PREVENTIVE PEDIATRIC MEDICINE PART 2 – DR.
CALIGAGAN
PREVENTIVE PEDIATRIC MEDICINE PART 2
Christian T. Caligagan, M.D.
SCREENING TEST FOR HEALTH PREVENTION
NEWBORN SCREENING (Neonatal Screening)
 Simple procedure to find out if the newborn has a congenital
metabolic disorder
 Explain to parents that Newborn Screening is used to
screen congenital metabolic disorders and not for ALL
disorders.
 Most babies with metabolic disorder look normal at birth
 Done on the 24th hour of life or ideally on the 48 hour
 Done on the 24th hour of life but not later than 3 days
 EXEMPTION: Those who are sick and were place in the
NICU (Newborn Intensive Care Unit)  Delayed test
but delay of the test is only until the 7th day of life
 Screen again after 2 weeks for more accurate results
 Done by heel prick method with few drops of blood blotted
on a special absorbent filter card, dried for 4 hours then sent
to the NIH at the UP-PGH
 If you encounter a patient who is positive for the
Newborn Screening Test, a more
definitive/confirmatory test is performed to
 VISUAL ACUITY TEST
determine which among the patients has the
congenital metabolic disorder.
Negative Screen - result is normal
Positive Screen - immediately recall patient for
confirmatory testing
 PHILIPPINE NEWBORN SCREENING PROGRAM
 Originally, there were 7 congenital metabolic
disorders under the Newborn Screening Program:
1. Congenital Hypothyroidism
2. Congenital Adrenal Hyperplasia
3. Galactosemia
4. Phenylketonuria
5. G6PD Deficiency
6. Maple Syrup Urine Disease
7. Cystinuria*
 Right now, we are screening for 6 disorders –
Congenital Hypothyroidsm, Congenital Adrenal
Hyperplasia, Galactosemia, Phenylketonuria, G6PD
Deficiency, and Maple Syrup Urine Disease*
 PRE-SCHOOL VISION SCREENING
 Maple Syrup Urine Disease was brought back
1. Congenital Hypothyroidism
 Most common inborn metabolic disorder
 Due to lack or absence of thyroid hormone
 If no hormone replacement within 4 weeks, results to
stunted physical growth & mental retardation
 TSH assay recommended as early as day 1
2. Congenital Adrenal Hyperplasia (CAH)
 Enzyme defect of cortisol synthesis
 Causes severe salt loss, dehydration, high level of male
sex hormone
 Babies may die within 9-13 days if not treated
3. Galactosemia (Gal)
 Failure of galactose utilization due to deficiency of
galactose-1-phosphate uridyl transferase
 Accumulation of excessive galactose results to cirrhosis,
cataract, mental retardation & death
4. Phenylketonuria (PKU)
 Cannot use phenylalanine, causes brain damage
5. Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD)
 Prone to hemolytic anemia due to oxidative substances
found in drugs, foods & chemicals
VISION
VISION
1-3 months old Tears are present with crying
Proper coordination of the eye
3-6 months old
movement
3 years old Visual acuity of 20/40
4 years old Visual acuity of 20/50
5-6 years old Visual acuity of 20/20
 Visual acuity of 20/20 is achieved at a latter age.
 In infants:
─ Assessment of their ability to fixate & follow a target
usually by a bright colored toy
 Young infants don’t know how to read yet so
Snellen Charts are useless for them.
