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S
PCOM Board Review: Pediatrics
Tod Winslow, DO March 5, 2016
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Overview
S Newborn
S Growth and Development
S Infectious Disease
S Musculoskeletal
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Newborn
S Neonate/Newborn: First month of life
S Infant: First year of life
S Neonatal resuscitation: Review BLS, NRP, ACLS, etc
S APGAR’s Appearance Pulse Grimace Activity Respirations
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Newborn Sign 0 1 2
HR Absent <100 ≥ 100
Respiratory effort Absent Slow/irregular Good/crying
Muscle tone Limp Some extremity flexion
Active motion
Response to bulb in nostril
No response Grimace Cough/Sneeze
Color Blue/pale Pink body/Blue extremities
Completely pink
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Newborn
S Nutrition S Breast milk (and most formulas) 20 calories/ounce (1oz =
30mL)
S Energy requirement = Fluid requirement
S 0-10kg 100 kcal/kg 100 mL/kg
S 11-20 50 kcal/kg 50 mL/kg
S ≥20kg 20 kcal/kg 20 mL/kg
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Newborn
S Can lose up to 10% of birth weight the first few days
S Should be back to birth weight by two weeks of life
S ≥ 6 wet diapers/day; 1-3 stools/day
S Vitamin D: 400 IU/day – should be sent home from nursery on Vitamin D (MVI)
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Newborn Rashes
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Newborn Rashes
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Newborn Rashes
S Erythema Toxicum Neonatorum: 50% full term infants, begin at 24-48 hours (can begin up to 10 days out). Fades within one week.
S Salmon Patch “Stork Bite” “Angel’s Kiss” >50% newborns, due to capillary malformations. Fade within first year.
S Capillary Hemangioma: Rapid growth first 6 months, plateau period, then slow involution: 25% disappear by age 3, 50% by age 4, 75% by age 6.
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Newborn Rashes
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Newborn Rashes
S Milia: S Retained keratin in the dermis
S 1 to 2 mm white/yellow papules
S Resolve in 1 to 3 months
S Miliaria Rubra: Heat Rash S Small erythematous papules and vesicles
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Newborn Rashes
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Newborn Rashes
S Acne Neonatorum S Hormonal stimulation of sebaceous glands S Resolves within 4 months S 2.5% benzoyl peroxide lotion
S Transient Neonatal Pustular Melanosis S Pigmented macules in Vesiculopustules - no erythema S Vesicle ruptures leaving scale/pigmented macule S Fades in 2 to 4 weeks
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Newborn Rashes
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Newborn Rashes
S Seborrheic Dermatitis S Erythema and greasy scale
S Scalp, face, ears, neck and diaper area
S Resolves in weeks to months
S White Petrolatum, Coal Tar shampoo, HCT 1%
S VS. Atopic Dermatitis – no pruritis S Develops after 3 months of age.
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Newborn Cardiology
S Cardiology
S VSD 25%, PDA 10%, most others 1-5%
S VSD: Loud holosystolic murmur, LLSB. May not hear in nursery due to higher right sided pressures first few days of life.
S PDA: Continuous machine-like murmur.
S Both represent left-to-right shunts and are often present with other cardiac anomalies.
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Newborn Cardiology
S Tetralogy of Fallot S Pulmonic Stenosis
S RVH S VSD
S Overriding Aorta
S Clinical manifestations: First few years of life S Play/DOE/Lay down/Play cycle S Tet spells: Exertional dyspnea, hypercyanosis, and possibly
syncope
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Newborn Jaundice
S Neonatal Jaundice in Term Infants
S Physiologic Jaundice S <5mg/dL/24 hours
S On 2nd or 3rd day of life
S Peak 2nd to 4th day
S Resolve 5th to 7th day
S Never reaches 12mg/dL
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Newborn Jaundice
S + Coombs: Rh, ABO, or minor antigen incompatibility
S - Coombs: S Breast feeding jaundice: due to decreased enterohepatic
circulation S Breast milk jaundice: Late onset jaundice due to antibodies S Hemorrhage (cephalohematoma) S G6PD deficiency, Hereditary spherocytosis, etc. Direct hyperbilirubinemia – rare – think biliary atresia or some other
cause of obstruction.
