First Aid for the Pediatrics Clerkship, 3 Ed.

Health Supervision and Prevention of Illness and Injury in Children and Adolescents

 

MORBIDITY AND MORTALITY

Image The leading cause of death in children under 1 year of age is grouped under the term perinatal conditions, which include:

Image Congenital malformation, deformations, and chromosomal abnormalities (number one cause).

Image Low birth weight.

Image Sudden infant death syndrome (SIDS).

Image Respiratory distress syndrome.

Image Complications of pregnancy.

Image Perinatal infections.

Image Intrauterine or birth hypoxia.

Image From 1 year to 24 years of age, the leading cause of death is injury (unintentional injuries).

PREVENTION

Prevention is of primary importance in caring for the pediatric patient and is promoted through:

Image Parental guidance (anticipatory guidance and counseling).

Image Screening tests.

Image Immunization.

PARENTAL GUIDANCE

Age-appropriate anticipatory guidance is provided to parents at various well-child visits.

1 Week–1 Month

Image

A 1-month-old infant is brought to the ED with poor feeding, weak suck, drooling, constipation, and Image spontaneous movements. He is exclusively breast-fed, and his mother has been giving him home remedy for “colic”. Physical exam is positive for hypotonia. Think: Botulism and its relationship with some home remedies prepared with honey. Treatment is with human botulism immune globulin (BIG-IV).

Image Place infant to sleep on back to prevent sudden infant death syndrome (SIDS).

Image Use a car seat.

Image Know signs of an illness.

Image Maintain a smoke-free environment (associated with SIDS and ear infections).

Image Maintain water temperature at < 120°F (48.8°C).

Image Do not give honey to a child under 1 year of age (risk for botulism).

Image Discuss normal crying behavior and give some suggestions for how to calm the infant.


Image

Be informed of social services and financial assistance available to parents and patients.


2 Months–1 Year

Image Childproof home to keep children safe from poisons, household cleaners, medications, buckets and tubs filled with water, plastic bags, electrical outlet covers, hot liquids, matches, small and sharp objects, guns, and knives.


Image

Any child with a rectal temperature > 100.4°F (38°C) in the first 3 months of life should be seen immediately.


Image The American Academy of Pediatrics (AAP) does not recommend syrup of ipecac anymore. Explain proper use of syrup of ipecac for poisonings, and give telephone number to local poison control hotline.

Image No solid food until 4–6 months.

Image Avoid baby walkers.

Image Do not put baby to bed with bottle, as it can cause dental caries.

Image Breast-feed or give iron-fortified formula, but no whole milk until after 1 year of age.

Image Avoid choking hazards such as coins, peanuts, popcorn, carrot sticks, hard candy, whole grapes, and hot dogs.

Image May start using cup at 6–9 months.


Image

Falls and drowning are major risks of injury and death in toddlers.


1–5 Years

Image Use toddler car seat (ages 1–4) and booster seat (ages 4–8) if proper weight and height.

Image Brush teeth, see dentist.

Image Wean from bottle (start by 9 months of age with the introduction of cup).

Image Make sure home is childproof again.


Image

Most infants drown in their own bathtub.


Image Restrict child’s access to stairs.

Image Allow child to eat with hands or utensils.

Image Use sunscreen.

Image Wear properly fitting bicycle helmet.

Image Provide close supervision, especially near dogs, driveways, streets, and lawnmowers.

Image Make appointment with dentist by 1 year of age.

Image Ensure that child is supervised when near water; build fence around swimming pool with latched gate.

Image Screen for amblyopia, strabismus, and visual acuity in all children younger than 5 years.

Image Strabismus: Cover test or Hirschberg light reflex test in children < 3 years.

Image Visual acuity: > 3 years and screen every 1–2 years throughout childhood.


Image

Temperature of the water heater should be kept below 120°F (49°C) to prevent accidental scalding injuries.


6–10 Years

Image Reinforce personal hygiene.

Image Teach stranger safety.

Image Provide healthy meals and snacks.

Image Keep matches and guns out of children’s reach.

Image Use seat belt always, and booster seat until 4 feet 9 inches in height.

11–21 Years

Image Continue to support a healthy diet and exercise.

Image Wear appropriate protective sports gear.

Image Counsel on safe sex and avoiding alcohol and drugs.

Image Promote a healthy social life, balanced diet, and at least 30 minutes of exercise every day.

Image Ask about mood or eating disorders (see below).

SCREENING

Blood Pressure

Image Routine monitoring of blood pressure should begin at age 3 years.

Image Most common cause of high blood pressure reading in children is inappropriate cuff size.

