general 3 Flashcards
when should infant have regained birth weight
2 weeks
how do you assess quality of feeds
weight gain
urine output
history –every 2-3 hours for 10-15 min per side
define lethargy
level of consciousness characterized by poor or absent eye movements or as failure of a child to recognize parents or to interact with persons or objects in the environment
what does a large fontanelle suggest?
skeletal disorders (rickets, osteogenesis imperfecta)
chromosomal abnormalities (trisomy 21)
hypothyroid
malnutrition
increased ICP
what does a small fontanelle suggest?
premature closure or just small
microcephaly
craniosynostosis
hyperthyroid
normal variant
what does a sunken fontanelle suggest
dehydration
what does a bulging fontanelle suggest
increased ICP (meningitis, hydrocephals, subdural heatoma, lead poisoning)
what is the most common cause of congenital hypothyroid in the US?
some form of thyroid dysgenesis i.e–
aplasia
hypoplasia
ectopic gland (2/3 of thyroid dysgenesis)
———–
in mothers with autoimmune thyroiditis, transplacental passage of thyrotropin-receptor-blocking antibody is associated with transient hypothyroid
infants born to mothers treated for graves can have transient hypothyroid
what is the most common cause of hypothyroid at birth worldwide
iodine deficiency
which is more common in neonates–primary or secondary hypothyroid
primary (95%)
–hypothalamic-pituitary axis is functioning and thus TSH is high
secondary or tertiary hypothyroid happen at the level of the pituitary or hypothalamus and these are more rare–> low TSH and low T4
how does congenital hypothyroid present
normal at birth because protected by maternal hormone –> may be several months before infants with CH show classic signs of hypothyroid
- feeding problems
- decreased activity
- constipation
- prolonged jaundice
- skin mottling
- umbilical hernia
if untreated–
large tongue
hoarse cry
puffy myxedematous facies
what is one of the most common preventable causes of intellectual disability
congenital hypothyroid
treatment of congenital hypothyroid
levothyroxine
ddx for lethargy in two week old infant
infection
intracranial pathology (hemorrhage, hydrocephalus, hydraencephaly)
metabolic disorder
chromosomal abnormality
ddx for neonate with poor feeding and decreased activity
- congenital hypothyroid
- shaken baby syndrome
- down syndrome
- sepsis
- CAH
- inborn error of metabolism
- hypoglycemia
- botulism
- hypoxic-ischemic encephalopathy
- polycythemia
- hyperbilirubinemia
risk factors for shaken baby syndrome
young/single parents
significant stressors in the home
lower education level
history of seizures or irritability raises suspicion for this
why do downs syndrome patients feed poorly
hypotonia
how does salt losing CAH present
lethargy, vomiting, dehydration that can progress to shock
what happens if you dont treat inborn errors or metabolism
progressive encephalopathy
what tests do you order in the infant with hypotonia
- serum sodium and potassium (CAH–low sodium and high potassium)
- serum ammonia (many inborn errors of metabolism; normal in congenital hypothyroid)
- glucose (critical)
- T4, TSH (thyroid disorders)
what does low sodium and high potassium suggest in the the hypotonic infant
CAH
signs of meningitis in less than 1 year old
often DONT have kernigs or brudzinskis sign
fever hypothermia bulging fontanelles lethargy irritability restlessness paroxysmal crying (crying when picked up) poor feeding vomiting diarrhea nucchal rigidity (extreme--hyperextension of entire spine--"opisthotonos")
*if have kernigs or brudzinskis must assume meningitis and do LP
what bug most often causes occult bacteremia in infants
strep pneumo (lower now because of vaccination)
also can be Hib, N. meningitidis and salmonella enteriditis
kernigs sign
resistance to extension of the knee
brudzinskis sign
flexion of hip and knee in response to flexion of neck
ddx of infant with fever
UTI
pneumonia
sepsis/bacteremia
occult bacteremia
bacterial meningitis
viral meningitis
roseola
primary HSV gingivostomatitis
otitis media
vaccine reacion
viral URTI
how does UTI usually present in kids
fever and no focus on physical exam and unremarkable ROS
fussiness and lack of appetite are common
risks for UTI
uncircumcised male under 6 months
any female under 24 months
signs or symptoms pointing towards UTI (suprapubic tenderness, history of UTI, foul smelling urine)
temp above 39C or fever more than 24 hours without source
how do most kids with pna present
cough tachypnea fever rales low Sa02
most common cause of bacterial meningitis in babies?
