First Aid for the Wards - "Pediatrics" Flashcards
The __________ temperature is the gold standard.
rectal
Axillary and tympanic can be unreliable. Oral temperatures are generally 1ºbelow rectal.
Head circumference is generally only done in children up to ________.
2 years of age
In pediatrics, you should not say “vital signs are stable.” Instead, say “_____________.”
vital signs are age-appropriate
What things should you comment on for pediatric general appearance?
- Hydration status: drooling, tearing
- Respiratory status
- Alertness/playfulness/consolable
- Nutritional status: obese or underweight
The way you pull a child’s auricle in an ear exam is different by age: ______________.
in an infant, you pull backward and downward, while in an older child you pull backward and upward
Describe the quality of innocent murmurs.
- I-II/VI intensity
- Musical quality
- Occurrence in systole
- Varies with respiration
In failure to thrive, children fall off of the height, weight, and head circumference curves in what order?
1) Weight
2) Height
3) Head circumference
How should you work up failure to thrive?
- Detailed history (feeding, social, developmental, and birth)
- Physical exam
- Trend weight across time
Apgar scores are assessed at what times?
1 and 5 minutes
What should you do as a pediatrician at a high-risk delivery?
- Dry and clean the infant
- Suction nose and mouth
- Vigorously stimulate the child
- Perform a head to toe exam
- Provide any support the child may need: CPR, mask oxygen, intubation
List the important steps to follow in writing a pediatric prescription.
- Find the correct total dose of the drug based on weight (mg/kg).
- Find the available compositions (because pediatric drugs are usually liquid: e.g., 400 mg / 5 mL).
- Try to use the strongest formulation to minimize volume.
- Calculate the volume needed per dose.
- Find the duration of treatment needed.
- Calculate the dispense amount.
What weight parameters are diagnostic of failure to thrive?
- Less than 5th percentile for weight or weight-for-length
* Decline of greater than 2 percentile lines on standard growth charts
Go through gross motor development.
- 1 month: can hold head up while prone
- 2-3 months: can hold head up in all directions
- 4 months: can hold torso up with arms while prone
- 6 months: can sit up
- 9 months: crawls and cruises
- 12 months: walks unassisted
- 15 months: walks backward; stoops and recovers
- 18 months: runs
- 24 months: walks up and down stairs without help
- 36 months: rides tricycle
- 48 months: hops and skips
- 60 months: jumps over low obstacles
Go through fine motor development.
- 2 months: tracks past midline
- 5 months: rake
- 6 months: transfers objects hand to hand
- 10 months: inferior pincer
- 12 months: fine pincer
- 15 months: 2 blocks
- 24 months: 6 blocks
- 36 months: draw circle
- 48 months: cross or square
- 60 months: triangle
Go through language development.
- 6 months: babble
- 9 months: mama dada nonspecifically
- 12 months: mama dad specifically
- 15 months: 4-6 words
- 18 months: 15-20 words
- 24 months: 50 words; 2-word sentences
- 36 months: 250 words; 3-word sentences
- 48 months: knows colors
- 60 months: can print name
Go through social development.
- 2 months: social smile
- 6 months: stranger anxiety
- 12 months: plays next to others
- 24 months: parallel play
- 36 months: group play
- 48 months: cooperative play
- 60 months: can follow rules
What is the moro reflex?
Sudden neck extension causes extension, adduction, then abduction of the arms; it disappears by 3-6 months
The palmar reflex typically disappears by what age?
9 months
Rooting is _____________.
when infants reflexively pursue an object placed near their face with their mouths
The stepping reflex typically disappears by ________.
2-3 months
Turning the infants head laterally typically causes what reflex?
The fencer pose: ipsilateral extension and contralateral flexion
This disappears by 4-9 months.
The Babinski reflex disappears by ___________.
six months
How do height and weight develop by one year?
- Height: doubles
* Weight: triples
What are some contraindications to vaccine administration?
- Current severe illness
- Severe allergy to past vaccine or vaccine component (includes eggs, neomycin, gelatin, polymyxin, streptomycin)
- Pregnancy and immunocompromized status (for live vaccines)
Kids usually lose about ________ of their weight in the first 5-7 days of life. If they lose more than this, consider other sources.
