CLIPP 4/18/17 Flashcards
treatment ladder for neuroblastoma in peds
surgical resectoin
chemo
radiation
for 4S can observe for tumor progression - tend to spontaneously regress… watch to make sure vs initiate treatment
how many cases of neuroblastoma are familial
1%
the minority
most are somatic mutations… arising in cells other than gametes, not passed to next generation
typical use of brain-stem auditory evoked potential hearing test (BAER)
infants who fail to meet language milestones if they cannot cooperate with other more comprehensive testing.
what signs of autism might you look out for at 3yo well-child visit
developmental delay, lack of symbolic play, repetitive movements, or poor sociability
1 yo skills gross motor fine motor vocal social
pulling to stand, standing alone, perhaps first steps.
Fine motor skills including putting a block in a cup and banging 2 cubes held in hands
imitate vocalizations/sounds and babble
1 or 2 words in addition to “mama” and “dada.”
waving bye-bye and playing pat-a-cake
15 month old skills gross motor fine motor vocal social
stoop and recover and walk well, put a block in a cup, have a vocabulary of a few words, wave bye-bye, and drink from a cup
18 month old skills gross motor fine motor vocal social
walk backward 50–90% can run at this stage. Scribble, build a tower of 2 cubes, have 3-6 words in vocabulary, and be able to help in the house and remove garments
jump up and throw a ball overhand. They can build a tower of 6–8 cubes, point to 6 body parts, name 1 picture, put on clothing, and wash and dry their hands
how old?
2.5yo
balance on each foot for 1 second, wiggle their thumbs, name 4 pictures, name 1 color, name a friend, and brush their teeth with help
how old?
age 3
walk backward 50–90% can run at this stage. Scribble, build a tower of 2 cubes, have 3-6 words in vocabulary, and be able to help in the house and remove garments
how old?
18 mos
stoop and recover and walk well, put a block in a cup, have a vocabulary of a few words, wave bye-bye, and drink from a cup
how old?
15 mos
pulling to stand, standing alone, perhaps first steps.
Fine motor skills including putting a block in a cup and banging 2 cubes held in hands
imitate vocalizations/sounds and babble
1 or 2 words in addition to “mama” and “dada.”
waving bye-bye and playing pat-a-cake
how old?
1yo
Wilm’s tumor commonly associated with this syndrome…
Beckwith-Wiedemann syndrome, a genetic overgrowth syndrome…. omphalocele, hemihypertrophy, hypoglycemia, large for gestational age, and other dysmorphic features
RCC typical patient
adult obese smoker
how does age impact prognosis of neuroblastoma
infants v18mos typically good prognosis
toddlers ^18mos typically poor prognosis
4S stage of neuroblastoma is reserved for..
prognosis is…
overall survival is…
infants less than 12 months who have resectable primary tumors and metastases to the liver, skin, and bone marrow
favorable prognosis
85% overall survival
favorable genetics in neuroblastoma
non-amplification of the n-myc gene
infant with RUQ mass, normocytic anemia, elevated urinary HVA and VMA, large heterogenous mass w scant calcification on CT, what to expect on bone marrow biopsy
dx
other dx with this hisotology
Small round blue cells with dense nuclei forming small rosettes
neuroblastoma
ewing sarcoma and medulloblastoma also are small round blue cell tumors in kids
most common vitamin supplement recommended for peds
vit D - difficult to attain recommended daily dose for kids through food and sun exposure
“the itch that rashes”
eczema
cycle of irritation leading to scratching, leading to rash - advice… avoid things that make itch
is eczema typically familial or environmental
mixed
typically multifactorial inheritance pattern with clear environmental allergic triggers
ddx for eczema in child includes these 2
psoriasis (rare in yuong children… will usually be a guttate (droplet-shaped) psoriasis precipitated by strep infection)
seborrhea - especially in early infancy e.g. cradle cap… rare to arise ^3yo
3 tenants of eczema treatment
lubricate to protect skin
antiinflammatories in short bursts (1st line topical steroids hydrocortisone, 2nd line calcineurin inhibitors, antihistamines may help with itch… non-sedating during day, can sedate at night)
treat associated skin infections aggressively
control skin itch with pharm in kid
try non-sedating antihistamines approved for children, loratidine, fexofenadine and cetirizine during day
try traditional antihistamines (with sedative side effects) such as diphenhydramine and hydroxyzine are often used at bedtime to decrease itch.
