PNP 1 Management Exam #1

-Exclusivly for 6 months
-Continued with other nutrients for 1 year

-The infant's top and bottom lips flanged out and their tongue extends forward over the lower gum line.
-Feedings are quiet—no “click” or “pop” sound.
-The infant's swallowing is audible.

-Breastmilk that has been defrosted, but not used within 24 hours, should be thrown away.
-It can be stored at room temperature for four hours or in the refrigerator for up to four days (referred to as the "Rule of 4s."
-If a baby has partially taken a bottle, leftover milk in that bottle should be discarded after two hours.
-Breastmilk may be served at room temperature or cold.
-If warmed, it should be done under running warm (not hot) water and never thawed in the microwave, which destroys the nutritional properties of breastmilk and increases the risk of burn.
-Optimally, breastmilk can be frozen for six months but 12 months is acceptable. Previously frozen milk that is thawed should never be refrozen.

-As the infant grows, breast milk changes
-Sequence of colostrum, transitional milk to mature milk

-Fewer calories, lower fat than mature milk
-Rich in immunoglobulins and antibodies
-Facilitates passage of meconium
-Meets all needs of term newborn in the first few days

-Appears between 32 and 96 hours after birth
-More lactose, calories, and fat, less total protein

-Replaces transitional milk by the second week after birth
-Provides, on average, 20 kcal/oz.

-Allows the growth of protective bacteria for a healthy microbiome

-IgA secretion
-Decreased inflammation in the intestinal epithelial cells and underlying tissues
Protective barrier in the intestines
-Lower risk of:
asthma
otitis media
excessive weight gain
type 2 diabetes
nonspecific bacterial infections
necrotizing enterocolitis
SIDS

Important in newborns because it coats the gut to protect against invasion of bacteria and decrease oberall gut inflammation

-Economical
-Bonding
-Decreased risk of breast and ovarian cancer
-Protects against:
cardiovascular risks
metabolic syndrome
hypertension

-Infants with galactosemia
-Materanl diagnosis of:
human T-cell lymphotrophic virus type I or II
untreated brucellosis
cancer and treatment
HIV
hepatic lesions on mothers nipples, areolas, or breast (expressed breast milk can be fed)
use of cocaine, phencyclidine and cannabis
-Invasive breast surgery (reduction in which areola is removed and reattached)

-Water
-Lipids
-Protein
-Carbohydrates
-Vitamins and minerals

-90% of breast milk
-Can meet the the fluid needs of an infant without any water supplementation

-30% to 55% of breast milk
-Variable percentages with each feeding
-Higher at the end of the feeling than it is in the beginning
-Cholesterol content is 240mg/100g of fat
-Play an important role in brain and retinal development

-0.9% of breast milk
-Protein is higher in colostrum than mature milk
-Casein (30%-40%): the clot that is formed when milk is heated or exposed to enzymes in digestion
-Whey (60%-70%): the clear mortion that remains which consists of alpha-lactalbumin and lactoferrin

-Primary carbohydrate is lactose (synthesized by the mammory gland from glucose)
-Highly concentrated (6.8g/100mL)
-Supports growth of pathogen competing microflora in the intestings
-Enhances absorption of calcium

-Vitamin A, E, K, C, B1, B2, and B6
-Not adequate amounts of vitamin D
-Low iron levels in breat milk, but it is highly absorbed.

-Vimtamin D
-400 IU/day
-Iron beginning at 4 months
-1 mg/kg/day

**Baby's weight gain is adequate and maintaining adequate trajectory on the growth chart**
-Feeding eight to ten times per day in early infancy
-Five to six wet diapers per day
-Beginning day three or four of life, at least three to four yellow, soft, seedy stools per day
-Mother's breasts feel full before feeding and has a let-down reflex with breast softening post-feeding
-Sucking is not painful and swallowing is audible
-Baby is satisfied and content following feedings
-Milk residue is evident on the baby's cheeks and lips, milk is easily expressed

-First 24 hours: fed 8-12 times (every 2-3 hours) for 20-45 minutes
-Exclusive breast feeding and no bottles for 4-6 weeks

-Gestational age and age at the time of the assessment.
-Overall health status
-Medications other than routine protocol, meds administered after birth.
-Congenital conditions, such as cardiac, respiratory, or orofacial
-Trauma or complications during delivery
-Activities including circumcision, use of bilirubin lights, or use of bottle, cup, or tube feeding.

-Examiner's finger should be inserted beyond the gum line nearly to the soft palate.
-The infant should be able to suck smoothly with upward motion of the tongue as the finger is drawn in for suckling.
-The hard and soft palate should be intact, without palpable clefts.
-The infant should be able to extend the tongue over the lower gum with no evidence of tight frenulum.
-Frenulum (tongue tie) should be evaluated to determine its effects on the maternal and newborn breastfeeding dyad.

-Used to describe those times during breastfeeding when the baby's growth demands exceed the breast milk supply at the moment.
-For 2 to 4 days, the infant seems to be "hungry all the time" and demands to be fed more frequently.
-Babies tend to cluster fed.
-Best response is to feed on demand and increase the number of feedings because increased stimulation of the breast increases milk production to the amount needed.
-Tend to occur every 3-4 weeks.

