Exam 4 Flashcards
1
Q
Renal Disease - clinical presentation and labs
A
o Abnormal growth
o Hypertension (HTN)
o Dehydration
o Edema
UA: blood or protein in urine
2
Q
acute renal failure - clinical presentation
A
altered mental status
nausea/vomiting
malaise
Due to electrolyte imbalance
note: this is also for end-stage chronic renal failure
3
Q
chronic renal failure
A
hypertension
lab abnormalities (proteinuria, elevated BUN or Cr, anemia, electrolyte abnormalities)
growth failure, rickets
poor feeding
Note: this is when they have not reached end-stage failure yet
- slow process
4
Q
acute renal failure - pre-renal causes
- including UA and lab findings
A
dec circulating vol: blood loos, dehydration, shock, hearty failure
blocked blood flow to kidneys: thrombi, masses, trauma
UA: inc. Na and H2O reabsorption, conc. urine (high SG), low urine output
Labs: high BUN and Cr (BUN>Cr), low urine Na, high specific gravity
5
Q
acute renal failure - renal causes
- including UA and lab findings
A
damage to tubules (ischemia, toxins), microvascular injury (HUS), glomerular injury (PSGN, HSP, SLE), or interstitial cell injury (drugs)
UA: high urine Na, urine sediment
Labs: high BUN and Cr (Cr>BUN)
6
Q
acute renal failure - post-renal causes
- including UA and lab findings
A
anything causing obstruction to urine flow, including anatomical abnormalities or acquire obstructions (renal stones, foreign body, mass, trauma)
- poor urine output
UA: high urine Na, low urine specific gravity
7
Q
chronic renal failure - causes
A
intrinsic damage (ischemia, toxins), microvascular injury (HUS), glomerular injury (PSGN, HSP, SLE), interstitial injury (drugs)
DM
renal scarring from missed CAKUT
PKD: polycystic kidney disease
8
Q
end-stage renal disease
A
GFR<15%; requires dialysis and medications (to take the place of hormones the kidney would have produced)
Optimal tx = renal transplantation
9
Q
HUS - clinical presentation
A
HUS: hemolytic-uremic syndrome
bacterial (E. Coli O:157) cause of ARF (<5y/o) - shiga toxin targets endothelial layer of blood vessels throughout body
- vomit, bloody diarrhea
- petechial rash
- kidney damage and ARF
Triad: microangiopathic hemolytic anemia, thrombocytopenia, renal injury
10
Q
using creatinine to estimate renal function
A
As renal fx decreases, serum creatinine level rise proportionally
- for every doubling of serum creatinine, the renal clearance (GFR) has been halved
11
Q
estimate of urinary protein loss using single UA (instead of 24 hrs)
A
Urine Protein/Creatinine Ratio (both expressed in mg/dl)
• <0.2 Normal
• >2.0 Nephrotic range (WU for urinary loss of protein)
12
Q
renal tubular acidosis: what happens and clinical presentation
A
either insufficient secretion of H+ (type I - permanent) or issue w/ HCO3 reabsorption (type II - kids outgrow by age 4)
- results in metabolic acidosis
Clinical Presentation:
- growth failure
- polyuria, dehydration
- rickets
- renal stones
13
Q
renal tubular acidosis - evaluation
A
CMP (included in work-up of a pt w/ growth failure): includes serum bicarbonate, all electrolytes, BUN & Cr
Venous blood gas: lungs should be increasing CO2 excretion in response to the metabolic acidosis
Renal U/S looking for renal stones or hydronephrosis:
• Metabolic acidosis, elevated BUN/Cr, renal stones → refer to nephrology for suspected RTA
• Patients with hydronephrosis → refer to urologist to look for obstructive anomalies
14
Q
differential diagnosis for red urine
A
trauma, external (perineal or meatus) irritation)
infants: urate crystals in 1st week of life - normal
Pyridium (urinary tract anestetic): causes red urine
