● Know Vital Signs (temperature, pulse, respiration and blood pressure); normal and abnormal for
infants, toddlers, preschoolers, school age, and adolescents.
Normal Pulse (beats/min)
Newborn – 120-170
1 year – 80-160
3 years – 80-120
6 years – 75-115
10 years – 70-110
17 years – 60-100
Normal Respiration (breaths/min)
Newborn – 30-80
1 year – 20-40
3 years – 20-30
6 years – 16-20
10 years – 16-20
17 years – 12-20
● Know the appropriate height, weight, head circumference and BMI for children and
adolescents.
■ 5-85% normal weight
■ Less than 5% underweight
■ 85-95% overweight
■ Greater than 95% obese
■ The average newborn's head circumference measures about 13 3⁄4 inches
(35 cm), growing to about 15 inches (38 cm) by one month
■ By 6 months need to double birth weight
■ By 12 months needs to triple birth weight
● Know immunizations for all age groups:
Immunizations should be checked at every visit
Types of Immunity:
Natural immunity (genetic characteristic)
Acquired immunity (previous exposure)
Active immunity (induces immunity by vaccinations)
Passive immunity (transient immunization)
○ Know contraindications for immunization
Immunocompromised, pregnancy and preterm infants
Pregnant women should not receive MMR vaccine
Pregnant women should wait until after giving birth
Women should avoid getting pregnant for 4 wks after the MMR vaccine
Anyone who has never had the chicken pox should get 2 doses of the varicella
vaccine
Pregnant women should wait to get chicken pox vaccine until after they have
given birth
Women should not get pregnant for 1 month after getting chicken pox vaccine
Meningococcal not given to pregnant women
If patient allergic to any component of vaccine - dont give
Flu vaccine info
It takes up to 2 wks for protection to develop. Children 6 months to 2 years old
receive the vaccine. Children 2 years to 49 years can take the LAIV
○ What to do if a family refused
Inform the parents and patient about the risk and benefits of vaccination.
Explain the disease the vaccine is meant to prevent.
Issue and review the VIS.
Discuss medical and religious exemptions.
Inform the parent if the vaccine is a mandatory vaccine.
Respect the parents’ or patient’s decision.
Every visit discuss taking the vaccine, again.
Sign refusal to vaccinate form.
Document the situation in the patient’s chart.
○ Parental concerns about immunizations
Concerned it may cause autism- this is speculation-educate
○ Care after a child receives an immunization
Look out for any adverse effects (anaphylaxis, rash, hives, gbs)
○ Guidelines for immunizations/catch up/modified schedule
Tanner stages: (male and female, stages 2, 3, 4), menarche and constitutional growth delay
Male Genital Development
Stage 1 Pre-adolescent: Testes, scrotum and penis are about the same
size and proportion as in early childhood
Stage 2 Scrotum and testes are enlarged. Skin of scrotum reddened and
changed in texture. Little or no enlargement of penis is present
at this stage
Stage 3 Penis is slightly enlarged, which occurs at first, mainly in
length. Testes and scrotum are further enlarged
Stage 4 Increased size of penis with growth in both diameter and
development of glans. Testes and scrotum larger; scrotal skin
darker than in earlier stages
Stage 5 Genitalia adult in size and shape
Female Breast Development
Stage 1 Pre-adolescent: Elevation of papilla only
Stage 2 Breast bud stage: Elevation of breast and papilla as small
mound. Enlargement of areola diameter
Stage 3 Further enlargement and elevation of breast and areola, with
no separation of their contours
Stage 4 Projection of areola and papilla to form a secondary mound
about the level of the breast
Stage 5 Mature stage: Projection of papilla only, due to recession of
the areola to the general contour of the breast
Both Sexes Pubic Hair
Stage 1 Pre-adolescent: no pubic hair
Stage 2 Sparse growth of long, slightly pigmented, down hair,
straight or curled, chiefly at the base of the penis or along
labia
