Pediatric Np Boards Review

Front 1

Morphogenesis:

Back 1

An early stage of development. It is genetically determined and environmentally dependent.

Front 2

Malformations:

Back 2

Abnormalities or incomplete development in tissue development.

Front 3

Mendelian inheritance patterns:

Back 3

How genetic characteristics of genes are expressed in offspring.

Front 4

Autosomal dominant:

Back 4

A single mutant gene produces an abnormal characteristic. A person who is heterozygous for a defective gene has a 50% risk of passing it on to each offspring.

Front 5

Autosomal recessive:

Back 5

A mutant gene produces an abnormal characteristic only when two are present. A person who is homozygous for a defect has a 25% risk of passing the gene on to each offspring and a 50% risk of an offspring being a carrier for the mutant gene and being phenotypically affected.

Front 6

X-linked inheritance:

Back 6

Mutant gene is located on the X chromosome.
X-linked dominant: Expressed in both males and females; affected males have normal sons, but all daughters are affected.
X-linked recessive: 50% risk for males to be affected and 50% risk of female offspring being carriers; no male-to-male transmission.

Front 7

Conditions that should alert to a possible genetic condition include:

Back 7

Intrauterine growth retardation or failure to thrive
Abnormal muscle tone (hypertonia or hypotonia)
Abnormal cry
Congenital or early-onset sensory deficits
Developmental delay
Seizures

Front 8

Achondroplastic dwarfism

Back 8

An AD disorder caused by a defect in cartilage-derived bone.
Most common skeletal dysplasia in humans
Occurs in approximately 1 in 12,000 births
Bony abnormalities lead to short stature, macrocephaly, flat midface with a prominent forehead, and rhizomelic shortening of the limbs

Front 9

Huntington's disease

Back 9

Degenerative disorder that can occasionally occur in childhood
Characterized by rigidity and Parkinsonian features
Speech abnormalities and behavioral disorders often precede dementia in over half of affected children
Also characterized by decreased facial movements, oculomotor apraxia, and impaired up-gaze
Corticospinal involvement causes hyperreflexia and Babinski responses

Front 10

Neurofibromatosis

Back 10

Most commonly occurring AD disorder
Present in 1 in 3500 individuals
Many individuals only present with mild features
Mild features include café au lait spots, axially or inguinal freckling, Lisch nodules, and neurofibromas
More severe symptoms include brain tumors, hypertension, skeletal involvement and craniofacial disfigurement

Front 11

retinoblastomas

Back 11

Sarcoma associated with mental retardation, skeletal malformations
Ophthalmologic signs include white pupils, leukokoria, squint, strabismus, and orbital inflammation

Front 12

Tuberous sclerosis

Back 12

Characterized by harmartomas mostly in the brain, eye, skin, kidneys, and heart
Occurs in approximately 1 in 10,000 births
Classic clinical features are facial angiofibromas, mental retardation, and severe epilepsy

Front 13

Myotonic dystrophy

Back 13

Muscle relaxation disorder
May present at birth (severe generalized hypotonia and weakness) or adolescence (slowly progressive facial and distal extremity weakness and myotonia).

Front 14

Tay-Sachs disease

Back 14

Occurs commonly in Jewish children of eastern European background
Develops around 6 months of age with listlessness, irritability, hyperacusis, intellectual retardation, and a retinal cherry spot
Blindness, convulsions, spasticity, and opisthotonos develop within months

Front 15

spinal muscular atrophy

Back 15

Most frequent autosomal recessive disease
Begins between 6 months and 6 years of age
Clinical manifestations include progressive proximal weakness, decreased spontaneous movement, and floppiness

Front 16

x-linked

Back 16

Affected males have the abnormal X-linked recessive gene; they are affected because they have no corresponding normal gene on their Y chromosome; they are hemizygous (have only one copy) for all genes on the X chromosome.
The X-linked recessive gene can be inherited from a carrier mother, or the gene defect may occur as a new mutation in that male.
Each male child of a female carrier has a 50% risk of being affected and a 50% chance of being unaffected.
Each female child has a 50% risk of being a carrier and a 50% chance of being a noncarrier.
There is no male-to-male transmission, because the father transmits his Y chromosome to his sons.
Female offspring of affected males are obligate carriers; they inherit their father's only X chromosome, which has the defective recessive gene.
Transmission occurs from one generation to the next through carrier females; only males are affected in a majority of families.
The disorder may "skip" a generation if only females inherit the recessive gene and males are unaffected.

Front 17

Lesch-Nyhan syndrome

Back 17

Self-mutilation in the Lesch-Nyhan syndrome, an x-linked disorder usually seen in boys, characterized by spasticity and self mutilation and diagnosed by a high level of uric acid

Front 18

Hurler's syndrome

Back 18

Most severe muchopolysaccharidosis (type II)
Normal until 6 months, then develop characteristic skeletal (dwarfism, kyphoscoliosis) and neurologic features
Mental deficiency, spasticity, deafness, and optic atrophy are progressive

Front 19

Agammaglobulinemia

Back 19

Results from the absence of B cells with subsequent absence or severe decrease in immunoglobulin levels and total absence of specific antibody

Front 20

Glucose-6-phosphate dehydrogenase deficiency (G6PD)

Back 20

A, Reddish urine and extreme pallor, B in 3-year-old African American male child who presented with lethargy and a hemoglobin value of 3.2 g/dL

Front 21

x-linked

Back 21

Affected males have the abnormal X-linked recessive gene; they are affected because they have no corresponding normal gene on their Y chromosome; they are hemizygous (have only one copy) for all genes on the X chromosome.
The X-linked recessive gene can be inherited from a carrier mother, or the gene defect may occur as a new mutation in that male.
Each male child of a female carrier has a 50% risk of being affected and a 50% chance of being unaffected.
Each female child has a 50% risk of being a carrier and a 50% chance of being a noncarrier.
There is no male-to-male transmission, because the father transmits his Y chromosome to his sons.
Female offspring of affected males are obligate carriers; they inherit their father's only X chromosome, which has the defective recessive gene.
Transmission occurs from one generation to the next through carrier females; only males are affected in a majority of families.
The disorder may "skip" a generation if only females inherit the recessive gene and males are unaffected.

Front 22

Lesch-Nyhan syndrome

Back 22

Self-mutilation in the Lesch-Nyhan syndrome, an x-linked disorder usually seen in boys, characterized by spasticity and self mutilation and diagnosed by a high level of uric acid

Front 23

Hurler's syndrome

Back 23

Most severe muchopolysaccharidosis (type II)
Normal until 6 months, then develop characteristic skeletal (dwarfism, kyphoscoliosis) and neurologic features
Mental deficiency, spasticity, deafness, and optic atrophy are progressive

Front 24

Agammaglobulinemia

Back 24

Results from the absence of B cells with subsequent absence or severe decrease in immunoglobulin levels and total absence of specific antibody

Front 25

Glucose-6-phosphate dehydrogenase deficiency (G6PD)

Back 25

A, Reddish urine and extreme pallor, B in 3-year-old African American male child who presented with lethargy and a hemoglobin value of 3.2 g/dL

Front 26

X linked dominant

Back 26

There is no male-to-male transmission, because the father gives his Y chromosome to his sons.
The affected male who reproduces has no affected sons; all daughters are affected.
The affected female's offspring have a 50% chance of being affected, whether male or female.
There is a positive family history in which the gene is transmitted from one generation to the next unless it represents a new mutation.
Twice as many females are affected as males if affected males reproduce.

Front 27

Vitamin D resistant rickets

Back 27

The kidney's ability to reabsorb phosphate is impaired. Phosphate levels and resulting rickets are not as severe in females as in males

Front 28

Incontinentia pigmenti

Back 28

Characteristic swirling skin pattern of hyperpigmentation that develops after a perinatal skin rash with blistering. Affected females also have variable involvement of the CNS, hair, nails, and eyes.

Front 29

Retts syndrome

Back 29

Females are normal at birth
At 6-18 months develop microcephaly and regression of developmental milestones followed by developmental arrest
50% develop seizures
Lose all purposeful hand movements by 2 years

Front 30

average birth weight

Back 30

Average: 3400 g
Range: 2500 g to 4300 g
Percentage of weight loss is more important than actual weight loss.

Front 31

average birth length

Back 31

Average: 49.6 cm
Range: 45 cm to 54 cm

Front 32

average temperature

Back 32

97.6°F to 99°F (36.5°C to 37.2°C)

Front 33

average pulse

Back 33

120 to 160

Front 34

average respiratory

Back 34

Abdominal: Irregular in depth and rate, transient tachypnea normal
Rate: 30 to 60 breaths/min
Ratio of respiration to pulse: 1:4
Respiratory rate increases with fever (four respirations per 1°F above normal)

Front 35

average blood pressure

Back 35

Average systolic blood pressure range: 50 to 90 mm Hg.
Average diastolic blood pressure range: 20 to 60 mm Hg.
Thigh and arm systolic pressure are equal.
Normal pulse pressure is half of the systolic pressure measurement; range 20 to 50 mm Hg.

Front 36

position and posture of newborn

Back 36

Position/Posture

The position/posture is tense with flexion or partial flexion of extremities (pithed "frog" position), muscle tone is firm, and the infant assumes the fetal position for comfort.

Front 37

activity level and disposition of newborns

Back 37

Spontaneous movement
Behavioral states (two sleeping, four waking)
Jitteriness and neonatal tremors are usually normal.

Front 38

Appearance and Body Proportion, Symmetry of Body Parts of newborns

Back 38

The trunk is longer than the extremities, the arms are longer than the legs, and the head is one quarter of the infant's total length.
Short neck or no-neck appearance is normal.

Front 39

Baby cries

Back 39

Cry is vigorous, especially after stimulation; tone and pitch are moderate.
Infant quiets when left alone, no tears.
Self-regulating behaviors are normal.

Front 40

color of infant

Back 40

Pink, acrocyanosis (normal in first week only)
Transient harlequin pattern or transient mottling
Occasional petechiae
"Normal" jaundice is physiologic after 48 hours

Front 41

infant skin texture

Back 41

Thin, delicate, soft, and smooth with evidence of fat pads
Resilient, elastic; good turgor
Dry and peeling (third day)

Front 42

Lanugo /hair distribution:

Back 42

Back, face, and shoulders are covered in fine downy hair

Front 43

Vernix caseosa:

Back 43

White, cheesy, protective coating on skin, especially in creases

Front 44

Pigmentation of infant

Back 44

Mongolian spot over sacrum, buttocks, shoulders, or back in dark-skinned infants

Front 45

skin lesions in infants

Back 45

Birthmarks, milia, Mongolian spot
Telangiectasia ("stork bites")
Erythema toxicum rash
Diaper rash
Red-mauve blotches
Xanthomas

Front 46

head circumferences in infants

Back 46

Range : 32 to 38 cm(40 weeks' gestational age)
Average male, 34.5 to 35.5 inches; average female, 33.5 to 34.5 inches
Average growth in occipitofrontal circumference per week during first 8 weeks of life:
Gestational Age Head Growth
38-40 wk 0.5 cm/wk
34-37 wk 0.8 cm/wk
30-33 wk 1.1 cm/wk
"Sick" preterm 0.25 cm/wk
Head 1 to 2 cm larger than chest

Front 47

fontanels

Back 47

Open, soft, flat; possibly visible slight pulsation
Average size: anterior fontanel, 4 to 6 cm anteroposterior and lateral measurement; posterior fontanel, 0.5 to 1 cm

Front 48

tympanic membrane infant

Back 48

The tympanic membrane is pearly gray and translucent; a light reflex is present, and it is mobile.

Front 49

hearing in infants

Back 49

There is a blink or Moro reflex reaction to loud noise or to a stimulus when using a neometer (70-80-90-100 dB at a distance of 30.5 cm).

