on 09-Feb-2017 (Thu)

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

1. ADOLESCENT MEDICINE (HEADSSS)

HEADDSSS

• Home: How are things at home? Who lives at home, age, occupation? How does everyone get along? What do you argue about? Have there been any changes lately? Have you ever run away from home?

• Education / Employment: Name of school, grade level, attendance pattern, amount of school missed, academic performance,favourite/least favourite courses, marks, behaviour at school, current and past jobs

• Activities: What do you do when not at school? For fun? On weekends? Do you feel you have enough friends? Who are your bestfriends? What do you do together? Sports / exercise, extra‐curricularactivities, hobbies, social groups? Do you go out to parties a lot? Howdo you pay for things you do?

• Drugs: Have you ever tried smoking or drinking alcohol? What did you think? What about other drugs? Have you ever tried Marijuana? Ever been drunk? Friends’ use and peer pressure? What age did you start? Frequency? Amount? What do you like/dislike? Why do you use? Use alone? Have you ever gotten into trouble because of using these substances? What would/does your family think if they knew that? What do you think about it?

• Dieting: Do you have concerns about/have you tried to change your weight/shape (dieting/exercise)? Presence of bingeing/purging behaviours, use of diuretics/laxatives. Tell me what you eat/drink in an average day

• Safety: Do you regularly use: seatbelts? Bike helmets? Appropriate gear when snowboarding/skateboarding? Does anyone at home own a gun? Has anyone ever hurt you or touched you in a way that was hurtful or inappropriate? Driving?

• Sexuality: Are you interested in the same sex, opposite sex or both? (DO NOT assume heterosexuality!) Are you dating someone now? Are you having sex? What do you use for contraception/STI prevention? Number of sexual partners /age of first sexual activity/STI history / last pelvic exam in females / ever tested for STIs, HIV? History of pregnancy? Sexual abuse?

• Suicide / Depression: Screen for depression (SIGMECAPS). Does the teen see themselves as generally happy or unhappy? Do they have difficulties with anger? When they feel sad, how do they cope with it? Have they ever thought about killing themselves? How recently? Has the teen had any prior suicide attempts?

1. 1. STIs

• 14yo ♂ comes after having urethral discharge and has had 3 sexual contacts (anal but no oral sex, I think). What should you do? What should you tell the child? What are the 5 tests you would do? (choose from menu)

• Plan: further Hx (S+S, sexual behaviours, RFs)

  • chlamydia

    • female: vag discharge, dysuria, abn vag bleed, lower abdo pain, dyspareunia, +/- fever, +/- conjunctivitis

    • male: urethral discharge, urethral pruritus, dysuria, testicular pain, +/- fever, +/- conjunctivitis

  • gonorrhea

    • female: cervicitis, PID, urethritis, inflm of lower 1/3 of vulva, vag discharge, dysuria, abn vag bleed, lower abdo pain, deep dyspareunia, +/- fever

    • male: urethritis, epididymitis, testicular pain, urethral itch, urethral discharge, +/- fever

    • both: pharyngeal inf, purulent conjunctiviti

...

1. CARDIOLOGY

• Down's + murmur, query VSD: name 3 things that would make you suspect it’s pathologic

• Innocent: Sensitive (position, resp), Short, Single, Small (area), Soft, Sweet, Systolic

• Pathologic: loud (>3/6), harsh, pansystolic/diastolic/late systolic/conntinuous, cannot modify with position, abnormal exam, PHx congenital heart disease, RFs (high LSB, pansystolic/diastolic, radiates to back/neck, >II, harsh, click

Congenital Heart Disease Functionally significant structural abnormalities of the heart and great vessels present at birth presented below.

Ebstein’s anomaly – opening of tricuspid valve is displaced towards the apex of the right ventricle = “atrialization” of the right ventricle. * CHD with cyanosis/tachypnea in first hours of life: TGA, Ebstein’s, Pulmonary atresia ^ CHD with CHF (excess pulm. flow): large VSD, AVSD, PDA, coarctation of the aorta # CHD with shock/catastrophy: critical coarctation or AS, interrupted aortic arch, Hypoplastic left heart5 most common types of Cyanotic Congenital Heart Defects (Five T’s)

• Tetralogy of Fallot (TOF): PA stenosis, RV hypertrophy, VSD,
overriding aorta
• Truncus arteriosus: A single trunk gives rise to the aortic arch,
pulmonary arteries and coronary arteries
• Transposition of Great Arteries (TGA): RV to aorta, LV to PA – the
pulmonary and systemic circulations are in parallel rather than in
series
• Tricuspid Atresia: Absence of the tricuspid valve forces all of the
systemic venous return across an ASD to mix with the pulmonary
venous return, often associated with pulmonary stenosis or atresia
• Total anomalous pulmonary venous connections (TAPVC): PV not
connected to LA
Note: Clinical presentations of these lesions usually differ markedly and may not
present with apparent cyanosis.

