Health Supervision and Prevention of Illness and Injury in Children and Adolescents
DIPHTHERIA, TETANUS, AND ACELLULAR PERTUSSIS (DTAP)
HAEMOPHILUS INFLUENZAE TYPE B (HIB)
INACTIVATED POLIOVIRUS VACCINE (IPV)
PNEUMOCOCCUS (CONJUGATE VACCINE)
RESPIRATORY SYNCYTIAL VIRUS (RSV)
DIFFERENCES BETWEEN CHILDREN AND ADULTS
SUDDEN INFANT DEATH SYNDROME (SIDS)
Morbidity and Mortality
The leading cause of death in children under 1 year of age is grouped under the term perinatal conditions, which include:
Congenital malformation, deformations, and chromosomal abnormalities (number one
cause).
Low birth weight.
Sudden infant death syndrome (SIDS).
Respiratory distress syndrome.
Complications of pregnancy.
Perinatal infections.
Intrauterine or birth hypoxia.
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:
Parental guidance (anticipatory guidance and counseling).
Screening tests.
Immunization.
Parental Guidance
Age-appropriate anticipatory guidance is provided to parents at various well-child visits.
1 WEEK–1 MONTH
A 1-month-old infant is brought to the ED with poor feeding, weak suck, drooling,
constipation, and ↓ spontaneous movements. He is exclusively breast-fed, and his mother
has been giving him a 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).
WARD TIP
Be informed of social services and financial assistance available to parents and patients.
Place infant to sleep on back to prevent sudden infant death syndrome (SIDS). Never
on the stomach or side.
Keep soft objects and loose bedding such as comforters, pillows, bumper pass, and
stuffed animals in crib with infant.
Use a car seat. Rear facing in back seat.
Know signs of an illness.
Use a rectal thermometer.
Maintain a smoke-free environment.
Maintain water temperature at <120°F (48.8°C). Takes 10 minutes to get a burn at
this temperature if baby is exposed.
Do not give honey to a child under 1 year of age (risk for botulism).
EXAM TIP
Exposure to second-hand smoke:
Increases incidence of SIDS
Increases URI
Increases lower respiratory tract infections (bronchiolitis, pneumonia)
Increases RAD, asthma
Increases ear infections
Discuss normal crying behavior and give some suggestions for how to calm the infant.
Techniques to calm infant: swaddling in a light blanket, rocking in a cradle, windup
swing, vibrating chair.
Never shake your baby.
Assess parental well-being. Baby blues are normal but if they persist beyond 2
weeks provide resources for mother’s postpartum depression.
2 MONTHS–1 YEAR
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.
EXAM TIP
Any child with a rectal temperature >100.4°F (38°C) in the first 2 months of life should be seen immediately, to rule out sepsis with GBS, Listeria, E. Coli.
The American Academy of Pediatrics (AAP) does not recommend syrup of ipecac anymore.
Give telephone number to local poison control hotline.
No solid food until 4–6 months.
Introduce single ingredient foods one at a time to assess for allergies.
Limit juice to less than 4 ounces a day.
Avoid baby walkers.
Do not put baby to bed with bottle, as it can cause dental caries.
Breast-feed or give iron-fortified formula, but no whole milk until after 1 year
of age.
Avoid choking hazards such as coins, peanuts, popcorn, carrot sticks, hard candy,
whole grapes, and hot dogs.
May start using sippy cup at 6–9 months.
Do not leave baby alone in tub or high places.
Do not drink hot liquids while holding your baby.
Importance of tummy time to meet milestones and decrease positional plagiocephaly.
Visit the dentist by 12 months or after first tooth erupts.
WARD TIP
Assess head control before allowing baby to start solid foods to decrease the risk of choking.
EXAM TIP
Falls and drowning are major risks of injury and death in toddlers.
1–5 YEARS
Use toddler car seat (ages 1–4) and booster seat (ages 4–8) if proper weight and
height. See car seat section.
Brush teeth, see dentist. Brush teeth twice daily with plain water and a soft toothbrush
EXAM TIP
Most infants drown in their own bathtub.
Wean from bottle (start by 9 months of age with the introduction of cup).
Make sure home is childproof again.
Restrict child’s access to stairs.
Allow child to eat with hands or utensils.
Use sunscreen (can use as early as 6 months).
WARD TIP
Early childhood caries (cavities) is the number 1 chronic disease affecting young
children.
Early childhood caries is five times more common than asthma and seven times more
common than hay fever.
Wear properly fitting bicycle helmet.
