Aquifer case study

Learning Objectives

Upon completion of the case, the student should be able to:

Discuss conditions that may contribute to a child’s failure in school. Summarize the signs, symptoms, and management of ADHD. Demonstrate ability to measure and assess growth including height/length, weight, and body mass index using standard growth charts. Discuss the epidemiology, risk factors, management, and complications of childhood obesity. Discuss diagnosis, causes, and management of hypertension in children. Discuss the risk factors for and diagnosis of type 2 diabetes mellitus Review the recommendations, formulations, and potential side effects for the influenza vaccine


Calculation of Body Mass Index (BMI)

BMI = weight (in kg) divided by height (in meters) squared. The BMI better reflects the amount of body fat (compared to weight from muscle or bone) than weight-for-height measurements.

Growth Curve Terms

Weight age = Age at which the patient’s weight would plot at the 50th percentile. Height age = Age at which the patient’s height would plot at the 50th percentile. Weight age and height age are particularly useful terms in communicating with parents, who often want to have some frame of reference for just how large or small their child is.

Attention Deficit Hyperactivity Disorder (ADHD)


The core symptoms of ADHD are: Inattention Hyperactivity Impulsivity


The estimated prevalence in the U.S. is about 8 to 10%, making ADHD the most common neurobehavioral disorder of childhood and among the most common chronic health conditions in school-aged children. Diagnosis

There is no laboratory test for the diagnosis of ADHD. Rather, the diagnosis is based on a set of characteristic clinical findings.

Diagnosing ADHD

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), criteria for diagnosis of ADHD include the presence of at least six of the symptoms listed below (or at least five for individuals 17 years of age and older): Symptoms of Inattention

Does not pay attention to detail or makes careless mistakes in school or at work Has trouble holding attention Does not seem to listen when spoken to directly Often does not follow through on instructions and fails to finish schoolwork, chores, or work duties Has difficulty with the organization of tasks Is reluctant to do tasks that require sustained mental effort (e.g., homework) Often loses things necessary for tasks and activities (e.g., school materials, keys, glasses)

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Is often easily distracted by extraneous stimuli Is often forgetful in daily activities

Symptoms of Hyperactivity and Impulsivity

Is fidgety, or squirms in seat Has difficulty remaining seated when this is expected (e.g., in classroom) Often runs about or climbs in inappropriate situations Has difficulty playing quietly Is often “on the go,” or acts as if “driven by a motor” Talks excessively Often blurts out an answer before a question has been completed Has trouble waiting for a turn Often interrupts others who are playing or speaking

In addition, the following conditions must be met:

Several inattentive or hyperactive-impulsive symptoms were present for at least six months and are inappropriate for the person’s developmental age Several symptoms must be present before age 12 Symptoms are evident in two or more settings, (e.g., at home, school, or work; with friends or relatives; in other activities). Symptoms interfere with the individual’s functioning socially or at school or work Symptoms are not better explained by another mental disorder

A patient can be diagnosed with one of three different types of ADHD based on which features they exhibit: ADHD, Combined Type ADHD, Predominantly Inattentive Type ADHD, Predominantly Hyperactive-Impulsive Type

Click here to see the 2019 AAP Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention- Deficit/Hyperactivity Disorder in Children and Adolescents

Important Causes of School Failure

Sensory impairment

Hearing and vision impairment in particular, may mimic inattention.

Newborns are universally screened for hearing prior to their discharge home after birth.

Vision and hearing should be screened subjectively (i.e., by history) in infants and toddlers.

Objective vision screening should be part of health maintenance visits beginning at 3 years old.

Objective hearing screening should be performed on all newborns and should be resumed at the 4-year-old health maintenance visit.

View the AAP Recommendations for Preventive Pediatric Health Care

Sleep disorder

Inadequate sleep may adversely affect school performance.

This may be due to a formal sleep disorder (e.g., obstructive sleep apnea, narcolepsy) or simply poor bedtime routines in the home (poor “sleep hygiene”).

Patients with ADHD often have poor sleep hygiene, but typically do not seem overtired.

Mood disorder

Prevalence of mood disorders increases with age.

Depression affects an estimated 3.2% of children aged 3 to 17 years.

Childhood depression is marked by a high rate of conversion to bipolar disorders.

Children with ADHD also have a higher rate of mood disorders than control populations.

Mood disorders may mimic OR accompany ADHD.