-Give drugs that are normally safe for infants or have been tested in infants.
-Avoid long-acting forms of drug.
-Schedule feeding at times when the drug level is the lowest.
-Observe the infant for changes in feeding pattern, fussy, vomiting, or rash.
-Consider all appropriate options and select the drug with the lowest level in breastmilk.
-Avoid drugs that inhibit prolactin release.
-Be cautious about the use of herbal preparations.

-Loses 5%-10% of weight in first few days of life
-Gains 0.5-1 oz/day or 4-7 oz/week
-Regains birth weight by 2 weeks
-Doubles weight by 4-6 monts
-Triples weight by 1 year old

-Continued weight after 5-7 days old
-Failure to regain after 2-3 weeks old
-Weight gain below the third percentile for age
-Lethargy, sleepy, inactive infant
-Sleeping longer than 4 hours between feedings
-Dry mucous membranes

-By day 2: urinate 1-3 times in 24 hours
-By day 3: urinates 3+ times in 24 hours
-By day 4: urinates 4-6 times in 24 hours
-Overtime have a minimum of 6-8 wet diapers in 24 hours

-In the first 24 hours: meconium stool
-By day 3: stools transition to loose, yellow and seedy
-Overtime, they increase and could stool every feeding

1. The child's weight in Kg and
2. The estimated daily energy requirement in kcal/kg/day for the child's age, gender and exercise/activity level.
EX: Knowing that 1 oz of formula or breastmilk is 20kcal, you DIVIDE the total estimated daily energy requirements to determine the # of ounces the child should eat in one day. Then split them into the appropriate # of meal frequency for the child's age.

-400 IU of Vitamin D for all breastfed infants until they are 1 year old
-Recommended assessment of BMI for all children 3 to 17 years old.
-Children ages 6 and older be screened for obesity, and that children who are overweight or obese be referred for comprehensive intensive behavioral interventions to improve weight.

-Positive examples of healthy intake.
-Appropriate portions
-Positive role models.
-Limits, but NOT prohibitions, on consumptions of sugars and other foods.
-Food prepared in form that stimulates children's appetites.
-Regular structured mealtimes when the family sits down to eat together.
-Clear, developmentally appropriate expectations for children behavior at mealtimes.
-Developmentally appropriate access to and instruction in the use of utensils.
-Appropriate supervision during mealtimes.
-Adequate exercise, sleep, and rest.

-Offer the food when children are hungry.
-Allow children to taste a little of the food rather than eating a full portion.
-Expose children to the food by preparing and serving the food without expecting them to eat.
-Provide an example of parents eating and enjoying the food.
-Prepare the food the way children prefer; few spices; lukewarm and recognizable.

-Introduce one food at a time to assess for adverse reaction.
-If there is a family history of allergies or atrophy, consider introducing iron-fortified rice and oatmeal cereals as the first food.
-Introduce home prepared fruits, veggies, and cereals.
-Prepare and provide variety of foods appropriate for child's developmental abilities-mashed, pureed, or finger foods.
-Serving size approximately one tablespoon for initial serving.
-Include the child in family mealtimes.

-Exposing children to new foods without expecting them to eat it.
-Positive role modeling with healthy eating choices by parents.
-Allowing frequent snacking on-demand with healthy choices.
-Ensuring adequate sleep and exercise to stimulate appetite.
-Removing foods that are refused without comment.

2 years old

Weight to height ratio

-Protein
-Carbohydrates
-Fats

-Vitamins (fat and water soluble)

-Broken down into amino acids
-10 essential amino acids are not synthesized by the body and must be provided in the diet:
phenylalanine
leucine
methionine
lysine
isoleucine
valine
threonine
tryptophan
histidine
arginine
-Should receive 5% to 30% of daily calories from proteins

-Major dietary source of energy
-Two forms: simple carbohydrates and complex carbohydrates

-Children 1-3 years old: 30%-40% of diet
-Children >3 years: 25%-35% of diet
-Lipids, fats and fatty acids are used to provide energy to facilitate the absorption of fat-soluble vitamins and to maintain the integrity of cell membranes and myelin
-Two essential polyunsaturated fatty acids: linoleic acid (LA) and alpha-linolenic acid (ALA), precursers of omega-6 and omega-3 fatty acids

-Vitamin A
-Vitamin D
-Vitamin E
-Vitamin K

-Vision
-Cellular differentiation
-Growth
-Reproductive
-Immune system function

-Liver
-Fish liver oils
-Fortified milk
-Eggs
-Red and orange vegetables
-Dark leafy green vegetables

-Anorexia
-Dry skin
-Keratinization of epithelial celss of respiratory tract
-Night blindness
-Corneal lesions
-Increased susceptibiliy to infections

-Toxic at 10x the RDA
-Excessive intake of carrots can cause hypercarotenosis (yellowing of the skin)
-Headache
-Vomiting
-Double vision
-Hair loss
-Dry mucosa
-Peeling skin
-Liver damage

-Bone growth and development
-Regulates intestinal absorption of calcium and phosphorus

