The 7th Annual MetropolitanNew York/New Jersey

Pediatric Board Review Course

General Pediatrics

Andrew D. Racine, M.D., Ph.D.April 22, 2012

Outline

• Screening• Immunizations• Breastfeeding and nutrition• Anticipatory Guidance• Psycho-social issues• Ethics and Professionalism in primary care• Patient Safety and Quality Improvement

Screening

Case #1A 9 month old female is brought to your office for her

regular health care maintenance visit. The components of developmental surveillance that you perform include all the following except:

A. Eliciting and attending to parental concernsB. Obtaining relevant developmental historyC. Administering a validated instrument to identify

developmental delaysD. Accurately observing the child/parent interaction in the

examination room

Answer C• Surveillance is, “… a flexible continuous process

whereby knowledgeable professionals perform skilled observations of children during the performance of health care.”

• It includes attending to parental concerns, obtaining a history, making accurate and informed observations, and sharing opinions and concerns with other relevant professionals.

• It does not involve the application of validated tools – that is the definition of screening.

Source: AAP Committee on Children with Disabilities, Pediatrics; 2001

ScreeningAppropriate criteria for a useful screening tool include

all of the following except:A. It is valid, i.e. it is sensitive and specificB. It is reliableC. It is inexpensive to administerD. The condition being screened for is prevalentE. The tool is acceptable to screened subjectsF. There are effective interventions available for

conditions identified by the tool

The correct answer is D

• Screening tools should be valid and reliable meaning that they accurately identify the condition of interest and that in repeated applications they give the same result. The tools should be inexpensive to administer in times of time and other costs, they should be acceptable to patients and the conditions identified should be amenable to intervention.

• We screen for rare as well as prevalent conditions

You and your colleagues are thinking of adding routine developmental screening to you office practice. In

looking into this possibility you have discovered that:

1 2 3 4 5

0% 0% 0%0%0%

1. Developmental surveillance should occur at the 9, 18, and 30 month visits.

2. The goal of developmental screening is to arrive at a diagnosis and a treatment plan.

3. The diagnosis of a specific developmental disorder is necessary to make an EI referral.

4. Sensitivity and specificity rates of 70%-80% are acceptable for developmental screening tests.

5. Subsequent screening is not necessary after a child passes two screening tests.

Countdown

6

Screening

The correct answer is D sensitivity and specificity rates of 70%-80% are acceptable for developmental screening tests.

A variety of screening tools with different psychometric properties are available for screening purposes but, in general, they have lower sensitivity and specificity than medical screening tests because of the underlying variability of the construct being measured and the absence of specific curative treatments for some conditions.

Screening

The American Academy of Pediatrics, in its 2006 policy statement on Identifying Infants and Young Children With Developmental Disorders recommends surveillance at every preventive care visit and the use of a standardized tool to screen low risk children at the 9, 18, and/or 30 month visits.

Screening• Early Intervention services are valuable for

children identified at high risk. They can provide evaluation services, developmental therapies, service coordination, transportation support, etc.

• The diagnosis of a specific developmental disorder is not necessary to refer a child deemed at risk to receive EI services.

Summary

• Surveillance is the process of recognizing children who may be at risk for developmental delays and should take place at every well child visit;

• Screening is the use of a standardized tool to identify and refine the recognized risk;

• Evaluation is a complex problem to identify a specific developmental disorder in a child.

Update on Immunizations

A 12 year old girl presents to your office for a regular checkup for school entry in September. She is a recent immigrant from Mexico. Her mother states that she does not have an immunization record. She denies any significant past medical history. There is no history of allergies. Physical exam reveals no abnormalities.Which immunizations would you give at this time?

