Common Pediatric Complaints Flashcards
Additional etiologies to consider for constipation in a child
- Hirschprung’s disease
- Voluntary holding
- Diet
- Anatomical features
- Neurologic disease
Voluntary holding
- Voluntary!!! (at least at first, may turn involuntary)
- Mostly due to pain or embarassment associated with passing stool. Intellectual disability is an important risk factor.
- Will present as overflow incontinence and encopresis (stooling in bed).
- Diagnosis: Clinical
- Treatment: Bowel regimen (stool softeners, motility agents) and behavioral counseling. If impacted, disempact under anesthesia.
Expressive vs language disorders
- Expressive disorders are problems with articulation
- Language disorders are problems with neurologic expression and reception of language
Leading cause of mortality through 4 months of life
Sudden infant death syndrome
Leading cause of childhood mortality after 4 months of life
Trauma, especially motor vehicle accidents
Second most frequent cause of childhood mortality
Drowning
Risk for choking and poisoning is highest for children from age range ___ to ___.
Risk for choking and poisoning is highest for children from age range 9 months to 3 years.
Basically, the toddler period
When teeth appear
A full set of primary teeth should erupt between 25 to 33 months of age
Fluorosis
Excessive fluoride intake leads to staining of tooth enamel permanently
Clinical definition of failure to thrive
- Note: It is a physical sign, not a final diagnosis
- Suspected when weight is below the fifth percentile. Usually seen in children under 5 years whose physical growth is significantly less than their peers
- Divided into organic and non-organic:
- Organic: Poor growth due to underlying medical condition, such as IBD, renal disease, or congenital heart defect.
- Non-organic: Poor growth without medical etiology, often related to poverty or child-caregiver interaction
Next step for failure to thrive with suspected non-organic etiology
- Two weeks of food, stool, and urine diary, with associated symptoms, then follow-up appointment
- Directly examine feeding session if young infant
Children with failure to thrive will require ___ as part of intervention
Children with failure to thrive will require catch-up calories as part of intervention
You can’t expect them to catch up just by giving them the same amount, they are already behind! They will require ~50-100% excess calories to get where they need to be.
The “picky eater” phenomenon
- Between ages 18 months and 30 months, children often become picky eaters
- Some will be so picky that they may actually fall off of their weight curve, which can be distressing for families
- However, this is completely normal and is just a phase. They child has no underlying condition and is not at risk of developmental issues due to this.
- Counsel parents to avoid force feeding and avoid providing snacks
- Schedule follow-up
___ is a common, but often missed, etiology of failure to thrive. Treat with ___.
Renal tubular acidosis is a common, but often missed, etiology of failure to thrive. Treat with bicarbonate.
An adolescent with new-onset truant behavior, depression, or declining grades is most commonly associated with ___
An adolescent with new-onset truant behavior, depression, or declining grades is most commonly associated with drug abuse
It is possible that there could be a brain tumor or psychiatric disorder, but these are nowhere near as common as drugs
A history of exposure to insecticides, working on a farm, or symptoms of lacrimation and salivation should make you think. . .
. . . organophosphate toxicity
Testing for organophosphate toxicity
- Decreased serum pseudocholinesterase
- Decreased erythrocyte cholinesterase levels
Treatment of organophosphate poisoning
- Decontamination (ie, CHANGE CLOTHES, clothes are contaminated if via spraying)
- Atropine or pralidoxime
- Supportive care
Various types of mercury poisoning
-
Acute inorganic mercury poisoning
- Takes a large quantity – a mercury thermometer would not be enough
- GI complaints
- Fever, headache, vision changes if vaporous
-
Chronic inorganic mercury poisoning
- Gingivostomatitis, tremor, and neuropsychiatric disturbance
-
Methylmercury poisoning
- From contaminated fish
- Ataxia, dysarthria, paresthesias
Symptoms of acute arsenic ingestion
-
GI symptoms
- N/V, hemorrhagic diarrhea, abdominal pain
- QT prolongation and Torsades
- Congestive heart failure
-
Cerebral edema and downstream consequences
- Seizure, encephalopathy, coma
Most chronic sexual abuse has findings of __ on physical exam
Trick question
None. Most have no findings at all.
