CPS High Yield Statements Flashcards
Lab findings in patient with ITP
Low platelets (<100, can be <20)
Normal Hb + other cell lines
Large plts on smear
Patient with ITP, no active bleeding, petechial rash - how to treat?
Observation 1st line, can discuss steroids/IVIG with parents, consider if child is young or very active
Patient with ITP and mucosal bleeding- how to treat?
Steroids- PO pred x4d-2wks (increase plts in 48hrs)
OR
IVIG 1g/kg once (increase plts in 24hr)
Patient with ITP + ICH: how to treat?
IVIG +methylpred +consider TXA (clotting risk so discuss with Heme 1st) + platelet transfusion (only give plts in ITP if life threatening bleed)
Counselling for pts with ITP? How many relapse?
-Avoid sports/activities with injury risk
- Avoid NSAIDS
- Even if treated with steroids or IVIG, 1/3 will relapse in 2-6 weeks
Vit K prophylaxis dosing (<1500g, >1500g, prems)? Timing of administration?
0.5mg if <1500g
1mg if >1500g
0.2-0.5mg if prem (give IM even if they have an IV)
GIVE BY 6HRS OF LIFE
What to do if parents decline IM Vit K?
- Tell them there is a serious risk of IVH!!!
- Give 2mg PO Vit K now, at 2-4 weeks and at 6-8 weeks (3 doses)
RF for early hemmorhagic disease of the newborn?
Maternal warfarin, antiepileptics
RF for late hemmorhagic disease of the newborn?
Oral Vit K
CF
Cholestatic disease
** present primarily as ICH
Patient with SCD is travelling, what should they receive?
Salmonella Typhi vaccine
Malaria prophylaxis
Abx prophylaxis for SCD (what, when?)
- 2mo-> 5yrs (longer if splenectomy (should get for at least 2yrs post splenectomy), if unimmunized or if history of invasive bacterial infections)
- Daily Amox or Penicillin
When to start hydroxyurea in SCD?
> 9mo
(hold if patient is cytopenic, otherwise give every day)
VOC Management
- IN fentanyl within 30 mins then PO morphine
- Observe x 2-3hrs in ED
- If pain improved-> d/c with oral morph
- If pain not improved -> Admit, morphine infusion with PCA, PEG, incentive spirometry, hydration at 1x maint (PO or IV), O2 with target sats >95
Transfusions in the setting of splenic sequestration for SCD
5-10ml/kg
Do not want Hb to rise above 100
ACS SCD workup and management?
- CXR
- Blood culture
- CBC
- Retics
- Cross match
- NP swab + mycoplasma
TX EMPIRICALLY WITH CTX + AZITHRO
Fever in SCD patient -> workup and initial management?
Oral temp >38, rectal temp >38.5
ALL FEBRILE PTS GET
- CBC, retics, bili, blood culture, type and screen, CXR
AND empiric CTX within 30 minutes
Low risk criteria for SCD + fever?
- well appearing
- Temp <40
- Age >6mo
- WBC 5-30
- Plts >100
- Hb >60 and not 20 less than baseline
- No specific features concerning for severe infection (meningitis, osteo, SA etc)
- First presentation for this illness
CAN D/C HOME WITH F/U IN 24HR
Screening for stroke in SCD patients?
TCD yearly age 2-16
Stroke prevention for SCD patients?
Exchange transfusion program
Risks for kids associated with second hand smoke?
-Prematurity
- SIDS
- Asthma
- Pneumonia
- Recurrent AOMs
- Becoming a smoker
Nicotine can induce epigenetic changes that sensitize the brain to other drugs - True or False?
True!!
Also impacts impulsitivity and attention and teens develop addiction at lower levels of nicotine than adults
Interventions that work to reduce smoking
Education and counselling
School based interventions
Legislation
(community interventions do not work well)
Factors that make you more likely to quit smoking?
Older age
Male
Pregnancy/Parenthood
Academic Success
Team sports
Peer and family support
Slow metabolizer
Side effects of nicotine replacement therapy?
skin irritation
tachycardia
hypertension
Most effective contraception?
LARC (IUD) = 1st line
What form of birth control is associated with bone demineralization?
Depo (give Ca, Vit D, weight bearing recommended)
Starting dose of estrogen for OCP to protect bone health?
30-35mcg
Quickstart method for OCP?
- Pregnancy test if unprotected sex since last period
- If neg, start that day +repeat preg test in 21d
- Backup condoms x7d
Children of adolescent parents are at increased risk of:
- prenatal death
- prematurity
- LBW
- poor growth
- accidental injury
- behavioral problems
- substance use
- delayed speech and language
Cannabis withdrawal symptoms
2/5 of
- Irritability
- Anxiety
- Depressed mood
- Sleep disturbances
- Appetite changes
1/6 of
- Abdo pain
- shaking
-fevers
- chills
- h/a
- diaphoresis
Sx start 24-72hrs after last use and persist 1-2 wks
Best intervention for cannabis use disorder?
Motivational interviewing
3 ways to set TGW for AN-R?
- based on prior growth curve
- % wt for height
- 2kg above when they lost menses
** reassess every 3-6mo
Yearly STI screening
<15yrs?
>15yrs?
<15= urine chlamydia and gonnorhea via NAAT + pharyngeal or anal if indicated
> 15 = urine NAAT, syphillis, HIV
Imaging in cases of abusive head trauma?
- Start with CT scan
- Skeletal survey, repeat in 10-14days if negative the first time (<2 with signs of NAT = needs skeletal survey!!)
- If LE elevated on labs, do abdo CT
- Optho exam <6mo
Red flags for bruising?
TEN-4-FACESp
Torso
Ears
Neck
<4 mo
Frenulum
Angle of mandible
Cheeks
Eyelids
Subconjunctiva
patterns
Other concerning features:
Feet
Buttocks
Torso
Upper arms
Patterned
Not in keeping with story
Red flag fractures for NAT
Age <1
Rib
Metaphyseal
Humerus <18mo
Femur in non-ambulatory
Scapula
Spinous processes
Sternal #
Multiple # in different stages of healing
First step if reported sexual abuse?
Call CAS before physical exam
Do not ask the child about the event
PE finding indicating hymenal trauma?
Complete cleft that extends through the base from 3-9 o clock
What are the only 2 things DIAGNOSTIC of sexual abuse?
Pregnancy
Semen taken from childs body
STI testing in pre-pubescent children with concern for sexual abuse?
- Swab for cx is gold standard
- Do not prophylactically treat pre-pubescent kids
- HIV testing at presentation, 6, 12, and 24 weeks
- HCV testing at 12 +24 weeks
When to give HIV PEP in cases of sexual abuse?
Within 72 hrs if significant exposure (penetration anywhere without a condom)
What can buffer childhood negative experiences/ACEs?
Safe, stable, nurturing relationship with one adult
When do temper tantrums peak?
Age 3
When are disruptive behaviors classified as a disorder?
- persist x 6mo
- persist in multiple settings
- impair functioning
- distressing for child and family
Stinging insect hypersensitivity, treatment for…
-Large local reactions
-Isolated systemic cutaneous
-Systemic
-Large local reactions: antihistamines
-Isolated systemic cutaneous: antihistamines, insect avoidance
-Systemic: epipen, refer to allergist for consideration of venom immunotherapy
Screen time cut offs based on age?
<2= no screen time
2-5 = 1hr (interactive and with family)
>5yrs= <2hrs, educational content preferred, watch with family
Lead toxicity: Acute symptoms? Treatment based on lead level?
Sx: headache, anemia, constipation, vomiting, clumsy, altered LOC, renal failure
Lead level 5-14 - test again at 3 + 6mo
Lead level >15 - abdo XR, gut decontamination if present in GI tract
Lead level >44- chelation
Indications for strict avoidance of amoxicillin or penicillin?
True IgE mediated allergy
SJS
SSLR
DRESS
AGEP
Gold standard to rule out beta lactam allergy?
Oral drug challenge
If there is a history of mild exantham with beta lactam, should you do SPT or oral drug challenge?
No! Neither!!
Can prescribe again with no testing
If parents ++ nervous give test dose 15mg/kg with 1hr observation to reassure so that they take it when they go home
First line management for challenging behaviors?
Parent training
Treatment for enuresis
Behavioral therapy 1st line (congratulate for going pee before bed, don’t drink fluids in the evening)
Alarm if >2x/week but not every night
DDAVP if wants to go to a sleepover (can try for 3mo at a time, MUST fluid restrict to <200ml in the evening or risk of hyponatremia)
Strategies for managing GERD in infant?
- 2 wk trial of thickening feeds
- Avoid cows milk protein x 2wks (continue breastfeeding)
- Infant positioning strategies (only when awake, do not prop up when asleep)
** DO NOT USE PPI
Natural history of infantile hemangiomas
proliferative phase in 1st 4 weeks, grow until 3mo-1yr -> plateau at 12-18mo-> involute between 1-7 yrs of age
50% leave scars
Indications to tx Infantile Hemangiomas?
Tx? Side effects of tx?
