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USMLE Step 3 Review Course

Part 1 of 1
Human Development
A. Akhter, MD

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USMLE Step 3 Video Review Course

Human Development
Part 1 of 1

A. Akhter, MD

Copyright 2009 by Premier Review, USMLE Step3 Review Course. All rights reserved. No part of this material may be reported or
transmitted in any form or by any means without the permission of the Premier Review.
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the
authors are not responsible for errors or omissions or any consequences from application of the information in this hand out and make
no warranty, express or implied, with respect to the contents of the material.

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USMLE Step 3 Review Course


Part 1 of 1
Human Development
A. Akhter, MD
Apgar Score
zero
One (1)
Two (2)
Heart beat / minute
Absent
Slow ( <100)
> 100
Respiratory efforts
Absent
Slow irregular
Good, crying
Muscle tone
Limp
Some flexion of extremity
Active motion
Reflex irritability
No response
Grimace
Cry or cough
Color
Blue or pale
Body pink, extremities blue
Completely pink
A score of 8-10 is considered normal.
Apgar score is given at 1 and 5 minutes.
If one minute Apgar score is low the infant needs resuscitation. It has no relationship with future
outcome.
5 minutes Apgar score Effectiveness of resuscitation. It also has significance in future outcome.
Apgar score at 5 minutes
1: 7-10 is normal
2: 4-7 needs further resuscitation
3: < 3: increased risk of Cerebral palsy
Neonatal Reflexes:
Reflex
Stimulation
Response
Duration
Babinski

Sole of foot stroked

Fans out toes and twists foot in

Disappears at nine months to


a year

Blinking

Flash of light or puff of air

Closes eyes

Permanent

Grasping

Palms touched

Grasps tightly

Weakens at three months;


disappears at a year

Moro

Sudden move; loud noise

Startles; throws out arms and


legs and then pulls them toward
body

Disappears at three to four


months

Rooting

Cheek stroked or side of


mouth touched

Turns toward source, opens


mouth and sucks

Disappears at three to four


months

Stepping

Infant held upright with


feet touching ground

Moves feet as if to walk

Disappears at three to four


months

Sucking

Mouth touched by object

Sucks on object

Disappears at three to four


months

Swimming

Placed face down in water

Makes coordinated swimming


movements

Disappears at six to seven


months

Tonic neck

Placed on back

Makes fists and turns head to the


right

Disappears at two months

Routine prophylaxis at birth


1% silver nitrate or 0.5% Erythromycin ophthalmic ointment
2.5% povidone iodine solution to prevent Chlamydial conjunctivitis.
Vitamin K- injection- To prevent hemorrhagic disease of newborn.
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USMLE Step 3 Review Course


Part 1 of 1
Human Development
A. Akhter, MD
Gonococcal conjunctivitis
Purulent conjunctivitis, with profuse exudates and swelling of the eyelids.
The infection can extend from the superficial epithelial layers into the subconjunctival connective tissue
and the cornea, leading to ulceration, scarring, and visual impairment.
The infection usually manifests in two to five days after birth
Chemical Conjunctivitis
Start after the infant receives the 1% silver nitrate.
Usually first day or second day of birth. at
Any infant presents with features of chemical conjunctivitis, A Gram stain of the conjunctival exudates
should be examined for the presence of typical Gram-negative intracellular kidney bean-shaped
diplococci
Chemical conjunctivitis can be prevented if Erythromycin eye drop or ointment is used.
Chlamydial conjunctivitis
Most common cause of conjunctivitis in the neonatal period.
The incubation period- 5 to 14 days.
Presentation before five days is unusual
Infection usually results in watery eye discharge that becomes purulent, with marked swelling of the
eyelids and red and thickened conjunctivae.
Treatment of chlamydial conjunctivitis usually results in healing without complications. However,
untreated infection may persist for months and cause corneal and conjunctival scarring
Increased risk of developing Chlamydial Pneumonia
Vitamin K
1mg of IM vitamin K to prevent Hemorrhagic disease of Newborn (HDN).
Typically develops within the first week of life.
Mechanism of disease process: Hemorrhagic disease of Newborn is due to immature liver, low vitamin
K content of breast milk, a sterile gut, and poor placental transfer of vitamin K.
The risk of developing HDN is increased in infants whose mothers took Warfarin, certain antibiotics
(i.e., cephalosporin), and some anticonvulsants during pregnancy.
The American Academy of Pediatrics recommends administration of injectible vitamin K at birth, and
supplementation of infant formulas with vitamin K
Birth Screening
1: Thyroid stimulating hormone (TSH) universally required
2: Phenylketonuria (Guthrie method) Whole blood required
3: Blood group of the infant and mother Blood group of mother and infant to detect incompatibilities
4: Syphilis serology
5: Sickle cell in certain high risk group
6: Hematocrit All newborns
7: Galactosemia screen in infants with jaundice
8: Maternal Hepatitis B status, if it is not available.
9: In some centers, CYP21A2 (21 hydroxylase) measurement is done to rule out Congenital deficiency of
CYP21A2.
10: All newborn should be screened for hearing loss by Otoacoustic emission (OAEs) before 1 month of
age. Those who fail this test, should undergo Auditory Brainstem Response test (ABR)
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USMLE Step 3 Review Course


