General Pediatrics II

Anemia
Lead poisoning
Hypercholesterolemia
Developmental Dysplasia of Hip
Hypertension
Sports Injury
Childhood Injuries
Preventive Medicine

David Johnson, M.D.

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A nine month old child has very pale
mucous membranes.
In children there is a physiologic anemia. Often it occurs - it peaks
between 2 and 3 months of age. Most children will get down to a
range of around 11 in about 3 months.

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 Anemia
Some people advocate screening between 9 and 12 months. It’s

# "Physiologic anemia" occurs 2-3 months a peak age for iron deficiency if they have switched off iron
formulas. Some people advocate 24 months. Another point is that
Age Hemoglobin Range if you do a peripheral hematocrit it could be lower than central so
(gm/dL) that if they are anemic, you should probably do a central test. Just
a picture of a tiny child that can show up. Pale mucous mem-
2 weeks 16.5 13-20
brane, pale skin. You see what are called red lines, concentrated
3 months 12.0 9.5-14.5 dense lines at the growth centers.

# Timing of "screening" is controversial.

• 9-12 months - peak age for Fe deficit
• 24 months
• Adolescence - especially in girls
# Peripheral hematocrit may be lower than central
venous hematocrit

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 Lead Poisoning
# Sources of Lead
• Lead-confining paint pre -1950's
• Leaded gasoline - industrial lead
• Fumes from burning batteries
• Glazed ceramic vessels and folk medicines
# Young children are at risk thru hand-mouth exposure
and thru respiratory tract
# Testing
• blood level - finger vs. venipuncture
• Lead levels >10 deserve attention
Lead Poisoning. In the 1980’s the average lead level was about
12. In 1991 the average lead level in our population was 3. Leaded
paint has been eliminated for the most part in this country, but
even today some paint is still leaded. Leaded gasoline, industrial
lead, and car batteries and then all this miscellaneous. Sometime
lead-containing ceramic vessels. The point is that young children
are particularly at risk for lead poisoning because of their hand-to-
mouth exposure. And also through the respiratory tract. In the past
we used to use the erythrocyte protoporphyrin test as a screen.
It’s no longer recommended. It was only useful when sort of there
were a lot of levels above 30. Venous lead level is the test to use.
You do a finger first and then you do a venipuncture if it’s elevated.
And the big news is, as most of you know this, is that we have
lowered our level of what’s acceptable. Any child that’s screened
that has a level of 10, an environmental assessment needs to be
done.
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A four year old presents with a family
history of high cholesterol and coro-
nary heart disease.

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 Hypercholesterolemia
Just to remind ourselves, total cholesterol is the low density which

# Childhood symptoms of hyperlipidemia are very rare
but may include xanthomas, corneal arcus, heart
disease, and hypertension.
# Family history will identify 40-60% of children with
hypercholesterolemia.
# Total cholesterol = LDL-cholesterol + HDL-cholesterol
+ Triglycerides/5
# Secondary causes of high total cholesterol include
is the bad guy, and high density which is the good guy and then
triglycerides. If you have a family history you should consider
screening the child once they have reached two years of age. You
could probably do a random sample but if it’s high, you must do a
fasting level to really interpret it. If the total cholesterol is greater
than 200 you should obtain a lipid profile. Basically the acceptable
is a total amount less that 170 and an LDL lower than 110. It’s
borderline if the total is 170-199 and LDL is 110-129. High is
above 200. There is a reluctance to use cholesterol lowering

endocrine, renal and hepatic disorders, and drugs. medicine in children. They certainly deserve nutritional counseling
and for selected families you might want to use drugs.
# Screening is recommended after age 2 for patients
with a family history of hypercholesterolemia. A fasting
level is preferred.

NCEP Classification of Hyperlipidemia

Category Total Choles- LDL-choles-

terol terol

Acceptable <170 <110

Borderline 170-199 110-129

High >200 >130

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A two week old presents with a unilateral
"hip click".

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 Developmental Dysplasia of Hip
Dislocated Hip. It’s new term is “Developmental Dysplasia of the

# The presentation can vary from mild instability to true Hip”. And it has to do with hips that are unstable and can come in
and out, versus those that are truly dislocated. And probably about
dislocation.
1:100 of newborn kids are actually dislocatable, where about
# Incidence: Dislocatable hip = 1:100
1:1000 are frankly dislocated at time of birth. The two main
Frank dislocation = 1:1000
symptomatology’s are Barlow’s and that’s where when you press
# Clinical Examination it from behind it comes out. And then Ortolani which when you are
• Barlow. Pressure dislocates the joint abducting it you can kind of feel it clunk as the hip goes back up,
• Ortolani. "Clunk" is felt when joint is reduced back into it’s out.
• Galiazzi. Aymmetric skin folds are visualized
• Limited abduction (>3 months)
• Ultrasound best imaging test

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A five year old boy is brought to the
office with a complaint of headaches.
Blood pressure is 120/70.