 2 ½ - 3 years old:
─ Schematic picture or illiterate eye chart
 LEA Card is used  Test visual acuity for the very
young (for those who do not know yet the
alphabet)
 E-Test
─ Most widely used visual acuity test for pre-school
 E-Test/Snellen Chart  Most widely used visual
acuity test for pre-school, older children, and
adults (for those who already know the alphabet)
 Is a means of decreasing preventable visual loss
 Done by a pediatrician during well child visits
 Examination by an ophthalmologist is needed when:
1. There is ocular abnormality or visual defect is noted
2. There is a risk of ophthalmologic problems such as
genetically inherited ocular conditions
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 PREVENTIVE PEDIATRIC MEDICINE PART 2 – DR. CALIGAGAN

 VISUAL FIELD ASSESSMENT HEARING SCREENING TEST

─ Formal visual field assessment (Perimetry & Scotometry) NORMAL AUDITORY MILESTONES
can be accomplished in school-aged children 0-4 months Awake for loud sounds
─ Confrontation technique & finger counting: most often 4-7 months Turns toward sounds
used 7-12 months Imitate sounds
─ Can often detect significant field changes 18 months 3 word vocabulary
 COLOR VISION TESTING 20-30 word vocabulary and 2 word
─ Fundus Examination: Best done with pupils dilated 2 years
sentences
─ Refraction: Determines the degree of nearsightedness,
farsightedness or astigmatism  In the auditory milestones, it is not only the response to
 CORNEAL LIGHT REFLEX TEST sound that we look at. During the latter ages, we also
─ Most rapid diagnostic test for strabismus look at the number of words/vocabulary spoken.
─ Projects a light source onto the cornea of both eyes  Most of the hearing impaired will be language delayed
─ Straight Eyes: Light reflection appears symmetrical
─ Strabismus: Reflected light is asymmetric  HEARING LOSS SCREENING TEST
 Ways in which vision loss may limit development:  HEARING IMPAIRMENT INCIDENCE
1. They do not receive full information ─ WHO:
2. They are not motivated to move out into space  1-3/1000 → live births
3. Loss of control  1:1000 → with profound deafness
 Development areas that are affected:  1:1000 → with acquired deafness in early childhood
1. Physical: Strength, coordination, range of motor skills ─ In 1991:
2. Cognitive: Range and depth  600,000 Filipinos with hearing impairment
3. Social: Non-verbal communication  AUDIOMETRY or BRAINSTEM-EVOKED POTENTIAL
 Ocular disorders causing visual loss in pediatric age group: TESTING
1. Ocular Anatomy
2. Disorders of Cornea - ulcers; tear in descemets  Most important, most objective, and most sensitive
3. Posterior Segment Disorders - retinitis pigmentosa, test for hearing loss
retinoblastoma, optic nerve disorder  Uses brain waves  Very objective
4. Cataracts
─ Mandatory for any child suspected of hearing loss
 Steps that you can take to help children develop:
─ Normal Hearing Infants  turn their heads toward a
─ Teach skills
physical stimuli
─ Change environment
─ Normally intelligent hearing-impaired toddlers are
─ Give assistance to prevent secondary handicaps
universally alert and respond appropriately to stimuli.
 ASPECTS OF VISION LOSS
 Parental concern is often a reliable indicator of
hearing impairment and warrants a formal hearing
assessment.
