Pediatrics Review: School-Age Children (Including Preschool)

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DANGER SIGNALS

Kawasaki Disease/Syndrome

Onset of high fever (up to 104°F) and enlarged lymph nodes in the neck. Bright-red rash (more obvious on groin area). Conjunctivitis (dry, no discharge), dry cracked lips, “strawberry tongue.” Swollen hands and feet. After fever subsides, skin peels off hands and feet. Treated with high-dose aspirin and gamma globulin.

Most cases (75%) occur in children younger the age of 5 years. Resolves within 4 to 8 weeks but may have serious sequelae, such as aortic dissection, aneurysms of the coronary arteries, and blood clots. Close follow-up with pediatric cardiologist done for several years because effects may not be apparent until child is older (or an adult).

Leukemia

Complains of extreme fatigue and weakness. Pale skin and easy bruising. May have petechial bleeding (pinpoint to small red spots). May have bleeding gums and nosebleeds. Some have bone or joint pain, lymphadenopathy, or swelling in the abdomen. The most common type in children is acute lymphocytic leukemia. Leukemias are the most common type of cancer in children and adolescents.

Acute Lymphocytic Leukemia (ALL)

Fast-growing cancer of the lymphoblasts, which are immature lymphocytes. CBC will show very high WBC count (>50,000 cells/mm³). Girls have slightly higher chance of cure compared with boys. African American and Hispanic children tend to have a lower cure rate compared with children from other races.

Acute Myelogenous Leukemia (AML)

Fast-growing cancer of the bone morrow that affects immature or precursor blood cells, such as myeloblasts (WBCs), monoblasts (macrophages, monocytes), erythroblasts (RBCs), and megakaryoblasts (platelets). Children with Down syndrome who have AML tend to have better cure rates, especially if the child is younger than age 4 years.

Reye’s Syndrome

History of febrile viral illness (chickenpox, influenza) and aspirin or salicylate intake (Pepto-Bismol, etc.) in a child. Abrupt onset with quick progression. Death can occur within a few hours to a few days. Mortality rate of up to 52%. Although most cases are in children, disease has been seen in teenagers and adults. This disease is now rare.

418Five Stages of Progression

Stage 1: Severe vomiting, diarrhea, lethargy, stupor, elevated ALT and AST

Stage 2: Personality changes, irritability, aggressive behavior, hyperactive reflexes

Stages 3 to 5: Confusion, delirium, cerebral edema, coma, liver damage, seizures, death

Theoretical risk of Reye’s syndrome after varicella immunization; avoid using aspirin before, during, and after immunization.

Down Syndrome: Atlantoaxial Instability

Up to 17% of Down syndrome patients have atlantoaxial instability (increased distance between the C1 and C2 joints). Medical clearance is necessary for sports participation. All children/adolescents (or older) with Down syndrome who want to participate in sports need cervical spine x-rays (including lateral view). Patients with atlantoaxial instability are restricted from playing contact sports (i.e., basketball, tackle football, soccer, etc.) and other high-risk activities (i.e., trampoline jumping). Persons with Down syndrome without evidence of atlantoaxial instability may participate in low-impact sports and sports not requiring extreme balance. For more information about medical conditions and athletic participation, see Table 22.1.

Absence Seizures

Brief episodes during which child stares and suddenly stops whatever he or she is doing. If in school, teacher may tell parent that child is daydreaming and inattentive. A common type of pediatric seizure. Also called petit mal seizure. Refer to pediatric neurologist.

Still’s Murmur

A benign systolic murmur that is described as having a vibratory or musical quality. Becomes louder in supine position or with fever. Minimal radiation. Grade I or II intensity. Most common in school-age children. Usually resolves by adolescence.

U.S. Health Statistics: School-Age Children

Top Causes of Death

Age 1 to 24 Years (Toddlers to Young Adults)

Accidents or unintentional injuries

Table 22.1 Medical Conditions and Sports Participation

Condition	Rationale
Hypertrophic cardiomyopathy	Sudden cardiac death
Atlantoaxial instability (Down syndrome, juvenile rheumatoid arthritis)	Instability between C1 and C2
Marfan syndrome with aortic aneurysm	Aortic aneurysm risk: Lens eyes displacement, joint hypermobility
Ehlers–Danlos syndrome (vascular form)	Cerebral or cervical artery aneurysm, spondylolisthesis, joint hypermobility
Acute rheumatic fever with carditis	Worsens condition, heart inflamed
Mitral valve prolapse, especially if significant mitral valve pathology	Sudden cardiac death
Fever	Heat stroke
Infectious diarrhea	Contagious
Pink eye	Contagious

Note: Some are approved to play low-contact or noncontact sports. List is not all inclusive.

Source: American Academy of Pediatrics (2008).

419Age 5 to 14 Years

Accidents or unintentional injuries

Cancers

Developmental and genetic conditions

IMMUNIZATIONS

Preschool (Ages 4 to 6 Years)

Administer vaccines: Measles, mumps, rubella (MMR); varicella, inactivated poliovirus vaccine (IPV); and diphtheria, tetanus, acellular pertussis (DTaP)

If history of chickenpox and documented on chart by health provider, does not need varicella.

If child is 7 years or older, give Tdap instead of DTaP.

Middle School (Ages 11 to 12 years; Table 22.2)

Tdap booster

Meningococcal conjugate vaccine/Menactra (MCV4)

Human papillomavirus (HPV) vaccine/Gardasil

Notes

HPV vaccine is now indicated for both girls and boys. Need a total of three doses of vaccine. Gardasil used for both genders. Cervarix for females only (sounds like cervix).