Indications to tx:
- airway compromise
- around the eye
- lip or nasal
- auditory canal involved
- ulcerative
- segmental facial hemangiomas
- risk of disfigurement
Tx= propanolol PO x 6 months
s/e: sleep disruption, mottling, hypotension, bronchospasm, hypoglycaemia, 2nd or 3rd degree heart block
Indication for AUS in infantile hemangiomas?
> 5 cutaneous hemangiomas
PHACES
Posterior fossa
Hemangiomas (large >5cm, segmental and on face)
Arterial abnormalities in brain/neck
Coarct
Eyes
Sternal cleft
Sternal Cleft
Mild head trauma = GCS ___
Moderate = GCS ___
Severe = GCS ___
Mild = 14-15
Moderate = 9-13
Severe = <8
Management of head trauma after ABCs
-mild
-moderate
-severe
Mild (GCS 14-15 + now asymptomatic) = d/c home, if headache or repeated vomiting can observe x 4-6 hrs
Moderate (GCS 9-13) = CT and admit
Severe (GCS<8)= Intubate, CT, ICU, maintain normal ICP (prevent hypotension, promote normothermia, hypercarbia, sedate well)
CATCH criteria for CT of minor head injury:
High risk
-> GCS <15 2hrs post injury
-> suspected open or depressed skull #
-> worsening headache
-> persistent irritability (<2yrs)
Medium risk-
-> basal skull fracture
-> large boggy hematoma in infant (XR first)
-> dangerous mechanism of injury (car accident, fall from 3ft, fall off of bike with no helmet, fall down 5 stairs)
Other indications
- focal neuro deficit
- coagulopathy
Premedication for intubation of the neonate?
- Atropine (prevent reflex bradycardia)
- Fentanyl
- Succ (risk of hyperkalemia)
Starting flow and FiO2 for HFNC?
1-2L/kg/min
FiO2 should start at 50%
When to use ondansetron for viral gastro? Dose? When to start ORT?
> 6mo with vomiting secondary to gastro + mild/moderate dehydration or who have failed ORT
Dose: 0.15mg/kg
Start ORT 15-30 mins after ondans given
Management of croup? When to admit?
Dex for ALL (0.6mg/kg PO)
Epi nebs for moderate - severe (must observe for 2-4 hours after neb)
Admit if: 4hrs post steroid AND continued resp distress, stridor at rest or indrawing
ETT sizing?
Cuffed:
3 if <1yr
3.5 if 1-2 yr
3.5 + (age/4) if >2yr
Uncuffed = cuffed +0.5
Post cardiac arrest care?
- Avoid hyperoxia (sat goals 94-99)
- Avoid hypotension (use fluids +pressors)
- Therapeautic hypothermia (32-34’C x 2 days, then 3-5d normothermia)
- No routine sz proph
- EEG within 7d to help prognosticate neurologic outcomes
Management of acute asthma exacerbation?
- Sat goals >92-94
- Salbutamol MDI (<20kg = 5 puffs per dose, >20kg = 10 puffs per dose) x 3 within first hour then stretch as tolerated to q30mins-1hrly in second hour
- Atrovent x 3 doses in first hour (<30kg = 4 puffs, >30kg = 8 puffs)
- Steroids PO within 1hr of presentation (0.3mg/kg)
- IV mag sulf if severe and not improving in 1-2hrs
- IV ventolin in ICU can be considered
- Non invasive is preferred over intubation
Admit vs ICU vs Discharge for Acute Asthma Exacerbation?
Admit if: need for O2, PRAM score >4 at 6hrs post steroid, ventolin more often than q4h
ICU if: severe and not improving in 1-2hrs
D/C if : O2 sats >92 on RA, PRAM <3 at 1-2hrs post ventolin, not needing ventolin more than q4h
Discharge plan after acute asthma exacerbation (when to prescribe ICS):
Rx ICS if:
- child with symptoms 2x per month
- moderate-severe exacerbation +steroids in the last year
- If preschool age with 8d per month of sx
If on ICS already:
<12 = increase to medium dose
>12= switch to Symbicort and use Symbicort as rescue
Most common cause of status epilepticus in kids per CPS statement?
Prolongued febrile seizure
Management of status epilepticus?
- ABCs
- suction if needed
- position on side
- O2 100%
- assisted ventilation if brady, hypotension, poor perfusion - Stop the sz
- Meds if >5-10 mins
- 2 doses of benzos (use IN or IM if no IV)
- Check glucose and give D10W bolus if <2.6
- Get IV access
- If still seizing 5 mins after second benzo dose -> try second line meds (fospheny/pheny/keppra/VPA/phenobarb)
- If still seizing 5 mins after 1st second line med -> try another second line med
- If still seizing after 2 second line meds -> ICU for midaz infusion
When should you avoid VPA?
Patients <2
Concern for unexplained devel delay (potential mitochondrial disease)
What second line med to use in status epilepticus if suspected overdose?
Phenobarb
Who is high risk for SIADH? What is the choice fluid for admitted patients?
-peri/post operative
-resp infections
- neurological infections
Choice fluid = D5NS (0.9)
When to consult anesthesia pre-op/prior to sedation?
- Difficult airway
- Resp disease uncontrolled
- Cardiac disease
- Prem until PMA 60wks
- Obese patient
- OSA
Fasting guidelines for procedural sedation?
1hr for clear liquids
4hrs human milk
6hr formula or light meals
Organism associated with early childhood caries?
Strep Mutans
When should kids see a dentist?
within 6 months of first tooth, no later than 1yr
Who should get flouride varnish and when?
Indigenous kids
- Biannually starting with first tooth and then q3-6 months regardless of other fluoride sources
Teeth brushing, how much toothpaste to use?
<3yrs = rice sized
3-6yrs = pea sized
Who is at risk of adrenal suppression from exogenous glucocorticoids?
> 2weeks systemic steroids
3mo ICS (particularly >500mcg/day of fluticasone)
1mo swallowed ICS
** can be at risk for up to one year after steroids are discontinued if there are several months of exposure
Testing for Adrenal Insufficiency
First AM cortisol
- diagnostic if <100, ruled out if >350
ACTH stim test as confirmatory or in children without normal sleep/wake cycle
Physiologic glucocorticoids? Stress dosing for those with adrenal suppression?
8mg/m2/day = physiologic
Severe illness/injury= 100mg/m2/day hydrocort initial dose then 100mg/m2/day divided q6hrly
Moderate illness: 30-50mg/m2/day Hydrocort divided q6hrly
DKA diagnostic criteria on labs:
pH <7.3, bicarb <18, AG >12
Serum ketosis (beta hydroxybuterate) or ketonuria
Hyperglycaemia (BG >11)
DKA severity
Mild = pH < 7.3, HCO3 10-18
Mod = pH <7.2, HCO3 5-9
Severe = pH <7.1, HCO3 <5
Risk factors for cerebral edema in DKA:
- New onset diabetes
- Longer duration of symptoms
- Young age
- Severe acidosis
- Laboratory evidence of severe dehydration (Cr,urea)
- Hypocapnea
- Insulin bolus or insulin in 1st hour
- Sodium bicarb given
- Rapid administration of hypotonic fluids
Treatment of DKA
+ when to add dex
+ when to add K
(talk through the pathway)
- Fluids
- ALL PTS get 10-20ml/kg NS over 20-30mins regardless of fluid status
- After bolus, start fluids at maintenance + correction of fluid deficit (4 - 6.5ml/kg)
- Add dextrose to IVF when Glu 15-17
- Do not drop glucose by more than 5mmol/hr - Insulin
- Start after 1hr of fluids and when K is >3
-0.1units/kg/hr
- If glucose drops by >5 in 1hr and glucose containing fluids are maxed out -> drop to 0.05units/kg.hr - Lytes
- Add 40K to IVF when K <5 and pt peeing
- Replace phos if <0.5
-Check lytes q2hrly
- Check glucose q1hrly
Pathway for workup of GDD?
1st
- Hearing/vision
- EEG if seizures
2nd
- Chromosomal microarray (best dx yield)
- Fragile X
- CBC, glu, lytes, urea/cr, liver enzymes, TSH
- CK, ammonia, lactate, plasma AA, acylcarnitine profile
- urine organic acids
- MECP2 (if hx suggestive of Rett)
3rd
- MR brain
- Consult genetics and metabolics
GDD, hepatomegaly, dystonia, abnormal liver function - what investigations should you add to your first tier labs for GDD workup?
Copper and ceruloplasmin (Wilsons!)
Red flags for Inborn Error of Metabolism? (list as many as you can!)
- Family hx unexplained SIDS or devel delay
- Consanguinity
- IUGR
- FTT
- Abnormal head circumference
- Recurrent vomiting, ataxia, sz, lethargy
- Regression
- Unusual dietary preferences
- Organomegaly
- Hypotonia
- Cataracts
- Coarse facies
Red flags for ASD?
- persistant head lag >6mo
- feeding/sleeping issue s
- Excessive reactivity, or passivity
- No reciprocal smile
- No babbling or gesturing <1yr
- Limited response to name
- Repetitive behaviors
- Unusual play
- Language delay
- No pointing by 12-15mo
- No pretend play
Risk factors for ASD:
- Male
- Family history
- Parents >35
- Maternal obseity, diabetes or HTN
- Maternal TORCH
- Maternal valproate
- LBW
- Prem
You suspect ASD in one of your patients, when should you refer for SLP/OT?