fruit juice recommendation for kids
no more than 4-6 oz/day… 1 cup
after vit D, next nutrition concern in peds
iron
meat, legumes, and iron fortified cereals
How does fluoride prevent dental caries
when should it be supplemented for child
by promoting re-mineraization of calcium into enamel
supplement if rural area water not fluoridated
or drinking bottled water mostly (not fluoridated)
-can apply priodically to decidious (baby teeth) as a varnish as well
to look for on HEENT well child exam
caries
middle ear effusion persisting after earlier URI and affecting hearing
strabismus
significance of shotty lymph nodes on peds exam
Many children have “shotty” nodes (pea or marble-sized, nontender, easily mobile lymph nodes that are not fixed to surrounding structures) in the anterior and occasionally posterior cervical chain. These are normal in the cervical and inguinal chains in children and may persist for years.
most common abdominal mass in well-child
stool
how is a 3yo expected to draw a person
with 3 body parts
gun safety stats for gun-owning parent of toddler
In a study from 2003, the authors found that 52% of parents who owned guns thought that their children were “too smart” or “knew better,” even though only 40% had given specific instructions to their children regarding guns. In this survey only 12% of parents who owned guns locked them.
Another study from 2001 found that, when given the opportunity, boys 8-12 would handle a gun (76%) and pull the trigger (48%). Parents’ opinions about whether or not their child would handle a gun were not predictive of which boys would handle the gun.
ask about family history of hypercholesterolemia
fam hx of
high cholesterol
or coronary heart disease before age 55
lab test to order for well child check concern for nutrition
fingerstick hb - for anemia
what is a RAST
when to get at well child check
radioallergosorbent test
blood test used to determine to which allergens a person is sensitized
for allergies, eczema, etc
who to check for blood lead levels per AAP
All children 12 to 24 months of age in areas where > 25% of housing was built before 1960 or where the prevalence of blood lead levels > 5 μg/dL in children is 5% or greater.
Individual children who live in or regularly visit homes/facilities built before 1960 that are in poor repair or have been renovated within the past 6 months.
routine well-child screening for anemia occurs at
12 mos (diet changing)
preschool/kindergarten entry
at any visit if concerns or risk factors
when to get PPD a well-child check
- Spending time with an individual known or suspected to have TB disease
- Being infected with HIV or another condition that weakens the immune system
- Having symptoms of TB disease
- Living in (or coming from) a country where TB disease is very common (most countries in Latin America and the Caribbean, Africa, Asia, Eastern Europe, and Russia)
- Living somewhere in the U.S. where TB disease is more common (e.g., a homeless shelter, migrant farm camp, prison or jail, and some nursing homes)
- Use of injected illegal drugs.
what to do if hb mildly depressed at well-child check
no further workup, check again next time, advise nutrition in meantime, if recovers - was probably iron deficiency anemia from nutrition… if not, work up further
hemoglobinopathies to consider in Mediterranean Asian or African descent
- alpha thalassemia
- G6PD deficiency
- sickle cell disease
causes of anemia in kids
iron deficiency e.g. 1yo diet changing
In children of Mediterranean, Asian or African descent, hemoglobinopathies:
•alpha thalassemia
•G6PD deficiency
•sickle cell disease
rare with a more severe anemia (Hgb less than 9 g/dL (90 g/L)):
•Decreased marrow production (e.g., aplastic anemia)
•Hemolytic anemia
•Vitamin deficiencies (e.g., folate and B6)
Unusual acquired causes of anemia include chronic or severe illnesses:
•Collagen vascular disease
•Malignancy
•Other chronic illnesses
Tie a knot, copy squares
Mature pencil grasp, print some letters and numbers
Skip, draw a person with 6 or more body parts
what age
5yo
Throwing a ball overhand, riding a tricycle, building a tower of 6-8 cubes, and copying a circle
what age
3yo
Tie a knot, copy squares
what age
4yo
It is best to stop the bottle by age …
why
1yo
Solid foods provide more complete nutrition, including iron
dental caries if stay on bottle
BMI vs weight-for-height
BMI = kg/m^2
better for body fat rather than weight from muscle or bones
labs to get in teen you suspect of bleeding disorder
CBC
coags pt ptt inr
von willebrand panel
von willebrand disease
prevalence
inheritance pattern
1% pop
autosomal dominant with variable penetrance
tanner stage 1 female
prepubertal
no breast glandular tissue
no pubic hair
v10yo usually
tanner stage II female
initial puberty
breast buds, areola widening
small amount of downy pubic hair on labia
tanner stage III female
elevated breast buds but no secondary mound
pubic hair on labia extending laterally but not to mons, still downy
tanner stage IV female
breasts elevated with secondary mound
pubic hair more adult and extending to mons pubis
tanner stage V female
adult breasts, areola countoured
adult pubic hair extending to medial thighs
most common hereditary bleeding disorder
von willebrand disease
1% pop
appropriate treatment of most bleeding problems associated with von willebrand disese
how to scale up and when necessary
intranasal or intravenous desmopressin - causes release of von willebrand factor from vessel endothelial cells
scale up to factor VIII concentrate administration e.g. in setting of major trauma, surgery, less common subtypes that do not respond to desmopressin
what comes first in girls, growth spurt or menarche?
