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279 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Neuro assessment move from what?? |
Highest to lowest level- cerebral, cranial nerves, motor, sensory, reflex’s |
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Behavior and mental status can be assessed how? |
Responsiveness, judgment, language, speech, voice, organization of thoughts, memory, mood and affect |
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What cranial nerve tests vision? |
CN II- blinking |
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What CN can test visual fields? |
III, IV, VI |
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What tests facial grimaces? |
V and VII |
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Rubbing fingers next to ears tests what CN? |
VIII |
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CN IX and X test what? |
Gag reflex |
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Motor exam tests what? |
Gait, coordination, balance, strength, symmetry, tone, muscles, reflex, posture |
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Sensory exam |
Pain sensation, stereognosis |
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How many reflexes are there? |
3 deep, superficial, primitive |
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What does a cranium exam need? |
Head circumference |
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Autonomic nervous system |
Alteration in BP, sweating and body temp |
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Finding of CP |
Non reversible disorders of movement and posture that originate in the infant brain from unknown cause |
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When do symptoms of CP first appear? |
First few years of life |
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Most common symptoms of CP? |
Disturbances in sensations, perception, communication, and behavior |
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What are the 3 types of CP |
Spastic (inability of muscles to relax causing muscle tightening), Athetoid: inability to control muscle movements, no smooth movements. Ataxic: problems with balance and coordination |
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What does diplegic CP mean? |
Effects more than just arms |
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Hemiplegic |
Effects one side of body |
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Tetraplegic/quadriplegic |
All four extremities effected, trunk and head |
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What is dystonia? |
Involuntary, slow, muscle contractions |
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Choreic |
Disorganized tone |
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What is an involuntary, rhythmic movement, of opposing muscles |
Tremor |
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What is ballimus?? |
Violent, Jerky movements that may effect one side of the body |
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What syndrome has symptoms of cafe au lait spots? |
CF |
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What kind of muscular skeletal issues can happen with CP? |
Scoliosis, dislocated hips and contractures |
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Neuro exam on a CP patient? |
Deep tendon reflexes increased Minimal muscle atrophy No fasciculation Tonic neck Moro after 6 months (delayed reflexes, asymmetric movements, abnormal head size) |
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Are motor milestone delayed with CP? |
Yes! |
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What diagnosis if there are feeding issues such as reversed swallow wave, uncoordinated suck and swallow, decreased tone of lips, sensitivity to food, delayed suck reflexes |
CP |
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What is the most common convulsive disorder in children under 5? |
Febrile seizures |
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Febrile seizures happen in how many children? |
2-5% |
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Most children require how many meds to recover from a febrile seizure? |
2 |
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How long do simple febrile seizures last? |
Less than 15 mins |
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Complex febrile seizures last how long? |
Longer than 15mins and can recur the same day and have postictal phase) |
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High risk febrile sezuires? |
Longer than 15mins |
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What is the range for febrile sezuires?? |
6-60months |
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What Seizures are excluded? |
Illness |
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Anticonvulsant therapy is not advised unless?? |
Abnormal neuro findings or developmental delays |
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Are motor deficits common in febrile seizures? |
No |
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T or F: the younger the age at onset of sezuires (<18 mth) the lower the temp to cause child to seize |
True |
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Characteristics of migraine |
2-72hrs Bilateral or unilateral Aldolecent onset Frontal or temporal (occuput unusual) Pulsing Aggravated by physical activity Vomiting and light sensitivity |
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Migraine have how many attacks a year? |
More than 5 |
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Symptoms of infants with migraines? |
Irridabilty, sleeplessness, pallor |
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Symptoms of abdominal migraine |
Midline pain, nausea, vomiting with no headache |
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What tests if suspected epilepsy |
CBC, bs, metabolic screening, urine and serum toxicology, LP (less than 6mth) |
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When is a CT scan indicated for sezuires? |
Marked cognitive, motor or neurological dysfunction |
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What test for nocturnal sezuires?? |
Polysomnography |
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Most TBI’s occur from what?? |
Secondary from acceleration or deceleration or rotational forces |
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What type of brain injury is more multifocal or diffuse |
Closed head injury |
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What type of head injury are more focal? |
