Pediatric Potpourri

Pediatric Potpourri

The approach—infant-- 30 days to first birthday • Infant—consistency of care is essential for an infant to develop trust; attend to expressed needs immediately and consistently; • The infant is observing your facial expressions and moods at one month • Causes of depression

Monkey see, Monkey do…Mirror neurons fire when we perform an action ourselves, as well as when we see others perform it

Learning, learning, learning…from their environment • Synapses are forming in the newborn and infant brain at the incredible rate of 3 billion/second

The approach—toddler– One to 3 years old • Toddler—autonomy; 300 words; begin to tolerate some separation from primary caregiver; temper tantrums are normal; enjoy rituals, consistency, learning toileting skills and locomotion; egocentricity; negativism is common; —don’t ever ASK if you can do something…can I look in your ears? NOOOOOOO

Which ear would you like me to look in first? • How do you look at the back of a toddler’s throat? • Open your mouth and pant like a doggie… • Turn them upside down if they won’t open their mouth… • (the diabetic toddler--Joey)

Life revolves around their “head”… DON’T go to the head first

The approach—the preschooler– 3-5 years old • Preschooler—may talk incessantly (900 words); evolving from “me, me, me” to seeing other’s viewpoints; use magical thinking to solve problems and make sense of their environment; may deny pain or other problems through magical thinking (KENDRA) May be dependent on security objects and items…HANDLE WITH CARE AND DO NOT LOSE!! “ my binkie, my bankie, my teddie, my sharkie” • Preschoolers are also very aware of surroundings; always include the child in conversations

The approach—school-age—Early: 6 to 10Late: 10 to 12 years • Acquisition of skills achieves a sense on competency • Conscience is forming and peer group interactions are highly influential

The approach—adolescence—13 to 18 years • Capable of thinking beyond the present, are logical and are capable of using reasoning (HAHAHA…)—doesn’t mean that they do… • Abstract thinking • Group identity is paramount and risk-taking is common secondary to peer pressures

The prefrontal cortex is not completely developed • What does the prefrontal cortex do? • It’s the center for judgment, insight, reasoning, organization, future planning and problem solving, and it has extensive connections with the already developed emotional and instinctual centers in the limbic system, especially the amygdala. • These levels are critical for emotional learning and high-level self regulation.

The teenage limbic system • Since the emotional, instinctive limbic areas mature earlier than those involved in judgment, organization, and reasoning there is a distinct DISCONNECT BETWEEN THE TWO areas • This discrepancy between expressing feeling vs. thoughtful evaluation accounts for many of the teen behaviors that dismay parents and teachers… • “but he was such a sweet little boy…”

The Teenage Brain • “I just don’t understand what happened…”

An easier way to put it—the prefrontal cortex is your “internal” MOTHER • And MOM is inhibitory---what’s the only word a MOM needs to know? NO.NO.NO.NO.NO. • She puts the checks and balances on behavior—especially on the amygdala—the wild beast within (the instinctual nucleus of the brain) • The two areas DON’T connect in the teenage brain necessitating a PERIPHERAL PARENT-- • Parents, who act like parents, do this for teenagers; parents who act like teenagers, do not

The biggest MISCONCEPTION: Looking like an adult means they act like an adult… • Even though they may “look like adults” adolescents find it more difficult to:

Think before acting… • Difficult to interrupt an action under way—ramming the back of the car in front of you…for example • The teenager freezes and screams (the limbic system--emotions) • The adult brakes hard and steers out of the way (the prefrontal cortex--insight) • Back to the prefontal lobe that underlies planning and voluntary behavior

Adolescents find it more difficult to: • Choose between safer behaviors vs. riskier alternatives • Difficulty resisting peer pressure • It’s that prefrontal cortex again—they’re using it somewhat, but it’s overtaxed…throw in peer pressure…”Aw c’mon, just once…” the stressful situation on an already taxed prefrontal lobe may give in to better judgment--

90% of all teenage pregnancies are UN-planned • “I can’t believe I’m pregnant…” • Old Chinese Proverb • “It take many nail to build crib; only one screw to fill it.”

