Acute Disease in Children Flashcards
Unconjugated bilirubin is a direct result of
hemoglobin breakdown
Bilirubin binds to ______ which brings it to the _____
albumin, liver
the liver turns unconjugated bilirubin into?
conjugated
conjugated bilirubin is excreted how?
through the stool
Babies with immature livers contain on ____% of the enzymes needed to convert unconjugated to conjugated
1%
Pre term Babies livers contain on ____% of the enzymes needed to convert unconjugated to conjugated
10
In the first week of life, ____ of full term and ____ of preterm infants have jaundice
60%, 80%
physiologic jaundice
normal breakdown of RBC that releases bilirubin, and an immature liver
Pathologic jaundice
any jaundice within the first 24 hours after birth
If TSB rises more than ____mg/dl/day or is higher than ____mg/dl in full term infant or ___-____ for preterm, they need further eval
5
12
10-14
etiology of pathologic jaundice
breast feeding difficulties, dehydration, weight loss, hemolytic anemia, RH incompatibility, certain maternal drugs, metabolic and endocrine disorders
Breast milk jaundice mechanism
unknown, thought that it may be a component of breast milk that blocks the protein in infant livers from breaking down bilirubin
Bilirubin induced neurologic dysfunction
Severe TSB >25mg/dl unconjugated bilirubin (unbound to albumin) crosses the blood brain barrier and binds to brain tissue resulting in brain injuries
results of bilirubin induced neurologic dysfunction
disorders in visuocortical pathways causing alteration in sensorineural hearing, proprioception, speech, and language deficits
Acute Bilirubin encephalopathy
may be reversible, three phases: drowsy, high pitched cry and hypotonic, hypertonicity, fever, apnea, twitching, seizures, respiratory failure, death
Chronic bilirubin encephalopathy
chronic, severe, progressive; permanent neuro sequelae such as choreo-athetoid cerebral palsy; upward gaze abnormalities, enamel dysplasia, sensorineural impairement
risk factors of jaundice
GA <36 weeks, low birth weight, suboptimal breast feeding, male infant, delayed cord clamping, birth trauma
maternal: age >25, maternal diabetes, drug use
genetic disease risk factor for jaundice
gilberts syndrome, galactosemia; family history of liver disease and hemolytic disorders
abx, metabolic acidosis
major risk factors for jaundice
predischarge TB in the high risk zone, jaundice observed in first 24 hours, blood group incompatibility, GA 35-36 weeks, siblings receiving phototherapy, cephalohematoma, poor breast feeding, East Asian race
clinical manifestations of hyperbilirubinemia
jaundice on entire body including palm and soles, loss of stool color, weight loss, drowsy infant, pallor, enclosed hemorrhage, bruising, hepatosplenomegaly
Physical exam with hyperbilirubinemia
visible in face, forehead, mucus membranes, appears on the trunk, hypotonia (mild), hepatosplenomegaly, petechiae, microcephaly
jaundice below ____ ___ is indicative of high bilirubin level
nipple line; indicates bilirubin over 12
DD for infant jaundice
breast milk jaundice, cholestasis, Dubin-Johnson syndrome, glacatosemia, hemolytic disease in newborn, hep B, biliary atresia, duodenal atresia, hypothyroidism
What do you use to determine the risk for jaundice?
bilitool; based on how old they are in hours and what their serum total bili is; helps direct next steps
lab work for jaundice
transcutaneous bilirubinometry, TSB, conjugated vs unconjugated if hepatomegaly, TSH, Rh, albumin, H&H, carbon monoxide, retic, LFT, parasites. ABG, ultrasound
treatment for jaundice
phototherapy, bili-blanket, exchange transfusion, phenobarbitol, IVIG
how does phototherapy work?
configurational isomerization makes bilirubin water soluble so it can be excreted-needs to cover eyes
thrush is caused by
candida albicans-white coating in mouths
what percent of infants develop thrush?
37
thrush is most common in?
infants or neonates on abx or steroids, immune diseases, polyendocrine disorders, mother with active yeast infection at birth, colonized breasts
thrush appearance
white plaques, unable to scrape off with a tongue blade, irritability in child, painful nipples in mother
DD for thrush
cytomegalovirus, diphtheria, echovirus, enteroviral infections, esophagitis, HSV, HIV, pharyngitis, syphilis
how to diagnose thrush
gram stain, KOH wet prep (pseudohyphae)
Thrush treatment
decolonize pacifiers and nipples
nystatin-0.5ml each cheek qidx10 days for neonates; 1-2 ml each cheek qidx10 days >1month old
if immunocompromised; fluconazole 3-6mg/kg
treatment for diaper dermatitis fungal infection
nystatin, miconazole, or clotrimazole cream
is reflux normal in babies?
