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xi CONTENTS SECTION 1 PROFESSION OF PEDIATRICS Ahmeneh Ghavam and Karen J. Marcdante 1 Population and Culture 1 2 Professionalism 3 3 Ethics and Legal Issues 4 4 Palliative Care and End-of-Life Issues 6 SECTION 2 GROWTH AND DEVELOPMENT David A. Levine 5 Normal Growth 11 6 Disorders of Growth 13 7 Normal Development 14 ... | SECTION 1 | SECTION 1 | Nelson Textbook of Pediatrics, 8th Edition | 13 | 0 |
Disorders and Bipolar Disorders 64 19 Obsessive-Compulsive Disorder 68 20 Autism Spectrum Disorder and Schizophrenia Spectrum Disorders 70 SECTION 5 PSYCHOSOCIAL ISSUES Kristine Fortin and Alison H. Downes 21 Failure to Thrive 77 22 Child Abuse and Neglect 80 23 Homosexuality and Gender Identity 84 24 Family Structure ... | SECTION 1 | SECTION 1 | Nelson Textbook of Pediatrics, 8th Edition | 13 | 1 |
126 34 Parenteral Nutrition 130 35 Sodium Disorders 131 36 Potassium Disorders 134 37 Acid-Base Disorders 138 SECTION 8 ACUTELY ILL OR INJURED CHILD Tara L. Petersen and K. Jane Lee 38 Assessment and Resuscitation 145 39 Respiratory Failure 149 40 Shock 151 41 Injury Prevention 154 42 Major Trauma 155 43 Drowning 157 4... | SECTION 1 | SECTION 1 | Nelson Textbook of Pediatrics, 8th Edition | 13 | 2 |
xii CONTENTS SECTION 11 FETAL AND NEONATAL MEDICINE Clarence W. Gowen Jr. 58 Assessment of the Mother, Fetus, and Newborn 217 59 Maternal Diseases Affecting the Newborn 235 60 Diseases of the Fetus 239 61 Respiratory Diseases of the Newborn 240 62 Anemia and Hyperbilirubinemia 247 63 Necrotizing Enterocolitis 254 64 Hy... | SECTION 11 | SECTION 11 | Nelson Textbook of Pediatrics, 8th Edition | 14 | 0 |
System 304 76 Hematopoietic Stem Cell Transplantation 306 SECTION 14 ALLERGY Kristen K. Volkman and Asriani M. Chiu 77 Allergy Assessment 311 78 Asthma 313 79 Allergic Rhinitis 323 80 Atopic Dermatitis 325 81 Urticaria, Angioedema, and Anaphylaxis 328 82 Serum Sickness 332 83 Insect Allergies 333 84 Adverse Reactions t... | SECTION 11 | SECTION 11 | Nelson Textbook of Pediatrics, 8th Edition | 14 | 1 |
Prophylaxis 363 95 Antiinfective Therapy 367 96 Fever Without a Focus 368 97 Infections Characterized by Fever and Rash 373 98 Cutaneous Infections 379 99 Lymphadenopathy 383 100 Meningitis 386 101 Encephalitis 389 102 Upper Respiratory Tract Infection 391 103 Pharyngitis 392 104 Sinusitis 394 105 Otitis Media 395 106 ... | SECTION 11 | SECTION 11 | Nelson Textbook of Pediatrics, 8th Edition | 14 | 2 |
Zoonoses and Vector Borne Infections 439 123 Parasitic Diseases 447 124 Tuberculosis 452 125 Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome 457 SECTION 17 DIGESTIVE SYSTEM Warren P. Bishop and Dawn R. Ebach 126 Digestive System Assessment 467 127 Oral Cavity 479 128 Esophagus and Stomach 480 129 In... | SECTION 11 | SECTION 11 | Nelson Textbook of Pediatrics, 8th Edition | 14 | 3 |
Assessment 535 140 Syncope 540 141 Chest Pain 541 142 Dysrhythmias 542 143 Acyanotic Congenital Heart Disease 545 144 Cyanotic Congenital Heart Disease 549 145 Heart Failure 553 146 Rheumatic Fever 556 147 Cardiomyopathies 556 148 Pericarditis 558 SECTION 20 HEMATOLOGY Amanda Brandow and J. Paul Scott 149 Hematology As... | SECTION 11 | SECTION 11 | Nelson Textbook of Pediatrics, 8th Edition | 14 | 4 |
Proteinuria 620 163 Glomerulonephritis and Hematuria 622 164 Hemolytic Uremic Syndrome 624 165 Acute and Chronic Renal Failure 625 166 Hypertension 627 167 Vesicoureteral Reflux 628 168 Congenital and Developmental Abnormalities of the Urinary Tract 629 169 Other Urinary Tract and Genital Disorders 631 SECTION 23 ENDOC... | SECTION 11 | SECTION 11 | Nelson Textbook of Pediatrics, 8th Edition | 14 | 5 |
181 Seizures 687 182 Weakness and Hypotonia 692 183 Ataxia and Movement Disorders 700 184 Altered Mental Status 703 185 Neurodegenerative Disorders 711 186 Neurocutaneous Disorders 714 187 Congenital Malformations of the Central Nervous System 716 SECTION 25 DERMATOLOGY Mary Kim and Yvonne E. Chiu 188 Dermatology Asses... | SECTION 11 | SECTION 11 | Nelson Textbook of Pediatrics, 8th Edition | 14 | 6 |
1 SECTION 1 PROFESSION OF PEDIATRICS Ahmeneh Ghavam | Karen J. Marcdante CHAPTER 1 Population and Culture CARE OF CHILDREN IN SOCIETY Health care professionals need to appreciate the interactions between medical conditions and social, economic, and envi- ronmental influences associated with the provision of pediatric c... | CHAPTER 1 | CHAPTER 1 | Nelson Textbook of Pediatrics, 8th Edition | 17 | 0 |
care; health disparities; supporting their social, cogni- tive, and emotional lives in the context of families and com- munities; and addressing environmental factors, especially poverty. Early experiences and environmental stresses interact with the genetic predisposition of every child and, ultimately, may lead to th... | CHAPTER 1 | CHAPTER 1 | Nelson Textbook of Pediatrics, 8th Edition | 17 | 1 |
on prognosis. Prenatal diagnosis and newborn screening improve the accuracy of early diagnosis and treatment, even when a cure is impossible. Functional magnetic resonance imaging allows a greater understanding of psychiatric and neurologic problems, such as dyslexia and attention-deficit/hyperactivity disorder. Challe... | CHAPTER 1 | CHAPTER 1 | Nelson Textbook of Pediatrics, 8th Edition | 17 | 2 |
