Your 2018 Pediatric Board Review Books – A Sneak Peek

Your 2018 Pediatric Board Review PREVIEW (and Discounted PREORDER Code) Is Here!

Unlike other board review courses, the PBR's Core Study Guide gets corrected and updated EVERY year. Many of the corrections and clarifications of the are made available to the PBR community (below) prior to the initial certification exam. This allows members to have a more secure pediatric board review experience.

For non-members who are trying to figure out how they will approach the board exam for next year, or for anyone preparing for the MOC, this is a great opportunity to essentially have a sneak peak into the 2018 edition.

In this article, you will:

Get a preview of the most EFFICIENT 2018 pediatric board review course available
Get a great review of several excellent and high-yield topics
Get a FREE MP3 Audio Chapter from PBR
Get 50 FREE High-Yield Images from PBR
Get a FREE Test-Taking Strategies Video Training Session
Get the opportunity to PREORDER the 2018 edition books for 50% off of the value of the Ultimate Bundle Pack or 85% OFF of the LIFETIME package called “PBR FOR LIFE!” Please note that the PBR FOR LIFE package is NOT typically available through the PBR catalog, so this is a SPECIAL opportunity!

A FEW WORDS OF THANKS TO THE PBR COMMUNITY

Every year I like to go through all PBR error submission and send corrections to PBR members before the initial certification exam. It’s an EXTREMELY time consuming task (takes several full days), but I believe it’s worth it.

If you have been following THE PBR EFFICIENCY BLUEPRINT, the information in this guide WILL NOT make or break your test-experience. Having said that, several test-takers have previously said that they enjoyed reading the clarifications, and that the review of the guide even helped them correctly answer several questions that came up on the exam.

THANKS TO YOU!

Thank you to EVERYONE who submitted spelling errors, typographical errors, corrections or requests clarifications from within the PBR by visiting the ERROR page:

www.pediatricsboardreview.com/error

For everyone who provided a page number, a clear question and a reference – oh my goodness… you rock!

Thank you to EVERYONE who submitted broken links from within the PBR and the PBR Picture Atlas by visiting the BAD LINK page:

www.pediatricsboardreview.com/badlink

An absolutely MASSIVE THANKS TO DR. JOHN COLE! John is a PBR alum, he’s been an OVC Summertime Q&A Webinar panelist and now he’s taken on the role of being PBR’s editor! He has a HUGE heart, and he does this to help you and the PBR community.

NOW… WHAT IS THIS THING?

I like to address as many concerns about the PBR content BEFORE the initial certification boards in October so this guide was specifically created and distributed to our members prior to the board exam

IN ORDER OF PRIORITY, MY FOCUS HAS BEEN….

Addressing error submissions from the PBR Error portal (www.pediatricsboardreview.com/error). Basically, stuff where folks are saying,“Ashish… I think (or I know) that this is wrong. You should fix it in the book and let folks know about it because it’s more than just a spelling or grammar issue.”
Addressing possible errors/concerns mentioned in our private members' only forum (the PBR Discord Community)! Yes… I kind of “stalk” the group and if I see something comes up that might warrant a correction in the PBR. I set it aside for this time of year to review.
Requests for content clarification through the portal.

The “PBR Discord Community!” is meant to help you get the help you need to understand a topic. But, if I see that there’s a topic that could be explained better based on CREW conversation, I make a note of it and try to polish it up for the next edition and address the issue in this guide.

Because the PBR membership continues to grow, there has been EXCELLENT chatter in “The PBR Discord Community.”

PEARL: If you are a member of the “The PBR Discord community” but you have NOT been seeing all of the channel, please visit the contact us. This is critical!

ARE YOU NERVOUS BECAUSE THERE ARE “CORRECTIONS” FOR THE PBR CONTENT?

ALL study guides have errors!

I’m simply the only author who is crazy enough, and passionate enough, to take on something like this prior the boards every year so that you can rest EASY. And instead of just giving you a one page errata sheet based on error submissions, we try to go much deeper in our explanations and we also SEEK OUT areas of improvement to share with you.

For some people, though, the idea that the PBR has errors can be anxiety provoking.

If you’re one of those members, please keep in mind that there are OVER 2000 topics within the PBR, and each topic has MANY salient points associated with it. There are probably over 10,000 individual pieces of information in the PBR. Therefore, the number of corrections below is relatively TINY.

So you should rest easy knowing that there is MORE THAN ENOUGH excellent content within your PBR to get you your PASS! The PBR CERTIFICATION SYSTEM has helped pediatricians get ABOVE the national average score after MULITPLE years of failing… so you’ll be fine!

WHAT ABOUT IMAGE LINK CORRECTIONS?

We have a very innovative system that allows you to view approximately 400 high-yield images across the web. Since the images that we refer you to are not owned by PBR, your timely submission of any broken links have helped us keep over 97% of our image links updated. Thank you!

If you happen to still find a broken link, please notify us immediately by visiting: www.pediatricsboardreview.com/badlink

The EASIEST way to go through all of these images is by using the online picture atlas created by Team PBR (called the Virtual Atlas of Pediatric Pictures). The VAPP gives you a SUPER fast and high-yield review of board-relevant images.

You can watch the video below to see how it works:

www.PediatricsBoardReview.com/vapp

GET 50 FREE IMAGES BY CLICKING THE IMAGE BELOW!

FREQUENTLY ASKED QUESTIONS

“Is this a complete list of everything that’s changing for the new edition?”

NO! The new edition will have MORE additions and modifications. This Corrections & Clarifications Guide includes:

A set of absolute notifications because they were true errors that we verified.
Several clarifications and discussion around confusing stuff.

“If I have the old book… Should I keep that one or get the new one?”

If you have a 2017 Edition, it DOES HAVE enough information in it to help you pass the initial certification exam or the recertification exam. But, we tend to add new information and sometimes even new chapters when we release a new edition.

Here are the 6 main reasons to get the new edition if you still have an old one:

SAVE AND MAXIMIZE YOUR TIME
- If you have an older version of the book and you are taking the boards several months from now, then this is NOT the time to spending your energy cross checking everything in this guide against your older version of the PBR. Please understand that your time is PRECIOUS and needs to be spent EFFICIENTLY and effectively. Plus, there is ALWAYS new content in a new release.
- Start with a fresh book, transfer any notes/drawings from your previous hardcopy to the new edition as you read through it the first time, and then use the new one as your bible!
COST (No… I’m not just talking about money!)
- By cost, I mean money and opportunity cost. The cost of a new book is minimal compared to the hard financial cost and the opportunity cost of FAILING the boards. The financial cost of FAILING includes over $2000 for your board fees, plus the cost of taking time off of work to study again next year (THOUSANDS of dollars of lost income). You also must include the stress and the time away from loved ones as a tremendous unmeasurable cost.
- If you have some OTHER reason to keep studying from an older edition, so be it… but if it’s due to financial concerns, that’s actually pretty silly. Sorry… this is the one place in this guide where I need to blunt (for your sake). I have such a passion for efficiency and QUALITY USE OF TIME that it pains me to hear about physicians that are trying to go back and forth between the corrections guide and their old study guide in order to save a few bucks.
REFERENCES TO PBR IN THE CREW!
- The PBR Discord Community comes alive with discussion as the boards approach. Many PBR alumni have said that the Discord community heavily contributed to their success on the boards. When your peers in “The CREW” are referring to a topic on a certain page, do you really want to (again) waste your precious time fumbling around and trying to find the topic they’re referring to because your pages don't match up with theirs?
UPGRADED FORMATS: Every edition is MUCH better than the previous.
- Corrections
- Clarifications
- New images
- NEW, TIME-SAVING Innovations. For example, our links used to be EXTREMELY long. Now we have a system that turns https://upload.wikimedia.org/wikipedia/commons/4/45/Aphthous_ulcer.jpg into something easy like pbrlinks.com/aphthous1. HOW COOL IS THAT! Try typing out the 2 different links and see HOW FAST you get to review images using the new PBR link. Innovating like this get me SO EXCITED!
NEW CORRECTIONS: There WILL be other corrections that will make their way into the new edition. MANY of the corrections below were included in this guide because of help from the PBR community, and many were done on my own. But there are more that need further investigation before the next edition is released.
NEW CLARIFICATIONS: Again, there was ACTIVE discussion within the members’ only PBR Discord Community! about board review topics that I THOUGHT were explained well within the PBR. Those discussion have allow us to create EVEN CLEARER topic explanations in our new editions.

