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August 23 rd , 2012. Preventive pediatrics. Test Question. What topic should we do for next month’s board review? A. Genetics B. Development. Screening!. Blood Pressure Screening. Hypertension affects 1 out of 4 adults Poorly controlled HTN is the leading cause of death globally

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    1. August 23rd, 2012 Preventive pediatrics

    2. Test Question What topic should we do for next month’s board review? A. Genetics B. Development

    3. Screening!

    4. Blood Pressure Screening • Hypertension affects 1 out of 4 adults • Poorly controlled HTN is the leading cause of death globally • High BP in childhood is a risk factor for hypertension in adulthood • Hence the need for frequent pediatric blood pressure screening

    5. Blood Pressure Screening • Children > 3 yrs old: screened at every health care encounter

    6. Blood Pressure Screening • Preferred method of BP screening is auscultation • If elevated BP detected with oscillometric device, confirm with auscultation • Correct measurement requires appropriate cuff (bladder) size for the child’s right upper arm • Width is ≥ 40% of the circumference of the arm • Length is 80-100% of the circumference of the arm • BP measurements are overestimated to a greater degree with a cuff that is too small than they are underestimated by a cuff that is too large

    7. Blood Pressure Screening • Normal range of blood pressure is based on sex, age, and height

    8. Lead Screening

    9. Lead Screening • Lead toxicities have been well documented throughout history • Used by ancient Egyptians for homicidal purposes • Common cause of morbidity and mortality in shipbuilders, wine drinkers, potters • Lead-based paints, gasoline, and food containers resulted in profound contamination in the early 20th century • In the 1970’s close to 90% of children had blood lead levels (BLLs) greater than 10mcg/dL

    10. Lead Screening • Banning of lead in gasoline and paints as well as wide-spread screening have lead to decreased average BLLs over the past several decades • However, there are still some potential exposures

    11. Question #1 All of the following are potential lead exposure sources, EXCEPT • Playing with antique, imported toys or makeup from India • Drinking bottled water • Jumping into dad’s arms after he comes home from a long day of automobile repairs and soldering • Living in a house built in 1948 • Eating dirt next to an old gasoline refinery

    12. Lead Screening • For all Medicaid patients: • Universal screening at ages 1 and 2 • For other types of insurance: • Based on local state/city health department guidelines • Typically at age 2; and at age 12 months for high risk population • ALL children should have at least one BLL between the ages of 36-72 months • At any time for high risk or concern: • Living in high-risk environment where more than 12% of children have elevated BLLs, siblings with elevated BLLs, recent immigrants, parental concern about exposure

    13. Question #2 You receive a lab report from a screening fingerstick blood lead level. The level is 18mcg/dL. What is the best next step? • Repeat the BLL with a venous sample • Administer oral succimer (DMSA) at 10mg/kg orally every 8 hrs for 5 days followed by every 12 hrs for 14 days • Reassure the parents and schedule routine follow up in 6 months • Hospitalize the patient for parenteralchelation • Contact the health department for an immediate transfer to a lead-free enviornment

    14. **Now < 5mcg/dL** 5

    15. Question #3 All of the following are reasons why children are at an increased risk of lead toxicity compared to adults, EXCEPT: • Increased hand-to-mouth behavior • Increased lead absorption • Preferential deposition of lead into bones as opposed to soft tissues • Immature blood-brain barrier leading to greater neurotoxicity • More common concomitant iron deficiency anemia

    16. Lead: Clinical Manifestations • Affects multiple organ systems, however most children are ASYMPTOMATIC • Greatest concern: neurotoxic potential • Even LOW BLLs can have toxic effects • School failure, cognitive loss, hyperactivity, aggression, inattention, distractibility, delinquent behaviors • Decline in IQ scores • However, rate of decline in IQ score may be HIGHER at levels LESS than 10mcg/dL • Lead-sensitive pathways that are rapidly saturated at levels below 10mcg/dL • Chronic mildly increased BLLs may have higher risk

    17. Lead: Clinical Manifestations • Abdominal colic • Constipation • Growth failure • Hearing loss • Renal disease • Seizures • Encephalopathy • Microcytic anemia • Depressed T-cell function • Altered cartilage mineralization • Osteopenia/decreased bone growth • Miscarriage, preterm births • CVD, HTN in adulthood

