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Barkleys Curriculum Review for Pediatric Nurse Practitioners Barkleys Curriculum Review for Pediatric Nurse Practitioners Thomas W. Barkley Jr. PhD ACNP-BC ANP FAANP President Barkley Associates Los Angeles California and Professor Director of Nurse Practitioner Programs California State University Los Angeles School of Nursing International Standard Book Number 978-0-9864021-5-9 Printed in the United States of America Managing Editor Taylor Spining Staff Coordinator Christopher Cud Cover Design Andres Morgan Contributing Writers Andrey Gordienko Roberto A. Rael Justin R. Searles Kaitlyn C. Sullivan P.O. Box 69901 West Hollywood CA 90069 BARKLEYS CURRICULUM REVIEW FOR PEDIATRIC NURSE PRACTITIONERS NATIONAL CERTIFICATION ISBN 978-0-9864021-5-9 Copyright 2016 by Barkley Associates All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means electronic or mechanical including photocopying recording or any information storage and retrieval system without permission from the publisher. Permissions may be sought directly from Barkley Associates by the following phone 1.866.938.5557 or 1.323.656.1606 fax 1. 323.656.1620 e-mail Contact_Usnpcourses.com. Notice Knowledge and best practices are subject to change as new research and further experience expand knowledge. Changes in practice treatment and drug therapy may be warranted or appropriate. It is recommended that readers verify the most up-to-date information regarding procedures featured or check the manufacturers of administered products so as to verify the recommended dose formula methods of administration and contradindications. It is the duty of practitioners relying on their experience and knowledge of the patients circumstances to determine dosages and the best treatment for each patient while taking all safety precautions. To the fullest extend of the law neither the Publisher nor the Editor Contributors or Reviewers assume any liability for any injury andor damage to persons or property arising out of or related to any use of the content in this book. The Publisher Preface Barkleys Curriculum Review for Pediatric Nurse Practitioners is a long-overdue resource in advanced practice nurse practitioner education. The text is written at a level appropriate for pediatric nurse practitioner PNP students faculty and practicing nurse practitioners. For students and faculty the text can be strategically utilized in several ways to enhance nurse practitioner curricula. First the text can be used as an excellent culminating work to review key subject areas of the entire PNP curriculum prior to national certification. For most faculty who adopt a modular approach to systems and special topics learning the book can be extremely valuable throughout the PNP students entire course of studies. Assigning chapter by chapter in conjunction with course topical outlines serves to reinforce classroom lectures and other learning activities as either pre- or post-class assignments. For the certified PNP a comprehensive review of the PNP curriculum is always rewarding to assist in revisiting those not-so-commonly seen patient diagnoses in individual practice. Whether being used by student faculty or certified nurse practitioner Barkleys Curriculum Review for Pediatric Nurse Practitioners is an outstanding asset. In light of the varied needs of the readers the text is designed for both practicality and flexibility. Barkleys Curriculum Review for Pediatric Nurse Practitioners is essentially two books in one comprising a Practice QuestionRationale Section and a comprehensive Discussion Section. Extensive question rationales feature not only why the correct answer is correct but also why all other answer choices are either incorrect or not the best answer. After the Practice Question Section in each chapter an extensive Discussion Section includes the following Overview incidencepredisposing factors Presentation signs and symptoms Workup laboratorydiagnostic tests and Treatment management options for all common diagnoses presented in the chapter. Further the book is supplemented with relevant figures tables and diagrams in color. As editor I sincerely thank the Distinguished Reviewers of this text who represent some of the most exceptional nurse practitioner experts in the country. In addition I am extremely grateful to the talented staff of Barkley Associates Inc. who tirelessly produced this work with never-ending enthusiasm. I trust that you will find Barkleys Curriculum Review for Pediatric Nurse Practitioners to be an invaluable educational tool. Thomas W. Barkley Jr. PhD ACNP-BC ANP FAANP Editor Acknowledgments We gratefully acknowledge the combined efforts of the staff of Barkley Associates whose knowledge and dedication provided the foundation for this review guide. We would additionally like to thank the outstanding contributors and reviewers of this text. Without the expertise of these scholars this work would not have been possible. We also thank the following people Pediatric Content Experts Sharyn Flavin Molly K. Rothmeyer Joetta D. Wallace Stacey A. Warner Managing Editor Taylor Spining Staff Coordinator Christopher Cud Cover Design Andres Morgan Contributing Writers Andrey Gordienko Roberto A. Rael Justin R. Searles Kaitlyn C. Sullivan whose combined efforts have produced what we believe is a state-of-the-art evidence-based excellent resource for the profession. v Reviewers Sharyn Flavin APRN DNP AGNP CPNP Long Beach Memorial Miller Childrens Hospital Long Beach CA Donna Susan Freeborn PhD FNP Assistant Professor Coordinator FNP Program Brigham Young University Provo UT Jane T. Garvin PhD RN FNP-BC Assistant Professor of Nursing Georgia Regents University Augusta GA Gay L. Goss PhD APRN-BC Professor Cal State University Dominguez Hills Carson CA Paula Gray FNPDNP CRNP NP-C Clinical Assistant Professor of Nursing Director Family Individual Across the Lifespan CRNP Program Widener University School of Nursing Chester PA Yvonne L. Joy MBA MSN APRN Assistant Professor of Nursing University of Saint Joseph West Hartford CT Vanessa M. Kalis DNP PNP-AC ACNP-BC CNS RN Assistant Professor Director Acute Care DNP Programs Pediatric and Adult-Gerontologic Brandman University Irvine CA Pamela L. King PhD FNP PNP FAANP MSN Program Director Spalding University School of Nursing Louisville KY Deborah Lee-Ekblad MSN FNP ACNP-BC Clinical Instructor Acute Care Nurse Practitioner Program University of Michigan School of Nursing Ann Arbor MI Denise M. Linton DNS FNP-BC Assistant Professor and Nurse Practitioner Coordinator University of Louisiana at Lafayette College of Nursing and Allied Health Professions Lafayette LA Ildiko E. Monahan MS ANP-C FNP Instructor SUNY Institute of Technology College of Health Sciences and Management Utica NY vi Martha J. Morrow PhD FNP-BC CNE Associate Professor Graduate Nursing Program Shenandoah University Eleanor Wade Custer School of Nursing Winchester VA Mary B. Neiheisel BSN MSN EdD FNP-BC CNS-BC FAANP FNAP Professor University of Louisiana at Lafayette Lafayette LA Michelle Pardee DNP FNP-BC Clinical Assistant Professor University of Michigan School of Nursing Ann Arbor MI Gloria M. Rose PhD NP-C FNP-BC Assistant Professor Coordinator of FNP Program Prairie View AM University Prairie View TX Molly K. Rothmeyer DNP APRN FNP-BC CPNP-AC Assistant Professor University of Alaska Anchorage AK Sharon L. Stager DNP FNP-BC Assistant Professor of Nursing Salve Regina University Newport RI Twila Sterling-Guillory RN FNP-BC PhD Associate Professor McNeese State University Lake Charles LA Joetta D. Wallace RN MSN NP-C Program Coordinator Pediatric Palliative Care Service Miller Childrens and Womens Hospital Long Beach CA Frankie Wallis DNP RN Associate Professor Samford University Ida V. Moffett School of Nursing Birmingham AL Stacey A. Warner RN MSN CPNP Assistant Professor California State University Los Angeles Los Angeles CA Ann Weltin DNP FNP-BC CNM