Open head injury |
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What areas are normally torn with head injury? |
Axons to distant areas and fibers in corpus collision connecting two hemispheres |
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What are secondary effects of head trauma? |
Hypoxia, ischemia, hypotension, brain swelling, hemorrhage, contusion, and sezuires |
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Mild (TBI) concussion symptoms |
Headache, N/V, difficulty with balance, changes in vision, altered memory, forgetfulness, drowsy, sleepy, difficult falling asleep, altered emotions |
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GCS of mild |
13-15, no focal deficit, no or brief loc |
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Moderate GCS |
9-12 focal signs, variable Loc |
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Severe GCS |
8 or < focal signs, prolonged LOC |
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Physical exam is head injury |
Vts, neuro exam, LOC, mental status, motor function, sensory function, cranial nerve function, reflexes |
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Palmar grasp |
Flexes fingers and toes around finger |
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Trunk incurvation (galant) |
Flexed toward stimulus |
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Planter |
Curls toes down |
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Crossed extension |
Leg extended and adduct |
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Landau reflex |
Lifts head and legs ( like land in parachute) |
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Neck righting reflex |
Trunk rotates direction of head |
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Parachute reflex |
Extends arms, hands and fingers |
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What is the ANS control? |
Blood vessels, GI, cardiac, glands |
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The ANS is composed of what systems? |
Sympathetic and parasympathetic |
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What controls the sympathetic and parasympathetic? |
Hypothalamus |
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Hypothalamus works as a switchboard for what systems? |
Visual, auditory and old factory |
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Sympathetic nervous system begins where? |
In the |
Thoracolumbar area of the spinal cord |
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Fight or flight what system? |
Sympathetic |
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Parasympathetic begins where? |
Medulla or midbrain (relays on thalamus) |
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What results in slowed activity, decreased metabolic rate and conservation of energy |
Enervations |
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Sympathetic neurotransmitters are what? |
Epi and norepinephrine- producing acetylcholine |
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What r symptoms of ANS problems |
BP alteration Sweating Temp |
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Parasympathetic symptoms |
Pupil constriction Eatery saliva Lacrimal glad vasodilation Vasoconstriction, bronchial constriction, peristalsis of stomach, colon peristalsis, genitalia vasodilation and skin vessel dials toon |
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Sympathetic symptoms |
Pupil dial action Thick saliva, coronary vessel vasodilation, bronchial relax, stomach constrict, adrenaline sic rested, skin vessels constriction |
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Can pain be rated by a 2 yr old? |
No, they can state they have pain but not rate it |
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Can a 3 year old describe pain? |
Can say degree little, medium, bad pain |
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4 yrs they can rate pain 1-5 T or F? |
True |
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At what age can kids indicate location, pain and intensity? |
8yr |
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What is the best way to measure pain? |
Self report because it’s subjective |
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Asses pain how? |
Assessing pain how? |
Cultural beliefs Past pain experiences Situation (parents present) Kids may underreport or overstate for attention |
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Dose for tylenol |
10-15mg/kg every 4-6hrs (don’t exceed 5 doses in 24hour) |
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Chronic pain lasts how long? |
3 months |
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Examples of recurrent pain |
Headache, abdominal, chest or limb pain |
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What is somatic pain? |
Injury or inflammation of tissues (lacerations, burns, fractures, infection, inflammatory conditions) |
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Visceral pain is related to what? |
Injury or inflammation of visceral organs ( bowel, pancreas and appendicitis) |
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Persistent pain related to peripheral or central nervous system? |
Neuropathic (examples post hepatic, sciatica, plexus) |
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Neuropathic pain |
Persistent pain related to abnormal peripheral and central nervous system from injury, inflammation. |
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Neuropathic pain |
Persistent pain related to abnormal peripheral and central nervous system from injury, inflammation. |
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What is neuropathic pain described like? |
Burning, pin and needles or electric feeling |
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Neuropathic pain |
Persistent pain related to abnormal peripheral and central nervous system from injury, inflammation. |
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What is neuropathic pain described like? |
Burning, pin and needles or electric feeling |
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Psychogenic pain |
Persistent pain that is caused by a psychiatric disorder; conversion disorder or somatization pain disorder |
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Side effects of opioids |
Constipation NV Sedation Pruritus Urinary retention |
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T or F: codiene can be used in toddlers |
No only adolescents |
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Hydromorphone/methadone considerations |
Wean off slowly!! Don’t abruptly stop |