yes
happy spittier
still growing and thriving, just spit up a lot
usual spit up volume
10-20ml
how do you know if their spitting up is problematic
esophagitis, losing weight, refusing to eat
What is rumination
voluntary regurgitation of stomach contents into the mouth for self-stimulation
what is BRUE
brief resolved unexplained event
Signs and symptoms of GERD
typical crying or irritability, apnea/bradycardia, poor appetite, vomiting, wheezing, stridor, abdominal pain, recurrent pneumonitis, sore throat, chronic cough, arching back
warning signs for obstruction or disease
bilious vomiting, GI bleeding, projectile vomiting, onset of vomiting after 6 months of life, constipation, diarrhea, abd tenderness, recurrent pneumonia, aspiration
usual causes of of GERD
immaturity of LES
Aggravating factors for GERD
eating habits, caregiver/child interaction, sleep habits, milk or soy protein intolerance
Secondary causes of GERD
asthma, obstruction, trachealmalacia
when does GERD disappear by?
9-12 months as patient sits up more with gravity and their sphincter strengthens
signs of a floppy airways
weakness, stridor, increased risk of aspiration
concerning Gerd if:
failure to thrive, intractable hiccups, crying and irritability, sleep disturbances, projectile vomiting, wheezing, recurrent pneumonia-likely related to aspiration
Concerning Gerd at child age if
dental problems, heartburn, retrosternal pain, dysphagia, odynophagia, esophagitis, herpes, candida, cytomegalovirus
when to do lab testing for GERD
if symptomatic and changes in feeding, positioning, and hypoallergenic diet failure
Labwork for GERD
CBC, electrolytes, review of newborn screening tests, celiac testing in older children exposed to wheat products
are thickened feeds supported by evidence?
no
procedures for GERD diagnosis
pyloric US, manometry, EGD, biopsy, UGI, swallow study!, pH testing probe
management of gerd in infants
can try thickening milk with oatmeal-doesnt really work; upright positioning, elevating head of bed, prone position in children >6months
management of GERD in older children
avoid tomatoes and citrus products, chocolate, peppermint, and caffeine; smaller more frequent meals, lower fat diet, proper eating habits, weight loss, avoidance of alcohol and tobacco
pharmacotherapy for GERD
antacids, H2 blockers (famotidine), PPI, nissan fundiplication
do PPI’s work in children
yes-but cause a lot of rebound GERD when stopped and long term complications such as bone growth stunting
when to test for celiacs?
when you see failure to thrive and stooling problems (late pre-school, early elementary school)
mode of infection for RSV
direct contact, also aerosol and droplet
RSV lives on fomites for how long?
up to 30 hours
Peak illness for RSV
3-7 days; usually day 5.
what percent of children require RSV hospitalization?
3%
incubation period for RSV
4-6 days
RSV virus sheds for how long?
10 days
if you have had RSV, are you immune?
no-previous infection does not preclude future infection even in children with high antibody titers
When to admit for RSV illness?
if it is day 2 of illness and they are quite sick, it is likely they will still get worse until day 5 and they probably need to go to hospital
how long with children cough after RSV?
3 weeks
RSV deaths occur in?
older adults with co-morbidities and children with underlying cardiac/respiratory issues
rsv is the leading cause of?
respiratory infections in infants and young children (nearly all children by 5 years of age)
risk factors for RSV
crowded spaces, infants younger than 6months, premature infants, congenital heart disease, chronic lung disease, respiratory diseases, asthma, CF, weakened immune systems
prevention of RSV
avoid daycare, avoid second hand smoke, hand washing and cough hygiene, isolate infants/children in the hospital with RSV infection
Palivizumab prophylaxis for RSV
monoclonal antibody against RSV F glycoprotein
can be used for infants and children <24 months at risk IM ; very expensive and difficult to get approval from insurance
RSV symptoms
presents as bronchiolitis, pneumonia, nasal congestion/runny nose, low grade fever, barking cough, tachypnea, intercostal and subcostal retractions, nasal flaring, decreased appetite, rhonchi
What should you encourage parents to use for children with RSV
bulb syringe or frieda nose cleaner; also saline nasal spray and humidifier help to keep mucus thin
if patients are hospitalized for RSV, how long are they usually there for?