Front 50

eye movement in infants

Back 50

Nonparalytic strabismus, uncoordinated eye movement; doll's eye reflex
Strabismus up to 6 months of age
Pseudostrabismus (common in Asian infants)

Front 51

mouth in infants

Back 51

Symmetrical grimace
Strong suck, rooting reflex
Palate is arched, short, and wide
No tonsils, scan saliva, teeth may be present, retention cysts, ulcers, Epstein pearls , pink mucous membranes
Uvula midline
Lips are moist, pink, and smooth
No remarkable odor
Mandible in proportion with face

Front 52

epstein pearl

Back 52

Epstein Pearl (gingival cysts) in an infant

Front 53

tonic neck reflex

Back 53

Tonic neck reflex may be present at birth or may not appear until first month of life; disappears by approximately age 4 months

Front 54

breast tissues in infants

Back 54

Full areola, 5 to 10 mm bud
Symmetrical placement (distance between)
Some breast engorgement is normal
Milk after 3 days normal
Extra nipples (supernumerary)

Front 55

infants abdomen

Back 55

Translucent or dry, no bleeding
Two arteries and one vein
Ventral hernias and diastasis recti abdominis may be present
Normal umbilical hernia, 2 to 5 cm

Front 56

infant female genitalia

Back 56

Check for a hymenal tag, a large clitoris in preterm infants, mucoid or sanguineous vaginal discharge, or a large labia minora (2.5 mm thick).

Front 57

infant male genitalia

Back 57

Slender penis, 2.5 × 1 cm
Scrotum length, 3 × 2 cm
Testes descended and average 1 × 5 cm at birth
Testes length, 0.5 to 2 cm
Glans should be tapered at tip, with meatal opening in center
Foreskin may not retract easily

Front 58

Reflexes infant

Back 58

Moro's sign, rooting, sucking, tonic neck, stepping, palmar and plantar grasp
Tonic neck is frequently absent or incomplete in healthy infants

Front 59

etiology of GBS

Back 59

Group B streptococcus (GBS), or Streptococcus agalactiae, is a type of bacterium.
It is the most common cause of sepsis and meningitis in newborns.
GBS is present in the rectum or vagina of 20% to 25% of pregnant women. A fetus may come in contact with GBS before or during birth if the mother is infected.
Seventy-five percent of the cases of GBS disease in newborns occur during the first week of life; most are apparent a few hours after birth ("early-onset disease").
GBS disease may develop in infants 1 week to several months after birth ("late-onset disease").
One half of infants with late-onset disease are infected from their mothers (GBS carrier); the source of infection for others is unknown.

Front 60

incidence of GBS

Back 60

GBS is the leading bacterial infection associated with morbidity and mortality of the newborn in the United States .
One of every 20 babies with GBS dies from the infection.
Infants that survive, especially those with meningitis, have long-term problems including hearing and vision deficits, and learning disabilities.
Approximately one of every 100 to 200 infants whose mother is a GBS carrier develops signs and symptoms of the disease.
Seventy-five percent of the GBS cases among newborns occur in the first week of life.
Premature infants are more susceptible to GBS infection than full-term infants, but 75% of infants who get GBS disease are full term.
GBS is a late-onset disease.

Front 61

risk factors for GBS

Back 61

Previous baby with GBS disease
Urinary tract infection caused by GBS
Positive GBS culture at 35 to 37 weeks' gestation
Labor or rupture of membranes before 37 weeks' gestation
Rupture of membranes before onset of labor or 18 hours or more before delivery
Intrapartum fever
Lower socioeconomic environment
Less than 20 years of age
African-American descent
Low-birth-weight infants

Front 62

early onset GBS

Back 62

Presents within 24 hours after birth in majority of cases but may appear during first 6 days of life
The most common manifestations are:
Septicemia without a focus.
Pneumonia/meningitis.
Initial clinical signs in over 80% of neonates regardless of the site involved are respiratory signs including apnea, grunting, tachypnea, or cyanosis.
Hypotension is an initial finding in 25% of the cases.
Other signs may include lethargy, poor feeding, hypothermia or fever, abdominal distension, pallor, tachycardia, or jaundice.

Front 63

late onset of GBS

Back 63

Presents 1 week to several months after birth.
Meningitis is more common with late-onset disease.
Presentation may be similar to early-onset disease but is more often localized to the lungs, meninges, bones, or joints.
Fever, without a localizing sign, may be the initial presentation.

Front 64

tx of GBS

Back 64

Prevention includes universal prenatal screening through vaginal and rectal cultures for GBS done at 35 to 37 weeks' gestation.
Guidelines have recently been updated for more information.
When GBS is identified in urine during pregnancy, it should be treated at the time of diagnosis.
Most GBS disease in the newborn can be prevented by giving antibiotic prophylaxis to women who are at increased risk for transmitting the infection to their newborns.
Infants suspected of having GBS disease should be referred to a physician.
Management of a neonate born to a mother who received intrapartum antimicrobial prophylaxis (IAP) for prevention of early-onset GBS is indicated.

Front 65

very-low-birth-weight

Back 65

1000- 1500

Front 66

extremely low birth weight

Back 66

less than 1000 g

Front 67

Adjusted age or corrected age:

Back 67

chronological age minus the months and weeks of prematurity

Front 68

for premature babies..

Back 68

Weight, height, head circumference, and weight-length ratio at each routine visit (plot for chronological and adjusted age until age 2 years).
Growth for premature infants may be below the fifth percentile but should parallel standard growth curves for weight and length. Head circumference is usually the first to catch up, then weight, and finally length.
Monitor development.

Front 69

vision assessment in premature infants

Back 69

Infants with gestational age less than 36 weeks with exposure to oxygen and infants with gestational age less than 32 weeks, whether or not they receive oxygen, are considered at risk for vision problems and should be referred to an ophthalmologist.
At 6 to 8 weeks of age, infants should undergo an initial ophthalmology examination, with follow-up depending on findings.
At 6 months of age, infants should be examined if no problems were noted at discharge.

Front 70

Blood test in premature infants

Back 70

CBC and reticulocyte count should be checked between 2 and 4 months of age because of higher risk for anemia, or sooner if epoetin alfa (Epogen) was used.

Front 71

fe in breastfeed babies

Back 71

Breast-fed infants should be given a multivitamin with iron or ferrous sulfate drops
(4 mg/kg per day of elemental iron).

Front 72

health preterm infants need...

Back 72

Healthy preterm infants need 110 to 130 kcal/kg per day to achieve adequate growth.

Front 73

Infants with bronchopulmonary dysplasia, gastroesophageal reflux (GER), cerebral palsy, cardiac problems, formula intolerance, or other chronic illnesses may need

Back 73

200 kcal/kg per day

Front 74

solid foods in preterm at 6 months

Back 74

Solid foods such as cereal for the older infant (6 to 12 months of age) may be used as a supplement, but do not replace high-calorie formulas. Rice cereal is often used for GER. The highest-calorie foods include bananas, avocados, sweet potatoes, and meats (at the end of the first year).

Front 75

pre-term infant immunization

Back 75

Preterm infants should receive full-dose immunizations according to their chronological age or birth age regardless of weight. This includes the diphtheria, tetanus, and pertussis (DTaP); inactivated polio (IPV); Haemophilus influenzae type B (Hib); pneumoccal conjugate (PCV7); measles, mumps, and rubella (MMR); and varicella-zoster virus (VZV) vaccines. The AAP recommends that pertussis be omitted for infants with active seizures or a previous history of a reaction to pertussis. Initiation of hepatitis B vaccination in an infant weighing less than 2 kg (4000 g or 4.4 lb) whose mother is HBsAg-negative should be delayed until just before hospital discharge if the infant weighs 2 kg or more, or until the infant is 2 months of age regardless of weight.
The influenza vaccine can be given at 6 months of age if chronic respiratory disease present.
Respiratory syncytial virus immune globulin intravenous (RSV-IGIV; RespiGam) is given to infants less than 2 years of age with a history of premature birth and less than 35 weeks' gestation for prevention of RSV. It should be initiated before RSV season and is given monthly during the RSV season.
See Module 14 for more information on immunizations.

Front 76

counseling preterm infants

Back 76

Assess parental adaptation and parent-child interaction.
Review infection control with parents.
Address differences in full-term and premature infants. Premature infants may have a poor suck, weak swallow, or breathing coordination problems that may lead to tiring during feeding, shorter feeding times, or more-frequent feedings. GER is more common in premature infants.
Premature infants spend less time awake and may be more fussy and less active when awake. They also have shorter sleeping-wake cycles and have a greater likelihood of awakening with fussiness during the night.
Because of hypertonia or hypotonia, premature infants may be difficult to hold, may appear to push away from their parent, and may have delays in motor self-help skills such as head control and sitting.
Teach about growth and development of the premature infants.
Discuss child care.
Group day care is generally not recommended for premature infants under 6 months of age because of exposure to viral illnesses, especially gastrointestinal tract and respiratory illnesses.
Provide education materials to parent.
Follow up as determined at discharge.

Front 77

tobacco effects on infants

Back 77

low birth weigh and prematurity

Front 78

majiuana and pregnancy

Back 78

Effects include prolonged, protracted, or arrested labor; marijuana can induce infertility problems.

Effects on Neonate of Marijuana


Effects include shortened gestation and possible increased meconium passage during delivery.

Front 79

cocaine

Back 79

Prepared from leaves of Erythroxylon coca plant.
The powder form is a water-soluble substance that can be cut with many other substances, including sugar or other stimulants.
The freebase form, crack, is a highly purified alkaloid that produces a rapid increase in blood concentration when smoked.

Front 80

cocaine prenatal complications

Back 80

Complications include tachycardia, hypertension, hyperthermia, agitation, anorexia, myocardial infarction or ischemia, cerebrovascular accident, placenta previa, preterm labor, seizures, and abortion.

Front 81

cocaine effects on neonates

Back 81

Effects include intrauterine growth retardation (usually of short duration, majority reach normal parameters by age 2 years), sleep disturbances, poor state control, decreased habituation, visual tracking difficulties, poor feeding, transient irritability and tremulousness (if the mother used immediately before birth), and a risk for congenitally acquired infections such as syphilis and human immunodeficiency virus.

Front 82

Hallucinogen

Back 82

D-Lysergic acid diethylamide (LSD) and phencyclidine hydrochloride (PCP) are occasionally seen in neonates.
Now a liquid form is available on the streets.

Front 83

Hallucinogen prenatal complications

Back 83

Complications include trauma (self-induced or accidental), self-destructive or combative behavior, labile mood swings, and violent agitation.

Front 84

Hallucinogen effects on neonates

Back 84

Effects include severe withdrawal, including flapping coarse tremors and facial grimaces with sudden and rapid changes in level of consciousness.

Front 85

Barbiturates
Nembutal, Seconal, and Fiorinal are prescription medications also sold illicitly and used in combination with other drugs to help addicts "come down."

Back 85

Effects include hyperactivity, excessive crying, restlessness, and hyperreflexia; sudden withdrawal may cause seizures.
Sedation

Front 86

Narcotics

Back 86

Heroin and methadone are the most common.
Oxycodone has a strong potential for abuse.
Methadone crosses the placenta in a 2:1 ratio, causing a more-prolonged withdrawal than heroin that is termed neonatal abstinence syndrome (NAS).

Front 87

narcotics prenatal

Back 87

Heroin: Associated with "addict lifestyle"(e.g., dirty needles, poor nutrition, homelessness, violence)

Methadone: Used increasingly by fetus as pregnancy progresses; mother may require increased doses by third trimester to avoid experiencing withdrawal (including nausea and vomiting and inability to sleep)

Front 88

narcotics effects on neonate

Back 88

NAS: High-pitched, insistent, inconsolable crying; sleep disturbance - no quiet sleep, abnormal rapid eye movement; irritability

Methadone: Tremulousness; tachycardia; tachypnea; temperature variation; mottling of skin; sweating, sneezing, yawning; hyperactive reflexes; disorganized suck/swallow; voracious suck; excoriation of nose, knees, and elbows; gastrointestinal upset; diarrhea/vomiting and cramping; severe weight loss; 10% to 20% higher incidence of neonatal seizures

Front 89

lab data for drug use

Back 89

Each state and institution has its own set of rules and guidelines. The gold standard for finding drugs passively transferred to the newborn from the mother has always been a urine drug screen, but recently laboratories have been able to test mecomium and hair samples.
A urine sample positive for any substance other than methadone (if the mother is on a maintenance dose in an established program) is reportable.

Front 90

From age 6 to 12 months, infants gain

Back 90

0.5 oz per day, or 1 lb per month.

