Gastrointestinal/Nutritional System Flashcards
1
Q
What is the first symptoms of an appendicitis?
A
crampy or “colicky” pain around the navel (periumbilical)
2
Q
What are the other symptoms of an appendicitis as it progresses?
A
- there is usually a marked reduction in or total absence of appetite, often associated with nausea, and occasionally, vomiting and low-grade fever
- as the inflammation increases, the abdominal pain tends to move downward - begins in epigastrium - umbilicus - RLQ
- right lower quadrant - “McBurney’s point” this “rebound tenderness” suggests inflammation has spread to the peritoneum
3
Q
What are the physical exam signs of appendicitis?
A
- Rovsing - RLQ pain with palpation of LLQ
- Obturator sign - RLQ pain with internal rotation of the hip
- Psoas sign - RLQ pain with hip extension
4
Q
What is the clinical diagnosis of appendicitis?
A
- imaging if atypical presentation - apply ultrasound or abdominal CT scan
- CBC - neutrophils supports the diagnosis
5
Q
What is the tx of appendicitis?
A
surgical appendectomy
6
Q
What is colic?
A
severe and paroxysmal crying in the late after to evening
-unexplained paroxysms of irritability, fussing, crying that may develop into agonized screaming, an infant may draw up knees against the abdomen
7
Q
What is the peak age of colic?
A
2-3 months, ends around 4 months
8
Q
What is the cause of colic?
A
unknown, very common though
9
Q
How is colic dx?
A
rule of 3’s = cry >3 hrs/day, 3 d/wk, for 3 weeks
- complete history
- physical exam: r/o pathology
10
Q
What is the tx of colic?
A
patient eduction and reassurance
- DONT SHAKE YOUR BABY
- assure them their baby is healthy and crying can increase and likely stop by 3-4 months
- assure them they are not to blame
- make sure the baby is not hungry, soiled, or tired
- swaddle, gentle motions, pacifier
- get help from family to get to break
- possible formula switch or GERD tx
11
Q
What are the characteristics of constipation?
A
- common and almost always functional without an organic etiology
- stool rendition can lead to fecal incontinence in some parties
- <2 bowel movements per week
- > 1 episode of encopresis per week (poop in the rectum, loose stool leaks)
12
Q
What is the diagnostic criteria used for constipation?
A
Rome III for diagnosing functional constipation in children
13
Q
What is included in the Rome II criteria?
A
at least two of the following in a child with a developmental age younger than four years
-two or fewer bowel movements per week
-at least one episode of incontinence per week after the acquisition of toileting skills
-history of excessive still retention
-history or painful or hard bowel movements
-presence of a large fecal mass in the rectum
-history of large diameter stools that may obstruct the toilet
At least two of the following in a child with a developmental age of four year os older with insufficient criteria for irritable bowel syndrome
-two or fewer bowel movements in toilet per week
-at least one episode of fecal incontience per week
-history of retentive posturing or excessive voluntary stool retention
-history of painful or hard bowel movements
-presence of a large fecal mass in the rectum
-history of large diameter stools that may obstruct the toilet
14
Q
What is timing 3 main transition of constipation?
A
- solid foods or cow milk
- toilet training
- school entry introduction to solid food
- pureed veggies, fruits and fiber infant
- decrease cow milk
15
Q
What are the issues with toilet training and constipation?
A
- stool withholding
- inadequate fiber (5-10 g/day)
- reluctant to use at school
16
Q
How is constipation dx?
A
- often, a medical history and physical examination are sufficient to diagnose functional constipation
- further evaluation for Hirschsprung disease, a spinal cord abnormality, or a metabolic disorder may be warranted in a child with red flags, such as onset before one month of age, delayed passage of meconium after birth, failure to thrive, explosive stools, and severe abdominal distension
- pain with defecation, bleeding, fissures, hard stool
- abdominal x-ray
17
Q
What is the tx of constipation?
A
- schedule time between classes, increase fiber to 11-24 g/day - wheat, fruits, veggies, fluids
- decreased cows milk = slow intestinal motility - <24 ounces/day
- mineral oil 15 to 30 ml per year of age per day
- lactulose 1 ml per kg day once or twice per day, single dose or in two divided doses
- fiber, decrease milk, increase fluids
- enema, bathroom training
- referral to a subspecialist is recommended only when there is a concern for organic disease or when constipation persists despite adequate therapy
18
Q
What is dehydration?