Assistant Professor of Nursing DNP Program Coordinator Clarke University Dubuque IA Johnnie Sue Wijewardane PhD APRN FNP-BC Associate Professor Mississippi University for Women Columbus MS Mary Ellen Wilkosz RN FNP-BC BSN MSN PhD Director FNP Program Sonoma State University Rohnert Park CA Alyssa N. Wislander MS BSN APN RN ACNP CPNP University of Illinois at Chicago Quad Cities Regional Campus Moline IL Carmen Wycoff DNP MBA ARNP CPNP Pediatric Nurse Practitioner Assistant Professor of Nursing Clarke University Dubuque IA Table of Contents 1. Growth and Development 3 2. Immunization Recommendations 25 3. Genetic Evaluation 34 4. Prenatal AssessmentScreening 43 5. Infant Health and Issues 61 6. ToddlerPreschool Health and Issues 73 7. School Age Health and Issues 87 8. Adolescent Health and Issues 104 9. Cardiovascular Disorders 115 10. Gastrointestinal Disorders 128 11. Dermatological Disorders 143 12. Eye Ear Nose and Throat Disorders 170 13. Respiratory Disorders 187 14. Musculoskeletal Disorders 199 15. Neurologic Disorders 213 16. Hematologic and Oncologic Disorders 227 17. Endocrine Disorders 243 18. Genitourinary Disorders 253 PEDIATRIC Curriculum Review C hapt er 1 Growth and Development 3 QUESTIONS 1. Which of the following is typically the most effective measure of the bone age of a young child a. X-ray of femur b. X-ray of tarsals and carpals c. Dental ossification d. X-ray of pelvis 2. When treating a child prone to seizures a nurse practitioner should primarily keep which childhood anatomical feature in mind a. Smaller circulating blood volume b. Large tongue compared to the oropharynx c. A thin cranium d. Large head in comparison to body proportion 3. A newborn is born weighing 9 lbs. After 2 weeks what would be the expected weight of the newborn a. Eight lbs. b. Eight lbs. 5 oz. c. Nine lbs. d. Nine lbs. 10 oz. 4. The Denver II assessment test commonly measures a child for all of the following except a. Personal-social development b. Language c. Fine motor development d. Intelligence 4 CHAPTER 1 7. Which of the following does not commonly impact temperature stability and regulation in a child a. Increased subcutaneous tissue with increased evaporative heat loss b. Decreased body surface area to mass ratio c. Thinner skin d. Increased energy expenditure 8. You ask Samuel a toddler to point to where his elbow is. He points directly to his elbow. Samuels mother states that he just started correctly pointing to body parts last week. If Samuel is properly reaching expected developmental milestones he would most likely be a. About 13 months old b. About 16 months old c. About 20 months old d. About 2 years old 9. Holly age 4 is at a well-child visit. During the visit her weight is recorded as being 40 lbs. Assuming expected growth parameters how much will Holly most likely weigh in 2 years a. Sixty lbs. b. Fifty-two lbs. c. Forty-five lbs. d. Forty-two lbs. 5. Kasey age 7 months is brought to the clinic by her concerned parents. They have been talking to other parents in their parenting group and need reassurance that Kasey is keeping up developmentally. As you observe Kasey you notice that she responds to her name consistently babbles crawls around on the floor and is able to pick up objects. Which of the following additional milestones would also be expected in a child her age a. Supports weight on feet b. Holds head steady c. Equal coordination of hands d. Plays independently 6. Isaac age 6 months has been brought to your practice by his parents for a routine check-up. As you enter the interview phase you would know all of these methods would be well-suited for the interview except a. Carefully phrasing potential health and safety concerns to respect the cultural practices of Isaacs parents b. Breaking from the assessment regularly to ensure the parents have accurately expressed their concerns c. Phrasing your questions in an open- ended fashion to ensure a non- judgmental approach d. Using play to keep the patient engaged regularly putting the assessment on hold to ensure to a proper response GROWTH AND DEVELOPMENT 5 2. b Developmentally the tongue of a child is often comparatively larger than the oropharynx which can potentially cause obstruction during a seizure and may lead to severe repercussions attributed to oxygen loss. Children have a smaller circulating blood volume in absolute terms but this is primarily a concern in cases of blood loss or bacterial infection not seizures. Children have thinner craniums which would place them at a greater risk of head injury if the skull is penetrated this may present a concern during convulsions but is less of a concern than the risk of obstruction. Lastly a childs large head in comparison to the childs body accounts for a smaller body surface area when compared with an adult but this does not greatly influence potential complications from seizures. 3. c The normal weight gain progression of an infant indicates that at the 12 week mark the weight will be approximately the same as it was at birth. The infant will typically lose 10 of the birth weight in the days after birth weighing a little over 8 lbs and then gain that weight back within 714 days. By 5 months the infants weight should be doubled. The weight will usually be tripled by the first year and will be four times the birth weight by the second year. 4. d Although the Denver II assessment test measures several aspects of child development it is not an intelligence test. The Denver II measures the fields of language personal-social development and fine and gross motor development. 10. All of the following accurately reflect the typical well-child care visit except a. After age 4 years a child should have a well-child care visit yearly. b. Children on ADHD medication should see a physician or nurse practitioner every 6 months. c. Well-child care visits are arranged around immunization schedules which are the key purpose of the visit. d. If the parents are experienced their newborn does not commonly need to have a check-up until 12 weeks after birth. RATIONALES 1. b An x-ray of the tarsals and carpals can effectively measure bone age in a child because there are multiple growth plates located in these regions that can be used to measure skeletal growth. An x-ray of the femur is more commonly the focus of a bone density test which would measure for osteoporosis not bone age. Dental calcification rather than ossification can be used to measure the developmental maturity of the child. Although the pelvis may be X-rayed to determine skeletal maturity via Risser stages this process most effectively measures bone age in adolescents not young children. 6 CHAPTER 1 8. b A properly-developing toddler would be expected to point to his body parts at 1518 months old. A 13-month-old can typically walk and understand a few words but would not be expected to point to body parts. A 20-month- old and a 2-year-old would already be expected to be able to properly indicate parts of their body. 9. b School-age children typically gain around 57 lbs annually so a 40 lb normally- developing child would often weigh between 50 and 54 lbs in 2 years as such 52 lbs is the only answer choice that falls within that range. Gaining only 58 lbs within 2 years as indicated by a final weight of 45 lbs or 48 lbs may suggest a developmental deficiency or malnutrition. A child who gains 16 or more pounds within 2 years exceeds the normal weight gain progression and may indicate obesity in later childhood. 10. c Well-child care visits commonly include physical exams to assess the physical well-being of a child preventative care i.e. immunizations communication with the parents developmental tracking and personal family issues are all equally important aspects of a well-child care visit. If there are no complications in development a child should have a well-child care visit yearly after the age of 4. However a child taking medication for ADHD should see a health care professional every 6 months. After a baby is born it is recommended that the newborn receive a check-up within 24 days however if the parents have experience with newborns they may not need to see a health care provider for 12 weeks. 