Provide close supervision, especially near dogs, driveways, streets, and lawnmowers.
Make appointment with dentist by 1 year of age.
Ensure that child is supervised when near water; build fence around swimming pool
with latched gate.
Screen for amblyopia, strabismus, and visual acuity in all children younger than
5 years.
Strabismus: Cover test or Hirschberg light reflex test in children <3 years.
Visual acuity: >3 years and screen every 1–2 years throughout childhood.
WARD TIP
Temperature of the water heater should be kept below 120°F (49°C) to prevent accidental scalding injuries.
6–10 YEARS
Reinforce personal hygiene.
Teach stranger safety.
Provide healthy meals and snacks. Eat 5+ servings of fruits and vegetables a day;
eat breakfast.
Limit screen time to less than 2 hours a day.
Be physically active 60 minutes a day.
Keep matches and guns out of children’s reach.
Use seat belt always, and booster seat until 4 feet 9 inches in height.
Brush teeth twice daily with pea-sized amount of fluoride toothpaste.
Limit screen time to less than 2 hours a day.
Visit dentist 2×/year.
Teach pedestrian safety.
Teach child to swim.
WARD TIP
Adolescent HEEADDSSS assessment
Home
Education
Eating
Activities
Drugs and Alcohol
Depression
Safety
Sex
Suicide
11–21 YEARS
Continue to support a healthy diet and exercise.
Wear appropriate protective sports gear.
Counsel on safe sex and avoiding alcohol and drugs.
Promote a healthy social life, balanced diet, and at least 60 minutes of exercise
every day, with 30 minutes of vigorous exercise 3×/week.
Ask about mood or eating disorders (see below).
Address school performance, homework, and bullying.
Screening
BLOOD PRESSURE
High blood pressure (hypertension) in children is blood pressure that’s the same
as or higher than 95% of children who are the same sex, age, and height as your child.
Routine monitoring of blood pressure should begin at age 3 years.
Most common cause of high blood pressure reading in children is inappropriate cuff
size.
High blood pressure can be primary or secondary, the younger the child and the
higher the blood pressure, the greater the high blood pressure has an identifiable
cause.
Other causes of high blood pressure in children: heart and kidney diseases; medications;
endocrine disorders.
Contributing factors: Family history, race, excess weight, or obesity.
METABOLIC SCREENING
At 24 hours of life, the neonate should receive screening for various metabolic disorders including hypothyroidism, phenylketonuria (PKU), sickle cell disease, and adrenal cortex abnormalities.
Newborn screens test for diseases that if caught early are manageable and will prevent long-term poor health outcomes
WARD TIP
Metabolic screening may vary from state to state in the United States.
LEAD SCREENING
Exposure is ↑ by:
Living in or visiting a house built before 1978 with peeling or chipped paint.
Plumbing with lead pipes or lead solder joints.
Common Causes of Hypertension by Age
Living near a major highway where soil may be contaminated with lead.
Contact with someone who works with lead.
Living near an industrial site that may release lead into the environment.
Taking home remedies that may contain lead.
Toys from abroad.
WARD TIP
Infants and young children are more likely to be exposed to lead than are older children. They may chew paint chips, and their hands may be contaminated with lead dust. Young children also absorb lead more easily and sustain more harm from it than do adults and older children.
Traditional cosmetics: Kohl is a traditional cosmetic, often used as eyeliner.
Having friends/relatives who have had lead poisoning.
Screen for lead levels at age 12 months and 24 months.
HEMATOCRIT
EXAM TIP
Children’s blood lead levels increase most rapidly at 6–12 months and peaks at 18–24 months.
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.
Second test 6 months later in high-risk communities for iron deficiency.
Anemia: Hemoglobin levels <11 g/dL.
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.
HYPERLIPIDEMIA
Screen for hyperlipidemia in children older than 2 years with appropriate risk
factors:
Family history of coronary or peripheral vascular disease before the age of 55
years in parents or grandparents.
Parent with a total serum cholesterol level >240 mg/dL.
Obesity.
Hypertension.
Diabetes mellitus.
Screening may also be considered in children with inactivity; also in adolescents
who smoke.
All children should be screened between 9 and 11 years and again between 17 and
21 years.
VISION AND HEARING
WARD TIP
Levels may be falsely low if screened during puberty because hormones require use of cholesterol to function.
A hearing screen is recommended shortly after birth, ideally before discharge from
the newborn nursery.
Vision screening may begin at age 3 years, sooner if concerns.