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Newborn Jaundice
S Prevention S Promote/support breast feeding – 10 to 12 feeds/24 hours
S Measure bilirubin in all jaundice infants < 24 hours
S Interpret levels based on age in hours
S Identify/monitor higher risk infants S Preterm - < 37 weeks
S Macrosomia/GDM
S Siblings
S Bruising/cephalohematoma
S Jaundice < 24 hours
S Provide written instructions for parents
S Follow-up after DC
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Newborn Jaundice
S Treatment: S Use Nomogram to plot bilirubin level based on age(hours)
S Fix underlying cause
S Phototherapy (converts indirect bilirubin into water soluble form). Decision to use based on plotting newborn on chart for age, TSB, and risk factors.
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Newborn - Eyes
S Conjunctivitis: S If chlamydia, occurs between 8 and 14 days with a watery
discharge. Need to treat with ORAL erythromycin.
S Esotropia: If intermittent, likely to resolve by 6 months of age, so no need to refer to ophthalmology until then.
S Lacrimal Duct Obstruction: Excessive tearing, usually unilateral. Likely to resolve by 12 months, so no need to refer to ophthalmology until then.
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Newborn - GI
S Failure to pass Meconium – 1st 24 hours
S Pyloric Stenosis: Non-bilious “projectile” vomiting at around 3 weeks of life. “Olive-like” mass palpated
S Gastroesophageal Reflux
S Gastroesophageal Reflux Disease
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SIDS
S Sudden Infant Death Syndrome S Unexplained death of infant < 1year during sleep
S RISK FACTORS S <37 weeks EGA, weight < 2500 gms
S Bed sharing < 12 weeks or at ANY time S Maternal ETOH S Household smoke exposure
S Soft bedding S Car seat/stroller use S No prenatal care and Poverty
S Males sex S Black, Native American, Native Alaskan S Overheating/excess Bundling
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SIDS
S BACK to SLEEP Campaign S PRONE and SIDE SLEEPING POSITIONS
S Including use of a care seat or stroller
S Risk Reduction S Exclusive BREASTFEEDING at 1 month of age S Pacifier use
S Asian/Pacific Islander ethnicity
S Home Apnea Monitors
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Growth and Development Age Expressive Response % intelligible speech to
stranger
12 months 1 word
2 years 2 word phrases (“want cookie”)
50%
3 years 3-4 word sentences. Uses pronouns and plurals (“I want a cookie.”)
75%
4 years Tells a story 100%
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Age Receptive Expressive12 months — Does not babble, point, or gesture
15 months Does not look at or point to 5 to 10 objects or persons when named by parents
Does not use at least three words
18 months Does not follow one-step directions Does not say “mama,” “dada,” or other names
2 years Does not point to pictures or body parts when named
Does not use at least 25 words
2.5 years Does not verbally respond or nod/shake head to questions
Does not use unique two-word phrases, including noun-verb combinations
3 years Does not understand prepositions or action words
Does not follow two-step directions
Does not use at least 200 words
Does not ask for things by name
Repeats phrases in response to questions (echolalia)
At any age — Has regressed or lost previously acquired speech/language milestones
Red Flags Suggesting Need for Immediate Speech-Language Evaluation
Adapted with permission from Schum RL. Language screening in the pediatric office setting. Pediatr Clin North Am.2007;54(3):432.
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Growth and Development
S Evaluation S Appropriate growth chart S Infants – weight, length, head circumference S 2 – 20 y/o – weight, height and BMI
S Variation should stay within 2 bands
S Birth weight S Doubles by 4 months S Triples by 12 months
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Growth and Development
S Birth to 18 months S Catch-up or catch-down
S Growth genetically determined by midparental height
S 2 years to Adolescents S Growth hormone
S Adolescents S Sex hormones are predominant factor
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Growth and Development
S Evaluation S History & PE S Growth Velocity S Midparental Height S Bone Age S LAB
S Endocrine – normal/over weight
S GI/Nutrition/Systemic Disease – under weight S Genetic
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Growth and Development
S Constitutional Growth Delay S Most common cause of short stature in children S Growth delay between 3 months and 3 years S Delay in puberty so remain behind on growth curves until later in
adolescence S Growth and development are appropriate for skeletal age, but not biologic
age
S Familial Short Stature S Follows growth curves and bone age S Look at the parents!
S Idiopathic Short Stature
S no identifiable pathology
S > 2 standard deviations below with normal bone age and growth velocity
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Infectious Disease
S Fever: 100.4 Fahrenheit/38 Celsius. Appropriate biologic response to infection. Not caused by teething.