5. a A child exhibiting the milestones of a 69 month old as evidenced by crawling babbling picking up objects and responding to her name is likely to be able to support her weight on her feet. The ability to hold her head steady is an age milestone that typically occurs around 25 months as such the patient should already be able to do this. At around 1012 months she should be able to play independently and exhibit equal coordination in her hands. 6. c Although a non-judgmental approach should be utilized at all times during the interview questions should be directed and purposeful not open- ended to ensure that key details of the patients history are not missed. Other proper techniques to utilize during an interview include ensuring cultural sensitivity ensuring accurate perception of the parents concerns using play to enhance the patients comfort and pausing to allow adequate time for a response. 7. a Temperature stability in children is commonly impacted by their limited not increased subcutaneous tissue with evaporative heat loss as well as a smaller body surface area to mass ratio thinner skin and increased energy expenditure. Due to the fact that more energy is needed to facilitate proper growth less energy is available for thermoregulation. These factors are important because they put children at an increased risk of hypothermia. GROWTH AND DEVELOPMENT 7 Nutritional Factors Caloric requirements for children vary according to the childs age. From birth to 6 months of age children should consume 120 kcalkgday. Some sources suggest 110 kcalkgday through 1 year of age with a decrease to 100 kcalkgday from 1 to 3 years of age. The daily caloric requirement decreases to 100 kcalkg for children 7 months to 1 year of age. Children 210 years of age may consume a daily caloric intake from 70 to 100 kcalkg. Lastly adolescents should consume 45 kcalkg daily.2 Typical weight gain progression consists of rapid decelerating growth followed by consistent growth. Neonates may initially lose 510 of their weight within the first few days of life and then regain their birth weight by 14 days.2 An infants weight typically doubles by 6 months of age triples by 1 year of age and quadruples by 2 years of age. Furthermore young children typically grow 2.5 inches and gain about 4 lbs annually from 3 years of age to school age7 and school-age children typically grow 2 inches and gain 6.5 lbs annually.7 Breastfeeding is the evidence-based standard for infant feeding as breast milk is the best source of nutrition during the first 6 months of a childs life.56 The AAP recommends in its policy statement on breastfeeding that women with no health problems should breastfeed infants for a minimum of 6 months.7 During these 6 months infants should be exclusively breastfed on demand. Furthermore the AAP recommends that breastfeeding continue for the first 12 months of life if possible. Breastfeeding offers numerous health benefits for both mothers and children such as improving gastrointestinal function and decreasing the incidence of acute illnesses.28 Breastfeeding may also decrease the risk of allergic diseases and prevent inflammatory diseases.6 Additionally breastfeeding may help prevent childhood problems of DISCUSSION Overview A childs growth and development progresses across four stages infancy preschool school age and adolescence.1 Knowing the major growth and development landmarks for each stage will allow the nurse practitioner NP to determine a patients expected developmental progression in addition to providing anticipatory guidance measures. Moreover being knowledgeable about the various stages will help to identify developmental warning signs or red flags in a childs development.2 A childs growth and development is monitored during regular health maintenance visits. Developmental surveillance occurs in three main domains physical cognitive and psychosocial. Guidelines for growth and development are contained in the American Academy of Pediatrics AAP Bright Futures Guidelines of Health Supervision of Infants Children and Adolescents.3 The Physical Domain Overview Physical growth occurs in an orderly sequence. Children progress at different rates through this sequence depending on a number of factors such as genetics culture nutrition and individual variability.2 Serial measurements are important for assessing a pediatric patients physical growth. The Centers for Disease Control and Prevention CDC recommend assessing the patients growth using standardized growth charts. The World Health Organization WHO in conjunction with the CDC and the National Center of Health Statistics have created standardized growth charts that allow health care providers to collect serial growth data in order to develop an overall clinical impression of the childs growth and development.4 8 CHAPTER 1 supplementation and multivitamins to ensure proper growth.12 At around 6 months of age infants should begin eating iron- fortified single-grain cereals.12 The AAP recommends that fluoride supplements be given to patients over 6 months of age whose local drinking water supply has less than 0.3 parts per million of fluoride however supplementation is not needed during the first 6 months of life.12 For low- to moderate-risk fluoride deficiency bottled water and toothpaste with fluoride may be recommended. For children who are at high risk for developing dental caries the dosage of fluoride supplementation depends on the patients age Children 6 months to 3 years of age should receive 0.25 mg per day children 36 years of age should receive 0.5 mg per day and 1 mg per day is recommended for patients 616 years of age.13 Eruption of the teeth begins with the central incisor followed by the lateral incisor canine first molar and second molar. This sequence is usually completed by the time the child is 3 years of age.17 being overweight or obese regardless of parental education or socioeconomic status. Consequently the longer the mother breastfeeds the less likely the child will become overweight. In mothers potential benefits of breastfeeding include analgesia during painful procedures more rapid involution of the uterus and a decreased risk of both ovarian and breast cancer.278 Adequate intake is confirmed by six to eight wet diapers per day in a newborn or young infant and is associated with satiety and appropriate weight gain. Well- nourished infants may also produce four or more stools per day by 2 weeks of age.9 The AAP recommends that daily vitamin D supplements of 400 international units IU begin a few days after delivery and continue until the child is weaned to whole milk at about 1 year of age.21011 Mothers of breastfed infants who are vegan or who have vitamin B12 deficiency should receive B12 supplementation to prevent neurological abnormalities.12 Term infants typically have sufficient iron stores for up to 6 months. However breast milk contains little iron and premature breastfed infants or infants with anemia should receive iron Figure 1.1. Primary teeth eruption. Figure 1.2. Permanent teeth eruption. GROWTH AND DEVELOPMENT 9 Table1.1DevelopmentalMilestonesandWarningSigns WhatMostChildrenDoAtThisAge DevelopmentalWarning SignsAgeSocialEmotional Language Communication Cognitive MovementPhysical Development 2months-Beginstosmileat people -Brieflycalmshimor herself -Triestolookat parent -Coosgurgling sounds -Turnsheadtowards sounds -Paysattentionto faces -Followsthingswith eyesrecognizes peopleatadistance -Beginstoactbored ifactivitydoesnt change -Canholdheaduppushes upwhenlyingontummy -Smootherarmandleg movement -Doesntrespondtoloud sounds -Doesntwatchthingsthat move -Doesntsmileatpeople -Doesntbringhandsto mouth -Cantholdheadupwhen lyingontummy 4months-Smiles spontaneously -Likestoplaywith