growth spurt
then menarche
first sign of puberty in male
and subsequent
testicular enlargement pubic hair growth of penis and scrotum first ejaculation growth spurt
dizziness, lightheadedness, sweating, nausea, weakness, and visual changes in child with/without syncope
likely dx
vasovagal reflex
(self-limited systemic hypotension due to altered neurocardiogenic reflexes leading to bradycardia and/or peripheral vasodilation)
when to suspect hypoglycemia as a cause of syncope
do you think hypoglycemia in healthy peds pt w episode of syncope? with lightheadedness, sweating, nausea, weakness, and visual changes?
not usually cause of syncope unless insulin-dependent diabetes
usually vasovagal
(self-limited systemic hypotension due to altered neurocardiogenic reflexes leading to bradycardia and/or peripheral vasodilation)
lightheadedness, sweating, nausea, weakness, and visual changes in child with syncope
think heat stroke?
if very high body temperature
otherwise
usually vasovagal
(self-limited systemic hypotension due to altered neurocardiogenic reflexes leading to bradycardia and/or peripheral vasodilation)
most common cause of chest pain in adolescents
precordial catch syndrome
-the most common cause of chest pain in adolescents and is of unknown etiology. It is a benign condition characterized by sudden, sporadic onset of sharp pain, usually along the left sternal border, which is often exacerbated with deep inspiration. These pains are brief, lasting seconds to a few minutes, and resolve spontaneously. The pain can often be “broken” with a forced deep inspiration. It is often not associated with exercise.
precordial catch syndrome
the most common cause of chest pain in adolescents.
Of unknown etiology. It is a benign condition characterized by sudden, sporadic onset of sharp pain, usually along the left sternal border, which is often exacerbated with deep inspiration. These pains are brief, lasting seconds to a few minutes, and resolve spontaneously. The pain can often be “broken” with a forced deep inspiration. It is often not associated with exercise.
when does a murmur in an adolescent deserve further evaluation
systolic murmurs I-II/VI are common, but eval further if:
Louder than grade III/VI
Any diastolic murmur
Any murmur that increases with standing or Valsalva (HOCM concern!)
TF
GU exam is part of preparticipation sports physical
T for BOYS
- hernia (sprinting, weight lifting concern)
- undescended teste (want to protect the good one even better!)
F for girls
routine meningococcal vaccine schedule
MCV4 at 11 years w booster at 16 years
MenB at 16 years
immunizations routinely administered at the 11-year-old well child visit
MCV4 (meningococcal)
Tdap
HPV
flu if in season
low-grade fever and malaise and findings of cervical lymphadenopathy and pharyngeal exudate in a teen…. next step throat culture?
EBV serologies!
this is a TEEN with LOW grade feveres… and malaise cervical LAN and pharyngeal exudate
teen with syncope on exertion and family history of young stroke death…
next step?
