RomqvrstI.Grun N.Dalianis 1.Human papillomavirus and tonsillar andbase of tongue cancer.Viruses 2015;7:1332-1343.

Rea.P.Clinical anatomy of thecramal nerves.Academic Press.2014.

RosenTield RM.Schwartz SR. Pynnonen MA.et al.Clinical practice guideline:tympanostomy lubes inchildren.Otolaryngol Head Neck Surg 2013:49:S1-S33.

RosenfeldRM.Brown L.Cannon CR.etal.Clinical practice guideline:Acute otitis externa.Otolaryngol Head Neck Surg 2006:134(4):S4-S23.

Rosenfeld FM.ShinJJ,SchwartzSR.et aL Clinical practice guideline:Otitis media with effusion (update).Otolaryngol Head Neck Surg 2016;154:S1-S41.

Sander R.Otitis Externa:A practical Guide to Treatment andPrevention.Am Fam Physician2001:63(5):927-937.

Schaefer P.Baugh RF. Acute Otitis Externa:An Update. Am Fam Physician 2012;86(11):1055-1061.

Schularick.HM.Mowry SE. Soken H.et al.Is eleclroneumgraphy beneficial in the management of Bell's palsy? laryngoscope 2013:123:1066-1067.

Schwartz SR.Magil AE. Rosenfeld RM.clat. Clinical Practice Guideline (Update):Earwax (Cerumen Impaction). Otolaryngol Head Neck Surg 2017:156:51-529.

Scholes MA.Ramakiishnan VR (editors).EN1 secrets. 4th ed. Philadelphia:Elsevier. 2016.

Smalt P.KeithPK.Kim H. Allergic rhinitis.Allergy Asthma Clin Immunol 2018:14:51.

Smith SS.Terence EH.Evans CT.etal.Ihe prevalence of bacterial infection in acute rhlnosinusitis:a systematic review and mela analysis.Laryngoscope 2015;125:57- 69.

SraffordIID.Wilde A. Parotid cancer.Surg Oncol1997:6:209-213.

Sur DKC.Ptesa ML.Chronic nonallergic rhinitis.Am Fam Physician 2018:98(3):171-176.

TehraniAS,Kattah JC,Kerber KA.etal.Diagnosing stroke inacute dizziness and verbgo:pitfalls andpearls.Stroke 2018:49(3):788-795.

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OT52 Otolaryngology Toronto Notes 2023

Valencucla CV.Newbill CP.Johnston C cl at. Proliferative laryngitis with airway obstruction Inan adult: consider herpes, laryngoscope 2016;126:945-948.

Vcnekamp HP.SandetsS,Glasclou PP.et at.Antibiotics lor acute otitis mediainchildren.Cochrane DB Syst Rev 2013:1:C0000219.

VenekampRP.Thompson MJ.Rovers MM.Systemic corticosteroid therapy lor acute sinusitis.JAMA 313:1258-1259.

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Wu V.Cooke B.Eilulis S.ctal.Approach to tinnitus management. Can Fam Physician 2018:64( 71 -191 -195.

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Paediatrics

Onyinyechukwu Esenwa, Anna Jiang, Kahna Rasouli,Mary Xie, and Tingting Yan,chapter editors

Ming Li and Dorrin Zarrin Khat, associate editors

Vijithan Sugumar, EBM editor

Dr. Tanvi Agarwal, Dr.Jillian Baker, Dr. Tyler Groves, Dr. Joey Latino, Dr. Shazeen Suleman, and Dr.

Janaki Vallipuram,staff editors

Acronyms

Paediatric Quick Reference Values

Primary Care

Visit Overview

Routine Immunization

Growth and Development

Nutrition

Circumcision

Common Complaints

Breath Holding Spells

Crying/Fussing Child

Infantile Colic

Dentition and Caries

Enuresis

Encopresis

Toilet Training

Failure to Thrive

Obesity

Poison Prevention

Rashes

Sleep Disturbances

Sudden Infant Death Syndrome

Adolescent Medicine

Child Abuse and Neglect

Physical Abuse

Sexual Abuse

Neglect

Cardiology

Congenital Heart Disease

Acyanotic Congenital Heart Disease

Cyanotic Congenital Heart Disease

Congestive Heart Failure

Dysrhythmias

Heart Murmurs

Infective Endocarditis

Development

Global Developmental Delay

Intellectual Disability

Language Delay

Specific Learning Disorder

Fetal Alcohol Spectrum Disorder

Attention Deficit Hyperactivity Disorder

Autism Spectrum Disorder

Motor Delay

Endocrinology

Antidiuretic Hormone

Diabetes Mellitus

Growth

Hypercalcemia/Hypocalcemia/Rickets

Hyperthyroidism and Hypothyroidism

Disorders of Sexual Development

Fluids and Electrolytes

Approach to Infant/Child with Dehydration

Gastroenterology

Vomiting

Gastroesophageal Reflux

Tracheoesophageal Fistula

Pyloric Stenosis

Duodenal Atresia

Malrotation of the Intestine

Diarrhea

P3 Gastroenteritis

Toddler's Diarrhea

Lactase Deficiency (Lactose Intolerance)

Irritable Bowel Syndrome

Celiac Disease

Cow's Milk Allergy

Inflammatory Bowel Disease

Cystic Fibrosis

Constipation

Abdominal Pain

Chronic Abdominal Pain

Abdominal Mass

Upper Gastrointestinal 8leeding

Lower Gastrointestinal Bleeding

Genetics,Dysmorphisms,and Metabolism

Hematology

Approach to Anemia

Physiologic Anemia

Iron Deficiency Anemia

Vitamin K Deficiency

Anemia of Chronic Disease

Sickle Cell Disease

Thalassemia

Hereditary Spherocytosis

Glucose-6-Phosphate Dehydrogenase Deficiency

Bleeding Disorders

Immune Thrombocytopenic Purpura

Hemophilia

von Willebrand's Disease

Oncology

Lymphadenopathy

Leukemia

Lymphoma

Brain Tumours

Wilms' Tumour (Nephroblastoma)

Neuroblastoma

Bone Tumours

Cancer Predisposition Syndromes

Infectious Diseases

Fever

Acute Otitis Media

Otitis Media with Effusion

Gastroenteritis

HIV Infection

Infectious Paediatric Exanthems

Infectious Mononucleosis

Infectious Pharyngitis/Tonsillitis

Meningitis

Mumps

Pertussis

Pneumonia

Periorbital (Preseptal) and Orbital Cellulitis

Sexually Transmitted Infections

Sinusitis

Urinary Tract Infection

Neonatology.