Ventricular Septal Defect
Defect in the formation of the intraventricular septum (varies in
size/location: muscular, perimembranous, or trabecular)
Clinical Findings
• Murmur: Holosystolic (soft or harsh):
o Soft murmur suggests the right sided pressures are high
o Harsh murmur suggests right sided pressures are relatively low
o Best heard at LLSB 􀃆 at >1 week old (when pulmonary vascular
resistance decreases enough for shunting L􀃆R)
• Heart sounds: loss of splitting of the second heart sound and a loud P2
suggests pulmonary hypertension
• CHF symptoms: respiratory distress, difficulty feeding (+diaphoresis),
FTT
Pathophysiology
Left to right shunt 􀃆 increased blood flow to lungs 􀃆 increased PV return
with LV overload and dysfunction, and later right heart dysfunction +/‐
pulmonary hypertension
Management
• For CHF symptoms: Diuretics and nutritional support
• If defect shows signs of closing, then monitor closely for any signs of
pulmonary hypertension
• Surgical correction of VSD if significant clinical symptoms not managed
medically (to avoid pulmonary vascular disease)

Atrial Septal Defect
Defect in the formation of the interatrial septum (varies in size/location:
ostium secundum, ostium primum, sinus venosus). Patent foramen ovale
does not ordinarily produce intracardiac shunts.
Clinical Findings
• Murmur: Systolic ejection murmur at pulmonic valve:
o Pressure gradient between atria is relatively small so shunt occurs
throughout cardiac cycle, the left‐to‐right shunt is silent.
o Murmur originates from pulmonary valve due to increased blood
flow producing a relative stenosis of the pulmonary valve (2‐3/6)
• Heart sounds: widely, fixed split S2
...

1. DERMATOLOGY

   1. Dermatitis

• Atopic dermatitis: what is Tx?

• MCQ: emollients and topical GCs for 10 d

• Child with itchy, erythematous, crusty eruption. DDx and 4 Tx?

• DDx: atopic dermatitis, nummular dermatitis, allergic contact dermatitis, scabies, psoriasis, tinea, drug eruption

• Tx (atopic dermatitis): avoid triggers, emollients, topical GCs, calcineurin inhibitors

• "Pruritic eruption" over child's finger web space, axilla, and neck web; sister has the same thing, but parents asymptomatic. What is the Dx (1 mark), 3 DDx (3 marks), the lab Ix that will definitively establish the Dx (1 mark), and most popular/standard Tx (1mark)?

• Dx: scabies Ix: microscopy (mites, ova feces)

• DDx: Urticaria Contact dermatitis Scabies Chicken pox Atopic dermatitis Bites

• Tx: permethrin 5% cream, 2 x 1wk apart for even asymptomatic family members

• A child presents to you with a diaper rash or is it? What else could it be?

• DDx: diaper candidiasis, irritant contact dermatitis, infantile psoriasis, others

2. 2. Rash/Exanthems

• A young ♂ with asthma gets a rash on his arms: itchy, red, and found on flexural surfaces. What are 2 possibilities?

• DDx: topic dermatitis, scabies, Pastia’s lines

• Rosy cheeks + lacy rash: give the Dx, causative organism, 1 complication, and Tx.

• Dx: erythema infectiosum (fifth disease) Causative agent: parvovirus B19

• Tx: NSAIDs (symptomatic arthropathy), otherwise none

• Complications: STAR (sore throat, arthritis, rash), glove and sock, aplastic crisis (sickle cell patients), fetal infection (anemia, fetal hydrops)

• Fever + erythematous rash: most likely Dx?

• MCQ: child is UTD on all immunizations, which eliminates 3 choices right away and narrows it down to either MRSA or GAS, take your pick ;-)

• Child with high fever x 4 days goes to walk-in clinic and gets amoxicillin. On the following day, he breaks out into generalized maculopapular rash.

• DDx (2 marks): Kawasaki disease, roseola, scarlet fever, drug reaction, etc.

