BRS – Pediatrics: Pediatric Health Supervision

BRS – Pediatrics: Pediatric Health Supervision

Source: BRS Pediatrics, 2019

I. Well-Child Care—General Concepts

A. The purpose of routine well-child care is to address the longitudinal health care needs of children from birth through adolescence. This is ideally achieved through a family-centered medical home model where the pediatric care team works in partnership with the family to ensure that all health-related needs are met. Features of well-child care include the following:

1. Age-specific health supervision according to recommended periodicity schedules
2. Disease detection through surveillance and screening:

a. Assessment of growth and development
b. Screening tests to detect asymptomatic diseases (e.g., vision, hearing, newborn metabolic screening, anemia, and lead screening)
c. Developmental screening

3. Disease prevention

a. Primary prevention
1. Sudden infant death syndrome, or SIDS, prevention (“back to sleep”), for example
2. Immunizations
b. Secondary prevention (e.g., care coordination for children with special health care needs)

B. The content of the well-child visit includes
1. Eliciting parental and patient concerns
2. History provides an opportunity to obtain diagnostic information and to form a doctor– patient–family alliance. The interview is shaped by family and patient concerns and by age-specific trigger questions about common problems (e.g., sleep, nutrition, behavior).
3. Developmental surveillance is gathered through age-specific questioning, developmental questionnaires, observations during the visit, screening tests, and a review of academic school performance.
4. Observation of parent–child interaction
5. Physical examination should be comprehensive and also should focus on growth (i.e., length/height, weight, head circumference, and body mass index).
6. Additional screening tests depend on the age of the child and may include lead level, hemoglobin, lipid levels, blood pressure, and hearing and vision assessment.
7. Immunizations
8. Anticipatory guidance includes a discussion of safety issues and upcoming developmental issues.

II. Growth

A. Normal growth
1. Weight, height, head circumference (until 2 years of age), body mass index (starting at 2 years of age), and sexual maturity are monitored routinely during well-child care to assess for adequacy of growth and development.
2. Standardized growth curves, produced by the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC), reflect average values for age for 95% of children and are used to plot weight, height, body mass index, and head circumference over time.
3. Tables 1-1, 1-2, and 1-3 detail general “rules of thumb” for expected gains in weight, height, and head circumference. Sexual maturity rating scales are found in Chapter 3, Figures 3-1, 3-2, and 3-3.
B. Growth disturbances are defined as growth outside of the usual pattern. Three common types of growth disturbance include failure to thrive (FTT), short stature, and head growth abnormalities. Short stature is discussed in Chapter 6, section I.
1. FTT
a. Definition. Although there are multiple definitions, FTT is a term most commonly used to describe a growth rate less than expected for a child, and is of particular concern when a child’s weight crosses two major percentile isobars on a growth chart.
b. FTT may involve all growth parameters, although weight gain is generally the most affected. FTT should be distinguished from isolated short stature, in which height is the most abnormal growth parameter (see Chapter 6, section I).
c. In children with FTT, weight is typically affected before linear growth, which is usually affected before head circumference growth. Head circumference is initially spared in FTT.
d. Classification. FTT was previously categorized as either nonorganic (due to psychosocial factors) or organic (due to underlying organ system pathology). This classification is no longer recommended because these categories coexist in many cases. A more appropriate categorization of FTT describes whether there is inadequate caloric intake, inadequate caloric absorption, inadequate utilization of nutrients, or excessive metabolic demand. The most common etiology of FTT is inadequate intake of calories, which may result from a disturbed parent–child bond. The differential diagnosis of FTT is outlined in Figure 1-1.
e. Evaluation of FTT requires a careful history and physical examination, a complete dietary history, and observation of the parent–child interaction. No laboratory tests are routinely indicated in the initial evaluation of FTT. Laboratory tests should be reserved for cases where the history or physical examination suggests a specific etiology for which laboratory testing will be helpful or for the child who fails to respond to nutritional interventions.
2. Head growth abnormalities include abnormalities in size (microcephaly/macrocephaly) or shape (deformational plagiocephaly/craniosynostosis).
a. General concepts. Almost all head growth occurs prenatally and during the first 2 years of life.
1. Head circumference at birth is 25% of the normal adult head size, and it increases to 75% of the normal adult head size by 1 year of age.
2. Note that caput succedaneum (scalp edema) and cephalohematoma
(subperiosteal hemorrhage of the newborn cranium after a traumatic delivery)

may interfere with accurate head circumference measurement in newborns.
b. Microcephaly
1. Definition. Head circumference is 2–3 standard deviations below the mean for age.
2. Incidence is 1–2/1000 children.
3. Etiologies are classified as either congenital or acquired (Table 1-4).
a. Congenital microcephaly is associated with abnormal induction and migration of the brain tissue.
b. Acquired microcephaly is caused by a cerebral insult in the late third trimester, perinatal period, or first year of life. Affected children are born with a normal head circumference that does not grow after the cerebral insult.
4. Clinical features
a. Because head size generally reflects brain size, microcephaly is always associated with a small brain.
b. Microcephaly is usually associated with developmental delay and
intellectual impairment.
c. Microcephaly may be associated with cerebral palsy or seizures.
c. Macrocephaly
1. Definition. Head circumference > 95% for age.
2. Unlike in microcephaly, the size of the head in a patient with macrocephaly does not necessarily reflect brain size.
3. Etiologies
a. Benign familial macrocephaly, associated with an otherwise normal physical examination and a family history of large heads
b. Overgrowth syndromes (e.g., Sotos syndrome), in which all growth parameters are enlarged
c. Metabolic storage disorders (e.g., Canavan syndrome, gangliosidoses)
d. Neurofibromatosis (see Chapter 19, Table 19-3)
e. Achondroplasia (see Chapter 5, section IV.H.1)
f. Hydrocephalus (see Chapter 12, section II)
g. Space-occupying lesions (e.g., cysts, tumors)
4. Evaluation includes measurement of parental head circumferences, and a careful physical examination that includes observation for split cranial sutures, bulging anterior fontanelle, irritability, or vomiting, all of which may suggest elevated intracranial pressure. Head ultrasound or computed tomography (CT) scan is performed to rule out hydrocephalus, if suggested by physical examination. Genetic evaluation may be useful if a genetic syndrome is suspected.
d. Craniosynostosis
1. Definition. Premature closure of one or more of the cranial sutures (Figure 1- 2).
2. Etiology is often unknown. 80–90% of cases are sporadic and 10–20% are familial or part of a genetic syndrome (e.g., Crouzon and Apert syndromes). Known risk factors include intrauterine constraint or crowding, and metabolic abnormalities including hyperthyroidism and hypercalcemia.
3. Clinical features. Head shape in craniosynostosis is determined by which suture closes prematurely, because bone growth perpendicular to the affected suture is arrested.
a. Premature closure of the sagittal suture results in an elongated skull

