WELCOME

PEDIATRICS
Greetings Friends
This is a crash course of the Pediatrics section
This material has some of the most tested material for both the AANP and the
ANCC NP Board Exam
Happy Studying
Miriam Tivzenda.MSN.APRN.FNP-BC, FNP-[C
Check us out at Https://www.NPexamprep.com for more NP review materials with
practice questions at very affordable rates.

MILESTONES aka Growth & Development

6 Months= child sits unassisted, plantar grasp, rolls from belly to back, and back to belly
9 months=pulls self to stand, pincer grasp, plays peek-a-boo. Stranger anxiety
12 months=say dada/mama, can use a sippy cup
12-18 months =anterior fontanelle closes
2-3 months= posterior fontanelle closes
12-18 months= can walk
12 months can put a block in a cup
15-18 months=can hold a cup, can scoop with a spoon
3 years (36 months) = can throw a ball, ride a tricycle, copy a circle
An infant develops hand dominance between 10-11 months
18-24 months potty training starts within this period, but parents need to look for signs of readiness
such as understanding instructions, pulling on and off of clothing, staying dry for 2 hours etc.
MILESTONES aka Growth & Development
4 years (48 months) can draw a cross, or copy a square
5-6 years (60-72 months)= can Ride a bicycle
4-6 months child should outgrow Strabismus
3-6 months palmar grasp should stop
2-3 years old: Genu varum (bow legged) should go
away
A child should hop on one foot between 3-5 years old
TANNER STAGING
● Stage 1: nothing happens
● Stage 2: female kids have breast buds

Males’ scrotum becomes a bit enlarged, a few fine pubic hair

It also marks the beginning of puberty for both males and females

● Stage 3: female kids have one breast mound

Males: penis elongates

● Stage 4:males kids experience penile width growth, the scrotum gets larger and darker

Females: secondary mound

● Stage 5 marks the end of puberty

TANNER STAGING
Remember Tanner Staging (aka Sexual maturity rating) is a
classification used by health care providers to tract and
document sequential development of secondary sex
characteristics of children during puberty
Tanner staging was developed by Marshall and Tanner while
conducting a longitudinal research during the 1940s-1960s in
England
Menarche starts for female from 2-3 years from the beginning of
puberty which is stage 2,if delayed, refer to endocrinology
EPIGLOTTITIS

S/S: Acute onset of high fever, chills, severe sore throat, drooling saliva. Hot
potato voice, anxiety, tachycardia, tachypnea.
Usually occurs between the ages of 2-6 years old.
For Prophylaxis treatment, use rifampin.
Treatment: Referral to the Emergency Room
Imaging result will show a ‘Thumb print sign” which means thickening of
the epiglottis
HIB Vaccine is used for prevention
Epiglottis is a reportable disease to the health dept
TERMS TO KNOW
CEPHALOHEMATOMA is the accumulation of blood
under the scalp, this occurs during the birth process,
swelling does not cross the midline
This Places a newborn at high risk for hyperbilirubinemia
(jaundice) due to breakdown of the extravasated blood from
the cephalohematoma
Caput succedaneum- crosses midline aka Coned-shaped
head.
TIME FOR SOME REFERRALS
16 Year old male with ,no testicular development, needs a referral
15 year old female never had menstrual period needs a referral
VESICOURETERAL REFLUX (VUR)-Urine flows backwards from the bladder
DX: CYSTOURETHROGRAM
Referral at grade 3 (grade 5 is very severe),
grade 1 is reflux only into the non-dilated
ureter
Grade 2:Reflux into the ureter and the renal pelvis without dilatation
Grade 3:Reflux with mildly dilated ureter 7 pyelocaliceal system
Grade 4:Reflux with the tortuous and moderately dilated ureter with blunting of the renal fornices
Anticipatory guidance Resolves if it is grade 1 or 2
UMBILICAL HERNIA: Referral by 3 years old
At 6 years old, child should have 20/20 vision
If vision is 20/40 or 20/30: Referral

Time for Referrals continues

Genu Valgum (Knock- knee),referral to Orthopedic Surgeon by the
age of 7 years old.
Scoliosis referral to Orthopedic Surgeon for a spine curvature > 40
degrees
A spine curvature of 20-40 degrees is considered moderate which
may require a boston brace.
Genu-Varum(Bow legs),referral after 4 years old, because it
resolves by 3-4 years old.
IMMUNIZATIONS aka Vaccinations
Influenza (FLU):Start at 6 months
Live vaccines start at 12 months
DTAP: for under 7 years old
TDAP: Above 7 years old
Do not give varicella/MMR <12 mo. since they are live vaccines
Hepatitis B vaccine is the only vaccine that can be given at birth
HPV youngest age 9 years.
Do not give TDAP <7 years
HPV Vaccine