• Tx (2 marks): depends on etiology

Definitions
MACULE
‐ Flat, circumscribed area of colour change
‐ Large (>1 cm) macule: patch
‐ E.g. vitiligo, port‐wine stain, café au lait
PAPULE
‐ Elevated, palpable lesion
‐ Large (>1cm) papule: plaque
‐ E.g. wart, mollusca
VESICLE
‐ Fluid‐filled elevation (pus, sanguinous)
‐ Large (>1 cm) vesicle: bulla
‐ E.g. impetigo
PUSTULE ‐ Circumscribed elevation of skin containing purulent exudate
‐ E.g. herpes simplex, varicella zoster
NODULE
‐ Palpable solid lesion
‐ Large (>1 cm) nodule: tumour
‐ E.g. dermatofibroma...

1. ENDOCRINOLOGY

   1. Diabetes mellitus

• Best marker for insulin resistance?

• MCQ: acanthosis nigricans

2. 2. Puberty

• 13yo ♀, no onset of menarche. What questions would you ask on Hx (6)? What would you do O/E? When and how would you investigate?

• Hx: Breast development, weight loss, pubic hair development, short stature, FHx, athlete, medical illness, high performance athlete

• O/E: assess nutritional status, dysmorphism, evidence of chronic disease, signs of abuse or neglect, sexual development (“boobs→pubes→grow→flow”)

• Ix (if no menarche >16 or pubertal >12): always (bone age, CBC/lytes, CRP, FSH/LH, EST/TEST, TSH/T4, IGF, U/A), consider (IBD panel, Celiac panel, etc.)

• Precocious puberty in ♀: when are you worried and which tests would you order?

Ix (if bone age > height age, <6, OR psychological issues): always (bone age, FSH/LH, EST/TEST, DHEAs/17-hydroxyPRO, TSH/T4), consider (pelvic U/S, MRI head, β-hCG, GnRH/ACTH stimulation)

Hypoglycemia (Infants and Children)
Definition
Plasma glucose (PG) ≤2.8 mmol/L
Etiology
• Endocrine causes: Ketotic hypoglycemia, GH deficiency,
panhypopituitarism, ACTH deficiency, Addisons disease, excess
exogenous insulin
• Nonendocrine
causes: Sepsis/shock, liver disease, ingestion (e.g.
ethanol, salicylates, beta‐blockers), inborn error of metabolism
Clinical Presentation
• Autonomic symptoms: Sweating, weakness, tachycardia, tremor,
feelings of nervousness and/or hunger
• Neuroglycopenic symptoms: Lethargy, irritability, confusion, unusual
behaviour, hypothermia, seizure and coma
Investigations
Send critical labs (prior to initiating treatment) if PG ≤2.8 mmol/L:
Serum glucose, blood gas, electrolytes, insulin, GH, cortisol, free fatty acids,
ß‐hydroxybutyrate, acylcarnitines, total and free carnitine, serum amino
acids, NH4, lactate, urine organic acids, c‐peptide, urine sample for glucose,
ketones and reducing substances
Management
• Treat if PG <3.3 mmol/L and neurologic symptoms (confusion, seizure)
or PG ≤ 2.8 mmol/L
• Initial bolus of dextrose (5 mL/kg of D10W or 2 mL/kg of D25W),
then continuous dextrose infusion to maintain PG
• If no IV access, give glucagon IM or SC. Children <20 kg = 0.03 mg/kg,
max 0.5 mg/dose. Children >20 kg = 1 mg/dose. May repeat q20
minutes as needed

Diabetes Mellitus
Introduction
• Type 1 DM (DM1) accounts for 5‐10% of all diabetes
• Most commonly presents in childhood
o Age of onset has bimodal distribution: peaks at 4‐6 and 10‐14 yrs
o Family history a significant risk factor (5% for first‐degree
relatives)
• Incidence varies with geographical location
• Major Emergencies
o Diabetic ketoacidosis (DKA) ‐ initial presentation in 15‐67%
- Risk for DKA increases if age < 6 yrs or low SES
o Intercurrent illness
o Hypoglycemia
Pathophysiology
Genetic susceptibility + environmental trigger 􀃆 autoimmune β‐cell
destruction 􀃆 progressive insulin deficiency
Differential Diagnosis
• Type 2 Diabetes Mellitus (DM2)
o Disorder of insulin resistance
o Typically presents after puberty
o Associated symptoms: metabolic syndrome, obesity, PCOS,
acanthosis nigracans
• Genetic defects in β‐cell function
• Medications: atypical anti‐psychotics, immunosuppressants...