1. Td, IPV, MMR, Varicella, Hep B, MCV42. Td, IPV, MMR, Varicella, Hep B, MPSV4,

Influenza3. Td, IPV, MMR, Varicella, Hep B, Hep A, HPV4. Tdap, IPV, MMR, Varicella, Hep B, MPSV45. Tdap, IPV, MMR, Varicella, Hep B, MCV4,

Hep A, HPV, Influenza

Pertussis Vaccine (Tdap) Two tetanus toxoid, reduced diphtheria toxoid and acellular

pertussis vaccines are approved by the FDA for:• Adolescents aged 11-18 years who completed their primary

series of DTP/DTaP and have not received a Td booster dose• Adolescents who have not received DTP/DTaP/Td/Tdap

vaccination (or have no documentation)• For wound management in adolescents who have not

received Tdap before• Children 7-10 with undocumented immunization status

Before you give the Tdap vaccine to the patient you ask your attending what is a true contraindication for the vaccine. Your attending responds that:

1 2 3 4 5

23%

10%

20%

23%23%1. Temperature greater than 105 F within 48 hours of a previous DTP/DTaP

2. Collapse or shock like state within 48 hours of a previous DTP/DTaP

3. History of encephalopathy within 7 days of previous DTP/DTaP

4. Latex Allergy5. Pregnancy

Contraindications of Tdap

• Anaphylaxis to any components of the vaccine

• History of encephalopathy (coma or prolonged seizure) within 7 days of administration of a pertussis vaccine that cannot be attributed to a different cause

Precautions of Tdap• History of an Arthus-type reaction following a

previous dose of tetanus- or diphtheria-containing vaccine

• Progressive neurological disorder, uncontrolled epilepsy, or progressive encephalopathy

• History of Guillain-Barre syndrome (GBS) within 6 weeks after a previous dose of tetanus toxoid-containing vaccine

• Moderate or severe acute illness

Not Contraindications• Temperature > 105F within 48 hrs of DTP/DTaP• Collapse or shock-like state within 48 hrs of DTP/DTaP• Persistent crying for 3 hrs or longer within 48 hrs of

DTP/DTaP• Convulsions with or without fever within 3 days of

DTP/DTaP• History of entire or extensive limb swelling after

DTP/DTaP/Td• Stable neurological disorder

Not Contraindications

• Brachial neuritis• Latex allergy other than anaphylaxis-BOOSTRIX

single dose and ADACEL are latex free• Pregnancy and breastfeeding• Immunosuppression• Intercurrent minor illness• Antibiotic use

Meningococcal Vaccine (MCV4)

Introduced in 2005 the meningococcal conjugate vaccine is recommended in

• Adolescents 11-12 years• Unvaccinated adolescents

at school entry• College freshmen living in

dormitories• Certain high risk groups• Booster dose now

recommended at age 16 (as of January, 2011)

FIGURE. Annual incidence of meningococcal disease by age , United States, 1999-2008

MCV4

Side effects include: Erythema, swelling and induration Guillain-Barre – 17 reported cases from March

2005 – September 2006. GBS incidence estimated at 0.20 per 100,000 person months after vaccine compared to 0.11 per 100,000 person months among 11-19 year olds generally.

Hepatitis A VaccineIn May of 2006 the ACIP broadened its

recommendations for the use of Hep A vaccine to include all children between 1-2 years of age.

The use of Hep A vaccine is also recommended for high risk groups including travelers to endemic areas, MSM, drug users, persons with chronic liver disease, those with clotting factor disorders

Human Papillomavirus• The most common sexually transmitted infection in

the United States (6.2 million new cases annually).• HPVs are non-enveloped double stranded DNA

viruses of over 100 types including several (16,18,31,33,35, and others) detected in 99% of cervical cancer cases.

• Risk of HPV associated with number of sexual partners, partner sexual behavior, and immune status.

Human Papillomavirus

• Most infections are transient, asymptomatic and clear within 1-2 years

• Of the 6.2 million new cases per year, about 74% occur in women 15-24

• Acquisition occurs soon after sexual debut• Prevalence of HPV 16 may be as high as 40%• Consistent condom use may help prevent

acquisition

Human Papillomavirus Vaccine

Two HPV vaccines have been licensed by the FDA for use in girls:

• A quadrivalent vaccine was approved in June 2006 (HPV4, Gardasil, Merke and Co.), and

• A bivalent vaccine was approved in 2009 (HPV2, Cervarix, GlaxoSmithKlein).