ECG and cardiology referral
-this is a HOCM risk, fh young death… don’t be fooled by “stroke”
kernicterus sequelae in newborn
and if survives to infancy
- lose the suck reflex
- become lethargic
- develop hyperirritability and seizures, and
- ultimately die
- 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
define erythroblastosis fetalis
hemolysis and resultant unconjugated hyperbilirubinemia caused by maternal IgGs to baby blood antigens (Rh… think just Rh not ABO?)
what kind of ancestry has greater risk for neonatal jaundice
mediterranean
define maternal-fetal ABO incompatitbility
how often is there a mismatch, how often clinically signifiant
Mom O
Baby A or B
and positive direct Coombs
20% ABO mismatch in any given pregnancy
and only 20% of those mismatched develop clinically significant jaundice
define physiologic jaundice
otal bilirubin level ≤ 15 mg/dL (≤ 257 μmol/L) in full-term infants who are otherwise healthy and have no other demonstrable cause for elevated bilirubin.
when does physiologic newborn jaundice typically get noticed and peak
Physiologic jaundice in a full-term baby is usually first noticed on the second or third day of life, with the bilirubin level reaching its peak at day three or four of life.
Numerous factors promote the increased enterohepatic circulation that results in physiologic jaundice:
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).breastfeeding-associated jaundice aka
“lack-of-breast milk jaundice”
mechanism of breastfeeding jaundice
- The low intake results in decreased gastrointestinal motility that in turn promotes retention of meconium.
- The β-glucuronidase in meconium deconjugates bilirubin and the unconjugated bilirubin is reabsorbed via the enterohepatic circulation, causing an elevation of serum levels.
which presents earlier, breastfeeding or breast-milk jaundice
breastfeeding jaundice
-in the first week
breast milk jaundice
-begins 4-7 days but peaks 10-14 days
mechanism of breast milk jaundice
While the cause is not completely understood, one explanation is that β-glucuronidase present in breast milk deconjugates bilirubin in the intestinal tract; the unconjugated bilirubin is then reabsorbed via enterohepatic circulation.
how long can breast-milk jaundice persist and how often does total bili reach concerning levels
can persist for up to 12 weeks, but total bilirubin concentration rarely, if ever, reaches concerning levels.
examples of antibody-negative neonatal hemolysis
spherocytosis
(RBC membrane defects)
G6PD
pyruvate kinase deficiency
(RBC enzyme defects)
examples of antibody-positive neonatal hemolysis
Rh incompatibility (mother is Rh-negative and baby is Rh-positive)
ABO incompatibility (mother is type O and baby is type A or B)
Incompatibilities with minor blood group antigens (much less common)causes of non-hemolytic red cell breakdown causing neonatal jaundice
Extensive bruising from birth trauma
Large cephalohematoma or other hemorrhage (e.g., intracranial)
Polycythemia
Swallowed blood (large amounts) during delivery.
Define Crigler-Najjar syndrome
hyperbilirubinemia results from decreased bilirubin clearance caused by deficient or completely absent UDPGT
ethnic predisposition to neonatal hyperbilirubinemia
more common in Asian newborn infants than in Caucasian infants and is less common in black infants
which of these contribute to neonatal hyperbilirubinemia
Prematurity
Bowel obstruction
Birth at high altitude
4 benefits of breast feeding for infant
Maternal-infant bonding
Protection against some infections (e.g. otitis media, respiratory infections, diarrhea)
Reduced rates of Sudden Infant Death Syndrome
Reduced rates of some allergic reactions
6 benefits of breast feeding for Mom
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
why important that an infant empty the breast before going to the next breast.
Approximately 50% of calories in human milk come from lipids.
The lipid concentration in breast milk increases as the nursing episode proceeds
most common enzyme problem that affects red blood cell metabolism worldwide
Glucose-6-phosphate dehydrogenase (G6PD) deficiency
G6PD deficiency inheritance pattern
X-linked recessive inheritance pattern:
Males with a mutation of the G6PD gene on the X-chromosome will have the complete enzyme deficiency. Females must have the mutation of the G6PD gene on both X-chromosomes to be enzyme deficient, although heterozygous females will be at risk for hyperbilirubinemia.
There are more than 100 distinct enzyme variants of G6PD associated with a wide spectrum of hemolytic disease. One of these variants in Greek babies can be a cause of hyperbilirubinemia and potential kernicterus.
for child with high risk of G6PD deficiency, how to counsel Mom on diet
avoid fava beans - can trigger hemolysis
TF
Infants with G6PD deficiency may be jaundiced without anemia
why/why not
T
Decreased bilirubin conjugation is now thought to be the most important factor in hyperbilirubinemia with G6PD deficiency.