Metabolic Screening

In the first month of life, the neonate should receive screening for various metabolic disorders including hypothyroidism, phenylketonuria (PKU), sickle cell disease, and adrenal cortex abnormalities.


Image

Metabolic screening may vary from state to state in the United States.


Lead Screening

Image Exposure is Image by:

Image Living in or visiting a house built before 1960 with peeling or chipped paint.

Image Plumbing with lead pipes or lead solder joints.

Image Living near a major highway where soil may be contaminated with lead.

Image Contact with someone who works with lead.

Image Living near an industrial site that may release lead into the environment.

Image Taking home remedies that may contain lead.

Image Having friends/relatives who have had lead poisoning.

Image Screen for lead levels at age 12 months.

Hematocrit

Image Screen for anemia at 9–12 months of age where certification is needed for WIC (Women, Infants, and Children) or if the appropriate risk factors are present.

Image Second test 6 months later in high-risk communities for iron deficiency.

Image Anemia: Hemoglobin levels < 11 g/dL.

Hyperlipidemia

Image Screen for hyperlipidemia in children older than 2 years with appropriate risk factors:

Image Family history of coronary or peripheral vascular disease before the age of 55 years in parents or grandparents.

Image Parent with a total serum cholesterol level > 240 mg/dL.

Image Obesity.

Image Hypertension.

Image Diabetes mellitus.

Image Screening may also be considered in children with inactivity; also in adolescents who smoke.

Image Risk factors for anemia include low socioeconomic status, birth weight under 1500 g, whole milk received before 6 months of age, low-iron formula given, low intake of iron-rich foods.

Vision and Hearing

Image A hearing screen is recommended shortly after birth.

Image Vision screening may begin at age 3 years, sooner if concerns.

Image Suspect hearing loss earlier if child’s speech is not developing appropriately.

Image A child’s cooperation is essential to obtaining an accurate result (~3 years).

CAR SEATS

Image Car seats should be used for travel in automobiles for children from birth until the child reaches at least 40 pounds.

Image Children under 20 pounds should be in an infant car seat, which belongs in the back seat and is rear-facing.

Image Children from 20 pounds to 40 pounds belong in a car seat that is in the back seat but may be forward facing.

Image Never place a car seat in front of an air bag (front passenger-side and side-impact air bags). The safest place for the infant is the middle portion of the rear seat.

Image Make sure parents understand the proper use of car seats.

Image Booster seats should be used until the child is 4 feet 9 inches tall (generally ages 4–8).


Image

Newborns should not leave the hospital without a car seat.


VACCINES

Image See page 13.

Image Site of injection:

Image Infants: Anterolateral thigh.

Image Children: Deltoid.

Hepatitis B

Image

A 25-year-old female who is hepatitis B surface antigen positive is about to deliver a baby and she asks what is the best way to prevent the baby from having hepatitis B. Think: Prevention.

Babies born to women who are hepatitis B surface antigen positive receive hepatitis B immunoglobulin and hepatitis B vaccine shortly after birth, and 1–2 months after completing three doses of hepatitis B vaccine, they should be tested for hepatitis B surface antigen as well as the antibody.

Image First given intramuscularly (IM) at birth or within first 2 months of life.

Image Second dose given 1 month after first dose.

Image Third dose given 4 months after first dose and 2 months after second dose, but not before 6 months of age.

Image Must give at birth along with hepatitis B immune globulin (HBIG) if baby is exposed transplacentally or if maternal status is unknown.

Image Infants born to HBsAg-positive mothers should be tested for HBsAg and antibody to HBsAg 1–2 months after completion of at least three doses of the HepB vaccine, at age 9–18 months.


Image

Fever is not a contraindication to receiving immunization. Moderate/severe illness is a contraindication. This holds true for all vaccines.


CONTENT

Adsorbed recombinant hepatitis B surface antigen proteins.

SIDE EFFECTS

Image Pain at injection site.

Image Fever > 99.9°F (37.7°C) in 1–6%.

CONTRAINDICATIONS

Anaphylactic reaction to vaccine, yeast, or another vaccine constituent.


Image

DTaP is preferred for children under 7 years of age. Td or Tdap is given after 7 years of age.


Diphtheria, Tetanus, and Acellular Pertussis (DTaP)

Image Minimum age: 6 weeks.

Image Given IM at 2, 4, and 6 months of age, then another between 12 and 18 months of age.

Image The fourth dose may be administered as early as age 12 months; must allow 6 months between third and fourth doses.

Image Administer the final dose at age 4–6 years.


Image

DTP has greater risks of side effects than DTaP.


