Block 3 Pediatrics Flashcards
Cause of blue sclera
Osteogenesis imperfecta
Name of cyst along scm in neck
Brachial cleft cyst
Name of cyst in midline of neck
Thyroglossal duct cyst
Breathing difficulty and chest retractions
Mild difficulty: subcostal, substernal
Moderate difficulty: plus intercostal
Severe: plus supraclavicular and suprasternal
Possible Dx in neonate with respiratory distress and flat abdomen
Diaphragmatic hernia
Normal blood vessels in umbilical cord
One vein two arteries
What MSK deformities of the extremities should be evaluated at different ages?
Hip dislocation in infants
Scoliosis in adolescents
Joint integrity in athletes
How do DTRs change with upper and lower motor neuron lesions?
LMN have decreased responses
UMN have increased response
What DTRs can be checked in a newborn?
Chin
Biceps
Brachioradialis
Patellar
What is altitudinal dissociation in terms of reflexes?
Finding at what level reflexes are present vs absent can give an idea where a lesion might be
What superficial reflexes are present in a newborn?
Abdominal
Cremasteric
Anal wink
Babinski
Where are developmental reflexes mediated?
Brainstem or spinal cord
Moro reflex
Infant abducts arms and extends elbows when head is dropped
Appears starting 32 weeks gestation
Well established by 37 weeks gestation
Absent after 3-6 months
Stepping reflex
Starting 32 weeks gone by 1-2 months
Hold infant vertically with feet on flat surface and child does slow stepping motions
Palmar and plantar grasp reflex
Starts 32 weeks, gone 3 months
Absence of plantar grasp in term infant associated with increased risk of cerebral palsy
Asymmetric tonic neck reflex
Turn baby’s head to side and causes fencing posture
Never normal if seen as a resting posture
Present after 35 weeks, established by 1 month postnatal, gone by 3-4 months
What are two components of the Neonatal Behavioral Assessment Scale that are commonly used? Describe them.
Consolability: using different techniques, crying child should be consolable within 15 seconds, abnormal is sign of brain injury
Habituation: child should respond less and less to stimuli such as light in eyes or clapping hands, abnormal sign of prenatal substance abuse exposure indicating cortical damage
In Cystic Fibrosis, what is common cause of pneumonia?
Under 20y staff aureus
Over 20 pseudomonas
Phenergan
Promethazine
Used for motion sickness, pre and post operative sedation, obstetric sedation
Demerol
Meperidine
Opioid analgesic
Can be used for labor
Narcan
Naloxone
Used to reverse opioid effects
How long are infants obligate nose breathers?
First four weeks of life. Possible for kids to be pink when crying but blue when calm because of nasal occlusion. They can only breath through mouth when crying.
Choanal Atresia
Blocking of the choana which are the posterior nasal passages
Failed recanalization during fetal development
What is the criteria for fetal macrosomia?
Birth weight over 8lbs 13oz or 4Kg regardless of gestational age
What is transient tachypnea of the newborn?
Transient tachypnea caused by delayed absorption or clearance of lung fluids after birth in term babies or those at least 35+ weeks
What are risk factors for TTN (transient tachypnea of newborn)?
C-section, male, macrosomia
Long-term outlook for babies with TTN (transient tachypnea of newborn)?
Benign disease that will resolve on its own
Will not recur
Not shown to predispose to any conditions later in life
What test could be done to help confirm TTN (transient tachypnea of newborn) and what findings would it show?
CXR: hyperinflation of the lungs including prominent vascular markings and flattening of the diaphragm with signs of fluid accumulation–fluffy densities representing fluid filled alveoli, fluid between lobes (fissures) and in the pleural space, perihilar streaking representing interstitial fluid and engorged lymphatics
What are some conditions that should be considered in an infant of a diabetic mother?
Most common complication is neonatal hypoglycemia.
Hyperglycemia in the mother early in gestation causes birth defects like neural tube defects. High sugar leads to hyperinsulinemia causing glycogen deposition in liver, heart, kidney, muscles. Large shoulders and abdomen lead to difficult delivery causing shoulder dystocia, clavicle fracture, brachial plexus injury.
Infants born to adolescent mothers are at a greater risk of what?
Low birth weight
Vertical transmission of STI’s
Poorer development outcomes
Increased risk of fetal death
In addition, the mothers are at a greater risk of premature death as compared to their non-pregnant peers.
What are the 3 leading causes of death in adolescents?
Accidents, Homicide, Suicide
What interview technique should be used with all adolescent patients to assess risk-taking behavior?
HEEADSSS assessment which looks for risks leading to accidents, homicide, suicide
What does HEEADSSS stand for?
Home Education/Employment Eating disorder Activities/Affiliations/Aspirations Drugs Sexuality Suicide behavior Safety
What are some questions that could accompany the Home aspect of a HEEADSSS assessment?
Who lives with you? Where do you live?
Do you have your own room?
What are relationships like at home?
What do your parents and relatives do for a living?
Have you ever lived outside your home? (ever incarcerated, institutionalized?)
Have you moved recently? Have you ever thought of running away?
Are there any new people in your home environment?
What are some questions that could accompany the Education/Employment aspect of a HEEADSSS assessment?
What are your favorite subjects? Worst subjects?
Have there been any changes in your grades?
Are you in any special programs in school?
Have you repeated any years? Have you failed any classes?
Have you changed schools recently?
Have you been suspended?
Do you have plans for future education and employment?
Are you working now?
How many hours do you work per week?
How are your relations with your teachers or employers?
What are some questions that could accompany the Eating disorder aspect of a HEEADSSS assessment?
Where and with whom do you eat?
What do you eat?
What are some questions that could accompany the Activities/Affiliations/Aspirations aspect of a HEEADSSS assessment?
What do you like to do for fun?
In what activities do you participate in school or outside of school?
Do you participate in any sports or get regular exercise?
Do you attend church or clubs, or take part in projects?
Do you have any hobbies or other home activities?
Do you read for fun: What?
How much TV do you watch weekly? What are your favorite shows?
What music do you like to listen to?
What do you want to do when you grow up?
What are some questions that could accompany the Drugs aspect of a HEEADSSS assessment?
Do any of your friends smoke or use alcohol or other drugs? If the answer is yes, How do you feel about their use?
Have you ever tried cigarettes, alcohol, marijuana or other drugs? Any performance-enhancing substances?
If yes, How much do you use and how often? Do you do this in any particular setting?
Do your family members use drugs, including alcohol and tobacco?
What are some questions that could accompany the Sexuality aspect of a HEEADSSS assessment?
Have you and your parents talked about sex?
Have you ever had a crush on anyone or has anyone ever had a crush on you?
Have you ever had sex?
Have you ever had unwanted or forced sex?
How many partners have you had?
Do you use contraception?
Do you know about sexually transmitted diseases?
Have you ever been pregnant?
What are some questions that could accompany the Suicide behavior aspect of a HEEADSSS assessment?
Do you feel sad or down more than usual?
Do you have trouble getting to sleep?
Have you ever thought that life isn’t worth living?
Have you thought a lot about hurting yourself or someone else?
What are some questions that could accompany the Safety aspect of a HEEADSSS assessment?
Have you ever been seriously injured? How?
Have you ever done anything that you thought was dangerous?
Have you ever ridden with a driver who was drunk or high? When? How often?
Do you use a seat belt in the car?
Is there violence in your home?
Have you every been physically or sexually abused?
In every pregnancy, what is the background risk of a birth defect?
3-5%
Other factors will add to this background risk that is present in all pregnancies.
Smoking and conception
Smoking makes conception more difficult, but these effects appear to decrease if a woman stops smoking.
Smoking and miscarriage
Smoking leads to an increased risk of miscarriage because it affects the blood flow through the placenta.
It also leads to increased risk of ectopic pregnancy.
Smoking and birth defects
Overall, not shown to have a huge risk for birth defects
May be associated with risk for cleft abnormalities especially if there is a Hx in the family
What are the primary adverse effects of smoking during pregnancy?