(termed dolichocephaly or scaphocephaly) and is the most common form of craniosynostosis (Figure 1-3).
b. Premature closure of the coronal suture results in a shortened skull (termed brachycephaly). This is more common in boys and may be associated with neurologic complications such as optic nerve atrophy.
c. Premature closure of the metopic suture leads to a triangular-shaped head and prominent longitudinal central ridge on the forehead (termed trigonocephaly).
d. Premature closure of multiple sutures is rare, and is associated with severe neurologic compromise.
4. Diagnosis is made by physical examination of the head. Craniosynostosis is usually noted by 6 months of age. The diagnosis may be confirmed by skull radiographs and head CT scan.
5. Management is surgical repair, most often indicated when cosmetic concerns are significant.
e. Plagiocephaly
1. Definition. Asymmetry of the infant head shape not associated with premature suture closure
2. Clinical features. The most common type of plagiocephaly is positional plagiocephaly (Figure 1-4), associated with flattening of the occiput and prominence of the ipsilateral frontal area. Viewed from above, the skull has a parallelogram shape with the back of the head, ear, and forehead of one side displaced anteriorly.
a. May be associated with congenital muscular torticollis (see Chapter 17, section II.A.1), in which fetal head constraint during the third trimester can result in both trauma to the sternocleidomastoid and deformations of the skull.
b. Incidence has increased as a result of recommendations that infants sleep on their backs to decrease the risk of SIDS.
c. Management may include range of motion exercises for associated torticollis, repositioning the head during sleep, and increased time in the prone position when awake (“tummy time”). Cranial remodeling helmet therapy was a common treatment, but the American Academy of Pediatrics (AAP) updated its position in 2011 stating that helmet therapy was unnecessary for most babies with plagiocephaly.

Table 1-1
Rules of Thumb for Expected Increase in Weight

Age Expected Weight Increase
Birth–2 weeks (average birth weight is 3.5 kg) Lose up to 10% of birth weight, usually in the first week of life
Regain birth weight by 2 weeks of age
2 weeks–3 months 30 g/day
3–6 months 20 g/day
Double birth weight by 4–6 months of age
6–12 months 10 g/day
Triple birth weight by 12 months of age
1–2 years 250 g/month or 3 kg/year
Quadruple birth weight by 2 years of age
2 years–puberty 2 kg/year
30 g = 1 oz body weight.

Table 1-2
Rules of Thumb for Expected Increase in Height

Age Expected Height Increase
0–12 months (average birth length is 50 cm) 25 cm/year
Birth length increases by 50% at 12 months of age
13–24 months 12.5 cm/year
2 years–adolescence 6.25 cm/year
Birth length doubles by age 4 years
Birth length triples by age 13 years
Table 1-3
Rules of Thumb for Expected Increase in Head Circumference

Age Expected Head Circumference Increase
0–2 months (average birth head circumference is 35 cm) 0.5 cm/week
2–6 months 0.25 cm/week
By 12 months Total increase = 12 cm since birth

FIGURE 1.1 Differential diagnosis of failure to thrive (FTT). Inadequate caloric intake is the most common cause of FTT, followed by excessive caloric requirements. Inadequate caloric absorption is the least common cause of FTT. IUGR = intrauterine growth restriction.

Table 1-4
Causes of Microcephaly

Congenital
Early prenatal infection (e.g., HIV infection, TORCH)
Maternal exposure to drugs and toxins (e.g., fetal alcohol syndrome)
Chromosomal abnormality (e.g., trisomy 13, 18, or 21)
Familial microcephaly (autosomal dominant or autosomal recessive inheritance)
Maternal phenylketonuria
Acquired
Late third trimester or perinatal infections
Meningitis or meningoencephalitis during first year of life
Hypoxic or ischemic cerebral insult
Metabolic derangements (e.g., hypothyroidism, inborn errors of metabolism)
TORCH = toxoplasmosis, other (syphilis), rubella, cytomegalovirus, herpes simplex virus; HIV = human immunodeficiency virus.

FIGURE 1.2 Cranial sutures in the neonatal skull.

Reprinted with permission from Pillitteri A. Maternal and Child Nursing. 7th Ed. Philadelphia: Lippincott Williams & Wilkins, 2013.

FIGURE 1.3 Types of craniosynostosis.

Reprinted with permission from Mongan P, Soriano SG, Sloan TB, Gravlee GP. Practical Approach to Neuroanesthesia. Philadelphia: Lippincott Williams & Wilkins, 2013.

FIGURE 1.4 Infant with positional plagiocephaly.

Reprinted with permission from Kyle T, Carman S. Essentials of Pediatric Nursing. 2nd Ed. Philadelphia: Lippincott Williams & Wilkins, 2013.

III. Immunizations
A. Immunizations are among the most important components of well-child care and disease prevention. Recommendations for routine immunizations are updated annually. For the most up-to- date recommendations on the childhood immunization schedule, please visit www.cdc.gov.
B. Types of immunizations
1. Active immunization involves induction of long-term immunity through exposure to live attenuated or killed (inactivated) infectious agents.
a. Live vaccines are more likely to induce long-lasting immunity, but carry the risk of vaccine-associated disease in the recipient, or in a secondary host. As a result, live vaccines should generally be avoided in patients with compromised immunity (e.g., cancer, congenital or drug-induced immunodeficiencies, acquired immune deficiency syndrome). Examples of live vaccines include intranasal influenza; varicella; and measles, mumps, and rubella (MMR) vaccines.
b. Nonlive vaccines are not infectious and tend to induce immunity for shorter periods, thus requiring booster immunizations. Examples include diphtheria, tetanus, and acellular pertussis (DTaP); hepatitis A (Hep A) vaccine and hepatitis B vaccine (HBV); inactivated polio vaccine (IPV); Haemophilus influenzae type b (HIB); inactivated influenza; pneumococcal and meningococcal vaccines.
2. Passive immunization involves delivery of preformed antibodies to individuals who have no active immunity against a particular disease, but have either been exposed to or are at high risk for exposure to the infectious agent. Examples include the following:
a. Varicella zoster immune globulin (VZIG) for immunocompromised patients who have been exposed to varicella and are at high risk for severe varicella infection, including newborns born to mothers who develop chicken pox between 5 days before and 2 days after delivery.
b. Hepatitis B immune globulin, given to newborns born to hepatitis B–positive women
c. Hepatitis A immune globulin, given as “predeparture” passive immunization to some visitors to high risk areas
C. Specific immunizations
1. Hepatitis B vaccine (HBV)
a. Rationale for vaccine: 90% of affected infants will develop chronic infection. 240 million people are chronically infected worldwide, with up to 30 million new cases every year. More than 750,000 people die annually from hepatitis B and its complications.
b. Type of vaccine: inactivated
c. Timing of vaccination: HBV is given as a three-shot series within the first year of life.
2. DTaP
a. Rationale for vaccine: Diphtheria, tetanus, and pertussis all may cause serious disease, especially in young infants. Outbreaks of pertussis with significant mortality continue to occur in the United States.
b. Type of vaccine
1. Vaccine is inactivated.
2. DTP, which contained whole-cell, killed Bordetella pertussis, had a high rate of side effects and was replaced with DTaP (1996), a vaccine that contains purified components (acellular) of B. pertussis, with lower rates of vaccine- associated fever, seizures, and local reactions. DTaP is safer but has a waning