Gestational Age and Size

Routine Neonatal Care

Neonatal Resuscitation

Common Conditions of Neonates

Apnea

Bleeding Disorders in Neonates

Bronchopulmonary Dysplasia

Cyanosis

P3

P4

P10

P50

P50

P17

P18

P20 P54

P26

P58

P30

P38

P70 P40 r->

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Paediatrics

Diaphragmatic Hernia

Hypoglycemia

Neonatal Hyperbilirubinemia

Necrotizing Enterocolitis

Persistent Pulmonary Hypertension of the Newborn

Respiratory Distress in the Newborn

Retinopathy of Prematurity

Sepsis in the Neonate

Skin Conditions of the Neonate

Nephrology

Common Paediatric Renal Diseases

Hemolytic Uremic Syndrome

Nephritic Syndrome

Nephrotic Syndrome

Hypertension in Childhood

Neurology

Cerebral Palsy

Febrile Seizures

Hypotonia

Neurocutaneous Syndromes

Recurrent Headache

Seizure Disorders

Respirology

Asthma

Bronchiolitis

Cystic Fibrosis

Pneumonia

Respiratory Distress

Rheumatology

Growing Pains

Juvenile Idiopathic Arthritis

Limb Pain

Lyme Arthritis

Reactive Arthritis

Septic Arthritis and Osteomyelitis

Systemic Lupus Erythematosus

Transient Synovitis of the Hip

Vasculitides

Common Medications

Landmark Paediatric Trials

References

P82

P87

P91

P95

P99

P100

P100

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Acronyms

AAP American Academy o( Pediatrics 01

ABG arterial blood gas

ACE angiotensin converting enzyme

ACEI angiotensin converting enzyme OKA

inhibitor

ADH antidiuretic hormone

AGA appropriate for gestational age OS

ALL acute lymphoblastic leukemia OSD

ALPS autoimmune lymphoprolilerativc EBV

syndrome

AML acute myelogenousleukemia

ANA antinuclear antibody

AOM acute otitis media

ARB angiotensin receptor blocker

ARBO alcohol-related birth defects FIT

ARNO alcohol-related

ncurodevclopmcntal disorder

ASD atrial septal delect

ASOT antistreptolysin-o titre

AIN acute tubular necrosis

AVM arteriovenous malformation GN

BRUE

CAH congenital adrenal hyperplasia

CAS Children's Aid Society

COGP constitutional delay of growth

and puberty

CF cystic fibrosis

CFIR cystic fibrosis transmembrane

conductance regulator

CHO congenital heart defect

CML chronic myelogenous leukemia

CMV cytomegalovirus

CP cerebral palsy

CPAP continuous positive airway

pressure

CPS Canadian Paediatric Society

DAT direct antiglobulin test

DDAVP 1-desamino-8-Darginine

vasopressin

diabetes insipidus

QIC disseminated intravascular

coagulation

diabetic ketoacidosis

DMARD disease modifying antirheumatic

drug

Down syndrome

disorder of sexual differentiation IVIg

Epstcin-Barr virus

Echo echocardiogram

FAS fetal alcohol syndrome

FASD fetal alcohol spectrum disorder LGA

FISH fluorescent insitu hybridization LLSB

FSS familial short stature

inflammatory bowel disease

ideal body weight

intracranial hemorrhage

immune thrombocytopenic

I6D

IBW PPHN persistent pulmonary

hypertension of newborn

PPV positive pressure ventilation

PUVA psoralen *

UVA

RAD right axis deviation

RAS renal artery stenosis

RBB8 right bundle branch block

RDS respiratory distress syndrome

RF rheumatoid factor

Rhesus factor

RL Ringer’s lactate

RSV respiratory syncytial virus

RUS8 right upper sternal border

RVH right ventricular hypertrophy

RVOTO right ventricular outflow tract

obstruction

ICH

IIP

purpura

intrauterine growth restriction

intraventricular hemorrhage

intravenous immunoglobulin

juvenile idiopathic arthritis

left atrial hypertrophy

low birth weight

large for gestational age

lower left sternal border

lower motor neuron

level of consciousness

IUGR

IVH

JIA

LAH

LBW Rh

LMN

failure to thrive LOC

gestational age

GAS group A Streptococcus

G8M glomerular basement membrane LV

GBS group B Streptococcus

GERD gastroesophageal reflux disease MAS

glomerulonephritis

brief resolved unexplained events GSO glycogen storage disease

GTPAL Gravidity Term Preterm Abortion MOD

Living

HBsAg hepatitis B surface antigen

HDN8 hemorrhagic disease of the

newborn

GA LP lumbar puncture

lower respiratory tract infection

left ventricle

left ventricular hypertrophy

LRII

SEM systolic ejection murmur

SGA small for gestational age

meconium aspiration syndrome SIAOH syndrome of inappropriate

MCAD medium-chain acyl-CoA

dehydrogenase

minimal change disease

metered dose inhaler

MEE middle ear effusion

MSUO maple syrup urine disease

NCS nerve conduction study

necrotizing enterocolitis

neurofibromatosis

NICU neonatal intensive care unit

normal saline

LVH

antidiuretic hormone

SIDS sudden infant death syndrome

STEC Shiga toxin-producing E. coli

SVT supraventricular tachycardia

TEF tracheoesophageal fistula

tympanic membrane

total parenteral nutrition

transient tachypnea of the

newborn

UMN upper motor neuron

URTI upper respiratory tract infection

UVA ultraviolet A

VCUG voiding cystourethrogram

VKDB vitamin K deficiency bleeding

VSD ventricular septal defect

VUR vesicoureteralreflux

WPW Wolff-Parkinson-White

r.

’

Li

1M

TPN

HEEADSSSHome Education/Employment NEC

Eating Activities Drugs Sexuality NF

Suicide/depression Safety/

violence

Haemophilus influenzae type b OOP

HIDA hepatobiliary iminodiacetic acid OME

HIE hypoxic ischemic encephalopathy ORT

HPA human platelet antigen

HRV human rotavirus

HSP Henoch-Schonlein purpura

HSV herpes simplex virus

HUS hemolytic uremic syndrome

TIN

NS

oral contraceptive pill

otitis media with effusion

oral rehydration therapy

obstructive sleep apnea

premature atrial contraction

polycystic ovarian syndrome

patent ductus arteriosus

phenylketonuria

Hib

OSA

PAC

PCOS

PDA

PKU

Paediatric Quick Reference Values

Table 1. Normal HR and RR at Various Ages

Age (yr) Pulse (bpm) Respiratory Rate (br/min)

Canadian Immunization Guide

National Advisory Committee on

Immunization. Canadian Immunization

Guide (CIG). Last Modified 2021.Public

Health Agency of Canada, 2006.

Available at https://www.canada.ca/

en/public-health/services/canadianimmunization-guide.html

Neonale (- 28 d)

Infant (1-12 mo)

Toddler (1-2 yr)

Preschool (3-5 yr)

School-age (6-11yr)

Adolescent (12-15 yr)

100-205

100-190

98-140

80-120

30-53

22-37

20-28

75-118 18-25

60100 12-20

Table 2. Normal sBP at Various Ages

Age sBP (mmHg)

Birth<1kg (12h)

Birth 3 kg (12h)

Neonate (96 h)

Infant (1-12 mo)

Toddler (1-2 yr)

Preschool (3-5 yr)

School-age (6-9 yr)

Preadolescent (10-11yr)

Adolescent (12-15 yr)

39-59

60-76

67-84

72-104

86-106

89-112

97-115

102-120

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Table 3. Normal Temperature Ranges

Method Normal Temperature Range Fever

36.6°Cto 38°C

35.8”C to 38"C

35.5”C 10 37.5’C

36.5"C to 37.5"C

Rectal >38“C +

Ear >38“C

>37.5“C

>37.5VC

Oral

Axillary

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P I Paediatrics Toronto Notes 2023

Table 4. Temperature Measurement Technique Recommendations

Age Suggested Technique

Birth to 2 yr 1.Rectal (definitive)

2. Axillary (screening low risk children)

Over 2yr to 1.Rectal (delinltive)

2.Axillary.Tympanic (or Temporal Artery if inhospital) (screening)

Older than 1.Oral (definitive)

2.Axillary,Tympanic (or Temporal Artery if in hospital) (screening)

5 yr

5yr

Primary Care

Visit Overview

•schedule of well-child visits

• newborn (within <18-72 h post-discharge), 2, <1, 6, 9, 12, and 18 mo

annually between ages 2-5; every 1-2 yr between ages 6-18

•content

history and physical exam including growth, development, and nutrition

routine immunizations

counselling and anticipatory guidance

see evidence based clinical tools such as Rourke Baby Record and Greig Health Record for more

information

According to the Centers for Disease

Control and Prevention (CDC).the weight

of currently available scientific evidence

does not support the hypothesis that

the Measles, Mumps and Rubella (MMR)

vaccine causes either autism or IBD. The

landmark paper linking autism to the

MMR vaccine (Lancet1998:351:637-641)

was retracted due to false claims in the Standard Paediatric History article (Lancet 2010:375:445)

• BINDS: Birth, Immunization, Nutritional, Developmental, Social

• ID: name, age, major chronic medical concerns

•chief complaint (GC)/reason for referral (RI-

'

R)

• HPI: child and caregiver

• OPQRSTU

• recent travel,sick contacts

•obstetrical history

• prenatal/pregnancy history

conception

GTPAL

screening:blood group, Rh, DAT, HBsAg, rubella,syphilis, HIV, GBS

genetic screening:maternal serum screening (MSS), first trimesterscreening (ITS),

integrated prenatal screening (IPS), amniocentesis,special tests

ultrasounds

complications: illnesses, infections, bleeding, gestational diabetes(GDM), gestational

hypertension (GHTN)

medications, vitamins, iron,smoking, drinking, drug use

• labour and delivery or birth history, and why

gestational age at birth, birth weight

labour complications: prolonged rupture of membranes, maternal fever, fetal tachycardia,

meconium

Adverse Reactions Associated with

Any Vaccine

• Local:induration,tenderness,

redness, swelling

• Systemic:fever,rash, irritability

• Allergic:urticaria,rhinitis,

anaphylaxis

Contraindication:

• Moderate/severe illness ± fever

• Allergy to vaccine component

• No need to delay vaccination for

mild URTI

Vaccination in Caseiol Asplenia or Hyposplenia

(such as SickleCell Disease)

• Should receive all routine lmiitaaiHUoat,ia(Mia|

the yearly inltuerna vaccine

• No vaccines are contraindicated, though

live vaccines can be contraindicated a

immunodeficienciessuch as DiGeorge syndrome

(22q11.2 deletion)

• Susceptible tu infection by encapsulated bactena

(*SHiNE KISS'

-S. poemotim.H.mftierae.I.

meomyifidrs,£ coll Klebsiella.SolmseHo.Croup

SSfreyx),so must add:

• Quadrivalent conjugated Meningococcal C

vaccine (Men-C -ACYW) and Meningococcal S

vaccine (4CMenB|at time of d agnosrsif >2

mo (2-4 doses given at least 8 vrk apart) vrith

booster every 5 yr thereafter

• Canonirtroutine Men - goccccal C Co - .gate

at 11 mo if received Men C -ACVWacd expected

to receive a second dose wittier 8 «k

• Pneumococcal polysaccharide vaccme

(Pneu P -23|at >2 yr and single booster >5yr

alter first dose

• Pneumococcal conjugate vaccine (Pneu-C-tt)1-2

doses8wk a pa rl if >12 mo at time of diagnosis

• Consider single booster Nib at >5yr

« spontaneous vaginal delivery, interventions required: forceps, vacuum, caesarean delivery

(CD)

medications used during labour

resuscitation: APGARs

length of hospital stay, N1CU stay

•past medical history

• hospitalizations, ED visits, past surgeries, chronic illnesses, accidents or injuries, community

resources/services involved or referrals in place, otherspecialistsinvolved in care

medications

•allergies

•immunizations (including contraindications,such as previous anaphylaxis, or immunosuppression)

•developmental history

• meeting major milestones

• behavioural concerns

• nutritional history

• breast vs. formula feeding

• milk intake

• solids, variety, etc.