Front 91

Infants reattain their birth weight usually by

Back 91

14 days

Front 92

Infants gain from birth to 6 months

Back 92

gain about 1 oz (30 g) per day, or 2 lb per month

Front 93

Infants should ______ their birth weight by age 6 months

Back 93

double
sometimes by 4 months

Front 94

By 1 year, babies usually _______ their weight

Back 94

triple

Front 95

During the first year of life, babies increase their growth by

Back 95

9 - 11 inches

Front 96

Birth length doubles by age ____

Back 96

4

Front 97

Birth length triples by age ____

Back 97

13

Front 98

From birth to age 6 months, length increases

Back 98

about 1 inch per month.

Front 99

From age 6 to 12 months, length increases

Back 99

about 0.5 inch per month.

Front 100

Head Circumference
from birth to age 3 months

Back 100

increases 2 cm per month

Front 101

Head Circumference
from age 4 to 6 months

Back 101

increases 1 cm per month

Front 102

Head Circumference from age 6 to 12 months

Back 102

increases 0.5 cm per month

Front 103

The posterior fontanel closes by

Back 103

2 months

Front 104

The anterior fontanel usually is not palpable after

Back 104

18 months of age

Front 105

Growth Guidelines: Age 1 to 3 Years

Back 105

Growth rates decline rapidly.
Birth weight quadruples by the end of the second year.
An infant gains about 5 lb per year from age 2 to 9 years.
Length increases 5 inches during the second year and 3 to 4 inches during the third year.
By the end of the third year, the growth rate settles into a steady, consistent pattern.

Front 106

By age 2.5, most toddlers have how many teeth?

Back 106

20 teeth

Front 107

Growth Guidelines: Age 3 Years to Puberty

Back 107

Weight gain averages 5 lb per year.
Height increases about 2.5 to 3 inches per year until a growth spurt during puberty.

Front 108

Patterns of Growth and Development
Development occurs in a sequential pattern and is viewed in terms of stages:

Back 108

Cephalocaudal
Proximodistal
General to specific

Front 109

Gesell Developmental Theorists

Back 109

Developmental tasks, predestined, practical applications, basis for Denver II

Front 110

Maslow Developmental Theorists

Back 110

Humanistic; hierarchy of needs

Front 111

Kohlberg:Developmental Theorists

Back 111

Moral development

Front 112

Piaget: Developmental Theorists

Back 112

Cognitive development

Front 113

Erickson: Developmental Theorists

Back 113

Psychosocial development

Front 114

What is the earliest signs of neuromuscular dysfunction?

Back 114

Persistent fisting of hands after age 3 months

Front 115

Spontaneous posturing such as frog legs and scissoring is an indication of

Back 115

provides visual clues to hypotonia/weakness or spastic hypertonia.

Front 116

parachute reflex

Back 116

Absence of intact protective mechanisms send a red flag for growth and devlopment

Front 117

Hand dominance before age ___months may indicate hemiparesis

Back 117

18

Front 118

lack of achieving developmental milestones: Unable to sit alone by

Back 118

9 months

Front 119

lack of achieving developmental milestones: Unable to transfer objects from hand to hand by

Back 119

age 1 year

Front 120

lack of achieving developmental milestones-Abnormal pincer grip or grasp by

Back 120

age 15 months

Front 121

lack of achieving developmental milestones-Unable to walk alone by

Back 121

age 18 months

Front 122

lack of achieving developmental milestones-No recognizable words by

Back 122

age 2 years

Front 123

Birth to 2 years: measure

Back 123

lying down

Front 124

DMStones at 2 months

Back 124

he infant smiles, squeals, coos, follows objects with its eyes past midline, and regards a face in the direct line of vision.

Front 125

DMStones @ 4 months

Back 125

The infant lifts the head and chest from the prone position, smiles at others (1.5 to 4 months), rolls over front to back, follows objects with the eyes 180 degrees, grasps a rattle, coos and says "ah," and plays with the hands

Front 126

DMStones @ 6 months

Back 126

The infant sits without support (5 to 8 months), transfers objects hand to hand (4.5 to 7 months), babbles ("babababa"), laughs, rolls both ways, bears weight, and displays a raking hand pattern.

Front 127

DMStones @ 9 months

Back 127

The infant bears weight, crawls, demonstrates pincer grasp (8.5 to 12 months), uncovers hidden toy, says nonspecific "mama/dada," cruises holding furniture, and understands "no."

Front 128

DMStones @ 12 months

Back 128

The infant stands alone (10 to 14 months), says "mama" or "dada" (9 to 13 months), walks well (11 to 15 months), and says three words in addition to "mama."

Front 129

DMStones @ 15 months

Back 129

The infant walks backward (12.5 to 21.5 months), self-feeds with the fingers, eats with a spoon, says 4 to 6 words, and walks alone.

Front 130

DMStones @ 18 months

Back 130

The toddler walks up steps (14 to 22 months), finds hidden objects (14 to 20 months), stacks four cubes (15 to 20 months), puts three words together, and says 7 to 20 words.

Front 131

DMStones @ 24 months

Back 131

The child pedals a tricycle (21 to 28 months), combines 2 words (14 to 24 months), says 50 words, and kicks a ball forward on request.

Front 132

DMStones @ 3 years

Back 132

The child uses plurals (21 to 36 months); balances on one foot (30 to 44 months); goes up stairs; knows his or her age, name, and sex; counts three objects; pedals a tricycle; and speaks well enough for a stranger to understand.

Front 133

DMStones @ 3-6 years old preschool

Back 133

The child stands 10 seconds on one foot by 5 years. By school age, the child knows colors, counts to 10, hops on one foot, can heel-toe walk, and speaks sentences of at least 10 syllables.

Front 134

DMStones @ 6-12 years old school age

Back 134

The child can take formal tests to assess the developmental level of achievement; sexual maturation begins around 10 years in girls and 12 years in boys.

Front 135

DMStones @ 18 months

Back 135

The toddler walks up steps (14 to 22 months), finds hidden objects (14 to 20 months), stacks four cubes (15 to 20 months), puts three words together, and says 7 to 20 words.

Front 136

DMStones @ 24 months

Back 136

The child pedals a tricycle (21 to 28 months), combines 2 words (14 to 24 months), says 50 words, and kicks a ball forward on request.

Front 137

DMStones @ 3 years

Back 137

The child uses plurals (21 to 36 months); balances on one foot (30 to 44 months); goes up stairs; knows his or her age, name, and sex; counts three objects; pedals a tricycle; and speaks well enough for a stranger to understand.

Front 138

DMStones @ 3-6 years old preschool

Back 138

The child stands 10 seconds on one foot by 5 years. By school age, the child knows colors, counts to 10, hops on one foot, can heel-toe walk, and speaks sentences of at least 10 syllables.

Front 139

DMStones @ 6-12 years old school age

Back 139

The child can take formal tests to assess the developmental level of achievement; sexual maturation begins around 10 years in girls and 12 years in boys.

Front 140

Developmental Warning Signs: Infant @ 2 weeks

Back 140

A femoral click or hip instability (through age 12 months) is noted or undue maternal anxiety (true for all ages) is present.

Front 141

Developmental Warning Signs: Infant @ 2 months

Back 141

A persistent heart murmur, an absent response to noise, a failure to fix the gaze on a face or poor eye contact, or a lack of responsive smiling is noted.

Front 142

Developmental Warning Signs: Infant @ 4 months

Back 142

A lack of bonding (a concern at any age), head drag, a continued grasp reflex, or scissoring of legs when supported under the arms is noted.

Front 143

Developmental Warning Signs: Infant @ 6 months

Back 143

A failure to follow objects 180 degrees, persistent fisting, strabismus, or a failure to reach for objects is noted.

Front 144

Developmental Warning Signs: Infant @ 9 months

Back 144

Nystagmus, an absence of babble, or an inability to sit alone is noted.

Front 145

Developmental Warning Signs: Infant @ 12 months

Back 145

An inability to transfer objects hand to hand or an absence of weight bearing while held is noted.

Front 146

Developmental Warning Signs: toddler @ 15 months

Back 146

An inability to pull self to standing position or an abnormal grasp or pincer grip is noted.

Front 147

Developmental Warning Signs: toddler @ 18 months

Back 147

An open anterior fontanel, an inability to walk alone, an absence of constructive play, or a lack of spontaneous vocalization is noted.

Front 148

Developmental Warning Signs: toddler @ 24 months

Back 148

An absence of recognizable words is noted

Front 149

Developmental Warning Signs: toddler @ 36 months

Back 149

Speech is unintelligible to strangers.

Front 150

Developmental Warning Signs: Infant @ 12 months

Back 150

An inability to transfer objects hand to hand or an absence of weight bearing while held is noted.

Front 151

Developmental Warning Signs: toddler @ 15 months

Back 151

An inability to pull self to standing position or an abnormal grasp or pincer grip is noted.

Front 152

Developmental Warning Signs: toddler @ 18 months

Back 152

An open anterior fontanel, an inability to walk alone, an absence of constructive play, or a lack of spontaneous vocalization is noted.

Front 153

Developmental Warning Signs: toddler @ 24 months

Back 153

An absence of recognizable words is noted

Front 154

Developmental Warning Signs: toddler @ 36 months

Back 154

Speech is unintelligible to strangers.

Front 155

Developmental Warning Signs: Preschool

Back 155

An inability to perform self-care tasks such as hand washing, simple dressing, or daytime toileting is noted.

Front 156

Developmental Warning Signs: School Age

Back 156

School failure or aggressive behavior such as fire setting is noted.

Front 157

Developmental Warning Signs: Adolescence

Back 157

School absenteeism or school failure is noted.

Front 158

Major Speech and Language Milestones by Age (Months) 1-2

Back 158

Receptive Language: Recognizes sounds
Expressive Language: Coos

Front 159

Major Speech and Language Milestones by Age (Months) 4- 6

Back 159

Receptive Language: Turns to bell
Expressive Language: Laughs and squeals

Front 160

Major Speech and Language Milestones by Age (Months) 8-9

Back 160

Receptive Language: Understands name, responds to "no"
Expressive Language: Says "mama/dada" as sounds, babbles

Front 161

Major Speech and Language Milestones by Age (Months) 10 - 12

Back 161

Receptive Language: Follows simple command, waves goodbye
Expressive Language: Says "mama/dada" specific, says four words

Front 162

Major Speech and Language Milestones by Age (Months) 14- 16

Back 162

Receptive Language: Points to one or two body parts
Expressive Language: Says six to 12 words
Speech: Less than 20% of speech is understood by strangers

Front 163

Major Speech and Language Milestones by Age (Months) 18 - 20

Back 163

Receptive Language: Points to pictures/objects, follows two-step commands
Expressive Language: Asks for food/drink, says 20 to 30 words
Speech: 50% of speech is understood by strangers

Front 164

Major Speech and Language Milestones by Age (Months) 22- 24

Back 164

Receptive Language: Points to all body parts
Expressive Language: Speaks in two-word sentences, says less than 50 words
Speech: 75% of speech is understood by strangers

Front 165

Major Speech and Language Milestones by Age (Months) 24 -30

Back 165

Receptive Language: Understands some prepositions
Expressive Language: Uses "me/you," "he/she" correctly; speaks in 4- to 8-word sentences

Front 166

Major Speech and Language Milestones by Age (Months) 30-36

Back 166

Receptive Language: Understands concepts: up-down, big-little, loud-soft
Expressive Language: Gives use of objects
Speech: Almost all speech is understood by strangers

Front 167

Live-attenuated vaccines

Back 167

(e.g., measles, mumps, rubella) induce the best immunity. Successful immunization provides lifelong immunity. No live vaccine should be administered to pregnant women. The administration of gamma globulin prevents effective immunization with live vaccines for 3 to 11 months, depending on the concentration and quantity of the gamma globulin product.

Front 168

killed vaccines

Back 168

include killed bacterial toxoids, various virus preparations, and antigenic proteins made by recombinant DNA technology in yeasts, bacteria, or tissue culture. These vaccines require a primary course of immunization including two or three injections at spaced intervals and a booster at specific times. These vaccines generally require an adjuvant.

Front 169

true or false
Vaccine doses administered less than 4 days before the minimum interval or age are counted as valid.

Back 169

true

Front 170

Live virus vaccines, such as MMR, must be separated by a minimum of ____ days, but more than one live virus vaccine can be given on the same day.