Still, NAAT on a urine sample should be performed for C. trachomatis and N. gonorrheae
Signs of penetrating anal trauma
- Loss of stellate pattern of anus
- Loss of anal sphincter tone (which may present with encopresis/loss of continence)
- Deep anal fissures
Single most common movement disorder in childhood
Cerebral palsy
Common comorbidities of cerebral palsy
- 33% have seizures
- 60% have mental developmental delay
- Thus, anyone diagnosed with CP should have an EEG and cognitive testing
Diagnosis of cerebral palsy in a neonate
. . . is impossible
The CNS is too immature at this point to tease these things out.
Diagnosis of cerebral palsy
- Head imaging by ultrasound or MRI
- May reveal periventricular leukomalacia, atrophy, or focal infarcts
- Beyond infancy, CP should be suspected whenever a child fails to meet an anticipated developmental milestone
- ex, retention of primitive reflexes:
- Moro reflex persisting beyond 6 months
- Fencer reflex beyond 6 months
- ex, retention of primitive reflexes:
Hemiplegia and Diplegia in cerebral palsy
- Hemiplegia: Unilateral, arms more effected
-
Diplegia: Bilateral, legs more effected
- Note: Remember your neuroanatomy! This makes sense. The apical-most region of the brain controls the legs, hence palsy involving legs is more likely to be bilateral. Arms are more lateral and thus topographically farther apart.
Motor quotient in cerebral palsy
Used to categorize CP by severity
Calculated as motor age / chronologic age
Where “motor age” is age at which their motor functionality would be developmentally appropriate
Signs and symptoms of CF
- Recurrent pulmonary infection
- Nasal polyps
- Reactive airways
- Clubbing
- Abdominal distension
- Rectal prolapse
- Subcutaneous fat and muscle tissue deficiency
- Frequent steatorrhea (which may then predispose to obstruction, volvulus, intussusception and ischemia)
What is the correct way to diagnose CF?
Sweat chloride test
If the results are equivocal or there are doubts in the results, THEN genetic testing may be utilized
How do we screen for CF?
- All infants in most states are screened with a blood test detecting immunoreactive trypsinogen (IRT), a pancreatic enzyme elevated in newborns with CF
- If the initial test is positive, it is repeated or DNA testing is performed
- DNA testing is diagnostic
- Two positive IRT tests is only a positive screen and warrants referral for diagnostic DNA testing or sweat chloride test
Pseudotumor cerebri
- aka idiopathic intracranial hypertension
- Nausea, positional headache, bulging optic disks, bulging anterior fontanelle, pulsatile tinnitus
- Cushing’s triad: High systolic blood pressure, bradycardia, bradypnea
- Etiologies:
- Vitamin A toxicity
- Tetracyclines
- OCPs
- Corticosteroid withdrawal
- among others
- Treatment: IV mannitol, acetazolomide
The Great Immitator
- Acute lymphoblastic leukemia
- May mimick MANY diseases
- Peak incidence of 4 years of age
- Symptoms:
- Hepatosplenomegaly
- Joint pain
- Fever
- Petechiae
- Malaise
- Anorexia
- Bruising/bleeding
- Almost HALF of those with ALL have <10,000 leukocytes
- Definitive diagnosis requires bone marrow biopsy
Therapy for ALL
- Induction: Prednisone, vincristine, asparaginase
- Consolidation: repeat above
- Maintenance therapy: methotrexate, 6-mercaptopurine, vinrcistine, and prednisone for 2-3 years
- Therapy is discontinued for those who remain in remission for 2-3 years
Beta agonists are great for asthma in general, but they don’t help at all with. . .