Risk of low birth weight and prematurity
Placenta previa and placental abruption
Potential increased risk for child to have asthma, bronchitis, and respiratory infections later in life
Should a woman who smokes breast feed?
Smoking while breast feeding can transfer nicotine and other chemicals to the baby.
If mother cannot stop smoking, it is still best for her to breast feed as the benefits of the breast milk outweigh the risks from the smoking.
Recommend not smoking around the child, though.
How much alcohol can be consumed during pregnancy?
There is no safe amount of alcohol consumption during pregnancy.
Studies have consistently shown that heavy and consistent drinking lead to birth defects.
Stopping at any point during the pregnancy will have beneficial effects on the baby.
Alcohol and birth defects
Alcohol causes many birth defects including:
Low birth weight
Small head size
Mental retardation leading to learning and memory difficulties
Higher chance of behavioral problems, not understanding consequences of behaviors, having poor judgment, and difficulty with social relationships
The above are components of FAS and FASD
Why is it not OK to drink alcohol later in pregnancy?
Alcohol affects the brain of the fetus which is developing throughout pregnancy. The body may not be small, but the head still can be.
Alcohol and breastfeeding
Alcohol passes into the milk at a similar concentration to maternal blood. Must wait 2-2.5 hours per drink for the alcohol to leave the milk. May decrease ability to produce milk.
May cause sleep changes in baby, motor development problems and others. However, these have not been well-studied.
Difference between SGA and IUGR
SGA is Dx at birth, either less than 3rd or 10th percentile based on weight depending on source
IUGR is Dx during pregnancy and is can be due to one or more causative factors
What are the TORCH infections?
Infections that can be transmitted in utero via placenta
T: Toxoplasmosis
O: Other (HIV, Hep B, HPV, Syphilis, Parvovirus, VZV)
R: Rubella
C: Cytomegalovirus
H: HSV 2
What are some maternal factors that can lead to limited fetal growth in utero?
Small or slender mother before conception Young or older mother Poor weight gain in last trimester Peeclampsia Prescription or other drug use Maternal infections Uterine abnormalities
What are some placental abnormalities that can lead to fetal growth restriction in utero?
Placenta previa
Placental abruption
Abnormal umbilical vessel insertions
What are some fetal abnormalities leading to restricted fetal growth in utero?
Fetal malformations
Metabolic disease
Chromosome disorders
Congenital infections
What labs are generally included in a prenatal lab screening?
Serologic testing for HIV, Rubella, Hep B
Blood type and Rh
UDS
What is Rh factor?
A group of proteins on the surface of blood cells that are second in importance to ABO type cells among a list of 35 groups of proteins on RBCs.
In the Rh group, there are 50 proteins among which D is the most important and this is what is checked when they say cells are Rh factor +/-.
Explain the ABO blood system
Most important group of proteins on the surface of RBCs, platelets, endothelium, and other cells. Can also cause complications with organ transplantation.
The associated antibodies are usually IgM and are produced in first years of life by sensitization to environmental substances like food, bacteria, and viruses.
What factors increase the risk of HIV transfer to infant?
High viral load from advanced disease
Frequent unprotected sex during pregnancy which can lead to chorioamnionitis and STI’s which all lead to increased risk of transmission
Vaginal delivery
Breast feeding
Rupture of membranes greater than 4 hours before delivery especially when mother is not on antiretroviral therapy
Delivery before 37 weeks gestation
What is group B strep?
Strep. agalactiae
What is the leading cause of early onset (1st week of life) sepsis and meningitis? What is the most important risk factor? What is the treatment?
Group B strep
Risk factor: mother colonization (about 10-30% of women)
Intrapartum antibiotics very effective in decreasing transmission
When should a mother be given intrapartum antibiotic prophylaxis to prevent GBS transmission?
Gestation of
If a mother tests positive for HIV, what steps should be taken to prevent transmission to the infant?
Treatment of the mother with combination antiretroviral therapy (if viral load > 1000 copies/mL)
When possible, a cesarean delivery should be performed prior to the onset of labor (at 38 weeks’ gestation) and the rupture of membranes.
In the U.S. and other developed nations where alternative sources of feeding are readily available, affordable, and are mixed with clean water, HIV-infected women should be counseled not to breastfeed their infants.
Explain APGAR score
A: Appearance (skin color) P: Pulse G: Grimace A: Activity (muscle tone) R: Respiration
Each category score from 0-2 for total score of 0-10, 3 or lower is critically low, 4-6 moderate, 7-10 normal
Its purpose is to assess child’s need for medical care and not a as a predictor of future problems
What is the word for cyanosis of the hands and feet?
Acrocyanosis
What are the signs of a newborn in respiratory distress?
Apnea
Poor respiratory effort
Tachypnea (rapid respiratory rate): A normal newborn’s respiratory rate will be in the 30s to 50s.
Nasal flaring
Chest wall retractions: Retractions are observed when the skin over the chest wall is “sucking in”; this is usually noted as intercostal (between the ribs), suprasternal (above the sternum) or subcostal (below the ribcage) retractions.
Grunting; Grunting is a noise that is heard on expiration when an infant in respiratory distress is working to keep his or her alveoli open to increase oxygenation and/or ventilation.
Symmetric vs Asymmetric IUGR
Symmetric has equal decrease in length, weight, and head circumference
Asymmetric spares the head circumference while everything else is decreased
An infant born SGA is at risk for what other conditions?
Hypothermia
Hypoglycemia
Polycythemia
What are the anatomical planes of the body?
Frontal/Coronal plane divides ventral from dorsal
Sagittal plane divides left from right
Transverse plane divides upper from lower
What are the sutures on the skull?
Frontal/Metopic: down the frontal bone, fuses by 3-9 months of age
Sagittal: separates left front right
Coronal: separates front to back
Lambdoid: runs left to right on the posterior aspect of the skull
Where is nasion?
The depressed area just above the bridge of the nose where the frontal bone meets the nasal bones
Where is the glabella?
Just superior to nasion between the eyebrows
Where is bregma?
Same point as the anterior fontanelle in infancy
Intersection of coronal and sagittal sutures
When does the fontanelles fuse in the skull?
Posterior and lateral fontanelles fuse by around 6 months
Anterior fontanelle is not completely closed until about the middle of the second year, full ossification starts in late twenties and finishes by age 50
What tests are performed to test for developmental dysplasia of the hip?
Barlow maneuver to dislocate and the Ortolani to put it back
Barlow: Flex hip to 90 degrees and adduct hip with posterior pressure
Ortolani: flex hip to 90 degrees and abduct while pressing anteriorly on the greater trochanter
Why are infants of diabetic mothers at higher risk for RDS?
High insulin levels in the baby interferes with cortisol’s ability to induce surfactant production so the baby can have respiratory difficulty.
Definition of gestational DM?
Fasting glucose over 95mg/dL or above limits of glucose challenge test
Infant Sx of hypoglycemia
Lethargy, listlessness, poor feeding, temperature instability, apnea, cyanosis, jitteriness, tremors, seizures, respiratory distress
Definition of macrosomia
Above 90th percentile for gestational age or over 4kg
Maternal hyperglycemia early in gestation leads to what complications?
Neural tube defects, congenital heart disease, anomalies of the kidneys and skeletal system including caudal regression syndrome
How is hypoglycemia managed in an IDM right after birth?
25-50% of infants will develop hypoglycemia. All should feed within the first hour of life and blood glucose measured 30 min after feeding. Any blood glucose below 40 with symptoms requires IV glucose. If no symptoms, they are re fed and levels measured again at 30 min. Glucose persistently below 25 in first four hours requires IV glucose. Continue monitoring for first 12 hours or until three preprandial are normal.
Besides sugar abnormalities in IDM, what other levels can be off and what are the Sx?
Hypocalcemia is also common in IDM
Sx: irritability, sweating, seizures
Require IV Calcium
What are the different swellings possible on the head of a newborn?
Caput succedaneum: collection of blood just under dermis
Cephalohematoma: blood under periosteum and doesn’t cross suture lines.
How is polycythemia defined in an infant LGA and what are the causes and complications?
