Case 1: General Pediatrics Flashcards
1
Q
Definition of apnea in a baby
A
RR <20
2
Q
Normal vitals signs in a pediatric patient (newborn:
A
RR 30-50
HR 120-160
SBP 50-70
Weight 2-3kg
3
Q
Normal vitals signs in a pediatric patient (infant = 1-12mo)
A
RR 20-30
HR 80-140
SBP 70-100
Weight 4-10kg
4
Q
Normal vitals signs in a pediatric patient (toddler= 1-3y)
A
RR 20-30
HR 80-130
SBP 80-110
Weight 10-14kg
5
Q
Normal vitals signs in a pediatric patient (preschool = 3-5y)
A
RR 20-30
HR 80-120
SBP 80-110
Weight 14-18kg
6
Q
Normal vitals signs in a pediatric patient (middle school = 6-12y)
A
RR 20-30
HR 70-110
SBP 80-120
Weight 20-42kg
7
Q
Normal vitals signs in a pediatric patient (adolescent = 13+y)
A
RR 12-20
HR 55-105
SBP 110-120
Weight >50kg
8
Q
Normal abdominal exam (v. adult)
A
liver / spleen tip may be palpable –> start low, ask for an exhale
kidneys, stool may be palpable
9
Q
Is strabismus normal in an infant
A
yes, intermittent, if <6mo
10
Q
seeing white when do the red reflex exam?
A
- retinoblastoma
- cataract (but can also look black)
11
Q
reasons for dental caries in a pediatric
A
- poor diet
- continuing to use the bottle
12
Q
at what age does the babinski reflex go away?
A
when the infant starts walking (3-6mo)
of >1y, considered pathological.
13
Q
you notice that a baby does not have the rooting reflex when you stroke his cheek near his mouth. what’s wrong?
A
likely nothing - babies only have the rooting reflex when hungry.
14
Q
definition of dehydration
A
(UOP + insensible losses) < intake
symptoms (tachycardic,
15
Q
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?
A
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).
16
Q
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?
A
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.
17
Q
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.
A
fluid deficit = mild / moderate (~8% fluid loss)
dehydrated b/c NPO
–> oral rehydration
dehydrated b/c emesis
–> 1L of fluids + maintenance over 24h
18
Q
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
A
free water / hypotonic (VERY SLOWLY).
monitor Na is decreased 1-2mEq/hr
+ patient education about formula mixing
19
Q
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?
A
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.
20
Q
Breastfeeding benefits for infants (if exclusive)
A
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
21
Q
breastfeeding benefits for mothers
A
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
22
Q
Recommendations of breastfeeding
A
- Exclusive breastfeeding for 6mo
- Supplemental breastfeeding (+ complementary foods): 6-12 mo
- premies –> breast milk + fortifiier
WHO = 24mo of breastfeeding
23
Q
Infants: recommendations for VitD
A
- 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
24
Q
Infants: recommendations for Iron
A
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
25
Common vitamin deficiencies in exclusively breastfed babies
VitD (start at birth)
Iron (start at 4mo)
Zn
26
Zn deficiency
common in exclusively breastfed infants
- -> dermatitis enteropathica (genetic deficiency)
- -> infectious gastroenteritis (in developing world)
27
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
28
Basics of infant formula
1) cow (sugar = lactose)
2) soy based (sugar = sucrose)
3) hydrolyzed cow's milk
29
Cow milk formula - what's the "premium" and "advance"
long chain fatty acids --> similar to what's in human milk.
30
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
31
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%
32
prevention of necrotizing enterocolitis
mother's milk
| b/c deficient in lots of calories & vitamins
33
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
34
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)
35
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)
36
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.
37
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
38
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
39
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.
40
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
41
```
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.
42
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
43
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
44
problems with sippy cups
excessive mild & juice intake, nutritional deficiency, dental decay
finger foods @ 6mo
pincer at 8-9mo
45
```
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
46
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.
47
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"
48
intrauterine factors that affect the growth of the fetus: placental
".
- placenta previa
- placental abruption
- abnormal umbilical vessel insertions"
49
intrauterine factors that affect the growth of the fetus: fetal
".