and sexual abuse, and violence. World unrest and terrorism, such as the September 11 attack on New York’s World Trade Center, have caused an increased level of anxiety and fear for many families and children. To address these ongoing challenges, many pediatricians now practice as part of a health care team that include... | CHAPTER 1 | CHAPTER 1 | Nelson Textbook of Pediatrics, 8th Edition | 17 | 3 |
are increasingly recognized. Infants who are relatively underweight at birth due to maternal malnutrition are at higher risk of developing certain health conditions later in life, including diabetes, heart disease, hypertension, metabolic syndrome, and obesity. Improved neonatal care results in greater survival of pret... | CHAPTER 1 | CHAPTER 1 | Nelson Textbook of Pediatrics, 8th Edition | 17 | 4 |
provide information about many of these issues. Some of the key issues include the following: • Health insurance coverage. Medicaid and the State Children’s Health Insurance Program provide coverage to health care access to more than 45 million children in 2013.The slow drop in uninsured children nationally over the pa... | CHAPTER 1 | CHAPTER 1 | Nelson Textbook of Pediatrics, 8th Edition | 17 | 5 |
in 2006 and has been slowly declining (9.6% in 2014). However, the rates of low birthweight infants (≤2,500 g [8% of all births]) and very low birthweight infants (≤1,500 g [1.4% of all births]) are essentially unchanged since 2006. | CHAPTER 1 | CHAPTER 1 | Nelson Textbook of Pediatrics, 8th Edition | 17 | 6 |
2 SECTION 1 Profession of Pediatrics • Birthrate in adolescents. The national birthrate among adolescents has been steadily dropping since 1990, reaching its lowest rate (24.2 per 1000) for 15- to 19-year-old ado- lescents in 2014. • Adolescent abortions. In 2010 the percent of adolescent pregnancies that ended in abor... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 18 | 0 |
The infant mortality rate (in deaths per 1000 live births) is 4.96 for non-Hispanic white infant mortal- ity, 5.27 for Hispanic infants, and 11.61 black infants. U.S. geographic variability persists with highest mortality rates in the South. • Initiation and maintenance of breast-feeding. Seventy-nine percent of newbor... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 18 | 1 |
(unintentional injuries), suicide, assaults (homicide), malignant neoplasms, and congenital malformations (Table 1.1). There was a slight improvement in the rate of death from all causes. • Hospital admissions for children and adolescents. In 2014, 7.2% of children were admitted to a hospital at least once. Respiratory... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 18 | 2 |
is slowly declining (23.6% 12th graders reporting drug use in 2015). The teen smoking rate is also declining (13% in 2002; 5.5% in 2015). However, in 2014 more teens reported using electronic nicotine delivery systems (ENDS) than any other tobacco product. ENDS, commonly referred to as e-cigarettes, pose significant he... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 18 | 3 |
and will not graduate from high school. OTHER HEALTH ISSUES THAT AFFECT CHILDREN IN THE UNITED STATES • Obesity. Obesity is the second leading cause of death in the United States (estimated 300,000 deaths annually). Childhood obesity has more than doubled in children and quadrupled in adolescents over the past 30 years... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 18 | 4 |
were injured. Preliminary data suggest a slight increase in 2015. The impact of mobile device use and increased speed limits is being considered. Carseat and seatbelt use can reduce the risk of serious injury and death by half for infants and children. On average, more than 12,000 children ages 0-19 years die each year... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 18 | 5 |
growing understanding of the interrelationship between biologic and developmental stresses, environmental exposure, and the genetic potential of patients is helping us recognize the adverse impact of toxic stressors on health and well-being. Screening for and acting upon factors that promote or hinder early development... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 18 | 6 |
injuries (accidents) Malignant neoplasms Suicide Congenital anomalies Homicide Diseases of the heart 15-24 Unintentional injuries (accidents) Suicide Homicide Malignant neoplasms Diseases of the heart From National Center for Health Statistics (US). Health, United States, 2015: with special feature on racial and ethnic... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 18 | 7 |
3 CHAPTER 2 Professionalism • Military deployment and children. Current armed conflicts and political unrest have affected millions of adults and their children. There are an estimated 1.3 million active duty and National Guard/Reserve servicemen and service- women, parents to more than a million children. An estimated... | CHAPTER 2 Professionalism | CHAPTER 2 Professionalism | Nelson Textbook of Pediatrics, 8th Edition | 19 | 0 |