Large babies need more oxygen than the placenta can provide so they produce EPO causing polycythemia. After birth, polycythemia causes Hct over 65 making the baby ruddy or plethoric. Leads to increased bilirubin, hyperviscosity syndrome with venous thrombosis in renal veins, cerebral sinus veins, or mesenteric veins.
What perinatal complications should be expected in an infant of a diabetic mother?
Hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia, birth trauma
What are the common general findings with TORCH infections?
Microcephaly, Purpuric Rash, HSM
Describe Rubella
“Little Red” in Latin
Known for lacy itchy red rash that starts weeks after exposure on the face and moves to the body. Mild fever, sore throat, fatigue. Adults have joint pain. Rash fades after 3 days. Posterior cervical LAD.
Not significant in most people, problem is Congenital Rubella Syndrome CRS.
CRS: cataracts, deafness, brain, heart problems
Spreads through the air, vaccine very effective, Americas declared free from Rubella transmission in April 2015 by WHO
What is coryza?
Same as rhinitis
Inflammation and irritation of the nasal mucosa leading to stuffiness, runny nose, post-nasal drip
What is Toxoplasmosis?
Parasitic infection acquired by eating poorly cooked food, or exposure to infected cat feces.
In adults, most people will never know they are infected. Some will have flu-like Sx for weeks or months with muscle aches and tender lymph nodes.
About half the world population is infected with it. Up to 20% of American infected.
Can infect any warm-blooded animal, but is only known to replicate in the cat family.
Transferred to infants during pregnancy leading to congenital toxoplasmosis: hydrocephalus, diffuse cerebral calcifications, chorioretinitis.
Tx: pyrimethamine, sulfadiazine, leucovorin for 12 months
How is CMV diagnosed in infants?
Urine culture
What medications or treatments are routinely administered to newborns and why?
Vitamin K to prevent hemorrhagic disease of the newborn
Hep B vaccine
Antibiotic for the eyes to prevent vertical transmission of gonococcal disease
What is the treatment protocol for newborns born to mothers positive for Hep B?
Give them HepB vaccine and immune globulin (HbIG) within 12 hours
CT scan of a child’s head shows calcifications around the ventricles. What is a likely Dx and what would the Dx be if the calcifications were more diffuse?
CMV has calcifications around the ventricles.
Toxoplasmosis has calcifications more diffusely distributed.
What will be seen on a scan of the brain in a child with congenital CMV?
Mineralizing microangiopathy and periventricular cysts
Lissencephaly (decreased number of gyri and thick cortex)
Enlarged ventricles
What is Behçet’s disease?
rare immune-mediated small-vessel systemic vasculitis[2] that often presents with mucous membrane ulceration and ocular problems.
What is the Uvea?
the pigmented middle of the three concentric layers that make up an eye.
What are the 5 W’s of post operative fevers?
Wind: pneumonia, atelectasis @ 1st 24-48hrs
Water: UTI anytime after post op day 3
Wound: wound infections anytime after POD5
Wonder drugs: especially anesthesia
Walking: walking can help reduce DVT and PE usually occur POD 7-10
What is JIA?
Juvenile Idiopathic Arthritis Used to be called Juvenile RA Less than 16yo, over 6 weeks Can be self limited or chronic Unknown cause, inflammatory condition of synovium Most often 7-12yo Majority of cases are RF negative
Sequelae of congenital CMV?
Hearing loss–can show up after the newborn period and is often progressive
Microcephaly and intracranial calcifications: can lead to developmental delay and intellectual disabilities
HSM and rash: will resolve with time
What is the treatment for kids with congenital CMV?
Parenteral ganciclovir or oral valganciclovir for 6 months
Tx has been shown to reduce hearing loss and developmental delay
How often should a mother nurse her baby?
Whenever there are signs of hunger. Usually 8-12 times per day.
Absolute contraindications for breast feeding
Mother has HIV Mother has active, untreated TB Mother has active herpes outbreak on breast Mother is on drug of abuse Infant has galactosemia
Benefits of breast feeding to the child
Stimulates GI growth and motility and maturity
Decreases acute illnesses during period being breast fed
Lower rates of diarrhea, otitis media, andUTI’s
Associated with lower rates of obesity, cancer, CAD, allergies, DM type I, IBD
Better cognitive and motor development
Maternal benefits of breast feeding
Decreased:
Breast cancer
Ovarian cancer
Osteoporosis
How soon after discharge should a newborn baby be re-evaluated and why?
24-48 hrs after discharge to be evaluated for appropriate urine and stool output and weight change
What are some of the diseases screened for in newborns?
PKU, hypothyroidism in all states
Galactosemia, biotinidase deficiency, hemoglobinopathy, maple syrup urine disease, homocysteinuria, congenital adrenal hyperplasia, CF, G6PD, toxoplasmosis
Congenital heart disease and deafness
What could be the adverse effects on an infant of a mother on anticonvulsant medication?
Heart defects, craniofascial abnormalities including microcephaly, hypoplastic nails and distal phalanges, IUGR.
What are the signs of PKU (phenylketonuria)?
Lack of phenylalanin hydroxlase
Vomiting, hypotonia, musty odor to body and urine, developmental delay, decreased pigment in hair and eyes
Features of homocysteinuria
Lacks enzyme cystathionine synthase
Dx by testing for increased methionine in urine or blood
Sx: marfanoid habitus, hypercoaguable state, developmental delay
Niemann-Pick disease
Lack sphingomyelinase causing a lysosomal storage disease
Present by 6m with hepatomegaly, ataxia, seizures, progressive neurological degeneration, fundoscopic exam shows cherry red macula
Hurler syndrome
Lack alpha-L-iduronidase causing lysosomal storage disease
Generally present around 1 year of age
Sx: hepatosplenomegaly, coarse facial features, frontal bossing, corneal clouding, developmental delay
Generally don’t live past 15y
Von Gierke’s disease
Defect in glucose 6 phosphatase causing glycogen storage disease (not the same as G6PD deficiency)
Hepatomegaly, hypoglycemia, metabolic acidosis
Through what process do newborns develop hyperbilirubinemia?
Most of bilirubin in newborns comes from hemolysis
As part of the pathway that removes bilirubin from the system, it is excreted in bile into the intestines where the intestinal flora processes it into urobilin that is lost in the stool.
Newborns don’t have the flora to perform this function, so the conjugated bilirubin becomes unconjugated again and re-enters the blood stream bound to albumin. This is the enterohepatic circulation.
The conversion from conjugated to unconjugated is performed by beta glucuronidase present in the brush border and in breast milk leading to jaundice.
Through what process do newborns develop hyperbilirubinemia?
Most of bilirubin in newborns comes from hemolysis
As part of the pathway that removes bilirubin from the system, it is excreted in bile into the intestines where the intestinal flora processes it into urobilin that is lost in the stool.
Newborns don’t have the flora to perform this function, so the conjugated bilirubin becomes unconjugated again and re-enters the blood stream bound to albumin. This is the enterohepatic circulation
What medication is used to prevent hemolytic disease of the newborn?
RhoGam
Anti-Rh immunoglobulin
What are signs of a newborn severely affected by kernicterus?
Lose suck reflex
Become lethargic
Develop hyperirritability and seizures
Can ultimately die
What are possible sequelae of kids who survive kernicterus?
opisthotonus (abnormal posturing that involves rigidity and severe arching of the back, with the head thrown backward) rigidity oculomotor paralysis tremors hearing loss, and ataxia
Direct vs indirect Coomb’s test
Direct Coombs test is used for autoimmune hemolytic anemia. It tests for autoantibodies and complement that are already bound “directly” to RBC’s. Coomb’s factor is added to washed RBC’s which is anti-human immunoglobulin.
Indirect Coombs test is used prenatally and before transfusions. It tests for the presence of autoantibodies unbound to RBC’s.
