Aquifer Pediatric Cases
Growth Curve Terms: Weight age
Age at which the pts weight would plot at the 50th %ile
Growth Curve Terms: Height age
Age at which the pts height would plot at the 50th percentile
Core sxs of ADHD
Inattention, hyperactivity, Impulsivity
Important causes of school failure
Sensory impairment (Hearing and vision), sleep disorder, mood disorder, learning
disability, conduct disorder
Objective vision screening should begin at which age?
3 y.o.
Objective hearing screening should be performed in which age groups?
All newborns (newborn screening) and > 4 y.o.
Difference in ADHD and Sleep Disorder
ADHD children often have poor sleep hygiene but don't seem overtired in daytime
True/False: Mood disorders may mimic OR accompany ADHD
True
Childhood depression is marked by a high rate of conversion to which
psychological disorder?
Bipolar Disorder
What percentage of school age children and adolescents does depression affect?
1-2% of elementary school age children and 5% of adolescents
True/False: Children with ADHD have a higher rate of mood disorders than
control populations?
True
True/False: Most states require documentation of a discrepancy between IQ (in
normal range) and academic achievement for the Dx of a learning disability
True
True/False: Comorbidity between LD and ADHD is common; many experts feel
one Dx should not be made w/out evaluation for the other
True
Red flags for learning disabilities
Hx maternal illness/substance abuse during pregnancy, complications of delivery, Hx of
meningitis/other serious illness, Hx serious head trauma, Parental hx of learning
disabilities
What % of kids with ADHD respond to stimulant medications?
80%
Adverse effects of ADHD Medications include:
Appetite suppression, insomnia, decrease in growth velocity
When is insomnia on ADHD meds usually the worst?
First days of medication use
Decreased growth velocity in ADHD medication use
usually 1-2 cm and effects diminish by the 3rd year of tx
Risk of developing substance abuse in tx for ADHD
,Some studies suggest a positive response to stimulant medication may reduce a pts
likelihood of substance abuse & other high-risk behavior later on in life
The probability of childhood obesity persisting into adulthood increases from
20% to what %age in adolescence?
80%
What %age of 6-19 y.o. are at or >95th percentile for growth charts?
15%
Genetic syndromes associated w/ obesity
Prader-Willi, Bardet-Biedl, Cohen
Prenatal/neonatal risk factors for obesity include:
High birth weight and maternal DM
Complications of obesity:
Sleep apnea, dyslipidemia, HTN, slipped capital femoral epiphysis (SCFE), type II DM,
steatohepatitis
Slipped Capital Femoral Epiphysis (SCFE)
Displacement of femoral head from femoral neck through the physeal plate.
-Occurs at onset of puberty in obese pts w/ delayed sexual maturation
-Typical sxs = antalgic gait due to pain referred from hip, thigh and/or knee w/ limited
ROM on hip exam
-Can be dx w/ plain x-rays of pelvis - shows widening of physis
Steatohepatitis in childhood obesity
Characterized by mild increase in liver transaminases, a hyperechoic liver on U/S, and
evidence of fatty infiltration and fibrosis on biopsy
Type II DM in kids
-Between 2002-2005, 19% of all DM cases in kids were type II
-New type II DM cases in adolescence has grown to >40%
-Rare cases in kids as young as 5 y.o.
Risk criteria to screen for type II DM at 10 y.o. and every 3 years after
Overweight (>85% BMI, >85% weight:height, >120% ideal for height), Family hx in 1st
or 2nd degree relative, race/ethnicity (native american, AA, hispanic, asian), signs
insulin resistance (acanthosis nigricans, HTN, PCOS, dyslipidemia), maternal hx
gestational DM
Classification of HTN in children:
Motivational Interviewing for change:
Get pt/caregiver to state their reason for wanting to change, set attainable goals, use
external motivators, be cautious of preaching to the choir
How much can holding adolescents arms down at their side raise systolic BP?
