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Pediatrics > Common ped medical problems > Flashcards

Common ped medical problems Flashcards

1
Q

Normal growth of a newborn?

A
  • gain 30g/day up to 3 months
  • infants: 20 g.day b/t 3-6 months
  • gain 10/g b/t 6-12 months
  • infants double their wt by 4 months
  • triple their wt by 1 year
  • kids gain 2 kg/year b/t 2 years and puberty
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2
Q

Epidemiology of pyloric stenosis?

A
  • 2-3/100 live births
  • male predominance 4:1, 6:1
  • genetics involved
  • more likely with maternal smoking
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3
Q

Clinical presentation of pyloric stenosis?

A
  • 3-5 weeks
  • projectile nonbilous vomiting
  • infant immediately hungry (hungry vomiter)
  • may be dehydrated (dry mucous membranes, sunken in fontanelles)
  • may be jaundiced
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4
Q

PE, labs, tx for pyloric stenosis?

A
  • check hydration
  • check for jaundice
  • palpate abdomen for olive (present in 50-90%)

-eval:
labs (total bili, electrolytes),
**US

tx: pyloramyotamy: incision is made longitudinally and then sutured at 90 degree angle from the original

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5
Q

DDx of newborn infant with vomiting 2 categories?

A
  • Billious: involves conditions with partial or complete bowel obstruction, examples: malrotation, volvulus, Hirschsprung disease, incarcerated hernia, intussusception, intestinal atresia
  • nonbillious: largely due to GERD, cow or soy milk protein intolerance, pyloric stenosis, gastritis
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6
Q

Age at presentation - differential?

A
  • newborns with persistent emesis often have intestinal atresias
  • toddlers compromise age group that most commonly presents with intussusception
  • pyloric stenosis often presents aroung 3-6 weeks of age
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7
Q

DDx for abdominal pain in a newborn? Infancy to 2 years?

A
  • newborn:
    GERD, necrotizing colitis (primarily seen in premature babies)
  • vovulus: twisting of gut - bloody stools
  • infancy to 2 years:
    intussusception
    meckel’s diverticulum
    bacterial enteritis
  • hirschsprung’s disease: megacolon, another cause of obstruction, congenital defect, no neural ganglion cells - can’t contract - stool builds up in colon - usually found early in life
    tx: if one segment - removal, or if greater area: colostomy
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8
Q

Warning signs of underlying pathology?

- When should workup be considered, what does this involve?

A
  • GERD is very common in healthy infants (happy spitters)
  • warning signs of underlying pathology:
  • GI: bilious vomiting, GI bleeding, forceful vomiting, prolonged constipation, diarrhea or abdominal distenstion
  • neuro: HSM, bulging fontanelle, seizures, microcephaly, or macrocephaly, hypertonia, or hypotonia, stigmata of genetic disease or chronic infections
  • nonspecific: fever, pneumonia, lethargy, FTT
  • if no warning signs and infant has hany of the following sxs:
    poor wt gain, irritability, feeding refusal, gross blood in stool
  • Then a workup can be considered:
  • esophageal pH monitoring, endoscopy
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9
Q

GERD tx options?

A
  • lifestyle changes: avoid all exposure to tobacco smoke (Lowers pressure of LES), smaller feedings: most relevant for infants who are bottle fed, trial of diet where all cows milk is removed in mother’s diet
    -positioning therapy:
    keep infant upright (on paren’ts shoulder) for 10-20 min after a feed, not in semi-supine position (promotes reflux)

indications for pharmacotherapy:

  • infants with mild esophagitis on endoscopic bxs
  • infants with significant sxs and in whom conservative measures have failed
  • 3-6 months of therapy with repeat endoscopy if erosive esophagitis is present
  • PPI is preferred as it is better acid suppressor, SE include increased risk for pneumonia and diarrhea
  • antacids are not useful for tx
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10
Q

Colic dx?