•family history

consanguinity, recurrent pregnancy losses, early childhood deaths

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P5 Paediatrics Toronto Notes 2023

• social history

• who lives at home? Siblings?

does the child attend daycare or school? Primary care givers?

• school adjustment, friends, activities,safety,stability,stressors

• HEhADSSS history for adolescents

ITHELPS -income, transportation, home, education, legal status, personal safety,support

Routine Immunization

Table 5.Publicly Funded Immunization Schedule for Ontario

DTaP- TdaP- Pneu- Rot

-5

IPV-Hib IPV C-13

MMR Var MMRV Men-C- HepB HPV-9 Tdap Inf

ACYW

Men'

Injection site

Infants (<12 mo):anterolateral thigh

C-C

2 mo

4 mo

AO -MM ^IM

-MM -4|M m

AO

6 mo

12 mo

15 mo

18 mo

4-6 yr’

Grade 7

^

IM AO A Systematic Review of the Effect of Rotavirus

Vaccination onDiarrhea OotcomesAmong

Oiildren Younger Than 5 Years

Pediatr Infect Dis J 2016:35(9)592-998

Purpose: To review evidence of rotavirus vaccine

efficacy and effectiveness by tMenm.m Development

Goal Region.

Method: RCIs and observaf studies on rotavirus

vaccine In children < 5 yfo were included m this review.

Primary oulcomes included rotavirus diarrhea or

diarrhea olunspecified ehofogy.Secondary outcomes

included diarrhea episodes of any severity,and

seveie diarihea episodes,hospitalization,and death.

Results: 48 studies were eligible for orelusion

in this review.Rotavirus vaccine was found to he

effective and efficacious.Across all millennium

development regions rotavirus vaccine prevented

rotaviiusdiarihea.seveie rotavirus diarrhea, and

rotavirus hospitalization, the vaccine also reduced

seveie diarihea and diarrhea related hospitalization

in general.

v'lM ^IM -

/SC

AC

^IM

•AM AC

^IM VIM 3

doses

(0.1.6

VIM 2

doses

(0.6

mo) mo)

14-16 yr VIM

Every autumn

(beginning at

age 6 mo)

VIM

IM - intramuscutar:PO = per oral:SC = subcutaneous

•Preferably given at 4 yt of age

DTaP'IPV-Hib *

diphtheria,tetanus,acellular pertussis,inoctivated polio,Haemophilus inlluenxue type b vaccine(ie.Pcdiacc! ) TdaP-IPV

diphtheria,tetanus,acellular pertussis. Inactivated polio vaccine (l.c. Adacel Polio):HepB •hepatitis B vaccine:HPV-4 •human papillomavirus

vaccine:Ini•Intluenza vaccine:MMR - measles,mumps, tubellu vaccine:Mun-C-C •meningococcal c conjugate vaccine:Mon

-C-ACYW •

meningococcal vaccine;MMRV - measles,mumps,rubella,vailcella vaccine;Pneu- C -13 « pneumococcal13-valent conjugate vaccine;Rul

-5 •

rotavirus oral vaccine:Var

- varicella vaccine

Table 6. Adverse Reactions and Contraindications of Routine Immunizations

Vaccine Adverse Reaction Contraindication

Prolonged crying

Hypotonic unresponsive state (rare)

Seizure on day ol vaccine (race)

Cough

Diarrhea,vomiting

fever

Intussusception

Measles-like cash (7-14 d)

Lymphadenopathy,arthralgia,arthritis

Parotitis (care)

Especially painful injection

transient thrombocytopenia (1430000)

Mild varicella-like papules or vesicles:

2 wk may gel local or generalized rash

Evolving unstable neurologic disease

Hypoiesponsivelhypotonic following previous vaccine

Anaphylactic reaction to neomycin or streptomycin

History ol intussusception

Immunocompromised

Abdominal disorder (e.g. Meckel'

s diverticulum)

TdaP-IPV

RolS

MMR Pregnancy

Immunocompromised infants (except healthy HIV positive children)

Anaphylactic ceaction to gelatin

Pregnant or planning lo gelpregnant within 3 mo

Anaphylactic leadion to gelatin

Anaphylactic reaction to Baker's yeast

Same as MMR and Var vaccines

1st trimester pregnancy

<6 mo of age

Immunocompromised

Egg-allergic individuals - Live attenuated influenza vaccine is not

recommended lor those wilh an egg allergy.In these individuals.

Irivalenl or quadrivalent vaccine can be givenin an environment

where anaphylaxis can be managed

Var

HepB

MMRV Same as MMR and Var vaccines

DTaP

Ini Malaise,myalgia

febrile seizure when given withPneu-C-13 or DTaP

Hypersensitivity reaction

HPV-9

Men-B'

Prerilus

Anaphylactic reaction to Men-B vaccine or its components in the past

Anaphylactic reaction to Men-8 vaccine or its components in the past

ri

Men-C-ACYW Syncope (rare) L J

* Currently onlypublicly funded lor select groups(asplenia. antibodyVcomplement deficiencies, cochlear implant recipients.HIV,close contacts

with infected individuals)

DTaP 3diphtheria,tetanus,acellular pertussis vaccine: TdaP-IPV 3 diphtheria,tetanus,acellular pertussis,inactivated polio vaccine (i.e.Adacel -

Polio);HepB 3 hepatitis B vaccine:HPV-4 3

humanpapillomavirus vaccine;Ini 3

intluenza vaccine:MMR 3measles,mumps,rubella vaccine:

Mun-B 3 multicomponent meningococcalB vaccine: Men-C-C > meningococcal c conjugate vaccine:Men-C-ACYW 3 meningococcal vaccine.

MMRV - measles,mumps,lubella,vailcella vaccine:Rot

-5 3 iotavirus oral vaccine:Var •varicella vaccine +

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P6 Paediatrics Toronto Notes 2023

• adverse effects following immunization:must be reported to the local or regional health unit when

the event: has a temporal association with a vaccine, has no other clear cause at the time of reporting,

meets one or more of the seriousness criteria, is unexpected

• temperature regulation in vaccine storage: cold chain generally + 2 to +8

#

C

Modifications to the Routine Vaccination Schedule

• catch-up immunization schedules for children not previously immunized

• additional immunizationsfor children at-risk due to underlying medical conditions

• update Dec 2020: current Ontario catch-up program for HPV vaccine - 2-3 dosesfor Grades 8-11

(males) and Grades8-12 (females)

Immunization of Immunocompromised Patients

• susceptibility to infection and vaccine response varies

• individualized vaccine schedule based on patient’s immune status

• inactivated vaccines: may be administered if indicated; responses may be reduced or absent and

duration of immunity may be reduced (compared to healthy individuals);dose increase or extra

booster doses may be indicated

• live attenuated vaccines:

avoid ifseverely immunocompromised or if uncertain of immune status

can be given to those with isolated IgA,IgG subclass or complement deficiency,or asplenia

live viral vaccines are okay for most children with phagocyte or neutrophil disorders, but live

bacterial vaccines are contraindicated

• additional vaccines: may need vaccines that are not usually recommended for otherwise healthy

children or not usually administered beyond a certain age

• timing: vaccinesshould be administered when maximum immune response is expected (i.e. when not

immunosuppressed medically, pharmacologically, or immediately post transplant)

• response:asimmune response may be inadequate, consider post-immunization antibody titresif

appropriate; positive serologic test may be due to immunoglobulin therapy or maternal antibody

(infants <18 mo)

Vaccine-Hesitant Parents

• healthcare professional vaccine advice plays a key role in parental decision-making

do not dismiss vaccine-hesitant familiesfrom your practice

• use a presumptive approach (for giving the vaccine) and motivational interviewing

use open-ended questions and listen to parent concerns and opinions - do not assume the health

concerns of the parent

• address concerns non-judgmentally and non-confrontationally; validate why parents may hold

their belief

use compelling stories of vaccine-preventable disease

• communicate clearly to discuss disease risks and vaccine benefits and risks

• address immunization pain

• community protection (herd immunity)