20 mmHg - 30 mmHg
Screening for Secondary HTN in children
-Umbilical arterial/Venous access (placement of umbilical arterial or venous line during
prenatal period may predispose to renal vascular disease)
-UTI = one of leading causes of HTN and renal insufficiency later in life (due to renal
scarring)
-Pheochromocytoma
-Coarctation of aorta
-Family Hx of renal disease
,Children with 90-95th %ile BP (PreHTN) mgmt
Lifestyle changes, BP f/u in 6 months, only work up potential secondary causes if PE or
Hx gives you a reason to
Children w/ primary HTN (>95 %ile) mgmt
-Meds usually for Stage 2 (>99 %ile) OR kids w/ end organ damage OR kids w/
secondary causes of HTN
-Lifestyle modifications
Criteria for ADHD Dx:
6 or more sxs in 2 or more settings for at least 6 months
Several of these sxs must be present before the age of 12
Sxs fall w/in 3 categories of inattention, hyperactivity and impulsivity
Coarctation of the Aorta
Sxs include chest pain, cold lower extremities, dizziness, syncope, exercise intolerance,
failure to thrive, poor growth, headache, and dyspnea
-May also be associated w/ other congenital heart defects (bicuspid aortic valve in 50%
pts) and chromosomal abnormalities (Turner syndrome)
ADHD is usually dx before age:
7 y.o.
Rett Syndrome
X-linked pervasive developmental disorder seen only in females
-regression of language and development
-intellectual disability
-ataxia
-hand-writing
-Dx around age 1-4 y.o.
Sign of hypothyroidism in adolescence
Cold skin, slowness, fatigue, preferring hot weather to cold, doing poorly at school,
coarse hair
Infectious Mononucleosis
Infection of lymphocytes by EBV
-Signs/sxs: extreme fatigue, pharyngitis, lymphadenopathy
In regards to depression/suicide risk - all adolescents should be asked:
Hx of self injury? Suicidal ideation? Suicide attempts?
Difference between depression in adolescents and adults
Adolescents don't usually experience early morning waking;difficulty falling asleep at
night
Dangerous electrolyte abnormalities in anorexia nervosa
Deficiencies of calcium and magnesium may lead to neurological changes, increased
reflex tone and compromised cardiac fx
Age of puberty in females:
8-13 years of age
Age of puberty in males:
10-15 years of age
Male Tanner Stages:
-Growth of testicles (12 yrs)
-Pubic hair appears (12 yrs)
, -Growth of penis, scrotum (13-14 yrs)
-First ejaculation (13-14 yrs)
-Growth spurt (14 yrs)
-Attainment of adult height (17 yrs)
Female Tanner Stages:
-Breast buds appear (10-11 yrs)
-Pubic hair appears (10-11 yrs)
-growth spurt (12 yrs)
-periods/menarche (12-13 yrs)
-attainment of adult height (15 yrs)
Constitutional Short Stature:
"Late bloomers," individual with delayed puberty, but will attain a normal adult height -
just later than his/her peers
von Willebrand's Disease (vWD) Epidemiology and Inheritance Pattern:
-most common hereditary bleeding disorder
-occurs in 1% population
-AD inheritance w/ variable penetrance
-Less common type 3 is AR
-Type 1 is most common and mildest (non life-threatening bleeding)
vWD Symptoms:
-Ecchymoses (small hematomas in areas of trauma)
-Epistaxis
-Menorrhagia
-Bleeding post-tonsillectomy/dental extractions
-Gingival bleeds
**In absence of major trauma: bruising in non-exposed areas (buttocks, back, trunk)
need to be thought of as abnormal
Dx of vWD
-aPTT may be normal!
-To confirm, check the vW factor antigen and/or platelet fxn analysis and factor VIII
levels
"HEEADSSS"
After Family Hx and before ROS
H=Home
E=Education and employment
E=Eating disorder screening
A=Activities
D=Drugs
S=Sexuality
S=Suicide risk and depression
S=Safety (fights, care, weapons)
What age should you begin to separate adolescents from parents/caregivers
during part of their history?
Early: 9-10 years old
What %age of cases of anorexia nervosa occur in males?