immunity to pertussis over time.
c. Timing of vaccination
1. DTaP is recommended at 2, 4, and 6 months of age with boosters at 12– 18 months and 4–6 years of age.
2. Tdap (has less diphtheria component compared with DTaP) is a booster immunization, offering continued protection from these diseases in the adolescent and adult age group. Tdap is recommended at age 11–12. After receiving at least one Tdap, the vaccine should be given every 10 years thereafter for continued protection. Note that Tdap rather than DTaP is given to children 7–10 years of age if they did not complete their series of DTaP by their seventh birthday.
3. Oral polio vaccine (OPV) and IPV
a. Rationale for vaccine: Poliovirus is an enterovirus with propensity for the central nervous system, which may cause transient or permanent paresis of the extremities and meningoencephalitis. Polio has been eradicated from the Western hemisphere and South Pacific, but remains in isolated pockets throughout the world.
b. There are two types of vaccines.
1. Live attenuated (OPV), administered orally
a. Advantages include ease of administration and induction of both host immunity and secondary immunity, because it is excreted in the stool of the recipient and may infect, and thus immunize, close contacts.
b. Disadvantages include the induction of vaccine-related polio, a rare complication. Because of the risk of vaccine-related polio, OPV is no longer used in the United States.
2. Nonlive or inactivated (IPV), administered subcutaneously or intramuscularly, does not cause vaccine-related polio, but also does not confer secondary immunity.
c. Timing of vaccination: In the United States, only IPV is recommended and is given at 2 and 4 months of age, with boosters at 6–18 months and 4–6 years of age.
4. Rotavirus vaccines
a. Rationale for vaccine: Rotavirus infections are the most common cause of severe acute gastroenteritis worldwide. Worldwide, each year approximately 2 million children are hospitalized and 450,000 children die from disease caused by rotavirus. Rotavirus is highly contagious and nearly every child is at risk of getting infected.
b. Type of vaccine: oral, live vaccine
c. Timing of vaccination: recommended at 2, 4, and 6 months of age
5. HIB vaccine
a. Rationale for vaccine: HIB was a serious cause of invasive bacterial infection, including meningitis, epiglottitis, pneumonia, and sepsis, before vaccine licensure in 1985. Since licensure, HIB has become a rare cause of such infections.
b. Type of vaccine: HIB vaccine is a conjugate vaccine (inactivated) with H. influenzae polysaccharide linked to various protein antigens, including diphtheria or tetanus toxoids, to augment immunogenicity.
c. Timing of vaccination: HIB vaccine is recommended at ages 2, 4, and 6 months with a booster at ages 12–15 months. After 15 months of age, the vaccine confers lasting immunity. Therefore, children who receive the HIB vaccine at 15 months of age or older do not require additional doses, no matter how many doses were given before 15 months of age.
6. MMR vaccine

a. Rationale for vaccine: MMR immunizes against three viral diseases. Especially important in areas where misinformation regarding the vaccine has led to decreased vaccination rates and unfortunate outbreaks of the following:
1. Measles is a severe illness with complications that include pneumonia associated with significant mortality. Classic signs include cough, coryza, conjunctivitis, and Koplik spots (an enanthem with white lesions on a reddened base on the inner cheek), followed by a classic rash (an exanthem described as morbilliform, starting on the face and moving caudally).
2. Mumps is most commonly associated with parotitis but may also cause meningoencephalitis and orchitis.
3. Rubella causes a mild viral syndrome in children, but may cause severe birth defects (commonly hearing loss and heart defects) in offspring of susceptible women who are infected during pregnancy.
b. Type of vaccine: live attenuated vaccine
c. Timing of vaccination: MMR vaccine is recommended at 12–15 months of age with a booster at 4–6 years of age. A special indication exists for infants 6–12 months of age traveling to countries where MMR is endemic. Because this dose is given before the recommended time of 12–15 months, it does not count toward the two-shot series and the child will subsequently need two additional doses at the appropriate times.
7. Varicella vaccine
a. Rationale for vaccine: Varicella is the virus responsible for chicken pox and zoster. Varicella often causes uncomplicated illness, but may cause severe disease in very young and in older or immunosuppressed patients.
b. Type of vaccine: live attenuated vaccine
c. Timing of vaccination: Vaccine is recommended at 12–18 months of age with a booster at 4–6 years of age. It is commonly given in conjunction with MMR vaccine.
8. Hep A vaccine
a. Rationale for vaccine: Hep A is the most common viral cause of hepatitis worldwide, although it is asymptomatic in up to 70% of infected children younger than 6 years. More severe disease is seen in older children and adults, although it is rarely associated with fulminant hepatitis.
b. Type of vaccine: inactivated
c. Timing of vaccination: Hep A vaccine is a two-dose vaccination series recommended for all children starting at 1 year of age. The booster should given at least 6 months later but ideally no later than 2 years of age. Children not fully vaccinated by 2 years of age should be vaccinated at subsequent visits.
9. Pneumococcal vaccines (PCV-13 and PPSV-23)
a. Rationale for vaccine: Pneumococcal (Streptococcus pneumoniae) disease causes more deaths in the United States each year than all other vaccine-preventable illnesses combined. It is a common cause of acute otitis media, pneumonia, and invasive bacterial infections (bacteremia and meningitis) in the pediatric population.
b. There are two types of vaccines. Both are inactivated.
1. PPSV23 is composed of polysaccharide capsular antigens from 23 pneumococcal serotypes.
a. Major advantage is that the vaccine contains antigens from pneumococcal strains causing almost all cases of bacteremia and meningitis during childhood.
b. Major disadvantage is that the vaccine has little immunogenicity in children younger than 2 years.

c. Indications. Vaccine is indicated in children with an immunocompromising condition and and for those with functional or anatomic asplenia. It is also indicated immunocompetent children with chronic heart disease, chronic lung disease, diabetes mellitus, cerebrospinal fluid (CSF) leak or cochlear implants.
d. Timing of vaccination: One dose should be given at 2 years of age and at least 8 weeks after the final dose of PCV13 (see below). Children with an immunocompromising condition or functional/anatomic asplenia should get a second dose 5 years after the first PPSV23.
2. PCV13 is composed of 13 pneumococcal serotypes. PCV13 includes the 13 serotypes that account for most invasive pneumococcal diseases.
a. Major advantages include immunogenicity and efficacy in preventing meningitis, pneumonia, bacteremia, and otitis media from the most common pneumococcal strains in children younger than 2 years.
b. Major disadvantage is that it does not confer as broad coverage against as many pneumococcal strains as PPSV-23.
c. Timing of vaccination: PCV-13 is recommended for all children at 2, 4, and 6 months of age, with a booster at 12–15 months of age. Healthy children who fall behind schedule should be caught up before their fifth birthday.
10. Influenza vaccines
a. Rationale for vaccine: Influenza can be a very serious illness that may result in hospitalizations and even death, regardless of a child’s medical history. About 20,000 children are hospitalized annually in the United States with influenza, and around 40% of children who die from influenza have no significant past medical history. Children under 5 years of age and those with conditions that predispose to complications of influenza are considered to be at high risk.
b. There are two types of vaccines, with recommendations for administration updated annually.
1. Live attenuated influenza vaccine (LAIV), administered intranasally
a. Advantages: no need for an injection.
b. Disadvantages: it is only available for children 2 years of age or older without contraindications to the vaccine. It can cause nasal congestion and rhinorrhea for several days.
2. Inactivated influenza vaccine (IIV), administered intramuscularly
a. Advantages: may be administered as early as at 6 months of age. There are no contraindications owing to underlying medical conditions, unless the child has a history of anaphylaxis to a previous influenza vaccination.
b. Disadvantages: requires injection
c. Timing of the vaccination: Every child aged 6 months and older should receive the influenza vaccination annually. Between 6 months and
8 years of age, first-time vaccine recipients need two doses of vaccine, spaced at least one month apart.
11. Human Papilloma Virus (HPV) vaccines
a. Rationale for vaccine: HPV is the most common sexually transmitted disease in the United States, affecting the majority of sexually active adults. There are about 150 different types of HPV, some of which cause significant health problems such as genital warts and certain cancers (e.g., cervical, vaginal, anal, penile, and oropharyngeal). Thus, HPV vaccine is one of the two cancer-preventive vaccinations, the other being Hepatitis B vaccine.