• “wait and see" approach to vaccinate in an outbreak scenario is not advisable

promote altruism - not receiving immunization can have consequences for others

• parents who refuse to immunize their children need to be informed of associated risks of diseases and

responsibilities- considerations include:

protection of child from acquiring illnesses (e.g. vaccine, avoid sick contacts)

not vaccinating risksthe health of others(weakened immune system, chronic conditions,

newborns, elderly)

inform healthcare professionals of lack of vaccination when child issick

if a vaccine-preventable disease is in your community: get vaccine, may be required to stay away

front school, consider disease-specific risks, learn whatsymptoms to look out for

tetanus(>10% mortality) does not have community protection

travel - vaccinesspecific to geographical regions, refused permission to travel

Growth and Development

Growth'

• growth is not linear

most rapid growth during first 2 yr and at puberty

• measurement of growth

• WHO Growth Charts used to monitor growth in infants and children

premature infants(<37 wk) use lenton Curve to assess for small for gestational age (SGA) vs.

large for gestational age (LGA);corrected GA until 2 yr

body proportion = upper/lower segment ratio (use symphysis pubis as midpoint)

newborn = 1.7,adult male = 0.9, adult female = 1.0

«. J

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P7 Paediatrics Toronto Notes 2023

Average Growth Parameters

Table 7. Parameters of Average Growth at Birth

Normal Growth Comments

3.25 kg|7 lbs)* Gain 20-30 g/d [term neonate)

2 x birth wt by 4- S mo

3

*

birth wl by 1yr

4 x birth wt by 2 yr

25 cm in 1st yr

12 cm in 2nd yr

8 cm in 3rd yr. then 4-7 tm/yr until

puberty

8-12 cm/yt in adolescence

1/2 adult height at 2 yr

2 cm/mo for 1st 3 mo

1cm/mo at 3-6 mo

0.5 cm/mo at 6-12 mo

Weight loss (up to 10% of birth

weight)in first 7 d ol life is normal

Neonate should regain birlh

weight by -10-14 d

Measure supine length until 2 yr,

then measure standing height

Birth Weight

Length/Height 50 cm (20 in)*

Head Circumference 35 cm(14 in)* Measure around occipital,

parietal,and Irontal prominences

to obtain the greatest

circumference

* note these ate averages,and may differ based on ethnicity and gestationalage

Reflexes

Table 8. Developmental or Primitive Reflexes

Reflex Maneuver to Elicit Reflex Appropriate Reflex

Response

Age of Disappearance

Abnormal Reflex Response (primitive

reflex response present in infancy;

tendon reflex response always present)

• Primitive reflex responses are

abnormal if: absent during neonatal

period; asymmetric;or persistent

after 4-6 mo (e.g. cerebral palsy)

• Tendon reflex responses:asymmetry

suggests focal motor lesions (e.g.

brachial plexus injury) and absence

or hyper-reflexia may suggest CNS

abnormality

• Upgoing plantar reflex (Babinski's

sign) normal in infants up to 2 yr

Abduction and extension of the 3-6 mo

arms,opening of Ihe hands,

followed by flexion and adduction

olarms

Infant placed semi-upright, head

supported by examiner's hand,

sudden withdrawal olsupportcd

head with immediate returnol

support

Infant held in ventral suspension

and one side ol back is stroked

along paravertebral line

Placement of examiner's finger in

infant's palm

(urn infant's head to one side

More

Galant Pelvis will move in Ihe direction of 2-3mo

stimulated side

Grasp Flexion of infant's ftngers 3- 4 mo

'Fencing" posture (extension of 4-61110

ipsilateral arm and leg. flexion of

contralateral arm andleg)

Flexion followed by extension

of ipsilateral limb up onto table

(resembles primitive walking)

Infant turns head and opens 2-3mo

mouth to suck on same side that

cheek was stroked

Ipsilateral arm extension, present Does not disappear

by 6- 8 mo

ATNR

Stepping Dorsal surface of infant's fool 2-3mo

placed touching edge of table

Rooting Stroke infant’s cheek

lateral Propping lilt infant to side white in sitting

position

ATNR = asymmetric tonic neck reflex

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PH Paediatrics Toronto Notes 2023

Developmental Milestones

Table 9. Developmental Milestones Developmental Red Flags

• Gross motor:not walking at 18 mo;

rolling too early at <3 mo

• Fine motor:hand preference at

<18 mo

• Speech:<6 words at 18 mo

• Social:not smiling at 4 mo:not

pointing at15-18 mo

• See the Nipissing District

Developmental Screen for a checklist

of important 18 mo milestones:www.

ndds.ca

• Regression (i.o.loss of a previously

acquired skill)is a red flag at any age

Fine Motor Speech and

Language

Cognitive/

Problem Solving

Age" Gross Motor Social/Emotional

Primitive reflexes:

step,place.Moro.

Babinski,ATNR;Hexed

posture

Primitive reflex:grasp Primitive reflexes:

root,suck:orients to

Fixes and follows slow Bonding between

horizontal arc;prefers parent and child

Newborn

sound:variable cries contrast,colours,

faces,high-pitched

voices:visual focal

length

-10"

2 mo Raises head 45'

when Hands open hall the

time,balsa!objects

Rolls prone to supine. Palmar grasp,reaches Squeals,laughs

sits with support. and obtains items,

raises head up 90'

brings objects to

and lifts chest when midline

prone

Tripod sit,rolls

both ways,postural

reflexes

Turns lo voice,cooing Prefers familiar

caregiver

Social smile

prone

Purposeful sensory Explores parent's face

exploration olobjects

(eyes,hands,mouth),

anticipates routines

4 mo

6 mo Transfers objects

from hand tohand,

raking grasp

Babbles (nonspecific) Stranger anxiety.

looks for dropped

object

Expresses emotions:

happy,sad.mad:

memory for ~24hr

Sils well without

support,crawls (not pokes objects

all),pulls lo stand

Walks a few steps,

wide gait

9 mo Inferior pincer grasp, " Mama,dada" Plays games (e.g. Separation anxiety

Gestures "bye bye”, peek - a-boo)

“up”,gesture games Object permanence

1word with meaning Uses objects

firesides mama, functionally,cause

dada).responds to and effect,trial and memory

own name,follows error,imitates

1-step command with

gesture

4-5 words,follows Looks for moved Shared attention:

1-step command hidden object if saw it points at interesting

without gesture.1 being moved

body part

15-25 words

3 body parts

12 mo Fine pincer

(fingertips),fingerfeeds cheerios.

voluntary release

Points at wanted

items,narrative

Slacks 2 blocks,uses

spoon

15 mo Walks without

support,crawls up

stairsfsteps items to show to

parent

18 mo Runs.stoops and

recovers

Tower of 4 blocks,

scribbling, fisted

pencil grasp,removes

clothing

Tower of 6 blocks,

handedness

established,uses

utensil

Symbolic play with Parallel play

doll or bear

24 mo 2-3 word phrases. New problem-solving testing limits,

uses "I.me.you." strategies without

50% intelligible. rehearsal

understands 2-step

commands.50*

words

3-step commands. Identifies shapes.

3- 4 word phrases. counts to3.simple

"W”questions time concepts

(“why?").200 words.

75% intelligible

Hops on Hoot, climbs Uses scissors,buttons Speech 100%

down stairs1fool clothes

per step

Skips,rides bicycle Prints name,ties

shoelaces,tripod tense

pencil grasp

Jumps on two feet,

up and down slalrs

'marking time'

tantrums,negativism

(“no!"), possessive

(••mine!")

3 yr Rides tricycle,climbs Toilet trained,

up stairs alternating undresses,draws

circle andcrossf*

)

Cooperative play,role

play (pretend play),

separates easily,

sharing

feet

Identifies 4 colours,

intelligible,uses past counts to 4

tense,tells a story

Fluent speech,future Counts to 10

accurately,recites

ABCs

Has a preferred

friend,elaborate

fantasy play

Has groupol friends

4 yr

Syr

'llpremature,use corrected GA until 2 yr

Nutrition

See Landmark Paediatric Inals table for more

information on LEAP trial,which details the benefits

of early introduction of peanuts in decreasing

prevalence of peanut a lergies inchildren deemed

at risk.

Dietary Requirements

<10 kg 10 -20 kg

1000 cal

*

SO kcaifkg/d for each

kg >10

>20 kg

1500 cal *

20 keal/kg/d for each

kg -20

Weight

Heeds 100 keal/kg/d

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Dietary Recommendations

• 0-6 mo: breast milk or formula

exclusive breastfeeding during first 6 mo is recommended unless contraindicated; breastfeeding

can continue beyond 2 yr as long as mother and child want

breastfed infants require supplements: vitamin D (400 lU/d or 800 lU/d if infant or maternal risk

factors present)

• if not consuming iron-fortified cereals, meats, meat alternatives after 6 mo, at risk of iron

deficiency: give iron (after at least 4 mo and before 6 mo)

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Dietary Exposures audAllergy Preventionin

High-Risk Infants

Paedratr Child Health 2013:I8|10|:545-549

thereis no evdence thatrestriction of highly

a ergenic foods is benefibal in thehist yr of life.