peoplecrieswhen playingstops -Copiesmovements andfacial expressions -Babbles -Copiessounds -Criesindifferent waystodemonstrate hungerpainbeing tiredetc. -Letsyouknowifheor sheishappysadetc. -Respondstoaffection -Reacheswithone hand -Useshandsandeyes together -Followsmovingthings witheyesfromsideto side -Watchesfacesclosely -Recognizesfamiliar peopleatadistance -Holdsheadsteadywhen unsupported -Pushesdownonlegs whenfeetareonasurface -Rolloverfromtummyto back -Holdstoyshakesand swingstoys -Bringshandstomouth -Pushesuptoelbowswhen lyingonstomach -Doesntwatchthingsthat move -Doesntsmileatpeople -Cantholdheadsteady -Doesntcooormake sounds -Doesntbringthingsto mouth -Doesntpushdownwith legswhenfeetareonhard surface -Hastroublemovingoneor botheyesinalldirections 10 CHAPTER 1 Table1.1DevelopmentalMilestonesandWarningSigns WhatMostChildrenDoAtThisAge DevelopmentalWarning SignsAgeSocialEmotional Language Communication Cognitive MovementPhysical Development 6months-Knowsfamiliarfaces andbeginstoknow ifsomeoneisa stranger -Likestoplaywith othersespecially parents -Respondstoother peoplesemotions andoftenseems happy -Likestolookatself inamirror -Respondstosounds bymakingsounds -Stringsvowels togetherwhen babblingaheh ohandlikestaking turnswithparent whilemakingsounds -Respondstoown name -Makessounds toshowjoyand displeasure -Beginstosay consonantsounds jabberingwithm b -Looksaroundat thingsnearby -Bringsthingstomouth -Showscuriosityabout thingsandtriestoget thingsthatareoutof reach -Beginstopassthings fromonehandtothe other -Rollsoverinboth directionsfronttoback backtofront -Beginstositwithout support -Whenstandingsupports weightonlegsandmight bounce -Rocksbackandforth sometimescrawling backwardbeforemoving forward -Doesnttrytogetthings thatareinreach -Showsnoaffectionfor caregivers -Doesntrespondtosounds aroundhimher -Hasdifficultygettingthings tomouth -Doesntmakevowel soundsahehoh -Doesntrolloverineither direction -Doesntlaughormake squealingsounds -Seemsverystiffwithtight muscles -Seemsveryfloppylikea ragdoll 9months-Maybeafraidof strangers -Maybeclingywith familiaradults -Hasfavoritetoys -Understandsno -Makesalotof differentsounds -Copiesothers soundsandgestures -Usesfingerstopoint -Watchesthepathof somethingasitfalls -Looksforthingshe sheseesyouhide -Playspeek-a-boo -Putsthingsinhisher mouth -Movesthings smoothlyfromone handtotheother -Picksupthingslike cerealosbetween thumbandindex finger -Standsholdingon -Cangetintosittingposition -Sitswithoutsupport -Pullstostand -Crawls -Doesntbearweighton legswithsupport -Doesntsitwithhelp -Doesntbabble -Doesntplayback-and- forthgames -Doesntrespondtoown name -Doesntrecognizedfamiliar people -Doesntlookwhereyou point -Doesnttransfertoysfrom onehandtotheother GROWTH AND DEVELOPMENT 11 Table1.1DevelopmentalMilestonesandWarningSigns WhatMostChildrenCanDoAtThisAge DevelopmentalWarning SignsAgeSocialEmotional Language Communication Cognitive MovementPhysical Development 1year-Isshyornervous withstrangers -Crieswhenmomor dadleaves -Hasfavoritethings andpeople -Showsfearinsome situations -Handsyouabook whenheshewants tohearastory -Repeatssounds oractionstoget attention -Putsoutarmorleg tohelpwithdressing -Playsgamessuch aspeek-a-booand pat-a-cake -Respondstosimple spokenrequests -Usessimple gestureslike shakingheadnoor wavingbye-bye -Makessoundswith changesintone soundsmorelike speech -Saysmama anddadaand exclamationslike uh-oh -Triestosaywords yousay -Exploresthingsin differentwayslike shakingbanging throwing -Findshiddenthings easily -Looksattheright pictureorthingwhen itsnamed -Copiesgestures -Startstousethings correctlyforexample drinksfromacup brusheshair -Bangstwothings together -Putsthingsina containertakesthings outofacontainer -Letsthingsgowithout help -Pokeswithindex pointerfinger -Followssimple directionslikepickup thetoy -Getstoasittingposition withouthelp -Pullsuptostandwalks holdingontofurniture cruising -Maytakeafewsteps withoutholdingon -Maystandalone -Doesntcrawl -Cantstandwhen supported -Doesntsearchforthings thathesheseesyouhide. -Doesntsaysinglewords likemamaordada -Doesntlearngestureslike wavingorshakinghead -Doesntpointtothings -Losesskillshesheonce had 12 CHAPTER 1 Table1.1DevelopmentalMilestonesandWarningSigns WhatMostChildrenCanDoAtThisAge DevelopmentalWarning SignsAgeSocialEmotional Language Communication Cognitive MovementPhysical Development 18months-Likestohandthings toothersasplay -Mayhavetemper tantrums -Maybeafraidof strangers -Showsaffectionto familiarpeople -Playssimple pretendsuchas feedingadoll -Mayclingto caregiversinnew situations -Pointstoshow otherssomething interesting -Exploresalonebut withparentcloseby -Saysseveralsingle words -Saysandshakes headno -Pointstoshow someonewhathe shewants -Knowswhatordinary thingsareforfor exampletelephone brushspoon -Pointstogetthe attentionofothers -Showsinterestina dollorstuffedanimal bypretendingtofeed -Pointstoonebody part -Scribblesonhisher own -Canfollow1-step verbalcommands withoutanygestures forexamplesitswhen yousaysitdown -Walksalone -Maywalkupstepsandrun -Pullstoyswhilewalking -Canhelpundresshim herself -Drinksfromacup -Eatswithaspoon -Doesntpointtoshow thingstoothers -Cantwalk -Doesntknowwhatfamiliar thingsarefor -Doesntcopyothers -Doesntgainnewwords -Doesnthaveatleast6 words -Doesntnoticeormind whenacaregiverleavesor returns -Losesskillshesheonce had 2years-Copiesothers -Getsexcitedwhen aroundotherchildren -Showsincreasing independence -Showsdefiant behavior -Playsbesideother childrenbeginsto includeotherchildren -Pointstothings pictureswhennamed -Knowsnamesof familiarpeopleand bodyparts -Says24word sentences -Repeatswords overheardin conversation -Pointstothingsina book -Findsthingseven whenhiddenunder2 or3items -Sortsshapesand colors -Completessentences andrhymesinfamiliar books -Playsmake-believe games -Buildstowerswith4or moreblocks -Mayuseonehand morethantheother -Followstwo-step instructions -Namesitemsina picturebook -Standsontiptoes -Kicksaball -Beginstorun -Climbsupanddown furniture -Walksupanddownstairs whileholdingon -Throwsballoverhand -Makescopiesstraightlines andcircles -Doesntuse2-word phrases -Doesntknowwhattodo withcommonthingsi.e. brushphonefork -Doesntcopyactionsand words -Doesntfollowsimple instruction -Doesntwalksteadily -Losesskillshesheonce had GROWTH AND DEVELOPMENT 13 Table1.1DevelopmentalMilestonesandWarningSigns WhatMostChildrenCanDoAtThisAge DevelopmentalWarning SignsAgeSocialEmotional Language Communication Cognitive MovementPhysical Development 3years-Copiesadultsand friends -Showsaffection forfriendswithout prompting -Takesturnsingames -Showsconcernfora cryingfriend -Understandsthe ideaofmineand hisorhers -Showsawiderange ofemotions -Separateseasily frommomanddad -Maygetupsetwith majorchangesin routine -Dressesand undressesself -Followsinstructions with2or3steps -Cannamemost familiarthings -Understandswords likeinonand under -Saysfirstnameage andsex -Namesafriend -SayswordslikeI meweandyou andsomeplurals carsdogscats -Talkswellenough forstrangersto understandmostof thetime -Carriesona conversationusing 23sentences -Canworktoyswith buttonsleversand movingparts -Playsmake-believe withdollsanimals andpeople -Doespuzzleswith3 or4pieces -Understandswhat twomeans -Copiesacirclewith pencilorcrayon -Turnsbookpagesone atatime -Buildstowersofmore than6blocks -Screwsandunscrews jarlidsorturnsdoor handle -Climbswell -Runseasily -Pedalsatricycle3-wheel bike -Walksupanddownstairs onefootoneachstep -Fallsdownalotorhas troublewithstairs -Droolsorhasveryunclear speech -Cantworksimpletoys suchaspegboards simplepuzzlesturning handle -Doesntspeakin sentences -Doesntunderstandsimple instructions -Doesntplaypretendor make-believe -Doesntwanttoplaywith otherchildrenorwithtoys -Doesntmakeeyecontact -Losesskillshesheonce had 14 CHAPTER 1 Table1.1DevelopmentalMilestonesandWarningSigns WhatMostChildrenCanDoAtThisAge DevelopmentalWarning SignsAgeSocialEmotional Language Communication Cognitive MovementPhysical Development 4years-Enjoysdoingnew