Learning disability

A learning disability (LD) is a disorder of cognition which manifests itself as a problem involving academic skills.

Most states require documentation of a discrepancy between IQ (in the normal range) and academic achievement for the diagnosis of a learning disability.

Learning disabilities clearly impair academic performance, but may also lead to behavioral and attention problems, particularly at school.

Comorbidity between LD and ADHD is common; many experts feel that one diagnosis should not be made without evaluating for the other.

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Conduct disorder

Oppositional defiant disorder (ODD) is characterized by a pattern of negativistic, hostile and defiant behavior.

Conduct disorder (CD) is a more severe disorder of habitual rule-breaking, characterized by a pattern of aggression, destruction, lying, stealing and/or truancy.

ODD/CD is the psychiatric condition with the highest comorbidity rates with ADHD.

Anxiety disorder

Like depression, anxiety is a mental health problem that can mimic some ADHD symptoms or be a comorbidity. According to an analysis of the 2016 National Survey of Children’s Health, 7.1% of children had anxiety.

“Red Flags” for Risk of Learning Disability

The following are “red flags” that might raise a clinician’s concern for learning disabilities: History of maternal illness or substance abuse during pregnancy Complications at the time of delivery History of meningitis or other serious illness History of serious head trauma Parental history of learning disabilities or difficulty at school

Response to ADHD Medication

Eighty percent of children with ADHD respond to stimulant medications such as sustained-release dextroamphetamine/amphetamine.

Adverse Effects of ADHD Medications

Appetite suppression

The most common adverse effect associated with stimulant use.

Weight loss, if any, is typically minor.

Insomnia A common, dose-related side effect.

Typically worse on the first days of medication.

Decrease in growth velocity

Studies have shown a slight decrease in growth velocity in children on stimulant medications for ADHD in the range of 1 to 2 cm, particularly when children were on higher and more consistently administered doses.

The effects diminished by the third year of treatment but no compensatory rebound effects were found.

Growth should be closely monitored for children on these medications.

With regard to other purported adverse effects: Risk of addiction: Children and adolescents do not exhibit signs of addiction to oral stimulant medication when taken at prescribed doses. However, stimulants may be addictive when abused or used for their euphoric effect. Risk of developing substance abuse: Patients who are treated appropriately with stimulant medication are at no higher risk for substance abuse than their peers. In fact, some data suggest that a positive response to stimulant medication may reduce a patient’s likelihood of substance abuse, as well as other high-risk behaviors. Personality changes: Some children may appear dull, overly restricted, or over-focused on medication. These are signs of excessive dosing, and a lower dose or different medication should be tried. Cardiovascular risk: In 2006, an advisory committee recommended a black box warning (the strongest warning that the U.S. Food and Drug Administration [FDA] issues) be placed on stimulant medications regarding sudden cardiac death (H); the FDA rejected this recommendation, at least for children without underlying cardiac disease, and issued a highlighted warning. The cardiovascular risks of these medications may be higher for adults (who account for about 10% of stimulant usage) than children. Stimulant medication use has been associated with increases in heart rate and blood pressure, but these effects are typically mild. Tics: A small subset of children with ADHD have underlying tic disorders. Use of stimulant medication does not cause tic disorders, but it may unmask tics or make them more prominent.

Television Viewing by U.S. Children

One study found the following: 32% of 2- to 7-year-olds have television sets in their bedrooms 65% of 8- to 18-year-olds have television sets in their bedrooms

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The average child 8 years and older in the U.S. watches television an average of three hours a day. Television viewing time does not provide the whole picture as it does not include the hours a day school-age children spend on the internet, on smartphones and tablets, and on video games. According to recent studies:

4 of 5 households own a device used to play video games Approximately 75% of adolescents own a smartphone 76% of teenagers use at least 1 social media site and 25% describe themselves as being “constantly connected” to the internet

Although media may serve as a positive educational medium, several negative associations have been described, including: Increased violent and aggressive behavior Poor body image Earlier initiation of sexual behaviors and substance use (drugs, alcohol, and tobacco) Disrupted sleep Obesity (through displacement of more active pursuits, encouragement of unhealthy diets, and negative effects on sleep habits)

The AAP recommends: For children younger than 18 months, avoid use of screen media other than video-chatting. For children ages 2 to 5 years, limit screen use to 1 hour per day of high-quality programs. For children ages 6 and older, place consistent limits on the time spent using media, and the types of media, and make sure media does not take the place of adequate sleep, physical activity and other behaviors essential to health.