CONTENT

Image DTaP is diphtheria and tetanus toxoids with acellular pertussis.

Image DTP contains a whole-cell pertussis.


Image

DTaP is not a substitute for DTP if a contraindication to pertussis exists.


SIDE EFFECTS

Image Erythema, pain, and swelling at injection site.

Image Fever > 100.9°F (38.3°C) in 3–5%.

Image Anaphylaxis in 1/50,000.

CONTRAINDICATIONS

Image Anaphylactic reaction to vaccine or another vaccine constituent.

Image Encephalopathy not attributable to another cause within 7 days of a prior dose of pertussis vaccine.

Haemophilus influenzae Type B (Hib)

Image Minimum age: 6 weeks.

Image Given IM at 2, 4, and 6 months of age, then again between 12 and 15 months of age.

CONTENT

Consists of a capsular polysaccharide antigen conjugated to a carrier.

SIDE EFFECTS

Erythema, pain, and swelling at injection site in 25%.

CONTRAINDICATIONS

Anaphylactic reaction to vaccine or vaccine constituent.

Measles, Mumps, and Rubella

Image

A 12-month-old boy is due for his vaccines in the middle of October. His mother mentions that he developed a skin rash as well as some respiratory problems 1 month prior after she fed him eggs for the first time. He is due for MMR, varicella, and influenza vaccines. Think: Egg allergy and the vaccines that are contraindicated: Influenza vaccine, yellow fever vaccine. MMR can be given safely to children with egg allergy.


Image

MMR is a live virus vaccine.


Image Minimum age: 12 months.

Image First dose given subcutaneously (SC) at 12–15 months of age, and second dose at 4–6 years of age.

Image Second dose may be given at any time after 4 weeks from first dose if necessary.

Image Must be at least 12 months old to ensure a sufficient response.

CONTENT

Composed of live attenuated viruses.

SIDE EFFECTS

Image Fever > 102.9°F (39.4°C) 7–12 days after immunization in 10%.

Image Transient rash in 5%.

Image Febrile seizures and encephalopathy with MMR vaccine are rare. Transient thrombocytopenia may occur 2–3 weeks after vaccine in 1/40,000.

CONTRAINDICATIONS

Image Anaphylactic reaction to prior vaccine.

Image Anaphylactic reaction to neomycin or gelatin.

Image Immunocompromised states.

Image Pregnant women.

Image Recent intravenous immune globulin (IVIg) administration requires delaying vaccinations by 12 months.

Inactivated Poliovirus Vaccine (IPV)

Image Minimum age: 6 weeks.

Image Given SC at 2 and 4 months, then again between 6 and 18 months, then a fourth between 4 and 6 years of age.

Image The final dose should be administered on or after the fourth birthday and at least 6 months following the previous dose.

Image If four doses are administered prior to age 4 years, a fifth dose should be administered at age 4–6 years.

Image OPV is given orally.

CONTENT

Image IPV contains inactivated poliovirus types 1, 2, and 3.

Image Live oral poliovirus vaccine (OPV) contains live attenuated poliovirus types 1, 2, and 3.

SIDE EFFECTS

Image Vaccine-associated paralytic polio (VAPP) with OPV in 1/760,000.

Image With prior IPV, risk is reduced by 75–90%.


Image

An all-IPV schedule is recommended in the United States to prevent VAPP (vaccine-associated paralytic polio). Under certain circumstances, OPV may be used.


CONTRAINDICATIONS

Image Anaphylaxis to vaccine or vaccine constituent.

Image Anaphylaxis to streptomycin, polymixin B, or neomycin.


Image

OPV is contraindicated in immunodeficiency disorders or when household contacts are immunocompromised.


Varicella

Image Minimum age: 12 months.

Image Given SC between 12 and 18 months of age; second dose between 4 and 6 years (may be administered before age 4, provided at least 3 months have elapsed since the first dose).

Image Susceptible persons > 13 years of age must receive two doses at least 4 weeks apart.


Image

Varicella vaccine contains live virus.


CONTENT

Cell-free live attenuated varicella virus.

SIDE EFFECTS

Image Erythema and swelling in 20–35%.

Image Fever in 10%.

Image Varicelliform rash in 1–4%.

CONTRAINDICATIONS

Image Anaphylactic reaction to vaccine, neomycin, or gelatin.

Image Patients with altered immunity, including corticosteroid use for > 14 days.

Image Patients on salicylate therapy.

Image Pregnant women.

Image Recent blood product or IG administration (defer at least 5 months).

Influenza Vaccine (Seasonal)

Image Minimum age: 6 months (trivalent inactivated influenza vaccine [TIV]); 2 years (live attenuated influenza vaccine) [LAIV]).