Compatibility of RBCs and Plasma in terms of donation to a recipient. (Transfusion)
RBC transfusion: O is the universal donor because the RBCs have on antigens on them to cause a reaction. AB is the universal recipient because the RBCs already have all antigens and therefore there are no antibodies present
Plasma transfusion: Pattern is opposite to RBC transfusion. O is universal recipient because there is nothing for incoming antibodies to react with. But O plasma can only be given to O blood individuals. AB is the universal donor because there are no antibodies present in the serum. AB people can only receive AB serum.
Direct Coombs test and hemolytic disease of the newborn. How good is the test?
The test may often be only slightly positive, or even negative even if there really is a problem. This is because newborn RBCs do not have as many AB binding sites as adult cells. Therefore, HDN may not cause significant jaundice and will only shorten the lifespan of the RBCs minimally.
What blood type combination is classic between mother and baby to cause hemolytic disease of the newborn?
Mother has O blood and the baby has something else. Having O blood means she has all antibodies leading to lysis of infant cells.
What is the normal progression of bilirubin levels in a newborn? Explain why.
Almost all newborns have hyperbilirubinemia. Usually first seen at day 2-3 and peaks at days 3-4.
Newborns have increased bili because:
Increased bilirubin production (from the breakdown of the short-lived fetal red cells)
Relative deficiency of hepatocyte proteins and UDPGT
Lack of intestinal flora to metabolize bile
High levels of β-glucuronidase in meconium
Minimal oral (enteral) intake in the first 2-4 days of life, resulting in slow excretion of meconium (especially common with breastfed infants).
What is physiologic jaundice?
Bili less than 15 mg/dL in kids that have no other demonstrable cause
Explain jaundice associated with breast feeding.
Two types: breastfeeding jaundice and breast milk jaundice
1) Breastfeeding: (lack of milk jaundice), in first week of life when milk levels are low leading to low enteral intake for the infant causing slow GI movement and delayed passing of meconium. Meconium has beta-glucuronidase which deconjugates bili so it can be reabsorbed into the serum. Difficult to distinguish from physiologic jaundice.
2) Breast milk: develops in first 4 to 7 days of life but may not peak until 10-14 days. Thought to be caused by increased beta-glucuronidase in the milk leading to increased enterohepatic circulation. Can last up to 12 weeks. Bili levels usually don’t get high enough to be concerning.
What are the most common hemolytic causes of jaundice in a newborn?
Rh factor incompatibility
ABO incompatibility
Minor blood group incompatibility
(the above are antibody positive hemolysis)
RBC membrane disorders like spherocytosis or enzyme disorders like G6PD deficiency (these are antibody negative)
What are causes of non-hemolytic red cell breakdown in a newborn leading to jaundice?
Bruising or trauma from birth
Large cephalohematoma or intracranial hemorrhage
Polycythemia
Swallowed blood during delivery
What are some metabolic diseases that can cause jaundice in a newborn?
Crigler-Nijjar syndrome where lack UDPGT in the liver and cannot conjugate effectively bili
Galactosemia and hypothyroidism can also cause significant high bili
What ethnicities are at greater risk for hyperbilirubinemia?
Asian more than caucasian more than black
What are some less-known factors that can lead to hyperbilirubinemia?
Bowel obstruction
Birth at high altitude
Prematurity
What is a typical breast feeding pattern?
Feed 8-12 times per day
10-15 minutes per breast
Feedings may initially last up to an hour, but they will decrease with time
If feedings are consistently long and the baby is not gaining weight, there is likely to be a problem.
What is a typical breast feeding pattern?
Feed 8-12 times per day
10-15 minutes per breast
Feedings may initially last up to an hour, but they will decrease with time
If feedings are consistently long and the baby is not gaining weight, there is likely to be a problem.
What are benefits of breast feeding for mothers?
Decreased postpartum bleeding and more rapid uterine involution
Lactational amenorrhea and delayed resumption of ovulation with increased child spacing
Earlier return to pre-pregnant weight (compared with women who formula-feed)
Improved bone remineralization postpartum with reduction in hip fractures in the postmenopausal period
Decreased cost, relative to formula
Ready availability without preparation time
Breast milk and lipids
50% of calories in breast milk comes from the fat
The fat content increases as the feeding episode proceeds, so it is important for the infant to completely drain the breast before moving to the next one.
Breast milk and lipids
50% of calories in breast milk comes from the fat
The fat content increases as the feeding episode proceeds, so it is important for the infant to completely drain the breast before moving to the next one.
How does a breast fed infant’s weight change early in life?
Typically lose 7-10% of weight in first few days of life, but regain in at least by 2 weeks of life
What are some signs of illness in a newborn?
High direct and indirect bili can be a sign of sepsis Temperature instability Respiratory distress Apnea Irritability Lethargy Poor tone Vomiting Poor feeding
How is G6PD deficiency inherited and where in the world is it most common?
X-linked recessive
Mediterranean or west African
What disease has to be careful with fava beans?
G6PD deficiency
In areas where this is more common, breast feeding mothers should be warned about fava bean consumption to protect the baby.
Define atresia
Absence or abnormal narrowing of an opening or passage in the body.
What would be the presentation of biliary atresia?
Otherwise healthy infant presenting with jaundice, dark urine, and acholic (pale) stools between 3-6 weeks of life
What surgical procedure is used to correct biliary atresia?
Kasai procedure
Anastomosis of the intrahepatic ducts with a loop of intestine for direct drainage of bile
Voiding and Stooling patterns in a newborn
Day 3: Voiding 3-4 times per day, Meconium should no longer be seen, stool should be turning yellow
Day 6: Voiding 6-8 times per day, 3-4 stools per day, though many have stool with every feeding
Stool of breast fed infants has no odor, beware of stool that gradually loses color as this is sign of biliary atresia
What does the AAP recommend concerning breast feeding and jaundice?
In every infant, promote and support successful breast feeding. In almost all cases, cessation of breast feeding is not necessary.
What are the major risk factors for severe hyperbilirubinemia?
Pre-discharge total serum bilirubin (TSB) or total conjugated bilirubin (TcB) level in the high-risk zone
Jaundice observed in the first 24 hours of life
Blood group incompatibility, with positive direct antiglobulin test
Gestational age 35-36 week
Previous sibling received phototherapy
Cephalohematoma or significant bruising
Exclusive breastfeeding, particularly if nursing is not going well and weight loss is excessive
East Asian race
What are the minor risk factors for severe hyperbilirubinemia?
Pre-discharge TSB or TcB level in the high intermediate-risk zone Gestational age 37-38 week Jaundice observed before discharge Previous sibling with jaundice Macrosomic infant of a diabetic mother Maternal age >25 y Male gender
What is Tylenol #3?
Acetaminophen and codeine
What does codeine metabolize into?
Codeine is metabolized into morphine and can transfer into breast milk
What are some recommendations to help a mom with breast engorgement?
Warm compresses before feeding and cold compresses between feedings
Mechanical/manual milk expression to relieve fullness and fascilitate latch-on
Frequent feedings to decrease milk in breast
What supplements should an infant get?
Breast fed infants should be given 400 IU of Vit D within days of birth to prevent Vit D deficiency Rickets that appears at 6-24 months
All infants should be given iron rich foods starting at 6 months of age, some recommend iron supplementation starting at 4 months
How does jaundice progress by location on an infant?
Jaundice will appear in a cephalocaudal progression as levels rise starting in the face and head and moving to the trunk and extremities.
Estimated levels of 4-5 when the face only is jaundiced, ~10-15 when jaundice to below the knees
Risk factors for developmental dysplasia of the hip.
Breech delivery
Female gender
Family history
AAP guidelines for DDH screening
Screen until 12 months of age
Hip imaging for female patients born breech
Infant has jaundice beginning day 5 and peaking in the second week of life, what is a potential cause?
Breast milk jaundice
Infant presents with jaundice in 3rd week of life with acholic stools. Cause?
Biliary atresia is most likely because of the timing and color of the stools.
Infant has jaundice and a small head and a rash, what is a likely cause? What else might be present?
TORCH infections
HSM is also likely
When would you see the onset of jaundice if the baby has G6PD deficiency?
Late-onset
Won’t be in the first days.