S Febrile Seizures: S Seizure in absence of: intracranial infection, history of afebrile
seizure, metabolic disturbance. S 2-5% children ages 6 months to 5 years (peak 18 months) S Risk of recurrence 14-70% depending on risk factors (<18 months,
fever less than 1 hour prior to seizure, temp < 104, first degree relative with febrile seizure)
S 2% lifetime risk of epilepsy
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Infectious Disease
S Sepsis
S <28 days with fever:
S Admit to hospital, LP, Blood cultures, Urine culture, IV antibiotics
S 28-90 days with fever:
S If non-toxic appearing with normal WBC’s and normal UA, blood and urine cultures, close follow-up, +/- LP & Ceftriaxone
S Otherwise, admit to hospital, LP, Blood cultures, Urine culture, IV antibiotics
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Infectious Disease Infection Bugs Antibiotics
Meningitis <1 month LEG Listeria, Enterics (especially E.coli), GBS
Ampicillin + Cefotaxime OR Ampicillin + Gentamicin
Meningitis 1-3 months NEHSG Neisseria meningitides, Enterics, H. flu, Strep pneumo, GBS
Ampicillin + Cefotaxime OR Ceftriaxone
Meningitis >3 months minus Enterics and GBS Cefotaxime or Ceftriaxone + Vancomycin
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Infectious Disease
S UTI S VCUG’s no longer recommended for febrile UTI’s in children
2-24 months unless abnormal renal ultrasound
S Still get renal sonogram for girls with febrile UTI’s 2-24 months and boys of any age
S PEES: Proteus, E. coli, Enterococcus, S. saprophyticus
S PO: Cephalosporins, TMP/SMX
S IV: Cephalosporins, Ampicillin + Gentamicin
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Infectious Disease
S Acute Otitis Media: S Acute onset, Middle Ear Effusion (MEE), Signs/Symptoms of
Middle Ear Inflammation
S MEE: Bulging, decreased mobility, or AFL behind TM.
S Inflammation: Erythema of TM on exam, or distinct otalgia
S Bacterial 75% of time: S. pneumo (40%), H. flu (30%), Morexella catarrhalis (15%)
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Infectious Disease Age Toxic appearing, persistent
otalgia for > 48 hours, temp ≥ 102.2, or uncertain access to follow-up
Non-toxic, otalgia not persistent, temp < 102.2, and certain access to follow-up
< 6 months Antibiotics Antibiotics
≥ 6 months Antibiotics Observe for 48-72 hours
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Infectious Disease
S Acute Otitis Media: S Amoxicillin 80-90mg/kg per day (high dose to overcome
resistant S. pneumo) divided twice daily
S Amoxicillin-clavulanate if accompanying conjunctivitis (think H. flu) or if failure with Amoxicillin
S Non-type 1 PCN Allergy – cephalosporins, if Type-1 PCN allergy, macrolides or Clindamycin
S Analgesics (oral and/or ear drops)
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Infectious Disease
S Otitis Media with Effusion (OME) S MEE without inflammation or severe illness
S Treatment is observation for up to three months, then tympanostomy tubes if not resolved
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Infectious Disease
S Bronchiolitis: S Most common cause of infant hospitalization in 1st year
S Lower respiratory tract infection/bronchiolar inflammation
S Most commonly caused by RSV
S Bronchodilators are now contraindicated in infants < 24 months – increased tachycardia/decreased O2 saturation
S Corticosteroids/Aerosolized Epi/Hypertonic Saline Saline/ Antibiotics – CONTRAINDICATED
S High Risk - <12 weeks, Prematurity, Cardiopulmonary Disease, Immunodeficiency
S Prophylaxis – Palivizumab(Synagis) – high risk infants only
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Infectious Disease
S Pneumonia S S. pneumo and Viral - high dose amoxicillin sufficient until
preschool age
S Add macrolides for atypical coverage at age 4
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Infectious Disease
S Pertussis: “Whooping Cough” S Catarrhal stage (common cold symptoms)
S Paroxysmal stage (paroxysmal cough)
S Convalescent stage (waning of cough over weeks to months)
S Treat with macrolides, most effective if given during catarrhal stage but should be given at any phase to prevent spread.
S Immunize, immunize, immunize!