. . . the late phase response of an asthma attack
Most useful agents for the acute management of asthma
- SABAs
- Anticholinergics
- IV Magnesium sulfate
- Oral corticosteroids
Timing of a late phase response in asthma
2-4 hours after initial wheezing episode
Usually more severe and less amenable to albuterol
___ is among the first steps in assessing growth failure of any etiology
Bone age is among the first steps in assessing growth failure of any etiology
Diagnostic test for GH deficiency
- Preliminary or screening test:
- Should always include IGF-1. . . . AND IGFBP-3
- You should never order an IGF-1 without an IGFBP-3
- Diagnostic test:
- GH challenge and interpretation of results by a pediatric endocrinologist
Most common cause of death for infants between 1 week and 1 year of age
SIDS
Investigation of an unexpected infant death includes thorough history, autopsy, and ___
Investigation of an unexpected infant death includes thorough history, autopsy, and death scene investigation
This serves a few purposes. One, it can help identify more occult causes of death such as CO poisoning and can reduce the risk of recurrence for infantile death. Second, it is legally required to investigate for infanticide.
The three benign murmurs heard specifically in childhood
- Murmur of peripheral pulmonic stenosis: Systolic mitral-area murmur that radiates to both axillae
- Venous hum murmur: Hum in the neck or clavicle that disappears with neck flexion
- Still’s vibratory murmur:“Musical” high-pitched murmur heard at LUSB when supine
Illness script for juvenile rheumatoid arthritis
- Daily high-spiking fevers
- Characteristic rash
- Generalized lymphadenopathy
- Organomegaly
- Anterior uveitis
- Joint swelling, especially phalanges
-
Hematologic changes (leukocytosis, thrombocytosis, anemia)
- Unfortunately, there are no diagnostic tests for JRA! Diagnosis is based upon clinical criteria and exclusion of other diagnoses.
Workup and treatment for JRA
- Workup:
- CBC
- ESR and CRP
- ANA
- RF
- Blood cultures
- Synovial joint aspiration (rule out septic etiology)
- Slit lamp exam (to assess for anterior uveitis, often done periodically once diagnosis is established)
- Treatment:
- NSAIDs, steroids, methotrexate, immunosuppressants
Things to know about feeding babies goat’s milk
- It has little or no B12, iron, or folate, so they will need supplementation of at least these three things, probably more
- It has a high risk of Brucellosis – therefore it should only be pasteurized and you should have a high clinical suspicion for this if infants display signs of infection
“Home renovation” should raise an alarm for. . .
. . . lead toxicity
How to intrepret the blood lead level
While definitely useful, it is not perfect
Significant quantities of lead may be stored within tissues, and so the BLL is not entirely sensitive. Consistent history, labs, signs and symptoms should warrant therapy even if BLL is not at the threshold level for diagnosis.
Therapy for lead toxicity
Chelation with either intramuscular calcium EDTA, oral DMSA, or (if an inpatient) IV 2-3-dimercaptopropanol (2,3-DMP) aka British anti-Lewisite (BAL)
Recurrent, painless gross hematuria in a child
IgA nephropathy
Will usually occur during or very shortly following a respiratory infection
Presentation and management of appendicitis
- Presents with periumbilical pain which eventually migrates to McBurney’s point, along w/ nausea/vomiting, anorexia, fever, and diarrhea
- Leukocytosis with left-shift and sterile pyuria may be present just due to the extent of the inflammatory response induced by appendicitis
- Management: If suspected, stat abdominal CT or ultrasound. Surgical management should be prompt following diagnosis to prevent perforation.
Dysfunctional uterine bleeding
- Excessive uterine bleeding that may occur with the regular cycle or between cycles
- Effectively idiopathic and is a diagnosis of exclusion
- More common in younger women
- After verifying that the patient is not pregnant and excluding other possibilities, next steps are stratified by hemoglobin:
- >12 mg/dL is considered mild and iron supplementation and followup are sufficient
- 9-12 mg/dL is considered moderate, and treatment is with iron supplementation and OCP
-
<9 mg/dL is considered severe, and may need hospitalization or transfusion along with intravenous estrogen and high dose OCP until bleeding stops. OCP is continued until 3-6 months after discharge, then patient may be trialed off of it.