Back 170

28

Front 171

MMR, a live virus vaccine, is recommended for HIV-positive children. T or F

Back 171

T

Front 172

Varicella vaccine may be given if the child's CD4T cell count is adequate for the child's age. T or F

Back 172

T

Front 173

Immunization during chemotherapy or radiation should be avoided because of poor antibody response. Immunization should be delayed until at least ___ months after treatments have been completed and adequate immune response is demonstrated.

Back 173

3

Front 174

HepB vaccine is not administered until the child weighs 2 kg (4.4 lbs) or at 2 months of age regardless of weight. T or F

Back 174

T

Front 175

Preterm infants born to HBsAG-positive mothers should receive

Back 175

HBIG and Hep B vaccine within 12 hours of birth regardless of their weight.

Front 176

Respiratory syncytial virus (RSV) prophylaxis is indicated (6 monthly doses) for infants with gestational age of

Back 176

32 weeks or less at birth if the RSV season is approaching. RSV prophylaxis is not considered an immunization.

Front 177

Immunize with full doses of DTaP, polio, Hib, MMR, and Var vaccines at the appropriate chronological ages regardless of their present weights. T or F

Back 177

T

Front 178

MCCV is the preferred vaccine for

Back 178

those 11 to 55 years of age.

Front 179

MPV can be administered to as young as

Back 179

2 years old

Front 180

If a child receives MMR or Var vaccine, tuberculosis (TB) skin testing must be postponed for_____ weeks.

Back 180

4 to 6

Front 181

DTAPS final dose should be given after

Back 181

should be given at age 4 years or older.

Front 182

Td boosters should be given every ____ years.

Back 182

10

Front 183

PPV23

Back 183

PV23 is recommended for any child with a high-risk medical condition on or after 2 years of age.

Front 184

Hib vaccine should never be administered before ____ weeks of age,

Back 184

6

Front 185

FASD is diagnosed by ?

Back 185

an interdisciplinary team.

Front 186

FASD characteristics are

Back 186

Confirmed prenatal or postnatal height or weight at or below the 10th percentile, adjusted for age, sex, gestational age, and race/ ethnicity
Central nervous system involvement, signaled by reduced head circumference and a variety of deficits
Facial dysmorphology
Maternal history of alcohol use during pregnancy (confirmed or suspected)

Front 187

FASD d/d in young children

Back 187

Slender build, with little body fat
Dental problems
Hearing problems
Vision problems

Front 188

FASD d/d in infancy

Back 188

Sensory integration problems
Microcephaly
Absence of or underdevelopment of the philtrum
Posteriorly displaced jaw
Prenatal or postnatal growth deficiency
Dental anomalies
Thin lips
Hyperactivity
Short palpebral fissures

Front 189

FASD families need

Back 189

drugs may be used to control behaviors such as hyperactivity and aggression.
Counseling
early intervention programs.

Front 190

lead poisoning can cause

Back 190

mental retardation, impaired growth, hearing loss, and behavioral problems.coma, convulsions, or death.

Front 191

Intervention is required for toxicity when the blood lead concentration is

Back 191

10 mg/dL or greater.

Front 192

once absorbed, it takes more than ____ years for the body to remove half of a given dose of lead.

Back 192

20

Front 193

Risk factors for Lead Poisoning

Back 193

Poverty
Residence in older, poorly maintained housing
Siblings with high lead levels
Living in a home or attending day care near a heavily traveled roadway
Age between 6 months and 6 years
Residence in housing painted before 1960
Minority race
Residence in the inner city
Pica
Warm weather (more outdoor activities, windows open, etc.)
Residence in a home built before 1960 that is being remodeled

Front 194

Infants do not need more than ____ounces of formula daily.

Back 194

32

Front 195

The infant should take ____ounces of formula every ____ hours by 2 months of age.

Back 195

3-4
3-4

Front 196

Formula contains ____ calories per ounce

Back 196

20

Front 197

Whole Milk

Back 197

@ 1 year

Front 198

Exclusive breastfeed need vit ____? at how many units?

Back 198

D, 400

Front 199

Fluoride at ____ months, if not in the local water supply

Back 199

6

Front 200

Infants are ready for solids when...

Back 200

Readiness for solids is determined by the infant's ability to sit unassisted, the presence of hand-to-mouth reflex, infant interest, and a decrease in tongue thrust.

Front 201

How do you introduce new foods?

Back 201

Each new food should be introduced separately and the infant observed for 3 to 4 days for symptoms of food intolerance (skin rash, diarrhea, or wheezing) before adding the next new food.

Front 202

How to store breast milk?

Back 202

Fresh mother's milk can be kept at room temperature for up to 10 hours, in the refrigerator up to 8 days, and in the freezer from 2 weeks to 4 months depending on the type of freezer.
Chilled mother's milk must be used within 1 hour of removal from the refrigerator.
Frozen mother's milk can be thawed and kept in the refrigerator for up to 9 hours.

Front 203

Growth concerns for toddlers in relationship to food intake

Back 203

The physical growth rate decreases, motor development matures, cognitive ability increases, and the personality continues to evolve during this period.
The child develops self-feeding skills, food preferences, and individual patterns of food intake.

Front 204

By the end of the second year of life, birth weight

Back 204

quadruples

Front 205

birth length doubles at approximately ___ years of age.

Back 205

4

Front 206

By the end of the second year of life, birth weight

Back 206

quadruples

Front 207

birth length doubles at approximately ___ years of age.

Back 207

4

Front 208

School age:Weight increases an average of 4.2 to 6.2 pounds a year until age 9 or 10 years.

Back 208

4.2

Front 209

School Age
Height increases 2.3 to 3.3 inches per year until the pubertal acceleration.

Back 209

2.3

Front 210

Obesity is also evident when the triceps skinfolds measurement is greater than or equal to the 85th percentile on standardized charts or triceps measurements.

Back 210

85th

Front 211

Medical conditions that may cause obesity:

Back 211

Prader Willi syndrome; hypothyroidism; growth hormone deficiency; Cushing syndrome

Front 212

Genetic patterns for obesity

Back 212

Patterns of repeated obesity within families are suggestive of genetic predispositions to various body shapes and sizes. It is estimated that 40% of obese children have one obese parent. The incidence increases to 80% when both parents are obese.

Front 213

Tx for obesity

Back 213

Dietary balance between caloric intake and energy expenditure.
Dietary suggestions that help to maintain current weight without increasing body fat stores.
Support groups for obese adolescents.
Diet logbook that includes date, time, quantity, and type of food eaten. For older children it should include emotion and activity at the time of eating.
Exercise program to increase caloric expenditure.

Front 214

counseling for obesity

Back 214

Tips to reduce caloric intake:
Decrease quantity of food purchased and serve smaller portions.
Make low-fat, reduced-caloric substitutions when possible (e.g., unbuttered popcorn versus buttered popcorn).
Suggest foods be eaten only at table, not at the refrigerator or while watching television.

Front 215

f/u with obesity tx

Back 215

Visits every 2 weeks initially after dietary changes have been made, then monthly to assess progress and provide positive encouragement and support.

Front 216

Referrals for obesity

Back 216

Refer to physician if suspect endocrine or metabolic disorders.
Nutritional consultation or referral for development of individualized diet.

Front 217

Physical examination of ears

Back 217

Temperature
Inspect the external ears. Note the position and shape of the pinna, as well as pain on movement of the pinna or tragus. Palpate for any tenderness or swelling over the mastoid process.
Otoscopic exam
Anatomic landmarks of the tympanic membrane
Normal tympanic membrane
Infant
Child over 3 years of age
Pneumoscopy
Weber test
Rinne test

Front 218

Weber Test

Back 218

The stem of a vibrating tuning fork is placed in the middle of the patient's scalp. The tone should be heard equally in both ears

Front 219

Rinne Test

Back 219

The stem of a vibrating tuning fork is placed on the mastoid until sound is no longer heard. The fork is then held 1-2 inches in front of the pinna and in a normal result air conduction is greater than bone conduction.

Front 220

pneumoscopy

Back 220

Air is blown or squeezed into the external canal to assess mobility of the tympanic membrane. The bulb and otoscope can be held up in one hand, freeing the other hand to manipulate the auricle, allowing for better visualization of the tympanic membrane.

Front 221

What diagnostic tests can be used for dx ear exams?

Back 221

Tympanometry
Acoustic reflectometry
Conventional, or pure tone, audiometry
Electrophysiologic audiometry
Screening tests for neonates and/or infants: high-risk register (HRR), evoked otoacoustic emission (EOE)
Computed tomography (CT)
Tympanocentesis
Myringotomy

Front 222

Tympanometry

Back 222

Detects fluid in the middle ear; determines the mobility of the tympanic membrane; most reliable in children older than 6 months

Front 223

Acoustic reflectometry

Back 223

Also known as sonar impedance analysis, alternative to immittance measures to determine middle ear effusion; measures the incident and reflected sound in the canal

Front 224

Electrophysiologic audiometry

Back 224

Measures the electrophysiologic response of the auditory system to sound; auditory brain stem response (ABR) test or brain stem auditory evoked response (BAER) audiometry; ABR is the standard for physiologic testing during infancy and most accurate available method for determining hearing function

Front 225

Tympanocentesis

Back 225

A needle is placed in the tympanic membrane; definitive in identifying fluid in the middle ear and the causative organism

Front 226

Myringotomy

Back 226

An incision is made into the tympanic membrane, and a flap is left open to drain fluid

Front 227

External ear canal infections:

Back 227

furuncle, otitis externa

Front 228

furuncles

Back 228

More common in older children
May be secondary to other infections such as impetigo or folliculitis

Front 229

otitis externa

Back 229

Overzealous cleaning of the canal
Allergies
Excessive wetness of the canal caused by swimming or other activities

Front 230

Middle ear infections

Back 230

acute otitis media (AOM), Otitis media with effusions (OME), perforation, cholesteatoma, mastoiditis

Front 231

AOM

Back 231

Less than age 2 years
History of ear infections
Enrollment in day care
Bottle-feeding
Exposure to secondary smoke
Immunocompromised
Pacifier use after age 6 months

Front 232

risk factors for mastoiditis

Back 232

Less than age 2 years
High antibiotic usage
Multiple AOM episodes

Front 233

risk factors for acute otitis media (AOM), Otitis media with effusions (OME), perforation, cholesteatoma,

Back 233

Less than age 2 years
History of ear infections
Enrollment in day care
Bottle-feeding
Exposure to secondary smoke
Immunocompromised
Pacifier use after age 6 months

Front 234

risk factor ear trauma

Back 234

Sports participation
Exposure to loud noises

Front 235

risk factor for hearing loss

Back 235

Positive family history
Prenatal/perinatal infection
Maternal ingestion of ototoxic drugs
Head/neck malformations
Birth trauma
Neurologic conditions
Frequent ear infections
Chronic nasal congestion
Head injury
Incomplete immunizations
Exposure to continual loud noises

Front 236

what health promoting factors during the prenatal period reduce ear complications?

Back 236

Early prenatal care
Screening pregnant women for prenatal infections (e.g., sexually transmitted diseases [STDs], herpes, cytomegalic inclusion disease [CID], rubella, toxoplasmosis)
Instruct women on safe sex practices, signs and symptoms of STDs, and importance of treatment.
Instruct women on danger to fetus of tobacco, alcohol, and other substances.
Rubella titer on women who are considering pregnancy and have no documented rubella immunization or immunity. Give rubella vaccine. Do NOT give to pregnant women or provide in immediate postpartum period.
Instruct pregnant women on dangerous effects of medications on fetus.
Stress need to notify health professionals of being pregnant before taking any medications, radiographic exams, or other diagnostic tests.

Front 237

What health promoting factors reduce the change of infection?

Back 237

Maintain general well being (e.g., good diet, sleep, careful handwashing)
Keep immunization status current
Identify and modify risk factors and behaviors (e.g., secondhand smoke, exposure to loud noises, breastfeed if possible, do not prop bottle, eliminate pacifier by age 6 months, smaller day care arrangements, tobacco use)

Front 238

what health promotion can help early identification of problems?

Back 238

Routine screening
Identify populations at risk and screen them more frequently. Also monitor language skills.
Importance of following prescribed treatment plans and follow-up
Signs and symptoms of hearing problems

Front 239

What health promotion activities prevent injury prevention?