Stage 3 Considerably darker, coarser and more curled. The hair
spreads sparsely over the junction of the pubes
Stage 4 Hair now adult in type, but area covered is still considerably
smaller than in adult. Not spread to medial surface of thighs
Stage 5 Adult in quantity and type with distribution of the horizontal
(or classically “feminine”) pattern. Spreads to the medial
surface of thighs, but not up linea alba or elsewhere above
the base of the inverse triangle
Stage 6 Spreads up linea alba
● How to examine an infant, toddler, preschooler, school-age child and adolescent
Infant
Start with extremities, head is examined last
Allow for exploration of instruments
Position self so child can see your actions
Allow child to sit on parent’s lap or stay close to parent
Give choices when possible
Toddler
General appearance of the child
Feet and gait once walking begins
Hearing and vision (subjective)
Tooth eruption/baby bottle caries
Red reflex and alignment of eyes
Evidence of abuse/neglect
Dx test - CBC, lead and TB screening
Pre-schooler (2-5 years old)
Preschooler health supervision
Developmental surveillance
History (focus on social history)
Physical examination
Diagnostic tests (vision, hearing, lead, UA, TB- ONLY for high-risk children)
Immunizations
Anticipatory guidance
School-Age
School-Age health supervision
Developmental surveillance
School performance
Child and parent (ask about family, friends, school and activities)
Physical examination
Anticipatory guidance
Adolescence
Full history which includes a reproductive history
Interview adolescent without parents in the room
Developmental surveillance and school performance
Parental Concerns
Physical examination
Labs (RPR, Lipid profile, GC/Chlamydia, offer HIV testing)
Immunizations (Boosters, College vaccines)
Anticipatory Guidance (smoking, drinking, safe sex, & driving)
SSHADESS – (strengths, school, home, activities, drugs/substance use,
emotions/eating/depression, sexuality, safety)
Summarize findings and visit arrangement for continuation of care
● Follow-up with parental concerns (assess, re-evaluate, reassure and/or refer)
● Discipline/Set limits: punishment must fit the crime, time out and time in.
● Anticipatory Guidance for all ages (dental care, potty training, nutrition, injury
prevention, and safety)
- Newborns: position baby on back when sleeping
Infants
Injury and Illness prevention is key
Water temperature
Keep toys with small parts, balloons and plastic bags out of reach
Keep dangerous objects, poisonous substances out of sight and reach
Use safety locks on cabinets cover electrical outlets
Stair gates
Never leave baby attended (with pets or younger siblings)
Keep syrup of Ipecac or activated charcoal on hand
Poison Control Center (800-222-1222)
Empty all buckets, tubs or small pools immediately after use
Learn infant CPR and first aid
Nutrition anticipatory guidance for infants
Breast milk - 10-15 min on each breast, every 2-3 hrs.
Formula – 1-2 months, consume 2-3 oz, every 2-3 hrs.
Formula – 6 months, consume 22-26 oz/day.
Solid foods maybe introduced at 4-6 months.
Some signs that the child is ready for solid food (more than 32 oz of formula, current
weight has doubled birth weight, increased demand for feeding).
First solid food introduced rice cereal, then other single-grain cereal.
Fruits and vegetables are introduced one at a time.
No more than two new food per week.
Age 6 months, encourage drinking from cup.
8-9 months, add chopped table food.
Limit juice to 2-4 oz a day.
Infant should not receive cow’s milk prior to 1 year age.
Avoid giving child: peanuts, raisins, hot dogs, grapes, popcorn, large pieces of raw
fruits/veggies to prevent choking/aspiration.
Toddler
Hand washing
Clean toys with soap water
Limit TV to 1 hour a day
Maintain a regular bedtime
Keep home smoke free
Protect child from insect bites, sunburn
Physical activities-going to parks
Burns
Nutrition: change infant formula to whole milk as tolerated. Infant should drink whole
milk NOT skim milk or fat free milk.