As of 2011, the quadrivalent vaccine is now recommended for boys as well

HPV Vaccine• Quadrivalent HPV vaccine (Gardasil®) targets HPV types

6, 11, 16 and 18• Bivalent HPV vaccine (Cervarix®) targets HPV 16 and 18.• HPV types 16 and 18 cause approximately 70% of

cervical cancers and types 6 and 11 cause approximately 90% of genital warts

• Both vaccines are administered in 3 doses with 2nd and 3rd doses given 2 and 6 months after the first dose

• Combined protocols indicate an efficacy of 98-100% in the prevention of CIN 2/3, AIS or genital warts caused by HPV 6, 11, 16 and 18.

Case # 2

In December of last year a mother comes into your office with her 4 month old infant daughter who is due for her health care maintenance visit. She brings along her 3 year old son as well. He has not yet received his flu vaccine for this year but did receive it last year. You advise this mother that:

Influenza VaccineA. Both children should receive seasonal flu vaccines;B. Neither child should receive seasonal flu vaccine;C. The three year old should receive seasonal flu

vaccine but the four month old should not;D. The 4 month old infant should receive seasonal flu

vaccine but if the three year old gets a rash from eggs he should not receive it this year;

E. The three year old needs two doses of the seasonal flu vaccine because he is less than 9 years old.

Influenza Vaccine

A. Both children should receive seasonal flu vaccines;B. Neither child should receive seasonal flu vaccine;C. The three year old should receive seasonal flu

vaccine but the four month old should not;D. The 4 month old infant should receive seasonal flu

vaccine but if the three year old gets a rash from eggs he should not receive it this year;

E. The three year old needs two doses of the seasonal flu vaccine because he is less than 9 years old.

Influenza Vaccine• Influenza vaccine risk factors now include children with

compromised respiratory function or children that have an increased risk of aspiration.

• ACIP recommends immunizing all children 6 months to 18 years of age. Previously unvaccinated children 6 months to 8 years of age should receive 2 doses of this vaccine.

• Available as Trivalent inactivated vaccine (TIV), or Live Attenuated Influenza Vaccine (LAIV)

• Those with reported egg allergy may receive the vaccine unless they have had severe reactions (anaphylaxis)

Breastfeeding

Case # 1

A female infant presents for her two week check-up. She was born after a 38 week uncomplicated pregnancy via spontaneous vaginal delivery at a birth weight of 3 kg. Her mother is breastfeeding and asks whether breast milk alone is sufficient for her baby. What advice should you give her?

True or False?1. The baby should receive oral iron supplements

for the first 6 months of life.

2. The baby does not need vitamin K after birth so long as the mother is taking oral Vitamin K.

3. Starting shortly after birth, the baby will need 400 IU of vitamin D daily while she is exclusively breastfed.

True or False?1. The baby should receive oral iron supplements

for the first 6 months of life.

2. The baby does not need vitamin K after birth so long as the mother is taking oral Vitamin K.

3. Starting shortly after birth, the baby will need 400 IU of vitamin D daily while she is exclusively breastfed.

Question # 1

False

Iron• Iron stores at birth are proportional to birth

weight or size. • Iron stores for term infants are sufficient to

meet needs for the first 4-6 months of life.• Breast milk contains <0.1 mg/100cc of iron

but it is in a highly bio-available form (50% of it is absorbed compared to 4% of iron in iron-fortified formulas).

• Infants’ adequate intake of iron is approximately 0.27 mg/day for the first 4-6 months of life.

True or False?1. The baby should receive oral iron supplements for the

first 6 months of life.

2. The baby does not need vitamin K after birth so long as the mother is taking oral Vitamin K.

3. Starting shortly after birth, the baby will need 400 IU of vitamin D daily while she is exclusively breastfed.

Question # 2

False

Vitamin KVitamin K is a fat soluble vitamin necessary for the

posttranslational carboxylation of glutamic acid residues of coagulation proteins Factors II, VII, IX and X.

lpi.oregonstate.edu/infocenter/vitamins/vitamink/kcycle.html

Vitamin K• Breast milk has inadequate amounts of

Vitamin K to satisfy infant requirements.• All breastfed infants should receive 0.5 - 1.0

mg of Vitamin K IM after the first feeding and within the first 6 hrs of life.

• Oral Vitamin K may not provide the stores necessary to prevent hemorrhage in later infancy and is not recommended at this time.

True or False?1. The baby should receive oral iron supplements

for the first 6 months of life.