disparities are the differences that remain after taking into account patients’ needs, preferences, and the availability of health care. Social conditions, social inequity, discrimination, social stress, language barriers, and poverty are antecedents to and associated causes of health disparities. Disparities in infant... | CHAPTER 2 Professionalism | CHAPTER 2 Professionalism | Nelson Textbook of Pediatrics, 8th Edition | 19 | 1 |
than children with private health insurance. • Rates of hospital admission are higher for people who live in low-income areas. • Children of ethnic minorities and those from poor families are less likely to have physician office or hospital outpatient visits and more likely to have hospital emergency department visits.... | CHAPTER 2 Professionalism | CHAPTER 2 Professionalism | Nelson Textbook of Pediatrics, 8th Edition | 19 | 2 |
firearms in the home; school violence; effects of media violence, obesity, and sexual activity; and substance use and abuse by adolescents. • It is estimated that 1 in 5 children, ages 13-18 years, has a mental health condition. Fifty percent of all lifetime cases of mental illness begin by age 14 years. The average de... | CHAPTER 2 Professionalism | CHAPTER 2 Professionalism | Nelson Textbook of Pediatrics, 8th Edition | 19 | 3 |
families, parental divorce, domestic violence, both parents working, and inadequate child care. Related pediatric challenges include improving the quality of health care, social justice, equality in health care access, and improving the public health system. For adolescents, there are special concerns about sexuality, ... | CHAPTER 2 Professionalism | CHAPTER 2 Professionalism | Nelson Textbook of Pediatrics, 8th Edition | 19 | 4 |
illness?” and “What do you think has caused your child’s illness?” One must address concepts and beliefs about how patients/families interact with health professionals, as well as their spiritual and religious approach to health and health care from a cultural perspective; this allows all to incorporate dif- ferences i... | CHAPTER 2 Professionalism | CHAPTER 2 Professionalism | Nelson Textbook of Pediatrics, 8th Edition | 19 | 5 |
for CAM include biochemical, lifestyle, biomechani- cal, and bioenergetic treatments, as well as homeopathy. It is estimated that 20-40% of healthy children and more than 60% of children with chronic illness use CAM. Only 30-60% of these children and families tell their physicians about their use of CAM. Screening for ... | CHAPTER 2 Professionalism | CHAPTER 2 Professionalism | Nelson Textbook of Pediatrics, 8th Edition | 19 | 6 |
are subject to explicit public rules of accountability. Governmental and other authorities at city, state, and federal levels grant limited autonomy to professional organizations and their membership thorough regulations, licensing requirement, and standards of service (e.g., Medicare, Medicaid, and the Food and Drug A... | CHAPTER 2 Professionalism | CHAPTER 2 Professionalism | Nelson Textbook of Pediatrics, 8th Edition | 19 | 7 |
4 SECTION 1 Profession of Pediatrics by a state licensing board, professional society, hospital, or health plan or named in medical malpractice judgments or settlements. Hospitals are required to review information in this data bank every 2 years as part of clinician recredentialing. There are accrediting agencies for ... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 20 | 0 |
encompasses the patient-physician relationship. Professionalism includes an appreciation for the cultural and religious/spiritual health beliefs of the patient, incorporating the ethical and moral values of the profession and the moral values of the patient. Unfortunately, the inappropriate actions of a few practicing ... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 20 | 1 |
regard for the highest standards of behavior and the refusal to violate one’s personal and professional codes. Maintaining integrity requires awareness of situations that may result in conflict of interest or that may result in personal gain at the expense of the best interest of the patient. • Reliability/responsibili... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 20 | 2 |
appropriate patient confidentiality. • Compassion/empathy requires the pediatrician to listen attentively, respond humanely to the concerns of patients and family members, and provide appropriate empathy for and relief of pain, discomfort, and anxiety as part of daily practice. • Self-improvement is the pursuit of and ... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 20 | 3 |
is crucial to providing the best care for patients. Pediatricians must work cooperatively and communicate effectively with patients and their families and with all health care providers involved in the care of their patients. • Altruism/advocacy refers to unselfish regard for and devotion to the welfare of others. It i... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 20 | 4 |
encounters may have an ethical component, major ethical challenges are infrequent. The legal system defines the minimal standards of behavior required of physicians and the rest of society through the legislative, regulatory, and judicial systems. Laws support the principle of confidentiality for teenagers who are comp... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 20 | 5 |