- fetal malformation
- metabolic disease
- chromosomal abnormalities
- congenital infections"
50
"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"
51
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)"
52
what does frequent, unprotected sex during pregnancy increase the risk for?
chorioamnionitis --> which increases the risk for HIV
53
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)"
54
key concepts in the clinical evaluation of gestational age & stability at birth
"Ballard score
| Apgar score"
55
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"
56
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"
57
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"
58
"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"
59
"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"
60
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
61
which infectious cause of conjunctivitis is more common in newborns? For which do we do prophylaxis? Why?
".
- Chlamydia trachomatis >> 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."
62
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"
63
"risks for SGA newborns: hypoglycemia
etiology?
Sxs?"
"etiology
- decreased glycogen stores
- heat loss
- possible hypoxia
- decreased gluconeogenesis
sxs = usually Asx; poor feeding, listlesness"
64
"risks for SGA newborns: hypothermia
etiology?
Sxs?"
"etiology:
- cold stress
- hypoxia
- hypoglycemia
- increased surface area
- decreased subcutaneous insulation
sxs = usually Asx; poor feeding, listlesness"
65
"risks for SGA newborns: polycythemia
etiology?
Sxs?"
"etiology:
- chronic hypoxia
- maternal / fetal transfusion
sxs = ""ruddy"" or red color to skin; respiratory distress; poor feeding; hypoglycemia"
66
hyperviscosity syndrome
"infants with sluggish blood flow
Etiology: critically elevated Hgb / Hct
sxs: respiratory distress d/t inadequate oxygenation of end-organ tissues"
67
epidemiology of CMV in newborns
"CMV = leading cause of congenital infection in US
>90% of children with congenital CMV have no sxs as newborns
wide variety of severity of illness
- mortality = 10-15% among infants with sxs
- for survivors - neonatal cinical abnormalities expected to resolve spontaneously"
68
for neonatal survivors of CMV infections, which of the CMV abnormalities will NOT resolve spontaneously
CNS and hearing deficits
69
"important physical finidngs of congenital CMV infection (system-based) - identify which of the manifestations is the most common
in descending order of most common"
"wide variety of severity of illness: some with 1-2 abnormalities; others with multisystem disease
- Skin - petechiae (#1), purpura, ecchymosis, jaundice
- hepatobiliary - dbili > 2mg/dL; ALT > 80 (#1s), hepatomegaly
- Heme - thrombocytopenia < 100K (#1), splenomegaly, anemia
- CNS - intracranial calcifications on CT, microcephaly (#1s), increased CSF protein > 120; poor feeding / lethargy; seizures
- auditory - sensorineural hearing loss
- visual - chorioretinitis"
70
long-term complications associated with CMV infection
"hearing loss
microcephaly; intracranial calcifications
hepatosplenomegaly
rash"
71
"long-term complications associated with CMV infection: hearing loss
when?
Prognosis?"
"time: after newborn period
prognosis: progressive (can even be normal in newborn hearing screen) - then progress to severe-to-profound b/l hearing loss during 1st year of life"
72
"long-term complications associated with CMV infection: microcephaly; intracranial calcifications
when?
Prognosis?
Management?"
"with developmental delay, progressing to intellectual disabilities and/or cerebral palsy
mgmt: ongoing developmental assessments"
73
"long-term complications associated with CMV infection: hepatosplenomegaly
when?
Prognosis?"
can resolve spontaneously within weeks
74
"brain imaging findings in congenital CMV
what to use?
What do we see?"
"MRI>CT due to concerns of radiation exposure
intracranial calcifications = bright areas on CT
diminished # of gyri & abnormally thick cortex = lissencephaly, agyria-pachygria"
75
define: lissencephaly, agyria-pachygria
"diminished # of gyri & abnormally thick cortex
often found in babies with congenital CMV"
76
"antiviral treatment of congenital CMV
- when to treat?
- treatment
- prognosis"
"treat those with CNS involvement
tx = parenteral gancyclovir; oral valgancyclovir
start within 1st mont o life, for 6 mo
--> improve hearing & developmental outcomes"
77
should we treat asymptomatic congenital CMV infections (i.e. those found incidentally on labs)
NO - no data supporting it
78
"f/up guidelines for CMV infections & post-treatment?
What?
How to test?
For how long?"