Car seat
Drowning
Falls (bike, stairs, windows)
Helmet
Continue with brushing teeth with soft brush
Praise good behavior
Encourage language development
Encourage to play alone with friends, siblings
Set limits
Discipline
Toilet training
Pre-schooler
Prevention of MVA/Machine-Related injuries
Prevention burns/scalding
Prevention accidental ingestion/poisoning
Prevention drowning
Prevention injury from falls
Prevention of other injuries (bad touch, strangers)
3 meals/day, with 2-3 healthy snacks
Brush teeth after every meal or 2-3 times a day
Floss teeth at least once a day
Praise good behavior and accomplishments
Model appropriate language
School-Age
Be a role model for your child to have a health living
Supervise your child’s activities, peers and family
Encourage physical activities
Encourage adequate sleep and rest
Encourage drinking water
Hand washing
MVA/Machine-Related Injuries
Swimming/drowning
Brush teeth after every meal
Learn to floss
Praise the child for cooperation and personal success
Encourage child to express feelings
Provide personal space
Adolescent
Drugs/alcohol/smoking
Sex, sexual orientation
STD/STI, safe sex
Nutrition
Family planning
Physical activity
Driving, wearing a seat belt
Bike riding, using helmet
Sleep and rest
Sunscreen
Chores/allowance/job
Learn how to swim
Use care in interacting with strangers (in person and online)
Limit TV watching
Learn ways to manage activities
Peer groups, mentors, clubs
● Cultural sensitivity: How to handle cultural differences
Understand different cultures, self-awareness, communicate and effectively interact with
people across cultures. Cultural competence-implies active volition in acquiring cultural
knowledge, becoming proficient, competent and skillful. Being sensitive to the patient’s
culture by being aware, engages, and application of intervention. Cultural humility-life-
long commitment to self-evaluation and self-critique, and to developing mutually
beneficial, and non-paternalistic partnerships.
● How to assess literacy during the patient care visit? The average patient reads on
the sixth-grade level (literatures are written on the 3rd, 5th, and 8th grade levels). It
Communicate clearly with plain and consistent language, confirm understanding with
confirmation of knowledge and patient participation, use visuals or models to aid in
teaching, clarify and ask open-ended questions
- Most read at 6th grade reading level
- To assess parents literacy level - ask child how many books they have/read at
home
● Screenings:
○ Lead - at ages 1 & 2
○ Hearing - at birth
○ Vision
○ Developmental screenings.
● Nutritional:
Gold standard is breastfeeding for neonates/newborns. Minimum up to 4 months of age
Do not introduce cow's milk prior to 1 year of age.
After 1 y/o can have cows milk but should be WHOLE milk not skim or soy because
need the fat from whole milk for growth
Introduction to solid food begins at 4-6 months of age
8-9 months can introduce chopped table food
No more than 2 new foods/week
Signs that the child is ready for solid food (more than 32 oz of formula, current weight
has doubled birth weight, increased demand for feeding).
Breastfed babies- which supplements they receive while breastfeeding?
Vitamin D
Adolescents encourage “My plate” - healthy snacks vs junk food
● Know the stages of the following theories: Freud and Erickson
Freud believed these stages were the areas where pleasure was obtained based on
different age stages. Infants though the oral stage of sucking, toddlers through potty
training, preschoolers through the phallic phase which was idenitfying with their gender
thorough their parents, school age was less focused on sexual drive and more on hobbies,
friends, activities, adolescent more with experimentation sexually.
● Sports physical examination (interview questions, contraindications, sports injury)
Interview questions to ask (medical history)
Past injuries that caused the athlete to miss practice or games
Any loss of consciousness or memory occurring after a head injury
Previous exclusion from sports for any reason
Allergies, asthma or exercise induced bronchospasm
Medications or supplements
Menstrual history in females
Any rapid changes in body weight
Family history of premature death
Family history of heart disease in close relatives
Personal history of heart murmur, HTN, or excessive fatigue
Personal history of syncope, excessive or progressive shortness of breath, or chest pain or
discomfort particularly with exertion.