and options in the provision of health care. Resolving these value differ- ences involves several important ethical principles. Autonomy, which is based on the principle of respect for persons, means that competent adult patients can make choices about health care that they perceive to be in their best interests after ... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 20 | 6 |
may be more appropriate than autonomy. Other important ethical principles are those of beneficence (doing good), nonmaleficence (doing no harm or as little harm as possible), and justice (the values involved in the equality of the distribution of goods, services, benefits, and burdens to the individual, family, or soci... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 20 | 7 |
5 CHAPTER 3 Ethics and Legal Issues assent of a child is the process by which the pediatrician involves the child in the decision-making process with information appropriate to their capacity to understand. The principle of shared medical decision-making is appro- priate, but the process may be limited because of issue... | CHAPTER 3 Ethics and Legal Issues | CHAPTER 3 Ethics and Legal Issues | Nelson Textbook of Pediatrics, 8th Edition | 21 | 0 |
and procedures, understand the risks and benefits of these interventions, and be able to communicate their decision. • Reason, deliberate, and weigh the risks and benefits using their understanding about the implications of the decision on their own welfare. • Apply a set of personal values to the decision-making proce... | CHAPTER 3 Ethics and Legal Issues | CHAPTER 3 Ethics and Legal Issues | Nelson Textbook of Pediatrics, 8th Edition | 21 | 1 |
the best interests of the child. It is important to become familiar with state law as it, not federal law, determines when an adolescent can consent to medical care and when parents may access confidential adoles- cent medical information. The Health Insurance Portability and Accountability Act (HIPAA), which became ef... | CHAPTER 3 Ethics and Legal Issues | CHAPTER 3 Ethics and Legal Issues | Nelson Textbook of Pediatrics, 8th Edition | 21 | 2 |
of certain public health considerations, as follows: • Mature minors. Some states have legally recognized that many adolescents can meet the cognitive criteria and emotional maturity for competence and may decide inde- pendently. The Supreme Court has decided that pregnant, mature minors have the constitutional right t... | CHAPTER 3 Ethics and Legal Issues | CHAPTER 3 Ethics and Legal Issues | Nelson Textbook of Pediatrics, 8th Edition | 21 | 3 |
but generally includes children who have graduated from high school, are members of the armed forces, married, pregnant, runaways, are parents, live apart from their parents, and are financially independent or declared emancipated by a court. • Interests of the state (public health). State legislatures have concluded t... | CHAPTER 3 Ethics and Legal Issues | CHAPTER 3 Ethics and Legal Issues | Nelson Textbook of Pediatrics, 8th Edition | 21 | 4 |
IN PRACTICE Clinicians should engage children and adolescents based on their developmental capacity in discussions about medical plans so that the child has a good understanding of the nature of the treatments and alternatives, the side effects, and expected outcomes. There should be an assessment of the patient’s unde... | CHAPTER 3 Ethics and Legal Issues | CHAPTER 3 Ethics and Legal Issues | Nelson Textbook of Pediatrics, 8th Edition | 21 | 5 |
of the basis for a trusting patient-family- physician relationship. Confidentiality means that information about a patient should not be shared without consent. If confidentiality is broken, patients may experience great harm and may not seek needed medical care. See Chapter 67 for a discussion of confidentiality in th... | CHAPTER 3 Ethics and Legal Issues | CHAPTER 3 Ethics and Legal Issues | Nelson Textbook of Pediatrics, 8th Edition | 21 | 6 |
important implications. Some genetic screening (sickle cell anemia or cystic fibrosis) may reveal a carrier state, which may lead to choices about reproduction or create financial, psychosocial, and interpersonal problems (e.g., guilt, shame, social stigma, and discrimination in insurance and jobs). Collaboration with,... | CHAPTER 3 Ethics and Legal Issues | CHAPTER 3 Ethics and Legal Issues | Nelson Textbook of Pediatrics, 8th Edition | 21 | 7 |
as breast cancer in some ethnic populations; and hemochromatosis. For their own purposes, parents may pressure the pediatrician to order genetic tests when the child is still young. Testing for these disorders should be delayed until the child has the capacity for informed consent or assent and is competent to | CHAPTER 3 Ethics and Legal Issues | CHAPTER 3 Ethics and Legal Issues | Nelson Textbook of Pediatrics, 8th Edition | 21 | 8 |
6 SECTION 1 Profession of Pediatrics make decisions, unless there is a direct benefit to the child at the time of testing. Religious Issues and Ethics The pediatrician is required to act in the best interests of the child, even when religious tenets may interfere with the health and well-being of the child. When an inf... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 22 | 0 |