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Hydrocodone with Tylenol use with caution with what age? |
Infants |
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Morphine can be used in what age? |
6mth or older |
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How is chronic pain treated |
Coordinated, planned, interdisciplinary approach |
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Children and teens are great risk for what with chronic pain? |
Anxiety and depression |
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History taking for chronic pain |
Listen to discription of pain Talk with teen alone Discuss developmental factors, school issues, family, coping and depression |
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Questions about onset of pain |
Time of day, duration, frequency, sudden/gradually, and what helps, what makes it worse |
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Physical exam key points for pain: |
Posture/gait Hypersensitivity and tender points lab and imaging CBC, sed rate, UA if nessasary |
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Physical exam key points for pain: |
Posture/gait Hypersensitivity and tender points lab and imaging CBC, sed rate, UA if nessasary |
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What questions about sleep? |
Hygiene? Psychological strategies Meds |
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Cognitive therapy |
Biofeedback, hypnotherapy, relaxation techniques |
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Cognitive therapy |
Biofeedback, hypnotherapy, relaxation techniques |
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School assessment |
Talk with pt and parents, school workers, |
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Cognitive therapy |
Biofeedback, hypnotherapy, relaxation techniques |
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School assessment |
Talk with pt and parents, school workers, |
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Prevention of bare risk meningitis |
If exposed must be carefully monitored Those with close contact with index case of 7 days before symptoms are high risk and should start prophylaxis: riphampin, cipro |
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Cognitive therapy |
Biofeedback, hypnotherapy, relaxation techniques |
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School assessment |
Talk with pt and parents, school workers, |
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Prevention of bare risk meningitis |
If exposed must be carefully monitored Those with close contact with index case of 7 days before symptoms are high risk and should start prophylaxis: riphampin, cipro |
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Meningitis vaccines |
MCV4: menacetra, menevo HibMenCY- menhibrux MPSV: Menomune MenB-bexsero,trumenba |
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Cognitive therapy |
Biofeedback, hypnotherapy, relaxation techniques |
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School assessment |
Talk with pt and parents, school workers, |
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Prevention of bare risk meningitis |
If exposed must be carefully monitored Those with close contact with index case of 7 days before symptoms are high risk and should start prophylaxis: riphampin, cipro |
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Meningitis vaccines |
MCV4: menacetra, menevo HibMenCY- menhibrux MPSV: Menomune MenB-bexsero,trumenba |
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Chicken pox spread by; |
Direct contact, airborne, droplets |
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Chicken pox peaks at what age? |
10-14yrs |
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Chicken pox peaks at what age? |
10-14yrs |
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Chicken pox incubation period is how many days? |
10-21 days |
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Chicken pox most contagious when? |
1-2 days before rash |
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Chicken pox most contagious when? |
1-2 days before rash |
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Prodromal Chicken pox symptoms |
Abdominal pain, low grade fever, URI symptoms, headache, anorexia, |
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Chicken pox rash looks like: |
Puritic lessons that turn teardrop appearance that cloud over and umbilcate in 24-48hrs |
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Complications of chicken pox |
Strep, staph, ITP, pneumonia, rye syndrome, encephalitis, |
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Complications of chicken pox |
Strep, staph, ITP, pneumonia, rye syndrome, encephalitis, |
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What is 5th disease caused by? |
Parvo virus (called 5th disease because it’s the 5th rash discribed in history) |
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How is 5th disease spread? |
Vertical transmission- mother to fetus, respiratory tract, blood |
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How is 5th disease spread? |
Vertical transmission- mother to fetus, respiratory tract, blood |
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5th disease most common in what ages? |
5-15 |
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Incubation period for 5th disease |
4-21 days |
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Incubation period for 5th disease |
4-21 days |
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5th disease rash occurs how long after exposure |
2-3 weeks |
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Prodromal symptoms for 5th disease |
Mild fever, myalgia, headache, malaise and URI |
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How long before the rash appears after prodromal phase of 5th disease? |
Rash 7-10days after. 3 phases 1. Slapped cheeks 2. Lacy macular rash on trunk 3. Rash moves to thighs and butt 4. No rash on soles and palms Rash may last 1 month Older kids might have arthralgia and mild itching |
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Incubation period for rubeola |
8-12 days (as long as 21) |
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Incubation period for rubeola |
8-12 days (as long as 21) |
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Any symptoms during incubation period for rubeola? |
No |
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Incubation period for rubeola |
8-12 days (as long as 21) |