Suspect hearing loss earlier if child’s speech is not developing appropriately.
A child’s cooperation is essential to obtaining an accurate result (~3 years).
AAP Car-Seat Recommendations
Infants and toddlers: Rear facing only or rear facing convertible (until 2 years and 20 lbs).
Toddlers and preschoolers: Convertible or forward facing with harness (until 4 years and 40 lbs).
School aged: Booster seats (until 4 feet 9 inches tall).
Older children: When large enough, use standard lap and shoulder belts. Younger than 13 should sit in backseat.
Other Car-Seat Note: 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.
WARD TIP
Newborns should not leave the hospital without a car seat.
Vaccines
See latest CDC vaccine schedule (Figure 6-1).
FIGURE 6-1. Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger—United States, 2017. (Source: Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html.)
Site of injection:
Infants: Anterolateral thigh.
Children: Deltoid.
HEPATITIS B
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.
First dose given intramuscularly (IM) at birth or within first 2 months of life.
Second dose given 1 month after first dose.
WARD TIP
Fever is not a contraindication to receiving immunization. Moderate/severe illness is a precaution, not a contraindication. This holds true for all vaccines.
Third dose given 4 months after first dose and 2 months after second dose, but
not before 6 months of age.
Must give at birth along with hepatitis B immune globulin (HBIG) if baby is exposed
transplacentally or if maternal status is unknown.
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.
CONTENT
Adsorbed recombinant hepatitis B surface antigen proteins.
SIDE EFFECTS
Pain at injection site.
Fever >99.9°F (37.7°C) in 1–6%.
CONTRAINDICATIONS
Anaphylactic reaction to vaccine, yeast, or another vaccine constituent.
Infants <2 kg.
DIPHTHERIA, TETANUS, AND ACELLULAR PERTUSSIS (DTaP)
EXAM TIP
DTaP is preferred for children under 7 years of age. Td or Tdap is given after 7 years of age.
Minimum age: 6 weeks.
Given IM at 2, 4, and 6 months, and a fourth dose between 15 and 18 months of age.
The fourth dose may be administered as early as age 12 months; provided 6 months between third and fourth doses.
Administer the final dose at age 4–6 years.
DT without pertussis vaccine can be used in children <7 years of age if pertussis
vaccine is contraindicated.
TDaP is administered at age 10–12.
CONTENT
EXAM TIP
DTP has greater risks of side effects than DTaP.
DTaP is diphtheria and tetanus toxoids with acellular pertussis.
DTP contains a whole-cell pertussis.
SIDE EFFECTS
EXAM TIP
DTaP is not a substitute for DTP if a contraindication to pertussis exists.
Erythema, pain, and swelling at injection site.
Fever >100.4°F (38°C).
Crying ≥ 1 hour.
Severe side effects (more common with DTP, rare with DTaP): crying >3 years; hypotonic-hyporesponsive
episode; seizures; fever >40.5°C.
CONTRAINDICATIONS
WARD TIP
A common misconception is that DTaP is contraindicated in patients with a family history of seizure or SIDS. This is NOT true.
Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine
component
Encephalopathy not attributable to another cause within 7 days of a prior dose
of pertussis vaccine.
PRECAUTIONS
Seizure disorder or seizures within 3 days of receiving a previous dose of DTaP.
Poorly controlled or new-onset seizures: Defer pertussis immunization until seizure
disorder is well controlled and progressive neurologic disorder is excluded.
Personal or family history of febrile seizures. Give DTaP and antipyretics around
the clock for 24 hours after immunization.
Temperature of 40.5°C (104.8°F) within 48 hours after immunization with previous
dose of DTaP.
Collapse or shock like state (hypotonic-hyporesponsive episode within 48 hours
of receiving a previous dose of DTaP).
Persistent inconsolable crying lasting >3 hours within 48 hours of receiving a
previous dose of DTaP.
Guillain-Barre syndrome within 6 weeks after a prior dose.
HAEMOPHILUS INFLUENZAE TYPE B (HIB)
Minimum age: 6 weeks.
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
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.
Minimum age: 12 months.
First dose given subcutaneously (SC) at 12–15 months of age, and second dose at
4–6 years of age.
Second dose may be given at any time after 4 weeks from first dose if necessary.
Must be at least 12 months old to ensure a sufficient response.
EXAM TIP
MMR is a live virus vaccine.
CONTENT
Composed of live attenuated viruses.
SIDE EFFECTS
Fever >102.9°F (39.4°C) 6–12 days after immunization can last up to 5 days in 10%.