    18. Lead: Prognosis • No RCTs that show that chelation therapy affects outcomes • Cannot reverse any neurologic deficits • Treatment based on clinical experience and judgment • Neurodevelopmental lags may not be evident immediately for a patient with elevated BLLs • Delays may not be apparent until more challenging school activities bring them out • Neurodevelopmental surveillance should continue throughout schooling • A nurturing and stimulating social environment can help to ameliorate the toxic effects of lead on the brain

    19. Vision Screening

    20. Vision • Vision problems are very common in children • 5-10% of all preschoolers have a vision problem • 5-7% have major refractive errors requiring correction • 4% have strabismus • Of those, 40% have amblyopia • 0.1% have cataracts • Screening and early detection improve visual acuity

    21. What do these terms mean?! • Refractive error: focusing problem • Myopia (nearsightedness) • Hyperopia (farsightedness) • Astigmatism • Strabismus: misalignment of the eyes • “tropia”: full time misalignment • “phoria: tendency to become misaligned • “eso” adducting (inward) • “exo” abducting (outward) • Amblyopia: loss of visual acuity due to active cortical suppression of vision in that eye • Strabismus, anisometropic, deprivational • Cataract: opacification of the lens

    22. Question #4 A mother brings her newborn infant in to your clinic. She asks if the baby can see her. What is your BEST response? • Infants cannot see colors until 6 months of age • Her baby’s vision is most likely 20/40 • Newborns have no light perception and gradually develop it over time • Infants do not have conjugate gaze • Newborns can fixate momentarily on a human face or high-contrast object

    23. Newborn visual acuity • Approximated to be 20/400 at 1 month of age • Some sources say 20/200 • Improves to 20/30 by 1 year of age • Newborns focus best on a facial construct • 12-24 inches from face

    24. Pediatrician Screening Tools • Red reflex • Look for bilateral equal color and brightness • Should fill entire pupil • Use ophthalmoscope set to “O” diopters • Defect could indicate: cataract, refractive error, retinoblastoma • Any concern  refer to ophthalmology • Fundoscopic exam • Requires more cooperation; difficult prior to age 3 • Evaluate anterior structures with plus lenses (black or green numbers) • Posterior structures with minus lenses (red numbers) • Can help diagnose ROP (dilated disc vessels)

    25. Pediatrician Screening Tools • Visual acuity testing • Varies based on age • Variations of Snellen chart (with cartoons, etc) • Difference of two lines between the eyes or vision less than 20/40 in either eye  refer to ophthalmology • Corneal reflex testing • Using a penlight to distinguish strabismus from pseudostrabismus • Cover testing • To identify tropias and phorias

    26. Question #5 What is the diagnosis? • Left Amblyopia • Right Esotropia • Right Exotropia • Left Esotropia • Left Exotropia

    27. Strabismus vsPseudostrabismus • Asymmetry of the amount of white visible on either side of the eye can raise concern • Pseudostrabismus: appearance of misalignment when there is no strabismus present • Use corneal reflex (penlight) test to distinguish

    28. Tropias (manifest strabismus) • Misalignment of the eye that is always present • Large angle deviations are obvious • Small angle deviations can be detected with the Cover-Uncover test • UNCOVERED affected eye will move

    29. Phorias (latent strabismus) • Misalignment that occurs some of the time • When synchronization between the eyes is broken • Can be detected with the Cross-Cover test

    30. Hearing Loss in Children

    31. Hearing Loss in Children • Childhood hearing loss can be a debilitating condition that affects 1-6/1000 newborns • The first 36 months after birth represent a critical period in cognitive and linguistic development • Early identification and intervention are CRITICAL • Allows deaf and hearing-impaired children to approach their peers in language skills and academics • Those identified late often won’t reach the same level

    32. Question #6 You are on your Well Baby rotation and asked by some well-educated, new parents what a hearing screen on their baby will involve. The nursery is currently using auditory brainstem response tests (ABR) because the OAE machine is broken. You tell them that • It’s simple…you put the baby in a room and see if he looks in the direction of different sounds. • You have an ENT doctor come and check out the ear anatomy to make sure it looks good! • Sounds are delivered through earphones, and electroencephalogram probes (EEG) records the results. • There is a probe in the ear that sends sounds in and then detects sounds being created by the inner ear during transmission.

