Pediatrics

01 Pediatric Anatomy & Physiology

Children are not small adults. Virtually every organ system differs from adult physiology in ways that have direct clinical consequences — from airway anatomy that predisposes to obstruction, to immature renal function that alters drug clearance, to a higher metabolic rate that demands proportionally greater caloric and fluid intake. Understanding these age-specific differences is the foundation of all pediatric care.

Airway & Respiratory Differences

The pediatric airway is narrower, more anterior, and more cephalad than the adult airway. The infant larynx sits at C3–C4 (versus C4–C5 in adults). The epiglottis is omega-shaped and floppy. The narrowest point is the cricoid ring (subglottic region) in children <8 years, unlike adults where the glottis is narrowest. Infants are obligate nasal breathers until approximately 4–6 months of age — nasal obstruction (e.g., choanal atresia, mucus from URI) can cause significant respiratory distress. The chest wall is highly compliant in neonates, leading to paradoxical breathing with subcostal and intercostal retractions as early signs of respiratory distress.

Cardiovascular Differences

The neonatal myocardium has fewer contractile elements and is less compliant than the adult heart. Cardiac output in infants is heart-rate dependent because stroke volume is relatively fixed — bradycardia is poorly tolerated and is the most common preterminal rhythm in children (unlike adults, where VF/VT predominates). Normal heart rates are much higher in infants (120–160 bpm in neonates) and decrease with age. Blood pressure is lower in young children; hypotension is a late sign of shock in pediatrics because children compensate with tachycardia and increased SVR until they decompensate precipitously.

Fluid & Caloric Requirements

Children have a higher body surface area-to-mass ratio and higher metabolic rate per kilogram than adults. Maintenance fluid is calculated using the Holliday-Segar formula:

Thermoregulation

Neonates, especially preterm infants, are highly susceptible to hypothermia due to large surface area-to-volume ratio, thin subcutaneous fat, and inability to shiver (neonates generate heat via non-shivering thermogenesis using brown fat). Hypothermia increases oxygen consumption, causes metabolic acidosis, and worsens respiratory distress. Maintaining a neutral thermal environment (36.5–37.5°C axillary) is critical in neonatal care.

Renal & Hepatic Maturation

The GFR at birth is ~20 mL/min/1.73 m² in term neonates and even lower in preterm infants; it does not reach adult values (~120 mL/min/1.73 m²) until 1–2 years of age. This affects drug clearance for renally eliminated medications (aminoglycosides, vancomycin). Hepatic enzyme systems (particularly glucuronidation via UGT) are immature at birth — this explains physiologic jaundice and the risk of gray baby syndrome with chloramphenicol.

Age-Specific Vital Signs

02 The Pediatric Assessment

The pediatric assessment begins the moment you enter the room. The Pediatric Assessment Triangle (PAT) provides a rapid (<30 second) visual assessment of severity before any hands-on examination. It evaluates three components: Appearance (TICLS: Tone, Interactiveness, Consolability, Look/Gaze, Speech/Cry), Work of Breathing (retractions, nasal flaring, grunting, positioning), and Circulation to Skin (pallor, mottling, cyanosis).

ABCDE Approach

Growth Charts & Percentiles

Growth monitoring is the cornerstone of well-child care. The WHO growth standards are used for children 0–2 years (based on breastfed children), and CDC growth charts for children 2–20 years. Parameters tracked include weight-for-age, length/height-for-age, head circumference (until age 2–3), and BMI-for-age (starting at age 2). A child consistently tracking along a percentile is reassuring; crossing two or more major percentile lines (either up or down) warrants investigation.

Developmental Screening Tools

03 Key Terminology & Abbreviations

Pediatrics uses age-specific terminology and abbreviations that differ from adult medicine in important ways. Mastering this vocabulary is essential for interpreting growth data, immunization records, neonatal documentation, and pediatric emergency protocols.

