03 preventive pediatrics

American Academy of Pediatrics PREP 2014

American academy of pediatrics 1

Item 94 You are giving a presentation to a community group about environmental effects on

pediatric health. One of the participants asks about the effects of air pollution in

developing countries.

Of the following, the statement you are MOST likely to make is

A. adult men are most susceptible to air pollution effects in the developing world

because of occupational exposures

B. air pollution causes proven respiratory effects in industrialized nations but has

not been shown to be a health hazard in the developing world

C. exposure to household air pollution caused by burning plant or animal

materials for cooking fuel increases a child's risk of developing pneumonia

D. the health effects of air pollution in the developing world are primarily

restricted to congested urban areas

E. in the developing world, outdoor air pollution accounts for a greater impact on

health and disability than does indoor air pollution

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Item 94 S SBP Preferred Response: C

According to the World Health Organization (WHO), 3 billion people, mostly in

developing countries, depend on biomass or solid fuels for cooking, lighting, and heating.

Bio-mass fuels include wood, crop residue, charcoal, and animal dung, whereas solid fuel

is primarily coal. People dependent on these fuel sources live at the lower end of the

energy lad-der, producing their energy needs locally and inefficiently in their own home,

whereas affluent populations depend on more efficient natural gas and centrally produced

electricity. In developing countries, these unprocessed, locally used energy sources may

be found in both urban and rural areas. Biomass and solid fuels present both health and

environmental hazards attributable largely to incomplete combustion and inadequate

ventilation. Because these fuels are inefficient, large amounts must be used, contributing

to deforestation, whereas incomplete combustion leads to carbon dioxide release into the

general environment. Perhaps the most important effects, however, are the health

consequences on women and children from exposure to open burning of these materials.

Men are often physically removed from household fuel burning during the day, but

women, who do most of the cooking, and the children they care for, can be exposed for

many hours per day to levels of byproducts that far exceed the safe exposure levels

designated by the US Environmental Protection Agency (US EPA). The byproducts of

incomplete combustion include particulate matter, carbon monoxide, sulfur dioxide,

nitrogen oxides, polyaromatic hydrocarbons, chlorinated dioxins, arsenic, lead, fluorine,

vanadium, and more than 200 additional chemical compounds.

The WHO designates indoor or household air pollution as a leading environmental cause

of death, accounting for 2.7% of the annual worldwide global burden of disease.

Approximately 5% of deaths in countries using unprocessed fuel are attributable to

household air pollution, or nearly 2 million deaths annually. As many as half of these

deaths occur among children younger than 5 years of age, for whom the best documented

health consequence is an increase in acute lower respiratory infections (ARI), especially

pneumonia. Several studies show a two- to threefold increased risk for ARI among

children exposed to solid fuel burning compared with unexposed children after adjusting

for confounding variables, including socioeconomic status. In addition, asthma rates are

suggested to be higher among exposed children, but data are still emerging with some

contradictory studies published. However, particulates, which are elevated with exposure

to open solid fuel burning, have been associated with asthma symptoms, so it is very

possible that exposure to indoor air pollution does have an effect on asthma symptoms.

Among adults, the leading health effects of open solid fuel exposure are non-smokers'

chronic obstructive pulmonary disease and lung cancer. Women exposed to household air

pollution have double the risk of developing lung cancer as nonexposed women;

household air pollution is the primary risk for lung cancer in women in developing

countries whereas cigarette smoking and occupational exposure were the leading

associations for men.

Additional health associations have been noted for household air pollution, though the

data are still emerging for several of these diseases. Other conditions that have been

associated include otitis media, cataracts, and tuberculosis. Several studies have linked

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household air pollution to lower birthweight; a proposed mechanism is that elevated

maternal carbon monoxide levels lead to hypoxia and limit fetal growth.

Although the primary effects of household air pollution are seen in the developing world,

more affluent populations are not entirely immune to the consequences of indoor

exposures. Many families in the developed world continue to burn solid fuels (eg,

fireplaces and wood stoves) for heating. Intriguing new information suggests that

byproducts of gas cooking in the developed world may have an effect on infant

neurodevelopment. Two studies from Spain found lower scores on Bayley Scales of

Infant Development among children who lived in households with gas cookers.

To address the health and environmental effects of household air pollution, the United

Nations Foundation established the Global Alliance for Clean Cookstoves (http://

cleancookstoves.org). The goal of this effort is to engage developing populations in

designing and distributing efficient cookstoves and fuels with plans to have 100 million

homes adopting their use by 2020.

PREP Pearls

• Indoor air pollution, largely the result of incomplete combustion of biomass

and solid cooking fuels, poses a major health risk to children in developing

countries.

• Among children, the primary health consequence of exposure to household air

pollution is an increase in acute lower respiratory infections.

• Indoor air pollution is a leading cause of non-tobacco-related lung cancer,

particularly among women.

American Board of Pediatrics Content Specification(s):

• Recognize that household fumes (eg, from cooking) may be harmful to

children

Suggested Reading:

• Kaplan C. Indoor air pollution from unprocessed solid fuels in developing

countries. Review Environ Health. 2010;25(3):221-242

• Kodgule R, Salvi S. Exposure to biomass smoke as a cause for airway disease

in women and children. Curr Opin Allergy Clin Immunol. 2012;12(1):82-90.

doi:10.1097/ACI.0b013e32834ecb65

• Martin WJ, Glass RI, Balbus JM, Collins FS. A major environmental cause of

death. Science. 2011;334(6053):180-181. doi:10.1126/science.1213088.

• Vrijheid M, Martinex D, Aguilera I, et al. Indoor air pollution from gas

cooking and infant neurodevelopment. Epidemiology. 2012;23:23-32.

doi:10.1097/EDE.0b013e31823a4023

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Item 128 A 3-month-old infant from your practice has died suddenly and unexpectedly in the sleep

environment. Law enforcement and the medical examiner are investigating the death.

You are considering what involvement you should have with this family.

Of the following, the BEST description of your role is to

A. arrange a meeting only if the parents request it

B. arrange to meet with the family and surviving siblings

C. discuss grief issues only if the parents report a concern

D. leave the medical examiner to review the autopsy and investigation with the

family

E. provide medical records to law enforcement but avoid discussing the case

with the family

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Item 128 P TE I-C SBP Preferred Response: B

Sudden unexpected infant death (SUID) is an overwhelming event, requiring a wide

range of coping skills within families. The pediatrician can play an important role helping

families deal with the community and legal response to the tragic event as well as their

own grief. Because of the unexpected nature of the death and the differential diagnosis

that includes child abuse, the death must be scrutinized with a scene investigation and

autopsy. In areas in which these deaths are rare, the pediatrician may need to advocate for

an appropriate investigation. Despite the involvement of law enforcement, the

pediatrician should remain a resource for families to help them understand the processes

in place and to review the results once they become available. Although many medical

examiners meet with families to review results, families may feel that discussing the

findings with a trusted professional such as the family pediatrician is valuable. For this

reason, many experts recommend that the pediatrician schedule a meeting with the family

within a few weeks after the infant's death. In addition, the physician can use this

opportunity to refer the family to community resources including family support groups

such as First Candle/SIDS Alliance (www.firstcandle.org). Beyond the immediate

response to SUID, the pediatrician should remain an important support for families. If

there are surviving siblings, their own as well as their parents' grief responses should be

assessed at subsequent well child and sick visits, and bereavement referrals made as

indicated for the siblings and the parents.

In addition to the official legal investigation, many com-munities have recently instituted

child fatality review pro-grams that may request information from the pediatrician.

Confidentiality restrictions vary among jurisdictions, so the practitioner should consult

with the local program to deter-mine the statutes regulating release of information in their

community. The purpose of these programs is to develop a greater understanding of the

causes of child mortality and to promote community responses that would decrease the

burden of child deaths.

PREP Pearls

• Many experts recommend that the family pediatrician schedule an

appointment with the family a few weeks after a sudden unexpected infant

death to review the findings of the investigation and provide referrals to

support groups or bereavement resources.

• Future health supervision visits provide an opportunity to discuss grief

responses in the surviving siblings and parents.

• Pediatricians may be contacted by their local child fatality review program for

information to aid in public health responses to sudden unexpected infant

death.

American Board of Pediatrics Content Specification(s):

• Recognize the importance of physician review of case with parents after SIDS

has occurred (including risk of SIDS in siblings)

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Suggested Reading:

• Linebarger JS, Sahler OJ, Egan KA. Coping with death. Pediatr Rev.

2009;30:350-355. doi: 10.1542/pir.30-9-350

• Moon RY, Fu LY. Sudden infant death syndrome. Pediatr Rev.