b. Type of vaccine: inactivated vaccine
c. Timing of vaccine: All children aged 11–12 years should receive the two-dose series of HPV, with the second dose administered 6 months after the first. If the first dose is not started until age 15 or older, three doses of vaccine are required. Young men may be vaccinated up to 21 years of age, and women may be vaccinated up to
26 years of age. Ideally, the series is initiated during the preteen years, to facilitate development of an immune response before the initiation of sexual activity.
12. Meningococcal vaccine (MCV)
a. Rationale for vaccine: Infection with Neisseria meningitidis can cause meningitis and sepsis, which is fatal in up to 15% of children. Up to 20% of survivors will develop permanent disabilities (e.g., loss of limbs, deafness, central nervous system damage). Rates of disease are highest in infants < 1 year of age, and in teens and young adults ages 16–23 years. Rates of meningococcal disease have been declining since 1990, which is thought to be a consequence of increased vaccination use.
b. Type of vaccine: inactivated vaccine
c. Timing of vaccine: All children aged 11–12 years should receive the quadrivalent vaccine to protect against serotypes A, C, W, and Y. A booster vaccination is given at 16–18 years of age. Children as young as 2 months old may receive the first dose of a four-dose meningococcal vaccine series if they are at high risk (e.g., anatomic or functional asplenia, complement deficiency, travel to hyperendemic or epidemic regions), with administration of doses recommended at 2, 4, 6, and 12–15 months of age. Vaccine for serotype B is recommended for children ≥ 10 years of age at increased risk of serotype B infection (e.g., community outbreak, functional/anatomic asplenia, and complement pathway abnormalities).
D. Adverse effects of immunization
1. Most vaccine side effects are mild to moderate in severity and occur within the first 24– 48 hours after administration (e.g., local inflammation and low-grade fever).
2. Because MMR and varicella vaccines are live attenuated vaccines, fever and rash may occur 1–2 weeks after immunization (i.e., after the incubation period of the virus).
3. Serious side effects, including those that are life-threatening or result in permanent disability, are rare (e.g., vaccine-related polio after OPV).
4. While there is no evidence that neither vaccines nor preservatives such as thimerosal are linked to developmental disabilities, as a precautionary measure the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) eliminated thimerosal from vaccines in 2001. Of the vaccines currently recommended for children younger than 6 years, only some forms of influenza vaccine contain small amounts of thimerosal.
5. There is no evidence of a link between vaccines and autism.
E. Contraindications and precautions to immunization
1. Contraindications to immunization include the following:
a. Anaphylaxis to a vaccine or its constituents
b. Encephalopathy within 7 days after DTaP/Tdap vaccine
c. Immunodeficient patients should not receive live vaccines including OPV, MMR, rotavirus, and varicella vaccines. Household contacts of immunodeficient patients should not receive OPV vaccine, as it is shed in the stool.
d. Patients with a history of intussusception should not receive rotavirus vaccine.
e. Pregnant patients should not receive live vaccines, including OPV, MMR, and varicella.
2. Precautions (i.e., caution should be exercised) to immunization include the following:
a. For all vaccines, moderate to severe illness (with or without fever). Note that mild

illnesses, including febrile illnesses, are not contraindications to immunization.
b. DTaP vaccine
1. Temperature of 40.5°C within 48 hours after prior vaccination
2. Collapse or shocklike state within 48 hours after prior vaccination
3. Seizures within 3 days after prior vaccination
4. Persistent, inconsolable crying lasting ≥3 hours occurring within 48 hours after prior vaccination
c. MMR and varicella vaccines: Intravenous Immunoglobulin (IVIG) administration within the preceding 11 months, which might interfere with the patient’s immune response to these live vaccines

IV. Well-Child Screening
A. The focus of each well-child visit is to identify undetected problems or the risks for such problems.
B. Screening assessments include a complete history and physical examination, growth measurements, blood pressure measurements, strabismus and vision screening, hearing screening, tuberculosis risk assessment, and laboratory screening.
C. Vision screening for ophthalmologic disorders begins at birth and is detailed in Chapter 18.
D. Hearing screening
1. Universal newborn hearing screening is recommended by 1 month of age, with confirmation of an abnormal screen by 3 months of age. Early intervention for hearing impairment is associated with better developmental language outcomes, and should be initiated no later than 6 months of age.
2. Two types of audiometric tests are used for the newborn.
a. Otoacoustic emission (OAE) measures sounds generated by normal cochlear hair cells that are detected by a microphone placed into the external auditory canal. This screening test is routinely performed in newborn nurseries before infant discharge. Administering the test takes only a few minutes and is painless, and the expenses for equipment and training are lower than for brainstem auditory-evoked response/auditory brainstem response (BAER/ABR) as below. OAE accuracy may be affected by debris or fluid within the external or middle ear.
b. BAER/ABR measures electroencephalographic (EEG) waves generated in response to clicks via electrodes placed on the infant’s scalp. Compared with OAE, BAER is a more accurate test, but it requires costly equipment, trained operators, and sometimes sedation. BAER is typically performed to confirm abnormalities found on OAE.
E. Neonatal metabolic (state) screening
1. Many metabolic diseases can be diagnosed and treated in the newborn period.
2. Although there is some variability among states as to which conditions are screened, all states screen for congenital hypothyroidism, phenylketonuria (PKU), and galactosemia. Each of these conditions is treatable, and if not detected early, each leads to irreversible brain injury.
3. Most states screen for sickle cell anemia and other hemoglobinopathies, because early intervention in a comprehensive treatment program significantly decreases morbidity and mortality.
4. Newborn screening tests for additional metabolic disorders (e.g., congenital adrenal hyperplasia) are performed in some states. The most extensive state screening panels screen for 50 disorders or more.
F. Cholesterol and lipid screening
1. Universal screening for hypercholesterolemia, regardless of body mass index (BMI) or risk factors, has been recommended by the National Heart, Lung and, Blood Institute (NHLBI) and endorsed by the American Academy of Pediatrics (AAP). Obtaining a nonfasting non-HDL cholesterol level is recommended for all children between 9 and
11 years of age, and again between 17 and 21 years of age. For children with an abnormal result on the screen, a fasting lipid profile should be obtained.
2. Targeted screening for hypercholesterolemia (consisting of fasting lipid profile performed twice within 2–12 weeks) is recommended for children between 2–8 years of age and 12–16 years of age with one of the following risk factors:
a. History of diabetes, hypertension, BMI > 95th percentile (if 2–8 years old) or

