Case 1: General Pediatrics Flashcards
Definition of apnea in a baby
RR <20
Normal vitals signs in a pediatric patient (newborn:
RR 30-50
HR 120-160
SBP 50-70
Weight 2-3kg
Normal vitals signs in a pediatric patient (infant = 1-12mo)
RR 20-30
HR 80-140
SBP 70-100
Weight 4-10kg
Normal vitals signs in a pediatric patient (toddler= 1-3y)
RR 20-30
HR 80-130
SBP 80-110
Weight 10-14kg
Normal vitals signs in a pediatric patient (preschool = 3-5y)
RR 20-30
HR 80-120
SBP 80-110
Weight 14-18kg
Normal vitals signs in a pediatric patient (middle school = 6-12y)
RR 20-30
HR 70-110
SBP 80-120
Weight 20-42kg
Normal vitals signs in a pediatric patient (adolescent = 13+y)
RR 12-20
HR 55-105
SBP 110-120
Weight >50kg
Normal abdominal exam (v. adult)
liver / spleen tip may be palpable –> start low, ask for an exhale
kidneys, stool may be palpable
Is strabismus normal in an infant
yes, intermittent, if <6mo
seeing white when do the red reflex exam?
- retinoblastoma
- cataract (but can also look black)
reasons for dental caries in a pediatric
- poor diet
- continuing to use the bottle
at what age does the babinski reflex go away?
when the infant starts walking (3-6mo)
of >1y, considered pathological.
you notice that a baby does not have the rooting reflex when you stroke his cheek near his mouth. what’s wrong?
likely nothing - babies only have the rooting reflex when hungry.
definition of dehydration
(UOP + insensible losses) < intake
symptoms (tachycardic,
4mo boy presents with RSV bronchiolitis and is admitted for hypoxia. in addition to respiratory sxs, he has not been eating / drinking his formula. he has post-tussive emesis. at hsi recent well visit , he weighed 6kg and now he weighs 5.5kg. propose a rehydration plan?
fluid deficit = 5%
1) bolus of 20ml/kg == 120mL
2) remaining fluid deficit (5% * 6kg) over next 10h
3) maintenance fluids + oral fluids.
4) baby admitted for hypoxia –> will be given O2 ==> will slow RR, baby will be hungry.
OR
oral rehydration once baby is able to take in PO (baby likely not eating).
5 1/2 yo girl has had 3-4d of vomiting, anorexia, fever 104. She’s irritable, and has been crying with no tears. She weighs 20kg. propose a rehydration plan?
Fluid deficit = mild / moderate (for an older child). ~6%
0.06 * 20kg == 1.2L deficit
1) Bolus of 20mL/kg = 400mL bolus
2) 800mL over the next 24h
3) maintenance.
8yo boy presents with perforated apppenix. hes had poor PO intake for 48h, including some emesis and fever. he’s made urine 2-3x in teh past 24h. on exam, he is 40kg. tachycardic, normal BP. alert, uncomfortable and tired by interactive. MMM. cap refil 3 sec.
fluid deficit = mild / moderate (~8% fluid loss)
dehydrated b/c NPO
–> oral rehydration
dehydrated b/c emesis
–> 1L of fluids + maintenance over 24h
1mo presents with weeks of watery diarrhea her parents are mixing the formula powder and when double-checked, it’s 3x as concentrated as it’s supposed to be. she weighs only 3.5kg (5%ile). birth-weight was 3kg (50% %ile). her serum sodium is 165mEq/L, K 3.5, Cr 0.3. propose a rehydration plan
free water / hypotonic (VERY SLOWLY).
monitor Na is decreased 1-2mEq/hr
+ patient education about formula mixing
4month old, 3.5kg baby with nephrogenic DI who had 1-2d of vomiting and diarrhea, presents with a seizure. he is NPO b/c scheduled for sedated MRI the next day. what do you want to do for him?
Give maintenance
Fluids = 3.5kg * 100mL/kg/d == 350mL/d
D5 - b/c baby
Saline
- need 2-4mEq/kg/d == 7-14mEq/d Na
- 1/4 NS ==> (30mEq/L)*(0.35L/d) == 10.5 mEq
1) NS bolus (b/c vomiting & diarrhea)
2) Maintenance = D5 + 1/4NS + K.