Which brings us to birth control methods in teenage girls • 1st question…do they have 2 neurons that synapse at the same time and CAN THEY REMEMBER to take a pill? • 2nd question…do they smoke? • 3rd question…are they overweight? • All 3 are important when choosing a method of birth control

Question #1 • Are they smart enough to remember to take a pill every day? • Today’s pills vs. yesteryear • MISS A PILL today?

The PILL and clotting risk • Pills of yesteryear—80 to 100 μg per pill • Could stop an elephant from ovulating • Pills of 2012—20-35 μg per pill • Less clotting risk, greater chance of pregnancy if you MISS A PILL • It’s not JUST the pill…weight plays a role too…

Question #2 • Do they smoke cigarettes?

Obesity and birth control—do COCs work as well in obese women? • Hypothesis is that COCs don’t work as well in the obese woman • Later hormone peak for pill—obese women don’t reach their prime hormone level for preventing ovulation until day 10 vs. day 5 for healthy weight women…? Implications? • Increased metabolism causes hepatically metabolized drugs, such as contraceptive steroids; theoretically the half life of these drugs might be shorter in obese women and serum levels might be insufficient to maintain contraceptive effect • Increased fat storage of contraceptive steroids decreasing bioavailability • All theory, no evidence-based studies

The Pill, obesity, and clotting risk • European Active Surveillance study (2000-2006); 59,000 women from seven European countries, looking at heart health in women using OCs • For every 100,000 years of pill-taking, 44 women had blood clots in the placebo group • For every 100,000 years of pill-taking, 90 women had blood clots (double the placebo group) • BUT, and that’s a big BUTT—when the study looked specifically at women with a BMI over 30, the number skyrocketed to 230 cases (5x more likely than those in the placebo group)

General Assessment--observation • The most useful information is often acquired by watching the child move and play. • Mood and behavior

The order of the exam is not carved in stone… • Try to do everything you can with infants and toddlers sitting on their parent’s ankles or on their lap • Lying the young child on the examination table increases vulnerability

Frown/smile Facial nerve (CNVII) Watch their facial expressions and the cranial nerve exam—remember SYMMETRY is the key

RASPBERRY • CN III (oculomotor) – eyes converging • Facial expression (CN VII)

Stick your tongue out… • CN XII (hypoglossal) • Mirror neurons and autism

Assessment of pain—body language helps

Weight … • Best index for a healthy child is appropriate weight gain • ALARM SIGN: Failure to gain weight is the first indication of a serious problem • Skinny but LOOOONG—congenital heart disease • And, weights are essential for determining fluid requirements and medication dosages

Height/length—compare with weight and use growth charts • Growth occurs in a step-wise pattern • Spurts and lulls • Vertical growth occurs during sleep when GH is released during the late stages of SWS • Adenoiditis, sleep apnea, and short stature

Don’t forget celiac disease… • As a cause of short stature • Inability to absorb iron in the duodenum

Back to sleep disorders • Tired kids often become inattentive and fidgety –misdiagnosed as hyperactive, behavior problem vs. tired adults that nod off and drive off the road • 12% of kids snore; 2% have sleep apnea (cranial facial abnormalities, cleft lip/palate; enlarged tonsils and adenoids) • How about tonsillectomies for hyperactive kids with big tonsils and adenoids?

Sleep disordered breathing and tonsillectomy • Tonsillectomy for sleep-disordered breathing—might benefit from tonsillectomy, particularly children with growth retardation, enuresis, poor school performance or behavioral problems, or tonsilar hypertrophy on physical exam Baugh RF et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg2010 Dec 31;144:S1. • (Ronald Chervin, University of Michigan)

Temperatures • For babies under 3 months old, temperatures should be taken rectally, and any fever in this age group is typically considered an ALARM sign • The AAP suggests rectal temps for all kids under age 3 • Forehead thermometers are fine; TM thermometers are less accurate • The diagnosis of fever is a rectal temperature of at least 38.0º C (100.4º F).