Later introduction of peanut,fish,or egg does not

prevent, and may increase the risk of developing

food allergy.There is also no evidence that dietary

restrictions during pregnancy or breastfeeding are

protective to the child.

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Pi) Paediatrics Toronto Notes 2023

• >6 mo:solid food introduction - do not delay beyond 9 mo

• 2-3 new foods per wk, wait at least 2 d in between each food to allow time for adverse reaction

identification

common allergens:eggs, milk, mustard, peanuts,seafood,sesame,soy, tree nut, wheat

• early introduction of highly allergenic foods is recommended

offer lumpy,soft-cooked, pureed, mashed textured foods

• encourage self-feeding and introduce open cup (should be done by 18 mo)

• 9-24 mo:switch to homogenized (3.25%) cow’s milk, offer 16 oz/d if non-breastfeeding

• offer vegetables, fruit, grains, and full-fat milk in any order after iron-rich foods are given

provide up to 3 large feedings (meals) with 1-2 smaller feedings (snacks),depending on child's

hunger/satiety cues

• foods to avoid

honey until past 12 mo (risk of botulism)

added sugar,salt

excessive milk (i.e. maximum 500 mL or 16 oz/d after 1 yr) - associated with iron deficiency

anemia

limit juice intake (not nutritious, too much sugar), maximum 4-6 oz (1/2 cup) daily

anything that is a choking hazard (chunks, round foods like grapes)

• 2-6 yr:switch to 2% milk (500 mL/d)

• can maintain breastfeeding during this time complementary to solids

Breastfeeding

• content of breast milk

colostrum (first few days postpartum): clear, rich in nutrients(i.e. high protein, low fat),

immunoglobulin

mature milk:70:30 whey:casein ratio,fat from dietary butterfat, carbohydrate from lactose

• advantages

easily digested, low renal solute load

• immunologic

reduction of acute illnesses(i.e. diarrhea, respiratory tract illnesses, acute otitis media) and

may have longer term benefits

contains IgA, macrophages, active lymphocytes, lysozymes, lactoferrin (which inhibits E. coli

growth in intestine)

lower pH promotes growth of Lactobacillus in (il tract

• parent-child bonding

economical, convenient

• maternal contraindications

absolute contraindications: HIV, HT'LV type 1 and II, infant galactosemia

relative contraindications: chemotherapy, radioactive compounds, or certain medications known

to cross to breast milk with neonatal effects

active untreated TB (2 wk), active HSV-2 lesions on breast (can still feed expressed breast milk

from unaffected breast)

OCPs are not a contraindication to breastfeeding (estrogen may decrease lactation, but is not

dangerous to infant)

• if poor weight gain: consider dehydration or 1 1 1 and may consider formula supplementation if

insufficient milk production or intake

• oral candidiasis(thrush): treat baby with antifungal such as nystatin and ensure all nipples, bottles,

pacifiers are sanitized to avoid re-infection;can occur in breast or bottle-fed infants

Medications that Cross into Breast Milk

Antimetabolites

Chloramphenicol

Diazepam

Ergots

Gold

Metronidazole

Tetracycline

Lithium

Cyclophosphamide

Signs of Inadequate Intake

• <6 wet diapers/d after first wk

• <7 feedsfd

• Sleepy or lethargic,sleeping

throughout the night <6 wk

• Weight loss >10% of birth weight

(past10-14 d of life)

• Jaundice

Signs of Adequate Intake

• 1wet diaper/d of age for first wk

. 1-2 black or dark green stools

(meconium)/don Day1and 2

• 3

- brown/grectVyellow stools/d on

Day 3 and 4

. 3+ yellow,seedy stools/d onDay 5+

Table 10. Common Formulas Compared to Breast Milk

Type of Nutrition Indications Content (as compared to breast milk)

Prematurity

Transition to breastfeeding

Contraindication to breastfeeding

tow birth weight

Prematurity

Lower whey:casein ratio

Plant fatsinstead of dietary butterfat

Cow’s Milk-Based

(Enfamil

*

Similar )

Fortified Formula Higher calotiesand vitamins A. C. D. K

May only be used in hospital due to risk ol

fat-soluble vitamin toxicity

Galactosemia Corn syrup solids orsucrose in place of lactose

Desire for vegetarianfvegan diet*

Delayed gastric emptying

Risk of cow's milk protein allergy

Malabsorption

Food allergy including cow's milk protein

allergy

SoyProtein

(Isomil •

; Prosobee •

)

Partially Hydrolyzed Proteins

(Good Starr )

Protein Hydrolysate

(llutramigen '

, Alimentum '

,

Pregestimil »,Portagen '

)

Protein is100% whey with no casein

Protein is100% casein with no whey

Corn syrup solids,sucrose,or tapioca starch

instead of lactose

Expensive

Free amino acids (no protein)

Corn syrup solids Instead of lactose

Very expensive

Various different compositions for children

with galactosemia, propionic acidemia,etc.

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Food allergy

Short gut

Amino Acid

(lleocate . PurAmino ')

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Metabolic Inborn errors of metabolism

’10- 35% of children with cow's milk protein allerg/ also have reactions to soy-based formula

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P10 Paediatrics Toronto Notes 2023

Injury Prevention Counselling

• injuries are the leading cause of death in children >1 yr

• main causes:motor vehicle crashes,burns, drowning, falls, choking, infanticide

Table 11. Injury Prevention Counselling

0-6 mo 6-12 mo 1-2 yr 25 yr

Do not leave atone on bed.on Installstair barriers

changing table,or in tub

Keep crib rails up

Check water temperature before

Hever leave unattended

Discourage use of walkers Keep pot handlesturned to back

Avoid play areaswith sharp- edged of stove

tables and corners

Bicycle helmet

Never leave unsupervised at

home, driveway,or pool

Caution with whole grapes, nuts, teach bike safety,strangersafely,

raw carrots, holdogs, etc. due to and street safety

Swimming lessons(>4 yr),

sunscreen (from 6 mo),fences

around pools

Appropriate carseats

Ensure large devices (such as TVs)

secured to walls

bathing Cover electrical outlets

Do not hold hot liquid and infant at Unplug appliances when not in use choking hatard

No running whileeating

Appropriate carseats

the same time Keep small objects, plastic

bags, cleaning products, and

medications out of reach

Check milk temperature before

feeding

Appropriate carseats are required Supervise during feeding

before leaving hospital Appropriate car scats

Avoid co-slecping with Infant

Note:Thislist is not exhaustive. For more details,see Rourke Baby Record (http://www.rourkebabyrecord.ca/downloads)

Circumcision

• elective procedure

CPS affirms that circumcision is not medically indicated, and does not recommend routine

circumcision for every newborn male

often done for religious or cultural reasons

• benefits: prevention of phimosis and slightly reduced incidence of UTI,S'

l

'

l, balanitis, cancer of the

penis

• complications (<1%):local infection,bleeding, urethral injury,meatal stenosis

• complication rate increased in children compared with infants

• contraindications: presence of genital abnormalities (e.g. hypospadias) or known bleeding disorder

Paediatr Child Health 2015;20(6):311-320

The Canadian Paediatric Society and American

A udemy of Pediatrics have both petviousty indicated

that cltcumelslon of newborn males Is not a med itally

indicated procedure.Some evidence hassubsequently

suggested decreased urinary tract infectiousand

incidence ofsome sexually transmitted infections,

including HIV,with circumcision.While such a

benefit may be present in some boys and high -risk

populationswhere the procedure may be considered

n the context of reduction or treatment,theCanadian

Paediatric Society continues to not recommend Common Complaints routine circumcision for every newborn male.