BMI > 85th percentile (if 12–16 years old), or smoking
b. History of one of the following moderate- or high-risk medical conditions: nephrotic syndrome, human immunodeficiency virus (HIV), Kawasaki disease with history of coronary aneurysms, and end-stage renal disease
c. Parent with total cholesterol > 240 mg/dL or known dyslipidemia
d. Parent, grandparent, aunt/uncle, or sibling with myocardial infarction, angina, stroke, or coronary artery bypass graft/stent/angioplasty at <55 years in males and
<65 years in females
3. Interventions for elevated cholesterol should include dietary and behavioral modifications, and may include referral to a registered dietician for nutrition counseling for the family.
G. Iron-deficiency anemia screening
1. Iron-deficiency anemia occurs most commonly in children < 6 years of age, peaking between 9 and 15 months of age, but may occur throughout the entire pediatric age range. More than 10% of 1 year olds are iron deficient.
2. Risk factors for iron-deficiency anemia include:
a. Prematurity
b. Low birth weight
c. Early introduction of cow’s milk (before 12 months of age) or consumption of 24 oz or more of milk a day
d. Insufficient dietary intake of iron
e. Low socioeconomic status
3. Universal screening of hemoglobin levels is recommended at 12 months of age. Subsequently, selective screening should be based on annual risk assessment.
H. Routine urinalysis screening is not recommended. Analysis of urine samples are recommended only when clinically indicated.
I. Tuberculosis screening
1. Screening for latent tuberculosis infections is recommended for children at risk for tuberculosis. Tuberculosis screening may be performed through the use of tuberculin skin testing with intradermal injection of purified protein derivative (PPD, Mantoux skin test). Alternatively, interferon-gamma release assays (IGRAs), which are in vitro tests of cell-mediated immune response, may be used in children older than 5 years to screen for latent tuberculosis. They are useful in the evaluation of children who have received the Bacillus Calmette–Guérin (BCG) vaccine. Screening is indicated for children with one or more of the following risk factors:
a. Birth place in a high-risk country other than United States, Canada, Australia,
New Zealand, or Western and Northern European countries
b. Travel to an endemic region (e.g., Africa, South America, Asia, Eastern Europe) for a cumulative total of 1 week or more
c. Exposure to anyone with tuberculosis
d. Close contact with a person who has had a positive screen for latent tuberculosis
J. Lead screening
1. Lead intoxication (plumbism): No safe blood lead level (BLL) in children has been identified, and lead intoxication remains a public health risk. While the incidence and severity of lead poisoning in the United States are decreasing, in large part owing to effective screening programs and increased public awareness, there is still a high number of affected children living in deteriorating housing built before the 1970s.
2. Risk factors for lead intoxication include the following:
a. Ingestion of lead-containing paint from homes built before 1978
b. Drinking water from lead-containing pipes

c. Exposure to lead smelters, industrial manufacturing sites, or to adults with occupational exposures leading to contamination of clothes and hands
d. Use of lead-glazed pottery, imported toys, and imported candies (Mexico,
Malaysia, China, and India) that contain tamarind, chili powder, or salt
e. Use of lead-containing folk remedies
f. Exposure to soil with high lead levels due to decades of burning leaded gasoline
3. Clinical features of lead intoxication
a. Children < age 6 are most susceptible to the effects of lead owing to a variety of mechanisms, including increased permeability of the blood–brain barrier to lead, higher rates of iron-deficiency anemia leading to increased lead absorption, and increased hand-to-mouth behaviors amongst infants and toddlers.
b. Acute lead intoxication may lead to anorexia, apathy, lethargy, anemia, irritability, and vomiting. These symptoms may progress to encephalopathy (see also Chapter 20, section VIII.D.4).
c. Chronic lead intoxication is most commonly asymptomatic; however, even patients with very low levels of lead (≥5 µg/dL) may suffer neurologic sequelae, including developmental delay, learning problems, and intellectual disability.
4. As the prevalence of childhood lead poisoning declines, there has been a movement to focus on primary prevention, and to transition from universal screening to targeted screening. AAP recommends that screening be performed in accordance with state laws when applicable. If no state screening program is in place, then universal screening at 1 and 2 years of age is recommended if the community has any of the following risk factors:
a. ≥27% of the housing was built before 1950.
b. ≥12% of children 12–36 months of age have BLLs ≥ 10 µg/dL.
c. Information on the prevalence of elevated BLLs in the community is unavailable or inadequate.
5. Intervention and management of lead poisoning is based on serum lead levels after repeat testing, and generally includes education to decrease exposure and chelation for very high lead levels.

V. Circumcision
A. Approximately 60% of male infants in the United States are circumcised.
B. Though the existing evidence is not sufficient to recommend routine circumcision, the AAP states that the health benefits of circumcision outweigh the risks, and these benefits justify access for families interested in circumcision.
1. Circumcision is associated with a significant reduction in risk of acquiring HIV and other sexually transmitted infections.
2. Circumcised patients have a lower risk of penile cancer, although this type of cancer is very rare in all males.
3. Urinary tract infections (UTIs) are 10 times more common in uncircumcised male infants, particularly in the first 3 months of life.
4. Uncircumcised males may ultimately require circumcision for the following conditions:
a. Phimosis is an inability to retract the foreskin. Physiologic phimosis usually resolves around 5–7 years of age but can be seen in older boys. Ballooning of the foreskin can be normal as long as the ballooning does not require manual compression by the patient. Signs of pathologic phimosis include dysuria, painful erection, bleeding from the preputial orifice, and recurrent balanoposthitis (inflammation of the glans penis and foreskin) and necessitate a referral for urologic evaluation.
b. Paraphimosis occurs when the retracted foreskin cannot be returned to its normal position and acts as a tourniquet, leading to edema from obstruction of venous and lymphatic flow. This is a urologic emergency because ischemia distal to the obstruction may occur. Surgery is required if attempts at manual reduction fail.
c. Balanitis is inflammation of the glans of the penis. It may be associated with Candida spp. or Gram-negative infections in infants, and with sexually transmitted infections.
C. Pharmacologic analgesia is strongly recommended during circumcision.
D. Complications from circumcision include bleeding, infection, poor cosmesis, phimosis (secondary to insufficient foreskin removal), urinary retention, and injury to the glans or urethra.
E. Contraindications to circumcision include anatomic penile abnormalities (e.g., hypospadias, penile torsion), because the foreskin may be required for the reconstruction, as well as medical concerns (e.g., prematurity, bleeding diatheses) associated with higher complication rates.