-Sunlight
-Artificial UV rays
-Fortified food products, especially milk and fish

-Inadequate bone mineralization
-Rickets or skeletal malformation
-Delayed dentition

-Anorexia
-N/V
-Diarrhea
-Weakness
-Hypercalcemia
-Hypercalciuria
-Calcium depositis in soft tissues
-Permanent renal or cardiovascular damage

-Antioxidant
-Traps free radicals
-Prevents oxidation of polyunsaturated fats

-Vegetable oils
-Margarine
-Nuts
-Seeds
-Wheat germ
-Green leafy vegetables

-Macrocytic anemia and dermatitis in infants
-Neurologic defects in severe malformation

-None known in dietary doses
-Supplements may cause hemorrhagic effects, especially if taken long term

Forms proteins that regulate blood clotting

-Green leafy vegetables
-Milk
-Dairy products
-Liver

-Defective coagulation of blood
-Hemorrhages
-Liver injury

-Vitamin K hemorrhagic condition, especially if patient is being treated with anticoagulants

-Vitamin C
-Vitamin B's

-Essential for collagen formation and function
-Promotes growth and tissue repair
-Enhances iron absorption
-Improves wound healing

-Vegetables and fruits (citrus fruits)
-Broccoli
-Collard greens
-Spinach
-Tomatoes
-Potatoes
-Strawberries
-Peppers

-Scurvy
-Cracked lips
-Bleeding gums
-Slow wound healing
-Easy bruising

-Unknown
-Excess is excreted in urine

-Necessary for carbohydrate metabolism
-Promotes normal appetite and digestion

-Whole grains
-Brewer's yeast
-Legumes
-Seeds and nuts
-Fortified grain products
-Organ meats
-Lean cuts of pork

-Beriberi:
muscle weakness
ataxia
confusion
anorexia
tachycardia
heart failture in infants

-None by oral intake
-Excreted in urine

-Necessary for exidation-reduction reactions
-Essential for function of vitamin B6 and niacin
-Helps maintain integrity of the skin, tongue and lips

-Dairy products
-Meat
-Poultry
-Fish
-Enriched or fortified grains
-Cereals
-Breads
-Green vegetables such as broccoli, spinach, asparagus, and turnip greens

-Oral-buccal cavitiy lesions
-Generalized seborhheic dermatitis
-Scrotal and vulva skin changes
-Normocytic anemia
-Dimness of vision

None known

-Metablosim for energy metabolism, glycolysis and fatty acids
-Maintains nervous system
-Integrity of skin, mouth and tongue

-Meats
-Fortified grains
-Cereals
-Legumes
-Milk
-Eggs
-Meats that contain tryptophan

-Pellagra
-Dermatitis
-Diarrhea
-Inflammation of mucous membranes
-Indigestion

-No known toxicity with dietary doses
-Heat rush and flushing with excess doses

Essential for metabolism of amino acids, lipids, nucleic acid and glycogen

-Chicken
-Fish
-Kidney
-Liver
-Pork
-Red meat
-Eggs
-Unrefined rice
-Soybeans
-Oats
-Whole wheat
-Peanuts
-Walnuts
-Fortified cereals

-Seen in combination with other B-complex vitamin deficiencies
-Dermatitis
-Anemia
-Convulsions
-Neurologic symtoms
-Abdominal distress in infants

-Ataxia
-Sensory neuropathy when taken in gram quantities for months or years

-Essential for amino acid metabolism and nucleic acid synthesis
-Red blood cell formation

-Liver
-Fortified grain products
-Yeast
-Dark green leafy vegetables
-Green vegetables
-Legumes
-Orange juice
-Wheat germ

-Megaloblastic anemia in severe cases
-Macrocytic anemia
-Glossitis
-Gastrointestinal distrubances
-Increased risk of neural tube defects
-Growth retardation in infant of folate-deficient mothers

-None known in dietary doses
-Excessive folic acid supplementation may reduce serum levels of phenytoin, carbamazepine and valporate and contribute to seizures in epilepsy controlled by these medications

-Essential for neurologic function
-Essential for adequate red blood cell formation
-DNA synthesis

-Animal products: meat, eggs, and milk
-Shellfish
-Fortified foods

-Metaloblastic anemia
-Neurologic symptoms
-Sore tongue
-Weakness

None known

-Calcium
-Magnesium
-Phosphorus

-Development of bone tissue
-Vital role in nerve conduction
-Membrane permeability
-Blood clotting
-Muscle contraction

-Milk and milk products
-Green leafy vegetables
-Broccoli
-Soft bones of fish
-Sardines
-Foods processed or fortified with calcium

-Decreased bone strength
-Increased risk for fractures
-Paralysis

-Constipation
-Increased risk for kidney stones
-Risk for decreased renal function

-Essential for bone integrity and general metabolism
-Provides essential energy during the metabolic process

-Almost all foods
-Meat
-Poultry
-Fish
-Milk
-Cereal grains
-Food additives in processed foods

-Bone loss
-Weakness
-Malaise
-Anorexia
-Pain

None known

-Activates enzymes
-Facilitates cell metabolism
-Maintains electrical potention of cell membranes
-Enhances transmission of nerve impulses
-Assists to maintain adequate serum levels of calcium and potassium

