1. p Pediatrics
Rachel Markin, Babak Rashidi, Tamar Rubin and Elizabeth Yeboah, chapter editors
Christophel' Kitamura and Michelle Lam, associate editors
Janine Hutson, EBM editor
Dr. Stacey Bernstein and Dr. Michael WeiDstein, staff editors
With contributions from Dr. Perla Lansang
Pediatric Quick Reference Values .......... 3 Precocious Puberty
Delayed Puberty
Primary Care Pediatrics . . . . . . . . . . . . . . . . . . 3 Short Stature
Regular Visits Growth Hormone (GH) Deficiency
Developmental Milestones Tall Stature
Routine Immunization
Other Vaccines Gastroenterology ••••••••••.••••••.•••• 36
Nutrition Vomiting
Normal Physical Growth Vomiting in the Newborn Period
Dentition Vomiting After the Newborn Period
Failure to Thrive (FTT) Acute Diarrhea
Obesity Chronic Diarrhea
Infantile Colic Chronic Diarrhea Without Failure to Thrive
Milk Caries Chronic Diarrhea With Failure to Thrive
Injury Prevention Counselling Constipation
Sudden Infant Death Syndrome (SIDS) Acute Abdominal Pain
Circumcision Chronic Abdominal Pain
Toilet Training Abdominal Mass
Upper Gastrointestinal Bleeding
Abnormal Child Behaviours .............. 12 Lower Gastrointestinal Bleeding
Elimination Disorders
Sleep Disturbances Genetics, Dyamorphisms, and Metabolism ••• 43
Breath-Holding Spells Approach to the Dysmorphic Child
Approach to the Crying/Fussing Child Genetic Syndromes
Dermatology Muscular Dystrophy (MD)
Associations
Child Abuse and Neglect ................ 15 Metabolic Disease
Phenylketonuria (PKU)
Adolescent Medicine . . . . . . . . . . . . . . . . . . . 17 Galactosemia
Normal Sexual Development
Normal Variation in Puberty Hematology •••••••••••••••.••••••.•••• 48
Physiologic Anemia
Cardiology ............................ 18 Iron Deficiency Anemia
Heart Murmurs Anemia of Chronic Disease
Congenital Heart Disease (CHD) Hemoglobinopathies
Acyanotic Congenital Heart Disease Bleeding Disorders
Cyanotic Congenital Heart Disease Immune Thrombocytopenic Purpura (ITP)
Congestive Heart Failure (CHF) Hemophilia
Infective Endocarditis von Willebrand's Disease
Dysrhythmias
Infectious Diseases . . . . . . . . . . . . . . . . . . . . . 52
Development •••••.••••••.•••••••••••.• 26 Fever
Developmental Delay Acute Otitis Media (AOM)
Intellectual Disability Meningitis
Language Delay Urinary Tract Infection (UTI)
Learning Disorders Pharyngitis and Tonsillitis
Fetal Alcohol Spectrum Disorder (FASD) Streptococcal (GAS) Pharyngitis
Infectious Mononucleosis
Endocrinology ......................... 29 Pertussis
Diabetes Mellitus (DM) Varicella (Chickenpox)
Diabetes Insipidus (DI) Roseola
Syndrome of Inappropriate Antidiuretic Measles
Hormone (SIADH) Mumps
Hypercalemia/Hypocalcemia/Rickets Rubella
Hypothyroidism Erythema lnfectiosum
Hyperthyroidism Reye Syndrome
Ambiguous Genitalia HIV Infection
Congenital Adrenal Hyperplasia (CAH)
Toronto Notes 2011 Pediatrics PI

2. p Pediatrics
Neonatology .......................... 62 Legg-Ca lve-Perthes Disease
Normal Baby at Term Slipped Capital Femoral Epiphysis
Gestational Age (GA) and Size Congenital Talipes Equinovarus
Routine Neonatal Care Scoliosis
Approach to the Depressed Newborn
Neonatal Resuscitation Otolaryngology ........................ OT
Sepsis in the Neonate Acute Otitis Media (AOM)
Cyanosis Otitis Media with Effusion (OME)
Persistent Pulmonary Hypertension of the Acute Tonsillitis
Newborn (PPHN) Tonsillectomy
Apnea Airway Problems
Respiratory Distress in the Newborn Signs of Airway Obstruction
Respiratory Distress Syndrome (RDS) Acute Laryngotracheobronchitis (Croup)
Transient Tachypnea of the Newborn (TTN) Acute Epiglottitis
Meconium Aspiration Syndrome (MAS) Subglottic Stenosis
Pneumonia Laryngomalacia
Diaphragmatic Hernia Foreign Body
Bronchopulmonary Dysplasia (BPD)
Hypoglycemia Plastic Surgery . . . . . . . . . . . . . . . . . . . . . . . . PL
Jaundice Cleft Lip
Bleeding Disorders in Neonates Cleft Palate
Necrotizing Enterocolitis (NEC) Syndactyly
Intraventricular Hemorrhage (IVH) Polydactyly
Retinopathy of Prematurity (ROP) Hemangioma
Common Neonatal Skin Conditions
Psychiatry ............................ PS
Nephrology ........................... 76 Autism Spectrum
Dehydration Asperger
Fluid and Electrolyte Therapy Attention Deficit and Hyperactivity Disorder
Hematuria Schizophrenia
Proteinuria Mood Disorders
Hemolytic Uremic Syndrome (HUS) Anxiety Disorders
Nephritic Syndrome Eating Disorders
Nephrotic Syndrome
Hypertension in Childhood Respirology •.••••••.•••••••••••.•••.•• 90
Approach to Dyspnea
Neurology ............................ 81 Upper Respiratory Tract Diseases
Seizure Disorders Croup
Febrile Seizures Bacterial Tracheitis
Recurrent Headache Epiglottitis
Hypotonia Lower Respiratory Tract Diseases
Cerebral Palsy (CP) Pneumonia
Neurocutaneous Syndromes Bronchiolitis
Acute Disseminated Encelphalomyelitis (ADEM) Asthma
Cystic Fibrosis (CF)
Neurosurgery ••.•••.•••••••••••••••••• NS
Neural Tube Defects Rheumatology ......................... 95
Intraventricular Hemorrhage (IVH) Evaluation of Limb Pain
Hydrocepha Ius Septic Arthritis
Brain Tumours Growing Pains
Dandy-Walker Cyst Transient Synovitis
Chiari Malformation Juvenile Idiopathic Arthritis (JIA)
Craniosynostosis Systemic Lupus Erythematosus (SLE)
Reactive Arthritis
Oncology ............................. 87 Lyme Arthritis
Leukemia Vasculitides
Lymphoma Henoch-Schonlein Purpura (HSP)
Brain Tumours Kawasaki Disease
Wilms' Tumour (Nephroblastoma)
Neuroblastoma Urology ............................... U
Rhabdomyosarcoma Urinary Tract Obstruction
Lymphadenopathy Vesicoureteral Reflux (VUR)
Genital Abnormalities
Orthopaedics .......................... OR
Fractures in Children Common Medications •••••••••••.•••.•• 99
Epiphyseal Injury
Pulled Elbow References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Developmental Dysplasia of the Hip
P2 Pediatrlc:a Toronto Notes 2011

