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.