Transient rash in 5%. May occur 1–6 weeks after vaccination.
Febrile seizures and encephalopathy with MMR vaccine are rare. Transient thrombocytopenia
may occur 2–3 weeks after vaccine in 1/40,000.
Swollen lymph nodes.
Pain or stiffness in joints.
CONTRAINDICATIONS
Anaphylactic reaction to prior vaccine.
Anaphylactic reaction to neomycin or gelatin.
Immunocompromised states.
Pregnant women.
PRECAUTIONS
Recent intravenous immunoglobulin (IVIg) administration requires delaying vaccinations
by 11 months.
Throbocytopenia or history of thrombocytopenic purpura, however, benefits outweigh
risks.
INACTIVATED POLIOVIRUS VACCINE (IPV)
Minimum age: 6 weeks.
Given IM or SQ at 2 and 4 months, then again between 6 and 18 months, then a fourth
between 4 and 6 years of age.
The final dose should be administered on or after the fourth birthday and at least
6 months following the previous dose.
If four doses are administered prior to age 4 years, a fifth dose should be administered
at age 4–6 years.
OPV is given orally. No longer used in the United States.
CONTENT
IPV contains inactivated poliovirus types 1, 2, and 3.
Live oral poliovirus vaccine (OPV) contains live attenuated poliovirus types 1,
2, and 3.
SIDE EFFECTS
EXAM TIP
An all-IPV schedule is recommended in the United States to prevent VAPP (vaccine-associated paralytic polio). Under certain circumstances, OPV may be used.
Vaccine-associated paralytic polio (VAPP) with OPV in 1/760,000.
Local reactions, fever.
CONTRAINDICATIONS
EXAM TIP
OPV is contraindicated in immunodeficiency disorders or when household contacts are immunocompromised.
Anaphylaxis to vaccine or vaccine constituent.
Anaphylaxis to streptomycin, polymixin B, or neomycin.
VARICELLA
EXAM TIP
Varicella vaccine contains live virus.
Minimum age: 12 months.
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).
Susceptible persons >13 years of age must receive two doses at least 4 weeks apart.
CONTENT
Cell-free live attenuated varicella virus.
SIDE EFFECTS
Erythema and swelling in 20–35%.
Fever in 10%.
Varicelliform rash in 1–4%.
CONTRAINDICATIONS
Anaphylactic reaction to vaccine, neomycin, or gelatin.
Patients with altered immunity, including corticosteroid use for > 14 days.
Patients on salicylate therapy. Avoid salicylates for 6 weeks after vaccine administration.
Pregnant women.
Recent blood product or IG administration (defer at least 11 months).
INFLUENZA VACCINE (SEASONAL)
WARD TIP
LAIV is no longer available because of inefficacy.
Minimum age: 6 months (quadrivalent inactivated influenza vaccine [TIV]); 2 years
(live attenuated influenza vaccine) [LAIV]).
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).
All children should receive this vaccine, especially high-risk children.
Caution! LAIV should not be given to children aged 2–4 years who have had wheezing
in the past 12 months.
CONTENT
Contains four virus strains, usually both type A and type B based on the expected
prevalent influenza strains for the coming winter.
Children <9 years of age should receive the “split” vaccine only.
Children receiving vaccine for the first time should receive 2 doses 1 month apart
in order to obtain a good response.
SIDE EFFECTS
WARD TIP
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.
Pain, swelling, and erythema at injection site.
Fever may occur, especially in children <24 months of age.
In children >13 years of age, fever may occur in up to 10%.
Guillain-Barré syndrome, if given at the same time as PCV13 and/or DTaP.
CONTRAINDICATIONS
Severe allergic reaction (e.g., anaphylaxis) after a previous dose of any IIV or LAIV or to a vaccine component, including egg protein.
PRECAUTIONS
WARD TIP
Influenza vaccine does not cause the disease. The vaccine has been associated with an ↑ risk of Guillain-Barré syndrome (GBS) in older adults, but no such cases have been reported in children.
Moderate or severe acute illness with or without fever.
History of GBS within 6 weeks of previous influenza vaccination.
Persons whose egg allergy reaction is limited to hives only may receive RIV (if
age 18–49) or, with additional safety precautions, IIV.9
PNEUMOCOCCUS (CONJUGATE VACCINE)
WARD TIP
Chemoprophylaxis against influenza is recommended as an alternative means of protection in those who cannot be vaccinated.