Physical examination focus
Height, weight, and body mass index (BMI)
Blood pressure and pulse
Visual acuity and pupil equality (20/40)
Skin: infections
Cardiac examination (supine, sitting and standing), pulses and murmurs
Abdomen: organomegaly
Genitalia: check for testis and hernia
Musculoskeletal: muscle strength, ROM, evaluation for structural abnormalities.
Laboratory tests are not recommended as routine screening tests for athletic participation.
Contraindications
Carditis - inflammation of the heart (No Participation is permitted)
Explanation: carditis may result in sudden death with exertion
Diarrhea (No Participation is permitted)
Explanation: diarrhea may increase the risk of dehydration and heat illness
Fever (No Participation is permitted)
Explanation: fever can increase the cardiopulmonary effort, reduce maximum exercise
capacity, make heat illness more likely and increase orthostatic hypotension during
exercise.
Acute liver enlargement (No Participation is permitted)
Explanation: high risk of rupture
Severe COVID-19 symptoms
Explanation: severe presentation must be treated as though they have myocarditis and
restricted from exercise and sports participation for 3 to 6 months.
Sports Injury
Concussions
Cervical Spinal Injuries
Cervical Muscle Strain
Stingers or Burners (common injury in football and contact sports during tackles)
Other Injuries (fractures, sprains, dislocation, broken bones, torn ligaments and tendons
and repetitive injuries)
● Accidental poisoning – prevention is the key and call poison control Hotline
Unintentional ingestion are most common in 1 to 5 years old.
Determine the substance the child ingested.
Complications: coma, toxicity, metabolic acidosis, heart rhythm aberrations,
gastrointestinal symptoms and seizures.
Treatment: supportive care, gastrointestinal decontamination (syrup of ipecac, gastric
lavage or activated charcoal).
Prevention
Cleaning equipments locked in high cabinet
Drugs and alcohol kept in high locked cabinets
Rubbish kept out of child’s area
Medications kept in high locked cabinet
Be aware of poisons and medications in home where child visits or in day care settings
● Child protective services – when to implement -> If abuse is suspected and not just
physical can be any of the below reasons:
Child abuse and neglect are often considered in broad categories:
Physical abuse (bruises, soft tissue injuries, fractures, burns)
Emotional abuse (calling child names)
Emotional neglect (FTT, hyperactivity, speech disorder)
Physical neglect (poor hygiene, lack of supervision)
Sexual abuse
Role of the NP in this:
Identify and make diagnosis of child abuse
Openly and candidly discuss abuse with parent
Treat for medical injuries or neglect
Report to Department of Welfare or Child Protective Services:
To protect child
Initiate steps to ensure abuse will not recur
Failure to report Child Abuse is a Class A Misdemeanor
Request referral or consultation to medical/surgical staff, social worker or other
specialists
Document complete abuse history
Physical examination, lab works, and x-rays
Report to Child Protective Services within 24 to 48 hrs
Follow-up with child and outcome of case
State Central Registry Mandated Reporter for Providers –1-800-632-1522
● Denver II Developmental screening is used to evaluate different components of the
child’s development (cognitive, language, social, motor, and adaptive) - this is a type of
early intervention or delayed intervention program
● Guidelines for TB screening:
■ only if pt is in high risk category- traveling, immigrant family, crowded population, in a
sports team with a lot of contact to same team members, immunocompromised
■ Screening test in children
● Low risk groups do not need to be tested routinely
● High risk groups should be tested
○ Born or traveled outside of the US to certain countries or region with
high TB-prevalence.
○ Close contact infected
○ Live in an area where there is a rise in TB infection
○ HIV positive
○ Homeless/correctional/residential institution/migrant farm family
○ Children with certain conditions (DM, CRF, malnutrition, Hodgkin
disease, those receiving tumor necrosis factor antagonists).