As soon as you suspect!! Even if diagnostic assessment is not complete/clear, refer as early as possible for early intervention services to improve outcome
Diagnostic Criteria for ASD:
Social communication impairment (all 3)
1. social emotional reciprocity
2. Impaired non verbal behaviors
3. cannot develop or maintain relationships
AND
Restricted/repetitive behaviors/interests (2/4)
1. Stereotyped speech and behaviors
2. Resistance to change
3. Fixed Interests
4. Hypo or hypersensitivity to sensory input
+ Present in early development
+interferes with functioning
+ symptoms not attributable to ID or GDD
Process for diagnosing ASD? (who can diagnose it)
If clearly meets criteria-> pediatrician can diagnose
If symptoms mild or atypical or <2yrs old -> pediatrician + consult development or psychology
If co-existing health concerns/complex hx-> consult development
What diagnostic tool has the highest sensitivity for ASD?
ADOS (validated >12months)
Other tool for kids:
- Childhood autism rating scale (>2yrs)
Questionnaires for parents:
- ADI (for kids >2)
- Social responsiveness scale (for kids >2.5)
What medications can be used in children >5 to manage irritability and aggression associated with ASD?
- Risperidone
- Aripiprazole
Post-diagnosis of ASD, next steps?
Test for associated medical conditions: hearing, vision, dental, genetic if indicated
Tx constipation, consider melatonin for sleep, RD for feeding challenges
Refer to SLP, OT, PT, psychoed
INITIATE BEHAVIORAL SUPPORTS EARLY, use parent training to manage challenging behaviors
Diagnostic criteria for ADHD:
- Sx present before age 12
- Sx persist x 6 mo
- need >6 symptoms in either inattention or hyperactivity
- Sx present in 2 settings
- Impair functioning
Genetic syndromes at high risk of ADHD:
- Fragile X
- Turners
- TS
- NF-1
- DiGeorge
Treatment for ADHD
<6yrs = parent behavioral training
>6yrs = meds if functionally impaired
Non pharm: exercise, psychoed, parent behavioral training, organizational skills training
Stimulant meds:
- Long acting = first line
- No routine ECG
- ECG only if abnormal cardio exam
Spastic diplegia CP is associated with what perinatal brain injury?
periventricular white matter injury (PVL)
Health surveillance for CP GMFCS 3+4:
Spasticity/Dystonia
- when causing pain or limiting function consider tx with oral baclofen or if focal consider botox
Hip Subluxation
- Hip and pelvis XR every 6-12 mo
Bone health
- Vit D, Ca
Aspiration
- Upright position during feeds, pacing, thickening feeds, consider G tube if recurrent aspirations
Siallorhea
- Anticholinergics
- Botox to submandibular +/- parotid glands
DCD Diagnostic Criteria and Soft Signs:
Diagnostic Criteria
A) motor skills below expectations
B) interferes with activity
C) onset in early development
D) not better explained by ID
Soft signs
- hand posturing when walking on heels/toes
- one hand copying the other
- looks at hands to do hand movements
- low to normal tone
Developmental Coordination Disorder Treatment
Refer to OT/PT
Normal growth:
- 1st year of life
- 2nd year of life
- 2-5yrs
1st yr: 7kg, 21cm
2nd yr: 2-3kg, 12cm
2-5 yrs: 1-2kg/yr, 6-8cm/yr
Management of picky eating:
- parents decide what to offer, child decides how much to eat
- allow some food preferences if growing well
- give smaller portions and add more as appetite increased
- no juice
- no grazing
- family meals
- 20 mins at the table
- no toys/distractions during meals
When to introduce first foods?
Can start purees at 4-6mo
Ideally exclusively BF x 6 mo
6mo start introducing foods, start with iron rich
When to introduce cows milk into the diet? How much to offer?
9-12 mo, homo milk only up to 2yrs
- offer only 500ml per day
When to introduce water to the diet?
6mo
What classifies an infant as “high risk” for food allergy? When to introduce allergenic solids?
High risk = personal or first degree relative with atopy
Introduce allergenic solids early at 4-6mo, continue to offer multiple times a week so that they do not become sensitized and allergic
Once cows milk has been given, it should be given daily to prevent loss of tolerence
BF does not prevent food allergy!!
Risk factors for iron deficiency anemia in infants:
- prem
- BW <2500g
- Mom obese or anemic
- Early cord clamping
- Male
- Exclusively BF for longer than 6mo
- Indigenous
- Too much cows milk
Iron supplementation for prevention of IDA?
BW <2000g: 2-3mg/kg/d x 1yr
BW 2000-2500g: 1-2mg/kg/d x 6mo
Start oral iron when at full feeds (120ml/kg/d)
Treatment dose of iron for anemia of prematurity?
4-6mg/kg/day x 3mo then reassess
FPIAP: presentation, tx, resolution?
Food Protein Induced Allergic Proctocolitis ie; CMPA
hematochezia in otherwise well infant generally within 1st 6mo of life
Tx: maternal elimination diet (1st milk and soy and then egg and corn)
Resolution: by 1yr
FPIES: presentation, treatment, resolution?
Bonus- do they need an epipen?
emesis 1-4hrs after ingestion of a food with profuse and repetitive vomiting, onset around 2-7mo of age, no cutaneous symptoms
Tx: IV fluids and ondans
Dx: oral food challenge with IVF available
No epipen needed
Resolution: by 2-5 years
* needs to be seen by allergist to re-introduce allergenic foods to diet
Vit D supplementation in Indigenous children
400IU per day in all <2
800IU per day if exclusively breast feeding
Children 1-5: 400IU per day if high risk
ROP who to screen? When to screen?
Who: all infants <31 weeks with BW <1250g
When: at 31weeks or 4 weeks of age whichever is LATER
Who needs treatment for ROP?
Zone 1-> any stage with PLUS
Zone 1-> Stage 3 without plus
Zone 2-> Stage 2 or 3 with PLUS
Treat within 72hrs of detection with retinal ablation or anti VEGF
When to stop screening for ROP?
Full retinal vascularization
PMA 50 weeks and no worsening ROP
ROP regressing
Risk factors for severe hyperbilirubinemia in the neonate:
- Jaundice in the 1st 24hrs
- GA <38wks
- Sibling with severe hyperbili
- Bruising or cephalohematoma
- Male
- Mom >25yrs
- Asian or European
- Dehydration
- Exclusively breastfed
For routine screening in a neonate, when should you check a bili?
TCB or TSB at 24-72hrs of life
Who should receive phototherapy?
All infants with severe hyperbilirubinemia (>340 at any time = severe)
Risk factors + TSB 35-50 below the treatment threshold
Check a bili within 2-6 hours of starting photo if baby has risk factors for severe hyperbili
Not CPS specific but thresholds to remember
150 at 24hrs
200 at 48hrs
250 at 72hrs
300 at 4 days
340 anytime after
Indication for exchange transfusion for neonatal hyperbili:
TSB 375-425
While awaiting exchange transfusion, do intensive photo, fluids and IVIG and then repeat TSB prior to starting exchange
List evidence based strategies for managing pain in the neonate:
Bonus: what pain management technique should be used for circumcisions?
- sucrose gel
- kangaroo care
- swaddle
- EMLA for IV and LP (not for heel pokes)
- Avoid NSAIDS
- Minimal evidence for acetaminophen
- Use a sub q ring block for circumcisions
Should you do the carseat challenge prior to discharge from NICU?
NO! Carseat test is unreliable and not associated with worse outcomes
Polysomnography is a better test if worried about baby maintaining sats after discharge
RF for AOM? (list as many as you can!)
- Young age
- Daycare
- Orofacial abnormalities
- Household crowding
- Exposure to cigarette smoke
- Pacifier use
- Short duration of BF
- Family history of ear infections
Physical exam feature needed to diagnose AOM?
MEE (buldging TM has high specificity as does perforated membrane)
If no MEE-> probably viral
Imaging modality of choice for suspected mastoiditis?
CT
Tx of AOM >6mo: who can wait 48hrs vs. who needs tx immediately?
Can wait:
- Temp <39
- Able to sleep
-<48hrs of illness
Tx immediately:
- T >39
- Severe pain/irritability
- Symptoms for >48hr
- Perforated TM
Treatment of AOM >6mo: who gets 5d vs 10d of abx?
10 days if: 6mo-2yrs, or perforated
5 days: >2yrs
Antibiotic of choice for AOM >6mo?
What about if AOM + conjunctivitis?
1st choice = Amoxicillin (can do 45-60mg/kg/day div tid, or 75-90mg/kg/d div bid)
If AOM + conjunctivitis-> suspect H flu and give amox clav or cefuroxime
If penicillin allergy: clarithro/azithro
If initial tx for AOM fails, what abx should you use?
If no improvement for 2-3d on amoxicillin -> treat with amox clav x 10days
Clinical features of congenital syphilis?
Bonus: features in older kids?
- snuffles/rhinitis
- barbershop pole umbilical cord (necrotizing funisitis)
- rash (dequamating, involves palms and soles)
- HSM
- Lymphadenopathy
- Osteochondritis/perichondritis
- Winged scapula
- SNHL
Older kid: saddle nose, frontal bossing, hutchinson teeth, mulberry molars
Mom had syphilis prior to pregnancy and was adequately treated PRIOR TO PREGNANCY, management of baby?