-Nuts
-Legumes
-Whole (unmilled) grains
-Green vegetables
-Bananas

-Nausea
-Muscle weakness
-Irritability

-None in healthy individuals
-In impaired renal function:
N/V
Hypotension
Bradycardia
Central nercous system depression

-Formation of the heme molecule
-Used in oxygen transport

-Meat
_eggs
-Vegetables
-Cereals
-Foods fortified with iron additives

**Children are particulary susceptible to iron deficiency during periods of rapid growth combined with low dietary iron intake: from about 6 months to 4 years old and during early adolescence**
-Anemia

-Iron poisoning can be fatal
-For a 2 year old, a fatal dose is approximately 3 grams
-For adolescents, 200-250 mg/kg may be fatal

- Three body process requires energy.
1. Basal Metabolism
2. Growth
3. Activity, Exercise

-Functions primarily to regulate extracellular fluid volume.
-Children 1-3 years old 1,000mg/day adequate intake.
-Children 4-8 years old 1,200mg/day adequate intake.
-Children 9-18 years old 1,500mg/day adequate intake.

-Helps to maintain intracellular homeostasis and contributes to muscle contractility and transmission of nerve impluses.

-Nutritional status of mother during pregnancy
-Food and fluid intake of child and of family (3 day diet recall)
-Eating patterns or behaviors for both child and family
-Reactions to and attitudes about foods
-Management of foods in the family
-Health status affected by nutrition

-Transition to cowsmilk at 12 months and continue until 24 months
-Vitamin D supplementation until 1 year old
-Premature and low birth weight infants that are exclusively breastfed require iron supplementation until 1 year

-For 0-2 months is 100 kcal /kg/day
-For 3 month baby is 95 kcal/kg/day
-For 4-35 months is 82 kcal/kg/day

-Food jags: only wanting to eat a few types of food
-Growth rate is slower than infants

-Prader-Willi syndrome
-Down syndrome
-Myelomeningocele
-Hypothyroidism

Metabolic conditions or defects of absorption or transport
-Inflammatory bowel disease
-Short bowel syndrome
-Celiac disease
-Cancer
-Infectious disease

-Cleft lip or palate
-Esophageal atresia
-Cerebral palsy
-GERD
-Pyloric stenosis

-95th perctentile for age
-BMI of 30

-85th to 95th percentile
-For children <2 years, weight-to-height ratio >95th percentile

-<18 monts avoid using screen media other than video-chatting
-Paretns of children 18-24 months of age who want to introduce digital media should choose high quality programming and watch it with their children to help them understand what they are seeing
-Children ages 2-5 years, limit screen time to 1 hr/day
-Children >6 years, place consistent limits on screen time

-10.5–18 hours/day
-Irregular schedule
-Encourage room sharing but avoid co-sleeping
-Position on back to sleep
-Pacifier use appears to be protective against SIDS but avoid attachment devices that could strangulate
-Use a flat, firm sleeping surface without excess pillows or bedding
-Avoid overheating
-Avoid secondhand smoke exposure
-Get immunizations on time

-Average 14–15 hours/day with napping
-Sleep training can begin at 3–4 months of age
-Place infant in bed drowsy but not asleep
-No nursing or bottle-feeding to sleep (associates feeding with return to sleep and unable to self-soothe)
-Allow time for hands-on exploration and face-to-face social interaction
-Use sleep aids such as pacifiers, blankets, or stuffed animals
-Circadian rhythm develops
-Spends 50% in REM
-Can sleep through the night with no feedings at 6 months

-Toddlers sleep an average of 12–14 hours/day with napping
-Nap cessation occurs at 18–22 months of age
-Preschoolers sleep an average of 11–13 hours/day
-Avoid screen time prior to 18 months (excepting video chatting)
-Promote regular daytime routines to help develop regular sleep patterns
-Choose high-quality programming with parent co-viewing interactively
-Limit screen use to 1 hour/day of high-quality programming
-Sleep resistance
-Separation anxiety
-Nighttime fears
-Nighttime terrors
-Nightmares
-Sleepwalking

-10–11 hours/night
-Needing naps in grade school is a reason for further evaluation
-Minimize caffeine ingestion
-Balance extracurricular and sports demands on time to allow for adequate sleep
-Place consistent limits on screen time
-Emphasize prioritization for physical activity
-Discuss online safety principles, especially for gaming platforms

-Designate media-free times
-Discuss digital citizenship on an ongoing basis
-Keep digital devices out of the bedroom
-Eliminate device use one hour before bedtime
-Discourage multitasking with devices while doing homework

-8–9 hours/night
-Advocate for late school start times
-Advocate for a balanced schedule to allow for adequate sleep
-Limit caffeine intake
-Stop screen time at least one hour prior to bed
-Designate an area for homework (not in the teen’s bed)
-Keep bed neat and clean
-Use a regular bedtime routine
-Seek medical evaluation for snoring
-Provide a dark, quiet, cool place to sleep

-NREM (75% to 80% of total sleep time): musculoskeletal recovery
-REM (20% to 25% of total sleep time): psychological recovery
-Each cycle is 90 minutes with about 6 cycles per night