HPV vaccine protects against human papillomavirus (HPV)

strains 6 & 11 which causes about 90% of genital warts
HPV vaccine is recommended between ages 11- 12 years for
only 2 doses
But may give starting at the age of 9 for only 2 doses
Second dose can be given 6-12 months after the first dose
But if started after age 15,the patient will have to receive 3
doses over a 6 months period.
It is approved for up to the age of 26 years old.
VACCINATIONS

Vaccines allowed during pregnancy are TDAP and Flu vaccines

Hepatitis B vaccine is the first vaccine given to a newborn shortly
after birth
Shingrix vaccines is for older adults
No live vaccines during pregnancy, babies under 12 months old and
Immunocompromised patients
THINGS TO NOTE
Do not give cow milk prior to 12 months old, because it causes
iron deficiency anemia & GI bleeding
Breast fed babies should be supplemented with vitamin D
Motor vehicle is #1 cause of unintentional deaths in 15-16 years
old.

Gynecomastia: should go away in 2–3-year-olds.

G6PD & SICKLE Cell Anemia
Glucose-6- Phosphate-Dehydrogenase aka G6PD protects red blood cells,
A G6PD deficiency causes hemolytic anemia, it is a x-linked recessive genetic
disease which is common in males
Need Genetic testing
SICKLE Cell Anemia is an autosomal recessive disease
Autosomal recessive, if both parents have sickle cell traits, it means one out of 4
children(about 25 %) may carry the disease.
Give vaccines as scheduled
Hemoglobin electrophoresis is the gold stand for diagnosing Sickle cell anemia

FETAL ALCOHOL SYNDROME & PKU

Fetal Alcohol Syndrome:

● Smooth philtrum (aka thin upper lip, Low nasal bridge)
● Microcephaly (aka small head)
● Shortened palpebral fissures (aka Narrow eyes)
● Underdeveloped ears ● Intellectual disability
PHENYLKETONURIA (PKU) is an Inherited disease in which the body
doesn't metabolize protein called phenylalanine. Newborn screen is
mandatory, test is done after infant has had breast milk or formula for about
48 hours
OSGOOD SCHLATTER
Common especially during growth spurts in young males, usually an
athlete. s/s may include: Knee pain bony mass on anterior tibial tubercle
near tendon insertion site.
Low impact sports are highly recommended
May outgrow when bone stops growing Treatment: Ice,
NSAIDS.
May order an Xray to rule out Avulsion fracture if pain is associated with trauma
The knee pain is due to an inflammation at the area where the patellar tendon
attaches to the tibial
SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
SLIPPED CAPITAL FEMORAL EPIPHYSIS (aka a SCFE) is a hip disorder, whereby the growth
plate is damaged and the femoral head ‘slips” common in adolescents (between ages 8 & 15 years
old)