Nothing! No workup or treatment if managed prior to pregnancy
Mom had syphilis and was treated during pregnancy >4weeks before delivery, her RPR dropped 4 fold, management of baby?
Send RPR/TT at 0, 3, 6, 18mo
If baby does not have syphilis -> RPR should drop by 3 months and be non-reactive by 6mo. TT should be neg by 18months
If infant RPR + at 6mo-> do full workup and treat
Mom had syphilis and was untreated OR had inadequate drop in RPR OR was treated with something that was not penicillin OR was treated <4weeks prior to delivery, management of baby?
RPR/TT (0,3,6,18mo)
XR long bones
CBC
Liver enzymes
Lumbar Puncture
TREAT (10d IV Pen G 50,000U/kg)
Baby born to mom with untreated syphilis, baby’s initial CSF was abnormal, when should you repeat it?
Repeat LP q6months until CSF normal
Baby treated for congenital syphillis,
____ fold drop in RPR and loss of treponemal Ab by ____ months would reflect adequate treatment.
4 fold drop in RPR and loss of treponemal Ab by 18 months would reflect adequate treatment.
Well appearing infant >3months with suspected MRSA skin abscess, no associated cellulitis. Tx?
I+D only for well appearing, afebrile infants >3mo with no cellulitis
<3months will always get antibiotics!
> 3mo WITH FEVER will always get antibiotics!
FEBRILE 5 month old infant with suspected MRSA skin abscess, tx?
If febrile and >3mo, even if well appearing -> IV antibiotics (consider vanc)
Well appearing 28d infant with suspected MRSA skin abscess, tx?
If <1mo with suspected MRSA skin abscess -> IV antibiotics (vanc)
UNLESS no fever and abscess <1cm, then can use PO clinda
Infant 1-3months of age, afebrile, suspected MRSA skin abscess. Tx?
What if they had surrounding erythema suspicious for cellulitis?
Remember <3mo will always get abx!
If no fever -> Septra PO
If concern for cellulitis-> Septra and Keflex PO
What is the best strategy to reduce recurrent UTIs?
Manage constipation!!
When would you consider prophylactic antibiotics for UTI?
Grade IV or V reflux or significant urogenital abnormality-> discuss with nephro or uro 1st!!
If you are going to use prophylactic abx for UTI:
- How long to use for?
- What abx to use?
No longer than 3-6 months
Choice Abx: Septra or Nitrofurantion at 1/4 the daily dose for treatment
If child with Grade IV VUR on prophylaxis has a bug resistant to septra/macrobid, what to do?
D/C prophylaxis!! Do not use more broad spectrum
You should not test children under ___ yrs old for C diff?
Do not test under 1yr
Treatment of mild C diff (<4 stools per day)
Stop precipitating abx and reassess in 48hr
Treatment of moderate C Diff (>4 stools per day, low grade temp)
PO metronidazole x 10-14d
Treatment of severe C Diff (systemic toxicity)
Vanco PO x 10-14d
If severe and complicated (pseudomembranous colitis) -> Vanco PO and metronidazole IV x 10-14 days
First reoccurrence of C diff, how to treat?
Initial regimen or PO vanco x 10-14d
Second reoccurance of C diff, how to treat?
Vanco x 4-6 week taper
When can a kid with chickenpox go to school/daycare?
As soon as she or he is well enough to participate normally in all activities, regardless of their state of rash (even if still infectious)
Feb2024 update: do not go out until rash crusted over
Infectious period
contagious 2d before rash onset until all crusted over
Mom presents in labor with undocumented HIV status, next steps?
Rapid HIV for mom
If rapid positive-> intrapartum and infant postnatal prophylaxis (zidovudine) and send serology
If Ab/serology test positive for Mom, send baby HIV PCR
If baby HIV PCR +-> start full treatment with 3 drug regimen x 6 weeks
Clinical features of cCMV?
- microcephaly
- IUGR
- HSM
- Petechial rash
- Jaundice
- Hypotonia
- Chorioretinitis
- SNHL
Laboratory features of congenital CMV
Low platelets
Increased ALT
Conjugated hyperbili
Risk Factors for cCMV (who to test)
- Clinical features of cCMV
- Fetal US with findings suggestive of CMV (microcephaly, IUGR, periventricular calcifications)
- HIV exposure
- Primary immunodeficiency
- Babies who fail the newborn hearing screen
HUS finding in congenital CMV?
periventricular calcifications
Gold standard test for congenital CMV
Urine CMV PCR prior to 21d
If CMV + newborn, what other investigations do you need to send?
- CBC
- Bili
- Liver enzymes
- HUS if normal neuro exam (MR if abnormal neuro exam)
- Hearing eval
- Optho eval
** DO NOT NEED TO SEND CSF UNLESS SZ OR SEPTIC
Indications for cCMV treatment
- CNS disease
- chorioretinitis
- severe single system
- multisystem (3+ systems + abnormal labs)
Treatment for cCMV
Valganciclovir for 6 mo
can use IV ganciclovir if very unwell child
** monitor CBC and LE while on treatment
How frequently do children with cCMV need their hearing checked?
at least every 1 yr until school age
Antibiotic choice/treatment duration for Febrile UTI?
Bonus: when can you use PO vs IV?
PO Cefixime 8mg/kg/d
IV Gent +/- Amp
IV Ceftriaxone (50-75mg/kg/d or IV Cefotax 150mg/kg/d)
Duration of tx: 7-10 days
(2-4d if not febrile)
PO:
-tolerating PO intake
- not seriously ill
- >2-3mo age
- no structural renal anomalies
Urine colony count cut offs for infection?
Clean catch: > 10e8 CFU/L
In and out: >10e7 CFU/L
Suprapubic: Any growth
Child with febrile UTI has been improving on CTX, sensitivities come back with bug resistant to CTX. What to do next?
Continue current abx
Repeat urinalysis and culture and change abx only if signs of persistent UTI
<3yrs old, looks happy and well but has a temp >39’C. No symptoms of upper resp infection. What investigation must you do?
Urinalysis in all <3yrs with unexplained fever >39 and no apparent source!
First febrile UTI <2yrs: workup?
KUB US during illness or within 2 weeks
VCUG not needed for 1st febrile UTIL unless US suggests VUR, renal anomalies or obstructive uropathy
Well infant, Mom has untreated gonorrhoea, what to do for baby?
IM CTX + conjunctival swab
If baby looks unwell = blood culture, CSF, consult ID, tx for 10 days
Well infant, Mom has untreated chlamydia, what to do for baby?
Nothing, swab only if symptomatic
If symptomatic and swab + = treat with erythromycin x 14d
Treatment of scabies?
Bonus: when can they return to school?
5% permethrin cream
- neck to toes overnight x 12 hrs (if its a baby do head to toes)
- repeat in 7days
- treat all household members
If low compliance with 5% permethrin-> PO Ivermectin as a single dose
** can return to school the day after the initial treatment
HPV vaccine for 9-14 yrs, how many doses, how far apart?
2 doses, 6 mo apart
HPV vaccine >15 yrs, how many doses, how far apart?
3 doses at: 0, 1, 6 mo
When to give Tamiflu?
ALL HOSPITALIZED W/ INFLUENZA and basically any underlying comorbidity = start even if >48hrs since symptom onset
If <5yrs and mild, start if <48hrs from symptom onset, otherwise supportive care
When should you consider screening for HCV? (RF)
- Mom from or lived in high HCV prevalence area (Asia, Eastern Europe, Latin America, Carribean, Middle East, Africa)
- Maternal drug use
- Unprotected sex
- Sexual assault
- Unsafe piercings/tattoos
- Medical procedures done in other countries
Risk of vertical transmission of HCV? Factors that increase risk?
6% w/o HIV, 10% w/HIV
Increase risk of transmission if:
- high maternal titres
- high ALT in yr before pregnancy
- IVDU
- fetal scalp monitoring
-prolonged ROM
-baby is female
- second born twin
**No difference between C/S or vaginal delivery
Testing of infant of HCV + mom?
Best method: serology at 12-18mo
If cannot ensure f/u: HCV PCR at >2mo, still need to rpt serology at 12-18 mo if neg to ensure Ab clearance
If serology negative at >6mo, NO REPEAT TESTING
If serology positive anytime earlier than 12-18mo, REPEAT AT 12-18 mo
If positive serology at 12-18mo, do HCV PCR to determine if spontaneously cleared or active infection
HCV restrictions for school/daycare?
None! Cannot be transmitted in saliva, urine or stool
What is the most sensitive and specific imaging modality for osteo?
MRI with gad (earliest finding is marrow edema)
Bone scan is second best
Most common bugs for Septic Arthritis?
Staph aureus
Kingella Kingae in infants
Most common bugs for Acute Osteoarthritis?
Staph aureus
Kingella Kingae
Strep pneumo
Strep pyogenes
Salmonella in SCD
First step in managing Septic Arthritis?
Urgent ortho consult!! (would like to aspirate joint before starting antibiotics if possible)
Joint aspirate = diagnostic test
US can confirm presence of fluid (but do not need it if high clinical suspicion)
Empiric treatment for Osteo or SA?