Sepsis can lead to jaundice, though high bilirubin would likely not be the only finding. What tests are done for newborn sepsis?
CBC and differential cell count
C-reactive protein
Blood cultures
Lumbar puncture with chemistry and culture
What test would be helpful if ABO hemolysis is suspected?
Blood smear to look for schistocytes and microspherocytes
When would urine testing for bilirubin be indicated?
When cholestasis is suspected. Liver function tests would also be performed in this case.
How old should a newborn be for newborn screening blood work?
Over 24 hours old. If initial sample taken before this, a repeat should be done within 1-2 weeks.
Which disorders tested for in the neonatal screen could lead to jaundice?
Hypothyroidism
Galactosemia
SSx of congenital hypothyroidism
Prolonged jaundice Lethargy Large fontanelles Macroglossia Umbilical hernia Constipation Abdominal distension Severe developmental delay
What kind of bilirubinemia does galactosemia cause?
Direct hyperbilirubinemia
What kind of jaundice is caused by hemoglobinopathies?
They do not cause jaundice
But thalassemias do cause jaundice (the two diseases are similar, but not the same)
When would manifestations of sickle cell disease appear in the lifespan of an infant?
Neonatal screens can pick up sickle cell disease, but manifestations of the disease will not appear until the second 6 months of life
If jaundice persists in an infant for several weeks, what signs should you look for to indicate a possible cause of the persistent jaundice?
Dark urine
Acholic stools
Indications of cholestasis
Climbing direct bilirubin would indicate biliary atresia or alpha-1 antitrypsin deficiency
If sepsis is the cause of jaundice, what other signs and symptoms would be present?
Respiratory distress Lethargy Poor feeding Apnea Vomiting Temperature instability
Inheritance pattern for PKU
What enzyme is deficient and what does it do?
Autosomal recessive
Phenylalanine hydroxylase
Converts phenylalanine to tyrosin
Increased phenylalanine leads to mental retardation, seizures, death
When does biliary atresia usually present?
Can be any time between birth and 8 weeks, but most likely after 2 weeks
What are the most notable causes of hemolysis in patients with G6PD deficiency?
Drugs such as primaquine and dapsone
Fava beans
What bacteria is GAS?
Strep. pyogenes
How good is the rapid strep test?
It has good specificity, but poor sensitivity
A positive result is significant, but a negative result has less significance.
Positive result does not require further testing, but a negative result requires culture follow-up
Within how many days of the onset of Sx do antibiotics need to be given to prevent Rheumatic Fever sequelae from a pharyngeal GAS infection?
Within 9 days of disease onset.
What are treatment options for GAS pharyngitis?
DOC is oral penicillin, but taste is bad so many Docs prefer oral amoxicillin
If 10 day regimen will be hard for the family to follow, and IM injection of penicillin is a valid option
Describe Kawasaki disease
Type of vasculitis
prolonged fever
a non-purulent conjunctivitis
mucosal changes of the oropharynx, including a strawberry tongue and red, cracked lips
unilateral cervical adenopathy
erythema and/or swelling of the hands and/or feet
a non-specific erythematous maculopapular rash
What are some causes of rashes on palms and soles
RMSF
Syphilis
Kawasaki
Hand-foot-mouth and other enteroviruses
What time of year do enterovirus infections tend to occur?
Late summer and early fall
Describe Erythema Infectiosum
Fifth disease caused by parvovirus B19
Mild or low grade fever
Can cause polyarthropathy syndrome
Rash starts 7-10 days after the onset of fever
Rash is erythematous and macular, starts on face and spreads to the rest of the body, central clearing leads to lacy appearance, tends to last longest on the extremities
Immune deficient people can develop aplastic anemia
Presentation of measles
Prodrome of mild fever, cough, coryza, conjunctivitis
Leads to maculopapular rash starting on neck, behind ears, and along hairline and spreading down to the feet by 2-3 days
Initial rash on buccal mucosa that is red with bluish-white spots (koplick spots)
Describe Roseola
Exanthem Subitum
Macular or maculopapular rash starting on trunk and spreading to extremities, involvement of the face and legs is less significant
Rash preceded by 3-4 days of high fevers that fade as the rash appears
Generally affects kids less than 2 years old
Where does Scarlet fever rash start?
Neck, groin, or axilla and spreads from there.
How long does chicken pox or varicella usually last?
About a week
What viruses can cause Mono?
EBV
CMV
Causes of unilateral cervical lymphadenopathy
Kawasaki disease Reactive node from oral infections Bacterial cervical adenitis from Staph aureus or Strep pyogenes Cat scratch disease Mycobacterial infection
What conditions are associated with a strawberry tongue?
Kawasaki disease
Strep pharyngitis, Scarlet fever
TSS
What findings are likely on CBC in kawasaki disease?
WBC: The white blood count is usually elevated, with a predominance of neutrophils.
Hbg/Hct: A normochromic, normocytic anemia is common.
MCV: The MCV is usually normal.
Platelets: The markedly elevated platelet count associated with Kawasaki disease is usually not seen until the second week of the illness.
What would a urinalysis show in kawasaki disease?
Will often show sterile pyuria with a clean catch, but no abnormalities with a catheter sample because the WBC’s come from urethritis.
Kawasaki disease is considered a diagnosis based on clinical findings. What are the diagnostic criteria?
In addition to high fever for at least five days, four of the following five criteria are needed for a diagnosis of Kawasaki disease:
Changes in oral mucosa Extremity changes (redness/swelling) Unilateral cervical lymphadenopathy Rash Conjunctivitis The one least likely to be present is cervical adenopathy.
The final criterion is that there is no other apparent cause for the presentation (i.e., a child presenting with an obvious site of infection, even if meeting all criteria for Kawasaki, cannot be given the diagnosis).
Epidemiology of kawasaki disease
Affects children, 75% cases under 5 years old, but can affect older children as well
Often in winter and spring months
Boys more often than girls
Not contagious
More prevalent in asian and pacific island descent
What is the most significant sequelae of kawasaki disease?
Aneurysms of coronary vessels
It is the most common cause of acquired heart disease in kids.
An echocardiogram is needed to identify these complications.
How quickly does treatment need to be started in kawasaki disease in order to prevent heart problems?
Within 10 days of fever onset
What is the treatment for kawasaki disease?
IVIG and high dose of aspirin
High dose aspirin is used initially for anti-inflammatory effects that shortens the fever but has no effect on the coronary aneurysms. It is given later in low doses for 6-8 weeks for anti-platelet effects.
What are some of the less-common symptoms of kawasaki?
Peeling of the fingers and toes and arthralgias
What are the 5 signs of inflammation?
Calor=heat Dolor=pain Rubor=redness Tumor=swelling Loss of function
How is asthma diagnosed?
A person with symptoms of asthma who responds to asthma treatment and has no other explanation for the symptoms has asthma by definition.
What is the difference between asthma and a URI in terms of treatment for wheezing and coughing?
URI’s typically do not respond to bronchodilators or steroids to relieve symptoms
Asthma, by definition, does respond to these agents
Asthma vs reactive airway disease (RAD)
Many kids with Sx of asthma early in life will no longer have Sx after 2-3 years of age, so many docs prefer to call it reactive airway disease instead of asthma so the kid is not given a label early in life that will follow them long-term.
When do you need to be careful with oxyhemoglobin saturation with a pulse oximeter?
Some conditions will make the reading inaccurate such as methemoglibinemia and carboxyhemoglobinemia where the reading is falsely normal.
The other pitfall is that O2 sats tell you nothing about ventilation and pt could have normal O2 values while having abnormal CO2 values such as in some cases of asthma.
What is one of the more concerning signs of severe respiratory distress?
Paradoxical breathing: during inspiration, belly goes up but chest wall goes in because of fatigue of the muscles of the chest wall
What are hyperpnea and hypopnea?
These refer to the depth of breathing
Remember that a respiratory rate might be normal, but the depth can be off, leading to inadequate ventilation.
Hyperpnea can indicate a non-pulmonary condition such as fever, acidosis, or extreme anxiety
What are two signs of accessory muscle use for breathing in an infant?