This is the result of a gene interaction between the G6PD deficiency and the variant promoter for the gene for the bilirubin-conjugating enzyme, UDP glucuronosyltransferase (similar to what is seen with Gilbert’s syndrome where there is a partial deficiency of this bilirubin conjugating enzyme)
A healthy-appearing infant who develops jaundice, dark urine, and acholic (pale) stools between 3 and 6 weeks of age may have…
biliary atresia
Any infant who develops jaundice after two weeks of age must be evaluated with
fractionated bilirubin (i.e., total and direct bilirubin levels)
When diagnosed early, biliary atresia can be treated surgically with
the Kasai procedure (anastomosis of the intrahepatic bile ducts to a loop of intestine to allow bile to drain directly into the intestine).
(will restore bile flow and prevent liver damage If done early)
Voiding and Stooling Patterns in the Newborn
day 3, day 6, is stinky stool ok? pale stool?
Day 3: The baby should be voiding 3-4 times a day.
Day 6: Baby should be voiding at least 6–8 times a day.
Day 3: Meconium should no longer appear in the stool and bowel movements should begin to appear yellow.
Day 6 or 7: Most newborns have 3–4 stools per day, although many infants pass stool with every feeding.
Stool passed by breastfed infants has little odor. You should be concerned if an infant’s stool gradually loses color and becomes “acholic,” as this may be a sign of biliary atresia
how often is stopping breast feeding necessary in hyperbilirubinemia
stopping breastfeeding is NOT necessary in almost all cases, although some pediatricians will recommend temporary cessation of breastfeeding (for 24–48 hours) if breast milk jaundice causes extremely high bilirubin levels
decreased risk factors in hyperbilirubinemic newborn
TSB or TcB level in the low-risk zone
Gestational age 41 week
Exclusive bottle feeding
Black race
Discharge from hospital after 72 hoursdefine newborn cephalohematoma
vs capput succedaneum
subperiosteal hemorrhage that is localized to the cranial bone that was traumatized during delivery.
The swelling does not extend across a suture line. As the blood is reabsorbed from the cephalohematoma it will contribute to hyperbilirubinemia
edematous swelling over the presenting portion of the scalp of an infant. It overlies the periosteum and the swelling crosses suture lines.
The swelling consists of serum and would not cause hyperbilirubinemia.
cause of Gilbert vs Crigler Najjar
Gilbert - reduced UDPGT activity
Crigler Najjar - absence or low level of UDPGT
TORCHS titers for…
congenital infections: TOxoplasmosis; Rubella; Cytomegalovirus; Herpes; and Syphilis
why test newborn urine bilirubin
suspect cholestasis
tf
hemoglobinopathies contribute to neonatal hyperbilirubinemia
f
HbF present for 6 months
ddx for persistent jaundice at 2 weeks in pretty healthy kid and how to check on these
breast milk jaundice
can keep feeding
cholestasis
check for either dark urine or acholic-appearing stools that might signify the development of cholestasis
biliary atresia a1 antitrypsin deficiency
check derect bili
when are fevers (and other sx) most likely to occur as an adverse reaction to vaccination
most likely 24-48hours after FIRST DOSE
however live attenuated e.g. MMRV can occasionally cause fever 7-10 days after administration
fever without source
vs
fever of unknown origin
without source - no identified source after complete H&P
unknown origin - fever ^101 (38.3) for 2+ weeks without diagnosis after 1+ week of workup
define sepsis
what is required for diagnosis
severe systemic illness caused by overwhelming infection of the bloodstream by toxin-producing bacteria. A diagnosis of sepsis typically requires positive blood cultures
most likely causes of fever without source in neonate
usually viral
must rule out sbi (serious bacterial infection)
oral empiric abx treatment for septic baby
amp and gent
ecoli resisting amp these days, so add gent unless cultures prov organism is sensitive to amp alone
treat septic baby probably due to pyelo
IV CEFTRIAXONE (3rd gen cephalosporin best for pyelo, given excellent gram negative coverage (except pseudomonas.. but that is unlikely cause of uti in child not regularly catheterized… so no need for gram negative and pseudomonas coverage with PIPTAZO)
CIPROFLOXACIN good complicated uti tx but has adverse rxns in young children so reserved for ^1yo with complications like resistant organism or urinary tract anomalies
baby UTI empiric abx therapy should cover
does a 3rd generation cephalosporin - ceftriaxone, cefotaxime cover?
ecoli
proteus mirabilis
klebsiella
yes, 3rd generation cephalosporin - ceftriaxone, cefotaxime cover
first imaging if pyelo suspected
renal ultrasound
-to assess for renal structural abnormalities or signs of obstructive uropathy (hydronephrosis).