rhabdomyolysis: see myoglobinuria due to severe muscle breakdown
renal stones (renal US/abd x-ray)
upper tract bleeding: dark urine, dysmorphic RBCs and cases (nephron level)
- PSGN, IgA nephropathy, HSP, SLE, MPGN
lower tract bleeding: red urine, whole RBCs, no casts (below nephron)
- usually UTI in PEDS
15
Q
main diseases that cause types of nephritis and resulting hematuria
A
post-streptococcal glomerulonephritis (PSGN)
IgA nephropathy
Henoch-Schonlein purpura
Systemic Lupus Erythematosus
Membranoproliferative glomerulonephritis
16
Q
post-streptococcal glomerulonephritis (PSGN) - clinical presentation
A
recent URI, sore throat, impetigo
dark urine, edema, HTN, proteinuria
low C3 (transient)
NOTE: most common cause of acute glomerulonephritis (immune-mediated inflammation)
17
Q
IgA nephropathy - clinical presentation - clinical presentation
A
males, recurrent hematuria (gross - red), possible URI
normal C3
NOTE: most common cause of chronic glomerulonephritis (immune-mediated inflammation)
18
Q
Henoch-Schonlein purpura - clinical presentation
A
most common form of vasculitis in kids (IgA vasculitis)
palpable purpura
arthritic/jt pain
abdominal pain
renal dz (nephritis = hematuria)
NOTE: if renal involved (hematuria) or HTN –> involved nephrology
19
Q
Systemic Lupus Erythematosus - clinical presentation
A
hematuria
recurrent/prolonged fever
malar/butterfly rash
arthritic jt sxs
low C3 (active phase - transient)
20
Q
membranoproliferative glomerulonephritis (MPGN) - clinical presentation
A
looks like PSGN, but does not resolve in 4-6 weeks
hematuria
edema
HTN
proteinuria
low C3 (persistent)
21
Q
proteinuria: definition and cause
A
abnormal levels of protein in urine (due to glomerular capillary membrane damage by disease)
22
Q
urine dipstick results and correlation to values for urinary protein loss
A
Trace or negative is normal • 1+: 30 mg/dl • 2+: 100 mg/dl • 3+: 300 mg/dl • 4+: 1000 mg/dl
23
Q
main diseases that cause nephrotic syndrome and resulting proteinuria
A
orthostatic proteinuria
nephrotic syndrome
Nil disease
mesangial nephropathy
focal segmental glomerulosclerosis
24
Q
orthostatic proteinuria - clinical presentation
A
adolescent / benign
asymptomatic (no edema, no HTN) - occurs w/ activity
- protein/Cr < 2.0
- found incidentally
Note: get F/U first AM UA to verify negative for protein (and get could times in coming yr)
25
nephrotic syndrome - clinical presentation
any age (2-5 yrs)
- sudden onset of pitting edema or ascites
- proteinuria (nephrotic range: protein/Cr >2.0)
- low serum protein (albumin)
- inc. lipids, inc. clotting, infections
NOTE: most likely dx for proteinuria
- tx w/ Pred - if does not resolve consider chronic dz
26
Nil disease (minimal change) - clinical presentation
idiopathic nephrotic syndrome (< 6yrs)
- periorbital/pretibial edema
- proteinuria (nephrotic range: protein/Cr >2.0)
- low serum protein (albumin)
- Cr may be low
- HTN and ascites (+/-)
- possibly hematuria
27
mesangial nephropathy - clinical presentation
occurs at any age
- proteinuria (nephrotic range: protein/Cr >2.0)
- low serum protein (albumin)
- edema
28
focal segmental glomerulosclerosis - clinical presentation
idiopathic nephrotic syndrome (> 6yrs)
- proteinuria (nephrotic range: protein/Cr >2.0)
- low serum protein (albumin)
- Cr is HIGH
- significant hematuria
- HTN
29
Ddx for peri-orbital edema
infection, CHF, renal disorders (nephrotic syndrome - Nil disease)
- MUST get a UA if not clear infection to look at protein or blood
30
nephrotic syndrome
syndrome comprising signs of nephrosis (proteinuria, hypoalbuminemia, and edema)