DISCLAIMERS/WARNINGS – PLEASE READ THIS BEFORE YOU GET STARTED

The page numbers in this guide refer to the 2017 Editions of the Pediatrics Board Review books (covers shown below).

DEAR NON-PBR MEMBERS… the PBR Discord community! is a private, members-only area for anyone who has signed up for a qualifying product. YOUR REQUEST TO JOIN WILL BE DENIED if you have only signed up to get free info from PBR (free GI & DERM study guides, free emails about new PBR web article, free Q&A discounts, free MP3, etc). We cross-check all requests before clicking the APPROVE button. This is done in order to keep it a spam-free, private and intimate area.
Reminder… I LOVE being told I’m wrong (sort of), so keep the comments coming! Just keep in mind that the best place to submit error submissions, corrections, requests for clarifications, etc. is here:

www.pediatricsboardreview.com/ERROR

Use PROMO CODE “PREORDER” and PREORDER the 2018 Edition of the PBR at 50% OFF the Value

Our goal is to release the 8th Edition of the PBR between December 15th and January 1st.

Lock in current pricing for either of these memberships:
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During our 2018 PREORDER Window, PBR is Offering theFollowing VIP Resources with the PBR All Access Pass

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HERE'S EVERYTHING YOU GET IN A PBR 12-MONTH ALL ACCESS PASS PREORDER

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===

LETS GET STARTED WITH THE CORRECTIONS!

OKAY…. This first section is going to cover TRUE ERRORS that were in the PBR

When it comes to the Corrections & Clarifications Guide, our primary goal is to make sure that we evaluate any content error submissions. Thank you guys SO much for these submissions! I REALLY appreciate it. Got more? Send ‘em over!

www.pediatricsboardreview.com/error

ADOLESCENT MEDICINE

In Anorexia, three consecutive missed periods is no longer part of the diagnostic criteria in DSM V as this does not account for males, premenarchal females, and athletes. Also, under the same heading, I have seen multiple sources that refer to the weight criteria as <75% expected (rather than <85%)

You are correct. Thank you! The 2018 Edition of the Pediatrics Board Review will say:

ANOREXIA

In patients with anorexia, look for laxative abuse, diuretic abuse (supportive labs include hypOkalemia, alkalosis, and HIGH FeNa!), emesis, bradycardia, ST depression, prolonged QT, Ventricular Tachycardia (V- tach), hypothermia, orthostasis. The patient’s history must include a distorted body image, intense fear of weight gain, and low body weight (<75%).

MNEMONIC: ProLONGed QT and ST Depression = “A LONG-faced anorexic QT/Cutie is a little too Skinny/Thin… Even so, she still can’t stop being DEPRESSED because her body just doesn’t look right when she looks in the mirror!”

MNEMONIC: Bradycardia and Hypothermia = Just imagine that the super skinny anorexic girl’s body is so STARVED, that her heart beats slow and her body produces LESS HEAT ENERGY (to go into a calorie conservation mode).

______________________________________________________________________________

ENDOCRINOLOGY

NO 2017 CORRECTIONS!

OB/GYN and some STD’s

NO 2017 CORRECTIONS!

ALLERGY AND IMMUNOLOGY

Is Hyper IgM Syndrome listed under the correct subheading? In the book on page 101 it is listed under the B Cell Deficiency subheading, but it also has T-Cell dysfunction

Good idea, let’s move it! Now Hyper IgG Syndrome can be found under T-CELL DEFICIENCIES AND COMBINED T-CELL/B-CELL DEFICIENCIES subheading for the next version of the PBR.

HYPER IGM SYNDROME

In hyper IgM syndrome, the IgM to IgG class switch does not occur due to a missing signal from T-cells to B-cells. There is LYMPHOcytosis and NEUTROPENIA. This is a T-cell abnormality but results in a functional B-cell deficiency. Therefore it shares features of both B-cell and T-cell deficiencies, but the presentations are more similar to B-cell deficiencies. Patients frequently have sinusitis, otitis media and pneumonia with the “HNS” encapsulated organisms mentioned in the B-cell deficiencies section (Haemophilus influenzae, Neisseria meningitides, and Streptococcus pneumoniae). It usually starts around 6 months of age. Because of the T-cell abnormality, there is an increased risk of lymphoma/cancer. Patients can also get diarrhea and opportunistic infections from Pneumocystis jirovecii, Histoplasma and Cryptosporidium. For treatment, give IVIG to make up for the missing immunoglobulins and Trimethoprim-Sulfamethoxazole (AKA Bactrim) for PCP prophylaxis.

MNEMONIC: Bactrim is used for PCP prophylaxis

MNEMONIC: Think of the LYMPHOcytosis as a compensatory mechanism in which there are high numbers of LYMPHOcytes circulating and releasing elevated levels of IgM to “make up” for the lack of IgG, IgE and IgA. Also, think of the neutropenia as being a relative “lack of neutrophils” on the WBC resulting from an excess number of lymphocytes.

PEARL: Infections are similar to agammaglobulinemia, but the CBC looks different. Also, these patients can get PCP so suspect this diagnosis in any HIV-negative patient diagnosed with PCP.

Page 96 in the PBR states CD8 cells = suppressor T cells. CD8 cells are cytotoxic T cells. Suppressor T cells are now called T regulatory cells (T regs) and are thought to derive from same cell line as naive CD4 cells.

Fixed, thank you! We also removed the incorrect mnemonic for suppressor T cells.

CD8 CELL

CD8 cells = cytotoxic T cells

CARDIOLOGY

NO 2017 CORRECTIONS!

DERMATOLOGY

NO 2017 CORRECTIONS!

NEONATOLOGY

The book says on page 83 that any child born to a mother who is GBS+ should be watched in the hospital for at least 48 hours.

Thank you, good point! PBR needs a softer statement here as the AAP now recommends that a hospital stay of less than 48 hours after delivery may be appropriate for some healthy term newborns. Criteria for early discharge at or after 24 hours include a term child (> 37 weeks gestation), adequate maternal antibiotic prophylaxis prior to delivery, and asymptomatic newborn. If these criteria are met than it is reasonable to discharge the baby at 24 hours with follow-up at 48-72 hrs. See the corrected version in the PBR below:

GROUP B BETA HEMOLYTIC STREPTOCOCCUS (GBS)

Any child born to a mother who is GBS+ should be closely monitored for signs of infection up to 48 hrs. The child can qualify for early discharge after 24 hours if the child is term (> 37 weeks gestation), the mother received adequately antibiotic prophylaxis prior to delivery, and the newborn is asymptomatic. In this case the child needs follow-up in 48-72 hrs.

Could I get clarification on amount of Vit D supplementation children should get? Page 158 of the PBR states 400 IU, but I think this is incorrect.

Yes, children older than 1 year should get 600 IU of Vitamin D per day according to the 2010 recommendations by the Institute of Medicine (IOM) of the National Academy of Sciences. PBR now says:

EXCLUSIVELY BREASTFED BABIES

In exclusively breastfed babies, look for Vitamin D and Vitamin K deficiencies.

PEARL: ALL BABIES under 1 year of age are supposed to get a total of 400 IU (international units) of Vitamin D per day in their diet. For formula-fed babies, this is usually attainable through the formula. Breastfed babies need supplementation. If supplemental Vitamin D is not provided to exclusively breastfed babies, they may develop Rickets!

PEARL: Children > 1 year old should get 600 IU of Vitamin D per day.

PEARL: Patients with CF (CYSTIC FIBROSIS) or RICKETS need > 1600 IU of Vitamin D per day!

DEVELOPMENTAL MILESTONES

How many hours does a child need to cry to diagnose colic?

Colic was added to Core Study Guide on page 168 of the MILESTONES chapter. Updated version is below.

MNEMONICS FOR CRYING BY AGE: By three months of age, babies cry approximately 1 hour/day. Use 1-2-3 and 3-2-1 to remember that at months 1, 2, and 3, babies usually cry a maximum of 3, 2, and 1 hours per day.