Image Given IM to children > 6 months of age yearly beginning in autumn, usually between October and mid-November (two doses 1 month apart for the first time).

Image All children should receive this vaccine, especially high-risk children.

Image Caution! LAIV should not be given to children aged 2–4 years who have had wheezing in the past 12 months.

CONTENT


Image

It is especially important to vaccinate for influenza those with asthma, chronic lung disease, cardiac defects, immunosuppressive disorders, sickle cell anemia, chronic renal disease, and chronic metabolic disease.


Image Contains three virus strains, usually two type A and one type B, and can be an inactivated whole-virus vaccine or a “split” vaccine containing disrupted virus particles.

Image Children < 9 years of age should receive the “split” vaccine only.

Image Children without prior exposure to influenza vaccine should receive two vaccines 1 month apart in order to obtain a good response.

SIDE EFFECTS

Image Pain, swelling, and erythema at injection site.

Image Fever may occur, especially in children < 24 months of age.

Image In children > 13 years of age, fever may occur in up to 10%.

CONTRAINDICATIONS

Children with anaphylactic reactions to chicken or egg protein.

H1N1 Vaccine


Image

Influenza vaccine does not cause the disease. The vaccine has been associated with an Image risk of GuillainBarré syndrome (GBS) in older adults, but no such cases have been reported in children.


Image Two doses separated by 4 weeks in children under 10 years of age.

Image Two preparations:

Image Inactivated vaccine (killed virus).

Image Nasal spray vaccine (live attenuated) approved for children > 2 years old.

Image The following patients should receive priority:

1.     Pregnant women.

2.     Caregivers for infants aged < 6 months.

3.     Health care providers.

4.     Children aged 6 months–4 years.

5.     Children and adolescents aged 5–18 years with medical conditions.

CONTRAINDICATIONS

1.     Children younger than 6 months of age.

2.     Severe allergy to chicken eggs.

3.     Severe reaction to an influenza vaccination.

4.     People who developed GBS within 6 weeks of getting an influenza vaccine previously.


Image

Chemoprophylaxis against influenza is recommended as an alternative means of protection in those who cannot be vaccinated.


Pneumococcus (Conjugate Vaccine)

Image Minimum age: 6 weeks for pneumococcal conjugate vaccine (PCV), 2 years for pneumococcal polysaccharide vaccine (PPSV).

Image Babies receive three doses (shots) 2 months apart starting at 2 months, and a fourth dose when they are 12–15 months old.

Image Also given to high-risk children ≤ 2 years of age.

Image PCV is recommended for all children aged younger than 5 years. Administer one dose of PCV to all healthy children aged 24–59 months who are not completely immunized for their age.

Image Administer PPSV ≤ 2 months after last dose of PCV to children aged 2 years or older with certain underlying medical conditions, including a cochlear implant.


Image

The pneumococcal vaccine helps to protect against meningitis, bacteremia, pneumonia, and otitis media caused by serotypes of Streptococcus pneumoniae.


CONTENT

Image The older PPV-23 vaccine (not indicated under age 2) contains the purified capsular polysaccharide antigens of 23 pneumococcal serotypes. The PPV-23 is usually reserved for high-risk children.

Image The newer PCV-7 is the conjugate vaccine described above.

SIDE EFFECTS

Image Erythema and pain at injection site.

Image Anaphylaxis reported rarely.

Image Fever and myalgia are uncommon.

CONTRAINDICATIONS

Usually deferred during pregnancy.

Hepatitis A Vaccine

Image Minimum age: 12 months.

Image Administer to all children aged 1 year (12–23 months).

Image Administer two doses at least 6 months apart.

Image Recommended for older children who live in areas where vaccination programs target older children, who are at Image risk for infection, or for whom immunity against hepatitis A is desired.

Meningococcal Vaccine

Image Minimum age: 2 years for meningococcal conjugate vaccine (MCV4) and meningococcal polysaccharide vaccine (MPSV4).

Image Administer MCV4 to children aged 2–10 years with:

Image Persistent complement component deficiency.

Image Anatomic or functional asplenia.


Image

Live attenuated vaccines include:

Image MMR

Image VZV

Image Nasal influenza vaccine

Image OPV

Image Smallpox

Image Typhoid

These should be avoided in the immunocompromised.


Rotavirus Vaccine

Image Minimum age: 6 weeks.

Image Administer the first dose at age 6–14 weeks (maximum age: 14 weeks 6 days). Vaccination should not be initiated for infants aged 15 weeks 0 days or older.

