01 History Taking and Physical Examination Merged

Pediatrics 1
History Taking and Physical Examination

Ma. Victoria M. Villarica RN, MD, DPPS, FPSECP | 09 August 2018 | Topic 1
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Transcribed by: SINGH, SHINOTSUKA, VELASCO, VILLEGAS, VITAL Page 1 of 13

PED201 HISTORY TAKING AND PHYSICAL EXAMINATION T1
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𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑘𝑖𝑙𝑜𝑔𝑟𝑎𝑚𝑠
𝑩𝑴𝑰 =
• (𝑙𝑒𝑛𝑔𝑡ℎ 𝑜𝑟 ℎ𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑚𝑒𝑡𝑒𝑟𝑠)2
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1.

Pediatrics 1
Childhood Accidents & Injuries
Doc Marietta Diaz | 11 September 2018 | Topic 2
Childhood Accidents and Injuries Psychosocial (endogenous) Predisposing Factors
I. INJURY VS ACCIDENTS
II. INTERACTIVE MODE OF INJURIES
– Unawareness of risks
III. PRIMARY FACTORS IN PEDIATRIC INJURIES – Lack of experience
A.
B.
Psychosocial (endogenous) Predisposing Factors
Environmental (exogenous) Predisposing Factors – Need to explore and innovate
C. Precipitating Factors – Role models (motorcyclist as hero)
IV. US injury Mortality
V. US Injury Morbidity – Risk-taking behavior
VI. Special Conditions Predisposing to Cardiopulmonary Arrest – Use of a motor vehicle to build up self-esteem
VII. Prehospital Arrest Most Common Causes
VIII.Child Development and Injuries – Psychological maladjustments (extreme personality traits,
IX. Pediatric Trauma unbalanced personality)
X. Cervical Spine Injury
XI. Hemorrhage in Pediatric Trauma – Sociopathic behavior (aggressiveness, deviance)
XII. Life-Threatening Chest Injuries – Family dysfunctions (chronic family syndrome)
XIII.Identifying Serious Illness inFebrile Children in the OPD
XIV. Principles of Injury Control
XV. Haddon’s 10 Strategies Environmental (exogenous) Predisposing Factors
XVI. Gustafsson Safety Equation
XVII. Three DELAYS that KILL Habitual use of a two-wheeled vehicle without due protection
Lack of body protection (helmet, gloves, etc.)
INJURY VS. ACCIDENTS Increased commercial advertising promoting vehicles that are
– Accident (WHO): an event independent of human willpower, dangerous
caused by an external force, acts rapidly and results in bodily Inadequate age-specific driving regulations
or mental damage Inadequate enforcement of existing laws
– Injury: “the physical damage that results when a human body Increasing need to make long trips to and from work, school,
is suddenly subjected to energy (mechanical, thermal,chemical etc.
or radiated) in amounts exceeding threshold of physiological Inadequately or excessively expensive public transport
tolerance or the result of a lack of one or more vital elements,
such as oxygen”
Precipitating Factors
– Accident implies random event that cannot be prevented while
injury indicates a medical condition with defined risk and  Heightened emotional tension (endocrinological and
psychological)
protective factors, hence, can be controlled and prevented
– Therefore, the term accident prevention has been replaced by  Alcoholic condition
 Driving under influence of medicines or drugs (especially
injury control
hallucinogenic)
 Heightened emotional tension (endocrinological and
INTERACTIVE MODE OF INJURIES psychological)
 Alcoholic condition
 Driving under influence of medicines or drugs (especially
hallucinogenic)
“Child injuries are a growing global public health
problem.”
PRIMARY FACTORS IN PEDIATRIC INJURIES
Transcribed by: Alej Aguilar Page 1 of 5

PED201 Childhood Injuries & Accidents T2
“About 2270 children die every day as a result of an

unintentional injury.”
US INJURY MORTALITY
 Injuries most common cause of death in pediatrics beyond 1st
few mo of life
 Motor vehicle injuries lead the list
 Drowning ranks 2nd overall, peaks in preschool and later
teenage years
 Fire and burn deaths nearly 5% of all unintentional trauma
deaths, 11% <5 yr of age
 Suffocation about 50% of all unintentional deaths <1 yr of
age, majority from choking on food
 Homicide 3rd leading cause of injury death in children 1–4 yr
of age (infantile) and 2nd leading cause in 15–19 yr old
(adolescent)
 Suicide 3rd leading cause of death for 15–19 yr old
US INJURY MORBIDITY
o Twenty to 25% of children receive medical care for injury
every year in hospital ERs, also in physician offices
o Falls leading cause of both ER visits and hospitalizations
o Bicycle-related trauma most common type of sports and
recreational injury

Special Conditions Predisposing to Cardiopulmonary Arrest Pediatric Trauma

– Trauma – Trauma is the leading cause of death and disability in the
– Burns pediatric age group
– Gastroenteritis – In the average multiple trauma victim: head injuries 59%
– Epiglottitis while extremities 26%
– Deterioration during positive-pressure ventilation – Two major causes of death:
– Tracheostomy 1. Airway compromise
– Seizures 2. Unrecognized haemorrhage
– Stroke
– Coma
– Traumatic injuries that may affect successful resuscitation:
– Critically ill
1. Cervical spine injury
Prehospital Arrest Most Common Causes 2. Hemorrhage
3. Chest trauma
During infancy: – Primary and secondary surveys to evaluate at ER
Injuries
Sudden Infant Death Syndrome (SIDS)
Respiratory diseases
Airway obstruction
Submersion
Sepsis
Neurological diseases
Beyond infancy:
Motor vehicle injuries
Pedestrian injuries
Bicycle injuries
Submersion
Burns
Firearm injuries
Child Development and Injuries
Temperament: 9-12 - Minor trauma

6-8 - Potentially life threatening
- a child’s behavioral style
0-5 - Life threatening
o Difficult child: irregular rhythm, high energy,
< 0 - Usually fatal
negative mood, low adaptability
**Pediatric Trauma Score of <8 indicates multisystem trauma
o Easy child: opposite
or significant mortality risk
o Slow to warm up child: low activity, positive
approach, highly adaptable, mild energy
Motivation Cervical Spine Injury
– interest in accomplishing a task
o Normal drive for autonomy - Less common in pediatric trauma because
o Interest in imitating behaviour o Child’s spine more elastic and mobile
o Risk-taking or self-destructive behaviors o Vertebrae softer, less likely to fracture
- But risk of injury increased when inertial forces applied to
neck during acceleration-deceleration e.g., motor vehicle
Competencies
injuries or falls from a height
– level of functioning - Spinal cord injury without radiographic abnormality
o Infants’ drive to explore and become autonomous (SCIWORA) now recognized as important cause of pediatric
but still underdeveloped spinal cord injury because of
o Preschool children have cognitive and motor o Relative laxity of cervical spine ligaments
limitations o Incomplete development of cervical musculature
o School children tend to be daring, impulsive and o Shallow orientation of facet joints
adventurous but have reduced ability to localize - SCIWORA accounts for large number of prehospital deaths
sounds and impaired perception of movement, previously thought to be due to head trauma
hence, unable to appreciate speed and danger
o Adolescents sometimes lose touch with reality
combined with innate need for experimentation and
tendency to imitate older persons

Hemorrhage in Pediatric Trauma

- Control external hemorrhage immediately by direct pressure
over the wound
- Hypotension will not be present until 25-30% or more of the
child’s blood volume is lost acutely
- Reliable vascular access must be obtained quickly
- If shock persists despite control of external hemorrhage and
volume resuscitation, internal bleeding is likely
- Isolated head injury rarely causes sufficient blood loss to
cause shock but scalp lacerations may produce significant
blood loss
- Intra-abdominal bleeding signs due to organ rupture:
abdominal tenderness, distention that does not improve with
NGT decompression and shock
Life-Threatening Chest Injuries

- Chest injuries uncommon in pediatric trauma because chest
wall extremely compliant
- When there is history of blunt trauma, intrathoracic injuries
must be ruled out
- Tension pneumothorax: ABCs, needle decompression
followed by chest tube
- Open pneumothorax (sucking chest wound) – rare but lethal:
ABCs, occlusive dressing followed by chest tube, positive-
pressure ventilation
- Flail chest: ABCs, prolonged positive-pressure ventilation
- Massive hemothorax: ABCs, urgent placement of a chest
tube

Identifying Serious Illness in Febrile Children in the

OPD Gustafsson Safety Equation
H = Hazard in environment
P = Proneness/“Personality factors”/Psychosocial
S = Supervision
E = Education
When, in any context, 1st term of equation balances the 2nd
one, there is no chance of accident
When it is not the case, risk of accidents arises
The equation is useful for preventive programs
Three DELAYS that KILL
DELAY in decision-making
DELAY in transporting patient
DELAY in managing patient
REFERENCES
1. Doc Diaz’s ppt
Score <10 - chance of serious illness 1-2%

Score >10 - risk serious illness increases at least 10X
Principles of Injury Control
- Education or persuasion
- Changes in product design
- Modification of social (laws) or physical environment
Haddon’s 10 Strategies
1. Prevent the creation of hazard

2. Reduce amount of hazard brought into being (decrease
number of cars manufactured; use fuel that permits only low
speed)
3. Prevent the release of hazard (drive only in daylight)
4. Modify the rate of release of the hazard from its source (use
seat belts, child safety seat)
5. Separate the hazard by time and space (separate bicyclists
from cars; use pedestrian lanes)
6. Separate the hazard by a physical barrier (install air bags)
7. Modify relevant basic qualities of the hazard (eliminate hard
surfaces in cars; use energy absorbing materials to increase
space within)
8. Make what is to be protected resistant (wear helmets)
9. Begin to counter the damage done by the hazard (maintain
airway, stop haemorrhage, immobilize neck)
10. Stabilize, repair, rehabilitate the object of the damage
(develop a regional trauma system, trauma and rehabilitation
center)

Pediatrics 1
POISONING IN CHILDREN
POISONING IN CHILDREN 3. Physical Examination should be comprehensive and may provide
I. Poisoning additional clues to the identity of the toxin. Below shows the link
A. General Concepts between some typical physical findings and associated toxins.
B. Evaluation
II. General Management Principles
III. Selected Toxins and their Antidotes
A. Acetaminophen Poisoning
B. Salicylate Poisoning
C. Iron Poisoning
D. Lead Poisoning
E. Caustic Poisoning
F. Carbon Monoxide Poisoning
POISONING
GENERAL CONCEPTS
Epidemiology
– Sixty percent of all poisonings occur in children younger than 6
years of age.
– Ninety percent of poisonings are accidental.
– The majority of poisonings occur at home when the child’s
caregiver is distracted.
– Most poisons are ingested, although poisons may also be inhaled,
spilled on the skin or into the eyes, or injected intravenously.
– Mortality is < 1%
Etiology
The most common toxic exposures involve commonly used household
products.
4. Laboratory Studies
o Cosmetics and personal-care products (most common toxic
- Screening laboratory tests include serum glucose, serum and
exposure). urine toxicology screens, and electrolytes.
o Cleaning agents o Anion gap [Na 5+ - (Cl- + HCO3-) should be calculated.
o Cough and cold preparations o Causes of an increased anion gap (>16) may be
o Vitamins, including iron recalled using the mnemonic AMUDPILES (alcohol,
o Analgesics (e.g., acetaminophen, non-steroidal anti-inflammatory methanol, uremia, diabetic ketoacidosis, paraldehyde,
drugs [NSAIDs], aspirin) iron and isoniazid, lactic acidosis, ethylene glycol,
o Plants (6-7% of all ingestions) salicylates).
o Alcohols (e.g., ethanol) and hydrocarbons (e.g., gasoline, paint - Radiographic imaging of the abdomen may reveal radiopaque
thinner, furniture polish) substances. These may be recalled using the mnemonic CHIPE
o Carbon monoxide (chloral hydrate and calcium, heavy metals, iodine and iron,
phenothiazines, enteric-coated tablets)
o Prescription medications
EVALUATION GENERAL MANAGEMENT PRINCIPLES

1. Consider poisoning in patients presenting with nonspecific signs
1. The ABCs are the initial management priority.
and symptoms, such as seizures, severe vomiting and diarrhea,
2. If the patient has altered mental status, administer dextrose for
dysrhythmias, altered mental status or abnormal behaviors,
hypoglycemia and naloxone for possible opiate overdose.
shock, trauma, or unexplained metabolic acidosis.
3. A poison control center may be consulted to assist with
2. History obtained from caregivers typically identifies the poison.
management.
 Information about the toxin should include the type or
name of toxin, toxin concentration (if known), and the 4. Gastric decontamination
route of exposure. a. Syrup of ipecac rapidly induces emesis by direct
1. Potential poison dose is calculated for the gastric irritation and CNS chemoreceptor stimulation
worst-case scenario. Toxicity is typically on  It is theoretically effective only within the
the basis of the amount ingested per kilogram first 30 minutes after ingestion, after which
of body weight. time toxic substances are beyond the
2. Consider multiple agents in adolescents. stomach.
 Information about the environment should include  It is contraindicated in victims with
location of victim when discovered and medications, decreased level of consciousness, caustic or
plants, vitamins, herbs, and chemicals in the home. hydrocarbon ingestions, and in children
Time of occurrence, if known, is very important. younger than 6 months of age.
 Evidence suggests that ipecac does not
improve clinical out of favor.

PED201 POISONING IN CHILDREN T2
b. Gastric lavage is performed with a large bore oro- ACETAMINOPHEN POISNOING
gastric tube placed into the stomach to evacuate the
stomach contents.
This drug is one of the most common medications ingested by children and
 Indications include life-threatening
adolescents.
ingestions presenting within 1-hour after
ingestion and ingestion of toxins that delay
gastric emptying (e.g., salicylates) Pathophysiology
 Contraindications include caustic, - Hepatic damage, the major sequelae of toxicity, is directly
hydrocarbon and nontoxic ingestions, and related to the depletion of glutathione, a cofactor used during
delayed presentation the metabolism of acetaminophen by the cytochrome P-450
 Evidence of improvement in clinical system.
outcome with its use is lacking. - Toxic intermediates produced when glutathione is depleted bind
c. Activated charcoal has a very large absorptive directly to hepatocytes, causing hepatocellular necrosis
surface area that binds toxins and minimize their
absorption. Clinical features
 Activated charcoal should be considered
There are four stages of acetaminophen poisoning (see Table below)
for all poisonings. However, it is ineffective
for some poisons such as iron, lithium,
alcohols, ethylene glycol, iodine, potassium
and arsenic. In addition, activated charcoal
interferes with visualization during
endoscopy and therefore should not be
used for caustic ingestions.
 Evidence suggests that activated charcoal
improves clinical outcome, especially if
given within 1-hour after ingestion.
d. Whole-bowel irrigation (WBI) is rapid, complete
emptying of the intestinal tract accomplished using
polyethylene glycol (an osmotic agent) and an
electrolyte solution (to prevent electrolyte
imbalance). Preliminary studies show that WBI may
be effective for ingestions of iron and other heavy
metals and sustained-release medications. Management
e. Antidotes exist for a relatively small number of
compounds. – Gastric lavage, if ingestion appears to be life threatening
– Activated charcoal
– Obtain serum acetaminophen level 2-4 hours after ingestion.
SELECTED TOXINS AND THEIR ANTIDOTES Level should be plotted on the Matthew-Rumack nomogram to
determine the potential for hepatitis.
– If the nomogram predicts hepatitis, the antidote, N-
acetylcysteine (NAC), a glutathione precursor, is indicated.
o NAC is given orally as a 140 mg/kg loading dose and is
followed with 70 mg/kg every 4 hours for 17 doses.
Intravenous NAC may also be used.
o NAC is hepatoprotective if given within 8 hours of
ingestion. It may still be helpful up to 72 hours after
ingestion.
SALICYLATE POISONING
- Salicylate poisoning has decreased as acetaminophen’s usage
has increased; however, salicylates remain an ingredient in many
compounds, such as Pepto-Bismol, Ben-Gay, and oil of
wintergreen.
Pathophysiology
o Salicylates directly stimulate respiratory centers. This causes
hyperventilation that may over compensate for metabolic
acidosis produced by the salicylate (it is a weak acid), resulting in
a respiratory alkalosis.
o Salicylates uncouple oxidative phosphorylation, producing lactic
acidosis and enhancing ketosis.
Clinical features.
Common signs and symptoms include
 Fever
 diaphoresis,
 flushed appearance;
 tinnitus
 Vomiting
 Headache

 Lethargy Clinical features
 restlessness – There are four stages of iron toxicity
 coma
 seizures
 hyperpnea
 dehydration
Laboratory findings
o Respiratory alkalosis with an anion gap metabolic acidosis is the
most common acid-base disturbance.
o Hyperglycemia, followed later by hypoglycaemia
o Hypokalemia
Management
 Gastric lavage may be useful, because salicylates may delay
gastric emptying.
 Activated charcoal is effective and may be readministered every
4 hours in severe poisonings
 Obtain serum salicylate level at least 6-hours after ingestion. The
level should then be plotted on the Done nomogram to assess
for potential toxicity
 Alkalinization of urine with sodium bicarbonate to a urine pH >7 Management
and large-volume intravenous fluids enhance renal excretion of – Gastric lavage should be performed.
salicylates. – Activated charcoal does not bind to iron.
 Dialysis may be required for life-threatening ingestions. – Hypovolemia, blood loss, and shock should be anticipated and
treated.
– WBI should be considered for life-threatening ingestion.
– Serum iron level should be obtained 2-6 hours after ingestion.
– Intravenous deferoxamine, an iron-binding ligand, should be
given if:
o Serum iron levels > 500 µg/dL, or if >300 µg/dL
and acidosis, hyperglycemia, or leukocytosis are
present
o Severe gastrointestinal symptoms are present
o More than 100 mg/kg of iron is ingested
– Before the serum iron level is known, a test dose of
deferoxamine may be administered. If the patient’s urine then
turns a red or pink (color of chelated iron), positive, indicating a
clinically significant iron ingestion.
Intravenous deferoxamine should then be continued.
LEAD POISONING
Epidemiology
– Sources of lead include ingestion of lead-based paint chips,
water carried by out-dated lead pipes, improperly glazed or
foreign-made ceramic food or water containers, and pica
(compulsive eating of non-nutrient substances such as dirt, paint
and clay)
IRON POISONING
Epidemiology.
– Iron is one of the most common and potentially fatal childhood
poisonings. As little as 20 mg/kg of iron is toxic.
– Adult-strength ferrous sulfate tablets and iron in prenatal
vitamins are the most common sources of accidental iron
ingestion.
Pathophysiology
– Direct damage to the gastrointestinal tract leading to
haemorrhage
– Hepatic injury and necrosis
– Third spacing and pooling of blood in the vasculature leading to
hypotension.
– Interference with oxidative phosphorylation

Pathophysiology
– CO interferes with oxygen delivery and utilization
Clinical features o CO displaces oxygen from the haemoglobin molecule,
Lead poisoning is typically chronic ingestion; however, children may also forming carboxyhemoglobin (CO-Hb), which can no
present with acute lead intoxication. longer carry oxygen. The bond between CO and
o Abdominal complaints include colicky pain, constipation, hemoglobin is more than 200 times stronger than the
anorexia and vomiting bond between oxygen and hemoglobin.
o CNS complaints include listlessness, irritability, seizures and o The oxygen-hemoglobin dissociation curve is shifted
decreased consciousness with encephalopathy. to the left. This leads to tighter binding of the
o Peripheral blood smear may show microcytic anemia, basophilic remaining oxygen bound to haemoglobin and
stippling, and red blood cell precursors. impaired release of oxygen to tissues.
o Radiopacities may be seen on abdominal radiographs, and dense o CO also interferes with cellular oxidative metabolism
metaphyseal bands may be present show on radiographs of the
knees and wrists (lead lines) Clinical features
– Depends on the CO - Hb level.
Diagnosis o Low levels are associated with nonspecific symptoms
An elevated lead level or elevated erythrocyte protoporphyrin is the basis of such as headache, flulike illness, dyspnea with
diagnosis. exertion and dizziness.
o High levels are associated with visual and auditory
Management changes, vomiting, confusion and later syncope,
slurred speech, cyanosis, myocardial ischemia, coma
Treatment for significant toxicity includes dimercaprol, British anti-lewisite
and death
(BAL), or calcium disodium ethylenediaminetetraacetic acid (EDTA)
Diagnosis
CAUSTIC POISONING
– Made by measuring the CO-Hb level.
– Caustic agents – It is important to remember that CO-Hb levels are not always
indicative of the degree of CO exposure and may even be low in
Pathophysiology. victims with significant intoxication. Other abnormal findings
o Acids (e.g., toilet bowl cleaner) cause coagulation necrosis that include anion-gap metabolic acidosis, low oxygen saturation
produces superficial damage to the mouth, esophagus and (however, PaO2 may be normal), and evidence of myocardial
stomach. More severe injury results from compounds that have ischemia on ECG or elevated cardiac enzymes.
a pH <2.
o Alkalis (e.g., oven and drain cleaners, bleach, laundry detergent) Management
cause liquefaction necrosis that produces deep and penetrating o One hundred percent oxygen is administered to displace CO
damage, most commonly to the mouth and esophagus. More from hemoglobin
severe injury results from compounds that have a pH >12. o If available, hyperbaric oxygen more rapidly displaces CO from
hemoglobin as compared to oxygen alone, and also improves
Clinical features oxygen delivery to tissues.
– Immediate burning sensation with intense dysphagia, salivation, o Hospitalization is indicated for CO-Hb levels > 25%, CO-Hb
retrosternal chest pain, and vomiting. levels > 10% during pregnancy, history or presence of neurologic
– Obstructive airway edema (especially with acid ingestion) symptoms, or presence of metabolic acidosis or ECG changes
– Gastric perforation and peritonitis may follow acid ingestion.
– Esophageal perforation with mediastinitis may follow alkali
ingestion. REFERENCES
Management 1. Doc Diaz’s ppt

Treatment initially includes the ABCs.
1. No attempt should be made to neutralize the caustic agent,
because the combination of acid and alkali will generate an
exothermic reaction and worsen any burn.
2. Ipecac, gastric lavage, and activated charcoal are all
contraindicated. Activated charcoal interferes with endoscopy.
3. Endoscopy is performed to assess the degree of
4. Household bleach has less corrosive potential and generally does
not require treatment.
CARBON MONOXIDE POISONING
Epidemiology
- Carbon monoxide (CO) is a by-product of incomplete combustion
of carbon-containing material. Excessive exposure may occur
from fires, tobacco, faulty home heaters, car exhaust, and
industrial pollution. CO is odourless, tasteless, and colourless.

Pediatrics 1
Immunology and Allergy Part 1-2
Eva L. Dizon, MD, FPPS | 03 – 17 August 2018 | Topic 3
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Transcribed by: Madrid, Menor, Morales, Padua, Palmes, Posadas, Ramos Page 1 of 6
PED201 IMMUNOLOGY AND ALLERGY T3
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PED201 IMMUNOLOGY AND ALLERY PART 3-4 T3
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Pediatrics 1
Growth and Development
Eric Olivares, MD | 11 September 2018 | Topic 1
of gene expression, without change
I. Overview and Assessment of Variability in DNA sequencing. These
• Pediatricians require knowledge of normal growth, epigenetic changes, such as DNA
development and behavior in order to effectively monitor methylation and histone acetylation,
children’s progress, identify delays or abnormalities in are a result of environmental insults.
development, obtain needed services and counsel
parents and caretakers. C. Neuronal Plasticity
• Growth- an indicator of overall well-being, status of o Critical to learning and remembering,
chronic disease and interpersonal and psychologic
which permits the central nervous
stress.
system to reorganize neuronal
networks in response to
A. Biopsychosocial model and Ecobiodevelopmental
Framework: Models of Development environmental stimulation, both
§ Biopsychosocial model positive and negative.
o Higher-level systems are o An overproduction of neuronal
precursors eventually leads to about
simultaneously considered with the
lower-level systems that make up the 100 billion neurons in the adult brain.
person and person’s environment. o Each neuron develops on average
15,000 synapses by 3 years of age.
o A patient’s symptoms are examined
and explained in the context of the o Synapses in frequently used pathway
patient’s existence are preserved, whereas less-used
number of synapses and
B. Ecobiodevelopmental Framework reorganization of neuronal circuits
also play important roles in brain
plasticity.
o The plasticity of the brain continues
into adolescence, with further
development of the prefrontal
cortex, which is important in
decision-making, future planning,
and emotional control; neurogenesis
persist in adulthood in certain areas
of the brain, including the
subventricular zone of the lateral
ventricles and in portions of the
hippocampus.
§ Children with different talents and
temperaments (already a combination of
genetics and environment) further elicit
different stimuli from their (differing)
environments.
1. Biologic Influences
o This framework emphasizes how to • Include genetics, in utero exposure to teratogens, the
ecology of childhood (social and long-term negative effects of low birth weight (neo-natal
physical environments) interacts with morbidities plus increased rates of obesity, coronary
biologic processes to determine heart disease, stroke, hypertension and type 2
outcomes and life trajectories. diabetes), postnatal illnesses, exposure to hazardous
o Early influences, particularly those substances and maturation.
producing toxic levels of stress, affect • Any chronic illness can affect growth and development,
the individual through modification either directly or through changes in nutrition,
parenting, or peer interactions.
Transcribed by: Page 1 of 22

PED201 LECTURE TITLE T1
MATURATIONAL CHANGES: • Attachment refers to a biologically

