In Children Flashcards
What is encopresis?
Fecal soiling in kid
Causes of encopresis
Retention
Constipation
Anal Fissures
Hemorrhoids
Relationship Difficulties
Stress/Anxiety
Hypothyroidism
Anorectal Malformations
Hirschsrpung Disease
Hypercalcemia
Spinal Cord/Neurological Lesion
What to ask in hx of constipation
Stool pattern (size, consistency, interval)
Large bowel movements suggest constipation
History of constipation/soiling (onset)
Incontinence during sleep suggesting constipation
Diet history (type and amount of food, changes in diet)
Decrease in appetite
Abdominal pain
Medications
Urinary symptoms (day or night enuresis, UTI)
Family history of bowel disease
Family/personal stressors
Toilet training, separation, change in schedule
Management of constipation/ retention encopresis
PEG 3350 1-1.5 g/kg PO daily x 3-6 days or until loose stool, then maintenance 0.4g/kg daily
Assessment and guidance regarding psychosocial stressors
Behavioural modification
Positive association with toilet sits
Schedule regular 3-5 times daily toilet sits (eg. after each meal)
While sitting, offer proper foot support, and enjoyable relaxing activities
Ensure soft, well formed stools
What to ask in hx of enuresis
Secondary (after >6mo of bladder control)
Frequency of wetting the bed (severity suggests prognosis)
Drinking habits
UTI
Dysuria, Change in urine colour, odour, stream
Neurological
Change in gait or stool incontinence
Overactive bladder
Diurnal enuresis (daytime)
Frequency of leakage
8+ voids/day
Sudden urgent need to urinate
Stool history (Constipation, encopresis)
Treatment of primary nocturnal enuresis
Reassurance (15% resolve spontaneously each year)
Behaviour modification
Limit fluids/caffeine
Void prior to sleep
Ensure easy access to toilet
Remove diapers
Include child in morning cleanup in non-punitive manner
Motivational therapy (eg. star chart)
Bladder retention exercises
Scheduled toileting overnight
“Wet” alarm wakes child upon voiding (70% success)
Consider referral if inadequate response to enuresis alarm
Medications (for sleepovers or camp)
DDAVP 0.2mg PO qHS (up to 0.6mg)
Causes of secondary enuresis
Stress
UTI
Constipation
Endocrine
DM
DI
Neurogenic bladder
CNS
CP
Seizures
Pinworms
DDx for pediatric hip pain
Infectious (acute, localized, severe - refusal to bear weight, fever, elevated WBC, ESR, CRP)
Septic arthritis hip or sacroiliac joint
Osteomyelitis of femoral head or pelvis
Lyme disease
Referred
Psoas/abdominal/pelvic abscess
Appendicitis
Discitis
Inflammatory (chronic, insidious except synovitis may be acute)
Systemic arthritis
Orthopedic (hip pain may be referred to thigh/knee, acute or insidious, worse pain on activity, decrease at rest, no systemic symptoms, ESR/CRP normal)
Slipped capital femoral epiphysis (SCFE)
Legg-Calvé-Perthes disease (LCP) / Avascular necrosis
Neoplastic (night-time pain, unrelated to activity, systemic symptoms, anemia, leukopenia, thrombocytopenia, high LDH or uric acid)
What hip XR views should you get in peds?
(anteroposterior and frog-leg views)
What does an XR vs US vs MRI r/o in ped hip pain?
Hip X-ray
r/o trauma, malignancy, advanced (not early) LCP, JIA, SCFE
Hip Ultrasounds
r/o effusion (bilateral suggestive of transient synovitis, unilateral r/o septic arthritis consider joint aspirate)
MRI
r/o osteomyelitis, early LCP, and early SCFE
What criteria to use to r/o septic arthritis + how to Ix?