2. The baby does not need vitamin K after birth so long as the mother is taking oral Vitamin K.

3. Starting shortly after birth, the baby will need 400 IU of vitamin D daily while she is exclusively breastfed.

Question # 3

True

Vitamin D

• Vitamin D (calciferol) is available from certain dietary sources and can be synthesized in skin upon exposure to UV light.

• Adequate intake of vitamin D for infants is 400 IU per day as per recent AAP guidelines (2008).

• Vitamin D content of human milk is low (22 IU/L).

Vitamin D

• Breastfed infants should receive supplements of 400 IU of vitamin D per day so long as the daily consumption of vitamin D-fortified formula or milk is below 1,000 ml.

• The recommended routine use of sunscreen in infancy decreases vitamin D production in skin.

Case # 1 (cont’d)

On further review of the mother’s history you discover that she is CMV positive, is taking anti-hypertensive medications, and has resumed her half-pack per day cigarette consumption since the baby was delivered.

When asked whether any of these factors present a problem for her continuing to breastfeed, what should you advise her?

Breastfeeding and viruses

Viruses can be transmitted into human milk but only the presence of certain viruses in the mother are contraindications to breasteeding in the United States. These include:

HIV-1, HIV-2, HTLV-1, HTLV-2 and HSV if there are lesions present on the nipple.

Hepatitis B, Hepatitis C, CMV, and rubella are not contraindications for breastfeeding.

Breastfeeding and medications

Like viruses almost all medications taken by the mother are excreted into breast milk but only a very few are contraindications to breastfeeding. These include:

Radioisotopes, anti-metabolites or immunosuppressive agents, lithium, chloramphenicol, iodides, bromocriptine, and ergot alkaloids.

Breastfeeding and smoking

Tobacco is not a contraindication to breastfeeding but nursing mothers should be advised not to smoke in the vicinity of the newborn and should be sensitively counseled to seriously consider abandoning this filthy, expensive, debilitating habit.

More on BreastfeedingCompared to the weight gain of formula fed infants in

the first year of life, the weight gain of breast fed infants:

A. Is less rapid during the first 3-4 months but then catches up

B. Is more rapid during the first 3-4 months but then slows down

C. Generally results in a slightly heavier infant by 12 months of age

D. Does not differ at all

More on BreastfeedingCompared to the weight gain of formula

fed infants in the first year of life, the weight gain of breast fed infants:

A. Is less rapid during the first 3-4 months but then catches up

B. Is more rapid during the first 3-4 months but then slows down

C. Generally results in a slightly heavier infant by 12 months of age

D. Does not differ at all

More on Breastfeeding

Breast fed infants tend to gain more weight than do formula fed infants in the first 3-4 months of life.

It is acceptable for their weight gain to cross one or two percentiles downward in the period after 4 months so long as they maintain their length and head circumference.

More on Breastfeeding

By the end of the first year of life, breast fed infants who had solids introduced at 4-6 months of age tend to be slightly leaner than formula fed infants.

Term infants require between 100 to 120 kcal/kg per day in order to grow.

Nutrition

Current recommendations are to delay the introduction of cow’s milk until 12 months of age. The rationale for this recommendation includes all of the following except:

A. Cow milk has a higher renal solute load delivered to the kidney than human milk;

B. The iron content of cow milk is inadequate to prevent iron deficiency;

C. Cow milk induces gastroesophageal reflux;D. Cow milk may cause increased fecal blood loss in

some infants;E. The caloric content of cow milk is sufficient for

infant growth by 12 months of age.

NutritionThe correct answer is C. Cow milk does not

induce GE reflux. It only contains 0.5mg/L of iron of which 10% is absorbed making it insufficient to prevent iron deficiency. It can induce fecal blood loss in some infants and it has higher concentrations of sodium and potassium than human milk or formula. It’s caloric content is sufficient for growth at 1 year.

You are rounding in the newborn nursery with a group of residents. In describing the choices of infant nutrition that might optimize growth and development you are MOST likely to tell them:

A. Preterm and term infants generally require between 100-120 kcal/kg/day of energy to grow;

B. Preterm infants generally require less caloric intake per kilogram to grow than do term infants;

C. Term infants generally require between 60-80 kcal/kg/day to grow;

D. Term infants generally require between 30-50 mL/kg/day of fluid intake;

E. Term infants with BW > 2,500 gms require more energy per kilogram to grow than those infants with BW less than 2,500 gm.