● Positive for latent TB infection or TB disease
○ Induration 5 mm or greater in high-risk group
○ Induration 10 mm or greater high-risk factors
○ Induration 15 mm or greater without any risk factors
● If skin test shows onset of induration after 72 hours – the TB test is read as positive.
● Skin testing is not always valid
● Do NOT give TB test after child received live vaccines; live vaccines should be given on the same day.
● Inferferon Gamma Release Assay – detect T-cell response to specific M. Tuberculosis antigens
● Results are Positive; indetermined (repeat); and negative
● Recommended:
○ For immunocompent children 3years old who received BCG vaccine
○ For person unlikely to return to the practice for PPD reading
○ For positive PPD in children who received BCG vaccine
Used in infant suspected of having congenital TBy in M. TB
● Fragile X syndrome
■ Fragile X syndrome is a genetic condition that causes a range of developmental
problems including learning disabilities and cognitive impairment. Usually, males
are more severely affected by this disorder than females. Affected individuals
usually have delayed development of speech and language by age 2
● Burn: how to assess and prioritize what is important
80-90% of injuries are preventable
Boys are burned twice as often as girls
Scald burns (caused by heat) most common during 1st two years
Flame burns most common in children over 3 years
Burns usually are classified by four criteria:
Depth of injury (degree of burn)
Percent of body surface area involved (15% of body surface are burn is serious)
Location of the burn (face and perineum are serious)
Association with other injuries
Depths of injury
First degree (red, painful and dry)
Second degree/partial thickness (mottled red kin appearance, blistering, moist to touch,
extremely painful to touch and exposure)
Third degree/full thickness burn (dry or waxlike, black or white appearance of skin
Inhalation injury (serious)
The triage decision is based on:
Extent of the burn
Body surface are involved
Type of burn
Associated injuries
Any complicating medical or social problems
Availability of ambulatory management
Treatment of Burns
ABCs of resuscitation
Remove clothing to stop burning process
Wound cleansing with water or saline and mild antibacterial solution
Blisters should be left intact; open blistered areas should be debrided
Silver sulfadiazine cream topically twice a day
Dry, sterile occlusive dressing
Acetaminophen or codeine for pain relief
Encourage oral fluids
Tetanus immunization if necessary
Assess child abuse or neglect
Refer out for more extensive burns
Follow-up wound assessment
● Adolescent confidentiality and when are adolescents permitted to act as their own
proxy
1. Mature minor -
2. Emancipated minor- legal procedure whereby minors become legally responsible
for themselves, and their parents or guardians are no longer responsible
(financially or otherwise). The minor can consent to medical, dental, or
psychiatric care. Statutes vary by state, but minors may become emancipated
when they marry, serve in active duty in the U.S. military, or obtain a declaration
from the court.
Adolescents can act as their own proxy if they are pregnant, married, in the armed
forces or emancipated. Minors can get birth control and STD care without
parental consent.
Usually they need parental consent except when they are mature minor (they have
a job which makes them independent, have court papers, emancipated minors
(teen parents, married), medical emergencies (if its urgent ie anaphylaxis)
Confidentiality applies for reproductive health, std, substance abuse.