3. Toronto Notes 2011 Pediatric Quick Reference Values/Primary Care Pediatrics Pediatrica P3
Pediatric Quick Reference Values
Table 1. Average V"ltals at Various Ages
Age Paisa (bpm) Resp. Rile (br/min) sBP (mmllg)
N•nllll 90-170 40-60 70-90
S-12 months 80-165 30-55 80-100
1-2J11n 80-125 25-45 90-100
:1-11 , ... 70-115 18-30 100-110
1Z..15YR" 60-100 12-18 110-130
Primary Care Pediatrics
Regular Visits
• usual schedule: newborn, within 1 week post-discharge, 1, 2, 4, 6, 9, 12, 15, 18, 24 months
• yearly until age 6, then every other year until yearly again after age 11
• history
• physical exam
• immunization (see Immunization, P4)
• counselling/anticipatory guidance (see Nutrition P6, Colic PIO, Sudden Infant Death
Syndrome (SIDS) Pll, and Injury Prevention Counselling Pll sections)
Developmental Milestones
Table 2. Developmental Milestones
Age Gro•MIIIIIr Fine Mlllllr Sp-=h and Llng111111 AdaptiV111nd Social
Skills G)
&weeb Prone: lilb chin SDCilll smie
intermittently PUJ.trlc o-lapmantaiiiiiiiiiiDn•
, year:
2 montlls Prone: IIIIlS extEnded Pulls at clathes Coos RecDgnizes parents - Single words
forward 2 years:
- 2word sentances
4 11111111111 Prone: raises head + Reach and grasp, objects Responds to voice, - Understands 2 stEp commands
chest. rolls IMII, no head to mouth laughs 3 years:
lag - 3word combes
- Rapeats 3
&montlls Prone: weight on hends, Ulmr grasp, tnnsfen Begins to babble, Stlanger anxisty beginning - Ridn1ricyc'-
1ripodsit objects from hand to hand responds to name of object pennenence • years:
- Draws squall
9 montlls Pulls to sllrld, crawls Finger-thumb grasp "Mama, dada" - Plays games, - Counb 4 object$
appropriate, imitates peek-a-boo, separation!
1word stranger anxiety
12 monthl Walks with support Pincer grasp, throws 2words. follows 1-step Drinks with cup. waves
command bye-bye
15 monthl Walks without support Draws a line Jal'!lon Points to needs
11 monthl Climbs up steps with help Tower of 3 cubes. scribbling 10 words, follows Uses spoon, points ID body Dnelopmental Red Flip
sirJ1lle commands parts Grcn motor: Not walking at 18 mos
Fi1111 IIIIIIDr: Handednass at < 10 mas
Z4 monthl Climbs up 2feet/step, Tower of 6 cubes, word ptoses, Parallel play, helps ID dress Spnch: <3 words at 18 mos
nns. kicks ball, walks undresses uses "I, me. you", Social: Not smiling at 3 mos
50% intelligible Cogmift: No peek-a-boo at 9mcs
up and down steps
3YNIS Tricycle. climbs up 1 foot/ Copies a circle and across, Prepositions, plurals, llresllunchss fully except
step, down 2fesVrtep, IM8 on shoes counts ID 10,75% buttons, knows •ax. age
sbrlds on one foot, jumps intelligible
4yell'l Hops on 1 foot. down Copie& a squarv, u&e& TBII& story, know& Coopntive toilst
1 foot/step scisson 4 coloun, speech trained, buttons dathes,
intelligible, uses past knows names of body
liln&e parts
Skips. rides bicycle Copies atriangle, prilts Auent speech, future
name, ties shoelacas lllnse, alphebat

4. P4 Pediatrica Primary Care Pediatrica Toronto Notes 2011
..... , Primitive Reflexes
• reflexes seen in normal newborns
R.nexn • may indicate abnormality (e.g. cerebral palsy) if persist after 4-6 months
• Rooting rdlx: infant pu!1U8s llllctile • Moro reflex
stimuli n- the mouth • infant is placed semi-upright, head supported by examiner's hand, sudden withdrawal of
• Puachulll nrftex: tilting the infant
to 1he side while in a sitting position
supported head with immediate resupport elicits reflex
results in ipsilateral arm extension • reflex consists of abduction and extension ofthe arms, opening of the hands, followed by
(appears by 1>-8 montha) flexion and adduction of arms
• Upgalng plant.r rwlleua • absence of Moro suggests CNS injury; asymmetry suggests focal motor lesions (e.g. brachial
aign): is normal in iniBnb (i.e. <2 yra)
plexus injury}
• Galant reflex
• infant is held in ventral suspension and one side of the back is stroked along paravertebral
line; the pelvis will move in the direction of stimulated side
• grasp reflex: flexion of infant's fingers with the placement of a finger in the infant's palm
• asymmetric tonic neck reflex: turning the head results in the ·fencing" posture (extension of
ipsilateral leg and arm and flexion of contralateral leg)
• placing and stepping reflex ("primitive walking"): infant places foot on a surface when it is
brought into contact with it
Routine Immunization
Tabla 3. Routine Immunization Schadula
V.C:dne Schale Route Reac:tion Canlnlinlklllians
2, 4, 6, 18 mos IM At24-48hl'l Previous anaphylactic reaction to
4-6yrs Minor: local radness, swelling. vaccine, evolvilg unstable neurologic
irritability dis111se, hypcnsponsiWi11ypotonic
Major: prolonged crying (1%), following previous vaccine,
hypotonic urresponsiw slli1e reaction to neomycin or
(1 :1750), seizure (1 :1 950) on day streplllmycin
of vaccine
Prophylaxis: acetaminophen
10-1 5 mllllqj given 4 hrs prior to
injection and q4h
Hib 2, 4, 6, 18 mos IM Minor: feve& local redness, swelling.
irritability
..... ,
...----------------.
Pneu-C 2, 4, 6, 15 mos IM Minor: fava& local radnass, swelling.
irritability
MMR• 12. 18 mos sc At7-14 days Pregnancy, immunocomiJllmised
S.r.ty of MMR Vaccine Fawr, measle-lib rash, infanb (except HIV positive
Acconling to 1he CDC, 1he weight of lymphadenopa1hy, artlnlgia, chilcnn), anaphylactic reaction to
cUIIWI!Iy availabllscilntilic IVidence arthritis, (RR) gelatin
does not support 1he hypo1hesis lhllt
MMR vaccine causes aithar autism
Man-e 2,4,6 mos IM Redn""swellilg (<50%), fewr
or lBO. OR 12mos (9%), irritability (<811%), rash (0. 1%)
The lll1d11111rk paper linking autism V.r• 15 mos sc Mild local reaction (211% but higher in Pregnant or to get pregnant
to 1ha MMR vaccine {Lanl:llt 1998; within next 3 mon1hs, anaphylactic
351(9103):637-41)was relm:led due to Mild papules or vesicles reaction to gelatin
false claims in 1he article (Lines! 201 0; (5%)
375(9713):445). Low-grade fever (15%)
HepB 3 doses: 0, 1, 6 mos; IM Local redness, swelling Anaphylactic reaction to Baker's yeast
given in SDII'II provinces
in grade 7 (given at birth
if at increased risk i.e.
from endemic country,
given with HBig mother
HBsAg +ve)
dlap S1art at 14-16 yrs IM Anali!ylaxis (very rare) Pregnancy (1st trinester)
Td Adultyrs, q10yrs IM Local erythema and swelling (711%)
Flu•• Start a& 6-23 mas, awry IM Local tendBII'IIss at injection site, Anaphylactic reaction to Bggs,
autumn fever, malaise, myalgia. rash, febrile <6 moso!Bge
seizures
Hypersensitivity reactions