View the AAP Policy Statements on Media and Young Minds and Media Use in School-Aged Children and Adolescents.

Epidemiology of Obesity

The prevalence of childhood obesity has doubled in the past 20 years in the U.S. The prevalence of obesity is 18.5% among youth in the U.S. with even higher rates among certain minority populations. The probability of childhood obesity persisting into adulthood increases from 20% at age four to 80% by adolescence. Multiple factors besides diet and activity level can contribute to obesity, including genetic and environmental risk factors.

Risk Factors for Obesity

Prenatal/neonatal risk factors for obesity include high birth weight, low birth weight (small for gestational age), and maternal diabetes. Having an obese parent increases a child’s risk for adult obesity, and the risk increases significantly if both parents are obese:

Odds ratio for one parent is 3 Odds ratio for both parents is more than 10 Before age 3 years, parental obesity is a stronger predictor of obesity in adulthood than child’s weight status.

Children from families of lower socioeconomic status have higher rates of obesity. This is likely due to multiple factors, including lack of safe places for physical activity and less access to nutrient rich, healthy foods and beverages. Certain genetic syndromes (such as Prader-Willi, Bardet-Biedl, and Cohen syndromes) are known to be associated with obesity.

Complications of Obesity

Sleep apnea Sleep apnea is cessation of breathing lasting at least 15 seconds while sleeping. It is obstructive, rather than central, apnea and is characterized by loud snoring and labored breathing. It is estimated to occur in approximately 7% of overweight children.

Dyslipidemia Hypertriglyceridemia and low HDL cholesterol is strongly correlated with metabolic syndrome, which occurs almost exclusively as a consequence of obesity. Several studies have shown that dyslipidemia may improve with weight reduction.

Hypertension Hypertension has been found to occur up to nine times more frequently in overweight children, and approximately1/3 of children with a BMI greater than the 95th percentile are hypertensive.

Slipped capital femoral epiphysis (SCFE)

SCFE involves the displacement of the femoral head from the femoral neck through the physeal plate. Most commonly, it occurs at the onset of puberty in obese patients with delayed sexual maturation. Typical symptoms include an antalgic gait due to pain referred to the hip, thigh and/or knee, with limited range of motion (especially internal rotation) on examination of the hip. SCFE can be diagnosed on plain x-rays of the pelvis, which shows widening of the physis. See a radiological case on SCFE.

Type 2 diabetes mellitus

Obesity is the most prominent risk factor for the development of type 2 DM in children. The average BMI for pediatric patients with type 2 DM ranges from 35 to 39 kg/m2.

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Steatohepatitis Nonalcoholic fatty liver disease, steatohepatitis, has been associated with obese adolescents and is typically characterized by a mild increase in liver transaminases, a hyperechoic liver on ultrasound, and evidence of fatty infiltration and fibrosis on biopsy.

Type 2 Diabetes Mellitus in Children

Rates of type 2 DM in children and adolescents have been increasing steadily over the past decade. According to data from the SEARCH for Diabetes in Youth Study, ~24% of newly diagnosed cases of diabetes in children during 2014-15 were Type 2 DM. The prevalence of Type 2 DM increases with age, tripling from age 10-14 to 15-18 years. Rare cases have been reported in children as young as 5 years old.

Diagnosis of Diabetes Mellitus


Diabetes mellitus (DM) has previously been classified by age of onset (i.e., juvenile vs. adult-onset) or by type of therapy (insulin- dependent vs. non-insulin dependent). Classification by etiology is now preferred: Type 1 DM is characterized by insulin deficiency, typically due to autoimmune destruction of pancreatic beta cells. Type 2 DM is more heterogeneous, but typically involves insulin resistance. American Diabetes Association (ADA) Diagnostic Criteria for Diabetes

HbA1c ≥ 6.5% (48 mmol/mol) (Test performed in an appropriately certified laboratory.), or Fasting plasma glucose ≥ 126mg/dL (7.0 mmol/L) (Fasting is defined as no caloric intake for at least 8 hours), or Two-hour plasma glucose ≥ 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test following a glucose load of 75 g glucose or In a patient with symptoms of hyperglycemia, a random plasma glucose ≥ 200mg/dL (11.1 mmol/L)


Patients with type 2 DM typically have a more indolent presentation than patients with type 1 DM. Weight loss is less common, and DKA is rare, although 25% of patients with type 2 DM will have ketonuria at diagnosis. “Accidental” diagnosis by routine laboratory screening, especially urinalysis, occurs in up to one-third of patients with type 2 DM; this is rare in type 1 DM. Type 1 DM is more likely to present in early childhood; age is not generally helpful in differentiating between type 1 and type 2 DM in adolescence.

