wt
4month 2x birth wt
12month 3x birth wt
24month 4x birth wt

Admission Note (Template)
Paediatric History and Physical Examination (as previous), and:
INVESTIGATIONS
• Blood work: CBC, electrolytes, glucose, renal function, liver function
• Microbiology: blood, urine, CSF, nasal, stool cultures
• Imaging: x‐ray, ultrasounds, CT, MRI
• Pathology: if relevant
IMPRESSION/ASSESSMENT (IMP)
This is a (year old) (sex) [who is previously healthy] or [with a history of
XYZ] presenting with (brief summary of pertinent positive/ negative
symptoms on history, signs on physical examination and relevant
investigations) with a most likely diagnosis of _____________.
DIFFERENTIAL DIAGNOSIS (DDX)
May chose to use broad categories by system or process when considering
specific diagnoses (i.e., use of VITAMINS ACD acronym)
Vascular, Infectious/Inflammatory, Traumatic/Toxin, Autoimmune/
Acquired, Metabolic/Medication, Iatrogenic/Idiopathic, Neoplastic, Social,
Allergic, Congenital, Degenerative, Endocrine
MANAGEMENT PLAN/ADMISSION ORDERS (PLAN)
• Admit: Admit to (your service) under (your consultant today).
• Diagnosis: This is what you suspect they have. (e.g., Asthma)
• Diet: DAT (diet as tolerated) NPO (nothing per os/by mouth; if going
for surgery or procedures), Breast feed ad lib, Formula, Tube feeds
(NG‐tube, G‐tube, GJ‐tube)
• Activity: AAT (Activity as Tolerated), bedrest
• Vital Signs: VS (Vital Signs q8‐12h = HR, RR, BP, O2 sat, Temp), VS
q4h (if particularly sick patient requiring more frequent vitals),
Special parameters (e.g., Neurological vitals)
• Monitoring: ECG, oxygen saturation, Ins & Outs, daily weights
• Investigations
o Bloodwork (Hematology, Biochemistry)
o Microbiology
o Imaging
o Consults
• Drugs
o Past: Medication Reconciliation – all regular medications (may not
need all; e.g., no need for previous PO antibiotics if starting IV)
o Present: what does patient need now
o Future: anticipate what patient may need; e.g., fever, nausea, pain,
stools

Progress Note (Template)
(Service) Progress Note
Date, Time
ID
Age, sex with a history of (non‐active/chronic issues) admitted with (list
active/acute issues for why the patient is admitted). Could also include a
list of recent events that occurred since the most recent note.
SUBJECTIVE
• How was patient overnight, how they feel that day, any new concerns
from the patient/parent
• What has changed since the previous note? Does the patient have any
new symptoms? Any pain? How is the patient coping with the active
symptoms, progression, better/worse.
• Ask the parents and patient’s nurse: behaviour, activity, sleep,
appetite, in and outs.
OBJECTIVE
Vitals: HR, BP, RR, SaO2, Temp, daily weight, pain
I/O: Inputs (Diet, IVF), Output (U/O, BM/Diarrhea, Vx, Drains), fluid
balance
General: what the patient is doing, appearance, behaviour, cognition,
cooperation, disposition
P/E: focused physical exam of system involved plus CVS, RESP, ABDO as it
is common for hospitalized patients to develop problems in these regions.
INVESTIGATIONS
New lab results, imaging or diagnostic tests/ interventions and relevant
results still pending
MEDS
Reviewed daily regarding changes such as new/held/discontinued/
restarted (e.g. Ampicillin day 2/10)
IMPRESSION/ASSESSMENT (IMP)
Summarize what the new findings mean, what progress is being made.
Stable vs. Unstable? Improved vs. Worsened? Waiting investigations/
consult? Differential diagnosis if anything has been ruled in/out?
PLAN (P)
1. Issue (1) 􀃆 plan (e.g., UTI on Day 2 of Empiric Abx, likely 14 day
course required, await urine C&S)
2. Issue (2) 􀃆 plan
3. Issue (3) 􀃆 plan
4. Disposition – plans for home, transfer