5. Toronto Notes 2011 Primary Care Pediatrics Pediatrics PS
Table 3. Routine Immunization Schedule (continued)
Vaccine Schedule Route Reaction Contraindications
HPV 3 doses: 0, 2, 6 IM Local tenderness, redness, itching,
mos for females swelling at injection site, fever
between 9-26
Given in some
provinces in grade
7 or 8
OTaP-IPV - d iptheria, tetanus, acellular pertussis, inactivated polio vaccine (for children under 7yrs)
MMR - measles, mumps, rubella vaccine Pneu-C- pneumococcal 7-valent conjugate vaccine
H - Hemophilus inftuenzae type bconjugate vaccine Var - varicella vaccine
tb
Mcn-C - meningococcal Ccoojugate vaccine dTap - diphtheria. tetanus, acellular pertussis vaccine fl)(mulationl
H B- H
ep epatitis Bvaccine Td- tetanus and diphtheria adult type formulation
flu- influenza vaccine HPV - human papilloma virus vaccine
' Hvaricelavaccine and MMR vaccinenot g during the same visit, they must beadministered a least 28 days apart
iven t
"*For children withsevere or chronic d isease, e.g. cardiac disease. ptjmonary disease, renal d isease. sickleeel disease, diabetes. endOCiine disorders, HIV,
immunosuppressed ,long·tenn aspirin therapy, or those who visit residents of clvonic care facaities
Ada from: National Advisi)(V C
pted OIMlittee on Immunizatio Recommended Immunization Schedule (Of Infants, Children and Youth (updated March 2005)
n.
Administration of Vaccines
• injection site
• infant (<12 months old): anterolateral thigh
• children: deltoid
• DTaP+IPV+Hib (Pentacel"', Pentavax'" ): 5 vaccines given as one IM injection
• two live vaccines (varicella, MMR) must be given subcutaneously either at the same visit or
separated by 4 weeks or more
Contraindications to Any Vaccine
• moderate to severe illness ± fever (no need to delay vaccination for mild URTI)
• allergy to vaccine component
Possible Adverse Reactions
• any vaccine
• local: induration or tenderness (MMR is especially painful!)
• systemic: fever, rash
• allergic: urticaria, rhinitis, anaphylaxis
• specific vaccine reactions (see Table 3)
Other Vaccines
Hepatitis A
inactivated monovalent hepatitis A vaccine (Havrix8 , Vaqta'", Avaxim.., Epaxal Berna"')
given as a series of 2 vaccinations 4-6 months apart
recommended as pre-exposure prophylaxis for individuals at increased ri sk of infection (travel
to endemic countries, residents of communities with high endemic rates, IV drug use)
can also be given as a combination vaccine with Hep B (Twinrix"')
inmmnoglobulin can be used for short-term protection in infants and immunocompromised
patients
BCG Vaccine
• infants of parents with infectious TB at time of delivery
• groups/communities with high rates of disease/infection (offered to aboriginal children on
reserves) , health care workers at risk
• only given if patient has a negative TB skin test
• side effects: erythema, papule formation 3-6 week after intradermal injection, enlargement of
regional lymph nodes
TB Skin Test (Mantoux)
• screen high risk population only (family history, HIV, immigrants from countries with
increased incidence, substance abu e in family, homeless, aboriginal)
• intradermal injection of tuberculous antigen, read result at 48-72 hrs
• TB test should be postponed for 4-6 weeks after administration of live BCG vaccine due to risk
of false positive result
• te t interpretation
• check area of raised INDVRATIO (not just area of erythema) at 48-72 hours
• positive re ult if:
• > 15 mm: children >4 years with no risk factor
• > lO mm: children <4 years, or at risk for environmental exposure
• >5 mm: children with close TB contact, immunosuppressed
• BCG hi tory irrelevant- does not usually give po itive response (unles <6 weeks previou ly)
• positive reaction means active disease or previous contact with TB

6. P6 Pediatrica Primary Care Pediatrica Toronto Notes 2011
Wwly -.llliclcyofu......_.v.r:cm.
Quadrivalent Meningococcal Vaccine (Menactra•)
• • r..nllotalhiGrrnr•«s • given in some provinces in Grade 9
NfJM 2006; 354:11-22 • protects against Neisseria meningitidis strains A, C, W-135, andY
llldr. Rlndomillld, ibJbl&bind. phue 31rill • in Canada, currently recommended for patients with asplenia, travelers to endemic areas (such
1'11111111: 63,225 haiM!1y inllllts from Latin Amarica
and Finllnd• as the Hajj in Mecca), laboratory workers, and military recruits
...........: Twucnl d-aiHIIVIIIICCinevs.
Epiladls al gllllrolnllriti 11111 -r,
Rotavirus Vaccine (RotaTeq®)
.....: Thlwccilw il Mllfficaciaus lglillll • oral vaccine given in 3 doses with first at age 6-12 weeks
-.JO!a'irusa---11111 hotpD!i!Dons • shown to reduce viral gastroenteritis in infants
llsoc:iiQd Mill 11m • not currently covered in Canada
lfbcious l!llllinst mllll IMll oastroentmis.
Nutrition
Breastfeeding
• colostrum for first few days = clear fluid with nutrients (high protein, low fat) and
immunoglobulins
• full milk production by 3-7 days; mature milk by 15-45 days
• support for mothers who want to breast feed should start while in hospital
• signs of inadequate intake: <6 wet diapers per day after first week, sleepy or lethargic, <7 feeds
per day, sleeping throughout the night <6 weeks, weight loss >10% of birth weight, jaundice
• rule of thumb: -1 stool/day of age for first week
• feeding schedule (newborn baby needs 120 kcal/kg/day)
• premature infants: q2-3 hours
• term infants: q3.5-4 hours, q5 hours at night until about 2-3 months of age
• breast-fed babies require the following supplements
• vitamin K (given IM at birth)
• vitamin D (Ddrops•) 400 IU/day, 800 IU/day in northern communities
• fluoride (after 6 months if not sufficient in water supply)
• iron: from 4 months to 12 months (iron fortified cereals or ferrous sulphate solution)
Contraindication• to Breastfeeding
• mother receiving chemotherapy or radioactive compounds
lhllntlhwllllld . . . . . . . . AIRI:illlll • mother with HIVI AIDS, active untreated TB, herpes in breast region
wit3MIIIIIIIIC.mpnd . . IM. . • mother using >0.5 g/kg/day alcohol and/or illicit drugs (decrease milk production and/or
bd............ directly toxic to baby)
111eAnllri:81 Joimll d Clini:ll Nulrililn 2003; • mother taking certain medications e.g. antimetabolites, bromocriptine, chloramphenicol, high
78:291-295
diflarancn in growth 11111 dose diazepam, ergots, gold, metronidazole, tetracycline, lithium, cyclophosphamide
belli! in irin excklsivelr hreaslled lor3'1ftls • Note: oral contraceptive pills (OCP) not a contraindication to breastfeeding (estrogen may
61110111b1. decrease lactation but is not dangerous to infant)
llldy:lllsemtiOOII t:Ohmt study IWII3483111m
II8WixirM Advantages of Breastfeeding
.....:11111111 itactions
-•igricdy llducad in lila graup al itlllll
• "Breast is Best" - exclusive breastfeeding during the first 4 months oflife is recommended by
wila WIIIIXCUsivll'f hlwlfld for 6 months. Health Canada, the Dietitians of Canada, and the Canadian Pediatric Society
This findlna- Died 111111e period between • breast milk is easily digested and has a low renal solute load
3 111:1 61111111111s {ldjullld Ill 0.35 {951 • immunologic
Cl: 0.13, 0.96). The brelstfed babies were • IgA, macrophages, active lymphocytes, lysozymes, lactoferrin (lactoferrin inhibits E. coli
111'11111 116111111111111 bullf'lllll-1111 cillamlt in
growth in intestine)
gruwlll w-llle two P4)S IJ;' 12111Gl'&.
No liQfurtllsoc:iltion-llllld . . _ • protection is greatest during early months, but is cumulative with increased duration of
lniiiiiMdina 11111 lila 1111 ai1C311'1 0118111i11101Y breastfeeding
ill1clilns. • lower allergenicity (decreased cow's milk protein allergy and eczema)
c:.cuan.: Thill is .. -ciltian '*-' • lower pH promotes growth of lactobacillus in the gastrointestinal tract (protective against
brelllleldina 11111 •ilwlr incidence a1 pathogenic intestinal bacteria)
gallnlilllltilal irilctilns in 111m innlt.
• parent-child bonding, economical, convenient
Complications of Braastfaading
• mother
• sore/cracked nipples: treat with warm compresses, massage, frequent feeds, soothing barrier
creams (Desitin•, Vaseline•), proper latching technique
• breast engorgement (usually in first week): continue breastfeeding and/or pumping
• mastitis (usually due to S. aureus): treat with cold compresses between feeds, cloxacillin for
mother, continue nursing, ± incision and drainage
• infant
• breastfeeding jaundice (first 1-2 weeks): due to lack of milk production and subsequent
dehydration (see Jaundice, P70)
• breast milk jaundice: rare (0.5% of newborns, persists up to 4-6 months); not fully
understood, thought to be due to substances in breast milk that inhibit conjugation of
bilirubin or increased enterohepatic circulation ofbilirubin
• poor weight gain: consider dehydration or failure to thrive
• oral candidiasis (thrush): check baby's mouth for white cheesy material that does not scrape
off; treat baby with antifungal such as nystatin (Mycostatin•) (treat mother topically to
prevent transmission)

