Pediatric Residency Training Program

1

Pediatric Health Supervision

Kathy L. Perkins M.D., Ph.D.

  1. Well Child Care—General Concepts
  2. The purpose of routine well child care

is to provide for the longitudinal health care needs of children from birth through adolescence. Components of well child care include:

  1. Anticipatory guidance(e.g., diet, healthy lifestyle promotion)
  2. Specific preventivemeasures (e.g., immunizations)
  3. Screening teststo detect asymptomatic diseases (e.g., vision, hearing, newborn metabolic screening, tuberculosis screening)
  4. Early detection and treatmentof symptomatic acute illness to prevent complications
  5. Preventionof disability in chronic disease
  6. Assessment of growth and development
  7. Content of the well child visit
  8. Historyprovides an opportunity to obtain diagnostic information and to form a doctor–patient–family alliance. The interview is shaped by family and patient concerns and by age-specific trigger questions about common problems (e.g., sleep, nutrition, behavior).
  9. Developmental surveillanceis gathered through age-specific questioning, developmental questionnaires, observations during the visit, screening tests, and review of academic school performance.
  10. Observation of parent–child interaction
  11. Physical examinationshould be comprehensive and also should focus on growth (i.e., length/height, weight, head circumference, and body mass index).
  12. Additional screening testsdepend on the age of the child and may include lead level, hemoglobin, and urinalysis screens and at 4 years of age, blood pressure and hearing and vision assessment.

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  1. Immunizations
  2. Anticipatory guidanceincludes a discussion of safety issues, and upcoming developmental issues.
  3. Growth
  4. Normal Growth
  5. Weight, height, head circumference(until 2 years of age), and sexual maturity are routinely monitored during well child care to assess for adequacy of growth and development.
  6. Standardized growth curvesrepresent normal values for age for 95% of children and are used to plot weight, height, body mass index, and head circumference. Special growth curves exist for children with particular genetic conditions (e.g., Down syndrome, achondroplasia).
  7. Tables 1-1, 1-2 and 1-3detail general “rules of thumb” for expected gains in weight, height, and head circumference. Sexual maturity rating scales are found in Chapter 3,Figures 3-1 and 3-3.
  8. Growth disturbances

are defined as growth outside of the usual pattern. Two common types of growth disturbance include failure to thrive and head growth abnormalities.

  1. Failure to thrive (FTT)
  2. Definition.FTT is a term used to describe a growth rate of less than expected for a child, and is of particular concern when a child's weight crosses two major percentile isobars on National Health Statistics charts.
  3. FTT may involve all growth parameters although weight gain is generally the most abnormal. This should be distinguished from isolated short stature, in which height is the most abnormal growth parameter (see Chapter 6, section I).
  4. In children with FTT, weight is usually affected before length, which is usually affected before head circumference (head circumference is initially spared in FTT).

Table 1-1. Rules of Thumb for Expected Increase in Weight

Age

Expected Weight Increase

Birth–3 months

30 g/day
Regain birth weight by 2 weeks

3–6 months

20 g/day
Double birth weight by 4–6 months

6–12 months

10 g/day
Triple birth weight by 12 months

1–2 years

250 g/month

2 years–adolescence

2.3 kg/year

30 g = 1 ounce body weight.

Table 1-2. Rules of Thumb for Expected Increase in Height

Age

Expected Height Increase

0–12 months

25 cm/year
Birth length increases by 50% at 12 months

13–24 months

12.5 cm/year

2 years–adolescence

6.25 cm/year
Birth length doubles by age 4 years
Birth length triples by age 13 years

  1. P.5
  2. Etiologiesof FTT are outlined in Figures 1-1 and 1-2, which include both inorganic or psychosocial causes and organic etiologies.
  3. The most common cause of FTTis inorganic FTT (i.e., a disturbed parent–child bond that results in inadequate caloric intake or retention).
  4. Organic etiologiessuggest underlying organ system pathology, infection, chromosomal disorders, or systemic illness.
  5. Evaluationof FTT requires a careful history and physical examination, a complete dietary history, and observation of the parent–child interaction.
  6. Routine screening tests are usually not useful, and laboratory evaluation should therefore be focused and directed by clues from the history and physical examination.
  7. Evaluation of potential organic etiologies will be directed by the timing or onset of FTT, i.e., prenatal onset of inadequate weight gain (as in intrauterine growth retardation) should be distinguished from postnatal onset of inadequate weight gain.
  8. Head growth abnormalitiesinclude microcephaly, craniosynostosis, deformational plagiocephaly, and macrocephaly.
  9. General concepts. Almost all head growth occurs prenatally and during the first 2 years of life.
  10. Head circumference at birth is 25% of the normal adult head size, and it increases to 75% of the normal adult head size by 1 year of age.
  11. Scalp edema or cephalohematoma(subperiosteal hemorrhage of the newborn cranium after a traumatic delivery) may interfere with accurate head circumference measurements.

Table 1-3. Rules of Thumb for Expected Increase in Head Circumference

Age

Expected Head Circumference Increase

0–2 months

0.5 cm/week

2–6 months

0.25 cm/week

By 12 months

Total increase = 12 cm since birth

 

Figure 1-1. Causes of inorganic failure to thrive (FTT).

  1. P.6
  2. Microcephaly
  3. Definition.Head circumference is 2–3 standard deviations below the mean for age.
  4. Incidence is 1–2/1000children.
  5. Etiologiesare classified as either congenital or acquired (Table 1-4).
  6. Congenital microcephalyis associated with abnormal induction and migration of brain tissue.
  7. Acquired microcephalyis caused by a cerebral insult in the late third trimester, perinatal period, or first year of life. Affected children are born with a normal head circumference that does not grow after the cerebral insult.
  8. Clinical features
  9. Because head size generally reflects brain size, microcephaly is always associated with a small brain.
  10. Microcephaly is usually associated with developmental delayand intellectual impairment.
  11. Microcephaly may be associated with cerebral palsyor seizures.
  12. Craniosynostosis
  13. Definition.Premature closure of one or more of the cranial sutures.
  14. Etiologyis often unknown. 80 to 90% of cases are sporadic and 10 to 20% are familial or a part of a genetic syndrome (e.g., Crouzon and Apert syndromes). Known etiologies or risk factors include intrauterine constraint or crowding and metabolic abnormalities, including hyperthyroidism and hypercalcemia.
  15. Clinical features
  16. Cranial sutures remain open until cessation of brain growth, which is 90% completed by age 2and complete by age 5.

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  1. Head shape in craniosynostosis is based on which suture closes prematurely.
  2. Premature closure of the sagittal sutureresults in an elongated skull (termed dolichocephaly or scaphocephaly) and is the most common form of craniosynostosis.