04 Developmental Milestones

Developmental milestones represent the expected acquisition of skills across four domains: gross motor, fine motor, language, and social-emotional. While there is normal variation, consistent delay in reaching milestones may indicate developmental disability, neurologic disease, or environmental deprivation. The CDC/AAP updated milestone checklists in 2022 to reflect when most children (75th percentile) achieve a skill, rather than the 50th percentile used previously.

Milestones by Age

Primitive Reflexes

05 Immunization Schedule

Vaccination is the single most effective preventive intervention in pediatrics. The CDC immunization schedule is updated annually and published by the Advisory Committee on Immunization Practices (ACIP). Understanding the schedule, minimum intervals, contraindications, and the distinction between live and inactivated vaccines is essential for every pediatric provider.

Routine Childhood Immunization Schedule (Birth–18 Years)

Live vs. Inactivated Vaccines

06 Growth & Nutrition

Expected Growth Patterns

Breastfeeding

Breast milk is the recommended sole source of nutrition for the first 6 months. It provides optimal nutrition, immunoglobulins (especially secretory IgA), and growth factors. The AAP recommends continued breastfeeding with complementary foods through at least 12 months. Breast milk is deficient in vitamin D (supplement 400 IU/day from birth) and iron after 4–6 months (supplement 1 mg/kg/day or introduce iron-rich foods).

Formula Feeding

Standard cow’s milk-based formula (20 kcal/oz) is the alternative when breastfeeding is not possible. Soy-based formula is for galactosemia or cow’s milk protein intolerance (but 10–14% cross-react). Extensively hydrolyzed (e.g., Alimentum, Nutramigen) or amino acid-based (EleCare) formulas are for true cow’s milk protein allergy. Whole cow’s milk should not be introduced before 12 months (low iron, excess protein/sodium, risk of GI blood loss).

Introduction of Solid Foods

Begin complementary foods at approximately 4–6 months when the infant shows developmental readiness (sits with support, good head control, loss of tongue thrust reflex). Introduce one new food every 3–5 days. Early introduction of allergenic foods (peanut, egg, milk) between 4–6 months is now recommended by the AAP and LEAP study data to reduce allergy risk, especially in high-risk infants (eczema, egg allergy).

Failure to Thrive (FTT)

Defined as weight <3rd percentile for age, weight-for-length <5th percentile, or crossing down 2 or more major percentile lines. Causes are classified as inadequate intake (most common — poverty, neglect, feeding difficulties, cleft palate), inadequate absorption (celiac, CF, cow’s milk protein allergy), or increased metabolic demand (CHD, chronic infection, hyperthyroidism). Workup includes a detailed feeding history, calorie count, CBC, CMP, urinalysis, and celiac screening. In FTT, weight is affected first, then length, then head circumference (this pattern distinguishes nutritional FTT from genetic/endocrine short stature).

Childhood Obesity

07 Anticipatory Guidance & Screening

Preventive care in pediatrics involves both surveillance for disease and anticipatory guidance for safety, nutrition, and development at each well-child visit.

AAP Recommended Screening Schedule

Anticipatory Guidance Highlights by Age

08 Newborn Assessment

APGAR Score

Assessed at 1 and 5 minutes after birth (and every 5 minutes thereafter if score <7). It is a rapid assessment of the newborn’s transition to extrauterine life, not a predictor of long-term neurologic outcome.

Gestational Age Assessment

The New Ballard Score uses neuromuscular maturity (6 items: posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear) and physical maturity (6 items: skin, lanugo, plantar surface, breast, eye/ear, genitals) to estimate GA from 20–44 weeks. Each item is scored −1 to +5; the sum maps to GA.

Common Birth Injuries

09 Neonatal Jaundice

Jaundice (hyperbilirubinemia) affects ~60% of term and ~80% of preterm newborns. Most is benign physiologic jaundice, but severe unconjugated hyperbilirubinemia can cause kernicterus (bilirubin encephalopathy) — irreversible brain damage to the basal ganglia, hippocampus, and cranial nerve nuclei, presenting as choreoathetoid cerebral palsy, sensorineural hearing loss, and upward gaze palsy.

