PNPSS cheat sheet

Bright Futures recommends a preventive visit schedule of 14 visits before age 12 months, then annual visits from age 3 through 21 years.

CDC/AAP immunization schedule: DTaP at 2, 4, 6, 15-18 months and 4-6 years; Tdap booster at 11-12 years; HPV series at 11-12 years (can start at 9).

Developmental screening: AAP recommends standardized screening at 9, 18, and 30 months; autism-specific screening at 18 and 24 months.

Newborn screening blood spot is ideally collected at 24-48 hours of life; repeat testing may be required for preterm or transfused infants.

Universal lead screening is required at 12 and 24 months for Medicaid-enrolled children; targeted screening is used elsewhere.

Anticipatory guidance topics by age: injury prevention (car seats, falls, drowning), nutrition, sleep, oral health, and screen time.

AAP recommends no screen time for children under 18-24 months and 1 hour or less per day of high-quality programming for ages 2-5.

Fluoride varnish is recommended every 3-6 months from first tooth eruption through age 5; systemic fluoride supplementation depends on water concentration.

Growth charts: use WHO growth standards for children under 2 years and CDC 2000 charts for ages 2-20 years in the US.

Normal growth velocity: approximately 25 cm/year in infancy, 5-6 cm/year from age 4 to puberty, and 8-12 cm/year during the pubertal growth spurt.

Red flag: crossing two or more major percentile lines on a growth chart warrants evaluation for failure to thrive or endocrine or chronic disease.

Developmental milestones: sit without support at 6-8 months, walk alone at 12-15 months, two-word phrases at 18-24 months, and three-word sentences at 36 months.

Red flag: no babbling by 9 months, no pointing or gestures by 12 months, no single words by 16 months, and no two-word phrases by 24 months.

Head circumference: rapid increase (crossing percentiles upward) suggests hydrocephalus; a bulging fontanel is a sign of increased intracranial pressure.

Denver II and ASQ-3 are common screening tools; the M-CHAT-R/F is the validated autism screen at 18 and 24 months.

Erikson stages: trust vs mistrust (infancy), autonomy vs shame (1-3 years), initiative vs guilt (3-6 years), industry vs inferiority (6-12 years).

Fever in an infant under 3 months is a red flag: full sepsis workup including blood, urine, and CSF cultures, and empiric antibiotics after cultures.

Acute otitis media diagnosis requires middle-ear effusion plus acute signs; first-line therapy is high-dose amoxicillin 80-90 mg/kg/day.

Bronchiolitis: supportive care is the mainstay; routine use of bronchodilators, steroids, and antibiotics is not recommended.

Group A strep pharyngitis: use the Centor or McIsaac score; confirm with rapid antigen test or culture; treat with penicillin or amoxicillin for 10 days.

Croup: a single dose of dexamethasone 0.15-0.6 mg/kg (max 10 mg) is first-line; nebulized epinephrine is for moderate to severe stridor.

Dehydration: use the Clinical Dehydration Scale; ORT is preferred for mild to moderate dehydration, and IV fluids for severe dehydration or shock.

Kawasaki disease: fever for 5 or more days plus 4 of 5 criteria; treat with IVIG 2 g/kg plus high-dose aspirin, and obtain an echocardiogram.

Appendicitis: migratory periumbilical to right lower quadrant pain, anorexia, and rebound tenderness; ultrasound is the preferred initial imaging in children.

Asthma: stepwise management per NAEPP/GINA; SABA as needed plus ICS for persistent asthma; assess control with ACT or C-ACT.

Type 1 diabetes: target HbA1c under 7% for most children; monitor for DKA (glucose over 250 mg/dL, ketones, acidosis) and hypoglycemia.

ADHD: DSM-5 criteria require 6 or more symptoms of inattention and/or hyperactivity-impulsivity for at least 6 months, with impairment in 2 or more settings.

Obesity: BMI of 95th percentile or higher for age and sex; screen for hypertension, dyslipidemia, and type 2 diabetes with HbA1c or fasting glucose.

Cystic fibrosis: sweat chloride of 60 mmol/L or higher is diagnostic; newborn screening with elevated IRT requires sweat testing confirmation.