5% - 10%
Birth weight should double by _________, triple by _________, and quadruple by ____________.
5 months; 1 year; 2 years
What is the average weight gain in these periods?
• First three months
•Four to twelve months
•Two years to puberty
- First three months: 25 g/day
- Four to twelve months: 15
- Two years to puberty: 5 pounds per year
What is the average birth height in inches and centimeters?
- 20 in
* 50.8 cm
How tall are kids at 1 year, 2 years, and 3 years (on average)?
- 1: 30 inches
- 2: 36 inches
- 3: 40 inches
The average birth head circumference is __________.
35 cm
Remember the 360º around the 36 cm head?
90% of head growth occurs by age __________.
2
Iron is recommended in breastfed infants at four months of age because ________________.
maternal stores of iron are usually depleted by that time
In addition to active HIV, HBV, and HTLV infection, breastfeeding is contraindicated in women with _________________.
illicit drug use, active breast herpes, or mothers on medicines that pass into breast milk (chloramphenicol, tetracycline, or chemotherapy)
What is a handy rule of thumb for infant formula needs in the first 2-3 months?
2-3 ounces every 2-3 hours for the first 2-3 months
The AAP recommends avoiding honey for the first __________ of life.
one year
What is the mnemonic for cyanotic heart defects?
- 1: pulmonic stenosis (one vessel)
- 2: transposition of the great vessels (two vessels)
- 3: tricuspid atresia (tri- = three)
- 4: tetralogy of Fallot (tetra- = four)
- 5: total anomalous pulmonary venus return (five words)
Large VSDs can cause __________.
CHF (and may require diuretics)
Where can you best hear VSDs and ASDs?
- VSDs: left-lower sternal border
* ASDs: left-upper sternal border
ASDs can cause what pathologic changes in the heart?
- Right atrial enlargement
- Right ventricular enlargement
- Right bundle-branch block
Strangely enough, you can hear a murmur in coarctation over _______________.
the left scapula
What two things need to be present in order to survive with transposition of the great vessels?
PDA or VSD
Note: if they have a PDA, then give PGE1 to maintain patency.
Chest x-rays of those with ____________ will show the “egg on a string” sign.
transposition of the great vessels
Remember, the hallmark sign of rubella that helps distinguish it from measles is ______________.
lymphadenopathy
What exanthem classically presents in the spring?
B19
____________ presents with a sandpaper-like rash that desquamates.
Scarlet fever
True or false: hand, foot, and mouth disease usually presents with the rash as its only symptom.
False.
Usually URI, GI symptoms, and fever accompany it.
What exanthem presents with football-like vesicles?
HFM
What defines precocious puberty?
The appearance of secondary sexual characteristics in girls prior to 7 (Hispanics and blacks) or 8 (whites) and in boys prior to 8
What can GnRH tests tell you in the evaluation of precocious puberty?
- If GnRH induces an LH surge, then precocious puberty is central.
- If GnRH fails to induce an LH surge, then the precocious puberty is peripheral (such as a germ-cell tumor).
All of the causes of gonadotropin-dependent precocious puberty are _______________.
central in origin: hypothalamic hamartoma, brain radiation, brain tumor, hydrocephalus, or head injury
Peripheral precocious puberty will typically have low _______________.
LH and FSH (because the peripheral source generally secretes sex hormones)
What are the treatments for central and peripheral precocious puberty?
- Central: GnRH agonists
* Peripheral: androgen antagonists or aromatase antagonists
Those with metabolic ____________ typically have an anion gap.
acidosis
Remember, it’s a number of anions (-OH) that you need to neutralize.
Intussusception usually occurs at or near the _____________.
ileocecal valve
What is the classic triad of intussusception?
- Intermittent colicky abdominal pain
- Bilious emesis
- Currant jelly stool
What predisposes to intussusception?
Any kind of GI inflammation:
- Henoch-Scönlein purpura
- Viral infection
- Rotavirus vaccine
Ultrasounds of those with ____________ can show the pseudokidney sign.
intussusception
When does pyloric stenosis often present?
2-8 weeks of life
What drug is associated with an increased risk of pyloric stenosis?