Kocher Criteria
Non-weight-bearing on the affected side
ESR > 40 mm/hr
Fever
WBC count > 12,000
If low pre-test probability + negative hip US for effusion, outpt FU
If moderate pre-test probability
Negative U/S
If <24h, Repeat U/S in 12h or MRI
If >24h, Outpatient follow-up
If positive ultrasound -> Arthrocentesis for synovial fluid analysis
Causes of FTT
Inadequate intake
Eating poorly (most common)
Anorexia associated with chronic disease
Eating/oral skills lacking
Inadequate absorption
Emesis
Malabsorption
Pancreatic disease (Cystic fibrosis, Scwachman-Diamond syndrome)
Cholestatic liver disease
Intestinal disase (celiac, Crohn’s)
Excessive caloric expenditure
Chronic disease/infections
Endocrine
Hypothyroidism
Growth hormone deficiency
Other (rare)
Diencephalic tumour
Renal tubular acidosis
RF for FTT
Cardiac findings suggesting congenital heart disease or heart failure (e.g., tachycardia, cyanosis/hypoxemia, murmur, edema, hepatomegaly)
Developmental delay
Dysmorphic features
Failure to gain weight despite adequate caloric intake
Organomegaly or lymphadenopathy
Recurrent or severe respiratory, mucocutaneous, or urinary infection
Recurrent vomiting, diarrhea, or dehydration
Initial workup for FTT
CBC (anemia, chronic infection, inflammation, and malignancy)
Urinalysis (glucosuria, renal disease)
Electrolytes
Blood urea nitrogen
Liver enzymes
Lead testing
CRP/ESR
Anti- TTG and Total IgA (celiac)
Buckle fracture features, management
Usually FOOSH
Removable wrist (volar) splint x 2-4 weeks
Start ROM if at 2w no tenderness (discontinue immobilization)
No need for repeat X-rays
Non-displaced greenstick fracture management
Short-arm cast x 2-4 weeks
displaced greenstick fracture management
Displaced >10 degrees angulation
Closed reduction (gentle steady pressure for physeal) under conscious sedation
Long-arm cast (elbow 90 degrees flexion, forearm in neutral rotation, and wrist in neutral flexion-extension
Repeat X-rays weekly
Remove cast at 4 weeks if healed clinically and radiographically
non displaced physis fracture management
Non-displaced (if X-rays normal initially, tenderness over growth plate, immobilize x 2 weeks, re-image and re-assess)
Short-arm cast x 3-6 weeks
What to assess on an elbow fracture
Assess Vascular (Brachial) and Nerve (Ulnar/Anterior Interosseous Nerve)
Capillary refill, distal neurovascularity
Immobilize at flexion 20-30 degrees (least nerve tension) before X-rays to avoid further injury
How to approach elbow XR, what signs are you looking for
Fat pad (sail) sign, posterior always indicates effusion (rule out fracture)
Anterior humeral line should intersect middle 1/3 of capitellum (if not think supracondylar fracture)
Radiocapitellar line shoulder intersect capitellum, if not think radial head dislocation (rule out Monteggia fracture-dislocation)
Remember CRITOE (Capitellum, Radial head, Internal epicondyle, Trochlea, Olecranon, External epicondyle)
Age 1, 3, 5, 7, 9, 11
Consider image bilaterally
Rx for supracondylar fractures
For non-displaced, neurovascular intact
Long arm posterior splint then long arm casting with less than 90° of elbow flexion x 4 weeks with repeat X-ray
Rx for lateral condylar fractures
FOOSH + Varus force
Non-displaced
Posterior splint, elbow 90°, weekly follow-up, if stable x2 weeks long-arm cast for 4-6 weeks
Proximal humerus acceptable deformity
Age 1-4yo = 70° without displacement
Age 5-12yo = 40° and displacement <51% width of shaft
Age >12yo = 15° and displacement <30% width of shaft
Rx for prox humerus fractures
discuss conservative measures and consider Sarmiento brace with repeat X-rays in 2 weeks
Clavicular fracture features + management
Most commonly middle third of clavicle after fall on shoulder (or may be from FOOSH)
Broad arm sling (or figure of 8) 2 weeks until comfortable and fracture site non-tender
Repeat X-ray if lateral third fracture at 1 week (no repeat X-ray at middle-third)
ROM as tolerated (elbow/wrist/hand ROM throughout recovery)
Return to non-contact sports 6 weeks after injury
Avoid contact sports 1-2 months after healing
Advise that bony deformity possible
Refer to ortho if displaced medial or lateral third fracture
Feature’s of toddlers fractures
Children <2yo learning to walk (often no history of trauma)
Fall with twisting motion or from significant height
Spiral fracture of distal/middle tibia (13-43% initial X-rays negative)
Pain with dorsiflexion of ankle
Rule out abuse (bruising, other fracture)
Rx for non-displaced fractures
Bent knee long-leg cast
X-rays weekly
May change to short-leg cast for 4-6 weeks if callus present