§ Decrements in growth rate and sleep determined tendency of a young child to seek
requirements around 2 years of age often proximity to the parent during times of stress
and also to the relationship that allows
generate concern about poor appetite and
securely attached children to use their parents
refusal to nap.
to reestablish a sense of well-being after a
§ Although it is possible to accelerate many stressful experience.
developmental milestones (toilet training a 12 • Insecure attachment may be predictive of later
months old or teaching a 3 years old to read), behavioral and learning problems.
the long-term benefits of such precocious • In early infancy, such contingent
accomplishments are questionable. responsiveness to signs of overarousal or
underarousal helps maintain infants in a state
§ Physical changes in size, body proportions and
of quiet alertness and fosters autonomic self-
strength, maturation brings about hormonal regulation.
changes. • Contingent responses (reinforcement
§ Sexual differentiation, both somatic and depending on the behavior of the other) to
neurologic, begins in utero. nonverbal gestures create the groundwork for
§ Both stress and reproductive hormones affect the shared attention and reciprocity that are
brain development as well as behavior critical for later language and social
development.
throughout development.
• Children learn best when new challenges are
just slightly harder than what they have already
TEMPERAMENT
mastered, a degree of difficulty dubbed the
“zone of proximal development”.
• The stable, early-appearing individual variations in
• Psychologic forces, such as attention problems
behavioral dimensions, including emotionality (crying, or mood disorders, will have profound effects
laughing, sulking), activity level, attention, sociability on many aspects of an older child’s life
and persistence.
Social Factors: Family Systems and Ecologic Model
THE CLASSIC THEORY PROPOSES 9 DIMENSIONS OF • Contemporary models of child development recognize
TEMPERAMENT the critical importance of influences outside of the
These characteristics lead to 3 common constellations: mother-child dyad.
• The easy child, highly adaptable child, who has regular biologic • Fathers play critical roles, both in their direct
relationships with their children and in supporting
cycles
mothers.
• The difficult child, who withdraws from new stimuli and is easily • Families function as systems, with internal and external
frustrated boundaries, subsystems, roles and rules for interaction.
• The slow to warm up child, who needs extra time to • In families with rigidity of defined parental subsystems,
adapt to new circumstances. children may be denied any decision-making,
• Temperament has long been described as biologic or “inherited”. exacerbating rebelliousness.
• Monzygotic twins are rated by their parents as temperamentally • In families with poorly defined parent-child boundaries,
children may be required to take on responsibilities
similar more often than are dizygotic twins.
beyond their years, or may be recruited to play a
• Estimated of heritability suggest that genetic differences account spousal role.
for approximately 20-60% of the variability of temperament • Family systems theory recognizes that individuals within
within a population. systems adopt implicit roles:
• Maternal prenatal stress and anxiety is associated with child o Troublemaker
temperament, possibly through stress hormones, o Negotiator
o Quiet
• Polymorphisms of specific genes moderate the influence of
o Birth order may have profound effects on
maternal stress on infant temperament (specifically irritability) personality development, through its
illustrating the interplay between genes and environment. influences on family roles and patterns of
• Longitudinal twin studies of adult personality indicate that interaction.
changes in personality over time largely result from non-shared o Families are dynamic.
environmental influences, whereas stability of temperament o The birth of a new child, attainment of
appears to result from genetic factors. developmental milestones such as
independent walking, the onset of nighttime
fears and the death of a grandparent are all
Psychologic Influences: Attachment and Contingency
changes that require renegotiation of roles
• Infants in hospitals and orphanages, devoid of within the family and have the potential for
opportunities for attachment, have severe healthy adaptation or dysfunction.
developmental deficits. o Bronfenbrenner’s ecologic model
Transcribed by: Idgee, Carl, Hana, Argie, Vence Edited by: Sarah Bee Page 2 of 22
ü Depicts these relationships as concentric DEVELOPMENTAL DOMAINS AND THEORIES OF

circles, with the parent-child dyad at the EMOTION AND COGNITION
center (with associated risks and
protective factors) and the larger society • Child development can also be tracked by the child’s
at the periphery. developmental progress in particular domains, such as
gross motor, fine motor, social, emotional, language
UNIFYING CONCEPTS: THE TRANSACTIONAL MODEL, and cognition.
RISK AND RESILIENCE • Developmental lines in gross motor domain:
v Transactional model o Rolling
o Proposes that a child’s status at any point in time is a o Creeping
function of the interaction between biologic and social o Independent walking
influences. o Several psychoanalytic theories are based on
o The influences are bidirectional: Biologic factors, such stages as qualitatively different epochs in the
as temperament and health status, both affect the child- development of emotion and cognition.
rearing environment and are affected by it.
o Children with biologic risk factors may do well
developmentally if the childrearing environment is
PSYCHOANALYTIC THEORIES
supportive.
o Premature infants with electroencephalographic • Freudian Theory
evidence of neurologic immaturity may be at increased o Is the idea of body-centered (or broadly,
risk for cognitive delay. This risk may only be realized “sexual”) drives; the emotional health of both
when the quality of parent-child interaction is poor. the child and the adult depends on adequate
o When parent-child interactions are optimal,
resolution of these conflicts.
prematurity carries a reduced risk of developmental
• Erickson recast Freud’s stages in terms of emerging
disability.
personality:
o The child’s sense of basic trust develops
through the successful negotiation of infantile
needs.
o It is predictable that a toddler will be
preoccupied with establishing a sense of
autonomy, whereas a late adolescent may be
more focused on establishing meaningful
relationships and an occupational identity.
COGNITIVE THEORIES
• A central tenet of Piaget’s work is that cognition changes
in quality, not just quantity.
o During the sensorimotor stage, an infant’s
thinking is tied to immediate sensations and a
Children at Risk: child’s ability to manipulate objects.
§ Children growing up in Poverty o The concept of ‘in’ is embodied in a child’s act
o Under nutrition
of putting a block into a cup.
o Lack of stimulation in the home
o With the arrival of language, the nature of
o Decreased access to interventional education and
therapeutics experiences thinking changes dramatically; symbols
o Withdrawal or acting out increasingly take the place of objects and
o Further discourage positive stimulation from those actions.
around them o Piaget described how children actively
§ Children of adolescent mothers construct knowledge for themselves through
o When early intervention programs provide timely,
the linked processes of assimilation (taking in
intensive, comprehensive and prolonged services, at-
risk children show marked and sustained upswings in new experiences according to exiting
their developmental trajectory. schemata) and accommodation (creating new
o The personal histories of children who overcome patterns of understanding to adapt to new
poverty often include at least 1 trusted adult (parent, information).
grandparent, teacher) with whom the child has a o Children’s understanding of cause and effect
special, supportive, close relationship.
may be considerably more advanced in the
context of sibling relationships than in the
manipulation and perception of inanimate o It is difficult to tell just how babies interpret the
objects. stimulus by simply recording whether they
o In many children, logical thinking appears well look at a stimulus.
before puberty, the age of postulation by
Piaget. PHYSICAL KNOWLEDGE DEVELOPMENT
• Piaget’s work is of special importance to pediatricians • From the time infants are very young they understand
for 3 reasons: some of the basic properties of physical objects.
1. Piaget’s observations provide insight into o In the first few months of life, they know that
many puzzling behaviors of infancy, such objects are 3-dimensional and extended in
as the common exacerbation of sleep space, that they can’t pass through other
problems at 9 and 18 months of age objects, and that they continue to exist when
2. Piaget’s observations often lend they move behind a screen. They also have a
themselves to quick replication in the basic concept of numbers, at least up to 3.
office, with little special equipment o Infants also have a surprisingly early
3. Open-ended questioning, based on understanding of relationships that cross
Piaget’s work, can provide insights into sensory modalities.
children’s understanding of illness and o They recognize parallelisms between lip
hospitalization. movements and vocal sounds, between the
feel of a pacifier and the way it looks, or
II. COGNITIVE DEVELOPMENT: DOMAINS AND between the visual image of a bouncing ball
THEORIES and the sound it makes.
Methodologies o Babies also have surprisingly early and
• Psychoanalysts sophisticated understanding of statistics and
o asked adults to remember their childhood probability.
• Behaviorists § Before they are 1 year old, they
o Extrapolated from experiments on animals expect that a ball taken at random
• Jean Piaget the founder of the field of cognitive from a box of 80 red and 20 white
development relied on observing the spontaneous balls is more likely to be red than
behavior of babies, or on clinical interviews in which he white.
asked children to say what they thought about mind o Infants can also recognize statistical patterns in
and body or life and death. both visual and auditory sequences.
o One group of methods involves seeing what o In their second year, babies have a basic
babies prefer to look at (visual preferences), or understanding of spatial relationships like
listen to, or even smell. gravity and containment.
o Other methods use the fact that babies pay § They can also categorize objects,
more attention to things that are unexpected recognizing that animals go together
that to those that are more predictable or and are different from artifacts.
familiar. o Preschoolers continue to learn about the
o Babies are habituated to a stimulus; they look physical world, but they also begin to learn
or listen until their attention wanders, and about the biologic world.
when they see a variant of that stimulus they § Preschoolers also have a first
focus attention to the new stimulus if it is understanding of basic biologic ideas
different. like inheritance, growth and illness;
• Violation-of-Expectation studies they are not animists as Piaget
o Experimenters present babies with events that though.
are surprising from an adult point of view § Preschoolers also have a much more
o sophisticated understanding of
o Example: causal relationships than we
§ One object apparently moving previously though.
through another, and see whether § Preschoolers also, against
babies look longer at those events conventional wisdom, can
than at similar unsurprising events. understand the difference between
• Looking-time technique the physical and the mental, reality
o Has a drawback and fantasy from a very young age.
§ Preschoolers may be intensely caregivers and then

emotionally affected by the products reunited
of fantasy, from imaginary friends to • Security- babies are
monsters in the closet. distressed at separation but
o Three and Four year olds are essentialists. are quickly comforted when
§ They assume that categories of the caregiver returns
animals or plants, such as birds or • Avoidant- babies seem to
daisies, will have the same insides repress their distress; they
and the same essence even if they are ignore the caregiver both
perceptually diverse. when she leaves and returns
o By 5 years of age, preschoolers have a more • Anxious- babies are very
unified concept of something like a life force. distressed and take a long
§ They believe that the presence of this time to comfort
st
force makes living things grow and o 1 year babies develop an even rich
thrive, and its absence leads to illness understanding of others.
and death. § One year olds don’t just imitate
§ They also start to understand the actions; they reproduce the results of
relationship between our beliefs and those actions.
the world around us. § One year old child are able to walk
nd
o Older children understand the mechanics of o 2 year old children also start to understand
simple physical systems. that their own perception, attention and
emotion may be shared by others.
SOCIAL KNOWLEDGE DEVELOPMENT § At this age they start to engage in
• Some of the most impressive kinds of early knowledge joint attention behaviors;
and learning involve children’s understanding of other • they will follow the gaze or
people. point of another person and
they will point to objects
Theory-of-mind themselves.
• Abilities are particularly important for social interaction § They also start to understand that
and appear to specifically impaired in children with closing your eyes or wearing a
autism. blindfold may make it more difficult
• From the time they are born, infants treat people as to see.
special. o Social referencing:
st
o 1 month: infants prefer to look at human faces § Babies will react appropriately to the
and listen to human voices, and rapidly prefer emotional expression of another
to look the face, voice and even smell of their person that is directed at an object; if
caregivers. 1 year olds see someone react to an
o Newborn infants also imitate facial ambiguous object with fear they will
expressions. To do this they must link what avoid the object themselves.
they see on the face of another person and o From 2-6 years of age, children discover
how it feels to be them inside. further fundamental facts about how their own
th
o 7 month old babies appreciate that human minds and the minds of others work.
actions are directed towards particular goals. o Between 3 and 5 years of age, children also
§ Seven month olds look longer when start to develop capacities for what
the hand goes to the teddy bear psychologists call executive control, which
instead if the ball. is the ability to control your own actions,
th
o 8 month old babies can imitate in an even thoughts and feelings.
more sophisticated way. o These capacities seem to be specifically
§ Also they start to show an related to Theory-of-mind abilities.
understanding of love.
• Attachment-babies behave THEORIES OF COGNITIVE DEVELOPMENT
differently when they are • On class approach, often called Nativism
separated from their
o Suggest that much of this abstract structure is • By preschool, what is

in place innately; babies are born knowing sometimes called implicit or
about crucial aspects of the world. intuitive pedagogy plays an
o Although babies are far from being blank increasingly important role
slates, there also seem to be significant in children’s learning.
changes in their understanding of the world. • Preschoolers tend to give
• The alternative approach, Empiricism grownup testimony that
o Suggest that all of children’s knowledge is benefit of the doubt, but
simply the result of a process of associating or they can also distinguish
combining particular sensory experiences, or between reliable and
detecting the statistics of the environment. unreliable teachers.
o Although children are able to associate • However, Preschoolers
particular experiences and to detect statistics, sensitivity to implicit
those abilities don’t seem to be sufficient to teaching can be a double-
explain their remarkable growth of knowledge. edge sword. Some studies
• Piaget originally articulated constructivism an show that children less
alternative to both nativism and empiricism. likely to engage in wide-
o The theory theory is the more current ranging exploration when
version of constructivism. adults provide them with
§ The idea is that children develop answers.
their knowledge of the world by • Preschoolers left to their
constructing every day or intuitive own resources are often
theories, much like scientific able to solve complex
theories. problems.
§ Unlike empiricism, proposes that • In addition because play is
even babies may be born with innate such an important
theory of the world, but unlike component of a preschool-
nativism, it proposes that those age child’s learning process,
theories may be radically the learning environment
transformed as children learn so may need to be less
much from the evidence they structured, more child-
encounter. focused, and with less
• Nativism, Empiricism and constructivism emphasis on traditional
o All focus on the process of learning from academic instruction.
evidence.
o Two other approaches describe other factors
that contribute to cognitive development. THE EMOTIONAL COMPONENT
§ Information-processing: • Malaguzzi believed that the concept of well-being leads
• Approaches stress the to educational approach.
development of genera • Creating an educational environment that recognizes
abilities to process and the child’s social-emotional well-being mean creating a
organize information, such place where every child is valued and respected as an
as memory or attention. individual and as an equal member of a group.
§ Sociocultural approach: • Malaguzzi believed that every moment should be
• Emphasizes the contribution enjoyable and satisfactory.
that expert adults can make
to children’s knowledge.
• There is growing evidence
that from very early in
infancy babes are THE ETHICAL COMPONENT
specifically and powerfully The following points characterize the Reggio Emilia ethical code:
tuned to information that • Education is not just a technique but is a shared process
comes to them from their for revealing values
caregivers.
• The school is a place that transmits and constructs

culture through experiences. The reciprocal relations
between transmission and construction gives schools
and teachers a responsibility and an active role in
THE IMAGE OF A CHILD
sustaining and generating a culture that is based on the
past yet looking ahead to the future • Loris Malaguzzi said “Each has inside ourselves an image
• The school, should focus not only on knowledge but of the child that directs you as you begin to relate a
child.
also on concepts, ideas and values
• The educator influences the future, and as such needs • Impact of the image to the awareness of the teachers, as
to generate the connections between the individual and only the awareness would enable the teacher to follow
the world. the desired image of children; one that sees and
accepts the child as an active competent partner,
• Children are born with myriad ways to construct and
plentiful with potential and capabilities.
process knowledge.
• Usually the strength and the talents of children are
underestimated and schools tend to suppress the
THE AESTHETIC COMPONENT child’s potential by creating an environment of
• Education must focus on the aesthetics because the transmission, instead of exploration.
child knows how to value beauty and is able to interact • The concept of a “blank slate” first mentioned by the
with all the expressive languages. philosopher John Locke, is presented here as a
• Malaguzzi’s innovative idea for approaching and characterizing traditional point of view in education that
embracing the expressive-aesthetic aspects to early does not believe in the child’s abilities and leaves no
childhood education was the atelier room for the child’s feelings, thoughts, imagination, and
o The atelier is a statement about the creativity.
importance of imagination, creativity, o It also reflects that the child is waiting for the
expression and aesthetics in the learning and school and society to “ write” on, nourish, and
knowledge construction processes. fill his or her slate.
PEDAGOGIC THINKING: CORE CONCEPTS AROUND 3 THE IMAGE OF THE EDUCATOR

MAJOR AREAS The role of the teacher in the above image encompasses the
following aspects:
• To define and create the context within which all
learning/ teaching processes would occur. The context
enables the landscape of learning to emerge and
develop
• To think and plan using symbols and concepts
• To interpret the child concepts and symbols with the
group
• To elaborate on the experiences and the interpretations
done with the children
• To review with the children a second round of
One of the cornerstones of this approach is the concept of experiences built on the previous day
images. • To add improvisations according to the previous
• All of the perceptions and interpretations are organized learning processes.
into clusters that serve as our inner compass and
navigate our way in the personal and social-cultural life There are reciprocal relationships between the image of the child
that we share with others. and the image of the teacher and each is complementary and
• When it comes to education, the images play a crucial bound to the other.
and determinative role as is reflected in the following
quote from Carla Rinaldi: “Everyone (you, us, each,
THE IMAGE OF THE CONTEXTUAL COMMUNITY
parent..) has his or her own image of the child and
consequently, we have our own educational theories • The concept at the core of the educational communal
that we develop based on personal, social, cultural and life is the idea of the other that is the essence of the
political experience and that we construct or acquire as Reggio Emilia pedagogic approach.
part of our society and culture.
• The “other” might be the child, the family or a • By 10 weeks, the face is recognizably human. The
colleague- in a sense, any person who is interacting with midgut return to abdomen from the umbilical cord,
the educational system. rotating counterclockwise to bring the stomach, small
• All members together, through the relations that are intestine and large intestine into their normal positions.
constructed among all, are part of creating a sense of • By 12 weeks, the gender of the external genitals become
belonging for the system and for its members. clearly distinguishable. Lung development proceeds,
• The feeling of belonging serves as a foundation for the with the budding of bronchi, bronchioles, and
community life. successively smaller dividions.
• When people who are part of the system feel they are • By 20-24 weeks, primitive alveoli have formed and
seen, heard and known, a culture of participation can surfactant production has begun; before that time, the
be developed. absence of alveoli renders the lungs useless as organs of
• The idea of crossing the boundaries of the subjectivity gas exchange.
rd
to arrive at the intersubjective landscape emerges from • During the 3 trimester, weight triples and length
a very important declaration that the school send to the doubles as body stores of protein, fat, iron, and calcium
community. increase.
• Concepts like welcoming, plurality, dialog and
intercultural dynamics are explored and new meanings NEUROLOGIC DEVELOPMWNT
rd
are attributed to them, as a realization that every • During the 3 week, a neural plate appears on the
word/concept or value could have different meanings. ectodermal surface of the trilaminar embryo.
• Neuroectodermal cells differentiate into neurons,
III. ASSESSMENT OF FETAL GROWTH AND astrocytes, oligodendrocytes, and ependymal cells,
DEVELOPMENT whereas microglial cells are derived from mesoderm.
th
SOMATIC DEVELOPMENT • By the 5 week, the 3 main subdivisions of forebrain,
midbrain and hindbrain are evident.
Embryonic Period • The dorsal and ventral horns of the spinal cord have
• By 6 days post conception age, the embryo consists of a begun to form, along with peripheral motor and sensory
spherical mass of cells with a central cavity (the nerves. Myelinization begins at midgestation and
blastocyst) continues for years.
• By 2 wks, implantation is complete and the • By the end of the embryonic period (8 weeks), the gross
uteroplacental circulation has begun; the embryo has 2 structure of the nervous system has been established.
distinct layers, endoderm and ectoderm, and the • On a cellular level, neurons migrate outward to form
amnion has begun to form. the 6 cortical layers.
rd • Migration is complete by the 6 months, but
• By 3wk, the 3 primary germ layer (mesoderm) has
appeared, along with a primitive neural tube and blood differentiation continues.
vessels. Paired tubes have begun to pump.
• During week 4-8, lateral folding of the embryologic BEHAVIORAL DEVELOPMENT
plate, followed by growth at the cranial and caudal ends • No behavioral evidence of neural function is detectable
rd
and the budding of arms and legs, produces a human- until the 3 months.
like shape. Precursors of skeletal muscles and vertebrae • Reflexive responses to tactile stimulation develop in a
(somites) appear, along with the brachial arches that will craniocaudal sequence. By week 13-14, breathing and
form the mandible, maxilla, palate, external ear and swallowing motion appear.
other head and neck structures. • The grasp reflex appears at 17 weeks and is well
• Lens placodes appear, marking the site of future eyes; developed by 27 weeks.
brain grows rapidly. • Eye opening occurs around 26-28 week. By
• By the end of wk 8, as the embryonic period closes, the midgestation, the full range of neonatal movements can
rudiments of all major organ systems have developed; be observed.
rd
the crown-rump length is 3 cm. • During the 3 trimester, fetuses respond to external
stimuli with heart rate elevation and body movements.
Fetal Period • As with infants in the postnatal period, reactivity to
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• From the 9 week on (fetal period), somatic changes auditory (vibroacoustic) and visual (bright light) stimuli
consist of rapid body growth as well as differentiation of vary, depending on their behavioral state, which can be
tissues, organs and organ systems depicts changes in characterized as quiet sleep, active sleep or awake.
body proportion. • Fetal behavior is affected by maternal medications and
diet, increasing after ingestion of caffeine.
• Behavior may be entrained to the mother’s diural

rhythms: asleep during the day active at night.
• Fetal movement increases in response to a sudden
auditory tone, but decreases after several repetitions.
PSYCHOLOGIC CHANGES IN PARENTS

• Many psychologic changes occur during pregnancy. An
unplanned pregnancy may be met with anger, denial or
depression.
• Ambivalent feelings are the norm, whether or not the
pregnancy was planned.
• Elation at the thought of producing a baby and the wish
to be the perfect parent compete with fears of
inadequacy and of the lifestyle changes that mothering
will impose.
IV. THE NEWBORN 2. Peripartum and Postpartum Influences

– Regardless of gestational age, the new born (neonatal) – The continuous presence during labor of a woman trained
period begins at birth and includes the first month of life. to offer friendly support and encouragement (a doula)
– Marked physiologic transitions occur in all organ systems results in shorter labor, fewer obstetric complications
– Infants thrive physically and psychologically including (including cesarean section), and reduced postpartum
parent’s roll as well. hospital stays. Early skin-to-skin contact between mothers
and infants immediately after birth may correlate with an
A. Parental Role in Mother- Infant Attachment increased rate and longer duration of breastfeeding.
– Parenting a newborn infant requires dedication because a – Postpartum depression may occur in the 1st wk or up to 6
newborn’s needs are urgent, continuous, and often unclear. mo after delivery and can adversely affect neonatal growth
Parents must attend to an infant’s signals and respond and development. Screening methods are available for use
empathically. Many factors influence parents’ ability to during neonatal and infant visits to the pediatric provider.
assume this role. Referral for care will greatly accelerate recovery.
1. Prenatal Factors
– Pregnancy is a period of psychological preparation for the B. Parental Role in Mother- Infant Attachment
profound demands of parenting. – The in utero environment contributes greatly but not
– For adolescent mothers, the demand that they relinquish completely to the future growth and development of
their own developmental agenda, such as an active social the fetus. These abnormal growth patterns not only
life, may be especially burdensome. predispose infants to an increased requirement for
– Bonding may be adversely affected by several risk factors medical intervention, but also may affect their ability to
during pregnancy and in the postpartum period that respond behaviorally to their parents.
undermine the mother– child relationship and may
threaten the infant’s cognitive and emotional development. 1. Physical examination
– Social support during pregnancy, particularly support from – Examination of the newborn should include an evaluation
the father and close family members, is also important. of growth and an observation of behavior. The average term
newborn weighs approximately 3.4 kg (7.5 lb); boys are
slightly heavier than girls. Average weight does vary by
ethnicity and socioeconomic status. The average length and
head circumference are about 50 cm (20 in) and 35 cm (14
in).
2. Interactional Abilities
– Neonates are nearsighted, having a fixed focal length of 8-12
inches, approximately the distance from the breast to the
mother’s face, as well as an inborn visual preference for
faces. The initial period of social interaction, usually lasting
about 40 minutes, is followed by a period of somnolence.
3. Modulation of Arousal A. 0-2 Months

– Adaptation to extrauterine life requires rapid and profound – In the full-term infant, myelination is present by the time of
physiologic changes, including aeration of the lungs, birth in the dorsal brainstem, cerebellar peduncles, and
rerouting of the circulation, and activation of the intestinal posterior limb of the internal capsule. The cerebellar white
tract. matter acquires myelin by 1 mo of age and is well
– Underaroused infants are not able to feed and interact; myelinated by 3 mo of age.
overaroused infants show signs of autonomic instability, – A newborn’s weight may initially decrease 10% below
including flushing or mottling, perioral pallor, hiccupping, birthweight in the 1st wk as a result of excretion of excess
vomiting, uncontrolled limb movements, and inconsolable extravascular fluid and limited nutritional intake. Nutrition
crying. improves as colostrum is replaced by higher-fat breast milk.
– Infants regain or exceed birthweight by 2 wk of age and
should grow at approximately 30 g (1 oz)/per day during the
1st mo.
– This is the period of fastest postnatal growth.
– Infants can differentiate among patterns, colors, and
consonants. They can recognize facial expressions (smiles)
4. Behavioral States as similar, even when they appear on different faces.
– Six states have been described: – Rhythmic patterns in native language
• Quiet
• Sleep – Crying occurs in response to stimuli that may be obvious (a
• Active Sleep soiled diaper), but are often obscure.
• Drowsy – Infants who are consistently picked up and held in
• Alert response to distress cry less at 1 yr and show less-aggressive
• Fussy behavior at 2 yr.
• Crying
– Alert state, infants visually fixate on objects or faces and
follow them horizontally and (within a month) vertically. A. 2-6 Months
– Active sleep, an infant may show progressively less – Crying occurs in response to stimuli that may be obvious (a
reaction to a repeated heel stick (habituation). soiled diaper), but are often obscure.
– Drowsy state, the same stimulus may push a child into – At about age 2 mo, the emergence of voluntary (social)
fussing or crying. smiles and increasing eye contact mark a change in the
parent–child relationship, heightening the parents’ sense of
C. Implication for Pediatrician being loved reciprocally.
– Pediatric visit allows pediatricians to assess potential – During the next months, an infant’s range of motor and
threats. social control and cognitive engagement increases
– Baby friendly hospitalhave shown great increase dramatically.
breastfeeding rates. – Mutual regulation takes the form of complex social
– Assess parent-infant interaction interchanges, resulting in strong mutual attachment and
– Teach about individual competencies in taking care of an enjoyment. Routines are established.
infant – Parents are less fatigued.
– rate of growth slows to approximately 20 g/day
– Increasing control of truncal flexion makes intentional
V. The First Year rolling possible.
– At 4 mo of age, infants are described as “hatching” socially,
– Neural plasticity, the ability of the brain to be shaped by
becoming interested in a wider world.
experience, both positive and negative, is at its peak.
– 1st stage of personality development
– Total brain volume doubles in the 1st yr of life and increases
– When face-to-face, the infant and a trusted adult can match
by an additional 15% over the 2nd yr. Total brain volume at
affective expressions (smiling or surprise) approximately
age 1 mo is approximately 36% of adult volume but by age 1
30% of the time
yr is approximately 72% (83% by 2 yr). The acquisition of
– Infants who do not show this reciprocal language and
seemingly “simple” skills, such as swallowing, reflect a series
movements are at risk for autism spectrum disorders
of intricate and highly coordinated processes involving
– Giving vaccines and drawing blood while the child is seated
multiple levels of neural control
on the parent’s lap.
– Myelination of the cortex begins at 7-8 mo gestation and
continues into adolescence and young adulthood. It
proceeds in a posterior to anterior fashion, allowing
progressive maturation of sensory, motor, and finally A. 6-12 Months
associative pathways. – With achievement of the sitting position, increased
mobility, and newskills to explore the world around them
– New tensions around the themes of attachment and
separation.
– Growth slows more by the 1st birthday, birth weight has – Height and weight increase at a steady rate during this year,
tripled, length has increased by 50%, and head with a gain of 5 in and 5 lb.
circumference has increased by 10 cm. – Head growth slows slightly. Eighty-five percent of adult
– These explorations are aided by the emergence of a head circumference is achieved by age 2 yr, with just an
thumb–finger grasp (8-9 mo) and a neat pincer grasp by 12 additional 5 cm gain over the next few years
mo. – Object permanence is firmly established
– Voluntary release emerges at 9 mo. – Cause and effect are better understood, and toddlers
– Some walk by 1 yr. demonstrate flexibility in problem solving
– Tooth eruption occurs, usually starting with the mandibular – Symbolic transformations in play are no longer tied to the
central incisors toddler’s own body, so that a doll can be “fed” from an
– 6 mo old infant has discovered his hands and will soon empty plate.
learn to manipulate objects – preceding half-year often gives way to increased clinginess
– A major milestone is the achievement by 9 mo of object around 18 mo. This stage, described as “rapprochement,”
permanence (constancy), the understanding that may be a reaction to growing awareness of the possibility of
objects continue to exist, even when not seen. separation.
– Infants look back and forth between an approaching – Separation anxiety will be manifest at bedtime special
stranger and a parent, and may cling or cry anxiously, blanket or stuffed toy as a transitional object, which
demonstrating stranger anxiety. functions as a symbol of the absent parent.
– child’s use of “no” is a way of declaring independence.
– Labeling of objects coincides with the advent of symbolic
– Tantrums make their first appearance as the drives for thought. child’s vocabulary balloons from 10-15 words at 18
autonomy and mastery come in conflict with parental mo to between 50 and 100 at 2 yr.
controls and the infants’ still-limited abilities. – toddlers understand 2-step commands, such as “Give
– 7 mo of age are adept at nonverbal communication me the ball and then get your shoes.”
– 9 mo of age, infants become aware that emotions can be – increasing mobility, physical limits on their explorations
shared between people become less effective
– Between 8 and 10 mo of age, babbling takes on a new
complexity, with multisyllabic sounds (“ba-da-ma”)
– Introduction of a transitional object may allow the
infant to self-comfort in the parents’ absence.
VI. The Second Year

– The toddler’s newly found ability to walk allows separation
and independence
– However the toddler continues to need secure attachment
to the parents
– At approximately 18 mo of age, the emergence of symbolic
thought and language causes a reorganization of behavior,
with implications across many developmental domains.
A. 12-18 Months
– Increase in head circumference 2 cm over the year
– Toddlers have relatively short legs and long torsos, with
exaggerated lumbar lordosis and protruding abdomens.
– Infants initially toddle with a wide-based gait, with the
knees bent and the arms flexed at the elbow
– Make-believe (symbolic) play centers on the child’s own
body (pretending to drink from an empty cup)
– Toddlers are described as “intoxicated” or “giddy” with their
new ability and with the power to control the distance
between themselves and their parents
– Infants speak their first words around 12 mo of age
– Toddlers also enjoy polysyllabic jargoning
A. 18-24 Months
– Improvements in balance and agility and the emergence of
running and stair climbing
• Decrease in cortical thickness