Erythromycin
Gastric peristaltic waves after feeding are a sign of ______________.
pyloric stenosis
____________ can mimic pyloric stenosis.
Overfeeding
The initial workup of Hirschprung’s includes ________________.
rectal manometry
Suction punch biopsy can provide definitive diagnosis.
List the four body systems that are primarily affect in Down syndrome.
- GI: duodenal atresia and Hirschprung’s
- Cardiac: VSD and ASD
- Neurologic: cognitive delay and hypotonia
- Hematologic: increased risk of ALL and AML
List the constellation of features seen in Patau syndrome.
- Holoprosencephaly
- Microphthalmia
- Polydactyly
- VSD
- Cutis aplasia
List the constellation of features seen in Edwards syndrome.
- Prominent occiput
- Rocker-bottom feet
- Horseshoe kidney
- Hypertonia (clenched fists)
List the manifestations of vaso-occlusive crisis in those with sickle cell.
- Priapism
- Dactylitis
- Femoral necrosis
What does acute chest syndrome show on x-ray?
Bilateral lower lung opacities
How common is stroke in those with sickle cell?
10% have a stroke by age 20, and an additional 20% show evidence of microvasculature infarctions on MRI.
Those with sickle cell are at increased risk of what renal disorder?
Papillary necrosis
When do those with sickle cell typically present?
After six months of life, when the fetal hemoglobin levels drop
Acute chest syndrome should be treated with ______________.
antibiotics, O2, fluids, analgesics, and exchange transfusion
What two drugs are those with sickle cell given prophylactically?
Penicillin and folate
What screening tests do those with sickle cell get?
- Yearly hip x-rays to assess for avascular necrosis
- Yearly retinal exams to assess for retinopathy
- Yearly transcranial dopplers to assess for stroke risk
- Echos for pulmonary arterial pressure every other year
What are the signs and symptoms of leukemia?
- Pallor (from anemia)
- Petechiae and purpura (from thrombocytopenia)
- Fatigue and lethargy (from anemia)
- Splenomegaly (from increased cell turnover)
- Bone pain (from primary malignancy)
Patients with ALL often get intrathecal ___________ for CNS prophylaxis.
methotrexate
Tumor lysis syndrome results in high levels of what three serum assays?
- Potassium
- Phosphate
- Uric acid
Why do those with Wilms’ tumor often get hypertension?
The tumor itself can secrete renin, and in other cases, it compresses the renal vasculature which promotes hypertensive changes.
What can cause a renal mass?
- Wilms’ tumor
- Neuroblastoma
- Hydronephrosis
- Multicystic dysplastic kidney
Neuroblastoma arises from what tissue?
Neural crest cells (hence can ber adrenal medulla or chain ganglia)
In addition to abdominal mass, list some of the signs and symptoms of neuroblastoma.
- Hypertension (from compression of renal vasculature)
- Watery diarrhea (from VIP secretion)
- Opsoclonus/myoclonus (dancing eyes dancing feet)
How long does inflammation need to be present to qualify as JIA?
Six or more weeks
Which joints are most commonly affected in JIA?
Large ones: knees, ankles
What number of joints marks the delineation of pauci-/oligoarticular and polyarticular?
5 or more = poly
Systemic JIA is also called __________.
Still’s disease
What symptoms characterize Still’s disease?
- Polyarticular arthritis
- Salmon-pink rash that waxes and wanes with fever
- Myalgias, growth delays, pericarditis
What condition presents with DIC in those with JIA?
Macrophage activation syndrome
True or false: normal ESR excludes JIA.
False
How is JIA treated?
- Systemic steroids for systemic disease
- Local steroids for local disease (e.g., steroid eye drops for uveitis, joint injections for arthritis)
- Etanercept or infliximab (both TNF inhibitors) for severe cases
- Calcium supplementation
The term “morbilliform” refers to rashes that look ______________.
like measles: erythematous macules that are 2-10 mm in diameter and confluence in places; occasional papules may be seen
What are the diagnostic criteria for Kawasaki disease?