- loss of protein through the kidneys (proteinuria) leads to low protein levels in the blood (hypoproteinemia including hypoalbuminemia), which causes water to be drawn into soft tissues (edema)
usually managed in primary care and resolves in 2-3 weeks
31
referral for obstructive uropathy on U/S
urologist
32
referral for renal damage (as indicated by proteinuria and possibly hematuria)
nephrologist
33
blood pressure classification - pediatrics
o Normal: <90%
o High: 90-95%
o Significant: 95-99%
o Severe: >99%
34
BP in PEDS - proper approach to dx of HTN
3 BP measurements on 3 separate occasions
- be sure have right cuff size
- check staff measurements
35
primary HTN (essential) in PEDS
unlikely unless obese and >12 y/o
- metabolic syndrome = obesity
Note: most common cause of HTN in adolescents
36
causes of secondary HTN in PEDS
Renal causes (70%):
- renal insufficiency
- nephrotic syndrome / glomerulonephritis
- congenital abnormalities
- structural disorders (Wilms tumor, polycysitc kidney dz)
Vascular causes:
- coarctation of aorta
- renal artery embolism or stenosis
- renal vein thrombosis
- vasculitis
Endocrine cases:
- hyperthyroidism
- pheocromocytoma and neuroblastoma
- hyperaldosteronism
- hypercortisolism (Cushings)
Neurologic causes:
- inc. sympathetic activity (stress, anxiety, pain)
- inc. ICP
Other:
- OSA
- medications
- illicit drugs
37
evaluation of pediatric pt with HTN
thorough history, ROS, physical exam (focus on secondary causes)
Level 1 work-up: : electrolytes, BUN/Cr, Ca++, thyroid, CBC, U/A + micro, renal U/S
- looks for evidence of renal insufficiency, vasculitis/anemia due to renal disease, renal artery stenosis, and thyroid disorders
- if results pt to specific dz process: treat or refer
- if etiology not discovered: contact nephrologist
38
management of pediatric pt with HTN
Asymptomatic stage I HTN w/o end organ damage or systemic disease:
• Step 1: therapeutic lifestyle changes
• Step 2: medication
Symptomatic stage II HTN
• Step 1: medication
Hypertensive emergency: prompt hospitalization (parenteral antihypertensive tx with nicardipine, labetalol, esmolol, sodium nitroprusside)
39
HTN medications used in PEDS
calcium channel blockers, ACE inhibitors, angiotensin receptor blockers, B-blockers, diuretics → more than 1 tx may be needed
- used as step 2 of asymptomatic and step 1 for symptomatic HTN in peds
40
urinalysis: macroscopic v. microscopic
Macroscopic: uses urine dipstick for pH, presence of protein, glucose, ketones, blood and leukocytes
- Nitrite test may detect bacteriuria if bacteria reduce nitrate to nitrite
Microscopic: confirms pyuria (pus = WBCs), hematuria, casts, crystals
41
UTI - what is the question you ALWAYS want to ask
about un-investigated or un-diagnosed febrile illness
| - sign of recurrent UTI
42
what can chronic NSAID use cause
proteinuria (spill protein)
43
anasarca
extreme swelling from nephrotic condition (must go to hospital)
- boys can get a lot of swelling in scrotal area
44
pediatric UTI - risk factors
Age:
- neonatal uncircumcised boys
- caucasian girls < 24 mo
Obstructive urological abnormalities:
o vesicoureteral reflux (VUR) obstruction
o ureteropelvic junction (UPJ) obstruction
o posterior urethral valves
Dysfunctional voiding (risk factor; also a cause of VUR)
45
pediatric UTI - most common organism
E. Coli (85%)
46
pediatric UTI: why so important to dx and tx early
Renal scarring: why UTI in children is important to catch early
- Most common in pts with a hx of recurrent febrile UTI, tx delays >72H, dysfunctional elimination, obstructive uropathies
- Results in renal insufficiency, hypertension and end-stage renal disease