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 Hypertension
What’s important is that you use the right size blood pressure cuff.
# Normal ranges for blood pressure varies at different Never too small. It has to be right or a little large. It is recom-

ages. mended that we take blood pressure annually after the third
birthday. In borderline cases anxiety can play a role.
# Appropriate size BP cuff should be used.
# Annual BP measurements are recommended for
asymptomatic children after age 3.
# In borderline cases, anxiety may be responsible for the
hypertension, and serial measurements should be
obtained.

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 Hypertension should be evaluated in three different occasions
Indications for Blood Pressure
unless you are talking about excessively high levels. Symptoms

Evaluation suggesting hypertension include headaches, dizziness, visual

changes, seizures and the child’s clinical encephalopathy. Renal
disease, cardiac disease, growth failure, seizures may be caused
# Symptomatic Patients by hypertension. And the acute ones are: having seizures, head
• headaches injuries, poisons and urinary changes, particularly hematuria.

• dizziness
• visual changes
• seizures
# Encephalopathy
• vomiting
• temperature elevation
• ataxia
• stupor
• acute seizures
# Chronic Conditions
• renal disease
• cardiac disease
• growth failure
• seizure disorder
# Acute Conditions
• seizures
• head injury
• poisonings
• urinary changes

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A 12 year old boy presents for a sports
physical before joining a junior high school
football team.

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 Sports Injury Prevention
# Injury Prevention Strategies
• Conditioning: Appropriate Training, warming up
and cooling down, overuse avoidance, correct
biomechanics of sport.
• Matching of athletes for size
• Protective equipment
• Proper treatment of injuries and rehabilitation
• Age-appropriate training
• Fluid replacement important during sweating
Warming up and cooling down, overuse, avoidance, correct
biomechanics. You should be careful that the athletes are
matched by age and size, particularly in contact sports. Protective
equipment, proper treatment when there is an injury, and then age-
appropriate training, specifically strength training. Weights should
only be used after Tanner 5 stage in boys. There is no handi-
capped child that shouldn’t be able to participate in some sport.
You might have to find that sport for that child but there is some
sport. Well children with chronic diseases like seizures and
diabetes are not a contraindication for almost any sport, with the
exception of something where a slight lapse of consciousness
could be dangerous, like scuba diving. Fluid replacements.
Children in general sweat. Everybody’s sweat is hypertonic,
particularly young children, and the replacement fluid is water.
Rapid weight loss due to dehydration is dangerous.
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 Morbidity in Children
There is an increasing association of illness in children associated

# Childhood injury causes more deaths than all child- living in poverty, which is related to poor nutrition, environmental
pollution, crowding, and lack of health care. There is more illness
hood diseases combined.
due to so-called risk-taking behaviors. Drug use, tobacco, sexually
# Illness is associated with poverty (eg, malnutrition,
transmitted disease, teenage pregnancy and violence in our
pollution, crowding, lack of health care)
children, which is probably on the increase.
# Illness is caused by risk-taking behaviors (e.g. drug
use, tobacco, STD, teenage pregnancy)
# Violence against children

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 Impact of Childhood Injuries
Childhood injuries. Every year in our country, there are 22,000
# 22,000 deaths annually age 19 and under children who are killed by injuries. This mortality is the tip of the

# 600,000 hospitalizations iceberg. There are at least 600,000 hospitalizations and

14,000,000 physician visits for injuries. Motor vehicle accidents are
# 14,000,000 physician visits
still the leading cause of death, both for pedestrians and occupants
of the car. But firearms has risen to second place so that 1 out of
5 children who are killed by injury are now killed by firearms.
Drowning, fire, choking, poisoning, falls, cuts are also causes.