s. pneumo and n. meningitidis
what commonly causes viral meningitis
enterovirus
what is roseola
common viral illness in kids under 2
caused by human herpes virus 6
high fever often only symptoms in first few days of illness…. 3-5 days
some develop rash as fever resolves–1-4 days
no therapy needed
what population is most common for primary herpes simplex gingivostomatitis
10 months to 3 years
what do you see on exam for otitis media
poor mobility and mild bulging (or more) of tympanic membrane
best choice oral abx for pyelonephritis
cephalexin
stages of pertussis
- catarrhal stage–1-2 week, URTI sx
- paroxysmal stage–4-6 weeks–repetitive, forceful coughing episodes followed by massive inspiratory effort–characteristic whoop (not usually in infants)
- convalescent stage
complications of pertussis in the infant
difficulty feeding because of cough
CNS complications like apnea
what type of vaccine is pertussis
acellular
vaccine efficacy for pertussis
70-90%…wanes with time
what is epiglottitis
uncommon thanks to widespread immunization but important to consider in child with stridor
life threatening
most common between ages 2-5
what organism causes epiglotittis
Hib previously–now more commonly staph or step because of immunizations
signs and symptoms epiglottitis
fever
stridor
drooling
dysphonia
dysphagia
respiratory distress
*most will appear toxic and may position airway in sniffing position
should you examine the child who you suspect has epiglottitis?
no because risk acute deterioration–get airway management team involved in the OR
what sign is seen on radiography for epiglottitis
thumb sign
what is diagnostic of diphtheria
gray pseunomembrane in pharynx
what causes stridor
airway narrowing above thoracic inlet
usually heard with inspiration
what causes wheezing
airway narrowing below the thoracic inlet
what is pneumonia
inflammation of lung parenchyma usualyl due to microorganisms or asporation
what are the four most common viral causes of pneumonia
adenovirus
RSV
parainfluenza
influenza
*viral more common in kids
how does pneumonia due to chlamydia pneumoniae present
staccato cough between 4-12 weeks of life
what is the most common cause of wheeze in infants
bronchiolitis
what is acute bronchiolitis
viral disease of lower respiratory tract
characterized by bronchiolar obstruction due to edema, mucus and cellular debris
most common cause of bronchiolitis
RSV
bronchiolitis on CXR
hyperinflation
increased interstitial markings
peribronchial cuffing
scattered atelectasis from bronchial obstruction
asthma on CXR
hyperinflation from air trapping
increased interstitial markings
patchy atelectasis
most commonly aspirated foods
hot dogs
hard candy
nuts
grapes
popcorn
what normally causes croup
parainfluenza or another virus
how does croup present
nonspecific URTI sx that progress to some degree of airway obstruction
barky cough and/or respiratory stridor
what does a hoarse voice or cry suggest
problem in the upper airway–pharynx or larynx
what part of the physical exam makes foreign body aspiration most likely
asymmetric wheezing
fixed hyperinflation of the affected lung on radiographc
list the possible causes of petechiae and purpura
- trauma
- platelet deficiency or dysfunction (immune mediated thrombocytopenia, BM infiltration or suppression, malignancy)
- coagulation abnormalities (hereditary or acquired clotting factor deficiencies)
- vascular fragility (immune mediated vasculitis
- combinations of the above(i.e infection causing coag abnormalities, vascular fragility, platelet consumption)
what 5 factors should be considered in evaluating a skin lesion
type
arrangement
location
pattern of distribution
progression over time
what are the possible ways to describe the following aspect of a skin lesion:
type
- shape (macules, papules, plaques, wheals, vesicles, pustules, nodules, cysts)
- size
- consistency (rubbery, fluctuant)
- colour
- secondary features (scaling, crusting, lichenification, excoriation, hypopigmentation)
what are the possible ways to describe the following aspect of a skin lesion:
arrangement
symmetric scattered clustered linear confluent discrete
what are the possible ways to describe the following aspect of a skin lesion:
location
scalp
trunk
extremities
sparing or including palms and soles
what are the possible ways to describe the following aspect of a skin lesion:
pattern of distribution
flexor surfaces
sun exposed skin
dependent areas
what are the possible ways to describe the following aspect of a skin lesion:
progression over time
i.e….