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Infectious Disease
S Antibiotic contraindications S Ceftriaxone in neonates (up to 28 days)
S Displaces bound bilirubin and thus can cause hyperbilirubinemia
S Tetracyclines under age 8 S Tooth discoloration
S Fluoroquinolones in children and adolescents S Cartilage/Joint damage
S Erythromycin under 1 month S Pyloric stenosis
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Infectious Disease/Rashes
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Infectious Disease/Rashes
S Roseola Infantum(exanthema subitum) S Human herpesvirus 6 S Infants/children <3 S Macular/maculopapular S High Fever >102, well appearing child S Mild cough, rhinorrhea, mild diarrhea S Fever resolves then onset of rash S Starts on trunk/spreads peripherally S Lasting 1 to 2 days S DDx: measles
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Infectious Disease/Rashes
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Infectious Disease/Rashes
S Fifth Disease “Erythema Infectiosum” S Human Parvovirus B19
S Slapped-cheek appearance
S Lace-like rash on trunk, moving to arms, thighs, and buttocks
S Rash preceded by brief and mild illness (fever, sore throat, malaise, myalgias, headache) by 7 days
S Facial rash 2 – 4 days, Reticular rash 1 to 6 weeks
S Can cause fetal hydrops, IUGR, and fetal death
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Infectious Disease/Rashes
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Infectious Disease/Rashes
S Henoch-Schonlein Purpura S Most Cases < 10 y/o, Peak age 6 S TRIAD: Palpable Purpura(normal PLT), Abdominal Pain(60%)
and Arthritis(75%) S Petechial rash that develops into purpura on buttocks, lower
extremities, and hands – trunk and face are spared S Abdominal pain ranges from mild colic to severe pain
(hemorrhage or intussusception in 5%) S Knees and ankles most common sites of arthritis S 40 - 50% have renal involvement (ranges from hematuria or
proteinuria to ESRD in 1 to 5%) S Early treatment with Prednisone
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Infectious Disease/Rashes
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Infectious Disease/Rashes
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Infectious Disease/Rashes
S Hand, foot, and mouth disease S Coxsackie Virus - enteroviruses
S Late summer/fall
S Prodrome of low grade temp, anorexia, malaise, URI symptoms
S 90% have oral lesions (palatal erythema and ulcers)
S 2/3 have shallow yellow ulcers surrounded by halos on hands and feet
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Kawasaki Disease/Rashes
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Kawasaki Disease/Rashes
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Infectious Disease/Rashes
S Kawasaki’s Disease
S “FEEL My Conjunctivitis” S Fever – x 5 days S Erythematous Rash – maculopapular/polymorphous S Extremity involvement – erythema/desquamation S Lymphadenopathy - cervical S Mucus membrane involvement –cracked/red lips, strawberry
tongue S Bilateral conjunctivitis
S Coronary artery aneurysms – Transthoracic Echo
S Treat with high dose aspirin and IVIG
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Infectious Disease/Rashes
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Infectious Disease/Rashes
S Scarlet Fever S 10% of Streptococcal tonsillopharyngitis S Group A beta-hemolytic streptococci – pyrogenic exotoxin S Fever, Sore Throat first S Sandpaper rash S Pastia lines S White strawberry tongue, palate petechiae S Rapid Strep Antigen test in office/Throat Culture S PCN/Cephalosporin/macrolides/Clinda
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Infectious Disease/Rashes
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Infectious Disease/Rashes
S Pityriasis Rosea S Herald Patch – 80%
S Peripheral scale overlying pink thin papules
S Bilateral, symmetrical, Christmas tree pattern
S Mild URI may precede rash
S 2 to 12 weeks
S ? Human herpes virus 6 and 7
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Infectious Disease/Rashes
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Infectious Diseases/Rashes
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Infectious Disease/Rashes
S Tinea Corporis/Capitis/Cruris/Pedis/Manus/unguium S KOH microscopy, fungal culture
S Scaling/circumscribed alopecia with broken hair follicles
S Erythematous annular patch with raised border and central clearing
S Capitis – oral griseofulvin or terbinafine(Lamisil)
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Infectious Disease/Rash
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Infectious Disease/Rash
S Impetigo S Vesicles or Pustules with thick yellow “honey” crust
S Face and extremities most common
S Streptococcus pyogenes
S Topical Mupirocin ointment or oral PCN
S Bullous form in neonates – Staph aureus
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Infectious Disease/Rash
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Infectious Disease/Rash
S Molluscum Contagiosum S Poxvirus
S Children 2 to 11, Adolescents – sexually active
S Flesh colored, pearly papules with central umbilication