The treatment of fever • 50% of Primary Care Practitioners alternate acetaminophen with Ibuprofen to reduce fever • This is NOT condoned by the American Academy of Pediatrics; the most common cause of overdose deaths in the US is acetaminophen, owing to its widespread availability and frequency of use in accidental and suicidal intoxications.

The treatment of fever • Use one or the other (exception??) • Acetaminophen is preferable for any viral illness • Acetaminophen (10-20 mg/kg PO q 4-6 hours—do NOT exceed 5 doses in 24 hours)(71 minutes to work to reduce fever) • Ibuprofen 5-10 mg/kg, every 4 hours (works faster, decreases inflammation) (44 minutes to work)

Fever • Aspirin can be used with Kawasaki’s disease and Juvenile Rheumatoid Arthritis • Aspirin should NOT be given to a child with a viral syndrome due to the ongoing risk of Reye’s syndrome

Hypothermia and infections • Hypothermia is an ALARM sign in a child with an infection (sepsis) • Salmonella sepsis • NO REPTILES FOR KIDS UNDER 6

Kids should be… • Pink (or brown, or black, or yellow, or purple…) and WARM • Not cold and ashen • Check FEET or FINGERS • Poor perfusion tends to show up in the extremities first

Simple febrile seizures • Common—observed in 2-5% of children • DEFINITION: a seizure accompanied by fever, but without a central nervous system infection or electrolyte imbalance; simple febrile seizures are primary generalized seizures that last for less than 15 minutes and do not recur within 24 hours

Simple febrile seizures • Usually observed with viral infections of the upper respiratory or GI tract (usually occurs within the first 24 hours of the illness); after a vaccination (6x greater on the day of DPT up to 72 h after (6-9 per 100,000); 8-14 days after MMR vaccine 25-34/100,000) • NO NEED TO PREMEDICATE WITH acetaminophen prior to vaccines!

Simple febrile seizures • Most common between the ages of 18 months to 3 years (range is 6 months to 60 months/5 years) • Any seizure under the age of 6 months, regardless of temperature, is an ALARM SIGN • Family history is common; M > F (pathway maturity) • Treatment? Rectal diazepam if needed…most of the kids have finished seizing by the time they arrive at the office or the ER

ALARM: COMPLEX febrile seizures: focal, lasting longer than 15 minutes or recurrence within 24 hours; potential long-term complications with complex although the risk is low; developing subsequent seizures WITHOUT FEVER may cause impaired cognition long-term

Heart rate (charts vary) • Newborn (120-160) • Infant (100-120) • Toddler (90-140) • School age (75-110) • Adolescent (60-90)

Respirations • Newborn (35-65) (obligate nose breathers for the first 8 to 12 weeks)—KEEP THEIR NOSTRILS PATENT • Infant (30-60) Place your hand on the chest of a neonate/infant to assess respirations; count for a full minute, especially with a resp. illness • Toddler (24-40) • School-age (20-30) • Adolescent (12-16)

Respirations • The respiratory tract of a young child has a narrow lumen until age 5—makes the child more prone to airway obstruction and respiratory distress from inflammation • Aspiration and obstruction of airway by a foreign object is the number 1 cause of death children less than a year old • Sudden onset of acute respiratory distress in an infant crawling on floor—consider foreign object!

Respirations • ALARM: Respiratory rates greater than 70 in infants—consider lower respiratory tract infection; under one year consider Respiratory Syncytial Virus (RSV), bronchiolitis* *underdeveloped intercostal muscles—severe retractions

Blood pressure • Recommend at age 3; • Ages 1 to 5 90 + age in years/56 4 yr- old? 94/56 • Ages 6 to 18 83 + 2 x age in years/52 + age in years 8-yr old? 83 + 16/52+8 = 99/60 • Proper cuff size (no less than ½ to no more than 2/3 of the length of the upper arm or upper leg)

Pediatric Potpourri