A
a significant depletion of body water and to varying degrees, electrolytes
19
Q
What are the there categories of dehydration?
A
mild (3-5%), moderate (6-9%), and severe (>10%) cases
20
Q
What is the most accurate signs of moderate or severe dehydration?
A
prolonged capillary refill, poor skin turgor, and abnormal breathing
-other useful findings (when used in combination) include sunken eyes, decreased activity, lack of tears, and a dry mouth
21
Q
What are some reassuring signs of dehydration?
A
normal urinary output and oral fluid intake
22
Q
What testing can be done for dehydration?
A
laboratory testing is of little clinical benefit is determining of the degree of dehydration and thus the use of urine testing or ultrasounds is generally not needed
23
Q
What is a duodenal atresia?
A
the congenital absence or complete closure of a portion of the lumen of the duodenum
24
Q
What does a duodenal atresia cause?
A
increased levels of amniotic field during pregnancy (polyhydramnios) and intestinal obstruction in newborn babies
-early biliary vomiting in newborn
25
What is duodenal atresia associated with?
Down's syndrome
26
How is duodenal atresia dx?
the diagnosis of duodenal atresia is commonly made prenatally, either as an isolated lesion or due to its association with other chromosomal abnormalities
- X-ray: double bubble
- Malrotation: corkscrew
27
What is the tx of duodenal atresia?
- suction/drain sections, respiratory
- elevate head, IV glucose and fluid, ABX
- definitive: surgery
28
What is encopresis?
defined as the developmentally inappropriate release of stool, unrelated to an organic etiology
29
What is encopresis associated with?
almost always associated with severe constipation: liquid stool leaks around a hard, retained stool mass and is involuntarily released through the distend anorectal canal
30
How is encopresis predominantly seen in?
males
31
What is the cause of encopresis?
- functional: chronic constipation
| - emotional: school, divorce, etc.
32
What are the signs and symptoms of encopresis?
- abdominal pain, fecal mass
- dilated rectum packed with stool
- urinary frequency
33
What is the goal of encopresis?
daily, soft stools without pain every 1-2 days without
34
What is the dx of encopresis?
rectal exam, KUB
35
What is the acute treatment of encopresis?
- peg/miralax
| - glycerin suppository for infants up to 3d
36
What is the chronic treatment of encopresis?
- elimination of cows milk 1-2 week trial
- maintenance laxatives for 6 months - 1 year
- high fiver diet and increase fluids
- toilet sitting: same time 5-10 minutes after meal
37
What is a foreign body aspiration?
ingestions are often unwitnessed and a child may not develop symptoms
38
Who do foreign body aspiration most often occur to?
children 6 months - 3 years of age
39
What are some characteristics of foreign body aspiration?
- majority of foreign bodies will pass spontaneously without ill effects, however complications can occur such as bowel peroration or obstruction
- aspiration of gastric contents, inert material toxic material, or poorly chewed food
- the degree of injury depends on the substance
40
What is typically swallowed when there is a foreign body aspiration?
radio-opaque objects are swallowed - coins, screws, button-batteries, small toy parts
41
What are the signs and symptoms of foreign body aspiration?
choking and coughing, wheezing or hemoptysis
42
What are the complications of foreign body aspiration?
asphyxia, pneumonia, acute gastric aspiration
43
What are the symptoms of esophageal foreign body?
- may be asymptomatic
- symptoms, when present, may include: bloody saliva, coughing, drooling, dysphagia, failure to thrive, decreased feeding, gagging, irritability, neck/throat/chest pain, recurrent aspiration pneumonia, respiratory distress, stridor, tachypnea, vomiting, wheezing
44
Where does a foreign body need to get pass through the body?
once beyond the esophagus, objects typically pass but with an increased risk of complications
45
What are the complications of a foreign body?
bowel obstruction, perforation, erosion to adjacent organs - abdominal pain, nausea/vomiting, fever, hematochezia, melena
46
Where are common obstruction locations for a foreign body?
- cricopharyngeal
- middle 1/3 esophagus
- lower esophageal sphincter
- pylorus
- ileocecal valve
47
What is the dx of foreign body?
- radiographs of the chest, neck, upper abdomen - regional hyperinflation caused by check valve effect
- a normal chest radiograph does not exclude the presence of a foreign body
48
What might a chest radiograph of a foreign body show?