- There is a theoretical risk of thrombosis here, but since the timecourse of this therapy is so short and patients are so young there has actually never been a reported episode
Simple febrile seizures
- An entity that is unique to children ages 6 months to 6 years
- Diagnosis that may be _made *only after* considering CNS infection_ as the cause. CNS infection should be suspected if:
- Meningitis signs are present OR child is unable to provide feedback
- Neurologic exam is abnormal following seizure
- Seizure occured several days into illness
- Child is < 1 year of age
- Typically generalized tonic-clonic seizures with no focal signs
- There is often a family history of febrile seizures
- Diagnosis: Rule out other etiologies. EEG and brain imaging unnecessary unless there are focal findings, recurrence, or prolonged seizures (1 episode > 15 min, multiple episodes together > 30 minutes). LP is not routine except as above.
- Treatment: Acutely, lorazepam or diazepam may be used to break a seizure lasting > 5 minutes (with careful monitoring of respirations). If refractory, fosphenytoin may be used instead. Manage the fever, put on seizure precautions now and whenever there is another fever. Educate the parents. Prognosis is quite good and typically without neurologic sequellae.
Simple vs complex febrile seizures
-
Simple:
- < 15 minute episodes without focal or lateralizing signs, sequellae, or recurrence
- If more than one seizure in a brief period, then the whole episode should last < 30 minutes
- Postictal state may be present for a time, but there should be no lingering deficits
-
Complex:
- Lasting longer than 15 minutes (or 30 minutes if multiple)
- Focal or lateralizing signs (not primary generalized tonic clonic seizure)
- Neurologic sequellae
- Recurrence
- May require LP or imaging, usually not EEG.
Duschene Muscular Dystrophy
- Characterized by progressive loss of balance, frequent falling, difficulty climbing stairs, waddling gate, and proximal muscle weakness. Typically appears before age 5.
- Pseudohypertrophy due to muscle inflammation is classical on exam
- Gower’s sign when going from sitting to standing, shown below
- The most common hereitable neuromuscular degenerative disease
- Complications:
- Cardiomyopathy
- Nonprogressive intellectual disability
- Often wheelchair bound by age 10-12
- Cause of death is usually respiratory failure
- Diagnosis: DNA blood analysis usually works. When it is negative of equivocal, muscle biopsy and staining for dystrophin makes the diagnosis.
- Treatment consists primarily of orthopedic intervention and physical therapy. There is no cure. Early cardiomyopathy may be responsive to digoxin.
Differential for Duschene’s muscular dystrophy
Becker’s muscular dystrophy: Similar to DMD, but later onset (age 5-15) and more mild course.
Myotonic dystrophy: Myotonia (impaired relaxation) is hallmark sign. Other features include V-shaped upper lip, thin cheeks, high arched palate, and temporal wasting.
If a neonate displays signs of muscular dystrophy and a family history of apparent muscular dystrophy is present, the diagnosis is highly likely to be. . .
. . . myotonic dystrophy
Duschene’s and Becker’s take time to develop, only myotonic typically occurs from birth. When it does, it can be very severe and require neonatal ventilatory support.
Inheritance of DMD, BMD, and myotonic dystrophy
DMD: X-linked recessive
BMD: X-linked recessive
Myotonic: Autosomal dominant
Therapy for eczema
- Mild: emolients and topical low-potency steroids
- Moderate: emolients, topical higher potency steroids
- Severe: emolients, topical and potentially oral higher potency steroids, topical calcineurin inhibitors
- Oral antihistamines may be helpful at any level of severity to reduce tiching. If lack of sleep due to pruritis is a problem, 1st generation antihistamines are preferred.
- Superinfection with staph or strep is treated with 1st generation cephalosporines. Superinfection with herpes is treated with acyclovir.
Pityriasis rosea
- Salmon-colored, scaly, itchy rash that spreads to cover the trunk and extremities
- “Herald patch” preceding dissemination is characteristic and often annular, while other patches are continuous
- Treatment is with antihistamines, antipruritic lotions and creams, low-dose topical corticosteroids, and phototherapy
- Lasts up to 6 weeks, then resolves
Seborrheic dermatitis
- Common in infancy and in adolescence
- Chronic, symmetrical eruption characterized by overproduction of sebum
- Affects the scalp, forehead, auditory meatus, cheeks, eyebrows, nasolabial folds
- Treat by softening scales with mineral oil (avoiding scrubbing), and daily shampooing with a mild shampoo. Low to medium potency topical corticosteroids or ketoconazole shampoo are also helpful.