• Changes in cortical volume
• Changes in gray and white matter tissue properties
• Increase in brain metabolic demands
-SCAFFOLDING
• Greater number of brain regions are required to
complete a task among younger children compared to
older ones.
B. Physical Development
nd
-End of 2 year of life:
• Somatic and brain growth slows with corresponding
decrease in nutritional requirements and appetite
• “Picky” eating habits
• Increase of approx. 2kg (4-5 lb) in weight and 7-8 cm (2-
3c inches) in height
-4x the birth weight by 2.5 years
-at 3 yrs of age, all 20 primary teeth have erupted
rd
-has a mature gait and runs steadily before end of 3 year
-4 year old (Average) is 40 lb in weight and 40 inches tall
- Head grows an additional 5-6 cm between 3-18 yrs old.
-Children with early increase in BMI are at increased risk for Adult
obesity
-has Genu Valgum ( knock-knees) and mild pes planus (flat foot)
-Physical energy peaks, declined need for sleep 11-13 hrs/day,
child eventually dropping the nap [SANA ALL!!! ;( ]
-Visual acuity 20/30 by age 3; 20/20 at age 4
-there is wide variation in ability
• throwing, catching and kicking balls; riding on bicycles;
climbing on playground structures, dancing and other
complex pattern behaviors
-toe walking is unlikely
-social environment plays a part on their cognitive and emotional
development
-parents or teachers who encourages physical activity=energetic
and coordinated child
-adults who value quiet play=child with lower energy
-HANDEDNESS (individual preference for use of hand) is
rd
established by 3 year
-Bowel and bladder control:
• (+)readiness for toileting.
• Girls tend to train faster than boys.
• Bed-wetting is normal up to age 4 year in girls and 5 year
in boys
• Refusal to defecate in the toilet or potty is common,
may lead to constipation and parental frustration.
Implications for parents and paediatricians

- Normal decrease in appetite at this age may cause parental
VII. The Preschool Years concern about nutrition.
• Growth charts should reassure parents that child’s
intake is adequate
A. Structural Development of the brain
• Complete multivitamin can be used to assure adequate
- The preschool brain experiences dramatic changes in its vitamin and mineral intake.
anatomical and physiologic characteristics, characterized by • Predictable eating schedule should be provided, with 3
growth and expansion: meals and 2 snacks per day, allowing the child to
• Increase in cortical area choose how much to eat
• Counselling about safety precautions • Common difficulties:

§ Risk for injury is increased at this age. § Pauses and repetitions of initial sounds made
worse by stress or excitement.
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C. Language, Cognition and Play § resolve in 80% of children by 8 year.
• Children with this condition should be referred for
1.Language evaluation if it is severe, persistent or associated with
anxiety, or if parental concern is elicited.
-Language development occurs most rapidly between 2 and 5
• Treatment
years of age. § Parental guidance to reduce pressure
• Vocabulary increases from 50-100 words to more than associated with speaking
2000.
• Sentence advances from telegraphic phrases (baby cry) 3.Cognition
to structured sentences. -Piaget’s Pre Operational (Pre-logical) Stage
• Number of words in a sentence=Child’s age • characterized by magical thinking, egocentrism and
• 21-24 months thinking dominated by perception, not abstraction.
§ Use of possessives (ex: “My Ball”), progressives
• Magical thinking
(-ing construction, as in “I playing”), questions § confusing coincidence with causality, animism
and negatives. and unrealistic beliefs about the power of
• 4 yrs wishes.
§ Count to 4 and use the past tense • Egocentrism
• 5 yrs § child’s inability to take another’s point of view,
§ use of future tense does not connote selfishness.
§ Do not use figurative speech, takes words
• Imitation
literally (ex: light as a feather) § goes beyond the mere repetition of observed
movements
2. Speech vs. Language
§ Ex. A child who watches an adult
unsuccessfully unscrew a lid will imitate the
-Speech is the production of intelligible sounds action but with the failed outcome
-Language refers to underlying mental act and includes both • Self-identification of Sex by age 3
expressive and receptive functions.
4.Play
-Receptive language (understanding) varies less in its rate of
acquisition than does expressive language, making it of greater -involves learning, physical activity, socialization with peers and
prognostic importance. practicing adult roles.
-Key determinants: -increases in complexity and imagination
• Amount and variety of speech directed towards • from simple imitation (2or 3 yrs)
children • more extended scenarios (3 or 4 yrs)
• Frequency of asking questions and encouragement of • creation of scenarios that have only been imagined (4 or
verbalizations 5 yrs).
• Economic status -Cooperative Play at age 3, and later on, a more structured
§ children raised in poverty has a lower role-play activity (as in playing house)
performance than those in economically -becomes increasingly governed by rule
advantaged families. • asking and taking (2 yrs)
-Language delays may be the first indication of an intellectual • according to desires of players (4 qnd 5 yrs)
disability, autism or is being maltreated. • beginning of the recognition of rules as relatively
-Language allows children to express feelings without acting immutable (5 yrs)
them out; Higher rate of tantrums are shown in language delayed -Electronic forms of play may be beneficial if it is interactive and
children educational.
-Preschool language development determines later success in -allows resolution of conflicts and anxieties and may serve as
school. creative outlets.
-Picture books are important for development of verbal language
5.Implications for parents and Paediatricians:
-Constantly reading to them improves vocabulary and receptive
language
-Parents can support emotional development by using words
-Dialogic Reading
that describe how the child is feeling
• ideal for child learning.
• done by repeatedly focusing the child on a particular • “You sound angry right now.”
picture, asking questions and feedback from the child. • urge the child to use words to express, rather than
-Period of Rapid Language Acquisition acting it out.
-Regular time for reading with their children
• when developmental dysfluency and stuttering
most likely to emerge. • promote language development
-Parental Guidance in watching quality television programs -Sense of control over his/her body and the surroundings is
• limit it to 2 hrs/day important for a pre-schooler.
-Children should be given simple and concrete explanation -Prepare the patient of what will happen will provide
regarding illness and treatment procedures. reassurance.
-Parents should: -Don’t ask permission if you won’t take no as an answer.
• acknowledge the fear -Only give options approved by the parents
• offer reassurance -encourage independence on self-care activities to avoid
• give a sense of security and control over the situation
conflicts.
-A brief introduction about private parts is important before any
D. Emotional and Moral Development genital examination
-Use of corporal punishment for disciplining the children is not
-Emotional challenges include: an effective behavioural control.
• accepting limits while maintaining a sense of direction
• As spanking is done habitually, children get used to it
• reining in aggressive and sexual impulse and parents need to spank even harder to get the
• interacting with a widening circle of adults. desired response, which might cause serious injury.
-Learning of acceptable behaviors and how much power they • In the later years, they are the ones demonstrating
have over important adults by testing limits . aggressive behaviors.
• Excessively tight limits undermine a child’s sense of -DISCIPLINE
initiative • process that allows the child to internalize controls on
• overly loose ones can provoke anxiety in a child feeling behaviour.
no one is in control. • It is characterized by consistent limit setting, clear
• Control communication of rules and frequent approval
§ central issue due to their lack of control in • should be Immediate, Specific to the behaviour and
many aspects of their lives( where to go or how time-limited.
long they will stay) • Time-Out, 1 min/ year of age , is found to be very
-Temper tantrums effective
• pre-schoolers tend to loose internal control
§ which may be caused by fear, overtiredness, VIII. The Middle Childhood
inconsistent expectations or physical
– Middle childhood (6-11 yrs of age) increasingly separate
discomfort
st from parents and seek acceptance from teachers, other
• normally appears toward the end of 1 year of life
adults and peers (Peer pressure)
• peaks bet 2 and 4 years of age
– They are now judged according to their ability to
• More than 15 mins or regularly occurring more than
produce socially valuable outputs
3x/day means an underlying medical, emotional or
• Ex. Getting good grades
social problems.
-Complicated feelings toward their parents starts to develop
which leads to fear of abandonment. A.Physical Development
-Play and language foster the development of emotional control
-Growth occurs discontinuously
by allowing them to express emotions
• 3-6 irregularly timed spurts each year
-Curiosity about genitals and adult sexual organs are normal,
• varies among individuals
even masturbation. -Average growth
• Excessive masturbation, mimicry of adult seductive • 3-3.5 kg(6.6-7.7 lbs)
behaviour and the like-suggest of sexual abuse or • 6-7cm (2.4-2.8 inches) per year
inappropriate exposure. -Head grows only 2cm in circumference the entire period,
• Parents should begin teaching them about private body reflecting a slowing of brain growth.
parts before school age -Myelinization
-At age 2 • continues in adolescence
• child’s sense of right and wrong • peak gray matter at 12-14 yrs.
§ desire to earn approval from parents and avoid -Body habitus more erect, long legs compared with the torso
negative consequences. -Growth of midface and lower face occurs gradually
• Empathic responses to other’s distress -Teeth:
-Fairness is important at this age, regardless of circumstances • Loss of deciduous teeth, beginning around 6 yr of age
• Ex. A 4 yr old child will acknowledge taking turns but • Replacement of adult teeth, 4/year
will complain if he/she didn’t got enough time • By 9 years, children will have 8 permanent incisors and
4 permanent molars.
Implications for parents and Paediatricians: • Premolars erupt by 11-12 years of age
-Lymphoid tissue hypertrophy, Gives rise to impressive tonsils
and adenoids.
-Muscular strength, coordination and strength and ability to do • Causes for school age concepts, academic and behavior
complex task increases progressively problems:
-Physical fitness declined among school-age children due to • deficits in perception
sedentary habits • Specific learning disabilities
-Body image perception develop early during this period. • Global cognitive delay(mental retardation)
• as young as 5-6 yrs, many already express dissatisfaction • primary attention deficit
with their body image • attention deficit secondary to family dysfunction,
• Some are reported to use ill-advised regimens for diet depression, anxiety or chronic illness
purposes, by age 8-9 yrs. -Identify child's strengths
-Interests in gender differences and sexual behavior increases -discipline strategies
progressively until puberty • involve negotiating and a clear understanding of
• due to increased gonadotropin release. consequences.
-Masturbation is common.
B. Social and Emotional Development
Implications for parents and Paediatricians:
-At this period, energy is directed toward creativity and
productivity
-Fears of being abnormal leading to avoidance of situations in -3 spheres where changes occur:
which physical differences might be revealed. • Home still remains the most influential.
• Ex.. Gym class or medical examinations § Parents should make demands for effort in
-Counselling on establishing healthy eating habits and limited school and extra-curricular activities, celebrate
screen time should be given to all families successes and offer unconditional acceptance
-Pre-pubertal children should avoid in engaging to high stress, when failures occur.
high impact sports § Siblings play a critical role as competitors, loyal
• skeletal immaturity increases the risk of injury. supporters and role models.
• Beginning of School increases importance of teacher
B.Cognitive Development and peer relationship.
-Concrete logical operations § Social groups contribute to a child's growing
• apply rules based on observable phenomena, factor in social development and competence.
multiple dimensions and point of view, and interpret § Popularity , being the central ingredient of
their perceptions using physical laws. self-esteem, maybe won through possessions,
• Interactional relational model personal attractiveness, accomplishments and
§ focuses on the child, the environment and the actual social skills.
interactions therein. § Attributions conferred by peers may become
§ recognizes the importance of early incorporated into a child's self-image and
experiences for later development. affect the child's personality and even their
§ Rather than delaying school entry, High quality school performance.
early education programs maybe the key to • Neighbourhood
ultimate school success. § Real dangers tax school-age child's common
-School makes increasing cognitive demands on the child. The sense and resourcefulness.
volume of work increases along with the complexity. § Media exposure to adult materialism,
sexuality, substance and violence may frighten
Implications for parents and Paediatricians: and make the child feel powerless in the larger
-The role of the paediatrician world.
• promote health through immunizations, adequate
nutrition, appropriate recreation and screening for
physical, developmental and cognitive disorders. C. Moral Development
Notes:
-American Academy of Pediatrics recommends the 5R's of early -by the age of 6,
education: • Conscience is starting to develop
• They believe that rules are established and enforced by
R-eading as a daily family activity
R-hyming, Playing, and cuddling together an authority figure (parent or teacher) and decision-
R-outines and regular times for meals, play and sleep making is guided by self-interest.
R-eward through praise for successes • Need of others are not strongly considered in decision
R-eciprocal nurturing relationships making.
• Social behaviors socially undesirable are considered
wrong
-Concrete operations allow children to understand simple -By age 10-11 yr,
explanations for illnesses and necessary treatments, although • combination of peer pressure, desire to please authority
they may revert to pre-logical thinking under stress. figures and understanding of reciprocity shapes their
-Find the problem areas: behavior.
Implications for parents and Paediatricians: § Females: appearance of breast buds(thelarche)

between ages 8-12 yr.
-Children is in need of unconditional support and realistic • Discharges
demands as they journey into the world. Exerting excessive § Males: Sperm may be found in the urine By
pressure on them to achieve success and not meeting it in the SMR
end may cause conflicts § Females: Physiologic leukorrhea (clear vaginal
-Home should be a secure base for refueling emotional energies discharge) maybe present prior to menarche
and not otherwise. § Menses begins 2.5 years after onset of puberty
-Bullying between SMR 3-4.
• indicates a need for evaluation o (Average age 12.5; normal range 9-15
• associated with mood disorders, family problems and yr)
school adjustment problems. C. Somatic Growth
• Parents should ensure exposure to hazards is reduced -Peak height velocity
-Pediatrician visits are infrequent so once they do, he/she must • Males
be able to assess children's function in all the 3 spheres: home, § 9-10cm/yr at a later SMR stage(3-4) and
School and the neighborhood. continue their linear growth for approx 2-3 yrs
-Television and internet exposure should be limited to 2hrs/day, after females have stopped growing
monitor what they watch. • Females
-Some useful tools in assessing a child's functioning: § 8-9cm/yr at SMR 2-3,approx 6 months before
• Draw-a-person (for ages 3-10 to draw a complete menarche
person) -Body Mass
• Kinetic family drawing (beginning at 5yr, to draw a • Males
picture of the family member doing something) § Increase in lean body mass (strength spurt)
• Females
§ development of higher proportion of body fat
IX. The Adolescent -Bone growth precedes increase in bone mineralization and
bone density
- undergo not only dramatic changes in physical appearance, but
• there is increased risk of fracture
also hormonally-driven physiologic changes and ongoing
neurologic development in the setting of social structures.
-3 phases: D. Cardiovascular changes
1. Early 10-13 yrs
2. Middle 14-17 -Increased heart size
3. Late 18-21 -Higher BP
A.Physical Development -increase in blood volume and haematocrit (particularly males)
-Increased lung vital capacity—-> greater aerobic capacity
-Puberty
• biologic transition from childhood to adulthood
E. Other changes
• Changes include:
§ appearance of the secondary sexual
-stimulation of sebaceous and apocrine glands
characteristics
§ Increase in height • may result to acne and body odor
§ change in body composition -Change in voice quality preceded by vocal instability(voice
§ Development of reproductive capacity cracking), in males
-As early as 6 yrs, • due to enlargement of larynx, pharynx and lungs
• Androgen , chiefly Dehydroepiandrosterone -Myopia due to the elongation of the optic globe
-Dental changes
sulfate (DHEAS ), may be produced
• maturation of Gonadotropin Releasing • Jaw growth
hormone(GRH). • loss of final deciduous teeth
§ stimulates the Pituitary gland to secrete LH and • eruption of the permanent cuspids, premolars and
FSH which increases gonadal androgens and molars
estrogens. -sleep pattern
-High concentration of the hormone Leptin • physiological changes
• associated with increased body fat and earliest onset of • increase in sleep requirement
puberty
F. Neurologic, Cognitive and moral development
B. Sexual Development
– Tanner Stages , or Sexual Maturity Rating (SMR) -adolescents develop and refine their ability to use formal
• First visible sign of puberty and hallmark of SMR 2: operational thought processes
§ Males: testicular enlargement, which begins as -Middle and late adolescents have now the ability to consider
early as 9.5 yr options and its long term consequences
-Enhanced capacity for verbal expression
-Neuromaturation continues into the 3rd decade. It is -Adolescents may take religious or political views, influential and
characterized by: appealing.
• decrease in gray matter(selective pruning of rarely used
synaptic connections) H. Psychosocial Development
• increase in white matter(increasing myelinization,
subsequent facilitation of integrated brain activity) -subjected to environmental and cultural influences
• increase in the efficiency of communication and
connectivity between diff brain regions. 1. Identity Formation
• Starts with the posterior cortex, progresses anteriorly
-moving away from nurturing protection of the family
-The immaturity of the pre frontal cortex which is
-increased affiliation with peer group
responsible for executive functions and early maturation of the
-defines himself/herself as an INDIVIDUAL.
amygdala and other limbic structures , involved in the
-Hallmark: Separation from parents
experience of fear and emotion, explains why they are more
-Early adolescence
likely to make poor decisions in highly emotionally charged
• independence from parents
situations in comparison with mature adults.
• may seek out alternative adult role models
-Middle Adolescence
-2 types of cognitive process:
• peak of Parental-child conflict
• Hot cognition
• Intermittence in seeking and rejecting parental advice
§ associated with strong affective experience
• accordingly, the adolescents need to conceive of the
• Cold cognition
parents as "wrong" to ameliorate the pain of separation.
§ less emotional state
-Late adolescence
-Early adolescence is characterized by:
• More adult-adult type of relationship with parents
• Egocentricity
• considers parental advice again upon entering
§ Believing that they are the center of everyone's
Adulthood
attention
§ Can be stressful, they may feel that others are 2. Increasing importance of peer group
constantly judging or evaluating them.
• a greater need for privacy
-Early adolescence
-Middle adolescence • same sex peer, both in individual friends or larger
• Recognizes the needs and feelings of other people groups
• enhanced creativity and intellectual abilities • group cohesion and sense of belonging becomes
• Risk takers important
§ feel the sense of immunity to the -Middle Adolescence
consequences of risky behaviors • increased importance of peers
-Late adolescence • may include both gender, both from organized
activities or friendships.
• more future-oriented • Gang membership is another form of peer acceptance.
• able to delay gratification -Late adolescence
• thinks more independently • Less vulnerability to peer group influence
• considers other's view and compromises • establishes their own stable identity
• Has a stronger sense of self
3. Sexual Awareness and Interest
• more stable interests
• (+) stress may cause them to go back to the cognitive
process and coping strategies at their younger age -Early adolescence
• Increased, may manifest as sexual talk and gossip,
G. Moral Development focused on sexual anatomy.
• Masturbation and other sexual exploration, sometimes
with same sex peers are common.
-Pre adolescence
• Romantic relationships lack emotional depth
• follow rules in order to please authority figures, avoids
-Middle Adolescence
punishments
• Sexual curiosity experimentation and activity become
-Early Adolescence
more common.
• stronger sense of right and wrong
• Sexual attraction over emotional intimacy
-Middle and Late Adolescence
-Late adolescence
• driven by desire to be seen as a good person
• relationships increasingly involve love and commitment
• based on perceived place in society and obligation to
and demonstrates greater stability
care for others.
• Late adolescents may develop a rational conscience 4. Body Image
and an independent system of values(usually goes with
parental values)
-Early and middle Adolescence
• distorted or poor body image
• eating disorders may arise they should be addressed by the parents and health care
• Early adolescent undergo rapid physical changes
§ Importance of reassuring them that what
they're going through is normal
• Middle adolescent experiences slow changes
§ Concern: whether they're attractive or not
-Late adolescent is characterized by:
• A shifting balance toward introspection, with less
emphasis on external characteristics.
5. Timing of Pubertal Change
-Males perceive progression of pubertal change as positive but

negatively for females.
-Early maturing females
• decrease in self esteem
• engage in more disruptive behavior
• more conflict with their parents than on-time or late
maturing ones.
-Early maturing males
• possess greater self confidence
• social and academic success
• late-maturing males are at risk for more internalizing
behaviors and diminished self esteem
•
Implication for Providers and parents
- reassure adolescents that some of the challenges are normal
developmental milestones and should be anticipated and
accepted.
-Early maturing females and late-maturing males should be
supported for they are at risk for psychosocial challenges
-Promotion of positive coping strategies to all youths
-Physical examination should be performed in private (with
parents outside the room to allow discussion of confidential
issues)
-Remind parents that adolescents are typically more
independent and an increase in parent-child conflict, doesn't
necessarily mean parent's inputs and perspectives are not valued.
-Parents should be encouraged to avoid categorically dismissing
their child's negative behavior. Instead, use this opportunity to
model critical thinking about its impact.
-Authoritative parenting
• strongly associated with a positive psychosocial
development.
• It is characterized by clear and appropriate setting of
negotiated limits, in the context of a caring and mutually
respectful Parent-child relationship
-Parental connectedness and close supervision/monitoring of
youth activity and peer group
• protective against early onset of sexual activity and
involvement in risk taking behaviors
• can foster positive youth development
-Encourage adolescents to anticipate the possibility of highly
affectively charged situations and by making a plan while they're
under conditions of cool cognition, it may change the way they
deal with it when the time comes.
• Ex: Unprotected sex if a romantic couple gets carried
away in a sexual situation
-When the adolescent's behaviors cause significant dysfunction
in the domains of home life, academics or peer relationships,
provider.
-Referral to a mental health provider, if the need arises, is also
considered.
X. ASSESSMENT OF GROWTH
• Essential to eradicate malnutrition
o Malnutrition has devastating effects
particularly on brain growth and development
o Poor growth may persist
• To improve a child’s health
o aberrant growth may be the first sign of an
underlying biophysiologic or psychosocial
problem.
• Most crucial during the first 3 years because growth is
most rapid and energy needs is the greatest.
GROWTH CHART
• Most powerful tool in growth assessment Figure. Sample growth chart (length/height for age boys)
• Will allow comparison of a specific child Specialized charts
a. With children of his age (norm) • very-low birthweight and prematurity
b. With his own pattern of development • Down
• The percentile curve indicates the percentage of • Turner
children at a given age on the x-axis whose measured • Klinefelter syndromes
value falls below the corresponding value on the y-axis • cerebral palsy
th
• Median or 50 percentile is also called the standard • achondroplasia.
value
• WHO CGS <5 y/o Premature Infants
• CDC/NCHS 5-19 y/o • Corrections for Gestational Age
Normal Variation 1. Weight up to 24 months of age

1. Familial – height 2. Stature up to 40 months of age
2. Posture – vertebral curves 3. HC up to 18 months of age
3. Race – Caucasians taller than Asians
4. Ethnic culture – physique
5. Sex – males heavier than female WEIGHT
6. Twins – smaller babies • < 2 y/o or cannot stand (Tared weighing or infant scale)
7. Understimulation – constitutional delay • Simple and reproducible parameter
• Ideally done without clothing or minimal clothing
Growth Charts for Clinical Use (1985 FNRI-FPS Anthropometric
(diapers)
Charts)
• >2 y/o : weighing alone (They can stand on their own)
• Weight and age (0-36 months and 2-19 yrs for boys and
• < 6 months old
girls) o Weight in Grams = Age in Months x 600 + Birth
• Height and age (0-36 months and 2-19 yrs for boys and
weight
girls) • 6-12 months
• Weight-for-length/ height and age (0-36 months and 2-
o Weight in Grams = Age in months x 500 + Birth
10 yrs for boys and girls) weight
• Head circumference and age (0-36 months for boys and
girls)
• Normally, a child is expected to remain in the same Changes in Weight at Different Ages
percentile grp from age to age • At 4-5 months 2x Birthweight
• Weight and height may differ in percentile positions but • At 1 year 3x Birthweight
should maintain the same general relationship. • At 2 years 4x Birthweight
• At 3 years 5x Birthweight
LENGTH/HEIGHT
• <3 y/o use recumbent length Screening for children’s
• Head part is fixed • language,
• Infantometer • motor
• 3 y/o and above are able to stand à use standing height • cognitive/academic
• Without footwear • self-help
• Eye level • social–emotional status
• Use a cardboard or anything flat to mark
• Make sure legs are standing straight XII. Loss, Separation and Bereavement
All children will experience involuntary separations, whether from
HEAD CIRCUMFERENCE/ OCCIPITAL FRONTAL illness, death, or other causes, from loved ones at some time in their lives.
CIRCUMFERENCE Relatively brief separations of children from their parents, such as
• At birth head circumference is 35 cm vacations, usually produce minor transient effects, but more enduring
• Should be monitored routinely during the first 3 years of and frequent separation may cause sequelae. The potential impact of
life each event must be considered in light of the age and stage of
• Especially in the first 2 years development of the child, the particular relationship with the absent
• Assessment of brain growth person, and the nature of the situation.
• Sometimes equal with the chest circumference (in the A. Separation and Loss
early years of life) Causes of Separations may be from: Temporary or Permanent
• Measured over the most prominent part of the occiput Ø Temporary Separation
and just above the supraorbital ridges 1. Vacations
2. Parental job restrictions
3. Natural disasters
BODY MASS INDEX (BMI)
4. Parental or sibling illness requiring hospitalization.
• >2y/o
• A valid predictor of adiposity Ø Permanent Separation
• Indirect measure of body fat 1. Divorce,
• Best clinical standard for defining obesity 2. Placement in foster care or adoption
• BMI = wt (kg)/Ht (m2) 3. Death.
OTHER INDICES OF GROWTH o Children Response to Separation and Loss

• Body proportions
The initial reaction of young children to separation of any duration may
• Skeletal maturation
involve crying, either of a tantrum-like, protesting type, or of a quieter,
• Dental development sadder type.
XI. DEVELOPMENTAL- BEHAVIORAL SCREENING AND

In General children’s behavior may appear:
SURVEILLANCE
1. Subdued,
2. Withdrawn
3. Fussy, or moody,
4. Resistance to authority.
In Specific problems may include:
1. Poor appetite,
2. Behavior issues such as acting against caregiver requests
3. Reluctance to go to bed
4. Sleep problems
5. Regressive behavior ( e.g requesting a bottle or bed-wetting)
School-age children reaction to separation may include:

1. Impaired cognitive functioning
2. Poor performance in school.
3. May repeatedly ask for the absent parent and question when
the absent parent will return.
4. Look or search for the absent parent;
5. Other children may not refer to the parental absence at all.
Response to reunion may be consisting of:
1. Surprise or alarm an unprepared parent.
2. A parent who joyfully returns to the family may be met by wary
or cautious children.
3. After a brief interchange of affection, children may seem
indifferent to the parent’s return. This response may indicate
anger at being left and wariness that the event will
happen again, or the child may feel, as a result of magical
thinking, as if the child caused the parent’s departure.
4. If the mother who frequently says “Stop it, or you’ll give me a
headache” is hospitalized, the child may feel at fault and During School-age
guilty. 1. Children may respond with evident depression, indifferent,
angry.
As a result of these feelings, children may seem to be more closely 2. Deny or avoid the issue, behaviourally or verbally.
attached to the other present parent than to the absent one, or 3. Guilt
even to the grandparent or babysitter who cared for them during 4. Adopt a “sick” role as a strategy for reuniting their parents.
their parent’s absence. Some children, particularly younger ones,
During Adolescents:
may become more clinging and dependent than they were before
the separation, while continuing any regressive behavior that
1. Show intense anger.
occurred during the separation. Such behavior may engage the 2.
th
5 Year after the breakup - intense unhappiness and
returned parent more closely and help to re-establish the bond that dissatisfaction with their lives and their reconfigured families,
the child felt was broken. Such reactions are usually transient and another 1 3 show clear evidence of a satisfactory adjustment,
within 1-2 wks., children will have recovered their usual behavior whereas the remaining 1 3 demonstrate a mixed picture, with
and equilibrium. good achievement in some areas and faltering achievement in
others.
th
3. 10 Year - approximately 45% do well, but 40% may have
Recurrent separations may tend to make children more wary and
academic, social, and/or emotional problems. As adults, some
guarded about re-establishing the relationship with the repeatedly are reluctant to form intimate relationships, fearful of repeating
absent parent, and these traits may affect other personal their parents’ experience.
relationships.
Good adjustment of children after a divorce is related to ongoing
involvement with 2 psychologically healthy parents who minimize
A dv ice t o Pare nt s :
conflict, and to the siblings and other relatives who provide a positive
Do not try to ameliorate a child’s behavior by threatening to leave.
support system.
A dv ice to Pa rents:
ü Divorcing parents should be encouraged to avoid adversarial
II. Divorce processes and to use a trained mediator to resolve disputes if
More sustained experiences of loss, such as divorce or placement in needed.
ü Parents should be informed that different children may have
foster care, can give rise to the same kinds of reactions noted earlier, different reactions
but they are more intense and possibly more lasting. Currently in the ü The continued presence of both parents in the child’s life, with
United States, approximately 40% of marriages end in divorce. minimal interparental conflict, is most beneficial to the child.
Divorce has been found to be associated with negative parent

functioning such as: III. Move/Family Relocation
1. Parental depression and feelings of incompetence,
For children, the move is essentially involuntary and out of their
2. Inconsistent discipline
3. Decreased communication control.
4. Decreased affection. Changes in family structure that can cause stress to the child:
5. Loss of contact with the noncustodial parent (Usually the 1. Divorce
father) 2. Death
3. Move or Relocation
Greater childhood distress is associated with greater parental 4. Parental sadness surrounding the move may transmit
distress. unhappiness to the children.
5. Loss of their old friends
Two of the most important factors that contribute to morbidity of the 6. The comfort of a familiar bedroom and house, and their
children in a divorce include: ties to school and community.
1. Parental psychopathology In the evaluation of migrant children and families, it is important to
2. Disrupted parenting before the separation. ask about the circumstances of the migration, including legal status,
violence or threat of violence, conflict of loyalties, and moral, ethical,
Problem following the divorce: and religious differences. Transient periods of regressive behavior
st
1 Year - Period when problems are most apparent
nd
may be noted in preschool children after moving, and these should
2 Year - Problems tend to dissipate
th be understood and accepted.
5 Year – Depression may be present
th
10 Year – Educational or Occupational decline may occur
A dv ice t o Pare nt s :
The degree of interparental conflict may be the most important factor ü Parents should assist the entry of their children into the new
associated with child morbidity. A continued relationship with the community, and whenever possible, exchanges of letters and
noncustodial parent, as long as there is minimal interparental conflict, visits with old friends should be encouraged.
was a factor associated with more positive outcomes. ü Parents should prepare children well in advance of any move
and allow them to express any unhappy feelings or misgivings.
Children Response following the divorce:
or those presumed
IV. PARENTAL/SIBLING DEATH responsible for the death.
At 12-14 years 1. Children begin to use
Parents should prepare children well in advance of any move and symbolic thinking, reason
allow them to express any unhappy feelings or misgivings. abstractly, and analyze
hypothetical, or “what if,”
scenarios systematically.
V. GRIEF AND BEREAVEMENT 2. Teenagers are often
Grief is a personal, emotional state of bereavement or an anticipated ambivalent about
response to loss, such as a death. dependence and
independence and may
Children need to know that their parents love them and will continue to withdraw emotionally from
protect them. Children need opportunities to talk about their relative’s surviving family members,
death and associated memories. A surviving sibling may feel guilty
only to mourn in isolation.
simply because he or she survived, especially if the death was the
3. Adolescents begin to
result of an accident that involved both children. Siblings’ grief,
especially when compounded by feelings of guilt, may be manifested by understand complex
regressive behavior or anger. physiologic systems in
relationship to death
4. Depression, resentment,
A dv ice to Pa rents:
mood swings, rage, and risk-
ü Parents should be informed of this possibility and encouraged taking behaviors can emerge
to discuss the possibility with their children
as the adolescent seeks
answers to questions of
values, safety, evil, and
fairness.
VI. DEVELOPMENTAL PERSPECTIVE
VII. Treatment
Age Remarks
Suggesting interventions outside the natural support network of family
Children younger than 3 1. Little or no understanding of
and friends can often prove useful to grieving families. Bereavement
years the concept of death.
counselling should be readily offered if needed or requested by the
2. Young children may respond
family. Interventions that enhance or promote attachments and security,
in reaction to observing
as well as give the family a means of expressing and understanding death,
distress in others, such as a
help to reduce the likelihood of future or prolonged disturbance,
parent or sibling who is crying,
especially in children. Collaboration between pediatric and mental
withdrawn, or angry.
health professionals can help determine the timing and appropriateness
of services.
Preschool children 1. Preoperational cognitive
stage REFERENCES
2. The primary care provider has
1. Kliegman, R.M Nelson Textbook of Pediatrics. 20
th
ed,
a very important role in updated. Philadelphia: Saunders-Elsevier, 2016.
helping families understand
the child’s struggle to
comprehend death.
3. Children conceptualize events
in the context of their own
experiential reality, and
therefore consider death in
terms of sleep, separation, and
injury.
Younger school-age children 1. Think concretely, recognize
that death is irreversible, but
believe it will not happen to
them or affect them, and
begin to understand biologic
processes of the human body
Children of 9 years 1. Older do understand that
death is irreversible and that it
may involve them or their
families.
2. Tend to experience more
anxiety, overt symptoms of
depression, and somatic
complaints than do younger
children.
3. Often left with anger focused
on the loved one, those who
could not save the deceased,
Pediatrics 1
Preventive Pediatrics – Part 1
Dra. Cabarles|9 August 2018|Topic 1: Anticipatory Guidance in Health Maintenance & Screening Tests
Outline  Genetic counselling among couples with

I. Definition/Purpose/Focus heredofamilial diseases so the couple can decide
II. Scope of Preventive Pediatrics
III. Periods of Pediatrics
whether to consider having a child or not.
IV. Levels of Prevention
V. Periodicity Schedule
Prenatal & Neonatal Periods
VI. Promotion of Welfare (Unborn and during pregnancy) – Even when the mother is pregnant, the unborn has its unique
VII. Overall Health Supervision
VIII. Pediatrics Preventive Healthcare focus of care intra-utero.
IX. Developmental Surveillance – Usually the management involved is for the preparation of
X. Immunization
XI. Deworming (Indication & Contraindication) the mother nutritionally and skills’ wise for breast feeding.
XII. Iron Supplementation – Teratogenic drugs (drugs that can potentially impose a
XIII. Vit. A Supplementation risk/threaten one’s pregnancy) and exposure to x-rays,
XIV. Zinc Supplementation
XV. Anticipatory Guidance smoking, alcoholism must be avoided.
XVI. Dental Visit – PREMATURITY & INFECTIONS are the leading cause of
neonatal death.
I. DEFINITON/ PURPOSE/ FOCUS & SCOPE – Follow-up check-up of a healthy neonate is every month.
– Also referred as “the promotion of positive health and the – Babies whose cord stumps do not fall off at the end of the
prevention of diseases, major disorders, disabilities and first week must be brought for consultation.
handicaps.” – All of these measures are aligned with the roles of both the
– Has an overall goal to promote overall optimum health from fetal B-GYN and the paediatrician.
life through adolescence. Infancy Period
– This results to an adult individual who should be optimally
– To ensure optimum health, follow-up schedule of monthly
healthy, physically, mentally, socially and emotionally.
during the first year and every other month for the second
– Preventive measures are much cheaper than curative
year of life is advised.
interventions.
– Feeding behaviour, developmental changes and the
– KEYNOTE: Health supervision of a well child.
occurrence of signs and symptoms during interval visits are
II. SCOPE OF PREVENTIVE PEDIATRICS (Del Mundo, MD) the focus of care during infancy period.
 Supervision of the physical growth and development of the – Infant’s anthropometric data must be obtained and plotted
individual from fetal life to adolescense. on the patient’s growth child for further assessment.
 Early detection of congenital anomalies and the recognition of – Also the supervision of the infant’s nutritional status, even
abnormal development and their correction. the child’s immunization profile and those of post-exposure
 Provision for the supervision of an adequate, balanced diet from prophylaxis.
infancy with special attention during the critical periods of a – Proper measures to ensure child’s safety is emphasized.
child’s life. – Parents’ outlook towards the child is also examined to rule
 Education of parents, health personnel and teachers in hygiene in out child neglect ideations.
the proper care of the child including accident prevention. Preschool Child Period (2 – 5 years old)
 Prevention of specific preventable diseases by: genetic
– Follow-ups here are ideally every 3 months.
counselling, proper nutrition, hygiene, specific positive
– NUTRITION is the most important aspect of healthcare.
measures, immunizations & drug prophylaxis.
Advised to have a glass of milk every meal & even vitamin
 Recognition of abnormal emotional tendencies.
and iron supplementation.
 Teaching and development of good health habits.
– Assessed also for probable parasitism and hence,
 Development of a healthy environment from womb to
gives an emphasis for observing proper hygiene
adolescence.
within the household.
 Early diagnosis and treatment of physical disease.
– Observed for any physical and/or mental afflictions present
 Education and encouragement of both parents and the youth
but not detectable at birth so that proper referral system can
regarding adequate spacing between births, limitations of number
be made before the condition become more difficult to
of children per family and the responsibilities that go alongside
manage.
with it.
– Since not all disease are preventable by immunization,
III. PERIODS OF PEDIATRICS (PPNIPSA) parents are advised to take in an overall precautionary
measure to the child.
Preconception Period – Dental care must also be given an emphasis. Dental visits
– Encouragement of discussing all the threatening risks of shall be done once teeth have started to erupt.
pregnancy to the family: – Child is also assessed for function of locomotion as the child
 Advised to talk with parents regarding proper becomes more prone to accidents. DROWNING is the leading
family planning. (recommended spacing is 3 years) cause of death associated with accidents.
 Infants born of grand multiparous & teenage
mothers
School Age Period (5 – 6 years old)
 Government setting of minimum age for marriage, – Follow-ups must be done 2x/year preferably before the start
banning of marriages between 1-2 degree relatives. of every school year.
 Nonimmune women should be immunized against – Care must prepare the child’s nutrition towards puberty.
RUBELLA & TETANUS.
Transcribed by: D.K. Oximoso, K.C. Pernecita, J. Ragadi, M.J. Serrano Page 1 of 12
PED201 PREVENTIVE PEDIATRICS T1
– They must be examined for any visual and hearing – activities aimed at patients with specific risk factors
impairment that is crucial for development, learning, – These interventions happen after an illness or serious risk
communication, emotional and for assymptomatic diseases. factors have already been diagnosed
– UNDERNUTRITION is a thing fir children at this age only eat – Disease strategies are individualized. It will depend on the
once in a regular school day within the school premises and risk factor that you have identified on the patient
tend to ponder on junk foods. – Goal is to halt or slow the process of disease in its earliest
– Often times, the school has its own physician but in case it stages
doesn’t have one, the child may be referred to their family – Example:
physician. o Obese patient. You know that these people will be
– Child may also be supervised for the exposure to drugs and prone to high blood pressures and high cholesterol
its abuse. It is advised that the parents shall fetch their level. For this group of people, you will ask if they have
children to ensure child safety and avoid them from regular blood pressure monitoring, and advise them to
unnecessary influences happening in school. also have their cholesterol level taken regularly
– ACCIDENTS, FALLS & BURNS are the leading causes of school o Screening tests (Pap Smear)
injuries respectively. (3º) TERTIARY PREVENTION
– Upon mentors’ discretion, children who exhibit difficulty in – Designed to arrest the progressed of the established disease
class should be evaluated for any possibility of learning and further, to control the occurrence of its negative
disability. consequences in its full-blown clinical course.
Adolescence Period – Measures to alleviate Negative Consequences are:
1. To reduce disability and handicaps
– Major problems in this period are mainly PHYSICAL,
2. To minimize suffering caused by existing departures
PHYSIOLOGIC, PSYCHOLOGIC & EDUCATIONAL.
from good health.
– Nutritional guidance is also important.
3. To promote patient’s adjustment to irremediable
– Much better if they are consulting for individual’s concern
conditions.
unaccompanied by their parents because:
– Focuses on helping people manage complicated, long-term
1. Gives the adolescent the chance to talk freely about his
health problems
problem;
2. Child’s autonomy and the feeling of a matured and – Goals include preventing further physical deterioration and
maximizing quality of life
independent person;
– Example: Stroke patients will undergo physical therapy;
3. PE gives an opportunity to discuss physical growth
Rehabilitation; also includes chronic diseases
4. Gives the physician an ample assessment for such
sensitive topics to the adolescent. V. PERIODICITY SCHEDULE
– Focus of care shall discuss the overall aspect of health. – Compilation of recommended well – child care activities
– Parents should be highly keen for symptoms of behavioural according to age.
problems (rebelliousness) and discrepancies like school – Guide to perform certain services and make observations at
truancy, rampant failing subjects and the like. age – specific visits
IV. LEVELS OF PREVENTION – Standard of pediatric preventive health services
– Derived from:
1. Evidence – Based practice and research
2. Expert consensus guidelines for care by the professional
organizations by the DOH & Philippine Pediatric Society (PPS).
(1º) PRIMARY PREVENTION

– Focuses on the prevention of the onset of the disease.
– Aims to reduce the incidence or the disease before it can
actually occur.
– Activities applied to a whole population
– Goal is to protect people from developing disease or
experiencing an injury
– Example: Immunization, Educating the people about good
nutrition and proper exercise.
(2º) SECONDARY PREVENTION
– Focuses on detecting the disease in its earliest stage possible
BEFORE the onset of the symptoms.
– This is because it is believed that earlier intervention is more
effective AND cost – effective than later.
3. Fetal UTZ 2D or 3D (18TH-22ND week)
4. Real-time UTZ (4D)

– May identify placental abnormalities (abruption
placenta/placenta previa) that increases possibility of brain
damage due to hypoxia.
5. Doppler Velocimetry
– Assesses fetal arterial blood flow through the use of Doppler utz
C. For Third Trimester

1. UTZ of the Amniotic Fluid Volume (24 th-32nd week)
o POLYHYDRAMNIOS: AF > 2,ooo mL
– Indicates multiple anomalies, GIT obstruction, fetal
neuromuscular dysfunction, fetal urination or edema
o OLIGOHYDRAMNIOS: AF volume <500mL

– ROM (Rupture of Membranes) – most common cause
– PULMONARY HYPOPLASIA – most common complication
VI. PROMOTION OF WELFARE – IUGR, severe renal, bladder or urethral anomalies or drugs
interfering fetal urination, twin relationships.
A. For Early Pregnancy (Unborn & Child Prenatal Screening) – Causes fetal compression abnormalities such as: distress,
1. Maternal Plasma Tests clubfoot, spadelike hands and flattened nasal bridge
– Blood type, Coombs Status, ToRCHes titer & HepB and HIV Ab.
2. Non-stress Test (NST)
2. Fetal UTZ ( 6th –8th week) – Monitors fetal heart tone (FHR) accelerations after movement.
– Most accurate assessment of AOG (Age of Gestation) by crown-
rump length measurement 3. Contraction Stress Test (CST)
– Observes FHR response to spontaneous, nipple/oxytocin-
3. Cell-free Fetal DNA (cffDNA) in Maternal Blood (10 th week) stimulated uterine contractions.
– Higher sensitivity (>99%) and lower false – positive rates for
Trismo 21 and other chromosomal abnormalities
4. Chorionic Villus Sampling (CVS) (10 th-12th week)

– Transabdominal/transcervical aspiration /biopsy of placental villi
– To determine fetal chromosomal / genetic disorders
B. For Second Trimester

1. Amniocentesis (15th-16th week)
– For genetic indications; most common; most advanced age
2. Maternal Serum alpha-fetoprotein (MSAP) (15TH-18TH week)

– High AFP: open neural tube defects, gastrochisis, omphalocele,
congenital nephrosis, twins, etc..
– Low AFP: incorrect AOG, trisomy 18 or 21, IUGR
4. Biophysical Profile (BPP) D. NEWBORN SCREENING ACT (NBS)

– Identifies accurately and safely fetal distress. – A heel-prick process where a blot of blood sample is affixed to a
 FULL BPP assesses fetal breathing, body movement, tone, HR specialized paper for NBS.
and AF volume with score of 2 given for each criteria. – In its initial implementation in 1998, this aims to detect the 6
o 8 – 10 score: reassuring primary congenital disorders namely:
o Score of equivocal 6, retest in 12-24 hours 1. Congenital Hypothyroidism (CH)
o Score of < 4 requires immediate evaluation and 2. Congenital Adrenal Hyperplasia (CAH)
possible delivery 3. Phenylketonuria (PKU)
 MODIFIED BPP combines AF index & NST 4. Glucose-6 Phosphate Dehydrogenase Deficiency
o Signs of progressive compromise on Doppler include (G6PD Deficiency)
reduced, absent or reversed diastolic waveform velocity 5. Galactosemia (GAL)
in fetal aorta or umbilical artery. 6. Maple Syrup Urine Disease (MSUD)
– However, the government aimed to profound the scope of NBS
from 6 detectable congenital problems to 22 diseases that include
hemoglobinopathies, metabolic disorders regarding fatty acid
oxidation, organic acid and amino acid disorders.
– Newborn screening is a procedure intended for early
identification of infants who are affected by certain genetic,
metabolic, or infectious conditions that may lead to mental
retardation or morbidity if left untreated. The NBS was integrated
into the public health delivery system with the enactment of
Republic Act 9288 or Newborn Screening Act of 2004.
– The expanded NBS was implemented last December 2014 and
offered as optional procedure to parents. First option was the
standard NBS for 550 Php and 1500 Php for the expanded NBS.
VII. OVERALL HEALTH SUPERVISION
– Principles
 Health promotion
 Establish partnership with each child and family
5. Fetal Scalp Sampling  Establish communication
– Low pH < 7.25uggests fetal distress and hypoxia o Demonstrate respect and empathy
– Also indicated by high lactate concentration >4.2mmol/L o Listen to concern of patients
o Use of nonjudgmental questions to promote dialogue
6. Umbilical Cord Blood Samples at Time of Delivery o Establish relationship with children by
communicating directly with them
– Umbilical Artery pH <7.o associated with greater need for
A. PERIODIC HEALTH SUPERVISION VISITS
resuscitation
– Higher incidence of respiratory, GIT, CVS and neurologic  History and physical examination
complications  Screening tests
 Immunization
7. Intrapartum Fetal Pulse Oximetry  Surveillance of developmental milestones
– Helps identify fetus with non-reassuring status  Observe parent-child interaction
 Anticipatory guidance and counselling
B. FREQUENT CONCERNS DURING HEALTH VISITS
 Child’s behavior
 Parenting
 Common issues on growth and development
 Teething
 Sleep problems (night terror vs. nightmares)
 Toilet training
 Temper tantrums
 discipline
VIII. PEDIATRIC PREVENTIVE HEALTH CARE

A. HISTORY
– Complete history and PE
 Should be done every visit
 History taking, observing the child and doing a thorough
physical examination remain to be the most powerful
instruments available to pediatrician in identifying concerns
that may need monitoring or referral.
B. PHYSICAL EXAM  th
BP <90 percentile for gender, age, ht percentile
– Measurement of weight and length/height  Encourage healthy diet, sleep and physical activity
– Prehypertensive
 Should be done in all children every visit from birth up to 18
 Average SBP or DBP >90th but <95th percentile
years
 Adolescents with BP levels >120/80
– Measurement of head circumference – Hypertensive
– Complete physical exam  Average SBP and/or DBP >95th on >3 occasions
 Should be done at each visit  Stage 1: BP between 95th% and 99th% plus 5 mm Hg
– needs great observation skills, flexibility, and attention to detail  Stage 2: BP >99th% plus 5 mm Hg
– No definite order to follow, individualize according to urgency of  Must be referred to subspecialist
situation, age and cooperativeness, and suspected system
2. HYPERTENSION
involvement
– The golden rule “Head to foot and back, but forget not the ear, – defined as average SBP and/or DBP equal to or greater than 95 th
throat and urine percentile on 3 or more occasions
– Begin by observing activity, color, cranial nerves, mental status, – Hypertensive patients must be referred to the subspecialist for
respiratory pattern, and interactions with family and environment further investigation and management
– Note presence of rashes, birthmarks, and dysmorphism
3 . How to get BP percentile in children?
– Pay particular attention to vital signs and growth parameters
– Least invasive examinations first such as heart and lungs – Step 1: Determine sex and age
– Step 2: Determine height percentile by CDC chart
– Flexibility important to maximize comfort of child
– A gentle progressive approach while avoiding direct eye contact is
better
C. LENGTH/ HEIGHT
– For <2years old – measure the RECUMBENT length
– If a child is age 2 years or more and able to stand, measure the
STANDING height
 STANDING HEIGHT: ~ 0.7 cm less than recumbent length
– If a child is less than 2 years old and will not lie down for
measurement of length, measure the standing height and add
0.7cm to convert it to length
– If a child is age 2 years or more and cannot stand, measure
recumbent length and subtract 0.7cm to convert it to height
D. WEIGHT FOR LENGTH/HEIGHT
– Reliable growth indicator even when the age is not known
E. BMI
– Enable early detection and prevention of overweight and obesity
problems
– BMI = kg/m2
 where kg is a person's weight in kilograms and m 2 is their
height in meters squared
 A BMI of 25.0 or more is overweight, while the healthy – Step 3: Determine BP percentile
range is 18.5 to 24.9
F. HEAD CIRCUMFERENCE
o The WHO Child Growth Standards are used as reference standard
for weight, height and head circumference. Interpretation of
growth points are based on Z scored (standard deviation) and not
on percentile scores.
G. BP (BP PERCENTILE)
– The Pediatric Nephrology Society of the Philippines recommends
routine blood pressure measuremet for children starting at
age 3 years old
– Must be performed
 in all ill patients
 and all patients at risk (with history & PE suggestive of
renal and non-renal causes of HPN) regardless of age
1. Blood Pressure
– Normotensive
H. SCREEENING FOR ATOPY
– any child (from birth up to 18 yrs of age) with a family history of

atopy who presents with recurrent/persistent symptoms of 1 or
more of the following should be investigated :
1. GI symptoms – diarrhea, colic, vomiting, bloody stools
2. Skin rash, dryness
3. Nasal symptoms – rhinorrhea, stuffiness, sneezing,
itchiness
4. Coughing with or without wheezing
5. Ocular symptoms: bluish brownish discoloration around
both eyes
IX. DEVELOPMENTAL SURVEILLANCE

– Process that recognizes children who may be at risk of
developmental–behavioural delays
– Ongoing monitoring of parental concerns, children’s progress
with milestones, psychosocial risk and resilience factors to detect
and address problems then follow-up outcomes
– Philippine Society for Developmental and Behavioural Pediatrics
(PSDBP) recommends it at every child visit
– 5 Components of Developmental Surveillance
1. Elicit and attend to parents’ concerns about
development
2. Keep a developmental history
3. Make accurate and informed observations of the child
4. Identify risk and protective factors
5. Record process and findings
A. RED FLAGS
1. POSITIVE INDICATORS
– Loss of developmental skills at any age
– Parental or professional concerns about vision, fixing, or
following an object or a confirmed visual impairment at any age
(simultaneous referral to an ophthalmologist)
– Hearing loss at any age
– Persistently low muscle tone or floppiness
– No speech by 18 months especially if the child does not try to
communicate by other means such as gestures
– Asymmetry of movements or other features suggestive of
cerebral palsy such as increased muscle tone
– Persistent toe walking
– Complex disabilities
– Doctor thinks something is wrong but uncertain
2. NEGATIVE INDICATORS (ACTIVITIES THAT THE CHILD CANNOT

DO)
– Sit unsupported by 12 months
– Walk by 18 months (boys) or 2 years for girls (check creatine
kinase urgently)
– Walk other than on tiptoes
– Run by 2.5 years
– Hold object placed in hand by 5 months (corrected for
gestation)
– Reach for objects by 6 months (corrected for gestation)
– Point at objects to share interest with others by 2 years
AGE MOTOR RED FLAGS • Making them ready to learn and read in schooL
4 mo Lack of steady head control while sitting
9 mo Inability to sit
18 mo Inability to walk independently
AGE RECEPTIVE LANGUAGE RED FLAGS

2 mo Does not alert or quiet to sound
6 mo Does not turn to the source of sound
10 mo Does not respond to own name
12 mo Does not follow verbal routines/games
15 mo Does not understand simple questions
Does not stop when told “NO”
Does not understand at least 3 different words
18 mo Does not point to 3 body parts
Does not follow simple commands
30 mo Does not follow 2-part commands
36 mo Does not answer simple questions
AGE EXPRESSIVE LANGUAGE RED FLAGS

6 mo Does not coo
10 mo Does not babble
12 mo Absence of nonverbal purposeful messages (show
objects) B. DEVELOPMENTAL SCREENING AND OR BASIC DEVELOPMENTAL
14 mo Absence of pointing MILESTONE
16 mo Does not say 3 different spontaneous words  Process of administering a standardized tool to identify children
24 mo Vocabulary of not more than 35-50 words at risk of developmental-behavioural disorders
Does not produce 2-word phrases  Screening for delays should occur across all domains:
36 mo No simple sentences o Motor (gross and fine
42 mo Intelligibility to unfamiliar adult at <50% o Language (expressive and receptive)
54 mo Not able to tell or retell a familiar story o Cognitive/academic (including ASD features)
60 mo Not fully intelligible to an unfamiliar adult o Self-help
>72 mo Not fully mature speech sounds o Social–emotional skills (including conduct,
attention, and mental health)
AGE SOCIAL EMOTIONAL RED FLAGS  PSDBP recommends developmental-behavioural
6 mo Lack of smiles or other joyful expressions screening at:
9 mo Lack of reciprocal (back-and-forth sharing of) o 9 mo old–motor skill issues, also visual and
vocalizations, smiles, or other facial expressions hearing abilities
12 mo Failure to respond to name when called o 18 mo old–communication and language
Absence of babbling delays
Lack of reciprocal gestures (showing, reaching, waving) o 30 months–most motor, language and
15 mo Lack of proto-declarative pointing or cognitive delays
other showing gestures o Every year thereafter– literacy skills, school
Lack of single words readiness and competencies
o Any time-when there is concern about
18 mo Lack of simple pretend play
development
Lack of spoken language/gesture combinations
o Screen early and more frequently-children
24 mo Lack of two-word meaningful phrases
with risk factors on surveillance
(without imitating or repeating)
Any age Loss of previously acquired babbling, speech,
C. PARENTS’ EVALUATIONS OF DEVELOPMENTAL STATUS (PEDS)
or social skills
(2013)
 Purpose: Screening/surveillance of development/socio-
– The Philippine Ambulatory Paediatrics Association, Inc.
emotional/ behaviour/ mental health via parents’ concerns
• Advises parents about the importance of reading aloud to
 Description: 10 questions eliciting parents’ (and providers’)
their children during the first years of life
concerns. Longitudinal Score and Interpretation Forms assign
• Research shows this helps them develop language and
literacy skills thus
risk levels, track decision-making and offer specific guidance on

how to address concerns.
 Age Range: Birth – 8 years
D. MODIFIED CHECKLIST FOR AUTISM IN TODDLERS

(M-CHAT) (1999)
• Purpose: Screening for ASDs
• Description: Parent report of 23 yes-no questions written at
4th-6th grade reading level.
• Age Range: 18-47 months
E. PAEDIATRIC SYMPTOM CHECKLIST (PSC)

• Purpose: Screening/surveillance of emotional/ mental health,
and conduct; a necessary pre-screen for sorting attention
problems from similar conditions
• Description: Administered by youth/parent, self-report or by
interview, 35 or 17 short statements of problem behaviors
producing cut-offs for attentional, internalizing, and
externalizing problem
• Age Range: 6-18 years
http://www.autismspeaks.org/sites/default/files/docs/sciencedocs/m-
chat/m-chat-r_f.pdf?v=1
Chlamydia for both

4. Immunization HPV, Tdap/Td, Influenza, Catch-up and/or
Booster doses
5. Anticipatory a. Breast self-examination for females