Discharge Summary (Template)
Check patient’s name, medical record number, date of birth, date of
admission, date of discharge, most responsible physician (MRP), referring
physician name.
FINAL DISCHARGE DIAGNOSIS
• Often only one diagnosis is responsible for admission (i.e. vasoocclusive
crisis, asthma exacerbation, bronchiolitis or Kawasaki
Disease)
• However sometimes there are associated diagnoses (i.e. Gastroenteritis
with dehydration and renal failure, osteomyelitis with bacteremia)
OTHER DIAGNOSIS (nonactive
or those affecting hospital stay)
Other diagnoses requiring treatment during hospitalization or underlying
medical diagnoses existing prior to admission
HISTORY OF PRESENTING ILLNESS
(Name) is a (year old) (sex) [who is previously healthy] or [with a past
medical history of XYZ] who presented with (X) day history of (summary
of pertinent positive and negative symptoms on history and other
relevant/contributing elements of birth history, development, past
investigations/treatment, immunizations as appropriate). Significant
signs on initial physical examination included__________. In the ER,
management included _______________.
COURSE IN HOSPITAL
(Name) was admitted to (name of service and ward)… [and describe
briefly the events and progression of illness while in hospital including
results and management. If the child has multiple medical issues, this
section can be done by system (cardiovascular, respiratory, fluids and
nutrition, ID, CNS, etc). List significant/complex investigations (with
results) under a separate heading.
At discharge, describe current symptoms, physical examination and
pending results.
DISCHARGE MEDICATIONS
Drug name, dose, route, dosing interval frequency, and duration
DISCHARGE GENERAL INSTRUCTIONS AND FOLLOWUP
All discharge summaries must include at least 3 essential elements
1. Discharge treatment plan including duration
2. Follow‐up with primary care physician in… (specify a reasonable time
frame)
3. Seek medical attention if…
May include other referrals and follow‐up appointments as necessary,
pending investigations and other community resources

Handover
At Sick Kids, IPASS
is the format used for handover.
• Illness severity
o Stable / Watcher / Unstable
• Patient Summary
o Summary statement
o Events leading up to admission
o Hospital course
o On‐going assessment
o Plan
• Action Items
o To‐do list
o Timeline and ownership
• Situational awareness and contingency planning
o Know what’s going on
o Plan for what might happen
• Synthesis by receiver
o Receiver summarizes what was heard
o Asks questions
o Restates key actions/to do items

Irritability may be the only way that a young child can express pain or discomfort from any source,
including:
Meningeal irritation
Headache from intracranial irritation
Simple exhaustion

Pediatric Vital Signs
As a child gets older, the normal ranges for vital signs change, making it important to look at ageappropriate
reference values.
The normal heart rate for a 5-year-old is 80 to 100 beats per minute

Rashes Associated with Fever (Part 1)
Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Cho Sooyoung - sooyoung.cho@mail.utoronto.ca 1/15
Enterovirus
Usually erythematous and maculopapular, and may involve the palms and
soles. Infrequently, it can be petechial.
In hand-foot-and-mouth disease (caused by Coxsackie virus), presents as a
vesicular rash on the hands and feet and with ulcers in the mouth.
Usually seen in late summer and early fall.
While the fever associated with enteroviruses may be high, it usually lasts only
a few days.

Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Erythema
infectiosum
Also called fifth disease, this is caused by parvovirus B19.
There is frequently an associated low-grade fever (37.8-38.3 degrees C, or
100-101 degrees F), with a rash appearing seven to ten days later.
The characteristic rash starts as facial erythema-the "slapped cheek"
appearance. This can spread to the trunk and have an erythematous macular
appearance. Central clearing of the rash appears, giving a lacy appearance.
The rash often lasts longest on the extremities, where it has a lacy, reticular
appearance.
People with fifth disease can also develop pain and swelling in their joints
(polyarthropathy syndrome).
Individuals with underlying immune deficiencies who are exposed to this virus
are at risk for developing aplastic anemia.

Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Measles
After a prodrome of fever (over 38.3 C, or 101 F), cough, coryza, and
conjunctivitis, this maculopapular rash starts on the neck, behind the ears, and
along the hairline.
The rash spreads downward, reaching the feet in two or three days.
The initial rash appears on the buccal mucosa as red lesions with bluish white
spots in the center (known as Koplik spots). These have frequently
disappeared by the time the patient presents to medical attention.
Immunization is very effective in preventing this infection.

Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Meningococcemia
Caused by the bacteria Neisseria meningitidis, onset is abrupt and
accompanied by fever, chills, malaise, and prostration.
The initial rash may be urticarial, maculopapular, or petechial (marked
by small, purplish, hemorrhagic spots).
In fulminant cases, it can become purpuric, marked by large
hemorrhages into the skin.
Immunization is effective in preventing this infection.

Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Roseola
This macular or maculopapular rash, also called exanthem subitum,
starts on the trunk and spreads to the arms and neck.
There is usually less involvement of the face and legs.
The rash is preceded by three or four days of high fevers, which end
as the rash appears.
Usually seen in children less than two years old.

Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Scarlet fever
This rash, caused by infection with group A Streptococcus, consists of
very fine papules, often described as feeling like sandpaper.
It is erythematous, but blanches.
The rash starts in the groin, axillae, and neck, but rapidly spreads.
The fever can be high, and the disease is usually self-limited, lasting
less than 10 days.
It is important to treat with antibiotics to prevent non-suppurative
complications of strep, including rheumatic fever.

Children get many different kinds of rashes-many, though not all, related to infections. Below are
descriptions and photos of rashes associated with fever.
Varicella
The rash, also known as chicken pox, starts on the trunk and spreads
to the extremities and head.
Each lesion progresses from an erythematous macule to papule
to vesicle to pustule, and then crusts over.
Lesions at various stages of development are seen in the same area of
the body.
There is usually a mild fever.
The disease is self-limited, lasting about a week.
Immunization is effective in preventing this infection.