Breastfeeding benefits for infants (if exclusive)
decreased
- ID = otitis media, respiratory infections, gastroenteritis, UTI
- SIDS
- (in preterm) necrotizing enterocolitis, sepsis
- obesity, Type 1 / 2 DM, childhood cancer, CAD, IBD
- allergic rxns
increased
- GI growth & motility = maturity of GI tract
- neurodevelopmental advantages (small) - cognitive, motor
- bonding
breastfeeding benefits for mothers
decreased
- breast and ovarian cancer
- CVD, T2DM
- osteoporosis
- post-partum bleeding, uterine involution
- ovulation (–> lactational amenorrhea)
- baby weight
- cost (v. formula)
- waiting time for baby
increased
- bone remineralization; protection against hip fractures in postmenopausal period
need to practice many months of breastfeeding over a lifetime
Recommendations of breastfeeding
- Exclusive breastfeeding for 6mo
- Supplemental breastfeeding (+ complementary foods): 6-12 mo
- premies –> breast milk + fortifiier
WHO = 24mo of breastfeeding
Infants: recommendations for VitD
- Newborns: 400IU (- 800IU)
- Children with malabsorption - can give 2000-4000IU (adult dose) - until 25-OH-VitD3 is >20.
OR
- Mother supplement with 4000-6000IU to achieve adequate levels in mild
Infants: recommendations for Iron
Most babies consolidate iron in uterus at last 4-6mo
- Start at 4mo for full term of 2mg/kg/day of elemental iron
6mo for >38w gestation
<6mo for <38w gestation
OR
- Red Meat
Common vitamin deficiencies in exclusively breastfed babies
VitD (start at birth)
Iron (start at 4mo)
Zn
Zn deficiency
common in exclusively breastfed infants
- -> dermatitis enteropathica (genetic deficiency)
- -> infectious gastroenteritis (in developing world)
When to use infant formula
When C/I to human milk
- HIV, HTLV,
- chemotherapeutic drugs
- active drug abuse
- galactosemia in infants
- active herpes simplex lesions on breast
- active untreated TB
Need formula supplementation
- metabolic d/o
- low mild production
Basics of infant formula
1) cow (sugar = lactose)
2) soy based (sugar = sucrose)
3) hydrolyzed cow’s milk
Cow milk formula - what’s the “premium” and “advance”
long chain fatty acids –> similar to what’s in human milk.
Nutrition for preterm infants
- basic needs
- options
- need: Ca, PO4, Protein
- if <34w gestation = fortified human milk
- at home: oral feeding exclusively on human milk
Milk protein allergy
cause
sxs
- allergy to whole cow milk protein ==> vomiting, atopic dermatitis, allergic colitis (blood in stools)
most common cause of GI bleeding in infants
- incidence = 15%
prevention of necrotizing enterocolitis
mother’s milk
b/c deficient in lots of calories & vitamins
mild protein allergy in a formula fed infant
tx
treatment
1) MILD - change to partially hydrolyzed formula
2) SEVERE - blood = fully hydrolyzed formula (cow mild protein is enzymatically broken down to small, less immunogenic pieces)
3) VERY SEVERE - amino acid formula
DO NOT give soy formula –> 40-50% cross-reactivity
mild protein allergy in a breastfed infant
tx
less likely to be due to mild protein allergy; concerns about breastfeeding benefits
1) MILD / new = change back to breastfeeding & eliminate dairy from diet / send to lactation specialist (2w)
a breastfed 1mo presents for a health maintenance visit. his mother changed from breastfeeding to formula at 1w of life. since this, he has started spitting up more freq, and there are small amts of red flecks in the stools. your recommendation is to:
a. change brands of cow mild formula
b. change to fully hydrolyzed infant formula
c. change to an elemental
d. change to soy formula (it’s much cheaper)
e. refer to a breastfeedign specialist so the mother can re-lactate.
B/D
now we know that
1) cowmilk protein allergy –> go straight to hydrolyzed
2)
at a 4mo WCC, a family of an exclusively breastfed infant wants to know when to start solid foods, and why they should start them then. you answer:
a. right away, to prevent iron and zinc deficiencies
b. right away, there is no added benefit to continuing exclusive breastfeeding at this time
c. closer to 6mo, as infants are not developmentally ready until then
d. closer to 6mo, as continuing breastfeeding until then is beneficial in preventing infectious diseases
e. closer to 4 mo, as continuing exclusive breastfeeding until then is beneficial in preventing atopy
4-6mo
@< 4mo –> tongue protrusion reflex; infectious disease prevention; high rate of autoimmune (allergy, celiac, DM).
@ > 6m –> high risk of allergies
–> start to introduce varied foods @ 4-6 mo.
at a 4mo WCC, a family of an exclusively breastfed infant wants to know when to start solid foods, and why they should start them then. you answer:
a. right away, to prevent iron and zinc deficiencies
b. right away, there is no added benefit to continuing exclusive breastfeeding at this time
c. closer to 6mo, as infants are not developmentally ready until then
d. closer to 6mo, as continuing breastfeeding until then is beneficial in preventing infectious diseases
e. closer to 4 mo, as continuing exclusive breastfeeding until then is beneficial in preventing atopy
Formula fed: 4-6mo
Breast-fed: 5-6mo
@< 4mo –> tongue protrusion reflex; infectious disease prevention; high rate of autoimmune (allergy, celiac, DM).