MNEMONICS FOR COLIC: Remember the “3’s” – 3 hours per day, 3 days per week, 3 weeks or more and resolves by 3 months of age

PEARL: If a baby is crying more often than the abovementioned parameters, then you should consider Colic as the cause. The definition of Colic includes a baby that cries more than 3 hours per day for more than 3 days per week for 3 weeks or more. It is usually worse in the evening and it resolves spontaneously in most babies by 3 months of age.

EMERGENCY MEDICINE AND TOXICOLOGY

Images on Page 180 of the calcium crystals are associated with the wrong descriptions. It should be reversed.

Fixed!

* (DOUBLE TAKE) CALCIUM OXALATE CRYSTALS: Calcium oxalate stones are the most common ones in humans. There are two types of calcium oxalate crystals. One is square and looks like it has an X on it. That one is very common. The other is elongated and looks like a rod. The long one is the one usually associated with ethylene glycol poisoning.

IMAGE: https://pbrlinks.com/CALOXCRYS1MNEMONIC: calcium oXalate crystals look like a big X on a crystal.

IMAGE: https://pbrlinks.com/CALOXCRYS2 (This one is related to ethylene glycol and kind of looks like a long can of beer, or needles.)

Isn’t Diazepam the best treatment for cocaine overdose on page 183?

Correct, haloperidol (antipsychotic) should be avoided in cocaine overdose as it may lower the seizure threshold, confuse the clinical picture, cause a dystonic reaction, or worsen an anticholinergic crisis. See corrected section in PBR below:

COCAINE

Cocaine may cause AGGRESSION, VIOLENCE, EUPHORIA, overconfidence, and HTN (which you should treat with nitroprusside). Death is not dose-dependent. Treatment for cocaine overdose includes IV benzodiazepines (diazepam or lorazepam) as this will reduce sympathetic outflow in patients who are anxious, agitated, hypertensive, or tachycardic.

Doing questions on toxidromes – (why do I torture myself) and choose deferoxamine for iron question but was wrong because the “level of 240 given wasn’t high enough.” Any idea what the level for chelation is? I can't find it.

I have no idea why you torture yourself, but the level is > 500 mcg/dL. Good addition for the book on page 187.

IRON OVERDOSE

Iron overdose results in CAPILLARY LEAK, hypotension, ANION GAP ACIDOSIS (mudpiles), AND possible cardiovascular collapse. There may also be associated hematemesis, scarring of the gastric pylorus, and hepatic toxicity. On presentation, obtain ABDOMINAL X-rays to look for undigested pills. There are 4–5 stages of toxicity (GI, Latent, Metabolic/Cardiovascular, Hepatic, and then Delayed). Obtaining serum iron levels at about 3–5 hours post-ingestion helps determine the risk of systemic toxicity. Treatment requires CHELATION with DEFEROXAMINE for levels > 500 mcg/dL. Do NOT pick charcoal because it does NOT bind well to iron. Chelation will result in pink urine, often referred to as “Vin Rose Urine.” Continue giving deferoxamine until the urine is no longer pink.

VITAMINS AND NUTRITIONAL DISORDERS

NO 2017 CORRECTIONS!

GASTROENTEROLOGY

NO 2017 CORRECTIONS!

PHARMACOLOGY

NO 2017 CORRECTIONS!

OPHTHALMOLOGY

NO 2017 CORRECTIONS!

GENETICS

NO 2017 CORRECTIONS!

HEMATOLOGY AND ONCOLOGY

On page 253, tumor lysis syndrome refers to a triad of hyperphosphatemia, hyperkalemia, and LDH. While LDH is also elevated, it is not considered part of the triad of TLS.

Correct! Thank you for that fix! Tumor lysis syndrome laboratory values include: low calcium (secondary to hyperphosphatemia) and elevated potassium, elevated phosphorus, and elevated uric acid due to release from lysed cells. LDH is used to stratify the risk level of different cancers and can also be elevated in TLS. The book has been changed and now reads as follows:

TUMOR LYSIS SYNDROME

Tumor lysis syndrome is an ONCOLOGIC EMERGENCY. It occurs due to lysis of large tumors or “blood tumors” (lymphoma). Potassium, phosphorus, and uric acid levels are elevated due to release from lysed cells. Treat with allopurinol or rasburicase, aggressive hydration, and careful monitoring and management of electrolytes. Urine alkalinization by giving sodium bicarbonate is no longer generally recommended.

INFECTIOUS DISEASES

What is the post exposure prophylaxis for a kid less than 6 months?

Any child < 6 months should get measles immunoglobulin (MIG) only. The book now reads as follows in the ID section, but there’s also a section in the VACCINES chapter which covered this:

* TREATMENT:

MEASLES (AKA RUBEOLA)

“COUGH, CONJUNCTIVITIS, and CORYZA” are the classic symptoms of measles (AKA rubeola). Coryza refers to rhinorrhea. Also look in the mouth for KOPLIK SPOTS and on the skin for a rash. The three C’s come first, then the Koplik spots, and the LAST symptom to appear is the RASH. The rash starts at the head (around the hairline) and progresses down. The rash resolves after about 5 days. The major cause of death is PNEUMONIA. The virus is transmitted via droplets and is so contagious that patients require negative pressure isolation. Patients are contagious from FOUR days prior to the onset of the rash until FOUR days after the rash appears.

* POSTEXPOSURE PROPHYLAXIS:

If < 6 days since exposure in a child < 6 months, give measles immunoglobulin (MIG) only. Anyone given MIG will need a first-time vaccination, or possibly a re-vaccination, 5 months after the MIG dose. No prophylaxis is needed after 6 days.
If < 3 days since exposure in an unimmunized child > 6 months old, give the vaccine (MMR). Also give if vaccination status is unknown. If the MMR was given for prophylaxis and the child was 6 to 12 months of age, s/he will need it again at one year of age.
If > 3 days but < 6 days since exposure in a high-risk, unimmunized child, including those who are immunosuppressed or under 5 years old, give measles immunoglobulin (MIG). Also give this if the patient’s vaccination status is unknown. Anyone given MIG will need a first-time vaccination, or possibly a re-vaccination, 5 months after the MIG dose.
IVIG is given to any exposed immunocompromised individual (immunodeficiency, on chemo, low CD4, etc.), regardless of immunization or vaccination status.* TREATMENT: The treatment for measles is supportive.* PEARL: Most measles exposures result in MIG being given when prophylaxis is indicated because the most obvious and scary symptom (the RASH) is the LAST thing to present. Late presentation to the doctor means MIG is the only prophylaxis option for anyone exposed.* NAME ALERT: Note that this is not the GERMAN MEASLES caused by the RUBELLA VIRUS.
(DOUBLE TAKE) MNEMONIC: Imagine a patient stuck in a NEGATIVE PRESSURE ISOLATION room. He’s watching MTV and gets pissed because he’s bored and all they ever show is reality shows. He grabs the phone and throws it at the “M.T.V.” – Negative pressure isolation is required for Measles, Mycobacterium Tuberculosis and Varicella. For VZV, droplet precautions are sufficient if only one dermatome is involved. As mentioned in the Aspergillus section, that, too, requires negative pressure isolation.

Why is answer B correct In the Q & A book, question 39? The explanation says “If mom was given ERYTHROMYCIN, TREAT the baby because it doesn’t cross the placenta.” The mom in the scenario was given erythromycin, but the correct answer is listed as B.1

1. A healthy-appearing child is born to a mother that had poor prenatal care. Late in her pregnancy, she was found to have syphilis that was confirmed with a positive FTA. She was treated with erythromycin 6 weeks prior to the delivery. Non-treponemal titers are obtained from both the mother and the neonate. Both are positive. What’s the next best step in management?

Treat the mother and the baby with penicillin.
Treat the mother with penicillin and check the FTA in the baby.
Do not treat the mother. Treat the baby with penicillin.
Recheck the baby’s non-treponemal titers in one month

Great catch! Answer B is wrong, and C is the most correct. The mother has been treated already, but the baby has not, so the baby needs treatment. Checking the FTA is useless since it may remain positive long after the infection is cleared. The baby still needs some clinical and lab evaluation to determine the exact regimen of penicillin required, but will require the drug in any case. Therefore, C is correct.1

VACCINES, IMMUNIZATIONS AND CONTRAINDICATIONS

On page 313 in the section that start’s with “another dose of all vaccines…” it says that an extra dose of IPV is given between 1-2 years of age. Is this correct?