Back 239

Clean ears gently. Do not put any objects into the ear canal.
Wear ear protection when participating in sports in which ears can be injured or if operating dangerous equipment
Reduce exposure to loud environmental noises

Front 240

the etiology of impacted cerumen?

Back 240

Overzealous cleaning of the ear canal with a
cotton-tipped applicator is the most common cause of impacted cerumen.
Narrow ear canals and dermatologic conditions of the preauricular skin and scalp are also causes.

Front 241

what is the incidence of increased chances of impacted cerumen?

Back 241

Often caused by normal individual variants
Common in children with Down syndrome
Possible in children with ear infections

Front 242

How remove impacted cerumen?

Back 242

If tympanic membrane must be visualized, removal is urgent (e.g., child has URI, fever, or decreased hearing)
Place 2 to 3 drops of mineral oil, hydrogen peroxide, or docusate disodium (Colace) in the canal to soften the wax.
Leave for 20 minutes and then attempt removal by
water pressure
curettes

Front 243

If there is no urgency for removal of impacted cerumen?

Back 243

Place 3 to 4 drops of mineral oil, olive or vegetable oil, or hydrogen peroxide in the ear to soften the wax
Insert a cotton wick to prevent the liquid from dripping out
Repeat for 2 to 3 nights
Treat otitis externa or OM if present

Front 244

What kind of counseling and prevention do you do for disimpacting cerumen?

Back 244

Removal process
Demonstrate all equipment
Do not use cerumen solvents. Cerumen is normal and protects the canal
Instillation of 2 to 3 drops of hydrogen peroxide, mineral oil, or baby oil in ears twice a week if impaction is a recurring problem

Front 245

What is a furuncle?

Back 245

A furuncle is a localized abscess of a hair follicle in the
outer part of the external canal.
Staphylococcus aureus most common cause
Pain and possible discharge
Visualized on otoscopic examination

Front 246

What is the tx for a furnuncle?

Back 246

Broad-spectrum systemic antibiotic
Cephalexin 50 mg/kg/day in four divided doses or
Dicloxacillin 12.5 to 25 mg/kg/day in four divided doses for 10 days
Incision and drainage may be needed (refer)
Acetaminophen and warm soaks for discomfort

Front 247

What is Otitis Externa?

Back 247

s an inflammation or infection of the external ear canal. It is commonly called "swimmer's ear" and is caused by the loss of the protective cerumen film from frequent exposure to the water, leading to chronic irritation and inflammation of the canal.

Front 248

What is the etiology of otitis externa?

Back 248

Causative agents for infection of the external ear canal include:
Bacteria
Pseudomonas aeruginosa — most common
Streptococci, Staphylococcus epidermidis, Proteus sp, and mycoplasma
Fungi (aspergilli and candida)
Viruses (herpes)
Trauma to the external canal caused by digital irritation or foreign body should be suspected, especially if indicated in the history.
Other causes:
Allergic reaction to chemical or physical agents (e.g., Ceruminex drops; detergents; hair sprays; chemical hair treatments; pigments in clothing; metallic, plastic, or rubber compounds)
Excessive wetness caused by swimming, bathing, or high humidity
Excess cerumen or loss of protective cerumen after exposure of the canal to excessive moisture
Stress
Excessive dryness (eczema) if the child/family has a positive history

Front 249

What is the pertinent hx of otitis externa?

Back 249

Sudden onset of pain, especially when the ear is touched or the earlobe moved
Hearing loss, or a feeling of the ear being blocked or clogged
Swimmer's ear or chronic infections: vague discomfort and pruritus, decreased hearing and malodorous discharge

Front 250

What will you find on PE with otitis externa?

Back 250

Pain on movement of the pinna or when pressure is applied to the tragus and when the speculum is inserted into the canal
External canal is red and swollen and there may be discharge

Front 251

tx for otitis externa?

Back 251

Clean debris from the canal; do not use cotton swabs
Insert a small gauze wick or absorbent sponge into the external canal to carry antibiotic corticosteroid solution into the canal if needed
Keep ear dry

Front 252

medication mgmt for otitis externa?

Back 252

Ciprofloxacin/hydrocortisone otic suspension (Cipro HC otic) has a broad spectrum for covering resistant organisms
Combination eardrops of antibiotics, hydrocortisone, and propylene glycol
Ofloxin (Floxin) solution 0.3% otic drops every 12 hours
Patients 1 year of age and older
Highly effective if P. aeruginosa or S. aureus is a cause
Analgesics for pain

Front 253

when should you refer for a complicated otitis externa?

Back 253

Consult physician in the following situations
Symptoms worsen after 24 hours of treatment
No response to treatment after 2 to 3 days
Visualization of a foreign body that cannot be easily removed
Child has a chronic illness or is immunologically depressed
Refer to ENT surgeon if incision and drainage needed

Front 254

what is the f/u for otitis externa?

Back 254

Immediate recheck if pain worsens or child develops sensitivity to eardrops
Return visit in 2 to 3 days if there is marked cellulitis or if the tympanic membrane is not visualized
Recheck in 10 days
Continue treatment if the infection is not completely resolved, and recheck again in 10 days
Return visit if symptoms worsen, do not improve within 48 hours, or recur
Telephone if severe pain

Front 255

what is the counseling and prevention for otitis externa?

Back 255

Explain cause
Acute pain should subside within 48 hours
Treatment plan, medications, and instillation of eardrops
Need to keep ears dry
Side effects of eardrops may include a local stinging or burning sensation and a rash where the drops have come in contact with the skin
Recurrences are common
After swimming or showering and during hot humid weather, instill 2 to 3 drops isopropyl alcohol in both canals as prophylactic treatment

Front 256

what is the pertinent hx of trauma to the external ear and canal?

Back 256

May report:
Painful blue discoloration of the pinna
Hematomas of the external ear
Smooth masses that distort the contour of the pinna
Discharge or history of inserting foreign objects in body orifices

Front 257

what is the etiology of trauma to the external ear and canal?

Back 257

Trauma to the external ear canal results in injury to the auricle and may be caused by athletic injury, fall, animal bite, or thermal injury (hot or cold). The resulting injury may be a laceration, hematoma, burn, or ear piercing.

Front 258

what is the PE of trauma to the external ear and canal?

Back 258

Athletic injuries may cause ecchymosis, hematoma, or seroma of the auricle
Abrasions to the external ear may be seen in
Animal/human/insect bites
Minor trauma
Lacerations
Bruises
Puncture wounds
Accidental falls
Frostbite and burns cause thermal damage to the external ear
Objects placed in the ear that are used to clean the ear, such as cotton-tipped applicators or bobby pins

Front 259

what is the tx of trauma to the external ear and canal?

Back 259

Minor trauma — treat symptomatically with ice and analgesics (acetaminophen) for pain

Front 260

when to refer for trauma of the external ear and canal?

Back 260

ENT if there is a history of:
Significant head trauma
Clear or bloody ear drainage
Loss of hearing
Vertigo or ataxia
Signs of basilar fracture
Laceration, hematoma, or burn of the pinna
Notify appropriate local authorities if physical abuse is suspected

Front 261

what is the counseling and prevention of trauma to the external ear and canal?

Back 261

Wear protective equipment when participating in sports in which ear or other trauma is possible
Age-appropriate injury prevention
Treatment plan and need for referral and follow-up, if indicated

Front 262

what is the etiology of foreign body in the external ear?

Back 262

Results from inquisitive children or their companions placing objects in the ear; insects may also become lodged in the ear

Front 263

what is the c/o of foreign body in the external ear?

Back 263

Pain, itching, buzzing (insect)
Feeling of fullness in the ear
Decreased hearing
Discharge from the ear

Front 264

when to refer a foreign body in the external ear?

Back 264

ENT when object is:
An alkaline button battery, which causes rapid tissue destruction, ulceration, and perforation of the tympanic membrane
Not easily removed
Tightly wedged into the canal
ENT when the:
Canal is bleeding or swollen
Child is unable to cooperate

Front 265

Causative bacterial agents for middle ear infection include:

Back 265

Streptococcus pneumoniae — the most common causative organism
Nontypeable Haemophilus influenzae
Moraxella (Branhamella) catarrhalis
Group A beta-hemolytic streptococcus
S. aureus
P. aeruginosa

Front 266

The following viral infections may put the child at risk for middle ear infection by possibly impairing eustachian tube function:

Back 266

Respiratory syncytial virus (RSV)
Influenza virus (types A and B)
Adenovirus

Front 267

OM: Viruses may be involved in about ____of cases.

Back 267

40%

Front 268

Certain strains of ______ and most strains of ________ are resistant to amoxicillin because of beta-lactamase production.

Back 268

H. influenzae
M. catarrhalis

Front 269

Drug-resistant S. pneumoniae (DRSP) has significantly increased in the United States in the past few years.
The groups most at risk for DRSP are:

Back 269

Children under age 24 months
Those who have recently received beta-lactam drugs, were recently treated with antibiotics, and/or had a recent ear infection
Children exposed to large numbers of other children — for example, day care attendance in children age 2 months to under age 5 years, or household crowding, was another risk factor after age 2 years
Those with immune deficiencies (e.g., sickle cell disease, HIV, malignancy)

Front 270

What is the peak age of OM?

Back 270

Its peak prevalence is from 6 to 36
months of age, and it declines at about 6 years
of age.

Front 271

What is the pertinent history of OM?

Back 271

Acute onset of signs and symptoms: otalgia or irritability and signs such as pulling on the ear, otorrhea, and/or fever

Front 272

What are the PE findings with an OM?

Back 272

Otoscopic exam
Presence of middle ear effusion:
Tympanic membrane is full or bulging
Air fluid level behind the tympanic membrane
Mobility is decreased or absent on insufflation
Otorrhea (discharge)

Front 273

What is the diagnositc criteria for OM?

Back 273

History of acute onset of signs and symptoms
Presence of middle ear effusion
Signs and symptoms of middle ear inflammation

Front 274

How would you treat OM?

Back 274

If the child is over age 2 years and is clinically stable and nontoxic, watchful waiting and symptomatic treatment alone for AOM are possible alternatives to antimicrobial therapy.
Otherwise-healthy children between the ages of 6 months to 2 years with nonsevere illness at presentation and uncertain diagnosis and children 2 years and older without severe symptoms at presentation or an uncertain diagnosis

Front 275

What is the pain management for OM?

Back 275

Especially important during first 24 hours, regardless of whether antibiotics are prescribed:
Warm compresses to affected ear
Mild to moderate pain: acetaminophen or ibuprofen
Moderate to severe pain: codeine or a codeine analog (requires a prescription, has some risks, do not use in infants or very young children)
Warm oil eardrops or eardrops with benzocaine and antipyrine (Auralgan) (may have limited effect)

Front 276

When does a child need surgical intervention for OM?

Back 276

Myringotomy and/or placement of tympanostomy tubes that is performed by an ENT surgeon is possible in children with:
Chronic middle ear fluid that fails to respond to antimicrobial therapy (age 3 months or more)
Recurrent AOM
Suppurative complications
Eustachian tube dysfunction
Adenoidectomy in children over 4 years of age with recurrent AOM is done as a substitute for, or in conjunction with, insertion of tympanostomy tubes.
Tympanocentesis usually performed by an ENT specialist and culture of the exudate in the following instances:
If the diagnosis is uncertain
The child is seriously ill or toxic
Response to antibiotic therapy is unsatisfactory
Suppurative complications develop
OM in a newborn or in immunologically deficient patients
AOM develops despite antibiotic therapy

Front 277

When to begin abx for OM?

Back 277

Begin antibiotic therapy if the condition worsens or if the condition has not improved in 48 to 72 hours.
If the child is less than age 2 years, antibiotic therapy is indicated for symptomatic AOM.

Front 278

What is the first line tx of OM ? ABX

Back 278

It is important to prescribe an adequate antibiotic dose for the initial treatment of symptomatic children.
The first drug of choice is amoxicillin. Oral cephalosporins (except cefuroxime axetil) and macrolides do not provide adequate coverage against resistant strains of S. pneumoniae.
If allergic to penicillin, treat with one of the following:
Azithromycin (for children allergic to penicillin)
Oral cephalosporins
Macrolides
Trimethoprim-sulfamethoxazole (TMP-SMX) (rates of resistance to pneumococci are high)
Treat for 10 days

Front 279

How to treat if OM reoccurs after abx treatment?