"1) audiometry --> ABR / otoacoustic emissions @ newborn, 3mo, 6mo, 9mo, 12mo, 18mo, 24mo, 30mo, 36mo - then annually until school age
2) ophthalmoscopy (vision fx) --> @ newborn, 12mo, 3y, preschool
3) neurologic / developmental assesssment --> @ each check-up until school age
4) neurology / neuropsychologcal --> NO SCREENING; diagnostic only if needed"
79
Infants born to adolescent mothers are at greater risk for:
"1) lower birth weight
2) vertically acquired STIs (d/t higher incidence of STIs in adolescent population) - HIV, gonorrhea, syphilis
3) poorer developmental outcomes
4) increased risk of fetal death
5) increased risk of maternal death
80
do infants born to adolescent mothers have an increased incidence of chromosomal abnormaltiies?
"no
| to older mothers"
81
Infants born to older mothers are at greater risk for:
chromosomal abnormaltiies - Trisomy 21
82
adverse effects of prenatal substance abuse: tobacco
"1) low birth weight
no characteristic facies assoc. with maternal tobacco use during pregnancy"
83
adverse effects of prenatal substance abuse: EtOH
"Fetal alcohol syndrome
1) characteristic facial abnrmalities
2) growth deficiency
3) cognitive disability - CNS dysfunction
4) other neurological deficits - poor motor skills and hand-eye coordination
5) learning problems - difficulties with memory, attention, judgment"
84
is there a "safe" amount of EtOH that can be consumed during pregnancy to ensure that fetal alcohol syndrome does not occur?
NO
85
adverse effects of prenatal substance abuse: marijuana
none identified
86
adverse effects of prenatal substance abuse: cocaine, other stimulants
"1) placental insufficiency
2) low birth weight
3) subtle, later deficits in cognitive performance, information-processing, and attention to tasks-abilities"
87
define: small for gestational age
SGA = weight < 10th percentile for gestational age
88
define: microcephalic
head circumference < 10% percentile for gestational age
89
define: term delivery
born @ >37w gestation
90
routine newborn discharge instructions for parents
".
- red flags requiring immediate eval (e.g. significant jaundice)
- feeding instructiosn: signs of poor feeding
- safety issues - e.g. placing newborn on back (supine), proper infant auto restraint; how to access emergency help"
91
adolescent interview - what's the acronym?
"HEEADDSSS
-H - ome (location, privacy, relationships, family, lived outside home / recently moved, thoughts of running away, new people)
- E - ducation / employment (fave / worse subjects; changes in grades; special programs, repeat years; changed schools, suspected, future plans, hours/week work, relationships)
- E - ating disorder (where & with whom, what)
- A - ctivities / affiliations / aspirations (fun, extracurricular activities, sports/exercise; groups / projects; hobbies; reading; TV / music; career goals)
- D - rugs (EtOH, tobacco, steroids - friends, self -tried; how much & how often / setting; family use)
- S - exuality (the talk?; crush; had sex; unwanted / forced; # partners; contraception; knowledge of STIs; pregnant)
- S - uicidal behavior (+ depression, mental health; SIGECAPS)
- S - afety (abuse, fights, weapons, seatbelts - seriously injured; dangerous behavior; surrounding people's behavior; violence in home; physical / sexual abuse)"
92
3 leading causes of death for adolescents in the US
"1) accidents
2) homicide
3) suicide"
93
special features of newborn resuscitation
"ABCs
- warm & dry infant; remove any wet linens immediately --> high SA: weight ratio - concerns of hypothermia
- stimulant infant to elicit a vigorous cry --> clear lungs, mobilize secretions
- suction amniotic fluid from infant's nose & mouth (if visible) --> to clear upper airway
- initiate further resuscitation if required (blow-by O2, positive pressure with bag-valve mask, ventilation with O2, chest compressions, meds)"
94
what % of newborns require some assistance in breathing? % requiring extensive resuscitations
"some assitance = 10%
| extensive resuscitation = <1%"
95
Routine newborn care (immediately after birth)
"1) Stabilize infant's temp (skin-to-skin contact, radiant warmer, incubator)
2) Apgar scores at 1 and 5 min"
96
"Primitive reflexes
| list & what are they"
".- Startle reflex (Moro)
- Palmar & plantar grasps