47
ABX used for suspected UTI based on hx, PE, and dipstick results (awaiting culture)
broad spectrum ABX (cephalosporin - cefixime, cephandir)
48
UTI: clinical presentation in pediatrics (varies with age)
Pre-term, < 3 mo: poor feeding, apnea/bradycardia, lethargy, tachypnea (fever often absent)
Full-term, < 3 mo: fever, poor wt gain, jaundice (conjugated bili – sign of infection), vomiting
<2yr: suprapubic tenderness, fever >102.2 w/o obvious source (>48hrs), fever >104, uncircumcised or w/ hx of UTI
>2yr: abd pain, enuresis (inability to control urine), back pain, dysuria, frequency, foul smelling urine
49
pediatric UTI: important history and PE clues
Previous UTI or frequent undiagnosed febrile illnesses
Family Hx: UTI, urologic abnormalities
Elevated BP and poor growth - suggest renal insufficiency
Enlarged bladder or kidney(s) - suggest an obstructive uropathy
Bladder/CVA tenderness
External genitalia exam: vulvovaginitis, pinworms, sexual abuse, trauma, STI
Lower back exam → sacral dimples, tufts of hair
50
Febrile UTI - who gets admitted (inpatient) for septic W/U
all infants < 2mo
toxic appearing kids
immuno-compromised
unable to tolerate oral meds (vomit)
concern for F/U
not improving after started tx (outpatient)
51
Febrile UTI: outpatient management
broad spectrum ABX (cephalosporin): 10 days
- change based on culture results
close F/U
all get imaging (renal U/S, VCUG)
52
uncomplicated cystitis (non-febrile UTI)
child > 2 yrs w/ lower tract sxs (dysuria, frequency, urgency, supra public pain) and NO FEVER
53
uncomplicated cystitis: management
broad spectrum ABX (cephalosporin): 5-7 days
- change based on culture results
select imaging:
- < 3 y/o girl 1st UTI
- all girl w/ recurrent UTI
- all boys w/ UTI
- signs of poor growth, hx of urological abnormalities, FH renal dz
54
urinary tract obstruction - typical presentation
febrile UTI
hydronephrosis
later in life: renal insufficiency
55
urinary tract obstruction - evaluation
renal U/S: right after UTI confirmed w/ c/s
VCUG: sensitive for VUR
Creatinine level: high may indicate UPJ
bladder distention (on palpation): may indicate posterior urethral valves
56
primary nocturnal emesis: definition and causes
child never achieved nighttime dryness
Hypotheses: CNS maturational delay, functionally small bladder capacity, decreased response to vasopressin, genetic/more common in boys, sleep disorder (e.g. OSA)
57
secondary nocturnal enuresis: definition and Ddx
new onset enuresis after nighttime dryness was achieved for a period of time
Ddx: diabetes mellitus/insipidus, UTI, pinworms, sexual abuse, dysfunctional voiding/elimination syndrome and chronic renal insufficiency
58
nocturnal enuresis - management
Urinalysis: all children should have this (at minimum)
- R/O serious secondary causes
Overall: assess commitment of family/patient (tx takes several months)
- Reward charts for dry nights
- Bladder training to increase capacity
- Fluid management: 80% of fluids in a.m. and early afternoon, 20% (and no caffeine) after 5pm
- Bed wetting alarm: most effective, $50, and 12-16 week commitment
- Alarm clock for timed voiding: less expensive option
- DDAVP tablets (vasopressin): highly effective but significant relapse rate after discontinuation
59
dysfunctional voiding - symptoms
very common, part of WCC
Sxs: urgency, accidents, and holding maneuvers (most parents do not recognize until asked)
- ask about “potty dance” (post potty-training) and need to go “right away” or will have accident
Later: develop hesitancy, dribbling and straining (lose typical neurologic/anatomical components of micturition)