Good catch! That is NOT correct. The book has been updated as followed:

VACCINE SCHEDULE REMINDERS

The details of the vaccine schedule are complicated and you should not try to memorize all of them. Know some of the standard vaccines and when they are given. Do not worry about all the “ifs, ands, or buts.”

2, 4, AND 6 MONTHS: Six vaccines are given: DTaP, IPV, Hepatitis B, Hib, Pneumococcus (PCV-13) and Rotavirus. Hep B is not required at 4 months if the newborn dose was given, but is allowed for simplification. Rotavirus is oral and live, the others are all injected and not live. No more vaccines are required in the first year.

* BETWEEN 12 and 15 MONTHS: These do NOT need to be given all at the same time and there are different schedules and regimens available for working them into two well-child visits.

The one-year virus shots: the live viruses plus Hepatitis A #1, so MMR #1, Varicella #1, and Hepatitis A #1
Another dose of all the vaccines of the first year except Hepatitis B, IPV, and Rotavirus, so DTaP #4, Hib #3,  and Pneumococcus #4 are given around the beginning of the second year.

* 18 MONTHS: Hepatitis A #2

* KINDERGARTEN (4-5 YEARS): DTaP #5, IPV #4, MMR #2 and VZV #2. Remember that Hib and pneumococcus are not important threats for immune competent children older than 5 so no further vaccine doses are needed.

* MIDDLE SCHOOL (11-12 YEARS): Tdap, HPV, and Meningococcus. HPV is a series of three shots.

* GRADUATION (16-18 YEARS): Meningococcus #2

On page 311, isn't there a vaccine for Meningococcal type B? the pearl said there is no vaccine?

Thank you! The book is now updated:

MENINGOCOCCAL VACCINE (AKA MENINGOCOCCUS VACCINE)

The meningococcal vaccine (subtypes ACWY), is recommended for ALL kids at 11 years of age, NOT just those starting at college and living in a dorm. It requires a booster. If started on time at 11 years of age, the booster is given at 16 years of age. Otherwise, at about 3 years after the first dose. For unimmunized freshman living in a dorm, give one shot and no booster. Another meningococcal vaccine (subtype B) is recommended for both low-risk (given between 16-23 years old) and high-risk populations (> 10 years old after an outbreak, spleen damage or removal, compliment immune deficiency, taking a drug called eculizumab, or microbiologists routinely working with N. meningitides). It also requires a booster.

PEARL: The minimum age to receive the vaccine is now 2 months. Children < 11 years of age may receive the vaccine if they are at high risk (asplenic, having complement deficiency, generally immunocompromised, or traveling to an endemic area).

PEARL: If a CLOSE INTIMATE contact of your patient has meningitis, give your patient prophylaxis with rifampin or ceftriaxone within 24 hours of diagnosis regardless of the immunization status. Close “intimate” contact includes nursery school, but not elementary school classmates or healthcare providers.

PEARL: Subtype B is Bad for Babies. Most meningococcal meningitis cases in babies are due to this subtype.

On page 311 it says that HPV has 3 required doses. I believe that is incorrect. There are only 2 doses required.

You’re right. Thanks! See update below:

HUMAN PAPILLOMA VIRUS VACCINE (HPV) The HPV vaccine requires only 2 doses given 6 months apart starting at 11 years of age. If the series is started after 15 years of age then 3 doses are required on a 0, 1-month (or 2-month), and 6-month schedule (#3 has to be given at least 6 months after #1). It’s recommended for males and females and can be administered as early as 9 years of age.

INBORN ERRORS OF METABOLISM

NO 2017 CORRECTIONS!

ACID-BASE DISORDERS

NO 2017 CORRECTIONS!

FLUIDS AND ELECTROLYTES

NO 2017 CORRECTIONS!

NEPHROLOGY

On page 351 in the section on PSGN it says to monitor the “C3 levels coming back DOWN to normal.” Bad wording because C3 is LOW and not high. As such, it should either way “If the C3 level does not come back UP to normal

Great point! The book has been updated to read

(DOUBLE TAKE) POST STREPTOCOCCAL GLOMERULONEPHRITIS (PSGN, AKA POST INFECTIOUS GLOMERULONEPHRITIS)

Post streptococcal glomerulonephritis (PSGN, AKA post infectious glomerulonephritis) is a Group A Streptococcus (GAS) syndrome. Look for HEMATURIA + PROTEINURIA ± swelling ± HTN. There may be a history of a skin infection one month before, or a throat infection 1–2 weeks earlier. Labs will show a low C3 and NORMAL C4 ± renal impairment. Biopsy will show LUMPY BUMPY IgG deposits (biopsy is not required to make the diagnosis). Treat with IVF and a loop diuretic if there’s HTN. This generally has a GOOD prognosis, but you may consider steroids or cyclophosphamide for cases that are not improving. C3 should be followed until it’s back up to normal.

PEARL: Antibiotics given for a Group A Strep infection can prevent rheumatic fever, but they CANNOT prevent PSGN. Also, PSGN can occur from pharyngitis OR skin infections, but rheumatic fever only occurs after PHARYNGITIS.

PEARL: If the C3 level does not come back up to normal after 6 weeks, consider a different diagnosis, such as membranoproliferative glomerulonephritis (MPGN has a low C3 and C4) or lupus nephritis (+ANA, low C3 and C4). If the renal impairment is severe, obtain a biopsy to look for rapidly progressive glomerulonephritis (RPGN).

On page 353 in the section on Autosomal Dominant Tubulointerstitial Kidney Disease, I am confused. The title is HIGHLIGHTED, which usually indicates a very important topic. However, the first thing said in the description is “LOW YIELD.” This is followed by a PEARL that says, “Highly testable. Look for Electrolyte abnormalities.” So which is it? High yield or low yield?

Agreed, that was an error brought up in our Online Video Course. Thanks for noting it. The first PEARL on page 353 doesn’t belong there and has been removed. Here is the updated topic with the PEARL removed.

AUTOSOMAL DOMINANT TUBULOINTERSTITIAL KIDNEY DISEASE (ADTKD)

Low yield. This rare autosomal dominant condition has several subtypes and has been called several different names, including Medullary Cystic Kidney Disease. It is a slowly progressive kidney disease. Renal dysfunction appears in the teenage years and progresses to end-stage renal disease over the course of years to decades (highly variable). Hyperuricemia and gout is a component of the disease for certain subtypes. Look for a strong family history of chronic kidney disease (CKD) or gout.

STATISTICS

NO 2017 CORRECTIONS!

NEUROLOGY

NO 2017 CORRECTIONS!

ORTHOPEDICS AND SPORT MEDICINE

NO 2017 CORRECTIONS!

RHEUMATOLOGY

NO 2017 CORRECTIONS!

PULMONOLOGY

Hopefully someone can clarify for me given the new (7th edition) NRP recommendations. If you have a non-vigorous newborn with a history of meconium, would you select warm/dry/stimulate now (instead of previous intubate as in the old guidelines)?

Correct, NRP does not recommend intubation for meconium in a floppy baby. For a non-vigorous newborn with history of meconium you would select warm/dry/stimulate as the correct answer choice initially followed by PPV after 30 seconds if HR < 100 to provide adequate ventilation. Intubation and suctioning of the airway with an endotracheal tube are no longer recommended for non-vigorous infants born through meconium-stained amniotic fluid per (7^th edition) NRP guidelines. Interestingly Canadian NRP has not recommended suctioning below the vocal cords to clear meconium in non-vigorous newborn and the outcomes of these babies have not been significantly different from US babies. An updated topic from PBR can be found below.

PATCHY AREAS OF DIFFUSE ATELECTASIS

If patchy areas of diffuse atelectasis are noted in a newborn with focal air trapping and increased lung volumes, pick meconium aspiration. Meconium is rarely passed in utero before 34 weeks. Do not intubate and suction below the cords in a baby that is non-vigorous. Instead, warm, dry, stimulate and provide respiratory support if needed. The most common complication is persistent pulmonary hypertension.

Do you think BRUE will be on exam vs. ALTE since the guidelines are new?