Physiologic vs. Pathologic Jaundice

Breastfeeding vs. Breast Milk Jaundice

Management

Use the Bhutani nomogram (hour-specific total serum bilirubin plotted against age in hours) to determine risk zone and guide management. Treatment includes phototherapy (blue-green light, 430–490 nm, converts unconjugated bilirubin to water-soluble photoisomers excreted without conjugation) and, in severe cases, exchange transfusion (double-volume exchange, ~160 mL/kg, to rapidly lower bilirubin and remove antibodies in hemolytic disease).

10 Neonatal Respiratory Distress

Respiratory distress is the most common reason for NICU admission. The differential is guided by gestational age, mode of delivery, and timing of symptom onset.

Causes of Neonatal Respiratory Distress

11 Neonatal Sepsis

Neonatal sepsis is a clinical syndrome of systemic infection in the first 28 days of life. It is the leading infectious cause of neonatal mortality. The immature neonatal immune system (poor opsonization, low complement, deficient neutrophil function) makes neonates uniquely susceptible to overwhelming bacterial infection.

Early-Onset vs. Late-Onset Sepsis

GBS Prevention

Universal screening with vaginal-rectal culture at 36–37 weeks gestation. Intrapartum antibiotic prophylaxis (IAP) is indicated for: GBS-positive culture, GBS bacteriuria during current pregnancy, previous infant with GBS disease, or unknown GBS status with risk factors (preterm <37 wk, ROM ≥18 hr, intrapartum fever ≥38.0°C). First-line IAP: Penicillin G 5 million units IV then 2.5–3 million units q4h until delivery. Penicillin allergy: cefazolin if low risk; clindamycin or vancomycin if high-risk allergy.

12 Congenital Anomalies

TORCH Infections

Newborn Metabolic Screening

All U.S. states screen for a core panel of conditions via heel-stick blood spot at 24–48 hours of life (and often a second screen at 1–2 weeks). The Recommended Uniform Screening Panel (RUSP) includes >35 core conditions:

Congenital Heart Disease Screening

Pulse oximetry screening is performed on all newborns after 24 hours of life (or before discharge if earlier). SpO2 is measured on the right hand (preductal) and either foot (postductal). The screen fails if any reading is <90%, if both readings are <95% on three measurements separated by 1 hour, or if there is >3% difference between right hand and foot. A failed screen requires echocardiography.

13 Asthma in Children

Asthma is the most common chronic disease of childhood, affecting ~8% of U.S. children. It is characterized by reversible airway obstruction, bronchial hyperresponsiveness, and chronic airway inflammation. The NAEPP EPR-4 (2020) guidelines provide stepwise therapy recommendations.

Classification of Asthma Severity (Ages ≥12, similar for younger with modifications)

Stepwise Therapy (Children 5–11 Years)

Acute Asthma Exacerbation Management

14 Croup & Epiglottitis

Croup (Laryngotracheobronchitis)

Croup is the most common cause of acute upper airway obstruction in children ages 6 months to 3 years (peak 1–2 years). It is caused by parainfluenza virus (types 1 and 3 most common) and produces subglottic edema with a characteristic "barking" or "seal-like" cough, inspiratory stridor, and hoarse voice. Symptoms are typically worse at night.

Epiglottitis

Differentiating Croup from Epiglottitis

15 Bronchiolitis

Bronchiolitis is the most common lower respiratory tract infection in infants <12 months (peak 2–6 months). RSV causes ~70% of cases (other causes: rhinovirus, human metapneumovirus, parainfluenza, adenovirus). It produces inflammation, edema, and mucus plugging of the small airways (bronchioles), causing wheezing, crackles, and respiratory distress.

AAP Clinical Practice Guideline (2014, reaffirmed 2023)

RSV Prevention

Nirsevimab (Beyfortus) — a long-acting monoclonal antibody — is now recommended for all infants <8 months entering their first RSV season and for high-risk infants 8–19 months entering their second season. It replaced palivizumab (Synagis), which required monthly injections and was limited to high-risk groups. Palivizumab is still available for eligible infants when nirsevimab is not available.

