CLIPP Flashcards
at what age is infant expected to regain brithweight
define failure to thrive
sings of generally adequate nourishment in first few weeks of life
regain brithweight by 2 weeks
-failure to regain birthweight by 3 weeks
-continuous weight loss after 10 days
= failure to thrive
-6 feedings per day
-at least 6 wet diapers per day
= signs of generally adequate nourishment
preferred feeding source for all infants
a rare exceptoin
human milk for all
HIV-infected mother is a rare exception, among others
average newborn weight loss in first few days of life, 2 SDs
6% birth weight lost in first few days on average
11-12% is two standard deviations (10% is typically used as red flag)
encourage this frequency of breastfeeds for newborn
e.g. offering the breast whenever the newborn…
encourage 8-12 feeds per 24 hrs
e. g. offering the breast whenever the newborn shows early signs of hunger
- increased alertness
- increased physical activity
- mouthing
- rooting
how to get an idea of adequacy of breast feeds for newborn
gaining weight
urine and stool output
6-12 wet diapers (half voids, half stools) in first week of life
feeding q2-3 hours for 10-15 minutes is average (concern if 4+ hours between feeds, shorter duration)
formal evaluation of breast feeding performance by trained observers 24-48hrs and 3-5 days after discharge
Vit D supplementation for newborns
breast fed
vs
formula fed
start 400IU vit D po within first few days for breast fed infants
(exclusively formula fed ingesting 1L or one quart of formula will get enough vit D)
Normal anterior fontanelle size
2cm avg diameter
.5-3.5 = 2 sd’s
Newborn hypotonia, large fontanels, an umbilical hernia, and jaundice
Think..
Congenital hypothyroidism
TF
Umbilical hernias and jaundice are more common in newborns with congenital hypothyroidism
T
common anyway, but more common w hypothyroid
Inborn error of metabolism
Pres
Prog
appear well for at least the first 1-2 days of life but then become symptomatic due to the protein load in breast milk or formula.
Initial signs include somnolence and poor feeding, usually followed by vomiting and lethargy.
Without treatment, patients develop a progressive encephalopathy.
Presentstion of hypoglycemia in a newborn
Asymptomatic Vs Hypothermic Irritable Jittery Tremors
S and s of intracranial bleed in shaken baby syndrome
AMS
hypotonia
Poor feeding
Large fontanelles
Bruising and retinal bleeding are possible comirbid signs of abuse (not specifically intracranial bleeding)
The most common form of congenital adrenal hyperplasia, 21-OH deficiency, causes decreased production of ____ and ____
Expect this in the first labs you order
Aldosterone
Cortisol
Hyponatremia
Hyperkalemia
(Salt-wasting)
Causes of congenital hypothyroidism
Iodine deficiency (world wide)
Aplasia hypoplasia ectopia
Mom’s autoimmune abs transplacenta transiently
Mom w graves antithyroid meds transplacenta transiently
Pres of congenital hypothyroidism
Usually a few months after birth because protected by mom’s thyroid home
Feeding problems Decreased activity Constipation Prolonged jaundice Skin mottling Umbilical hernia
With time, if untreated, large tongue, hoarse cry and puffy myxedematous facies.
intellectual disability. The longer treatment is delayed, the greater the risk.
Treat congenital hypothyroidism in newborn
Levothyroxine
- maintain TSH 1 μIU/mL (1mIU/L) and T4 in the upper half of the normal range for age
- aim for normalized TSH by 1-2 mos old for good neurologic outcome
- frequent follow-up
peds endocrinology consult
PKU
presentation
advice for pregnant women with PKU
normal at birth
then fail to attain early developmental milestones
develop microcephaly
progressive cognitive impairment
seizures
albinism
musty odor of sweat and urine (due to phenylacetate).
pregnant women with PKU, maintain low phenylanine levels to protect the developing fetus. Though the developing fetus may only be a carrier of the PKU gene, high intrauterine levels of phenylalanine can result in growth retardation, microcephaly, intellectual disability and congenital heart disease for the child.
So get newborn screening
why is early detection of sickle cell disease important
early institution of penicillin prophylaxis can prevent sepsis secondary to infection with Streptococcus pneumoniae.
A two-month-old female presents to clinic for a well-baby checkup. Mom has been happy because the “baby rarely cries and sleeps all the time.” On exam, the baby has yellowing of the skin, decreased activity, appears to have decreased tone, and a large anterior fontanel. What is the most likely diagnosis?
Congenital hypothyroidism
body temperature change, changes in respiration, increased or decreased heart rate, reduced movement, reduced feeding, low blood sugar, seizures, and jaundice
think..
sepsis (blood infection)
abnormal genitalia (females), poor feeding, vomiting, dehydration, and electrolyte changes think...
congenital adrenal hyperplasia
A 6-week-old infant girl whose family recently immigrated from Mexico is brought to clinic for “excessive sleepiness.” The mother states the infant is not easily aroused for feedings and is not as active as she was previously. She is also concerned about her daughter’s large “outtie” belly button. On exam, the patient is afebrile and jaundiced, with a puffy myxedematous face. The fontanels are large but flat. There is a large umbilical hernia. When asked about the results of a newborn screening exam, mom states that the screening was never performed. What would be an expected abnormal lab value(s) associated with her condition?