Image The maximum age for the final dose in the series is 8 months 0 days.

Image If Rotarix rotavirus vaccine is administered at ages 2 and 4 months, a dose at 6 months is not indicated.

Respiratory Syncytial Virus (RSV)

Image Palivizumab (synagis) is a monoclonal antibody used for prophylaxis against infections with RSV.

Image Given IM once a month at the beginning of RSV season, usually beginning in October and ending in March.

Image Children < 2 years of age with chronic lung disease who have required medical therapy 6 months before the anticipated RSV season should receive the vaccine.

Image Children born at 32 weeks’ gestation or earlier with other risk factors for lung disease should receive the vaccine.

CONTENT

RSV immune globulin intravenous (RSV-IGIV) consists of RSV-neutralizing antibodies collected from donors selected for high serum titers.

Tuberculosis (TB)

The Mantoux test contains five tuberculin units of purified protein derivative (PPD).

SCREENING

Image Asymptomatic children at high risk for tuberculosis should be screened with a PPD test annually.

Image The test is placed intradermally in:

Image Children having contact with persons with confirmed or suspected disease.

Image Children with radiographic or clinical findings of TB.

Image Children from medically underserved populations (eg, low income, homeless, injection drug users).

Image Children with travel history to endemic countries.

Image Children with HIV.

Image Children with clinical conditions that make them high risk.

Image Interpretation: See Table 6.1.

TABLE 6-1. Guidelines for Determining a Positive Tuberculin Skin Test Reaction

Image

Image The QuantiFERON®-TB Gold test (QFT-G) is a newer alternative for detection of TB, approved by the U.S. Food and Drug Administration (FDA) in 2005.

Image Advantages:

Image Requires a single patient visit to draw a blood sample.

Image Results can be available within 24 hours.

Image Does not boost responses measured by subsequent test, which can happen with tuberculin skin tests (TSTs).

Image Is not subject to reader bias that can occur with TSTs.

Image Is not affected by prior BCG (bacille Calmette-Guerin) vaccination.

Image Disadvantages:

Image Blood samples must be processed within 12 hours after collection while white blood cells are still viable.

Image Limited data in children < 17 years of age, among persons recently exposed to Mycobacterium tuberculosis, and in immunocompromised persons.

Image Errors in collecting or transporting blood specimens or in running and interpreting the assay can Image the accuracy of QFT-G.

Image Limited data on the use of QFT-G to determine who is at risk for developing TB disease.

MEDICATIONS

Only 25% of Food and Drug Administration (FDA)-approved drugs have been approved for pediatric use.

Differences Between Children and Adults

ABSORPTION

Image Infants have thinner skin; therefore, topical substances can more likely cause systemic toxicity.

Image Children do not have the stomach acidity of adults until age 2, and gastric emptying time is slower and less predictable, Image Image absorption of some medications.


Image

Controls with Candida, measles, or diphtheria can be placed along with the PPD to test for anergy, although opinion may vary in practice.


DISTRIBUTION

Image Less predictable in children.

Image Total body water Image from 90% in infants to 60% in adults.

Image Fat stores are similar to adults in term infants, but much less in preterm infants.

Image Newborns have smaller protein concentration, therefore less binding of substances in the blood.

Image Infants have an immature blood–brain barrier.

METABOLISM

Infants metabolize some drugs more slowly or rapidly than adults and may create a different proportion of active metabolites.

ELIMINATION

Kidney function Image with age, so younger children may clear drugs less efficiently.

DOSAGE

Pediatric medications are generally dosed by milligrams per kilogram (mg/kg).

POISONING

EPIDEMIOLOGY

More often accidental in younger children and suicide gestures or attempts in older children/adolescents.

SIGNS AND SYMPTOMS

See Table 6-2.

PREVENTION

Image Childproof home, including cabinets and containers.

Image Store toxic substances in their original containers and out of children’s reach.

Image Supervise children appropriately.

Image Have poison control center number easily accessible.

MANAGEMENT

Image Frequently, ingested substances are nontoxic, but if symptoms arise or there is any question, a poison control center should be contacted.

Image History:

Image Precise name of product (generic, brand, chemical—bring container or extra substance/pills).

Image Estimate amount of exposure, time of exposure.

Image Progression of symptoms.

Image Other medical conditions (eg, pregnancy, seizure disorder).

Image Gastric decontamination: Emesis (induced by syrup of ipecac) and gastric lavage remove only one third of stomach contents and are not generally recommended, though the combination of the latter with activated charcoal may be most effective.