Highly associated with constipation (30-88%), development of UTI, acquired VUR, and hx of ADHD
60
dysfunctional voiding - work-up
Urinalysis: look for infection and proteinuria (evidence of renal damage from constant back-pressure)
- proteinuria: first am urine is best; if positive, follow w/ serum creatinine (renal fx)
Urine culture/screen
Renal US: needed if obstruction is suspected
61
dysfunctional voiding - management
Behavior modification (timed voids q 2-3 hrs): wear a timer
Tx of constipation
Urinate prior to urgency
No straining, complete bladder emptying
Avoid caffeine & bubble baths (due to their risk of UTI)
Reward chart for adherence
Note: urology referral may be needed
62
dysfunctional voiding - Ddx
```
UTI
vesicoureteral reflux (VUR)
vulvovaginits (include pinworms)
adenovirus cystitis (which is hemorrhagic)
STI
urethral strictures
foreign body
sexual abuse
```
63
cryptorchidism: course, risks, management
1 or more of the testes fail to descend into the scrotum; testes not found in scrotum and cannot be manipulated into scrotum by age 6m
course: many descend on own, may need orchiopexy
Risks:
- ay be indicative of genetic syndrome (examine for dysmorphisms)
- testicles are at higher risk of cancer; affixing in scrotum allows for frequent pt self-exams
Management:
- 1st 6 moths: watchful waiting
- After 6 months: US to determine location, possible orchiopexy
64
retractile testes: course, risks, management
testicle may move back and forth between scrotum and groin; common
Course: placing child cross-legged & sitting often allows the testicle to relax into the scrotum
Risks: testicle may be on a short spermatic cord
• Increased stature may result in a testicle that resides in the inguinal canal
Management:
- noted in the patient’s chronic problem list
- parents told that son needs exam at his pubertal growth spurt to assess testicular location (in case on short spermatic cord)
65
hydrocele: clinical presentation
common, large, sometimes unilateral, swelling to scrotum
| - red glow of fluid w/ dark testes on transillumination
66
hydrocele: management
Resolve spontaneously by 6 months of age
If not resolved by age 1y, refer to urology
67
balanitis: signs and sxs
infected glans of penis (circumcised); associated with poor hygiene or aggressive cleaning with soap
Signs and symptoms:
• Pain, dysuria, penile discharge and the swelling and erythema
68
balanoposthitis: signs and sxs
infected glans and foreskin of penis (circumcised); associated with poor hygiene or aggressive cleaning with soap
Signs and symptoms:
• Pain, dysuria, penile discharge and the swelling and erythema
69
fever: causes in developed countries (with vaccines)
viral infections: 90%
bacteremia: 1% for vaccinated; 5% for unvaccinated
- meningits, UTI, pneumonia, osteomyelitis, septic joint, cellulitis
other causes:
- Kawasaki's
- Cancer
- rheumatic dz: JIA, SLE
70
most common serious bacterial infection: relative risk
meningitis: most serious (0.5%)
- most serious; N. Meningitides is concern (WBC poor predictor - sneaky
UTI: 2-5% (E. coli most common)
- 1 of 2 most common
Pneumonia: 5%
- only order CXR in presents of clinical signs
- 1 of 2 most common
Septic joint, osteomyelitis, cellulitis
71
viral causes of fever that are a concern in infants
Varicella and Herpes: risk of disseminated dz
RSV: risk of respiratory compromise (also simultaneous UTI)
Influenza: risk of secondary infections and respiratory compromise
72
pneumonia - clinical signs of LRI
tachypnea, cough, inc. WOB (runny nose, abnormal breath sounds)
73
what is common with RSV
To also have a UTI causes by bacteria (7%)!