VI. Pediatric Dental Care
A. Counseling about dental care is an important component of anticipatory guidance.
B. Tooth eruption
1. Range for initial tooth eruption is between 3 and 16 months of age, with an average age of 6 months.
2. The first tooth is generally a lower central incisor.
3. Primary teeth (20 teeth in total) are generally established by 2–3 years of age.
4. Secondary (permanent) tooth eruption also begins with the lower central incisor, between 5 and 7 years of age, and generally finishes by 13–14 years of age. There are 32 secondary teeth.
5. Tooth eruption may be early or delayed.
a. Early dental eruption is defined as primary eruption before 3 months of age. Causes include familial causes, hyperthyroidism, precocious puberty, and growth hormone excess.
b. Delayed dental eruption is defined as primary eruption that has not occurred by 18 months of age. Causes include familial delayed eruption, hypothyroidism, hypopituitarism, vitamin D deficiency, and genetic syndromes such as Down syndrome and ectodermal dysplasia (associated with conical-shaped teeth, dysmorphic facial features, decreased numbers of sweat glands, and alopecia).
C. Dental hygiene
1. Tooth brushing should begin as soon as teeth erupt. A moist washcloth or gauze pad may be used initially, and a soft toothbrush may be used as early as tolerated. Parents should initially do the brushing to ensure that the teeth are actually being cleaned. A rice-sized amount of fluoride toothpaste should be used after tooth eruption. At age
3 years, a pea-sized amount of fluoride toothpaste should be used.
2. Dental floss to remove plaque from between teeth should be initiated when tight contact exists between teeth.
3. Fluoride
a. Children who consume optimal amounts of fluoride from birth until adolescence have 50–75% less dental decay than expected. Fluoride protects against demineralization, promotes remineralization, and decreases the negative effects of cariogenic bacteria in the mouth.
b. Sources of fluoride include food, tap water, some bottled waters, fluoride varnish, and fluoride toothpaste. Fluoride varnish, applied every 3–6 months starting at tooth emergence through age 5, has been shown to prevent early childhood cavities.
c. Excess fluoride can lead to fluorosis.
1. Fluorosis affects permanent teeth and leads to abnormalities in dental enamel and dentin. Most cases of fluorosis are mild; moderate and severe forms are uncommon in the United States.
2. Effects are usually cosmetic and include white streaks, pitting, or brown-gray staining. Structural abnormalities associated with fluorosis are extremely rare.
3. Children are most vulnerable to fluorosis between 15 and 30 months of age. After 8 years of age, children are no longer at risk for fluorosis because permanent tooth enamel is fully mineralized.
d. Although care must be taken to prevent fluorosis, oral fluoride supplementation remains important starting at 6 months of age for children whose water supply is deficient in fluoride (<0.3 ppm).
D. Dental abnormalities

1. Early dental eruption. Occasionally infants are born with teeth or have teeth that erupt within the first month of life.
a. Definitions
1. Natal teeth are those that are present at birth.
2. Neonatal teeth are those that emerge during the first month of life.
b. Among early erupting teeth, mandibular central incisors are the most common. More than 90% of early erupting teeth are primary teeth and 10% are supernumerary teeth (teeth in excess of usual number).
c. Management. Extraction is indicated if the teeth are hypermobile, are at risk for aspiration, cause breastfeeding difficulty, or cause trauma to the infant’s lip or tongue.
2. Dental caries
a. Epidemiology. Early childhood caries is the most common chronic infection in children <6 years of age. Up to 60% of 12–19 year olds have at least one documented cavity. Caries disproportionately affect poor and minority populations.
b. Etiology. Development of dental caries requires four components: teeth, carbohydrate exposure, bacteria, and time.
1. Once teeth have erupted, they can be colonized by cariogenic bacteria. Children can acquire these bacteria from colonized parents and siblings. Streptococcus mutans and Lactobacillus species are the most common bacterial agents.
2. Carbohydrates that are retained around the teeth may serve as a substrate for bacteria capable of causing caries. Severe tooth decay among infants with excessive exposure to sugar from milk, formula, or juice are sometimes called “baby bottle” or “early childhood” caries.
3. The bacteria metabolize the carbohydrates and create acidic by-products. Over time, the acid leads to demineralization of the enamel. Multiple insults can cause collapse of the enamel’s surface, leading to cavities.
c. Clinical features. Caries commonly involve the maxillary incisors, canines, and grooved surfaces of the molars. Cavities are initially chalky white or yellow, signifying loss of enamel. After further demineralization, the lesion will become brown and irreversible.
d. Management of dental caries involves a combination of restorative therapy (e.g., fillings) and preventive measures (e.g., limited sugar intake, fluoridated water, toothpaste, varnishes, etc.). Severe cases may require surgical interventions, such as placement of dental crowns or extraction.
E. Dental trauma
1. A permanent tooth that has been traumatically avulsed may be reimplanted if the avulsed tooth is placed into the socket rapidly.
a. Extraoral time is the most important factor affecting the prognosis for successfully reimplanting a tooth. The tooth should be held by the crown and washed in water for 10 seconds and then reimplanted.
b. If the tooth cannot be reimplanted at home, prognosis is highest if the avulsed tooth is stored in liquids such as cold milk, which extends viability time for the tooth when compared with that for a tooth stored in water.
c. After 30 minutes or longer, a dry stored tooth is unlikely to be successfully reimplanted.
2. Management. After referral to a dentist, radiographs should be obtained to rule out fractures if there is a history of trauma. Even if the avulsed tooth is a primary tooth,

radiographs are indicated to assess the status of other unerupted permanent teeth.
3. Avulsed primary teeth do not require reimplantation.

VII. Developmental Screening
One of the most important surveillance measures of well-child care is assessment of developmental milestones, which occurs during each visit from infancy through school age. School performance substitutes for formal developmental assessment in typically developing children older than 5–
6 years. Development is discussed in depth in Chapter 2.

VIII. Anticipatory Guidance
A. Anticipatory guidance includes both patient and parent education, and is provided during each well-child visit. Guidance is tailored to the child’s developmental level and to anticipated changes in the child’s development before the next scheduled well-child visit. It is one of the most important aspects of the well-child visit.
B. Topics covered by anticipatory guidance include
1. Family support
2. Child development
3. Mental health
4. Healthy weight and nutrition
5. Physical activity
6. Oral health
7. Healthy sexual development and sexuality
8. Safety and injury prevention
9. Community relationships and resources
C. Age-appropriate anticipatory guidance topics for children from birth to 5 years of age are detailed in Table 1-5.

Table 1-5
Age-Appropriate Anticipatory Guidance Topics for Discussion for Children From Birth to Age 5

Age Child Development/Healthy
Habits Safety and Illness Prevention
Healthy Weight and Nutrition
Family Support
Newborn
Cord care Circumcision care
Skin and nail care
Normal vaginal discharge and bleeding Normal sneezing and hiccups
Stools change from meconium to transitional Amount of clothing needed and temperature regulation
Rear-facing car seat until 2 years of age Sleep on back
Hot water heater
<120°F
Never leave alone Early signs of illness: fever, failure to eat, vomiting, diarrhea, dehydration, irritability or lethargy, jaundice, or rash
Use of thermometer
Breastfeeding Feeding schedule for
breastfeeding or formula feeding on demand (8–
12 times/day) for 4–6 weeks of age
Supplement with vitamin D (400 IU) in the first year of life to prevent rickets for both breastfeeders and infants taking in less than
1 L/day of formula
If formula feeding, ensure proper preparation of formula
Talk, read, and sing to baby Approach to crying Burping and spitting up Thumb sucking and pacifiers Normal sleep patterns and sleeping arrangements Never shake a baby
Screen for maternal depression
1 month
Sleeping 18–
20 hours/day, 3–4 hours at a stretch Stooling decreasing in frequency and changes to brown and more formed
Same as newborn
Same as newborn No cereal
No solids
No honey until age 1 Relief bottle for breastfeeding moms Colic may begin at 3–4 weeks of age and last till 3–
4 months of age