Nutrition

The correct answer is A, preterm and term infants require 100-120 kcal/kg/day to grow. Determinants of energy requirements for infants include gestational age, illness, a history of surgery or wound healing, local environment and other factors.

NutritionEnergy requirements can

be thought of as divided into the following needs

Category Kcal/kg/d

RMR 50-60Activity 0-10Temp. reg 0-10Growth 10-15Storage 20-30Loss 10-15Total 90-140

Your are seeing a 10 year old girl in your office who comes in for health care maintenance. On exam she is noted to have a BMI of 28 putting her over the 95%ile for her age in girls. You recall that BMI, as a measure of adiposity has been shown to be associated with all of the following except:

A. Socio-economic statusB. GenderC. BirthweightD. RaceE. Pubertal status

Nutrition• The correct answer is C. A distinct socio-

economic gradient in obesity has been demonstrated in national data sets as have differences by race and ethnicity. Girls have higher rates of obesity than do boys and obesity increases with the onset of puberty. Birthweight per se is not highly correlated with later measures of adiposity (although SGA babies may be at greater risk).

Nutrition

After leaving the exam room with your medical student, a discussion about trends in obesity takes place. You point out to your trainee that, with respect to the epidemiology of obesity all of the following statements are true except:

NutritionA. The prevalence of obesity and overweight has doubled

in the U.S. in the past 20 years;B. Each extra hour per day of TV watching among 12-17

year olds increases the prevalence of obesity by 2%;C. The concordance rate of obesity among monozygotic

twins is between 0.7 and 0.9;D. The increase in obesity has occurred despite the fact

that the majority of school-aged children still report 4 hours of vigorous activity per week;

E. By 19–24 months of age, French fries are the most commonly consumed vegetable in the U.S.

Nutrition• The correct answer is D. Obesity rates have

doubled in the past 2 decades. One extra hour of TV watching is associated with an increase in the prevalence of obesity by 2%. Obesity is highly heritable and French fries are the most commonly eaten vegetable by 19-24 months. School children average less than 2 hours of vigorous exercise per week according to national data.

Anticipatory Guidance

“There are things that’ll knock you down you don’t even see coming”

Anticipatory Guidance: Injury Prevention

Injury Prevention

A 6 month old boy is at your office with his father for a routine health care maintenance visit. In discussing injury prevention for his infant, the father wants to know what he should be most concerned about with respect to his infant’s safety. What should you tell him?

Leading Causes of Death by Age Group 2001

< 1 yr 1-4 yrs 5-9 yrs 10-14 yrs1 Congenita

l Anomalies

5,513

Unintentional Injury1,714

Unintentional Injury1,283

Unintentional Injury1,553

2 Short Gestation

4,410

Congenital Anomalies

557

Malignant Neoplasms

493

Malignant Neoplasms

5153 SIDS

2,234Malignant Neoplasms

420

Congenital anomalies

182

Suicide 272

Leading Causes of Injury Deaths

by Age Group 2001

0%

20%

40%

60%

80%

100%

1-4 Years 5-9 Years 10-14 Yrs

OtherFirearmsBurnDrownMotor Veh

Deaths Due to Injury in Childhood

• SIDS is the leading preventable cause of death in children less than 1 year of age.

• Unintentional injury is the leading cause of death in children from 1 to 15 years of age.

• Motor vehicle incidents, drowning and deaths from burns taken together account for over 75% of all deaths from injury in children between 1 and 15 years of age.

Water Safety

The father of a 4 year old boy asks you about keeping the child safe from injury around the family pool. When counseling him about the epidemiology of childhood drowning, a TRUE statement is:

A.Drowning is the leading cause of death due to injury

B.For every one drowning victim there are 5 near drownings

C.Pool alarms have eliminated the need for fencing

D.Residential pools are the most common drowning sites

E. The ratio of male-to-female drowning deaths is 1:1

A.Drowning is the leading cause of death due to injury

B.For every one drowning victim there are 5 near drownings

C.Pool alarms have eliminated the need for fencing

D.Residential pools are the most common drowning sites

E. The ratio of male-to-female drowning deaths is 1:1

Water SafetyResidential pools are the most common site of

drowning for children younger than 5. Infants drown in bathtubs most often and adolescents in fresh water lakes and rivers.