-State of drowsiness and occurs at the transition to sleep
-Eye-rolling movements, decreased body movements, and possible opening and closing of eyelids

-Deeper than N1
-Muscles weaken, slowing of eye movements, breathing and heart rate

-Also known as deep, delta or slow wave sleep (SWS)
-Less responsove and can be very difficult to awaken a child
-Occurs in longer periods during the first half of the night
-intense fatigue if deprived

-increased EEG activity ad is similar toa wake state
-Vivid dreams with simultaneous muscle paralysis
-Higher percentage in infancy (55%) and decreases by age 5 (20%-25%)
-Excitable and anxious if deprived
-Happens later in the night just before natural awakening

-Sudden unexpected death in infants
-Suffication
-Asphyxia
-Entrapment
-Infection
-Ingestions
-Metabolic disease
-Trauma

-Subcategory of SUIDs
-Infant deaths that are unexplained after a thorough case investigation including autopsy, a scene investigation and clinical history

-Sleep in the same room but not same bed for 6 months
-Pacifiers
-Parental avoidance of illicit drugs, alcohol and smoking
-Supine position
-Avoiding bumper pads

-Increased insomnia
-Hard to regulate high arousal negative emotions

-Specific sleep disorders:
Behavioral insomnia
Sleep disordered breathing (SBD)
Restless leg syndrome
-First line medication for ADHD that can increase insomnia: methylphenidate

-Behaviors associated with sleeping problems:
Cosleeping
Poor sleep efficiency
Difficult self-setting
Frequent night walking
Sleep onset latency
Early waking
Poor sleep hygeine
Irregular sleep-wake patterns
Daytime sleepiness

-Early establishment of a dark, quiet, and slightly cool room
-Establishing cues to establish a routine

-First line therapy is behavioral therapy
-Melatonin has no dosage guidelines for pediatrics
-Antihistamines: benadryl and hydroxyzine are widely used in pediatrics
-Benadryl is not recommended in children with parainsomnias
-guanfacine (Intuniv): for children with ADHD that have severe sleep problems

Describe a group of sleep disorders that occur during NREM and REM
-Confusional arousal
-Somnambulism (sleep walking)
-Night terrors
-Rhythmic movement disorders
-Benign neonatal sleep myoclnus
-Bruxism
-Nocturnal enuresis
-Nightmares (REM)

-SDB
-RLS
-Sleep deprivation
-Stress
-Fever
-Being overheated
-Full bladder
-Use of central nervous system depressants
-Benadryl usage

-Confusional arousals
-Sleep walking
-Night terrors

-Occurs when a child is awakened from a deep sleep during the first part of the night and is known as excessive sleep inertia or sleep drunkenness
-Children will sit up, appear dazed and react slowly
-Begin at 2 years old and diminish by 5 years old

-Begins at confusional arousals, but can also begin with the child getting out of bed and running with complex movements
-Child appears dazed with open eyes and the speech is mumbled
-Begins around 4 years old and resolves by 8 years old

-Extreme state of agitation when a child awakes from N3 screaming
-Dilated pupils, increased heart rate and sweating
-Asleep during event with no recollection
-Beings around 18 months and resolves by 6 years

Nightmares

-Sudden arousal from sleep to a fully awake state
-Begins at 36 to 72 months and resolve by 6 years old
-Occur during last portion of the night

Can be normal, but if prolonged or is causing harm, further evaluation is warrented

-Delayed sleep phase
-Advanced sleep phase
-Inappropriate or unpredictable schedule

-Sleep beigns at a late hour and is followed by late awakening
Management:
1. Keep the nighttime routine in place, but awaken the child earlier each morning in 15 minute increments
2. For older children or adolescents who are off schedule by many hours (summer vacation), it could take weeks to back up the cycle appropriately using 15 minute increments. In this case, it is better to go forward in time. In other words, have the child remain awake until the next evening and then go to bed at the desired hour, beginning the desired routine from that point.
3. Have the child or family keep a sleep log to document gradual change.

-Sleep cycle begins too early with correlated early rising
-Meals, naps and bedtime should be delayed until the desired times

Poorly organized sleep-wake cycle

-Occurs in children who have never attained dryness at night
-Strong family predisposition

-Occurs in children who have previously been potty trained
-Associated with sleep disordered breathing
-Resolution occurs usually after treatment for SDB

-Sensory and motor disorder characterized by irritating sensations in the legs accompanied by an irresistable urge to move legs, which typically helps
-Etiology: altered brain acquisition of iron while iron levels are normal
-Secondary causes: peripheal neuropathy, uremia, and medications (SSRIs, sedating antihistamines, and dopamine receptor antagonists)

-Repetitive jerks, typically in the legs, that occur ever 5 to 90 seconds.
-PLMs can occur without RLS
-Etiology: genetic factors, dopaminergic dysfunction, and low iron storage status
-PLMs and nighttime arousals are increased with zoloft and other SSRI's

-Awakening 1-3 hours of sleep followed by screaming, kicking, crying and slapping the legs or by verbally expressing that their legs hurt
-Itchy/crawly sensation
-Associated with fragmented sleep, unrefresed sleep, insomnia, daytime sleepiness, and hyperactivity

-Based off of history and physical examination
-If there is a suspicion for SDB, a PSG is warranted and if 5 or more PLMs per hour are experiences, PLM is diagnosed
-Ferritin levels: <50 is associated with RLS and PLM

-A study or test done while you're fully asleep.
-A doctor will observe you as you sleep, record data about your sleep patterns, and may identify any sleep disorders.
-During a PSG, the doctor will measure the following to help chart your sleep cycles: brain waves. skeletal muscle activity.