16 Pneumonia in Children

The most likely causative organisms vary significantly by age group, which determines empiric therapy.

Etiology by Age

Parapneumonic Effusion & Empyema

Complicated parapneumonic effusions occur in ~5% of pediatric pneumonias. Ultrasound is the initial imaging modality. Pleural fluid pH <7.2, glucose <40 mg/dL, or positive Gram stain/culture indicates empyema requiring drainage (chest tube or VATS). S. pneumoniae and S. aureus (including MRSA) are the most common organisms.

17 Fever in Children

Fever is the most common presenting complaint in pediatric emergency departments. The approach to fever varies dramatically by age because the risk of serious bacterial infection (SBI) — UTI, bacteremia, meningitis — is highest in the youngest infants who may appear well despite serious illness.

Age-Based Approach to Fever Without a Source

18 Otitis Media & Pharyngitis

Acute Otitis Media (AOM)

AOM is the most common reason for antibiotic prescriptions in children. Peak incidence is 6–24 months. Diagnosis requires: (1) acute onset of symptoms, (2) middle ear effusion (bulging TM, impaired mobility on pneumatic otoscopy, air-fluid level), and (3) signs of middle ear inflammation (erythematous TM, otalgia). Most common organisms: S. pneumoniae, nontypeable H. influenzae, and Moraxella catarrhalis.

Pharyngitis — Group A Streptococcus (GAS)

GAS pharyngitis accounts for ~15–30% of pharyngitis in children ages 5–15 (rare <3 years). Treatment prevents rheumatic fever (ARF) but primarily targets symptom relief and reduced transmission.

19 Common Childhood Exanthems

20 Meningitis in Children

Bacterial meningitis is a medical emergency in pediatrics. Prompt recognition and treatment reduce mortality and long-term neurologic sequelae (hearing loss, intellectual disability, seizures).

Age-Based Empiric Therapy

CSF Interpretation

Chemoprophylaxis

21 UTI in Children

UTI is the most common serious bacterial infection in febrile infants. Presentation varies dramatically with age: neonates present with nonspecific signs (fever, irritability, poor feeding, jaundice), while older children present with classic dysuria, frequency, and suprapubic/flank pain. E. coli causes 80–90% of first UTIs in children.

AAP Guidelines (2011, reaffirmed 2016) — Children 2–24 Months

Vesicoureteral Reflux (VUR) Grading

22 Vomiting & Dehydration

Assessment of Dehydration Severity

Rehydration

Pyloric Stenosis

Hypertrophic pyloric stenosis presents at 2–6 weeks of age (classic: firstborn male) with projectile, nonbilious vomiting after feeds, "hungry vomiter" who wants to feed immediately after vomiting. Physical exam may reveal a palpable "olive" in the right upper quadrant. Labs show hypochloremic, hypokalemic metabolic alkalosis (from loss of HCl in vomitus). Ultrasound diagnostic criteria: pyloric muscle thickness >3 mm, pyloric length >15 mm. Treatment: correct electrolytes and dehydration first, then Ramstedt pyloromyotomy.

Intussusception

Most common cause of intestinal obstruction in children 6 months–3 years (peak 5–9 months). Most cases are ileocolic and idiopathic (hypertrophied Peyer patches serving as lead point after viral illness). Classic triad (present in <50%): colicky abdominal pain (episodic, drawing up legs), "currant jelly" stools (blood and mucus), and sausage-shaped abdominal mass. Diagnosis: ultrasound showing "target sign" (concentric rings). Treatment: air or contrast enema (both diagnostic and therapeutic) — ~90% success rate; surgery if enema fails, peritonitis, or perforation.