2007;28:209214. doi:10.1542/pir.33-7-314

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American Academy of Pediatrics 2013 PREP SA on CD-ROM

Copyright 2013 © American Academy of Pediatrics 1

Question: 27

You are the consulting pediatrician at the health clinic in a junior high school. The coach of the after-school bicycling club asks you to address his students and their parents regarding safety issues because many of the students refuse to wear a helmet despite a state law that mandates helmet use. Of the following, the statement regarding bicycle safety that you are MOST likely to include in your counseling isA. abdominal injuries from handlebar trauma are the most common cause of death related to bicycle accidents

B. bicycle helmet laws have not been shown to reduce serious brain injuries from bicycle accidents

C. children are less likely to wear helmets if their parents wear them

D. cost is the primary reason that most adolescents refuse to wear helmets

E. helmets need to be replaced after an accident even if there is no visible external damage to the

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Preferred Response: ECritique: 27

Bicycling is one of the most popular recreational sports among children and adolescents, so pediatricians should routinely include counseling on bicycle safety during health supervision visits. Parents should be advised that traumatic brain injuries are the most common cause of death related to bicycle accidents, although blunt abdominal injuries, fractures, facial injuries, and abrasions occur as well. Bicycle helmet laws have been shown to reduce serious brain injuries from bicycle accidents; accordingly, the most effective safety measure for children who ride bicycles is the use of a helmet when riding. Other important safety measures include proper supervision and assurance of skill in riding. When selecting a helmet, the child should try on several sizes to ensure a proper fit. Helmets should sit low on the forehead and be parallel to the ground when the head is upright. The chin strap should be tight enough that only 2 fingers can be inserted between the strap and the chin. Helmets should be replaced at least every 5 years. If a child has a bicycle accident and sustains a blow to the head, the helmet should be replaced even if there is no apparent damage because it could be less effective at preventing injury with the next accident. Children are more likely to wear helmets if their parents do, so pediatricians should recommend parental helmet use as well. Children who refuse to wear helmets cite several reasons for their refusal, including peer pressure, style concerns, and perceived lack of importance. Cost is not a major factor because many helmets are available at a modest price. SUGGESTED READING: American Academy of Pediatrics, Committee on Injury and Poison Prevention. Bicycle helmets. Pediatrics. 2001;108(4):1030-1032. doi:10.1542/peds.108.4.1030 Cheng TL. Counseling about bicycle safety. Pediatr Rev. 2001;22(9):321-322. doi:10.1542/pir.22-9-321 Okun A, Adam HM. Safety on bicycles, skateboards, scooters, and skates. Pediatr Rev. 2008;29(10):366-367. doi:10.1542/pir.29-10-366

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Question: 44

A worried father calls you because his son returned from camping today with a tick embedded in his neck. He asks you how to remove it. Of the following, the advice that you are MOST likely to offer is that the father shouldA. cover the tick with petroleum jelly prior to removal

B. heat the tick with a match prior to removal

C. pull the tick up with steady, even pressure

D. remove the tick using a twisting motion

E. squeeze the tick while pulling on it

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Preferred Response: CCritique: 44

The best defense against tick-borne infections is to prevent the tick bite from occurring. Avoidance of tick-infested areas and the use of tick repellents and protective clothing are important preventive measures. In addition, children should be examined thoroughly when they return from any area where they might have been exposed. If a bite does occur, the tick should be removed as soon as it is discovered. The most appropriate way to remove a tick is to grasp the tick firmly with tweezers or gloved fingers and pull up with steady, even pressure without squeezing the tick (Item C44). The tick should be grasped as close to the skin as possible; twisting should be avoided. The skin should be disinfected before and after removal, but there is no need for antibiotic treatment. There is no need to cover the tick with petroleum jelly or nail polish. Heating the tick with a match is ineffective and places the child at risk for a burn. SUGGESTED READING: Ozuah PO, Adam HM. Tick removal. Pediatr Rev. 1998;19(8):280. doi:10.1542/pir.19-8-280 Razzaq S, Schutze G. Rocky mountain spotted fever: a physicians challenge. Pediatr Rev. 2005;26(4):125-130. doi:10.1542/pir.26-4-125

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Question: 88

The mother of a 15-month-old boy asks about whether her son should receive the measles, mumps, and rubella (MMR) vaccine. She did not allow him to be vaccinated when he was 12 months old because she had read on the internet that egg-allergic children should not receive MMR vaccine. The boys past medical history reveals that he was given a few spoonfuls of scrambled egg 4 months ago and developed generalized hives, coughing, and wheezing within 15 minutes of ingestion. At that time, he was taken to the emergency department and given diphenhydramine and injectable epinephrine. Of the following, you are MOST likely to recommend that her sonA. be referred to an allergist for skin testing and graded challenge to the MMR vaccine

B. be tested to determine his current level of IgE specific to egg before receiving his MMR vaccine

C. never receive MMR vaccine

D. receive the MMR vaccine but remain in the clinic for 2 hours after the vaccination in case he has a reaction

E. receive the MMR vaccine today and be discharged to home immediately after the vaccine is administered

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Although the child in the vignette has had an anaphylactic reaction to egg, he can receive the mumps, measles and rubella (MMR) vaccine and go home soon after. The recently released National Institute of Allergy and Infectious Diseases (NIAID) Food Allergy guidelines, as well as guidelines by the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) recommend that children with egg allergy, even those with a history of severe reactions, receive the MMR vaccine. The measles component of the vaccine is produced in chicken-embryo fibroblasts, which was initially thought to be of concern to children with egg allergy. Although ovalbumin is only 1 of the egg proteins in vaccines grown in chick embryos or embryonic tissues, its concentration is often used as a surrogate for the total egg protein concentration. MMR, MMR with varicella (MMRV), and rabies vaccine may be given without concern and without previous skin testing in patients with egg allergy because the ovalbumin concentrations are known to be very low. Less commonly, allergic reactions have been reported to occur in nonegg vaccine components, including gelatin. Therefore, the child with egg allergy does not need to be watched for 2 hours after the vaccine to observe for serious allergic reactions. There is also no need to deny him the MMR vaccine or refer him for skin testing and graded challenge to MMR or measure specific IgE levels to egg. In contrast to MMR vaccines, inactivated influenza vaccines are prepared by inoculation into chicken egg yolk sacs and may contain trace amounts of ovalbumin. Although hypersensitivity to eggs is listed as a contraindication to influenza vaccine in package inserts, recent studies have reported safe administration of killed influenza vaccines in patients with egg allergy, except in those with severe anaphylactic reactions. Similar to the MMR vaccine, the risk of reactions with other vaccines that use inoculation of chicken eggs was thought to be related to ovalbumin content, but studies have demonstrated lack of reactions in egg-allergic patients receiving ovalbumin content up to 1.4 mg/mL. In general, skin testing with vaccines is considered a poor predictor of allergic reaction. According to ACIP guidelines, patients with egg allergy and mild symptoms of egg allergy (eg, hives) may be given the influenza vaccine with the following precautions: (1) the killed influenza vaccine should be given rather than the live influenza vaccine because studies have not been conducted on the live vaccine; (2) the vaccine should be administered by a healthcare professional who is familiar with the potential manifestations of egg allergy; and (3) patients should be observed for at least 30 minutes after the administration of each dose of the vaccine to monitor for signs of reaction (Item C88). Patients needing influenza vaccine who report having had reactions to egg - such as angioedema, lightheadedness, respiratory distress, or recurrent emesis - and patients who had to be given epinephrine or go to the emergency department to be treated within minutes to hours of having ingested egg are more likely to have had a serious reaction upon reexposure to egg proteins. Such patients should be referred for further risk assessment to a physician with expertise in the management of allergic conditions. There is a recent practice parameter published by the Joint Task Force of Allergy, Asthma, and Immunology that details methods of evaluating and administering vaccines to patients with severe egg allergy.