What if they are unimmunized and <4yrs?
Cefazolin 100-150mg/kg/d
if unimmunized and <4yrs: cefuroxime preferred to cover for H flu
Criteria for stepdown from IV to PO antibiotics for osteoarticular infections?
Total course of abx?
Stepdown abx?
- Afebrile
- CRP downtrending
- 3-7d IV completed
Duration of tx: 3-4 wks (6 wk if hip SA)
PO abx: Keflex 120mg/kg/d
**CRP must have normalized before stopping PO abx
Risk factors for early onset sepsis in term infants?
-GBS bacturia during pregnancy
- Infant with previous invasive GBS
- Maternal GBS colonization
- Maternal fever >38 at time of delivery
Adequate Intrapartum Prophylaxis for GBS?
1 dose of Pen G or Amp or Cefazolin 4 hours before birth
(**do not need IAP if C/S prior to rupture of membranes)
GBS+ Mom, adequate prophylaxis, no risk factors: management of baby?
Routine
GBS+ Mom, inadequate prophylaxis, no other risk factors: management of baby?
VS q2-3hrs x 24hrs
D/C 24-48hrs
GBS + Mom, WITH RISK FACTORS, regardless of adequate prophylaxis: management of baby?
VS q2-3hrs x 24hrs
D/C 24-48hrs
Mom GBS -/unknown, WITH RISK FACTORS: management of baby?
1 risk factor only = Routine
> 1RF=VS q3-4hrs x 24hrs
D/C 24-48hrs
Mom GBS -/unknown, with no risk factors: management of baby?
Routine
Maternal chorio, term infant who looks well: management of baby?
VS q3-4hrs x 24hrs
Consider CBC at 4hrs
RF for Invasive GAS Disease?
- recent pharyngitis
- recent varicella
- recent soft tissue infection
- NSAID use
Strep TSS Diagnostic Criteria:
Hypotension or shock PLUS two or more of:
- Renal impairment
- Coagulopathy (Plts <100 or DIC)
- Hepatic abnormalities (high AST, ALT, bili)
- ARDS
- Generalized macular rash
need to isolate strep pyogenes (GAS) from normally sterile body site
Empiric therapy for Strep TSS?
Cloxacillin + Clindamycin +/- Vanco
Definitive diagnostic test for Nec Fasc?
Surgical exploration
What counts as SEVERE invasive GAS?
- Strep TSS
- Soft tissue necrosis
- Meningitis
- Pneumonia (with isolation of GAS from pleural fluid)
- Death
Non severe: bacteremia, cellulitis, abscess, lymphadenitis, SA or osteo
Chemoprophylaxis for close contacts for Invasive Group A Strep?
ONLY FOR SEVERE IGAS
use keflex x 10d
close contacts: (within past 7d)
- household >4 hr/day or 20 hr total during the previous 7 days
- non-household: shared bed, sex, direct contact with mucous membranes/secretions/open skin
Diagnostic test for malaria?
Thick and thin smears, 3 samples over 24-48hrs
Treatment for severe malaria?
Artesunate
Fever in return traveller presenting with fever, chills, headache, myalgias, LACY RASH OVER THE THORAX, FACE, and FLEXOR REGIONS. Labs show leukocytosis, neutropenia and high AST/ALT. Dx and tx?
Dengue
- Supportive care, avoid NSAIDS!!
Abx choice for uncomplicated pneumonia:
- Outpatient?
- Inpatient (no shock/resp failure)?
- Inpatient (shock/resp failure)?
- Multilobar?
- Empyema?
- Outpatient: PO Amox
- Inpatient (no shock/resp failure): IV Amp
- Inpatient (shock/resp failure): IV CTX
- Multilobar: Add vanc
- Empyema: IV CTX or cefotax
- Atypical: Azithro x5d or clarithro x 7d
Duration of tx for uncomplicated pneumonia:
- Outpt
- Inpt
- Empyema
- Outpt: 5 days
- Inpt: 7-10days
- Empyema: 3-4 weeks
Imaging for complicated pneumonia?
CXR then US
(do not use CT unless suspecting malignancy)
Most common bugs for complicated pneumonia?
Strep pneumo
Staph aureus
GAS
Management of complicated pneumonia (empyema)?
Empiric abx?
Duration of tx?
Stepdown?
Procedural?
Empiric abx: IV CTX or cefotax (+vanc if suspected MRSA)
Duration of antibiotics: 3-4 weeks
PO stepdown agent: amox unless pleural fluid cultures H flu or MRSA
Recommend early use of chest tube with fibrinolytics for source control (use TPA x 3 days)
When TB is suspected CLINICALLY, what test should you do?
Sputum for culture - send for AFB stain and culture
- All patients with TB needs HIV testing
TST cut offs for positive test
> 5mm for contact cases + immunosuppressed
> 10mm for everyone else
TST is a better test for TB than IGRA/Quantiferon in patients <age ___?
TST better for <2yrs old
Management of close contacts for TB?
ALL GET TST +CXR
If <5yrs and TST <5 = WINDOW PROPHYLAXIS (one agent effective for index case +Vit B12)
- rpt TST 8-10 weeks after last contact with + case
If >5yrs and TST <5 = no treatment
- rpt TST 8-10 weeks after last contact with + case
If any age and TST >5 = TREAT: INH and Rifampin x 12 weeks
Patient with TB + in resp secretions, isolation requirements?
isolate until 3x sputum negative and after 2 weeks of therapy
Treatment for LTBI (TST and IGRA +, CXR clear)
Isoniazid and Rifampin x 12weeks
Non-typhoidal salmonella:
- Clinical presentation
- Workup
- Treatment
- Return to daycare
- Clinical presentation: non-bloody diarrhea +/- fever and vomiting. Hx contaminated food or contact with reptiles
- Workup:
Send stool cx -> if stool cx comes back +, and pts is <3mo, >3mo and febrile, or immunocompromised -> send blood culture
-> send CSF if <3mo - Treatment: start CTX if blood culture comes back positive
** if BCx neg BUT fever, or <3mo, or immunocomprimised = give azithro PO - Return to daycare: once asymptomatic
Typhoid Fever
- Clinical presentation
- Workup
- Treatment
- Return to daycare
- Clinical presentation: travel to Asia or Africa, fever, abdo pain, HSM, diarrhea (+/- blood), macular rash on abdomen
- Workup: blood culture for all with fever in returning traveller (regardless of stool culture)
- Treatment:
->if unwell, BCx positive= IV CTX x 10-14d
-> PO stepdown = azithro once blood culture negative (fever not contraindication to stepdown) - Return to daycare: 2-3 neg stool tests 24hr apart
Antifungals for Outpts: Tx of Pityriasis Versicolor?
Topical ketoconazole or selenium sulfide shampoo on skin nightly x 1-2 weeks then once per months x 3mo
Antifungals for Outpts: Tx of Tinea Corporis?
Topical ketoconazole 1-2x/d for 2-3 weeks
Antifungals for Outpts: Tx of Tinea Capitis?
PO terbinafine x 2-6 weeks
(take fungal scraping first)
Antifungals for Outpts: Tx of oral thrush?
Nystatin suspension = 1st line
Oral fluconazole if nystatin fails
Needle stick injury, child is not fully vaccinated for Hep B, next steps?
Test HBsAg and HBsAb
- If both neg-> give HB vacc and HBIG
- If HbSAb+ -> complete vaccine series at 1mo and 6 mo
- If no results available within 48hr, give both HB vacc and HBIG
Child fully vaccinated against Hep B with needle stick, next steps?
Test HBsAb
If positive -> no further action
If negative -> send HBsAg
- If HBsAg negative-> vaccine and HBIG
Baseline and follow up labs for needle stick injury
Baseline: HBV, HIV, HCV (Ab/status)
Follow up labs:
-1mo-> HIV
-3mo-> HIV and HCV
-6mo-> HIV, HCV, HBV
Factors that influence vertical transmission risk for HSV?
- Mode of delivery (decreased risk with C/S)
- Duration of ROM (longer = worse)
- Instrumentation (fetal scalp= worse)
- First episode of primary infection (mom has no Ab = worse)
- Prophylaxing women with recurrent genital HSV from 36 weeks onward can decrease viral shedding
Testing of asymptomatic infant potentially exposed to HSV at delivery?
Swab mouth, NP, and conjunctiva 24hrs post delivery
Asymptomatic baby, Mom has active HSV lesions, first presentation of HSV, baby delivered by C/S prior to ROM: management?
Swab at 24hrs
D/C home
Asymptomatic baby, Mom has active HSV lesions, first presentation of HSV, baby delivered by any method AFTER ROM: management?
Swab baby at 24hrs
Start IV acyclovir x 10days
If swabs (+) ->do blood and CSF PCR to determine duration of tx
If swabs (-) ->complete 10d tx
Asymptomatic baby, Mom has active HSV lesions, RECURRENT, baby delivered by C/S prior to ROM: management?
Swab at 24h
D/C home
Asymptomatic baby, Mom has active HSV lesions, RECURRENT, vaginal delivery: management?
Swab at 24hrs
D/C home pending neg swabs
Treatment duration for neonatal HSV:
- SEM?