    33. Hearing Screening • The AAP recommends that congenital hearing loss be detected by 1 month, diagnosed definitively by 3 months, and receive intervention by 6 month of age. • Objective newborn hearing test by 1 month!!! • Hearing-impaired infants still reach early milestones on time (cooing, smiling, babbling, gesturing) • OAE or ABR in newborn nursery • 2-stage screen where ABR confirms abnormal OAE yields lowest # of false positives!

    34. Hearing Screening • Any infant that fails screen = full audiology evaluation by 3 months!! • OUR responsibility to make sure it happens. Minimally affected by outer and inner ear debris; screens for auditory neuropathy

    35. Hearing Screening • Hearing loss can also be acquired • PCPs should assess risk factors at each visit and audiology referral if warranted • Screening with conventional audiometry starting at age 4

    36. Question #7 The parents of a 4-year old girl bring her to see your for difficulty paying attention, frequent temper tantrums, problems at preschool. Her only PMH is frequent ear infections. Your in-office screen suggests hearing loss that you suspect is caused by… • Sensorineural hearing loss • Conductive hearing loss • She can hear just fine but probably has ADHD and couldn’t pay attention for the screen. • Central hearing loss

    37. The Ear • Conductive loss results from problems with mechanical transmission • External canal • Tympanic membrane • Middle ear ossicles • Sensorineural hearing loss • Failure to transduce vibrations in cochlea to neural impulse • Failure to transmit to vestibulocochlear nerve • Central hearing loss • Defects in brainstem or higher centers

    38. Conductive Hearing Loss • Congenital • Malformations of the external ear • Abnormal ossicular chain • Acquired • Otitis media with effusion is most common cause • Fluid in middle ear from altered Eustachian tube fx • Fluid restricts TM mobility • Cerumen impaction, otitisexterna, foreign body • Cholesteatoma OME: No antibiotics needed; observe for 3mo then referral for hearing test and possible ENT referral; sooner referral if developmental delay or hearing loss obvious

    39. Question #8 You are seeing a newborn with sensorineural hearing loss on her newborn hearing screen. Mom’s reports prenatal history as unremarkable. On exam, the baby has microcephaly and hepatomegaly with NO other obvious physical abnormalities. The MOST likely cause of the hearing loss is • Congenital cytomegalovirus infection • Alport syndrome • Middle ear effusion • Prenatal rubella exposure • Usher syndrome

    40. Safety

    41. Unintentional Injuries in Peds • Leading cause of morbidity and mortality among children in the U.S. • Understandable, predictable, and preventable • Risk factors • Young children and teenagers • Males twice the risk • Greater exposure to activities that result in injury • Patterns of risk-taking and rougher play • Substance abuse, especially alcohol • Provide age-appropriate home safety information at every visit

    42. Motor Vehicle Injuries • Leading cause of injury death and disability in all age groups • More than 1/3 of children fatally injured were with drunk drivers • Child safety seats reduce the risk of death by 50-70% • Teenagers are at higher risk • Newly licensed and distractible • Often speed and use alcohol* • *Talk to parents about a safe ride agreement if alcohol is involved • Major cause of head injury

    43. Question #9 A mom is talking to you about her son. He is always getting upset with her because she wants to hold his hand when they cross the street. At what age should a child be allowed to cross the street independently? • 15 years • 5 years • 8 years • 13 years • 10 years

    44. Other Injuries • Young children are at risk for pedestrian injuries • Not aware of traffic threats • Should not be allowed to cross the street independently until age 10! • Bicycles • All parents should be counseled about importance of bicycle helmets • Reduce pediatric head injury by 85% • 75% of all bicycle-related fatalities can be prevented with helmet • Snell or ANSI approved and proper fit

    45. Poisons • Annually, more than 1 million kids <6 experience toxic exposures, and 90% of these occur at home! • The proper storage of poisonous substances should be discussed at the 6mo visit • Most likely agents in pediatrics • Cosmetics and personal care products • Cleaning substances • Analgesics • Cough and cold preparations • Plants • Pharmaceutical products

    46. Poisons • Pediatricians should emphasize the importance of contacting the poison control center IMMEDIATELY upon suspicion of toxic ingestion by a child 1-800-222-1222 • Pediatric poisoning deaths have declined substantially over the past 30 years…childproof caps has helped with this!! • Syrup of ipecac is no longer recommended for the home management of pediatric poisonings