Minimum age: 6 weeks for pneumococcal conjugate vaccine (PCV), 2 years for pneumococcal
polysaccharide vaccine (PPSV).
Babies receive three doses (shots) 2 months apart starting at 2 months, and a fourth
dose when they are 12–15 months old.
Also given to high-risk children ≥ 2 years of age.
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.
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.
CONTENT
WARD TIP
The pneumococcal vaccine helps to protect against meningitis, bacteremia, pneumonia, and otitis media caused by serotypes of Streptococcus pneumoniae.
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.
The newer PCV-13 is the conjugate vaccine described above.
SIDE EFFECTS
Erythema and pain at injection site.
Anaphylaxis reported rarely.
Fever and myalgia are uncommon.
CONTRAINDICATIONS
For PCV13, severe allergic reaction (e.g., anaphylaxis) after a previous dose of
PCV7 or PCV13 or to a vaccine component, as well as to any vaccine containing diphtheria
toxoid.
For PPSV23, severe allergic reaction (e.g., anaphylaxis) after a previous dose
or to a vaccine component.
HEPATITIS A VACCINE
Minimum age: 12 months.
Administer to all children aged 1 year (12–23 months).
Administer two doses at least 6 months apart.
Recommended for older children who live in areas where vaccination programs target
older children, who are at ↑ risk for infection, or for whom immunity against hepatitis
A is desired.
are <24 months of age
HUMAN PAPILLOMAVIRUS (HPV)
May be given between age 9 and 26 years to both girls and boys.
Three dose series, with second dose 2 months after the first dose and the third
dose 6 months after the first dose.
Contains nine strains of HPV.
SIDE EFFECTS
Pain, swelling, dizziness, syncope.
MENINGOCOCCAL VACCINE
WARD TIP
Recommend observation for syncope for 15 minutes after administration of HPV vaccine.
Available against groups A, C, Y, W-135.
New vaccine available against group B.
All children receive tetravalent conjugate vaccine (MCV-4) at age 11, booster at
age 16.
Minimum age: 2 years for meningococcal conjugate vaccine (MCV4) and meningococcal
polysaccharide vaccine (MPSV4).
Administer MCV4 to children aged 2–10 years with:
Persistent complement component deficiency.
Anatomic or functional asplenia.
SIDE EFFECTS
EXAM TIP
Live attenuated vaccines include:
MMR
VZV
Nasal influenza vaccine
OPV
Smallpox
Typhoid
Yellow fever
These should be avoided in the immunocompromised.
Localized erythema and pain.
Fever.
Headache.
Fatigue.
CONTRAINDICATION
Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component.
PRECAUTION
History of Guillain-Barré syndrome.
ROTAVIRUS VACCINE
Minimum age: 6 weeks.
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.
The maximum age for the final dose in the series is 8 months 0 days.
If Rotarix rotavirus vaccine is administered at ages 2 and 4 months, a dose at
6 months is not indicated.
CONTRAINDICATION
SCID.
PRECAUTIONS
Preexisting chronic gastrointestinal disease, history of intussusception, spina bifida, or bladder exstrophy.
SIDE EFFECTS
Diarrhea, intussusception.
RESPIRATORY SYNCYTIAL VIRUS (RSV)
Palivizumab (synagis) is a monoclonal antibody used for prophylaxis against infections
with RSV.
Given IM once a month at the beginning of RSV season, usually beginning in October
and ending in March.
Who should receive the vaccine:
Children <2 years of age with chronic lung disease who have required medical therapy
6 months before the anticipated RSV season.
Children born at 32 weeks’ gestation or earlier with other risk factors for lung
disease.
Infants born <29 weeks, if less than 12 months old at the start of the RSV season.
Infants born 29 to <32 weeks, if <6 months at the start of the RSV season.
Infants born at 32–35 weeks who are <3 months at the start of the RSV season and
who are likely to have increased RSV exposure (child care exposure or siblings <5
years old).
Infants with congenital abnormalities of the airway or neuromuscular disease.
Infants with hemodynamically significant cyanotic or acyanotic congenital heart
disease.
TUBERCULOSIS (TB)
WARD TIP
Ask the following questions to determine the need for a PPD:
Has a family member or contact had tuberculosis disease?
Has a family member had a positive tuberculin skin test?
Was your child born in a high-risk country (countries other than the United States,
Canada, Australia, New Zealand, or Western European countries)?
Has your child traveled (had contact with resident populations) to a high-risk
country for more than one week?
Children at risk include:
Children living in a household with an adult who has active tuberculosis or has
a high risk of contracting TB.