- Rooting reflex
- Suckling reflex
- asymmetric tonic neck response
- stepping response
- babinski"
97
Rooting reflex
turns his head toward your finger when you touch his cheek
98
Suckling reflex
sucks on finger when you touch roof of mouth
99
Startle reflex (Moro)
"1) support newborn's head (one hand) & buttock (other hand). Head in midline
2) drop hand supporting head quickly --> will drop 10cm & head caught in new position
- -> 3) newborn will flex thighs & knees, fan then clench fingers, arms first thrown outward then brought together as though embracing something
- -> used to detect peripheral problems: congenital MSK abn / neural plexus injuries
- up to 4mo"
100
Palmar & plantar grasps
"grasps finger when stroke against palm of hand or plantar surface of foot
- palmar: up to 2-3mo (when infant voluntarily grasps objects)
- plantar: up to 8mo (when infant begins to take steps)"
101
asymmetric tonic neck response (Fencing)
"1) turn newborn's head to one side
- -> 2) newborn's gradual extension of arm torward direction of infant's gaze with C/L arm flexion (~ fencer)
- up to 6mo (when infant starts visual / reaching coordination)"
102
stepping response
legs make a stepping motion when you hold him vertically above table & stroke dorsum of foot against table edge
103
Babinski
stroking lateral & plantar foot - toes upgoing + fanning of the toes
- up to 1yo (when start walking)
104
diffdx for SGA newborn with microcephaly and purpuric rash
-
what they would cause
".
- TORCH infection (rubella, toxo, CMV) --> hepatosplenomegaly, purpuric rash, microcephaly
- Fetal alcohol syndrome --> will have other sxs pointing toward EtOH as problem
- chromosomal abnormality --> SGA [no hepatosplenomegaly, rash]
- prenatal tobacco exposure --> SGA (placental insufficiency)
- HIV infection --> hepatosplenomegaly and/or microcephaly (most newborn Asx at birth)"
105
prenatal lab screening
".
- serological screening for infections (HIV, rubella, HBV)
- blood type & Rh
- urine drug screen"
106
preparing the formula for babies
ready-to-feed?
powder?
formula concentrate?
ready-to-feed - directly from the bottle
powder - 2 scoops powder : 4oz water
formula concentrate - 1 part concentrate: 1 part water
107
for a formula-fed baby, do you need to give an infant extra bottles containing water only?
No - b/c formula or breast milk fulfills maintains fluid requirements
108
education / assessment for breastfeeding mothers after delivery
1) evaluation of adequacy of latch-on, suckling and milk transfer, progress of lactogenesis
2) 24-48h after discharge = in-home lactation specialist / physician to assess adequate urine/stool output, weight change.
109
A 17yo pregnant patient presents with rupture of membranes at 38w gestation. What are the privacy laws regarding this?
Most states authorize minors to give consent for pregnancy-related care and contraception; dx & tx of STIs, counseling & tx for HIV/AIDS, substance abuse and sexual assault. And mental health
110
Risks of teen pregnancy to
- mother?
- child?
mother:
- high school dropout
- lower educational & income attainment
- health problems
child
- health problems
- incarceration
- teen pregnancy
- unemployment
- foster care
111
what are key questions to ask a pregnant teenager?
Social hx
1) smoking, EtOH, other drugs (cocaine)
2) intended / unintended pregnancy
3) prenatal care
4) support system - is FOB involved? do her parents know? does she want her parents to know
5) what is she going to do about school?
PMH - asthma, HTN
112
what factors may limit fetal growth?
A Maternal factors during pregnancy such as poor weight gain, preeclampsia, drug use, and infections.
B placental abnormalities, such as placenta previa or placental abruption.
C Fetal abnormalities such as malformations, metabolic diseases and multiple gestation.
A, B, C
113
Which of the following are possible etiologies of small newborn size?
re some possible etiologies for her baby's apparent small size? (Select all that apply.)
Multiple Choice Answer:
A Tobacco use
B Asthma during pregnancy
C Intrauterine infections
D Alcohol use
E Pregnancy-induced hypertension or preeclampsia
F Constitutional factors in the fetus that affect fetal growth
G Dates may be inaccurate: She may be earlier than 38 weeks.