3-4 days
mortality rate for RSV
<1% normal newborn
3-5% in kids with lung disease, congenital heart disease, or prematurity
criteria to meet prior to hospital discharge for RSV
showing signs of improvement, on RA, and have good oral intake
do not send them home until the virus has peaked
RSV DDX
bronchiolitis, croup, human metapneumovirus, influenza, neonatal sepsis, parainfluenza virus, bronchitis, pneumonia
do you test for RSV
No as it will not change the treatment plan; more likely to test for influenza as there is medication you can give for that (tamiflu)
Lab work/diagnostics for RSV
CBC, electrolytes, O2 sats, PCR assay, CXR if concerned for pneumonia
AAP recommendations for RSV
purely supportive; no CXR, no steroids, no bronchodilator, no viral testing,
should hypertonic saline nebs be done at home?
no, they can cause bronchospasm and need to be done with resources available; helps to loosen secretions for deep suctioning though
Treatment for RSV
symptom management and supportive care;
constipation is defined as
a period of 8 weeks with stool <3x/week, fecal incontinence, large stool that clogs toilet, palpable fecal mass, stool withholding, or painful defecation
functional constipations
no underlying medical problem; acquired megacolon, chronic constipation and rectal distention can cause loss of rectal sensitivity and urge to defecate; may lead to encopresis
organic neurogenic constipation
DMD, spina bifida, CP, hirschsprungs
organic endocrine or metabolic
hypokalemia, DM, vitamin D toxicity, hypothyroid, immune diseases, CF, lead poisoning
organic anatomic constipation
anorectal anomalies (imperforate anus, small left colon syndrome, obstruction)
organic constipation other
celiac, meds
what exam technique is helpful for locating stool in the colon
percussion
fecal incontinence
is it loose stool or are they constipated so minimal amounts of stool are leaking around the impaction
Physical exam in constipation
palpate, percuss, auscultate, assess anus for fistulas, imperforate anus
rectum should allow for a pink finger to enter
constipation DDX
functional, anorexia, neurofibromatosis type 1 and 2, hirshsprung, hypercalcemia, hypokalemia, hypothyroidism, imperforate anus
anorexia and constipation
if they do not have a lot of intake, they will not poop a lot; also anorexia slows down their GI tract so even if they increase their intake, they may have difficulty
criteria for assessing constipation in children
Rome IV criteria
work up for constipation
abdominal xray not indicated; TSH, celiac, UA/UC, electrolytes, calcium, lead level
Treatment and management of constipation
evacuation of colon, remove impaction, laxatives (miralax), stool softeners, enema, lidocaine ointment, dietary modification, pediatric GI referral
if miralax helpful yes
for initial treatment and maintenance
is lactulose helpful in kids
no
enema conconction
pink elephant; mag citrate and senna- usually helps to clean things out
initial cleanout regimen
3-5 yo: 4 caps of miralax in 20oz and 5 dulcolax before and after
6-11: 6 caps of miralax in 32 ox gatorade with 5 dulcolax before and after
12+ 10 caps of miralax in 32 oz gatorade and 10mg dulcolax before and after
1 thing to improve comstipation
diet
how much water per day?
40-60 oz
BRAT diet
bananas, rice, applesauce, tea: these foods are constipating-avoid them!
how often can breast fed babies poop without concern
1x every 10 days
what other foods can be constipating
milk and dairy foods
when using maintenance protocol for constipation-how do you titrate
based on stool-if it is very loose, give less, if not pooping enough give more
do not use PRN; needs to be daily
Goal for constipation regimen
train the bowel to go at the same time every day; develop a toileting schedule and use miralax to train the bowel; goal is for miralax use for 6 months-1year and then the bowel should be trained by then
is constipation or diarrhea more common?
constipation
time frame for diagnosis if diarrhea?
increased frequency or loose or watery stools for greater than 1 week
causes of diarrhea
diet, viruses, bacteria, parasites, abx associated
what is one of the main causes of diarrhea?
viruses
how to differentiate between virus and bacteria diarrhea?
virus-fever, cramps, lack of appetite, headache, 12hours to 5 days after rotavirus exposure
bacteria- use history to try and trace back to ecoli or poultry food contamination or lake water
diarrhea treatment
hydration, complex carbs, probiotics, avoid high fat food, half strength apple juice, prevent spread, immunize for rotavirus
can clear liquids help with diarrhea?
no-can make it worse, also avoid sports drinks
if having diarrhea: beware of these signs
bloody diarrhea, refusal to eat, dehydration, abdominal pain, behavioral change, lethargy
Average colds per year for kids?
<6;8 colds/year
toddlers: 10-12/year
transmission of cold viruses
direct contact, inhaled viral particles from person to person
how long is a person contagious
2-4 days; usually 1 day before symptoms start
how many different strains of rhinovirus are there?
100
other viruses that cause colds?
enterovirus, coronavirus
cold symptoms
nasal congestion, nasal discharge, fever >100.4 for first 3 days, sore throat, irritability, difficulty sleeping, decreased appetite, swollen glands
when to be concerned of sinus infection
if the cold has been going on for 10 days or more
complications of colds
ear infection (5-19%), asthma symptoms worsen, sinusitis, pneumonia
can you use antihistamines and cough medicine in children?