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Any symptoms during incubation period for rubeola? |
No |
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Rubeola prodromal signs? |
4-5 days- uri, low grade temp, cough, Coryza, conjunctivitis (3 C’s), |
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Incubation period for rubeola |
8-12 days (as long as 21) |
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Any symptoms during incubation period for rubeola? |
No |
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Rubeola prodromal signs? |
4-5 days- uri, low grade temp, cough, Coryza, conjunctivitis (3 C’s), |
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What diagnosis has koplik signs and where is it located? |
Oral mucosa opposite of the lower molars- they are small, irregular, bluish white granules on erthematous background. Shows in last 12-15 hours and ate pathognomonic of measles |
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Incubation period for rubeola |
8-12 days (as long as 21) |
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Any symptoms during incubation period for rubeola? |
No |
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Rubeola prodromal signs? |
4-5 days- uri, low grade temp, cough, Coryza, conjunctivitis (3 C’s), |
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What diagnosis has koplik signs and where is it located? |
Oral mucosa opposite of the lower molars- they are small, irregular, bluish white granules on erthematous background. Shows in last 12-15 hours and ate pathognomonic of measles |
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Rubeola rash |
Unmodified measles rash appears on 3rd or 4th day of illness. As rash appears temp increases. |
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Incubation period for rubeola |
8-12 days (as long as 21) |
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Any symptoms during incubation period for rubeola? |
No |
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Rubeola prodromal signs? |
4-5 days- uri, low grade temp, cough, Coryza, conjunctivitis (3 C’s), |
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What diagnosis has koplik signs and where is it located? |
Oral mucosa opposite of the lower molars- they are small, irregular, bluish white granules on erthematous background. Shows in last 12-15 hours and ate pathognomonic of measles |
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Rubeola rash |
Unmodified measles rash appears on 3rd or 4th day of illness. As rash appears temp increases. |
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Where does the rash first appear for rubeola? |
Behind the ears and forehead |
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Incubation period for rubeola |
8-12 days (as long as 21) |
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Any symptoms during incubation period for rubeola? |
No |
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Rubeola prodromal signs? |
4-5 days- uri, low grade temp, cough, Coryza, conjunctivitis (3 C’s), |
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What diagnosis has koplik signs and where is it located? |
Oral mucosa opposite of the lower molars- they are small, irregular, bluish white granules on erthematous background. Shows in last 12-15 hours and ate pathognomonic of measles |
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Rubeola rash |
Unmodified measles rash appears on 3rd or 4th day of illness. As rash appears temp increases. |
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Where does the rash first appear for rubeola? |
Behind the ears and forehead |
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How does the rubeola rash move?? |
Behind ears, to face and down the body. As legs are worse upper body is better |
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Incubation period for rubeola |
8-12 days (as long as 21) |
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Any symptoms during incubation period for rubeola? |
No |
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Rubeola prodromal signs? |
4-5 days- uri, low grade temp, cough, Coryza, conjunctivitis (3 C’s), |
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What diagnosis has koplik signs and where is it located? |
Oral mucosa opposite of the lower molars- they are small, irregular, bluish white granules on erthematous background. Shows in last 12-15 hours and ate pathognomonic of measles |
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Rubeola rash |
Unmodified measles rash appears on 3rd or 4th day of illness. As rash appears temp increases. |
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Where does the rash first appear for rubeola? |
Behind the ears and forehead |
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How does the rubeola rash move?? |
Behind ears, to face and down the body. As legs are worse upper body is better |
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When are respiratory symptoms worse with Rubeola |
On day 3 of the rash |
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Incubation period for rubeola |
8-12 days (as long as 21) |
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Any symptoms during incubation period for rubeola? |
No |
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Rubeola prodromal signs? |
4-5 days- uri, low grade temp, cough, Coryza, conjunctivitis (3 C’s), |
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What diagnosis has koplik signs and where is it located? |
Oral mucosa opposite of the lower molars- they are small, irregular, bluish white granules on erthematous background. Shows in last 12-15 hours and ate pathognomonic of measles |
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Rubeola rash |
Unmodified measles rash appears on 3rd or 4th day of illness. As rash appears temp increases. |
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Where does the rash first appear for rubeola? |
Behind the ears and forehead |
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How does the rubeola rash move?? |
Behind ears, to face and down the body. As legs are worse upper body is better |
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When are respiratory symptoms worse with Rubeola |
On day 3 of the rash |
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Treatment of rubeola? |
Supportive treatment. Give measles vaccine within 72hr of exposure to those eligible |
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What is Lyme disease caused by? |
Borrelia |
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What is Lyme disease caused by? |
Borrelia |