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As a result of reviewing this information, do you intend to make a change in practice to provide better patient care? Yes No SUGGESTED READING: Centers for Disease Control and Prevention. Prevention and control of influenza with vaccines: recommendations of the advisory committee on immunization practices (ACIP), 2011. MMWR Morb Mort Wkly Rep. 2011;60(33):1128-1132 Cox JE. Egg-based vaccines. Pediatr Rev. 2006;27(3):118-119. doi:10.1542/pir.27-3-118 Greenhawt MJ, Li JT, Bernstein DI, et al. Administering influenza vaccine to egg allergic recipients: a focused practice parameter update. Ann Allergy Asthma Immunol. 2011;106(1):11-16. doi:10.1016/j.anai.2010.11.015 James JM, Burks AW, Roberson PK, Sampson HA. Safe administration of the measles vaccine to children allergic to eggs. N Engl J Med. 1995; 332:1262-1266. doi:10.1056/NEJM199505113321904

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Question: 112

At a health supervision visit for a 13-year-old boy, you discover that he has become very involved in in-line skating and skateboarding. He admits that he doesnt like to wear a helmet or protective guards and pads and tells you about his plans to build a skateboarding ramp in his backyard. You offer counseling on the best safety practices for these activities. Of the following, the statement regarding skating and skateboarding you are MOST likely to make isA. backyard ramps and jumps are safer than those built in community parks

B. bright clothing has been shown to reduce the incidence of skateboarder injuries by motor vehicles

C. concussions are the most common injury reported for skateboarders and skaters

D. skateboarders and skaters should be encouraged to ride in the streets when there is no traffic

E. wrist guards should be worn at all times when skateboarding or in-line skating

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At health maintenance visits for school-age children and adolescents, pediatricians should inquire about recreational activities and provide appropriate safety counseling. Skateboarding and in-line skating are among the most popular recreational sports, especially among boys. The most frequent injuries for skateboarders and in-line skaters are extremity fractures and facial injuries; accordingly, safety equipment to protect against these injuries should be recommended. Skateboarders and in-line skaters should be advised to wear helmets, knee pads, elbow pads, and wrist guards while skating. They should also be informed that specially designed parks with professionally designed ramps and jumps are safer than those constructed at home. Skateboarders and in-line skaters should not ride in the streets, regardless of the amount of traffic present, and they should never participate in “skitching,” or “truck-surfing,” which involves holding onto the back of a moving motorized vehicle while on in-line skates or a skateboard. Wearing bright clothing has not been proven to reduce injury, but it could potentially improve visibility to drivers. SUGGESTED READING: American Academy of Pediatrics, Committee on Injury and Poison Prevention, Committee on Sports Medicine and Fitness. In-line skating injuries in children and adolescents. Pediatrics. 1998;101(4):720-722 American Academy of Pediatrics, Committee on Injury and Poison Prevention. Skateboard and scooter injuries. Pediatrics. 2002;109(3):542-543. doi:10.1542/peds.109.3.542 Okun A, Adam HM. Safety on bicycles, skateboards, scooters, and skates. Pediatr Rev. 2008;29(10):366-367. doi:10.1542/pir.29-10-366

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Question: 129

You are seeing the 2-year-old and 4-year-old children of a family who is new to your practice. Their mother reports that she and her husband are hoping to host several of their friends families for parties at the local lake over the summer. She tells you that they are buying a boat, but she is concerned that taking their children out on the boat poses a significant risk to their safety. Of the following, the statement that you are MOST likely to include in your discussion of boating safety isA. adults planning to pilot the boat on the lake should limit themselves to 2 alcoholic drinks

B. enrolling her children in swimming lessons will prevent drowning deaths

C. ensuring that an adult is present when children are near the water will prevent drowning deaths

D. inflatable arm bands can be used in the place of life jackets for young children while boating

E. the best way to prevent drowning while boating is to wear a personal flotation device

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Drowning is one of the most common causes of deaths related to injury in children, and lifelong neurologic dysfunction can occur in children who suffer nonfatal submersion. Preventive measures should be discussed at all health supervision visits and any time a parent expresses concern or has questions regarding water safety. Drowning occurs in both aboveground and inground swimming pools as well as open water, such as rivers, lakes, and ponds. Most drowning and submersion injuries are associated with a temporary lapse - rather than a complete lack - of supervision. Accordingly, having an adult present when children are in the water is not sufficient. Adults who plan to pilot a boat should refrain from drinking alcohol. The relative risk of drowning has been directly related to blood alcohol concentration. Using a personal flotation device (PFD), or life jacket, is the best way to prevent drowning related to boating accidents. Inflatable arm bands are an insufficient substitute. While some studies have shown that some drowning prevention skills may be learned by young children, there is insufficient evidence to show that taking swimming lessons prevents drowning deaths. Therefore, the recommendation from healthcare providers should be individualized to the childs situation and the parents position on the importance of swimming ability. Misconceptions about toddler water safety, such as believing that swimming ability obviates the need for adult supervision, should be addressed if parents decide to enroll their children in swimming lessons. SUGGESTED READING: American Academy of Pediatrics, Committee on Injury and Poison Prevention. Policy statement: personal watercraft use by children and adolescents. Pediatrics. 2000;105(2):452-453. doi:10.1542/peds.105.2.452 Weiss J; American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Technical report: prevention of drowning. Pediatrics. 2010;126(1):e253-e262. doi:10.1542/peds.2010-1265

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Question: 197

You are giving a lecture on poisoning in children to a group of medical students. One student asks you the best way to prevent poisoning. You explain the preventive measures that should be taken and that anticipatory guidance counseling should be provided during health supervision visits. Of the following, the health supervision visit at which it is MOST appropriate to begin discussing poisoning prevention strategies with parents isA. 2 months

B. 6 months

C. 9 months

D. 12 months

E. 2 weeks

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Preferred Response: BCritique: 197

The anticipatory guidance that providers offer at health supervision visits is an essential factor in keeping infants and children safe from poisonings and other injuries. The guidance should relate directly to the child's current developmental stage and what is expected with respect to development before the subsequent visit. Because many children will begin to explore their environment by either crawling or creeping before 9 months, childproofing the home by safely storing poisonous substances and medications should be discussed at the 6-month visit. Waiting until the 9- or 12-month visit may be too late if the infant has begun to move around freely. All medications should be stored in bottles with childproof caps and in elevated cabinets. In addition, parents should be made aware of the risk of choking on small toys and some finger foods, such as hot dogs, hard vegetables, and hard candies. At the 2-week visit, it is important to discuss a safe sleeping environment (supine in a crib without soft materials or pillows), burn prevention (setting hot water temperature in the home at a maximum of 48.9°C [120°F]), and car seat use (rear-facing seat in the middle of the cars back seat). In addition, parents should be advised about drowning prevention (avoidance of fluid-filled buckets and constant supervision while in the bathtub). These issues should be reinforced at subsequent visits. Providing caregivers with poisoning-prevention strategies before the 6-month visit is unnecessary from a developmental perspective and may result in “information overload.” As a consequence, caregivers may fail to remember the crucial information needed to keep their infants safe at these early ages. SUGGESTED READING: Committee on Injury, Violence, and Poison Prevention. Policy statement: prevention of choking among children. Pediatrics. 2010;125(3):601-607. doi:10.1542/peds.2009-2862 Gardner HG; Committee on Injury, Violence, and Poison Prevention. Office-based counseling for unintentional injury prevention. Pediatrics. 2007;119(1):202-206. doi:10.1542/peds.2006-2899

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Question: 3

A mother brings her 7-year-old son to your office because he is having pain from a sunburn. As partof his care, you discuss sun protection with the boy and his mother.

Of the following, the MOST important information to provide is that

A. sun exposure in childhood sufficient to cause sunburn increases the risk of developing melanoma

B. sunscreen is less important on cloudy than on sunny days

C. sunscreen should not be used on babies younger than 6 months of age

D. sunscreen with a minimum SPF rating of 45 is recommended for children

E. ultraviolet B (UVB) protection is the only value to consider when choosing sunscreen

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Preferred Response: ACritique: 3

Skin cancers are among the most common neoplastic conditions in developed countries, and theincidence in both adults and children is increasing. Among adults in the United States, approximately 1million cases of skin cancer occur per year, of which 80% are basal cell, 16% squamous cell, and 4%melanoma. Between 1992 and 2006, a 76.9% increase in non-melanoma skin cancers was reportedamong Medicare beneficiaries, and melanoma rates per 100,000 American adults more than doubledbetween 1973 and 2000. Melanoma incidence among United States children has also been increasing,although it remains a rare disease. Risk factors for adult skin cancers include family history of skin cancer; age; propensity to freckle;and light skin, hair, and eye color. Most affected persons are white, although more than 15% of youngchildren may be of another race or ethnicity. The most recognized preventable environmental risk factoris excessive ultraviolet light exposure. Because up to 80% of lifetime sun exposure is estimated to occurbefore age 18 years, efforts to prevent skin cancer should begin during childhood with prevention ofexcessive sunlight exposure. Melanoma among children, particularly those younger than 10 years ofage, appears to be biologically distinct from adult melanoma, and ultraviolet exposure may be less of astimulus than in adults. However, nearly 75% of pediatric melanomas occur in teens 15 to 19 years old,and it is unclear what role sun exposure plays in this older age group. Sunlight is composed of ultraviolet B (UVB) (290 to 320 nm wavelength) and UVA (320 to 400 nmwavelength) radiation as well as UVC. UVA causes darkening of existing skin melanin, resulting in animmediate tan. It is also absorbed in the dermis, resulting in long-term damage to blood vessels anddeep structures, and it can ultimately lead to skin aging and loss of elasticity. UVB affects the epidermis,causes development of increased melanin, and is primarily responsible for causing sunburn. Its effectsare seen 6 to 12 hours after exposure, peaking at 24 hours. UVB exposure is most related todevelopment of skin cancer, with even one blistering sunburn during childhood increasing a person's riskof developing melanoma as an adult. Accordingly, the mother in the vignette should be told that sunexposure sufficient to cause sunburn increases the risk of developing melanoma in her son. Sun protection begins with avoidance of prolonged unprotected exposure, particularly during themiddle of the day, when UV radiation is highest (10 am to 4 pm). Cloud cover does not provideprotection against UV exposure. If infants and young children are going to be outside for a period oftime, protective clothing and hats are important for sunburn prevention. For older children andadolescents, chemical sunscreens are typically the first line of defense. They should be appliedfrequently (every 2 hours) during times of exposure and should have an SPF (Sun Protective Factor)level of at least 15 (SPF = minimal dose of sunlight causing cutaneous erythema with sunscreenuse/minimal dose of sunlight causing cutaneous erythema without sunscreen use). SPF is a measure ofUVB protection, and the higher the number, the greater the defense. To prevent UVA damage, parentsshould look for broad-spectrum sunscreens that include both UVA and UVB protection. The UVA starrating ranges from 1 star (lowest protection) to 4 stars (highest).The most commonly used chemicalsunscreens are benzophenones, cinnamates, sulisobenzone, salicylates, and avobenzone. Sunscreencan be used on infants, even those younger than 6 months of age, but usually is limited to a small