-Ferrous sulfate supplementation (3 mg/kg/day)
-Clonazepam and gabapentin if ferritin levels are normal and other casuses have been ruled out

-Rhythmic movement disorder can occur while a child is attempting to fall asleep and may repeat throughout the night when the child is trying to return to sleep
-Seen commonly before the age of 2
-Self limiting and rarely needs intervention

-Teeth grinding and clenching of teeth
-Occurs in ages 10-20 years
-Associated with stress
-Rarely associated with temporal lobe seizure activity

-Good clinical history can distinguish seizures from parainsomnias
-Frontal lobe seizures occur during sleep

-Occurs as an interited form (autosomal dominant NFLE) or sporatically and the events can be more complex than typical seizure with volcalizations, complex automatisms, and ambulation
-Wakes up fully after the event and has full recollection
-Typical academic decline
-Routine EEGs and MRIs show no abnormalities

-Used to differentiate NFLE and parainsomnias
-Contains specific questions about the age of onset, duration, timing, characterists such as stereotypical movements and vocalizations and recall

Continum of simple snoring and upper airway resistance to OSA

-Characterized by upper airway obstruction, abnormal respiratory pattersn and fragmented sleep
-Age prevalence is 2-6 years old
-Untreated OSA can cause: physical, mental and cognitive problems

-Snoring
-Gasping
-Apneas
-Increased work of breathing with paradoxic respirations
-Neck hyperextension
-Night sweating
-Tachycardia
-Restless sleep
-Disturbed sleep
-Persistent parainsomnias
-Behavioral problems
-ADHD

-Tonsillar or adenoid hypertrophy
-Obesity
-Craniofacial abnormalities
-GERD
-Neuromuscular disorders
-Untreated allergic rhinitis

-First-line therapy: adentonsillectomy (TA)
-PSG to confirm diagnosis before a TA
-Partial tonsillectomy,
-Craniofacial surgery (mandibular distraction for micrognathia),
-Trach (severe cases)

-Positive airway pressure (PAP)
-Nasal steroids
-Leukotriene receptor antagonists (Montelukast)
-NS rinses
-Rapid maxillary expanision (RME)
-Oral appliances
-Weight loss

-Can be used as first line therapy for SDB
-Orthodontic procedure used to expand a constricted maxillary or mandibular arch correcting posterior crossbites and malocclusions
-Placing a temporary brace on the upper or lower maxilla that can be manipulated manually to widen the area for typically 8 months
-Improve SDB by widening the width of the nasal cavity, improving mouth breathing, and reduce airway resistance

-22 item questionnaire
-Asks about snoring frequency, observed apneas, difficulty breathing during sleep, daytime sleepiness, and inattentive or hyperactive behavior

-Absences of airflow that are related to failure of the venilator control system to stimulate breathing
-Not associated with a snore or gasp, but with a sigh
-Common in premature infants, narcotic usage or those with neurologic conditions such as cerebral palsy, brainstem lesions or Chiari malformations
-BIPAP may be needed if hypoventialtion is involved

-Characterized by exessive daytime sleepiness, fragmented nocturnal sleep and signs of REM intrusion (cataplexy)
-Imbalance among wakefullness, REM and SWS states that can range from mild to severe
-Symptoms

-Sleep-onset paralysis
-Hyponogogic hallucinations: vivid dreamlike visual, tactile or auditory hallucination that occur as the patient is falling asleep (may hear someone whispering in their ear)

-Brief sudden loss of skeletal muscle tone which is trypically brought on by laughter but can also be stimulated by other strong emotions
-Symptoms: neck, facial, and knee weakness (respiratory muscles are not affected)

-Rare and requires a sleep specialist and medication
-Caused by a deficiency of hypothalamic hypocretin or orexin

-A primary care nurse practitioner delivers comprehensive chronic continuous care characterized by a long-term relationship.
-An acute care nurse practitioner delivers restorative care characterized by rapidly changing clinical conditions.
-PNP's working in specialty care may move between the inpatient and outpatient care settings.

-NAPNAP historically defined the age population cared by PNPs as all children from birth through 21 years old.
-In specific situations, indivduals older than 21 years can continue to receive health care from PNPs until care can be successfully transitioned to adult health care providers.

Absence of unfair or remediable differences in health services and health outcomes among populations.

-Greatest challenges is how to access, acknowledge, and include the child's voice.
-Two patients, the child who is the focus and the parent who is considered the authority in terms of decision.

Encompasses an understanding of oneself as a cultural being and one's conscious and unconscious biases toward others.

Being open-minded to all cultures and attitudes is key to cultural sensitivity.