Table 1-4. Causes of Microcephaly

Congenital

Early prenatal infection (e.g., HIV, TORCH)
Maternal exposure to drugs and toxins (e.g., fetal alcohol syndrome)
Chromosomal abnormality (e.g., trisomy 13, 18, or 21)
Familial microcephaly (autosomal dominant or autosomal recessive inheritance)
Maternal phenylketonuria

Acquired

Late third trimester or perinatal infections
Meningitis or meningoencephalitis during first year of life
Hypoxic or ischemic cerebral insult
Metabolic derangements (e.g., hypothyroidism, inborn errors of metabolism)

TORCH = toxoplasmosis, other (syphilis), rubella, cytomegalovirus, herpes simplex virus.

  1. P.8
  2. Premature closure of the coronal sutureresults in a shortened skull (termed brachycephaly). This is more common in boys and may be associated with neurologic complications such as optic nerve atrophy.
  3. Premature closure of the metopic suture leads to a triangular-shaped head (termed trigonocephaly).

iii.        Premature closure of multiple sutures is rare but is associated with severe neurologic compromise.

  1. Diagnosisis made by physical examination of the head. Craniosynostosis is usually noted by 6 months of age. The diagnosis is confirmed by skull radiographs and head CT scan.
  2. Managementis surgical repair, most often indicated when cosmetic concerns are significant.
  3. Plagiocephaly
  4. Definition.Asymmetry of the infant head shape usually not associated with premature suture closure.
  5. Clinical features.The most common type of plagiocephaly is positional plagiocephaly, associated with flattening of the occiput and prominence of the ipsilateral frontal area. Viewed from the top, the skull is shaped like a parallelogram.
  6. May be associated with congenital muscular torticollis(see Chapter 17, section II.A.1)
  7. Incidence has increased as a result of current recommendations that infants sleep on their backs to prevent sudden infant death syndrome.
  8. Managementmay include range of motion exercises for associated torticollis, repositioning the head during sleep, helmet therapy, and increased time in the prone position when awake (“tummy time”).
  9. Macrocephaly
  10. Definition. Head circumference > 95% for age.

P.9

 

  1. Unlike microcephaly, the size of the head in patients with macrocephaly does not necessarily reflect brain size.
  2. Etiologies
  3. Familial, associated with an otherwise normal physical examination and a family history of large heads
  4. Overgrowth syndromes(e.g., Sotos syndrome), in which all growth parameters are enlarged
  5. Metabolic storage disorders(e.g., Canavan syndrome, gangliosidoses)
  6. Neurofibromatosis(see Chapter 19, Table 19-3)
  7. Achondroplasia(see Chapter 5, section III.D.2)
  8. Hydrocephalus(see Chapter 12, section II)
  9. Space-occupying lesions (e.g., cysts, tumors)
  10. Evaluationincludes measurement of parental head circumferences and a careful physical examination that includes observation for split cranial sutures, bulging anterior fontanelle, irritability, or vomiting, all of which may suggest elevated intracranial pressure. Head ultrasound or CT scan is performed to rule out hydrocephalus, if suggested by physical examination. Genetic evaluation may be useful if a genetic syndrome is suspected.
 

Figure 1-2. Organic causes of failure to thrive (FTT).

III. Immunizations

  1. Immunizations are one of the most important components of well child care and are the cornerstone of pediatric preventive care
  2. Types of Immunizations
  3. Active immunizationinvolves induction of long-term immunity through exposure to live attenuated or killed (inactivated) infectious agents.
  4. Live vaccinesare more likely to induce long-lasting immunity, but carry the risk of vaccine-associated disease in the recipient or secondary host. As a result, live vaccines should generally be avoided in patients with compromised immunity (e.g., cancer, congenital or drug-induced immunodeficiencies). Examples of live vaccines include oral polio (OPV); varicella; and measles, mumps, and rubella (MMR) vaccines.
  5. Non-live vaccinesare not infectious and tend to induce immunity for shorter periods, thus requiring booster immunizations. Examples include diphtheria, tetanus, and acellular pertussis (DTaP); hepatitis A and B; inactivated polio (IPV); Haemophilus influenzae type b (HIB); influenza; pneumococcal and meningococcal vaccines.
  6. Passive immunizationinvolves delivery of preformed antibodies to individuals who have no active immunity against a particular disease but who have either been exposed to or are at high risk for exposure to the infectious agent. Examples include:
  7. Varicella zoster immune globulin (VZIG) for immunocompromised patients who have been exposed to varicella and are at high risk for severe varicella infection.

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  1. Newborns born to hepatitis B–positive mothers receive hepatitis B immune globulin at birth.
  2. Visitors to high-risk areas may receive hepatitis A immune globulin before travel.
  3. Specific Immunizations
  4. Hepatitis B vaccine (HBV)
  5. Rationale for vaccine: hepatitis B infects 300 million worldwide.
  6. Type of vaccine: HBV in the United States is a recombinant vaccinewith particles of hepatitis B surface antigen (HBsAg).
  7. Timing of vaccination: HBV is given as a three-shot series within the first year of life.
  8. Diphtheria, tetanus, and acellular pertussis vaccine (DTaP)
  9. Rationale for vaccine: Diphtheria, tetanus, and pertussis all may cause serious disease, especially in young infants.
  10. Type of vaccine
  11. Vaccine is inactivated.
  12. DTP, which contained whole-cell, killed Bordetella pertussisand had a high rate of side effects, has now been replaced with DTaP, a vaccine that contains purified components (acellular) of B. pertussis and has lower rates of vaccine-associated fever, seizures, and local reactions.
  13. Timing of vaccination
  14. DTaPis recommended at 2, 4, and 6 months with boosters at 12–18 months and 4–6 years.
  15. dT(diphtheria and tetanus combined) contains one tenth the dose of diphtheria toxoid and is recommended at age 11–12 and every 10 years thereafter. Note that dT rather than DTaP is given to children ≥ 7 years of age.
  16. Oral and inactivated polio vaccines (OPV/IPV)
  17. Rationale for vaccine: Poliovirus is an enterovirus with propensity for the central nervous system, causing transient or permanent paresis of the extremities and meningoencephalitis. Polio has been eradicated from the Western hemisphere and South Pacific but remains in isolated pockets throughout the world.
  18. There are two types of vaccines.
  19. Live attenuated (OPV), administered orally
  20. Advantagesinclude induction of both host immunity and secondary immunity because it is excreted in the stool of the recipient and may infect, and thus immunize, close contacts (i.e., herd immunity).
  21. Disadvantagesinclude the possibility of vaccine-related polio. In recent years, the only cases of polio in the United States have been associated with OPV.
  22. Non-live or inactivated (IPV), administered subcutaneously or intramuscularly, has the advantage of no vaccine-related polio but the disadvantage of not inducing secondary immunity.