Breath Holding Spells

• clinical features

cyanotic type (more common), usually associated with anger/frustration

pallid type, usually associated with pain/surprise

• epidemiology: 0.1-5% of healthy children 6 mo-4 yr, usually start during first yr of life

• etiology

cyanotic type:child is provoked (usually by anger or upsetting event) -> holds breath and

becomessilent > spontaneously resolves or loses consciousness

pallid type: child falls or is frightened > heart rate is reduced by vagal stimulation -> cerebral

hypoperfusion -> loses consciousness

• management

usually resolvesspontaneously and rarely progresses to seizure;median age of remission is 4 yr,

and almost all children stop by 8 yr

• help child control response to frustration and avoid drawing attention to spell

may be associated with iron deficiency anemia, improves with supplemental iron

if episodes prolonged/frequent, triggered by non-traumatic stimuli, or if there is a family history

ofsyncope orsudden death -» in-depth cardiac evaluation indicated - check for prolonged QT

syndrome

Crying/Fussing Child

• common etiologies:functional (e.g. hungry'

, irritable), colic, trauma, illness

• history

description of baseline feeding,sleeping, crying patterns

« infectioussymptoms:fever, tachypnea, rhinorrhea, ill contacts

feeding intolerance:gastroesophageal reflux with esophagitis, N/V, diarrhea, constipation

• physical injury (unintentional or non-accidental)

recent immunizations (vaccine reaction) or medications (drug reactions), including maternal

drugs taken during pregnancy (neonatal withdrawal syndrome) and drugs that may be

transferred via breast milk

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inconsistent history, pattern of numerous emergency department visits,difficult social living

conditions(e.g. parental substance use, precariousliving circumstances) can raise concerns for

maltreatment

consider broad array of possible underlying causessuch as meningitis,sepsis, respiratory distress,

constipation, etc.

Infantile Colic

• clinical features: unexplained paroxysms of irritability and crying for >3 h/d, >3 d/wk for >3 wk in an

otherwise healthy, well-fed baby (rule of 3s- Wessel criteria)

• epidemiology:10% of infants; usual onset 10 d to 3mo of age with peak at 6-8 wk

• etiology: unknown,

'

theories: alterations in fecal microflora, cow'

s milk intolerance, Gl immaturity or

inflammation, poor feeding, maternalsmoking

• diagnosis: diagnosis of exclusion after thorough history and physical exam to rule out identifiable

causessuch as otitis media, cow’

s milk intolerance,Gl problem,fracture

• management

parental relief, rest, and reassurance

change breastfeeding or bottle-feeding technique

hold baby,soother, car ride,music, vacuum, check diaper

limited evidence for probiotics;further research required

» breast-fed infants: time-limited trial (typically 1-2 wk) ofa hypoallergenic maternal diet (i.e. no

cow’s milk, eggs, nuts, wheat) while monitoring baby’s behaviour

formula-fed infants:time-limited trial (typically 1-2 wk) of hydrolyzed formula

prognosis:all resolve, most in the first 3-6 mo of life, no long-term adverse effects

Dentition and Caries

Dentition

• primary dentition (20 teeth)

first tooth at 5-9 mo (lower incisor), then 1/mo

6-8 central teeth by 1 yr

assessment by dentist 6 mo after eruption of first tooth and certainly by 1 yr of age (Grade B

recommendation)

• secondary dentition (32 teeth)

first adult tooth is 1st molar at 6 yr,then lower incisors

Caries

• early childhood caries: presence of one or more decayed, missing (due to caries), or filled tooth

surfaces in any primary tooth in a preschool-aged child

• etiology:multifactoriai with biomedical factors (e.g. diet, bacteria, host) and social determinants of

health

inappropriate feeding practices (e.g. frequent, prolonged bottle feeding, putting to bed with

bottle, prolonged breastfeeding, and excessive juice consumption) are important factors

• prevention

no bottle at bedtime, clean teeth after last feed

minimize juice and sweetened pacifier

dean gums with damp washcloth or soft-bristle toothbrush (no toothpaste) when no teeth present

<3 yr:daily brushing with fluoridated toothpaste (size of a grain of rice) assoon as teeth are

present

3-6 yr: assisted to brush teeth using pea sized amount of fluoridated toothpaste

ensure every child visits dentist by I yr

1 yr and beyond:involve dental public health programs (e.g. Healthy Smiles) to support access for

children in low-income households

Enuresis

Definition

• involuntary urinary incontinence by day and/or night in child >5 yr

General Approach

• should be evaluated if:dysuria; change in colour, odour, or stream;secondary or diurnal;change in

gait;orstool incontinence are present

Primary Nocturnal Enuresis

• clinical features: enuresis when bladder control has never been attained

• epidemiology:10% of children age 6,3% of children age 12,1% of children age 18,family history

important

• etiology: developmental disorder or maturational lag in bladder control while asleep

Treatment for primary nocturnal enuresis

should not be considered until 7 yr due

to high rate of spontaneous cure

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P12 Paediatrics Toronto Notes 2023

•management

• time, reassurance (~20% resolve spontaneously each yr), and avoidance of punishment or

humiliation to maintain self-esteem

behaviour modification (limiting fluids and avoid caffeine-containing food before bedtime, void

prior to sleep, ensure access to toilet, take out of diapers)

conditioning: “wet"

alarm wakes child upon voiding (70% success rate)

• medications (for children >7 yr, considered second line,short

-term therapy, may be used for

sleepovers/camp):desmopressin (DDAVP) oral tablets (similar success rate as “wet"

alarm

therapy but higher relapse rate),imipramine (Tofranil") (rarely used;lethal if overdose;side

effects: cardiac toxicity, anticholinergic effects)

Management andtreatment of Nocturnal

Enuresis - An UpdatedStandardization Document

f rom theInternationalChildren'

s Continence

Society

J Pcdiati Urol 2020.10 19

Additional Investigationsere not warranted In

aneisuretic child crithoutcertain waningsigns.

Key comorbidities to considerinclude psychiatric

disorders, constipation, urinary tract infections, and

snoring nr sleep apneas, floating constipation and

daytime incontinence tan lead to symptom resolution.

Irealingconcomitant sleepdisorder may alsu lead

to symptom resolution and is indicated.If enuresn

is non-monosymptomatic. treatmentshould begin

with advice on eveningdrinklng and voiding habits.

In monosymptomatic enuresis,treatmentshould

begin with either desmopressin oi an enuresisalaim.

Second line treatment includes anticholinergic

medications.Antidepressants may be considered

in rehactoiy enuresis though eipert opinion should

besought.

Secondary Enuresis

•clinical features:enuresis develops after child hassustained period of bladder control (>6 mo)

•etiology: inorganic regression due to stress or anxiety (e.g. birth of sibling,significant loss,

family

discard,sexual abuse),secondary to organic disease (UTI, DM, Dl,sleep apnea, neurogenic bladder,

CP,seizures, pinworms)

•management; treat underlying cause,specialist referral as appropriate

Diurnal Enuresis

•clinical features:daytime wetting (60-80% also wet at night)

•etiology: micturition deferral (holding urine until last minute) due to psychosocial stressor (e.g.shy),

structural anomalies(e.g. ectopic ureteral site, neurogenic bladder). UT I. constipation,CNS disorders,

DM

•management:treat underlying cause, behavioural (scheduled toileting, double voiding,good bowel

program,sitting backwards on toilet, charting/incentive system,relaxation/biofeedback),good

constipation management, pharmacotherapy

Encopresis

•clinical features: fecal incontinence in a child >4 y r, at least once per mo for 3 mo

•prevalence: 1-1.5% ofschool-aged children (rare in adolescence); M:l-

'

=6:1 in school-aged children

•causes: chronic constipation (retentive encopresis), Hirschsprung disease, hypothyroidism,

hypercalcemia,spinal cord lesions,CP, hypotonia, anorectal malformations, bowel obstruction

Retentive Encopresis

•definition:child holds bowel movement, develops constipation,leading to fecal impaction and

seepage of soft or liquid stool (overflow incontinence)

•etiology

physical:painfulstooling often secondary to constipation

emotional:disturbed parent-child relationship, coercive toilet training,socialstressors

•clinical features

history

crosseslegs orstands on toesto resist urge to defecate

distressed by symptoms,soiling of clothes

toilet training coercive or lacking in motivation

may show oppositional behaviour

abdominal pain

physical exam

digital rectal exam or abdominal x-ray:large fecal mass in rectal vault

anal fissures (result from passage of hard stools)

palpable stool in LLQ abdomen (50% of children with fecal incontinence)

staining of underwear with stool

•management

complete clean-out of bowel:PEG 3350 given orally is most effective and first line; enemas and

suppositories may be second line therapies, but these are invasive, often less effective, and not

recommended as first line

maintenance of regular bowel movements (see Constipation, P46)

assessment and guidance regarding psychosocial stressors

behavioural modification

•complications: recurrence, toxic ntegacolon (requires >3-12 mo to treat), bowel perforation

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P13Paediatrics Toronto Notes 2023

Toilet Training

• 90% of children attain bowel control before bladder control

• generally, females train earlier than males

• 25% by 2 yr (in North America), 98% by 3 yr have daytime bladder control

• signs of toilet readiness(usually 18-24 mo)

ambulating independently,stable on potty,desire to be independent or to please caregivers(i.e.

motivation),sufficient expressive and receptive language skills (2-step command level), can stay

dry for several hours(large enough bladder), can recognize need to go, able to remove clothing

• stepwise approach used to familiarize child with the potty chair and create a connection between

elimination and the potty chair;praise with use of potty chair

Failure to Thrive s • definition

• weight <3rd percentile, falls across two major percentile curves on growth chart,or <80% of

expected weight for height and age

inadequate caloric intake most common factor in poor weight gain

may have other nutritional deficiencies (e.g. protein, iron, vitamin D)