- radio-opaque foreign bodies
- obstruction hyperinflation (asymmetric)
- collapse/atelectasis
- normal (15% of lower airway foreign body aspirations)
49
Who is bronchoscopy indicated for with a patient with foreign body?
indicated for all patients with suspected inhaled foreign body even if the chest radiograph is 'normal' - unless the child is completely asymptomatic with a normal physical and radiographic examination
- consider the possibility of radiolucent foreign body if no abnormality seen on radiograph (wooden, plastic or glass items, fish/chicken bones)
- other imagine studies may be used - US, CT, MRI
- cultures is post-obstruction pneumonia suspected
50
How do you treat a foreign body aspiration?
acutely with Heimlich maneuver
| -bronchoscopy - diagnostic and therapeutic
51
What do you do if an object is thought to be in the esophagus (based on imaging and clinical presentation)?
- observe for 24 hours with serial radiographs and remove endoscopically if the object does not pass distally within the time-frame
- if the object causes symptoms or time-point of ingestion is unknown attempt immediate endoscopic removal
- if the ingested item appears relatively benign and has already progressed inferior to the diaphragm on imaging, observe and wait for spontaneous passage
- if the ingested object is sharp then remove immediately with endoscopy
- consider using a Foley catheter to remove retrograde from esophagus or bougienage to pass the object distally into the stomach
52
What do you do about an object distal to the esophagus (in stomach most commonly)?
-if symptomatic remove immediately with endoscopy
asymptomatic
-small blunt object - follow with serial radiographs, remove endoscopically if does not advance past pylorus in 3-4 weeks
-large object (>3 cm) - beyond pylorus then monitor with serial imaging, in the stomach then remove endoscopically
-sharp object - before pylorus then remove endoscopically, beyond pylorus monitor with serial imaging and remove if no progress for 3 daysw
53
What do you do about a button/disc batteries?
- always remove button/disc batteries as soon as possible for their risk of causing corrosive burns or tissue damage to the GI tract (unless it has already passed the pylorus and is making swift progress through GI tract)
- if acid/alkali is ingested
- do not induce emesis
- monitor ABC's
- endoscopy 2-3 weeks later to assess the damage
54
What is gastroenteritis?
-also known as infectious diarrhea, is inflammation of the gastrointestinal tract that involves the stomach and small intestine
55
What are the signs and symptoms of gastroenteritis?
include some combination of diarrhea, anorexia, vomiting, and abdominal pain
-fever, lack of energy, myalgia, and dehydration may also occur
56
How long does gastroenteritis last?
typically lasts less then two weeks, it is unrelated to influenza though it has been called the stomach flu
57
What kind of exposures can cause gastroenteritis?
foreign travel, playing in creek, daycare. poultry
58
What are the causes of gastroenteritis?
usually caused by viruses, however bacteria, parasites, and fungus can also cause gastroenteritis
- if the stool is bloody, the cause is less likely to be viral and more likely to be bacterial
- viral in children, rotavirus is the most common cause of severe disease, norovirus (#1 in adults), adenovirus, enterovirus
- parasitic: cryptosporidium, giardia
- bacterial: campylobacter, e.coli, clostridium, salmonella (reptiles)
- some foods commonly associated with illness include raw or undercooked meat, poultry, seafood, and eggs, raw sprouts, unpasteurized milk and soft cheese, and fruit and vegetable juices
59
How is gastroenteritis dx?
- typically diagnosed clinically, based on a person's signs and symptoms = determining the exact cause is usually not needed as it does not alter the management of the condition
- stool cultures should be performed in those with blood in stool, those who might have been exposed to food poisoning, and those who have recently traveled to the developing world
- it may also be appropriate in children younger than 5, old people, and those with poor immune function
60
What are the labs done for gastroenteritis?
- electrolytes and kidney function should also be checked when there is a concern about severe dehydration
- CBC: WBC, bands
- BMP/CMP: CO2, BUN/Cr
- Stool: culture, O&, virus (GE panel)
- UA: dehydration
61
What are the concerns with gastroenteritis?
- presence of blood or mucus
- weight loss
- low BP, sunken fontanelle, dry mucous membrane = want to know if crying, peeing
- decreased urine output
- reactive arthritis occurs in 1% of people following infections with campylobacter species
62
Traveler's diarrhea is caused by what bacteria?