- Fever for ≥ 5 days without other explanation plus 4 or more of the following:
- Bilateral conjunctivitis (without exudate)
- “Strawberry tongue”; dry, red, cracked lips; diffuse erythema of the oral cavity
- Erythema and/or edema of the hands and feet
- Polymorphic rash (usually truncal)
- Cervical lymphadenopathy (1 lymph node ≥ 1.5 cm)
The purpura in HSP most often presents on the _____________.
legs and buttocks
HSP is the systemic version of ____________.
IgA nephropathy
How is HSP treated?
Steroids for GI or renal involvement
Admit a child with ITP whose platelet count is less than _____________.
20,000
List the treatment options for ITP.
- Based on the severity of bleeding; > 80% of patients recover within several months without treatment
- Admit if platelet count is < 20,000/ml
- IVIG or anti-Rho antibodies
- IV methylprednisolone
- Splenectomy is appropriate for children > 4 years of age and those with severe or chronic ITP (> 1 year)
- Platelet transfusion is of no benefit
Using age, what is a good way to narrow down what immunodeficiency a child with recurrent infections is likely to have?
- B-cell deficiencies and antibody deficiencies typically present after 6 months of age (when the maternal antibodies fall)
- T-cell deficiencies present around 3 months of life
- B-cell and antibody deficiencies present with ______________ infections.
- T-cell deficiencies present with ____________ infections.
- Phagocytic deficiencies present with ______________ infections.
sinopulmonary and GI
disseminated intracellular and fungal
sinopulmonary and soft-tissue
Milk allergies and diarrhea are common in which immunodeficiency?
IgA deficiency
Describe common variable immunodeficiency.
- Defect in B-cell maturation
- Low levels of Ig
- Bimodal age distribution (1-5 and 15-20)
- Autoimmune disorders common
Explain the pathophysiology of hyper-IgE syndrome.
T cells fail to produce IFN-gamma which leads to impaired neutrophil chemotaxis. The body responds by upregulating IgE.
What is the mnemonic for Job syndrome?
Job was FATED to suffer: •Facies •Abscesses •Teeth (retained primary) •igE elevated •Dermatitis
Chronic mucocutaneous _______________ results from inability of T cells to properly recognize antigens.
candidiasis
Typically, ins and outs are reported on a _____________ basis in pediatrics.
mL/kg/day
BMI should only be used in those ______________.
older than 2
Ataxia, telangiectasias, and ____________ are diagnostic of ataxia telangiectasia.
IgA deficiency
What immunoglobulin profile is consistent with Wiskott-Aldrich syndrome?
- Decreased IgM
- Increased IgA and IgE
(Think about it like this: the mnemonic is WATER –Wiskott-Aldrich Thrombocytopenia Eczema Recurrent infections; just remember that there is an A and an E in wAtEr, but the M is tipped upside-down –WAtEr.)
How is fever in a 28-90 day-old different than in a neonate?
If the child is non-toxic and does not have identified cause of infection (such as a positive UA or CXR), then you can culture blood, urine, and observe them.
Typically, UAs and other tests are reserved for toddlers with temperatures greater than ________.
39
One of the age-specific signs of meningitis (for neonates) is paradoxical irritation. Explain what this is.
The infant will be irritable when held and not irritable when not held (because the act of holding manipulates the meninges and causes pain).
Discuss the differences in lung auscultation in viral and bacterial pneumonia.
- Viral: diffuse crackles
* Bacterial: focal crackles (with possible egophony)
The three pathogens that are the most common cause of AOM are ________________.
S. pneumo, H. influenzae, and M. catarrhalis
The AAP advocates for an additional ______________ in kids older than 2 with suspected AOM.
72 hours of observation
List three treatment options for Streptococcal pharyngitis.
- Amoxicillin for 10 days
- Benzathine penicillin for 1 IM shot
- Macrolides or clindamycin for 10 days
Don’t forget that Sydenham chorea includes _____________ and motor jerks.
emotional instability
Go through the SEEKS PP mnemonic for UTI pathogens.
- S. saprophyticus
- E. coli
- Enterbacter
- Klebsiella
- Serratia
- Proteus
- Pseudomonas
Go through the treatment recommendations for uncomplicated and toxic UTIs.
- Uncomplicated: 7-14 days of Bactrim or cefixime
* Toxic: cefotaxime, amp/gent, pip/taz, ticar/clav
Greater than ____________ bilirubin levels is pathologic no matter the age.
15