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 Injury Deaths, Age 0-19
With firearms, there is a 6:1 ratio of male to female; overall, boys
are 2½ times more likely to be killed by injuries than females.
Cause Male Female Total

Motor vehi- 42661 21438 64099 If you look by intent, and that is trying to get away from intentional
cle acci- versus nonintentional, clearly most of the injuries are unintentional

dent injuries so we have rates of 21 per 100,000. Suicide and homicide

are coming up there. These account for about 30% of the deaths.
Firearm 26504 4381 30885
70% of child injury deaths are unintentional and 30% qualify as
Drowning 9481 2994 12475 abuse, homicide or suicide.

Fire or 5421 3953 9374

flame

Suffocation 5343 2261 7604

Cutting 1954 807 2761

Total 107,347 44,221 151,568

Boys are at 2 1/2 times greater risk.
Ref: Injury to Children & Teenagers, Baker et al, 1996

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 Injury Deaths by Intent Age 0-19

Total Rate per

100,000/year

Unintentional 107,756 21.47

Suicide 15,424 3.07

Homicide 26,324 5.24

Unknown 2,064 0.41

Total 151,568 30.20

70% of Child Injury Deaths are Unintended Injuries

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 Motor Vehicle Accidents
Motor vehicle accidents are the biggest cause of mortality. For

# Incidence of Motor Vehicle Accidents (<age 15)
Annually:
• Involvement in car crash 1 in 50
• Injury in car crash 1 in 200
# Unrestrained children are 2.7 times more likely to be
injured.
# Children are properly restrained in cars in only 40%
# On average 21 child die in motor vehicle accidents each
children under 15, 1 in 50 annually is involved in a car crash and
1 in 200 is injured in a car crash. Children who are not restrained
are 2.7 times more likely to be injured than those who were
properly restrained. And then overall for accidents, he found that
children were properly restrained in the car only 40% of the time
they were in the car accident. On the average, 21 children die
everyday in a motor vehicle accident. Not surprisingly, new drivers
are most common, 15 to 19-year-olds account for 63% of all these
deaths. Males to females is 2:1 and one-third of these children who

day. were killed in car accidents had a blood alcohol level above the
legal limit for being intoxicated. For children less than age five, for
# Children age 15 to 19 are the most at risk (63% of
those that died, 63% of them were unrestrained in the car.
deaths)
• The male to female ratio is 2 to 1
• One third of motor vehicle accidents are associated
with a blood alcohol level of greater than 0.10%
• For age under age 5 years, 63% of deaths occur
when the child is unrestrained

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 Prevention of Motor Vehicle Acci-
dent Injury So what are our interventions? First of all, the big one is car seats.
Birth to 20 lbs, infant seats are recommended, beyond that
convertible seats and booster seats up to about 40 lbs or age four
# Recommendations: at which point they can go into the lap harness. The results are
• Car seats Birth to 20 lbs: Infant seat that child car seats do reduce the risk of death and serious injury

Birth to 40 lbs: Convertible by 70% (properly used). So we know that proper use can prevent
at least 500 deaths and 53,000 injuries. The current recommenda-
seat
tion is that children under age 12 should always sit in the back
>30 to 40 lbs: Booster seat
seat. There is one little exception and I've heard a lot of parents talk
• Lap-harness >age 4
about it. The infant who is still in the rear facing car seat and they
# Child car seats reduce risk of death and serious are put in the back and the parents can't see him. There have been
injury by 70% a few reports now about premature babies who don't breathe well.
# Proper use can prevent 500 deaths and 53,000 So, there are going to be ongoing issues and there is some
injuries annually discussion about airbags being able to be disengaged.

One of things that we can really do is to tell our parents about the
use of proper car restraints and warn them in advance that this is
not one of those things parents negotiate on. All parents have to
pick their battles. You can't be the perfect parent on everything, but
there are some things you can compromise on and some things
you can't and I think the child who is never out of a car seat will
stop objecting. We all know that parents who let their kids out a
few times because they are tired are in for a battle forever.

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 Childhood Poisonings
# 1.2 million episodes per year of poisoning in children
# 69,000 hospitalizations per year
# 539 deaths per year
# Black children have a three-fold increased risk of death
Childhood poisonings. The statistics tell us that there are 1.2
million episodes each year in children, resulting in 69,000 hospital-
izations and a little under 550 deaths. Here again, though, this is
not pure accident. These are injuries are somewhat predictable. An
African-American child under age nine in our country is three times
more likely to die from poisoning than a comparable child in other
ethnic groups. So it has to do with education and access and
supervision.
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 Prevention of Childhood Poison-
ings
# After age 6 months, "child proofing" is recommended
# Syrup of ipecac should be kept in the home
The practice of child-proofing a home has been stressed a lot in
Anticipatory Guidance. Telling parents, asking them, and giving
them handouts on how actually to childproof their home. Putting
syrup of ipecac in their home along with phone numbers for poison
control centers so you have them.
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 Baby Walkers
Baby walkers. At least 25,000 children less than 15 months of age