Some infants strain with stool
2 months
Sleep 4–8 hours
Risk of aspiration of
Same as 1 month old
Establish
at a stretch small objects bedtime
Feed every 3– routine
4 hours Encourage
Stooling qod to vocalizations
3–4 times/day Most
working
mothers
return to
work by 2–
4 months
4 months
Feeding every
Aspiration risk
Breastmilk/formula
Continue
4–5 hours No infant walkers continues to be primary encouraging
Sleeping 6– source of nutrition through vocalizations
8 hours at a 1 year of age. —talking,
stretch Maintenance amounts of iron singing, and
should be added to the reading to
vitamin D supplementation. infant
Iron-fortified infant cereal Introduce
and solids can be introduced transitional
object (e.g.,
toy, stuffed
animal,
blanket)
6 months
Feedings
Baby-proof home
More solids introduced
Provide
spaced out Pool and water Continue breast- or bottle- opportunities
Sleeping safety feeds plus solids for
through night Weapons and pet Avoid foods with aspiration exploration
for many safety risk or choking risk (e.g., Establish
Child gates on stairs peanuts, popcorn, hot dogs, nighttime
Aspiration risk carrots, celery sticks, whole routine
Sunscreen use grapes, raisins, corn) Transitional
No infant walker object
To discipline,
use
distraction
and routines
Discuss
separation
anxiety
Encourage
reading, and
give infant
the first book
9 months
Drinks from
Same as 6 months
Same as 6 months
Observe
cup increasing
Eats independence
appropriate and
finger foods autonomy
Anticipate
separation
anxiety and
sleep
disturbances

12 months Feeding Child-proof house Switch to whole milk Praise good
3 times/day Drink from cup behavior
plus 2–3 snacks Table food—watch Encourage
Establish sleep aspiration risk language
hygiene— Weight gain slows down, development
transitional intake decreases, do not force —read to
objects, bedtime foods toddler
routine, Encourage
sleeping exploration
through night and initiative
Begin weaning Discipline
from bottle with
distraction,
gentle
restraint,
“time out”
No “screen
time”
(television,
phones,
tablets)
15 months
Feeds self
Same as 12 months
Same as 12 months
Begin
Naps 1– discussion of
2 times/day toilet training
readiness; do
not push; be
patient
18 months
Feeds self
Same as 12 months
Avoid cookies and sweets as
View
May begin bribe to eat negativism as
toilet training Whole milk < 24 oz/day budding
Naps 1– independence
2 times/day Encourage
language
development
by reading,
singing, and
talking
Make
discipline
brief and
specific
Anticipate
night terrors,
nightmares,
night fears
Do not expect
toddler to
share
2 years
Change to bed
Same as above,
Food struggles are common
Anticipate
from crib plus the following: Change to 2% milk new fears,
Initiate toilet Can make car seat Never force child to eat indecision—
training if not forward facing Offer nutritious foods provide
prior Will not transition to reassurance
booster seat until at Anticipate
least 4′9″ (8–12 years parallel play,
old). sibling rivalry
if new baby
expected
Acknowledge
conflict but

do not allow behavior; biting and hitting are common
No more than 2 hours of “screen time”
3 years
90% bowel trained
85% bladder trained (day) 65% bladder trained (night)
Bicycle helmets Street safety Stranger danger Firearm safety Tricycle safety
Pet and water safety
Continue healthy food choices
Use correct terms for genitalia Introduce notion that some areas of the body are private Anticipate preschool Observe beginning of sharing during play
4 years
95% bowel trained
90% bladder trained (day) 75% bladder trained (night)
Swimming lessons Scissor and pencil use
Firearm safety Bicycle helmets
Continue healthy food choices
Anticipate imitating peers in eating choices
Provide opportunities for socialization with other children Establish and enforce consistent, explicit rules for safe behavior Observe beginning of imaginative play
Observe discovery of sexual identity
5 years
Sleeps 10–
12 hours/night Teach personal care and hygiene
Bicycle helmets Stranger danger Firearm safety Phone number memorized
Continue healthy food choices, including school lunch
Library cards, learning to read
Rules for bedtime, TV watching Age- appropriate chores School participation encouraged

Review Test
1. A 6-month-old girl has been noted to fall off her growth curve, and her weight is now <5% for her age. You suspect failure to thrive (FTT) and consider the most common causes. Which one of the following is the most common cause of FTT?
A. A disturbed parent–child bond that results in inadequate caloric intake or retention
B. Prenatal onset of inadequate weight gain that persists in the postnatal period
C. A skeletal abnormality resulting in short stature with associated poor weight gain
D. Malabsorption or the inability to completely absorb ingested calories and nutrients
E. Endocrinologic abnormalities, such as growth hormone deficiency or hypothyroidism
2. A 2-month-old male infant is seen for routine well-child evaluation. At birth, his head circumference was <5% for age. His head circumference has increased 1 cm in size since birth. Which one of the following is the most likely cause of the infant’s condition?
A. Intraventricular hemorrhage
B. Perinatal asphyxia
C. Third trimester infection with cytomegalovirus
D. Craniosynostosis
E. First trimester infection with toxoplasmosis
3. A 4-week-old boy is evaluated for macrocephaly. In addition to a head circumference >95%, his coronal and sagittal sutures are split 1 cm and his fontanelle is bulging. Both of his parents’ head circumferences are >95%. Which one of the following is the most likely explanation for the infant’s macrocephaly?
A. Familial
B. Achondroplasia
C. Hydrocephalus
D. Metabolic storage disorder
E. Neurofibromatosis
4. A 9-month-old girl is diagnosed with iron deficiency anemia. Her past medical history includes an uncomplicated delivery at 38 weeks. The infant was fed with formula until
6 months of age, at which time she was switched to baby foods and whole milk. Which one of the following is correct regarding her iron-deficiency anemia?
A. Her age is atypical for the presentation of iron deficiency anemia.
B. Her early birth at 38 weeks gestation has led to the anemia.
C. Early introduction of cow’s milk is the likely cause of her anemia.
D. Insufficient dietary intake of iron is the likely cause of her anemia.
E. The patient’s early introduction of solids is the likely cause of her anemia.
5. An asymptomatic 12-month-old girl is screened for lead exposure. Which one of the following is correct regarding lead screening and lead intoxication?
A. Most patients exposed to lead are asymptomatic.
B. Children between 5 and 10 years of age are at highest risk for lead effects.
C. Low lead levels on screening indicate that a child is at no risk for the neurologic sequelae of lead exposure.
D. Chelation has not been shown to be effective for patients with high lead levels.
E. Ingestion of paint from a home built in 1990 would place a child at risk for lead poisoning.
6. At a prenatal visit, the expectant parents of a first-born male child ask you to summarize the benefits, risks, and contraindications to performing a circumcision on their son. Which one of the following statements is correct?
A. Circumcision has not been shown to decrease the risk of urinary tract infection.