23 Abdominal Pain in Children

Appendicitis

Most common surgical emergency in children. Classic presentation: periumbilical pain migrating to right lower quadrant (McBurney point), anorexia, nausea/vomiting, low-grade fever. The Pediatric Appendicitis Score (PAS) and Alvarado score help risk-stratify. Diagnosis: ultrasound first in children (avoids radiation); CT if ultrasound equivocal. Nonperforated appendicitis: appendectomy (laparoscopic) within 24 hours; some centers now offer antibiotic-first approach for uncomplicated cases. Perforated: IV antibiotics (piperacillin-tazobactam or ceftriaxone + metronidazole) ± percutaneous drainage if abscess, with interval appendectomy 6–8 weeks later.

Meckel Diverticulum

The "rule of 2s": 2% of population, 2 feet from ileocecal valve, 2 inches long, presents by age 2, 2 types of ectopic tissue (gastric and pancreatic). Most common presenting symptom in children is painless rectal bleeding (dark red or brick-colored) due to acid secretion from ectopic gastric mucosa causing ulceration of adjacent ileal tissue. Diagnosis: Meckel scan (technetium-99m pertechnetate scintigraphy — tags ectopic gastric mucosa). Treatment: surgical resection.

Malrotation with Midgut Volvulus

Hirschsprung Disease

Congenital absence of ganglion cells in the distal colon (aganglionosis), most commonly affecting the rectosigmoid. Presents with failure to pass meconium within 48 hours of birth, abdominal distension, and bilious vomiting. Can present later with chronic constipation (ribbon-like stools, failure to thrive). Diagnosis: barium enema (transition zone), rectal suction biopsy (gold standard — absent ganglion cells, hypertrophied nerve trunks). Treatment: pull-through procedure (Soave, Swenson, or Duhamel).

24 Pediatric GI Emergencies

Necrotizing Enterocolitis (NEC)

NEC is the most common GI emergency in premature neonates (primarily <32 weeks GA and <1,500 g). Pathogenesis involves mucosal injury from ischemia, formula feeding, and bacterial invasion. Presentation: feeding intolerance, abdominal distension, bloody stools, bilious aspirates, and systemic signs (apnea, lethargy, temperature instability, DIC).

Pyloric Stenosis — Quick Reference

See Section 22 for full details. Key points: projectile nonbilious vomiting at 2–6 weeks; "olive" mass; hypochloremic hypokalemic metabolic alkalosis; US >3 mm thickness, >15 mm length; pyloromyotomy after correcting metabolic derangements.

Intussusception — Quick Reference

See Section 22 for full details. Key points: 6 months–3 years; episodic colicky pain; currant jelly stools; US target sign; air enema reduction 90% success; surgery if failed enema or perforation.

25 Celiac Disease & Food Allergies

Celiac Disease

An immune-mediated enteropathy triggered by gluten (wheat, barley, rye) in genetically predisposed individuals (HLA-DQ2 or DQ8). Prevalence ~1% in Western populations. Classic presentation in children: chronic diarrhea, abdominal distension, failure to thrive, irritability, and iron deficiency anemia beginning after introduction of gluten-containing foods (typically 6–24 months). Older children may present with constipation, short stature, delayed puberty, or dermatitis herpetiformis.

Food Allergies

IgE-mediated food allergy affects ~6–8% of children <3 years. The most common allergens are cow’s milk, egg, peanut, tree nuts, soy, wheat, fish, and shellfish. Milk, egg, soy, and wheat allergies are usually outgrown by school age; peanut, tree nut, and shellfish allergies tend to persist.

26 Congenital Heart Disease — Acyanotic

Acyanotic (left-to-right shunt) lesions present with signs of pulmonary overcirculation: tachypnea, poor feeding, diaphoresis with feeds, recurrent respiratory infections, and failure to thrive. They do not cause cyanosis initially, but long-standing shunts can cause pulmonary hypertension and eventually Eisenmenger syndrome (shunt reversal → cyanosis).

27 Congenital Heart Disease — Cyanotic

Cyanotic CHD presents with hypoxemia that does not significantly improve with supplemental oxygen (the "hyperoxia test": PaO2 remains <150 mmHg after 10 minutes of 100% FiO2, suggesting intracardiac right-to-left shunt rather than lung disease). The "5 T’s" of cyanotic CHD:

28 Kawasaki Disease

Kawasaki disease (KD) is an acute, self-limited vasculitis of medium-sized arteries with a predilection for the coronary arteries. It is the leading cause of acquired heart disease in children in developed countries. Peak incidence: 6 months to 5 years; male predominance (1.5:1); highest incidence in Asian/Pacific Islander populations.

