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Pediatric Exam 2 Study Guide

Newborns (2–28 Days)

Language Development & Milestones

  • Crying
    • Primary communication tool; signals hunger, discomfort, overstimulation, need for attention.
    • Average crying time: 2\text{–}3\ \text{hours/day} during the first 6 weeks.
    • Clinical significance: Helps caregivers learn infant cues and promotes bonding when responded to promptly.
  • Cooing & Early Babbling (≈ end of 1st month)
    • Indicates maturation of vocal cords and auditory recognition (especially caregiver’s voice).
    • Serves as precursor to later speech and language development.
  • Bonding & Attachment
    • Encouraged by skin-to-skin contact, sustained eye contact, gentle vocal interaction.
    • Enhances brain myelination, stress regulation, and long-term emotional security.

Crying vs. Colic

  • Colic Definition: Persistent crying >3\ \text{hrs/day},\ >3\ \text{days/week},\ >3\ \text{weeks}.
  • Possible Etiologies
    • Immature GI tract, excessive gas, cow’s-milk protein allergy, parental overstimulation.
  • Management Strategies
    • Soothing (rocking, swaddling, white noise).
    • Adjust feeding technique/position; consider hypoallergenic formula.
    • Infant massage, probiotic drops, reassuring and educating parents to reduce anxiety.

Primitive Reflexes (Neurologic Screening)

  • Rooting, Sucking, Moro, Tonic-neck (“fencing”), Palmar grasp, Babinski, Stepping.
  • Normal disappearance timetable guides neurologic maturation; persistence may indicate cerebral pathology.

Car-Seat Safety

  • Rear-facing in back seat until at least 2 yrs.
  • Chest clip at armpit level; harness snug (no bulky coats—use blanket over straps).
  • Base movement <1\ \text{inch} at belt path.

Cow’s-Milk Protein Allergy

  • Clinical Signs: Vomiting, diarrhea, eczema-like rash, wheezing, hematochezia.
  • Management: Maternal dairy elimination (if breastfeeding); switch to extensively hydrolyzed or amino-acid formulas.

Infants (1 Month – 1 Year)

Developmental Milestones

  • Gross Motor
    • 2 mo: lifts head when prone.
    • 4 mo: rolls front→back.
    • 6 mo: tripod sitting.
    • 9 mo: crawls.
    • 12 mo: pulls to stand, cruises.
  • Fine Motor
    • 2 mo: hands mostly fisted, visually tracks.
    • 4 mo: reaches, grasps.
    • 6 mo: transfers object hand-to-hand.
    • 9 mo: immature pincer.
    • 12 mo: refined pincer, self-feeds.

Play & Social Development

  • Social smile emerges 4\text{–}6 weeks; cooing parallels.
  • By 6 mo: enjoys reciprocal games (peek-a-boo) → fosters object permanence.
  • Toy guidance: bright colors, varied textures, large non-detachable parts for safety.
  • Play promotes sensory integration, motor skills, caregiver bonding.

Separation Anxiety

  • Typical onset 6\text{–}8 mo.
  • Manifestations: clinginess, sleep disruption, heightened crying when caregiver departs.
  • Interventions: predictable routines, short practice separations with assured return, comfort objects.

Nutrition: Breastmilk vs. Formula

  • Exclusive Breastfeeding first 6 mo; continue alongside solids to ≥12 mo.
    • Contains IgA, lactoferrin; reduces otitis media, NEC, obesity risk.
    • Supplement 400\ \text{IU/day} vitamin D.
  • Formula
    • Use iron-fortified; essential when breastfeeding contraindicated (e.g., HIV in resource-rich settings) or inadequate.
    • Strict preparation (clean water, correct dilution) & storage protocols critical.

Complementary Food Introduction (≈ 6 mo)

  • Readiness cues: sits with minimal support, loss of tongue-thrust reflex, interest in others’ food.
  • Start with iron-rich options (single-grain cereals, puréed meats).
  • Introduce one new food per 3\text{–}5 days to observe allergies.
  • Early introduction (<12 mo) of allergenics (peanut, egg) linked to ↓ future allergy risk.

Safe Sleep (AAP) Guidelines

  • Supine position on firm sleep surface; share room (not bed) for ≥6 mo.
  • No soft bedding, pillows, plush toys.
  • Avoid prolonged sleep in car seats/swings to prevent positional asphyxia.

Communicable Diseases & Immunizations

Transmission-Based Precautions

  • Droplet: surgical mask – pertussis, mumps, scarlet fever.
  • Airborne: N95 + negative pressure – varicella, measles, TB.
  • Contact: gown/gloves – scabies, impetigo.

Core Pediatric Vaccines (selected schedule highlights)

  • DTaP: 2,4,6,15\text{–}18 mo; booster at 4\text{–}6 yrs.
  • MMR (live): 12\text{–}15 mo, 4\text{–}6 yrs (contraindicated in pregnancy/immunodeficiency).
  • PCV13 (pneumococcal): 2,4,6,12\text{–}15 mo.

Representative Diseases

  • Varicella (Chickenpox)
    • Pruritic vesicular rash starting on trunk → extremities; contagious until crusted.
  • Scabies
    • Nocturnal pruritus, serpiginous burrows (interdigital, wrist, groin).
    • Treat with permethrin 5\%; wash linens >50 °C; treat household.

Cardiac Conditions

Tetralogy of Fallot (TOF)

  • Four lesions: VSD, pulmonary stenosis, overriding aorta, RV hypertrophy.
  • Cyanotic “tet spells” relieved by knee-to-chest (↑ SVR ↓ R→L shunt).
  • Surgical repair typically 2\text{–}6 mo.