things -Playsmomand dad -Ismoreandmore creativewithmake- believeplay -Wouldratherplay withotherchildren thanbyhimherself -Cooperateswith otherchildren -Canttellwhatsreal andwhatsmake believe -Talksaboutwhat heshelikesandis interestedin -Knowssomebasic rulesofgrammar suchascorrectly usingheandshe -Singsasongorsays poemfrommemory -Tellsstories -Cansayfirstandlast name -Namessomecolors andnumbers -Understandscounting -Startstounderstand time -Rememberspartsof stories -Understandsideaof sameanddifferent -Drawsapersonwith 24bodyparts -Usesscissors -Startstocopycapital letters -Playsboardorcard games -Tellsyouwhathe shethingsisgoingto happennextinbook -Hopsandstandsonone footupto2seconds -Catchesbouncedballmost ofthetime -Pourscutswith supervisionandmashes ownfood -Cantjumpinplace -Hastroublescribbling -Showsnointerestin interactivegamesor make-believe -Ignoresotherchildrenor doesntrespondtopeople outsideoffamily -Resistsdressingsleeping usingtoilet -Cantretellfavoritestory -Doesntfollow3-part commands -Doesntunderstandsame anddifferent -Doesntusemeand youcorrectly -Speaksunclearly -Losesskillshesheonce had GROWTH AND DEVELOPMENT 15 Table1.1DevelopmentalMilestonesandWarningSigns WhatMostChildrenCanDoAtThisAge DevelopmentalWarning SignsAgeSocialEmotional Language Communication Cognitive MovementPhysical Development 5years-Wantstoplease friends -Wantstobelike friends -Morelikelytoagree withrules -Likestosingdance act -Isawareofgender -Cantellwhatsreal andwhatsmake believe -Showsmore independence -Sometimes demanding sometimes cooperative -Speaksclearly -Tellsasimplestory usingfullsentences -Usesfuturetense -Saysnameand address -Counts10ormore things -Candrawaperson with6bodyparts -Canprintlettersor numbers -Copiesatriangleand othershapes -Knowsaboutthings usedeverydayi.e. foodmoney -Standsononefootfor 10secondsorlonger -Hopsmaybeabletoskip -Candoasomersault -Usesforkandspoon -Canusetoiletonhisher own -Swingsandclimbs -Doesntshowwiderange ofemotions -Showsextremebehavior -Usuallywithdrawninactive -Easilydistracted -Doesntrespondtopeople orrespondssuperficially -Canttellwhatsrealor makebelieve -Doesntplayavarietyof games -Cantgivefirstandlast name -Doesntusepluralsor tensesproperly -Doesnttalkaboutdaily activitiesorexperiences -Doesntdrawpictures -Cantbrushteethwash anddryhandsorget undressedwithouthelp -Losesskillshesheonce had Note.AdaptedfromDevelopmentalmilestones.CDC.httpwww.cdc.govncbdddactearlymilestonesindex.html.Published2014.AccessedApril2015.Reproducedwithpermission. 16 CHAPTER 1 Psychosocial Domain Overview Erik Eriksons theories of growth and development consist of psychosocial stages in which children mature by resolving social crises and developing a series of life skills.18 As with all of Piagets cognitive theories the age ranges listed are approximate beginning with the trust versus mistrust stage which begins at birth and lasts until 18 months of age. During this stage the infant learns that the world is an uncertain place and seeks some measure of stability from caregivers and the environment. Afterward the child enters the autonomy versus shame and doubt stage which lasts until 3 years of age and is characterized by self-assertion and developing confidence in ones own skills and abilities. Next the initiative versus guilt stage lasts from 3 to 6 years of age wherein the child begins interacting with peers and develops confidence in his or her ability to make decisions. This is followed by the industry versus inferiority stage which lasts from 6 to 11 years of age and involves the child learning to be productive in his or her particular competencies. The final Erikson stage before young adulthood is the identity versus role confusion stage which lasts from 12 to 18 years of age and focuses on defining ones own place in society.18 According to Sigmund Freuds psychosexual theories three components of personalities are developed by experiences in particular stages of a childs development. These three components are the id the principle of pleasure the ego the principle of reality and self- interest and the superego the principle of morality or conscience. Freuds stages of psychosexual development begin with the oral stage which lasts from birth to 18 months of age and is marked by focus on the sensations of feeding which can lead to the development of a sense of trust and comfort between child and mother. This is followed by the anal stage which begins Cognitive Domain Overview Jean Piagets theory of cognitive domain assigns various stages to the cognitive development of a child. The sensorimotor stage which lasts from birth to about 2 years of age is characterized by rapid cognitive growth and learning through trial and error. A primary component of this stage is the concept of object permanence which consists of an infant understanding that objects exist independently of their own actions or perceptions.18 Additionally infants develop greater awareness of their surrounding environment and adapt to the world by relating their actions to the results of those actions.18 The preoperational and preconceptual stage lasts from approximately 2 to 4 years of age. During this stage the child can focus on a single aspect of a situation and begin developing intuitive thought however children at this stage are not yet capable of cause-and-effect reasoning. The preoperational stage is also marked by egocentrism manifested as the inability to see situations from another persons point of view.18 Additionally children also exhibit animism which is the belief that inanimate objects have human feelings.18 The intuitive and preoperational thinking stage lasts from 4 to 7 years of age and marks the beginning of causation with the child beginning to make logical assumptions about how one phenomenon produces another.2 When children reach roughly 7 years of age they enter the concrete operational stage which lasts until about 11 years of age. During the concrete operational stage the child becomes capable of solving problems logically and gains the ability to conserve numbers and liquid understanding that quantity may remain the same despite disparities in presentation.18 Finally formal operational thought lasts from around 11 to 15 years of age. Children in this stage become capable of thinking abstractly solving complex problems and reaching logical conclusions.18 GROWTH AND DEVELOPMENT 17 expressed as percentiles of height weight and head circumference in accordance with the patients age. Serial measurements should be examined historically any child whose measurement crossed over two or more percentile lines needed further evaluation. Although this remains true the issue of further workup is much more complex than originally thought. Other factors to consider for further investigation include but are not limited to growth out of proportion to expected norms for ethnicity body type and familial trends and nutrition. Body mass index BMI uses a baseline of height and weight to measure a patients body fat. The CDC and AAP recommend BMI screenings for overweight and obese children as early as 2 years of age.22 The Denver II test does not measure intelligence but serves as a generalized assessment tool that can be used from birth to 6 years of age. This test assesses a childs development by measuring his or her growth use of language personal-social skills and gross and fine motor skills.23 Although normal development is widely variable any child who is unable to meet the majority of developmental milestones during the well-child visit should be referred for a full developmental assessment. Growth and Development Milestones see table 1.1 Well Child Checks WCC Workup Well Child Checks WCCs are stage appropriate screenings in which specific tools are used to screen the health of pediatric patients. In the initial screening a comprehensive health and development history is taken. Subsequent visits include interval histories to update the patients records. These screenings