 RISK FACTORS that indicate a need for testing during the
first few months of life:
─ Family history of deafness
─ Prematurity
 It could start off from ROP (Retinopathy of ─ Severe asphyxia
Prematurity)  Babies who are delivered prematurely ─ Use of ototoxic drugs in the newborn period
+ Excessive oxygenation ─ Hyperbilirubinemia
 If ROP is not corrected, it may lead to visual impairment ─ Congenital anomalies of the head and neck
 Patient can have decreased visual acuity ─ Bacterial meningitis
 Again, if this is not corrected, it may lead to visual ─ Congenital infection due to TORCH
disability  Patient is unable to read whether near/far  RISK FACTORS FOR HEARING LOSS:
 A patient may become handicapped if continuously you 1. Asphyxia (low APGAR score <3)
have not addressed the problem  Inability to read 2. Bacterial Meningitis
now becomes a reason for poor school performance 3. Congenital Perinatal Infections
4. TORCHS
 What is a child's functional vision? 5. Defect of the Head and Neck
1. Usable Vision 6. Elevated Bilirubin
2. Peripheral Vision: For navigating 7. Family History
3. Central Vision: For reading/spotting 8. Birth Weight of <1.5 kg

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 PREVENTIVE PEDIATRIC MEDICINE PART 2 – DR. CALIGAGAN
 AUDITORY ASSESSMENT
─ Behavioral Assessment
1. Behavioral Observation Audiometry (BOA)  For <6
months old
2. Visual Reinforcement Orientation Audiometry (VROA)
 For 6 months up to 3 years old
3. Play Audiometry  For > 3 years old
─ Objective Assessment
1. Otoacoustic Emission (OAE)  Assesses the cochlear
status
 OAE = Otoacoustic Emission
 All children who are candidates for hearing
screening, meaning all newborns are tested
 May yield a positive result but the child does
not have hearing impairment  Submit to a
formal test for hearing
2. Otoscopy  Detects impacted cerumen, aural atresia,
and auditory canal stenosis
 Can also detect whether a person has
conductive or sensory hearing loss
 RESPONSIBILITIES OF A PEDIATRICIAN:
1. Investigate on the risk factors
2. Monitor language development
 MANTOUX TEST:
3. Inform parents of the availability of screening tests
4. Refer to appropriate specialists without delay
 EFFECTS OF LATE DETECTION AND INTERVENTION FOR
HEARING LOSS
─ Delay in language acquisition
─ Poor communication skills
─ Social and emotional immaturity
─ Poor educational development
─ Poor quality of life
TUBERCULIN TEST/PURIFIED PROTEIN DERIVATIVE (PPD)
 Method to determine persons who are infected with M.
tuberculosis and who do not have TB disease
 (+) PPD Test  TB infected
 If PPD is positive but you don’t have exposure, x-ray
and sputum exam is negative  TB infected only
(You don’t have the disease yet)
 Safe and cost-effective test used worldwide as a clinical and
epidemiology tool for TB diagnosis and tuberculin surveys
 Based on a delayed hypersensitivity reaction
 Classic example of Type IV Hypersensitivity Reaction
 FEATURES OF THE DELAYED HYPERSENSITIVITY REACTION:
1. Its delayed course
 Reaction starts 5-6 hours after injection
 Maximal induration is noted within 48-72 hours post-
injection and subsides over a period of days
 The best time to read the PPD test wherein you
observe for maximal induration and not
erythema is between/within 48-72 hours from
the time you administered the tuberculin reagent
 NOT 48 hours/72 hours = Not acceptable
 It is not read earlier because the reagent has not
reacted yet that you would not see any reaction
before 48 hours
 It is also not read beyond 48 hours because the
reaction could have subsided already  You will
not be able to appreciate the induration already
2. Its indurated character
 The area of induration (palpable raised hardened area)
around the site of injection is the reaction to tuberculin
 AREA OF INDURATION is read, NOT ERYTHEMA
 The diameter of the indurated area is measured in
millimeter transversely to the long axis of the forearm:
a. By Palpation
b. By Ballpoint Pen Technique – draw a straight line from
5-10 mm away from both the opposite sides of the
margin of the skin induration and drawn towards the
center until a resistance is felt
3. Its occasional vesiculation and necrosis
 Single puncture test wherein you need a tuberculin
reagent that is injected on the volar aspect of the right
forearm
 Standard and recommended method of giving the
tuberculin for screening
 0.1 ml of either 2 TU of PPD RT23 or the 5TU of PPD-S
intradermally into the volar aspect of the right forearm
 TU = Tuberculin Units
 5TU = More commonly used
 Positive Tuberculin Test
 A tuberculin test is considered positive if:
 The induration is more than or equal to 5 mm 
If with (+) risk factors:
─ Patient happens to have a positive x-ray for TB,
positive exposure to a somebody who has TB
recently diagnosed, or a positive sputum exam
 The induration is more than or equal to 10 mm 
If only for screening = (-) risk factors
─ Patient happens to have a negative x-ray for
TB, no exposure to a somebody who has TB
recently diagnosed, or a negative sputum
exam
 But usually they use 10 mm for adults and 5 and 10
for pediatrics.