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Stage 1 of Tick disease |
1-2 weeks after bite. Rash might appear at site |
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What is Lyme disease caused by? |
Borrelia |
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Stage 1 of Tick disease |
1-2 weeks after bite. Rash might appear at site |
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What symptoms can present with Lyme? |
Flu like fever, malaise, headache, arthralgia, myalgia and stiff neck. |
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What is Lyme disease caused by? |
Borrelia |
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Stage 1 of Tick disease |
1-2 weeks after bite. Rash might appear at site |
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What symptoms can present with Lyme? |
Flu like fever, malaise, headache, arthralgia, myalgia and stiff neck. |
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Stage 2 Lyme disease |
Hematological or lymphatic channel and secondary lesions may appear. Headache, tiredness, neck pain, mood swings, irritability, motor and sensory impairment |
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What illness most effects the thoracic dermatomes, cranial neuropathies, cardiac or generalized illness?? |
Lyme |
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What illness most effects the thoracic dermatomes, cranial neuropathies, cardiac or generalized illness?? |
Lyme |
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How long can stage 2 of Lyme disease last? |
Weeks to 2 years |
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Stage 3 Lyme disease |
Arthritis (pauciarticular/ monoarticular) that occurs weeks to months after tick bite. Knew most commonly affected. Joints hot and swollen |
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Stage 3 Lyme disease |
Arthritis (pauciarticular/ monoarticular) that occurs weeks to months after tick bite. Knew most commonly affected. Joints hot and swollen |
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What is Lyme disease treated with?? |
Amoxicillin 50mg/kg TID for 14 days or doxycycline 200mg daily or 4mg/kg BID for 14days |
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Symptoms of fever of unknown origin |
No etiology after 1 week of evaluation Mostly lupus (arthritis), EBV, cat scratch disease, uncomplicated UTI, osteomyelitis |
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Symptoms of fever of unknown origin |
No etiology after 1 week of evaluation Mostly lupus (arthritis), EBV, cat scratch disease, uncomplicated UTI, osteomyelitis |
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Assessment of fever of unknown origin |
Analysis of symptoms Past medical hx/ infections Medications Family hx Pets, rodents reptiles Pica |
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Symptoms of fever of unknown origin |
No etiology after 1 week of evaluation Mostly lupus (arthritis), EBV, cat scratch disease, uncomplicated UTI, osteomyelitis |
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Second varicella dose given how long after first? |
3 months or 4-6yrs after initial dose |
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Short period of what after varicella vaccine? |
Fever 5-12 days after, mild maculopapular rash, varicelliform eruption |
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Symptoms of cat scratch fever |
Enlarged node around scratch site. Can last 1-2 months or up to a year |
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Urine collection |
First urine of the day, clean catch- most concentrated and likely to show elements and bacteria. Collect before activities. Put in fridge, need to test within 1 hour |
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What is a valuable diagnostic test for UTI and also failure to thrive and malaise?? |
Dipstick urinalysis |
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What does the AAP Recommend for patients high risk for chronic kidney disease? |
Dipstick urinalysis |
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High or low incidence of CKD in kids? |
Low |
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Does early detection of CKD alter outcome? |
No |
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What result could hypoplastic kidneys have? |
Proteinuria |
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Renal Diseases that might improve with treatment include?? |
Focal glomerulosceltorosis, IgA, nephrology |
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Assessment of fever of unknown origin |
Analysis of symptoms Past medical hx/ infections Medications Family hx Pets, rodents reptiles Pica |
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Worries of not diagnosising hearing loss? |
Delay in development of language and speech |
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Test children by what age for hearing loss?? |
1 month |
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Identify hearing loss by what age? |
3 months |
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Treat hearing loss children by what age? |
6 months |
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Primary goal for infant hearing? |
Identify congenital or in uterine hearing loss to ensure speech development |
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How often should an infant receive hearing services? |
Every 6 months for the first 3 years |
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All infants with heating loss should receive services and developmental survaliance beginning at what age? |
2 months |
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Objective physiological measures for hearing loss include: |
Otoacoustic emissions Auditory brain stem response (ABR) |
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NICU babies admitted for over 5 days should receive what? |
ABR testing for increased risk of neural hearing loss and auditory neuropathy |
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Any baby with readmit to the hospital should have what before discharge? |
Repeat hearing |
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What is the most common cause of purine to skin and soft tissue infections |
MRSA |
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Physiologic measures used to screen heating should be completed by what age? |
1 month |
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Infants who do not pass initial and subsequent screening should have follow up screening by what age? |
3 months |
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Intervention for hearing loss should be _____ centered |