VCUG screening is recommended only for
recurrent UTI or when there is abnormal renal ultrasound
why do infants v1month get full workup and empric abx for any fever with suspicion of sepsis
v1mo immature immune systems, do not localize infections as well as older children
the most common bacterial illness in a female infant
presentation
UTI
high fever, fussiness, and decreased appetite
All children with chronic cough (more than three weeks) should be evaluated with
for…
TB
lung abscess
malignancy
tf
prolonged labor with use of forceps during delivery can contribute to neonatal jaundice
T
Difficult deliveries and birth trauma may result cephalohematomas, or hemorrhage of blood between the skull and the periosteum. These result from the rupture of blood vessels crossing the periosteum, usually caused by a prolonged second stage of labor or the use of forceps or other instrumentation during delivery. As the cephalohematoma resolves over weeks and the blood is reabsorbed, the breakdown of RBCs from the hematoma can result in increased bilirubin levels
PKU aka inheritance path sx
Phenylketonuria
autosomal recessive
phenylalanine hydroxylase mutation (impaired phenylalanine to tyrosine conversion), so phenylalanine can build up in brain
mental retardation, seizures, death if not treated early.
what mediterranean hereditary diseases cause jaundice
G6PD
thalassemias (not till after HbF wears off)
TF
PKU causes jaundice
F
not jaundice
buildup of phenylalanine in the brain, leading to mental retardation, seizures, and death if not detected and treated early
how does breast feeding jaundice occur
low feeding
low gi motility
meconium contains β-glucuronidase, which hydrolyzes the conjugated bilirubin to an unconjugated form, which is reabsorbed and re-circulated into the blood through the enterohepatic circulation, increasing bilirubin levels in the blood
when does biliary atresia present
sx
first lab
usually after 2 weeks
range birth - 8 weeks
Jaundice usually first
acholic stools
dark urine (from increased bilirubin excretion)
hepatosplenomegaly if the problem goes unrecognized
increased direct or conjugated bilirubin > 2 mg/dL
Caput succedaneum
define
increase in serum ABOVE the periosteum of an infant that crosses suture lines (as opposed to cephalohematoma which is subperiosteal and does not cross suture lines)… DOES NOT CAUSE JAUNDICE just serum, not RBCs…
methacholine challenge is reserved for cases in which
asthma is suspected and spirometry is normal or near normal
Habitual cough
is caused by
typical quality of cough
how affected by exercise, cold air, sleep
habitual perpetuation of a cough that begins with a viral URI. Continued coughing further irritates the airway, leading to stronger stimulation to cough
cough is typically very loud, short, dry, brassy, and spasmodic
unchanged by exercise or cold air, and classically resolves during sleep
intermittent asthma
symptom frequency
treatment
(2days/wk 2nights/month)
(2 and 2)
symptoms fewer than two days a week or two nights a month
Rescue inhaler (a short-acting beta agonist) i PRN
mild persistent asthma symptom frequency
treatment
(6days/week 4nights/month)
(every other day to almost every day)
3–6 days/week and 3–4 nights/month
add Low dose inhaled corticosteroid to saba rescue inhaler
moderate persistent asthma
symptom frequency
treatment
(7days/week ^1night/week)
(every day and every week)
daily and more than one night per week
Medium dose inhaled corticosteroids with a course of oral corticosteroids
(in addition to saba rescue ihaler)
severe persistent asthma
symptom frequency
treatment
More severe than Moderate
(daily and more than more than one night per week)
So something like Symptoms Throughout The Day
Medium dose inhaled corticosteroids, LABA, and oral corticosteroids
(in addition to saba rescue ihaler)
habitual cough
vs asthma cough
which is worse at night
asthma worse at night, waking from sleep
habitual cough disappears at night
paroxysmal cough think…
bacterial infections such as pertussis, chlamydia, or mycoplasma
barking cough think…
croup or other forms of subglottic disease, foreign bodies
dry cough with wheezing and nighttime exacerbations
think..