Guidelines for Screening for Diabetes Mellitus in Children

Screening guidelines for children and adolescents at risk were issued by the ADA in 2003 and were most recently revised in 2018. Risk criteria

Testing should be considered in pediatric patients who are overweight (BMI </= 85th percentile) or obese (BMI >/= 95th percentile) and have one or more additional risk factors for diabetes:

FHx of type 2 DM in first- or second-degree relative Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, polycystic ovary syndrome, hypertension, dyslipidemia) Maternal history of diabetes or gestational diabetes during the child’s gestation

Age of initiation of screening

10 years of age or at onset of puberty, whichever is earlier Recommended screening frequency

Every three years if tests are normal; more frequently if BMI is increasing Screening tests

There is currently no consensus on the preferred screening test to use in children, and so any of the three tests (HbA1c, fasting serum glucose, or glucose tolerance test) may be used. See the associated reference ranges in conventional and SI units.

Other Screening Recommendations for Pediatric Overweight or Obese Patients

In addition to recommendations for screening for DM, the 2007 Expert Committee Recommendations state that: For BMI 85th to 94th percentile with no risk factors, a fasting lipid profile should be obtained. For BMI 85th to 94th percentile with risk factors in the history or physical examination, a fasting lipid profile should be

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obtained and AST and ALT levels should be obtained every 2 years starting at age 10 to assess for possible nonalcoholic fatty liver disease. For BMI >/= 95th percentile, a fasting lipid profile should be obtained, and even in the absence of risk factors. AST and ALT should be measured every 2 years starting at age 10 years.

Classification of Hypertension in Children

View blood pressure norms

For Children Aged 1-13y For Children Aged ≥ 13 y

Normal BP <90th% <120/<80 mmHg

Elevated BP ≥90th % to <95th % OR 120/80 mmHg to <95th % (whichever is lower) 120/<80 to 129/<80 mmHg

Stage 1 HTN

95th % to [95th % + 12 mmHg] OR 130/80 to 139/89 mmHg (whichever is lower)

130/80 to 139/89 mmHg

Stage 2 HTN ≥[95

th % + 12 mmHg] OR ≥140/90 mmHg (whichever is lower) ≥140/90 mmHg

Hypertension is defined as SBP and/or DBP meeting the standards for Stage 1 or Stage 2 HTN measured on three or more occasions

Acanthosis Nigricans

Acanthosis nigricans is associated most commonly with obesity and may be a marker for insulin resistance (with or without polycystic ovary syndrome). Lesions often improve with weight loss. It is characterized by hyperpigmentation and hyperkeratosis: Lesions are dark, “velvety,” “dirty-looking” areas of thickened skin. Most commonly involved sites include:

Posterior neck Axillae Intertriginous areas (areas where opposing skin surfaces touch and may rub —e.g., skin folds of the groin, axillae, and breasts) Over bony prominences.

Link to photos of acanthosis nigricans. (Note: Although the examples show acanthosis nigricans in African Americans, the condition can occur in people of any race.)

The Importance of the Influenza Vaccine

Influenza is a significant cause of morbidity and mortality with the severity of illness varying from year to year. The CDC estimates that since 2010, between 7,000 and 28,000 children younger than 5 years old have been hospitalized for flu each year in the United States and between 130 and 1,200 children have died from flu each year. The flu vaccine has been shown to decrease the risk of complications and death from influenza. For more information on the burden for flu disease and the impact of the vaccine, see the CDC’s most up-to-date data. The flu vaccine is licensed for children 6 months and older and comes in two forms—a killed injected form and a live intranasal form. The intranasal form can only be given to children 2 years and older. There are certain children who should not receive the intranasal vaccine, including patients with asthma and patients with weakened immune systems. For more information on contraindications and precautions for the live intranasal flu vaccine, click here. The flu vaccine cannot cause the flu. Side effects are generally mild and self-limited and include: soreness/redness/swelling at the shot site, headache, fever, muscle aches, and nausea. The CDC recommends pediatric patients be vaccinated as soon as possible each flu season, ideally before the end of October each year if possible. For the first year of immunization—(with either form of the vaccine) children less than 9 years of age need two doses given a month apart. In subsequent years an annual vaccine is all that is required.