also consist of a complete physical examination developmental screening and questions about the childs well-being.2 The AAP recommends a screening schedule that at 18 months of age lasts until 3 years of age and involves the child developing a sense of independence by mastering control of his or her bodily needs.19 The phallic stage lasts until the child is 6 years of age and is marked by the development of the ego love of the opposite sex and the Oedipus complex which is characterized by an increased attachment towards the opposite sex parent and resultant jealously towards the same sex parent. The latency stage lasts from 6 to 12 years of age and is marked by socialization repression of sexual drive and development of the childs superego and morality. Lastly the genital stage occurs during adolescence from 12 to 18 years of age during this stage adolescents direct their sexual urges onto their peers.19 Growth and Development Landmarks Overview Growth measurements are the gold standard by which the NP can assess a childs health and well-being.20 Individual stages of growth and development with a comprehensive outline of developmental milestones follow in the subsequent sections. Assessment of developmental milestones should be determined using corrected age for premature infants this is especially true when performing the Denver Developmental Screening Test second edition Denver II assessment.2 The corrected gestational age is the adjustment of developmental expectations for premature infants through 2 years of age at which point most infants catch up developmentally.21 Workup Every well-child visit requires a physical examination to assess the childs growth in relation to expected growth and developmental milestones. The growth parameters of pediatric patients are measured by growth charts with norms 18 CHAPTER 1 Injury Prevention see table 1.2 Overview Injury prevention is particularly important in pediatric patients as injuries are a leading cause of death in infants and children in the United States and worldwide.26 Unintentional injury is one of the major types of injuries in children and includes injuries due to poisonings motor vehicle accidents drownings and falls among others.27 To prevent poisoning in children it is important to have poison control numbers nearby at all times and keep all poisons locked and out of reach.2 Firearms are another major cause of injury to children proper storage and safety concerns should be discussed with parents and children when appropriate.28 It is important that children be properly placed in adequate restraint systems in passenger vehicles as motor vehicle accidents are the leading cause of death in children 4 years of age and older.29 The childs home should likewise be fitted to protect against injuries resulting from fires and other unintentional injuries.30 Domestic violence and other types of child maltreatment are a common source of injuries. NPs are encouraged to minimize the risk of child maltreatment by promoting awareness of the issue in the community engaging in home visits and educating parents in proper techniques to ensure a positive environment for their child.31 If domestic violence is identified most states have mandatory reporting statutes that require NPs to report the incident to the proper authorities.32 Developmental Considerations During a childs growth and development the NP must be mindful that children cannot be treated as small adults due to many unique anatomical physiological cognitive and psychological differences.33 begins at birth and continues at regular intervals throughout childhood and adolescence.24 A WCC measures a childs health by both objective and subjective data. Subjective data consists of an interval history that evaluates the childs nutrition appetite elimination sleep and development among other factors.25 Furthermore this stage of the WCC should include discussion of any concerns the childs parents or caregivers may have. Objective data of a WCC includes physical examinations laboratory testing and developmental screening which may include the Ages and Stages questionnaire ASQ or the Denver II test. The management plan of a WCC should include health promotion strategies with anticipatory guidance and the initiation of the primary series of immunizations.2 The Interview Overview The NPs general approach to interviewing a pediatric patient should begin with ascertaining who will be present and ensuring that privacy is maintained. It is important to use a non-judgmental approach during an interview and ensure accurate perceptions of the concerns of the childs parents. Additionally the NP should phrase his or her questions purposefully use non- threatening words convey interest and attention allow adequate time for response and employ cultural sensitivity. The NP should play with the child and engage the child as well as the parents during the interview process. When seeing an infant or toddler the conversation will be mostly with the parents however as the child grows he or she should be increasingly included in the interview process. Finally the child should be kept clothed during an interview until physical examination or until it is otherwise necessary to remove clothing.2 GROWTH AND DEVELOPMENT 19 Smaller Circulating Blood VolumeLess Fluid Reserve Blood loss of even a small amount can be considered significant in children. A 5 kg child who has a hemorrhage of 100 ml will lose approximately 10 of their total blood volume.33 Skeletal Childrens bones are more susceptible to fractures and offer less protection to the internal organs.37 Moreover due to the disproportion of the head in relation to the body cervical vertebrae are cartilaginous in an infant and slowly become replaced by bone thus childhood cervical spine injuries occur at a higher rate than adult cervical spine injuries. Other injuries are then more likely to result which may include damage to cartilaginous-osseus structures and surrounding ligaments as well as spinal cord compression or transection.37 Due to the increased elasticity of childrens bones they are most prone to having greenstick fractures which occur when a bone bends before cracking.38 Head Children have larger head-to-body ratios than adults. Because of their larger head sizes children are more vulnerable to head Anatomic Differences Size Because their bodies are not fully mature children are at increased risk from environmental hazards. Body surface area BSA to mass body ratio is highest at birth and diminishes with age.34 Because children have a higher BSA to body mass ratio they may absorb larger doses of pollutants than adults.35 Small Body Mass The body mass of a child typically has less fat less elastic connective tissue and a closer proximity of the chest to the abdominal organs. Because of these anatomic differences flying objects falls and blunt or blast trauma may result in increased injury to multiple organs.33 Young children have a very large head size in comparison to their body size which causes them to lead with their heads when falling. This leads to an increased incidence of head injuries. As brain development continues through 20 years of age any head injuries sustained by children or young adults can have deleterious effects and result in long term sequelae. Table 1.2 Leading Causes of Unintentional Injury Death Among Children 019 Years by Age Group United States Age Group in years Rank Younger than 1 14 59 1014 1519 1 Suffocation MVT-related MVT-related MVT-related MVT-related 2 MVT-related Drowning Other injuries Other injuries Other injuries 3 Drowning Other injuries Fires or burns Drowning Poisoning 4 Other injuries Fires or burns Drowning Fires or burns Drowning 5 Fires or burns Suffocation Suffocation Suffocation Falls 6 Poisoning Falls Falls Poisoning Fires or burns 7 Falls Poisoning Poisoning Falls Suffocation Note. MVT motor vehicle traffic. Adapted from CDC childhood injury report Patterns of unintentional injuries among 019 year olds in the United States 20002006. CDC. httpwww.cdc.govsafechildimagesCDC-childhoodinjury.pdf. Published 2008. Accessed April 2015. Reproduced with permission. 