Drowning is the 2nd leading cause of death in this age group (remember earlier) with peak incidence in the summer months and highest rates in the west and the south.

Water Safety

Four sided fences 5 ft high with self-closing self-locking gates are the most effective enclosures for residential pools.

Pool alarms, pool covers, swimming lessons for young children and floatation devices are not as effective as proper enclosures in preventing drowning deaths.

Male to female ratio is 3:1 and 50% of submersion victims are declared dead at the site (drowning to near drowning ratio of 1:1).

Burns

You are approaching the end of a health care maintenance visit for a 2 year old girl. The mother explains that the family recently moved into a private house having lived previously in an apartment. What four concrete pieces of advice can you give her about how she might make her new home safe from the standpoint of preventing burn injuries to her toddler?

Burns1. Don’t smoke in the home.Home fires cause three fourths of all fire deaths

and children below the age of 5 are at highest risk.

Adults who smoke carelessly or who fall asleep while smoking are responsible for the largest percentage of home fires that kill or injure children.

Burns

2. Install smoke detectors on each floor in the house and test them every 6 months.

Smoke detectors provide the best protection should a home fire begin since: a) most fires start in the early morning hours; b) most fires burn for a long time before discovery; and c) deaths are usually due to CO poisoning so early alerts can help prevent injury and death.

Burns

3. Prepare emergency escape plans for use in the event of a fire.

Even children as young as 3 can be taught how to safely get out of the house in the event of a fire. If fire extinguishers are available in the home (and they should be) children should always be taught to leave the house rather than try to put out a fire themselves.

Burns

4. Set hot water heaters at no higher than 120o F.

Tap water at 160o F can produce a full-thickness scald burn in less than 1 second. At 120o F the scalding time is increased to between 2 and 10 minutes.

Anticipatory Guidance: Development

DevelopmentA six month old breast fed male infant is at your office for

a well child check-up. He has been previously well and on exam babbles, reaches for your stethoscope and pulls to a sitting position without head lag. He can also:

1. Finger feed himself2. Imitate sounds3. Pull to stand4. Transfer objects from one hand to the other5. Use a scissors grasp to obtain a piece of cereal

DevelopmentCorrect answer is 4, transfer objects.As part of his normal development this infant probably

began to hold a rattle briefly at 2 months, reached for objects and and lifted himself onto extended elbows at 4 months. He probably also began to roll over at 4 months and could roll both ways by 6 months. He likely began to coo at 2 months, to laugh out loud at 4 months, and to begin to babble at 6 months. Pulling to stand usually begins around 8 months. Finger feeding and imitating sounds usually starts at 9 months.

DevelopmentYou are examining a young boy during a health supervision

visit. His mother reports that he says “mama,” “dada,” “bye,” “up,” and “ball.” While playing on the floor he sees a toy truck on the shelf and points to it. His mother asks him to bring her the truck which he does. These developmental milestones suggest the child is CLOSEST to:

A. 12 months of age D. 21 months of ageB. 15 months of age E. 24 months of ageC. 18 months of age

DevelopmentThe correct answer is B. 15 months of age.

At this age infants generally have a vocabulary of about 6 words, can follow simple commands, point to parts of their bodies and use gestures and jargon to express themselves. 18 month olds have a vocabulary of about 10-15 words and 21 month olds know 30 to 50 words. Two year olds are beginning to put two word phrases together and generally know about 100 words. They can follow complex commands.

Development

Familiarity with expected language milestones is important for the calculation of the language developmental quotient according the formula:

LQ = language age/chronological age X 100

A child with an LQ of less than 70 should be referred for further evaluation.

Psycho-social Issues

Case #1

You are seeing a set of parents with their 8 year old boy for a health care maintenance visit. The mother asks you whether allowing her son to watch TV when he comes home from school is a bad idea.