B. Because of the young age at which circumcision is performed, analgesia is generally not required, thus decreasing the risks of the procedure when performed in the newborn period.
C. If their child is not circumcised in the newborn period, he may require circumcision at 9 months of age if he is subsequently diagnosed with phimosis.
D. The American Academy of Pediatrics recommends routine circumcision for medical benefit.
E. Hypospadias is a contraindication to circumcision.
7. A 20-month-old boy is seen for routine well-child care. Physical examination reveals caries involving the maxillary incisors. Which one of the following is most likely to have contributed to this condition?
A. The use of both fluoride drops and fluoride toothpaste simultaneously, which has caused fluorosis
B. Falling asleep with a water-filled bottle in the mouth
C. Falling asleep while breastfeeding
D. Oral colonization with Staphylococcus aureus
E. Living in an area in which tap water contains no fluoride
8. A 1-year-old child living in an apartment with old chipping paint is suspected of being at high risk for lead intoxication. Which of the following findings on a routine health maintenance visit would support this diagnosis?
A. Failure to thrive
B. Anemia
C. Fluorosis
D. Microcephaly
E. Impaired hearing
9. On a routine health maintenance visit, a 4-month-old infant is noted to have normal growth and development and an unremarkable physical examination. Which of the following should be included in your counseling of the parents at this time?
A. Vitamin D supplementation with iron should be initiated, especially if the child is breastfed.
B. The patient should be encouraged to begin using a walker to stimulate gross motor development.
C. The infant should now be placed in a forward-facing car seat.
D. Toilet training should be initiated.
E. Honey may now be introduced into the infant’s diet.
10. You receive a telephone call from the parents of a 10-month-old infant, who are concerned that their baby does not yet have any teeth. A review of the infant’s growth chart reveals that the patient’s weight, length, and head circumference are at the 50th, 25th, and 25th percentiles, respectively. The infant’s developmental milestones are normal. Which of the following would be the most appropriate course of action?
A. Refer the patient to a pediatric dentist.
B. Refer the patient to a geneticist.
C. Reassure the parents that their infant’s pattern of dental eruption is within the normal range.
D. Order radiographs to assess the patient’s bone age.
E. Order radiographs of the patient’s oral cavity.

Answers and Explanations
1. The answer is A [II.B.1.d]. The most common etiology of failure to thrive (FTT) is inadequate intake of calories. Conditions that lead to malabsorption, increased metabolic demand, or decreased utilization of nutrients should also be in the differential diagnosis but are much less common causes. Short stature should be distinguished from FTT. Those with FTT have primary failure of weight gain (and subsequent poor linear growth and poor head circumference growth), whereas those with short stature have primary failure of linear growth.
2. The answer is E [Table 1-4, II.B.2.b]. Given his small head circumference at birth, this patient’s microcephaly is congenital. Causes of congenital microcephaly include TORCH (toxoplasmosis, other-syphilis, rubella, cytomegalovirus, herpes simplex virus) infections during the first trimester, in utero exposure to drugs and toxins, and chromosomal abnormalities. In addition, congenital microcephaly may be familial. Perinatal asphyxia, intraventricular hemorrhage, craniosynostosis, and late prenatal and perinatal infections may all cause acquired microcephaly. Patients with acquired microcephaly are usually born with a normal head circumference.
3. The answer is C [II.B.2.c]. This patient has signs of increased intracranial pressure, which include split sutures and a bulging fontanelle. Other symptoms of intracranial pressure include irritability and vomiting. Hydrocephalus is the only option that is associated with increased intracranial pressure. Metabolic storage disorders, neurofibromatosis, achondroplasia, and familial macrocephaly are associated with enlarged head circumference but are not associated with increased intracranial pressure in a patient of this age.
4. The answer is C [IV.G.2.c]. The introduction of cow’s milk should occur only after 12 months of age, as its early introduction (in this case at 6 months) is a known risk factor for iron deficiency anemia and is the likely cause in this case. This is because whole cow’s milk offers less bioavailable iron and may also result in stool blood loss. Although insufficient dietary intake of iron is a possible cause, this patient received iron-fortified formula for at least
6 months, making this cause less likely. Prematurity (defined as <37 weeks) may result in lower iron stores with resultant anemia. Pediatricians start screening for iron-deficiency anemia at 12 months of age. The prevalence of iron-deficiency anemia in the United States is estimated to be more than 10% at 1 year of age. Finally, solids were introduced at an appropriate time in this patient (6 months) and this is not a risk factor for anemia.
5. The answer is A [IV.J]. Most patients with elevated lead levels are asymptomatic. Children younger than 6 years of age are at highest risk for the effects of lead. Risk factors include a history of ingestion of lead-containing paint or soil from homes, drinking water from lead pipes, use of lead-glazed pottery in food preparation, use of lead-containing folk remedies, and eating high-risk imported candies. Even patients with very low lead levels may suffer from developmental delay and learning problems. Chelation is required for very high lead levels.
6. The answer is E [V.B–E]. Contraindications to circumcision can be broken down into two main groups: anatomic and medical. Anatomic contraindications include hypospadias, ambiguous genitalia, and penile torsion. Medical contraindications include bleeding diathesis, connective tissue disorders that impair normal healing, and prematurity. Although phimosis is an indication for circumcision in some patients, it is considered normal unless they have signs of pathologic phimosis (e.g., dysuria, painful erection, bleeding from the preputial orifice, recurrent balanoposthitis). Other indications for circumcision include recurrent balanitis and unreducible paraphimosis. The American Academy of Pediatrics states that the medical benefits of circumcision outweigh the risks, but the benefits are not great enough to

recommend universal circumcision. No matter the patient’s age, circumcision should be performed with analgesia/anesthesia.
7. The answer is E [VI.C.3.c, VI.D.2] This patient has dental caries. Those who live in areas with low fluoride levels in their water are at increased risk for caries. Water fluoridation has been named one of the 10 greatest public health achievements in the 20th century by the Centers for Disease Control and Prevention because of its effect on decreasing the risk of developing dental caries. In addition to decreasing the negative effects of cariogenic bacteria, fluoride decreases demineralization and promotes remineralization of enamel. Excess fluoride may cause cosmetic abnormalities to the enamel, but the risk of caries is not increased. Any exposure to carbohydrates (e.g., juice, milk) can serve as a substrate for infection. The evidence suggesting that breastfeeding can also increase the risk of caries is mixed. Streptococcus mutans and Lactobacillus are the most common bacterial agents.
8. The answer is B [IV.J.3]. Lead intoxication may cause a variety of clinical manifestations, including neurocognitive impairment, lethargy, microcytic anemia, constipation, and irritability. Most patients exposed to lead, however, are asymptomatic. Fluorosis is not associated with lead exposure, and lead exposure has not been known to result in microcephaly, failure to thrive, or hearing impairment.
9. The answer is A [Table 1-5]. Oral vitamin D supplementation is recommended to prevent the development of rickets in all children. The addition of iron to vitamin D supplementation is recommended at 4 months of age for exclusively breastfed infants and in formula-fed babies who are taking less than 1 L of formula/day. Infant walkers are not recommended because of the risk of injury associated with their use. Infants should be placed in a rear-facing car seat until they are 24 months of age. Toilet training is generally initiated between 2 and 3 years of age. Because of the risk of botulism, honey should be avoided until at least 1 year of age. After this time, honey is acceptable and is recommended for management of cough for children with upper respiratory infections.
10. The answer is C [VI.B]. Although the average age of initial tooth eruption is 6 months of age, there is a wide range of normal variability, ranging from 3 to 16 months of age. Delayed dental eruption is defined as primary eruption after 18 months of age and may be related to endocrine disorders (hypothyroidism and hypopituitarism), vitamin D deficiency, genetic syndromes (Down syndrome and ectodermal dysplasia), or may be familial.