spreading head to toe or peripheral to central
changing from papules to vesicles to crusts
what are some causes of hepatomegaly (generally)
inflammation (i.e viral hepatitis)
infiltration (leukemia/lymphoma)
accumulation of storage products (glycogen storage disease)
congestion (CHF)
obstruction (biliary atresia)
what is henoch-schonlein purpura
HSP (aka anaphylactoid purpura)
self-limited, IgA mediated small vessel vasculitis
typically involves the skin, GI tract, joints, kidneys
what immunoglobulin mediates HSP
IgA
what organs are often involved in HSP
skin
GI tract
joints
kidneys
what is the most commonly dx vasculitis in kids
HSP
what is the hallmark of HSP
non-thrombocytopenic purpura
what % of kids with HSP have renal involvement
30%
what is the most common manifestation of renal involvement in HSP
hematuria
renal involvement is less common in kids under two
what % of kids with HSP experience arthralgia or arthritis
75%
mainly knees and ankles
what % of kids with HSP have colicky abdo pain
65%
about 50% may develop intestinal bleeding with guiaic positive stool
what % of patients with HSP report a recent URTI
2/3
what % of kids with HSP progress to renal failure
5%
fewer than 1% will develop end stage renal disease
is HSP serious/severe?
it is considered a benign childhood disease but occasionally requires hospitalization for management of severe abdo pain, GI bleeding, intussusception and renal involvement
how do you treat HSP
steroid treatment controversial but data suggests early corticosteroids in hospitalized kids with HSP may have benefit in reducing GI manifestations
no demonstrated benefit for corticosteroids for preventing renal problems
what is ITP
caused by binding of an antiplatelet antibody to the platelet surface, leading to removal and destruction of platelets by the spleen and liver
what is the most common cause od isolated thrombocytopenia in otherwise healthy kids
ITP
where is the rash of HSP usually located
unique in that it tends to involve primarily the lower extremities
how can HSP sometimes present
arthritis or arthralgia
is HSP associated with splenomegaly
no
is ITP associated with splenomegaly
no
what are some common findings with leukemia
splenomegaly and lympohadenopathy
how does a coagulation disorder usually present
may present with petechiae or superficial bruising but more often presents with easy bruising in deep tissues or hemarthrosis
how do bleeding disorders often present
i.e hemophilias or vWD
easy bruising in response to minor trauma
spontaneous superficial bruising is less common
how may hemophilias present
painful bleeding into joints (hemarthrosis)
how does ITP often present
asymptomatic petechiae
non specific URTI precedes ITP more than 50% of then time
how does leukemia usually present
constitutional symptoms such as fever, malaise, weight loss
bone pain common presentation –> pain from infiltration of bone marrow by malignant cells
petechiae can be caused by thrombocytopenia due to bone marrow replacement by malignant cells
what virus can present with pretechial rash
i.e enteroviruses
kids usually have low grade fever
can coughing or vomiting cause petechiae
yes–usually above the nipple line
what are the typical presenting sx of bacterial endocarditis
fever, fatigue, weight loss
petechial rash commonly seen
bruising not characteristic
fever usually present but may be low grade
how do kids with meningococcal septicemia often present
petechiae and purpura
early stages may have only mild sx–by the time the hemorrhagic rash appears, patients are usually very ill appearing and require emergent care
describe the presentation of rocky mountain spotted fever