• factors affecting physical growth: genetics, intrauterine factors, nutrition, endocrine hormones,

chronic infections/diseases, psychosocial factors

• clinical features

• history

nutritional intake

currentsymptoms

past illnesses

family history:growth, puberty, parental height and weight (including mid-parental height)

psychosocial history

• physical exam

growth parameters, plotted

<2 yr:height, weight, head circumference

>2 yr:height, weight, BMI

vital signs

complete head to toe exam

dysmorphic features or evidence of chronic disease

upper to lower segment ratio

sexual maturity staging

signs of maltreatment or neglect

• investigations (asindicated by clinical features)

CBC, blood smear, electrolytes,Tt, TSH. urea, ferritin, Ca ,celiac screen, and vitamins A, D, H

bone age x-ray

chromosomes/karyotype

chronic illness: chest (CXR,sweat Cl -), cardiac (CXR, ECG, echo), Gl (celiac screen, inflammatory

markers, malabsorption), renal (urinalysis),liver (enzymes, albumin)

Mid-Parental Height

• Boys target height-(father height

mother height *13) /2

• Girls target height

-(father height*

mother height-13) /2

Note:heightshould be taken in cm

Clinical Signs of FTT

SMALL KID

Subcutaneousfat loss

Muscle atrophy

Alopecia

Lethargy

Lagging behind normal

Kwashiorkor

Infection (recurrent)

Dermatitis

Upper to Lower Segment Ratio

• Increased in achondroplasia,short

limb syndromes, hypothyroidism,

storage diseases

• Decreased In Marfan’s. Klinefelter’s,

Kallman’ssyndromes, and

testosterone deficiency

• Calculation:uppersegment/lower

segment

• Upper segment:top of head to pubic

symphysis

• Lower segment:pubic symphysis

to floor

Table 12. Failure to Thrive Patterns

Growth Parameters Suggestive Abnormality

Decreased Wt Normal Ht Normal HC Caloric insufficiency

Decreased intake

Structural dystrophies

Endocrine disorder

DecreasedWl Decreased HI Normal HC

DecreasedWt Decreased Ht DecreasedHC Intrauterine insult

BA - bene age:CA » chronological age: HC * head circumference:Ht * height:Wl *weight

Etiology

• an interplay between pathophysiology and psychosocial influences

• investigationsshould assess:

1.complex factors in the parent-child relationship

dietary intake, knowledge about feeding, improper mixing of formula

feeding environment

parent-child interaction, attachment

child behaviours, hunger/satiety cues

postpartum depression

social factors:stress, poverty, neglect, child/domestic abuse, parental substance misuse,

restricted diets

2.inadequate caloric intake:inadequate milk supply/latching, mechanical feeding difficulty (cleft

palate), oromotor dysfunction, toxin-induced anorexia

3.inadequate absorption: biliary atresia, celiac, 1BD,CP, inborn errors of metabolism, milk protein

allergy, pancreatic cholestatic conditions

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4.increased metabolism: chronic infection, CP,lung disease from prematurity, hyperthyroidism,

asthma,1BD,malignancy, renal failure

5.increased losses

6.increased utilization (e.g.chromosomal disorders)

7. prenatal factors:placental insufficiency, intrauterine infections,genetic,maternal

Management

•most as outpatient using multidisciplinary approach: primary care physician, occupational therapist,

dietitian, psychologist,social work, CAS

•medical:oromotor problems, iron deficiency anemia, gastroesophageal reflux

•nutritional:educate about age-appropriate foods, calorie boosting, mealtime schedules, and

environment;goal to reach 90-110% 1BW, correct nutritional deficiencies,and promote catch-up

growth/development

•behavioural:positive reinforcement, mealtime environment, no distractions(e.g.toys, books, or TV)

during mealtime

Energy Requirements

•see S

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utrition, P8

Obesity Periaatal aid EartjCttdkood Factorsfor

Overweight aad Obesity iw Young Canadian

CCJ Public Heads 2013304(lteS9 H

Purpose: Id assess pcSutal eartj-lrfe factors and

their atenbtetiocsfcpjw ~ obesity among young

C a - ac:a t* :r

Methods Oatafromasa'jouDyreiitesentatne

sample of clddren ages6 Tt a the Canadian Health

MeasuresSurrey were anatyted.the associations

of permatal acd ea'y ctTdhood heterosis and

socioecooosic facarswitb oeecwtrgbt or obesity

were erabated sagsuA-enete logtsbc regression

models.

Jesuits:0*

'

55a term-bom ctidren.21% were

orerweigbt and another 13% were obese.Maternal

smoking faring pregsanq was posiStely associated

will obesity.Tbs assotiatba wasseriated by

bvth weight and onceoufroleithestrength of

the association between saoksg and ch ild obesity

increased by12%.Srtd weigti per 100 g (1.05;

1.005-1.09)wassjgn bcanyassociated with obesity.

Eidushe treastfeedwgfor Smo.adequate sleep

hon.and Seng ptyscaly actne were found to be

protect*

,fceasr'

eedtag.whether eidusnreor not,

sigmSundjredsced obesity risk among children

w:set:re s -tie- - . e; .•

Coodasm:ffesstndy rdeafied mgitp'

e perinatal

and chidhood factors associated wits obesity in

yoong Canadian children,ESectnre preientun

slraagestargeting fotr oodAaKe onatemal and

chid risk factors may rednee cbidhood obesity by op

to 54% la Canada.

• definition

Age Overweight Obese

0-2 yr eight for length >97th percentile

BMI >97Ui percentile

BUI >1511!percentile

Weight lor length >995th percentile

BMI >99.9th percentile

BMI >97th percentile

2-5yr

5-19 yr

• risk factors:genetic predisposition (e.g. both parents obese-80% chanceof obese child), psychosocial/

environmental contributors

• etiology

increased intake (dietary,social/behavioural, and iatrogenic such as drugs and hormones)

• decreased energy expenditure

• organic causes are rare (<5%):neuroendocrine (e.g. hypothyroidism,Cushing,PCOS), genetic

(e.g.Prader-Willi,Carpenter,Turner Syndromes)

plications:association with HTN, dyslipidemia,slipped capital femoral epiphysis, T2DM,

asthma,OSA,gynecomastia, polycystic ovarian disease, early menarche, irregular menses,

psychological trauma (e.g.bullying, decreased self-esteem, unhealthy coping mechanisms,

depression)

• childhood obesity often persistsinto adulthood

• investigations:BP, pulse,screen for:dyslipidemia,fatty liver disease (ALT),T2DM (based on risk

factors)

• com

• management

encouragement and reassurance; engagement of entire familv

• diet:qualitative changes (do not encourage weight loss, but allow for linear growth to catch up

with weight),special diets used by adults and very low calorie diets are not encouraged

• behaviour modification:increase activity, change eating habits/meal patterns,limit juice/sugary

drinks,ensure adequate sleep

• education:multidisciplinary approach, dietitian, counselling

• surgery and pharmacotherapy are rarely used in children

increase physical activity (1 h/d), reduce screen time (<2 h/d)

small changes in energy expenditure and intake (lose 1 lb/mo)

• long term goal:maintain BMI <85th percentile

Screen Time Guidelines (Canadian

Society foe Exerdse Physiology)

• Screen time is not recommended for

children under 2 yr

. <1 h/d screen time is appropriate for

children 2-5 yr

. <2 h/d screen time is appropriate for

children 5-17 yr

Poison Prevention

• keep all types of medicines, vitamins, and chemicals locked up in a secure container,out ofsight, and

out of reach

• potentially dangerous:medications, illicit drugs, drain cleaners,furniture polish, insecticides,

cosmetics, nail polish remover, automotive products

• do not store any chemicals in juice,soft drink, or water bottles

• keep alcoholic beverages out of reach:3oz hard liquor can kill a 2 y/o

• always read labels before administering medicine to ensure correct medication drug and dose and/or

speak with a pharmacist or healthcare provider

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Rashes

Table 13. Common Paediatric Rashes

Type of Rash Differential Appearance Management

Diaper Dermatitis Shiny, red macules/palches, no

skin fold involvement

Irritant contad deimatitis f llininale direct skin contact with urine

and feces, allow peiiods ol rest without

a diaper. Irequentdiaper changes,

topical barriers Ipelrolalum. zinc oxide

or pastel,short-term low potency topical

corlicostcroids(severe cases)

Short- term, mostuiiscrs. topical

antifungal (kctoconaiolc), low potency

topical corticosteroids

Seborrheic dermatitis Yellow,greasy macules/plaques

on erythema,scales

Candidal dermatitis frylhematous macerated papules! Antrlungal agents le g. dotrimarole.

plaques,satellite lesions,

involvement of skin folds

nystatin)