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 PREVENTIVE PEDIATRIC MEDICINE PART 2 – DR. CALIGAGAN
 FALSE POSITIVE MANTOUX TEST may be due to:
1. Non-Tuberculous Mycobacteria (NTB)
2. BCG Vaccination
─ Most patients who receive BCG lose their cutaneous
hypersensitivity reaction within 5 years
 FALSE NEGATIVE MANTOUX TEST may be due to:
1. Factors related to the person being tested
a. Anergy
b. Very Young Age (<6 months)
c. Recent TB Infection
d. Overwhelming TB Disease
e. Live-Virus Vaccination (OPV, Varicella, MMR)
─ Tuberculin test should be administered either on
the same day as the vaccines or 4-6 weeks after
f. Immunosuppression
2. Factors related to the tuberculin used
a. Improper storage
b. Improper dilution
3. Factors related to the method of administration
a. Too little antigen
b. Too deep injection
4. Factors of error in reading and recording of results
POST EXPOSURE DRUG PROPHYLAXIS
 Prophylaxis for exposure to infectious diseases
 There are several cases that when you get exposed to
infectious diseases you can actually take prophylactic
medication or antibiotics to prevent having a full-blown
disease.
HEALTH ADVISE FOR CHILDREN TRAVELING
INTERNATIONALLY
 Seek consultation 4-6 weeks before departure
 For those with medical problem:
1. Medical summary
2. Sufficient supply of medications
3. Directory of physicians
4. Travel health kit
 Safety:
1. Use safety belts
2. Avoid stray dogs, venomous animals and scorpions
3. Avoid swimming in contaminated water
 SPECIAL VACCINATIONS FOR TRAVEL
 CHOLERA
─ Should be at least 3 weeks apart from yellow fever
vaccination
─ Oral cholera vaccine for 2 years old and above
 JAPANESE ENCEPHALITIS
─ For children 1 year and older
─ Administered in 3 doses subcutaneously
─ Should be completed 2 weeks before travel
 MENINGOCOCCAL
─ For children 2 years and older
─ 0.5 ml SC/IM
 TYPHOID FEVER
─ Given IM for 2 years and above
 YELLOW FEVER
─ Mosquito-borne viral illness
─ Vaccine to children >9 months old traveling to an
endemic area
─ Live attenuated vaccine 0.5 ml SC
INJURY CONTROL AND PREVENTION
 It was used to be called ACCIDENT PREVENTION – usually
pertains to mechanical accidents only
 Encompasses everything from mechanical accidents
(falls, vehicular accidents) to accidental ingestion,
poisoning, to drowning, fire and burn accidents, etc.