I would focus on learning the new terminology. We’ll be changing it in the 2018 Pediatrics Board Review Core Study Guide. Here’s the new section:

BRIEF RESOLVED UNEXPLAINED EVENTS (BRUE)

Event observed in a child < 1 year old for < 1 minute in which one or more of the following occurs: cyanosis or pallor, irregular breathing, change in muscle tone, or altered responsiveness. Only diagnosed when there is no other explanation for the observed symptoms. For a low risk child, admission is not required. Offer the family CPR training and community resources. Consider a 12-lead EKG, pertussis testing and spot checking oxygen with pulse oximetry. There is no need in most cases for additional testing or prescription medications.

PEARL: Infant must be well-appearing and back to baseline at the time of presentation to qualify as a BRUE.

PSYCHIATRY AND SOME SOCIAL ISSUES

NO 2017 CORRECTIONS!

ETHICS

NO 2017 CORRECTIONS!

PATIENT SAFETY AND QUALITY IMPROVEMENT

NO 2017 CORRECTIONS!

STRONG WORK EVERYONE!

THANK YOU SO MUCH FOR CALLING ME OUT!

NOW LET’S GO OVER THE CLARIFICATION REQUESTS!

Again… I’ve tried to be as concise as I can this year because I know your time is short.

This section is going to cover CLARIFICATION REQUESTS from members, as well as anything that we felt might warrant a clearer explanation.

“Do you think we should study tympanograms?”

I don’t usually like to answer these types of questions in this guide, BUT… I think my answer could help a lot of you from straying too far off of the PROVEN PBR PATH right now.

It’s possible you’ll get ONE question on this. That’s too low yield for you to pursue studying now. Focus on the rest of PBR, which covers ALL of the very LOW HANGING AND HIGH-YIELD FRUIT!… AND SO MUCH MORE!

“I've seen a couple of practice questions about XXXXXXX and about XXXXXXX. I think you should consider maybe including these topics in the PBR.”

Thanks so much for ALL of your submissions. My answer to this question is a resounding “NO.” Trust me when I say that it’s VERY realistic/possible to pass the exam with a first edition of the PBR from 2011. PBR will NEVER be a mini-Nelsons. Meaning, it’ll NEVER be a book where you can turn to for every pediatric diagnosis known to man. It’s not meant to help you be the most well-rounded and knowledgeable pediatrician in the world. It is DEFINITELY meant to give you MORE than what you need to pass the pediatric boards with a score that is ABOVE the national mean!

Know it inside and out… and ignore everything else. Otherwise, you’ll find that there’s ALWAYS going to be more information that you could potentially chase. It’ll lead you down a rabbit hole… or the BLACK HOLE of Google Search.

ADOLESCENT MEDICINE

NO 2017 CLARIFICATIONS!

ENDOCRINOLOGY

For the sex syndromes, the disorders of sex development (DSDs) as they are called now, do we need to know the new classifications for them or should we stick with the older nomenclature?

Know both, see the table below for further clarification.

Reference: https://icurology.org

How can you differentiate DKA from HHS?

See table below

DKA	HHS
Typically occurs in Type 1 diabetes	Occurs in Type 2 Diabetes
Bicarbonate <15 and/or pH < 7.3	Plasma BG > 600
Plasma BG > 300	Absent or mild ketosis (non-ketotic acidosis)
+B-hydroxybutyrate or large ketones present	VERY dehydrated (10-15%) so it can take 2-3 days to recover.
Typical symptoms of diabetes	Neurologic signs and symptoms present (coma, seizures, etc.)
Main line of treatment is Insulin + hydration	Main line of treatment is IV hydration.

In acidosis the excess H+ ions moves into the cell and pushes the K into the ECF—> causing hyperkalemia. Why do our DKA patients have Hypokalemia when their PH is in acidotic range.

Though total body potassium levels are low in DKA due to renal losses, hypokalemia (low serum levels) at presentation of DKA is not typically found (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896141/). Serum potassium levels can fluctuate due to insulin administration quite a bit due to insulin’s affect on the activity of the sodium-potassium pump. The important thing to remember about potassium and DKA is the need to add potassium to IVF to maintain a level between 4 and 5 mEq/L. This usually means adding potassium if the serum level is between 3.3 and 5.3 mEq/L.

Can someone please explain the hyperparathyroidism occurring with renal failure? I keep reading the same passage over and over again but I'm not getting it…I'm missing a step…

Is it possible that you’re referring to maternal hyperparathyroidism? Maternal hyperparathyroidism causes the infant to develop early hypocalcemia, but does not cause renal failure itself. Chronic renal failure is a separate cause of late hypocalcemia and can eventually cause secondary hyperparathyroidism. Failing kidneys do not convert enough vitamin D to its active form, and they do not adequately excrete phosphate. When this happens, insoluble calcium phosphate forms in the body and removes calcium from the circulation. Both processes lead to hypocalcemia and hence secondary hyperparathyroidism.

OB/GYN AND SOME STDs

NO 2017 CLARIFICATIONS!

ALLERGY AND IMMUNOLOGY

NO 2017 CLARIFICATIONS!

CARDIOLOGY

Some of what is said in the cardiology video contradicts what is said in your PBR book. For example, the PBR book says that right atrial enlargement caused peaked P wave in V1 but the video says that RAE caused a P wave shaped like an “m” in V1. A second example is that the PBR book says that a T wave is positive/upright in newborns in V1 but the first week of life the T wave becomes negative… the video states the opposite

The book is correct.

The P wave is peaked in V1 of Right Atrial Enlargement
Newborns are born with right axis deviation leading to upright T waves in the V1 (right precordial leads). The T waves become negative in V1 (right precordial leads) within the first week of life as the pulmonary vascular resistance decreases. The T wave in V1 should never be positive before 6 years of age and may remain negative into adolescence. A positive T-wave in this earlier time frame can indicate right ventricular strain.

I’m stuck in the cardiology section as I can't seem to grasp why the handgrip increases the MVP murmur. I thought that increased LV volume (which should be a result of the handgrip as it increases peripheral resistance) would provide more tension in the chordae of the valve and thus improve the floppiness (soften the murmur). Can someone please explain why this is not the case?

There is an increase in peripheral vascular resistance (afterload) with the handgrip which increases the pressures in the LV. This increase in pressure in the LV and blood is squeezed through the mitral valve therefore accentuating the MVP murmur. Also remember this murmur is always preceded by a click.

In HCM the increase in pressure in the LV means you open up the aortic outflow tract more resulting in a softer murmur due to less turbulence of blood flow.

Under pericarditis on page 128 the book state that muffled heart sounds are heard with pericarditis. I thought muffled heart sounds were heard with a pericardial effusion?

You are correct that muffled heart sounds are heard in both pericarditis and pericardial effusion. The important thing to remember is to pay attention to other clues in the vignette which will help you differentiate the cause of the muffled heart sounds. In pericarditis, there may be clues such as a friction rub on exam or diffuse ST elevations on EKG and in pericardial effusion look for associations with cardiac tamponade caused by chest trauma.

DERMATOLOGY

Page 132 in the PBR mentions HSV culture for diagnosis of ezcema herpeticum. How about HSV PCR and DFA?

Based on my reading, I think that PCR and DFA are also great options, but for now I’d still go with PCR. According to one article I read, and according to UpToDate, culture still seems to be the standard though PCR is more sensitive.

ARTICLE: Visit https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3520662/ and do an on page search for “early diagnosis.
UpToDate: Visit https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-herpes-simplex-virus-type-1-infection?source=machineLearning&search=eczema%20herpeticum&selectedTitle=1~17§ionRank=1&anchor=H31627071#H29 or the summary section.

For concern for HSV meningitis, use PCR.> Failure to detect HSV in genital lesions by culture or PCR assay does not indicate an absence of HSV infection, because viral shedding is intermittent.

For genital ulcers or other mucocutaneous lesions – HSV PCR assay and/or HSV culture are the preferred tests
For neonatal HSV infection – obtain a swab of mouth, nasopharynx, conjunctivae, and anus for HSV culture and/or HSV PCR assay; skin vesicles for HSV culture and/or PCR assay; CSF for HSV PCR assay; whole blood sample for HSV PCR assay.

On all the HSV explanations on pages 146 and 147 said to treat except the gingivostomatitis didn't mention so I wanted to find out if we are supposed to treat.

There is limited data on treatment in immunocompetent hosts. The therapeutic benefit has been noted in a limited number of children with primary gingivostomatitis treated with oral acyclovir. Treat immunocompromised hosts with IV acyclovir.