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surfaces such as hands, face, and neck. For children who are sensitive to chemical sunscreens or whowill have prolonged exposure, physical sunscreens (zinc oxide or titanium dioxide) should be used,particularly on areas such as the nose and ears.

SUGGESTED READING:

American Academy of Pediatrics. Sun safety. Healthy Children. 2010. Accessed January 2011 at:http://www.healthychildren.org/English/safety-prevention/at-play/Pages/Sun-Safety.aspx

Cercato MC, Nagore E, Ramazzotti V, et al. Self and parent-assessed skin cancer risk factors inschool-age children. Prev Med. 2008;47:133-135. DOI: 10.1016/j.ypmed.2008.03.004. Abstractaccessed January 2011 at: http://www.ncbi.nlm.nih.gov/pubmed/18420261

Ferrari A, Bono A, Baldi M, et al. Does melanoma behave differently in younger children than inadults? A retrospective study of 33 cases of childhood melanoma from a single institution. Pediatrics.2005;115:649-654. DOI: 10.1542/peds.2004-0471. Accessed January 2011 at:http://pediatrics.aappublications.org/cgi/content/full/115/3/649

Lange JR, Palis BE, Chang CD, Soong SJ, Balch CM. Melanoma in children and teenagers: ananalysis of patients from the National Cancer Data Base. J Clin Oncol. 2007;25:1363-1368. DOI:10.1200/JCO.2006.08.8310. Accessed January 2011 at:http://jco.ascopubs.org/content/25/11/1363.long

Morelli JG. The skin: photosensitivity. In: Kliegman RM, Stanton BF, St. Geme JW III, Schor NF, andBehrman RE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Saunders Elsevier;2011:2254-2259

Rogers HW, Weinstock MA, Harris AR, et al. Incidence estimate of nonmelanoma skin cancer in theUnited States, 2006.Arch Dermatol. 2010;146:283-287. Abstract accessed January 2011 at:http://www.ncbi.nlm.nih.gov/pubmed/20231499

Tung R, Vidimos A. Melanoma. In: Carey WD, ed. Cleveland Clinic: Current Clinical Medicine. 2nded. Philadelphia, PA: Saunders Elsevier; 2010:250-258

Dr_Faqehi



Question: 4

The intern rotating through the newborn nursery reports on rounds that she ordered a hematocritmeasurement for a term newborn who appeared plethoric on physical examination at 6 hours of age.She suspects the infant has polycythemia, and the hematocrit is 65% (0.65). When you examine theinfant, he appears to be a bit "ruddy." Other findings on the examination are normal, including his vitalsigns; feeding and elimination patterns are also normal. You ask the intern what method she used toobtain the specimen, and she reports that a heelstick specimen was obtained.

Of the following, the MOST appropriate method for confirming the hematocrit in this infant is toobtain a sample via

A. brachial artery

B. peripheral venipuncture

C. repeat heelstick

D. umbilical artery

E. umbilical vein

Dr_Faqehi




Plethora and polycythemia are common clinical problems in the newborn period. Polycythemia isdefined as a hemoglobin or hematocrit value greater than 2 standard deviations above the mean in avenous blood sample. For a term infant, this represents a hematocrit greater than 65% (0.65) andhemoglobin of greater than 22 g/dL (220 g/L). The incidence of polycythemia is estimated to be 1% to5% in healthy term newborns. Neonatal polycythemia may be due to twin-twin transfusion or maternal-fetal hemorrhage and is more common in infants of diabetic mothers or infants who have intrauterinegrowth restriction or chromosomal anomalies. The maximum hematocrit is found at 2 hours of age, aftera period of equilibration following delivery. In the newborn period, hemoglobin and hematocrit measurements usually are drawn by capillaryvenous sampling from a heelstick. However, hemoglobin and hematocrit values from capillary samplesmay be as much as 15% higher than those from venous samples, particularly if the peripheral blood flowis diminished due to prematurity, sepsis, congenital heart disease, or other conditions. Therefore, it isimportant to obtain a venous sample, either from a peripheral vein or the umbilical vein to confirm theelevated hematocrit of the infant described in the vignette. Since the infant is not exhibiting clinicalmanifestations of polycythemia (eg, poor feeding, respiratory distress, poor perfusion), there is noindication for cannulation of the umbilical vessels or brachial artery. A repeat heelstick most likely wouldyield the same results as the first test.

SUGGESTED READING:

Brandow AM, Camitta BM. Polycythemia (erythrocytosis). In: Kliegman RM, Stanton BF, St. GemeJW III, Schor NF, and Behrman RE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA:Saunders Elsevier; 2011:1683

Kates EM, Kates JS. In brief; anemia and polycythemia in the newborn, Pediatr Rev. 2007;28:33-34.DOI: 10.1542/pir.28-1-33. Accessed December 2010 at:http://pedsinreview.aappublications.org/cgi/content/full/28/1/33

Linderkamp O. Blood viscosity of the neonate. NeoReviews. 2004;5:e406-e416. DOI: 10.1542/neo.5-10-e406. Accessed December 2010 at: http://neoreviews.aappublications.org/cgi/content/full/5/10/e406

Dr_Faqehi



Question: 20

A game warden accompanies his wife, new baby, and 13-year-old stepson to the infant's 2-weekhealth supervision visit. He explains that he must store the gun he is required to carry for his job athome, but he is concerned about the risks of having a gun in the home.

Of the following, the BEST advice to give this father is to

A. enroll his stepson in a formal firearm safety course

B. show the stepson how to handle the gun appropriately

C. store the gun locked and loaded in a high, secret cabinet

D. store the gun locked and unloaded with ammunition locked and stored separately

E. store the gun unloaded in a locked gun safe with the ammunition stored adjacently

Dr_Faqehi



Preferred Response: DCritique: 20

Firearm injuries are common in the United States, which has the highest rate of gun injuries amongdeveloped nations. In 2004, the Centers for Disease Control and Prevention recorded 2,852 firearm-related deaths in children as well as 13,846 nonfatal gun-related injuries. In 2007, there were 12.5firearm deaths per 100,000 children in the United States. Males 15 to 19 years of age are eight timesmore likely to die of firearm-related injuries than females and African American male youth sustained thehighest rates of firearm related deaths (combined homicide, suicide, and accidental deaths) at 70 per100,000 adolescents in 2007. A 2005 study in the Journal of the American Medical Association documented that safe storage ofboth long guns and handguns reduced the risk of suicide and accidental injury due to firearms. Thus,parents who own guns should be advised of the need to safely store guns. Unfortunately, some parentsmay not wish to discuss their gun ownership with their child's physician and since most firearms areowned and stored by men, mothers may not know if there is a gun in the home and how it is stored. Children also may be at increased risk for firearm injury if there are accessible guns in the homes oftheir playmates or child care provider. Therefore, parents should also be advised to ask child careproviders and others who may care for their child about accessible guns in their homes and it may beadvisable to discuss firearm injury prevention with all families regardless of gun ownership. Ideally, safe storage of firearms involves placement of unloaded and locked firearms and ammunitionin separate storage areas with separate locks since a loaded firearm or easy availability of ammunitionwhich is stored near the firearm increases the risk that an unsupervised child will be injured. There is noevidence that firearm education is an effective way to prevent firearm injury.