Diagnostic Criteria (Classic KD)

Fever ≥5 days PLUS ≥4 of the following 5 criteria:

Treatment

Coronary Artery Follow-Up

Echocardiography at diagnosis, 1–2 weeks, and 6–8 weeks. Coronary artery aneurysms are classified by z-score: small (z 2.5–5), medium (z 5–10), giant (z ≥10 or absolute diameter ≥8 mm). Giant aneurysms require long-term anticoagulation (warfarin + aspirin) and carry risk of thrombosis, stenosis, and MI.

29 Short Stature & Growth Disorders

Short stature is defined as height <3rd percentile or >2 SD below the mean for age and sex. The differential is broad, but most children have either constitutional delay of growth and puberty or familial (genetic) short stature, both of which are normal variants.

Differential Diagnosis

Workup

Initial evaluation: growth velocity calculation (plot serial heights), bone age X-ray (left hand and wrist, Greulich-Pyle atlas), CBC, CMP, ESR, TSH/free T4, celiac panel (TTG-IgA), IGF-1 and IGFBP-3 (GH axis screening). If IGF-1 low, GH stimulation testing (clonidine or arginine) is the gold standard for GH deficiency diagnosis. Karyotype in all short girls (to rule out Turner syndrome).

30 Precocious & Delayed Puberty

Tanner Staging

Precocious Puberty

Defined as onset of secondary sexual characteristics before age 8 in girls or 9 in boys.

Delayed Puberty

No breast development by age 13 in girls; no testicular enlargement by age 14 in boys. Most common cause in both sexes: constitutional delay. Pathologic causes include hypogonadotropic hypogonadism (Kallmann syndrome — associated with anosmia), hypergonadotropic hypogonadism (Turner syndrome in girls, Klinefelter syndrome in boys), chronic disease, and eating disorders.

31 Pediatric Diabetes

Type 1 Diabetes

Autoimmune destruction of pancreatic beta cells; accounts for ~95% of diabetes in children <10 years. Presentation: polyuria, polydipsia, polyphagia, weight loss over days to weeks. ~30–40% present in DKA at diagnosis. Autoantibodies: GAD65, IA-2, insulin autoantibodies (IAA), ZnT8.

DKA Management in Children

Type 2 Diabetes in Adolescents

Rising incidence parallel to the obesity epidemic, particularly in minority populations (Native American, Black, Hispanic, Asian/Pacific Islander). Typically presents in overweight/obese adolescents (age ≥10 or pubertal) with acanthosis nigricans, family history, and insidious onset. C-peptide is normal or elevated (vs. low in T1DM). Treatment: lifestyle modification + metformin (FDA-approved ≥10 years); insulin if HbA1c >8.5% or symptomatic hyperglycemia at presentation.

32 Febrile Seizures

Febrile seizures are the most common seizure type in children, affecting 2–5% of children ages 6 months to 5 years. They occur in the setting of fever (≥38°C / 100.4°F) without evidence of CNS infection or other defined cause.

Simple vs. Complex

Management

33 ADHD

Attention-deficit/hyperactivity disorder is the most common neurodevelopmental disorder in children, affecting ~8–10% of school-age children. Boys are diagnosed 2–3× more often than girls (partly due to more externalizing behavior; girls more often present with inattentive type).

DSM-5 Diagnostic Criteria

≥6 symptoms (or ≥5 if age ≥17) of inattention and/or hyperactivity-impulsivity, present for ≥6 months, in ≥2 settings (school, home, work), with onset before age 12. Symptoms must cause functional impairment and not be better explained by another mental disorder.