Wiskott-Aldrich triad
- Immunodeficiency
- Thrombocytopenia
- Atopy
Neuroblastoma syndrome, diagnosis, and treatment
- Neuroblastomas are tumors derived from primitive neuroendocrine tissue
- Commonly occur in the very young, < age 10, and especially in infants
- Most commonly occur in abdomen from adrenals, are irregular, and cross the midline
- May occur in thorax and cause spinal compression or respiratory distress and wheezing
- May occur in cervical region and cause Horner’s syndrome
- Associated with proptosis, perioral bluish discoloration, bone pain, pancytopenia, and generalized lymphadenopathy – all due to the presence of metastatic disease
- Paraneoplastic syndrome: Opsoclonus-myoclonus syndrome
- Diagnosis: Staging with CT and MRI, lab studies showing elevated vanillylmandelic acid and homovanillic acid are observed in most cases
- Treatment: Surgical excision of tumor following chemotherapy and/or radiotherapy to decrease tumor size. Cure rates are >90%, with infants generally having the best prognosis
Wilm’s tumor
- Kidney tumor of the very young associated with heritable mutations (WT1)
- Associated with hematuria, hypertension, and a localized abdominal mass that usually does not cross the midline
Mesenteric lymphadenitis
Describes irritation of the mesentery and mesenteric lymphadenopathy in the context of viremia, often from an established upper respiratory infection.
Clinical picture is usually URI symptoms + diarrhea + abdominal tenderness
Opsoclonus-myoclonus syndrome
Paraneoplastic syndrome associated with neuroblastomas, trophoblastic tumors, and some others
Due to an autoantibody against neuronal elements
Characterized by chaotic eye movements and myoclonic jerks (“dancing eyes, dancing feet”)
Malrotation with volvulus
- Occurs when intestinal rotation is incomplete during fetal development
- Resultant volvulus may happen any time from neonatal period to adulthood, but is most common in infants
- Radiographic signs: Ligament of Treitz on R side, malposition of colon
- When volvulus is present: Bird’s beak duodenum or corkscrew duodenum
- Presentation: Bilious vomiting, abdominal distension, bright red blood per rectum, lethary, colicky abdominal pain. May progress to peritonitis, acidosis, and sepsis if bowel becomes necrotic.
- Treatment of acute volvulus: fluids, correction of electrolyte abnormalities, NG tube to aid in GI decompression, parenteral antibiotics, emergent exploratory laporotomy.
- Treatment of incidentally discovered malrotation: Requires nonemergent surgical intervention, as frequency and morbidity of volvulus are high.
Intussusception
- Classical fatures include fever, intermittent colicky abdominal pain, currant jelly stools, and a “sausage-like” abdominal mass
- Incidence is higher in infants > 1 year of age
- Diagnosis is made with air contrast enema
- Requires emergent surgical management to save intestinal tissue.
Pyloric stenosis
- Classical features: projectile non-bilious vomiting, olive-shaped abdominal mass (the hypertrophied pyloric sphincter), and hypochloremic metabolic alkalosis
- Classically occurs in infants that are a few weeks to months old (the pylorus has hypertrophied since birth and is only now becoming symptomatic)
- Diagnosis is with abdominal and chest radiograph
- Treatment is surgical
Side effects of oral isotretinoin (apart from its teratogenicity)
- Cheilitis
- Conjunctavitis
- Hyperlipidemia
- Blood dyscrasias
- Elevated liver enzymes
- Photosensitivity
Tetracycline, taken orally for acne or infection, should be taken. . .
. . . on an empty stomach, when you know you will not be lying down for at least 2 hours, and try to stay out of the sun
Oral antibiotics may decrease the effectiveness of ____
Oral antibiotics may decrease the effectiveness of oral contraceptive pills
So, any patient taking an oral antibiotic for any indication who uses OCPs for contraception should also use a second backup form of contraception