7. Toronto Notes 2011 Primary Care Pecliatrlcs Pediatrica P7
Alternatives to Breastfeeding
Table 4. Infant Nutrition Source
Type ul Nutrition lndic:rionl•l Canlllnt leamPin=d to brent nilkl
Bl'lllt nilk Most babies 70:30 whey: casein ratio
Fat tom distary butiBrfat
Carbohydnrte fnrn lactuse
Cow's milk buad Premature babies Plant fats inmd a! diellly butterfat
(Enfamilill, Sinilaclt] Lower whey:cesein ratio
Contnlindication to breartleeding
Forlifilld farmull Low birth weight More calories
Premature babies Higher amounts of vitamins A, C, D. K
May only be used in hospital due to risk a! fat-soluble
vitamin toxicity
Soy prollin Galactosemia Com syrup solids or sucrose instead of lactuse
llsomii®, ProsobeeiliJ Lactose intolera'lce
Partially hvdrolyzad prollins Dulayud gi151ric emptying Protein is 100% whay no casein
(Good StartiliJ Risk of cow's milk allergy
Prollin hvdrolysate Malabsorption Protein is 100% casein no whey
(Nutramigenlll, Alimentwnlll, Food allergy Com syrup solids, sucrose, OR tapioca starch
Pregestimil®, Portagen®J instead of lactose
Expensive
Amino acid Food allergy No proteins, ju&t he amino acids
(Neocate®J Short gut Com syrup solids in&tead a! lactose
Very expensiw
Melilbolic lrtom el1tll1i a! mstaboli&m Various different compositions for children
galactosemia. propionic acidemia, etc.
Mostlomlllu con1Bin 670 Clbias per litre. Theha6{11nn inflntNCJJiiM -100 callqd fGI 0.6 mos and -IOC&Vqd fal&-12 mos."Friild' fonnulas falpnmnn
babillllll' conllil more CllarifliS. RlmU•IIlll' also be IIIPPiemented v.ilh '!Ide nutrillnts ill billies v.ilh mallblorplion True llcloM irloi81111C8 is
lllmnll;" 1n ill cliklr111 und• 1111
Infant Feeding
Tabla 5. Dietary Schadula
Foad
0 18 4-6 monlhs Breast millr. formula
Iron enriched cereals Rice cereals first because less allergenic
..... ''
4 18 9 montlis Restriction of a08fllllllic foods (e.g. egg
Pureed vegetables Yellow/orange vegetables first and green whillls and 1M$ I in the first
year of life is controversial. There is a
last (more bulky) recent tr1lnd tnWllllll alll1y irtroduction
Avoid vegetables high nitrite content ofthiHfoodl.
(beets, spinach, turnips)
Introduce vegetables before
yallow and graen wgstables daily] •
Pureed fruits Avoid juices I M-1• CIIDidnglluarU up ta tile
Ate Df 4:
Pureed meats, fish, poLJtty, egg yolk 1. Hot dogs (uncutl
2. GrapH (uncutl
!181211111111111 Finger foods, peuled fruit, cheese and No honey until > 12 monlhs (risk a! 3. CllltiWolher IIIW vegetables
cooked vege1llbles, homo milk botulism] 4.Nuts
No peanuts or raw, hard vegetables Llllil 5. Fish with bones
age 3to 4 years &.Popcorn
7 Hard candies
0
No added sugar, salt. fat or seasonings B. Gum
• do not delay introduction of solid foods beyond 9 months
• introduce 2-3 new foods per week (easier to identify adverse reactions) and allow a few days
between each introduction
• avoid excessive milk/juice intake when >1 year

8. P8 Pediatrica Primary Care Pediatrica Toronto Notes 2011
...... ,
•t-----------------, Normal Physical Growth
ScoliOiil Screening
lle8pil8 man school scrvening
• newborn size influenced by maternal factors (placenta, in utero environment)
implernan!rld in parb of1hl USA 111d • premature infants (<37 weeks): use c:orrected gestational age until2 years
Canada in the 1970&-901, the Canadian • not linear: most rapid growth during first two years and growth spurt at puberty
{1994) and American {2004) Task • dllferent tissue growth at different times
Fonces on Preventive Carv do
NOT cur111ntly rvcommlllld routine
• first two years: CNS
screening using the Forward Bend Test • mid-clrlldhood: lymphoid tissue
{FBn. Cohort studies indicate that the • puberty: gonadal maturation (testes, breast tissue)
forward bend test hu poor sensitivity • body proportions: upper/lower segment ratio - midpoint is symphysis pubis
for iderrtifyW1g pathological
{Kar.chalias et al. 1999, Yawn et al.
• newborn 1.7; adult male 0.97; adult female 1.0
1999, Pruijs st al. 1996). Furthermora, • poor correlation between birth weight and adult weight
there is no evidence to suggest that
screening and incruased bracing ielld to T1ble 6. Aver1ge Growth Par1meters
batter autcorn.s.
Nonnal Commants
...... , BirthWaight 3.25 kg (71bs) 2 x birth wt by 4-5 mas
3 X birth wt by 1 y&lll'
Weight loss
isnonnal
1II% of birth wt) in first 7days of
oowbf---am sh_ould ga_in ZB-_30 g}_da_y.---,
__ __ __ __ 4 X birth wt by 2y&llll Neonate should 11gain birth weijlt by -10 days of age
Lcngthllllliglrt 50 em (20 in) 25 em in 1st yaar Measure supine length unti12 yaan of age, then
12 em in 2m year measure slllnding height
8 em in 3rd year then
4-7 ern/year until puberty
1/2 adult hsight at 2yea11
Hllll 35em (14 in) 2crnfmonlhfor1st3 mos Measure around occipital, pariellll, and frontal
1crnfmonlh at 3-6 mas prominancas to obtain the gl'llllt8st circumference
0.5 em/month at 6-12 mas
liNd Circlllllflnnce
Remnlll• 3, 9, and Muldpllls llf 5: Dentition
Newborn IS em
3mos 40cm • primary dentition (20 teeth)
9mos 45cm • first tooth at 5-9 months (lower incisor), then 1 per month until20 teeth
3yrs50cm
9yrs 55cm • 6-8 central teeth by I year
• seoondary dentition (32 teeth)
• first adult tooth is 1st molar at 6 years, then lower incisors
• 2nd molars at 12 years, 3nl molars at 18 years
Failure to Thrive (FTT)
T1bla 7. Failure to Thrive Patterns
Suggative Abnunnality
..... ,,
•.t-----------------,
GI'IIWth Pirillllrten
Decreased WI Nonnal HI Normal HC Caloric insufficiency Hypennelabolic state
Decreased intake Increased IOS$e$
En•gy Requinlmtnts Decreased WI Decreased HI Normal HC Strut111ral dystrophies Constitutionai!JDWih delay
• 0-10 ku: 100 cal/kWday
• 1-ZO kQ: 1,000 cal+ 50 calllqVday Emocrine disorder Ftmilial short slalure
for llch ku >10
• +ZO kg: 1,500 cal+ 20 callkG'day Decreased WI Decreased HI Decreased HC lntralllerine insult Genetic abnonnality
for llch ku > 20 HC = held cin:unferm:e; Ht = he9rt; WI = weight
..... ,, Definition
•.t-----------------, • weight <3rd percentile, or falls across two major percentile curves, or <80% of expec:ted weight
Upper tu L.aw. [U/LI Sqment Retia
for height and age
is". • inadequate caloric intake most oommon factor in poor weight gain
lncrRIId in achondroplasia, short • may have other nutritional deficiencies (e.g. protein, iron, vitamin D)
limb syndromn, hypothyroid, starega ·history
diseases. • duration of problem and growth history
Decrulld in Marian, Klinefultur,
Kallman. testosterone deficiency. • detailed dietary and feeding history, appetite, behaviour before and after feeds, bowel habits
• pregnarn;y, birth, and postpartum history; developmental and medkal history (including
..... ,...-----------------,
, medic:ations); social and family history (parental height, weight, growth pattern)
• assess 4 areas of func:tioning: child's temperament, c:hild-parent interac:tion, feeding
behaviour and parental psyc:hosocial stressors
Calcalating Up,_.tD (IIIli • physical exam
SqmentRIItio • height (Ht), weight (Wt), head circumference (HC), arm span, upper-to-lower (U/L)
Upper Top of haed to pubic
symphysis. segment ratio
.._.segment: symphysis to • assessment of nutritional status, dysmorphism, Tanner stage, evidence of c:hronic disease
floor. • observation of a feeding session and parent-clrlld interac:tion
11/1.: upper • signs of abuse or neglect