P.11

 

  1. Timing of vaccination: In the United States, only IPV is now recommendedand is given at 2 and 4 months, with boosters at 6–18 months and at 4–6 years.
  2. Haemophilus influenzae type b vaccine (HIB)
  3. Rationale for vaccine: H. influenzaetype b was a serious cause of invasive bacterial infection, including meningitis, epiglottitis, and sepsis, before vaccine licensure in 1985. Since licensure it has become a rare cause of such infections.
  4. Type of vaccine: HIB is a conjugate vaccinewith H. influenzae polysaccharide linked to various protein antigens, including diphtheria or tetanus toxoids, to augment immunogenicity.
  5. Timing of vaccination: HIB is recommended either at 2, 4, and 6 months with a booster at 12–15 months or at 2, 4, and 12 months, depending on the type of vaccine conjugate.
  6. Measles, mumps, and rubella vaccine (MMR)
  7. Rationale for vaccine: immunizes against three viral diseases:
  8. Measlesis a severe illness with complications that include pneumonia associated with significant mortality.
  9. Mumpsis most commonly associated with parotitis but may also cause meningoencephalitis and orchitis.
  10. Rubellacauses a mild viral syndrome in children but may cause severe birth defects in offspring of susceptible women infected during pregnancy.
  11. Type of vaccine: live attenuated vaccine
  12. Timing of vaccination: MMR is recommended at 12–15 months with a booster at either 4–6 years or 11–12 years of age.
  13. Varicella vaccine
  14. Rationale for vaccine: Varicella is the virus responsible for chicken pox and zoster. Varicella often causes uncomplicated illness but may cause severe disease in very young and in older patients.
  15. Type of vaccine: live attenuated vaccine
  16. Timing of vaccination: Vaccine is recommended at 12–18 months.
  17. Hepatitis A vaccine (Hep A)
  18. Rationale for vaccine: Hepatitis A is the most common viral cause of hepatitis worldwide, although it is asymptomatic in up to 70% of infected children younger than 6 years of age. More severe disease is seen in older children and adults, although it is rarely associated with fulminant hepatitis.
  19. Type of vaccine: inactivated
  20. Timing of vaccination and recommendations: Hep A vaccine is recommended at 2 years of age or older, with a booster 6 months later for the following groups:
  21. Susceptible children living in communities with high hepatitis A rates (i.e., incidence twice the national rate) and those traveling to endemic areas.
  22. Individuals in other groups with high hepatitis A rates, including

P.12


those with chronic liver disease, homosexual and bisexual men, users of illicit drugs, patients with clotting factor disorders receiving blood products, and patients at high risk for occupational exposure.

  1. Pneumococcal vaccines (Pneumovax and Prevnar)
  2. Rationale for vaccine: Pneumococcus (Streptococcus pneumoniae) is the most commoncause of acute otitis media and invasive bacterial infections in children younger than 3 years of age.
  3. There are two types of vaccines.
  4. Pneumovaxis composed of polysaccharide capsular antigens from 23 pneumococcal serotypes.
  5. Major advantageis that the vaccine contains antigens from pneumococcal strains causing almost all cases of bacteremia and meningitis during childhood.
  6. Major disadvantageis that the vaccine has little immunogenicity in children younger than 2 years.
  7. Indications.Vaccine is used primarily for older children and adults at high risk for pneumococcal disease (e.g., patients with sickle cell anemia who are functionally asplenic, immunodeficiency, chronic liver disease and nephrotic syndrome, and patients with anatomic asplenia).
  8. Prevnaris composed of seven pneumococcal serotypes.
  9. Major advantagesinclude immunogenicity and efficacy in preventing meningitis, pneumonia, bacteremia, and otitis media from the most common pneumococcal strains in children younger than 2 years of age.
  10. Major disadvantageis that it does not confer as broad coverage against pneumococcal strains as Pneumovax.
  11. Indication.Vaccine is recommended for all children younger than 2 years of age and for selected children older than 2 years of age who are at high risk for pneumococcal disease. Prevnar is recommended at 2, 4, and 6 months with a booster at 12–15 months.
  12. Adverse Effects of Immunization
  13. Most vaccine side effects are mild to moderate in severity and occur within the first 24 hours after administration (e.g., local inflammation and low-grade fever).
  14. Because MMRand varicella vaccines are live attenuated vaccines, fever and rash may occur 1–2 weeks after immunization (i.e., after the incubation period of the virus).
  15. Serious side effects that may result in permanent disability or be life-threatening are rare (e.g., vaccine-related polio after OPV).
  16. Contraindications and precautions to immunization
  17. Contraindicationsto immunization include:
  18. Anaphylaxisto a vaccine or its constituents
  19. Encephalopathywithin 7 days after DTaP vaccine

P.13

 

  1. Patients with progressive neurologic disorders, including uncontrolled epilepsy, should not receive the DTaP vaccine until neurologic status is stabilized.
  2. Immunodeficient patients should not receive OPV, MMR, and varicella vaccines.Household contacts of immunodeficient patients should not receive OPV vaccine as it is shed in the stool.
  3. Pregnant patients should not receive live vaccines.
  4. Precautions(i.e., caution should be exercised) to immunization include:
  5. For all vaccinesmoderate to severe illness(with or without fever). Note that mild illnesses, including febrile illnesses, are not contraindications to immunization.
  6. DTaP vaccine
  7. Temperature of 40.5°C within 48 hours after prior vaccination
  8. Collapse or shocklike state within 48 hours after prior vaccination
  9. Seizures within 3 days after prior vaccination
  10. Persistent, inconsolable crying lasting ≥ 3 hours occurring within 48 hours after prior vaccination
  11. MMR and varicella vaccines:Immunoglobulin (IVIG) administration within the preceding 3–11 months, which might interfere with the patient's immune response to these vaccines.
  12. Well Child Screening
  13. The focus of each well child

visit is to identify undetected problems and to identify the risks of such problems.

  1. Screening assessments

include a complete history and physical examination, growth measurements, blood pressure measurements, strabismus and vision screening, hearing screening, tuberculosis screening, and laboratory screening.

  1. Vision screening

for ophthalmologic disorders begins after birth and is detailed in Chapter 18.

  1. Hearing Screening
  2. Until recently, healthy children without risk factors had formal audiometric testing beginning at 4–5 years of age, as most types of screening require the patient's participation. However, universal newborn hearing screening, preferably before hospital discharge, is now recommended because of evidence that moderate-to-profound hearing loss in early infancy is associated with impaired language development.Early detection and intervention for hearing loss may improve speech and language acquisition.
  3. Two types of audiometric tests are used.
  4. Brainstem auditory evoked response (BAER)measures electroencephalographic (EEG) waves generated in response to clicks via electrodes pasted to the infant's scalp. BAER is the most accurate test, but it requires costly equipment and trained operators.