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Human Development
A. Akhter, MD
11: Primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to
preschool children older than 6 months of age whose primary water source is deficient in fluoride.
12: Screening for sickle cell disease in newborns using thin-layer isoelectric focusing (IEF) or high
performance liquid chromatography (HPLC) techniques performed on capillary blood collected from a heel
stick and absorbed onto filter paper.
Immunity
Active immunization: can be achieved by whole or killed bacteria or virus, live attenuated bacteria or
virus or subunit of or part of the organism or toxoids produced by the bacteria.

Live attenuated: when virulence of the organism is reduced.


Toxoid: Toxoids are modified toxins,that has lost toxicity but still retains ability to act as an antigen
and produce active immunity
Passive immunity: Passive immunity is the acquisition of preformed antibodies from an external source,
such as the administration of intramuscular or intravenous human immunoglobulin (Ig).
Passive immunity is also acquired during human gestation by the transplacental transfer of maternal
IgG, and postnatally via colostrum and breast milk.
Maternal IgG is gradually lost, with very little remaining after the first year of life
Primary immune response
When a vaccine or toxoid is given, it stimulates the host to produce a primary immune response (usually
by inducing B-cell proliferation, antibody response, and T-cell sensitization) and production of IgM and
IgG.
If an individual is subsequently exposed to the pathogen against which the vaccine is directed, the
exposure results in a secondary response that includes increased proliferation of B-cells and formation of
antibodies. The secondary response protects the individual from developing disease, ideally for life.

First response to an antigen is production of IgM followed by IgG


The lag period (exposure to an antigen and production of antibody is longer if the exposure is initial
Follow up response to antigen is production of IgG with lesser lag period.
Live attenuated vaccine are not given during pregnancy or when the patient is receiving immunoglobulin
(passive immunization)

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Human Development
A. Akhter, MD

Hepatitis B Vaccine
Recombinant vaccine given IM in deltoid region to avoid deposition in fat of gluteal area.
Mandatory for children in USA, 0-1-6 months

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Human Development
A. Akhter, MD
Diphtheria, Tetanus & Pertussis (DTaP)
DT- diphtheria vaccine is in high dose for children
dT- smaller dose of diphtheria vaccine in adolescents and adults.
aP- Acellular Pertussis- recommended even after 7 years of age.
Childhood vaccines: 2, 4,6,15 months primary vaccines.
Two booster dosages at 4 years and 11 years.
Side Effects (Most side effects are seen after 4th and 5th dose) Fever, Redness, Swelling, Tenderness
(25%). Seizure, non-stop crying and high fever- 1in 16000, Long term seizure, coma and permanent
brain damage 1 in a million.
Hemophilus Influenza Vaccine (Hib)
Conjugate Vaccine- 2-4-6 month (primary), one booster.
Side Effects: Mild fever, redness and swelling can appear within a day and disappears within 2-3 days.
Inactivated Poliovirus vaccine (IPV)
4 dosage of IPV (2,4,6 months and at 4 years of age)
Streptomycin, Neomycin and Polymyxin B component in IPV
OPV is not recommended in USA- risk of Paralytic Polio.
OPV is also not given to people who have someone in the household with immunodeficiency.
Mumps, Measles & Rubella (MMR)
First dose at one year and second dose any time after 4 weeks of the first vaccination upto 12 years.
Usually at 4-6 yrs of age.
Live Vaccine
Contraindicated in Pregnancy and Immunocompromised Patients. Except in HIV +ve children with CD4
+ T lymphocyte count is >500/L or >15% of total lymphocyte
Neomycin, Gelatin component in the vaccine.
Side Effects: Swelling of glands and cheeks 7-12 days after the vaccine.
Seizure and temporary low platelet count (rare)
Varicella (Chicken Pox)
Live attenuated virus vaccine, one dose at 12 month of age and another one at 4 years of age.
Should be given to asymptomatic HIV +ve children >12 months. Two dosages 3 months apart. If the
CD4 + T lymphocyte count is >500/L or >15% of total lymphocyte
Should not be given to pregnant woman.
Not to administer in patients who has Neomycin sensitivity.
Avoid using Aspirin for 6 weeks after vaccination to avoid Reyes syndrome.
Side effects Mild rash in 20% can appear up to a month.
Seizure: 1in 1000 and Pneumonia very rare.
Pneumococcal Conjugate Vaccine (PCV7)
Pneumococcal conjugate vaccine
3 primary and two booster doses
Child vaccine is a conjugate vaccine. Adult vaccine is purified Polysaccharide (PPV23).
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USMLE Step 3 Review Course