Children infected with HIV or another condition that weakens the immune system.
Children born in a country that has a high prevalence of TB.
Children visiting a country where TB is endemic and who have extended contact with
people who live there.
Children from communities that generally receive inadequate medical care.
Children living in a shelter or living with someone who has been in jail.
The Mantoux test contains five tuberculin units of purified protein derivative
(PPD).
SCREENING
Asymptomatic children at high risk for tuberculosis should be screened with a PPD
test annually.
Interpretation: See Table 6-1.
TABLE 6-1. Guidelines for Determining a Positive Tuberculin Skin Test Reaction
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.
Advantages:
Requires a single patient visit to draw a blood sample.
Results can be available within 24 hours.
Does not boost responses measured by subsequent test, which can happen with tuberculin
skin tests (TSTs).
Is not subject to reader bias that can occur with TSTs.
Is not affected by prior BCG (bacille Calmette-Guérin) vaccination.
Disadvantages:
Blood samples must be processed within 12 hours after collection while white blood
cells are still viable.
Limited data in children <17 years of age, among persons recently exposed to Mycobacterium tuberculosis, and in immunocompromised persons.
Errors in collecting or transporting blood specimens or in running and interpreting
the assay can ↓ the accuracy of QFT-G.
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
Infants have thinner skin; therefore, topical substances can more likely cause
systemic toxicity.
Children do not have the stomach acidity of adults until age 2, and gastric emptying
time is slower and less predictable, → ↑ absorption of some medications.
DISTRIBUTION
WARD TIP
Controls with Candida, measles, or diphtheria can be placed along with the PPD to test for anergy, although opinion may vary in practice.
Less predictable in children.
Total body water ↓ from 90% in infants to 60% in adults.
Fat stores are similar to adults in term infants, but much less in preterm infants.
Newborns have smaller protein concentration, therefore less binding of substances
in the blood.
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 ↑ 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.
TABLE 6-2. “Toxidromes,” Symptoms, and Some Causes
PREVENTION
Childproof home, including cabinets and containers.
Store toxic substances in their original containers and out of children’s reach.
Supervise children appropriately.
Have poison control center number easily accessible.
MANAGEMENT
Frequently, ingested substances are nontoxic, but if symptoms arise or there is
any question, a poison control center should be contacted.
History:
Precise name of product (generic, brand, chemical—bring container or extra substance/pills).
Estimate amount of exposure, time of exposure.
Progression of symptoms.
Other medical conditions (e.g., pregnancy, seizure disorder).
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.
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.
WARD TIP
Can only administer activated charcoal if ingestion was <1 hour prior
Dilution of stomach contents with milk has limited value except in the case of
ingestion of caustic materials.
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.
Ocular decontamination: Rinse eyes with water, saline, or lactated Ringer’s for
> 15 minutes; consider emergency ophthalmologic exam.
Respiratory decontamination: Move to fresh air; bronchodilators may be effective,
inhaled dilute sodium bicarbonate may help acid or chlorine inhalation.
Antidotes: See Table 6-3.
Treat seizures, respiratory distress/depression, hemodynamics, and electrolyte
disturbances as they arise.
Adolescence
Adolescence comprises the ages between 10 and 21 years.
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.
PREVENTION
WARD TIP
The leading causes of death for adolescents are accidents, homicide, and suicide.
Be on the lookout for adolescents at high risk for health problems, including physical,
mental, and emotional health.
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.
Look for:
Decline in school performance, excessive school absences, cutting class.
Frequent psychosomatic complaints.
Changes in sleeping or eating habits.
Difficulty in concentrating.
Signs of depression, stress, or anxiety.
Conflict with parents.
Social withdrawal.
Sexual acting-out.
Conflicts with the law.
Suicidal thoughts, preoccupation with death.
Substance abuse.
SCREENING
WARD TIP
One percent of adolescents have made at least one suicide gesture.
Routine health care should involve audiometry and vision screening, blood pressure
checks, exams for scoliosis.
Breast and pelvic exams in females may also be necessary, and self-exams should
be emphasized.
Likewise, examination for scrotal masses is necessary in males with emphasis on
self-examination.
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.
Screen with Pap smears within 3 years of the onset of sexual activity or at 21
years of age.
Adolescents who are engaged in one risk-taking activity such as smoking cigarettes
are at greater risk for experimenting with drugs and alcohol.
Mental health screening at each yearly visit.
PHYSICAL EXAM
Sexual maturity should be assessed at each visit.