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

Irritability may be the only way that a young child can express pain or discomfort from any source

Enterovirus
Usually erythematous and maculopapular, and may involve the palms and
soles. Infrequently, it can be petechial.

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.

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.

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.

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.

When you enter the examination room, introduce yourself to the teenager first and shake hands before addressing the parent (if present).

When the parent has a laundry list of concerns, make sure to interject occasionally and politely ask the adolescent whether he shares those concerns, which can be addressed one-on-one with the teenager later in the visit.

With a new patient and family, I find it invaluable to discuss confidentiality up front. I usually say, "At this office, we encourage teens be honest with their doctor. It helps ensure that health concerns and questions are addressed. It also helps teens prepare for a rapidly approaching adulthood, when they will have to know how to discuss health concerns with their physician. Occasionally, we discuss sensitive issues such as sexuality and drugs and, for the most part, we agree to keep these conversations private. We expect teens to ask questions that will ultimately keep them healthy and safe."

I also discuss the contingencies of when confidentiality must be broken. Specifically, I explain that when there are issues that may put the teen's (or someone else's) life or health at risk, confidentiality must be broken and adults must be brought in who can help keep him/her safe. I tell the adolescent that I never break confidentiality without telling him first. The teen always has the option to decide how he would like the parent to find out.

Home

•Try to get a general picture . . . Who lives with the patient? Does the family live in a house? Cramped quarters? Does the adolescent have any privacy?

•Do the parents live together? If not, is the out-of-house parent involved with the patient--and to what extent?

•Have there been recent changes in the family dynamic--a new sibling, the death of a close grandparent, a parental separation or divorce? Is a family member sick? If so, how is this affecting the patient?

•How many siblings live at home and where in the birth order is the patient? In some large families, the responsibilities for younger children may fall on the oldest child. This level of responsibility may seem appropriate or it may overwhelm the teen.

These questions are best asked when the parent is present so that objective information (that can be discussed with the teen alone) can be obtained.

School is the adolescent's primary job, and almost all teens want to succeed. When things are going poorly in school, I see this as a manifestation of some other process that is inhibiting success. Such processes frequently include ADHD, learning disabilities, depression, anxiety, bullying, or school phobia.

It can be immensely helpful to ask the teen how well school is going while the parent is in the room. Teens often report that everything is "fine"; parents may counter that the adolescent has been skipping classes or is earning poor grades.

Some other key issues to inquire about:

•Have there been any changes (for better or worse) in the teen's academic progress during the past year?

•If the teen is doing poorly, find out why. Does he have difficulty paying attention in class or during homework time? Do homework assignments take forever to complete? Positive answers suggest the possibility of ADHD.

•Have teachers mentioned any problems with the student's ability to learn, digest, and understand information? Positive answers suggest possible learning disabilities. In this situation, the student might benefit from psychoeducational testing and/or the development of an individualized education plan.

•Is the student skipping classes? Has he joined a new peer group? Do the parents suspect any drug or alcohol use? Any significant mood changes recently? Could there be an underlying mood disorder (depression, anxiety) that prevents the student from focusing?

•Is the student having trouble waking up to get to school on time? Is he falling asleep in class? Are homework assignments incomplete because the student sleeps for hours each afternoon or early evening? The duration and quality of sleep can profoundly influence an adolescent's academic performance and should be addressed whenever academic concerns arise.

•What are the student's life plans and goals? Younger teenagers may simply want to be a "pro basketball player," a developmentally appropriate goal. By high school, there should be some discussions about the teen's post-high school plans. If the student is planning on going to college, is he pursuing the academics and activities necessary to meet this goal?

Activities

After-school activities (or lack thereof) can profoundly affect an adolescent's physical well-being. I generally obtain this history without the parent in the room because the teen usually answers more honestly. If the history suggests participation in an activity that could be detrimental to the patient's health, this may warrant a private or a 3-way discussion with the parent.

Other key points to ask about:

•What activities does the teen participate in after school? Most adolescents need to be involved with some activity in addition to academics. Watching TV or Internet chatting all afternoon does not count as a healthy activity. The American Academy of Pediatrics recommends no more than 1 to 2 hours each day of "screen time."

•Simple "chilling" and "hanging out" generally spell trouble. With whom does the adolescent spend time? Is he home alone with a girlfriend or out on the street with peers? If an adolescent spends afternoons alone every day, some investigation of possible mood disorder or social issues is warranted.

The adolescent who naps for 2 to 3 hours every afternoon may require an evaluation for depression, substance use, or sleep cycle disorders.