Pain in knee, medial thigh, hip. May walk with a

limp, decreased range of motion of the hip
● Overweight or being obese is one of the risk
factors
● Serious complication is Avascular Necrosis
● Referral to surgery for surgical repairs
LEGG CALVE-PERTHES
Legg Calve- Perthes is the Osteonecrosis of the capital femoral epiphysis due to
interrupted vascular supply or avascular necrosis of the femoral head, may affect one hip
at a time. Common in ages 3-12 (pre-pubescent)
● More common in males
● Pain or stiffness in the hip, groin, thigh, or knee
● Insidious painless Limp
● Limited range of the hip
● Hip pain is worse with activity, and improves with rest
 ● Positive Trendelenburg’s Test (asking child to stand on affected side causes pelvic
tilt – affected side is lower)
Treatment : Referral to Ortho where they may offer treatments including crutches,
physical therapy, NSAIDS,
No jumping, no running or other high impact activities which may damage the hip further.
Hip X-ray may show an osteonecrosis of the head of the femoral bone
DEVELOPMENTAL HIP DYSPLASIA
Affected leg seems shorter
Barlow’s sign (performed for < 6 months old),(the test is
performed by adducting the hip while pushing the thigh
posteriorly, if the hip goes out of socket or pops out of the
socket, you hear a “clunk” sound the test is positive )
Ortolani’s sign
Galeazzi’s (Allis) sign- knee high discrepancy
Referral Ortho
BABY WEIGHT
Breast -feeding: once the baby has 6-8 wet diapers/day and is
gaining weight, the baby is feeding good,
An ounce of breast milk of formula contains 20 calories
remember breast fed babies get vitamin D supplementation
Birth weight: doubles at 6 months
Birth weight triples at 12 months
Premature babies catch up by the age of 2 years old
Bilirubin level >15, baby should receive phototherapy
CRYPTORCHIDISM
Cryptorchidism (undescended testicles)
Treatment: Referral for surgery (surgery known as
Orchiopexy)
Undescended testicles places the patient in the
future for increased Risk for testicular cancer
SALTER HARRIS FRACTURE
Salter-Harris Fracture is a fracture at the growth
plate categorized according to involvement of the
physis, metaphysis and epiphysis, If not corrected,
may affect a child’s growth
KAWASAKI
Signs & symptoms include: high fever > 5 days
Dry cracked lips, “strawberry tongue” peeling
rash ( after fever subsides),Conjunctivitis
Enlarged lymph nodes
Occurs in kids under 5 years of age
Kawasaki can affect the cardiovascular system think blood clots, future heart problems
etc. The patient must be referred to a pediatric cardiology for monitoring for several years
to come
Treatment: high dose aspirin & Intravenous immunoglobulin (aka IVIG).
Mucocutaneous lymph Node Syndrome is another name for Kawasaki
Kawasaki is also the most common cause of Acquired heart disease in developed countries
INTUSSUSCEPTION
● Bouts of inconsolable crying
● Jelly currant stools
● clutching stomach
● Crampy abdominal pain alternates with no pain.
PE: Palpable sausage mass in the upper right mid upper abdomen
Common between 3 & 36 months old.
Do not give Rotavirus vaccine
It is a medical emergency
Diagnosis: Ultrasound
Treatment: Referral to the emergency room
VARICELLA (CHICKEN POX)
VARICELLA (CHICKEN POX)
Generalized rash new lesions daily starting from
papules, vesicles, pustules to crusts for about 5 days
Child can return to school when all lesions are crusted
Varicella vaccine must be given from 12 months and up
PYLORIC STENOSIS
PYLORIC STENOSIS: is when the pylorus muscle becomes thickened
thereby blocking food from entering the intestine s/s include
● Projectile vomiting
● irritability
● Abdominal pain
● baby may seem hungry even if she has just eaten.
On palpation, the provider will feel an Olive-shaped mass
Diagnostic test is Abdominal Ultrasound
Treatment: Referral for surgery known as pyloromyotomy
Pyloric stenosis is common in kids under 6 months old.
RETINOBLASTOMA
Retinoblastoma is the most common type of eye cancer in
children
During a fundal eye exam: You will see white reflex (leukocoria)
instead of red reflex
Also note there is a white reflex noted with congenital cataract as
well
WILMS TUMOR(NEPHROBLASTOMA)
Wilms tumor (Nephroblastoma)- malignant kidney tumor, it is a painless Palpable
smooth abdominal mass and does NOT cross the midline of the abdomen.
do not palpate to avoid rupturing the renal capsule.
Diagnosis: Abdominal Ultrasound
Treatment: Referral to Surgery
Think Nephro doesn’t cross. Stays where kidney is.
Most common renal malignancy in children
Wilms tumor (aka Nephroblastoma) can occur at any age, but commonly seen in kids from
3-4 years, very uncommon after the age of 5
Wilms tumor is associated with the following abnormalities at birth:
Aniridia (meaning the absence of the eye iris)
Hemihypertrophy meaning one side of the body or part of the body is noticeably bigger
than the other side
MOLLUSCOM CONTAGIOSUM

Is a Viral contagious Pearly dome shaped papules

Central umbilication with white plug
Suspect child abuse if found around the genitals of a
child
TURNER SYNDROME
The patient is usually a female adolescent with following features:
● Short stature
● Webbed neck (aka Pterygium Colli)
● Ovarian failure (missing a sex character)
● Amenorrhea
Females with ONLY ONE X chromosome instead of 2
Anticipatory guidance: Delayed puberty & infertility
Note 15-35% has Horseshoe kidney (aka fusion of the poles of the kidney)
Treatment: Estrogen hormone replacement is standard
TEENAGE CONSENTS