SUGGESTED READING:

Committee on Injury and Poison Prevention. American Academy of Pediatrics. Firearm-relatedinjuries affecting the pediatric population. Pediatrics. 2000;105:888-895. Accessed January 2011 at:http://pediatrics.aappublications.org/cgi/content/full/105/4/888

Coyne-Beasley T, Baccaglini L, Johnson RM, Webster B, Wiebe DJ. Do partners with children knowabout firearms in their home? Evidence of a gender gap and implications for practitioners Pediatrics.2005;115:e662-e667. DOI: 10.1542/peds.2004-2259. Accessed December 2010 at:http://pediatrics.aappublications.org/cgi/content/full/115/6/e662

Grossman DC, Mueller BA, Riedy C, et al. Gun storage practices and risk of youth suicide andunintentional firearm injuries JAMA. 2005;293:707-714. DOI: 10.1001/jama.293.6.707. AccessedDecember 2010 at: http://jama.ama-assn.org/content/293/6/707.full.pdf+html

Guralnick S, Serwint JR. In brief: firearms. Pediatr Rev. 2007;28:396-397. DOI: 10.1542/pir.28-10-396. Accessed January 2011 at: http://pedsinreview.aappublications.

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org/cgi/content/full/28/10/396

Okoro CA, Nelson DE, Mercy JA, Balluz LS, Crosby AE, Mokdad AH. Prevalence of householdfirearms and firearm-storage practices in the 50 states and the District of Columbia: FINDINGS FROMthe Behavioral Risk Factor Surveillance System, 2002. Pediatrics. 2005;116:e370-e376. DOI:10.1542/peds.2005-0300. Accessed December 2010 at:http://pediatrics.aappublications.org/cgi/content/full/116/3/e370

Teen homicide, suicide, and firearm deaths. Child Trends Data Bank. 2010. Accessed January 2011at: http://www.childtrendsdatabank.org/?q=node/124

Dr_Faqehi

2011 PREP SA on CD-ROM

Question: 29

You are examining a 5-year-old boy who was bitten on the hand by a raccoon. The raccooncannot be found. You clean the wound with soap and water, but sutures are not required.According to his medical record, the boy received diphtheria-tetanus-acellular pertussisimmunization 1 year ago.

Of the following, the MOST appropriate next step in management is administration of

A. immune globulin and a tetanus booster

B. immune globulin and rabies vaccine

C. rabies immune globulin and a tetanus booster

D. rabies immune globulin and rabies vaccine

E. rabies vaccine and a tetanus booster

Copyright © 2010 by the American Academy of Pediatrics page 1

Dr_Faqehi



Rabies exists in wild animals throughout the United States, except Hawaii, and most often istransmitted to humans and domestic animals from infected bats, raccoons, skunks, foxes, andcoyotes. Rabies in small rodents and rabbits is unusual. Rarely, the virus is transmitted bycontamination of mucosa or skin lesions by saliva or neural tissue from the infected animal. Theincubation period of the virus ranges from a few days to years but usually is 4 to 6 weeks.

In cases where prompt testing of the animal for rabies is not possible, such as in thevignette, rabies immune globulin (RIG) and rabies vaccine for prophylaxis should be administeredas soon as possible, ideally within 24 hours of exposure. Human RIG is the only productavailable in the United States for passive immunization. Intravenous immune globulin containspooled immunoglobulin G extracted from the plasma of more than 1,000 blood donors and is notappropriate for rabies postexposure prophylaxis because it does not contain much, if any,antibody against rabies. Equine RIG is as safe and effective as human RIG and is availableoutside of the United States. RIG should be administered within 7 days of exposure and shouldbe given with the first dose of vaccine to protect against rabies between the time of exposureand antibody production from vaccine. A dose of 20 IU/kg of RIG should be infiltrated around thewound(s), with the remainder administered intramuscularly (IM) at a distant site from thevaccine.

Two rabies vaccines are available for use in the United States: human diploid cell vaccine(HDCV) and purified chicken embryo cell vaccine (PCECV). Rabies vaccine adsorbed is licensedbut no longer distributed in the United States. Rabies vaccine is administered as a 1.0-mL IMdose in the deltoid muscle or the anterolateral thigh on the day of exposure or first day ofpostexposure prophylaxis (day 0) and is repeated on days 3, 7, and 14 after the initial dose inimmunocompetent individuals. For immunosuppressed individuals, an additional 1.0-mL dose ofvaccine should be provided on day 28 of postexposure prophylaxis. Documentation ofseroconversion 1 to 2 weeks after the completion of prophylaxis is reserved forimmunosuppressed persons.

Adverse reactions to rabies vaccines are more common in adults than children. Localreactions such as pain, swelling, induration, or erythema occur in 60% to 90% of adultsreceiving HDCV and 11% to 57% of adults receiving PCECV. Mild systemic reactions such asfever, headache, dizziness, and gastrointestinal symptoms have been reported in 0% to 56%.One study documented mild-to-moderate clinical reactions in only 7% of children receivingPCECV. All suspected serious systemic, anaphylactic, or neuroparalytic reactions to a rabiesvaccine should be reported to the Vaccine Adverse Event Reporting System athttp://www.vaers.hhs.gov/

All wounds resulting from an animal bite should be flushed and washed with soap andwater. A tetanus booster is recommended for contaminated wounds if 5 years have elapsedsince receipt of a tetanus toxoid-containing vaccine. The 5-year-old boy in the vignette does notrequire a tetanus booster because he received a diphtheria-tetanus-acellular pertussisimmunization only 1 year ago.

Suggested reading:


Dr_Faqehi


American Academy of Pediatrics. Rabies. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS,eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk GroveVillage, Ill: American Academy of Pediatrics; 2009:552-559

Centers for Disease Control and Prevention. Use of a Reduced (4-Dose) Vaccine Schedule forPostexposure Prophylaxis to Prevent Human Rabies. Atlanta, Ga: Centers for Disease Controland Prevention; 2010 at:http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5902a1.htm?s_cid=rr5902a1_e

Mani CS, Murray DL. Rabies. Pediatr Rev. 2006;27:129-136. DOI: 10.1542/10.1542/pir.27-4-129.Available at: http://pedsinreview.aappublications.org/cgi/content/full/27/4/129


Dr_Faqehi


Question: 60

You diagnose Kawasaki disease in a 2-year-old child who has fever, conjunctival injection, rash,and mucositis. You recommend therapy with intravenous immune globulin (IVIG) and aspirin.The parents ask you about potential adverse reactions to IVIG.

Of the following, the MOST common adverse event associated with IVIG is

A. aseptic meningitis

B. hepatitis B infection

C. hepatitis C infection

D. human immunodeficiency virus infection

E. intravenous site phlebitis


Dr_Faqehi



Adverse reactions to intravenous immune globulin (IVIG) are primarily inflammatory orhypersensitivity. Although not seen commonly, aseptic meningitis may occur, beginning withinseveral hours to 2 days after IVIG administration and presenting with severe headache,nuchal rigidity, drowsiness, fever, photophobia, nausea, and vomiting. It may occur morecommonly in recipients of high-dose (2 g/kg) treatment and is self-limited, resolving over severaldays.

Infusion of IVIG, as with other blood products, should be monitored for hypersensitivityand anaphylactic reactions, including fever, nausea, vomiting, hypotension, stridor, respiratorydistress, urticaria, and pruritus. Reducing the rate of infusion may ameliorate these symptoms,but epinephrine should be available to address potential life-threatening reactions. Preparationsof IVIG are more than 90% IgG, but they may contain small amounts of IgA, which couldprompt potential anaphylactic reactions if administered to IgA-deficient individuals. IgA-freepreparations are available for use in such patients.

Although derived from pooled human plasma (>1,000 donors per lot), IVIG undergoesmultiple procedures to prevent transmission of infectious organisms, including hepatitis B,hepatitis C, and human immunodeficiency virus (HIV). Prior to standardization of presentpurification procedures, rare cases of hepatitis C infection were reported after IVIG infusion.Current purification processes include cold alcohol fractionation from plasma, followed byultrafiltration, ion exchange chromatography, treatment at an acid pH in the presence ofdetergents, and lyophilization.

Intravenous site phlebitis is not specifically associated with IVIG infusion (as opposed toinfusion of drugs such as nafcillin and chemotherapeutic agents). Other adverse reactionsassociated with IVIG include acute renal failure, fluid volume overload, transient decrease inwhite blood cell count, hemolytic anemia, myalgias, and arthralgias.

The clinician should be aware that IVIG can interfere with immune responses to live viralvaccines. Therefore, administration of live vaccines (measles, mumps, and rubella; varicella)must be delayed for up to 11 months, based on the dose of IVIG administered.

Pediatric indications for the use of IVIG include primary immunodeficiencies, Kawasakidisease, pediatric HIV infection, recent stem cell transplantation, and immune-mediatedthrombocytopenia.