H Structural abnormality in the fetus, such as renal dysplasia or a diaphragmatic hernia
I Chromosomal abnormality, such as trisomy 13
J Placental abnormality such as chronic placental abruption
K Undiagnosed gestational diabetes
Tobacco use (A)
Intrauterine infections (C)
Alcohol use (D)
Pregnancy-induced hypertension or preeclampsia (E) --> if mother had HTN, proteinuria, or swelling during pregnancy
Constitutional factors (F)
Inaccurate dates (G)
Structural or chromosomal abnormalities (H), (I)
Placental insufficiency (J)
ASTHMA- only if there was severe chronic lung disease & maternal hypoxia
GDM --> macrosomia
114
Indications for intrapartum antimicrobial prophylaxis against Group B Strep --> if:
1) mother is in labor with ruptured membranes
and?
-Gestation of < 37 weeks
-Membranes have been ruptured ≥ 18 hours
-Temperature of ≥ 38°C (100.4°F)
-Intrapartum nucleic acid amplification test (NAAT) is positive for GBS
-Previous infant with invasive GBS disease
-GBS bacteriuria during any trimester of the current pregnancy
-Positive GBS vaginal-rectal screening culture in late gestation during current pregnancy
-Unknown GBS status at the onset of labor (culture not done, incomplete, or results unknown) and any of the following:
Delivery at < 37 weeks' gestation
Amniotic membrane rupture ≥ 18 hours
Intrapartum temperature ≥ 38°C (100.4°F)
Intrapartum NAAT positive for GBS
115
assign an Apgar score:
Description of findings at one minute of life
- Pulse - Palpation of umbilical cord shows heart rate > 100 beats/minute
- Color- pink centrally but still has acrocyanosis [cyanosis of the hands and feet]
- Respiratory
effort -Active with a strong cry
No signs of respiratory distress
- Tone - Arms and legs are flexed (normal neuromuscular tone)
- Grimace - His facial expression shows that he is responding (and not happy with!) your interventions; he scowls when you use the bulb suction to clear out his oral secretions and when you warm him vigorously with the towel.
A 10 : 2 points each for heart rate, respiratory effort, grimace (facial response), color and tone.
B 9 : 2 points each for heart rate, respiratory effort, grimace and tone, with 1 point for color.
C 8 : 2 points each for heart rate, maturity and tone; 1 point each for respiratory effort and for color.
D 7 : 2 points each for heart rate, respiratory effort and grimace; 1 point for tone; zero points for color.
```
Appearance (color) = 1
Pulse = 2 (nml: 120-160)
Grimace = 2!
Activity = 2
Respiratory effort -2
```
B
116
A newborn infant Thomas is < 10% in weight and height on growth charts. Ballard exam shows a score of 36. Which of the following conclusions can you come to?
A Thomas is small for gestational age (SGA).
B Thomas is microcephalic.
C Thomas is normocephalic.
D Thomas is a term infant.
A, B, D
Even though SGA, can still be term --> likely underlying risks based on mom, placenta, and baby
B --> <10% head circumference
important b/c means that this is a symmetric growth restriction - likely that happened early in pregnancy.
If normocephalic, would be asymmetric growth restriction (where head circumference is "spared')
117
Define symmetric v. asymmetric IUGR and what might cause each
Symmetric IUGR refers to a growth pattern in which head, length, and weight are decreased proportionately.
= earlier (T1) --> likely fetal anomalies; multi-system problems, chronic intrauterine infection
Asymmetric IUGR refers to a greater decrease in the size of the length and/or weight without affecting head circumference ("head-sparing phenomenon").
= later (T3) --> likely placental insufficiency
118
If you had to choose between HBsAg and HBcAb to test for a pregnant mother for concerns of vertical transmission, which would you choose and why?
HBsAg ==> more important for vertical transmission
HBcAg - does not predict risk for vertical transmission
119
Why is it important to check blood glucose in SGA infant? How often / long do you check
b/c SGA infant is at risk for hypoglycemia
several times in first 24h of life
120
```
Interpret the following:
Mother
Rapid HIV antibody test: Negative
Hepatitis B surface antigen: Negative
Rubella IgM: Negative
Rubella IgG: Positive
```
```
Infant
Rubella IgM: Negative
Rubella IgG: Negative
Toxoplasma IgM: Negative
Toxoplasma IgG: Negative
Urine cytomegalovirus (CMV): Positive
```
Mother: rubella IgG is positive, she has evidence of protection against the virus and therefore would not benefit from rubella vaccination.