@ > 6m –> high risk of allergies
–> start to introduce varied foods @ 4-6 mo.
allergies if given complementary foods <4mo and >6mo
Solids = iron and zinc rich foods with fruits, vegetables, meat, poultry fish, eggs
an exclusively breastfeeding term infant is leaving the hospital. the family intention is to breastfeed exclusively for 6mo and continue for 1-2y. what is an acceptable way to provide nutritional supplementation from birth
a. the mother can take 4000-8000IU of Vitamin D
b. the infant can take 200IU of vitamin D each day
c. the mother can take 325 mg/d of ferrous sulfate
d. the infant can take 2mg/kg/d of elemental iron
A
Vit D = at birth
Iron = at 4mo
at a 18-mo WCC, in your nutritional hx, you find that the child drinks 28oz of whole milk and 16oz of juice each day in a sippy cup, and eats 3 meals and 3 snacks. while early height and weight percentiles were 50%, both are now >90%. you recommend:
a. change to skim milk and limiting juice to a 4-6oz /d
b. change to skim milk and limiting juice to a 8-12oz /d
c. limiting intake of whole milk to < 16oz / day, and that of juice to 4-6oz a day
d. limiting intake of whole milk to < 16oz / day, and that of juice to 8-12oz a day
C
Milk < 16oz
juice 4-6oz
water at 6mo.
when do you change from whole milk to skim milk
formula fed
- -> whole cow’s milk (@ 1y)
1) young infants can’t digest cow’s milk as completely/easily as they digest breast milk/formula
2) cow’s milk contains high conc. of protein and minerals –> stress immature kidneys
3) cow’s milk lacks iron, vitC, etc.
4) cow’s milk prevents you from absorbing iron
5) irritate lining of stomach and intestine –> blood loss in stool
6) does not contain optimal fats
–>skim milk (@2y)
b/c need fats for myelination
doesn’t seem to help to change weight loss
at a 18-mo WCC, in your nutritional hx, you find that the child drinks 28oz of whole milk and 16oz of juice each day in a sippy cup, and eats 3 meals and 3 snacks. while early height and weight percentiles were 50%, both are now >90%. this child is at most risk for deficiency in a. vitD b. Vit A c. Vit C d. Iron E. Zinc
D
milk doesn’t have iron; and will also make you lose milk (due to absorption problems)
Milk = VitD, VitC, Zinc.
at 10y WCC, a pt new to you is well > 97%ile for weight (with upward trajectory), about 90% for height. what can the family choose from to combat childhood obesity
a. eliminate sweetened beverages from the diet
b. limiting screen time to 1-2h per day
c. a diet with high content of fruits & vegetables
d. increased physical activity for the entire family
limiting childhood obesity
- Limit screen time
- Increase physical activity
- Decrease sugar-sweetened beverages
- Decrease juice intake
- Improve rates of exclusive breastfeeding
a 56o girl presents with iability to walk. her height & weight cures hae decreased to <5th%ile from the 25th over the last year. in addition to joint pain and swelling , she also has gingival hyperplasia and soe gum bleeding.
a. vitA
b. iron
c. vitamin C
d. VitD
e. Zinc
C. Scurvy. likely due to limited diet (chips & soda)
vit C = problems with Collagen I, poor wound healing
bone pain, rash, gingival hypertrophy
problems with sippy cups
excessive mild & juice intake, nutritional deficiency, dental decay
finger foods @ 6mo
pincer at 8-9mo
15mo ssomali refugee presents with growth failure & failure to gain weight (both < 3rd%ile). he entered teh US at 7mo of age. he is exclusively breastfed, with minimal intake of complemetary foods. on PE he has wide wrists. what micronutrient deficiency might cause this? what lab abnormalities would you see? a. vitA b. iron c. vitamin C d. VitD e. Zinc
D
widened metaphyses @ wrists, ankles
might not see the bowed-legged b/c not yet walking.
low Calcium, low phosphate
high alk phosphate ==> due to lots of bony turnover
weight changes in breastfed baby
v. formula fed
first 6mo = gain weight quickly, “fat”
next 16mo - failure to thrive
formula fed –> looks like continuing to gain too much after 6mo.
intrauterine factors that affect the growth of the fetus: maternal
”.
- poor weight gain in T3
- preeclampsia
- maternal prescription / illicit drug use
- maternal infections
- uterine abnormaltiies”
intrauterine factors that affect the growth of the fetus: placental
”.