petechial–starts on EXTREMITIES before MOVING CENTRALLY
fever is hallmark
what things should you look for on exam of lymph nodes
size location distribution texture mobility
what do you think in a child with supraclavicular lymph nodes
lymphoma
what causes diffuse LAD
generalized infection
malignancy
storage diseases
chronic inflamm disease
describe normal lymph node texture
smooth
soft to mildly firm
non tender
mobile
what test should you do to decide between HSP and ITP
platelet count
i.e HSP is non thrombocytopenic and ITP is thrombocytopenic
HSP has normal platelets
what tests should you do to evaluate HSP
platelet count
urinalysis–> renal involvement
BUN and creatinine–> if either hematuria or proteinuria are present, to check extent of renal disease
are ESR and ANA helpful in diagnosis of HSP
no, too non specific
list the causes of spenomegaly
- infection–EBV, CMV, bacterial sepsis, endocarditis
- hemolysis–sickle cell
- malignancy–leukemia, lymphoma
- storage diseases–gaucher disease
- systemic inflamm disease–SLE, JIA
- congestion–complication of portal HTN
what is the most frequent cause of splenomegaly in kids
infection
do more girls or boys get HSP? ITP?
HSP–more boys
ITP–same
where is the rash in HSP
may begin as erythematous macules or urticarial wheals that evolve to petechiae and PALPABLE PURPURA
rash symmetrically distributed to gravity dependent or pressure sensitive areas–> lower extremities, elbows
younger patients are more likely to have involvement of the face or upper extremities
what % of kids with ITP develop severe epistaxis or other mucous membrane hemorrhage
3%
what is the most concerning complication of ITP and how common is it
intracranial hemorrhage
0.1-0.5% of cases
what is the recurrence rate of HSP
about 30%
tx of ITP
options:
observation
oral corticosteroids
IVIg
anti-D immunoglobin (rhogam)
how long does HSP usually last
about a month and goes away on its own without tx
how does intussucseption appear on abdo xray
abdo mass with a central ring of hypoattenuation –> corresponds to mesenteric fat in the intussuscpetum
what is the most common form of bowel obstruction in kids between ages 6 months and 6 years
intussusception
80% occur in kids under 2, boys more than girl
why does intussusception happen
occurs when proximal segment of bowel invaginates into the distal segment adjacent
accompanying mesentary becomes entrapped, causing vascular compression and eventual ischemia
how does intussusception usually present
- paroxysms of severe abdo pain with inconsolable crying
- passage of “currant jelly” stool containing blood and mucus
- palpation of a “sausage shaped” mass in the right abdomen
minority of patients present with this classic triad–> you need high index of suspicion for diagnosis (may also have vomiting, lethargy, toxic appearance)
what should you think if kid is passing “currant jelly” stool
intussusception
how do you usually treat intussusception
air or barium enema
in HSP, it is usually ileo-ileal rather than ileo-colic and thus will not be reduced by air or barium enema–> dx requires abdo US and tx is usually surgical
most common cause of vomiting and diarrhea in kids
viral gastroenteritis –> primary concern is dehydration
what would severe or localized abdo pain in the setting of vomiting or diarrhea suggest
more serious condition than viral gastroenteritis
what are the most reliable questions to ask when assessing hydration status by phone
childs level of activity
kids ability or desire to take fluids by mouth
dont ask parents to do physical exam by phone
what is the most accurate method of determining the patients degree of dehydration?