9. Toronto Notes 2011 Primary Care Pecliatrlcs Pediatrica P9
• investigations (as indicated by clinical presentation)
• CBC, blood smear, dectrolytes, urea, ESR, T4, TSH, urinalysis
• bone age x-ray (left wrist- compared to standardized wrist x-rays)
• karyotype in all short girls and in short boys where appropriate
• any other tests indicated from history and physical exam: renal or liver function tests, venous
blood gases, ferritin, immunoglobulins, sweat chloride, fecal fat
Organic FTT (10%)
• inability to feed
• insufficient breast milk production
• poor retention (GERD, vomiting) Clinlul Signs of FTT
• CNS, neuromuscular, mechanical problems with swallowing and sucking
SMAI1111D
• anorexia (associated with chronic disease) Subcuteneous fat 1011
• inadequate absorption (see Pediatric Gastroenterology. P39) Muscle atrophy
• malabsorption: celiac disease, cystic fibrosis (CF), pancreatic insufficiency Alopecia
• loss from the GI tract: chronic diarrhea, vomiting Lethargy
Lagging behind nonnal
• inappropriate utilization of nutrients Kwashiorkor
• renal loss: e.g. tubular disorders Infection (recunent)
• inborn errors of metabolism Dennlllitis
• endocrine: type 1 diabetes, diabetes insipidus (DI), hypopituitarism, congenital
hypothyroidism
• increased energy requirements
• pulmonary disease: CF
• cardiac disease
• endocrine: hyperthyroidism, Dl, hypopituitarism
• malignancies
• chronic infections
• inflammatory: systemic lupus erythematosus (SLE)
• decreased growth potential
• specific syndromes, chromosomal abnormalities, GH deficiency
• intrauterine insults: fetal alcohol syndrome (FAS), TORCH infections
• treatment: cause-specific
Non-Organic FTT (90%)
• often due to malnutrition, inadequate nutrition, poor feeding technique, errors in making
formula
• these children may present as picky eaters, with poor emotional support at home or poor
temperamental "fit" with caregiver
• may have delayed psychomotor, language, and personal/social development
• emotional deprivation, poor parent-child interaction, dysfunctional home
• child abuse and/or neglect
• parental psychosocial stress, personal history of suffering abuse or neglect
• treatment: most are managed as outpatients with multidisciplinary approach
• primary care physician, dietitian, psychologist, social work, child protection services
Obesity
• a quarter of Canaadian children ages 2-17 are overweight or obese, 8% are obese (2004)
Definition
• BMI >95th percentile for age and height
• caused by a chronically positive energy balance (intake exceeds expenditure)
Risk Factors
• genetic predisposition:
• if 1 parent is obese - 40% chance of obese child
• if both parents are obese - 80% chance of obese child
• genetic heritability accounts for 25-40% of juvenile obesity
Clinical Presentation
• history: diet, activity, family heights and weights, growth curves
• body mass index (BMI) tends not to be used by pediatricians prior to adolescence
• physical examination: may suggest secondary cause, e.g. Cushing syndrome
• organic causes are rare (<5%)
• genetic: e.g. Prader-Willi, Carpenter, Thmer syndromes
• endocrine: e.g. Cushing syndrome, hypothyroidism

10. P10 Pediatrics Primary Care Pecliatria Toronto Notes 2011
• complications
. . . . -..
...,._ .. llnlwliF! c-111 CIMII • childhood obesity is an unreliable predictor of adult obesity
11(51:16&-73 • unless > 180% of ideal body weight
..,....Todlnnaii80IIflllli;lf1d • however, 70% of obese adolescents become obese adults
demopilic millill ilfle IJIMience ri • association with: hypertension, dyslipidemia, slipped capital femoral epiphysis, type 2
-ightCndl111 cliililn.
SlUr. Assessl11lll al Ire!* ill BMIIIIi'G dl1il diabetes, asthma, obstructive sleep apnea
mlill 1181 Cntill FilnM &.wy 1111 1111 • boys: gynecomastia
1H6 Nllionlll LDI9Uhl SIMi al Clildrell • girls: polycystic ovarian disease, early menarche, irregular menses
111dYoulh. • psychological: teasing, decreased self-esteem, unhealthy coping mechanisms, depression
lllil a..-: Thepi"MIInCiaf a.vniglt-
obel8 chih 11U1J7 Ill 13 ,_., IIICUWirundi • management
from 118110 1996 I)AlYillCI, nd provilcilll • encouragement and reassurance; engagement of entire family
'lllilliollll!!adjuslilgfol lf1d • diet: qualitative changes; do not encourage weight loss but allow for linear growth to catch
cllmopilic ch-mrilllcs. up with weight; special diets used by adults are not encouraged
. . . .:i1199&,33alllcJwslllldMalan
W8l'1l dU8iiad •• CIW!Mi;d. end 1 ol boys
O!i • evidence against very low calorie diets for preadolescents
111d "al gils- ciB1iieiiiS ollese. The odds • behaviour modification: increase activity, change eating habits/meal patterns
llllioeaDI:ilbld wilh 1111 1111 111 1116 c:llngl • education: multidisciplinary approach, dietitian, counselling
il1111prMilncefl cliitirn IIIII
l24 {1!1'1. 2n.JJOI f1lr Canida• • Mole.
• surgery and pharmacotherapy are not used in children
Thera 111 cll•llgionll wilh b II
A*llic c-dl more iketf1D be IMIWeiQit •d
l'rliil cliimn lin lily. Thill Infantile Colic
nol dcielllly eiXUIIBd far II' dlllnnces il
socioeconomic ci!unlllalces.
pleUIIelce al childllood *tily • rule of 3's: unexplained paroxysms of irritability and crying for >3 hours/day and >3 days/week
is iiiCIII!ilg i l l l - al t.ID. lilhlllgh 11'111111 for >3 weeks in an otherwise healthy, well-fed baby
• in Allrict.lldL • occurs in 10% of infants
• etiology: generally regarded as a lag in the development of normal peristaltic movement in
gastrointestinal tract; other theories suggest a lack of self-soothing mechanisms
• other reasons why babies cry: wet, hunger or gas pains, too hot or cold, overstimulated, need to
suck or be held
• timing: onset 10 days to 3 months of age; peak 6-8 weeks
• child cries, pulls up legs and passes gas soon after feeding
• management
• parental relief; rest and reassurance
• hold baby, soother, car ride, music, vacuum, check diaper
• medications (Oval• drops, gripe water) of no proven benefit
• ifbreastfeeding, elimination of cow's milk protein from mother's diet (effective in very small
percentage of cases)
• try casein hydrosylates formula (Nutramigen•)
Milk Caries
• decay of superior front teeth and back molars in first 4 years of life
• often occur in children put to bed with a bottle of milk or juice
• can also be caused by breastfeeding (especially prolonged night feeds)
• prevention
• no bottle at bedtime (unless plain water}
• use water as thirst quenchers during the day, do not sweeten pacifier (> 1 year)
• can clean teeth with soft damp cloth or toothbrush and water
• avoid fluoridated toothpaste until able to spit (>3 years) due to fluorosis risk (stains teeth)
• Canadian Dental Association recommends assessment by dentist 6 months after eruption of
first tooth, or by 1 year of age