Nasal flaring
Head bobbing–seen best while pt is sleeping
What happens to the signs of respiratory distress as muscles of respiration become fatigued?
As muscle fatigue sets in, the signs of distress will diminish such as retractions and use of accessory muscle. However, paradoxical breathing should become more apparent with fatigue.
If an infant chokes, gags, or coughs with feeding, what might this indicate?
suggestive of aspiration, as can occur with a laryngeal cleft or tracheoesophageal fistula
If a child has a cough or is wheezing, why might it be important to ask about a hoarse voice or cry?
Indication of upper airway problems including:
pharyngitis, tonsillitis, epiglottitis and other infections
Difference between a wheeze and stridor
Wheeze: high-pitched and continuous and usually expiratory and best heard with a stethoscope
Typically due to airway narrowing below the thoracic inlet.
With mild airway obstruction, wheezing is usually heard only in expiration.
With increasing obstruction, wheezing may become biphasic and may even disappear altogether when obstruction is severe.
Although typically diffuse, focal wheeze may be heard in some settings such as mucus plugging.
Wheezing can also be characterized as polyphonic or monophonic: Polyphonic wheeze is characterized by multiple pitches and is typical of asthma; monophonic wheeze is characterized by only a single pitch and is typical of focal airway obstruction.
Stridor: tends to be inspiratory and has a rougher sound though it can also be high-pitched and it is a continuous sound
Due to airway narrowing above the thoracic inlet.
Usually heard with inspiration, but can be biphasic if obstruction is severe.
Describe the course of Bordetella Pertussis
Pertussis has a triphasic course:
The initial catarrhal stage lasts 1-2 weeks and is characterized by upper respiratory tract infection symptoms.
The paroxysmal stage that follows lasts 4-6 weeks and is characterized by repetitive, forceful coughing episodes followed by massive inspiratory effort, which results in the characteristic “whoop.” Infants generally do not develop a “whoop” due to relative weakness of their inspiratory effort.
The paroxysms of cough gradually decrease in frequency and severity as the convalescent stage is entered. Episodic cough may persist for months.
What is the likely cause of epiglottitis?
Classically, HIb
Since the introduction of the vaccine in the 1980’s if a case presents, it is more likely to be a staph or strep infection
What is the most common age for epiglottitis?
2-5 years
SSx of epiglottitis?
The diagnosis should be considered in a child or adult of any age with the presence of: fever stridor drooling dysphonia dysphagia, and respiratory distress. Most patients will appear toxic and may position their airway in a sniffing position (sitting, leaning forward, with neck hyperextended and chin protruding).
What are some inheritable and environmental factors that should be asked about in a child with a cough?
Family Hx of: asthma, environmental allergies, cystic fibrosis
Environment: sick contacts, daycare, tobacco smoke
What are some potential causes of an acute cough in a 10 month old?
Allergic rhinitis Asthma Bronchiolitis Croup FBA CAP Pertussis Sinusitis Viral URI CF Anatomic abnormality GERD
Describe rhonchi
Coarse, low-pitched rattling sounds heard best in expiration.
Thought to be due to secretions and narrowing of airways.
Describe crackles
Finer breath sounds heard on inspiration.
Associated with either fluid in the alveoli or with opening and closing of stiff alveoli (as in interstitial disease).
Sometimes described as either coarse or fine. (Coarse crackles are usually thought to be associated with purulent secretions in the alveoli as with pneumonia; fine crackles are often associated with pulmonary edema or interstitial lung disease.
What breath sound finding would point you most strongly towards considering a foreign body aspiration?
Asymmetrical breath sounds
What kind of imaging would be helpful to workup suspected foreign body aspiration?
PA and lateral CXR
Bilateral decubitus or inspiratory/expiratory CXR
These look for the lungs to deflate appropriately for the test. Presence of a foreign body would prevent deflation as expected.
What is Bronchiolitis?
Viral infection of the lower respiratory tract that is the most common cause of wheezing in infants.
RSV is most common cause, but can be from influenza and parainfluenza
SSx of bronchiolitis?
Generally start with URI Sx and frequently with a fever. Will also have cough, wheezing, dyspnea, and irritability.
How might you differentiate asthma from bronchiolitis?
Both have coughing, wheezing, and SOB, but bronchiolitis has fever and URI Sx.
In basic terms, what is pneumonia?
Inflammation of the lung parenchyma generally caused by microorganisms, but can also come from aspiration of gastric contents or hydrocarbons.
What is the most common cause of pneumonia in kids?
Viral cause including:
Adenovirus, RSV, Parainfluenza, Influenza
Describe the bacterial causes of pneumonia in neonates and kids.
In neonatal period, must consider bacteria from the maternal genital tract including GBS, E. coli, Klebsiella
Chlamydia pneumoniae cause will present with a staccato cough at 4-12 weeks of age
Strep pneumo is the most common cause after neonate age and up to 5-6 years
Mycoplasma pneumo is most common in school aged with Strep pneumo as close second
How do viral and bacterial pneumonias present differently?
Viral will often present with a preceding URI with cough and rhinorrhea. The cough progresses and is accompanied by fever, tachypnea, and crackles on chest exam.
Bacterial will often present more suddenly, but can follow a URI, typically fever, cough, and signs of respiratory distress (dyspnea, tachypnea, retractions, etc.) are present. On chest examination, crackles or decreased breath sounds may be noted.
How do radiographic findings differ between viral and bacterial pneumonia?
Findings of viral pneumonia on chest x-ray are variable and may show diffuse or patchy interstitial infiltrates, hyperinflation and small pleural effusions.
Chest x-rays in bacterial pneumonia typically show airspace disease with lobar or segmental consolidation and air bronchograms.
How do lab findings differ between viral and bacterial pneumonias?
In viral pneumonia, peripheral white blood cell counts tend to be normal or only slightly elevated.
In bacterial pneumonia, peripheral white blood cell counts are usually elevated and have a neutrophilic predominance.
What are the antibiotics of choice for Pertussis?
Azithromycin, Clarithromycin, Erythromycin
These will prevent transmission, but won’t alter the course of the disease.
When forming a differential, always include the two…?
Include the two L’s:
Likely
Lethal
What are the 3 categories used in the glasgow coma scale and how does the scoring work?
Best eye-opening (1-4) Best verbal response (1-5) Best motor response (1-6) Each category is scored from 1-4/5/6 Score of 3 is the lowest and 15 is the highest
What are some physical findings of dehydration to look for?
Neurological: alert to irritable to obtunded Pulse: increases Mucosa/lips: dry out Eyes: become sunken Tears: decrease Urine output: decreases or cease Fontanelle: becomes soft or sunken Skin: becomes dry and clammy Turgor: decreases and starts to tent Cap refill: goes from less than 2 sec to 3-5 sec
Do kids or adults have a higher risk of dehydration and why?
Kids are at increased risk because:
Greater surface area to mass
Higher metabolic rate
Higher percentage of weight is water (70% compared to 60%)
What condition is described by the following Sx?
Vomiting, diffuse abdominal pain, enuresis, polydypsia, dehydration, altered mental status, tachypnea
Diabetic ketoacidosis
Vomiting, tachypnea and abdominal pain comes from the acidosis
Enuresis and polydypsia come from diabetes
Altered mental status comes from the dehydration from vomiting and increased urine output
In a child with dehydration, what fluid bolus should be given and how much?
- 9% NS at 20ml/kg over 60 minutes
0. 45% SALINE and D5W are used for maintenance and are not appropriate for bolus
What is the most common cause of diabetes-associated death in children?
Cerebral edema
In correcting DKA in kids, what two things should not be given as part of the IV bolus because of risk of cerebral edema?
Bicarbonate
Insulin
Why should a CBC be done in a patient with suspected DKA?
Looking for signs of infection that may have precipitated the DKA
Caution must be taken because DKA alone can lead to an increased WBC level
What breathing pattern is seen with metabolic acidosis and why? How does it differ from what is seen with heart and lung disease induced breathing changes?