-Toilet training should NOT start before 18 to 24 months.
-PCPs should emphasize that every child is unique, and the child's development, readiness, when begining toilet training.

-External examination of the perineum.
-Anus
-Urinary Meatus
-Base of the spine
-Auscultation and Palpation of the abdomen for bowel sounds, softness, masses, peristalsis, and tenderness.
-Perform an age-appropriate gross motor neurologic exam.
-A rectal digital exam is NOT warranted for healthy children.

Fecal soiling or fecal incontinence in the underwear or inappropriate places after an age when the child should be able to control bowel movements, usually 4 years old

In children who have never been potty trained

In children who have been potty trained

-Associated with stool retention, constipation, and incontinence overflow (functional retentive fecal incontinence)
-Stool retention leads to distention of the rectum, stretching of the rectum, ineffective peristalisis, weakened rectal and sphincter muscles and decreased sensory threshold in the rectum

-No stool retention
-Overflow incontinence or voluntary bowel movmeents in their clothing or other innapropriate places
-Behavioral problems

-First line: PEG or Lactulose.
-Second Line: milk of magnesium, mineral oil, and stimulant laxatives.
-Enemas NOT recommended for maintenance therapy.

Child demonstrates a pattern of successfully using the toilet to urinate, but refuses to use the toilet for bowel movements.

-Individualized
-Helps the adolescent understant, respond to, and take responsibility for their own behavior and development
-Separate discussions need to be conducted with parents to helo them understand and support their child's maturation and need for independence

-Process by which the body is artificially induced to mount a defense against certain foreign antigens
-The immune system is primed to provide future protection with the next exposure to these same antigens

Involves introducing either a live attenuated vaccine or a toxoid (inactivated toxin)

Involves administering an exogenous antibody, such as an immunoglobulin

-Concerns vaccines are not safe
-Cause autism
-Overload and weaken the child's immune system
-Feel their child is vulnerable to adverse reactions given a family history
-Child was premature
-Underlying medical condition
-Unsatifactory past experiences with healthcare system
-Distrust in government agencies
-Live in a community supporting under-immunization
-Personal religious beliefs against immunizations
-Lack of access to care
-State poilicies that ake it easy to exempt their child
-Believe there are other effective measures to avoid infection (handwashing/face masks)

-Presumptive: "these shots are due today"
-Participatory: "what shots do you want your child to receive today"

-Acknowledge and respect the trusted relationship between provider and parent
-Communicate a strong shared commitment with the parent to the health and well-being of their child
-Listen to and query parents' reasons for refusing or delaying vaccines; not all vaccine-hesitant individuals have the same concerns
-Be familiar with misconceptions and controversies regarding vaccines and be prepared to address them (thimerosal-free vaccines)
-Emphasize the safety of vaccines, the extensive testing before licensure, and the postlicensure safety surveillance programs
-Explain the serious consequences of not vaccinating
-Educate the family about the safety of multiple vaccines at the same time (a child can handle 2000-6000 antigens daily and there are 150 antigens in the entire immunization schedule)
-Emphasize the balance between risk and benefits that the risk associated with diseases is greater than the risk of a seious adverse vaccine reaction
-Provide a vaccine information statement (VIS) or other educational materials

-Do not include a live organism in them, just the protein remnants that induce antibody responses
-Provides systemic protection (IgG) but may fail to trigger local mucosal antibody (IgA) production, which can result in local colonization or infection that can be a problem during an epidemic

-Have an attenuated form of the virus, which induces immunity but does not produce disease
-Usually confer broader and longer-lived immunity than the inactivated types which require booster vaccines

-MMR, varicella zoster, influenza, Hep B, meningococcal, and tetanus: containing vaccines are linked to anaphylaxis
-Vaccine injections can cause syncope, fainting, deltoid bursitis, shoulder pain, and loss of shoulder motion
-After MMR, febrile seizures (benign without sequelae) and measles inclusion body encephalitis (rare) in immunocompromised children can occur within a year of vaccination
-Varicella zoster vaccine has a casual relationship to some adverse events: chickenpox rash, pneumonia, meningitis, hepatitis in children with immunodeficiencies; viral reactivation leading to meningitis or encephalitis

-Multipdose vials of inactivated flu vaccines
-Multidose vials of one meningococcal vaccine

-Requires standardized VIS consent forms for all vaccines, warning parents and caregivers about possible adverse events
-Vaccine lot number, site of inoculation, and name of the person administering the vaccine must be included
-Healthcare providers are required to report adverse events that occur after immunizations
-Suspected reactions should be reported to the Vaccine Adverse Event Reporting System (VAERS)

1. For children 0-6 years old
2. For children 7-18 years old
3. A catch-up schedule for children 4 months to 18 years old who start their vaccines late, who is delayed or for whom an immunization history is unknown

-If 2 live virus parenteral vaccines are given less than 28 days apart, the vaccine given second should be disregarded; repeat this second vaccine at least 4 weeks later
-Do not aspirate the syringe before injection; do not recap the needle after use
-When multiple vaccines are given on the same extremity, the sites of injection should be 1 inch apart
-Use only written dated records. Parents or guardians recollection of a child's immunization status may not be reliable
-Reimmunization of an immune individual is not harmful
-Reduced or divided doses of vaccines should not be given
-In some circumstances (travel, country epidemics, delayed immunizations) an accelerated schedule is available