Back 279

If recurrence of acute symptoms occurs after a full course of amoxicillin, treat again with a second-line antibiotic. A second-line antibiotic is also indicated if:
Persistent fever, ear pain, irritability
Tympanic membrane findings of redness, bulging, or otorrhea after 3 days of therapy

Front 280

What is 2nd line treatment for OM?

Back 280

Second-line therapy includes:
Oral amoxicillin clavulanate (Augmentin)
Higher doses, 80 to 90 mg/kg/day, of the amoxicillin component
Clavulanate dose should remain at ~10 mg/kg/day
Oral cefuroxime axetil (Ceftin), 30 mg/kg/day or
Intramuscular ceftriaxone (Rocephin) for severe infections
AOM caused by S. pneumoniae is least likely to be resolved without therapy

Front 281

How to treat persistent AOM?

Back 281

Persistent AOM is likely to be caused by a different pathogen than the initial infection. Treat with an antibiotic, such as cefaclor, TMP-SMX, erythromycin/sulfisoxazole, amoxicillin/clavulanate potassium, or cefixime.If antibiotics must be prescribed, sulfisoxazole is the most effective at preventing recurrences.

Front 282

What counseling would you do for an AOM?

Back 282

Causes of ear infections
Risk factors and ways to modify them:
Avoid exposure to secondhand smoke
In children over 6 months of age, limit or eliminate pacifier use
Avoid supine bottle feeding (bottle propping)
Using smaller child care center or having child attend less frequently (fewer viral URIs) might significantly reduce the incidence of recurrent AOM
Treatment plan
Conjugate pneumococcal vaccine in children under age 2 years and high-risk children over age 2 years
Influenza vaccine in high-risk children and children over age 2

Front 283

What two types of patients would you f/u with for an AOM?

Back 283

Less than age 3 months — return in 1 to 2 days because of the increased risk of treatment failure
3 months of age and older — return visit if no improvement in 48 to 72 hours or condition worsens (need to change antibiotic); return visit in 4 to 8 weeks to evaluate for OME

Front 284

When would you refer for an AOM?

Back 284

Consult or refer to a physician in the following situations:
Infant less than 2 months of age
Signs and symptoms of meningitis
Unresponsive to appropriate antibiotics in 48 to 72 hours
More than three episodes of AOM in 6 months or four episodes in 12 months
Refer for audiologic testing any child who fails a hearing screen or if hearing loss is suspected. Allow the acute infection to clear before testing.

Front 285

What is the etiology of AOM with effusion?

Back 285

The causes of OME are multifactorial:
Infection
Eustachian tube dysfunction
Allergy

Front 286

What is the most common agent in AOM with effusion?

Back 286

The most common bacteria are the same as for AOM except that the relative frequency of H. influenzae is greater in OME than in AOM.

Front 287

What is the pertinent hx in AOM with effusion?

Back 287

Gradual or insidious onset
Often asymptomatic
May present with hearing loss, clogged ear, or crackling sensation in the ear

Front 288

What would you expect in PE for AOM with effusion?

Back 288

The tympanic membrane appears concave or retracted with decreased or irregular mobility. Middle ear effusion is evident on pneumatic otoscopy, but there are no signs of acute inflammation.

Front 289

What is the tx and management of AOM with effusion?

Back 289

Watchful waiting for 3 months from onset of effusion if child is not at risk for speech, language, or learning problems.
Hearing tests should be conducted when OME persists for 3 months or longer, or at any time language delay, learning problems, or significant hearing loss is suspected.
Corticosteroids, antihistamines, or decongestants are not recommended.
Myringotomy/tympanostomy tubes (bilateral): consider this option in otherwise-healthy children age 1 to 3 years whose OME has lasted 4 to 6 months and who have a hearing deficit of 20 dB or more in the better-hearing ear.
Adenoidectomy: consider this option only in the presence of adenoid pathology.
Tonsillectomy: not appropriate for treating OME in a child of any age.
Go to http://www.aafp.org/x1596.xml for more information regarding OME treatment.

Front 290

what is the counseling for AOM with effusion?

Back 290

Explain the diagnosis, and state that most often, OME resolves within 3 months
Treatment plan and medications
Signs of hearing loss
Relationship between speech/language development and hearing
Importance of follow-up and testing to evaluate for hearing loss
f/u in next month if symptoms arise

Front 291

When do you refer for AOM with effusion?

Back 291

Refer to audiologic testing—any child age 1 to 3 years with one or more of the following: OME for 3 months, fails a hearing screen, or has school or behavior problems related to hearing difficulty
Refer to ENT if OME does not resolve with appropriate treatment in 3 months or if significant hearing loss is present on audiometric testing
Note to the school nurse and the child's teacher explaining that the child has temporary hearing loss

Front 292

Perforations of the Tympanic Membrane/Cholesteatoma
What is the pertinent hx?

Back 292

The presenting symptom is usually a foul-smelling discharge.
There is no pain, and fever is rare.

Front 293

Perforations of the Tympanic Membrane/Cholesteatoma
What would you find on PE?

Back 293

The perforation is visualized on otoscopic exam.
Suspect cholesteatoma if discharge is foul-smelling and a pearly white mass is seen within the perforation.

Front 294

Perforations of the Tympanic Membrane/Cholesteatoma
What is the treatment?

Back 294

For perforations with serous or purulent discharge, culture the discharge
treat with antibiotic/corticosteroid eardrops (suspensions are less irritating) 3 times a day for 1 week
Culture the discharge
For systemic symptoms, select an antibiotic that is effective against beta-lactamase organisms and schedule a recheck in 2 weeks

Front 295

Perforations of the Tympanic Membrane/Cholesteatoma: What is the counseling?

Back 295

Condition and treatment plan
Relationship between the condition and hearing loss
Need for follow-up and the importance of keeping scheduled appointments with specialists
The ears need to be protected before bathing or shampooing
Cotton plugs covered with petrolatum ointment help to keep the ears dry
No swimming at this time

Front 296

Perforations of the Tympanic Membrane/Cholesteatoma: What is the f/u?

Back 296

By specialist or scheduled weekly visits until the discharge has cleare

Front 297

Perforations of the Tympanic Membrane/Cholesteatoma: What is the reasons for referrals?

Back 297

ENT if cholesteatoma is present (immediate referral)
ENT if chronic perforations are present

Front 298

Mastoiditis- what is it?

Back 298

Mastoiditis is an infection of the mastoid area that causes destruction of the mastoid air cells.
Acute mastoiditis involves pus in the mastoid area.
The patient presents with fever and tenderness.
Chronic mastoiditis is destruction of the mastoid
bone.

Front 299

Mastoiditis- what is the etiology?

Back 299

Most common pathogens are S. pneumoniae and Streptococcus pyogenes.
S. aureus and H. influenzae are occasionally seen.

Front 300

Mastoiditis- what is the incidence?

Back 300

Can occur in any age group — 60% of the patients are under 2 years old.
Antibiotics may affect the incidence and morbidity of acute mastoiditis.
In the United States, antibiotics are used routinely to treat AOM, yet the incidence of acute mastoiditis has been rising.

Front 301

Mastoiditis- what is the Pertinent hx?

Back 301

Postauricular pain and swelling
Fever
Outwardly displaced pinna
Ear pain

Front 302

Mastoiditis- what is the PE?

Back 302

Mastoid area often appears red and swollen.
Earliest sign: severe tenderness on percussion of the mastoid
AOM: usually present
Late sign: pinna is pushed forward by postauricular swelling

Front 303

Mastoiditis- what is the tx?

Back 303

Typically myringotomy with or without tube placement to obtain material for culture
Hospitalization and intravenous antibiotics
Initial therapy: ceftriaxone plus nafcillin or clindamycin until culture result is obtainedTypically myringotomy with or without tube placement to obtain material for culture
Hospitalization and intravenous antibiotics
Initial therapy: ceftriaxone plus nafcillin or clindamycin until culture result is obtained

Front 304

Internal Ear Trauma- what is the etiology?

Back 304

Middle ear trauma is often caused by foreign bodies placed in the ear, slapping (child abuse), poking, perforations, or barotrauma.
Inner ear trauma can be caused by head trauma (concussion) or exposure to loud noise.

Front 305

Internal Ear Trauma- what is the pertinent hx?

Back 305

History of trauma
May complain of pain, itching, buzzing (with an insect), a feeling of fullness in the ear, decreased hearing, or discharge from the ear

Front 306

Internal Ear Trauma- what is the PE?

Back 306

A foreign object or insect visualized on otoscopic examination
Possible hemotympanum, or bleeding into the middle ear space, and a conductive hearing loss
Barotrauma — a serosanguinous effusion and a moderate-to-severe conductive hearing loss; history may indicate recent airline travel or underwater diving
Blunt head trauma — injury to the inner ear structures, resulting in persistent or transient high-tone sensorineural hearing loss and vertigo
Objects stuck in the ear and blunt trauma; may cause perforation of the tympanic membrane; a conductive hearing loss is immediate

Front 307

Internal Ear Trauma- what is the tx

Back 307

Minor trauma: symptomatically with ice and analgesics (acetaminophen) for pain

Front 308

Internal Ear Trauma- what is the counseling?

Back 308

Wearing protective equipment when participating in sports in which ear or other trauma is possible
Age-appropriate injury prevention
Treatment plan and need for referral and follow-up, if indicated?

Front 309

When to refer an internal ear trauma?

Back 309

ENT if there is a history of:
significant head trauma
clear or bloody ear drainage
loss of hearing
vertigo or ataxia
signs of basilar fracture
laceration, hematoma, or burn of the pinna
Notify appropriate local authorities if physical abuse is suspected.

Front 310

What are the three catagories of hearing loss?

Back 310

Conductive hearing loss
Sensorineural hearing loss
Mixed conductive-sensorineural hearing loss

Front 311

Hearing Impairment: Incidence

Back 311

Approximately 15% of school-age children have significant conductive hearing losses.
OM and its sequelae are the most common causes of conductive hearing losses during childhood.
Acquired conductive hearing losses are the most common types of hearing loss in childhood.

Front 312

What is conductive hearing loss?

Back 312

Conductive loss, or middle ear hearing loss, results from
a blockage of the transmission of sound waves from the external ear to the middle ear. Most commonly it involves
an interference with the volume of the sound and is
usually responsive to treatment.

Conductive hearing loss is characterized by normal bone conduction and reduced air conduction hearing.

Front 313

What are the causes of conductive hearing loss?

Back 313

Causes include:

Middle ear effusions
OM and its sequelae
Blockages of the ear canal (foreign body or impacted cerumen)

Front 314

Conductive Hearing Loss: Diagnosis- what is the pertinent hx?

Back 314

Hearing loss
Symptoms of AOM or middle ear effusion
History of foreign body and/or impacted cerumen
History of allergies
History of head or ear trauma
Middle ear anomalies
Cholesteatoma

Front 315

Conductive Hearing Loss: Diagnosis- what is the PE?

Back 315

Possible otitis externa, OM, foreign body, impacted cerumen, tympanic membrane perforation, growth or tumor, cholesteatoma may be visualized
Rinne test on affected side: bone conduction (BC) > air conduction (AC)
Weber test sound lateralized to involved side
Average hearing loss 27-31 dB (mild), intermittent, may occur in one or both ears

Front 316

Sensorineural Hearing Loss

Back 316

Sensorineural hearing loss, or perceptive or nerve deafness, is a result of a lesion in the cochlear structures of the inner ear or the neural fibers of the acoustic nerve (cranial nerve VIII). This type of hearing loss results in the distortion of sound and problems in discrimination and often involves high-range frequencies.

Hearing deficits can be caused by genetic or hereditary factors, environmental or acquired disease, or malformations. In one third of the cases the cause is unknown.

Front 317

What are the causes of Sensorineural Hearing Loss?

Back 317

Congenital causes include:
Perinatal infections
Premature birth
Autosomal recessive and dominant inheritance of deafness syndromes
Consequences of acquired conditions include:
Infection (e.g., AOM, OME, meningitis)
Ototoxic medications
Exposure to loud noises

Front 318

Sensorineural Hearing Loss- What is the pertinent hx?