~25%
Growth Curve Terms: Weight age
Age at which the pts weight would plot at the 50th %ile
Growth Curve Terms: Height age
Age at which the pts height would plot at the 50th percentile
Core sxs of ADHD
Inattention, hyperactivity, Impulsivity
Important causes of school failure
Sensory impairment (Hearing and vision), sleep disorder, mood disorder, learning
disability, conduct disorder
Objective vision screening should begin at which age?
3 y.o.
Objective hearing screening should be performed in which age groups?
All newborns (newborn screening) and > 4 y.o.
Difference in ADHD and Sleep Disorder
ADHD children often have poor sleep hygiene but don't seem overtired in daytime
True/False: Mood disorders may mimic OR accompany ADHD
True
Childhood depression is marked by a high rate of conversion to which
psychological disorder?
Bipolar Disorder
What percentage of school age children and adolescents does depression affect?
1-2% of elementary school age children and 5% of adolescents
True/False: Children with ADHD have a higher rate of mood disorders than
control populations?
True
True/False: Most states require documentation of a discrepancy between IQ (in
normal range) and academic achievement for the Dx of a learning disability
True
True/False: Comorbidity between LD and ADHD is common; many experts feel
one Dx should not be made w/out evaluation for the other
True
Red flags for learning disabilities
Hx maternal illness/substance abuse during pregnancy, complications of delivery, Hx of
meningitis/other serious illness, Hx serious head trauma, Parental hx of learning
disabilities
What % of kids with ADHD respond to stimulant medications?
80%
Adverse effects of ADHD Medications include:
Appetite suppression, insomnia, decrease in growth velocity
When is insomnia on ADHD meds usually the worst?
First days of medication use
Decreased growth velocity in ADHD medication use
usually 1-2 cm and effects diminish by the 3rd year of tx
Risk of developing substance abuse in tx for ADHD
,Some studies suggest a positive response to stimulant medication may reduce a pts
likelihood of substance abuse & other high-risk behavior later on in life
The probability of childhood obesity persisting into adulthood increases from
20% to what %age in adolescence?
80%
What %age of 6-19 y.o. are at or >95th percentile for growth charts?
15%
Genetic syndromes associated w/ obesity
Prader-Willi, Bardet-Biedl, Cohen
Prenatal/neonatal risk factors for obesity include:
High birth weight and maternal DM
Complications of obesity:
Sleep apnea, dyslipidemia, HTN, slipped capital femoral epiphysis (SCFE), type II DM,
steatohepatitis
Slipped Capital Femoral Epiphysis (SCFE)
Displacement of femoral head from femoral neck through the physeal plate.
-Occurs at onset of puberty in obese pts w/ delayed sexual maturation
-Typical sxs = antalgic gait due to pain referred from hip, thigh and/or knee w/ limited
ROM on hip exam
-Can be dx w/ plain x-rays of pelvis - shows widening of physis
Steatohepatitis in childhood obesity
Characterized by mild increase in liver transaminases, a hyperechoic liver on U/S, and
evidence of fatty infiltration and fibrosis on biopsy
Type II DM in kids
-Between 2002-2005, 19% of all DM cases in kids were type II
-New type II DM cases in adolescence has grown to >40%
-Rare cases in kids as young as 5 y.o.
Risk criteria to screen for type II DM at 10 y.o. and every 3 years after
Overweight (>85% BMI, >85% weight:height, >120% ideal for height), Family hx in 1st
or 2nd degree relative, race/ethnicity (native american, AA, hispanic, asian), signs
insulin resistance (acanthosis nigricans, HTN, PCOS, dyslipidemia), maternal hx
gestational DM
Classification of HTN in children:
Motivational Interviewing for change:
Get pt/caregiver to state their reason for wanting to change, set attainable goals, use
external motivators, be cautious of preaching to the choir
How much can holding adolescents arms down at their side raise systolic BP?
