Vital Signs by Age 1-1

Vi ta l S i g ns b y A g e BP (SBP/DBP)   75–55/45–35   85–65/55–45   90–70/65–50 100–80/65–55 105–90/70–55 110– 95/75–60 120–100/75–60 135–110/85–65 ...
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Vi ta l S i g ns b y A g e BP (SBP/DBP)   75–55/45–35   85–65/55–45   90–70/65–50 100–80/65–55 105–90/70–55 110– 95/75–60 120–100/75–60 135–110/85–65

Age  1-1

Respiratory Rate 40–70 35–55 30–45 25–40 20–30 20–25 14–22 12–18

by

Heart Rate 120–170 100–150 90–120 80–120 70–110 65–110 60–95 55–85

Vital Signs

Premature 0–3 mo 3–6 mo 6–12 mo 1–3 yr 3–6 yr 6–12 yr 12+ yr

Reproduced from Nelson Textbook of Pediatrics. 18th ed. Saunders; 2007:70–74, 677, 2434.

• A recent systematic review of 69 observational studies suggests that previously published reference ranges for HR & RR may require updating. These centile charts & an interactive calculator available at http://madox.org/tools-and-resources (Lancet 2011;377:1011) Median Centiles

Respiratory rate (breaths per min)

70 60 50 40 30

99th 90th 75th

20

25th 10th 1st

10 0 0 1 2 3 6 9 Age (months)

12

2

4

6

8 10 12 Age (years)

14

16

18

Above: Respiratory rate centiles for children from birth to 18 yr 200

Median Centiles

Heart rate (beats per min)

180 160 140 120

99th

100

90th 75th

80 60

25th 10th

40

1st

20 0 0 1 2 3 6 9 Age (months)

12

2

4

6

8 10 12 Age (years)

14

16

18

Above: Heart rate centiles for children from birth to 18 yr

Develo p m e n ta l Mi l e sto n e s (Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. 2008:39; Pediatr Rev 2010;31:267; Pediatr Rev 2010;31;364; Pediatr Rev 2011;32;533)

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Vital Signs by Age  1-2

Age 1 mo

Gross Motor Fine Motor • Lifts chin when • Hands tightly prone fisted • Turns head • Hands to when supine mouth

2 mo

• Lifts chin when • Tracks past prone midline (by • Head bobs if 4 mo) held sitting • Hands unfisted ¹/² of time, holds hands together • Props on • Tracks to 180º wrists when • Shakes rattle prone • Mouths objects • No head lag • Reaching for when pulled objects to sit • Rolls front to back • Sits • Reaches w/ unsupported one hand (by 9 mo) • Transfers hand • Commando to hand crawls (8 mo) • Raking grasp • Pincer grasp • Pulls to stand • Cruises (9–12 mo) • Crawls • Bangs blocks together

4 mo

6 mo

Cognition and Communication • Throaty noises • Startles to sounds • Coos • Alerts to voice & sounds

• Orients to voice (by 6 mo) • Alt vocalization w/ speaker; “converses” • Repeats actions if results are interesting • Babbles “dada” • Listens, then vocalizes when speaker stops (by 9 mo) • Babbles “mama” (by 12 mo) • Imitates sounds • Responds to name (by 12 mo) • Primitive marks • 1 word on paper • Immature jargon • Finger feeds part of meal

Social–Emotional & Self-help • Fixates on faces (should do by 2 mo) • Discriminates parent’s voice • Social smile (by 6 mo) • Recognizes parent

• Laughs out loud • Enjoys looking around • Smiles spontaneously

• Recognizes strangers

• Waves “bye-bye” • Reciprocates gestures (by 12 mo) • Uses sound to get attention • Stranger anxiety • Proto-imperative 12 mo • Stands alone pointing • Walks few • Pat-a-cake steps alone • Imitates (by 18 mo) • Follows 1-step command w/ gesture • 3–6 words (by • Follows single15 mo • Walks carrying • Scribbles in 24 mo) step command imitation objects w/o gesture • Stacks 3–4 • Says no correctly • Stoops & • Protocubes recovers declarative • Turns pages • Climbs on pointing • Uses spoon, cup furniture • Scribbles • Helps in house • 10–25 words 18 mo • Walks up spontaneously • Points to people • Removes steps with • 4-cube tower hand held clothing and 3 body parts • Runs well • Imaginative when named • Throws ball play • Spoken language/ gesture combos • Follows series of • Lines cubes up • >50 words 50% 2 yr • Walks down intelligible 2 independent as train steps using rail commands • Imitates circle • 2-word • Throws ball phrases • Takes off clothing and/or line overhand, • Parallel play kicks ball 2.5 yr • Jumps • Turns paper • Uses pronouns • Washes & dries • Walks on toes pages in book • Recites parts of hands • Alternates feet • 8-cube tower known books • Puts on clothing going up stairs • Imitates adult activities 9 mo