Back 318

May report distortion of sound and problems with sound discrimination
Congenital abnormality may be present
Speech delay difficulties

Front 319

Sensorineural Hearing Loss- What is the PE?

Back 319

May be normal, possible dysmorphic facial features suggesting presence of a syndrome
Head and/or neck abnormalities
Abnormalities of pinna and external ear canals
Weber test: sound louder in unaffected ear
Rinne test: normal ear or ear with sensorineural hearing loss air conduction greater than bone conduction
Audiometric testing: soft sounds not well-perceived, loud sounds perceived almost normally
Acquisition of language skills affected

Front 320

Mixed Conductive-Sensorineural Hearing Loss

Back 320

This type of hearing loss involves blockage of sound transmissions in the middle ear and along neural pathways. Mixed conductive-sensorineural hearing loss results from recurrent OME causing damage to the structures of the middle and inner ear.

For etiology, see screens 61 through 64 for conductive and/or sensorineural hearing loss.

Front 321

Hearing Loss Management

Back 321

Treatments and Medications

Refer for audiologic testing.
May include medication or surgery for a conductive hearing loss.
Amplification (hearing aids; bilateral is best) benefits most children.
Cochlear implants have shown good results in postlingual children with sensorineural loss if done within 4 years of hearing loss.
Children with identified hearing losses are best managed by an interdisciplinary team.

Front 322

Hearing Loss- Counseling?

Back 322

Early detection is imperative. The earlier the hearing impairment occurs, the more serious the consequences can be for language and other development.
Disease process, type of loss, and causes:
Conductive loss is usually reversible
Sensorineural loss is often irreversible
Effect on the child of being hearing impaired:
Speech and language development
Social development
Learning process
Care and function of hearing aids if indicated

Front 323

When to refer to an audiologist?

Back 323

Audiologist, for all children who:
fail the hearing screen.
have frequent or chronic OM.
have facial or external ear deformity.
ENT specialist if surgery for conductive hearing loss (usual bilateral myringotomy with tympanostomy tubes)
Refer to multidisciplinary team, hearing center, or ENT specialist if hearing impairment detected

Front 324

summary of hearing loss

Back 324

Conductive loss – usually reversible
Sensorineural loss – usually irreversible
Mixed conductive-sensorineural involves damage of structures – may be irreversible

Front 325

What are the Allen cards? What ages?

Back 325

The Allen card test is made up of 4 flash cards containing 7 figures: a truck, house, birthday cake, bear, telephone, horse, and tree. When viewed at 20 feet, these figures represent 20/30 vision. It is important that a child identify verbally or by matching all 7 pictures before actual visual testing.

3/4 y/o

Front 326

When would you use Fluorescein Staining?

Back 326

Fluorescein staining identifies corneal abrasion.
Fluorescein pools and stains; stain is brighter in
areas of abrasion.
Fluorescein staining reveals a foreign body trapped beneath the upper eyelid as a faint vertical pattern
on the cornea.

Front 327

What is the etiology of blindness or visual impairment?

Back 327

Congenital defects (e.g., congenital cataract)
Malignancy
Chronic diseases (e.g., diabetes)
Infections
Drugs (e.g., chloramphenicol)
Trauma
Radiation
Enzyme deficiencies

Front 328

What is the incidence of blindness or visual impairment?

Back 328

Retinoblastoma is the most common ocular tumor of childhood.
Of children with congenital cataracts, 60% have other ocular problems. The most common is a lens defect in the neonate.

Front 329

What is the common reasons of blindness or visual impairment?

Back 329

Preterm birth
Congenital rubella
Chromosomal abnormalities
Ophthalmia neonatorum
Congenital syphilis
Toxoplasmosis

Front 330

what are your dd for blindness or visual impairments?

Back 330

Congenital cataract
Acquired cataract
Retinoblastoma
Glioma
Craniopharyngioma
Optic neuritis
Glaucoma

Front 331

what is the etiology of eye deviation?

Back 331

The misalignment of the eyes is called strabismus.
Amblyopia, or loss of vision, may be caused by strabismus, refractive error, or cataracts.
The eyes may appear to be misaligned in some children because of enlarged epicanthal folds and a flat nose; this is called pseudostrabismus.
Nystagmus is the involuntary rapid movement of the eyes in the horizontal, vertical, or rotary planes of the eyeball. It may be idiopathic, familial, or secondarily caused by visual loss from other systemic problems.

Front 332

what is the incidence of eye deviation?

Back 332

Strabismus is a common condition that affects approximately 5% of all children.
Strabismus may be present at birth or shortly thereafter or may not manifest until 2 to 3 years of age.
Amblyopia occurs in 50% of children with strabismus.
Amblyopia is the most common cause of visual loss in American children and affects between 2% and 2.5% of the general population.
Esotropia is the most common eye movement disorder in young children.

Front 333

what is the risk factors of eye deviation?

Back 333

Prematurity
Family history
Illness
Trauma
Large refractive errors

Front 334

what is the dd of eye deviation?

Back 334

Strabismus
Esotropia
Exotropia
Hyperphoria/hypertropia
Hypophoria/hypotropia
Third cranial nerve palsies
Nystagmus

Front 335

Strabismus

Back 335

Strabismus is a condition in which the normal binocular alignment of the eyes is disturbed. Extraocular movement (EOM) is abnormal, and esotropia or exotropia is possible. The corneal light reflex is off center in one eye. Eye movement is detected with the cover-uncover test. Vision screening reveals possible decreased vision in one eye.

Front 336

Esotropia

Back 336

Esotropia is an inward deviation of the eye. The deviation is always present. Surgical correction is required. EOM, corneal light reflex, and cover-uncover test results are abnormal (covered eye moves inward). Vision screening results are abnormal.

Front 337

Exotropia

Back 337

Exotropia is the outward deviation of the eye. EOMs, the corneal light reflex, and the results of cover-uncover tests are abnormal.

Front 338

hypertropia

Back 338

Hyperphoria/hypertrophia is the upward deviation of the eye. EOM, the corneal light reflex test (displaced in the lower part of cornea), and results of the cover-uncover test (eye moves inward) are abnormal. Vision screening results are abnormal.

Front 339

hypotropia

Back 339

Hypophoria/hypotropia is the downward deviation of the eye. It may occur with a blow-out fracture of the orbit. The EOMs are abnormal. Light is reflected in the upper quadrant of the pupil in the corneal light reflex. Vision screening results are abnormal. Double vision is possible.

Front 340

Third Cranial Nerve Palsies

Back 340

With third cranial nerve palsies, EOMs show a loss of abduction of the eye. Cover-uncover test results are abnormal because of eye paralysis. The corneal light reflex is displaced medially. Visual acuity can be normal or abnormal; it depends on the cause of the disease. It is common in children and may indicate neurologic disease. It may be a benign condition occurring 1 to 3 weeks after a febrile illness.

Front 341

Nystagmus

Back 341

Nystagmus is a spontaneous, rhythmic, back-and-forth movement of one or both eyes. Intracranial tumors and/or CNS lesions are associated with nystagmus.

Front 342

what is the management of eye deviations?

Back 342

Esotropia, exotropia, hypertropia, hypotropia, nystagmus, third cranial nerve palsy: Refer to an ophthalmologist/physician.
Sixth cranial nerve palsy: Refer to a physician. If indicated, obtain a lead level.
Amblyopia: Refer to an ophthalmologist. Treatment is based on cause; for refractive error, glasses are prescribed; for strabismus, patching and surgery are recommended; for a cataract, surgery is recommended.
Pseudostrabismus: No management recommended.

Front 343

what is the etiology of an eye injury?

Back 343

One third of all blindness in children results from trauma, usually trauma that is avoidable. Most injuries are related to sports, projectile toys, sticks, and BB guns.
Other causes include chemical burns caused by children using sprays or nozzles on chemicals or cleansers for the garden, garage, or home.
Sunlamps, sun reflection off snow, and welding are common causes of ultraviolet burns. Thermal burns tend to damage the eyelid.

Front 344

what is the incidence of an eye injury?

Back 344

Forty percent of eye injuries occur in the home.
Boys are the most frequent victims (4:1).
Basketball and baseball have the highest injury rate.
Every year 100,000 eye injuries occur in school-age children as a result of sports activities.

Front 345

common risk factor for eye injury

Back 345

Under age 16 years
Male
Participation in sports
Wearing contact lenses

Front 346

what are the dd for eye injury?

Back 346

Eyelid injury
Corneal abrasion
Foreign body in or on the cornea
Black eye
Orbital fracture
Chemical burns -True ocular emergency

Front 347

What is the management for eye injury?

Back 347

Treatments
Irrigate the tissues and debride with saline.
Use polysporin ophthalmic ointment four times a day and a sterile dressing.
Use cold compresses to decrease swelling.
Counseling
Discuss the condition and the treatment.
Discuss application of ointment on the lid.
Follow-Up: Schedule a visit if there is an increase in tissue edema, erythema, and/or tenderness to rule out cellulitis or if there is pain on movement of the eye.
Referrals: Refer to an ophthalmologist and/or a plastic surgeon if the lid injury is deep and requires suturing.

Front 348

Management: Corneal Abrasions

Back 348

Treatments
Proparacaine 0.5% is used as a topical anesthetic.
For gross eye examination, remove the contact lens, if present. Inspect under the upper eyelid for a foreign body.
Fluorescein staining is used to assess for corneal abrasion and/or a foreign body.
For a small abrasion, use an antibiotic ointment or drops with gram-positive coverage, such as gentamicin ophthalmic drops, every 2 hours for first day, then every 4 hours for the next 2 days.
Apply a dressing to the closed eyelid of the affected eye.
Consult a medical doctor (MD) when patching is used with infants; amblyopias may develop even with only a 24-hour patch.
Give tetanus booster if needed.
Never use topical steroids.
Counseling
Discuss the condition and the treatment.
Discuss the instillation of the eye drops.
Discuss application of the eye patch.
Follow-Up:
Return for immediate follow-up if the pain worsens or if sensitivity to eye drops occurs.
Return for regular follow-up in 24 hours for reexamination.
Referrals: Refer to an opht

Front 349

Management: Foreign Body

Back 349

Lightly patch the eye after estimating visual acuity.
If vitreal fluid or an irregular pupil is present, cover both eyes to decrease eye movements after visual acuity is established, and send the patient immediately to the emergency room with the head elevated 30 degrees.
Give a tetanus booster if needed.
Counseling: Discuss the course and treatment plan.
Follow-Up: Schedule visits as needed. If the lens is involved, careful follow-up by an ophthalmologist is required.
Referrals: Refer to a physician for removal of the foreign body; refer to an ophthalmologist if loss of vision (i.e., a cataract) occurs or if development of a rust ring on the cornea occurs.

Front 350

Management: Black Eye (Ecchymosis)

Back 350

Treatments
For minor trauma, apply ice to the area.
Use x-ray examination for possible nasal bone fracture or skull fracture.
Counseling
Discuss the cause and the course of the injury.
Discuss the discoloration cycle: black-blue-purple-green-yellow.
Discuss applying ice (a frozen package of peas or a cold pack) to the area for 5 to 10 minutes every hour for the first day.
Discuss the possibility of bilateral ecchymosis.
Follow-Up
Return for immediate follow-up if changes occur or pain increases.
Return for regular follow-up in 72 hours.
Referrals:
Refer to a neurologist if blunt head trauma and/or a skull fracture has occurred.
Refer to an ear, nose, and throat (ENT) specialist if a nasal fracture has occurred.
Refer to a physician and social services if there is suspicion of child abuse.

Front 351

Management: Orbital Fracture

Back 351

Treatments: Use Waters' projection x-ray examination or a computed tomography (CT) scan.
Counseling
Discuss the injury and the treatment.
Discuss eye/face protection for sports activities.
Discuss the use of molded polycarbonate sports goggles secured to the head by an elastic strap for sports that do not require a helmet or face mask.
For sports with helmets and face masks, discuss the use of polycarbonate face shields and guards.
Never wear orthodontic head gear while playing sports.
If the patient has amblyopia, he or she is able to participate in most sports but not boxing, wrestling, and martial arts or any other sport without eye protection.
Follow-Up: This is directed by the physician.
Referrals: Immediate referral to a physician is required.

Front 352

Management: Chemical Burns

Back 352

TRUE EMERGENCY!

