21.2 Pediatrics

Pediatrics

Quick Answer: Pediatric items on NBCE Part II test age-specific milestones, newborn screening, vaccine schedules, and infection patterns by age group. Memorize key developmental anchors (sits 6 months, walks 12 months, two-word phrases 24 months), recognize that fever in infants under 60 days is a sepsis workup, and know non-accidental trauma skeletal patterns. Chiropractic pediatric questions focus on when gentle supportive care is appropriate versus when developmental delay, abuse, or systemic illness demands referral.

Newborn Care and Assessment

The APGAR score is assigned at 1 and 5 minutes (and at 10 minutes if persistently low) to assess newborn transition:

Scores of 7–10 are reassuring; 4–6 need assistance; ≤3 require immediate resuscitation. A score below 7 at 5 minutes predicts increased neurologic morbidity and warrants follow-up.

Newborn Screening and Early Conditions

• Newborn metabolic screening (heel stick): phenylketonuria (PKU), congenital hypothyroidism, galactosemia, sickle cell disease, and state-specific panels — timing is 24–48 hours after birth
• Hearing screening: otoacoustic emissions or auditory brainstem response before discharge
• Vitamin K injection: prevents hemorrhagic disease of the newborn (vitamin K deficiency bleeding)
• Erythromycin ophthalmic prophylaxis: prevents gonococcal ophthalmia neonatorum
• Physiologic jaundice: appears day 2–3, peaks day 4–5, resolves by day 7–10; breastfeeding jaundice is early (insufficient intake); breast milk jaundice is late (weeks 2–3). Pathologic jaundice within 24 hours suggests hemolysis (Rh/ABO incompatibility, G6PD deficiency)
• Respiratory distress syndrome (RDS): surfactant deficiency in premature infants — grunting, retractions, ground-glass on chest X-ray; treat with surfactant and supportive care
• Transient tachypnea of the newborn (TTN): delayed clearance of fetal lung fluid in term/near-term infants — improves within 24–72 hours

Growth and Development

Growth charts (WHO charts under age 2; CDC charts 2–20 years) track weight, length/height, head circumference, and BMI. Failure to thrive is weight below the 5th percentile or crossing two major percentile lines downward — requires evaluation for inadequate intake, malabsorption, chronic disease, or neglect.

Developmental Milestones (Approximate Ages)

Loss of previously acquired milestones (developmental regression) is never normal and mandates urgent evaluation for neurodegenerative disease, seizure disorder, or autism spectrum disorder.

Autism Spectrum Disorder (ASD) Red Flags

• No babbling by 12 months, no single words by 16 months, no two-word phrases by 24 months
• No social smile by 3 months, poor eye contact, not responding to name by 12 months
• Loss of language or social skills at any age
• Repetitive behaviors, insistence on sameness, sensory sensitivities

Screen with M-CHAT-R at 18 and 24 months. Early intervention improves outcomes.

Congenital Disorders

Childhood Infections and Immunizations

Age-Specific Fever Approach

• Neonate (0–28 days) with fever ≥38°C (100.4°F): full sepsis workup (blood, urine, CSF) and empiric IV antibiotics — admit
• Infant 29–60 days: risk-stratify (ill-appearing = full workup); well-appearing may use Rochester or Philadelphia criteria
• Older infant/child: source often identifiable (otitis, UTI, viral URI); focus exam on identifying bacterial vs. viral

High-Yield Childhood Infections

Immunization schedule highlights (birth through adolescence): HepB at birth; DTaP/IPV/Hib/PCV13/Rotavirus series in infancy; MMR and Varicella at 12–15 months; HepA at 12–23 months; HPV at 11–12 years; Tdap and meningococcal at 11–12 years. Live vaccines (MMR, Varicella, LAIV) are contraindicated in severe immunocompromise.

Pediatric Pathology, Injuries, and Abuse

Common Musculoskeletal Conditions in Children

• Developmental dysplasia of the hip: limited abduction, Galeazzi sign, positive Ortolani/Barlow in infancy
• Legg-Calvé-Perthes disease: avascular necrosis of femoral head in boys 4–8 years; insidious hip/groin pain, limited internal rotation
• Slipped capital femoral epiphysis (SCFE): obese adolescent with hip/knee pain and limited internal rotation — do not adjust; surgical pinning required
• Osgood-Schlatter disease: tibial tubercle apophysitis in active adolescents; self-limited with activity modification
• Nursemaid's elbow (radial head subluxation): child held by the hand and pulled; refuses to use arm; reduced by supination-flexion maneuver

Non-Accidental Trauma (Child Abuse)

Red flags include injuries inconsistent with the stated mechanism, delay in seeking care, and specific injury patterns:

• Posterior rib fractures (from squeezing) and metaphyseal corner (bucket-handle) fractures in non-ambulatory infants
• Retinal hemorrhages with subdural hematoma (shaken baby syndrome)
• Burns with clear demarcation (immersion, cigarette)
• Patterned bruises matching belt, hand, or cord marks

Chiropractors are mandated reporters in all states — suspected abuse must be reported to child protective services without notifying the family first.

Emotional, Learning, and Nutritional Disorders

ADHD and Learning Disorders

ADHD requires ≥6 symptoms of inattention and/or hyperactivity-impulsivity (≥5 if age 17+) persisting ≥6 months in ≥2 settings with functional impairment before age 12. First-line pharmacotherapy in school-age children is stimulants (methylphenidate, amphetamines). Atomoxetine is a non-stimulant alternative.

Specific learning disorder (dyslexia, dyscalculia) involves difficulty in reading, writing, or math despite normal intelligence — distinguish from intellectual disability and vision/hearing deficits.

Childhood Nutrition

• Breastfeeding is recommended exclusively for ~6 months with continued breastfeeding alongside complementary foods through at least 12 months
• Iron supplementation at 4 months in exclusively breastfed infants; iron-fortified formula if formula-fed
• Vitamin D 400 IU/day for all breastfed infants
• Obesity: BMI ≥95th percentile for age/sex; complications include type 2 diabetes, fatty liver, obstructive sleep apnea
• Failure to thrive: inadequate caloric intake most common cause; evaluate feeding dynamics, organic disease, and neglect
• Eating disorders in adolescents: anorexia and bulimia occur in teens — bradycardia, electrolyte disturbance, and growth delay are medical red flags

Chiropractic Relevance in Pediatrics

Pediatric patients may receive gentle, low-force supportive care for musculoskeletal conditions when clinically indicated. Absolute caution or contraindication applies with:

• Undiagnosed fever, irritability, or lethargy in infants
• Suspected non-accidental trauma
• SCFE, osteomyelitis, septic arthritis, or malignancy (Ewing sarcoma, osteosarcoma) mimicking sports injury
• Unexplained neurologic deficits, developmental regression, or congenital spinal anomalies without imaging clearance

Document guardian consent, developmental history, growth parameters, and any red-flag screening at each visit. Refer promptly when milestones are delayed, abuse is suspected, or systemic illness is present.

Takeaways: APGAR below 7 at 5 minutes needs follow-up; sits at 6 months, walks at 12 months, two-word phrases at 24 months; fever in infants under 60 days is a sepsis workup; Kawasaki needs IVIG to protect coronaries; posterior rib fractures in infants suggest abuse; and ADHD requires symptoms in two settings for six months.