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• Balance on each foot for 3 sec • Pedals tricycle • Heel–toe walk • Catches ball

• Copies a circle • Strings beads • Unbuttons clothes

4 yr

• Hops on one foot • Gallops

• Copies a cross and square • Draws 4–6part person • Buttons

5 yr

• Skips

• • •

6 yr

• Tandem walk

• • •

• >200 words • 3-word sentences • Speech 75% intelligible • Uses plurals

• Follows 3-step commands • 100% intelligible • Knows colors • Has memorized songs • Understands adjectives Copies a • Identifies most letters, numbers triangle out of order Cuts w/ • Counts to 10 scissors • Future tense Writes first • Reads 25 words name Ties shoes • 8–10 word Draws diamond sentences Writes first & • Knows days of last names, the week short sentences • Reads 250 words

• Brushes teeth w/ help • Names friends • Imaginative play • Begins sharing • Knows name, age, sex • Toilet trained • Tells tall tales • Interactive play (elaborate fantasy) • Group play • 1 close friend

Health Mainten  1-3

3 yr

• Has group of friends • Apologizes for mistakes • Same-sex best friend • Distinguishes fantasy from reality

Bolded milestones are red flags if missed by age specified in parentheses.

Red Flags • Missed milestones (particularly bolded ones) or loss of previously acquired milestones should prompt further developmental & medical assessment • Persistent fisting at 3 mo may represent earliest indication of neuromotor dysfxn • Rolling 4 hr • Succimer (DMSA); indication: VLL 45–69 mcg/dL • Side effects: Hypersensitivity reactions, GI sx, transient transaminitis, ↓ hemoglobin, reversible neutropenia; monitoring: LFTs and CBC • Dimercaprol (BAL = “British anti-Lewisite”): Indication: VLL 70 mcg/dL or lead enceophalopathy • Side effects: Pain, hemolysis in G6PD, toxic complexes if given w/ iron, HTN, N/V, fever, lacrimation, paresthesia, renal dysfunction, zinc depletion, headache, leucopenia, tachycardia, hyperpyrexia • Contraindications: G6PD, hepatic disease, peanut allergy • Monitoring: CV and mental status; alkalinize urine during tx

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Contraception The Oral Contraceptive Pill (OCP) • Either combo synthetic estrogen (ethinyl estradiol [EE] or mestranol pro-drug) and progestin (of varying potency) or a progestin only pill (POP) • Estrogen suppresses gonadotropin surge → prevention of ovulation • Progestins thicken cervical mucus, alter tubal peristalsis, and create endometrial atrophy → deter sperm motility, egg fertilization, and implantation • Theoretical failure rate ∼0.3%; typical use failure rate: ∼8%. 2/2 poor adherence • “Estrogen-dominant” (full-figured, significant menstrual symptoms) pts may benefit from less estrogenic or more potently androgenic pill. “Androgen-dominant” (hirsute, acne, PCOS) pts may benefit from more estrogenic vs. less androgenic • Generics have equivalent tolerability and efficacy; often significantly more affordable • New extended-cycle formulations (w/ 1–4 withdrawal bleeds/yr) have good efficacy and can reduce effects of hormone w/drawal • Benefits: Help tx DUB, dysmenorrheal, acne, hirsutism, PCOS, and dec risk of uterine and ovarian cancers • Initiate with either monophasic or multiphasic but at low dose estrogen (20–35 mcg) and titrate up as needed after 3-mo trial. Initiate on d 1 of menstrual cycle or on Sunday after menstrual cycle begins; take pill same time every day. Encourage condoms in ­conjunction with OCPs. F/up 6 wk to 2 mo after initiation

Contraception  1-19

(Pediatrics 2007;120:1135; Pediatr Rev 2008;29:386)