Overactivity also needs to be identified. Teenagers (like everyone else) need time to relax and have fun. Some teens (or their parents) may require a friendly "prescription" from the doctor instructing them to incorporate this into their busy schedules.

Drugs and Drinking

There is no one "right" way to approach the topic, but the following tactics can be helpful:

•Start with a generalized conversation and open-ended questions: eg, "Many of my teenage patients tell me their friends sometimes try drugs and alcohol. What kinds of things have your friends talked about trying?"

•As the adolescent answers, start bringing the conversation closer to home. "It must be a challenge for you to be at a party where your friends are drinking and getting drunk. How do you deal with it when they offer you (or pressure you with) something to drink?"

•Congratulate the teen who continually insists that he has never indulged in any of these substances for making good, mature decisions for his health.

•If the teen admits to trying various substances, be careful not to sound judgmental. Explore the benefits (and consequences) the teen gets from the substance use, how it makes him feel the next day, how often he is using the substance.

•When you identify a substance use problem, encourage a follow-up appointment. Let the teen know that you can see why he is attracted to the substance, but that you have concerns for his safety.

•Suspected habitual substance use by a teenager who will not follow up with you constitutes a safety issue that requires breaking confidentiality.

"I see lots of teenagers, and we frequently talk about sex. Some like girls, some like guys, some like both, and some are just not sure. When you think about dating or having sex, do you think about guys, girls, or both?"

Teens hate lectures. Rather than lecturing on safer sex, involve the teen in a discussion on how he would approach various situations. For example, ask a female patient how she would negotiate not having sex with a partner who did not have a condom. Ask a teenage boy how he might behave if he was about to have intercourse and his girlfriend changed her mind.

Inquire about persistent irritability--a presenting symptom of depression in teens.

MALTREATMENT: phys/emo/sex/neglect/exploitationàactual/potential harm to child’s health/survival/development/dignity within relationship of responsibility/trust/power

• Child isn't walking, but XR shows spiral fracture in femur. What's next?

• MCQ: full body XR

Red Flags: inj inconsistent w/ hx (mechanism, force, age/developmental stage), hx inconsistent/changes, medical attn delay, multiple inj, different age inj, bruises (non-amb bruises, well-cushioned, patterned), # (non-amb, different ages, location)

• Fractures: metaphyseal/ribs/scapula/vertebrae/sternum/mult skull #s

Hx: events leading up to injury

• Location & time, who present, detailed events, child’s response, caregiver’s response, other children at risk, relevant PHx

Thorough O/E (completely undress): head, skin (ears, genitalia, buttocks), neuro (fontanelle, HC, fundi), mouth (frenulum), abdo, msk (swelling, pain), g/u (by specialized team)

• Palpate everywhere

Document all injuries on a body diagram: type, location, size, shape, colour, pattern

Ix (suspected non-accidental in non-ambulating children/infants): skeletal survey (all <2yo if NAI suspected), CT head, direct ophthalmoscopy, labs for occult trauma (AST, ALT, lipase, UA)

Fractures: bone density on XR, Ca²⁺, Mg²⁺, Phos, ALP, PTH, VIT D

• Ddx: accidental inj, osteogenesis imperfecta, Menkes dz, osteopenia (rickets, prematurity, meds), osteomyelitis, bone tumours

Bruising: CBC, diff, smear, INR, PTT, von Willebrand, clotting factors VII, IX, X, XIII.

• Ddx: accidental inj, bleeding d/o (ITP, thrombocytopenia, hemophilia), connective tissue d/o (Ehlers Danlos), Mongolian spots, folk healing practices, phytophotodermatitis, ink/paint

Intracranial bleed: bruising workup + urine organic acids

• head trauma often missed b/c: non-specific sx’s (vomiting, crying, irritable)

CAS duties: 1) report (reasonable grounds to suspect needs protection) 2) ongoing report (additional reasonable grounds) 3) no delegation

• àinvestigation (CAS (safety) + police (criminal charges))

How to report

• Provide basis for suspicion, address, religion, relationship w/ offender, other children

• A father is known to hit his son for discipline. The child says his dad hits him with a ruler. Father says he hits his son only with a hand. How can you tell O/E how the child was hit? Is this discipline or child abuse?