subtract the patients current weight from his or her weight immediately prior to the illness
presume that weight lost is water lost (weight loss in grams equal to water loss in mL…weight loss in kg is water loss in L)
convert to percent dehydration–> total euvolemic body weight lost as water
what are some things on physical exam that tell you a kids dehydration status
weight
vital signs
HEENT exam–fontanel, sunken eyes, mucous membranes)
skin turgor, temp, character of perfusion
mental status/level of activity
how do you treat mild to moderate dehydration
(5-9%)
oral or enteral rehydration using appropriate oral rehydration solution
50-100mL/kg of ORS over 2-4 hours
10mL/kg ORS for each additional diarrheal stool
2mL/kg ORS for each additional emesis
treatment for moderate to severe dehydration
(10-15%)
initial hydration should be via IV bolus using isotonic, non dextrose containing solution (NS or lactated Ringers)
20mL/kg IV bolus
repeat bolus after re-evaluation until the patient is clinically improved (awake, altert, well perfused, interested in and tolerating oral fluids, urine output is present)
often 60-100mL/kg total of bolus fluid is required
can then switch to oral
what is ORS
contains glucose and electrolytes
is as effective, safer and cheaper than IV fluid for mild-mod dehydration
can be used effectively even when there is still some vomiting
what is GER
regurgitation/spitting up may be difficult to distinguish from true vomiting
infants who reflux with overfeeding may sometimes have forceful vomiting
severe esophagitis may result in blood streaked emesis
pain from reflux or esophagitis may lead to feeding aversion when GER is severe
infant who is dehydrated from severe reflux may also have FTT
what is the hallmark of infectious gastroenteritis
large watery stool
“enteritis” is not truly present if diarrhea is not present
would you expect to see bilious emesis in gastroenteritis or GI tract obstruction above the ligament of Treitz?
no (small amounts of bile may accompany repetitive vomiting)
does intestinal malrotation always cause symptoms?
no
malrotation can be present without volvulus (twisting of intestine causing obstruction)
however–malrotation may result in volvulus and result in vomiting and other signs of obstruction
what type of emesis is common in malrotation/volvulus
bilious emesis (if below ligament of treitz)
what causes the pain assoc with volvulus
bowel ischemia
how may kids with malrotation/volvulus present
may present in shock which makes dx difficult
what should be considered in kids with recurrent emesis
inborn error of metabolism
what is pyloric stenosis and how does it present
escalating pattern of forceful/projectile, non-bilious vomiting
bilious emesis not typical because obstruction is above ligament of treitz
what is the hallmark of pyloric stenosis
escalating pattern of forceful/projectile, non-bilious vomiting
also presence of hypochloremic, hypokalemic metabolic alkalosis with dehydration
how does pyloric stenosis affect appetite
kids often have a vigorous appetite until late in the course
how do kids with pyloric stenosis often present
mild to moderate dehydration due to persistent vomiting
if you see also presence of hypochloremic, hypokalemic metabolic alkalosis with dehydration in the context of forceful vomiting, what should you consider
pyloric stenosis
why might you see bloody emesis in pyloric stenosis
mallory weiss tear
what might you observe in the abdominal exam of a kid with pyloric stenosis
visible peristaltic wave especially just after eating
what is the physical exam finding on palpation suggestive of pyloric stenosis
palpable “olive” (the hypertrophic pyloric muscle) in the epigastric region (not uniformly perceptible)
what CNS diseases may cause vomiting
hydrocephalus
intracranial neoplasm
trauma
what cause of vomiting must you always consider, especially in the absence of fever or diarrhea
CNS diseases
how do you work up pyloric stenosis
pyloric US–> study of choice
if US unavailable–> upper GI contract study–> “string sign” of very narrow pyloric channel
electrolyte studies–> often associated with electrolyte abnormalities because of loss of stomach fluid and inadequate fluid intake
what should you consider in a vomiting infant and no other localizing symptoms
UTI