Guidance and b. Healthy lifestyle: physical activity, diet,
Counseling avoidance of alcohol, smoking, drug
(directed now use
to patient with c. Sexual behavior and risk of acquiring
less STDs
participation of d. Injury and accident prevention: use of
parent/guardia sports protective gear, seat belts, no
n) driving under the influence of alcohol,
no smoking in bed, no hand gun use
F. ADOLESCENT ANNUAL HEALTH SCREENING (AAHS)

(BY PHILIPPINE SOCIETY OF ADOLESCENT MEDICINE SPECIALISTS)
COMPONENT RECOMMENDATIONS
3. History Adolescent psychosocial risk screening

using the tool HEADSSSS
2. Physical a. Tanner Staging/Sexual Maturity Rating

Examination b. Breast examination
(preferably by c. Spine and shoulders examination,
check for scoliosis and kyphosis
same gender
d. Inspection of genitals and anus, more
health care thorough in symptomatic patients
provider)
3. Laboratory a. CBC (or at least Hgb/Hct) at every stage

Tests of adolescence G
b. Urinalysis on first encounter R
c. Vaginal wet mount and PAP smear for
R
sexually active females

d. Serologic test for syphilis for sexually
active males
e. Non-culture test for gonorrhea and
XIII. IRON (Fe) SUPPLEMENTATION

X. IMMUNIZATION – Iron is an important trace mineral needed for hemoglobin
– the process of inducing immunity against a specific disease formation
– administration of antibody thru immunizations (active) or actively – Iron deficiency is the most common form of nutritional deficiency
by administering a vaccine (passive) and the leading cause of anemia
– vaccinations stimulate the system to produce humoral or cellular – will reduce the risk of anemia by 49% and iron deficiency by 76%
immune response shielding it from recurrent infection or diseases – all LBW (low birth weight) should receive 0.3ml OD to start at 2
– should be updated with every visit months until 6 months
– As of 2015, infants, children and adolescents in the US are – For 6-11 months: 0.6ml OD (once daily) for 3 months
routinely immunized against 16 diseases. – For 1-5 yrs old: 5ml for 3 months or 30mgs once a week for 6
– In the Philippines, the vaccinations mandated are as follows: months
o At birth, babies are given BGC (Bacillus Calmette– – For adolescent girls: 1 tablet OD
Guérin), which is an anti-tuberculosis vaccine, as well as
the Hepatitis B vaccine
Given for low birth wt. <2500gram
o DPT-Hib-Hep B Vaccine, which is a 5-in-1 vaccine that
protects against Diphtheria, Tetanus, Pertussis, Polio
and Hib disease
o Measles-Mumps-Rubella vaccine (MMR): Pediatricians
recommend that the first dose of MMR be
administered at 12 months of age
o Rotavirus vaccine: The first dose of rotavirus vaccine
should be given orally at 1 1/2 months or 6 weeks old
o Pneumococcal conjugate vaccine (PCV): Pneumonia
has been one of the leading causes of death in kids
under the age of 5 in the Philippines
o Tetanus-Diptheria vaccine (Td)
o Human Papillomavirus vaccine (HPV)
o Polio vaccine
XI. DEWORMING FOR CHILDREN

– As per DOH’s Administrative Order that recommends
deworming for all children 12 mos to 14 years
– Mebendazole (Antiox) given orally at 500mg one dose OR
– Mebendazole 100mgs 2x day for 3 days
– Health undersecretary back in 2015 explained that the benefits
should always outweigh the side effects
– He explained that by not getting your child dewormed, a risk for
the 3Ps is highly possible = PPP – pandak (short), payat (thin) and
poor performance in school
Side effects:
– Local hypersensitivity (Allergy)
CAUSES of deficiency:
– Mild abdominal pain
– Diarrhea – Lack of iron rich food in the diet
– Lack of Vitamin C, which helps with iron absorption
– Chronic blood loss due to parasitism or menstruation
Contraindications for deworming is – Increased demand of the body during pregnancy and lactation
– severe malnutrition – Low iron absorption
– high-grade fever – High requirement of infants, adolescent girls (menstruation),
– profuse diarrhea pregnant and lactating women
– abdominal pain
– other illness – previous hypersensitivity to anti-helminthic the
SIGNS of deficiency:
drug (urticaria)
– Weakness
– Insomnia
XII. VITAMIN A SUPPLEMENTATION – Easily fatigued
– for the prevention of vitamin A deficiency, xerophthalmia and – Lack of appetite
nutritional blindness in infants and children 6–59 months of age – Lack of concentration
(3) – pallor
– For infants 6-11 months: 100,000 IU given anytime but usually at 9
months we give it with measles immunizations
– For children 12-59 months: 200,000 IU given 1 cap every 6 months
XIV. ZINC SUPPLEMENTATION o For children 6 months to 2 years of age, you can use
1000 parts per million (2.5mm) (like in Colgate or close
– Preventive zinc supplementation in populations at risk (moderate
up) so even if they swallow that would not cause any
to high prevalence studies >20) reduces the risk of morbidity from
complications.
childhood diarrhea and acute lower respiratory tract infections
o Don’t cover the course surface of the tooth brush with
– might increase linear growth and weight gain in infants and young
the toothpaste, because they can develop fluorosis and
children
it will appear worse.
– Daily dose of 10 mg zinc (any salt) over 24 weeks (6 months)
o For 2-6 years of age, just a pea size, and 6 years or more
they can take the full length of the bristles already.
XV. ANTICIPATORY GUIDANCE
– This distinguishes the well child health supervision visit from all
other encounters with the health care system
– part of the 4 tasks of preventive pediatrics
– 4 tasks of child health supervision or preventive pediatrics:
o Disease detection
o Disease prevention
o Anticipatory guidance
o Health promotion
– preventive pediatrics incorporate health promotion and
anticipatory guidance because other encounters with children in
the healthcare system, ex: Hospital –has disease detection and
disease prevention but health promotion and anticipatory
guidance are only integrated in preventive pediatrics or child
health supervision
– Counsel parents and children about adopting behaviors to
prevent injuries from birth to adolescence
– Not only you promote disease detection and disease prevention
but you also do anticipatory guidance and health promotion –
FAMILY is involved along with health care professionals
– Nutrition counselling
– opportunity to help the family address relationship issues
– Prevention of child maltreatment, family violence, and other
mental illness
– Prevention of lead poisoning in children
– REMEMBER: Addressing the parent’s concern is the most
important priority
XVI. DENTAL VISIT

– First visit at the time of eruption of the first tooth and not later
than 12 months of age
– During the first dental visit, the dentist assesses:
REFERENCES
o The child’s general health, growth and behavior
o The child’s oral hygiene and periodontal health 1. Del Mundo & Navarro textbooks
o The risk for developing oral disease 2. Lecturer’s ppt & Recordings
o Provide education on infant oral health and evaluate 3. DOH website for NBS
and optimize fluoride exposure
– Preventive dental care includes:
o Use of fluoride toothpaste -2x daily as a primary
preventive measure, young children should be
supervised
o Topical Flouride treatment proven to prevent and
reverse enamel demineralization, children at high risk
for dental carries should receive this more frequently
o Other anticipatory measures: guidance on oral hygiene
and proper diet, cleansing of infant’s teeth as soon as
they erupt with washcloth or soft brush to reduce
bacterial colonization, use of dental floss for children to
prevent and reduce any dental problem
o Twice daily usage of fluoride containing toothpaste is
recommended as a primary prevention measure.
o Even for babies and young children, you can use fluoride
tooth pastes. Even for adults, as long as it contains 1000
parts per millions of fluorides.
o Young children must be supervised in brushing and
should be taught to spit out the toothpaste and to
avoid rinsing after brushing.
Pediatrics 1
Viral Infections
Catherine G. Gironella, MD | 02 August 2018 | Topic 1
Outline < (Less than) 1 cm > (More than) 1 cm
I. Virus Plaque / Wheal / Hive
A. Types of Virus Elevated Papule
B. Common Viral Infections (e.g. Urticaria)
II. Skin Lesions With Watery
A. Exanthem Vesicle Bullae
B. Enanthem Content
C. Hemorrhagic type of Skin Lesion
With Pus Pustule
I. Virus B. Enanthem
– Acellular, Smallest Micro-organism (1932 onwards)that infects – Lesion in Wet Surfaces (e.g. Oral Mucosa)
man – Examples: Koplik's (Measles) & Forschhimer's (German Measles)
– Viroids - Smaller form of Viruses spot
– Prions - Smallest infectious agent (A Proteinaceous Particle)
• Parts: C. Hemorrhagic type of Skin Lesion
1. Genetic Material - Either DNA or RNA DISCLAIMER - There's no proper classification of this type of skin lesion &
2. Capsid - Protein Coat of Genetic Material the transer just connote it this way
3. Envelop - Either with or Without – Petechiae, Purpura, & Ecchymosis, if present, indicates a hemorrhagic
**NOTE: Naked (Without Envelop) viruses are more virulent
type of viral infection & the patient is monitored closely (See table 2)
Types of Viruses Color Size
1. DNA Virus Petechiae < 1 mm
– Usually Double Stranded Purpura Reddish or Purplish 2-3 mm

– Examples: Herpes, HepaDNA (Hepa B), Adeno, Papilloma, & Pox
– Parvoviridae - Single Stranded, Naked Virus Ecchymosis > 3 mm
2. RNA Virus
REFERENCES
– Usually Single Stranded
– Examples: Poliovirus & Dengue Virus 1. Lecture Notes
– Double-stranded RNA: Rotavirus & Reoviridae
Common Viral Infections

1. Rubeola Virus (Measles)
2. Rubella Virus (German Measles)
3. Rubula Virus (Mumps / Viral Parotitis)
4. Human Herpes Virus 6 (Roseola Infantum)
5. Rabies Virus
II. Skin Lesions

– Can either be:
• Exanthem or Enanthem - in Dry (Skin) or Wet (Oral Mucosa)
Surface
• Centrifugal or Centripetal - Starts from the trunk or from
periphery (face is included as periphery)
• Symmetrical or Asymmetrical
• Localized or Disseminated
• Blaschkoid or Dermatomal - Follows the line of skin cell
migration during embryogenesis or the skin's innervation by
cutaneous branches of a single spinal nerve
A. Exanthem
– Cutaneous Lesion or Patches (See Table 1)
Table 1. Different Types of Skin Lesion

< (Less than) 1 cm > (More than) 1 cm
Non-Elevated Macule Patch
Transcribed by: ML, PTRP Page 1 of 1

Pediatrics 1
Bacterial Infections
Dr. Fajardo | 11 September 2018 | Topic 1 – Part 1
Outline 3 STAGES
I. PERTUSSIS
II. SYPHILIS
1. CATARRHAL
III. SALMONELLOSIS • Most contagious stage
IV. SHIGELLOSIS • Nonspecific manifestations, challenging diagnosis, just
V. CHOLERA
VI. E. COLI INFECTION like regular common cold and cough
VII. TETANUS • Very important to diagnose early because early
VIII. STAPHYLOCOCCAL INFECTION
IX. STREPTOCOCCAL INFECTION
treatment can shorten the disease course
X. PSEUDOMONAS • Mild URI, low grade fever, 1-‐3 weeks, sneezing,
lacrimation and conjunctival suffusion
• Begins insidiously after an incubation period ranging
from3-‐12 days with no distinctive symptoms of
I. PERTUSSIS congestion and rhinorrhea
• ETIOLOGIC AGENT: Bordetella pertussis
 Small, fastidious, gram (+) coccobacilli 2. PAROXYSMAL
 Sole cause of epidemic pertussis and the usual cause of • Obvious stage
sporadic pertussis • Successive coughs ending with a high pitched
 Commonly affects immunocompromised persons or inspiratory whoop (initial cough begins as a dry,
young childer with intense exposure to animals intermittend irritative hack and evolves into the
• MOT: Pertussis toxin transmitted thru close contact via resp. inexorable paroxysms -‐ hallmark of pertussis)
secretions → highly communicable (highly contagious) • Gagging, apnea, tongue protrusion, eyes pop, face
• INCUBATION PERIOD: 6-‐20 days reddens
• Now seen more often in adolescents and adults (milder) – serve • Coughing incessantly for the next 2-‐4 weeks
as index cases, but can occur in all ages • Clinical pertussis
• No lifelong immunity • Machine gun burst of coughing to the point na
• DIAGNOSIS nangingitim na yung mukha ng bata
 CBC: Very high leukocyte count (15,000-‐100,000) with
absolute lymphocytosis/leukemoid reaction 3. CONVALESCENT
 CxR: prehilar infiltrate, atelectasis, or emphysema • Less violent cough
 Total duration: up to 12 weeks • Reduced frequency and severity of coughs
 Demonstrated by darkfield microscopy or direct • Lasts for 100 days
fluorescent antibody testing on specimens form skin
lesions, placenta or umbilical cord II. SYPHILIS
 PCR
 Serologic testing – principal means for diagnosis • ETIOLOGIC AGENT: Treponema pallidum
• DIFFERENTIAL DIAGNOSIS (DDX)  Spirochete
 Atypical pneumonia, Mycoplasma, Chlamydia, • MOT: Direct contact lesions, body fluids, perinatal intrauterine
Adenovirus, Tracheobronchial TB, foreign body, infection
Bronchiolitis, and other causes of spasmodic cough ADULT SYPHILIS CONGENITAL SYPHILIS
• Complications and hospitalizations occur most commonly in the
young infant population under 6 months of age and include:
Pneumonia, apnea, otitis, conjunctival hemorrhage, epistaxis, Sexually transmitted Intra/perinatal
seizures (not due to CNS infection but because of lack of oxygen
from too much coughing), acute encephalopathy, hernia, and
pneumothorax (spontaneous, pumutok yung lungs sa sobrang Transmission to fetus can
intrapulmonary pressure) Prevalent in adolescents
occur at any stage
• Confirmation of diagnosis can be made by isolation of organism
from Bordet Gengou culture of nasopharyngeal mucus. Best Usually infected fetus die in
yield during first 3 weeks of illness
utero or shortly after birth
 PCR, Fluorescent Antibody & Serology
• TREATMENT Surviving babies have severe
 Most effective during the first two weeks of illness congenital and developmental
 Infants (<6 mos.) and patient with severe disease anomalies
commonly require admission Table 1. Comparing differences between adult syphilis and
 DOC: oral erythromycin 40-‐50mg/kg/d(max 1gm/day)
congenital syphilis
for 14 days
• Other drugs: Azithromycin, Clarithromycin
 All household contacts should receive 3 STAGES
chemoprophylaxis regardless of age and immunization 1. PRIMARY
status (Erythromycin for 14 days) • Site of penetration
 Supportive • PAINLESS indurated ULCER (usually seen in genitalia,
• Paracetamol, IV fluids also callced CHANCRE. Then after few weeks, ulcer
 Vaccination heals then goes to secondary)
• Initiate, continue or booster (DTP, DTaP,
Tdap)
Transcribed by: L. Agcaoili, A. Aguilar, C. Alipio, N. Antonio, ItalianHerb, K. Bungalon, K. Caraan, G. Castillo, A. Celera Page 1 of 7
PED201 BACTERIAL INFECTIONS T1.1
2. SECONDARY • <5 years old – at high risk (outbreaks during summer)
• Dissemination • DIAGNOSIS
• CONDYLOMA LATA -‐ wart-‐like lesion on the anal verge 1. Fecalysis – pus cells, RBC in stools
• Skin lesions, fever, rash 2. Culture of blood (1 -‐3wks.), stool/rectal swab (2nd-‐4th
week),duodenal fluid, urine(first 2 weeks), bone marrow
3. TERTIARY aspirate (90% sensitive)
• Deep organ involvement ‒ Last resort: BONE MARROW because it is an
• GUMMA -‐ granulomatous lesion invasive procedure but it has the highest
• Neurosyphilis (tabes dorsalis) → MOST prominent, specificity
cardiosyphillis ‒ Confirmatory: CULTURE *BUS (Blood-Urine-Stool)
 Not due to bacteria but by the tissue 3. Widal Test – useful in nonendemic areas (hindi na ginagamit
damage brought about by the bacteria because it’s endemic already, maraming nagpapositive na Ab
kahit wala naming typhoid fever, although useful in the
*In a child, you MUST always suspect child abuse; if it is a teenager, it provinces)
could also be part of adolescent curiosity 4. CBC
‒ Leukopenia -‐ in typhoid fever
CONGENITAL Syphillis ‒ Leukocytosis – nontyphoid fever
• Acquire through VERTICAL transmission ‒ Lymphocytosis – typhoid fever
• NO PRIMARY STAGE (Chancre) – kasi hematogenous ‒ Thrombocytosis
dissemination, from mother to baby, no sexual contact involved 5. Serologic tests – Latex particle, agglutination, ELISA,
• Transmision can occur at any time during pregnancy Typhidot
(1st/2nd/3rd) ‒ Typhidot: detects specific IgM and IgG

EARLY ONSET LATE ONSET • Mean IP: 24hrs
• Clinical features: Watery, mucoid/bloody diarrhea, fever,
• First 2 years of life abdominal cramping, myalgia, headache
• Hepatosplenomegaly, • 2 years old and above • DIAGNOSIS
snuffles (bloody nasal • Bone malformations  Food intake history
discharge, overwhelming (frontal bossing, saddle ‒ Uncooked poultry, pork, eggs, dairy products,
bacterial infection erodes nose, saber shin – bowing vegetable, fruit
bone of nasal cavity), of tibia), neurosyphilis,  Fecal leukocytes on stool exam
lymphadenopathy, mulberry molars,
mucocutaneous lesions, rhagades (fissures which
pneumonia, appear at the CLINICAL FEATURES
osteochondritis, rash, mucocutaneous junction), 1. S. typhi (Typhoidal)
pseudoparalysis, hemolytic Hutchinson’s triad (bulag, • Can be mild to severe and prolonged in presentation
anemia, thrombocytopenia bingi, bungal) (Keratitis, • Congenital infection/fetal typhoid
• Can be mistaken with Hutchinson’s teeth, 8th – mother with infection can be transmitted to baby,
neonatal sepsis – maternal nerve deafness) baby with high fever and low BW, high risk of
history is important miscarriage or stillbirth, very rare
• Typhoid fever, high grade intermittent fever (stepladder
• Stigmata of congenital syphilis: Snuffles, saddle nose, rhagades, -‐ on & off for 2weeks, hindi ka lalagnatin ng isang linggo sa
Hutchinson’s teeth dengue), diarrhea (pea soup) or constipation, abdominal
pain, distention, rose spots (Salmon colored) appears on the
• DIAGNOSIS
 Darkfield or DFA 7th to 2nd week of illness on the trunk (light pink),
 Serology (MAINSTAY beause very hard to culture) bradycardia, hepatosplenomegaly, meningeal signs –
headache, convulsions, psychosis, and apathy
o Non-‐treponemal – VDRL, RPR (Screening,
monitor response to therapy → quantitative • Starts as a GIT infection but the bacteria disseminates so
test to measure Ab titers), uses beef heart or later it becomes a systemic infection
reagin antigen, – from Peyer’s patches → lymph node →
o Treponemal – FTA, TPHA (Confirmatory) reticuloendothelial system → blood → other organs
 TREATMENT (even to the CNS: typhoid psychosis)
 DOC: IV PENICILLIN G • COMPLICATIONS
 Newborn: Aqueous crystalline Pen G/Procaine Pen G – Occurs 2nd to 3rd week of illness
 Children: Benzathine Pen G o Intestinal hemorrhage/ perforation
 Alternatives: Erythromycin or Tetracycline  MOST dreaded complication
(because it invades the peyer’s
patches, magang-maga,
III. SALMONELLOSIS numinipis ang lining and
• ETIOLOGIC AGENT: Salmonella typhi (typhoidal, human source) mabilis mag-rupture)
and Salmonella enteritidis, Salmonella cholerasuis (non-‐typhoidal, o Others: Peritonitis, jaundice, splenic
animal/zoonitic source) rupture, pneumonia, encephalitis,
• Animals: poultry, reptiles, pets nephritis, meningitis, psychosis
• MOT: feco-‐oral, contaminated food and water ingestion, person • Salmonella gastroenteritis
to person – Most common presentation of salmonellosis
 Bacteria go to terminal ileum submucosal lymph nodes, – The intestinal hemorrhage is secondary to
monocytic infiltration of Peyer’s patches Typhoid Typhlitis/Typhoid Ileitis
• Nontyphoidal: Contaminated meat, dairy products, water, o Ileum inflammation of the colorectal
pastries, rare fruits, vegetables area
• Typhoidal: humans
2. Other non typhoidal Salmonellas o STEC
• Bacteremia with or without metastatic focal infection – o Yersinia enterolitica
abscess formation in any organ o Clostridium difficile
• Asymptomatic chronic carrier state – among those with o E. histolytica
previous AGE/enteric like fever. Occur in 7% of <5 years old • TREATMENT
• Salmonellosis/Salmonella gastroenteritis – can also cause o Supportive and 3-‐5 day course antibiotic (cefixime,
food poisoning ceftriaxone, ciprofloxacin, azithromycin)
• Enteric fever – includes Typhoid Fever and infection due to o Nirereserba pa ang ciprofloxacin sa mga <18yo kasi
S.paratyphi and S. enteritidis, S. cholerasius natutunaw yung cartilage, hindi na tumatangkad. If
• TREATMENT you’re going to give it for 3-5d, baka naman hindi
o SALMONELLOSIS: Supportive only, antibiotics prolong mangyari yung cartilage degeneration
colonization – NO ANTIBIOTICS! (TYPHOID FEVER: o Pag di na gumagana yung iba, ciprofloxacin na yung
Yes to antibiotics ) binibigay kahit sa pediatric age group
o Bacteremic: 3rd gen cephalosphorins while cultures o Cotrimoxazole & Ampicillin – NOT recommended
pending unless organism still susceptible
• PREVENTION o Ciprofloxacin: previous backup drug, now the DOC for
o Personal hygiene bloody diarrhea for all ages (WHO)
o Public health measures – food processing and storage
and preparation V. CHOLERA
o Infection control
o Vaccine -‐ Vi capsular polysaccharide vaccine. 1 dose • ETIOLOGIC AGENT: Vibrio cholerae, V. Parahemolyticus
via IM (used for people who are travelling to endemic • Cholera
areas) o Dehydrating diarrheal disease that can rapidly lead to
• OTHER COMPLICATIONS death if untreated
o Acute dehydration • Toxin producing strains 01 and 0139 are responsibe for
o Can seed many organ systems, leading to osteomyelitis epidemic
in children with sickle cell disease, among other • The toxin (also known as choleragen) causes a severe secretory
infections diarrhea
o Reactive arthritis may follow Salmonella • Voluminous diarrhea (rice water)
gastroenteritis, usually in adolescents with the HLA-‐ o The problem is not the diarrhea but the volume loss
B27 antigen due to massive diarrhea. Severe dehydration is the
main problem
• Emesis, low grade fever
IV. SHIGELLOSIS • Shock due to volume depletion
• ETIOLOGIC AGENT: Shigella dysenteriae, Shigella flexneri, Shigelle • Food intake history (shellfish) -‐ this is associated with Vibrio
boydii, Shigella sonnei parahaemolyticus food poisoning or pwede my nakain na hindi
o Shigellosis nailuto
 Causes an acute invasive enteric infect ion • DIAGNOSIS
clinically manifested by diarrhea that is often o Stool, rectal swab culture
bloody o Elevated urine SG, hemoconcentration are evident
 Dysentery – syndrome of bloody diarrhea o Hypoglycemia
with fever, abdominal cramps, rectal pain o Serum K+ = normal or high
and mucoid stools o Isolated from stools, vomitus or rectal swabs
 Bacillary dysentery  Stool exam – few fecal WBCs and RBCs
• Mean IP: 24 hours o Darkfield microscopy – rapid identification of typical
• As few as 10 organisms can cause diarrhea (Shiga toxin) “darting motility”
• TRIAD on infants • DDx
o Dysentery o Cholera differs from other diarrheal diseases in that it
o High grade fever often occurs in large outbreaks affecting both children
o Seizures/Convulsions (due to shiga toxin) and adults
• Bloody diarrhea (dysentery), fever, abdominal cramps, o ETEC
neurologic (seizure, confusion, hallucinations) o Rotavirus
• Food intake history: Egg, salad, lettuce, fecal leucocytes o Microbiologic isolation -‐ gold standard
(invasive), stool culture • COMPLICATIONS
• According to WHO: Shigella is the MOST COMMON cause of o Most are mild and inapparent
bloody diarrhea in the whole wide world o Following an incubation period of 1-‐3 days, acute
• COMPLICATIONS: watery diarrhea but some patients have a prodrome of
o Septicemia, seizure, HUS (just like your EHEC), crampy anorexia and abdominal discomfort and the stool may
(borborygmous) abdominal pain, pneumonia be initially be brown
o Ingestion of shigallae is followed by incubation period o Diarrhea can progress to painless purging of profuse
of 12hr to several days before symptoms ensue. rice-‐water stools (suspended flecks of mucus) with a
 Severe abdominal pain, high fever, emesis, fishy smell
anorexia, generalized toxicity, urgency and o Cholera gravis – most severe form. Results to
painful defecation dehydration manifested by decreased urine output, a
o Shiga toxin incites a cytotoxic, neurotoxic, and sunken eyes, absence of tears
enterotoxic effect o Renal -‐ Renal and pre-‐renal failure
• DDx: o Cardiac -‐ due to hypovolemic shock
o Campylobacter jejuni o Coma -‐ due to poor cerebral perfusion, volume
o Salmonella spp. depletion, due to diarrhea
o EIEC
• TREATMENT VII. TETANUS
o Correct hydration and electrolyte -‐ very important
supportive measure, antibiotic is not enough since it is • ETIOLOGIC AGENT: Clostridium tetani
given for 3 days only o Anaerobic, sporeformer (terminal spores
o Antimicrobial: doxycycline, tetracycline, TMP-‐SMZ, location), neurotoxin
erythromycin, ciprofloxacin, cotrimoxazole o Drumstick or tennis racket appearance
o Doxycycline and tetracycline -‐ not recommended to 8 o Tetanus -‐ acute spastic paralytic illness,
y/o patients because of its side effects: yellowish teeth historically called “lockjaw”
staining, since 3 days lang naman ibbigay to, hindi o Tetanospasmin – second most poisonous
magkakaroon ng yellow stain unless one week mo substance known (surpassed by botulinum toxin)
ibigay  Human lethal dose: 10-‐5 mg/kg
• Source: soil, dust, human and animal feces, unsterile suture,
rusty instruments, nails, scissors or pins
VI. E.COLI INFECTION • MOT: spores introduced into an area of injury or wound
• ETIOLOGIC AGENT: Escherichia coli (direct inoculation)
o Facultative anaerobe; Gram (-‐) bacilli • Neonate -‐ cut umbilical cord with unsterile scissors perhaps
• K1 capsular-‐associated with neonatal sepsis, meningitis by traditional birth attendant—leading to neonatal tetanus,
• Diarrhea strains: ETEC, EPEC, EAEC, EIEC unimmunized mothers
• Older child – contamination of wound
• UTI strains
• Portals of entry: Dental carries & otitis media
• Gram negative bacteria, belongs to Enterobacteriaceae • Penetrating wounds, illicit drug injections, abscesses, ear
• Strains: Enterotoxigenic E. coli (ETEC), Enteroinvasive E. coli piercing, firecracker injuries
(EIEC), Enteropathogenic E. coli (EPEC), Enteroaggregative E. coli • Greatest risk in deep punctures wound avulsions, crushing
(EAEC), Serotype O157:H7 (STEC) injuries
o EPEC and EAEC -‐ watery stool • IP: 2-‐14 days after injury
o EPEC – infantile diarrhea • Clinical: tetanospasmin (bind NMJ, prevent neurotransmitter
o ETEC and EHEC -‐ bloody stool release) -‐ hypersympathetic state due to blocked inhibitory
o ETEC -‐ traveller’s diarrhea, watery stool neurons leading to nonstop tetanic spasm

o EHEC – Enterohemorrhagic E. Coli
CLINICAL FORMS
o 0157 H7 -‐ it produces shiga-‐like toxins
1. NEONATAL TETANUS
 Diarrhea that is initially watery but within a
• usually at 3-10 days old after delivery, (usually pag day 1 –
few days become blood-‐streaked or grossly
meningitis)
bloody
• difficulty in sucking, jaw stiff, excessive cry-‐hoarse to
 5-‐50% of children with STEC develop
strangled, opisthotonous, apnea, paralysis, constipation or
hemolytic uremic syndrome (HUS)
urinary retention, spasms
• Colitis with bloody diarrhea