Family |
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What is the hirschburg test used for? |
Quantify strabismus |
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When can an infant fixate on an object? |
3 months |
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Testing for strabismus |
Use penlight 12in from eyes, asymmetry of light reflection on corneas, assessing ocular motility while following bright colored objects |
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What should be documented on UA? |
Color, clarity, odor,specific gravity, and osmolality |
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What number indicates intact renal concentrated ability? |
1.023 |
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What urine concentration is considered concentrated? |
1.020 |
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Urine ph normal values |
4.6-8 and reflects body’s ability to maintain acid base balance |
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Labs for fever of unknown origin |
CBC, ESR, CRP, blood culture, UA, IGRA, man touch skin test, CXR, sinus, mastoid, GI, liver panel, ANA, bone marrow, echo, CT, MRI, US or biopsy |
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What does a dipstick positive for blood indicate? |
Presence of hemoglobin |
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What can cause spotty changes on a dipstick? |
Intact erythrocytes |
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What causes uniform change on dipstick? |
Hemoglobin or myoglobin |
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What indicates WBC in urine? |
Positive leukocytes |
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What indicates bacteria in urine? |
Nitrites (urine should be in bladder for at least 4 hours) |
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Urine under microscope to look for what? |
RBC, wbc, bacteria, casts, crystals |
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2-20 per HPF in spun urine normal or abnormal? |
Abnormal |
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2-5 HPF in unspun indicates what? |
Abnormal |
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If urine cells are dysmorphic the origin of blood is most likely what? |
Kidneys |
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What are exsamples if casts in urine?? |
RBC, hyaline, waxy, epithelial, leukocytes |
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What has altered PCN binding protein with decreased sensitivity to beta lactum antibiotics?? |
MRSA |
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Leukocytes greater than 100,000 indicate what? |
Bacteria |
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Are amorphous crystal normal or abnormal in the urine? |
Normal |
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What is bilirubin bound to? |
Albumin |
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Conjugated Bili is also know as what? |
Direct Bili |
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Where does direct bilirubin travel? |
Liver to small intestine |
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What tests might indicate high bilirubin levels? |
Hepatitis, gallstones, blockages |
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What measures adrenal function? |
Cortisol |
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A level of less than 5 for cortisol indicates what? |
Adrenal insufficiency |
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Cortisol level of over 14 indicates what? |
No insufficiency |
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What does HBV protect against? |
Hep B |
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Treat skin lesions with topical bacitry or mupirocin ointment to area TID for 7-10days for what diagnosis?? |
MRSA skin abscess, boil, spider bite Aka: cephloxin (augmentin) |
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What vaccine causes bacterial illnesses including meningitis, epiglottis, pneumonia, septic arthritis and cellulitis (hib was the most common cause of bacterial disease in children) |
Hib |
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What was the leading cause of invasive bacterial disease in children? |
Strep pneumonia |
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What is the leading cause of febrile bacteremia, bacterial sepsis, meningitis and pneumonia |
Pneumococcal |
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What is most common cause of otitis media and sinusitis |
Pneumococcus |
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How is polio spread? |
Fecal/oral route |
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What does the IPV vaccine prevent? |
Polio |
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What irradiated disease causes flaccid muscles and paralysis |
Polio |
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How old to get flu shot? |
6 months |
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Should high risk kids get flu shot? |
Yes |
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What illness causes 36,000 deaths each year? |
Flu |
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What should be used with widespread impetigo?? |
Antimicrobial- topical antibiotics. Mupirocin |
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What illness use to cause serious pregnancy complications before irradiated? |
Rubella |
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What irradiated disease is coming back? |
Measles |
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Hep A Is at a all time low or high? |
Low |
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What is the most common STD? |
HPV |
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What STD can cause cervical cancer? |
HPV |
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What vaccine is used to reduce mortality rates for meningitis?? |
Meningococcal |
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Deep seeded skin infections should be treated with: |
Warm compress to localize puss, oral antibiotics, return for I and D in 24-36hra |
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How effective is the varicella vaccine?? |
100% |
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How many doses is varicella vaccine? |
2 doses in healthy kids aged 12mth or older and older children or adults without immunity |
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Adrenal insufficiency |
<5 |
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