Assess for scoliosis at each visit until Tanner stage 5 is achieved.
PREGNANCY
EPIDEMIOLOGY
In 2014, a total of 249,078 babies were born to women aged 15–19 years, for a birth
rate of 24.2 per 1,000 women in this age group. This is another historic low for U.S.
teens and a drop of 9% from 2013(CDC).
CONTRACEPTION
EXAM TIP
An ↑ in the number of years of schooling for a woman delays the age at which a woman marries and has her first child.
EPIDEMIOLOGY
Among U.S. high school students surveyed in 2015:
41% had ever had sexual intercourse.
30% had had sexual intercourse during the previous 3 months, and, of these
43% did not use a condom the last time they had sex.
14% did not use any method to prevent pregnancy.
21% had drunk alcohol or used drugs before last sexual intercourse (CDC).
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
Abstinence, condoms (male and female), diaphragm, cervical cap, spermicides, or
some combination of these.
Hormonal methods include oral contraceptive pills and injectable or implantable
hormones, and hormone patches.
Intrauterine devices are not recommended for adolescents because of the ↑ 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.
SIDE EFFECTS
WARD TIP
Adolescents who smoke may ↑ their risk for side effects from oral contraceptives.
Short-term effects may include nausea and weight gain.
Other possible effects include thrombophlebitis, hepatic adenomas, myocardial infarction,
and carbohydrate intolerance.
POTENTIAL BENEFITS
Long-range benefits may include ↓ risks of benign breast disease and ovarian disease.
HIV/AIDS
See the Infectious Disease chapter.
EPIDEMIOLOGY
HIV/AIDS is the sixth leading cause of death among adolescents aged 15–24 years.
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
WARD TIP
If the story doesn’t make sense, suspect 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:
Physical abuse
Sexual abuse
Neglect
RISK FACTORS
WARD TIP
Mongolian spots can be confused with bruises.
Parental risk factors:
Low socioeconomic status.
Mother’s age (young).
History of being abused as a child.
Alcoholism, substance abuse, psychosis.
EXAM TIP
A baby should never be shaken for any reason.
Social isolation.
Child risk factors:
Children with special needs, handicapped children (chronic illness, congenital
malformation, mental retardation).
Prematurity.
EXAM TIP
The most common reason for shaking a baby is inconsolable crying.
Age <3 years.
Nonbiologic relationship to the caretaker.
“Difficult” children.
Family and environmental factors:
Unemployment.
Intimate partner violence.
Poverty.
PHYSICAL ABUSE
WARD TIP
Sometimes abusive parents “punish” their children for enuresis or resistance to toilet training by forcibly immersing their buttocks in hot water.
Suspect if:
Injury is unexplained or unexplainable.
Injury is inconsistent with mechanism suggested by history.
History changes each time it is told.
There are repeated “accidents.”
There is a delay in seeking care.
Skin Manifestations
Bruises
EXAM TIP
Skeletal injuries suspicious of abuse: “Some Parents Are Maliciously Mean” (or Parents Should Manage Anger)
Most common manifestation of physical abuse
Suspicious if:
Seen on nonambulatory infants.
Have geometric pattern (belt buckles, looped-cord marks).
Burns
Suspicious if:
Involve both hands or feet in stocking-glove distribution or buttocks with sharp
demarcation line (forced immersion in hot water).
Cigarette burns—if nonaccidental, usually full-thickness, sharply circumscribed.
“Branding” injuries (inflicted by hot iron, radiator cover, etc).
Skeletal Injuries
Suspicious if:
Spiral fractures of lower extremities in nonambulatory children (see Figure 6-2A and B).
FIGURE 6-2. (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.
Posterior rib fractures (usually caused by squeezing the chest).
Fractures of different Ages.
Metaphyseal “chip” fractures (usually caused by wrenching).
Multiple fractures.
Scapular and clavicle fractures.
EXAM TIP
CNS injuries suspicious of abuse: “Mothers, Refuse Shaking!” (Metaphyseal fractures, Retinal hemorrhages, Subdural hematoma)
Central Nervous System (CNS) Injuries
WARD TIP
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.
Most common cause of death in child abuse: “Shaken baby syndrome.”
Occurs due to violent shakes and slamming against mattress or wall while an infant
is held by the trunk or upper extremities.
Findings include:
Retinal hemorrhages.
Subdural hematoma (from rupturing of bridging veins between dura mater and brain cortex).