P.14

 

  1. Evoked otoacoustic emission (EOE)measures sounds generated by normal cochlear hair cells that are detected by a microphone placed into the external auditory canal. EOE accuracy may be affected by debris or fluid within the external or middle ear. It requires less expensive equipment and less operator training.
  2. The most effective screeningis thought to be use of both of the above tests in combination.
  3. Neonatal Metabolic (State) Screening
  4. Many metabolic diseases can be diagnosed and treated in the newborn period.
  5. Although there is variability from state to state in which conditions are screened, all statesscreen for congenital hypothyroidism and phenylketonuria (PKU), and the majority of states also screen for galactosemia. Each of these conditions is treatable and, if not detected early, each leads to irreversible brain injury.
  6. The majority of states screen for sickle cell anemiaand other hemoglobinopathies because early intervention in a comprehensive treatment program (e.g., penicillin prophylaxis) significantly decreases morbidity and mortality.
  7. Newborn screening tests for additional metabolic disorders (e.g., congenital adrenal hyperplasia) are in use in some states.
  8. Cholesterol and Lipid Screening
  9. Routine screeningof cholesterol and lipid panels is not recommended because of the lack of information about the risks and benefits of treating hyperlipidemia during childhood and because of the costs and limitations of currently available screening tests.
  10. Screening is recommendedfor children > age 2 with a family history of hypercholesterolemia, hyperlipidemia, or early myocardial infarction as follows:
  11. Screening cholesterol if either parent has a history of hypercholesterolemia
  12. Screening fasting lipid panel if either parents or grandparents have a history of cardiovascular disease or sudden death at ≤ 55 years of age
  13. Children with elevated cholesterollevels (75th–90th percentile) should have a fasting lipid panel that includes total cholesterol, triglycerides, high-density lipoprotein (HDL), and low-density lipoprotein (LDL).
  14. Iron-Deficiency Anemia Screening
  15. Iron-deficiency anemia occurs most commonly in children < 6 years of age, peaking between 9 and 15 months of age.
  16. Risk factorsfor iron-deficiency anemia include:
  17. Prematurity
  18. Low birth weight
  19. Early introduction of cow's milk (before 9 months of age)
  20. Insufficient dietary intake of iron
  21. Low socioeconomic status

P.15

 

  1. Universal screeningof hemoglobin levels is recommended between 9 and 15 months of age and between 4 and 6 years of age.
  2. Urinalysis screening

has been recommended by some physicians, although there is little evidence that routine surveillance of urinalysis or routine urine cultures are efficacious or cost effective. Urine studies are recommended only when clinically warranted or when required for school entry or by local health departments.

  1. Tuberculosis Screening
  2. Tuberculin skin testing with intradermal injection of purified protein derivative (PPD, Mantoux skin test) is recommended for children at risk for tuberculosis, including:
  3. Contactsof persons with confirmed or suspected infectious tuberculosis
  4. Children in contact with high-risk groups, including adults incarcerated or institutionalized during the preceding 5 years, HIV-infected household members, homeless persons, users of illicit drugs, and migrant farm workers
  5. Children with radiographic or clinical findings suggestive of tuberculosis
  6. Children who have immigrated from endemic areas, those with a history of travel to endemic areas, or those with significant contact with indigenous persons from endemic areas (e.g., Asia, Africa, Middle East, Latin America)
  7. Children with HIV
  8. Children without specific risk factors who reside in high prevalence areas
  9. Skin testsare analyzed at 48–72 hours after placement and are interpreted on the basis of the level of risk for tuberculosis in the particular child (see also Chapter 7, section XVII.C.6).
  10. Lead Screening
  11. Lead intoxication (plumbism)is a public health risk among children < age 5. Up to 4% of all children in the United States have evidence of increased lead absorption, including up to 20% of inner city children.
  12. Risk factorsfor lead intoxication include:
  13. Ingestion of lead-containing paintor putty from homes built before 1978
  14. Drinking water from lead pipesor pipes with lead-containing solder
  15. Exposure to lead smelters or lead-painted commercial structures during demolition
  16. Use of lead-glazed potteryin food preparation
  17. Use of lead-containing folk remedies
  18. Clinical featuresof lead intoxication
  19. Children < age 6 are most susceptible to the effects of lead.
  20. Acute lead intoxicationmay lead to the acute onset of anorexia, apathy, lethargy, anemia, irritability, and vomiting. These symptoms may progress to encephalopathy (see also Chapter 20, section VIII.D.4).

P.16

 

  1. Chronic lead intoxicationis most commonly asymptomatic; however, even patients with very low levels of lead may suffer neurologic sequelae, including developmental delay, learning problems, and mental retardation.
  2. Because lead intoxication may be asymptomatic, lead screeningis recommended for the following groups:
  3. All children 9 months–6 years of age living in older, dilapidated housing.
  4. All children 9 months–6 years of age who are siblings, visitors, or playmates of children with lead intoxication.
  5. All children 9 months–6 years of age living near lead smelters or lead-processing plants or whose parents or family members have a lead-related occupation or hobby.
  6. Children of any age living in older housing where renovation is occurring.
  7. All children of any age living in areas in which the percentage of 1- to 2-year-olds with elevated lead levels exceeds 12%.
  8. Although no threshold for the toxic effects of lead has been identified, even blood lead levels ≤ 10 µg/dL have been associated with effects on cognition in young children.
  9. Managementof lead poisoning is based on serum lead levels after repeat testing and generally includes education to decrease exposure and chelation for very high lead levels.
  10. Circumcision
  11. Approximately 60% of male

infants in the United States are circumcised.

  1. Medical benefits

of circumcision are controversial.

  1. Although there is a slightly increased incidence of penile cancerin uncircumcised adult men (possibly associated with human papilloma virus) and a possible increased incidence ofcervical cancer in the female sexual partners of uncircumcised men, these associations may be influenced by other factors.
  2. Circumcision for medical reasons is notrecommended by the American Academy of Pediatrics.
  3. Urinary tract infections(UTIs) are 10 times more common in uncircumcised male infants. However, there is insufficient evidence that circumcision decreases the risk of UTIs in male infants.
  4. Ten percentof uncircumcised males ultimately require circumcision for any of the following conditions:
  5. Phimosisis an inability to retract the foreskin. Phimosis is normal up to age 6 but is always abnormal if ballooning of the foreskin occurs during urination.
  6. Paraphimosisoccurs when the retracted foreskin cannot be returned to its normal position and acts as a tourniquet, resulting in obstruction to lymphatic flow and edema. Surgery is required emergently should venous return also become obstructed.