■ NOT CONFIDENTIAL-abuse, SI/HI,
● Infectious Disease
○ Viral infections are not treated with antibiotic, only comfort measures
○ Viral infections present with fever, exanthems and/or enanthems
○ Bacterial infections are treated with antibiotic depending on the organism
○ Measles, Mumps, and Rubella
Measles - highly contagious, viral, airborne precautions
Koplik spots in the mouth, rash especially in the forehead, then general rash
throughout the body, malaise, fever, headache
Symptomatic treatment
Mumps- contagious, keep pregnant women away because can cross the placental
barrier, droplet precautions
Parotid gland swelling is the hallmark, neck pain, fever , headache
Orchitis (inflammation of testicle) in males if after puberty get the disease
Contagious 1-2 days prior to onset of parotid gland swelling and 5 days post
Symptomatic treatment
Rubella or German Measles- contagious, droplet precautions
Can cause abortion, miscarriage or stillbirth in early pregnancy (caution near
pregnant women)
Lymphadenopathy, fever, malaise, forschheimer spots , rash that starts in the face
and travels to trunk of body and extremities
comfort/supportive measurement for treatment
○ Cat Scratch- must have exposure to cats in the HPI
○ Scarlet Fever
Caused by group A betahemolytic strep bacteria
Rash (feels like sandpaper) that begins first in the armpits, groin & neck then
moves throughout, strawberry tongue, forschheimer spots, sore throat, high fever,
malaise, cheeks reddened with a pallor circular area
Will do throat culture, strep test
Treat with supportive measures, antibiotics (PCN) or erythromycin x 2 weeks
○ Infectious Mononucleosis
Caused by EBV, transmitted via kissing or sharing of objects PO
Sore throat, swollen tonsils with exudate, hepatosplenomegaly , n/v, fever,
malaise, abdominal pain, cervical lymphadenopathy
Will check labs- monospot (+) , strep test (+) , labs (+) for cbc and lfts
comfort/symptomatic treatment
Don't share objects PO, treat with antibiotics if + for strep, self resolving, fluids,
rest, short course of steroids for swollen tonsils, no contact sports due to
splenomegaly - wait 4-8weeks until recovered
Milestones
AGE PHYSICAL MOTOR LANGUAGE SOCIAL COGNITIVE
SKILLS
12 Months Triples birth Uses pincer Follows one-step Can play Masters object
weight. Stands grasps, points, commands. with a toy. permanence.
alone. stacks blocks, Mama-dada Picture book.
stands (specific)
15 Months Growth is at a Able to drink Understand new Builds tower Points to and
slower pace. from a cup, words. Says of two vocalizes wants.
Walks. hold utensils several words. blocks. Temper tantrums.
and stacks two
blocks.
18 Months Growth slows Walks up Two words Performs Use mental
down. steps, kicks together. simple imagery.
ball and Learn to say tasks.
throws ball. “NO.” Names
objects.
2 Years Skeletal growth Walks Follows two-step Learning to “Mine.”
continues. downstairs, commands. 2–3- manage Toilet-training.
Anterior Copy vertical word sentences. feels and
fontanelles. line. sharing.
AGE PHYSICAL MOTOR SKILLS LANGUAGE SOCIAL COGNITIVE
3 Years Add B/P Jumps from Knows full Potty trained; Cognitive
measurement to bottom of the name. Uses dresses with develop
anthropometric step; rides four words help. through symbol
measurement. tricycle. Zips sentences. systems and
Hearing and and unzips. language.
vision
screening.
4 years Rules of four Hops on one Uses five words Separates from Love stories,
Wt: 40 lbs foot; running sentences. Can parents; pretend and
Ht: 40 ins and jumping. sing songs. bathes self. fantasy.
Laces shoes;
button clothes.
5 years Skeletal growth Skips, balances Counts to 10; Dresses and Moves away
continues. on one foot. and asks “why” undresses self from self-
May tie without help. centered
shoelaces. behavior.
AGE PHYSICAL MOTOR LANGUAGE SOCIAL COGNITIVE
SKILLS
Early Growing out, Continue to Receptive and Develop and Intuitive problem-
childhood organs are refine. expressive maintain solving.
5 to 7 years growing. skills improve. friendships. Development of
Same sex conscience.
friends.
Middle Skeletal Expanding Able to Develop and Intellectual
childhood growth skills discuss ideas. maintain stimulation.
8 to 10 years friendships.
Late Skeletal Controlled Able to answer Separate self Able to answer
childhood growth and questions with from family. questions logically.
11 to 12 purposeful sophisticated May have
answers. friends of
opposite sex.