11. Toronto Notes 2011 Primary Care Pecliatrlcs Pediatrics Pll
Injury Prevention Counselling
• injuries are the leading cause of death in children >1 year of age
• main causes: motor vehicle crashes, burns, drowning, falls, choking, infanticide
Tabla 8. Injury Pnwantion Counsalling
0-6 months li-1 2 months
Do not IB11V8 alone on bad, on Instal stair barriers Never IBIMI unattended Bicycle halmat
change table or in tub
Discourage use of walkers Keep pot handles turned to Never leave unsupervised at
Keep crib rails up back of stove home, driveway or pool
Avoid play areas sharp·
Check WliiBr tBfll) before bathing edged tabiBS and comars No nuts, lliW caii'DIB, Teach bib safety, stranger
etc. due to choking hazard safety, and street safety
Do nat hold hat liquid and infant at Caver electrical outlets
the s1111e tine Unplug appliances when nat No running while eating Swimming lessons, sunscreen,
tllddler seals in the car, fences
Turn dawn hat watar heater in use
around pools. dentist by age 3
Check mile temp before feedilg Keep small objects. plastic
bags, cleaning products, and
Have appropriate car seats -
medications out of reach
before aiiOMd to leaw
hospital Supervise during feeding
• <9 kg: rear-facing
• 10.18 kg: front-facing
• 18-36.4 kg: booster seat
• always have Poison Control number by telephone
• have smoke and carbon monoxide detectors in the house and check yearly
Poison Prevention
• keep all types of medicines, vitamins, and chemicals locked up in a secure container
• potentially dangerous: 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: 3 oz hard liquor can kill a 2-year-old
• always read label before administering medicine to ensure correct drug and dose
Sudden Infant Death Syndrome (SIDS)
Definition
• sudden and unexpected death of an infant <12 months of age in which the cause of death cannot ..... ,
be found by history, examination or a thorough postmortem and death scene investigation
Appilrut Uflt.Threat.ning Evwm
Epidemiology (ALT&I
• 0.5/1,000 (leading cause of death between 1-12 months of age}; M:F = 3:2 A group of conditions often milked
by an epilode of apnea. cy•nosil,
• more common in children placed in prone position change in tc1111, or in 1111111111
• in full term infants, peak incidence is 2-4 months, 95% of cases occur by 6 months llatul occurring in • cllild. whn an
• increase in deaths during peak respiratory syncytial virus (RSV) season obsamrfears the child may ba dying.
• most deaths occur between midnight and 8 AM It is unclear whether or not there is 1
conn action lmwNn ALTEs and SIDS,
and 1 thorough workup should be done
Risk Factors looking for 1 cause oftha ALTE (e.g.
• more common in prematurity, if smoking in household, minorities (higher incidence in infection, cardiac, neurologicl
aboriginals and African Americans}, socially disadvantaged
• risk of SIDS is increased 3-5 times in siblings of infants who have died of SIDS
Prevention - •aack to Sleep, Front to Play•
• place infant on back, NOT in prone position when sleeping
• allow supervised play time daily in prone position
• alarms/other monitors not recommended- increase anxiety and do not prevent life-threatening
events
• avoid overheating and overdressing
• appropriate infant bedding (firm mattress, avoid loose bedding and crib bumper pads)
• nosmoking
• pacifiers appear to have a protective effect; do not reinsert if falls out

12. P12 Pediatrics Primary Care PediatricaJAbnonoal Chllcl Behaviours Toronto Notes 2011
Circumcision
• elective procedure to be performed only in healthy, stable infants
• contraindicated when genital abnormalities present (e.g. hypospadias) or known bleeding
disorder
• usually performed for social or religious reasons (in Ontario, not covered by OHIP)
• complications (<1%): local infection, bleeding, urethral injury
• medical benefits include prevention of phimosis, slightly reduced incidence of UTI, balanitis,
cancer of the penis
• 2 recent RCTs (Lancet 369, Feb 2007) suggested that routine circumcision significantly reduced
HIV transmission (studies conducted in high endemic areas, i.e. Africa); circumcision also
appears to reduce HPV transmission
• routine circumcision is not currently recommended by the CPS or AAP
Toilet Training
• 90% of kids attain bowel control before bladder control
• generally females train earlier than males
• 25% by 2 years old (in North America), 98% by 3 years old have daytime bladder control
• signs of toilet readiness:
• 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)
Abnormal Child Behaviours
Elimination Disorders
ENURESIS
• involuntary urinary incontinence by day and/or night (typically by 5-6 years old)
• wetting at least twice a week for at least 3 consecutive months or causing significant distress to
the child
• treatment should not be considered until6 years of age; high rate of spontaneous cure
• should be evaluated if >6 years old; dysuria; change in gross colour, odour, stream; secondary or
diurnal
Primary Nocturnal Enuresis
• wet only at night during sleep, can be normal up to age 6
• prevalence: 10% of 6-year olds, 3% of 12-year olds, 1% of 18-year olds
• developmental disorder or maturational lag in bladder control while asleep
• more common in boys, family history common
• treatment:
• time and reassurance (-20% resolve spontaneously each year), behaviour modification
(limiting nighttime fluids, voiding prior to sleep), engage child with rewards, bladder
retention exercises, scheduled toileting
• conditioning: "wet" alarm wakes child upon voiding (70% success rate)
• medications (considered second line therapy): DDAVP by nasal spray or oral tablets (high
relapse rate, costly), oxybutynin (Ditropan•), imipramine (Tofranil•) (rarely used, lethal if
overdose, cholinergic side effects)
Secondary Enuresis
• develops after child has sustained period of bladder control (6 months or more)
• nonspecific regression in the face of stress or anxiety (e.g. birth of sibling, significant loss, family
discord)
• may also be secondary to urinary tract infection (UTI), diabetes mellitus (DM), diabetes
insipidus (DI), neurogenic bladder, cerebral palsy (CP), sickle cell disease, seizures, pinworms
• may occur if engrossed in other activities
• treatment depends on cause
Diurnal Enuresis
• daytime wetting (60-80% also wet at night)
• timid, shy, temperament problems
• most common cause: micturition deferral (holding urine until last minute)
• may also result from psychosocial stressors, rule out structural anomalies (e.g. ectopic ureteral
site, neurogenic bladder), UTI, constipation, CNS disorders
• treatment: depends on cause; behavioural (scheduled toileting, double voiding, good bowel
program), pharmacotherapy