Weight Gain Versus Underlying Endocrinological Disorder

Endocrine diseases that cause weight gain usually limit growth and lead to short stature. Only 1% of overweight patients have endocrine problems. In most cases, obesity stimulates statural growth and leads to tall stature for age. It also typically advances bone age and leads to early puberty.

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Motivational Interviewing

Motivational interviewing is a counseling technique based on identifying the patient’s motivation for changing his/her behavior. Here are some helpful hints for counseling behavior changes: Get the patient and/or caregiver to state their reasons for wanting to change.

This sets the tone that this is something they are working on because they want to, not just because you said so. Set a goal.

Make sure that you and the patient agree upon the goal. Make it attainable (e.g., no weight gain over the next month); you want your patient to have success. Your patient may have the best sense of what is attainable at this time.

Use external motivators.

The use of star charts or other reward programs may be especially important motivation for kids who have a limited understanding of more esoteric goals such as good health.

Be cautious of preaching to the choir.

Despite the increasing incidence of single-parent homes, almost all kids have someone else involved in their care. Parents, grandparents, babysitters, or teachers who are not present at the office visit may be among the biggest impediments to your plan for change.

Clinical Skills

Growth Charts and Body Mass Index

Pediatric growth charts have been used to track growth during childhood in the U.S. since 1977. Weight-for-age curves do not take into consideration the height of a child, clearly an important factor in assessing appropriate weight. Therefore, these curves cannot be used to assess obesity for any patients except those of average height. The most significant new feature of the 2000 revised CDC growth charts was the addition of BMI charts for children 2 years of age and older. Terminology

Because of the negative connotations associated with the term “obesity,” the terms “at risk for overweight” and “overweight” were used in the 2000 guidelines for BMI 85th to 95th percentile and greater than 95th percentile, respectively. The 2007 American Academy of Pediatrics (AAP) guidelines revised the accepted medical terminology:

BMI 85th to 94th percentile for age (BMI 25 to 29.9 kg/m2 for adults) is now classified as “overweight” BMI greater than or equal to 95th percentile for age (BMI greater than or equal to 30 kg/m2 for adults) is now classified as “obese”

The negative connotations still exist, however, and surveys show that patients prefer to use “overweight” or “gaining too much weight” over “obese” in conversation. Review the CDC’s guidelines on determining BMI in children.

Addressing Obesity in Children

One of the major challenges in working with families on obesity is that many families or children do not consider it a major issue or concern. Not surprisingly, children at this age are dependent on their families for the majority of their food and beverage choices. Effective strategies include:

Inquiring whether weight is a concern for the parent or the child, and Talking about immediate effects (to the patient) and long-term effects (to the parent).

Using the BMI as a visual aid to demonstrate that the child is overweight by national standards has been shown to be an effective motivator for changing eating, drinking, and exercise habits. The family must be engaged if any health behaviors are to be altered.

Causes of Elevated BP Measurements

“White coat” hypertension due to the anxiety of being at the clinician’s office is a common cause of elevated BP measurements.

Taking several BP readings in succession may reveal a steady decline in the BP toward the normal range in such cases. A school nurse may be a valuable asset in obtaining serial BP readings over time in a less-threatening environment.

Positioning may influence BP readings. The patient should be seated, in a relaxed state, with the arm held at the level of the heart. Holding the arm down at the side may elevate the systolic BP as much as 20 mmHg to 30 mmHg in an adolescent.

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Studies have shown that painful stimuli can acutely raise BP. Remember that a cuff that is too large will give a falsely low BP measurement; conversely, a cuff that is too small may give a falsely elevated BP.

The internal bladder width should be >/= 40% of the patient’s upper arm circumference. The internal bladder length should encircle 80% to 100% of the arm circumference.

Although obesity is commonly associated with hypertension, it is also common that obese children have their BP checked with a cuff that is theoretically appropriate for their age but inappropriately small for their size.

Screening for Secondary Hypertension in Children

Umbilical Arterial or Venous Access

Placement of an umbilical arterial or venous line during the perinatal period may predispose to renal vascular disease. Urinary Tract Infection

Although less common in boys, UTIs in childhood are one of the leading causes of hypertension and renal insufficiency later in life. This is due to renal scarring following the infection.