74
fever in child 0-36 months (< 3yrs): Ddx
Viral: RSV, croup, varicella, cocksackie, herpetic gingivostomatitis, AOM (low prevalence <3mo)
Bacteremia (2-3%, <0.5% S.pneumoniae)
- Meningitis (0.5%), UTI (2-5+%), pneumonia (5%), septic joint, osteomyelitis, cellulitis
Kawasaki’s
Cancer,
Rheumatological dz (JIA, lupus)
75
fever in child > 3 yrs: Ddx
Viral: AOM, RSV, varicella, cocksackie, herpetic gingivostomatitis, croup (less likely)
Bacteremia (2-3%, <0.5% S.pneumoniae)
- Meningitis (0.5%), UTI (2-5+%), pneumonia (5%), septic joint, osteomyelitis, cellulitis
Kawasaki’s
Cancer, Rheumatological dz (JIA, lupus)
76
likelihood of various illnesses being fever source
Bacterial gastroenteritis: if hx of diarrhea (esp. w/ blood or mucous) consider this possibility
Rapid influenza test: false positives are frequent, (+) results only helpful if flu season
RSV if cough and inc. WOB (in season): 1.1-7% risk of concomitant SBI (UTI)
Croup, varicella, obvious cocksackie (hand, foot, mouth) or herpetic gingivostomatitis (HSV on gums): unlikely to have concomitant SBI
- feel comfortable that these dx explain the fever
Otitis media: low prevalence in children < 3m/o
- be sure PE matches dx for AOM → many children wrongly dx w/ AOM (missing a SBI)
77
causes of prolonged fever
| - viral causes typically last 3-5 days
SBI that has not been located: do a CRP / ESR
CMV, EBV: common culprits of prolonged fever (important tests in primary care)
```
Tuberculosis
Lymphoma and Leukemia
Juvenile Idiopathic Arthritis
Endocarditis
Malaria
Hyperthyroidism
Kawasaki’s disease
- FWS may be only sx in infants
```
78
what MUST you do before giving empiric ABX for child with fever W/O source
get a lumbar puncture - once begin ABX, results will not be accurate and may be difficult to know what bacteria is present and how to treat
79
what additional test many be helpful to determine low v. high risk in infants w fever W/O source: age 29 to 60/90 days
rapid viral testing (nasal wash with PCR) to look for RSV, flu, etc.
- may help to avoid invasive testing (lumbar puncture)
80
low risk criteria for bacteremia (used in children >29 days old)
```
WBC normal
Bands: no “left shift”
U/A normal
CSF (if obtained) <8 wbc/hpf
CXR negative (pneumonia)
Stool gram stain <5wbc/hpf (if obtained; bacterial gastroenteritis)
Inflammatory markers (CRP and PCT)
```
Note: also consider rapid nasal wash viral testing
81
best lab tet predictor of serious bacterial infection (SBI)
Inflammatory markers (CRP and PCT (procalcitonin)): if both are positive, best predictor of SBI (compared to WBC or band count)
82
ill child - clinical signs
```
lethargy
poor perfusion (general color, capillary refill, turgor, blood pressure)
very slow or very fast breathing
cyanosis
abnormal cry
```
Young children who are hypothermic (<37C), esp. neonates who may not mount febrile response
83
ill child - management
regardless of fever, children who appear ill need admit to hospital for stabilization, complete SWU, empiric IV ABX (LP first!) pending culture results
84
Kawasaki Disease - signs and sxs
cause: unknown (likely viral)
- cardiac complications
Pronged fever (> 5d): may be only sxs; consider Kawasaki if…
- Infants < 6 mo with FWS > 7 d
- All children with FWS > 5 ds and 2-3 sxs of Kawasaki’s:
Non-exudative conjunctivitis
Cracking, fissuring of lips, oral mucosa
Unilateral cervical lymphadenopathy
Non-specific rash to trunk, extremities
Palmar/solar erythema & edema followed by peeling
Arthralgia: non-verbal child shows refusal to walk or crawl
85
whimpering
sign of serious illness (meningitis) in neonate / young infant
- crying increases ICP so avoid due to pain
86
pearl: test for very sick neonate / infant
pull on extremities - even neonate will pull back unless very sick with sepsis or meningitis
87
WBC differential - sign of bacterial infection
increase in band (left shift): body sending immature WBCs into periphery to fight bacterial infection