How do one differentiate between Kasabach Merritt Syndrome and Klippel Trenaunay Syndrome? both pictures appear similar and both have limb enlargement.

The PBR has some great mnemonics that will help. Practice the mnemonics and make a notebook with quick facts that you can review often.

Kasabach-Merritt syndrome (most common in infants with thrombocytopenia)

Large, congenital vascular tumors
Severe CONSUMPTIVE COAGULOPATHY leading to thrombocytopenia and the consumption of coagulation factors and death

Klippel-Trenaunay syndrome (look for unilateral limb overgrowth and CHF)

AV fistulae, causing skeletal or limb OVERGROWTH (hemihypertrophy)
Port Wine Stains
Overgrowth of tissue, bones, and soft tissue

NEONATOLOGY

Not sure if correction or more of clarification. Papilladema on Page 155 of neonatology is the result of an acute process vs. on page 192 of Emergency medicine says is late finding of ICP that takes weeks or months to develop. What am I missing here?

The timeframe for papilledema is relative to the context of the underlying disease process. The point of this tip is to show that if the ABP gives you a newborn with macrocephaly or hydrocephaly without any other acute process going on (such as traumatic brain injury), then the answer is that you would NOT see papilledema. In the context of increased ICP in the Emergency Medicine chapter, papilledema is a later finding in comparison to other physical exam findings after an acute process occurs such as traumatic brain injury.

I am getting a hard time recalling the Ballard for newborns for questions like, what do u expect in a premie or post-term? Any hints or mnemonics's?

This is generally going to be a lower yield topic. Please only focus on these details if you have mastered all the material in PBR first.

Preemie – less degrees of flexion in arms and leg, but greater angles of flexion at the wrist, able to touch heel to ear, skin is friable and translucent, eyes are fused, prominent clitoris and small labial minora in females
Post-term – no lanugo, foot creases over entire plantar surface, breast buds, well curved pinna with firm cartilage, descended testis in males with rugae on scrotum

DEVELOPMENTAL MILESTONES

In PBR It says “when we're given a patient with various milestones, we look at the milestone that is most ADVANCED and then we choose the child's age based on that milestone”….but then does that mean they are “delayed” in the other milestones? So if you have a kid who can draw a circle (3yo) but only knows 50-100 words (2yo), do you choose 3yo?

Sounds like you understand the general idea regarding how to approach those questions. So, yes… always pick the answer with the age of the oldest milestone mentioned in the vignette. In this case the answer is 3 years old because the child can draw a circle even though the other developmental milestones indicate a younger age.

Developmental question: object permanence. Which age?

According to PBR, object permanence is from 12 months (crawls to last place toy was seen) to 18 months (seeks out hidden objects). It can get confusing when you start to think about the social developmental milestone at 9 months in which a baby can recognize objects and people. Just keep in mind that it doesn’t mean that the child can necessarily remember where that object is located when it’s out of sight.

In the developmental milestones chapter under drawing shapes the on page 167 the ages don’t agree with Nelson’s or medstudy. Can you clarify?

Great question. There’s a lot of variability out there between different sources. If you look at the DENVER II, you’ll see that the age ranges for the circle, cross and square actually line up with PBR fairly nicely. And if you do an online search for milestones, you’ll see that they are extremely variable depending on where you go. Our chapter has served the author (me) VERY well, and it’s done the same for other members. Their scores in that section have SKYROCKETED. My recommendation is that you use ONE resource for this section (PBR’s) and know it inside and out!

Last, PUT NELSON’S DOWN! Do not use it to study. Bad, bad, bad idea. It’s overwhelming and not high-yield. My hope is that you used it for just a few minutes as a reference.

EMERGENCY MEDICINE AND TOXICOLOGY

On page 183 it seems there is an error in the table about toxic drums stating that the sympathomimetics are reported as having down bowel sounds but I had believed they have up bowel sounds? I didn't want to submit this error if I could just find the content of the air updates elsewhere.

The book and table are correct. Sympathomimetics such as cocaine lead to less blood perfusion to the gastrointestinal tract which result in decreased bowel sounds. In severe toxicity it can even lead to necrosis of the bowel.

VITAMIN AND NUTRITIONAL DISORDERS

NO 2017 CLARIFICATIONS!

GASTROENTEROLOGY

NO 2017 CLARIFICATIONS!

PHARMACOLOGY AND DRUG PEARLS

NO 2017 CLARIFICATIONS!

OPTHOMOLOGY

In the opthalmology video, it says vision for a 5 year old should be 20/50 and 6 year old 20/40. The book on page 225 says 3yo: 20/50, 4yo 20/40. Please let me know which is correct and most up to date.

The book is correct.

Until now, the book has always been more up-to-date than the videos because we selectively update the videos. Starting in 2018, we’ll have a great system that will allow us to update the videos almost simultaneously with the books every year!

VISUAL ACUITY BY AGE

Refer to an ophthalmologist if a child’s visual acuity in either eye is worse than the acuity listed below for age:

Three-year-olds: 20/50

Four-year-olds: 20/40

Five-year-olds and above: 20/30

* MNEMONIC: The acuity required to pass the vision screen starts at 50 for three-year-olds and drops by 10 each year after that. So, the cut offs are 50 40, 30 for ages 3, 4 and 5.

GENETICS

X-linked recessive disorders mnemonic (thanks Zac)

> This is a mnemonic that was shared by a PBR member. You might just find it useful!

> An American Indian (Sioux to be specific) HUNTER was out for some AB BLOOD. He hid in the RECESSES of 2 very tall trees that were crossed like a giant X. But then he got stuck. “Can’t Get Down” he shouted and he spent a Good 6 months PercheD in the trees and ended up getting DaMmeD sick. When he got down he bought a NEDI pot over the counter (OTC). When he tried mixing the treatment powder in the pot he was so deranged that he started talking to it: “BRO! TONS A GLOBS! Hmmm…my WISK OUTTA DO THE TRICK.” He got better after treating himself for 10 Days.

American Indian Sioux = AIS = Androgen Insensitivity Syndrome
Hunter = Hunter Syndrome
AB Blood = Hemophilia A and Hemophilia B
Couldn’t Get Down = CGD = Chronic Granulomatous Disease
Good 6 mo PercheD = G6PD = Glucose 6 Phosphade Deficiency
DaMmeD = DMD = Duchenne Muscular Dystrophy
NEDI = Nephrogenic Diabetes Insipidis
Over the Counter = OTC = Ornithine Transcarbamylase
BRO! TONS OF GLOBS! = Bruton's Agammaglobulinemia
WISK OUTTA DO THE TRICK = Wiskott Aldrich
10 Days = 10 disorders on the list
Recesses of crossed X trees = X linked Recessive

Chance of having another child with an autosomal dominant disorder? (person sent in a practice question with this basic question).

AUTOSOMAL DOMINANT DISORDERS

An autosomal dominant disorder may be passed on from either parent to male OR female children with each child having a 50% chance of getting the dominant gene from the parent.

What mode of inheritance is responsible for the condition below?

X-linked recessive is the best answer.

From PBR, page 234 for X-linked recessive inheritance: “If the mom is a carrier and the dad is unaffected, there is a 50% chance of a SON being affected and a 50% chance of a daughter being a carrier.”

HEMATOLOGY AND ONCOLOGY

Would you be able to explain how acute or chronic blood loss would present in a neonate?

Acute anemia from blood loss could present with an unstable neonate with normal RBC morphology (normal MVC because there is no time for the MCV to change), In a neonate with chronic blood loss, you should expect to see iron deficiency, microcytosis an elevated reticulocyte count and a wide RDW due to the variation between the RBCs and the reticulocytes.

INFECTIOUS DISEASE

I have gotten a question on Cdiff a few times now and need clarification. Treatment – metro po then if relapse metro again po then if relapse vanco po OR metro po then if relapse Vanco po

If the patient is on an antibiotic that is causing the problem, stop it. If the disease is SEVERE or if this is the 2^nd recurrence, use vancomycin. If there is mild-moderate disease and this is the initial presentation or a first-time recurrence, then use metronidazole.

What is the most common cause of Chorea in kids in US?