P.17

 

  1. Balanitisis inflammation of the glans of the penis. It may be associated with Candida spp. or Gram-negative infections in infants and with sexually transmitted infections in adults.
  2. Anesthesia and analgesia

are strongly recommended during circumcision.

  1. Complications from circumcision include

bleeding, infection, poor cosmesis, phimosis (secondary to insufficient foreskin removal), urinary retention, and injury to the glans or urethra. Repeat circumcision is needed in 10%.

  1. Contraindications to circumcision

include penile abnormalities (e.g., hypospadias), prematurity, and bleeding diatheses.

  1. Pediatric Dental Care
  2. Counseling about dental care issues

is an important component of anticipatory guidance.

  1. Tooth Eruption
  2. Range for initial tooth eruption is between 3 and 16 months, with an average of 6 months.
  3. The first tooth is generally a lower central incisor.
  4. Primary teeth(20 teeth in total) are generally established by 2 years of age.
  5. Secondary tooth eruptionalso begins with the lower central incisor between 6 and 8 years of age. There are 32 secondary or permanent teeth.
  6. Tooth eruption may be delayed or early.
  7. Delayed dental eruptionis defined as primary eruption occuring after 16 months of age. Causes include familial, hypothyroidism, hypopituitarism, and genetic syndromes such as Down syndrome and ectodermal dysplasia (associated with conical-shaped teeth, dysmorphic facial features, decreased numbers of sweat glands, and alopecia).
  8. Early dental eruptionis defined as primary eruption before 3 months of age. Causes include familial, hyperthyroidism, precocious puberty, and growth hormone excess.
  9. Dental Hygiene
  10. Tooth brushingshould begin as soon as teeth erupt. A moist washcloth or gauze pad may be used initially, and a soft toothbrush may be used as early as tolerated. Once children are 2–3 years of age, they are often able to assist in brushing their own teeth. A fluoride toothpaste may be used at this time.
  11. Dental flossto remove plaque from between teeth should be initiated when tight contact exists between teeth.
  12. Fluoride
  13. Children who consume optimal amounts of fluoride from birth until adolescence have 50–75% less dental decay than expected.

P.18

 

  1. Sources of fluorideinclude fluoridated water, fluoride supplements, and fluoride toothpaste. Note that water is not fluoridated at a uniform level in the United States.
  2. Excess fluoridecan lead to fluorosis.
  3. Fluorosis affects permanent teethand leads to abnormalities in dental enamel and dentin.
  4. Effects are cosmetic onlyand include white streaks, pitting, or brown-gray staining.
  5. The most critical time for dental vulnerability to excess fluoride is between 2 and 4 years of age.
  6. Although care must be taken to prevent fluorosis, fluoride supplementation remains important for the following children:
  7. Exclusively breastfed children older than 6 months, as breast milk contains little fluoride.
  8. Children who live in areas where tap water contains < 0.3 ppm fluoride.
  9. Dental Abnormalities
  10. Neonatal and natal teeth.Occasionally infants are born with teeth or have teeth that erupt within the first month of life.
  11. Definitions
  12. Natal teethare those that are present at birth.
  13. Neonatal teethare those that emerge during the first month of life.
  14. Teeth most commonly present early are mandibular central incisors.More than 90% are primary teeth that erupt early and < 10% are supernumerary teeth (teeth in excess of usual number).
  15. Etiology is often unknownbut may be caused by exposure to environmental toxins or may be familial.
  16. Management.No intervention is needed unless the teeth are hypermobile, cause breastfeeding difficulty, or cause trauma to the infant's lip or tongue. Aspiration of a natal or neonatal tooth is feared but is very unlikely.
  17. Nursing or bottle caries
  18. Epidemiology.Occurs in 3–6% of children and is most often seen in the child at 24–30 months of age
  19. Etiology
  20. Most frequently associated with a history of falling asleep with a nipple(breast or bottle) in the mouth or in children who breastfeed excessively or who carry around a bottle as a habit.
  21. Any liquid, other than water, that is retained around the teeth may serve as a substrate for bacteria capable of causing caries (including human and cow's milk).
  22. Streptococcus mutansis the most common bacterial agent. It does not appear in the oral cavity until teeth erupt, and children acquire this bacteria from colonized parents or siblings.
  23. Clinical features.Caries involve the maxillary incisors, canines,

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and primary first molars.
 The lower teeth are spared initially because they are covered by the tongue.

  1. Managementmay include placement of dental crowns or extraction.
  2. Dental Trauma
  3. A permanent tooththat has been traumatically avulsed may be re-implanted if the avulsed tooth is placed into the socket rapidly.
  4. Extraoral timeis the most important factor affecting the prognosis for successfully re-implanting a tooth.
  5. Prognosis is highest if the avulsed tooth is stored in liquids, especially milk.
  6. dry-stored toothhas a poor prognosis for re-implantation, even after only 30 minutes.
  7. Managementincludes gentle rinsing of an avulsed tooth with saline, placement into the socket, and referral to a dentist.
  8. Avulsed primary teeth do not require re-implantation.

VII. Developmental Screening

One of the most important preventive measures of well child care is assessment of developmental milestones. Development is therefore assessed at each well child visit from infancy through school age. School performance substitutes for formal developmental assessment in developmentally normal children older than 5–6 years of age. Development is discussed in depth in Chapter 2.

VIII. Anticipatory Guidance

  1. Anticipatory guidance

is patient and parent education and is provided during each well child visit. It is tailored to the child's current developmental level and to anticipated changes in the child's development in the interim before the next scheduled well child visit.

  1. Topics covered by anticipatory guidance include
  2. Health habits, including counseling about tobacco, drugs, and alcohol
  3. Prevention of illness and injury(e.g., safety counseling)
  4. Nutrition
  5. Dental care
  6. Social development and family relationships
  7. Sexuality
  8. Parental health
  9. Self responsibility
  10. School and vocational achievement
  11. Age-appropriate anticipatory guidance

topics for children from birth to 5 years of age are detailed in Table 1-5.