INJURIES
 INJURIES
 Most common cause of death during childhood and
adolescence beyond the first few months of life
 Most common cause of death that is nonmedical-
related
 FALL
 Leading cause of both emergency visit and hospitalization
 BICYCLE-RELATED TRAUMA
 Most common type of sports and recreation injury
 SCOPE OF INJURIES
1. Motor Vehicle Injury
 Leading cause of death due to accidents among
adolescents
 Includes motor accidents, vehicular accidents,
and even being ran over by a car
2. Drowning
 Peak in the preschool and late teenage years
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 PREVENTIVE PEDIATRIC MEDICINE PART 2 – DR. CALIGAGAN

 Leading cause of death in children 3. Use of non-flammable fabrics

4. Check tap water temperature
 Drowning is also a medical diagnosis – When you 5. Adult supervision of use of all fireworks
are diagnosed with DROWNING, it means that the
patient is already DEAD. The term used for those OBESITY
who were REVIVED after they drowned is NEAR-  OBESE - BMI is >95th percentile or 20% higher than the ideal
DROWNING body weight
 OVERWEIGHT - BMI is between 85th-95th percentile
3. Fire and Burn
 UNDERWEIGHT - BMI is < the 5th percentile
 6% of all unintentional trauma deaths 𝐖𝐞𝐢𝐠𝐡𝐭 (𝐤𝐠)
4. Suffocation  𝐁𝐨𝐝𝐲 𝐌𝐚𝐬𝐬 𝐈𝐧𝐝𝐞𝐱 (𝐁𝐌𝐈) =
𝐇𝐞𝐢𝐠𝐡𝐭 (𝐦𝟐)
 Half of unintentional deaths in less than 1 year old CLASSIFICATION BMI (kg/m2)
5. Homicide Severe Malnutrition <16.0
 TWO PATTERNS OF HOMICIDE:
Moderate Malnutrition 16.0-17.0
a. INFANTILE HOMICIDE
Mild Malnutrition 17.0-18.5
─ < 5 years old
Normal Weight 19.0-24.9
─ Represent child abuse
Overweight 25.0-29.9
─ Perpetrator is usually a caretaker
b. ADOLESCENT HOMICIDE Class 1 Obesity 30.0-34.9
─ Involves peers and acquaintances Class 2 Obesity 35.0-39.9
─ Due to firearms in >80% of cases Class 3 Obesity >40.0
𝐖𝐚𝐢𝐬𝐭 𝐂𝐢𝐫𝐜𝐮𝐦𝐟𝐞𝐫𝐞𝐧𝐜𝐞 (𝐜𝐦)
 SUICIDE → Increased markedly after 10 years old  𝐖𝐚𝐢𝐬𝐭 − 𝐇𝐢𝐩 𝐑𝐚𝐭𝐢𝐨 (𝐖𝐇𝐑) =
𝐇𝐢𝐩 𝐂𝐢𝐫𝐜𝐮𝐦𝐟𝐞𝐫𝐞𝐧𝐜𝐞 (𝐜𝐦)
 PRINCIPLES OF INJURY CONTROL
MEN WOMEN
1. Examine the physical and social environment
Normal WHR <1 <0.85
2. Injury control includes
Central Obesity >1 >0.85
a. Education of parents to change their behavior
Normal Waist
 Child car seat restraints <102 cm <88 cm
Circumference
 Bicycle helmets
 Smoke detectors
b. Changes in product design DENTAL HYGIENE
 DENTAL CARIES:
 Most common substance ingested
accidentally among children = KEROSENE   Common in the lower economic strata because they
Usually contained in bottle of soft drinks hardly go to the dentist, have poor dental hygiene,
and lack of education regarding dental hygiene
 Child resistant caps on medicine
 Remained increase in low income group
c. Modification of social and physical environment
 Depend on the interrelationship between the tooth
 Decrease speed limits in the neighborhood
surface, dietary carbohydrates and specific bacteria
 Elimination of guns from the households
 RISK FACTORS FOR THE DEVELOPMENT OF DENTAL CARIES:
 PEDESTRIAN INJURIES
1. Increased sugar consumption
 Most important cause of traumatic coma
2. Prolonged and frequent drinking and sipping
 PREVENTION OF PEDESTRIAN INJURIES:
3. Low socio-economic group
1. Education of the child in pedestrian safety
 PREVENTIVE MEASURES
2. Major streets should not be crossed alone until the child
1. Fluoride
is 10 years old
 Added to drinking water is the best preventive measure
3. Measures to slow the speed of traffic and to route
 Topical fluoride
traffic away from school and residential areas
 Fluoride
4. Proper placement of bus stops and sidewalks
2. Oral Hygiene
 FIRE AND BURN RELATED INJURIES PREVENTION
 Daily brushing with fluoridated toothpaste
1. Not drinking hot drinks while holding an infant
3. Diet
 Increases risk for scald burns  Decrease sugar ingestion