# 25,500 children per year are treated in emergency have been treated in ERs, most of them for falls, mostly down
steps.
departments for baby walker injuries
# 83% of injuries involve children falling down stairs or
between steps

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 Prevention of Baby Walker Injuries
• Efforts to ban walkers have failed
• Improved design (eg, no collapsible x-frame models)
• Voluntary requirements: Size larger than basement
doorways, improved stability
We have tried to ban baby walkers. We do not recommend them.
It is not going to make the baby walk any sooner. They like their
kids upright. So what we can do is we can work to improve
structures. Certainly, there are no more collapsible x-frame
models. Those old models that used to collapse on them and pinch
fingers. They are going to come out with some voluntary require-
ments for manufacturers hoping to make the size larger than the
basement doorways.
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 Firearm Safety
# 102 people per day die from gun wounds, including 14
persons under the age of 20 years old.
# Firearm homicides are the leading cause of death in
black teenaged males and females
# A firearm in the home is 43 times more likely to kill
family or friends than to kill intruder
# 50% of children shot accidentally are shot in their home,
and 38% are shot in the home of relative or friend
# Suicide risk 5 times higher if a gun is present in the
home
# Educational efforts should encourage gun storage and
safety. "If you keep a gun, empty it out and lock it up"
Firearms. Every day in our country, 102 people die from gunshot
wounds including 12 children under the age of 20. Firearm
homicide is the leading cause of death in our African-American
teenage males and females. There are 200 million guns. Sixty
seven million handguns. If you have a firearm in your home, you
are 43 times more likely to kill a family member or a friend than to
kill an intruder. Children are shot accidentally 50% of the time in
their own home and 38% of the time in a home of a relative or a
friend. There is a 5 times increased chance that there will be a
suicide if the home has a gun. In 1992 there were 13,000 people
in our country killed with guns of which 4,400 were children.
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 Prevention Efforts: Age 0-10 years
# Child safely car seats < age 5
# Car lap-shoulder belts > age 5
# Bicycle helmets, bicycle safely
# Smoke detector
# Hot water heater temperature (<120-130)
# Window and stair guards, pool barriers
# Syrup of ipecac, poison control phone number
# Safe storage of poison, drugs, firearms, matches
# CPR training of caregivers
What are some of our interventions? They are controversial and
none of us have the right answer. There certainly have been, and
should be, a need for more educational efforts about gun storage
and safety. And again the American Academy says, "If you keep
a gun, empty it out and lock it up."
Things that have been proven to improve their health. Child safety
car seats. Car lap-shoulder belts after age 5. Bicycle helmets and
bicycle safety programs. Smoke detectors. Flame retardant
materials. And lowering the hot water heater to 120. Window and
stair guards, pool barriers. Syrup of ipecac, the poison control
phone number. Safe storage of poison, drugs, firearms, matches.
CPR training of caregivers in high risk situations.
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 Prevention Efforts: Age 11-24
# Car lap and shoulder belts
# Bicycle and motorcycle helmets
# Smoke detectors
# Safe storage and care of firearms
# Avoid tobacco use
# Avoid underage alcohol or illicit drug use
# Avoid alcohol or drugs with water sports
# STD prevention
# Abstinence, condoms
# Contraception
If you go to the older age group, it is not as clear that what we do
makes a difference. Those things that have been proven are: use
of car lap/shoulder belt, bicycle and motorcycle helmet, using a
helmet for all terrain vehicles, smoke detectors, and safe storage
of firearms.
Avoiding tobacco use. Avoidance of that tobacco use--our
educational efforts have been shown to be effective. But when we
get to avoiding underage alcohol and drug use, it is not clear that
our training programs have made a difference. Avoid alcohol/drugs
with water sports, STD prevention, abstinence, condoms.
Injury deaths have decreased. The child death rate from injuries
has actually decreased by 26%. And this is majority due to
decreased poisonings, some decrease in our car accidents and
some improvement in pool safety features. Unintentional deaths,
"accidental deaths", have actually decreased almost by 40%. But
the bad news is that intentional injuries, which again only account
for 30% of the deaths, the homicide, suicide, child abuse, has
actually increased 47% in the last 14 years. So we are making
dramatic improvements.
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