(consistent with past infection or immunization)
Infant: A urine culture positive for cytomegalovirus (CMV) in the first three weeks of life is evidence of congenital CMV infection.
121
Which of the following are true statements regarding CMV in an infant?
A The hearing loss in congenital CMV is often progressive.
B Because of microcephaly and intracranial calcifications, he is at risk for developmental delay.
C The hepatosplenomegaly and rash will likely resolve over the next several weeks.
D He is a candidate for antiviral therapy.
A, B, C, D
Neurological clinical abnormalities will persist, the rest will spontaneously resolve within weeks.
122
Children with inborn errors of metabolism can present with one or more of a wide variety of signs and symptoms. These include which of the following?
```
A Metabolic acidosis
B Lethargy
C Vomiting
D Seizures
E Anorexia
F Unusual odors
```
All of the above
usually 24-72h after birth
123
A 33-year-old G1P0 female with a history of medically controlled seizures gives birth vaginally to a boy with IUGR at 38 weeks' gestation. The newborn is noted to have dysmorphic cranial features and his head circumference is 28.5 cm (< 5th percentile). What is another associated abnormality you might expect to see in this newborn?
```
A Hepatosplenomegaly
B Cardiac defects
C Absent red reflex
D Chorioretinitis
E Tremors
```
B. The mother was on an anticonvulsant for her seizures. Taking anticonvulsants during pregnancy may lead to cardiac defects, dysmorphic craniofacial features, hypoplastic nails and distal phalanges, IUGR, and microcephaly. Mental retardation may be seen. A rare neonatal side effect is methemoglobinuria.
Likely was taking phenytoin / carbamazepine.
Diffdx hepatosplenomegaly in newborns: metabolic diseases, storage diseases, HIV vertical transmission, intrinsic liver disease, and in congenital infections
Diffdx: absent red reflex = congenital cataracts or a retinoblastoma
Diffdx: chorioretinitis = congenital toxoplasmosis and CMV infections
Diffdx: tremors = maternal substance use
124
```
A 19-year-old female in her 38th week of pregnancy goes into active labor. Shortly after birth her baby is noted to have a high-pitched cry, tremulousness, hypertonicity, and feeding difficulties. The baby is otherwise developmentally normal and the remainder of the physical exam also is normal. What is the drug the baby's mother likely used during her pregnancy?
A Heroin
B Alcohol
C Marijuana
D Cocaine
E Tobacco
```
A - Opiate use during pregnancy may result in several different symptoms, including CNS findings (irritability, hyperactivity, hypertonicity, incessant high-pitched cry, tremors, seizures), GI symptoms (vomiting, diarrhea, weight loss, poor feeding, incessant hunger, excessive salivation), and respiratory findings (including nasal stuffiness, sneezing, and yawning).
EtOH = would hav distinctive facies
Marijuana = little evidence of ill effects / withdrawal
Cocaine - SGA, poor later neurological development
Tobacco - SGA
125
A 19-year-old G1P0 presents in labor to the ED at 38 gestational weeks. On interview it is discovered that the patient had irregular prenatal care, drank a couple of beers every weekend, and smoked 4 cigarettes a day. She delivers a baby boy who is small for gestational age. On exam, it is noted the baby has microcephaly, a smooth philtrum, and a thin upper lip. What do you suspect caused these features in the baby?
```
Single Choice Answer:
Please select one answer.
A Tobacco exposure
B Alcohol exposure
C Congenital rubella
D Vertically transmitted HIV
E Congenital CMV infection
```
B. Fetal alcohol syndrome has very characteristic facial features, including a smooth philtrum, thinning of the upper lip, and small palpebral fissures.
Tobacco - SGA
Rubella = sensorineural deafness, eye abnormalities (retinopathy, cataracts), and patent ductus arteriosus.
HIV - no recognizable sxs at birth
CMV - microcephaly, jaundice, hepatosplenomegaly, low birth weight, and petechiae at birth.