Other Dermatitis Atopx dermatitis Erythematous, papules/

plaques, oonng. excoriation,

lichenification. classic areas ol

involvement

Annular erythematous plaques,

oozing,crusting

Eliminatecxaccrbating factors,

maintain skin hydration (daily baths and

moisturisers), corticosteroids, topical

calcineurin inhibitor (2nd line)

Avoid irritant if identified, potent topical

steroid in emollient base,short-term

systemic steroids tantibiotics (severe)

Mild:soothing lotion (e.g.calamine lotion)

Moderate:low-to-intermediate potency

topical corticosteroids

Severe:systemic corticosteroids and

antihistamine

Avoid skin contact

Nummular dermatibs

Red papules/plaques/vesicles/

bullae,only in area ol allergen

Allergic contact dermatitis

Irritant contact dermatitis

Dyshidrotic dermatibs

Morphology depends on irritant

Papulovesicular, cracking/ Mild/moderate:medium/potent topical

Assuring, hands and feet (“tapioca corticosteroids

pudding") Severe:systemic corticosteroids,local

PUVA or UVA treatments

Infectious Scabies Polymorphic (red excoriated Permethrin (Nix5) 5% cream for patient

papules/nodules, burrows), in web and family (2 applications,1wk apart)

spaces/folds, very pruritic

Often affects multiple lamily

members

Honey-coloured crusts or

superficial bullae

Mild:topical anlibiolics (e.g.fucidic acid or

mupirocin cream)

Severe: oral antibiotics (e.g.cephalexin /

erythromycin )

Round erythematous plaques, topical antifungal for skin,systemic

central clearing and scaly border anlilungals for nalls/head

Impetigo

Tinea corporis

Paediatric Exanthcms (see fn/ec/rous Pocdiotiic Iwnthems,

Acne (see Oermaloloqy.014)

Neonatal skin conditions|see Skin Conditiom ollhe Heonolc. P82)

Sleep Disturbances

Types of Sleep Disturbances

• BEARS screening tool

• insufficient sleep quantity

• difficulty falling asleep (e.g. limit setting sleep disorder)

preschool and older children

bedtime resistance

due to caregiver’sinability to set consistent bedtime rules and routines

often exacerbated by child’s oppositional behaviours

• poor sleep quality

frequent arousals (e.g.sleep-onset association disorder)

infants and toddlers

child learns to fall asleep only under certain conditions or associations (e.g.with parent, held,

rocked or fed, with light on, in front of television), and loses ability to self-soothe

Daily Sleep Requirement

6 co 16 h

6 mo H.5 h

12 13.5 h

2p 13 h

< P 11.5 h

6 y> 9.5 h

12 yr 8.5 h

BP 8h

Nap n

Patterns

2'dat1yi

Vd at 2 yr(2-3 h long)

0.5 d at 5yr (1.7 h longl

. OSA

• definition:partial or intermittent complete airway obstruction during sleep causing disrupted

ventilation and sleep pattern

diagnostic criteria:clinical suspicion ( based on features like snoring, daytime sleepiness, and

witnessed apneas, and /or risk factors like neuromuscular disorders and Down syndrome); a

polysomnography is the gold standard for definite diagnosis

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epidemiology: 1-5% of preschool aged children, more common in Black children

• clinical features:snoring/gasping/noisy breathing during sleep and irritable/tired/hyperactive

during the day

complications:cardiovascular (HTN/LV remodelling due to sympathetic activation), growth,

cognitive, and behavioural problems

etiology: adenotonsillar hypertrophy, craniofacial abnormalities, obesity

investigations: polysomnography can be done, but is not required (expensive, inaccessible);

treatment can be initiated based on clinical judgement

• management: adcnotonsillectomy and weight management are first-line tx, follow-up for residual

OSA. Watchful waiting acceptable in mild-moderate cases

adcnotonsillectomy does not improve executive function/attention, but improves behaviour,

QOL, polysomnographic findings

use (.

'

PAP if adcnotonsillectomy is contraindicated (deft palate/bleeding disorder/acute

tonsillitis), OSA with minimal adenotonsillar tissue, residual OSA

avoid pollutants/tobacco smoke, allergens

avoid use of corticosteroids and antibiotics

•parasomnias

episodic nocturnal behaviours (c.g.sleepwalking,sleep terrors, nightmares)

often involves cognitive disorientation and autonomic/skeletal muscle disturbance

Management of Sleep Disturbances

•setstrict bedtimes and “wind-down" routines

•do not send child to bed hungry

•positive reinforcement for: limit setting sleep disorder

•alwayssleep in own bed, in a dark, quiet, and comfortable room

•avoid screens before bedtime and avoid caffeine-containing food

•do not use bedroom for timeouts

•systematic ignoring and gradual extinction for:sleep-onset association disorder

Nightmares

•epidemiology: common in boys, 4-7 yr

•associated with RKM sleep (generally last one third ofsleep)

•clinical features:upon awakening, child is alert and clearly recallsfrightening dream ± associated

with daytime stress/anxiety

•management:reassurance

Night Terrors

•epidemiology: 15% of children have occasional episodes

•usually in first one third of night;arousal from deep (slow wave) sleep

•clinical features:abruptsitting up, eyes open,screaming/vocalization, occurs in early hours of

sleep,stage 4 ofsleep;signs of autonomic arousal with no memory of event, disoriented if awakened,

inconsolable,stress/anxiety can aggravate them

•management: reassurance from parents,ensure child issafe (e.g. ifsleepwalks), parents can try to

identify pattern and wake up child 15 min before to disrupt pattern, often remitsspontaneously before

puberty

Brief Resolved Unexplained Events

(BRUE)

These arc sudden, brief (<1min) and

now resolved episodesin an infant

with one or more of the following:

cyanosis or pallor; absent, decreased or

irregular breathing:change in tone; and/

or altered level of consciousness. The

observer fears the child may be dying.

The child should be asymptomatic on

presentation and there is no c xplanation

after a history and physical for the

cause.There is no clear connection

between most BRUEs and SIDS.

Evaluating for a cause of the BRUE (e g.

infection, cardiac, neurologic, child

Diels abuse. metabolic disease, toxins, etc.)

KISK rciCIOrS quide<J by history, physical exam,

• prematurity (<37 wk), early bed sharing (<12 wk), alcohol use during pregnancy,soft bedding, low amJ o( observation. Etiology:

birthweight. Indigenous background, male, no prenatal care,smoking in household, prone sleep inherently unknown, but affected

position, poverty Wants ®PPe»to have (1) underlying

• risk of SIDS is increased 5-6x in siblings of infants who have died of SIDS genetic or anatomic (e.g. brainstem

• bed sharing:sleeping on a sofa, adult sleeping with an infant after consumption of alcohol/street drugs ujOTerevent (e g maternal smoking

or extreme fatigue,sleeping on a surface with a fixed wall (couch/sofa), infantsleeping with someone airflow obstruction).A BRUE appearsto

other than primary caregiver happen when (1) and (2) occur during a

vulnerable stage of development

Sudden Infant Death Syndrome

Definition

• sudden and unexpected death of an infant <12 mo in which the cause of death cannot be found by

history, examination, or a thorough postmortem and death scene investigation

Epidemiology

• 0.5 in 1000 (leading cause of death between 1 -12 mo); M:l

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*3:2

• more common in children placed in prone position

• in full term infants, peak incidence is 2-4 mo, 95% of cases occur by 6 mo

• increase in deaths during peak KSV season

• most deaths occur between midnight and 8 AM

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Prevention

• “Back to Sleep, Front to Play” (place infant on back when sleeping, daily supervised play/“tummy

time” in prone position)

• avoid sharing bed with infant

• avoid tobacco smoke exposure

• avoid overheating and overdressing

• appropriate infant bedding (firm mattress, avoid loose bedding, pillows,stuffed animals, and crib

bumper pads)

• exclusive breastfeeding in first mo and no smoking

• pacifiers appear to have a protective effect; do not reinsert if falls out during sleep

• infant monitors do not reduce incidence

Adolescent Medicine

Adolescent Psychosocial Assessment

Adolescent History (HEEADSSS)

• review confidentiality and its limits with adolescent prior to taking history

• tailor your history according to the clinical context

Home: W ho do you live with? What kind of place do you live in? Do you get along with your parents

and/or siblings? Is your home a safe place for you?

HEEADSSS

Home

Education/Employment

Eating

Activities

Drugs

Sexuality

Suicide and depression

Safcty/violcnce

Education/Kniploymcnt: What grade are you in? What are your favourite subjects? Tell me about your

grades. How often do you missscnool/dass? Do you work (ifso, how much)? Do you get along with

teachers/employers?

Eating:Tell me about your meals/snacks In a typical day. Have you ever gone on a diet? What are your

favourite and least favourite foods? (see Psychiatry. Hating Disorders, PS39)

Activities: What do you do after school? On the weekends? How much time do you spend on the

computer/watching TV every day? Do you use social media (i.e. I

'