Image Activated charcoal is effective for absorbing many drugs and chemicals, though it does not bind heavy metals, iron, lithium alcohols, hydrocarbons, cyanide. It may be used in conjunction with cathartics such as sorbitol or magnesium sulfate.

Image Dilution of stomach contents with milk has limited value except in the case of ingestion of caustic materials.

Image Skin decontamination: Remove clothing, use gloves, flood area with water for 15 minutes, use other mild material such as petroleum or alcohol to remove substances not removed by water.

Image Ocular decontamination: Rinse eyes with water, saline, or lactated Ringer’s for > 15 minutes; consider emergency ophthalmologic exam.

TABLE 6-2. “Toxidromes,” Symptoms, and Some Causes

Image

Image

Image Respiratory decontamination: Move to fresh air; bronchodilators may be effective, inhaled dilute sodium bicarbonate may help acid or chlorine inhalation.

Image Antidotes: See Table 6-3.

Image Treat seizures, respiratory distress/depression, hemodynamics, and electrolyte disturbances as they arise.

TABLE 6-3. Drug Toxicities

Image

Image

Image

ADOLESCENCE

Image Adolescence comprises the ages between 10 and 21 years.

Image The most common health problems seen in this age group include unintended pregnancies, sexually transmitted diseases (STDs), mental health disorders, physical injuries, and substance abuse.


Image

The leading causes of death for adolescents are accidents, homicide, and suicide.


PREVENTION

Image Be on the lookout for adolescents at high risk for health problems, including physical, mental, and emotional health.

Image Screen for depression. Suicide is the third leading cause of death in adolescents. Depression in the adolescent can manifest as irritability, anger, new drug use, and drop-off in school performance.

Image Look for:

Image Decline in school performance, excessive school absences, cutting class.

Image Frequent psychosomatic complaints.

Image Changes in sleeping or eating habits.

Image Difficulty in concentrating.

Image Signs of depression, stress, or anxiety.

Image Conflict with parents.

Image Social withdrawal.

Image Sexual acting-out.

Image Conflicts with the law.

Image Suicidal thoughts, preoccupation with death.

Image Substance abuse.


Image

One percent of adolescents have made at least one suicide gesture.


SCREENING

Image Routine health care should involve audiometry and vision screening, blood pressure checks, exams for scoliosis.

Image Breast and pelvic exams in females may also be necessary, and self-exams should be emphasized.

Image Likewise, examination for scrotal masses is necessary in males with emphasis on self-examination.

Image STDs (gonorrhea and chlamydia), including HIV should be considered in those adolescents with high-risk behaviors. Counsel sexually active adolescents on contraception and protection against STDs.

Image Screen with Pap smears within 3 years of the onset of sexual activity or at 21 years of age.

Image Adolescents who are engaged in one risk-taking activity such as smoking cigarettes are at greater risk for experimenting with drugs and alcohol.

PHYSICAL EXAM

Sexual maturity should be assessed at each visit.


Image

An Image in the number of years of schooling for a woman delays the age at which a woman marries and has her first child.


Pregnancy

EPIDEMIOLOGY

Image Over 750,000 teenage girls become pregnant in the United States each year (see Table 6-4).

Image One fifth of all sexually active girls become pregnant each year.

Contraception

EPIDEMIOLOGY

Image According to a 2004 Centers for Disease Control and Prevention (CDC) report, 62% of high school seniors report having ever had intercourse.

Image Ninety-eight percent of sexually active teens report using at least one form of birth control.

Image Thirty-three percent of ninth graders report having had sex.

Image Most common contraceptions methods are condoms (94%) and oral contraceptives (61%).

RISK FACTORS

Factors associated with early sexual activity include poor academic performance, lower expectations for education, poor perception of life options, low school grades, and involvement in other high-risk behaviors such as substance abuse.

FORMS OF CONTRACEPTION

Image Abstinence, condoms (male and female), diaphragm, cervical cap, spermicides, or some combination of these.

TABLE 6-4. 2002 Teenage Statistics

Image

Image Hormonal methods include oral contraceptive pills and injectable or implantable hormones, and hormone patches.

Image Intrauterine devices are not recommended for adolescents because of the Image risk of sexually transmitted infections.

COMBINATION ORAL CONTRACEPTIVES

Usually consist of either 50, 35, 30, or 20 μg of an estrogenic substance such as mestranol or ethinyl estradiol plus a progestin.


Image

Adolescents who smoke may Image their risk for side effects from oral contraceptives.


SIDE EFFECTS

Image Short-term effects may include nausea and weight gain.

Image Other possible effects include thrombophlebitis, hepatic adenomas, myocardial infarction, and carbohydrate intolerance.