 Scald Burn  Most common form of burn among 4. Dental Sealants
children  Sealants are resins applied on the teeth
 Most effective when placed soon after teeth erupt
2. Keeping children away from cooking areas (within 1-2 years) in deep grooves and fissures

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 PREVENTIVE PEDIATRIC MEDICINE PART 2 – DR. CALIGAGAN
CANCER
 CANCER
 2nd leading cause of death by disease
 FACTORS THAT MAY ACCOUNT FOR ABOUT 75% OF ALL
CANCERS:
1. Tobacco → lung cancer
2. Sexual behavior → invasive cervical cancer
3. Diet → colorectal cancer
4. Alcohol → esophageal cancer
 PRIMARY CANCER PREVENTION IN PEDIATRIC PRACTICE:
1. Prevention of tobacco use in all forms =  Lung Cancer
2. Altering sexual habits in teenagers =  Cervical Cancer
3. Dietary modification =  Colorectal Cancer
4. Decrease alcohol usage =  Oral and Esophageal Cancer
 CERVICAL CANCER
 Increased incidence of cervical cancer in adolescents
 The most important risk factor is age at first coitus
especially if it occurs between 15-17 years of age
 PREVENTION
1. Counseling adolescents regarding sexual activity
2. Initial sexual history and discussion of contraception
3. Sexually active = screen annually
4. All suspicious (+) signs of cervical pathology should be
biopsied
 BREAST CANCER
 PREVENTION
1. Self-breast examination monthly
2. Periodic professional breast examination
3. Screening mammography for 35 years of age and above
 TESTICULAR CANCER:
 RISK FACTORS
1. Undescended Testes
2. Atrophic Testes
1% of all inguinal testes and 5% of abdominal testes will
become malignant
 PREVENTION
─ Monthly testicular self-examination
 CRYPTOCHIDISM (Undescended Testes)
 Most common disorder of sexual differentiation in boys
 Majority spontaneously descend during the 1st 3 months
of life
 CONSEQUENCES:
─ Infertility
─ Malignancy
─ Associated hernia
─ Torsion
─ Psychological effect of empty scrotum
 Orchiopexy should be done at 9-15 months
CHILD ABUSE
 Republic Act 7610 = Anti-Child Abuse Law  States that
you have to report any child who is a potential or a
suspected victim of abuse within 48 hours
 Report suspected child abuse within 48 hours
 Non-Reporting: Fine of Php 2,000.00
 TYPES OF CHILD ABUSE
1. Physical Abuse
a. Bruising
b. Burns
c. Fracture
d. Head injuries from routine falls
e. Shaken Infant Syndrome = 50% of deaths of children
caused by non-accidental trauma
2. Sexual Abuse
 Decide which physical injuries are accidental and which are
abusive
 Accidental bruising is more common in 2-5 years old who are
still developing their coordination and motor skills
 In a healthy child, in the absence of a traumatic history to
produce a fracture, the first diagnosis should be abuse
 Suspect abuse in a child with serious head injury or
evidences of repeated inflicted injuries
 Retinal hemorrhages associated with subdural hematomas
in children <2 years old should be considered child abuse
 PREVENTION:
1. Convey to all parents NEVER shake their small children to
avoid Shaken Baby Syndrome.
2. Diagnosis and treatment must be swift to avoid sepsis and
hypovolemic shock.
3. Always check the abdomen of an abused child for
tenderness and do trauma-screening laboratory studies.
4. There should be a meticulous search for other injuries.
5. Careful follow-up to document and treat sequelae of
trauma.
6. Psychological assessment of the caretakers.
7. Child protection need to be available immediately.
8. Home visitation program and unannounced visits.
9. To decrease the risk of SIDS:
a. Put the baby on his or her back to sleep
b. Let the baby sleeps on a firm mattress/surface
c. Have a smoke free and comfortably warm room
d. Regular doctor/clinic visits
e. Early and regular prenatal care
LEA THERESE R. PACIS 6