Kussmaul breathing with metabolic acidosis is rapid and deep breathing that helps to blow off the excess CO2, it is also assoc. with kidney failure.
Heart and lung problem induced tachypnea tends to be fast but shallow.
What should be suspected when you see the following Sx: Vomiting Weight loss Dehydration Shortness of breath Abdominal pain, or Change in the level of consciousness?
Diabetic DKA
If a patient with diabetes starts to vomit, what should be assumed unless proven otherwise?
DKA
Pathophysiology of DKA
Type 1 diabetes is caused by a relative or absolute deficiency of insulin. Insulin facilitates the entry of glucose into peripheral tissues, and inhibits lipolysis, glycogenolysis, and tissue catabolism.
The lack of insulin and excess counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone) causes a catabolic state characterized by increased gluconeogenesis, lipolysis, and glycogenolysis, and an inhibition of glycolysis, which result in hyperglycemia and ketogenesis.
The increased lipolysis leads to increased mobilization of free fatty acids, which are then converted into ketones (acetoacetic and beta-hydroxybutyric acids).
The increased production of ketones lowers the blood pH, and leads to metabolic acidosis, which is worsened by lactic acidosis from dehydration and poor tissue perfusion.
When circulating blood glucose levels reach ~180 mg/dL, an osmotic diuresis occurs, leading to hypovolemia, dehydration, and a loss of sodium, potassium, and phosphate in the urine.
Intravascular volume depletion stimulates catecholamine release, which causes further lipolysis. The osmotic diuresis and hyperglycemia cause serum hyperosmolarity. Dehydration can result in renal impairment, which will exacerbate hyperglycemia.
What will serum sodium levels show in DKA?
Hyponatremia because of dilution from hyperosmotic blood from high glucose drawing fluid into the extravascular space, Na is also lost from the kidneys because of polyuria
Potassium levels and DKA
K+ is lost through increased flow of the kidneys, but the acidosis and the low insulin drive K+ out of the cells and into the serum, this makes the K+ levels look normal or even elevated when in fact they are low
This needs to be anticipated and watched for as the acidosis is corrected. K+ is added to IVF as hypovolemia and acidosis are corrected.
What are the 3 types of potassium that can be given?
Potassium phosphate
Potassium acetate
Potassium chloride
What will be the levels of bicarbonate in DKA?
Low because the high levels of acid will bind to the bicarb and reduce its numbers
Corrected sodium levels and DKA
Increased blood glucose lowers serum sodium in a linear manner
The corrected value tells you how much of the low sodium is due to the high sugar and whether or not you need to replace sodium
Example:
Serum sodium = 135 meq/L
Serum glucose = 608 mg/dL
Corrected sodium = [{(608 - 100) / 100} x 1.6] + 135 = 143.1
What is the result of rapid correction of hyponatremia?
Central Pontine Myelinolysis
Damages the myelin of the nerves in the pons of the brainstem
What happens if hypernatremia is corrected too quickly?
Cerebral edema
What are the 4 basic steps to fluid management?
Bolus to restore fluid volume
Correct dehydration
Provide maintenance fluids
Replace ongoing losses
At what level of glucose will you start to see glucose in the urine?
180
When giving a bolus of fluids, how do you know you have given enough? Normal patient and in DKA
In a normal patient, you do serial bolus until urination
In DKA, urination will happen quickly because of osmotic diuresis, so you bolus until improvement of vital signs like BP and HR and improvement of mental status
Why is the initial bolus of fluid 0.9% saline when maintenance fluids are 0.45%?
To prevent the initial bolus and increase in blood volume from diluting the blood and decreasing osmolality.
Patient presents with HA, vomiting, restlessness, irritability, lethargy, and abnormal pupillary responses. What is likely Dx and how will BP and HR change?
These are signs of cerebral edema
BP will increase and heart rate will decrease
What is a very serious complication of DKA?
Cerebral edema
21-24% of patients with this complication will die
Components of an admit order
A =Admit (floor, room, service, attending, resident)
D=Diagnoses (list in order of priority)
C=Condition (good, fair, guarded, critical)
V=Vitals (q 2 hrs, q shift, routine)
A=Activity (ad lib, bed rest, up to chair, walk 3x/d)
N=Nursing (ins and outs, drains, wound care, etc.)
D=Diet (regular, low sodium, diabetic, NPO, etc.)
I=IV fluids (type and rate)
S=Studies (imaging, EKG)
M=Medications (include both scheduled and prn)
A=Allergies (drug or food)
L=Labs (CBC, lytes, cultures, etc.)
What should a new-onset type I diabetic patient also be screened for while being treated?
DM I is considered an autoimmune disease, so they are at high risk of developing other similar diseases like thyroid disease and celiac disease being most common.
However, thyroid function tests should not be performed until after the patient has stabilized for some time.
What molecules are tested for when looking for celiac disease?
Anti-endomysial and anti-tissue transglutaminase antibodies with a serum IgA level
What is the honeymoon phase in pediatric patients newly diagnosed with DM I?
It is common for there to be a period early after initial diagnosis of DM I where almost no insulin is needed and it is tempting to think the child is cured, but this is a normal period that most often passes.
Why do individuals with insulin resistance tend to have dyslipidemia?
Insulin inhibits lipolysis, so when resistant, lipolysis floods the blood with FFA’s and other lipids.
What kids should be screened for DM II?
Kids that are obese and have two of the following risk factors:
Maternal history of diabetes or gestational diabetes during the child’s gestation.
Family history of type 2 diabetes in a first- or second-degree relative
Race/ethnicity (Native American, African American, Latino, or Asian American, Pacific Islander)
Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome).
Appendicitis can present atypically in peds patients compared to adults. How do they present differently?
Pain may not migrate to RLQ
Rovsing’s sign can be negative
Not have involuntary guarding or fever
What is Cushing’s triad?
Indication of ICP
Hypertension
Bradycardia
Cheyne-Stokes respirations
Why would ICP cause epigastric discomfort?
ICP causes vagal stimulation leading to gastric acid secretion leading to discomfort
How long is corrected age used for premature infants?
Until they are 2 years
Most kids are caught up by this time at least in height, though may lag slightly in weight.
95% of kids start walking between what ages, and what does this depend on?
Most kids walk between 9-17months
Depends on neuro and motor development and kid’s temperament
If kids are pigeon-toed when young, will they always be that way?
No
Kids are often that way and most will grow out of it with time. Braces are no longer used for this because was not helping outcomes.
What is the most important thing to check in a child’s foot when parents are concerned about flat feet?
Flexibility of the foot and ankle are most important. If not flexible, referral might be necessary.
Pedal arch develops in first 8 years of life, so can take some time.
Why are walkers discouraged for kids?
They do not help the child learn any faster to walk
They increase the risk of injuries from falls, burns, and other accidents from being more mobile.
Developmental milestones surveillance includes what 5 domains?
Gross motor Fine motor Communication Personal-Social Problem solving
What gross motor milestone is present at 12 months?
Able to stand/walk alone
What fine motor milestone is present at 12 months?
Fine pincer grasp
What communication/social milestone is present at 12 months?
One word other than mom/dad
Follows one-step commands with gesture
What cognitive/adaptive milestone is present at 12 months?
Points to get desired objects
What is the most variable component of development?
Expressive language
At what age should kids be screened for autism?
18 and 24 months
By what age should a babinski test be negative or down-going?
By 2 years at the latest, or by the time they are walking.
What are cortical thumbs?
Thumbs held persistently in the palm grasped by the fingers. It is a sign of CNS dysfunction.
What is the definition of spasticity?
Increased muscle resistance that is velocity-dependent. The faster you move the muscle passively, the more resistance you will encounter.
Kids under 6 with conjunctivitis are more likely to have what etiology?
Bacterial
Which conjunctivitis etiology is more likely to be bilateral?
Bacterial
Also assoc. with purulent discharge sticking eyelids together in the morning.
Important to remember that both viral and bacterial start in one eye and both can spread to the other eye.
Which conjunctivitis etiology is frequently bilateral and assoc. with pharyngitis and pre-auricular LAD?