POTENTIAL BENEFITS

Long-range benefits may include Image risks of benign breast disease and ovarian disease.

HIV/AIDS

See the Infectious Disease chapter.

EPIDEMIOLOGY

Image HIV/AIDS is the sixth leading cause of death among adolescents aged 15–24 years.

Image One half of all new infections in the United States occur in people younger than 25 years of age.

SCREENING

Screening should include adolescents with risk factors such as previous STD, unprotected sex, practicing insertive or receptive anal sex, trading sex for money or drugs, homelessness, intravenous drug or crack cocaine use, being the victim of sexual abuse.

CHILD ABUSE

DEFINITION

Child maltreatment encompasses a spectrum of abusive actions, and lack of action, that result in morbidity or death. Forms of child abuse include:

Image Physical abuse

Image Sexual abuse

Image Neglect


Image

If the story doesn’t make sense, suspect abuse.


RISK FACTORS

Image Parental risk factors:

Image Low socioeconomic status.

Image Mother’s age (young).

Image History of being abused as a child.

Image Alcoholism, substance abuse, psychosis.

Image Social isolation.


Image

Mongolian spots can be confused with bruises.


Image Child risk factors:


Image

A baby should never be shaken for any reason.


Image Children with special needs, handicapped children (chronic illness, congenital malformation, mental retardation).

Image Prematurity.

Image Age < 3 years.

Image Nonbiologic relationship to the caretaker.

Image “Difficult” children.

Image Family and environmental factors:

Image Unemployment.

Image Intimate partner violence.

Image Poverty.


Image

The most common reason for shaking a baby is inconsolable crying.


Physical Abuse

Suspect if:

Image Injury is unexplained or unexplainable.

Image Injury is inconsistent with mechanism suggested by history.

Image History changes each time it is told.

Image There are repeated “accidents.”

Image There is a delay in seeking care.


Image

Sometimes abusive parents “punish” their children for enuresis or resistance to toilet training by forcibly immersing their buttocks in hot water.


SKIN MANIFESTATIONS

Bruises

Image Most common manifestation of physical abuse

Image Suspicious if:

Image Seen on nonambulatory infants.

Image Have geometric pattern (belt buckles, looped-cord marks).

Burns

Image Suspicious if:

Image Involve both hands or feet in stocking-glove distribution or buttocks with sharp demarcation line (forced immersion in hot water).

Image Cigarette burns—if nonaccidental, usually full-thickness, sharply circumscribed.

Image “Branding” injuries (inflicted by hot iron, radiator cover, etc).


Image

Skeletal injuries suspicious of abuse: “Some Parents Are Maliciously Mean” (or Parents Should Manage Anger)


SKELETAL INJURIES

Suspicious if:

Image Spiral fractures of lower extremities in nonambulatory children (see Figure 6-1A and B).

Image Posterior rib fractures (usually caused by squeezing the chest).

Image Fractures of different Ages.

Image Metaphyseal “chip” fractures (usually caused by wrenching).

Image Multiple fractures.

Image Scapular and clavicle fractures.


Image

CNS injuries suspicious of abuse: “Mothers, Refuse Shaking!” (Metaphyseal fractures, Retinal hemorrhages, Subdural hematoma)


CENTRAL NERVOUS SYSTEM (CNS) INJURIES

Image Most common cause of death in child abuse: “Shaken baby syndrome.”

Image Occurs due to violent shakes and slamming against mattress or wall while an infant is held by the trunk or upper extremities.

Image

FIGURE 6-1. A. Spiral fracture (arrow) of the femur in a nonambulatory child, consistent with nonaccidental trauma. B. Same child 2 months later. Note the exuberant callus formation at all the fracture sites in the femur and proximal tibia and fibula.

Image Findings include:

Image Retinal hemorrhages.

Image Subdural hematoma (from rupturing of bridging veins between dura mater and brain cortex).

Image Symptoms include:

Image Lethargy or irritability

Image Vomiting

Image Seizures

Image Bulging fontanelle


Image

Epiphyseal-metaphyseal injury is virtually diagnostic of physical abuse in an infant, since an infant cannot generate enough force to fracture a bone at the epiphysis.


Abdominal Injuries

Image Second most common cause of death in child abuse.

Image Usually no external marks. Most commonly, liver or spleen is ruptured.

Image Symptoms include vomiting, abdominal pain or distention, shock.


Image

Shaken baby syndrome can mimic meningitis or sepsis.


Sexual Abuse

Image Includes genital, anal, oral contact; fondling; and involvement in pornography.

Image Most common perpetrators—fathers, stepfathers, mother’s boyfriend(s) (adults known to child).