Teens do not need parental consent for

Sexually transmitted Diseases treatment
Contraception (aka Birth control)
Pregnancy test pregnancy
Management
MONGOLIAN SPOTS
MONGOLIAN SPOTS is the bluish, or gray, or green skin
discoloration that extends from neck to tailbone, or the
lumbosacral area, but may appear on any other part of the
body. This is common in Blacks, Hispanic, Native American
The Mongolian spots are Benign
Anticipatory guidance: they fade away or remain to
adulthood.
Other names include Slate gray nevi or Congenital Dermal Melanocytosis
Layman term is birth mark
EAR COMPLAINTS
The 3 main Ear complaints are:
1) Acute Otitis Media
2) Otitis Externa
3) Tympanic membrane rupture
ACUTE OTITIS MEDIA
Child pulls on ear, decreased hearing
PE: Bulging inflamed Tympanic membrane
Treatment: AMOXICILLIN(may wait 2-3 days prior to commencing antibiotics)

OTITIS EXTERNA
OTITIS EXTERNA (OE) is an infection of the outer ear
Itching and irritation in and around the outer ear
Pressure and fullness in the ear
Tragal pain
Pseudomonas and Staphylococcus aureus are the most common bacteria
Treatment: antibiotics drops (e.g. Ofloxacin) & analgesic drops
Other Antibiotics ear drops for Otitis Externa includes Acetic acid, Cipro, Neomycin
drops
CHOLESTEATOMA (cauliflower): Treatment: Referral to ENT
Chronic Otitis Media & Otitis Media with Effusion
Please note Chronic Otitis Media could lead to hearing loss and/or
speech delay
OTITIS MEDIA with Effusion: wait and watch, no antibiotics
required .*tympanic membrane does not require treatment because
it heals on its own
ERYTHEMA INFECTIOSUM (aka 5th Disease)
5th Disease (ERYTHEMA INFECTIOSUM) is caused by the Parvovirus B19
Signs and symptoms include:
Prodrome symptoms: headache, coryza, pharyngitis, GI upsets
“slapped cheek” rash,(aka cheek erythema) which spares the periorbital
region and chin
High fever, then Maculopapular lace- like rash on chest, soles of feet
No longer contagious after rash appears, and can return to daycare or school
The parent should be educated that the patient is no longer contagious after
appearance of the rash
It may cause miscarriage in pregnancy
HIRSCHSPRUNG DISEASE & CLUB FOOT

Hirschsprung Disease is failure to pass meconium within 24-48 hours of

life
There may be abdominal distension
Gradual onset of vomiting
Fever
DX is by rectal biopsy
Referral
DOWNS SYNDROME
A child with downs syndrome (trisomy 21) may play some
sports if neck x-ray does not show any cervical spine instability.
Down Syndrome increases the risks:
● for early onset of Alzheimer’s disease
● Hyperthyroidism
● cervical spine instability
● Intellectual Disability
Contact sports such as soccer, football, gymnastics may
increase the risk of spinal cord injury
Atlantoaxial instability is another name for Cervical spine
instability
MARFAN SYNDROME
Marfan’s syndrome is an inherited (an autosomal dominant) connective tissue disorder

The patient may have some of these features:

● Extremely tall and slender

● Disproportionate long arms, fingers, and legs
● Abnormally curved spine (scoliosis)
● Heart murmurs (e.g. Mitral valve Prolapse)
● Abnormally curved spine

Biggest issues are Aortic Root Dilation(aka Aortic aneurysm),Aortic Dissection, Retinal
problems, early onset of cataracts or glaucoma
The patient must be monitored per a cardiology and an Ophthalmology for life

CROUP (aka LARYNGOTRACHEITIS)

Presents with a harsh barking cough

Physical Exam :Inspiratory stridor at rest, cyanosis
and marked intercostal retractions Referral to the
Emergency room
Treatment: Nebulized Epinephrine, Dexamethasone
Some Pearls

Regression in children occurs when there is a major

change in life such as parents divorcing, loss of a parent
EARLY PUBERTY:
● Precocious puberty Girls <8 years old : referral to
endo
● Boys < 9 years old : referral to endo puberty starts
at tanner stage 2
Most common causes of death amongst adolescents include:
Accidents, Homicide, Suicide