13. Toronto Notes 2011 Abnormal Chlld Behaviours Pediatrics P13
ENCOPRESIS
• fecal incontinence in a child >4 years old, at least once per month for 3 months
• prevalence: 1-1.596 of school-aged children (rare in adolescence); M:F = 6:1 in school-aged children
• usually associated with chronic constipation
• must exclude medical causes (e.g. Hirschsprung disease, hypothyroidism, hypercalcemia,
spinal cord lesions, anorectal malformations)
Retentive Encopresis
• causes
• physical: anal fissure (painful stooling)
• emotional: disturbed parent-child relationship. coercive toilet training. social stressors
• history
• child withholds bowel movement, develops constipation, leading to fecal impaction and
seepage of soft or liquid stool (overflow incontinence)
• crosses legs or stands on toes to resist urge to defecate
• distressed by symptoms, soiling of clothes
• toilet training coercive or lacking in motivation
• may show oppositional behaviour
• physical exam
• digital rectal exam: large fecal mass in rectal vault
• anal fissures (result from passage of hard stools)
• treatment
• complete clean-out ofbowel
• enemas and suppositories
• maintenance of regular bowel movements - compliance is crucial
• stool softeners (e.g. Colace•, Lactulose•, Lansoyl•, mineral oil regularly)
• diet modification (see Pediatric Gastroenterology. P40)
• toilet schedule and positive reinforcement
• assessment and guidance regarding psychosocial stressors
• behavioural modification
• complications: continuing cycle, toxic megacolon (requires >3-12 months to treat), bowel perforation
Sleep Disturbances
Types of Sleep Disturbances
• insufficient sleep quantity
_._______________
.... ' 1
• di.fficulty falling asleep (e.g. Limit Setting Sleep Disorder) Daily Sleep llel(uir-nt
• preschool and older children • < 6 morrlh5 16
• bedtime resistance • 6 months 14.5 holliS
• due to caregiver's inability to set consistent bedtime rules and routines • 12 months 13.5 holliS
• 2 yeat1 13
• often exacerbated by child's oppositional behaviours • 4 yHI1 11.5 holliS
• poor sleep quality • 6 yeat1 9.5 hours
• frequent arousals (e.g. Sleep Onset Association Disorder) • 12 yem 8.5 hours
• infants and toddlers • 18 yean a hours
• child learns to fall asleep only under certain conditions or associations (with parent, with lbplldtlma
light on, in front oftelevision) • 2/8v at 1 year
• 1/day at 2 years: 2-3 hours
• child loses ability to self soothe • 0.5/day Ill 5 '(81rs: 1.7 hours
• during the normal brief arousal periods of sleep (q90-120 min), child cannot fall back
asleep because same conditions are not present
• parasomnias
• episodic nocturnal behaviours
• often involves cognitive disorientation and autonomic/skeletal muscle disturbance
• e.g. sleep walking, sleep terrors, nightmares
Management of Sleep Disturbances
• set strict bedtimes and "wind-down" routines
• do not send child to bed hungry
• always sleep in bed, in a dark, quiet and comfortable room, without "associations"
• do not use bedroom for timeouts
• systematic ignoring and gradual extinction for sleep onset association disorder
• positive reinforcement for limit setting sleep disorder
Nightmares
• prevalence: common in boys, 4-7 years old
• associated with REM sleep (anytime during night)
• upon awakening. child is alert and clearly recalls frightening dream
• may be associated with daytime stress/anxiety
• treatment: reassurance

14. P14 Pediatrics Abnormal Child Behaviours Toronto Notes 2011
Night Terrors
• prevalence: 15% of children have occasional episodes
• abrupt sitting up, eyes open, screaming
• panic and signs of autonomic arousal
• occurs in early hours of sleep, non- REM. stage 4 of sleep
• no memory of event, parents unable to calm child
• stress/anxiety can aggravate them
• course: remits spontaneously at puberty
• treatment: reassurance for parents
Breath-Holding Spells
• occur in 0.1-5% ofhealthy children 6 months-4 years of age
• spells usually start during first year of life
• 2 types
• cyanotic (more common), usually associated with anger/frustration
• pallid, usually associated with pain/surprise
• child is provoked (usually by anger, injury or fear), starts to cry and then becomes silent
• spell resolves spontaneously or the child may lose consciousness; rarely progresses to seizures
• treatment: behavioural- help child control response to frustration and avoid drawing attention
to spell; avoid being too permissive in fear of precipitating a spell
Approach to the Crying/Fussing Child - - - - - -
History
• description of infant's baseline feeding, sleeping, crying patterns
• infectious symptoms - fever, tachypnea, rhinorrhea, ill contacts
• feeding intolerance - gastroesophageal reflux with esophagitis
• nausea, vomiting, diarrhea, constipation
• trauma
• 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
• inconsistent history, pattern of numerous emergency department (ED) visits, high-risk social
situations all raise concern of abuse
Physical Examination
• perform a thorough head-to-toe exam with the child completely undressed
Table 9. The Physical Examination of the Crying/Fussing Child
Organ System Exlminl1ian Findinp Poaibla Oilgnlllil
HEENT Bulging fontanelle Meningitis, shaken baby syndrome
Blepharospasm. tearing Comeal abrasion
Retnal hemorrhage Shaken baby syndrome
Oropharyng•l infections Thruah, gingivostDITllltitis, harp11ngina. otitis media
Neuralogictl lrrilllbility or lelhiiQV Meningitis, shaken baby syndrome
C.nliavllcullr Poor perfusion Sepsis, anomalous coronary artery, meningitis,
myocarditis, congestive heart faiure (CHF)
Tachycanlia Supravenbiculartachycardia
RaiiPilltory Tachypnea Pnewnonia, CHF
Grunting Respiratory disease, response to pain
AIHiami111l Mass, empty RLQ Intussusception
Genitourillry Scrollll swelling Incarcerated hernia, testicular torsion
Penile/clitoral swelling Hair tourniquet
Anal fissure Constipation or diarrflea
Hamoccutt positive stool Intussusception, nacrotizi-4j enterocolitis, volvulus
Point tenderness or decreased movement Fracture, syphilis, osteomyelitis, toll/finger hair tourniquet