High TSH, low T4
A 45-day-old infant is brought in by his mother due to lethargy, constipation, and yellow skin color noted since birth. The mother and the baby moved to the U.S. from a foreign country that does not screen its newborns. The baby has been fed only formula since birth. Physical exam of the neonate reveals additional findings of large fontanelles, umbilical hernia, a large tongue, and abdominal distension. What is the next best step in diagnosis?
TSH
first year of life with hypotonia, lethargy, constipation, weak cry, eventually lead to respiratory failure. absent DTRs.
think…
botulism
ornithine transcarbamylase deficiency
presentation
diagnosis
3-day-old has become lethargic and doesn’t want to feed. She has vomited twice and is showing no interest in feeding. On physical exam you note a lethargic infant with an enlarged liver
Hyperammonemia and elevated urine orotic acid
wheezing in infant think…
give bronchodilators and steroids?
viral respiratory infection
eg RSV - can cause airway inflammation and wheezing in infants
maybe asthma if strong family history and clear response to bronchodilators
but IN GENERAL bonchodilators and steroids are NOT helpful in wheezing infants with VIRAL respiratory illness
3 hallmarks of asthma
Airway inflammation
Mucus hypersecretion, and
Reversible airflow obstruction due to bronchoconstriction.
? Remodeling - some evidence suggests that smooth muscle hyperplasia and hypertrophy develop in the setting of longstanding asthma.
1 sentence summary of clinical manifestation of asthma in majority of children
recurrent coughing and/or wheezing that is responsive to bronchodilators (such as beta-agonists) and to anti-inflammatory medications (such as steroids).
triggers for peds asthma (bronchoconstriction)
URTI most often
also allergies cold air exercise smoke exposure
diagnose asthma in peds
child with symptoms of asthma who responds to therapy for asthma and has no other identifiable cause for wheezing has asthma by definition, regardless of age.
asthma vs RAD reactive airway disease
Many children with wheezing early in life do not continue to wheeze beyond 2 to 3 years. Many physicians are therefore reluctant to make a diagnosis of asthma in very young children, fearing that a child would be persistently labeled as having asthma when in fact their symptoms of this condition have resolved.
Some physicians prefer to use the term “reactive airways disease” (RAD) when children appear to have signs and symptoms of underlying airway hyperresponsiveness that is characteristic of asthma, but in whom a diagnosis of asthma is not yet definite.
The use of this term has been somewhat controversial
what is O2 sat
percent hemoglobin saturation
normal O2 sat in healthy person, by age
^94% regardless of age
how can O2 sat be misleading in asthma
and what to get
compensated asthma, hyperventilation will lead to a decrease in PCO2 of the blood. As a child begins to tire and can no longer maintain adequate ventilation, the PCO2 may normalize and even become elevated despite continued normal oxygenation.
Thus, blood gas analysis can be helpful in distinguishing compensated from uncompensated asthma, and in predicting impending respiratory failure.
the WORST sign of respiratory distress in peds
and others
Paradoxical breathing
-diaphragm contracts hard but chest wall muscles not expanding so chest sucks in and belly flares out
tachypnea
retractions
nasal flaring
head bobbing (neck strap accessory breathing muscles)
grunting (forced expiration against closed glottis… to keep airways open with positive pressure
tachypnea vs
hyperpnea vs
hypopnea
rapid rate deep breathing (inc tidal volume) shallow breathing (dec tidal volume)
when should oxygen be withheld for severe hypoxemia
NEVER
Although some patients with chronic hypercarbia (sometimes referred to as “CO2 retainers”) depend on their hypoxemia for their respiratory drive, oxygen should never be withheld in cases of severe hypoxemia. Rather, these patients should be MONITORED CLOSELY and given ONLY AS MUCH OXYGEN AS THEY NEED to MAINTAIN A REASONABLE SATIRATION. Endotracheal intubation should be reserved for patients in whom respiratory failure is imminent or loss of the airway is anticipated.
4 common
3 less common
causes of wheezing in infants and toddlers
viral bronchiolitis
asthma
foreign body aspiration
GER
- tracheomalacia
- extrinsic compression (vascular ring or sling, or other anatomic airway lesion)
- cystic fibrosis
5 questions to ask wheezing infant or toddler
timing of wheeze
assoc with food
change with position or activity
other exacerbating factors
has it happened in past, if so, did it respond to bronchodilators or steroids
5 common causes of cough in toddlers and infants
Viral upper respiratory tract illnesses
Pneumonia
Post-nasal drip due to allergies and/or sinusitis
Foreign body aspiration
GE reflux
dry cough vs wet/junky cough in infant / toddler
dry cough is typical of CHRONIC ASTHMA
whereas a wet cough suggests the presence of SECRETIONS in the airway, whether due to a viral infection, post-nasal drip, gastroesophageal reflux or bronchiectatic disease such as cystic fibrosis.