20 CHAPTER 1 stability and regulation of children include thin skin evaporative heat loss due to lack of subcutaneous tissues and increased caloric and energy expenditures. The use of thermal blankets as well as warmed resuscitation rooms fluids and inhaled gases may be required for treatment.2 Ventilation When managing a childs ventilation the NP should consider the anatomic differences of pediatric patients airways when compared to those of adults. For instance children have a shorter trachea a larger tongue and a glottic opening that is anterior and superior to that of an adult.33 The Broselow-Hinkle measuring tape is recommended for selecting drug doses and equipment sizes during a pediatric resuscitation. This tape has drug dosages and equipment sizes printed directly on the apparatus thus eliminating the need for the practitioner to perform calculations during resuscitation efforts.41 Meticulous fluid management is critical in pediatric patients and normal saline or lactated Ringers solution should be administered to restore intravascular volume.42 Glycogen Energy Stores A limited store of glycogen with higher relative metabolism puts children at risk for hypoglycemia. Hypoglycemia is most common in newborns and may also appear in older children as a complication of insulin therapy for diabetes.43 Immunologic Differences An immature immunologic system creates a greater risk of infection for children. As a result certain conditions can be magnified or are more likely to appear in pediatric patients than adults. One example is eczema which can manifest over the childs entire body. As children grow older the manifestation of these conditions becomes more similar to that of an adults presentation. and spine injuries as well as heat loss and hypothermia.33 Furthermore the brain which typically doubles in size by 6 months and is 80 of adult size by 2 years of age continues to perform functions such as myelination synapse formation neuronal plasticity and biochemical stability all of which are at risk for arrest and resultant permanent changes.2 Chest Childrens chests are mobile and pliable and their abdominal walls are relatively thin. Additionally their small size leads to closer proximity of organs resulting in an increased likelihood of multiple organs being injured during a given traumatic event.33 Airway The anatomy of the pediatric respiratory system is significantly different from that of an adult. Children have a smaller trachea smaller lung volume a more compliant chest wall and a smaller forced residual capacity than adults. Thus they are more vulnerable to respiratory distress.3339 Physiological Differences Circulatory System Depending on their stage of development children may have smaller absolute blood volume lower systemic vascular resistance smaller blood vessels and more subcutaneous tissue than adults.33 Furthermore children are vulnerable to certain types of shock most commonly hypovolemic shock. This occurs from a decreased preload from extravascular or intravascular fluid loss which subsequently results in decreased cardiac output.40 A rapid deterioration with little warning may follow.2 Temperature Stability and Regulation Because of their larger head size and increased BSA children are at increased risk for heat loss and hypothermia.33 Additional factors that affect the temperature GROWTH AND DEVELOPMENT 21 References 1. Normal growth and development. A.D.A.M. Medical Encyclopedia. httpwww.nlm.nih. govmedlineplusencyarticle002456.htm. Updated February 26 2014. Accessed April 3 2015. 2. Barkley TW Jr. Pediatric Primary Care Nurse Practitioner Certification ReviewClinical Update Continuing Education Course. West Hollywood CA Barkley and Associates 2015. 3. Hagan JF Shaw JS Duncan P. Eds.. Bright Futures Guidelines for Health Supervision of Infants Children and Adolescents Pocket Guide. 3rd ed. Elk Grove Village IL American Academy of Pediatrics 2008. 4. United States Department of Health and Human Services Centers for Disease Control and Prevention. Growth charts. httpwww.cdc.govgrowthcharts. Last updated September 9 2010. Accessed April 3 2015. 5. Wagner CL. Counseling the breastfeeding mother. In Rosenkrantz T ed. Medscape. httpemedicine.medscape.com article979458-overview. Updated February 5 2015. Accessed April 3 2015. 6. Fleischer DM. The impact of breastfeeding on the development of allergic disease. In Basow DS ed. UpToDate. Waltham MA UpToDate 2015. httpwww.uptodate.com contentsthe-impact-of-breastfeeding-on- the-development-of-allergic-disease. Last updated September 24 2014. Accessed April 3 2015. 7. American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2012 1293 e827e841. httppediatrics.aappublications.org content1293e827.full.pdfhtml 8. Schanler RJ. Infant benefits of breastfeeding. In Basow DS ed. UpToDate. Waltham MA UpToDate 2015. httpwww. uptodate.comcontentsinfant-benefits-of- breastfeeding. Last updated March 22 2015. Accessed April 3 2015. Developmental Differences Because of limited verbal abilities children may not be able to describe symptoms or localize pain. Dependence on caretakers may make children more vulnerable to food source limitations when potential sources are unavailable or contaminated. Children have limited motor skills to escape injury as well as limited cognitive abilities to conceptualize their way out of danger follow directions from others or recognize threatening circumstances. Moreover children are emotionally labile due to their developing brain which is especially taxed during stressful encounters. Reactions to danger and threats may be dictated by the childs developmental stage and there are additional concerns when the child has special health care needs.2 Psychological Differences Developmental stages alter the childs emotions in specific ways. Hyperactive startle responses may begin to occur during the newborn stage and last up to 2 months of age. A child may begin to cry more around the third month of life whereas separation anxiety is developmentally appropriate around 912 months of age. Toddlers and preschool age children may exhibit regressive behaviors such as temper tantrums clinginess and problems with separation or sleep.2 These regressive behaviors may be exacerbated by a major change in a childs life. Mental health problems tend to develop in late childhood and early adolescence and can have a detrimental impact on school relationships and overall health. The WHO suggests that depression is the leading healthcare concern among children and adolescents.44 Depression does not have a single cause but a number of factors may contribute to depression in children including genetics stressful situations and the childs home environment.45 Furthermore depression may manifest itself in the form of risk-taking behaviors such as alcohol and drug use unplanned pregnancies and violent behavior.44 22 CHAPTER 1 17. Domino FJ. Teething. In Domino FJ Baldor RA Golding J Grimes JA eds. The 5-Minute Clinical Consult 2015. 23rd ed. Philadelphia PA Wolters Kluwer Health 2014 11561157. 18. Jarvis C. Physical Examination and Health Assessment. 6th ed. St. Louis MO Elsevier Saunders 2012. 19. Felluga D. Modules on Freud On psychosexual development. Introductory Guide to Critical Theory web site. httpwww.purdue.eduguidetotheory psychoanalysisfreud.html. Last updated January 31 2011. Accessed April 3 2015. 20. Phillips SM Shulman RJ. Measurements of growth in children. In Basow DS ed. UpToDate. Waltham MA UpToDate 2015. httpwww.uptodate.comcontents measurement-of-growth-in-children. Last updated February 10 2014. Accessed April 3 2015. 21. American Academy of Pediatrics. Corrected age for preemies. Healthy Children web site. httpwww.healthychildren.org Englishages-stagesbabypreemiepages Corrected-Age-For-Preemies.aspx. Last updated January 8 2015. Accessed April 3 2015. 