Human Subjects in Research The goal of research is to develop new and generalized knowl- edge. Parents may give informed permission for children to participate in research under certain conditions. Children cannot give consent but may assent or dissent to research protocols. Special federal regulations have been develo... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 22 | 1 |
is not treatment. This fact should be addressed as sensitively and compassionately as possible. CHAPTER 4 Palliative Care and End-of-Life Issues The death of a child is one of life’s most difficult experiences. The palliative care approach is defined as patient- and family- centered care that optimizes quality of life ... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 22 | 2 |
expected standard at the end of life. Palliative care in pediatrics is not simply end-of-life care. Children needing palliative care have been described as having conditions that fall into four basic groups based on the goal of treatment. These include conditions of the following scenarios: • A cure is possible, but fa... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 22 | 3 |
symptoms). These conditions present different timelines and different models of medical intervention while sharing the need to attend to concrete elements affecting the quality of a child’s death and mediated by medical, psychosocial, cultural, and spiritual concerns. Families without time to prepare for the tragedy of... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 22 | 4 |
CARE Palliative treatment is directed toward the relief of symptoms as well as assistance with anticipated adaptations that may cause distress and diminish the quality of life of the dying child. Elements of palliative care include pain management; expertise with feeding and nutritional issues at the end of life; and m... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 22 | 5 |
providing a sup- portive network for the caregivers. Caregivers involved may be pediatricians, nurses, mental health professionals, social workers, and pastors. A model of integrated palliative care rests on the following principles: • Respect for the dignity of patients and families. The clini- cian should respect and... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 22 | 6 |
the multiple perspectives, reflecting on possible conflicts, and altruistically coming to agreements that validate the patient and family perspectives yet reflect sound practice. Hospital ethics committees and consultation services are important resources for the pediatri- cian and family members. • Access to comprehen... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 22 | 7 |
7 CHAPTER 4 Palliative Care and End-of-Life Issues human suffering, providing treatment options. Respite should be available at any time during the illness to allow the family caregivers to rest and renew. • Use of interdisciplinary resources. Because of the complexity of care, no one clinician can provide all of the n... | CHAPTER 4 Palliative Care and End-of-Life Issues | CHAPTER 4 Palliative Care and End-of-Life Issues | Nelson Textbook of Pediatrics, 8th Edition | 23 | 0 |
family, and friends need opportunities to address their own emotional concerns. Team meetings to address thoughts and feelings of team members are crucial. Institutional support may include time to attend funerals, counseling for the staff, opportunities for families to return to the hospital, and scheduled ceremonies ... | CHAPTER 4 Palliative Care and End-of-Life Issues | CHAPTER 4 Palliative Care and End-of-Life Issues | Nelson Textbook of Pediatrics, 8th Edition | 23 | 1 |
ary team including specialists in the bereavement and end-of-life process. In 2010, legislation was passed allowing children covered under Medicaid or the Children’s Health Insurance Program (CHIP) to receive access simultaneously to hospice care and curative care. BEREAVEMENT Bereavement refers to the process of psych... | CHAPTER 4 Palliative Care and End-of-Life Issues | CHAPTER 4 Palliative Care and End-of-Life Issues | Nelson Textbook of Pediatrics, 8th Edition | 23 | 2 |
than other types of grief. Most parents work through their grief. Complicated grief, a pathologic manifestation of continued and disabling grief, is rare. Parents who share their problems with others during the child’s illness, who have access to psychologic support during the last month of their child’s life, and who ... | CHAPTER 4 Palliative Care and End-of-Life Issues | CHAPTER 4 Palliative Care and End-of-Life Issues | Nelson Textbook of Pediatrics, 8th Edition | 23 | 3 |
own complexities, based on the child’s age, cognitive development, disease, timeline of disease, and parental psychologic state. Parents are more likely to regret not talking with their child about death than having done so. COGNITIVE ISSUES IN CHILDREN AND ADOLESCENTS: UNDERSTANDING DEATH AND DYING The pediatrician sh... | CHAPTER 4 Palliative Care and End-of-Life Issues | CHAPTER 4 Palliative Care and End-of-Life Issues | Nelson Textbook of Pediatrics, 8th Edition | 23 | 4 |