• O/E: shape of imprint/bruise, type of injury
• Abuse: potentially meets definition (depends on injury)

2 DTaP-IPV-Hib Pneu-C-13 Rot-1 4 DTaP-IPV-Hib Pneu-C-13 Rot-1 6 DTaP-IPV-Hib 12 Men-C-C Pneu-C-13 MMR 15 Var 18 DTaP-IPV-Hib 4-6 Tdap-IPV MMRV Gr 7 Men-C-ACYW HPV-4 HB 14-16 Tdap Yr Infl Live (MMR + V)àSC Td q10y >24, Pneu q5y, shingles >65

IMMUNIZATIONS (know Ontario immunization schedule)

1. All IM excl MMR & V (SC) & Rota (oral)

• “Do vaccines cause ASD?” How do you advise the parents? Discuss
  how you would calm mom's fear of autism in a child receiving MMR.

• Understand concern: worries, understanding of dz risks &

Vaccine benefits & risks, validate why may have belief

• if concerned re: ASD, discuss how original info was fraud &

no evidence to support link; give anecdotes of children
affected by vaccine-preventable dz’s

• stick to msg: vaccines are safe & effective & serious dz can

be prevented w/ imm

• vaccine benefits & risks, herd protection not 100% (tetanus from soil), ‘wait and see’ not good b/c many need mult doses & take time to protect
• vaccine safety system: held to higher safety standard than drugs, usually approved in Canada after use in other countries
• address pain assc w/ imm
• don’t dismiss from practice if parents refuse: majority of parents accept when concerns addressed

• Adverse reaction of MMR vaccine? (give 3)

• MMR: measles rash (7-14d), ITP, parotitis, febrile seizure
  • Local: induration, tenderness, redness, swelling
  • Allergic: urticaria, rhinitis, anaphylaxis
  • Systemic: ↑T, rash, irritability, lymphadenopathy, arthr/myalgia, arthritis
  • CIs: moderate/severe illness ± fever (not mild URTI), component allergy

AEs of DTaP-IPV-Hib: serious s/e rare. Mild pain, swelling, redness x few days at site. Some get fever/rash/lose appetite/fussy/drowsy x1-2d after shot (acetaminophen to prevent pain & fever).

• Mother being counselled about HPV vaccine. Which of the following are correct?

• protects against genital warts T (not 100%)
• HPV causes cervical and anal cancer T (HPV 16,18)
• most of us will get the infection and clear it on our own F (10% incidence)
• injection at 0, 2, 6 months T (0, 1-2, 6)
• side effects are common F
• protects against four high-risk subtypes F (not HPV 6,11)
• doesn’t require yearly paps T (q3y)
• average time from acquiring high-risk genotype to cancer is 30-40 y F (15y)

Growth monitoring should be performed at primary care visits for
children and youth ages 17 and younger

BMI = mass (kg) / height (m2)

Birth to 2 years
‐ Risk of overweight – Weight for length > 85th
‐ Overweight – Weight for length > 97th
‐ Obese – Weight for length > 99.9th

2 to 5 years
‐ Risk of overweight – BMI > 85th
‐ Overweight – BMI > 97th
‐ Obese – BMI > 99.9th

5 to 19 years
‐ Overweight – BMI > 85th
‐ Obese – BMI > 97th
‐ Severely obese – BMI > 99.9th

Over 60% of overweight children will have at least one CV risk factor

History
• What concerns, if any, do you have about your child’s weight? When
did weight gain start? Has gain been slow over time or sudden?
• What, if any, past attempts at weight loss have been made?
• Review of systems for comorbidities and etiologies of obesity:
o Headaches, blurred vision (hypertension, intracranial
hypertension)
o Breathing pauses when sleeping, snoring, daytime sleepiness (OSA)
o Joint pain (slipped femoral capital epiphysis, blount disease)
o Menstrual history, hirsutism, acne (hyperandrogenism, PCOS)
o Polyuria, nocturia (T2DM)
o Increased fatigue, cold intolerance, constipation, dry skin
(hypothyroidism)
o Stunted growth, striae (Cushing’s)
• Family History
o Identify obesity in first degree relatives
o Evaluate history of cardiovascular disease, type 2 DM, cancer in
first degree or second‐degree relatives
• Diet
o Identify caretakers who feed the child
o Identify foods high in calories and low in nutritional value that can
be reduced, eliminated, or replaced
o Assess eating patterns (e.g. timing, content, location of meals and
snacks)
o Estimate the type and quantity of beverage intake (sugar
sweetened beverages, juice, pop)
o Frequency of dining out
• Activity
o Identify barriers to walking or riding a bike to school
o Evaluate time spent in play
o Evaluate school recess and physical education (frequency, duration
and intensity)
o Assess after‐school and weekend activities
o Assess screen time (television, computer, movies, video games)
• Assess psychological impact of weight on child (bullying, depression,
anxiety, social isolation etc.)

