P Pediatrics Rachel Markin, Babak Rashidi, Tamar Rubin and Elizabeth Yeboah, chapter editors Christopher Kitamura and Michelle Lam, associate editors Janine Hutson, EBM editor Dr. Stacey Bernstein and Dr. Michael Weinstein, sta! editors With contributions from Dr. Perla Lansang Pediatric Quick Reference Values .......... 3 Precocious Puberty Delayed Puberty Primary Care Pediatrics .................. 3 Short Stature Regular Visits Growth Hormone (GH) Deficiency Developmental Milestones Tall Stature Routine Immunization Other Vaccines Gastroenterology ...................... 36 Nutrition Vomiting Normal Physical Growth Vomiting in the Newborn Period Dentition Vomiting After the Newborn Period Failure to Thrive (FTT) Acute Diarrhea Obesity Chronic Diarrhea Infantile Colic Chronic Diarrhea Without Failure to Thrive Milk Caries Chronic Diarrhea With Failure to Thrive Injury Prevention Counselling Constipation Sudden Infant Death Syndrome (SIDS) Acute Abdominal Pain Circumcision Chronic Abdominal Pain Toilet Training Abdominal Mass Upper Gastrointestinal Bleeding Abnormal Child Behaviours .............. 12 Lower Gastrointestinal Bleeding Elimination Disorders Sleep Disturbances Genetics, Dysmorphisms, and Metabolism ... 43 Breath-Holding Spells Approach to the Dysmorphic Child Approach to the Crying/Fussing Child Genetic Syndromes Dermatology Muscular Dystrophy (MD) Associations Child Abuse and Neglect ................ 15 Metabolic Disease Phenylketonuria (PKU) Adolescent Medicine ................... 17 Galactosemia Normal Sexual Development Normal Variation in Puberty Hematology ........................... 48 Physiologic Anemia Cardiology ............................ 18 Iron Deficiency Anemia Heart Murmurs Anemia of Chronic Disease Congenital Heart Disease (CHD) Hemoglobinopathies Acyanotic Congenital Heart Disease Bleeding Disorders Cyanotic Congenital Heart Disease Immune Thrombocytopenic Purpura (ITP) Congestive Heart Failure (CHF) Hemophilia Infective Endocarditis von Willebrand’s Disease Dysrhythmias Infectious Diseases ..................... 52 Development .......................... 26 Fever Developmental Delay Acute Otitis Media (AOM) Intellectual Disability Meningitis Language Delay Urinary Tract Infection (UTI) Learning Disorders Pharyngitis and Tonsillitis Fetal Alcohol Spectrum Disorder (FASD) Streptococcal (GAS) Pharyngitis Infectious Mononucleosis Endocrinology ......................... 29 Pertussis Diabetes Mellitus (DM) Varicella (Chickenpox) Diabetes Insipidus (DI) Roseola Syndrome of Inappropriate Antidiuretic Measles Hormone (SIADH) Mumps Hypercalemia/Hypocalcemia/Rickets Rubella Hypothyroidism Erythema Infectiosum Hyperthyroidism Reye Syndrome Ambiguous Genitalia HIV Infection Congenital Adrenal Hyperplasia (CAH) Toronto Notes 2011 Pediatrics P1 P Pediatrics Neonatology .......................... 62 Legg-Calve-Perthes Disease Normal Baby at Term Slipped Capital Femoral Epiphysis Gestational Age (GA) and Size Congenital Talipes Equinovarus Routine Neonatal Care Scoliosis Approach to the Depressed Newborn Neonatal Resuscitation Otolaryngology ........................ OT Sepsis in the Neonate Acute Otitis Media (AOM) Cyanosis Otitis Media with Effusion (OME) Persistent Pulmonary Hypertension of the Acute Tonsillitis Newborn (PPHN) Tonsillectomy Apnea Airway Problems Respiratory Distress in the Newborn Signs of Airway Obstruction Respiratory Distress Syndrome (RDS) Acute Laryngotracheobronchitis (Croup) Transient Tachypnea of the Newborn (TTN) Acute Epiglottitis Meconium Aspiration Syndrome (MAS) Subglottic Stenosis Pneumonia Laryngomalacia Diaphragmatic Hernia Foreign Body Bronchopulmonary Dysplasia (BPD) Hypoglycemia Plastic Surgery ........................PL Jaundice Cleft Lip Bleeding Disorders in Neonates Cleft Palate Necrotizing Enterocolitis (NEC) Syndactyly Intraventricular Hemorrhage (IVH) Polydactyly Retinopathy of Prematurity (ROP) Hemangioma Common Neonatal Skin Conditions Psychiatry ............................PS Nephrology ........................... 76 Autism Spectrum Dehydration Asperger Fluid and Electrolyte Therapy Attention Deficit and Hyperactivity Disorder Hematuria Schizophrenia Proteinuria Mood Disorders Hemolytic Uremic Syndrome (HUS) Anxiety Disorders Nephritic Syndrome Eating Disorders Nephrotic Syndrome Hypertension in Childhood Respirology ........................... 90 Approach to Dyspnea Neurology ............................ 81 Upper Respiratory Tract Diseases Seizure Disorders Croup Febrile Seizures Bacterial Tracheitis Recurrent Headache Epiglottitis Hypotonia Lower Respiratory Tract Diseases Cerebral Palsy (CP) Pneumonia Neurocutaneous Syndromes Bronchiolitis Acute Disseminated Encelphalomyelitis (ADEM) Asthma Cystic Fibrosis (CF) Neurosurgery ......................... NS Neural Tube Defects Rheumatology ......................... 