Infective Endocarditis

  • High risk in CHD or indwelling lines.
  • Empiric IV antibiotics 2\text{–}6 weeks; prophylaxis pre-dental work.

Pediatric Hypertension

  • Diagnose after 3 separate elevated measurements (use right-size cuff).
  • Primary vs. secondary (renal, endocrine).
  • Tx: lifestyle; consider ACE-I, β-blocker.

Cardiomyopathy

  • Dilated/hypertrophic subtypes; leads to CHF.
  • Management ranges from medical (afterload reduction, β-blockers) to transplant.

Atrial Septal Defect (ASD)

  • Often asymptomatic; may close spontaneously by <2 yrs.
  • Large defects → fatigue, FTT; closure via device or surgery if persistent.

Blood-Pressure Technique

  • Proper cuff width 0.4\times arm circumference; length 80\text{–}100\% circumference.
  • Measure upper & lower limbs if coarctation suspected.

Dyslipidemia Screening

  • Universal non-fasting lipid panel at 9 yrs; earlier if high-risk family history.

Hematology

Disseminated Intravascular Coagulation (DIC)

  • Consumptive coagulopathy → microthrombi + bleeding.
  • Secondary to sepsis, trauma, malignancy.
  • Tx: address cause, replace platelets/cryoprecipitate, possibly heparin.

Aplastic Anemia

  • Pancytopenia due to marrow failure.
  • Presents with infections, pallor, bruising.
  • Curative therapy: hematopoietic stem-cell transplant.

Bleeding Disorders

  • Hemophilia A/B: factor VIII/IX deficiency (X-linked).
  • von Willebrand Disease: qualitative/quantitative vWF defect.
  • Avoid NSAIDs; use desmopressin (vWD) or factor concentrate.

Iron-Deficiency Anemia (IDA)

  • Most common; risk ↑ with cow-milk >24\ \text{oz/day} (low iron, blocks absorption).
  • Symptoms: pallor, irritability, pica.
  • Tx: elemental iron 3\text{–}6\ \text{mg/kg/day} with vitamin C.

Beta-Thalassemia Major

  • Defective β-globin → severe microcytic anemia.
  • Needs chronic transfusions; chelation (deferoxamine) to prevent hemosiderosis.

Immune System Disorders

Juvenile Idiopathic Arthritis (JIA)

  • Chronic synovitis ≥6 weeks.
  • Morning stiffness, growth disturbances.
  • Tx: NSAIDs → DMARDs (methotrexate) ± biologics.

Systemic Lupus Erythematosus (SLE)

  • Multisystem autoimmunity; classic malar rash, nephritis.
  • Manage with corticosteroids, hydroxychloroquine, immunosuppressants.

Allergic Reactions

  • Range from urticaria → anaphylaxis.
  • Use intramuscular epinephrine 0.01\ \text{mg/kg} (max 0.5 mg).
  • Antihistamines for mild cases; observe biphasic risk.

Pediatric HIV

  • Common transmission: perinatal, blood products.
  • Monitor CD4, viral load quarterly; start ART promptly.
  • Live vaccines generally contraindicated when CD4 low.

Neurology

Concussion

  • Transient neuro-metabolic dysfunction; no structural lesion on imaging.
  • Management: cognitive/physical rest 24–48 h → graded return.
  • Red-flag: worsening headache, vomiting, focal deficit → imaging.

Febrile Seizures

  • Generalized, <15 min (simple type).
  • Occur 6 mo–5 yrs with rapid T° rise.
  • Prognosis excellent; antipyretics for comfort (do not prevent recurrence).

Epilepsy

  • ≥2 unprovoked seizures >24 h apart.
  • EEG for classification; mainstay Tx: antiepileptic drugs (levetiracetam, valproate, etc.).

Infant Botulism

  • Ingestion of C. botulinum spores (honey, soil).
  • Floppy baby, poor suck, descending paralysis.
  • Give human botulism immune globulin (Baby BIG) + supportive care.

Chronic Migraines

  • ≥15 headache days/month, ≥8 migraine days.
  • Identify triggers (sleep deprivation, certain foods); abortive triptans, preventive meds (topiramate).

Tetanus

  • Neurotoxin → muscle rigidity, lockjaw.
  • Prevention: DTaP series + Tdap boosters; clean wounds.
  • Treatment: TIG (immune globulin), metronidazole, sedation, airway support.

Endocrine

Congenital/Acquired Hypothyroidism

  • Detected on newborn screen (↑ TSH, ↓ T4).
  • Untreated leads to cretinism (intellectual disability).
  • Lifelong levothyroxine; monitor TSH/T4 q4-6 weeks in infancy.

Diabetes Insipidus (Central)

  • ADH (vasopressin) deficiency → polyuria ≥2\ \text{L/m}^2/24\text{h}, hypernatremia.
  • Desmopressin acetate intranasally/orally; ensure free water access.

Growth Hormone Therapy

  • Indications: GH deficiency, Turner syndrome, chronic renal failure.
  • Monitor growth velocity, IGF-1, bone age to avoid epiphysial closure.

Type 1 Diabetes Mellitus

  • Autoimmune β-cell destruction → absolute insulin deficiency.
  • Presents with polyuria, polydipsia, weight loss, DKA (pH<7.30).
  • Intensive insulin therapy (basal-bolus); carb counting; BG targets age-adjusted.

Type 2 Diabetes Mellitus

  • Insulin resistance + relative deficiency; rising in adolescents with obesity.
  • First-line: lifestyle (dietary modification, ≥60 min daily physical activity).
  • Pharmacologic: metformin ≥10 yrs; consider insulin if A1C >9\% or ketosis.