E. coli
63
What bacteria causes diarrhea after a picnic and egg salad?
Staphylococcus aureus
64
What bacteria causes diarrhea from shellfish?
Vibrio cholerae
65
What bacteria causes diarrhea from poultry or pork?
salmonella
66
What bacteria causes diarrhea in patient post antibiotics?
C. difficile
67
What bacteria causes diarrhea in poorly canned home foods?
C. perfringens
68
What bacteria causes diarrhea breakout in a daycare center?
Rotavirus
69
What bacteria causes diarrhea on a cruise ship?
Norovirus = vomiting and horrible muscle cramps
70
What bacteria causes diarrhea after drinking (not so) fresh mountain stream water?
guardia lamblia - incubates 1-3 weeks, causes foul-smelling bulky stool and may wax and wane over weeks before resolving
71
What is the tx for gastroenteritis?
- involves getting enough fluids
- for mild to moderate cases, this can typically be achieved by drinking oral rehydration solution ( a combination of water, salts, and sugar)
- in those who are breastfed, continued breastfeeding is recommended
- for more severe cases, intravenous fluids may be needed
72
What is the tx for viral gastroenteritis?
- symptomatic, fluids
| - children infected with rotavirus usually make a full recovery within three to eight days
73
What is the tx for bacteria gastroenteritis?
- antibiotics are recommended for young children with a fever and blood diarrhea
- cipro, doxy, azithro, Bactrim
74
What is gastroesophageal reflux disease?
a small degree of reflux is common in all infants
75
What are the complications of gastroesophageal reflux disease?
failure to thrive, aspiration pneumonia, esophagitis, choking or apneic episodes, hematemesis, anemia, and fussiness
76
What might incompetence of the esophageal sphincter result in?
prematurity, esophageal disease, obstructive lung disease, medication or overeatign
77
What is the most common causes of GERD?
overfeeding - careful history of formula, how it is mixed, how much the infant eats during each feeding, and how often the child is fed
-if emesis is independent of meals, it is probably not reflux
78
How is gastroesophageal reflux disease dx?
- mild reflux can be diagnosed with a careful history
- in moderate to severe reflux diagnosis can be confirmed with
- upper GI examination
- PH probe placement
- If severe reflux or projectile emesis obstructions should be considered - abdominal US or barium swallow
- CBC usually normal
- CMP may demonstrate hypochloremic, hypokalemic metabolic alkalosis
- CXR is abnormal chest examination = aspiration pneumonia
79
What is the tx of gastroesophageal reflux disease?
- infants with GERD should receive small, frequent feedings in the upright position and be maintained in the prone head-up position for at least 20 minutes after a feeding
- feeds should be thickened with cereal
- if these fail metoclopramide may be used to improve gastric motility and increase the rate of gastric emptying
- if esophagitis is suspected an H2 blocker or PPI may be helpful
- surgery = nissen fundoplication
- in older children and adolescents = small frequent meals, eat slowly, maintain upright position after meals, and avoid meals after 7 pm
80
What is neonatal hepatitis?
idiopathic hepatic inflammation during the neonatal period
| -it is a diagnosis of exclusion
81
What is the neonatal hepatitis the most common cause of?
cholestasis
82
What is the incidence of neonatal hepatitis
1 in 5,000 or 10,000 live births, with a male predisposition
83
What are the clinical features of neonatal hepatitis?
- symptoms may range from transient jaundice and alcoholic stools to liver failures, cirrhosis, and portal hypertension
- presenting features in the first week of life include jaundice and hepatomegaly in 50% of patients,
- FTT and more significant live disease occur later in infancy in 33% of patients
- the course of disease is generally self-limited, with full recovery during infancy in as many as 70% of patients
84
How is the dx of neonatal hepatitis made?
based on clinical presentation, results of liver biopsy and exclusion of other causes of cholestasis
85
What is the tx of neonatal hepatitis?
- management is supportive
- decreased fat absorption may lead to growth failure and vitamin deficiencies
- increased nutritional support with concentrated calories, used of medium-chain triglyceride-containing formulas, and provision of fat-soluble vitamins A, D, E, and K are indicated, TPN may be needed if growth remains problematic
- ursodeoxycholic acid, a bile acid, is used to enhance bile flow and to reduce bile viscosity
- ursodeoxycholic acid is not used until biliary obstruction has been excluded as a possibility
- liver transplantation may be necessary in cases of severe liver failure
86
What are the characteristics of viral hepatitis?