A
  • dx of exclusion
  • ask about feeding habits, how long they cry, sleeping patterns
  • exam and measure wt, length, circumference of head, chest

rule of 3s:

  • greater than 3 hours a day of crying
  • greater than 3 days a week
  • lasts at least 3 weeks
  • and infant less than 3 months old
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11
Q

Colic epidemiology?

A
  • occurs in 18-40% infants
  • males: females equal
  • starts 3-6 weeks
  • ends at 3-4 months
  • normal infants can cry up to 2 hrs a day
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12
Q

Assoc characteristics of colic?

A
  • paroxysmal
  • occurs more in evening
  • qualitatively diff from normal crying
  • assoc with hypertonia
  • inconsoloability
  • infant is normal when not colicky
  • first few weeks of life are unremarkable
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13
Q

Colic soothing maneuvers?

A
  • pacifier
  • take infant for car or stroller ride
  • hold infant or place them in front carrier
  • rock infant
  • minimize visual stimuli
  • infant swing
  • give warm bath
  • rub abdomen
  • provide white noise
  • play CD of heartbeats
  • sing to baby
  • give baby quiet time in crib for 5-10 minutes
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14
Q

Colic tx suggestions?

A
  • trial of elemental formula for 1 week
  • if breast fed - hypoallergenic diet (take out anything that could be irritating to baby)
  • trial of probiotic: esp in formula fed babies
  • not a trial of soy milk
  • not simethacone
  • not infant massage
  • not homeopathic remedies
  • MOST impt: is parenteral support!!
    tell parents to stay positive, take care of themselves, ok to let someone else take care of baby
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15
Q

Key to dx a dehydrated infant?

A
  • lethargic!!

- sunken in fontanelles, no tear production, dry mucous membranes, abnormal skin turgor

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16
Q

Most common cause of acute diarrhea and vomiting in young kids?

A
  • rotavirus
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17
Q

What is the significance of bilious vomiting?

A
  • obstruction somewhere
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18
Q

When do you decide that child needs IV therapy?

A
  • When they are lethargic, dry mucous membranes, tachycardic
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19
Q

What is number one killer of kids worldwide?

A
  • diarrhea
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20
Q

What is oral rehydration therapy?

A
  • small amts of liquid taken orally to replace fluids and electrolytes
  • pedialyte is first choice, homemade solns as well
  • idea is to coat esophagus w/o causing a large enough bolus in the stomach (which will irritate the stomach and induce emesis)
  • increase as tolerated
  • use a syringe 5 ml q 2-3 minutes
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21
Q

Antiemetic therapy recommendation if child can’t keep fluids down?

A
  • Odansetron (zofran) safe and effective
  • available in ODT (oral dissolving tablets) and IV
  • problem: very sedating
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22
Q

When is ORT recommended?

A
  • preferred tx of fluid and electrolyte losses caused by diarrhea in children with mild - moderate dehydration
  • good outcome compared with IV tx
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23
Q

Tx of severe hypovolemia?

A
  • tx initially with rapid infusion of 20 mL/Kg of isotonic saline
  • pt should then be reassessd and saline bolus repeated as needed until adequate perfusion is restored
  • conversion to ORT can take place once pt adequately hydrated
24
Q

Reasons to hospitalize a child with diarrhea?

A
  • dx or strong clinical suscpicion of life-threatening diarrhea
  • severe dehydration or electrolyte abnormality
  • lack of improvement with rehydration
  • continues copious diarrhea that will lead to recurrent dehydration if ongoing IV rehydration not continued
  • inability to drink
25
Q

Define constipation?

A
  • decrease in person’s normal frequency of defecation accompanied by difficult or incomplete passage of stool and or passage of excessively hard, dry stool
  • wide range of normal stooling patterns. 2/day or 2/week
26
Q

Big 3 reasons why people in US are constipated?

A
  • lack of fiber
  • inadequate consumption of fluids
  • sedantary lifestyle
  • 4th: too busy!
  • tell pts to make time to have BM
27
Q

Constipation occurence in kids?

A
  • 10% of all kids

- defined in kids older than 4 as abnormally reduced defectation

28
Q

Majority of the causes for constipation are?