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Table 1-5. Age-Appropriate Anticipatory Guidance Topics for Discussion for Children from Birth to Age 5

Age

Healthy Habits

Injury and Illness Prevention

Nutrition

Parent–Child Interaction

Newborn

Cord care
Circumcision care
Skin and nail care
Normal vaginal discharge and bleeding
Normal sneezing and hiccups
Stools change from meconium to transitional
Amount of clothing needed, temperature regulation

Rear-facing car seat until 1 year and 20 lb
Sleep on back
Hot water heater < 120° F
Never leave alone
Early signs of illness: fever, failure to eat, vomiting, diarrhea, dehydration, irritability or lethargy, jaundice, rash
Use of thermometer

Breastfeeding
Feeding schedule for breast or formula on demand (8–12 times/day) for 4–6 weeks
If no sunlight exposure, supplement with vitamin D during the first year of life to prevent rickets
Instruct regarding preparation of formula with iron

Approach to crying
Burping and spitting up
Thumb sucking and pacifiers
Normal sleep patterns, sleeping arangements
Never shake a baby
Screen for maternal depression

1 month

Sleeping 18–20 hours/day, 3–4 hours at a stretch
Stooling decreasing in frequency and changes to brown and more formed
Some infants strain with stool

Same as newborn

Same as newborn
No cereal
No solids
No honey until age 1
Relief bottle for breast-feeding moms

Colic may begin at 3–4 weeks

2 months

Sleep 4–8 hours at a stretch
Feed every 3–4 hours
Stooling qod to 3–4 times/day

Risk of aspiration of small objects

Same as 1 month old

Establish bedtime routine
Encourage vocalizations
Most working mothers return to work by 4 months

4 months

Feeding every 4–5 hours
Sleeping 6–8 hours at a stretch

Aspiration risk
No infant walkers

Milk continues to be primary source of nutrition through 1 year of age
Iron-fortified infant cereal and solids introduced

Encourage vocalizations—talking, singing, and reading to infant
Introduce transitional object (e.g., toy, stuffed animal, blanket)

6 months

Feedings spaced out
Sleeping through night for many

Baby-proof home
Pool and water safety
Weapons and pet safety
Child gates on stairs
Aspiration risk
Sunscreen use
No infant walker

More solids introduced
Continue breast or bottle feeds plus solids
Avoid foods with aspiration risk or choking risk (e.g., peanuts, popcorn, hot dogs, carrots, celery sticks, whole grapes, raisins, corn)
Avoid egg whites, fish, citrus, chocolate, nuts, wheat until 1 year

Provide opportunities for exploration
Establish nighttime routine, transitional object
To discipline, use distraction and routines
Discuss separation anxiety
Encourage reading

9 months

Drinks from cup
Eats appropriate finger foods

Same as 6 months

Same as 6 months

Observe increasing independence and autonomy
Anticipate separation anxiety and sleep disturbances

12 months

Feeding 3 times/day plus 2–3 snacks
Establish sleep hygiene—transitional objects, bedtime routine, sleeping through night
Begin weaning from bottle

Child-proof house
Switch to toddler car seat and face front

Switch to whole milk
Drink from cup
Table food—watch aspiration risk
Weight gain slows down, intake decreases

Praise good behavior
Encourage language development—read to toddler
Encourage exploration and initiative
Discipline with distraction, gentle restraint, “time out”
Limit TV to 1 hour/day

15 months

Feeds self
Naps 1–2 times/day

Same as 12 months

Same as 12 months

Begin discussion of toilet training readiness; do not push; be patient

18 months

Feeds self
May begin toilet training
Naps 1–2 times/day

Same as 12 months

Avoid cookies and sweets as bribe to eat
Whole milk < 24 oz/day

View negativism as budding independence
Encourage language development by reading, singing, talking
Make discipline brief and specific
Anticipate night terrors, nightmares, night fears
Don't expect toddler to share

2 years

Change to bed from crib
Initiate toilet training if not prior

Same as above

Food struggles are common
Change to 2% milk
Never force child to eat
Offer nutritious foods

Anticipate new fears, indecision—provide reassurance
Anticipate parallel play, sibling rivalry if new baby expected
Acknowledge conflict but don't allow behavior; biting and hitting are common

3 years

90% bowel trained
85% bladder (day)
65% bladder (night)

Bicycle helmets
Street safety
Stranger danger
Firearm safety
Tricycle safety
Pet and water safety

Continue healthy food choices

Use correct terms for genitalia
Introduce notion that some areas of the body are private
Anticipate preschool
Observe beginning of sharing during play

4 years

95% bowel trained
90% bladder (day)
75% bladder (night)

Child booster seat (4 years and 40 lb)
Swimming lessons
Scissor and pencil use
Firearm safety
Bicycle helmets

Continue healthy food choices
Anticipate imitating peers in eating choices

Provide opportunities for socialization with other children
Establish and enforce consistent, explicit rules for safe behavior
Observe beginning of imaginative play
Observe discovery of sexual identity

5 years

Sleeps 10–12 hours/night
Teach personal care and hygiene

Bicycle helmets
Stranger danger
Firearm safety
Phone number memorized
Booster seat

Continue healthy food choices, including school lunch

Library cards, learning to read
Rules for bedtime, TV watching
Age-appropriate chores
School participation encouraged

Review Questions and Answers

  1. A 6-month-old girl has been noted to fall off her growth curve and now is < 5% for her age. You suspect failure to thrive (FTT) and consider the most common causes. Which one of the following is the most common cause of FTT?

(A). A disturbed parent–child bond that results in inadequate caloric intake or retention

(B). Prenatal onset of inadequate weight gain that persists in the postnatal period

(C). A skeletal abnormality resulting in short stature with associated poor weight gain

(D). Malabsorption, or the inability to completely absorb ingested calories and nutrients

(E). Endocrinologic abnormalities, such as growth hormone deficiency or hypothyroidism

  1. A 2-month-old male infant is seen for routine well child evaluation. At birth, his head circumference was < 5% for age. His head circumference has increased 1 cm in size since birth. Which one of the following is the most likely cause of the infant's condition?

(A). Intraventricular hemorrhage

(B). Perinatal asphyxia

(C). Third trimester infection with cytomegalovirus

(D). Craniosynostosis

(E). First trimester infection with Toxoplasmosis

  1. A 4-week-old boy is evaluated for macrocephaly. In addition to a head circumference > 95%, his coronal and sagittal sutures are split 1 cm and his fontanelle is bulging. Both of his parents' head circumferences are > 95%. Which one of the following is the most likely explanation for the infant's macrocephaly?

(A). Familial

(B). Achondroplasia

(C). Hydrocephalus

(D). Metabolic storage disorder

(E). Neurofibromatosis

  1. A 9-month-old girl is diagnosed with iron-deficiency anemia. Her past medical history includes an uncomplicated delivery at 38 weeks. The infant was fed with formula until 6 months, at which time she was switched to baby foods and whole milk. Which one of the following is correct regarding her iron-deficiency anemia?

(A). Her age is atypical for the presentation of iron-deficiency anemia.

(B). Her early birth at 38 weeks gestation has led to the anemia.

(C). Early introduction of cow's milk is the likely cause of her anemia.

(D). Insufficient dietary intake of iron is the likely cause of her anemia.

(E). The patient's early introduction of solids is the likely cause of her anemia.

  1. An asymptomatic 12-month-old girl is screened for lead exposure. Which one of the following is correct regarding lead screening and lead intoxication?

(A). Most patients exposed to lead are asymptomatic.

(B). Children between 5 and 10 years of age are at highest risk for lead effects.