OCP Side Effects, Monitoring, and Contraindications • Estrogen side effects include blood clots, irregular menses, breast tenderness, fluid retention, nausea, increased appetite, headache, and hypertension (can trial pill ­containing lower estrogen dose) • Progestin effects include menstrual ∆, bloating, mood ∆, HA, nausea, weight gain. Drospirenone (in Yasmin) has diuretic and antiandrogenic activity; caution in pts at risk of hyperK+ or with renal insufficiency • Androgenic side effects (less common; incl acne, hirsutism, male pattern hair loss) • Class IV contraindications: H/o DVT, PE, CVA, AMI, Factor V Leiden or other ­thrombophilia, migraine w/ aura or neurologic changes. (Refer to complete WHO guidelines at http://www.who.int/reproductive-health/publications/mec/3_cocs.pdf) Other Options • Vaginal rings: (NuvaRing®) Combined hormone-containing silicone ring, hormones absorbed vaginally, avoids 1st-pass metab. Intravaginal 3 wk, ↑ rate of pt satisfaction • Transdermal: Absorb E&P through skin; less effective in pts >90 kg, avoids 1st-pass metab • Each patch should be worn for 7 d before replacing, on a new site each time • FDA warning: 60% more total estrogen in patients’ blood c/w 35 mcg OCP • Injectable: Depot medroxyprogesterone acetate (progestin only, Depo-Provera) IM q3mo, ↓ reliance on pt adherence • High discontinuation 2/2 side effects (menstrual irreg, wt gain, ↓ in bone density) • Fertility can take up to 10 mo to return • Combined injectable contraceptives injected q1mo and offer advantage of both improved adherence w/o side effect profile of progestin only injections • Subdermal contraceptive implants: Progestin-only rod (Implanon) inserted below the skin, effective for up to 3 yr. Fertility returns promptly after removal • Irregular bleeding is a common side effect, but diminishes with continued use • Intrauterine devices (IUD) • The levonorgestrel-releasing IUD has been approved for up to 5 yr of use • Copper-containing IUD acts via a local inflammatory response • Chance of ectopic pregnancy is African-American and Latino • Evidence for moderate to substantial heritability. Risk factors: Obese girls or early puberty, perfectionism, concerns over self-control, low self-esteem, past hx of abuse, certain sports (cheerleading, gymnastics, running) • Suicidality and cardiac complications are leading causes of death

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Eating Disorders  1-21

Evaluation: Eating Disorders Examination-Questionnaire (http://www.psychiatry.ox.ac.uk/research/reserachunits/credo/assessment-measures-  pdf-files/EDE-Q6.pdf) • Hx obtain past, current, and ideal body weight; eating patterns, binge/purge, restrictive and other behaviors, exercise hx, body image concerns, menstrual hx; confirmation from family as patients may be manipulative • ROS and PMH assess sx of malnutrition (i.e., constipation, feeling cold or faint), vomiting (chest pain, hematemesis) • Assess for comorbid mental illness: Major depression, anxiety disorders, OCD, anxiety disorder, social phobia, other mood disorders, substance use, high-risk sexual behavior; ask about suicidality • Labs: CBC, CMP, TSH, amy/lipase, ESR, hCG. Consider LH/FSH, estradiol, prolactin • ECG if electrolyte abn, cardiac symptoms, significant weight loss, or bulimia • Radiographic studies (upper or lower GI, abd, and/or head imaging) when indicated • DEXA recommended if amenorrhea >6 mo, annually if amenorrhea persists Medical Complications/Physical Findings • Derm/orofacial: Erosion of tooth enamel/cavities, parotid gland hypertrophy, calluses on knuckles (Russell sign), hypercarotenemia, alopecia, acne, lanugo, halitosis • Metabolic derangements: Hypernatremia 2/2 restricted intake; hyponatremia 2/2 water loading; hypokalemic, hypochloremic metabolic alkalosis 2/2 vomiting, and diuretics; hypophosphatemia as part of refeeding syndrome in rx phase • Cardiac: Bradycardia, HoTN, orthostasis, arrhythmia, prolonged QT, MV prolapse/ murmur, pericardial effusion, cardiomyopathy and CHF, sudden cardiac death • Pulmonary: Aspiration PNA and PTX from forceful vomiting, pulm edema 2/2 refeeding • GI: Vague abn pain, constipation, delayed gastric emptying, esophageal irritation and chest pain, hematemesis 2/2 Mallory–Weiss tears/esoph rupture, gallstones, rectal prolapse, SMA syndrome, LFT abn, usually nml albumin (if ↓, eval for other dx) • GU: Renal stones, atrophic vaginitis, atrophy of genitalia • Neuro: Szr (hypoNa), peripheral neuropathy, brain atrophy, long-term neurocog abn • Endocrine: ↓LH/FSH and estrogen, amenorrhea, osteopenia, and osteoporosis (fractures); ↓ thyroid fxn (hypothermia), often sick euthyroid • Heme/immuno: Mild anemia (folate or iron def), ↓ ESR, WBC, plt count, altered ­immunologic markers Treatment: Requires multidisciplinary team; use of eating disorder protocol with privileges as incentives. Often stabilized inpatient, transferred to residential tx center. • Monitoring and rx of electrolyte disarray, sudden death may occur from hypoK • Cautious nutritional support in severely malnourished (