Part 1 of 1
Human Development
A. Akhter, MD
Rotavirus Vaccine
RotaTeq, a live, oral, vaccine for use in preventing rotavirus gastroenteritis in infants
RotaTeq is a liquid vaccine that is given by mouth in three doses, 2, 4 and 6 months.
Rota ShieldTM vaccine was withdrawn in 1999 due to increased incidence of intussusceptions in children
who had received Rota Shield.
Side Effects: Mild diarrhea and vomiting can appear within 7 days
Influenza Vaccine- yearly
Influenza vaccine in children: Healthy children age 6-59 months should be encouraged to get influenza
vaccine to reduce hospitalization.
Children age 6 months to 18 years recommended for patients with chronic illnesses and on long term
aspirin therapy.
Children and adults of any age with Chronic Pulmonary disease and asthma, Diabetes, Chronic Renal
diseases.
Adults: 50 yr. old
Residents, health care workers and employees of chronic care facility.
Pregnant Women: Women who will be in their 2nd and 3rd trimester during the influenza season.
Severe egg sensitivity is an contraindication
Pharmacological treatment and Prevention of Influenza
Drug
Type of Influenza
Amantadine
A
Rimantidine
A
Zanamivir
A&B
Oseltamivir
A&B

Usage
Treatment and Prevention
Treatment and Prevention
Treatment only
Treatment and Prevention

If one should be treated with antiviral drugs, best results are achieved if given within 24-30 hours. In USA, only
Zanamivir and Oseltamivir are recommended. Antiviral treatment reduces the severity and duration of
influenza.
Meningococcal Conjugate Vaccine (MCV4)
Routine vaccination: Adolescents at the 11 to 12 year visit up to 18 years of age one dose is enough for
life long protection.
Children- 2-10 years of age, with terminal complement deficiency and anatomical or functional asplenia.
N. meningitidis is endemic Children 11 years of age that were immunized with the polysaccharide
vaccine (MPSV4) within the past 3 to 5 years and remain at risk for meningococcal disease.
Side effect: Increased incidence of Guillain-Barr syndrome
Hepatitis A vaccine
Inactivated Hepatitis A virus.
Recommended two shots as part of childhood vaccination program at one year of age.
Total two dosages at least 6 months apart

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USMLE Step 3 Review Course


Part 1 of 1
Human Development
A. Akhter, MD
Immunization should not be stopped
Low grade fever.
Antibiotic treatment
Post-vaccination fever less than 105F (40.5C)
Prematurity
Pregnant woman in home
Malnutrition
Family history of seizure or SIDS
Egg sensitivity or gelatin sensitivity or minor neomycin sensitivity.
Anaphylaxis to neomycin is a true contraindication
Lapsed immunization
Someone misses a dose of suppose DTaP, HBV, IPV and Hib there is no need to repeat the entire
series. The next visit should be treated as if the usual interval. The chart should be flagged to complete
the immunization at the next available visit.
Unknown or uncertain immunization
These patients should be treated as disease susceptible and should be immunized accordingly. There is
no harm even if the individual is already immunized. If the individual is > 7 yr old, dTaP in place of
DTaP should be given
Immunization received outside United States
All international adoptee, immigrants should be immunized as per the immunization schedule provided there is
written documentation indicates the comparable adequate immunization has been done as per United States
guidelines. If the documentation is adequate and comparable still Rubella titer should be done since in some
part of the world Rubella component is not a part of MMR vaccine

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