Physical Exam
• Obtain and plot weight, height, BMI on WHO Growth Charts for Canada
Complete physical exam
• Findings to look for
o Hypertension
o Enlarged thyroid
o Acanthosis nigricans (insulin resistance)
o Striae
o Hepatomegaly
o Hirsutism
o Hip/knee pain or decreased ROM (Blounts, SCFE)
o Sexual maturity rating

Investigations
• Investigations can be performed for children who meet cut‐off point
for obesity
• Lipid profile, glucose, HbA1C
• Liver enzymes (specifically ALT) every 2 years
• Consider ultrasound of liver if liver enzymes are abnormal
• Fasting lipid profile every 2 years
• Fasting plasma glucose, HbA1C every 2 years, if severe obesity
(consider 2 h OGTT (1.75 mg/kg upto max 75 g)
• Sleep study if symptoms present

Structured behavior programs should not be offered to children/youth
who are at a healthy weight to prevent obesity

o Ask for permission to discuss weight
o Assess obesity related risk and potential ‘root causes’of weight gain
o Advice on obesity risks, discuss treatment benefits and options
o Agree on a realistic SMART plan to achieve health behavior
outcomes
o Assist in addressing drivers and barriers, offer education and
resources, refer as necessary and arrange follow‐up

Stress the importance of achieving behavioural and health‐related
improvements rather than focusing primarily on numbers on a scale.

Behaviour modification – can produce weight loss of 5‐20% over 3‐6
months

Lifestyle modification strategies can be broadly categorized as:
o Controlling the environment – include the entire family in healthy
changes rather than child alone
o Monitoring behavior
o Assessing motivation
o Setting realistic goals
o Rewarding successful changes in behavior
o Arrange short‐term follow‐up to review progress

• Involve a multidisciplinary team (dietitian, exercise therapist, social
worker, psychologist)
• There is no role of medications (such as orlistat) for healthy weight
management in children 2‐11 years old or for routine use in youth 12‐
17
• Surgical management can be offered in a select group of adolescents –
there is no role for routine referral for surgical management for
overweight/obesity

‘Healthy living’ is described by Health Canada as making choices that
enhance physical, mental, social and spiritual health

Canadian guidelines for physical activity and sedentary behavior

Short stature: differential ABCDEFG:
Alone (neglected infant)
Bone dysplasias (rickets, scoliosis, mucopolysaccharidoses)
Chromosomal (Turner's, Down's)
Delayed growth
Endocrine (low growth hormone, Cushing's, hypothyroid)
Familial
GI malabsorption (celiac, Crohn's)

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.

Streptococcus pneumoniae continues to be the most common cause of bacterial pneumonia in children

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.

Classification of bacteria
• Gram stain
▫Gram positive vs. gram negative
▫Don’t stain (acid fast organisms – mycobacteria, no cell wall – mycoplasma)
•Other factors to considerCan the antibiotic(s) get to the site of infection?
Will the antibiotic(s) be active at the site of infection?
Is the drug bactericidal or bacteristatic?
Are there any potential drug interactions?
▫Oxygen requirements (anaerobic, aerobic)
▫Motility
▫Spore production

Gram positive bacteria
Cocci
>>pairs & chains (S pneumoniae, S pyogenes, Grp B strep, Viridans Strep, enterococci)
>>clusters
>>>>>coagulase + (S aureus)
>>>>>coagulase - (seen more in neonates)
Bacilli
>>aerobic or facultative anaerobes (Listeria spp)
>>anaerobes
>>branching

Gram negative bacteria
Bacilli
>>Enterobacteriaceae (E. coli, Klebsiella spp., Enterobacter spp., Salmonella spp., Shigella spp.)
>>Various (respiratory ones) (Haemophilus influenzae, Bordetella pertussis)
>>non-fermenters (pseudomonas spp)
>>anaerobes
Cocci
>>Neisseria gonorrhoeae (commonly in babies w/ conjunctivitis), Neisseria meningitidis, Moraxella catarrhalis

Principles of antibiotic use and spectrum of activity
Selecting the correct antibiotic - Think bug, drug, host
>>Bug - What are the likely pathogens? What is the likelihood of antibiotic resistance?
>>Drug - Can the antibiotic(s) get to the site of infection? Will the antibiotic(s) be active at the site of infection? Is the drug bactericidal or bacteristatic? (eg meningitis vs UTI) Are there any potential drug interactions?
>>Host - Are there any underlying medical or surgical conditions? (eg renal failure, liver dysfn) Is the host immunologically normal? Are there any foreign bodies in place? Does the patient have any drug allergies? How expensive will the treatment course be?