concrete operations, and formal operations. For children up to 2 years of age (sensorimotor), death is seen as a separation without a specific concept of death. The associated behaviors in grieving children of this age usually include protesting and difficulty of attachment to other adults. The degree of difficulty dep... | CHAPTER 4 Palliative Care and End-of-Life Issues | CHAPTER 4 Palliative Care and End-of-Life Issues | Nelson Textbook of Pediatrics, 8th Edition | 23 | 5 |
the death may be seen psychologically as being caused by the child’s wishful thinking. They can feel overwhelmed when confronted with the strong emotional reactions of their parents. In children ages 6-11 years of age (late preoperational to concrete operational), the finality of death gradually comes to be understood.... | CHAPTER 4 Palliative Care and End-of-Life Issues | CHAPTER 4 Palliative Care and End-of-Life Issues | Nelson Textbook of Pediatrics, 8th Edition | 23 | 6 |
instead relying on anger or disdain. Adolescents can discuss withholding treatments. Their wishes, hopes, and fears should be attended to and respected. CULTURAL, RELIGIOUS, AND SPIRITUAL CONCERNS ABOUT PALLIATIVE CARE AND END-OF-LIFE DECISIONS Understanding the family’s religious/spiritual or cultural beliefs and valu... | CHAPTER 4 Palliative Care and End-of-Life Issues | CHAPTER 4 Palliative Care and End-of-Life Issues | Nelson Textbook of Pediatrics, 8th Edition | 23 | 7 |
family in decision- making. For some families, dying at home can bring the family bad luck; others believe that the patient’s spirit will become lost if the death occurs in the hospital. In some traditions, the health care team cleans and prepares the body, whereas in others, family members prefer to complete this ritu... | CHAPTER 4 Palliative Care and End-of-Life Issues | CHAPTER 4 Palliative Care and End-of-Life Issues | Nelson Textbook of Pediatrics, 8th Edition | 23 | 8 |
8 SECTION 1 Profession of Pediatrics spiritual or cultural practices may include prayer, anointing, laying on of the hands, an exorcism ceremony to undo a curse, amulets, and other religious objects placed on the child or at the bedside. Families differ in the idea of organ donation and the acceptance of autopsy. Decis... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 24 | 0 |
and level of development; the child’s understanding and involvement in end-of-life decision-making; the parents’ emotional acceptance of death; their coping strategies; and their philosophical, spiritual, and cultural views of death. These may change over time. The use of open-ended questions to repeatedly assess these... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 24 | 1 |
of life, when life ceases to be worth living, and religious/spiritual, cultural, and philosophical beliefs may differ between families and health care workers. The most important ethical principle is what is in the best interest of the child as determined through the process of shared decision-making, informed permissi... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 24 | 2 |
Family members and the patient should agree about what are appropriate do not resuscitate (also called DNR) orders. Foregoing some measures does not preclude other measures being implemented based on the needs and wishes of the patient and family. When there are serious differences among parents, children, and physicia... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 24 | 3 |
death or through a process of donation after circulatory death (DCD). DCD has only recently gained acceptance in pediatrics. Organ procurement, donation, and transplantation are strictly regulated by governmental agen- cies to ensure proper and fair allocation of donated organs for transplantation. It is important that... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 24 | 4 |
social, financial, and follow-up; insurance-coverage; and public awareness of the need for organ donors. Organ donation and organ transplantation can provide significant life-extending benefits to a child who has a failing organ and is awaiting transplant, while at the same time place a high emotional impact on the don... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 24 | 5 |
for U.S. children: National Health Interview Survey, 2012. National Center for Health Statistics. Vital Health Stat. 2013;10(258):1–72. National Center for Health Statistics. Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. Hyattsville, MD: National Center for Health Statistics... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 24 | 6 |
• The significant increase in the number of children with a chronic medical condition (e.g., asthma, obesity, attention- deficit/hyperactivity disorder) affects both inpatient and outpatient care. • Addressing the following as a part of routine health care allows pediatricians to impact health care outcomes: • Toxic st... | SECTION 1 Profession of Pediatrics | SECTION 1 Profession of Pediatrics | Nelson Textbook of Pediatrics, 8th Edition | 24 | 7 |
9 CHAPTER 4 Palliative Care and End-of-Life Issues • The use of electronic nicotine delivery systems or e-cigarettes • The sedentary lifestyle as children spend an increased amount of time in front of a screen (TV, videogames, computers, cell phones) • Early recognition of mental illness (It is estimated that 1 in 5 ad... | CHAPTER 4 Palliative Care and End-of-Life Issues | CHAPTER 4 Palliative Care and End-of-Life Issues | Nelson Textbook of Pediatrics, 8th Edition | 25 | 0 |