Treatment

Monitoring

Before starting stimulants: height, weight, blood pressure, heart rate, personal/family cardiac history. Monitor every 3–6 months: growth parameters (stimulants can suppress appetite/growth), BP, HR, symptom control, side effects (insomnia, appetite suppression, irritability, headache). No routine ECG required unless cardiac history or symptoms.

34 Autism Spectrum Disorder

ASD is a neurodevelopmental disorder characterized by persistent deficits in social communication/interaction and restricted, repetitive behaviors/interests. Prevalence: ~1 in 36 children (CDC 2023), with 4:1 male-to-female ratio.

DSM-5 Criteria (Both Required)

Screening & Diagnosis

AAP recommends universal screening with M-CHAT-R/F at 18 and 24 months. Early signs include lack of pointing by 12 months, no single words by 16 months, no 2-word phrases by 24 months, lack of joint attention, and regression of language or social skills. Diagnosis is made by comprehensive developmental evaluation (developmental pediatrician, child psychologist, or multidisciplinary team) using standardized tools (ADOS-2, ADI-R).

Management

35 Pediatric Resuscitation

Pediatric cardiac arrest is most often due to respiratory failure or shock (asphyxia), unlike adult arrest which is usually primary cardiac (VF/VT). The most common preterminal rhythm in children is bradycardia progressing to PEA/asystole. Early recognition of respiratory distress and shock, before arrest occurs, is the most impactful intervention.

PALS Key Algorithms

Weight-Based Equipment & Dosing

The Broselow tape (length-based resuscitation tape) provides rapid weight estimation and corresponding drug doses, equipment sizes, and defibrillation energy for children up to ~36 kg. Weight estimation formula: weight (kg) = (age in years × 2) + 8 for children 1–10 years.

Vascular Access

If IV access cannot be obtained within 60–90 seconds in a critically ill child, intraosseous (IO) access should be established. Preferred site: proximal tibia (1–2 cm below tibial tuberosity on medial flat surface). Alternative sites: distal tibia, distal femur, humeral head. Any medication or fluid that can be given IV can be given IO.

36 Non-Accidental Trauma

Child abuse is tragically common: ~700,000 confirmed cases annually in the U.S., with ~1,750 fatalities per year. Children <3 years are at highest risk. All healthcare providers are mandatory reporters in all 50 states — suspected abuse must be reported even without proof. Reporting in good faith is legally protected.

Red Flags for Non-Accidental Injury

Workup

Skeletal survey (full body radiographic series) in all children <2 years with suspected abuse. Head CT for all children <6 months with suspected abuse (or any age with neurologic symptoms). Ophthalmologic exam for retinal hemorrhages. Labs: CBC, CMP, coagulation studies, lipase, urinalysis (to rule out bleeding disorders and assess for occult organ injury).

37 Foreign Body Ingestion & Poisoning

Foreign Body Ingestion

Common Pediatric Poisonings

38 Pediatric Vital Signs by Age

ETT Size by Age

39 Classification Systems

APGAR Score

See Section 08 for full APGAR scoring table. Assessed at 1 and 5 minutes. Score 7–10 = reassuring; 4–6 = moderately depressed; 0–3 = severely depressed.

Tanner Staging

See Section 30 for full Tanner staging table. Stages I (prepubertal) through V (adult) for breast/genital and pubic hair development.

WHO Dehydration Classification

Asthma Severity Classification

See Section 13 for full classification table (Intermittent, Mild Persistent, Moderate Persistent, Severe Persistent).

VUR Grading (International Reflux Study)

See Section 21 for full VUR grading table (Grades I–V based on VCUG findings).

Modified Bell Staging for NEC

See Section 24 for full NEC staging (Stage I = suspected, Stage II = definite with pneumatosis, Stage III = advanced with perforation).

Westley Croup Score

40 Medications Master Table

Common Pediatric Antibiotics (Weight-Based Dosing)

Antipyretics & Analgesics

Asthma Medications

PALS Resuscitation Drugs

41 Abbreviations Master List

42 Growth Charts & Screening Schedules

Well-Child Visit Schedule (AAP / Bright Futures)

Growth Chart Reference Points