- placenta previa
- placental abruption
- abnormal umbilical vessel insertions”
intrauterine factors that affect the growth of the fetus: fetal
”.
- fetal malformation
- metabolic disease
- chromosomal abnormalities
- congenital infections”
“define: TORCH
what tests do you use for testing?”
“T - oxoplasmosis –> newborn toxo-specific IgM / IgG / IgA, infant toxoplasma titer increasing in first year, persistently positive IgG titers beyond 1yo
O - ther (HIV, HBV, parvovirus, syphilis) –> maternal HBsAg [no need for HBcAb b/c does not predict for vertical HBV transmission]
R - ubella –> maternal and infant rubella titer IgM, especially if stable / increasing serum conc. over few mo.
C - MV –> infant urine culture (lots shed in saliva & urine, respiratory, blood, CSF w/in 2-3w of life); or PCR
H - HSV2”
factors that increase maternal-to-fetus HIV transmission
”.
- frequent, unprotected sex during pregnancy +/- chorioamnionitis & other STIs
- advanced maternal HIV disease ==> high viral load
- membrane rupture > 4h prior to delivery if mother is not on antiretrovial therapy
- vaginal delivery
- breastfeeding
- premature delivery (<37w gestation)”
what does frequent, unprotected sex during pregnancy increase the risk for?
chorioamnionitis –> which increases the risk for HIV
factors that play a role in the prevention of vertical HIV transmission
”.
- treatment of mother with combo antiretroviral therapy (if viral load > 1000 copies/mL), ideally before labor starts
- C/S prior to onset of labor (38w gestation) and rupture of membranes
- NOT breastfeeding (where formula is a safe and viable option)”
key concepts in the clinical evaluation of gestational age & stability at birth
“Ballard score
Apgar score”
Ballard scre
“evaluating gestational age and stability at birth: using signs of physical & neuromuscular maturity to estimate gestational age
- esp. useful when there is no prenatal U/S to help confirm dates or if gestational age is in question”
Apgar score
"evaluating gestational age and stability at birth A - ppearance (skin color) P - ulse (HR) G - rimace (reflex irritability) A - ctivity (muscle tone) R - espiration
newborn receives a score of 0, 1, 2”
routine screening for newborns & what test is used
“metabolic d/o - PKU, hypothyroidism (other: galactosemia, biotinidase deficiency, hemoglobinopathy, maple
syrup urine disease (MSUD), homocystinuria, congenital adrenal hyperplasia, cystic fibrosis, G6PD deficiency, and toxoplasmosis)
congenital deafness - hearing test
congenital heart defects - transcutaneous O2 sat”
“sxs of inborn errors of metabolism
when do they present?
Incidence?”
“Some insidious onset; some obviously ill:
- anorexia
- lethargy
- vomiting
- seizures
1/5 sick full-term neonates w/out risk factors for infection will have a metabolic d/o
–> present 24-72h after birth”
“what medications are routinely given to all newborns
how? Why?”
”.
- Vit K (IM) - prevent hemorrhagic dz of newborn (““vit K deficiency bleeding””)
- Hepatitis B vaccine (IM, fo rbabies > 2000g) - for all infants regardless of maternal status
- Erythromycin / tetracycline / silver nitrate (topical): eye infection prophylaxis against gonococcal conjunctivitis”
is HbIg given to all newborns at birth?
if not, to whom do we give it? (And what do we give specifically)
“No
only to those at risk for vertical transmission of HepB virus”
- infants <2000g born to others + HBSAg
1) Hep B vaccine + HBIG within 12h of delivery
2) Routine series of 3 doses of vaccine beginning at age 1mo (total = 4 doses)
3) 9-18mo of age –> test for anti-HBsAg and HBsAG. If needed, should re-immunize
infants (>2000g) to mother with unknown HBsAg status
- Hep B vaccine within 12h of delivery
- DELAYED HBIg until maternal status is known –> effective if given up to 7d after delivery
which infectious cause of conjunctivitis is more common in newborns? For which do we do prophylaxis? Why?
”.
- Chlamydia trachomatis»_space; gonococcal
- prevention for gonococcal (erythromycin)
- don’t give prophylaxis for chlamydial b/c it occurs 7-14d after birth, and so prophylaxis doesn’t help prevent it.”
risks for SGA newborns
What additional risks should you consider for a baby known to be SGA? Select all that apply.
A hypoglycemia
B hyperthermia
C hypothermia
D polycythemia (increased hemoglobin/hematocrit).
“hypoglycemia
hypothermia
polycythemia”
“risks for SGA newborns: hypoglycemia
etiology?
Sxs?”
“etiology
- decreased glycogen stores
- heat loss
- possible hypoxia
- decreased gluconeogenesis
sxs = usually Asx; poor feeding, listlesness”