Symptoms include:
Lethargy or irritability
Vomiting
Seizures
Bulging fontanelle
ABDOMINAL INJURIES
WARD TIP
Shaken baby syndrome can mimic meningitis or sepsis.
Second most common cause of death in child abuse.
Usually no external marks. Most commonly, liver or spleen is ruptured.
Symptoms include vomiting, abdominal pain or distention, shock.
SEXUAL ABUSE
Includes genital, anal, oral contact; fondling; and involvement in pornography.
Most common perpetrators—fathers, stepfathers, mother’s boyfriend(s) (adults known
to child).
Suspect if:
Genital trauma.
STDs in small children.
Sexualized behavior toward adults or children.
Unexplained decline in school performance.
Runaway.
Chronic somatic complaints (abdominal pain, headaches).
Symptoms include:
May be totally absent.
Tears/bleeding in female or male genitalia.
Anal tears or hymenal tears (not very reliable symptoms).
EVALUATION OF SUSPECTED ABUSE
WARD TIP
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.
Physical Abuse
Bleeding disorders must be ruled out in case of multiple bruises.
X-ray skeletal survey (skull, chest, long bones) in children < 2 years of age (to
look for old/new fractures).
Computed tomographic (CT) scans of the head/abdomen as indicated.
Ophthalmology consult.
Sexual Abuse
Sexual abuse includes any sexual activity (nonconsensual and consensual) between an adult and a child.
Cultures for STDs, test for presence of sperm, if indicated (usually within 72
hours of assault).
MANAGEMENT
WARD TIP
A child who presents with multiple fractures at multiple sites and in various stages of healing should be considered abused until proven otherwise.
If abuse is suspected, it must be reported to child protective services (CPS) (after
medical stabilization, if needed).
All siblings need to be evaluated for abuse, too (up to 20% of them might have
signs of abuse).
Disposition of the child (i.e., 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.
Family must receive intensive intervention by social services and, if needed, legal
authorities.
Remember: If sent back to abusive family without intervention, up to 5% of children can be
killed and up to 25% seriously reinjured.
NEGLECT
WARD TIP
Management of abuse:
Suspect
↓
Report
↓
Disposition
↓
Family counseling
DEFINITION
Neglect is the most common form of reported abuse.
Neglect to meet nutritional, medical, and/or developmental needs of a child can
present as:
Failure to thrive.
Poor hygiene (severe diaper rash, unwashed clothing, uncut nails).
Developmental/speech delay.
Delayed immunizations.
Not giving treatment for chronic conditions.
MANAGEMENT
If nonorganic (i.e., due to insufficient feeding) failure to thrive is suspected:
Patient should be hospitalized and given unlimited feedings for 1 week; 2 oz/24
hours of weight gain is expected.
All suspected cases of neglect must be reported to CPS.
MUNCHAUSEN SYNDROME BY PROXY
DEFINITION
Parent/caregiver either simulates illness, exaggerates actual illness, or induces
illness in a child.
Psychiatrically disturbed parent(s) gain satisfaction from attention and empathy
from hospital personnel or their own family because of problems created.
EPIDEMIOLOGY
EXAM TIP
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.
Affected children are usually < 6 years old.
Parent (usually mother) has some medical knowledge.
SIGNS AND SYMPTOMS
Vomiting (induced by ipecac).
Chronic diarrhea (from laxatives).
Recurrent abscesses or sepsis (usually polymicrobial, from injecting contaminated
fluids).
Apnea (from choking the child).
Fever (from heating thermometers).
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 hospitalization. Usually, child without access to parent will have all/most symptoms resolved; testing will also usually be normal.
MANAGEMENT
Admission to the hospital for observation, possibly using hidden video cameras.
All cases of suspected Munchausen syndrome by proxy must be reported to CPS.
SUDDEN INFANT DEATH SYNDROME (SIDS)
DEFINITION
Sudden death of an infant (< 1 year old) that remains unexplained after thorough
case investigation, autopsy, and review of the clinical history.
SIDS is one of the leading causes of death of infants.
ETIOLOGY
Apnea hypothesis.
DIAGNOSIS
Difficult to differentiate from intentional harm.
PREVENTION
WARD TIP
Infants unable to roll over should be placed on the back while sleeping.
There has been a vast ↓ in the number of cases since the trend of having infants
sleep on their backs (supine).
The number one preventive measure to date is parental education, though the use
of cardiorespiratory monitoring in the home is being debated.
Limiting passive smoke exposure.
Do not use soft bedding, pillows, stuffed animals, loose blankets.
Co-sleeping with the parent increases the risk.