95 Intraventricular Hemorrhage (IVH) Evaluation of Limb Pain Hydrocephalus Septic Arthritis Brain Tumours Growing Pains Dandy-Walker Cyst Transient Synovitis Chiari Malformation Juvenile Idiopathic Arthritis (JIA) Craniosynostosis Systemic Lupus Erythematosus (SLE) Reactive Arthritis Oncology ............................. 87 Lyme Arthritis Leukemia Vasculitides Lymphoma Henoch-Schönlein Purpura (HSP) Brain Tumours Kawasaki Disease Wilms’ Tumour (Nephroblastoma) Neuroblastoma Urology ............................... U Rhabdomyosarcoma Urinary Tract Obstruction Lymphadenopathy Vesicoureteral Reflux (VUR) Genital Abnormalities Orthopaedics ..........................OR Fractures in Children Common Medications .................. 99 Epiphyseal Injury Pulled Elbow References ............................ 99 Developmental Dysplasia of the Hip P2 Pediatrics Toronto Notes 2011 Toronto Notes 2011 Pediatric Quick Reference Values/Primary Care Pediatrics Pediatrics P3 Pediatric Quick Reference Values Table 1. Average Vitals at Various Ages Age Pulse (bpm) Resp. Rate (br/min) sBP (mmHg) Neonate 90 – 170 40 – 60 70 – 90 3-12 months 80 – 165 30 – 55 80 – 100 1-2 years 80 – 125 25 – 45 90 – 100 3-11 years 70 – 115 18 – 30 100 – 110 12-15 years 60 – 100 12 – 18 110 – 130 Primary Care Pediatrics Regular Visits • usual schedule: newborn, within 1 week post-discharge, 1, 2, 4, 6, 9, 12, 15, 18, 24 months yearly until age 6, then every other year until yearly again a!er age 11 • history • physical exam • immunization (see Immunization, P4) • counselling/anticipatory guidance (see Nutrition P6, Colic P10, Sudden Infant Death Syndrome (SIDS) P11, and Injury Prevention Counselling P11 sections) Developmental Milestones Table 2. Developmental Milestones Age Gross Motor Fine Motor Speech and Language Adaptive and Social Skills 6 weeks Prone: lifts chin — — Social smile intermittently Pediatric Developmental Milestones 1 year: 2 months Prone: arms extended Pulls at clothes Coos Recognizes parents – Single words forward 2 years: – 2 word sentences 4 months Prone: raises head + Reach and grasp, objects Responds to voice, – Understands 2 step commands chest, rolls over, no head to mouth laughs 3 years: lag – 3 word combos – Repeats 3 numbers 6 months Prone: weight on hands, Ulnar grasp, transfers Begins to babble, Stranger anxiety beginning – Rides tricycle tripod sit objects from hand to hand responds to name of object permanence 4 years: Pulls to stand, crawls Finger-thumb grasp “Mama, dada” – Plays games, plays – Draws square 9 months – Counts 4 objects appropriate, imitates peek-a-boo, separation/ 1 word stranger anxiety 12 months Walks with support Pincer grasp, throws 2 words, follows 1-step Drinks with cup, waves command bye-bye 15 months Walks without support Draws a line Jargon Points to needs 18 months Climbs up steps with help Tower of 3 cubes, scribbling 10 words, follows Uses spoon, points to body Developmental Red Flags simple commands parts Gross motor: Not walking at 18 mos Fine motor: Handedness at <10 mos 24 months Climbs up 2 feet/step, Tower of 6 cubes, 2-3 word phrases, Parallel play, helps to dress Speech: <3 words at 18 mos runs, kicks ball, walks undresses uses “ I, me, you”, Social: Not smiling at 3 mos up and down steps 50% intelligible Cognitive: No peek-a-boo at 9 mos 3 years Tricycle, climbs up 1 foot/ Copies a circle and a cross, Prepositions, plurals, Dress/undress fully except step, down 2 feet/step, puts on shoes counts to 10, 75% buttons, knows sex, age stands on one foot, jumps intelligible 4 years Hops on 1 foot, down Copies a square, uses Tells story, knows Cooperative play, toilet 1 foot/step scissors 4 colours, speech trained, buttons clothes, intelligible, uses past knows names of body tense parts 5 years Skips, rides bicycle Copies a triangle, prints Fluent speech, future name, ties shoelaces tense, alphabet P4 Pediatrics Primary Care Pediatrics Toronto Notes 2011 Primitive Reflexes • re!exes seen in normal newborns Reflexes • may indicate abnormality (e.g. cerebral palsy) if persist a"er 4-6 months • Rooting reflex: infant pursues tactile • Moro re!ex stimuli near the mouth infant is placed semi-upright, head supported by examiner’s hand, sudden withdrawal of • Parachute reflex: tilting the infant to the side while in a sitting position supported head with immediate resupport elicits re!ex results in ipsilateral arm extension re!ex consists of abduction and extension of the arms, opening of the hands, followed by (appears by 6-8 months) !exion and adduction of arms • Upgoing plantar reflexes (Babinski absence of Moro suggests CNS injury; asymmetry suggests focal motor lesions (e.g. brachial sign): is normal in infants (i.e. <2 yrs) plexus injury)