- incidence varies with a specific virus and the majority of infections in children and adolescents are caused by hepatitis A and B
- prenatally infected infants are usually asymptomatic
- hepatitis B and hepatitis C infection are usually silent in the patient complains of no symptoms unless chronic infection has caused significant hepatic damage
- scleral icterus and jaundice are notes in some children with HAV, 50% of children with hepatitis B virus, 20-30% of children with hepatitis C, hepatomegaly and right upper quarant tenderness may be present
- a benign-appearing rash may be present early in the course
87
What are the clinical signs of viral hepatitis?
acute hepatitis include anorexia, nausea, malaise, vomiting, jaundice, dark urine, abdominal pain, and low-grade fever
- children with hepatitis A and hepatitis E virus may have diarrhea
- a wide range of severity exists and as many as 30 to 50% of infected children are asymptomatic
88
How is viral hepatitis dx?
- liver enzymes are uniformly elevated in hepatitis
- because the clinical manifestations are so similar, specific serologic tests are indispensable for securing an accurate diagnosis
- the presence of anti-HAV IgM antibody confirms hepatitis A infection
- HCV antibody is present in both acute and chronic infection
- HCV RNA can be detected by PCR within 1 week of infection, whereas the "window period" from infection to antibody response for HCV may be as long as 12 weeks
89
What is HBV surface antigen (HBsAg)?
- is pathognomonic for active disease
| - it is the antigen used in the hepatitis B vaccine
90
What is the HBV surface antibody (HBsAb)?
is protective and can results from vaccination or natural infection
91
What is HBV core antibody (HBcAb)?
results from natural infection (not vaccination) and persists lifelong
92
What is the HBV e antigen (HBeAb)?
rises very early in active infection and is therefore useful in diagnosing acute infection
93
What is the HBV e antibody (HBeAb)?
rises late in infection
94
What is the HBV polymerase chain reaction (PCR)?
may be used for both diagnosis and assessing the response to therapy
95
What is the treatment for viral hepatitis?
- both active and passive forms of immunization are available, depending on the source of infection
- HAV immunization is recommend for all children
- HAV immunoglobulin will prevent clinical disease when administered within 14 days of exposure
- The HBV vaccine series is recommended for all infants in the United States
- infants of infected mothers should receive both the vaccine and HBV immunoglobulin at delivery to prevent the diesel and the development of a carrier state
- children with chronic hepatitis B who develop persistently abnormal ALT values should be referred for consideration of treatment to clinicians with expertise in managing pediatric hepatitis
- the development of direct-acting antiviral agents (DAAs) and combination drug regimens represents a major milestone in the treatment of HCV
96
What is another name for Hirschsprung disease?
congenital ganglionic bowel disease
97
What is Hirschsprung disease caused by?
a lack of caudal migration of the ganglion cells from the neural crest
-it produces contraction of a distal segment of colon, causing obstruction with proximal dilation
98
What is Hirschsprung disease?
absent plexuses (regular bowel function) = intestine muscles permanently constriction - passing stool difficult, impossible
99
What is the incidence of Hirschsprung disease?
1: 5,000 live births
| - five times more frequent in male infants, and in 80% of cases there is a family history
100
Are infants asymptomatic or symptomatic with Hirschsprung disease at birth?
asymptomatic
101
What is the first sign of Hirschsprung disease?
baby's inability to pass meconium, 48 hours postpartum
102
What are the clinical features of Hirschsprung disease?
constipation, vomiting, and abdominal distention
103
How is Hirschsprung disease dx?
- diagnosis is by rectal suction biopsy, revealing the absence or paucity of ganglion cells
- barium assisted radiography
- digital rectal exam
104
What is the tx of Hirschsprung disease?
management includes resection of the affected segment or colostomy
105
What is the most common inguinal hernia?
indirect
106
What is an indirect inguinal hernia?
passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum
- often congenital and will present before age one
- indirect goes through the internal inguinal right (an "I" for an "I")
107
What is a direct inguinal hernia?