Image Suspect if:

Image Genital trauma.

Image STDs in small children.

Image Sexualized behavior toward adults or children.

Image Unexplained decline in school performance.

Image Runaway.

Image Chronic somatic complaints (abdominal pain, headaches).

Image Symptoms include:

Image May be totally absent.

Image Tears/bleeding in female or male genitalia.

Image Anal tears or hymenal tears (not very reliable symptoms).


Image

Children too young to talk about what has happened to them (generally younger than 2) should have a complete skeletal survey if you suspect abuse.


Evaluation of Suspected Abuse

PHYSICAL ABUSE

Image Bleeding disorders must be ruled out in case of multiple bruises.

Image X-ray skeletal survey (skull, chest, long bones) in children < 2 years of age (to look for old/new fractures).

Image Computed tomographic (CT) scans of the head/abdomen as indicated.

Image Ophthalmology consult.


Image

A child who presents with multiple fractures at multiple sites and in various stages of healing should be considered abused until proven otherwise.


SEXUAL ABUSE

Image Sexual abuse includes any sexual activity (nonconsensual and consensual) between an adult and a child.

Image Cultures for STDs, test for presence of sperm, if indicated (usually within 72 hours of assault).

MANAGEMENT

Image If abuse is suspected, it must be reported to child protective services (CPS) (after medical stabilization, if needed).

Image All siblings need to be evaluated for abuse, too (up to 20% of them might have signs of abuse).

Image Disposition of the child (ie, whether to discharge the patient back to parents or to a CPS worker if medically cleared) has to be decided by CPS in conjunction with treating physician.

Image Family must receive intensive intervention by social services and, if needed, legal authorities.

Image Remember: If sent back to abusive family without intervention, up to 5% of children can be killed and up to 25% seriously reinjured.


Image

Management of abuse:

Suspect

Image

Report

Image

Disposition

Image

Family counseling


Neglect

DEFINITION

Image Neglect is the most common form of reported abuse.

Image Neglect to meet nutritional, medical, and/or developmental needs of a child can present as:

Image Failure to thrive.

Image Poor hygiene (severe diaper rash, unwashed clothing, uncut nails).

Image Developmental/speech delay.

Image Delayed immunizations.

Image Not giving treatment for chronic conditions.

MANAGEMENT

If nonorganic (ie, due to insufficient feeding) failure to thrive is suspected:

Image Patient should be hospitalized and given unlimited feedings for 1 week; 2 oz/24 hours of weight gain is expected.

Image All suspected cases of neglect must be reported to CPS.

Munchausen Syndrome by Proxy

DEFINITION

Image Parent/caregiver either simulates illness, exaggerates actual illness, or induces illness in a child.

Image Psychiatrically disturbed parent(s) gain satisfaction from attention and empathy from hospital personnel or their own family because of problems created.


Image

Baron von Munchausen was an 18th-century nobleman who became famous because of his incredible stories, which included travel to the moon and flying atop a cannonball over Constantinople, as well as visiting an island made of cheese. His name became a synonym for gross confabulations.


EPIDEMIOLOGY

Image Affected children are usually < 6 years old.

Image Parent (usually mother) has some medical knowledge.

SIGNS AND SYMPTOMS

Image Vomiting (induced by ipecac).

Image Chronic diarrhea (from laxatives).

Image Recurrent abscesses or sepsis (usually polymicrobial, from injecting contaminated fluids).

Image Apnea (from choking the child).

Image Fever (from heating thermometers).

Image Bloody vomiting or diarrhea (from adding blood to urine or stool specimens).

DIAGNOSIS

Diagnosis is difficult, but is initiated by removing child from parent via hospitilization. Usually, child without access to parent will have all/most symptoms resolved; testing will also usually be normal.

MANAGEMENT

Image Admission to the hospital for observation, possibly using hidden video cameras.

Image All cases of suspected Munchausen syndrome by proxy must be reported to CPS.

Sudden Infant Death Syndrome (SIDS)

DEFINITION

Image Sudden death of an infant (< 1 year old) that remains unexplained after thorough case investigation, autopsy, and review of the clinical history.

Image SIDS is one of the leading causes of death of infants.

ETIOLOGY

Apnea hypothesis.

DIAGNOSIS

Difficult to differentiate from intentional harm.

PREVENTION

Image There has been a vast Image in the number of cases since the trend of having infants sleep on their backs (supine).

Image The number one preventive measure to date is parental education, though the use of cardiorespiratory monitoring in the home is being debated.

Image Limiting passive smoke exposure.


Image

Infants unable to roll over should be placed on the back while sleeping.



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