Suggested reading:

American Academy of Pediatrics. Active immunization of people who recently received immuneglobulin. Passive immunization, Immune globulin intravenous. In: Pickering LK, Baker CJ, KimberlinDW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed.Elk Grove Village, Ill: American Academy of Pediatrics; 2009:37

American Academy of Pediatrics. Passive immunization: immune globulin intravenous. In:Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committeeon Infectious Diseases. 28th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2009:58-61


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Silvergleid AJ. Berger M. General principles of the use of intravenous immune globulin. UpToDateOnline 17.3. 2009. Available at:http://www.uptodate.com/online/content/topic.do?topicKey=lab_med/2914&selectedTitle=4%7E150&source=search_result12


Dr_Faqehi


Question: 116

An 8-year-old girl presents for follow-up assessment for obesity management with a body mass

index (BMI) of 24 kg/m2, only slightly improved from 25 kg/m2 at her visit 6 months ago. At thatvisit, a consultation with a nutritionist was arranged, and the girl’s parents report successfulreduction in her consumption of sweets, juice, and fast food. Because of bullying at school andneighborhood crime, she is not allowed to play outside alone. She spends 8 hours each daywatching television.

Of the following, the next BEST step in anticipatory guidance is to recommend

A. removal of the television from the child’s bedroom

B. restriction of television and video games to no more than 4 hours per day

C. substitution of video games for passive television viewing

D. watching television only when eating with the family

E. watching videos rather than commercial television


Dr_Faqehi



The girl and her family described in the vignette have made modest progress with dietarychanges in addressing her obesity, but she remains significantly overweight. Therefore, furthersteps must be taken to reduce her weight. Risk factors for obesity include limited outdoor playand social isolation. Most importantly, excessive television viewing and a television in herbedroom place her at risk not only for continued obesity but also for the psychosocial risks ofpotentially unsupervised television watching and exposure to substance use and sexuality intelevision.

Although technology affords opportunities for young children to develop early computerskills, the independent use of this technology may be harmful in excess. In particular, there areconcerns that independent television and computer use may replace valuable time spent inoutdoor play and socialization that the traditional playground has offered. The impact oftelevision viewing on children has been of concern for the last 2 decades, along with other"screen time" elements of computer and video games. Substituting other forms of "screen time"(eg, videos, computer) for television time will not address the need for exercise or reduce thesocial isolation associated with excessive screen time. Negative effects of television viewinginclude increased aggressive behavior and greater acceptance of violence as well as trivializingsexual activity. Television viewing also blurs the distinction between fantasy and reality. Specifictelevision programming also can increase the risk of obesity, lead to early onset of sexualactivity and smoking. Increased screen time also results in less time spent in healthier activities,including unstructured play. Results of numerous studies, including those that are prospectiveand randomized in a variety of settings in industrialized countries, suggest that television hassignificant effects on child behavior. However, confounders in the studies include ethnicity,poverty, parental education, and parental health habits. In general, more television viewingoccurs in households that have many of those factors.

Parents should be made aware of the recommendations to limit television viewing to 2 hoursper day or less for all children; should be discouraged from placing a television in a child’sbedroom; and should be made aware of links between television viewing, obesity, anddiminished academic performance.

There is no evidence that television viewing in young children provides any benefit overreading and playing with parents and other children. Further, television viewing may contribute toobesity through both the time spent in the sedentary activity and exposure to advertising forfood and largely sedentary toys. Watching television while eating decreases familycommunication during meals.

The recommendation for ensuring less than 2 hours of total screen time per day still allowsfor sharing of family-oriented programming, limited amounts of computer experience and skilldevelopment, and very limited access to "educational" programming. Older children may findlimiting such activity to be a challenge because of homework requirements using the computer,use of social networking sites, casual television watching, and playing video games, some ofwhich may have benefits for social interaction.

Placing a television in the child’s bedroom is especially problematic in terms of adultsupervision for both the time and quality of programming. Research has demonstrated thatchildren who have televisions in their rooms have increased risks of obesity, sleep disturbance


Dr_Faqehi


(especially sleep latency prolongation), and lower academic performance.

Suggested reading:

Dworak M, Schierl T, Bruns T, Strüder HK. Impact of singular excessive computer game andtelevision exposure on sleep patterns and memory performance of school-aged children.Pediatrics. 2007;120:978-985. DOI: 10.1542/peds.2007-0476. Available at:http://pediatrics.aappublications.org/cgi/content/abstract/120/5/978

Funk JB, Brouwer J, Curtiss K, McBroom E. Parents of preschoolers: expert mediarecommendations and ratings knowledge, media-effects beliefs, and monitoring practices.Pediatrics. 2009;123:981-988. DOI: 10.1542/peds.2008-1543. Available at:http://pediatrics.aappublications.org/cgi/content/abstract/123/3/981?rss=1

Sargent JD, Beach ML, Adachi-Mejia AM, et al. Exposure to movie smoking: its relation to smokinginitiation among us adolescents. Pediatrics. 2005;116:1183-1191. DOI: 10.1542/peds.2005-0714.Available at: http://pediatrics.aappublications.org/cgi/content/abstract/116/5/1183

Schmidt ME, Rich M, Rifas-Shiman SL, Oken E, Taveras EM. Television viewing in infancy andchild cognition at 3 years of age in a US cohort. Pediatrics. 2009;123:e370-e375. DOI:10.1542/peds.2008-3221. Available at:http://pediatrics.aappublications.org/cgi/content/full/123/3/e370


Dr_Faqehi


Question: 192

You are giving a talk to a community group about water safety. One of the attendees asks aboutways to prevent children from drowning in home pools.

Of the following, the MOST effective drowning prevention measure is to

A. have young children use inflatable arm floats ("water wings") when they are in the pool

B. install four-sided fences around backyard pools

C. provide swimming lessons to all children 2 years of age and older

D. recommend adult supervision

E. use a water motion detection alarm in the pool


Dr_Faqehi



Drowning is the second leading cause of unintentional injury-related death for childrenyounger than 14 years of age. Males are four times more likely to drown than females. Inchildren younger than 1 year, bathtubs, toilets, and buckets pose the greatest threat; toddlersdrown most commonly in home pools and adolescents in natural bodies of water. Minorities areat particular risk, with Native American, African American, and Native Alaskan childrendemonstrating a 1.2 to 1.8 times higher incidence than white children of the same age. Thisdisparity is presumably due to differential access to pools and sociocultural issues such asvalue placed on swimming skills.

The most common location for drowning events involving toddlers is backyard swimmingpools. This is especially true in states such as California and Florida, where home pools arecommon and used throughout the year. Most common in male toddlers, 75% of backyardswimming pool deaths occur in children between the ages of 1 and 3 years and most deaths areseen in pools owned by the family or friends.

Physical barriers between the child and the pool are the most effective means forpreventing swimming pool drownings. Experts recommend that the pool be surrounded by a four-sided fence that is at least 4 feet high. The gate should open inward and be secured with a self-closing latch or lock.

Although adult supervision is critical for children who are swimming, it is not adequate toprevent drowning. In most cases of fatal drowning or near-drowning, the child was reported tobe under the supervision of an adult at the time of the event and out of sight for less than 5minutes before being found.

Some new but limited data suggest that swimming lessons and water survival skills trainingmay lower drowning rates in 1- to 4-year-old children. However, there is insufficient evidence tosupport a recommendation that all 1- to 4-year-old children receive swimming lessons.

Inflatable arm floats (or water wings) and other foam or air-filled floating devices are toysand not intended to prevent drowning. Because most drowning events in toddlers are "silent"(involve minimal splashing or water motion), pool motion detectors do not reliably alert adults toan impending drowning event.

Suggested reading:

Brenner RA, Taneja GS, Haynie DL, et al. Association between swimming lessons and drowningin childhood: a case-control study. Arch Pediatr Adolesc Med. 2009;163:203-210. Abstractavailable at: http://www.ncbi.nlm.nih.gov/pubmed/19255386

Centers for Disease Control and Prevention. Unintentional Drowning: Fact Sheet. 2010. Availableat: http://www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html

Committee on Injury, Violence and Poison Prevention. Policy Statement — Prevention ofDrowning. Pediatrics. 2010; 126: e253 - e262. DOI: 10.1542/peds.2010-1265. Available at:http://pediatrics.aappublications.org/cgi/reprint/126/1/e253


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United States Consumer Product Safety Commission. Safety Barrier Guidelines for Home Pools.Washington, DC: United States Consumer Product Safety Commission; 2004. Available at:http://www.cpsc.gov/cpscpub/pubs/pool.pdf


Dr_Faqehi


Question: 4

You are seeing a 1-year-old patient in your clinic for a health supervision visit. You explain therecommended screening tests for this visit to the medical student who accompanies you.