The MOST accurate statement you can make to her about the influence of television viewing on children is:

MediaA. Most adolescents have difficulty discriminating

between what they see on TV and what is real.B. Nearly 2/3 of all programming includes

violence and children’s programming contains the most violence.

C. 50% of 2-7 year olds have a TV in their room.D. A majority of parents report that they always

watch TV with their children to monitor the content of what is seen.

MediaA. Most adolescents have difficulty discriminating

between what they see on TV and what is realB. Nearly 2/3 of all programming includes

violence and children’s programming contains the most violence

C. 50% of 2-7 year olds have a TV in their roomD. A majority of parents report that they always

watch TV with their children to monitor the content of what is seen

MediaAlthough young children and adolescents are vulnerable

to the messages conveyed on television, it is predominantly younger children who cannot discriminate between what is real and what they see on TV. In a random survey of parents with children from kindergarten through 6th grade published in 1996, 37% reported that their child had been frightened or upset by a TV program seen during the preceding year.

Cantor J, Nathanson AI. Children’s fright reactions to television news. J Commun. 1996;46: 139-152.

MediaAbout one third of parents of 2-7 year olds

report that their children have a television in their room.

Less than half of all parents state that they always watch television with their children to monitor the content of what is being seen.

Media

A recently completed 3 year National Television Violence Study reported that:

• Nearly 2/3 of all programming contains violence;

• Children’s shows contain the most violence;• Portrayals of violence are usually glamorized; • Perpetrators of violence often go unpunished.

Federman J. ed. National Television Violence Study Vol 3. Thousand Oaks, CA: Sage; 1998.

The much beloved grandfather of one of the families in your practice has just died of a heart attack. All five children in the family are expressing their grief in various ways. Considering the cognitive and behavioral aspects of the understanding of death, which of the following correctly matches the age of the child with their most likely response to their grandfather’s death?

1 2 3 4 5

17%

13% 13%

23%

33%

1. The 18-month-old feels her grandfather died because she was mad at him

2. The 3-year-old wonders if Grandpa will still be able to go fishing with him this summer

3. The 4-year-old worries that she is going to die soon

4. The 8-year-old asks, “Why not me?”5. The 13-year-old develops separation anxiety

Countdown

6

Coping with Death• Children less than 2 years of age, in what Piaget

refers to as the sensori-motor stage of development have very little concept of death. They can sense emotional discomfort in those around them and may withdraw or become irritable.

• Children between 2 and 6 are in a preoperational stage of development and may engage in magical thinking, lacking a sense of the permanence of death or its causes.

Coping with Death• Sometime around 6 years of age concrete

operational thinking allows children to develop a sense of the permanence and irreversibility of death which leads to morbid fascination with death, phobias, school avoidance reactions or separation anxiety.

• It is in adolescence with the formal operational stage of development and abstract thinking that the existential implications of death emerge giving rise to questions like, “Why not me?”

Case #3

Two bleary-eyed yawning parents come to your office with their smiling two month old infant girl complaining that the baby ‘never sleeps’. In counseling them regarding normal sleeping patterns for infants, you tell them that:

SleepA. Most babies can’t distinguish night from day until 4

months of age;B. In the first 2 – 3 months of life most babies sleep up

to 16 hours per day in 3-4 hour spurts;C. The best treatment if the baby is not sleeping is to

place her in her crib and let her cry until she falls asleep;

D. Like adults, 2 month olds cycle through REM and non-REM sleep every 90 – 110 minutes;

E. Cereal in her bottle may help her sleep at night.

SleepA. Most babies can’t distinguish night from day until 4

months of age;B. In the first 2 – 3 months of life most babies sleep up

to 16 hours per day in 3-4 hour spurts;C. The best treatment if the baby is not sleeping is to

place her in her crib and let her cry until she falls asleep;

D. Like adults, 2 month olds cycle through REM and non-REM sleep every 90 – 110 minutes;

E. Cereal in her bottle may help her sleep at night.

Sleep

• Most babies begin to distinguish day from night beginning at 2 months of age and by 4 months, many are sleeping through the night.

• Their REM non-REM sleep cycles, however, are shorter than adults, lasting usually about 50 minutes.

Sleep• Sleep onset disorders may be forestalled if

young infants and toddlers are put into their cribs drowsy but awake, providing them the opportunity to learn how to self-soothe in the transition to sleep but active “sleep training” should probably wait until a baby is at least 6 months of age.