A 
fxnl retention (great majority of cases) which can result from:
-traumatic events:
painful passage of hard stools, painful diarrhea, physical or sexual abuse
-difficult psychosocial situations or enviro changes: difficulty with potty training, divorce
29
Q

What is the functional retention cycle?

A
  • withholding of stool - intensifies painful passage of hard stools which intensifies withholding of stool
30
Q

What is encopresis?

A
  • often the result of fxnl retention causes stretching of rectum and decreased senstion to empty bowel
  • liquid stool leaks around a retained stool mass and is involuntarily passed
  • oftentimes the hx is very similar to this but the parent may complain of child soiling his/her underwear
  • sometimes the parent will complain that the child has diarrhea
31
Q

What are organic causes of constipation?

A
  • less than 5% as an etiology of constipation
  • Hirschsprungs disease (aganglionic colon)
  • anatomic abnormalities of anus or colon
  • meds: antacids, opiates, phenobarbitol
  • spinal cord abnormalities
  • infant botulism
  • hypothyroidism
  • celiac disease
  • DM
  • CF
  • cow’s milk intolerance
32
Q

Warning signs with constipation?

A
  • wt loss or poor wt gain
  • anorexia
  • delayed growth
  • delayed passage of meconium (48 hrs after birth)
  • urinary incontinence or bladder disease
  • blood in stool (unless anal fissure present)
  • constipation present from birth or infancy
  • acute constipation
  • assoc fever, vomiting or diarrhea
  • extraintestinal sxs
33
Q

Concerning findins on PE of pt with constipation?

A
  • FTT
  • abdominal distension
  • lower spin abnormalities
  • anteriorly displaced anus
  • tight, empty rectum in presence of palpable fecal mass
  • absent anal wink
  • absent cremasteric reflex
  • decreased lower extremity tone or strength
  • absence of delay in relaxation phase of lower extremity DTRs
34
Q

Findings that support a fxnl etiology of constipation?

A

-onset of constipation coincides with:
dietary change, toilet training, painful BM
- stool withholding behavior
- good response to conventional laxatives

35
Q

Gastrocolic reflex?

A
  • peristalsis within 5-15 minutes after eating - body’s way of telling you to have a BM
  • train kids to go to bathroom after eating, helps with functional causes of constipation
36
Q

Diff laxatives used for constipation?

A
  • stool softeners: Docusate sodium (colace)
  • osmotic agents (these work the best: polyethylene glycol (miralax), mineral oil and lactulose
  • bulking agents: psyllium (metamucil), methylcellulos (citrucel)
  • peristalic inducers: these cause abdominal cramping, senna (ex-lax), bisacodyl (dulcolax)
37
Q

Tx of encopresis?

A

begins with clearing child’s bowel:
-use of osmotic laxative for 3 days, child will usually have diarrhea when bowel is clear

  • educate the parents - start a toilet training process:
  • cont daily use of chosen laxative, regular toilet sitting time for 5-10 minutes after meal 2-3x a day, stool b toilet, rewards for sitting on toilet, note time when BM occurs, may need to take laxative for several months b/f weaning off
38
Q

What is enuresis?

A
  • involuntary d/c of urine after age at which bladder control should have been established
  • control usually est by 5 yo
  • by 5 - 10-20% of children still wet the bed (1% at 18)
  • more frequent in boys (2:1)
  • sig genetic component
  • exacerbated with stress and emotional problems
39
Q

What is monosymptomatic enuresis?

primary, secondary?

A
  • children w/o any h/o of urinary tract symptoms or bladder dysfxn
  • nocturnal: no daytime sxs
  • primary: 80% have this have never had nighttime dry period
  • secondary: child develops enuresis after dry period of at least 6 months
40
Q

Underlying etiologies of enuresis?

A

small % have underlying neuro or anatomic problem:

  • urinary tract abnormality/UTI/kidney disease
  • trauma or disease of spinal cord
  • diseases: seizures, hyperthyroidism, DM
  • sleep apnea
  • pin worms
41
Q

Eval for enuresis?