88
WBC differential - sign of viral infection
increase in lymphocytes
89
hydration status in neonates / young infants
Sternal cap refill is best (central perfusion)
Depressed fontanels and skin turgor (tenting) are late signs (severe dehydration)
90
juvenile idiopathic arthritis: definition
autoimmune disease that targets that synovial joints, resulting in inflammation with synovial tissue hypertrophy and increased amounts of joint fluid
- often FH of autoimmune disease
91
juvenile idiopathic arthritis: diagnostic criteria
Age of onset < 16 years
Arthritis in 1+ joints
• Arthritis: joint swelling or effusion OR presence of 2 or more of → limited ROM, tenderness or pain with motion, and warmth
Duration of disease ≥ 6 weeks
92
arthritis
joint swelling or effusion OR presence of 2 or more of → limited ROM, tenderness or pain with motion, and warmth
93
systemic JIA: sxs, exam findings, complications
Symptoms (girls/boy equal):
- polyarticular arthritis, affects both small and large jts
- brief fever (>39C) 1-2 times daily (afternoon/evening)
- fever accompanied by Still’s rash
Exam findings:
- hepatosplenomegaly, LAD, serositis, hepatitis and tenosynovitis
Complications:
- serositis, tenosynovitis
94
serositis
inflammation of the serous tissues of the body (tissues lining the lungs (pleura), heart (pericardium), and the inner lining of the abdomen (peritoneum) and organs within)
- can see on CXR (fluid)
95
tenosynovitis
inflammation of the lining of the sheath that surrounds a tendon
96
oligo JIA: sxs, exam findings, complications
Symptoms (girls more common):
- arthritis in < 4 joints, larger joints, asymmetrical
Exam
- Leg discrepancy (faster growth in affected limb)
- Often keep leg flexed
- Muscle atrophy in area
Complications:
- uveitis
97
poly JIA: types, sxs, exam findings, complications
Types:
- Rheumatoid factor negative: not associated with more destructive pattern
- Rheumatoid factor positive: associated w/ rheumatoid nodules, chronic arthritis, and joint destruction
Symptoms (most common girls, RF):
- involves > 5 joints, both large and small joints affected in a symmetric pattern
- fatigue, anemia of chronic dz, growth failure
Exam: RF (possibly positive), synovitis, rheumatoid nodules (large bumps)
Complications: destructive pattern seen with RF+
98
spondyloarthropathies
- ankylosing spondylitis
Sxs, exam findings, complications
Symptoms:
- Male predominance of 6:1, onset in late childhood/early adolescence
- Begins w/ peripheral arthritis (enthesitis - inflammation at insertion of tendons), and later moves axial/central involvement
Exam:
- RF and ANA are negative, HLA-B27 is + in 90% of pts, often a positive family history
Complications:
- inflammatory manifestations outside the joints: uveitis, aortic valve insufficiency
99
painful joint Ddx
acute trauma
transient synovitis / reactive arthritis
bacterial infections: septic arthritis, osteomyelitis, sepsis
viral infections: parvovirus, EBV, reactive arthritis
malignancy: leukemia, neuroblastoma
rheumatic dz: SLE, HSP, vasculitis
growing pains
100
key rheumatology concern questions
When does pain occur: pain in the morning and after naps is suggestive of inflammatory process
Will child let you touch / massage jt: typically, kids do not like inflamed joints (due to systemic arthritis) touched
- versus growing pains that get better with massage
101
reactive arthritis: clinical presentation and lab/imaging findings
umbrella term which includes transient synovitis (hip only)
Clinical:
- acute onset, well appearing, difficulty wt bearing (if hip, knee, ankle), limp, limited internal rotation of affected side (hip)
- common after a viral illness
Lab/imaging: none
102
septic arthritis: clinical presentation and lab/imaging findings
Clinical:
- rapid onset of limp / refusal to wt bear in an ill-appearing child, fever, affected leg held rigidly, major resistance to any ROM
Lab/imaging: YES!