-passage of intestine through the external inguinal ring at Hasselbach triangle, rarely enters the scrotum
108
How is a inguinal hernia dx?
based on history and physical exam
-an ultrasound examination may be helpful when the etiology of an acute groin swelling cannot be determined on clinical examination
109
How is an indirect inguinal hernia tx?
management includes referral for elective repair
- optimal timing is debatable, a waiting time less than 14 days is advisable for asymptomatic inguinal hernias in this pediatric age group
- an emergent referral is necessary if evidence of bowel incarceration is noted (erythema of overlying skin, pain, and tenderness)
110
What is the tx of direct inguinal hernia?
(asymptomatic) monitor, surgical repair if preferred
111
What is intussusception?
is the telescoping or invagination of a more proximal portion of the intestine into a more distal portion
112
What is the incidence of intussusception?
1.5-4 in 1,000 live births, with a slight male predominance
113
When is the peak incidence of intussusception?
occurs at 5-9 months of age
114
What is intussusception the most common cause of?
bowel obstruction after neonatal period in facts less than 2 years
115
Who does intussusception affect?
children after viral infections or adults with cancer
116
What are the signs and symptoms of intussusception?
- previously healthy infants or children may present with sudden onset of crampy or colicky abdominal pain
- the pain occurs in intervals followed by periods of calm
- infants may cry and draw their legs toward the chest
- vomiting and leathery are common
- stools may be normal or have a bloody, "current jelly" appearance because of intestinal ischemia and mucosal sloughing
- occasionally, a sausage-shaped mass may be palpated in the abdominal right upper quadrant, representing the intussusception
117
What is the dx/tx of intussusception?
- barium enema is both diagnostic and therapeutic in children
- an abdominal x-ray will reveal a "present sign" or a "bull's eye/target sign/coiled spring lesions" representing layers of the intestine within the abdomen
- if the contrast enema fails to reduce the intussusception, or if the child has signs of peritonitis or pneumoperitoneum, an operative reduction is indicated
- the risk of recurrence is 5% after contrast reduction and 1% after surgical repair
118
What is lactose intolerance?
individuals have insufficient levels of lactase, an enzyme that catalyzes the hydrolysis of lactose into glucose and galactose, in their digestive system
119
What are the symptoms of lactose intolerance?
in most cases, this causes symptoms which may include abdominal bloating and cramps, flatulence, diarrhea, nausea, borborygmi (rumbling stomach), or vomiting after consuming significant amount of lactose
- clinical symptoms typically appear within 30 minutes but may take up two hours, depending on food and activities
- patients may need calcium supplementation
120
How is lactose intolerance dx?
- a presumptive diagnosis of lactose intolerance can be made in patients with mild symptoms that occur with significant lactose ingestion (eg >2 servings of dairy/day or >1 serving in a single dose that is not associated with a meal) and resolve after five to seven days of avoidance of lactose-containing foods, with recurrence on rechallenge
- lactose hydrogen breath test - definitive diagnosis
- the hydrogen breath test is positive for lactose malabsorption if the post lactose breath hydrogen value rises greater than 20 ppm over the baseline measurement
- stool acidity test (fecal pH test)
121
What is the tx of lactose intolerance?
focuses on avoidance of dairy products, use of lactose-free products, or the use of lactose supplements
122
What does niacin (vitamin B3) deficiency cause?
pellagra (meaning "raw skin"), which is characterized by a photosensitive pigmented dermatitis (typically located in sun-exposed areas), diarrhea, and dementia, and may progress to death
123
What is the cause of niacin (vitamin B3) deficiency?
- diets low in tryptophan or niacin = corn stable diets
- niacin is widely distributed in plant and animal foods, good sources include yeast, meats (especially liver), grains, legumes, corn treated with alkali (as in corn used in tortillas), and seeds
- dietary supplement, enriched grain, cereal, milk
124
What are the RDAs of niacin (vitamin B3) deficiency?
- children 9-13: 12 mg
- 19+ male: 16 mg; 19+ female: 14 mg
- pregnancy: 18 mg
- lactation: 14 mg
125
What are the signs and symptoms of niacin (vitamin B3) deficiency?
pellagra (diarrhea, dermatitis, dementia, and death)
126
What are the "4 Ds" that severe as a mnemonic for the manifestations of niacin deficiency?
- dermatitis = photosensitive, pigmented
- diarrhea = potentially also vomiting
- dementia = potentially all anxiety, disorientation
- death untreated pellagra potentially fatal
127
How is niacin (vitamin B3) deficiency dx?