Of the following, the MOST appropriate recommended screening test at this visit is

A. blood lead concentration by fingerstick

B. blood lead concentration by venipuncture

C. complete blood count with differential count

D. serum ferritin

E. serum iron


Dr_Faqehi



The diagnosis of lead poisoning or increased lead absorption depends on the measurementof blood lead concentrations. In the 1990s, both the American Academy of Pediatrics and theCenters for Disease Control and Prevention recommended universal blood lead screening of 1-and 2-year-old children, but because of the substantial decrease in the prevalence of elevatedblood lead concentrations, the criteria for screening are changing in many communities. Thus, itmay be helpful to contact your local health department to determine if children in your area are atrisk for environmental lead exposure.

Although blood lead concentration can be measured most accurately from a sample obtainedby venipuncture, a capillary specimen obtained by fingerstick is the most appropriate screeningtest for the toddler described in the vignette. The specimen must be obtained carefully to avoidcontamination from lead on the skin. Capillary specimen values greater than 10 mcg/dL (0.5mcmol/L) must be confirmed by a venous sample because of the possibility of skin contamination

causing a false-positive result. Although obtaining a complete blood count with smear and measuring serum ferritin and

serum iron may be useful in the diagnosis and management of children who have anemia,including that associated with environmental lead exposure, these tests are not definitive fordetermining exposure to environmental lead. Finally, hair evaluation for lead poisoning is neithersensitive nor specific due to the lack of correlation with blood lead values and should not beused.

References:

American Academy of Pediatrics Committee on Environmental Health. Lead exposure in children:prevention, detection, and management. Pediatrics. 2005;116:1036-1046. Available at:http://pediatrics.aappublications.org/cgi/content/full/116/4/1036

Binns HJ, Campbell C, Brown MJ for the Advisory Committee on Childhood Lead PoisoningPrevention. Interpreting and managing blood lead levels of less than 10 mcg/dL in children andreducing childhood exposure to lead: recommendations of the Centers for Disease Control andPrevention Advisory Committee on Childhood Lead Poisoning Prevention. Pediatrics.2007;120:e1285-e1298. Available at:http://pediatrics.aappublications.org/cgi/content/full/120/5/e1285

Laraque D, Trasande L. Lead poisoning: successes and 21st century challenges. Pediatr Rev.2005;26:435-443. Available at: http://pedsinreview.aappublications.org/cgi/content/full/26/12/435

Rischitelli G, Nygren P, Bougatsos C, Freeman M, Helfand M. Screening for elevated lead levelsin childhood and pregnancy: an updated summary of evidence for the US Preventive ServicesTask Force. Pediatrics. 2006;118:e1867-e1895. Available at:http://pediatrics.aappublications.org/cgi/content/full/118/6/e1867

Yeoh B, Woolfenden S, Wheeler D, Alperstein G, Lanphear B. Household interventions for


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prevention of domestic lead exposure in children. Cochrane Database Syst Rev.2008;2:CD006047


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Question: 12

A family comes to your office for consultation regarding a 3-week trip to India they are planningto take in 3 months. The children, a 9-year-old boy and a 7-month-old girl, are well, and theirimmunizations are up to date.

Of the following, the MOST appropriate prophylaxis to provide in preparation for travel is

A. chloroquine for both children

B. hepatitis A vaccination for both children

C. measles vaccination for the girl

D. polio vaccination for the boy

E. typhoid vaccine for both children


Dr_Faqehi



Protection against infectious diseases is an important issue in preparing children and adultsfor international travel. Clinicians can obtain specific knowledge of available vaccines andprophylaxis for certain conditions from the American Academy of Pediatrics 2009 Report of the

Committee on Infectious Diseases (Red Book®) and the travelers’ health site of the Centers forDisease Control and Prevention. Travel to India involves a potentially increased exposure tomalaria, hepatitis A, measles, polio, and Salmonella typhi. However, there are otherconsiderations in recommending various preventive measures for travelers.

Measles may be encountered more commonly in many parts of the world, including India.Accordingly, measles vaccine is recommended for 6- to 11-month-old children, and the 7-month-old girl in the vignette should be given a dose of measles vaccine. She still will require twodoses of measles-containing vaccine after 1 year of age because the immune response may besuboptimal at her young age. If the 9-year-old boy is up to date on immunizations, he requires noadditional measles vaccination.

Although exposure to malaria is a concern on a prolonged trip to India, resistance tochloroquine is a major concern in this region, as it is in all of South and Southeast Asia, sub-Saharan Africa, and tropical areas of South America. Available agents for resistant malariaprophylaxis in infants and children include atovaquone/proguanil and mefloquine. Doxycyclinecan be used in children older than 8 years of age.

Hepatitis A is a concern, but hepatitis A vaccine is not approved in children younger than 1year of age. Intramuscular immunoglobulin is recommended for children younger than 1 year ofage, as the baby in the vignette, traveling to an endemic area. The boy should receive his firstdose of hepatitis A vaccine at least 2 to 4 weeks before departure if he has not been immunizedpreviously, with completion of the two-dose series 6 to 12 months later.

Although polio exposure may be a concern, if both children are up to date in theirvaccination series, no additional polio vaccine is indicated. Finally, typhoid vaccine might beindicated for a trip to India that lasts longer than 2 weeks, but neither of the two licensedvaccines is indicated in children younger than 2 years of age.

References:

American Academy of Pediatrics. International travel. In: Pickering LK, Baker CJ, Kimberlin DW,Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. ElkGrove Village, Ill: American Academy of Pediatrics; 2009:98-104

Centers for Disease control and Prevention. Travelers’ Health Web site. Available at:http://wwwn.cdc.gov/travel/default.aspx

Centers for Disease Control and Prevention (CDC). Update: measles—United States,January–July 2008. MMWR Morbid Mortal Wkly Rep. 2008;57:893-896. Available at:http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5733a1.htm


Dr_Faqehi


Question: 36

You are the physician at a summer camp for special needs children. An adolescent who is ajunior counselor comes to the infirmary after being stung by a bee. Physical examination revealsswelling, pain, erythema, and tenderness in a well-circumscribed area on the right upper arm.On close examination, you see a small foreign body in a punctum.

Of the following, the MOST appropriate means of removing the stinger is to

A. apply duct tape and rapidly pull it off

B. pass a needle subcutaneously alongside the stinger

C. probe for the stinger with tweezers

D. scrape the stinger from the skin gently with a tongue blade

E. wait for the stinger to extrude by itself


Dr_Faqehi



The honeybee is unique among hymenoptera species in that it may leave a stingerembedded in skin; wasps, hornets, and yellow jackets do not. The stinger should be removed toavoid continued envenomation from the accompanying venom sac.

Simple scraping away of the stinger can avoid rupture of the venom sac. In a medical setting(such as a camp infirmary), a tongue blade may be available, but in other settings, the blunthandle of a spoon or other such instrument may be used. The area should be cleansed withsoap and water after removal of the stinger. Because allergic reactions are more likely to occurwhen the stinger is not removed promptly, tweezers may be used if nothing is available toscrape out the stinger. However, use of tweezers in a pincer motion may release more venom.Unnecessary probing using blunt or sharp instruments should be avoided if the stinger cannotbe extracted readily. In recent years, a variety of methods, including home remedies using

common household product adhesives such as duct tape and Superglue®, have becomepopular for removal of transdermal foreign bodies and superficial lesions such as cactus spinesand common warts. There is no evidence to suggest their efficacy in removing bee stingers.Waiting for the stinger to extrude increases the risk for allergic reaction.

References:

Booker GM, Adam HM. In brief: insect stings. Pediatr Rev. 2005;26:388-389. Available at:http://pedsinreview.aappublications.org/cgi/content/full/26/10/388

Mendez E, Sicklick MJ. In brief: hymenoptera reactions. Pediatr Rev. 1995;16:355-356. Abstractavailable at: http://pedsinreview.aappublications.org/cgi/content/abstract/16/9/355

Vankawala HH, Park R. Bee and hymenoptera stings. eMedicine Specialties, EmergencyMedicine, Environmental. 2008. Available at: http://emedicine.medscape.com/article/768764-overview

Visscher PK, Vetter RS, Camazine S. Removing bee stings. Lancet. 1996;348:301—302. Abstractavailable at:http://www.ncbi.nlm.nih.gov/pubmed/8709689?ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum


Dr_Faqehi


Question: 69

A family has just relocated to your community, and you are evaluating their 12-year-old son forthe first time this afternoon. Family history reveals that the boy’s father and grandmother hadpremature cardiovascular disease. The boy’s parents are concerned about his risk of heartdisease.

Of the following, the MOST important next step in this child’s evaluation is

A. echocardiography

B. electrocardiography

C. fasting lipoprotein analysis

D. random cholesterol measurement

E. referral to the cardiology clinic


Dr_Faqehi



In recent years, an increasing body of literature has indicated that atherosclerotic diseaseand its effect on the cardiovascular system are progressive processes that begin during earlychildhood. Research has demonstrated that the complex process of acquired cardiovasculardisease is the result of genetic predisposition to disease susceptibility along with factors suchas diet, physical activity, and other comorbidities.