(C). Low lead levels on screening indicate that a child is at no risk for the neurologic sequelae of lead exposure.

(D). Chelation has not been shown to be effective for patients with high lead levels.

(E). Ingestion of paint from a home built in 1990 would place a child at risk for lead poisoning.

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  1. At a prenatal visit, the expectant parents of a first-born male child ask you to summarize the benefits, risks, and contraindications to performing a circumcision on their son. Which one of the following statements is correct?

(A). Circumcision has been demonstrated definitively to decrease the risk of urinary tract infection.

(B). Because of the young age at which circumcision is performed, analgesia is generally not required, thus decreasing the risks of the procedure when performed in the newborn period.

(C). If their child is not circumcised in the newborn period, he may require circumcision at 9 months of age if he is subsequently diagnosed with phimosis.

(D). The American Academy of Pediatrics recommends routine circumcision for medical benefit.

(E). Hypospadias is a contraindication to circumcision.

  1. A 20-month-old boy is seen for routine well child care. Physical examination reveals caries involving the maxillary incisors. Which one of the following is most likely to have contributed to this condition?

(A). The use of both fluoride drops and fluoride toothpaste simultaneously, which has caused fluorosis

(B). Falling asleep with a water-filled bottle in the mouth

(C). Falling asleep while breastfeeding

(D). Oral colonization with Staphylococcus aureus

(E). Living in an area in which tap water contains < .2 ppm fluoride

  1. A 1-year-old child living in an apartment with old chipping paint is suspected of being at high risk for lead intoxication. Which of the following findings on a routine health maintenance visit would support this diagnosis?

(A). Failure to thrive

(B). Anemia

(C). Fluorosis

(D). Microcephaly

(E). Impaired hearing

  1. On a routine health maintenance visit, a 9-month-old infant is noted to have normal growth and development, and an unremarkable physical examination. Which of the following should be included in your counseling of the parents at this time?

(A). Vitamin D supplementation should be initiated if the patient has minimal exposure to sunlight.

(B). The patient should be encouraged to begin using a walker to stimulate gross motor development.

(C). The infant should now be placed in a forward-facing car seat.

(D). Toilet training should be initiated.

(E). Eggs and fish may now be introduced into the infant's diet.

  1. You receive a telephone call from the parents of a 10-month-old infant, who are concerned that their baby does not yet have any teeth. A review of the infant's growth chart reveals that the patient's weight, length, and head circumference are at the 50th, 25th, and 25th percentiles, respectively. The infant's developmental milestones are normal. Which of the following would be the most appropriate course of action?

(A). Refer the patient to a pediatric dentist.

(B). Refer the patient to a geneticist.

(C). Reassure the parents that their infant's pattern of dental eruption is within the normal range.

(D). Order radiographs to assess the patient's bone age.

(E). Order radiographs of the patient's oral cavity.

The response options for statements 11–13 are the same. You will be required to select one answer for each statement in the set.

(A). Immunization with a non-live vaccine is indicated.

(B). Immunization with a live vaccine is indicated.

(C). Immunization is indicated, and both live and non-live vaccine options are available.

(D). Passive immunization is indicated.

(E). No immunization is indicated at this time.

For each patient, select the appropriate type of immunization indicated at this time, if any.

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  1. A 2-year-old child living in a region of the country at high risk for hepatitis A exposure presents for a routine health maintenance visit. His immunizations are up-to-date through 18 months of age.
  2. A 5-year-old child with otherwise up-to-date immunization status presents with no known history of chicken pox exposure and no record of having received the varicella vaccine.
  3. An HIV-positive patient presents 24 hours after being exposed to varicella, with no prior history of chicken pox, nor any record of having received the varicella vaccine.
  4. The diagnosis of plagiocephaly is made at a 4-month routine health maintenance visit. Parents report the child has a preference for looking to the right side. Which of the following would be the most appropriate course of action at this time?

(A). Obtain a head ultrasound if the patient's anterior fontanelle is still open, or a head CT scan if the anterior fontanelle is closed.

(B). Obtain skull radiographs to better delineate which cranial sutures may have fused prematurely.

(C). Reassure the parents that this is a normal variant that will resolve spontaneously during the subsequent 6–8 months.

(D). Reassure the parents that this is likely positional plagiocephaly, and recommend stretching exercises, repositioning the head during sleep, and increased time in the prone position when awake.

(E). Counsel the parents that this condition may be associated with a genetic syndrome and refer the patient for a consultation with a geneticist.