S Watchful waiting – months to years
S Cryotherapy, imiquimod(Aldara) or intralesional immunotherapy
S Treat underlying atopic dermatitis to prevent spread
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Infectious Disease/Rash
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Infectious Disease/Rashes
S Herpes Gladiatorum S Wrestlers - 75%+ exposure by college
S Vesicular rash on red base
S Localized patches – associated with areas of abrasions/friction
S Highly contagious
S Treat with antiviral – valacyclovir, acyclovir
S Suppression therapy for season
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Infectious Diseases
S Mononucleosis/EBV S Sore throat, fever
S tonsilar enlargement
S Fatigue
S Lymphadenopathy
S pharyngeal inflammation
S palatal petechiae
S 15 to 24 years of age
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Infectious Disease
S Mononucleosis/EBV Diagnosis S Heterophile Antibody – up to 90% accuracy S CBC – absolute lymph > 4,000 mm3 S EBV specific IgM and IgG
S Treatment S Glucocorticoids S Antiviral Therapy
S Complications S Splenic rupture/sports – 0.5% risk S Airway compromise S X-linked lymphoproliferative disorders/immunocompromised
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Musculoskeletal
S Nursemaid elbow S Traction injury of 2-3 year olds
S Can treat with hyperpronation or supination/flexion
S Hyperpronation is the preferred method
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Musculoskeletal
S Female Athlete’s Triad S Anorexia, osteoporosis, and amenorrhea
S Transient Synovitis, Septic Hip, and Osteomyelitis S Assuming normal radiographs, if afebrile and normal CBC/
ESR/CRP then likely Transient Synovitis (observe/NSAID’s) S If any of the above are present, obtain hip ultrasound and
aspirate if effusion or, if no effusion, check MRI to rule out osteomyelitis
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Musculoskeletal
S Slipped Capital Femoral Epiphysis (SCFE) S Overweight, Adolescent, Male > Female S Ice cream falling off of cone on hip x-ray S Treat with surgery
S Apophysitis S Osgood Schlatter – Tibial tuberosity S Sever’s Disease – Insertion of Achilles tendon into calcaneous S Treat with rest, ice, and NSAID’s
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Questions
S During rounds, you notice a new rash on a full-term 2-day old white female. It consists of 1-mm pustules surrounded by a flat area of erythema, and is located on the face, trunk, and upper arms. An examinatiion is otherwise normal, and she does not appear ill. Which one is the most likely diagnosis?
A. Erythema toxicum neonatorum
B. Transient neonatal pustular melanosis
C. Acne neonatorum
D. Systemic herpes simplex
E. S. aureus species
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Questions
S During rounds, you notice a new rash on a full-term 2-day old white female. It consists of 1-mm pustules surrounded by a flat area of erythema, and is located on the face, trunk, and upper arms. An examinatiion is otherwise normal, and she does not appear ill. Which one is the most likely diagnosis?
A. Erythema toxicum neonatorum
B. Transient neonatal pustular melanosis
C. Acne neonatorum
D. Systemic herpes simplex
E. S. aureus species
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Questions
S A 12 year old male is brought to your office by his parents because he has been limping for the past month. He says he has pain in the groin and knee, but the pain is poorly localized. On examination he is noted to be obese, with normal findings on examination of the knee. There is some decrease in internal rotation of the hip on the involved side. His gait is antalgic. The most likely cause of this problem is
A. Unreported trauma
B. Aspectic necrosis of the femoral head
C. Reactive arthritis
D. Juvenile rheumatoid arthritis
E. Slipped capital femoral epiphysis
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Questions
S A 12 year old male is brought to your office by his parents because he has been limping for the past month. He says he has pain in the groin and knee, but the pain is poorly localized. On examination he is noted to be obese, with normal findings on examination of the knee. There is some decrease in internal rotation of the hip on the involved side. His gait is antalgic. The most likely cause of this problem is
A. Unreported trauma
B. Aspectic necrosis of the femoral head
C. Reactive arthritis
D. Juvenile rheumatoid arthritis
E. Slipped capital femoral epiphysis
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Questions
S Which one of the following is an appropriate rationale for antibiotic treatment of Bordatella pertussis infections?
A. It delays progression from the catarrhal stage to the paroxysmal stage
B. It reduces the severity of the symptoms
C. It reduces the duration of the illness
D. It reduces the risk of transmission to others
E. It reduces the need for hospitalization
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Questions
S Which one of the following is an appropriate rationale for antibiotic treatment of Bordatella pertussis infections?