asthma
lower eyelid ___ aka ____ and skin rashes suggest atopy
lower eyelid darkening aka “allergic shiners” and skin rashes suggest atopy
TF
Group A Strep is rarely a cause of pharyngitis in young children and notably does not cause the feared sequelae (rheumatic fever) in those < 3 years
T
Most common cause of the common cold
rhinovirus
first choice abx for acute otitis media
next up on the ladder
High-dose amoxicillin is the most common first-line treatment for acute otitis media due to its general effectiveness against susceptible and partially resistant S. pneumo, in addition to being low cost and having a high safety profile
Amoxicillin/clavulanate (Augmentin) is the treatment of choice for patients with moderate to severe otalgia or high fever, and is used for additional beta-lactamase coverage for Haemophilus influenzae and Moraxella catarrhalis, and when failure with amoxicillin is suspected
high fever celsius
^39.0
102.2 F
when is tympanocentisis used as a diagnostic procedure for acute otitis media
Tympanocentesis is recommended as a diagnostic measure to confirm a bacterial etiology after a patient has failed repeated courses of antibiotics or if an unusually resistant organism is suspected
…basically… to speciate the bacteria when resistant
tf
gas pyogenese is a common cause of acute otitis media
F
not gas pyogenes (v5% of cases)
but Strep Pneumo Yes very common (25-50% of cases)
tf
a fully vaccinated 18mo with acute otitis media may have resulted from H Flu infeciton
T
hib vaccine does not cover unencapsulated strains of h flu that still cause 15-52% of cases
which is more common cause of acute otitis media
rhinovirus or bacteria
bacterial strep pneumo 25-50% of cases h flu (unencapsulated) 15-50% of cases moraxella catarrhalis 3-20% of cases
rhinovirus much less frequent but possible
yellow, opaque, and bulging tympanic membrane in peds pt fussy for 3 days. What organisms are the most likely cause of the child’s condition?
acute otitis media bacterial strep pneumo 25-50% of cases h flu (unencapsulated) 15-50% of cases moraxella catarrhalis 3-20% of cases
rhinovirus much less frequent but possible
4 months earlier diagnosis of acute otitis media together with current findings of bilateral yellow and poorly mobile tympanic membranes on physical exam make what diagnosis most likely
Otitis media with effusion
tf
nocturnal cough is frequently associated with allergies
t
tf
cobblestoning of posterior pharynx is a finding that can be associated with allergies
t
peds sinusitis - likelihood of which sinus by age
maxillary and ethmoid sinuses are large enough to harbor infection in infancy.
sphenoid sinuses do not become large enough until the third to fifth year of life
frontal sinuses are rarely large enough until the sixth to tenth year of life
peds sinusitis symptoms and findings
preceeding URI
fever, purulent nasal secretions, malodorous breath, nocturnal cough
mid-face tenderness, pus drainage from meatus
pus draining from middle meatus suggests sinusitis of which sinus
maxillary, anterior ethmoid, or frontal sinuses
maxillary and ethmoid sinuses are large enough to harbor infection in infancy.
frontal sinuses are rarely large enough until the sixth to tenth year of life
peds frontal sinusitis is characterized by
pain over the frontal bone and perhaps facial swelling in an older child or adolescent
(frontal sinuses are rarely large enough to harbor infection until the sixth to tenth year of life)
peds migraine symptoms
treat?
get MRI?
trial TCAs for migraine prophylaxis (or other migraine ppx)
no MRI… that for intracranial mass suspicion… probably would be infratentorial, increased ICP - headaches with laying down and with valsalva cough, potentially ataxia dysarthria and nystagmus from cerebellar compression… supratentorial mass would show FNDs
when to suspect intracranial mass in peds pt with headache
infratentorial - increased ICP
headaches with laying down and with valsalva cough,
potentially ataxia dysarthria and nystagmus from cerebellar compression
supratentorial mass would show FNDs, and also signs of increased ICP potentially
when NSAIDS for peds headache
tension headache - band-like pattern around head
ped with pmh headaches now with increased freq and sev, vomiting ,wide stance and tripping
CT or MRI?
MRI, best detail of posterior fossa (most common location of pediatric brain tumors), so get this despite slower and more expensive and requires sedation in peds
CT does not visualize posterior fossa as well as MRI… use to rule out hemorrhage but not mass in peds
Intraventricular pressure monitoring involves what
placement of an intraventricular catheter, which measures pressure inside the skull and sends measurements to a recording device