- X-ray/US: widened jt space
- CBC: high WBC w/ lt shift
- ESR and CRP elevated
- Blood culture (obtain!):
- Joint aspiration w/ cell count, gram stain, and culture
103
systemic lupus erythematosus (SLE): definition and pathology
auto-immune disease
multi-system
pts have variety of sxs that come and go
- remission and exacerbation
pathology:
- inflammation, vasculitis (swollen), immune complex deposition, and vasculopathies
- complement-consuming disease (low C3 during exacerbations)
104
systemic lupus erythematosus (SLE): presentation (including dx criteria)
multi-system disease, sxs come and go
Diagnostic criteria (4+ for dx):
- malar rash: “butterfly rash” on cheeks and nose
- discoid rash: raised, red patches with scaling and plugging of hair follicles (rare in PEDS)
- photosensitivity: caused by sun
- oral/nasal ulcerations: usually hard palate of mouth or nasal septum
- serositis
- arthritis: involves 2+ peripheral jts
- nephritis
- CNS disease: seizures, psychosis, strokes, chorea, headaches, pseudotumor and depression/anxiety (not diagnostic)
- heme abnormalities: hemolytic anemia, leukopenia, thrombocytopenia
- ANA positive
- positive SLE serologies
105
systemic lupus erythematosus (SLE): laboratory eval (before and after diagnosis)
Initial:
- CBC and U/A with microscopy (tests that look for criteria for dx)
- consult pediatric rheumatologist: prior to ordering ANA titer or SLE-specific serologies
After Dx:
- CBC, ESR, UA, double-stranded DNA, and complement (C3,C4)
- used to monitor disease activity and drug side effects
106
systemic lupus erythematosus (SLE): complications
infection: leading cause of death (low complement)
GI bleeding, MI, malignancy
renal disease: transplant and dialysis have made this manageable
osteoporosis, infertility and psychosocial impairment
107
systemic lupus erythematosus (SLE): epidemiology
females > males
peak onset in late adolescence / young adult (sex hormones may play role)
- OCP / pregnancy
African ancestry > Asian > Latino > Caucasians
cause unknown: 10% have FH and 13% have another autoimmune disorder
108
5 hospital maternity care practices to improve breastfeeding success
o 1. Infants are breastfed in the first hour after birth.
o 2. Infants stay in the same room as their mothers.
o 3. Infants are fed only breast milk and receive no supplementation.
o 4. No pacifier is used.
o 5. Staff gives mothers a telephone number to call for help with breastfeeding.
109
WHO recommendations for breastfeeding
exclusively breastfed for 6 mo
continue breastfeeding, with the introduction of appropriate complimentary foods
continue through the second year of life and beyond
110
two major things breastmilk has that formula does not
Enhance the immune system (colostrum, secretory IgA (special antibody), enzymes, WBCs, and other immune components
Promote optimal brain development
111
benefits of breastmilk - general
species-specific (bioavailable)
reduce risk of disease in baby: DM, SIDS, IBD, atopy
Protect against diarrhea and ear infections
reduce risk of childhood obesity: baby led amounts; hormones (leptin and gherlin) associated with satiety long-term prevention of obesity
maternal / infant bonding
maternal bebefits: weight loss, lowers risk of breast and ovarian cancers, convenience, calming benefits
112
vitamins lacking in breastmilk
vitamins K and D
113
contraindications for breastfeeding
galactosemia: genetic metabolic disorder where baby cannot digest galactose
PKU: lack enzyme needed to breakdown protein phenylalanine
- proceed with caution
CF: need supplemental pancreatic enzymes
114
HIV: recommendations for breastfeeding in US
AAP recommends no breastfeeding for women living in US (can be transmitted through breast milk)
115
TB: recommendations for breastfeeding in US
no breastfeeding if dx w/ active pulmonary TB, tx has not started, or on tx for < 2wks
• Airborne transmission necessitates separation of mother and infant
• TB is not transmitted through milk (mom can pump and store)
• IHN prophylaxis for all infants whose mothers have been dx w/ active pulm TB postpartum
116
nutritional parameters for breastfeeding newborns - rules of 5's and 10's
1. Weight loss (up to 10%)
2. Regain birth weight by DOL 10, gaining approx. 20-30 grams/day
3. Colostrum: a teaspoon (5ml) at a good feed on DOL 1-2, about 40-50 ml (1-2 oz) in the first 24 hrs (8-10 feeds)
4. Yellow stools by Day 5
117
frequency of breastfeeding newborn in 24 hours
10-12 is ideal (minimum of 8 times)
118
newborn early hunger cues
rooting, hands to mouth, mouthing moments, waking up, fists clenched
119
3 good areas of education before mom leaves hospital
nutritional parameters
hand expression (engorgement / stimulates production)
asymmetrical latch and positioning
120
reasons for low milk supply
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Stress, dehydration, obesity, PCOS
Sheehan’s Syndrome: pituitary hemorrhage
Retained placenta
Hypothyroidism
Medications (high estrogen birth control, etc.)
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