15. Toronto Notes 2011 Abnormal Chlld BehaviousJChild Abuae and Neglect Pediatric. PIS
Dermatology
Tabla 1D. Common Paediatric Rashes
Type of Rnh Diffli...UI Appearanc:1
Diaper Dennatiti1 lnitant ctrrtact Shiny, red macule$1'plltches. no flexural nwlvement
Sebonheic d81111atitis Yellow, greasy rnacuiBB/plaquas on erythema. scales
Candida! Eiythematous macerated papule$1'plaques. satelite lesions
Dlh• Dlllnlllitis Atopic dermatitis Eiythematous papule!li'plaques, oozilg. excoriation.
lichenification. classic areas of involvement
NuiTIITillar dermatitis Amular erythematuus plaques. oozing. crustilg
Allergic contact dermatitis Red papuleWplaques/Vasici&BI'bullae, in area of allergen
lnitant ctrrtact Morphology depends on irritant
Dyshidrotic dermatitis Papulovesicular, craclcin{ll'fissuring. hands and feet ("Tapioca
pudding1
Sebonheic d81111atitis See above, sellaceous areas such as nasolabial folds and
scalp
Plp!Hsquamous Enlptions Psoriasis Eiythematous plaques silvery scales, nail pittinw
onycholysis
Pityriasis rosea Salmon11ink plaques, herald patch with smaler papules
rchristmes tree" pattern)
Scabies Polymorphic (red IIIICOriilllld papulas/nodules, burrows), in
well spaces,lfulds, very pruritic
lmpatigo crusts or superficial
Tinea corporis Round erythematous plaques. central clearing and scaly
border
Exlnlllems (HI DIQD!!Iqlcm. D40)
Dnlg llaldions (HI QlrD!Itp!ggy. D22)
Acne (HI Dei!Dilplpgy, D1Z)
Child Abuse and Neglect
Definition
• an act of commission (abuse- physical, sexual, or psychological) or omission (neglect) by a
caregiver that harms a child
Legal Duty to Report
• upon reasonable grounds to suspect abuse and/or neglect, physicians are required by law to
contact the Children's Aid Society (CAS) personally to disclose all information
• duty to report overrides patient confidentiality; physician is protected against liability
• ongoing duty to report: ifthere are additional reasonable grounds to suspect abuse and/or
neglect, a further report to the CAS must be made
Risk Factors
• environmental factors
• social isolation
• poverty
• domestic violence
• caregiver factors
• parents were abused as children
• psychiatric illness
• substance abuse
• single parent family
• poor social and vocational skills, below average intelligence
• child factors
• difficult temperament
• disability, special needs (e.g. developmental delay)
• premature

16. Pl6 Pediatrics Child Abuse and Neglect Toronto Notes 2011
Presentation of Physical Abuse
l·r
• history inconsistent with physical findings, or history not reproducible
no cruising, no bruising."
• delay in seeking medical attention
• injuries of varied ages, recurrent or multiple injuries
• distinctive marks: belt buckle, cigarette burns, hand prints
• patterns of injury: bruises on the face, abdomen, buttocks, genitalia. upper back; posterior rib
fractures; immersion burns (e.g. hot water)
I'Nunlmion af Negl.at • altered mental status: head injury, poisoning
• Failure to thrive, developmental delay
• lnadequat& or dirty clothing. poor • physical findings not consistent with any underlying medical condition
hygiene • shaken baby syndrome
• Child uxhibits poor attachment to • violent shaking of infant resulting in intracranial hemorrhages, retinal hemorrhages, and
peran11, no anxifiy posterior rib fractures
• head trauma is the leading cause of death in child maltreatment
Sexual Abuse
• prevalence: 1 in 4 females, 1 in 10 males
• peak ages at 2-6 and 12-16 years
• most perpetrators are male and known to child
• in decreasing order: family member, non-relative known to victim, stranger
• presentation
• disclosure: diagnosis usually depends on child telling someone
• psychosocial: specific or generalized fears, depression, nightmares, social withdrawal, lack
of trust, low self-esteem. school failure, sexually aggressive behaviour, advanced sexual
knowledge, sexual preoccupation or play
• physical signs: recurrent UTis, pregnancy, STis, vaginitis, vaginal bleeding, pain, genital
injury, enuresis
• investigations depend on presentation, age, sex, and maturity of child
• sexual assault examination kit within 24 hours if prepubertal, within 72 hours ifpubertal
• rule out STI, un, pregnancy (consider STI prophylaxis or morning after pill)
• rule out other injuries (vaginal/anal/oral penetration, fractures, head trauma)
Management of Child Abuse and Neglect
• history
• from child and each caregiver separately (if possible)
• physical exam
• head to toe (do not force)
• emotional state
• development
• document and/or photograph all injuries: type, location, size, shape, colour, pattern
• be aware of"red herrings• (e.g. Mongolian blue spots vs. bruises)
• investigations
• blood tests to rule out medical causes (e.g. thrombocytopenia or coagulopathy)
• STI work-up
• skeletal survey/bone scan
• CT/MRI
• fundoscopy to rule out retinal hemorrhage
• report all suspicions to CAS; request emergency visit if imminent risk to child or any siblings in
the home
• acute medical care: hospitalize if indicated or if concerns about further or ongoing abuse
• arrange consultation to social work and appropriate follow-up
• may need to discharge child directly to CAS or to responsible guardian under CAS supervision

17. 'IbroDlo Nota 2011 Adolescent Medidne PecUatrica Pl7
Adolescent Medicine
Normal Sexual Development
• puberty occurs with the maturation of the hypothalamh:-pituitary-gonadal W&
o increases In the pulsatile release of gonadotropin hormone (GnRH) -+ increased release of LH
and FSH -+ maturation ofgonads and release of sex steroids -+ secondary sexual characterlatl.cs Ad.._...l'qdi_clll Allt.ellllt
• also requires adrenal production of androgens
IIEEADIIS
llome
fem•les EducetiarVEmpoyment
• occurs between age 8-13 years (may start early as 6 yean in African-American girls) Eating
• usual sequence Aetivitiel
Drugs
• thelarche: breast budding (breast asymmetry may occur as one breast may grow faster than
the other; becomes less noticeable as maturation continues)
• adrenarche: uillary hair, body odour, mUd acne
• growth spurt
...,
lexulllity
luili:laandd...,....ian
• menarche: mean age 13 years; occurs 2 years after breast development and indicates that
growth spurt is almost complete (Thnner Stage 4)
• early puberty is common and often constitutional, late puberty is rare
M•lea
• occurs between age 9-14 years (starts 1 years later than In girls)
o usual sequence
• testicular enlargement
• penile enlargement occurs at Tanner Stage 4
• adrenarcbe: axillary and facial hair, body odour, mild acne
• growth spurt: OCCill'S later in boys (Tanner Stage 4)
• early puberty is uncommon (need to rule out organic disease) but late puberty is common and
often constitutional
FEMALE BIEAST
Step 1: llq1l 2: Bl..t IDI St.g. 3: of llqll4: Anlala IDI St.gll 5c Millin, niptlla
en., papi1IIIIMil8d 11 s11111 11'111111, na papil1 fllnn S8Candily projiiCis, na _,.,.,
mound, 1111largemllll af contour •pa!Biion mound mcun:l
noll
FEMALE GENITAL
Stlp Z: Small amount Stap 3: Derbr, COII'IIII', Stlp 4: Adl.ft-type hair, Stlglli: M111ura
of larc. 81rlight cr Cllted. curlier her diltrtutld na IIC!nion tD medial liltrilution widleiiMd
lllilirtlv Pill111111111d hair IPII"Iv DYa' plbia thiWII tD mdal thp
lllangllllbillllllj!D.
MAlE GENITAL
(r
Step 1: No hei;
PQPI.tlerbll
Stlp Z: Small amount
af larc.ltnlight cr Cllted,
lllilirtlv pigmanbld hair
liang bile of panis.
Stap 3: DeJtar; conar, Stlp 4: JWt.type hlir,
curliar hllirdiatltlulal
•pa!Hy DYa' pUNa.
t.ngtheri'lg of p.ril,
I
na IIC!Inaion tD medial
thir#IL lnciiiiiU in paris
li'cii'Tiflra1CI and langth.
Stlglli: M111ura
liltrilution widlslft8d
tD mdal thir#IL AdUt
siza
&Wgamlllllll1llltll furtlw eniiiiiiiJllnt Df dlvelop11111nt rl
.nd IICIUium, lllddri'lg """ and KIUUn blh..-enlaiJIIIrtr/1
111111111•nd KIUU!l,
of acrallll - dlrkwiing GIICIU!IIIIIkil Cl Dlllt Acconl ZD11
Figun 1. TaiDar Stagiag