• Food intake history: Uncooked beef 2. GENERALIZED TETANUS (MOST COMMON)
• 22%develop HUS (microangiopathic hemolytic anemia, • stiffness of voluntary muscles -‐trismus/lockjaw, risus
thrombocytopenia, acute renal dysfunction), Hemocolitis sardonicus (grimace), dysphagia, opisthotonous (arching of
• Watery or bloody mucoid diarrhea with tenesmus (dysentery) the back), board-‐like rigid abdomen, flexed arms, extended
• Most Common: Feco-‐oral route legs, laryngeal spasm, airway obstruction, respiratory
• Most common cause of UTI is E. Coli muscles spasm, high fever, tachycardia, sweats
o It is a coliform; normal flora of the colon. Kung poor ang • Excitants provoke painful spasms and seizures
perineal hygiene, there will be ascending infection from • Sensorium is intact, he is aware of what is happening but
vaginal area going up into ureter and kidney cannot control it
• DIAGNOSIS • Dysuria, urinary retention
o Stool culture – gold standard • Accumulation of secretions
o Serotype O157:H7 • Intact sensorium
 Cannot ferment sorbitol on MacConkey • Hyperactive DTR
Sorbitol medium
• TREATMENT 3. CEPHALIC TETANUS
o Rehydration/Fluid and electrolye therapy – • Rare form
cornerstone of management • Occurs in association with chronic otitis media
o ETEC -‐ most are self limited • Involve bulbar musculature, retracted eyelids, deviated
gaze, trismus, risus, spastic paralysis of tongue and
o Antibiotic is contraindicated in EHEC (or STEC or
pharyngeal muscles (cranial nerves 3,4,7,9,10 and 11)
VTEC) as it may increase in likelihood of developing
HUS - kapag napatay mo bacteria sa EHEC, nawasak, • With sardonic smile and there is also clenching of teeth
release lahat ng toxin
4. LOCALIZED TETANUS
o UTI: Amoxicillin-‐claculanate or ampicillin-‐sulbactam,
• painful spasms of muscles adjacent wound site
cotrimoxazole
• DIFFERENTIALS
o Sepsis, meningitis, pneumonia (invasive disease): o Rabies
Ceftriaxone or cefotaxime o Tetany
o Polio
o Bacterial meningitis
o Drug reaction or withdrawal syndrome

• DIAGNOSIS • Abscess – hallmark of staph. infection
o Diagnosis based mainly on clinical, lab testing • *Pus -‐ Staph. Aureus
can't confirm or exclude disease • Can cause direct bacterial or toxin mediated disease
o CBC: mild PMN leucocytosis, CSF normal with mild • *Hematogenous means (not by direct contact)
elevation opening pressure • Can cause infection through:
• COMPLICATIONS o DIRECT BACTERIAL INVASION
o Aspiration pneumonia , atelectasis. laryngospasm,  Skin
vertebral fractures, IM hematoma, tongue  Folliculitis (maliit na pigsa), furuncles,
lacerations -‐ if the patient bites his tongue while carbuncles (malaking pigsa), impetigo
seizuring  Abscesses and surgical wound infections
• TREATMENT  Most common cause of osteomyelitis
o 3 important things to remember: Neutralize and septic arthritis in children (acquired
toxin from diffusing, eliminate bacteria producing hematogenously)
toxin and support the patient  Example: Bullous impetigo
o Tetanus immune globulin (TIG) 500 units IM for  Erythema > bullae > rupture
infants. 3000-‐6000 units IM (children and adults)  *non-bullous impetigo – Streptococcus
o Alternative: Antitetanus Serum (ATS) Caution  Staph. pneumonia
(side effect) serum sickness  rapid, progressive necrotizing,
o Active immunization against tetanus should be empyema, pneumatocoeles or abscesses
started with other DTP for children <7years old or (malaking bubble sa loob ng lungs),
tetanus toxoid for older children andR adults pyopneumothorax
o Antibiotic: prevent multiplication of C.tetani and  rapidly progressive pneumonia
stop exotoxin release.  empyema (thoracic cavity)
o Recommended are Pen G and metronidazole  pneumatocoeles (bullae inside lungs)
o Aqueus Pen G: Neonates -‐100,000u/kg/day IV in 2  Septicemia
divided doses (7 days old) or 4 divided doses (>7  Meningitis following bacteremia or
days old) ; Children -‐ 100,000 unit/kg/day IV in 4 iatrogenic; brain abscess
divided doses for 10 days  Enterocolitis, endocarditis, renal
o Metronidazole: 30-‐50mg/kg/day abscess, myositis
o Alternatives: erythromycin, tetracycline (>8 years • DIAGNOSIS
old) o Gram stained smear, culture of exudates, pus,
o Wound care/debridement abscess, blood, or bone, pleural aspirate -‐ grape
o Supportive: airway -‐ tracheostomy, ventilator, like clusters
seizures -‐ use either diazepam or midazolam, o CONS-‐ pathogen or contaminant
muscle relaxant, nutrition -‐NGT feedings or TPN, o Cultures of exudates, pus and abscess, blood, bone
etc and pleural aspirate
o Good nursing care : admit to a quiet area with o CBC: moderate leukocytosis with
minimal stimuli, pulmonary toilet, bed sore polymorphonucleosis
precautions o Total WBC < 5000/mm or a PMN response, 50% =
o Tetanus-‐an "inexcusable disease" GRAVE SIGN
• Prevention and control • TREATMENT
o Tetanus is a preventable disease o Serious life threatening
o ≥ 0.01 units/ml serum antibody titer – considered o DOC: OXACILLIN 100-‐200 m/k/d
protective o CLOXACILLIN OR NAFCILLIN IV 4-‐6 div.dose
o Immunization of women with tetanus toxoid o cefazolin, Clindamycin, Amoxy-‐clav, Ampicillin,
prevents neonatal tetanus Sulbactam, Imipinem, meropenem
o Tetanus prophylaxis post injury o MRSA: VANCOMYCIN
o Skin, soft tissue infection: oral antibiotic or brief
VIII. STAPHYLOCOCCAL INFECTION parenteral followed by oral antibiotic
o Cloxacilin, cephalexin, amoxyclav
• ETIOLOGIC AGENT: S. aureus (most common) -‐ abscesses o MUPIROCIN TOPICAL; intranasal for carriers, eto
and toxin related ung mga bacitracin
o Colonizer of anterior nares
• C.O.N.S (Coagulase Negative Staph) TOXIN MEDIATED DISEASES
o *in culture, can be a pathogen or contaminant • Food poisoning = preformed enterotoxins
o S. epidermidis – dismissed as contaminants but • IP: 2-6 hours. No antibiotic needed
can cause bacteremia in NICU,
immunocompromised and in catheters and shunts TOXIC SHOCK SYNDROME TOXIN 1 (TSST1)
 normal skin flora • tampon, nasal pack, cutaneous lesion, childbirth or abortion,
 opportunistic infection (artificial surgical wound infection
medical devices) • fever, macular erythroderma (keyword: with
o S. saphrophyticus desquamation) hypotension, organ dysfunction/multi-‐organ
 UTI in young sexually active adults dysfunction
• Reservoir: Humans • associated with shock
• Skin -‐ S. Epidermidis; Anterior nares – S. aureus • DDx:
• MOT: hands, nasal discharge, infection may follow o Kawasaki disease, scarlet fever, measles,
colonization leptospirosis, strep TSS
• Direct contact • TREATMENT
• IP: variable, usually within a week o Antistaph antibiotic – oxacillin or cloxacillin to
eradicate focus of TSST 1 producing S. aureuS
o Supportive Management Sequelae: Rheumatic Fever, AGN—this is not
o
o Manage hypotension because of the bacteria anymore but because of
the immunity against the bacteria
SCALDED SKIN SYNDROME (RITTER’S DISEASE) o if you have recurrent sorethroat, you can develop
• Negative results in blood, throat, CSF, cultures rheumatic fever and if you have recurrent
• Negative for RMSF, leptospirosis, measles pyoderma, you can develop AGN
• Epidermolytic toxin or exfoliatin • TREATMENT
o DOC: BENZATHINE PEN G 600,000(<5yr old) to
• Focus infection:
1.2 M units (>5yr old) IM, single dose
• Impetigo, conjunctivitis, gastroenteritis, pharyngitis Phenoxymethylpenicillin25-‐50mg/kg/day in 4
• MANIFESTATIONS divided doses orally for 10 days
o Fever, skin tenderness o Penicillin allergic: Erythromycin, clarithromycin,
o rapid extension of brightly erythematous skin azithromycin
o large peeling epidermidis (+ Nikolsky sign) o Secondary prophylaxis in RHD
o Blister, perioral erythema o Patients diagnosed to have rheumatic fever and
o Abortive type -‐ eruption no blister those who have definite evidence of RHD should
• Complications: cellulitis, pneumonia, septicaemia be given continuous antibiotic prophylaxis
• DIAGNOSIS & TREATMENT because aymptomaticas well as optimally treated
o based on clinical grounds, skin biopsy, frozen GAS infection may trigger recurrence.
histologic exam skin o Long term prophylaxis should be initiated as soon
o Antistaph antibiotics, saline compress or burrows as the diagnosis of active RF or RHD is made
solution o Benzathine Pen G 1.2 units IM every 21 days or
o Wound care is important phenoxymethylpenicillin 200,000-‐4,000,000 units
(125-‐250mg) orally twice a day Painful IM

IX. STREPTOCOCCAL INFECTION STREPTOCOCCAL SKIN INFECTION
GROUP A STREPTOCOCCUS/ STREPTOCOCCUS PYOGENES (GAS) • MOT: Scratching insect bites, wounds or objects with dirty
• Gram (+) fingernails
• MOT: Droplet or direct contact (Skin to skin) • Most common in children under 6 years old, more common
• Age: any age but most frequent among school age (6-‐12yr in summer
old) • Impetigo or pyoderma-‐bulluous, honey colored crust
• Most common clinical illness produced by GAS is acute • non-‐bullous impetigo (pyoderma)
tonsilitis and pharyngitis • ecthyma
• Common cause of infection in URT and skin in children • cellulitis -‐ warm, tender, erythema and edema, with
• Causes distinct clinical entities like scarlet fever, erysipelas, lymphangitis and fever
strep toxic shock syndrome, and necrotizing fascitis • Erysipelas (St. Elmos fire)
• Necrotizing fascitis –gangrene(*”flesh-‐eating”)
STREPTOCOCCAL PHARYNGITIS
• Most important cause of bacterial sore throat IMPETIGO CONTAGIOSA
• Infants under 6 mos. of age -‐ Febrile nasopharyngitis (no • honey crusted, cigarette burn appearance
tonsils yet) • poor hygiene, local injury
• Children above 3 years old -‐ Acute exudative • papulovesicular
tonsillopharyngitis-‐ with tonsils • associated with Acute Glomurolonephritis
• white tonsillopharyngeal exudates with enlarged cervical • Cigarette burn appearance
lymph nodes • Papulovesicular lesion
• Bacterial or viral throat • More in lower extremities
• Strep pharyngitis -‐ no cough, cold, URI
• Bacterial pharyngitis -‐ enlarged "beefy red" tonsils with ERYSIPELAS (ST. ELMOS FIRE)
patchy exudate, palatal petecchiae – another important clue • Sharply defined, slightly elevated border, swollen, red,
• Red edematous uvula, tender anterior cervical adenopathy tender
• Tonsil or throat swabculture • Deeper layers skin and subcutaneous tissue
• DIAGNOSIS • Generalized redness
o CBC: moderate leucocytosis with • Para syang apoy na kumakalat sa ilalim ng balat
polymorphonucleosis
o Rapid diagnostic test-‐kits – ELISA base ECTHYMA
o Immunologic response to strep antigen-‐rise in • Associated with strep. pyogenes
titer 2-4weeks apart ASO titer>166 Todd units- • Produced necrotic ulcer
body is producing Antibody against Streptolysin O
• DIFFERENTIAL DIAGNOSIS CELLULITIS DUE TO GROUP A STREPTOCOCCUS
o diptheria • Acutely, rapidly spreading skin and subcutaneous tissue
o herpangiana • Abrasion, insect bite, and etc.
o infectious mononucleosis (EBV) • Inflammation of soft tissue
• COMPLICATIONS • Warm, tender, erythematous, edematous with lymphangitis
o cervical adenitis, peritonsillar (Quinsy) and fever
o retrophryngeal or pharyngeal abscess, meningitis, • DIAGNOSIS
empyema, septic arthritis,otitis media o Gram stain exudates from lesions
o sinusitis, mastoiditis, pneumonia, osteomyelitis, o Culture of pus
septicaemia

• COMPLICATIONS • DIAGNOSIS
o pneumonia, necrotizing fascitis, osteomyelitis, o Gram stain + lancet diplococci
arthritis, endocarditis o Culture (blood, body fluids and secretions)
o Non-suppurative sequelae: acute hemorrhagic o WBC (*neutrophils), leukocytosis with
glomerulonephritis neutrophilia WBC>15,000mm in infacnt increase
• TREATMENT likelihood bacteremia and positive blood culture
o Pen G or Pen V o Carrier state: culture recovery not proof of
infection
SCARLET FEVER o Capsular antigen detection (latex, ELISA)
• GAS strains with erythrogenic exotoxin • TREATMENT
• Manifestation: o Drug of choice: PENICILLIN G
o acute exudative tonsillopharyngitis o Alternative: Ceftriaxone cefotaxime, meropenem
o characteristic changes in tongue with confluent o Allergy to Pen G – erythromycin or TMP-‐SMZ
o red finely papular sand paper like rash which later o Treatment of carriers not needed
desquamates • PREVENTION
o Scarlet fever strawberry tongue or mouth -‐ o 13 valent conjugate pneumococcal vaccine
swollen tongue, magenta tongue or purple o For >2yrs old : polysacharide vaccine
o Special indication: at least 2 weeks before
TOXIC SHOCK SYNDROME 2 (STREPTOCOCCUS) splenectomy, cancer chemotherapy, radiotherapy
• Super antigen exotoxin TSST-‐2
• Focus of infection: associated with soft tissue like cellulitis, X. PSEUDOMONAS
abscess, necrotizing fascitis, may also be associated with
invasive infections • ETIOLOGIC AGENT: Pseudomonas aeruginosa
• Highest among young children, particularly those with o Gram (-‐) rod aerobe, oxidase positive
varicella o Multiply with minimal organic compounds
• TX: Penicillin + Supportive management o Strains produce pigments
o Classic opprotunist
GROUP B STREPTOCOCCUS/ STREP AGALACTIAE o Infects people w/ compromised immunity
• Common in obstetrics history and newborn baby
o Increases colonization with prolonged
important!-‐ yan ang target ng infection na to J hospitalization (Nosocomial infection)
• GBS is a part of normal maternal vaginal flora
• Produces: endotoxin, exotoxin A. exoenzyme S
• Cause: Neonatal sepsis
• Source: maternal genitalia, contaminated supplies, or septic • Important cause of nosocomial infection in children with
surrounding cystic fibrosis, neoplastic disease, extensive burn, prlonged
• MOT: transplacental, direct or indirect contact (unsterile spectrum antibiotics, immunocompromised
scissors, contaminated hands) • Most common cause of infection in burn patients
• Predisposing factors: prematurity, traumatic, septic delivery • Can be community acquired
• TYPES: • CLINICAL MANIFESTATION
o Early onset-‐critically within hours after birth with o Endocarditis,
unexplained respiratory failure and shock o Pneumonia,
o Delayed onset-‐occurs between first and twelfth o CNS infection,
weeks of life. Purulent meningitis o Chronic mastoiditis, osteomyelitis, septic arthritis
• Treatment: PEN G or AMPICILLIN with AMINOGLYCOSIDE o UTI, GIT infection,
o Skin -‐ ecthyma gangrenosum
PNEUMOCOCCAL INFECTION
o Wound with blue green pus with fruity /grape
• Upper Respiratory Tract Infection (URTI)
like odor
• ETIOLOGIC AGENT: Streptococcus pneumonia
• DIAGNOSIS & TREATMENT
o Encapsulated diplococcic; 90 seroytypes identified
o Culture -‐ blood, CSF, lung aspirate
• Part of the flora of repiratory tract
o Treatment : Carebenecillin, Ticarcillin, gentamicin,
• Transient colonizer of nasopharynx
tobramicin, amikacin ceftazidime
• Most common type of strep pneumonniae
• Most common cause of pneumonia and meningitis in
children > 5 years old REFERENCES
• Source: upper respiratory tract(many person are carriers) 1. Kliegman, Stanton, St. Geme, Schor. Nelson Textbook of
• MOT: droplet direct person-‐person th
Pediatrics. 20 ed. Philadelphia: Elsevier, 2016.
• Predisposing factors: viral respiratory disease,
2. Dra. Fajardo’s powerpoint lecture
immunodeficient, cardiac, pulmonary diseases CSF leak,
chronic renal insufficiency, Diabetes Mellitus
• This bacteria can go anywhere of the body but most
commonly in respiratory tract and CNS
• Causes:
o Acute pneumonia
o Acute otitis media
o Bacteremia in infants in 1-‐24 months, with fever
without localizing signs
o Meningitis
o Others: septic arthritis, osteomyelitis

Pediatrics 1
Bacterial Infections
Dr. Fajardo | 11 September 2018 | Topic 1 – Part 2
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– → •
→ •
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▪ → •
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Pediatrics 1
Genetics 1 and 11
Ma. Victoria M. Villarica RN, MD, DPPS, FPSECP | 14 August 2018 | Topic 2
-
-
-
-
-
-

-

-

 

 

- -
-
-
-
-
-
- -
- -
-
Transcribed by: SINGH, SHINOTSUKA, YU, SORIANO, TOLENTINO & TABJAN Page 1 of 10
PED201 GENETICS I & II T2
- -
-
- -

o -
o  α
o 


-
- -
- 
- 
- 
3.
-
-
-
-
-
-
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-
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 -

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 -
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-

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-
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- 
-
-
-
-
- 
-
-
→
-
-
-
-
- β
β - 1 out of 3,500
- Defect on the tumor suppressor gene NF-1 on chromosome 17
(neurofibromin protein – nerve cells: oligodendrocytes, Schwann
cells; tumor suppressor, keeping cells from growing and dividing
rapidly)
- Manifestations: multiple neurofibromas, café-au-lait spots, Lisch -
nodules (benign growth in the iris), optic pathway gliomas,
learning disabilities, short stature, seizures, hypertension, -
malignancies
- -
-

-
α β
-
  -
 -
  -

-
-
-
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- -
-
- α β
- β α
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Pediatrics 1
Preventive Pediatrics 2
E. Cabarles, MD | 14 August 2018 | Topic 2
–
– •
– ▪
• •
▪
▪
•
•
▪
•
▪
•
–
–
•
▪
•
– ▪
o
o
–
–
Transcribed by: Peña, Punzalan, Sison Page 1 of 5

– •
• ℞
–
–
•
–
–
–
–
– –
•
•
•
•
•
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▪
•
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–
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•
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o ≤
o ≤

o
–
o •
•
▪ •
▪
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▪ –
▪ •
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– –
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•
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–
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Pediatrics 1
Infectious Disease (Viral)
Catherine G. Gironella, MD | 13 August 2018 | Part 2
Outline
I. Paramyxoviridae Infections
A. Rubeola (Measles)
B. Subacute Scleoring Panencephalitis (SSPE)
C. Mumps (Viral Parotitis)
D. Parainfluenza Virus
E. Respiratory Syncytial Virus
F. Rubella (German Measles)
G. Congenital Rubella Syndrome (CRS)
H. Exanthem subitum (Sixth Disease, Roseola Infantum)
I. Erythema infectiosum (Fifth disease)






o

o
o
o 
o 
o o
o
o
o
→ → →
o
→
o

o
o
o
o
→ →
o
o 
o
Transcribed by: Marmar, A. Page 1 of 5

o 
o
o o
o
o
 o
   

 
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o
o
o
o

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o
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


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o
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o

Transcribed by: Marmar Page 2 of 5

 o

 o

 
 o
 o
o
o
o
o
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o
o 
o o
o
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o
o
o 
o
o o
o
o
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o 
o  
 

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o
o
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o
o
o
o

o
o

o
o
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o
o

 o
o o
o

o
 o
o
o


o

 o
o


o

o → 
→ →
o
o

 o

o
 o
o





o
o
o
o
o
o
o 
o
o →

o
 

 o



o

o

o


o
o

o

o REFERENCES
o
1. Lecture
o 2. Recordings
o
Some of the questions I remembered during our post test:
o 1. Presence of Warthin – Finkeldey giant cells? Measles
2. Koplik’s spot? Measles
3. Amount of Vit A for >12 months? 100,000 units
4. What type of MMR for children 12-15 months of age?
MMR1
5. One of its complications is Pancreatitis. Mumps
6. Presence of Forchimer spots? Rubella (German Measles)
7. Three day measles. Rubella
B
R
G
R
R

Pediatrics 1
Paediatric Therapeutics
Elena Lim-Cabarles, MD | 28 August 2018 | Topic d/dx
–
•
• –
• –
–
•
• ▪
• •
–
– •
•
•
•
–
•
▪ –
•
•
•
▪
–
–
–
•
•
•
– •
• –
• ➢
➢
–
–
–
–
–
Transcribed by: Yann, Hope, Mokong Page 1 of 3

PED201 PAEDIATRIC THERAPEUTICS T d/dx
– •
•
–
– •
–
•
•
–
•
•
•
–
–
– •
–
–
•
–
•
– •
– –
➢ •
➢
➢
➢ –
•
– • ↑ ↑
➢ –
–
–
–
•
•
–
–
–
–

PED201 PAEDIATRIC THERAPEUTICS T d/dx
–
– –
–
– •
– •
–
–
– –
• –
–
–
•
–
•
•
–
•
–
–
–
–
–
–
•
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Pediatrics 1
Viral Infections
Catherine G. Gironella, MD,| 22 August 2018 | Topic 3
Outline o
I. Herpes Virus o
A. Herpes Simplex Virus
1. Oral-facial Herpes o
B. Varicella Zoster Virus
1. Herpes Zoster (Shingles) o
2. Congenital Varicella o
3. Neonatal Varicella
C. Epstein-Barr Virus o
1. Infectious Mononucleosis
HERPES VIRUSES 
o
 o

o   o

 
o 
o 
o   
o
o 
o o
o o
o o
o


o
o
o o
HERPES SIMPLEX VIRUSES


o

o o
o
o
o
o

o
o

o 
o
 
 
 
o
o
Transcribed by: Liana Morales, Almerah Marmar Page 1 of 4

PED201 VIRAL INFECTIONS T3
o 


o o


 o

o
o
o



o
 
 



o o
o
o o

VARICELLA – ZOSTER VIRUS


o
o
o
o Notes:
Tzanck Smear – smear at the base of the vesicle

o

o o
o o
o
o
o

o
o  

o 

 



 
o
o
 →

 
o
→




o
o 
o 

o
CONGENITAL VARICELLA

o
 o
 o
o
o
o
o
EPSTEIN-BARR VIRUS
 
o 

o
o o


o

o o



o o
 o


o

o


o

o

o

o
o
o

o

o


o


o
o
o
o

o
o
o
 

o
o
REFERENCES
1. Dr. Gironella’s Lecture

2. Recordings

Pediatrics 1
Burn Injuries in Children
MARIETTA M. DIAZ,MD, FPPS, FCNSP, MAeD SPED | 6 September 2018
Outline and the absence of laws and regulations relating to building
I. What is a burn? codes, smoke detectors and flammable clothing.
A. Morbidity and Mortality
B. Approaches to Reducing Burns
C. Epidemiology and Risk PROVEN EFFECTIVE APPROACHES TO REDUCING BURNS
D. Mechanism of Injury – Establishing and enforcing legislation requiring the installation
II. Classification of Burn Injury
III. Clinical Examination and Evaluation of working smoke alarms on all levels, including the sleeping
IV. Management of Burns areas, of homes., regulation of temperature from household
taps
WHAT IS A BURN? – Developing and enforcing standards for the design and
– A burn is defined as an injury to the skin or other human provision of child-resistant lighters.
tissue caused by heat. It occurs when some or all of the cells – Establishing, operating and maintaining dedicated burn
in the skin or other tissues are destroyed by hot liquids centres to attain better outcomes and less costly
(scalds), hot solids (contact burns), or flames (flame burns). management
Injuries from radiation, radioactivity, electricity, friction or
contact with chemicals are also regarded as burns.
RESIDENTIAL BURN INJURY PREVENTION
RECOMMENDATIONS
SCALE OF THE PROBLEM: MORTALITY
– In the kitchen
– Globally, nearly 96 000 children under the age of 20 were  Turn pot handles toward the back of the stove.
fatally injured as a result of a fire-related burn
 Purchase a stove with controls on the front or side to
– The death rate in low-income and middle-income countries is
reduce the likelihood of clothing ignition as one reaches
eleven times higher than that in high-income countries – 4.3
per 100 000 as against 0.4 per 100 000. across the hot elements.
 Place a screen around any heating appliance to
– Most of the deaths occur in poorer regions of the world –
Africa and South-East Asia, and the low-income and middle- function as a barrier.
income countries of the Eastern Mediterranean Region. – In the home:
 Adjust the thermostat setting on the water heater to
– Studies from high-income countries suggest that smoke
produce a temperature no higher than 48.8°C.
inhalation is the strongest determinant of mortality from burns,
 Install water temperature-regulating valves (anti-scald
mostly from fires in the home. For children over three years of
age, smoke inhalation is strongly associated with mortality, device) that obstruct the flow of water when the water
temperature exceeds a preset level.
despite improvements in the care of burns.
– Infants have the highest death rates, while those aged 10 -
14 years have the lowest. The death rate climbs again for 15– PREVENTION TIPS
19 year olds. – Be alarmed. Install and maintain smoke alarms in your home
– Burns are the only type of unintentional injury where females – Have an escape plan.
– Cook with care. Use safe cooking practice,
have a higher rate of injury than males. The fire related death – Check water heater temperature. Set your water heater’s
rate for girls worldwide is 4.9 per 100 000 population versus thermostat to 120 degrees Fahrenheit or lower. Infants who
3.0 per 100 000 for boys aren’t walking yet can’t get out of water that may be too hot,
and maintaining a constant thermostat setting can help
SCALE OF THE PROBLEM: MORBIDITY control the water temperature throughout your home—
preventing it from getting too high.
– Scalds and contact burns are an important cause in overall
morbidity from burns, and a significant cause of disability
EPIDEMIOLOGY AND RISK
– In high-income countries, children under the age of five have
– Bimodal distribution- 0-4 yrs; adolescents
the highest rate of hospitalization from burns, followed by 15–
– Boys are also more likely to incur injury than girls
19-year-olds. Nearly 75% of burns in young children are from – The majority of these injuries occur in the home
hot liquid, hot tap water or steam. Infants under the age of one – Other causes of injury are contact with hot surfaces such as
run a significant risk from burns, even in developed countries. oven doors, fireplace screens, irons and hair care products.
– Burns place a heavy economic load on health-care services – In developed countries, scalds and contact burns are the
most common mechanisms, whereas in developing countries
cooking fires gain primacy
RISK FACTORS
– Cases of child abuse -6-20% of all abuse cases, severe burns
– Gender- females> males are reported in an estimated 10% of all children suffering
– Income level – low income> high income physical abuse
– Heating and lighting sources – Exposure to electricity -2-10% of burn centre admissions, but
– Flammable substances these injuries may often result in amputation
– Fireworks – In relation to the home environment, most burns occur in the
– Socio-economic factors-low rate of literacy overcrowded kitchen
– Inhalation injury-the single most important predictor of
dwellings or with cluttered areas in the home; failure to
mortality in burn victims and occurs in 50% of children less
properly supervise children; a history of burns among siblings; than 9 years old involved in home fires other important
Transcribed by: GAC Page 1 of 6