In adults, the strongest risk factors for the development of cardiovascular disease include ahigh concentration of low-density lipoprotein, a low concentration of high-density lipoprotein,elevated blood pressure, type 1 or 2 diabetes mellitus, cigarette smoking, and obesity. Researchin children and adolescents has shown that some of these risk factors may be present in earlychildhood. It is imperative, therefore, for pediatricians to take proactive roles in stressing theimportance of healthy cardiovascular lifestyles and identifying children at risk for cardiovasculardisease.

The importance of the history, especially the family history, cannot be overemphasizedbecause the clinical manifestations of hypercholesterolemia are variable and may not bephysically present until later in childhood, adolescence, or even adulthood. Some children whohave homozygous familial hypercholesterolemia may demonstrate cutaneous or tendinousxanthomas, but often these findings are not apparent until early adulthood. As a result, somechildren who have significant hypercholesterolemia may have normal findings on physicalexamination.

The American Academy of Pediatrics has adopted the recommendation that childrenundergo cholesterol screening when there is a family history of premature cardiovasculardisease, such as for the boy in the vignette, or when there is a family history of high bloodconcentrations of cholesterol. It is also important to screen children for whom the family historyis not known if there is a history of other risk factors for cardiovascular disease such asobesity, hypertension, or diabetes mellitus. Accordingly, the boy in the vignette should undergo ascreening test for lipoproteins that includes cholesterol, high-density lipoproteins, and low-density lipoproteins in the fasting state.

Random cholesterol screening may provide important information, but taken in isolation, willnot offer as much information as a fasting lipoprotein panel. Referral to a specialized clinic suchas cardiology or endocrinology may be indicated in some patients, but this should be consideredonly after more complete information is obtained from the diagnostic evaluation. Neitherechocardiography nor electrocardiography is indicated for this patient at this time, and neither isused as a screening test for cardiovascular risk factors in children.

References:

Daniels SR, Greer FR and the Committee on Nutrition. Lipid screening and cardiovascular healthin childhood. Pediatrics. 2008;122:198-208. Available at:http://pediatrics.aappublications.org/cgi/content/full/122/1/198

Kwiterovich PO Jr. Recognition and management of dyslipidemia in children and adolescents. JClin Endocrinol Metab. 2008;93:4200-4209. Abstract available at:


Dr_Faqehi


http://www.ncbi.nlm.nih.gov/pubmed/18697860

Lambert M, Lupien P-J, Gagné C, et al. Treatment of familial hypercholesterolemia in children andadolescents: effect of lovastatin. Pediatrics. 1996;97:619-628. Abstract available at:http://pediatrics.aappublications.org/cgi/content/abstract/97/5/619


Dr_Faqehi


Question: 242

The mother of a healthy infant in the newborn nursery notes that her daughter has a good abilityto focus when held close but not while lying in bed. She asks you whether her child really isseeing her.

Of the following, your BEST response is that infants

A. cannot see colors at birth

B. do not have a conjugate gaze at birth

C. focus best on a facial construct

D. focus only on their mothers’ faces

E. have visual acuity equivalent to a 1-year-old child


Dr_Faqehi



The visual acuity in a term newborn is approximately 20/200. Throughout the first 4 to 8months of postnatal life, vision improves dramatically and reaches 20/30 by age 1 year. If shownan object or provided a light stimulus, the newborn may demonstrate any of a number of

responses, including:

•Staring

•Cessation of movement of the arms and legs

•Blinking

•Fixation and visually following the object brieflyAlternatively, the infant may have no response.

Infants fixate best on the construct of the human (eg, parent or examiner) face but also mayfixate on a graphically depicted face or a bright red object. The usual gaze is conjugate, andcolor detection is apparent at greater distances than closer distances (18 to 24 inches). Thesharper the contrast of opposing lines or figures, the greater the newborn’s ability to detect it.Gradations of shading are not appreciated well by newborns, but this aspect of vision improvesover the first 2 to 3 postnatal months.

The newborn’s ability to focus and attend to a face or object is best within 12 to 24 inches(30 to 70 cm) of his or her own eyes. The infant’s ability to show signs of attention or "see"objects at both closer and more distant lengths is reduced markedly during the first 2 postnatalmonths. Although memory for the mother’s face develops over time at a rate that is quicker thanfor a stranger’s face, newborn infants do, indeed, focus on a stranger’s face.

References:

Bushnell IWR. Mother's face recognition in newborn infants: learning and memory. Infant andChild Development. 2001;10:67-74. Abstract available at:http://www3.interscience.wiley.com/journal/79502688/abstract

Lissauer T. Physical examination of the newborn. In: Martin RJ, Fanaroff AA, Walsh MC, eds.Fanaroff and Martin's Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. 8th ed.Philadelphia, Pa: Mosby Elsevier; 2006:513-528

Ricci D, Cesarini L, Groppo M, et al. Early assessment of visual function in full term newborns.Early Hum Dev.2008;84:107-113. Abstract available at:http://www.ncbi.nlm.nih.gov/pubmed/17513071


Dr_Faqehi


Question: 245

You are evaluating an 11-year-old girl who recently moved to your community. During the history-taking, you learn that her 42-year-old father has extremely high blood cholesterol concentrations(>500.0 mg/dL [12.9 mmol/L]). The girl’s mother states that her husband’s sister also has veryhigh cholesterol values. Findings on the girl’s physical examination are normal.

Of the following, the MOST appropriate next step is to

A. begin therapy with a lipid-lowering medication

B. institute a low-fat diet plan and follow up in 3 months

C. measure fasting cholesterol and triglycerides

D. obtain a blood sample for genetic testing

E. order baseline electrocardiography


Dr_Faqehi



Population approaches to lowering cholesterol concentrations in children and adolescentshave focused on encouraging the adoption of diets that are lower in saturated fat, total fat, andcholesterol. However, the young girl in the vignette has a family history that is alarming for apossible genetic disorder of cholesterol metabolism and requires an individualized approach tofacilitate early diagnosis and management. Children and adolescents who have family historiesof premature cardiovascular disease or at least one parent who has high blood cholesterolvalues should be considered for selective screening. Children who have family histories of anyof the genetic hyperlipidemias also should undergo early screening of cholesterol andtriglycerides.

Several genetic syndromes affect the normal metabolic processes of cholesterol-richlipoproteins and are characterized by early onset of frequently severe atherosclerotic changesin the coronary artery system. Among these syndromes are: familial hypercholesterolemia,familial combined hyperlipidemia, familial hypertriglyceridemia, familial dysbetalipoproteinemia, andfamilial decreased high-density lipoprotein. Although the enzyme or protein abnormality varies ineach of these rare entities, the end result is similar in that affected children are at high risk forthe development of coronary artery disease at a young age.

Initiating therapy with lipid-lowering medications is not appropriate for the girl in the vignetteuntil a diagnosis has been made. Similarly, genetic testing may not be of value as a first step.Electrocardiography does not have a diagnostic or prognostic role in the asymptomatic patient.Instituting a low-fat diet plan with 3-month follow-up does not aid in establishing this patient’sdiagnosis.

References:

Cohen MS. Fetal and childhood onset of adult cardiovascular diseases. Pediatr Clin North Am.2004;51:1697-1719. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/15561181

Daniels SR, Greer FR and the Committee on Nutrition. Lipid screening and cardiovascular healthin childhood. Pediatrics. 2008;122:198-208.Available at:http://pediatrics.aappublications.org/cgi/content/full/122/1/198

Kwiterovich PO Jr. Recognition and management of dyslipidemia in children and adolescents. JClin Endocrinol Metab. 2008;93:4200-4209. Abstract available at:http://www.ncbi.nlm.nih.gov/pubmed/18697860

Kwiterovich PO. Disorders of lipid and lipoprotein metabolism. In: Rudolph CD, Rudolph AM,Hostetter MK, Lister G, Siegel NJ, eds. Rudolph’s Pediatrics. 21st ed. New York, NY: McGrawHill; 2003:693-711

Lambert M, Lupie P-J, Gagné C, et al. Treatment of Familial hypercholesterolemia in children andadolescents: effect of lovastatin. Pediatrics. 1996;97:619-628. Abstract available at:http://pediatrics.aappublications.org/cgi/content/abstract/97/5/619


Dr_Faqehi


Lauer RM, Snetselaar L, Muhonen LF. Hyperlipidemia in children and adolescents. In: Moller JH,Hoffman JIE, eds. Pediatric Cardiovascular Medicine. Philadelphia, Pa: Churchill Livingstone;2000:793-803


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03 preventive pediatrics

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