Treatments/medications
Immediately irrigate the eye with water or saline for 10 to 30 minutes while consulting with a physician.
Do not apply an eye patch; continue to irrigate the eye until the emergency room is reached.
Obtain the name of the chemical in the eye, but do not stop irrigating.
Counseling
Discuss the nature of the emergency situation while irrigating.
Ascertain the name of the chemical and whether it is an acid or an alkali. Acid burns affect the cornea and anterior chamber of the eye. Alkali chemicals are progressive and can continue causing damage for days.
Follow-Up: This is directed by the ophthalmologist.
Referrals: Immediate referral is required.

Front 353

what is the etiology of eyelids and orbit infection?

Back 353

Eye and eyelid abnormalities are most likely caused by infection, inflammation, allergy, or trauma.
Infections of the orbit itself are life threatening and need to be referred immediately.

Front 354

what is the incidence of eyelids and orbit infection?

Back 354

Hordeolums tend to recur frequently, especially with itching caused by allergies.
Blepharitis is seen more often in adolescents than in children.
Orbital cellulitis is more common in children over 5 years of age.
Periorbital cellulitis is more common than orbital cellulitis and occurs more frequently in children under 5 years of age.

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Common Risk Factors of eyelid and orbit infections

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Lack of or inadequate immunizations
Infection
Chronic disease
Skin conditions
Trauma

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DD of eyelid and orbit infections

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Differential Diagnosis

Hordeolum (sty) or chalazion
Lid cellulitis (periorbital)
Orbital cellulitis
Blepharitis

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Management of eyelid and orbital infections

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Infections of the orbit are life-threatening: Refer the patient immediately for medical treatment

Hordeolum (Sty) and Chalazion

Treatments
Apply hot, moist compresses for 5 to 10 minutes, 4 to 5 times per day.
Scrub the lids at bath time with a cotton swab or washcloth and diluted baby shampoo.
Apply trimethoprim sulfate polymyxin B (Polytrim ophthalmic ointment) (one of many options) 4 times daily during the acute stage.
If repeated infections occur, rule out possible diabetes mellitus.
With chalazion, recurrences are very common.
Counseling
Discuss that the cause and the course of the condition may be chronic.
Discuss warm soaks; tell patient not to pick or squeeze the lesion; discuss instillation of the ointment; tell the patient to stop using the ointment if there is pain or burning.
Follow-Up: Return for follow-up if there is no improvement in 48 hours - sooner if the condition worsens (e.g., fever, pain with movement of the eye, swelling of the eyelid).
Referral:
Refer to an ophthalmologist if the condition persists, if the lesion obstructs the vision, or if the child complains of eye pain.
If it becomes a chronic condition, an immunologic work-up or examination for systemic disease may be required.
Lid Cellulitis

Refer the patient immediately for hospitalization.

Orbital Cellulitis

Refer the patient immediately for hospitalization. This is a life-threatening illness.

Blepharitis

Treatments
Use warm soaks with baby shampoo or warm compresses only to remove crusts on lids several times a day.
Use trimethoprim sulfate polymyxin B ophthalmic ointment on lid at bedtime.
For concurrent seborrhea of the scalp, use anti-dandruff shampoos.

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pink eye etiology

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Common causes include trauma (corneal abrasions, foreign bodies, and perforating injuries), congenital anomalies (nasolacrimal duct obstruction, congenital glaucoma), allergies (vernal conjunctivitis), herpes infection, neonatal conjunctivitis (chemical, gonococcal, and chlamydial), and conjunctival infections.
The primary causative agents of bacterial conjunctivitis are H. influenzae (50%) and S. pneumoniae (40% to 50%).
Viral conjunctivitis is caused by adenovirus and epidemic keratoconjunctivitis by adenovirus types 3, 8, and 19.

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incidence of pink eye

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Pink eye occurs in 1.6% to 12% of all newborns.
Chlamydia trachomatis is the most frequent cause of infectious conjunctivitis in infants.
Nasolacrimal duct stenosis occurs in 2% of newborns.
Bacterial infection is the cause of conjunctivitis in 50% of cases.
Adenovirus is the most common cause of viral conjunctivitis.

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common risk factors of pink eye

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Common Risk Factors

Lack of prenatal care or poor prenatal care
Day care attendance
Trauma
Maternal infection
Prophylactic chemical use (neonate)
Prolonged rupture of the membranes
Frequent swimming in swimming pools

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neonatal conjunctivitis

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Neonatal Conjunctivitis

Neonatal chemical conjunctivitis
Chlamydia trachomatis
Neisseria gonorrhoeae conjunctivitis
Herpes simplex conjunctivitis
Bacterial conjunctivitis
Dacryocystitis
Nasolacrimal duct obstruction

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management of pink eye

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Neonatal Conjunctivitis: Management

Chemical Conjunctivitis

Treatments: None
Counseling: Discharge is self-limiting and should resolve in 24 to 36 hours.
Follow-Up: For a neonate, schedule a return visit in 3 days if no improvement or sooner if the condition worsens.
Referrals: None
Chlamydia Trachomatis

Treatments: Give erythromycin ethylsuccinate 50 mg/kg/day orally divided into four doses for at least 2 weeks.
Counseling
Early identification and treatment of the infected mother are important.
Explain that the disease is usually transmitted vaginally during delivery.
Eye infection is also associated with neonatal pneumonitis. This pneumonia usually develops during the first 6 weeks of life and is characterized by a nasal discharge, cough, and fast breathing. A chest x-ray indicates infiltrates.
The efficacy of erythromycin therapy is 80%; the patient may need a second course of therapy.
Explain that discharge is self-limiting and should resolve in 24 to 36 hours.
Follow-Up
Schedule a visit in 3 days to monitor the eye infection.
Schedule a visit if there are signs of C. pneumoniae or if there is concern about the infant's vision.
For a neonate, schedule a return visit in 3 days if there is no improvement, or sooner if the condition worsens.
Referrals: Refer to a physician if C. pneumoniae. Refer the mother and her sexual partner for treatment with a gynecologic practitioner.
N. gonorrheae

Treatments: Hospitalization is probably necessary for treatment and to evaluate for signs of disseminated infection.
Prevention
A screening culture of the mother should be done prenatally.
Instillation of prophylactic eye drops is mandatory for all newborns at delivery.
Follow-Up: Contact the Public Health Service or health department.
Referrals: Refer to a physician for hospital admission. Refer the mother and her partner to a gynecologic practitioner for evaluation and treatment of N. gonorrheae before delivery, if known, or after delivery if unknown.
Herpes Simplex Virus

Treatments: Refer to an ophthalmologist.
Prevention: Cultures of the mother should be taken at a prenatal visit. Caesarean section is recommended for a mother who has a history of active herpes.
Follow-Up: This is directed by a physician.
Referrals: Immediately refer the patient to a physician/ophthalmologist.
Bacterial Conjunctivitis (Neonate)

Treatments:
This is based on Gram's stain and culture and sensitivity.
If the organism is Staphylococcus, apply erythromycin ophthalmic ointment every 2 to 4 hours.
If the organism not yet identified, apply erythromycin ophthalmic ointment until the culture results are received.
If the infant has a fever or signs of systemic toxicity (e.g., poor eating), refer for septic work-up.
Counseling
Close monitoring of the mother with prolonged membrane rupture is necessary.
Discuss need to prevent the spread of this disease to others by washing hands carefully and avoiding sharing washcloths and towels.
Discuss the instillation of eyedrops.
Tell mother to wash hands after diaper changes to prevent the spread of disease.
Follow-Up
Obtain reports of culture and sensitivities as soon as possible.
Schedule a visit in 2 days to evaluate the treatment - sooner if the patient is not improving or is getting worse.
Dacryocystitis

Treatments
In an afebrile, systemically well, mild case with a reliable parent, give amoxicillin-clavulanate potassium 20 to 40 mg/kg 3 times daily for 14 days.
With fever or systemic signs of toxicity, refer for hospitalization.
Counseling
Discuss the cause and treatment plan.
Discuss the possible side effect of amoxicillin-clavulanate potassium (increased number of stools).
Follow-Up: Schedule daily visits until the condition improves.
Referrals: Refer for hospital admission if the child is febrile or appears ill.
Nasolacrimal Duct Obstruction

Treatments
Massage the nasolacrimal sac region 3 to 4 times a day.
If there are signs of infection, treat as a bacterial infection with erythromycin ophthalmic ointment.
Avoid aminoglycosides, gentamicin, or tobramycin because of corneal toxicity.
Apply warm compresses 2 to 4 times per day to keep the eyelids clean when discharge is present.
Counseling
Explain that most obstructions are temporary and resolve without surgical probing by age 8 months.
Discuss the technique used to massage the duct.
Discuss the signs and symptoms of infection.
Follow-Up: Telephone monthly and check at well-child visits. Schedule a visit if the condition worsens or the parents are unsure.
Referrals: Refer to an ophthalmologist if the condition worsens or does not improve in 6 months.

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Nonneonatal Conjunctivitis

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Bacterial conjunctivitis
Viral conjunctivitis
Acute allergic conjunctivitis
Vernal conjunctivitis
Primary herpes simplex

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Management: Nonneonatal Conjunctivitis

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Bacterial Conjunctivitis

Treatment
Nongonococcal bacterial conjunctivitis can be treated with polymyxin-bacitracin ophthalmic ointment 4 times a day for 7 days, erythromycin ophthalmic ointment 4 times a day for 4 days, or ofloxacin ophthalmic solution 0.3% on days 1 and 2 (1 to 2 drops every 2 to 4 hours in the affected eye) and days 3 through 7 (1 to 2 drops 4 times a day). An alternate is sulfacetamide sodium 10%, 1 to 2 drops in each eye every 2 hours for the first 2 days then every 4 hours for 3 more days.
Do not use soaks or occlude the eyes; this may increase bacterial growth.
Counseling
Discuss the cause of the disease.
Discuss instillation of eye drops.
Explain that vision will be blurred if ointment is prescribed because it smears over the cornea.
Discuss instillation of ointment or drops.
Discontinue use of the medication if the eye shows a hypersensitivity to the medication.
Explain prevention of spread: good hand washing and no sharing of towels or washcloths.
No school for 24 hours after the start of antibiotics because of the contagiousness of the condition.
Follow-Up: Schedule a visit in 2 days if no improvement, sooner if worse, for culture and sensitivity.
Referrals: Notify the school nurse regarding the child's condition. Refer to a physician if the condition does not improve in 48 hours, sooner if the condition worsens.
Viral (Epidemic Keratoconjunctivitis)

Treatments: None
Counseling
Cause and course of the disease.
Frequent hand washing to prevent spread to others and use personal towel and bed linen.
No school until the virus clears, usually 1 week.
Follow-Up: Visit if the symptoms become worse or pain develops. The condition should resolve in 2 weeks; call if not improving.
Referrals: Ophthalmologist in severe cases.
Acute Allergic Conjunctivitis

Treatments
Remove the allergen (e.g., hair spray, shampoo, cosmetics, animals).
Discontinue any eye drops/ointments.
Apply cool compresses to the eyes.
Counseling
Discuss the cause and course of the illness and the importance of allergen removal in the child's environment.
Use of over-the-counter eye drops may make the condition worse.
Wash the child's hair at night to prevent allergens from going on pillows and subsequently into eyes.
Discard eye makeup applicators when empty; do not refill and reuse them.
Do not share eye makeup applicators with others.
Follow-Up: Schedule a visit if the condition persists or the discharge changes color and/or consistency.
Referrals: Refer to an ophthalmologist if the condition is chronic.
Primary Herpes Simplex

Treatments
Refer the patient for treatment to an ophthalmologist.
Never give steroids if herpes is present.
Counseling
Discuss the cause and course of disease and need for referral.
Anyone with a cold sore on the lips should avoid kissing a child on or near the eyelids.
Follow-Up: Directed by the ophthalmologist.
Referrals: Refer the patient to an ophthalmologist.
Herpes Zoster

Treatments: Refer the patient to an ophthalmologist.
Counseling/Prevention: Explain that the condition is caused by varicella-zoster virus. The virus remains dormant in the trigeminal ganglion until reactivated. It is most commonly encountered in young children and older adults.
Follow-Up: Directed by the ophthalmologist.
Referrals: Refer the patient to an ophthalmologist.