TF
wheeze is always expiratory
and
stridor is always inspiratory
f
generally yes, but not always… both can be heard anytime in respiratory cycle
triphasic course of pertussis
initial catarrhal stage lasts 1-2 weeks and is characterized by upper respiratory tract infection symptoms.
paroxysmal stage that follows lasts 4-6 weeks and is characterized by repetitive, forceful coughing episodes followed by massive inspiratory effort, which results in the characteristic “whoop.” Infants generally do not develop a “whoop” due to relative weakness of their inspiratory effort.
The paroxysms of cough gradually decrease in frequency and severity as the convalescent stage is entered. Episodic cough may persist for months.
acellular pertussis vaccine efficacy and longevity
even with full immunization, vaccine efficacy is only 70-90%. Additionally, protection from the vaccine wanes with time such that many adolescents are unprotected from pertussis unless reimmunized
rare causes of epiglottitis now that Hib vaccine is a thing
staphylococcal or streptococcal organisms
TF
absence of fever lowers the likelihood of community-acquired pneumonia but does not eliminate it entirely.
T
stridor is due to…
and occurs in which phase of respiratory cycle…
Due to airway narrowing above the thoracic inlet.
Usually heard with inspiration, but can be biphasic if obstruction is severe
wheezing is due to…
and occurs in which phase of respiratory cycle…
diffuse or focal…
polyphonic vs monophonic…
Typically due to airway narrowing below the thoracic inlet.
With mild airway obstruction, wheezing is usually heard only in expiration.
With increasing obstruction, wheezing may become biphasic and may even disappear altogether when obstruction is severe
Although typically diffuse, focal wheeze may be heard in some settings such as mucus plugging.
Polyphonic wheeze is characterized by multiple pitches and is typical of asthma; monophonic wheeze is characterized by only a single pitch and is typical of focal airway obstruction.
ronchi
what do they sound like
what phase of respiratory cycle
what are they due to
Coarse, low-pitched rattling sounds
heard best in expiration.
Thought to be due to secretions and narrowing of airways.
crackles
cause
coarse vs fine
Finer breath sounds heard on inspiration.
Associated with either fluid in the alveoli or with opening and closing of stiff alveoli (as in interstitial disease).
Sometimes described as either coarse or fine. (COARSE crackles are usually thought to be associated with PURULENTsecretions in the alveoli as with pneumonia; FINE crackles are often associated with pulmonary EDEMA or ILD interstitial lung disease.
bronchial breath sounds
describe
cause
Lower in pitch and more hollow-sounding than normal breath sounds.
Caused by air moving through areas of consolidated lung.
most suggestive physical exam finding for airway foreign body
Significant asymmetry of breath sounds
TF
cough, tachypnea, retractions, and absence of fever all support a diagnosis of an asthma exacerbation
T
TF
Cough, tachypnea, and mild retractions are typical features of bronchiolitis
T
TF
asymmetric breath sounds essentially rules out viral URI (I) as the sole process.
T
imaging to get if suspect airway foreign body in kid
pa lat chest
biilateral decubitus
(each lung deflates when on down-side unless hyperinflated by obstruction)
or
inspiratory/expiratory chest films
(asymmetric deflation with expiration.. but more subtle than bilateral decubitus)
chest fluoroscopy - no need to hold breath, can get dynamic evalutaiton
bronchoscopy down the line here
rigid
vs
flexible
bronchoscopy
rigid bronchoscope is a straight metal tube that can only be inserted through the mouth. It allows one to examine the upper and large airways. Because they can accommodate forceps, rigid bronchoscopes are often used for performing transbronchial biopsies and for removing foreign bodies.
Flexible bronchoscopes can be inserted through either the nose or the mouth, and can be used to visualize more distal airways than can be seen with rigid scopes. Because they are smaller than rigid bronchoscopes, flexible scopes used in young children often cannot accommodate forceps.
All but the very smallest scopes include a suction port and can be used to collect lavage specimens.
Asthma pathophys basics
infiltration of inflammatory cells into the airway mucosa
mucus hypersecretion
mucosal edema - accompanied by bronchoconstriction.
Acute asthma predentation
And if severe…
Cough Dyspnea Tachypnea Wheezing Decreased breath sounds
Quiet/stopped wheezing because poor airflow
Cyanosis
Pulsus paradoxus
Chronic asthma is characterized by …. gimme 2
recurrent dyspnea and cough
Is wheezing in asthma focal or diffuse
Typically diffuse
May get focal wheeze with mucus plugging
3 findings on cxr for asthma
Air trapping
Increased interstitial markings
Patchy atelectasis
coughing with liquids suggests…
vs dysphagia with solids
coughing with liquids suggests aspiration
dysphagia with solids suggests narrowing of posterior oropharynx or esophagus
recurrence of fever several days into a respiratory illness makes you think…
bacterial superinfection