honesty/integrity, reliability/responsibility, respect for others, compassion/ empathy, self-improvement, self-awareness/knowledge of limits, communication/collaboration, and altruism/advocacy. CHAPTER 3 Ethics and Legal Issues • Key ethical principles in the care of pediatric patients include autonomy (addressing when... | CHAPTER 4 Palliative Care and End-of-Life Issues | CHAPTER 4 Palliative Care and End-of-Life Issues | Nelson Textbook of Pediatrics, 8th Edition | 25 | 1 |
is made (e.g., trisomy 13); and (4) when treatments are available for severe, non-progressive disabilities. • Organ donation can occur after fulfilling criteria for neurologic death or through donation after circulatory death. | CHAPTER 4 Palliative Care and End-of-Life Issues | CHAPTER 4 Palliative Care and End-of-Life Issues | Nelson Textbook of Pediatrics, 8th Edition | 25 | 2 |
11 CHAPTER 5 Normal Growth HEALTH MAINTENANCE VISIT The frequent office visits for health maintenance in the first 2 years of life are more than physicals. Although a somatic history and physical examination are important parts of each visit, many other issues are discussed, including nutrition, behavior, development, ... | CHAPTER 5 | CHAPTER 5 | Nelson Textbook of Pediatrics, 8th Edition | 27 | 0 |
it is convenient to refer to growth as the increase in size and development as an increase in function of processes related to body and mind. Being familiar with normal patterns of growth and development allows those practitioners who care for children to recognize and manage abnormal variations. The genetic makeup and... | CHAPTER 5 | CHAPTER 5 | Nelson Textbook of Pediatrics, 8th Edition | 27 | 1 |
at 1, 2, 4, 6, 9, 12, 15, and 18 months; at 2, 2 12, and 3 years; and then annually through adolescence/young adulthood (see Fig. 9.1; the Bright Futures’ “Recommendations for Preventive Pediatric Health Care” found at https://www.aap. org/en-us/documents/periodicity_schedule.pdf). Deviations in growth patterns may be ... | CHAPTER 5 | CHAPTER 5 | Nelson Textbook of Pediatrics, 8th Edition | 27 | 2 |
value remains within statistically defined normal limits (percentiles). Following the trend helps SECTION 2 GROWTH AND DEVELOPMENT David A. Levine define whether growth is within acceptable limits or warrants further evaluation. Growth is assessed by plotting accurate measurements on growth charts and comparing each se... | CHAPTER 5 | CHAPTER 5 | Nelson Textbook of Pediatrics, 8th Edition | 27 | 3 |
and plateaus, so some shifting on percentile graphs can be expected. Large shifts in percentiles warrant attention, as do large discrepancies in height, weight, and head circumference percentiles. When caloric intake is inadequate, the weight percentile falls first, then the height, and the head circumference is last. ... | CHAPTER 5 | CHAPTER 5 | Nelson Textbook of Pediatrics, 8th Edition | 27 | 4 |
Weight loss in first few days: 5-10% of birthweight Return to birthweight: 7-10 days of age Double birthweight: 4-5 months Triple birthweight: 1 year Daily weight gain: 20-30 g for first 3-4 months 15-20 g for rest of the first year HEIGHT Average length: 20 in. at birth, 30 in. at 1 year At age 4 years, the average ch... | CHAPTER 5 | CHAPTER 5 | Nelson Textbook of Pediatrics, 8th Edition | 27 | 5 |
12 SECTION 2 Growth and Development %LUWKWRPRQWKV %R\V /HQJWKIRUDJHDQG:HLJKWIRUDJHSHUFHQWLOHV FIGURE 5.1 Length-by-age and weight-by-age percentiles for boys, birth to 2 years of age. Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Preven... | SECTION 2 Growth and Development | SECTION 2 Growth and Development | Nelson Textbook of Pediatrics, 8th Edition | 28 | 0 |
WHO Child Growth Standards. Atlanta, GA; 2009. Available at http://www.cdc.gov/growthcharts/who_charts.htm.) 2 to 20 years: Girls Stature Weight-for-age percentiles -for-age and kg 10 15 20 25 30 35 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 cm 150 155 160 165 170 175 180 185 190 kg 10 15 20 25 30 35 1... | SECTION 2 Growth and Development | SECTION 2 Growth and Development | Nelson Textbook of Pediatrics, 8th Edition | 28 | 1 |
for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion. (From Centers for Disease Control and Prevention. Atlanta, GA; 2001. Available at http://www.cdc.gov/ growthcharts.) 2 to 20 years: Girls Body mass index-for-age percentiles 2 5 4 3 6 7 8 9 10 11 12 13 1... | SECTION 2 Growth and Development | SECTION 2 Growth and Development | Nelson Textbook of Pediatrics, 8th Edition | 28 | 2 |
13 CHAPTER 6 Disorders of Growth the face of a falling height percentile suggests hypothyroidism. Head circumference may be disproportionately large when there is familial megalocephaly, hydrocephalus, or merely catch-up growth in a neurologically normal premature infant. A child is considered microcephalic if the head... | CHAPTER 6 Disorders of Growth | CHAPTER 6 Disorders of Growth | Nelson Textbook of Pediatrics, 8th Edition | 29 | 0 |