20 mmHg - 30 mmHg
Screening for Secondary HTN in children
-Umbilical arterial/Venous access (placement of umbilical arterial or venous line during
prenatal period may predispose to renal vascular disease)
-UTI = one of leading causes of HTN and renal insufficiency later in life (due to renal
scarring)
-Pheochromocytoma
-Coarctation of aorta
-Family Hx of renal disease
,Children with 90-95th %ile BP (PreHTN) mgmt
Lifestyle changes, BP f/u in 6 months, only work up potential secondary causes if PE or
Hx gives you a reason to
Children w/ primary HTN (>95 %ile) mgmt
-Meds usually for Stage 2 (>99 %ile) OR kids w/ end organ damage OR kids w/
secondary causes of HTN
-Lifestyle modifications
Criteria for ADHD Dx:
6 or more sxs in 2 or more settings for at least 6 months
Several of these sxs must be present before the age of 12
Sxs fall w/in 3 categories of inattention, hyperactivity and impulsivity
Coarctation of the Aorta
Sxs include chest pain, cold lower extremities, dizziness, syncope, exercise intolerance,
failure to thrive, poor growth, headache, and dyspnea
-May also be associated w/ other congenital heart defects (bicuspid aortic valve in 50%
pts) and chromosomal abnormalities (Turner syndrome)
ADHD is usually dx before age:
7 y.o.
Rett Syndrome
X-linked pervasive developmental disorder seen only in females
-regression of language and development
-intellectual disability
-ataxia
-hand-writing
-Dx around age 1-4 y.o.
Sign of hypothyroidism in adolescence
Cold skin, slowness, fatigue, preferring hot weather to cold, doing poorly at school,
coarse hair
Infectious Mononucleosis
Infection of lymphocytes by EBV
-Signs/sxs: extreme fatigue, pharyngitis, lymphadenopathy
In regards to depression/suicide risk - all adolescents should be asked:
Hx of self injury? Suicidal ideation? Suicide attempts?
Difference between depression in adolescents and adults
Adolescents don't usually experience early morning waking;difficulty falling asleep at
night
Dangerous electrolyte abnormalities in anorexia nervosa
Deficiencies of calcium and magnesium may lead to neurological changes, increased
reflex tone and compromised cardiac fx
Age of puberty in females:
8-13 years of age
Age of puberty in males:
10-15 years of age
Male Tanner Stages:
-Growth of testicles (12 yrs)
-Pubic hair appears (12 yrs)
, -Growth of penis, scrotum (13-14 yrs)
-First ejaculation (13-14 yrs)
-Growth spurt (14 yrs)
-Attainment of adult height (17 yrs)
Female Tanner Stages:
-Breast buds appear (10-11 yrs)
-Pubic hair appears (10-11 yrs)
-growth spurt (12 yrs)
-periods/menarche (12-13 yrs)
-attainment of adult height (15 yrs)
Constitutional Short Stature:
"Late bloomers," individual with delayed puberty, but will attain a normal adult height -
just later than his/her peers
von Willebrand's Disease (vWD) Epidemiology and Inheritance Pattern:
-most common hereditary bleeding disorder
-occurs in 1% population
-AD inheritance w/ variable penetrance
-Less common type 3 is AR
-Type 1 is most common and mildest (non life-threatening bleeding)
vWD Symptoms:
-Ecchymoses (small hematomas in areas of trauma)
-Epistaxis
-Menorrhagia
-Bleeding post-tonsillectomy/dental extractions
-Gingival bleeds
**In absence of major trauma: bruising in non-exposed areas (buttocks, back, trunk)
need to be thought of as abnormal
Dx of vWD
-aPTT may be normal!
-To confirm, check the vW factor antigen and/or platelet fxn analysis and factor VIII
levels
"HEEADSSS"
After Family Hx and before ROS
H=Home
E=Education and employment
E=Eating disorder screening
A=Activities
D=Drugs
S=Sexuality
S=Suicide risk and depression
S=Safety (fights, care, weapons)
What age should you begin to separate adolescents from parents/caregivers
during part of their history?
Early: 9-10 years old
What %age of cases of anorexia nervosa occur in males?
~25%