- CNS or disseminated?
- SEM: 14 days IV (if ocular add drops of trifluridine)
- CNS or disseminated (blood or CSF PCR +): 21days IV and repeat LP at end of treatment
** after 21d IV acyclovir-> do suppressive therapy with PO acyclovir x 6mo for babies with CNS disease
Mom HepB unknown at delivery, how to manage the baby?
HepBsAg STAT for Mom, if results available within 12 hrs can wait for results to treat baby
If Mom HBsAg - = no treatment
Mom HBsAg + = Hep B vaccine and immunoglobulin within 12hrs
If no results available in 12hrs, give HB vaccine within 12hrs, can wait up to 7d for HBIG
** complete baby’s vaccines series at 1mo and 6mo
When to do Hep B serology in an infant born to Mom with Hep B?
HBsAg and HBsAb at 9-12 mo (at least one month after finishing vaccine series - 3 doses for most, 4 doses if <2kg at birth)
**baby will have gotten Hep B vacc and HBIG within 12 hours of birth!
Empiric antibiotics for sepsis (non neonatal)?
CTX +/- Vanco
When to consider pressors in septic shock?
- Cold shock pressor of choice?
- Warm shock pressor of choice?
> 60ml/kg fluid
Cold shock pressor of choice: Epi
Warm shock pressor of choice: Norepi
Contraindications to doing an LP?
Coagulopathy
Cutaneous lesion on the back @ puncture site
Herniation
Shock
** if papilledema, new onset symptoms, focal neuro deficits, decreased LOC or coma-> CT before LP
Empiric treatment for Meningitis >2mo?
CTX or Cefotax + Vanco
- add ampicillin for listeria if patient is immunocompromised
Steroids for bacterial meningitis in pts >2mo:
- When to give? For how long?
Give within 4 hours of antibiotics (ESP if H flu/gram negative coccobaccili seen on gram stain)
If bug is not H flu-> stop at 48hrs
If it is H flu-> continue x 4d
*there is some evidence for continuing x 4 days in Strep Pneumo
Duration of treatment for bacterial meningitis >2mo old based on bug:
- N. Meningiditis
- Hib
- Strep Pneumo
- GBS
- N. Meningiditis: 5-7d
- Hib: 7-10d
- Strep Pneumo: 10-14d
- GBS: 14-21d
Patient with bacterial meningitis must have a ____ assessment prior to discharge.
hearing!!
Bacterial meningitis with gram negative rod in CSF, repeat LP at ____.
Suspected E coli meningitis
Repeat LP at 24-48hrs recommended
When would you give HiB chemoprophylaxis?
- If any occupant of the home that the child resides in is <4 and incompletely immunized or anyone immunocompromised lives there
prophylaxis = rifampin x 4d
Most common cause of neutropenia in immunocompetent patient >3mo?
Viral illness
Workup for immune-competent patient >6months with febrile neutropenia?
CBC, retic, smear in all
if ANC >1= nothing else to be done
ANC 0.5-1= re-check in 1-3 months
ANC <0.5= draw blood and urine cultures and follow up in 24-28hrs
Name 4 bacteria that asplenic patients are at higher risk of infection with?
Strep pneumo
H flu
Neisseria Meningitides
Salmonella species
Capnocytophagia with animal bites
Please SHINE my SKiS
- Pseudomonas
- Strep pneumo
- HiB
- Neiseria
- E. Coli
- Salmonella
- Klebsiella
- gbS
Immunization for Asplenic Patients (super hard one!!):
- what vaccines do they need extra doses of?
- what extra vaccines do they need?
BONUS: when do they get these extra doses/vaccines?
All routine vaccinations
+Additional 1 dose Hib at >5yrs (after initial 3-4 dose series)
** if >1yr, give 2 doses 8 weeks apart, if >2yr can give one dose
+ 1 extra dose of Pneu-C-13 at 6mo (total series 2mo, 4mo, 6mo, 12mo)
** if >1yr give 2 doses 8 weeks apart, if >2yr can give one dose
+PPV23 at 2yrs and booster 5 years after 1st dose
+ Men-C-ACYW at 2mo, 4mo, 6mo, 12mo + booster every 5 years
** if >1yr, 2 doses 8 weeks apart
+4CMenB at 2mo, 4mo, 6mo, 12mo
** if >1yr, 2 doses 8 weeks apart
Antibiotic prophylaxis for asplenic patients?
Amoxicillin
All asplenic and hyposplenic patients <5
If >5, at least two years post splenectomy up to lifelong
Name two infections an immunocompromised kid could get from a cat?
Bartonella Henselae
Toxoplasma gondii
Name an infection that an immunocompromised kid could get from a rodent?
Lymphocytic choriomeningitis virus (LCMV)
When would you offer post exposure prophylaxis for Lyme disease?
Tick attached >36hrs
Give 1 dose doxy within 72hrs of tick removal
Classic rash associated with early cutaneous Lyme Disease?
Erythema Migrans (7-14 days after tick bite)
- central clearing target lesion
- resolved spontaneously in 4wks
Late extracutaneous Lyme Disease- clinical presentation? Diagnostic test?
- facial nerve palsy
- large joint arthritis (knees)
- heart block or carditis
- meningitis (lymphocyte predominant)
Dx: two tier serology- ELISA then Western Blot
Treatment of Lyme Disease/Duration of Tx:
- Rash __ days
- Arthritis ___ weeks
- Facial Nerve palsy ___ days
- Rash 10 days PO doxy
- Arthritis 4 weeks PO doxy
- Facial Nerve palsy 14 days PO doxy
Fever, headache, malaise and myalgias onset within 24hrs of treatment for Lyme Disease. What is this called? How do you tx?
Jarisch- Herxheimer Reaction
NSAIDs and keep giving doxy!
CENTOR score for GAS Pharyngitis
Age 3-14
1 point for each:
- exudate/swollen tonsils
- anterior cervical LN
- fever >38
- no cough
> score of 3 = swab
Treatment for GAS Pharyngitis?
Amoxicillin or Penicillin x 10d
If anaphylaxis to amox-> azithro, clarithro, clinda
Patient with post-COVID vaccine myocarditis, activity restriction?
Stop high intensity/competitive spots for 3-4 weeks
- do not give a second dose
Cough, runny nose, conjunctivitis followed by descending maculopapular rash. White spots on a red background in the mouth. Dx and PPE requirements?
Measles
Airborne precautions
Congenital rubella triad?
PDA
Cataracts
SNHL
When can you give live vaccines after high dose steroids?
1mo after treatment
Inactive can be given now
*High dose = 2mg/kg/d pred equiv x 14d
When can you give live vaccines after chemotherapy?
3 months after tx
When can you give live vaccines after IVIG?
11mo
Dose of Epi for anaphylaxis?
EPINEPHRINE IM 0.01mg/kg 1:1000
Adjunctive therapies for anaphylaxis?
- Inhaled beta 2 agonists
- H1 and H2 receptor antagonists
- Corticosteroids
- Nebulized epi for upper airway obstruction
- Epi IV (continuous infusion for hypotension- titrate to effect)
- Glucagon IV -> IF ON A BETA BLOCKER w/ persistent hypotension (activated adenylate cyclase independent of the beta receptor, attempt to reverse cardiovascular effects of anaphylaxis)
Factors that make it more likely to have a biphasic anaphylactic reaction?
- delayed administration of epinephrine
- needed more than one dose of epinephrine
- initially presented with more severe symptoms
Epipen dose <25kg, >25kg?
10-25kg: 0.15mg
>25kg: 0.3mg
How will kids react to divorce based on age?
<3?
4-5?
School age?
<3yo may reflect caregivers distress/grief (irritability, poor sleep/wake rhythms, separation anxiety, feeding disturbances or developmental regression)
4-5 blame themselves and become increasingly clingy
School age: prone to loyalty conflict and may take sides
Choice SSRI for child/adolescent mental illness?
Fluoxetine
Bronchiolitis admission criteria?
- Signs of severe respiratory distress (eg, indrawing, grunting, RR >60/min)
- Supplemental O2 required to keep saturations >90%
- Dehydration or history of poor fluid intake
- Cyanosis or history of apnea
- Infant at high risk for severe disease
- Family unable to cope
Factors that increase risk of suicide?
- Mental illness
- Prior suicide attempt - previous attempt is one of strongest predictors
- Impulsivity (greater risk of acting and w/ more lethal means)
- Precipitating factors (break up, family/peer conflict, bullying, academic disappointment, gender identity, legal involvement
- Exposure to suicide via media/people they know is associated w/ increased suicidal behaviour
- Family conflict, poor parent child-communication, parental mental illness, fam hx suixide
- Lack of connection to psychosocial support (lack of clear f/u plan with appropriate psychosocial support may be an indication for hospitalization)
Contraindications to circumcision?
Hypospadias (needs assessment by urologist first)
Bleeding disorder
Physical activity recommendations for school aged children:
60min/day of moderate to intense physical activity and >3d/week include muscle and bone strengthening
First line treatment for head lice?
Pyrethrins and permethrin (>2mo age, both require repeat treatment in 7 days)
If 2 treatment applications of permethrin >7 days apart does not eradicate live lice, what is your next step?