PED201 BURN INJURIES IN CHILDREN T1
predictor of death is deficiency or delay in resuscitation which

has been measured as length of time to intravenous access.
– Respiratory failure and sepsis are the leading causes of death
in severely burned children, with acute lung injury and
respiratory distress syndrome (ARDS) accounting for.
MECHANISM OF INJURY
– Injuries in pediatric patients are the result of behavior that can
be intuitively related to developmental stages and
epidemiology data. Toddlers, in which the highest overall rate
of injury exists, are becoming mobile and are actively
searching their physical environment.
– When motor skill development outpaces cognitive
development, disaster may result
– Skin damage may result from a variety of different
mechanisms whereby temperatures in excess of
approximately 49ºC causes cellular damage, though the
exact temperatures required depends on contact time.
– Young children are mentally inquisitive and physically
unstable and they sustain burn-related injuries having applied
downward traction on cords or handles in the kitchen.
– Contact with hot objects is the second most commonly
occurring burn mechanism in small children, 5and in order to
sustain a burn either the temperature must be extremely high
or the contact abnormally long
– Children posses the motor function to strike a match or lighter
but lack the cognition to comprehend the danger involved
CLASSIFICATION OF BURN INJURY

– According to degree of severity
 First degree
 Second degree
 Third degree
 Fourth degree
– According to depth of injury
 Partial thickness
 Full thickness BURN INJURY CLASSIFICATION ACCORDING TO DEPTH OF
INJURY:

Edema formation after burn injury to the face and neck. Edema
worsens over the first 24 to 48 hrs after injury.
CLOCKWISE FROM LEFT: (A) FIRST-DEGREE BURN, (B) CLOCKWISE FROM LEFT: (A) 3 hrs after burn; (B) 8 hrs after;
SECOND-DEGREE BURN, (C AND D) THIRD-DEGREE BURN (C) At 24 hrs, when edema has typically maximized; (D)
Complete healing after 40 days
BURN ASSOCIATION SEVERITY CLASSIFICATION FOR BURN

INJURIES
PARTIAL THICKNESS BURN INJURY (SECOND DEGREE

BURN)
FULL THICKNESS BURN INJURIES (THIRD DEGREE BURN)

THERMAL INJURY
– Children less than 6 years old have thinner skin than do older
children and adults and they are therefore at higher risk for
burn injury even when exposure time is short
– Causal and physical characteristics define the features of a
scald
– The classifications of burns commonly grade depth as first,
second or third degree
ELECTRICAL INJURY
– Usually occur at home
– 2 groups- low ( infants, at home)and high (adolescents, power
lines, lightening strikes)voltage
– Major damage concealed, visible areas are necrotic tissues
– Thermal injuries seen following electrical exposures vary in
proportion to the degree of electrical current.
– Other factors that determine the nature of the injury are type
of current and path of flow through the body-alternating and
flash current
– Sequelae - muscle necrosis, vascular damage, compartment CLINICAL EXAMINATION AND EVALUATION
syndrome
– Regardless of the etiology of the burn, the initial assessment
CHEMICAL INJURY should first include airway, breathing and circulation
– Fluid resuscitation must be commenced as soon as possible
– The mechanism of tissue damage is usually a direct chemical
reaction although the former may result from an exothermic – Estimations in pediatrics can be undertaken using the Lund
and Browder chart, or more simply by using the child’s palm,
reaction.
– Acid burns produce a coagulative necrosis, alkaline products including fingers, as a representation of 1% TBSA in all ages
result in liquefactive necrosis of tissues – Head-to-toe assessment
– First aid is paramount and involves removal of contaminated – Additional monitoring
clothing, copious irrigation regardless of the type of chemical
burn to topical exposures and dilution in the form of a glass of MANAGEMENT OF BURNS
water for chemical ingestions – Fluid Resuscitation Formulas Used in Burn Care
– Energy Calculation Formulas Used for the Burn-Injured
INTENTIONAL INJURY – Topical Antimicrobial Agents Used in Burn Care
– Confirmed or suspected burn injuries- 10-12% – Temporary Wound Covering Used in Burn Care
– More extensive and severe18with longer hospital stays and – Infection control
increased intensive care admissions.
– Acute family stress and lack of external support powerful ENERGY CALCULATION FORMULAS USED FOR THE BURN-
precipitants of intense frustration and compounded in low-
income, single parent families of multiple children. INJURED
– Clinical features often distinguish intentional from
unintentional burns and assessment is grounded in a
thorough history and physical examination together with
observation of parental behavior and parental-child
interaction.
SELF-INFLICTED INJURY
– Associated often with intolerable situations involving a
perceived loss of control and over-whelming the patient’s
ability to cope
– Common findings in the history of a patient with self-inflicted
burns are previous psychiatric problems, often depression or
borderline personality disorder, a failed suicide attempt or
poor response by others to suicide ideation and a recent life
stress.
INHALATION INJURY
– The airway should be evaluated immediately for potential
compromise when smoke inhalation injury is suspected in any
burned patient
– 5Consequent edema may not be apparent until 48 hours after
a burn and subsequent intubation is under the most difficult
circumstances
– All patients who are victims of house or indoor fires should be
evaluated for carbon monoxide toxicity

FLUID RESUSCITATION FORMULAS USED IN BURN CARE
TOPICAL ANTIMICROBIALS USED IN BURN CARE

TEMPORARY WOUND COVERING USED IN BURN CARE

BASIC PRINCIPLES OF INFECTION CONTROL

1. Thorough and-washing should be done before and after each
contact with the burn-injured client.
2. Protective garb (aprons or gowns) should be donned before
each contact and promptly discarded after leaving the bedside
or room.
3. Gloves should be changed when they become contaminated
with secretions or fluids from one anatomic site before contact
with another site.
4. Equipment, materials, and surfaces are considered
contaminated for the individual client and should be properly
decontaminated before use with another client.
COMPLICATIONS OF BURNS
Model is wearing a custom-fitted antiscar support garment.

When word 23 hrs a day, this garment is effective in providing
pressure over healing burn wounds. Pressure therapy helps to
minimize the development of hypertrophic scarring.
REFERENCES
1. Doc Diaz’s ppt
HARVESTING DONOR SKIN FROM THE LATERAL PORTION

OF THE CLIENT’S THIGH

Pediatrics 1
Near Drowning in Children
Dra. Marietta Diaz | 13 September 2018 | Topic 4
NEAR DROWNING IN CHILDREN D. PATHOPHYSIOLOGY OF DROWNING
I. DEFINITION
A. CAUSES OF NEAR DROWNING
B. SYMPTOMS OF NEAR DROWNING
C. INCIDENCE OF NEAR DROWNING
D. PATHOPHYSIOLOGY OF DROWNING
E. MANAGEMENT OF PEDIATRIC DROWNING
F. PREVENTION OG INJURY
I. DEFINITION
– Near-drowning is a term used to describe almost dying from
suffocating under water.
– It is the last stage before actual drowning, which often results
in death.
– Near-drowning victims still require medical attention to
prevent related health complications.
A. CAUSES OF NEAR DROWNING
1. An inability to swim
2. Panic in the water
3. Leaving children unattended near bodies of water
4. Falling through thin ice
5. Alcohol consumption while swimming or on a boat
System Features
6. Concussion or seizure while in water
7. Suicide attempt PULMONARY o Apnea
o Fresh water: surfactant
washout and
B. SYMPTOMS OF NEAR DROWNING
atelectasis
 Cold or bluish skin o Salt water: pulmonary
 Abdominal swelling edema
 Chest pain o V/Q mismatch and
 Cough shunt
 Shortness or lack of breath NEUROLOGIC o Cerebral ischemia
 Vomiting caused by hypoxia
 Unconsciousness o Cerebral edema and
increased ICP
C. INCIDENCE OF NEAR DROWNING CARDIOVASCULAR o Bradycardia
o Increased SVR
o Decreased cardiac
output
ELECTROLYTES o Metabolic acidosis
o Significant electrolyte
changes are rare

PED201 NEAR DROWNING IN CHILDREN T4
E. MANAGEMENT OF PEDIATRIC DROWNING F. PREVENTION OF INJURY
– Dependent on the age of the child

– The site of submersion
– Circumstances surrounding the event.
Newborn Infants and Children through 4 Years of Age

– Never leave children alone even for a moment
– remove all water from containers
– attention of the supervising adult should be focused on the
child
– Parents, caregivers, and pool owners should learn CPR and
keep a telephone and equipment approved
Children 5 to 12 Years of Age

– Children need to be taught to swim
– Know the various safety requirements for swimming in natural
bodies of water, such as lakes, streams, rivers, and oceans
– Children need to be taught never to swim alone and never to
swim without adult supervision.
– Children should be required to use an approved personal
flotation device whenever riding in a boat or fishing
– When swimming or taking a bath, children with seizure
disorders should be supervised closely by an adult at all times
Adolescents 13 to 19 Years of Age

– In addition to the topics listed for children 5 to 12 years of age,
pediatricians should counsel adolescents about the dangers of
alcohol and other drug consumption during aquatic recreation
activities
– Boys are at much higher risk of water-based injuries than are
girls, they warrant extra counseling.
– Adolescents should learn CPR
B
R
G
R
R

Pediatrics 1
PREVENTIVE PEDIATRICS PART 3
| AUGUST 2018 | Topic 3: IMMUNIZATION
Outline Note:
I. Principles of Immunization From Dra’s Discussion:
A. Immunization
B. Types of Immunization – Immunization is a moment’s cry for the baby but it is for his/her own
1. Active benefit.
2. Passive – Recall: Acquired and Adaptive Immunity
II. Classification of Immunization
A. Live-attenuated – In acquired immunity, it’s either active or passive.
B. Inactivated – Under active you can either get it through infection (natural) or
C. Polysaccharied immunization (passive).
III. Schedules and Administration Concerns
A. Lapsed Immunization – Under passive, you can either get it through maternal antibodies via
IV. Vaccinatiion breastmilk, mainly in the colostrum, (active) or gamma globulin/
A. 17 preventable diseases immunoglobulin (passive).
B. Available for Hirh Risk Group Vaccines
C. Contraindications to all vaccines – The predominant antibody seen in mother’s breastmilk is IgA. It is
D. Contraindications to all Live vaccines different from the antibody that crosses the placenta which is IgG.
F. Simultaneous Administration of multiple vaccines
V. Polysaccharide vaccines
a. Contraindications to all vaccines B. Types of Immunization
b. Contraindications to all Live Vaccines
c. Simultaneous administration of Multiple VaccinesLapsed immunization 1. Active Immunization
VI. Vaccines Included in the National Immunization Program
a) BCG Vaccine – Stimulation of endogenous antibody production by the patient (ex.
b) DPT Vaccine Tetanus toxoid)
c) Poliomyelitis
d) Hepatitis B Vaccine – Mediated primarily by B lymphocytes, which produce antibodies that
e) Measles Vaccine can
f)
g)
MMR Vaccine
Hib  Inactivate toxins
h) Rotavirus  Neutralize viruses by preventing their attachment to cellular
VII. Vccines Not Included in the National Immunization Program
a) Hepatitis A
receptors
b) Varicella Vaccine  Facilitate phagocytosis and killing of bacteria
c)
d)
Influenzae Vaccine
Pneumococcal Vaccine
 Interact with complement to lyse bacteria
e) Typhoid  Prevent bacterial adhesion to mucosal surfaces by interacting
f) HPV with their cell surface
VIII. Vaccines for Special Cases
a) Rabies – IgM serum antibodies can be detected about 7-10 days after injection
b) Dengue of antigen, tending to decline as IgG antibodies increase and peak
c) Cholera
d) Meningococcal approximately 1 months after
e) PCV / PPSV
f) Yellow Fever
g) Japanese Encephalitis
IX. Expanded Program on Immunization
I. PRINCIPLES OF IMMUNIZATION
A. Immunization
– provision of an individual with antibodies possessing power to
destroy or inactivate the disease-producing agent, or to neutralize its
toxins - Textbook of Pediatrics and Child Health by del Mundo et al
– Process of inducing immunity against specific disease by vaccination
– A moment’s cry in the name of prevention
– One of the key elements of your pediatric well child visit
– Vaccines used in ACTIVE immunization:

 Whole microorganism
 Dead or inactivated (Pertussis vaccine)
 Alive but attenuated (trivalent oral Polio vaccine)
 Component of the microbe which includes only the known
antigenic portion
 acellular pertussis vaccine and the recombinant DNA
hepatitis B vaccine
 Toxoids which are detoxified
 Tetanus toxoid
Transcribed by: Page 1 of 8

PED201 IMMUNIZATION T4
Note: II. CLASSIFICATION OF IMMUNIZATION

From Dra’s Discussion:
– IgM antibodies tend to go down. In this reason, you receive dose A. Live-attenuated microorganisms:
interval shots and booster shot. – Viruses
– IgG level stay for a longer period of time as compared to IgM.  rotavirus, measles, mumps, rubella, varicella, OPV, yellow
– Microorganisms used in active immunization can be given as fever
whole or portion but killed, live-attenuated or toxoids.
– Bacteria
 Bacille-Calmette Guérin, oral typhoid
2. Passive Immunization – Tend to induce long-term immune responses in 1- or 2-dose
– Administration of preformed human or animal antibodies to
schedules
individuals already exposed or about to be exposed to certain – Active replication ensues after administration, similar to natural
infections but modified, and little or no adverse host effect expected
infectious agents (ex. Giving of tetanus or other anti-toxins)
– Evoke more effective and longer lasting immunologic responses than
– Administration of preformed antibodies to induce transient
protection against an infectious agent inactivated
– Can also be induced naturally through transplacental transfer of – Contraindicated in:
antibodies during gestation  Pregnant women
 In immune deficiency states
Note:  Suppressed immune system (because of treatment of
From Dra’s Discussion: leukemia, malignancy, therapy with steroids, antimetabolites,
– Example: A mother was not sure if she had rubella vaccine or
radiation, alkylating agents)
German measles during her childhood days. During her pregnancy,
she got exposed to a person with the disease. The mother will not be
affected but rather the baby. So, advice the mother to receive gamma Note:
globulin/ immunoglobulin to protect her baby from congenital From Dra’s Discussion:
rubella syndrome. – Yellow fever vaccine is not included in the expanded program of
– Triad of Congenital Rubella Syndrome: Deafness, Cataract and immunization (EPI)
Congenital Heart Disease  Indication: Person travelling in a yellow fever-endemic area
– Oral typhoid nowadays is not available. Only injectables are available.
B. Inactivated microorganisms:
– Whole organisms:
 Viral - IPV, hepatitis A, rabies, cholera
 Bacterial – Pertussis
– Parts of organisms: acellular pertussis, influenza
– Modified products of organisms
 Toxoids: tetanus, diphtheria
 Polysaccharide capsules: pneumococcal, typhoid,
meningococcal
 Polysaccharide capsules conjugated to protein carriers: Hib
(Haemophilus influenzae Type B), pneumococcal,
meningococcal conjugate vaccines
 Genetically engineered subunits: hepatitis B, HPV
Note:
– Tend to require multiple doses to induce an adequate immune
– Active Natural: Infection response (booster doses)
 Example: – Mucosal protection after administration generally inferior than
 Chickenpox – when you get infected with this, you induced by live-attenuated vaccines but still high efficacy against
won’t be infected for the second time because you have invasive infection
produced antibodies against it. If you get along with a
person infected with chickenpox and your immunity is
– Viruses and bacteria in inactivated vaccines cannot replicate or be
low, you’ll get shingles rather than chickenpox. excreted by recipients as infectious agents so do not present same
 Measles safety concerns for immunosuppressed vaccines or contacts of
– Active Artificial: Vaccination vaccines
– Natural Passive: Maternal antibodies through breastmilk
– Artificial Passive: Immunoglobulin
C. Polysaccharide Vaccine
– A type of inactivated subunit vaccine composed of long chain of
sugar molecules that make up the surface of certain bacteria
– The immune response to pure PS vaccine is T-cell independent,
therefore not immunogenic in children<2 years of age
 Examples: pneumococcal, meningococcal & typhoid
polysaccharide vaccines
– Repeat dose of PS vaccine do not cause a booster response;
predominant antibody produced in response to PS vaccine is IgM
– Conjugation of PS vaccine with a protein molecule changes the
immune response from T-cell independent to T-cell dependent-
Transcribed by: Yani OH, K. Pernecita, J. Ragadi & M. Serrano Page 2 of 8

increased immunogenicity in infants & booster response; Hib A, – Varicella (Chickenpox)
Pneumococcal & Meningococcal conjugate vaccine – Pneumococcus (PCV 13)
– Meningococcus
– Influenza
– Human Papilloma Virus (HPV)
– Japanese B encephalitis
B. Available Optional or for High Risk Group Vaccines

– Rabies
– typhoid
– Dengue
– cholera
– meningococcal
– pneumococcal polysaccharide vaccines
Note:
– If you have a lot of pets specially dogs at home, you better get an
III. SCHEDULES AND ADMINISTRATION CONCERNS anti-rabies shot.
– Schedules:
 Inactivated vaccine that are different--‐ no interval needed. It
D. Contraindication to ALL VACCINES:
can be given one after the other
 Hep B – Serious allergic reaction (anaphylaxis)
 Live parenteral vaccine--‐ 28 days or 4 weeks interval
 Chicken pox, MMR E. Contraindication to ALL LIVE VACCINES:
 Same inactivated vaccine--‐ 1month interval or 28 days before – Immunocompromised patients
you give the next vaccine – Patients given immunoglobulin and blood products for the past 3
 Oral Vaccine and Parenteral live vaccine--‐ no interval needed
months
 Inactivated vaccine and live vaccine--‐ no interval needed
– Pregnancy and possibility of getting pregnant within 3 months
– Concerns: – Household contacts of immunocompromised patients (OPV)
 Every visit should be an opportunity to update the child’s
immunization Note:
 For females of childbearing age, before you give live From Dra’s Discussion:
immunizations, you have to warn them that they cannot get – OPV is excreted in the feces. So, you cannot give an individual an
pregnant until 3 months after. OPV if he/she handles immunocompromised patients because he/she
 Pregnant women and immunocompromised children cannot be might transmit the infection to them.
immunized with live vaccines
 Those who have allergies to the components of the vaccine or F. Simultaneous administration of MULTIPLE vaccines:
the vaccine itself cannot be immunized also. – No contraindication for multiple vaccines routinely recommended
– Immune response to one vaccine generally does not interfere with
A. Lapsed Immunizations: other vaccines
– In general, intervals between vaccine doses that exceed those that are – There should be an interval of 28 days between administration of live
recommended do not adversely affect the immunologic response vaccines
provided immunization series is completed
V. POLYSACCHARIDE VACCINES
IV. VACCINATION – A type of inactivated subunit vaccine composed of long chain of
– Administration of a vaccine either oral or injection in the form of: sugar molecules that make up the surface of certain bacteria
 killed pathogen – The immune response to pure PS vaccine is T-cell independent,
 An attenuated form therefore not immunogenic in children<2 years of age
 a portion of the pathogen
 Examples: pneumococcal, meningococcal & typhoid
– Types of protection induced:
polysaccharide vaccines
 Complete protection for life
 Partial protection (booster doses) – Repeat dose of PS vaccine do not cause a booster response;
predominant antibody produced in response to PS vaccine is IgM
A. 17 Vaccine Preventable Diseases – Conjugation of PS vaccine with a protein molecule changes the
– Tetanus immune response from T-cell independent to T-cell dependent-
– Diphtheria increased immunogenicity in infants & booster response; Hib A,
– Pertussis (Whooping Cough) Pneumococcal & Meningococcal conjugate vaccine
– Hemophilis influenza type b (Hib)
– Polio Contraindication to ALL VACCINES:
– Hepatitis A
– Serious allergic reaction (anaphylaxis)
– Hepatitis B
– Rotavirus
– Mumps
– Measles
– Rubella (German Measles)

Usual Reaction vs Accelerated Reaction
Contraindication to ALL LIVE VACCINES:

– Immunocompromised patients Usual reaction Accelerated Reaction
– Patients given immunoglobulin and blood products for the past 3 – induration: 2-4 wks – induration: 2-3 days
months – pustule : 5-7 wks – pustule : 5-7 days
– Pregnancy and possibility of getting pregnant within 3 months – scar formation: 2-3 months – scar formation: 2-3 weeks
– Household contacts of immunocompromised patients (OPV)
B. DPT (DIPHTHERIA, PERTUSSIS, TETANUS)
Simultaneous administration of MULTIPLE vaccines: – DTaP
– No contraindication for multiple vaccines routinely recommended  DT are toxoids
– Immune response to one vaccine generally does not interfere with  aP is acellular pertussis
other vaccines – DTP or DTwP
– There should be an interval of 28 days between administration of live  DT are toxoids
vaccines  P is killed or inactivated whole cell pertussis
– Given intramuscularly (IM)
Lapsed Immunizations: – Given at a minimum age of 6 weeks with a minimum interval of 4
– In general, intervals between vaccine doses that exceed those that are weeks
recommended do not adversely affect the immunologic response – The recommended interval between 3rd and 4th dose is 6 months but a
provided immunization series is completed minimum of 4 months is valid.
– Fully immunized children should be given Td booster doses every
10 yr, a single dose Tdap can be given in place of due Td dose
VI. VACCINES INCLUDED IN THE NATIONAL
regardless of interval since last Td containing vaccine
IMMUNIZATION PROGRAM – Fully immunized defined as 5 doses of DTP or 4 doses of DTP if 4 th
A. BCG VACCINE dose administered on or after 4 th birthday
– Bacillus- Calmette Guarin – For fully immunized pregnant adolescent, administer 1 dose of
– Live attenuated bacterial vaccine Tdap after 20 wk AOG
– Given intradermally (ID) – For unimmunized pregnant adolescent, give 3-dose series Td/Tdap
– Given at earliest possible age after birth preferably within the first 2 at 0-1-6 mo, Tdap should replace 1 dose of Td given preferably after
months of age 20 wk AOG
– The dose of BCG is 0.05ml for children <12 mos and 0.1ml for – Catch-up Vaccination: 5th dose may not be given if the 4 th dose was
children > 12 months of age administered at age 4 years or older
– For healthy infants and children > 2months who are not given the
Usual Side Effects:
BCG at birth, PPD prior to vaccination is not necessary. However,
PPD is recommended prior to BCG vaccination if any of the – fever up to 72 hours (low to moderate grade)
following is present: – restlessness and irritability
 Suspected congenital TB – local reaction: pain and swelling at the site of injection
 History of close contact to known or suspected infectious
Contraindications:
TB
– continuous high-grade fever within 48 hours after injection
 Clinical and/or CXR findings suggestive of TB
– ongoing neurologic illness
– In presence of any above conditions, PPD >5 mm induration is
– moderate to severe illness with fever
considered positive
– previous adverse reaction to a previous dose
Contraindications:
Adverse Reaction:
– immunodeficiency
– fever greater than 40 0C 48 hrs after administration
– Progressive dermatoses
– seizures within 3-7 days of administration of a previous dose
Adverse Reaction: – persistent inconsolable crying lasting for 3 hours and within 48 hrs
after receiving the vaccine
– abscess at the site
– progressive neurologic disorder (encephalopathy)
– axillary lymphadenopathy
– keloid scar
– suppurative regional adenitis C. POLIOMYELITIS VACCINE
– disseminated BCG infection & osteomyelitis in – 2 types:
immunocompromised 1. OPV- live attenuated (Sabin)
2. Inactivated or killed/ Salk vaccine (IPV)
– OPV given per orem (PO)
– IPV given intramuscularly (IM)
– Given at a minimum of age of 6 weeks with a minimum interval of 4
weeks.
– The primary series consists of 3 doses.
– Catch-up Vaccination:

– For children given OPV series, single dose IPV should be given E. MEASLES VACCINE
with 3rd dose OPV
– Live attenuated
– Final dose (2nd booster) should be given on or after the 4 th
– 0.5ml given subcutaneously (SC)
birthday and at least 6 months from the previous dose.
– given at 9 months but may be given as early as 6 months during
epidemics
ORAL POLIO VACCINE Absolute Contraindications:
– altered immune states (malignancies, lymphoma, leukemia), therapy Adverse Reaction:
with alkylating agents, high dose steroids
– fever with or without rashes ( 5-12 days after administration)
– pregnancy
– hypersensitivity reaction
– household contacts of immunocompromised patients
Contraindication:
ORAL POLIO VACCINE Relative Contraindications:
– immunocompromised state
– vomiting
– pregnancy
– diarrhea
Relative Contraindications:
ORAL POLIO VACCINE Adverse Reaction:
– untreated active TB
– paralysis
F. MEASLES-MUMPS-RUBELLA (MMR)
INACTIVATED POLIO VACCINE (IPV/ Salk) VACCINE
– Recommended to decrease incidence of VAPP (vaccine associated – Live attenuated
paralytic polio) – given subcutaneously (SC)
– given at a minimum age of 12 months but may be given at an earlier
D. HEPATITIS B VACCINE age if recommended by public health authorities.
– Inactivated viral vaccine – Two (2) doses of MMR are recommended (2-dose series)
– Given intramuscularly (IM) – The minimum interval between doses is at least 4 weeks with 2nd
– The first dose should be given at birth or within the first 12 hours of dose usually at 4-6 yr old but may be given earlier
life. The minimum interval between doses is 4 weeks. The final dose – Children below 12 months of age given any measles containing
is administered not earlier than age 24 weeks. Another dose is needed vaccine (Measles, MR, MMR) should be given 2 additional doses
if the last dose was given at age <24 weeks. – Catch-up Vaccination:
– 0,1,6 months  Ensure that all school aged children and adolescents have had 2
– 4th dose is given if: doses of MMR vaccine; the minimum interval between the 2
• 3rd dose is given at <24 weeks of age doses is 4 weeks
• Preterm infant (<2 kg)
MMR Reactions:
• Mother is Hepa B Positive
– Preterms: – fever with or without rashes (5-14 days after administration –
• Infants >2 kg and stable may receive a birth dose Measles)
• If born to HBsAg (-) mother and <2 kg at birth, HBV deferred – fever, swelling of parotid gland – Mumps
until 30 days of age – Fever, mild rash, transient arthritis or arthralgia, post auricular
• Another dose needed for <2 kg if 1 st dose received at birth lymphadenopathy - Rubella
• If born to HBsAg (+) mother, all preterm LBW should receive
Reasons for giving 2 doses of MMR:
HBV and HBIg within 12 hr of birth but should receive
additional 3 doses starting 30 days of age – Only 87-90% of children actually receive the measles vaccine
– If mother is HBsAg (+): – 5% of children who receive the first vaccine won’t develop immunity
• give HBIg (0.5ml) and HepB#1 within 12 hours after birth. HBIg – Children who had an immune response to the first dose could get a
should be administered not later than 7 days of age, if not “booster’ effect
immediately available G. ROTAVIRUS
• HepB#2 @1month • Given per orem (PO)
• HepB#3 @6months • 2 currently available are interchangeable for dosing
Catch-up Vaccination: – RotaTeq® (RV5)
 Unvaccinated persons should complete a 3 dose-series – Rotarix® (RV1)
 A 2-dose series (doses separated at least 4 months) of adult • Narrow administration window
formulation Recombivax HB is licensed for use in children aged – First dose must be before 15 weeks
11 through 15 years. – Last dose must be before 8 months
Adverse Reaction: Precautions:

– Rare: arthralgia, neurologic reactions – Moderate or severe acute illness with or without
– Local reactions: soreness, erythema and swelling fever
– Immunosuppression
– Receipt of an antibody-containing blood product
within 6 weeks