Answers and Explanations

  1. The answer is A[II.B.1]. The most common etiology of failure to thrive (FTT) is inorganic FTT, in which there is a problem with the parent–child bond that interferes with either food intake or retention. Underlying biomedical causes of FTT, including malabsorption, endocrinologic abnormalities, and intrauterine growth retardation are much less common causes of FTT. Short stature should be distinguished from FTT. Those with FTT have primary failure of weight gain (and subsequent poor linear growth and poor head circumference growth), whereas those with short stature have primary failure of linear growth.
  2. The answer is E[Table 1.4; II.B.2.b]. Given his small head circumference at birth, this patient's microcephaly is congenital. Causes of congenital microcephaly include TORCH (toxoplasmosis, other-syphilis, rubella, cytomegalovirus, herpes simplex virus) infections during the first trimester, in utero exposure to drugs and toxins, and chromosomal abnormalities. In addition, congenital microcephaly may be familial. Perinatal asphyxia, intraventricular hemorrhage, craniosynostosis, and late prenatal and perinatal infections may all cause acquired microcephaly. Patients with acquired microcephaly are born with a normal head circumference.
  3. The answer is C[II.B.2.e]. This patient has signs of increased intracranial pressure, which includes split sutures and a bulging fontanelle. Other symptoms of intracranial pressure include irritability and vomiting. Hydrocephalus is the only option that is associated with increased intracranial pressure. Metabolic storage disorders, neurofibromatosis, achondroplasia, and familial macrocephaly are associated with enlarged head circumference but are not associated with increased intracranial pressure in a patient of this age.
  4. The answer is C[IV.G]. The introduction of cow's milk should occur only after 9 months of age, as its early introduction (in this case at 6 months) is a known risk factor for iron-deficiency anemia and is the likely cause in this case. This is because whole cow's milk offers less bioavailable iron and may also result in stool blood loss. Although insufficient dietary intake of iron is a possible cause, this patient received iron-fortified formula for at least 6 months, making this cause less likely. Prematurity (defined as < 37 weeks) may result in lower iron stores with resultant anemia. Iron-deficiency anemia classically peaks between 9 and 15 months of age. Finally, solids were introduced at an appropriate time in this patient (6 months) and are not a risk factor for anemia.
  5. The answer is A[IV.J]. The majority of patients with elevated lead levels are asymptomatic. Children younger than 6 years of age are at highest risk for the effects of lead, and risk factors for intoxication include ingestion of lead-containing paint from homes built before 1978, drinking water from lead pipes, use of lead-glazed pottery in food preparation, and use of lead-containing folk remedies. Even patients with very low lead levels may suffer from developmental delay and learning problems. Chelation is sometimes required and is effective for very high lead levels.
  6. The answer is E[V.B, C, D, and E]. Contraindications to circumcision include hypospadias, bleeding diathesis, and prematurity. Although phimosis is an indication for circumcision in some patients, it is considered normal up until 6 years of age. Other indications for circumcision include balanitis and paraphimosis; however, the American Academy of Pediatrics does not recommend routine circumcision for medical benefit. Circumcision has also not been conclusively demonstrated to decrease the incidence of urinary tract infections. No matter the patient's age, circumcision requires analgesia and anesthesia.
  7. The answer is C[VI.D.2 and VI.C.3.c]. Because of the patient's age and involvement of the maxillary incisors, this patient likely has nursing or bottle caries. Nursing or bottle caries are found in 3–6% of children and are associated with falling asleep with a bottle or a nipple in the mouth. Any liquid other than water can serve as a substrate for infection, including breast milk. Streptococcal mutans is the most common bacterial agent. Those who live in areas of low fluoride (< 0.3 ppm) are at higher risk for caries. Excess fluoride may cause cosmetic abnormalities to the enamel, but the risk of caries is not increased.
  8. The answer is B[IV.J.3]. Lead intoxication may cause a variety of clinical manifestations, including neurocognitive impairment, lethargy, anemia, vomiting, and irritability. Most patients exposed to lead, however, are asymptomatic. Fluorosis is not associated with lead exposure, and lead exposure has not been known to result in microcephaly, failure to thrive, or hearing impairment.
  9. The answer is A[Table 1.5]. Oral vitamin D supplementation is recommended to prevent the development of rickets in patients who are exposed to minimal sunlight during the first year of life. Infant walkers are not recommended because of the risk of injury associated with their use. Infants should be placed in a rear-facing car seat until they are 12 months of age and weigh 20 pounds. Toilet training is generally initiated between 1 and 2 years of age. Because of the risk of allergy, fish, egg whites, wheat, citrus fruits, nuts, and chocolate are avoided until at least 1 year of age.
  10. The answer is C[VI.B]. Although the average age of initial tooth eruption is 6 months, there is a wide range of normal variability, ranging from 3 months to 16 months. Delayed dental eruption is defined as primary eruption after 16 months of age and may be related to endocrine disorders (hypothyroidism and hypopituitarism) or to genetic syndromes (Down syndrome and ectodermal dysplasia) or may be familial.
  11. The answers are A, B, and D, respectively[III.B. and III.C]. Immunizations are categorized as active (live or non-live) or passive. Active immunizations stimulate an immune response in the patient, whereas passive immunization involves the delivery of preformed antibodies to those who previously had no immunity to a particular disease. Examples of live vaccines include the varicella and the measles, mumps, and rubella vaccines. Examples of non-live vaccines include Haemophilus influenzaetype b, diphtheria, tetanus, and acellular pertussis, and hepatitis A and B vaccines. Note that polio vaccines are available in both live (OPV) and non-live or killed (IPV) forms. Children living in regions of the country with a high incidence of hepatitis A infection should receive the hepatitis A vaccine (a non-live vaccine) at 2 years of age, with a booster 6 months later. An immunologically intact child with no immunity to varicella may receive the varicella vaccine (a live vaccine) at any age ≥ 12 months. An immunocompromised patient, such as a child with HIV, exposed to varicella, would be at high risk for acquiring a severe varicella infection and should therefore receive varicella zoster immune globulin (an example of passive immunization), ideally within 96 hours of exposure to the disease.
  12. The answers are A, B, and D, respectively[III.B. and III.C]. Immunizations are categorized as active (live or non-live) or passive. Active immunizations stimulate an immune response in the patient, whereas passive immunization involves the delivery of preformed antibodies to those who previously had no immunity to a particular disease. Examples of live vaccines include the varicella and the measles, mumps, and rubella vaccines. Examples of non-live vaccines include Haemophilus influenzaetype b, diphtheria, tetanus, and acellular pertussis, and hepatitis A and B vaccines. Note that polio vaccines are available in both live (OPV) and non-live or killed (IPV) forms. Children living in regions of the country with a high incidence of hepatitis A infection should receive the hepatitis A vaccine (a non-live vaccine) at 2 years of age, with a booster 6 months later. An immunologically intact child with no immunity to varicella may receive the varicella vaccine (a live vaccine) at any age ≥ 12 months. An immunocompromised patient, such as a child with HIV, exposed to varicella, would be at high risk for acquiring a severe varicella infection and should therefore receive varicella zoster immune globulin (an example of passive immunization), ideally within 96 hours of exposure to the disease.
  13. The answers are A, B, and D, respectively[III.B. and III.C]. Immunizations are categorized as active (live or non-live) or passive. Active immunizations stimulate an immune response in the patient, whereas passive immunization involves the delivery of preformed antibodies to those who previously had no immunity to a particular disease. Examples of live vaccines include the varicella and the measles, mumps, and rubella vaccines. Examples of non-live vaccines include Haemophilus influenzaetype b, diphtheria, tetanus, and acellular pertussis, and hepatitis A and B vaccines. Note that polio vaccines are available in both live (OPV) and non-live or killed (IPV) forms. Children living in regions of the country with a high incidence of hepatitis A infection should receive the hepatitis A vaccine (a non-live vaccine) at 2 years of age, with a booster 6 months later. An immunologically intact child with no immunity to varicella may receive the varicella vaccine (a live vaccine) at any age ≥ 12 months. An immunocompromised patient, such as a child with HIV, exposed to varicella, would be at high risk for acquiring a severe varicella infection and should therefore receive varicella zoster immune globulin (an example of passive immunization), ideally within 96 hours of exposure to the disease.
  14. The answer is D[II.B.2]. Plagiocephaly is defined as asymmetry of the infant head shape and is usually not associated with premature closure of a cranial suture. The most common type of plagiocephaly is positional plagiocephaly, and it is often associated with congenital muscular torticollis. The initial management of this patient should include range of motion stretching exercises for associated torticollis (the likely cause of the gaze preference), repositioning the head during sleep, and increased time in the prone position when awake (“tummy time”). Radiographic studies are not indicated, and there is no association between positional plagiocephaly and underlying genetic syndromes, In contrast, the diagnosis of craniosynostosis, or premature closure of one or more cranial sutures, may require radiographic confirmation (either with skull radiographs or CT scan) and may be associated with underlying genetic syndromes.