A
  • History!!!!
  • family hx
  • behavior, personality and emotional status
  • daytime sxs, voiding pattern
  • number of episodes of nighttime wetting
  • fluid intake diary/hydration hx
  • nutrition hx
  • voiding diary
42
Q

What should you keep in mind (ddx) when eval enuresis?

A
  • overactive bladder or dysfxnl voiding
  • cystitis
  • constipation
  • neurogenic bladder
  • sleep disordered breathing
  • urethral obstruction
  • major motor seizure
  • ectopic ureter
  • DM or DI
43
Q

PE of pt with enuresis?

Labs?

A
  • BP
  • perianal area
  • lumbosacral spine/neuro exam
  • genitalia exam
  • palpate abdomen for masses
  • palpation of renal and suprapubic areas
  • lab: UA!!
44
Q

Tx considerations for enuresis?

A
  • don’t make child feel guilty
  • generally due to developmental lag
  • normal fluid intake, regular bowel and bladder schedules
  • use bathroom b/f bed
  • minimize caffeinated and high sugar drinks
  • enuresis alarms
  • desmopressin acetate (works only while on it)
  • anticholinergic agents: oxybutynin
  • behavior modification - reward system
  • bedwetting alarms
  • meds
45
Q

For visual development to proceed normally a child needs what?

A
  • normal visual enviro
  • well-aligned eyes
  • freedom from visually threatening disease
  • freedom from sig refractive errors
  • in normally developing child, if one eye is dominating visual acuity, blindness can occur in opposite eye
  • small children won’t show signs of losing eyesight in one eye
  • a disorder may not be entirely obvious and therefore careful exam and screening is critical
46
Q

What is amblyopia?

A
  • unilateral or bilateral reduction in central visual acuity due to sensory deprivation of well-formed retinal image that occurs with or w/o a visible organic lesion commensurate with the degree of visual loss
  • can only occur during critical period of visual development in first decade of life
  • best screening test: visual acuity in each eye
  • in preverbal child - ambloygenic factors are sought such as strabismus, refractive errors and deprivation
47
Q

Types of amblyopia?

A
  • strabismus ambylopia (occurs in nondominant eye of strabismic pt)
  • refractive ambylopia (results from refractive errors, can be unilateral or bilateral)
  • deprivation ambylopia (occurs with congenital cataracts, unilateral ptosis, corneal opacities, or vitriol hemorrhage
48
Q

How do you test for amblyopia of the nonverbal child?

A
  • fixation test (occluding the not tested eye)
  • differential occlusion test: monitoring infants response to occlusion of vision in each eye, normal sight in both eyes won’t bother an infant, if one occluded the eye with poor vision the infant will get fussy
  • prism test
  • cover uncover test - strabismus
49
Q

What is strabismus?

A
  • misalignment of visual axes of 2 eyes
  • 2-3% of kids
  • esotropia: inward turning misalignment of eyes
  • exotropia: outward turning of eyes
  • child may be intermittenly esotropic over first few months of life but should be well aligned by 5-6 months
50
Q

Strabismus may be a marker for what other disorders?

tx?

A
  • other oculr or systemic disease
  • 20% of pts with retinoblastoma have strabismus
  • other disorders that may cause this include hydrocephalus and space occupying lesion
  • dx with cover uncover and look at light reflex in each cornea
  • tx ranges from glasses, patches to surgical correction
51
Q

What does bilious vomiting indicate?

A
  • complete or partial obstructive process and almost alway warrants a corrective or exploratory surgical intervention
52
Q

Most impt thing to assess initially with CC of vomiting and/or diarrhea?

A
  • hydration status
53
Q

Tx of encopresis?

A
  • result of fxnl retention constipation
  • give enema, use polyethylene glycol or lactulose to normalize then follow with std therapies plus rewarding kid for number 2
  • enuresis is generally thought be from developmental lag, educate pts
54
Q

Main cause of enuresis?

A
  • developmental lag, educate parents on this
55
Q

When should eyes become well aligned?

A
  • 5-6 months of age

- may be intermittently esotropic over first few months

Pediatrics (20 decks)

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