Adenovirus
What are some causes of eye swelling?
Conjunctivitis Seasonal allergies URI Sinusitis Acute allergic reaction Cellulitis
Where is the easiest place to see generalized edema in kids?
Scrotum in males
Labia in females
When is the peak time of lymphoid tissue growth in a child?
4-6 years
This makes it normal to see enlarged tonsils in a kid this age if they are not erythematous and show no discharge. And, kids of this age often have many viral URI’s causing some enlargement.
What heart sound will appear and indicate an overloaded left ventricle from heart failure?
S3 sound
What are some of the signs that would be seen in a patient with CHF?
Edema Hepatomegaly Heart murmur Heart gallop Tachycardia
What is the most prominent sign of nephrotic syndrome?
Edema
How is fluid retention/accumulation different between nephrotic syndrome and acute glomerulonephritis?
Nephrotic syndrome: fluid accumulates in interstitial space so no change in BP
AGN: fluid accumulates intravascularly leading to HTN
What is the most common form of nephrotic syndrome in kids under 10?
Minimal change disease
Characterized by fusion and effacement of the foot processes of the glomerulus
In what diseases do you see low complement values?
Membranoproliferative glomerulaonephritis
SLE
Post-streptococcal glomerulonephritis
When can you see benign proteinuria?
During a fever or after significant exertion
Orthostatic proteinuria in adolescents–morning urine will be negative for protein
What urine protein to creatinine ratio is diagnostic of nephrotic syndrome?
Any value above 2.5
If a patient has tea-colored urine, what questions should you ask?
Ask about recent throat and skin infections as this is associated with post-streptococcal glomerulonephritis
Presentation of strep pharyngitis
Pharyngitis caused by Streptococcus pyogenes classically presents with sudden onset of fever, sore throat, headache, and abdominal pain with absence of rhinorrhea, congestion, or cough.
On exam, patients may have an exudative tonsillitis with palatal petechiae, strawberry tongue, tender anterior cervical lymph nodes, and sometimes an accentuation of skin lines in the flexor surfaces (Pastia’s lines) and a fine papular sandpaper-like rash (scarlitiniform rash).
What should be done in a case of strep pharyngitis to prevent PSGN?
Treating strep throat with antibiotics will prevent the complication of acute rheumatic fever, but will not prevent the occurrence of PSGN.
How is PSGN diagnosed?
Elevated antistreptolysin-O (ASO) titer
Positive streptozyme test
Elevated anti-DNAase B antibodies, or
Low C3
What is the worst case of acne called?
Nodulo-cystic
Hidratenitis suppurativa vs acne vulgaris
Hidratenitis suppurativa:
Pustular lesions caused by occlusion of the apocrine follicular units (instead of the pilosebaceous units).
Often superinfected with Staphylococcus aureus or Streptococcus pyogenes.
Distribution markedly different from acne. Areas most likely affected in women: Axillae Groin Inframammary regions
In men:
Perineal and perianal areas more commonly affected.
What pustular rash has:
More often seen in adults.
“Early” form seen in adolescents is characterized by inflammatory papules and micropustules, and redness.
No comedones.
Worsens with alcohol, spicy food, temperature extremes, and stress.
Can be treated with topical metronidazole and various other medications.
Rosacea
Seen on malar and nasal surfaces
Perioral dermatitis
A variant of rosacea also commonly seen in adolescents, and treated the same way.
See erythema, scaling, and papules or pustules, but no comedones.
“Perioral” almost a misnomer, as this may be seen around the mouth, nose, or eyes.
What is pseudofolliculitis?
Consists of papules, but not pustules.
Is often seen in the beard area.
Can be distinguished from acne because the inflammation is adjacent to hair follicles.
The hair grows out of the follicle and, when shaved closely, often grows back in to the surrounding skin, causing irritation and inflammation
Most common drugs oral drugs used to treat moderate to severe acne and their side effects?
Doxycycline and Minocycline
Both have serious potential side effects to be aware of before prescribing (i.e., doxycycline may cause photosensitivity, esophagitis, dental staining in children under age 9, teratogenicity, and pseudotumor cerebri; minocycline can cause neurological side effects [like vertigo], pseudotumor cerebri, skin pigmentation [blue/gray after multiple doses], and a lupus-like reaction).
For females, birth control pills can be used
What drug is used for nodular-cyctis acne?
Isotretinoin
Categories of acne?
Mild: Comedonal acne with perhaps a few papules or pustules mixed in
Moderate: Significant inflammatory lesions with concern for scarring
Severe: Nodulo-cystic type, with an even higher risk for significant scarring
Drugs of choice for mild acne?
Retinoids (e.g., tretinoin [Retin-A] or adapalene [Differin]) work by normalizing follicular keratinization and are considered the drugs of choice for comedonal acne.
Or, benzoyl-peroxide OTC
What topical antibiotics are used for acne?
Clindamycin
Erythromycin
Timing of retinoid administration for acne
Timing of treatment with retinoids is important:
Retinoids need to be used at night, because they can cause photosensitization and lead to a significant sunburn.
Tretinoin is also inactivated by oxidation of BPO (so the BPO cream should be applied in the morning).
Tretinoin also must be applied to bone-dry skin or it may be significantly irritating.
It is important to make sure teens know that retinoids can make acne transiently look worse.
Side effects of topical steroid use
Skin atrophy
Telangiectasias
Hypopigmentation
Suppression of the hypothalamic-pituitary axis
Even low-potency topical steroids can cause these problems when used for long durations or over large areas of the body. Particular caution should be used when considering the use of steroids on the face or genitalia.
First line treatment for tinea versicolor?
Selenium sulfide lotion
Treatment of choice for tinea capitis
Griseofulvin
What condition?
Characterized by scaly papules and plaques in the hallmark “christmas tree” distribution on the back and trunk, following the lines of skin cleavage.
Lesions may also be found on the upper thighs and in the groin area.
The initial lesion, called the “herald patch,” is usually the largest scaly plaque with a raised border and can easily be confused with tinea corporis.
Pityriasis Rosea
What condition?
A nonspecific dermatitis characterized by patches of hypopigmentation on the face, neck, upper trunk, and proximal extremities.
Lesions range from 0.5 to 5 cm in diameter with well-defined, irregular borders and fine scale.
Aassociated with sun exposure.
May be mistaken for tinea versicolor.
Pityriasis alba
Warts vs Molluscum Contagiosum
Warts are commonly caused by one of the human papillomaviruses (HPV).
Molluscum contagiosum, another virus, causes a similar skin condition. These lesions are small, smoother than common warts, and many have a central dimple, making them “umbilicated.”
Three common causes of diaper rash?
- Irritant dermatitis
- Diaper candidiasis
- Bacterial infection, especially caused by perianal Group A streptococcus
Irritant Dermatitis diaper rash
Most common cause of diaper rash.
Due to prolonged exposure to moisture, friction, and digestive enzymes (worse with diarrhea).
Presents as irregular areas of erythema with skin maceration on the convex surfaces of the skin
Typically spares the intertriginous creases.
Treatment
Most physicians recommend keeping the diaper area as clean and dry as possible and using zinc oxide-containing creams or ointments. The barrier provided by the zinc oxide helps limit contact of urine and feces with the skin allows the rash underneath to heal.
Diaper candidiasis
Starts off as erythematous papules that become confluent, bright red plaques.
The inflamed plaques are surrounded by more erythematous papules called “satellite” lesions.
Treatment
The anti-fungal medication nystatin is effective against candida and is probably the most often used as it is approved for all ages by the FDA. Imidazole antifungals such as miconazole and ketoconzole can also be effective, but some of these products are not approved for use in infants.
Bacterial infection diaper rash
A bacterial infection, especially of the perianal area with Group A Strep (Streptococcus pyogenes) is another, less common, cause of diaper dermatitis.
This can be potentially serious, leading to cellulitis and even dissemination via bacteremia.
These infants may also be irritable and have streaks of blood on their stools.
Treatment
Standard treatment with oral antibiotics is effective.
Deficiency of what nutrient can lead to diaper rash?
Zinc