Non-antibiotic considerations
>>Source control – consider the role of surgery (eg need to drain abscess first before abx use)
>>Anatomic and tissue related factors
▫Blood brain barrier
▫Osteomyelitis, sequestrum
▫Vegetations or necrotic tissue (devascularized tissue)
>>Ability of antibiotic to act at site of infection
▫Hard to eradicate organisms from foreign-body material
▫Abscess fluid
Many antibiotics do not penetrate well
Some antibiotics inactive in acid pH (e.g. aminoglycosides)

Cidal versus static
>>Bactericidal antibiotics kill bacteria (Cidal antibiotics preferred for serious life-threatening conditions)
▫Cell wall active agents (beta-lactams, vancomycin)
▫Daptomycin, quinolones, metronidazole, co-trimoxazole
>>Bacteristatic antibiotics inhibit bacterial growth and reproduction without killing them
▫Inhibitors of protein synthesis (macrolides, tetracyclines, clindamycin, chloramphenicol)
▫Sulfonamides, trimethoprim

Penicillin: spectrum of activity
>>Gram positive cocci (streptococci or any relatives/similar ones)
▫Group A, B, C, G streptococci, S. pneumoniae, S. bovis, viridans streptococci, enterococci
>>Gram negative cocci and rods
▫Neisseria gonorrhoeae & N. meningitidis, Pasteurella multocida
>>Other
▫Oral anaerobes (non-β-lactamase producing; fusobacteria, peptostreptococcus, prevotella spp., Bacteroides fragilis)
▫Syphilis
▫Selected gram positive bacilli including Clostridium spp., Actinomyces spp., Bacillus spp., C. diphtheriae

Penicillin class antibiotics (Antibiotic & Spectrum and advantage over penicillin)
>>Aminopenicillins (amoxi PO or ampi IV) - a bit more GN coverage, esp respiratory. same as penicillin + non-β lactamase producing H. influenzae, some gram negative enterics (E. coli, K. pneumoniae, Salmonella), Listeria (ampi is drug of choice), enterococci
>>β-lactamase stable (ie cloxacillin) - Methicillin sensitive S. aureus (basically S aureus abx) & coagulase negative staphylococci, streptococci
>>Ureidopenicillins (ie pipracillin) - Improved gram negative coverage including enterobacteriaceae (much expanded GN coverage, incl pseudomonas), P. aeruginosa
>>β-lactamase inhibitor combo’s (eg pip-tazo) - Improved activity against β lactamase producing gram positive (most common mechanism of resistance, so get very broad coverage, overcoming lots of GNs & anaerobes), gram negative and anaerobic organisms

Antibiotic class - Antibiotics - Spectrum of activity and comments
>>1st generation (usually GP but some GN coverage for simple inf's) - IV: cefazolin, PO: cephalexin - Gram +ve organisms (streptococci, staphylococci), Variable coverage against enteric gram negatives
that cause UTI (E. coli, K. pneumoniae)
>>2nd generation - IV: Cefuroxime, PO: Cefuroxime, Cefprozil - Gram +ve organisms (streptococci, staphylococci), H. influenzae, M. catarrhalis
>>3rd generation (covers streptococci well, which is why use for meningitis) - IV: Ceftriaxone, Cefotaxime, PO: Cefixime - Gram −ve organisms except P. aeruginosa. Streptococci including S. pneumoniae, group A
strep, group B strep (cefixime less so)
>>>>IV: Ceftazidime - Gram −ve organisms including P. aeruginosa, Poor gram positive coverage
**Enterococci are resistant to all current cephalosporins**

•Meropenem, ertapenem
•Broad spectrum coverage of gram positives, gram negative and anaerobes
•Spectrum of activity DOES NOT include (if drug of choice doesn't work, carbapenems likely won't either):
▫Methicillin resistant S. aureus & coagulase negative staph.
▫Ampicillin resistant enterococci
▫Occasional highly resistant gram negatives (enterics, pseudomonas)
▫Highly penicillin resistant S. pneumoniae may have reduced susceptibility
▫Stenotrophomonas maltophilia
▫Atypical organisms (mycoplasma, chlamydia, rickettsia, mycobacteria)