-niacin status can be assessed by measuring urinary N-methylnicotinamide or by measuring the erythrocyte NAD:NADP ratio
128
What is the tx of niacin (vitamin B3) deficiency?
niacin replacement
| -RDA for niacin is 6 to 12 mg daily in children, 16 mg for adult males, and 14 mg daily for non pregnant adult females
129
What is pyloric stenosis?
a congenital condition where a newborn's pylorus undergoes hyperplasia and hypertrophy, leading to obstruction of the pyloric valve which causes vomiting (that might be projectile), as well as dehydration and metabolic alkalosis
130
Who does pyloric stenosis occur in?
pediatric patients < 3 months
131
What are the signs and symptoms of pyloric stenosis?
non bilious projectile vomiting after most or every feeding
132
What is the physical exam findings of pyloric stenosis?
physical exam - palpable epigastric olive-shaped mass (is pathognomonic for the disorder)
133
How is pyloric stenosis dx?
- diagnosis is by ultrasound
- on ultrasound, you will see a "double track"
- barium studies will reveal a "string sign" or "shoulder sign"
- labs: hypochloremic, hypokalemic metabolic alkalosis (secondary to dehydration)
134
What is the tx of pyloric stenosis?
surgical correction - pyloromyotomy (ramstedt's procedure)
135
What is an umbilical hernia?
is very common, generally congenital and appears at birth
| -due to a persistent opening of the umbilical ring, which normally spontaneously closes
136
When does the closure of the umbilical ring occur?
- closure of the umbilical ring is complete in almost all children by five year of age
- although closure is complete in most children by five years of age, this is not true for all children, as closure continues well into the teenage years for some children
- 4 to 5 years of age - 14 percent
- 6 to 7 years of age - 4 percent
- 8 to 9 years of age - 3 percent
- 10 to 11 years of age - 2 percent
- the majority of pediatric patients with umbilical hernias are asymptomatic, in rare cases, the hernia can interfere with feeding, especially in young infants with hernias that contain bowel
137
How is umbilical hernia dx?
- history and physical exam, including an attempt to reduce the mass
- umbilical hernias are detected during the newborn abdominal examination, particularly when there is increased intraabdominal pressure from crying
138
What is the tx is umbilical hernia?
- many umbilical hernias resolve on their own and rarely require intervention
- refer to surgery if an umbilical hernia persists > 2 years of life
- children with large, trunk-like hernias without any decrease in the size of the umbilical ring defect over the first two years of life, generally require surgery, because their hernias are unlikely to close spontaneous
139
What can Vitamin A deficiency result from?
from inadequate intake, fat malabsorption, or liver disorders
140
What does Vitamin A deficiency impair?
immunity and hematopoiesis and causes rashes (dry skin) and typical ocular effects (xerophthalmia (dry eyes), night blindness)
141
What are the common food sources of Vitamin A?
liver, kidney, egg yolk, and butter
- ancient Egyptians recognized that night blindness could be treated by the consumption of liver
- provitamin A (beta-carotene) is mostly found in green leafy vegetables, sweet potatoes, and carrots
- these are metabolized by mammals into vitamin A, with varying efficiencies
142
What is the prevalence of Vitamin A deficiency?
- rarely seen in the United States and other resource-rich countries
- the prevalence of vitamin A deficiency is approximately 30 percent among children under age 5 worldwide and nearly 50 percent in young children in South Asia and sub-Saharan Africa
- approximately 500,000 preschool children become blind each year and many die
143
How is Vitamin A deficiency dx?
the diagnosis of Vitamin A deficiency is usually made by clinical findings, but can be supported by measurement of serum retinol levels
-levels less than 20 micrograms/dL [0.7 micro mol/L] suggest deficiency
144
What is the tx of Vitamin A deficiency?
universal periodic distribution - periodic supplementation is recommended for populations endemic for vitamin A deficiency, at the following doses (where 1 microgram retinol = 3.3 international units)
- infants 6 to 12 months of age, 100,000 international units orally (30 mg retinol equivalent) - one dose
- children 12 to 59 months of age: 200,000 international's units orally (60 mg retinol equivalent) - dose repeated every four to six months
- routine supplementation is no longer recommended for neonates, infants one to five months of age, or to mothers during the postpartum period living in endemic areas
145
What is Vitamin C deficiency cause?
scurvy
146
What is the presentation of scurvy?