Catecholamine Excess

Although some children with catecholamine excess, e.g. pheochromocytoma or neuroblastoma, may not have symptoms such as flushing or sweating or palpitations, a positive response to a screening question in a hypertensive child would merit urine catecholamine testing.

Family History of Renal Disease

Ask about family history for hypertension and kidney disease. Inquiring whether a family member has needed dialysis is a good screening question for severe kidney disease.

Coarctation of the Aorta

Some children with coarctation of the aorta may go undetected until presenting with hypertension at a school-age visit. On exam, pay special attention to the femoral pulses and consider documenting BP measurement in a lower extremity.


Management of Primary Hypertension in Children

According to the 2017 guideline published in the journal Pediatrics for a child with elevated blood pressure: Therapeutic lifestyle changes should be implemented BP should be followed up in six months Guidelines do not recommend a diagnostic workup for a secondary cause of hypertension for children with blood pressure values in the elevated blood pressure range unless there is a concern for a possible underlying cause in the patient’s medical history, exam, or family history.

According to the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, appropriate first-line therapies for primary hypertension may include:

Medications (typically reserved for children with Stage 2 HTN, children with secondary hypertension, and children with evidence of target-organ effects) Dietary changes (diets lower in sweets and added sugars, fats, and red meats have been associated with lower blood pressures; lower dietary sodium has also been associated with reduced blood pressure) Weight loss (if overweight) Physical activity

Developing a Weight Management Plan With the Family

Making sure the patient and family understand and agree with the management plan are key to its success. Planning to address overweight or obesity in a young child is multifactorial. Your plans should include specific goals for:

Diet: Recommend low-calorie snacks, especially fruits and vegetables, and sugar-free beverages (preferably water). Screen time: Total TV/video game/computer/phone time should have consistent limits and efforts made to ensure screen time does not take the place of adequate sleep, physical activity, and other behaviors essential to health. It is recommended that children not have TVs, computers, tablets, phones, or video games in their bedrooms. Physical activity: A child this age should have at least 60 minutes of moderate to vigorous physical activity a day.

Resources for clinicians:

AAP’s Institute for Healthy Childhood Weight AAP’s Policy Statement on the Prevention of Pediatric Overweight and Obesity

Initial Treatment of ADHD © 2021 Aquifer, Inc. – Daniela Fernandez ([email protected]) – 2021-08-11 15:50 EDT 8/10



Starting a medication: It is a good idea to write down for the family the name of the medication, the dose, and frequency, and to make sure they understand how it is to be taken. Monitoring for efficacy: Reaching the optimal dose of medication relies on the child’s teachers being informed of the medication and asked to report any changes in behavior or possible side effects. The parents’ observations as well as the teachers’ will be used together to assess response. Additional consults: It can be helpful to engage a school psychologist about educational achievement testing in case there are additional learning supports that could be put in place for the child while at school. Resources for parents and clinicians:

A website about ADHD for parents. Children and Adults with Attention Deficit Hyperactivity Disorder: CHADD AAP Clinical Practice Guideline: Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents


Evaluation of Hypertension

Blood pressure monitoring: In the evaluation and monitoring of hypertension, it can be very helpful to have regular blood pressure checks outside the clinician’s office. This is a request that is commonly made of school nurses, who can then periodically share their record with the requesting clinician. Diet: A formal low-salt diet, in which the patient or family is expected to count milligrams of sodium, is unrealistic for many families. Recommending that the child avoid or decrease intake of particularly high-sodium foods, such as fast food and salty snack foods, and put down the saltshaker is a good start. Intake of fresh fruits and vegetables and water should be encouraged. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents


2020 National Diabetes Statistics Report. The Center for Disease Control and Prevention. Accessed April 19, 2021.

American Academy of Pediatrics, Council on Communication and Media. Policy Statement: Children, Adolescents, Obesity, and the Media. Pediatrics, 2011, 128(1):201-08.

American Academy of Pediatrics, Council on Communications and Media. Policy Statement: Media Use in School-Aged Children and Adolescents. Pediatrics. 2016 Nov;138(5). pii: e20162592

American Academy of Pediatrics, Council on Communications and Media. Policy Statement: Media and Young Minds. Pediatrics. 2016. 138(5):e20162591.

American Diabetes Association. 13. Children and adolescents: Standards of Medical Care in Diabetes – 2019. Diabetes Care. 2019;42(Suppl. 1):S148-S164.