A. It delays progression from the catarrhal stage to the paroxysmal stage
B. It reduces the severity of the symptoms
C. It reduces the duration of the illness
D. It reduces the risk of transmission to others
E. It reduces the need for hospitalization
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Questions
S Four weeks after successful initial treatment of unilateral otitis media in a 2-year-old male enrolled in day care, you reevaluate the child. He is asymptomatic, but you detect a middle ear effusion in the affected ear. They tympanic membrane is otherwise normal. The best management at this time would be
A. Inflation of the eustachian tube by the Valsalva maneuver
B. An antihistamine for 30 days
C. Low-dose corticosteroids for 30 days
D. Referral to an ENT specialist
E. No further treatment, with reevaluation in 2 months
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Questions
S Four weeks after successful initial treatment of unilateral otitis media in a 2-year-old male enrolled in day care, you reevaluate the child. He is asymptomatic, but you detect a middle ear effusion in the affected ear. They tympanic membrane is otherwise normal. The best management at this time would be
A. Inflation of the eustachian tube by the Valsalva maneuver
B. An antihistamine for 30 days
C. Low-dose corticosteroids for 30 days
D. Referral to an ENT specialist
E. No further treatment, with reevaluation in 2 months
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Questions
S A full term infant weighing 6lb 8oz at birth will typically weight 20lb at what age?
A. 6 months
B. 9 months
C. 12 months
D. 15 months
E. 18 months
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Questions
S A full term infant weighing 6lb 8oz at birth will typically weight 20lb at what age?
A. 6 months
B. 9 months
C. 12 months
D. 15 months
E. 18 months
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Questions
S Which one of the following jaundiced infants can be treated expectantly without a full workup for pathologic causes?
A. A 12-hour-old term infant with a total bilirubin of 10 mg/dL
B. A 1-day-old term infant with a total bilirubin of 20 mg/dL
C. A 2-day-old term infant with a total bilirubin of 10 mg/dL
D. A 1-week-old term infant with a total bilirubin of 25 mg/dL
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Questions
S Which one of the following jaundiced infants can be treated expectantly without a full workup for pathologic causes?
A. A 12-hour-old term infant with a total bilirubin of 10 mg/dL
B. A 1-day-old term infant with a total bilirubin of 20 mg/dL
C. A 2-day-old term infant with a total bilirubin of 10 mg/dL
D. A 1-week-old term infant with a total bilirubin of 25 mg/dL
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Questions
S Which one of the following is recommended to prevent SIDS? S A. Infants should sleep on a soft mattress.
S B. The crib should be kept in the parents’ room, preferable next to the parents’ bed
S C. A car seat may be used in place of a crib for naps
S D. Infants with gastroesophageal reflux should be placed in the prone position for sleep
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References
S Kliegman RM, Behrman RE, Jenson HB, Stanton BF. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: Saunders Elsevier; 2007
S Zitelli BJ, Davis HW. Atlas of Pediatric Physical Diagnosis. 4th ed. Philadelphia, PA: Mosby; 2002
S American Academy of Pediatrics. In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006
S Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary Tract Infection: Clinical Practice Guidelines for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics 2011; 128;595
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References
S McLaughlin, MR. Speech and Language Delay in Children. Am Fam Physician. 2011 May 15;83(10):1183-1188
S Raghuveer TS, Cox AJ. Neonatal Resuscitation: An Update. Am Fam Physician. 2011 Apr 15;83(8):911-918.
S Graves RC, Oehler K, Tingle LE. Febrile Seizures: Risks, Evaluation, and Prognosis. Am Fam Physician 2012 Jan 15;85(20:149-153.
S Kalyanakrishnan R, Sparks RA, Berryhill, WE. Diagnosis and Treatment of Otitis Media. Am Fam Physician. 2007 Dec 1;76(11):1650-1658.
S American Academy of Pediatrics. The Diagnosis and Management of Acute Otitis Media Pediatrics. 2013 Mar 1 vol 131 e964-e999.
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References
S O’Connor, McLaughlin, Newborn Skin: Part 1 Common Rashes, American Fam Physician, 2008 Jan 1; 77(1):47-52
S McLaughlin, O’Connor, Newborn Skin: Part 2 Birth Marks American Fam Physician, 2008 Jan 1, 77(1):56 -60
S Adams, Ward, Garcia, Sudden Infant Death Syndrome, American Fam Physician, 2015 June 1, 91(1):778-783