-presents with swollen gums, bruising, petechiae, hemarthrosis, anemia, poor wound healing, perifollicular, and subperiosteal hemorrhages, and corkscrew hair
147
What are the characteristic of Vitamin C deficiency?
- the body cannot synthesize, must obtain from the diet
| - risk factors include food insecurity, feeding infants evaporated/boiled cow's milk
148
How is Vitamin C deficiency dx?
there are no reliable determinants of functional Vitamin C status, however, plasma and leukocyte vitamin C levels are the mainstay for assessment and are reasonably well correlated with vitamin C intake
- MRI: sclerotic, Lucent metaphyseal bands, soft tissue edema
- the most specific symptoms (occurring as early as three months after deficient intake) are follicular hyperkeratosis and perifollicular hemorrhage, with petechiae and coiled hairs
- other common symptoms include, ecchymoses, gingivitis (with bleeding and receding gums and dental caries)
149
What is the tx for Vitamin C deficiency?
the treatment for scurvy is vitamin C supplementation and reversal of the conditions that led to the deficiency
- for children, recommended doses are 100 mg ascorbic acid given three times daily (orally, intramuscularly, or intravenously) for one week, then once daily for several weeks until the patient is fully recovered
- adults are usually treated with 300 to 1000 mg daily for one month
- many of the constitutional symptoms improve within 24 hours of treatment, bruising and gingival bleeding resolve within a few weeks
150
What are important food sources of vitamin C?
- citrus fruits, tomatoes, potatoes, Brussels sprouts, cauliflower, broccoli, strawberries, cabbage, and spinach
- in children, breast milk provides an adequate source of ascorbic acid for newborns and infants
151
What is the role of Vitamin D?
plays an important role in calcium homeostasis and bone health
152
What does Vitamin D deficiency?
severe deficiency of vitamin D causes rickets in infants and children, and osteomalacia in all age groups
153
What is rickets?
softening bones = bowed legs, fractures, costochondral thickening ("rachitic rosary"), dental
154
What is the prevalence of Vitamin D deficiency in the United States?
in the pediatric age range is approximately 15 percent
155
Who is Vitamin D deficiency common in?
in infants who have dark skin pigmentation and those who are exclusively breastfed beyond three to six months of age
-breastfed infants need to be exposed to sunlight for at least 30 minutes/week while wearing only a diaper in order to maintain 25OHD levels at >20 ng/ml
156
How is Vitamin D transferred?
from the mother to the fetus across the placenta and reduced vitamin D stores in the mother are associated with lower vitamin D levels in the infant
157
Who is Vitamin D deficiency particularly common in?
dark-skinned pregnant mothers, especially those living at higher latitudes and in the winter months
158
Who are Vitamin D levels particularly low in?
premature infants because they have less time to accumulate vitamin D from the mother through transplacental transfer
159
How is Vitamin D deficiency dx?
serum 25OHD levels recommended in certain high-risk populations
- serum concentrations of 25OHD
- vitamin d sufficiency - 20 to 100 ng/mL (50 to 250 mol/L)
- vitamin d insufficiency - 12 to 20 ng/mL (30 to 50 mol/L)
- vitamin d deficiency -<12 ng/mL (<30 mol/L)
160
What is the tx of Vitamin D deficiency?
- the primary natural (unfortified) dietary sources of vitamin D are oily fish (salmon, mackerel, sardines), cod liver oil, and organ meats, and egg yolk
- these natural dietary sources are rarely consumed by children in sufficient amounts to maintain target 25OHD concentrations in the absence of other sources
- Vitamin D is fortified in many foods, particularly milk and milk products, orange juice, bread, and cereals
- infant formulas in the US are required to contain Vitamin D
161
What are the targets for vitamin D intake?
- these doses are designed to maintain 25-hydroxyvitamin D (25OHD) levels >20 ng/mL (50 nmol/L) in most population
- all exclusively breastfed infants should receive 400 international units (10 micrograms) daily of vitamin D supplements, beginning within a few days after birth
- infants (born at term) - 400 international units (10 micrograms) daily
- infants who are exclusively breastfed require vitamin D supplements to achieve this target, as do some formula-fed infants
- use of supplements in exclusively breastfed neonates and infants may be avoided if maternal intake of vitamin D is 4000 to 6000 international units (100 to 150 micrograms) daily
- children 1 to 18 years of age - 600 international's until (15 micrograms) daily