Get Resultz!!
(isopropyl myristate/ST cyclomethicone )
Premature infants are at lower risk of NAS - true or false?
True!
- shorter in utero time
- decreased placental transmission
- minimal fat stores
- immature brain
- decreased ability to excrete the drugs (so less likely to withdraw)
When to start pharmacological treatment for NAS (based on Finnegan scores)
3 consecutive scores >8
2 consecutive scores >12
How long to you need to observe a baby at risk of NAS?
Minimum 72hrs (ideally 120hrs if mom was on methadone)
When can a baby with NAS be discharged home on morphine?
- Good followup ensured
- Tolerating wean with scores consistently <8
- Documented weaning plan
What risk of blood transfusion is reduced by irradiation?
GVHD
What risk of blood transfusion is reduced by leukoreduction?
CMV
If antibody screen in cord blood is negative, when do you need to start cross matching for transfusions for infants?
4 months
5d old neonate on respiratory support, transfusion threshold?
Hg 115 (HCT 35)
3 week old baby not on resp support, transfusion threshold?
Hg 75 (HCT 23)
4 week old baby on respiratory support, transfusion threshold?
Hg 85 (HCT 25)
Transfusion thresholds for week 2 life, on and off respiratory support?
On resp support- Hg 100 (HCT 30)
Off resp support- Hg 85 (HCT 25)
> ____ weeks GA we recommend resuscitation for preterm neonates
25
<___ weeks we recommend palliation for preterm neonates
21
When should pulse ox screening be done in neonates to detect congenital heart disease?
Between 24-36 hours of life in all prem and late prem infants
** use right hand and either foot
Pulse Ox screening:
<___ in any limb = FAIL
> ___ in one limb and <___ difference between limbs = PASS
___-___ or >___ difference between limbs = BORDERLINE
<90 in any limb = FAIL
> 95 in one limb and <3 difference between limbs = PASS
90-94 or >3 difference between limbs = BORDERLINE
Next steps if a neonate has a borderline pulse ox screen?
90-94 and >3 difference between limbs = BORDERLINE
Repeat in 1 hr, if still borderline, repeat in another hour
If still borderline on TWO repeats = FAIL
Next steps when a newborn fails a pulse ox screen?
<90 in any limb = FAIL, 3x borderline results = FAIL
- 4 limp BP
- ECG
- CXR
- Consider echo or cardio consult based on above results
Who should be treated with hypothermia in the setting of HIE?
> 36 wks AND <6hrs old with either A or B, AND C
A) cord pH <7, base def >-16
B) pH 7.01-7.15, base def -10 to -15.9 AND acute perinatal event AND Apgar <5 at 10 mins or needed 10 mins PPV
C) Moderate to severe encephalopathy (sz, altered LOC, altered tone or reflexes, autonomic dysfunction)
What are the indications to stop cooling for HIE and rewarm the infant? (side effects that require stopping)
- Hypotension refractory to ionotropes
- Coagulopathy refractory to medical management
- Persistent pulmonary hypertension with impaired oxygenation
Cooling for HIE: what is the target temp, how long do you cool for?
Target 33.5 (+/- 0.5)
Cool for 72hrs then start rewarming (rewarm by 0.5’C every 1-2hrs)
Adjunctive therapies to use while cooling a baby with HIE?
- Low dose morphine infusion
- Early minimal enteral feeding (10-20mL/kg/d)
For HIE what imaging should be done after cooling? When?
MRI at 4-5 days of life after re-warming
Who qualifies for routine HUS in preterm infants?
<32 = HUS for you!!
32-36+6 if RF present (low birth weight, no maternal corticosteroids, resp distress, hemodynamic instability)
Timeline for routine HUS in infants <32 weeks or <37 weeks with risk factors?
Who qualifies for corrected term imaging?
1st HUS: 4-7 days of life
** if grade 2 or >, repeat in 7-10 days
2nd HUS: Repeat imaging at 4-6 weeks if <32wks
Term corrected imaging: <26 weeks
When does the germinal matrix involute?
34-36 weeks
Starts at 32 weeks
Grading of IVH:
Grade 1- in GM only
Grade 2- in ventricles but no ventricular distension
Grade 3- blood distending ventricles
Grade 4- parenchymal involvement
Grade 3+4 = severe
Factors on preterm head imaging that predict abnormal motor function?
- Severe IVH
- Cystic PVL
- Periventricular hemmorhagic infarct
- Cerebellar injury
- Abnormal myelination in posterior limb of internal capsule
Risk factors for brachial plexus injury:
- Shoulder dystocia
- Uterine abnormality
- Humoral or clavicular fracture
- Maternal diabetes
- Forceps or vacuum assist
- Episiotomy
- Birth asphyxia
- Macrosomia (>4.5kg)
Classification of brachial plexus injury:
1 - Erbs Palsy (C5-C6)
-> No shoulder movement but can flex and extend wrist
2- Extended Erbs Palsy (C5-C7)
-> No shoulder movement, cannot extend wrist, but can flex
3- Total palsy without Horners (C5-T1)
-> complete flaccid paralysis of arm
4- Total palsy with Horners (C5-T1 +sympathetic chain)
-> complete flaccid paralysis of arm + Horners +/- phrenic nerve palsy (ipsilateral elevation of the diaphragm)
When to refer brachial plexus injury to PT/OT/surg?
- Total palsy with no signs of recovery
- No elbow extension by 1mo
- No recovery of biceps by 3 mo
- Failed cookie test by 9mo
When to consider prophylactic indomethacin for PDA management?
- extremely low GA
- born outside tertiary care centre
- no antenatal steroids
** otherwise prophylactic closure of PDA not indicated
Clinical signs of a hemodynamically significant PDA in a neonate?
- precordial murmur
- hyperdynamic precordial impulse
- tachycardia
- bounding pulses
- wide pulse pressure
- worsening resp status
** MUST DO ECHO TO CONFIRM BEFORE TREATING. PDA >1.5mm more likely to be hemodynamically significant
Treatment of symptomatic PDA in premature infant?
- Conservative x 1-2 weeks (lasix, increased PEEP)
- Ibuprofen = treatment of choice for symptomatic PDA (10mg/kg followed by 2 doses of 5mg/kg at 24hr intervals)
- If 2 courses of ibuprofen fail -> can try acetaminophen and consider procedural closure (surgical ligation = method of choice)
What needs to be done before/on discharge of healthy term infant? (list at least 4 things)
- Minimum 2 successful feeds
- Passed urine and mec
- Counselling for parents
- NMS
- Hearing screen (done or arranged)
- Screen for hyperbili at 24-72hrs
- Vit K IM given
- Follow up arranged within 2-3 days
When to give maternal corticosteroids for neuroprotection of baby?
GA <35 with potential delivery in the next 7 days
- want >48hrs between last dose and birth
- Mom should get 2 doses IM 24hrs apart
When to give MgSO4 to mom for neuroprotection of baby?
GA <34 with suspected delivery in the next 24hrs
Infants at risk for hypoglycemia (will require screening):
- SGA
- IUGR
- Prem <37wks
- Beckwidth Wiedeman
- Maternal labetalol use
- Late preterm w/exposure to antenatal steroids
- Perinatal asphyxia
** need 24hrs screening - LGA
- IDM
** needs 12 hrs screening
When to check BG in neonates at risk for hypoglycemia?
Check at 2hrs of life and then q3-6hrs pre-feed
Cut offs for hypoglycemia in neonates:
<72hrs?
>72hrs?
When to send critical sample?
<72hrs: 2.6
>72hrs: 3.3
When to send critical sample: >72hrs and <2.8
Treatment pathway for neonatal hypoglycemia?
IV if <1.8 or <2.6 and symptomatic -> 2mL/kg D10W over 15 mins
If <2.6 + asymptomatic:
40% dextrose gel 0.5mL/kg +BF
OR
5ml/kg formula +BF
If <2.6 after first intervention:
dextrose gel + formula 5ml/kg + BF
OR
formula 8ml/kg +BF
If <2.6 after third intervention -> IV
** always check BG 30 mins after intervention
Appropriate GIR for newborns?
5.5mg/kg/min (80ml/kg/d of D10)
GIR = (dex (%) x rate) / (6 x weight)
** If neonate is requiring a GIR of >10 to maintain BG, send a metabolic workup
When to give postnatal corticosteroids for prevention of BPD?
<28wks or prem exposed to chorio
** give physiologic hydrocort in the first 48hrs and continue x 10d
Can consider low dose dex after 1 week of life for infants on a vent with worsening lung disease
Until what age should you correct for GA in prems?
3 years old
Name some early signs of CP:
- Hand preference <1yr
- Inability to sit by 9 months
- Fisting of the hand past 4 months
- Asymmetrical movements
Inhaled NO in prems: who to treat? starting dose? when should they respond?
Who to treat:
- late prem +term infants with hypoxic resp failure despite optimal management
- consider in CDH with persistent hypoxic respiratory failure
Starting dose: 20-40 ppm
** need echo before treating to confirm normal LV function and no ductal dependent heart disease
Should respond within 30 mins, if no response at 40ppm-> stop
Side effects of iNO
- methemoglobin production
- decreased platelet aggregation
- increased risk of bleeding
- surfactant dysfunction
Indications to give surfactant to neonates? When to re-treat?