Sickle cell disease: penicillin prophylaxis from 2 months to 5 years; pneumococcal vaccination; annual transcranial Doppler to screen for stroke risk.

Autism spectrum disorder: refer for behavioral intervention (ABA) and speech therapy; screen for coexisting conditions such as seizures, sleep problems, and GI issues.

Care coordination: a medical home model reduces emergency visits and improves outcomes for children with special health care needs.

Weight-based dosing: verify pediatric doses in mg/kg; acetaminophen 10-15 mg/kg every 4-6 hours (max 75 mg/kg/day) and ibuprofen 10 mg/kg every 6-8 hours.

Avoid aspirin in children with viral illness due to Reye syndrome risk; aspirin is used in Kawasaki disease and selected chronic conditions.

Amoxicillin is first-line for acute otitis media, strep pharyngitis, and community-acquired pneumonia in children; check for penicillin allergy.

Corticosteroids: dexamethasone 0.15-0.6 mg/kg for croup; prednisolone 1-2 mg/kg/day for asthma exacerbations.

Antibiotic stewardship: avoid antibiotics for viral upper respiratory infections, bronchiolitis, and most acute otitis media in children over 2 years with mild symptoms.

Medication errors: use the 5 rights, double-check high-alert medications, and use volume-based dosing for liquid medications to reduce errors.

Vaccine administration: follow the CDC catch-up schedule; live vaccines are contraindicated in severe immunocompromise and pregnancy.

ADHD medications: stimulants (methylphenidate, amphetamine) are first-line; monitor growth, blood pressure, and appetite.

Family-centered care principles: dignity and respect, information sharing, participation, and collaboration with the family.

Shared decision-making: present options, discuss risks and benefits, elicit family values, and reach a mutually agreed plan.

Teach-back method: ask the family to explain the plan in their own words to confirm understanding.

Health literacy: use plain language, limit to 3-5 key points, and avoid jargon; confirm understanding with teach-back.

Cultural humility: recognize one's own biases, ask about the family's beliefs and preferences, and avoid assumptions based on culture.

Interpreter use: use qualified medical interpreters, not family members, for discussions involving consent or complex decisions.

Adolescent confidentiality: discuss confidentiality limits (safety concerns) and provide time alone with the adolescent at preventive visits.

Breaking bad news: use a structured approach (SPIKES) that includes setting, perception, invitation, knowledge, empathy, and strategy.

Informed consent for minors: parents or guardians consent; assent is obtained from children old enough to understand (typically 7 years and older).

Emancipated minors and mature minor doctrines vary by state; minors can consent to confidential services such as STI testing and mental health care in many jurisdictions.

Mandatory reporting: report suspected child abuse or neglect to child protective services; reporting is required regardless of proof.

AAP advocacy priorities: Medicaid and CHIP funding, vaccine access, mental health services, and injury prevention.

Ethical principles: autonomy, beneficence, nonmaleficence, and justice guide pediatric decision-making, with the child's best interest as the standard.

Health policy: ACA provisions include coverage for children up to age 26 on parents' plans and preventive services without cost sharing.

Quality measures: HEDIS pediatric measures include well-child visits, immunization status, and asthma medication ratio.

Professionalism: maintain boundaries, document accurately, and disclose errors to families and institutions.

Evidence hierarchy: systematic reviews and meta-analyses of RCTs rank above individual RCTs, cohort studies, case reports, and expert opinion.

PICO framework: Population, Intervention, Comparison, Outcome - used to formulate a searchable clinical question.

Quality improvement: use PDSA cycles (Plan-Do-Study-Act) to test changes on a small scale before spreading.

Model for Improvement: three questions - aim, measures, and changes - plus PDSA cycles.

Run charts and control charts distinguish common-cause from special-cause variation in QI data.

Care coordination: a medical home with a care coordinator improves outcomes and reduces costs for children with special health care needs.

Team-based care: clear roles, shared goals, and closed-loop communication reduce medical errors and improve handoffs.

EBP steps: ask, acquire, appraise, apply, and assess; integrate evidence with clinical expertise and family values.