PATTERN REPRESENTATIVE DIAGNOSES TO CONSIDER FURTHER EVALUATION Weight, length, head circumference all <5th percentile Familial short stature Constitutional short stature Intrauterine insult Genetic abnormality Midparental heights Evaluation of pubertal development Examination of prenatal records Chromosome analysis Di... | CHAPTER 6 Disorders of Growth | CHAPTER 6 Disorders of Growth | Nelson Textbook of Pediatrics, 8th Edition | 29 | 1 |
growth hormone testing Decision-Making Algorithm Available @ StudentConsult.com Short Stature The most common reasons for deviant measurements are technical (i.e., faulty equipment and human errors). Repeating a deviant measurement is the first step. Separate growth charts are available and should be used for very low ... | CHAPTER 6 Disorders of Growth | CHAPTER 6 Disorders of Growth | Nelson Textbook of Pediatrics, 8th Edition | 29 | 2 |
assessment are summarized in Table 6.1. Evaluating a child over time, coupled with a careful history and physical examination, helps determine whether the growth pattern is normal or abnormal. Parental heights may be useful when deciding whether to proceed with a further evaluation. Children, in general, follow their p... | CHAPTER 6 Disorders of Growth | CHAPTER 6 Disorders of Growth | Nelson Textbook of Pediatrics, 8th Edition | 29 | 3 |
length, and head circumference is commonly associated with familial short stature (see Chapter 173). These children are genetically normal but are smaller than most children. A child who, by age, is preadolescent or adolescent and who starts puberty later than others may have the normal variant called constitutional sh... | CHAPTER 6 Disorders of Growth | CHAPTER 6 Disorders of Growth | Nelson Textbook of Pediatrics, 8th Edition | 29 | 4 |
between 6 and 18 months of age until they match their genetic programming; then they grow along new, lower percentiles. They usually do not decrease more than two major percentiles and have normal developmental, behavioral, and physical examinations. These children with catch-down growth should be followed closely, but... | CHAPTER 6 Disorders of Growth | CHAPTER 6 Disorders of Growth | Nelson Textbook of Pediatrics, 8th Edition | 29 | 5 |
may have led to being born small or early may contribute to nonorganic failure to thrive (see Chapter 21). Conversely infants who recover from being low birth- weight or premature have an increased risk of developing childhood obesity. Growth of the nervous system is most rapid in the first 2 years, correlating with in... | CHAPTER 6 Disorders of Growth | CHAPTER 6 Disorders of Growth | Nelson Textbook of Pediatrics, 8th Edition | 29 | 6 |
14 SECTION 2 Growth and Development and light reflex should be performed at early health main- tenance visits; interventions after age 2 decrease the chance of preserving binocular vision or normal visual acuity (see Chapter 179). SCHOOL AGE/PREADOLESCENT Older school-age children who begin to participate in competi- t... | SECTION 2 Growth and Development | SECTION 2 Growth and Development | Nelson Textbook of Pediatrics, 8th Edition | 30 | 0 |
A child with a history of dyspnea or chest pain on exertion, irregular heart rate (i.e., skipped beats, palpitations), or syncope should also be referred to a pediatric cardiologist. A family history of a primary (immediate family) or secondary (immedi- ate family’s immediate family) atherosclerotic disease (myocardial... | SECTION 2 Growth and Development | SECTION 2 Growth and Development | Nelson Textbook of Pediatrics, 8th Edition | 30 | 1 |
67 and 68). Sexual maturity is an important issue in adolescents, and all adolescents should be assessed to monitor progression through sexual maturity rating stages (see Chapter 67). Other issues in physical development include scoliosis, obesity, and common orthopedic growth issues (e.g., Osgood Schlatter; see Chapte... | SECTION 2 Growth and Development | SECTION 2 Growth and Development | Nelson Textbook of Pediatrics, 8th Edition | 30 | 2 |
sequence within specific age ranges (see Chapter 8). The development of the neuromuscular system, similar to that of other organ systems, is determined first by genetic endowment and then is molded by environmental influences. Although a sequence of specific, easily measured behaviors can adequately represent some area... | SECTION 2 Growth and Development | SECTION 2 Growth and Development | Nelson Textbook of Pediatrics, 8th Edition | 30 | 3 |
the changes in the developing brain (i.e., cognition, language, behavior) are changes in the physical development of the body. NEWBORN PERIOD Observation of any asymmetric movement or altered muscle tone and function may indicate a significant central nervous system abnormality or a nerve palsy resulting from the deliv... | SECTION 2 Growth and Development | SECTION 2 Growth and Development | Nelson Textbook of Pediatrics, 8th Edition | 30 | 4 |
lowed by adduction and flexion. The legs respond with flexion. The rooting reflex is elicited by touching the corner of the infant’s mouth, resulting in lowering of the lower lip on the same side with tongue movement toward the stimulus. The face also turns toward the stimulus. The sucking reflex occurs with almost any... | SECTION 2 Growth and Development | SECTION 2 Growth and Development | Nelson Textbook of Pediatrics, 8th Edition | 30 | 5 |
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