Rheumatic (Sydenham) Chorea

SYDENHAM CHOREA (AKA SYDENHAM’S CHOREA)

Sydenham chorea (AKA Sydenham’s chorea) is specifically the finding of choreiform movements after a Streptococcal infection by Group A Streptococcus (GAS). Unlike tics, these are WORSE with purposeful movements. Can be associated with hypotonia, jerky movements and even emotional lability after a GAS infection. CSF findings are normal. The movements improve during sleep. Sydenham chorea does can be a stand-alone diagnosis OR it can be part of rheumatic fever (carditis, polyarthritis, erythema marginatum, subcutaneous nodules, etc.). Order an antistreptolysin titer (ASO titer) to look for recent streptococcal infection.

PEARLS: A negative ASO does NOT rule out a Group A Streptococcal (GAS) infection. The titer may have already come down if the chorea is presenting months after an infection. For the exam, if you see Sydenham Chorea in a patient, choose RHEUMATIC FEVER. In reality, though, a patient can get the chorea after a GAS infection, and that alone can be used to assign a diagnosis without any of the other findings of fever. Please know the rheumatic fever section very well (see the Cardiology chapter for a very detailed discussion on RF).

VACCINES, IMMUNIZATIONS, AND CONTRAINDICATIONS

Can you tell us more about catch up vaccines?

It’s highly unlikely that you will be asked about a specific catch up regimen. Just be aware that there is a catch-up vaccine schedule and the different types of vaccines included in it. Pediatricians have to look it up every time.

What If a patient gets IVIG. Is it 9 months or 12 months to hold off on giving vaccines?

Fortunately, there is variability depending on the KIND of IVIG that was received and the specific vaccine in question (https://wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/general-recommendations-for-vaccination-immunoprophylaxis). So if you just remember that you have to wait, that should be good enough. The table above is overwhelming, so do an on page search for IVIG and you’ll find the section pretty quickly. The range is from 8-11 months.

Is rotavirus contraindicated if there is h/o intussusception?

No it is not contraindicated. An older version of the vaccine, RotaShield, FDA-approved in 1998, withdrawn from US market in 1999, was withdrawn from the market because of associated intussusception. None in the pre-licensure trials of Rotateq and Rotarix showed any risk of intussusception. However, in 2010, the FDA approved a label change for Rotarix advising possible increased risk of intussusception from a study in Mexico (however, much lower rate than RotaShield). Rotateq has not been associated with intussusception.

Do the DTaP contraindications also apply to the Tdap?

Yes, they contain the same components in both vaccines so the contraindications would be the same.

A practice question about the catch-up vaccine schedule for a child that is 28 months old and unvaccinated for pneumococcal or Hib Vaccines. What is the appropriate catch-up schedule?

According to the CDC catch-up immunization schedule this child would need one dose of Pneumococcal Conjugate Vaccine (PCV) and 1 dose of Hib Vaccine. I had to look these up on the CDC website. Do not worry about memorizing these charts. They are way too detailed and the ABP and you are more likely to get general questions such as what is mentioned in the PBR on page 213 which states that “PCV13 and Hib are NOT recommended for kids over 5 years old”

I have a super late question about DTaP. On page 314 it says that progressive neurological disorders are relatively contraindicated. Can you give an example of the type of diseases? Are we talking like an SMA or a muscular dystrophy or something more central?

Progressive neurological disorders are only a relative contraindication for DTaP and if the neurologic disorder has been stabilized or is no longer progressive, then you may give DTaP. Progressive neurologic disorders are conditions with progressive deterioration in functioning. It can be gradual over years to decades or rapidly over weeks to months. These disorders affect an individual for the rest of their life.

Some examples are listed below and can be broken up into two major groups:

Acquired causes include infectious (progressive Rubella syndrome, Chronic HIV, SSPE), metabolic causes (chronic lead poisoning, hypothyroidism, Vit B12 and E deficiency, and anticonvulsant drugs) and demyelinating (multiple sclerosis, Wilson’s disease, Huntington’s disease, Friedrich’s ataxia, and ataxia telangiectasia), etc.
Inherited causes include Niemann pick disease, Gaucher disease, Rett Syndrome, Menke’s kinky hair disease, maple syrup urine disease, leukodystrophies (Krabbe disease, Adrenoleukodystrophy), etc.

I think there is an error on the answer of question 37 in the Q&A book – From what I've learned and read on the CDC website you can give DT from 6w and you will go ahead and give the DT at 4m, 6m and 15/18m instead of the DTaP. Can you support the second part of the answer choice – C?

The correct answer is that the child should no longer receive DTaP as the prolonged seizure occurred < 7 days after receiving the vaccine. The pertussis component is contraindicated in future vaccinations; thus the DT should be given at a later date. You are correct that it can be given at the 6-month visit, however out of all the answer choices, only C is correct because it gives the option to give DT at a later date (1 year in this case).

For steroids and vaccines on page 309, please clarify if it’s for all vaccines to be on hold or just the live ones.

Just live vaccines, as mentioned in the 2017 edition. See the section below:

STEROIDS AND IMMUNIZATIONS  In general, the types of steroid regimens commonly prescribed are not a contraindication to immunizations. If a course of steroids is given for less than 14 days, then REGARDLESS OF THE DOSE given, ANY vaccination is allowed (including all live vaccines). If > 20 mg/day, or > 2 mg/kg/day of prednisone is prescribed for > 14 days, then live vaccines should be held for one month after the course is over.

MNEMONIC: If > 20 mg/day or > 2 mg/kg/day is given for > 2 weeks, then HOLD the live vaccines for at least 1 month after the steroids have been stopped. For anything else, go ahead and give.

INBORN ERRORS OF METABOLISM

A mnemonic was submitted to us for the sphingolipidoses on page 326 (thanks K.J.!). We thought we’d share!

Everyone loves Seinfeld right?! (this plays off Ashish's mnemonic).

Jerry Seinfeld is famous and develops a HUGE HEAD (macrocephaly) from his success. He's now a smooth and LOOSE (hypotonia) talking player. Everything is fine until a jealous PREGNANT ASHKENAZI JEWISH RABI (he meets at the soup place) shoves a NEEDLE in his belly (amnio) and a CHERRY in his eye (cherry red macula). He is HUGELY STARTLED (startle reflex) by how his fame has done him in. NEWMAN then PICKS (Nieman Pick) on Jerry, calling him JER-TAY (Tay Sachs). Jer-TAY can’t take it anymore and punches Newman in the MACULA (cherry red macula also found in Nieman Pick). Jer-TAY also puts a HEX-ON-HIS-DAY (Hexosaminidase A def in Tay Sachs) and causes Newman's ORGANS to BLOW UP (organomegaly in Nieman Pick). He then ties a SPHRING (syringomyelinase def) on Newman's foot as he floats away

ACID-BASE DISORDERS

If you look at the pH and PCO2 won't it always be a respiratory problem as the overarching disorder? …because if pH is low and the PCO2 is high then have respiratory acidosis and if the pH is high and pco2 low then you have respiratory alkalosis so what ABG will let you know there's an overarching metabolic disorder?

> Respiratory acidosis – pH low and PCO2 high

> Respiratory alkalosis – pH high and PCO2 low

> Metabolic acidosis – pH low and PCO2 low

Metabolic alkalosis – pH high and PCO2 high

FLUIDS AND ELECTROLYTES

NO 2017 CLARIFICATIONS!

NEPHROLOGY

On page 348 it says antibiotics are required for vesicoureteral reflux (VUR). I thought they were no longer indicated? Do I have an old version of this book? I just bought it this year!

Prophylactic antibiotics still recommended for VUR. The best supporting evidence is from the RIVUR trial published in 2014 which looked at children diagnosed with VUR and the effectiveness of TMP-SMX vs. placebo over a 2-year study period. The results demonstrated that children in the TMP-SMX group were less likely to have recurrent febrile or symptomatic UTI than the placebo group, thus supporting the above recommendation.

NEUROLOGY

On page 364 of PBR it is stated in the last line of the section on Epidural abscess of the spine that “you should give dexamethasone for this or any other spinal cord compression syndrome.” I said dexamethasone on a question and got it wrong.

Upon reviewing the literature, it appears that both dexamethasone and methylprednisone have been used as treatments for spinal cord compression. This topic is still controversial given the increased risk of complications with methylprednisone. A set of guidelines published in Neurosurgery in 2013 about the management of acute cervical spine and spinal cord injuries did not recommend methylprednisolone and down-graded the evidence to level III. I would choose dexamethasone for these reasons as stated in the PBR. The ABP will not likely ask you a question about a controversial topic like this.