• There is no evidence that early introduction of solid foods hastens good sleep hygiene and should be avoided.

Ethics and Professionalism

Ethics

The mother of a 12 year old boy who is doing quite well in school comes to you to ask for a prescription for Concerta because she believes that his use of the medication will enhance his academic performance and maximize his chances of being accepted to an elite university.

The decision whether or not to accede to this mother’s request pits which two ethical principles against one another?

Ethics

A. Autonomy and beneficenceB. Justice and non-malfeasanceC. Altruism and non-discrimination

Ethics

Autonomy: The right to make decisions and to act on them freely - specifically the patient’s right to control what happens to his or her body. In pediatrics this right is normally invested in the parent or guardian as pediatric patients are considered to lack capacity to make such decisions for themselves.

Ethics

Beneficence:An obligation to act for the benefit of others which, in a medical context, obligates the physician to act in the interest of his or her patient.When a mother insists on a treatment for her child that is not in the child’s best interest, the principles of autonomy and beneficence come into conflict with one another.

Ethics

Justice and non-malfeasanceJustice refers to the fair distribution of resources that is not dependent upon social status, race, ethnicity, gender or other non-relevant characteristics. Non-malfeasance is the primary duty of physicians to, “Do no harm”. Neither principle is at issue in this case since Concerta is neither in short supply nor likely to harm the patient if taken.

Ethics

Altruism and non-discriminationAltruism refers to the unselfish regard or devotion to the welfare of others.Non-discrimination is a duty to treat all patients equally regardless of social class, religious background, race, ethnicity, gender, or other features. This mother’s request does not invoke either of these ethical elements.

A fifteen year old girl comes to your practice concerned because she has missed three menstrual periods. A urine pregnancy test confirms that she is pregnant. She pleads not to have this information disclosed to her mother. This patient is making an appeal to which feature of your professionalism?

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17% 17%

20%20%

27%

1. Honesty and integrity2. Reliability and responsibility3. Respect for others4. Compassion/empathy5. Self-awareness and knowledge of

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Professionalism

Honesty and integrity refers to the ability to meet commitments and to be intellectually honest and straightforward in interactions with peers and with patients. Withholding information from this patient’s parents at her request does not represent an appeal to honesty and integrity on your part.

Professionalism

Reliability and responsibility represent accountability to patients, families, colleagues, medical systems and the society, specifically the willingness to identify and acknowledge errors and to discuss consequences and alternatives with any affected party. The outcome of this clinical scenario is not the result of a medical error and does not involve this professional concept.

Professionalism

Respect for others refers to regard for the individual worth and dignity of all persons including sensitivity to gender, race, sexual orientation and other features as well as the maintenance of patient confidentiality. Your patient is making a direct appeal to this aspect of professional conduct by asking you to refrain from communicating the results of her test to her mother at the present time.

Professionalism

Compassion/empathy refers to the ability to understand a patient’s or family’s pain or discomfort from their point of view rather than from the point of view of the pediatrician. Although one might argue that your patient is appealing to your empathy on some level here, the central issue is not her anxiety so much as the duty to maintain her confidentiality that is at issue.

Professionalism

Self-awareness and knowledge of limits involves the maturity to recognize when a clinical problem involves issues beyond the knowledge or skills of a particular provider and the willingness to solicit guidance from others. There is nothing in this scenario that could be construed to be beyond the competence of a primary care pediatrician.

Patient Safety and Quality Improvement

In developing a culture of safety from a quality improvement perspective, all of the following elements are critical except:

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17%

27%

23%

10%

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1. Encouragement of reporting2. Ability to be flexible to changing demands

and circumstances3. Emphasis on individual behavior 4. Establishment of a non-punitive

environment5. Creation of a culture that learns from its

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Correct Answer is 3

A well functioning patient safety approach recognizes human fallibility as an unavoidable element in high-risk endeavors and focuses on systems rather than individuals. It encourages the reporting of mistakes in a non-punitive environment , maintains an ability to be flexible and to change with emerging circumstances by creating a self-sustaining culture that actively learns from its mistakes.

I think we’re done