NO-they have not been studied and have high alcohol content
treatment for pain related to colds
tylenol and ibuprofen (only if >6months)
can you give ASA to kids?
NO!!!
other treatment modalities for common cold
honey if >12months, nasal saline sprays, fluids, vitamin c, wash hands, cover cough
when to seek help for colds
refusing to drink, behavior changes, difficulty breathing, fever >101 for more than 3 days, nasal congestion longer than 14 days, eyes red or jaundice, s/sx of ear infection
fever is considered when it is?
> 100.4
types of temperatures to take
rectal only for trauma and newborns or neuro issues; axillary and infrared and appropriate
does teething cause fevers?
no evidence of that
most common cause of fevers
bacterial or viral infections
red flags when associated with fevers
difficulty breathing, cyanosis, pallor, lethargy, poor tone, altered LOC, infants less than 60 days old (more prone to sepsis)
antipyretics are advised for fever greater than?
103-104
do antipyretics helps prevent febrile seizures
no; they do not decrease the incidence
acetaminophen dosing
10-15mg/kg q 6 hours
ibuprofen dosing
10mg/kg every 6 hours
alternate or give ibuprofen and tylenol together
can do either: it appears that they have a synergistic effect when given together that makes them work better, and easier for parents to bundle them and give that at once
cool baths for fevers?
body temperature baths are better to prevent hypothermia or temperature shock
how to rehydrate with fluids?
a medicine cup full every 10 minutes; do not need to give a lot at once
most common virus to cause conjunctivitis
adenovirus
symptoms of viral conjunctivitis
watery discharge, FB sensation, redness, URI symptoms, usually bilateral, preauricular lymph node enlargement
exam for conjunctivities
assess acuity and vision, look for foreign body, observe type of discharge, assess ears, nose, throat, lymph
treatment for viral conjunctivitis
symptomatic; cool compress, hand washing-do not need to stay home if viral
common pathogens for bacterial conjunctivitis
staph aureus, strep pneumo, H flu., GC
symptoms of bacterial conjunctivitis
thick/yellow discharge, diffuse injection, unilateral onset, normal fundus and eye movement
treatment for bacterial conjunctivitis
warm compress, antimicrobials for 5-7 days, steroids not necessary, hand hygiene, need to see optometrist immediately for vision changes
antibiotic choices for bacterial conjunctivitis
trimethoprim polymixin B. azithromycin, gentamycin, tobramycin, neomycin, ciprofloxin, ofloxacin, gatifloxacin, erythromycin
chlamydia conjunctivitis treatment in neonate
erythromycin 50mg/dkg/d for 2 weeks
GC IV aqueous penicillin G 100units/kg/day
is erythromycin ointment or drops better?
ointment can be easier to apply and seems to stay longer and coats the eye; children cannot blink it away
symptoms of allergic conjunctivitis
injected conjunctivitis, allergic shiners, allergic creases, stringy or watery discharge
treatment for allergic conjunctivitis
topical or oral antihistamines, topical steroid optivar (rarely used), vasoconstrictors such as oxymetazoline, mast cell stabilizer (patanal-OTC), NSAID ketorolac
when should you consider foreign body?
always
s/s of foreign body in eye
conjunctiva and sclera injected, clear/watery discharge, light sensitivity, pain, sensation of something in the eye
eye exam for foreign body
visual acuity, woods lamp, fluorescein stain, turn eyelid inside out
treatment for foreign body
remove the FB, rust rung, eye rest, moisture
what is the most common pediatric illness that causes stridor in 6-36 months?
croup
what is croup caused by
a virus in children RSV, parainfluenza types 1, 2, and 3, rhinovirus
croup symptoms start with
nasal discharge and coryza
croup symptoms progress to include
fever, hoarseness, barking cough, stridor, prolonged respiratory phase with tachypnea
how long does croup cough last?
3 days- other symptoms can last up to 7 days
croup DDX
adenovirus, RSV, enterovirus, human bocavirus, coronavirus, rhinovirus, echovirus, reovirus, metapneumovirus, influenza A and B, measles, herpes, varicella
croup complications
rare, death in 0.5%, 2% hospitalized, pneumonia and tracheitis can occur
croup physical exam findings
cherry red epiglottis, unilateral swelling petechiae strep, diphtheria membrane, excessive drooling, lymphadenopathy
lab work for croup
WBC (may be high or low), increased lymphocytes or neutrophils, influenza testing, lateral neck xray for steeple sign, rarely need CXR
croup treatment
dexamethasone 0.15mg/kg to 0.6mg/kg or oral prednisone and nebulized racemic epi
if rebound stridor 3 hours after racemic epi, then?
give more racemic epi and admit to hospital
other croup treatments
cool mist, increased oral intake of warm clear fluids, frozen popsicles, elevate head, oxygen and helium mix