American Diabetes Association. 2. Classification and diagnosis of diabetes: Standards of Medical Care in Diabetes – 2019. Diabetes Care. 2019;42(Suppl. 1):S13-S28.

Arslanian S, Bacha F, Grey M, Marcus MD, White NH, Zeitler P. Evaluation and management of youth-onset type 2 diabetes: a position statement by the American Diabetes Association. Diabetes Care. 2018;41:2648-2668.

Barlow S. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics. 2007;120;S164-S192.

Brady TM. Hypertension. Pediatrics in Review. 2012; 33; 541-52.

Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. Accessed April 12, 2021.

Committee on Nutrition. American Academy of Pediatrics Policy Statement: Prevention of pediatric overweight and obesity. Pediatrics. 2003 (reaffirmed 2006); 112(2):424-30.

Copeland KC, Silverstein J, Moore KR, et al. Management of newly diagnosed Type 2 diabetes mellitus (T2DM) in children and adolescents. Pediatrics. 2013; 131; 364-382.

D’Adamo E, Caprio S. Type 2 diabetes in youth: epidemiology and pathophysiology. Diabetes Care. 2011; 34(Supplement 2):S161-65.

Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(Supplement 5):S213-S256.

Flannery B, Reynolds S, Blanton L, et al. Influenza Vaccine Effectiveness Against Pediatric Deaths: 2010-2014. Pediatrics. 2017 May;139(5):e20164244.

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Flynn JT, Kaelber DC, Baker-Smith CM, et al; SUBCOMMITTEE ON SCREENING AND MANAGEMENT OF HIGH BLOOD PRESSURE IN CHILDREN. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017; 140(3):e20171904. Accessed November 2, 2018.

Ghandour RM, Sherman LJ, Vladutiu CJ, et al. Prevalence and Treatment of Depression, Anxiety, and Conduct Problems in US Children. J Pediatr. 2019;206:256-267.e3. doi:10.1016/j.jpeds.2018.09.021

Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity among adults and youth: United States, 2015–2016. NCHS data brief, no 288. Hyattsville, MD: National Center for Health Statistics. 2017.

Hamman R, Bell R, Dabelea D, et al. The SEARCH for Diabetes in Youth Study: Rationale, Findings, and Future Directions. Diabetes Care. 2014

Krebs N, Himes J, Jacobson D, et al. Assessment of Child and Adolescent Overweight and Obesity. Pediatrics. 2007;120;S193-S228.

Nam H and Lee K. Small for gestational age and obesity: epidemiology and general risks. Ann Pediatr Endocrinol Metab. 2018 Mar;23(1):9-13.

Perou R, Bitski R, Blumberg S, et al. Centers for Disease Control and Prevention (CDC). Mental health surveillance among children- United States, 2005-2011. MMWR Suppl. 2013 May 17;62:1-35.

Williamson S, Greene S. Incidence of thyrotoxicosis in childhood: a national population-based study in the UK and Ireland. Clin Endocrinol (Oxf). 2010;72(3):358-63.

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  • Pediatrics 04: 8-year-old male well-child check
    • Learning Objectives
    • Knowledge
      • Calculation of Body Mass Index (BMI)
      • Growth Curve Terms
      • Attention Deficit Hyperactivity Disorder (ADHD)
      • Diagnosing ADHD
      • Important Causes of School Failure
      • “Red Flags” for Risk of Learning Disability
      • Response to ADHD Medication
      • Adverse Effects of ADHD Medications
      • Television Viewing by U.S. Children
      • Epidemiology of Obesity
      • Risk Factors for Obesity
      • Complications of Obesity
      • Type 2 Diabetes Mellitus in Children
      • Diagnosis of Diabetes Mellitus
      • Guidelines for Screening for Diabetes Mellitus in Children
      • Other Screening Recommendations for Pediatric Overweight or Obese Patients
      • Classification of Hypertension in Children
      • Acanthosis Nigricans
      • The Importance of the Influenza Vaccine
      • Weight Gain Versus Underlying Endocrinological Disorder
      • Motivational Interviewing
    • Clinical Skills
      • Growth Charts and Body Mass Index
      • Addressing Obesity in Children
      • Causes of Elevated BP Measurements
      • Screening for Secondary Hypertension in Children
    • Management
      • Management of Primary Hypertension in Children
      • Developing a Weight Management Plan With the Family
      • Initial Treatment of ADHD
    • Studies
      • Evaluation of Hypertension
    • References

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