25 Flashcards
Infant colic
Infant colic is a syndrome of crying several hours a day, usually in the evening, more than 5 nights a week. During episodes of crying, the baby is difficult to console.
The etiology of infant colic is unknown.
The crying typically starts after 2 weeks of age, peaks at 6 weeks, and gradually lessens by age 3 or 4 months.
The infant eats normally and has normal growth.
The crying can create feelings of rejection, frustration, and anxiety in caregivers.
Organ system Diff dx for apnea
Causes
The differential diagnosis for apnea in an infant is extensive. One approach to thinking about causes of apnea is to begin with broad categories based on organ systems:
Organ System Potential Causes
Central nervous system
Seizures in infants can occur due to many etiologies including CNS bleeding, infection (e.g., meningitis, encephalitis), or structural abnormalities, metabolic disorders, electrolyte abnormalities, genetic syndromes or epilepsy.
Breath-holding spells occur in approximately 0.1-5% of healthy children from age 6 months to 6 years. The term breath-holding is a misnomer in that it connotes prolonged inspiration. In fact, breath-holding occurs during expiration and is reflexive in nature. The child starts to cry and then suddenly falls silent in the expiratory phase of respiration. This is followed by a color change. Spells can be described as pallid (acyanotic) or cyanotic. Pallid spells are typically associated with an injury such as a fall and cyanotic spells with anger. The spell may resolve spontaneously, or the child may lose consciousness. Only rarely does a spell proceed to a seizure or asystole.
An infant’s CNS respiratory center is sensitive to any event that causes increased intracranial pressure: a bleed, trauma, tumor or infection. Any of these may result in abnormalities of breathing or apnea.
Cardiac
An infant with bradycardia secondary to congenital heart block or long QT syndrome is at risk for apnea. SVT (supraventricular tachycardia) is a more common arrhythmia in infants, but it is an unlikely cause of apnea.
Congenital heart disease, particularly ductal-dependent lesions, may present with acute decompensation in the first few weeks of life. Children with unrepaired Tetralogy of Fallot may have acute episodes of cyanosis (“Tet” spells) associated with a drop in pulmonary blood flow.
Pulmonary
The most common respiratory cause of apnea is respiratory syncytial virus (RSV) infection. Premature infants and infants younger than 2 months are at highest risk for apnea with RSV.
Pertussis can also cause apnea, especially in infants.
Other lower respiratory infections (e.g., viral and bacterial pneumonias) may also cause apnea.
Gastrointestinal
Gastroesophageal reflux has been blamed for apnea, however a true correlation has not been proven. In fact, some experts state that apnea occurs first; the apnea leads to hypoxia resulting in relaxation of the lower esophageal sphincter resulting in reflux. Others believe that reflux of the infant’s stomach contents may cause choking, gagging, color changes and laryngospasm resulting in apnea.
Swallowing abnormalities
Tracheoesophaeal fistula should be considered in any infant who has a chronic history of coughing or difficulty with feeds.
Systemic
Infants with systemic sepsis may present with apnea, pallor, tachycardia, tachypnea, fever or hypothermia, decreased feeding or change in tone. Common etiologies include Group B Strep, pneumococcus, and E. coli. Listeria (causing meningitis) and herpes simplex virus (causing encephalitis) should be included in the differential for infants less than 1 month of age.
Infants born in the U.S. are screened for many metabolic disorders shortly after birth. Nevertheless, inborn errors of metabolism should remain on the differential diagnosis for any young infant with apnea or altered mental status.
Ingestions of medications and other toxins can result in respiratory depression, cardiac arrhythmias, or seizures.
Exposure to botulinum toxin (in soil or in honey) can lead to hypotonia, constipation, paralysis, and respiratory failure-usually in infants under one year of age.
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Environmental exposures, such as carbon monoxide, can lead to mental status changes, hypoxia and respiratory distress.
Brief resolved unexplained event BRUE 4
Brief Resolved Unexplained Event “BRUE” is a term that replaced “ALTE” (apparent life threatening event) in 2016. A BRUE is defined as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode that includes one or more of the following:
cyanosis or pallor
absent, decreased, or irregular breathing
marked change in tone (hyper- or hypotonia)
altered level of responsiveness.
BRUE is used to define events only when no underlying etiology is found, and the infant has returned to baseline state of health. Thus, BRUE is a diagnosis of exclusion. The patient must have a reassuring history, physical examination, and vital signs at the time of evaluation.
Role of the Rapid Response Team in the Case of an Infant with Head Trauma
When infants deteriorate neurologically, they often stop breathing or seize. Initial steps should include calling a rapid response team. Realistically, this team can take many steps simultaneously, including:
Ensuring that CPR equipment and trained personnel are readily available
Obtaining IV access in case the baby deteriorates further and needs medications or IV fluid
Congenital Dermal Melanocytoses (Mongolian Spots) is:
Location
Onset/duration
Congenital dermal melanocytoses/Mongolian spots are flat birthmarks that can sometimes be confused with bruising.
They are most common in babies with darker skin pigmentation, but can be seen in up to 10% of Caucasian infants as well.
Location
Most often they are found in the sacral/buttocks areas, but they can also occur on the arms, legs, back, or flanks.
Time of Onset/Duration
Mongolian spots are present at or very soon after birth.
They usually fade over several months and-unlike bruises-should not change appearance over a short period of time.
Causes of subdural hematomas
Subdural hematomas result from head trauma, either accidental or non-accidental:
They are often found in infants who have experienced violent shaking as in abusive head trauma (see below), in which case they may be associated with retinal hemorrhages. (In abusive head trauma, the bridging vessels tear when the infant is shaken-or shaken and thrown-achieving an extreme rotational cranial acceleration force to the brain and diffuse axonal injury to the neurons.)
Accidental trauma, such as motor vehicle accidents, can also cause subdural hematomas.
Subdural hematoma is a known but uncommon complication of delivery-especially in vacuum extraction or forceps deliveries. These all resolve within 4-6 weeks after birth.
Subdural hematomas do not occur as a result of CPR or seizures and do not occur from short falls (e.g., falls from a height of less than 4 feet).