126
A mother brings her 20-day-old male infant to your clinic for the child’s first visit. You learn that the infant was born at home to a 28-year-old G1P1, and the infant has not yet received newborn screening. During your history, you learn that the infant has been vomiting 2 to 3 times per day, and the mother reports that her son seems fussier than her friends’ infants. On exam, you note an eczematous rash and a musty odor to the infant’s skin and urine. Which enzyme deficiency would you expect the infant to display?
```
Single Choice Answer:
Please select one answer.
A Phenylalanine hydroxylase
B Cystathionine synthase
C Sphingomyelinase
D Alpha-L-iduronidase
E Glucose-6-phosphatase
```
==> A. This infant likely has phenylketonuria (PKU), an autosomal recessive disorder of amino acid metabolism caused by a deficiency in the enzyme phenylalanine hydroxylase. Affected infants are normally detected by newborn screening, but can present with vomiting, hypotonia, musty odor, developmental delay, and decreased pigmentation of the hair and eyes. The best developmental outcomes occur if a phenylalanine-restricted diet is initiated in infancy.
B. A defect in cystathionine synthase ==> homocystinuria, a disorder of amino acid metabolism; AR --> Marfanoid body habitus, a hypercoaguable state, and possible developmental delay. Dx = increased methionine in a urine or blood.
C. Defect in sphingomyelinase occurs in Niemann-Pick disease = lysosomal storage disease. Present by six months of age with hepatomegaly, ataxia, seizures, and progressive neurologic degeneration. Fundoscopic exam = “cherry-red” macula.
D. A defect in alpha-L-iduronidase == Hurler syndrome, AR lysosomal storage disease: >/= 1yo - Symptoms include hepatosplenomegaly, coarse facial features, frontal bossing, corneal clouding, and developmental delay. Affected individuals typically do not live past fifteen years old.
E. A defect in glucose-6-phosphatase = Von Gierke’s disease, a glycogen storage disease. AR, present with hypoglycemia, hepatomegaly, and metabolic acidosis.
127
by what age in a male is the foreskin able to be retracted?
2-5y
128
in what age ranges are genu varum and genu valgum normal?
Genu varum "bow legs" = from 0-3yo
genu valgum "knock knees" = from 2-6yo
129
in what ages are strabismus normal?
only intermittent after 2mo
resolved by 6mo
130
Name that syndrome:
brachycephaly/flat occiput, a short neck, straight hair, upward slanting of palpebral fissure, a protruding fissured tongue, hypotonia
Down's
131
Name that syndrome:
microcephaly, epicanthal folds, short palpebral fissure, flat midface, short nose, indistinct philtrum, thin upper lip, micrognathia
fetal alcohol syndrome
132
Fontanelles - at what ages do they close?
Posterior closes at 2-3mo
Anterior closes at 18-24mo
133
where is the anterior fontanelle and what does it look like?
at the junction of the coronal (L-R) and saggital (A-P) sutures
diamond shaped
134
where is the posterior fontanelle and what does it look like?
at the junction of the lamboid (L-R) and saggital (A-P) sutures
triangle shaped
135
what can the fontanelles tell you?
If sunken ==> dehydrated
if swollen ==> increased ICP
136
common breastfeeding problems
- enlarged, tender breasts --> engorgement, mastitis, plugged ducts (galactocele)
- improper latch, suckle
- prolonged feedings
- infants fall asleep
- maternal inexperience / anxiety
137
breast milk nutrients / composition
```
#1) colostrum
- non-nutritive: Abx, oligosaccharides, lactoferrin, lysozyme, growth factors, bifidobacteria
```
#2) mature human milk = more nutritive
- carbohydrates = lactose (major),
- lipids = 50% of calories in human milk; increase as nursing episode progresses.
- proteins = whey (70%); casein (30%)
138
if mother does not want / cannot breastfeed, what should she use instead?
FORMULA - cow's milk or soy protein isolate
139
can an newborn be fed with straight cow's milk?
No
infants <12mo should not be fed unmodified cow's milk --> b/c it has 3x the protein content of human milk, with 80% casein and 20% whey (which is the opposite of what human milk has)
FORMULA - cow's milk or soy protein isolate
140
do newborns get lactose intolerance?
uncommon in first 12mo
| --> lactose is the most common carbohydrate in human milk
141
why is it important that a baby empty one breast before going onto the next?