- RDS with FiO2 >50
- RDS before transport if intubated
- FiO2 >50% in intubated MAS
** give within 2 hours if needed to improve outcomes
** retreat if FiO2 remains >30% 6 hrs after first treatment
Contraindications to breastfeeding?
- HIV
- HTLV
- Chemo drugs
- Cocaine, heroin, PCP
Evidence based strategies to improve mom’s milk supply for babies in NICU?
- Express breast milk if infant cannot breast feed
- Skin to skin
- Domperidone
- Lactation consultant
Poor Neonatal Adaptation Syndrome (PNAS) - signs and symptoms, tx, resolution?
Sx: poor tone, tremors, jitters, irritability, seizures, feeding issues, sleep disturbance, hypoglycemia, resp distress
Tx: supportive. Safe to BF
Resolution: self resolves in days to weeks with no long term risks
When is RSV prophylaxis indicated?
<30 weeks and <6mo
<36 weeks and <6mo if rural
CHD or CLD <1yr
Consider for home O2 with CLD <2yrs
When to d/c caffeine in infants with apnea of prematurity?
32-37 weeks
Monitor for 5 d off caffeine before discharge home
If discharged on caffeine, continue until 44wks
Duration of delayed cord clamping for prems and term singletons?
Prems = 60-120sec
Term singletons= 60 sec
** never milk the cord!!
Contraindications to delayed cord clamping?
- need for immediate resus for mom or baby
- TTTS
- fetal hydrops
- CDH
- disrupted circulation (abruption or previa)
Age of consent for sexual activity in Canada?
12-13 = within 2 yrs of age
14-15 = within 5 yrs of age
>16= not in a position of power, no porn, no prostitution
What medication can you administer to treat laryngospasm that occurs during procedural sedation?
Succinylcholine
Treatment of COVID vaccine associated pericarditis?
- NSAIDs (ibuprofen 10mg/kg/dose q8h x1 week, then 5 mg/kg/dose q8h x1 week)
- Consider colchicine in those that don’t respond to NSAIDs (relieves pain, may prevent recurrence)
Hospitalize: high and persistent fever, large pericardial effusion, cardiac tamponade, poor response to NSAIDs/colchicine), distance from care
Diagnostic criteria and ECG findings for pericarditis?
Diagnosis 2 of 4:
1) Pericardial chest pain (sharp, pleuritic, improved when sitting up and leaning forward)
2) Pericardial rub
3) Widespread ST elevation or PR depression on ECG
4) Pericardial effusion (new or worsening)
Supportive findings:
- Elevated inflammatory markers (CRP, ESR, WBC count)
- Evidence of pericardial inflammation (CT, CMR)
ECG
- Widespread concave ST elevation, PR depression
- Reciprocal ST depression and PR elevation in aVR (+/-V1)
- Sinus tachycardia
Brachial Plexus Injury, chance of recovery for:
- Neuropraxia
- Axonotmesis
- Neurotmesis
Neuropraxia: temporary conduction block due to interruption of myeline sheath, with full recovery within weeks
Axonotmesis: disruption of the nerve fibers and, likely, the myelin sheath, with some function returning within months but incomplete recovery
Neurotmesis: nerve disruption and avulsion of the nerve roots from the spinal cord, with no chance of recovery
Minimum weight for infant carseat?
1.8kg (4lbs)
When are probiotics recommended?
- Prem/LBW infants with sepsis to lower mortality risk
- Reducing incidence of NEC in prems > 1 kg (does not reduce mortality for NEC)
- L. reuteri for reducing colic
- Prevention of antibiotic associated diarrhea and c.diff (not treatment)
- Decrease some symptoms of IBS
- Help with H. Pylori eradication/decrease side effects of treatment
- Consider to help prevent eczema (weaker evidence)
Management of sports related concussion?
- Remove from play immediately
- Brief period of rest (24-48h)
- Supervised, stepwise return to learn and play - initiation of light exercise at 72h
- Maintain level of activity that does not produce/worsen symptoms
- Return to school (ASAP) symptom free before returning to sport
- Medical clearance required prior to full contact sport
Definition for pediatric osteoporosis?
One or more vertebral fractures in the absence of local disease or high-energy trauma is indicative of osteoporosis. No BMD threshold is required.
OR
A clinically significant fracture history (two or more long bone fractures by 10 years old OR three or more at any age up to 19 years) AND a reduced BMD Z-score ≤-2.0 indicates osteoporosis.
Recommended Ca and Vit D dietary intake >age 9:
Ca 1300mg
Vit D 600IU
Radiographic assessment for Rickets?
Wrist XR
Clinical manifestations of rickets?
- Lower limb deformities (e.g., bowed femurs or tibias)
- Spinal deformities
- Enlargement of growth plates (wrist, ankles, costochondral junctions (rachitic rosary))
- Hypocalcemic seizures
- Dental abnormalities
- Delayed motor milestones
- Failure to thrive
Maternal risk factors for Vitamin D deficiency:
- Low intake of VitD-rich foods (consuming <2 cups/day of milk or fortified soy beverage, low consumption of fish and sea mammals)
- Lack of VitD supplementation during pregnancy
- Use of antiretrovirals and antiepileptics
- Multiple pregnancies
- Smoking
- Darker skin pigmentation
- Food insecurity
- Obesity
- Living in communities north of 55° latitude
If Mom is high risk, so is baby!!
Diagnostic Criteria for Asthma in Preschool Age Children?
1. Documentation of airflow obstruction
- Preferred = Documented wheezing/airflow obstruction by health care practitioner
- Alternative = Convincing parental report
2. Documentation of reversibility
- Preferred = Documented improvement w/SABA ± oral corticosteroids by health care practitioner
- Alternative= Convincing parental report of response to a 3-month trial of a medium dose of ICS (with as-needed SABA)
- Alternative = Convincing parental report of response to SABA
3. No clinical evidence of an alternative diagnosis
These diagnostic criteria apply to children with recurrent (≥2) asthma-like symptoms or exacerbations (episodes with asthma-like signs)
1-5yrs w/ >2 episodes of wheeze, but no documented airflow obstruction/response to SABA by healthcare provider.
Next steps if:
Symptoms <8d/mo /mild?
Symptoms ≥8 d/month OR 1 mod/severe event (steroids/admit)?
If sx ≥8 days/month OR 1 mod/severe event -> therapeutic trial with MEDIUM DOSE ICS (200 µg to 250 µg daily dose) for 3 months with PRN SABA
- if they get better = asthma diagnosis + down-titrate ICS to lowest effective dose
- if they do not get better = stop trial
If <8d sx and no mod/severe events -> monitor and consider PRN SABA x 3mo
- if they develop documented airflow obstruction or have clear improvement with SABA = Asthma diagnosis
- if they have no change = stop trial
- if they get worse after stopping trial = asthma
Child 1-5 presents with current signs of airflow obstruction + 1 documented asthma-like exacerbation. They respond to SABA on your assessment. Can you diagnose them with asthma?
Yes!
If this was their first episode of documented airflow obstruction with response to SABA = suspected asthma
2nd episode = Asthma
ICS daily dosing for children 1-5yrs, low and medium doses for:
QVAR?
Alvesco?
Flovent?
Beclomethasone (QVAR)
- low =100
- med= 200
Ciclesonide (Alvesco)
- low = 100
- med = 200
Fluticasone (Flovent)
- low = 100-125
- medium = 200-250
Therapeutic trial for diagnosis = medium dose
Once Dx confirmed = trial low dose
Preschool asthma: At what age should they use a facemask with spacer vs. mouthpiece?
1-3yrs = a spacer with a correctly sized facemask is preferred.
4-5yrs = a spacer with a mouthpiece
When to refer to resp for preschool asthma?
- Diagnostic uncertainty or suspicion of comorbidity
- Repeated (≥2) exacerbations requiring rescue oral corticosteroids or hospitalization or frequent symptoms (≥8 days/month) despite moderate (200 μg to 250 μg) daily doses of inhaled corticosteroids
- Life-threatening event such as an admission to the intensive care unit
- Need for allergy testing to assess the possible role of environmental allergens
When can you start giving time-outs?
Age 3 (but try time ins!!!)
Risk factors for seizure after acute head injury?
- Young age
- GCS <8
- Cerebral edema
- Subdural hematoma
- Open or depressed skull fracture
Contraindications to HHFNC?
- Nasal obstruction
- Epistaxis
- Severe upper airway obstruction
How long can you do a pulse check for before starting CPR?
<10 seconds
PRAM score:
Mild: ___
Moderate: ___
Severe:___
Mild: 0-3
Moderate: 4-7
Severe: >7
Define status epilepticus
- continuous tonic clonic seizure activity x 30 mins
- 2 or more discrete seizures without return to baseline mental status
Impending status = >5 mins seizure activity without full recovery
Which second line AED for status epilepticus would you use in a patient <6mo with prolonged febrile seizure?
Phenobarb
Side effects of cooling babies with HIE?
- bradycardia
- hypotension
- thrombocytopenia
- pulmonary hypertension
- subcutaneous fat necrosis with hypercalcemia