-Applying pressure or rubbing near the injection site for about 10 seconds before vaccination
-Putting sucrose on the tongue or pacifier of an infant
-Having children blow a pinwheel or bubbles during the procedure
-Having the child sit upright on the caregivers lap or hug the caregiver chest to chest
-Pretreatment of acetaminophen and ibuprofen is no longer recommended

-Anaphylaxis with a prior dose or to a vaccine component
-Severe allergy to latex

-Diphtheria-tetanus-pertussis
-Polio
-Hib
-Hep A
-Hep B
-HPV
-Meningococcus
-Pneumococcus

-Mild to moderate fever
-Local swelling
-Pain
-Erythemia usually within the first 24-72 hours

-DTaP is used for children 7 years and younger
-Tdap is for 7 years and older
-Sterile abscesses can occur due to a vaccine hypersensitivity response or hypersensitivity of a component of the vaccine such as aluminum
The pertussis component is less effective
-Adolescents should receive boosters to protect infants from pertusses since they are a predominant source

Hib is the most virulent accounting for pneumonia, meningitis, epiglottitis, septic arthritis, cellulitus, bacteremia, otitis media, purulent pericarditis and other common infections in children <4 year old

-Either immunoglobulin or a single dose of HAV vaccine shows efficacy for preventing symptomatic disease if given within 14 days of exposure.
-Reccomendations of those who should receive the vaccine:
Those traveling to countries where HAV is endemic
Those residing in and in contact with others from communities with a high HAV incidence or outbreak
Children in diapers in day care centers with high rates of HAV
Men who have sex with men
Individuals with severe illness (chronic liver disease)
Illicit-drug users
Those with blood-clotting disorders (hemophiliacs)
Unvaccinated persons >1 year who are household members and/or close contacts of an international adoptee from a country of high or intermediate endemicity within 60 days after the adoptee's arrival

-Preterm infants weighing <2000g should be immunized when they are 1 month old, while infants weighing >2000g should be vaccinated prior to hospital discharge
-Rcommendations of those who should receive the vaccine:
Hemophiliac patients and other recipients of certain blood products
IV drug users
Individuals with HIV, chronic liver disease or on hemodialysis
Herterosexual persons with a history of multiple sex partners in the previous 6 months or with recent sexually transmitted infections
Men who have sex with men
Household and sexual contacts of those who have HBsAg positive
Foreigh-born individuals (including adoptees) from countries with HBsAg
Susceptible child who bit a person with chronic HBV infection
Staff and residents of residential institutions for the developmentally disabled
Staff and attendees of nonresidential day care and school programs for developmentally delayed if an identified HBV carrier is known to attend or poses a risk of infecting others
Healthcare workers and others with occupational risk
International travelers who travel to areas where endemicity for HBV is >2% and who otherwise may be at risk
Innmates in juvenile detention and other correctional facilities if unimmunized or under-immunized
Individuals with diabetes between the ages of 19-59 years old

-The influenza vaccine is formulated yearly based on epidemiologic forecasts
-2 influenza vaccines are available:
1. Either contain 3 virus strains (influenza A and one lineage of influenza B)
2. Or the 2 influenza A stains plus 2 lineages of influenza B (quadrivalent)

-Measles-Mumps-Rubella
-Rotavirus
-Bacille Calmette-Guerin
-Smallpox

-Important for providers to consult with infectious disease experts and authoritative reference resources when contemplating administering a live vaccine to immunocompromised individual’s
-An individual with a low T-cell count or a cellular immunodeficiency can be seriously compromised if given an LAIV

-Measles component is responsible for almost all the adverse reactions to the MMR vaccine
-Transient rash and fevers of 103 degrees can occur 5-12 days post vaccine
-Contraindications: pregnancy, anaphylaxis to eggs, gelatin, neomycin or prior MMR vaccine, and febrile seizures

-Entails injecting individuals with a solution of preexistin antibodies to prevent or ammend an infectious disease
-Reserved for individuals who suffer from immunodeficiencies in whom a live or attenuated vaccine could be dangerous or for those who have a problem making antibodies
-People at high risk for developing severe complications from an infectious disease should receive postexposure passive immunization
-Some individuals who suffer from disease-produced toxins benefit from antitoxin passive immunization (poisonous snakebite, tetanus, botulism and diphtheria)

-Passive immunization
-Indicated for unimmunized or under-immunized patients exposed to an infectious disease and those whose incubation period is not long enough to allow complete active immunization

-Infants born before 29 weeks during RSV season until they are 12 months old
-Children born prematurely before 32 weeks, who are younger than 2 years old with chronic lung disease and who required treatment for the CLD within 6 months of the onset of RSV season
Given to 2-year old children with CLD of prematurity who continue to require medical support during the 6 months prior to the onset of RSV season
-Infants up to 12 months with hemodynamically significant cyanotic or complicated congenital heart disease
-Infants up to 12 months with neurmusclular disorder or congenital abnormalities that compromise clearing of respiratory secretions