% of breastmilk that contains lipids increases with progression of breastfeeding episode --> fats = 50% of calories in breast milk.
142
what type of nutrient does formula provide more of v. human milk
proteins
143
voiding and stooling in the newborn
VOIDING (pale yellow)
- By day 3 of life = 3-4x per day
- by day 6 of life = 6-8x per day
STOOLING
- Birth = meconium (green, dark)
- By day 3 of life = yellow, mustard
- by day 6 of life = 3-4x per day, usually withevery feeding
- if "acholic" ==> concerns for biliary atresia
144
timing of neonatal screen
1) >/= 24h after birth
THEN
2) 1-2w after birth
if<24h==> can miss PKU, other disorders of metabolite accumulation
145
newbaby visit = key components
NEW PARENTS
- baby's current weight; rate of weight gain
- answer family's questions
- how other children have reacted to baby
- maternal depression
- sources of support (transportation, finance)
- breastfeeding for mother-infant interaction
- nutritional/growth concerns
146
weight changes in newborns
1) 4-5d of life == 7-10% birth weight loss
2) 2w of life == regain birth weight
- -> concerns with more rapid rate of decline
a) compare newborn's birth weight / discharge weight with current office weight
147
what supplementation do newborns need?
1) Vit D
2) Iron
3) fluoride
148
what supplementation do newborns need?
EXCLUSIVELY BREASTFED
1) Vit D = 400IU; w/in days - for 6mo
2) Iron = w/in 4mo; add iron-containing foods @ 6mo
3) fluoride = @ 6mo
NOT BREASTFED [if not in formula]
1) Vit D = 400IU during summer, 800 IU during winter
2) Iron = @ 4mo
3) fluoride = @6mo
149
when does vitD deficiency rickets appear?
| tx?
- appear between 6-24mo
| - tx = vitD
150
what supplementation do newborns need?
EXCLUSIVELY BREASTFED
1) Vit D = 400IU; w/in days - for 6mo
2) Iron = w/in 4mo; add iron-containing foods @ 6mo
3) fluoride = @ 6mo
NOT BREASTFED [if not in formula]
1) Vit D = 400IU during summer, 800 IU during winter
2) Iron = @ 4mo
3) fluoride = @6mo
151
when does vitD deficiency rickets appear?
| tx?
- appear between 6-24mo
| - tx = vitD
152
describe breast changes expected with breastfeeding
4w of gestation = colostrum comes in
day 2 = breast changes will start - with fullness in breasts in axillae and up top
week 2 = full milk comes in
153
ideal targets for newborn screening
| - examples
where have effective treatment, & early diagnosis/treatment can prevent morbidity and mortality
- congenital hypothyroidism
- phenylketonuria (PKU)
==> BIRTH: normal
==> LATER: fail early develomental milestones, progressive cognitive impairment
- galactosemia
- hearing = b/l hearing loss in 0.1-0.3%
154
what types of diseases that are screened for in newborns MUST have timely follow up?
==> rapidly fatal until treatment is instituted quickly
- maple syrup urine disease
- congenital adrenal hyperplasia
- galactosemia
- sickle cell disease ==> early penicillin prophylaxis = prevent sepsis 2/2 Strep pneumoniae infection
155
what are the risks of newborn screening?
- Failure to identify some children who actually have the condition (false negative result).
- Parental anxiety after false-positive results.
- Genetic tests' revelation of misattributed paternity.
- Detection of disorders for which treatment is not effective.
156
checklist for first newborn visit
- Pregnancy and birth history
-Status of Hepatitis B vaccine administration
- hearing screening
-Feeding history (breast or formula, how much, how often)
-Developmental milestones (e.g., a 2-week-old infant should fix on and follow a human face
with their eyes; a Moro reflex will still be present.)
157
how to measure fontanelles
mean fontanelle size = average of length (A/P) & width (transverse)
ANTERIOR FONTANELLE mean = 2.1cm +/- 1.5
POSTERIOR FONTANELLE: <0.5-2cm
158
risks with home deliveries
- neonatal tetantus
- omphalitis = serious infection of umbilical stump
- hemorrhagic disease of the newborn = esp. when no vitD is administered
159
those at risk for umbilical hernias
- premature
- congenital hypothryoidism
==> risk incarceration