Also, please try to remember that we want you to use question for PRACTICE of your test-taking strategy. Use the PBR for the knowledge. Stick to ONE knowledge resource and know it inside and out. There WILL be discrepancies between practice questions and what ANY board review book says. PBR members have even found incorrect answers in PREP® which on cross-referencing was found to be correct in the PBR. So, put your faith in your one trusted resource try not to spend too much time on individual questions.

ORTHOPEDICS AND SPORTS MEDICINE

NO 2017 CLARIFICATIONS!

RHEUMATOLOGY

NO 2017 CLARIFICATIONS!

PULMONOLOGY

Core study guide for 2016 – says for patients with CF #1 etiology of pneumonia is still Strep Pneumoniae vs 2017 says it's Staph or Pseudomonas… which is it?

The 2017 PBR book is correct on this point. It was updated last year. Staph or pseudomonas are the most common cause of pneumonia in patients with Cystic Fibrosis. The role of Strep pneumoniae in Cystic Fibrosis children is debatable as it is not usually a colonizer. Therefore, in children with Cystic Fibrosis the correct answer would be given to you by paying close attention to the specifics in the vignette as either Pseudomonas (lung abscess) or Staph (nodular pneumonia).

PEARL: The answer may be reveled on an X-ray they show you. Read carefully and make sure that you correctly answer the question that they are asking. This is a common pitfall for people taking the pediatric boards.

PSYCHIATRY AND SOCIAL ISSUES

NO 2017 CLARIFICATIONS!

ETHICS

NO 2017 CLARIFICATIONS!

AWESOME! YOU’RE DONE! – WHAT NOW?

Read the PBR “Exam Day” article. It’s a MUST read. It will give you a great deal of insight into your exam day. I’ll list the link at the end of the document.
Go back to your core PBR study material! At the end of the day, THAT is what will help you pass the boards.
If you’re not a PBR member yet, this is a GREAT time to join!
If you’re feeling pretty good about your pediatric KNOWLEDGE/CONTENT, then work on your TEST-TAKING STRATEGY by going through the CRASH COURSE on Test-Taking Strategies (it has been a HUGE HIT)!

IF YOU ARE NOT A PBR MEMBER, YOU SHOULD BE!

PBR has had streaks as long as 3 years in a row of 100% pass rates for general pediatricians who are first-time test-takers of the ABP recertification exam.

PBR also has an estimated pass rate of well over 95% for first-time test takers of the ABP initial certification exam (based on the insanely low number of requests we get for the 100% Money Back First-Time Pass Guarantee that we offer).

Also, the “PBR Certification System” has helped pediatricians pass the boards after they had FAILED UP TO SIX TIMES using other resources. That means they failed SIX times, and then passed on their LAST possible chance because they finally decided to use the PBR!

So What Are YOU Waiting For?

Pediatrics Board Review…

YOUR RESOURCE FOR EFFICIENCY IN STUDYING…ESPECIALLY DURING CRUNCH TIME!

As the final days of preparing for the pediatric initial certification exam come up, there’s often a sense of PANIC. Please BREATHE! If you’ve been studying the PBR thoroughly and you have a fair handle on your test-taking skills, you should be in GREAT shape!

What can you do to MAXIMIZE your remaining study time? Go over your PBR over and over again. Focus on the areas that you still need to master and SKIP the areas that you know well.

Get the DOWNLOADABLE MP3 audio course from PBR so that you can eat, sleep and breathe PBR no matter where you are. Yes… even between seeing patients!

www.PediatricsBoardReview.com/MP3

You can also WATCH 31 videos that cover ALL of the PBR through PBR’s Online Video Course, Conference & Live Webinars in a single day!

www.PediatricsBoardReview.com/VIDEOS

You’ll get chapter videos PLUS our webinar replays for the 2017 Summertime Q&A Webinars.

For the Acid Base chapter, I’ve even included a short impromptu practice question session as well as additional practice questions for our Online Video Course and All Access Pass members to enjoy. The Acid Base discussions and resources show how confused pediatricians are about the delta delta, when to check for compensation, Winter’s formula, etc… but by these talks and practice sessions, we get comments like, “This is so much easier!… The light bulb just went off!”

www.PediatricsBoardReview.com/VIDEOS

And if you want to CRANK THROUGH the videos and webinars in just 12-14 hours, you can do so at different speeds by clicking on the gear icon at the bottom of the video and increase the speed up to 2X!

Okay! That’s it!

Now go study in whatever way is going to give you the MOST REPETITION AND LEARNING. If that’s simply reading over and over again, GREAT!

PBR 12-MONTH ALL ACCESS PASS + BONUSES(PROMO CODE: PREORDER)

During our 2018 PREORDER Window, PBR is Offering theFollowing VIP Resources with the PBR All Access Pass

**90-Day Personalized Study Schedule Created by Team PBR****CORE CONCEPTS in Test-Taking Strategies Webinar**

HERE'S EVERYTHING YOU GET IN A PBR 12-MONTH ALL ACCESS PASS PREORDER

Hardcopy Core Study Guide ($170)
Hardcopy Q&A Book ($25)
Online Core Study Guide ($75)
- Desktop-Compatible, Mobile-Compatible, Searchable!
Online Q&A Book ($25)
MP3 Streaming Course ($97)
MP3 DOWNLOADABLE Course ($147)
ONLINE VIDEO COURSE ($495)
Private Discord Community Access ($197)
(BONUS) CORE CONCEPTS in Test-Taking Strategies Webinar ($197)
Free Expedited Shipping ($25)
7-Day Access to the Core Concepts inn Test-Taking Strategies Webinar ($197 BONUS)
Online Picture Atlas ($97)
- Not Available in Our Catalog Area
Downloadable PDF Picture Atlas ($97)
- Not Available in Our Catalog Area
Live Summertime Q&A Webinars with Content Experts ($145)
- Not Available in Our Catalog Area
16+ HOURS of Pre-Recorded Coaching Webinars ($200)
- Not Available in Our Catalog Area
(VIP BONUS) 90-Day Personalized Study Schedule Created by Team PBR ($297)
- Not available in our Catalog Area

PBR FOR LIFE!

During Our 2018 Edition PREORDER Window, PBR is Offering

Hardcopy Core Study Guide ($170)
Hardcopy Q&A Book($25)
Online Core Study Guide with LIFETIME Access ($750)
Online Q&A Book with LIFETIME Access ($25)
15+ Hours of Test-Taking Strategies Webinar Archives ($200)
50% Off of All Future Hardcopy Editions of the PBR ($500)
FREE EXPEDITED SHIPPING ($25)

First-Time Money Back PASS Guarantee

Ultimate Bundle Pack

During Our 2018 Edition PREORDER Window, PBR is Offering FREE SHIPPING & AN ADDITIONAL $15 DISCOUNT!

Hardcopy Core Study Guide ($170)
Hardcopy Q&A Book ($25)
Online Sore Study Guide ($75)
- Desktop-Compatible, Mobile-Compatible & Searchable!
Online Q&A Book ($25)
Online Access for 1 Full Year
$15 PREORDER DISCOUNT ($15)
GET FREE SHIPPING ($15)
16+ Hours of Test-Taking Strategy Webinar Archives ($200)
LIFETIME Online Access ($1000)
50% Off of All Future Hardcopy Editions of the PBR

LOCK IN 2017 PRICING & GET IMMEDIATE ONLINE ACCESSFirst-Time Money Back PASS Guarantee

===

HAVE YOU FAILED?

If you have failed while feeling as though you had a strong handle on the content, it’s likely that you have a test-taking technique issue. Reach out to us and ask about our Test-Taking Strategies course which covers test-taking skills, test-day planning, anxiety management, diet and much more. We also offer LIVE coaching courses

www.PediatricsBoardReview.com/STRATEGIES

Lastly, don’t forget to read some excellent information about your exam and how you should structure your big day. The article below is a MUST read, so please click the link below and take 5 minutes to read it:

www.PediatricsBoardReview.com/EXAMDAY

Alright guys… Team PBR has worked VERY HARD this year to help you with the tools and guidance you needed to prepare for the boards. If you followed our lead, then I’m sure you’re going to rock your exam! Trust me, if I can do it… so can you!

Best of luck on your board exam.

Sincerely,

Ashish & Team PBR