22. United States Department of Health and Human Services Centers for Disease Control and Prevention. About BMI for children and teens. httpwww.cdc.gov healthyweightassessingbmichildrens_bmi about_childrens_bmi.html. Last updated July 11 2014. Accessed April 3 2015. 23. Willacy H Tidy C. Denver Developmental Screening Test. Patient web site. http www.patient.co.ukdoctordenver- developmental-screening-test. Reviewed December 3 2014. Accessed April 3 2015. 24. Health supervision of the well child. In Porter RS Kaplan JL eds. The Merck Manual Online. httpwww.merckmanuals. comprofessionalpediatricsapproach_to_ the_care_of_normal_infants_and_children health_supervision_of_the_well_child. htmlv1077060. Last reviewed April 2014. Accessed April 3 2015. 9. Hellings PJ. Breastfeeding. In Burns CE Dunn AM Brady MA Starr NB Blosser CG Garzon DL eds. Pediatric Primary Care. 5th ed. Philadelphia PA Elsevier Saunders 2013 186201. 10. Vitamin D supplementation for infants. American Academy of Pediatrics web site. httpwww.aap.orgen-usabout- the-aapaap-press-roomPagesVitamin- D-Supplementation-for-Infants.aspx. Published March 22 2010. Accessed April 3 2015. 11. Pettifor JM. Nutritional rickets. In Glorieux FH Pettifor JM Jppner H. Pediatric Bone. 2nd ed. London ElsevierAcademic Press 2012 625654. 12. Bright Futures. American Academy of Pediatrics. Nutrition supervision. In Holt K Wooldridge N Story M Sofka D eds. Bright Futures Nutrition. 3rd ed. Elk Grove IL American Academy of Pediatrics 2011 17111. httpsbrightfutures.aap.orgpdfs BFNutrition3rdEditionSupervision.pdf 13. Oral health topics Fluoride supplements. American Dental Association web site. httpwww.ada.orgenmember-centeroral- health-topicsfluoride-supplements. 14. Boom JA. Normal growth patterns in infants and prepubertal children. In Basow DS ed. UpToDate. Waltham MA UpToDate 2015. httpwww.uptodate.comcontentsnormal- growth-patterns-in-infants-and-prepubertal- children. Last updated March 13 2014. Accessed April 3 2015. 15. American Academy of Pediatrics. Physical appearance and growth Your 2 year old. Healthy Children web site. httpwww. healthychildren.orgEnglishages-stages toddlerPagesPhysical-Appearance-and- Growth-Your-2-Year-Od.aspx. Last updated August 6 2013. Accessed April 3 2015. 16. American Academy of Pediatrics. Physical changes during puberty. Healthy Children web site. httpwww.healthychildren.org Englishages-stagesgradeschoolpuberty PagesPhysical-Development-of-School- Age-Children.aspx. Last updated December 19 2014. Accessed April 3 2015. GROWTH AND DEVELOPMENT 23 33. How are children different Royal Childrens Hospital Melbourne web site. httpwww. rch.org.aupaed_traumamanual11_How_ are_children_different. Accessed April 3 2015. 34. Brandt BL. Household environmental toxins and neurodevelopment in children professional paper. Bozeman MT Montana State University 2012. http scholarworks.montana.eduxmlui bitstreamhandle1966BrandtB0512. pdfsequence1isAllowedy 35. United States Department of Health and Human Services Centers for Disease Control and Prevention Agency for Toxic Substances and Disease Registry. Principles of pediatric environmental health How are newborns infants and toddlers exposed to and affected by toxicants httpwww.atsdr.cdc.govcsemcsem. aspcsem27po9. Issued February 15 2012. Renewed February 15 2014. Accessed April 3 2015. 36. American Academy of Pediatrics. Curriculum for managing infectious diseases in early education and child care settings Module 1 understanding infectious diseases. Healthy Child Care American web site. httpwww.healthychildcare.orgPDF InfDiseasesModule1.pdf. Published 2010. Accessed April 3 2015. 37. Thompson GH Stern LC Wilber JH Son-Hing JP. The multiply injured child. In Mencio GA Swiontkowski MF eds. Greens Skeletal Trauma in Children. 5th ed. Philadelphia PA Elsevier Saunders 2015 5985. 38. Mayo Clinic Staff. Greenstick fractures. Mayo Clinic web site. httpwww. mayoclinic.orgdiseases-conditions greenstick-fracturesbasicsdefinition con-20027302. Reviewed June 18 2013. Accessed April 3 2015. 39. Kache S. Pediatric airway and respiratory physiology. Stanford School of Medicine Pediatric Housestaff web site. httppeds. stanford.eduRotationspicupdfs10_Peds_ Airway.pdf. Accessed April 3 2015. 25. Haupt M. 4 Month Well Child visit. University of Chicago Department of Pediatrics web site. httppediatrics. uchicago.educhiefsClinicCurriculum documents4MonthWellChild.pdf. Accessed April 3 2015. 26. Norton R Kobusingye O. Injuries. N Engl J Med. 2013 36818 17231730. doi 10.1056NEJMra1109343. 27. Kelly NR. Prevention of poisoning in children. In Basow DS ed. UpToDate. Waltham MA UpToDate 2015. http www.uptodate.comcontentsprevention- of-poisoning-in-children. Last updated December 9 2014. Accessed April 3 2015. 28. Gill AC Wesson DE. Firearm injuries in children Prevention. In Basow DS ed. UpToDate. Waltham MA UpToDate 2015. httpwww.uptodate.comcontentsfirearm- injuries-in-children-prevention. Last updated October 30 2014. Accessed April 3 2015. 29. Committee on Injury Violence and Poison Prevention Durbin DR. Child passenger safety. Pediatrics. 2011 1274 788793. doi10.1542peds.2011-0213 30. Protecting children in your home. Safe Kids Worldwide web site. httpwww.safekids. orginfographicprotecting-children-your- home. Accessed April 3 2015. 31. Merrick MT Latzman NE. Child maltreatment A public health overview and prevention considerations. Online J Issues Nurs. 2014 191 2. doi 10.3912OJIN. Vol19No01Man02 32. United States Department of Health and Human Services Administration for Children and Families Administration on Children Youth and Families Childrens Bureau. Mandatory reporters of child abuse and neglect. httpswww. childwelfare.govpubPDFsmanda. pdfpage1viewProfessionals Required to Report. Published 2014. Accessed April 29 2015. 24 CHAPTER 1 40. Pomerantz WJ Roback MG. Physiology and classification of shock in children. In Basow DS ed. UpToDate. Waltham MA UpToDate 2015. httpwww.uptodate. comcontentsphysiology-and-classifica- tion-of-shock-in-childrensourcesearch_ ultsearchshockchildrenselectedTi- tle4150H8. Last updated December 17 2014. Accessed April 3 2015. 41. Jevon P. Paediatric advanced life support A practical guide for nurses. 2nd ed. Chich- ester West Sussex John Wiley Sons 2012. 42. Pomerantz WJ Roback MG. Hypovole- mic shock in children Initial evaluation and management. In Basow DS ed. UpToDate. Waltham MA UpToDate 2015. httpwww.uptodate.comcontents hypovolemic-shock-in-children-initial-eval- uation-and-managementsourcesee_ linkH13. Last updated September 18 2014. Accessed April 3 2015. 43. Hypoglycemia and low blood sugar in children. Boston Childrens Hospital web site. httpwww.childrenshospital. orghealth-topicsconditionshypoglyce- mia-and-low-blood-sugar. Accessed April 3 2015. 44. Adolescents and mental health. World Health Organization web site. httpwww. who.intmaternal_child_adolescenttopics adolescencemental_healthen. Accessed April 3 2015. 45. Continuing medical education Frequently asked questions. American Academy of Child Adolescent Psychiatry web site. httpwww.aacap.orgaacapFamilies_and_ YouthResource_CentersDepression_Re- source_CenterFAQ.aspx. Accessed April 3 2015. www.NPcourses.com Simply the Best Text Overview Over 260 pages of questions rationales and discussions along with tables and figures Test questions cover diagnosis laboratorydiagnostics assessment pharmacology managementtreatment and professional practice Up-to-date management options for conditions are provided in a succinct and easy-to-read format Conditions are organized by body system for quick reference when treating patients Each condition lists defining terms incidence predisposing factors subjective and physical examination findings diagnostic tests and management strategies Practice questions allow students to identify areas of knowledge and discussions provide a comprehensive overview to supplement areas of weakness