– Pre-existing gastrointestinal disease VII. VACCINES NOT INCLUDED IN THE NATIONAL
– Previous history of intussusception
IMMUNIZATION PROGRAM
– Because most severe cases of rotavirus gastroenteritis
occur earlier in life, vaccination of children older than A. Hepatitis A Vaccine
24 months is not encouraged. – Inactivated viral antigen
– recommended for universal administration to all children at 12
Rotavirus Vaccines through 23 mo of age and for certain high-risk groups
– given to children 1 year and above
RotaTeq (RV5) – 2 doses, 6 months apart
Rotarix (RV1)
– Children who have received 1 dose of hepatitis A vaccine before 24
– 5 reassortant live rotaviruses – Live human rotavirus strain mo of age should receive a 2nd dose 6-18 months after the 1st dose
from 5 human and 1 bovine G1P1A – For anyone 2 yr of age or older who has not yet received the 2 dose
strain – 2-dose series hepatitis A vaccine series, 2 doses of vaccine separated by 6-18 mo
– 3-dose series • 2, 4 months may be administered if immunity against hepatitis A infection is
• 2, 4, 6 months – Requires reconstitution desired
• The 1st dose should be – 85% efficacy against severe – Indications:
gastroenteritis a) persons travelling to endemic areas
administered between 6
and 12 wk of age, with b) occupational hazards
c) Hemophiliacs – contacts of infected persons
all 3 doses completed
by 32 wk of age.
B. Varicella Vaccine
– Primary efficacy of 98%
– Live attenuated
against severe rotavirus
– routinely given at 12-15 months but can be given as early as 9
gastroenteritisPre-filled months
(ready to dose) – Can be given within 5 days after exposure
– can develop shingles but less frequent and less severe
CDC states no preference between formulations
C. Influenzae Vaccine
– Inactivated vaccine
H. Hib – present schedule, excluding in influenza vaccine, can require as many
• Haemophilis Influenzae Type B Conjugate Vaccine (HiB) as 34 doses, including 31 that must be administered by injection
• Vaccine Against invasive Hemophilus influenzae type B – 25 are recommended prior to 2 yr of age, including 22 injections
• 40% of diseases occur at 18 months or older – starting at 6 months of age, can add an additional 20 injections
• Given Intramuscularly (IM) through 18 years of age
• Schedule: Minimum age start 6 wk, – Ideally should be given before the start of flu season Feb-June,
3-dose primary series anually
at least 4 wk apart D. Pneumococcal Vaccine
 Booster dose given between 12-15 mo of age with interval of 6 – Indicated for children with high risk medical conditions: chronic
mo from 3rd dose heart, lung, kidney disease, DM, CSF leak, cochlear implant, sickle
cell disease and other hemoglobinopathies, anatomic/functional
Catch Up vaccination
asplenia, HIV, and congenital immunodeficiency,
 If dose 1 was administered at ages 12 through 14 months, immunosuppression, malignancy, and solid organ transplantation.
administer a second (final) dose at least 8 weeks after dose 1, – Children >2 to 5 yr old:
regardless of Hib vaccine used in the primary series. o Incomplete 3 doses any PCV, 1 dose PCV13
 If both doses were PRP-OMP (PedvaxHIB or COMVAX), and o Unvaccinated, 2 doses PCV13 at least 8 wk apart
were administered before the first birthday, the third (and final) o Complete or 4 doses PCV7 given previously, supplemental 1
dose should be administered at age 12 through 59 months and at dose PCV13
least 8 weeks after – No history of receiving PPSV give PPSV at least 8 wk after most
 the second dose.
recent PCV13
 If the first dose was administered at age 7 through 11 months,
administer the second dose at least 4 weeks later and a third (and E. Typhoid Vaccine
final) dose at age 12 through 15 months or 8 weeks after second – Minimum age start 2 yr; revaccination every 2-3 years.
dose, whichever is later. – Available: oral live attenuated and IM inactivated
 For unvaccinated children aged 15 months or older, administer – Recommended for travelers to areas where there is risk of exposure and
only 1 dose. for outbreak situations as declared by public health authorities
One dose should be considered for unimmunized children aged
F. HPV Vaccine
>5yr with sickle cell disease, leukemia, HIV infection or who
 Inactivated vaccine
had splenectomy  3 dose series of HPV vaccine to all adolescents 11 through 12 yr of
age (Nelson)
 Either HPV4 or HPV2 is recommended in a 3 dose series to females,
and only HPV4 in the same schedule is recommended for males
 The vaccine series can be started at 9 yr of age
 Administer the 2nd dose at 1-2 months after the 1st dose, and the
3rd dose 6 months after the 1st dose (at least 24 wk after the 1st
dose)
 Given from 9-26 years old at 0, 1 and 4 months

VII. VACCINES FOR SPECIAL CASES C. Cholera

– Minimum age start 1 yr,
A. Rabies
– 2-dose series 2 wk apart
– Vaccines anti-Rabbies are cell culture-based preparations
– Bivalent inactivated vaccine containing killed whole cells of V.
consisting og inactivated viruses in cell cultures or embryonated cholerae 01 and V. cholerae 0139
eggs. – Recommended for outbreak situations and natural disasters as
o HUMAN DIPLOID CELL RABBIES VACCINES declared by health authorithies
(HDCV) are propagated in humandiploid fibroblasts.
o PURIFIED VERO CELL RABIES VACCINES (PVRV) D. Meningococcal
are cultured in African green-monkey kidney cells. – MCV4-D (Menactra): minimum age 9 mo; for 9-23 mo, 2
o PURIFIED CHICK EMBRYO CELL VACCINES doses 3 months apart; for >2 yr, 1 dose
(PCECV) – MCV4-TT (MenHibrix): for >1 yr, 1 dose
o PURIFIED DUCK EMBRYO CELL RABIES – MCV4-CRM (Menveo): for >2 yr, 1 dose
VACCINES (PDECV) – MPSV4 (Menomune): for >2 yr, 1 dose
– Required potency should be 2.5 IU per IM or at least 0.5 IU per ID – Indicated for those at high risk of invasive disease: persistent
complement component deficiencies, anatomic/functional
asplenia, HIV, travelers to or residents of areas hyperendemic or
Vaccine Immunogenicity and Efficacy
epidemic for meningococcal disease or belonging to a defined risk
– Efficacy is based on post-exposure prophylaxis following group during a community or institutional outbreak
Category II or III exposure to animals confirmed to be rabid – Revaccinate with MCV4 every 5 years as long as person remains
through laboratory analysis at increased risk of infection
– Pre-exposure Prophylaxis shall be given before an exposure to – If MPSV4 used for high risk group as 1st dose, a 2nd dose using
potentially rabid animals (e.g. veterinarians) MCV4 should be given 2 months later
– Post exposure Prophylaxis: consists of wound care and the – Booster doses of MPSV4 not recommended
successful administration of the vaccine with or withour Igs. – MCV4-D and PCV13 should be at least 4 wk apart
o INTRAMUSCULAR ADMINISTRATION (Essen):
1. Standard Full IM regimen: Single 0.5mL PVRV or 1mL
E. Yellow Fever
PCEV on days 0,3,7,14 and 28
2. 2-1-1 IM Regiman (Zagreb): – All Yellow Fever Vaccines are live attenuated viral vaccines
Two 0.5mL PVRV or 1 mL PCEV on Day 0, then 0.5mL prepared using chick embryos and derived from the original 17D
or 1mL IM on Days 7 and 21. yellow fever vaccine strain
o INTRADERMAL ADMINISTRATION:
1. Updated 2-site ID Regimen : Two 1mL PVRV or Vaccine Immunogenicity & Efficacy
PCECV intradermal (ID) on separate sites on Day 0,3,7
– Immunity has been studied to persist for up to 10 years
and 28.
2. 8-site ID Regimen: Eight 1Ml ID dosesat separate sites
– Clinical trials have confirmed the efficacy of this vaccine
documenting seroconversion rates as high as 93% among children
on Days 0, then Four 1mL ID doses given on Days 7, and
One 1mL ID on one site on days 28 and 90. Vaccination Indication and Schedule
– Patients who shall receive this vaccines that are – For primary immunization, a single SQ injection of vaccine is
immunosuppressed shall recive on Days 0,3,7,1,4 and 28 IM. administered to adults and children more than 9 mos of age travelling
– Booster doses are only recommended for those who have to areas with high transmission
continued risk of contracting rabies and whose anti-rabies – WHO recommends to revaccinate at 10-year interval
antibody titers fall below 0.5 IU/mL.
– Booster however are given every 5 years. Adverse Reactions
– Headache, myalgia and low-grade fever were noted 5-10 days after
Adverse Reactions the administration.
– Serious ones were rarely documented such as: immediate
– Anti-rabbies vaccines are generally tolerated by the population
hypersensitivity, other yellow fever associated neurotropic diseases
– No other adverse reactions were noted except for local erythema
like encephalitis, yellow-fever associated viscerotropic diseases.
and pain and even swelling to some of its injection sites.
Contraindications
Contraindications
– Other precautionary measures observe in administrating LIVE
– In PRE-EXPOSURE PROPHYLAXIS, previous severe reaction
attenuated vaccines shall also be observed in here.
to any components is contraindicated for its usage. – Not recommended for pregnant and lactating mothers
– Since rabies is a fatal disease, there is NO contraindications – Patients with underlying diseases that suppresses their immune
when its on POST-EXPOSURE PROPHYLAXIS system
– Patients with anaphylactic reactions to eggs should not received this
vaccine
B. Dengue
– Minimum age start 9 yr; maximum age 45 yr, F. Japanese Encephalitis
– Shall be given in a 3-dose series at 0, 6 and 12 – This is an inactivated mouse brain-derived vaccine and has been in
use since 1968 in Japan, Taiwan and Korea.
– Live-attenuated tetravalent vaccine containing dengue serotypes 1
– Only formulation approved for pediatric patients at least 1 year of
to 4 age.
Vaccine Immunogenicity and Efiicacy

– From non-endemic areas, this vaccine has reported more than 80%
efficacy after receiving this in 3 doses

– In contrast, yielded 96% efficacy to those who received it only in 2 – Declining Oral Polio Vaccine (OPV) third dose coverage since
doses. 2008 from 91% to 83%. A least 95% OPV3 coverage need to
– Circulating antibodies are proven to appear at least for 2-3 years after be achieved to produce the required herd immunity for
immunization, however the actual duration is unknown.
protection.
– There is an on-going polio mass immunization to all children
Vaccination Indication and Schedule
ages 6 weeks up to 59 months old in the 10 highest risk areas
– The inactivated mouse brain-derived vaccine is the only formulation
for neonatal tetanus. These areas are the following: Abra,
approved to be given to children.
– The primary dosagine are as follows: Banguet, Isabela City and Basilan, Lanao Norte, Cotabato City,
SQ administration on days 0, 7 and 30. Maguindanao, Lanao Sur, Marawi City and Sulu.
o For children 1-2 years old: 0.5mL – Acute Flaccid Paralysis (AFP) reporting rate has decreased from
o For children greater than 3 years: 1mL 1.44 in 2010 to 1.38 in 2011. Only regions III, V and VIII have
– Booster doses may be administered after 2 years, but the actual achieved the AFP rate of 2/100,000 children below 15 years old.
duration of an existing immunization is still unkown.
(Source: NEC, DOH). A decreasing AFP rate means we may
Adverse Reactions not be able to find true cases of polio and may experience
resurgence of polio cases
– Some of the documented reactions were hypersensitivity reactions,
local and systemic reactions.
– Local erythema is always been reported.  MEASLES ELIMINATION
– On its extremes, severe neurologic adverse reactions have also been – Implemented the 2-dose measles-containing vaccine (MCV) in
noted, however, the vaccine’s version marketed in US now has not 2009
reported any of this on its surveillance. o MCV1 (monovalent measles) at 9-11 months old
o MCV2 (MMR) at 12-15 months old.
Contraindications ansnd Precautio
– Implemented and strengthened the laboratory surveillance for
– Contraindicated to patients with hypersensitivity reactions to rodents confirmation of measles. Blood samples are withdrawn from all
or neural origin, to thimerosal or to a previous dose of JE vaccine.
measles suspect to confirm the case as measles infection.
– History of urticaria should also be emphasized because generalized
urticaria and angioedema can occur within minutes and can last up to – A supplemental immunization campaign for measles and rubella
2 weeks after vaccination. (German measles) was done in 2011. This was dubbed as
– With these common reported cases, patients are advised to stay near “Iligtas sa Tigdas ang Pinas”
medical facility for emergency hypersentivity reactions.
 MATERNAL AND NEONATAL TETANUS ELIMINATION
IX. EXPANDED PROGRAM ON IMMUNIZATION – Three (3) rounds of TT vaccination are currently on-
going in the 10 highest risk areas. An estimated
A. Rationale 1,010,751 women age 15 - 40 year old women regardless
– The Expanded Program on Immunization (EPI) was established in of their TT immunization will receive the vaccine during
1976 to ensure that infants/children and mothers have access to these rounds. This is funded by the Kiwanis International
routinely recommended infant/childhood vaccines. Six vaccine- through UNICEF and World Health Organization .
preventable diseases were initially included in the EPI: tuberculosis,
poliomyelitis, diphtheria, tetanus, pertussis and measles. G. Control of other common vaccine-preventable diseases
B. Over-all Goal: (Diphtheria, Pertussis, Hepatitis B and
Meningitis/Encephalitis secondary to H. influenzae
– To reduce the morbidity and mortality among children against the
type B)
most common vaccine-preventable diseases.
– Republic Act No. 10152 has been signed. It is otherwise known
C. Specific Goals:
as the “Mandatory Infants and Children Health Immunization
– To immunize all infants/children against the most common vaccine-
Act of 2011, which requires that all children under five years
preventable diseases.
old be given basic immunization against vaccine-preventable
– To sustain the polio-free status of the Philippines.
diseases. Specifically, this bill provides for all infants to be
– To eliminate measles infection.
given the birth dose of the Hepatitis-B vaccine within 24 hours
– To eliminate maternal and neonatal tetanus
of birth.
– To control diphtheria, pertussis, hepatitis b and German measles.
– One strategy to strengthen Hepatitis B coverage is to integrate
– To prevent extra pulmonary tuberculosis among children.
birth dose in the Essential Intrapartum and Newborn Care
D. Mandates: Package (EINC). In 2011, 11 tertiary hospitals are already
– Republic Act No. 10152“MandatoryInfants and Children Health EINC compliant.
Immunization Act of 2011 – The goal of Hepatitis B control is to reduce the chronic hepatitis
– The mandatory includes basic immunization for children under 5 B infection rate as measured by HBsAg prevalence to less than
including other types that will be determined by the Secretary of 1% in five-year-olds born after routine vaccination started 100%
Health Hepatitis B at birth vaccination.
E. Introduction to New Vaccines
– Rotavirus and Pneumococcal vaccines will be introduced in the References
national immunization program. 1. DOH Website
2. Preventive Pediatrics Handbook 2016
 POLIO ERADICATION 3. Nelson’s Pediatrics
– The Philippines has sustained its polio-free status since October 4. Del Mundo’s and Navarro’s Textbooks on Pediatrics
2000. 4. PPT and class recordings

Pediatrics 1
Viral Infections
Catherine G. Gironella, MD | August 24, 2018 | Topic 4
Outline o 
I. Rabies  
II. Picornaviridae
A. Echovirus 
B. Coxsackie A  
C. Coxsackie B
III. Poliomyelitis
A. Polio Virus 

o
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o o
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↑
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Transcribed by: Naceno Page 1 of 3

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REFERENCES
- 1. Lecture
2. Recordings
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Pediatrics 1
Foreign Body Obstruction
FOREIGN BODY OBSTRUCTION
I. FACTORS PREDISPOSING CHILDREN TO FOREIGN BODY AIRWAY OBSTRUCTION – The most tragic cases occur when acute aspiration causes
II. COMMON ENTITIES CAUSING AIRWAY OBSTRUCTION total or near-total occlusion of the airway, resulting in death
III. EPIDEMIOLOGY
IV. SITES OF OBSTRUCTION or hypoxic brain damage.
V. HISTORY
VI. PHYSICAL EXAMINATION
VII. IMAGING STUDIES – The more difficult cases are those in which aspiration is not
VIII. CLINICAL MANIFESTATIONS witnessed or is unrecognized and, therefore, is unsuspected.
IX. DIAGNOSIS
X. TREATMENT
In these situations, the child may present with persistent or
XI. HEIMLICH-MANEUVER recurrent cough, wheezing, persistent or recurrent
XII. CONSCIOUS INFANT (UNDER ONE YEAR OLD) pneumonia, lung abscess, focal bronchiectasis, or hemoptysis.
XIII. UNCONSCIOUS CHILD (OVER ONE YEAR OLD)
VI. PHYSICAL EXAMINATION
I. FACTORS PREDISPOSING CHILDREN TO FOREIGN BODY – Major findings include new abnormal airway sounds, such as
AIRWAY OBSTRUCTION wheezing, stridor, or decreased breath sounds. These sounds
– The lack of molar teeth in children decreases their ability to are often, but not always, unilateral.
sufficiently chew food, leaving larger chunks to swallow. – Sounds are inspiratory if the material is in the extrathoracic
– The propensity of children to talk, laugh, and run while chewing trachea. If the lesion is in the intrathoracic trachea, noises are
also increases the chance that a sudden or large inspiration may symmetric but sound more prominent in the central airways.
occur with food in the mouth. These sounds are a coarse wheeze (sometimes referred to as
– Children often examine even nonfood substances with their expiratory stridor) heard with the same intensity all over the
mouth. chest.
– Children have less chewing capacity and higher respiratory rates, – Once the foreign body passes the carina, the breath sounds
so any objects placed in their mouths are more likely to be are usually asymmetric. However, remember that the young
aspirated than in older children. chest transmits sounds very well, and the stethoscope head
is often bigger than the lobes. A lack of asymmetry should
II. COMMON ENTITIES CAUSING AIRWAY OBSTRUCTION not dissuade the observer from considering the diagnosis.
– Small food items such as nuts, raisins, sunflower seeds – Similarly, a lack of findings upon physical examination does
– Improperly chewed pieces of meat and small, smooth items not preclude the possibility of an airway foreign body
such as grapes, hot dogs, and sausages. VII. IMAGING STUDIES
– Small items that are round, smooth, or both (eg, grapes, hot
dogs, sausages, marbles) are more likely to cause tracheal – Most aspirated foreign bodies are food material and are
obstruction and asphyxiation. radiolucent. Thus, one has to look indirectly for signs of the
– Dried foods may cause progressive obstruction as they absorb foreign body.
water. – If the diagnosis is in doubt, pediatric radiologists can be
helpful if they know the child is being evaluated for a foreign
III. EPIDEMIOLOGY body.
– 2009 caused 220 deaths in children aged 14 years or younger. – CT scanning-Chest CT scanning may reveal the material in the
– Airway foreign bodies are the third most common cause of death airway, focal airway edema, or focal overinflation not
due to unintentional injury in children younger than 1 year detected using plain radiography.
– 2008- foreign body aspiration accounted for more than 17,000 VIII. CLINICAL MANIFESTATIONS
emergency department visits
– Occur in children < 3 years than in other age groups, with a peak – Three stages of symptoms may result from aspiration of an
between 1 and 2 years. object into the airway:
1. Initial event: Violent paroxysms of coughing,
IV. SITES OF OBSTRUCTION choking, gagging, and possibly airway obstruction
– In a review of 1068 foreign body aspirations in children, the occur immediately when the foreign body is
authors found : aspirated.
– 3% in the larynx, 2. Asymptomatic interval: The foreign body becomes
– 13% in the trachea lodged, reflexes fatigue, and the immediate
– 52% in the right main bronchus irritating symptoms subside. This stage is most
– 18% in the left main bronchus, and 5% in the left lower lobe treacherous and accounts for a large percentage
bronchus; 2% were bilateral. 3. Complications: Obstruction, erosion, or infection
o In a child in an upright position, the right-sided airways develops to direct attention again to the presence
are direct entries from the trachea. The left main of a foreign body. In this 3rd stage, complications
bronchus is smaller than the right main bronchus and is include fever, cough, hemoptysis, pneumonia, and
slightly angled. atelectasis.
o In a child in a supine position, material is more likely to IX. DIAGNOSIS
enter the right main 6% in the right lower lobe bronchus,
fewer than 1% in the right – A positive history must never be ignored.
– Choking or coughing episodes accompanied by new onset
V. HISTORY wheezing are highly suggestive of an airway foreign body.
– Sudden episode of coughing or choking while eating with – Nuts are the most common bronchial foreign body, the
subsequent wheezing, coughing, or stridor. physician specifically questions the toddler’s parents about

PED201 FOREIGN BODY OBSTRUCTION T5
nuts. If there is any history of eating nuts, bronchoscopy is STEP 2
carried out promptly.
– Most airway foreign bodies lodge in a bronchus (right Call Emergency Services.
bronchus ~58% of cases); the location is the larynx or trachea Preferably, ask someone else
in approximately 10% of cases. to do it, while you start to
– Occasionally, fragments of a foreign body may produce clear the blocked airway in the
bilateral involvement or shifting infiltrates if it moves from baby
lobe to lobe.
– An esophageal foreign body can compress the trachea and
be mistaken for an airway foreign body. The patient is
asymptomatic and the radiograph is normal in 15-30% of
cases.
– History is the most important factor in determining the need
for bronchoscopy.
X. TREATMENT
– Heimlich maneuver
o If the child has respiratory distress and is unable to
speak or cry, complete airway obstruction is
probable, a Heimlich maneuver may be performed.
If the child is able to speak, the Heimlich maneuver STEP 3
is contraindicated because it might dislodge the
material to an area where it could cause complete – Prepare to give back
airway obstruction. blows. Turn the conscious
– The treatment of choice for airway foreign bodies is prompt baby face down on your lap
endoscopic removal with rigid instruments. for the back blows.
– Hold the baby in this
– Bronchoscopy is deferred only until preoperative studies
secure face down position and
have been obtained and the patient has been prepared by
be sure to support the baby's
adequate hydration and emptying of the stomach.
head.
– Airway foreign bodies are usually removed the same day the – The front of the baby
diagnosis is first considered. Medications are not necessary is supposed to be firmly
before removal, although the endoscopist may observe leaning against your arm; you
enough focal swelling after the material is removed to can use your thigh for support.
recommend a short course of systemic corticosteroids. Then, use the palm of your
– Unless the airway secretions are infected with organisms hand to perform five firm but
present, antibiotics are not necessary. gentle back blows, right
XI. HEIMLICH-MANEUVER between the shoulder-blades
of the baby.
STEP 1 – The blows should not
be hard enough to injure the
baby though.
– Check if the baby is
– Check the mouth for an object. If you find one, remove
breathing. If the baby is it immediately.
turning blue, or is waving his
STEP 4
arms desperately without
making any sound, quickly Re- check if the child
check his chest to see if it's is breathing. If not,
moving up and down, and alternate between
listen for breathing sounds. the back blows and
If you think the baby is chest thrusts as
choking on something, then
outlined above until
try to dislodge the foreign
object with your finger the ambulance
formed as a hook. Only do arrives.
this if you can see the
object in the child's throat!
– Check the baby's
pulse as well.
– If the baby is
unconscious, remove any
visible objects from the
mouth and begin CPR until
the ambulance arrives. Be
aware that there may be
resistance to inflation
initially until the stuck object is removed.

PED201 FOREIGN BODY OBSTRUCTION T5
CONSCIOUS INFANT (UNDER ONE YEAR OLD)

– Support head and neck with one hand. Place the infant face
down over your forearm, head lower than torso, supported
on your thigh.
– Deliver up to five back blows, forcefully, between the infant's
shoulder blades using the heel of your hand.
– While supporting the head, turn the infant face up, head
lower than torso.
– Using two or three fingers, deliver up to five thrusts in the
sternal (breastbone) region. Depress the sternum ½ to 1 inch
for each thrust. Avoid the tip of the sternum.
– Repeat both back blows and chest thrusts until the foreign
body is expelled or the infant becomes unconscious.
– Do not perform blind finger sweeps or abdominal thrusts on
infants.
– Alternative method: Lay the infant face down on your lap,
head lower than torso and firmly supported. Perform up to
five back blows. Turn the infant on his or her back as a unit
and perform up to five chest thrusts.
– Support head and neck with one hand. Place the infant face
down over your forearm, head lower than torso, supported
on your thigh.
– Deliver up to five back blows, forcefully, between the infant's
shoulder blades using the heel of your hand.
– While supporting the head, turn the infant face up, head
lower than torso.
– Using two or three fingers, deliver up to five thrusts in the
sternal (breastbone) region. Depress the sternum ½ to 1 inch
for each thrust. Avoid the tip of the sternum.
– Repeat both back blows and chest thrusts until the foreign
body is expelled or the infant becomes unconscious.
– Do not perform blind finger sweeps or abdominal thrusts on
infants.
– Alternative method: Lay the infant face down on your lap,
head lower than torso and firmly supported. Perform up to
five back blows. Turn the infant on his or her back as a unit
and perform up to five chest thrusts.
UNCONSCIOUS CHILD (OVER ONE YEAR OLD)
– Unconscious Child (Over one year old)
– If the child becomes unconscious, continue as for an adult,
except:
– Do not perform a blind finger sweep in children up to 8 years
old. Instead, perform a tongue-jaw lift and remove the
foreign body only if you can see it.
REFERENCES
1. Doc Diaz’ ppt

Pediatrics 1
Viral Infections
Catherine G. Gironella, MD| 26 August 2018 | Topic 5
Outline 
I. Dengue o
A. Fever and Hemorrhagic fever
B. Dengue virus
o
C. New classification of dengue o
D. Laboratory Diagnosis
DENGUE
–

o
–
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FEVER AND HEMORRHAGIC FEVER

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• 
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DENGUE VIRUS

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NEW CLASSIFICATION OF DENGUE
 
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Transcribed by: Almirah Marmar Page 1 of 3

o o
o o
o o
o
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o
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REFERENCES
1. Doc Gironella’s Lecture

2. Recordings

o
o
o

01 History Taking and Physical Examination Merged

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Pediatrics 1

History Taking and Physical Examination

Transcribed by: SINGH, SHINOTSUKA, VELASCO, VILLEGAS, VITAL Page 1 of 13

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PRIMARY FACTORS IN PEDIATRIC INJURIES

Transcribed by: Alej Aguilar Page 1 of 5

“About 2270 children die every day as a result of an

Transcribed by: Alej Aguilar Page 2 of 5

Special Conditions Predisposing to Cardiopulmonary Arrest Pediatric Trauma

Child Development and Injuries

Temperament: 9-12 - Minor trauma

Transcribed by: Alej Aguilar Page 3 of 5

Hemorrhage in Pediatric Trauma

Life-Threatening Chest Injuries

Transcribed by: Alej Aguilar Page 4 of 5

Identifying Serious Illness in Febrile Children in the

Three DELAYS that KILL

Score <10 - chance of serious illness 1-2%

Principles of Injury Control

1. Prevent the creation of hazard

Transcribed by: Alej Aguilar Page 5 of 5

EVALUATION GENERAL MANAGEMENT PRINCIPLES

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Management 1. Doc Diaz’s ppt

CARBON MONOXIDE POISONING

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Transcribed by: Page 1 of 22

MATURATIONAL CHANGES: • Attachment refers to a biologically

ü Depicts these relationships as concentric DEVELOPMENTAL DOMAINS AND THEORIES OF

§ Preschoolers may be intensely caregivers and then

o Suggest that much of this abstract structure is • By preschool, what is

• The school is a place that transmits and constructs

PEDAGOGIC THINKING: CORE CONCEPTS AROUND 3 THE IMAGE OF THE EDUCATOR

• Behavior may be entrained to the mother’s diural

PSYCHOLOGIC CHANGES IN PARENTS

IV. THE NEWBORN 2. Peripartum and Postpartum Influences

3. Modulation of Arousal A. 0-2 Months

VI. The Second Year

• Decrease in cortical thickness

Implications for parents and paediatricians

• Counselling about safety precautions • Common difficulties:

Implications for parents and Paediatricians: § Females: appearance of breast buds(thelarche)

5. Timing of Pubertal Change

-Males perceive progression of pubertal change as positive but

Normal Variation 1. Weight up to 24 months of age

OTHER INDICES OF GROWTH o Children Response to Separation and Loss

XI. DEVELOPMENTAL- BEHAVIORAL SCREENING AND

School-age children reaction to separation may include:

Divorce has been found to be associated with negative parent

Outline  Genetic counselling among couples with

(1º) PRIMARY PREVENTION