No evidence that casting speeds healing, but may decrease risk of displacement
Healing usually by 6-10 weeks
Varus deformity should remodel if <10 degrees
When to refer toddler’s fractures
Refer to ortho if open, pathologic, displaced >10 degrees anterior angulation, >5 degrees varus/valgus angulation, >1cm shortening, concurrent tibia/fobular fracture
DDx for purpura
Infection
Bacterial
Meningococcemia
Streptococcus
H influenzae
Infective endocarditis
Viral
Parvovirus - glove-socks distribution, may be associated with slapped cheek syndrome
Rockey Mountain Spotted Fever in North america
Epidemic typhus, Queensland tick typhus
Mechanical
Cough/vomiting (limited to head and neck)
Local pressure/tourniquet (distal to tourniquet)
Strangulation
Hematological
Thrombocytopenia (Plat <100)
ITP - likely diagnosis if otherwise normal CBC and no hepatosplenomegaly, or lymphadenopathy
Leukemia
Hypersplenism
Vascular
Vasculitis - Henoch-Schonlein purpura HSP
Scurvy (perifollicular purpura on lower limbs)
Drugs - steroids
Cushing’s syndrome
Fat embolism
Dysproteinemia
Management of non-mechanical purpura
CBC, CRP, blood culture
Consider INR
Observe child for 4 hours in ED
Discharge if well, petechiae do not progress, and labs reassuring (CRP <8, WBC 5-15)
If unwell (irritable, lethargic, abnormal vital signs, poor peripheral circulation)
ABC
Fluid resuscitation
Third generation cephalosoprin (ceftriaxone, cefotaxime)
Admit
Dx of Henoch Schonlein purpura
Palpable purpura without thrombocytopenia/coagulopathy, and with one of: DRAB
Diffuse abdominal pain
Renal involvement (any hematuria or proteinuria)
Arthritis (acute, any joint) or arthralgia (50-75%)
Biopsy-proven (immunoglobulin A deposition)
What is HSP?
Common vasculitis in children 2-8yo
What to examine on physical exam if suspicious for HSP
Blood pressure (r/o Hypertension)
Height/Weight (to calcualte normal BP based on sex/age/height/weight)
Palpable purpura, petechiae
Painful subcutaneous edema (periorbital, hands, feet, scrotum)
Joint exam (usually no significant effusion/warmth)
Abdomen (rule out obstruction, intussussception)
Resp (rule out hemorrhage)
Neuro
Ix for HSP
CBC with platelets
UA (hematuria, proteinuria)
Renal function (lytes, BUN, creat, UA)
Consider blood cultures, Coags
Consider throat swab, ASOT (if current/recent sore throat)
May consider IgA (elevated)
Complications of HSP
Renal (glomerulonephritis, renal failure)
Orchitis, scrotal swelling (may cause torsion)
CNS involvement (seizure, hemorrhage)
Intusessception
Myocardial infarction
Pulmonary hemorrhage
Rx for HSP
Acetaminophen
NSAIDs (avoid if renal involvement), eg. Naproxen 10-20mg/kg divided BID (max 500mg BID)
Steroids for severe abdominal or joint pain
Prednisone 1-2mg/kg daily (max 60mg daily) x 2 weeks, taper 25% per week
Home urine dipstick weekly x 1 month
BP and UA monthly or q2 months until 1 year
Serum BUN and creat if hematuria or proteinura
Refer patients with persistent hematuria, proteinuria, hypertension, renal insufficiency
Counselling for HSP
> 90% resolve spontaneously within 4w
Joint pain and abdominal pain resolve within 2-3d
HSP recurs at least once in 25-35% of patients (usually milder)
Advise that purpura may recur as they increase activity
Dx of ITP
Sudden petechiael rash/brusing in well child
Platelet <100, otherwise normal CBC/reticulocyte
Normal blood smear (no hemolysis, blasts)
Negative DAT (Coombs)
Negative history/physical examination (no lymphadenopathy, hepatosplenomegaly, systemic symptoms eg. fever, weight loss, family history)
Ix for ITP
CBC, platelet
Reticulocytes
Peripheral blood smear
Blood type and direct antiglobulin test (DAT, formerly Coombs)
Rx for ITP
Consider Hematology consultation
Provide safe platelet count to avoid important bleeding
Severe bleeding or platelet <30 should get platelet transfusion with IVIG and glucocorticoids (with hematology consultation)
If no bleeding and platelet >30, observe as no treatment usually required
Pros of circumcision
Decrease
Penile cancer (NNT 900-322,000)
Phimosis (NNT 67)
UTI (NNT 111)
HPV (NNT 5), HIV (NNT 298), HSV (NNT 16)
Decrease cervical cancer and STI in partner
Cons of circumcision
Surgery risks: Infection (NNH 67), bleeding (NNH 67)
Meatal stenosis (NNH 10-50)
Ethical concerns
When is circumcision CI?
Hypospadia
Counselling for babies milk
Exclusive breastfeeding recommended for first 6 months and continued into second year of life
Breastfed babies should receive Vitamin D 400 units PO daily
Vitamin D 800 units daily if high risk (limited sun exposure, darker skin, obesity)
Express breast milk can refrigerate up to 3d and freeze up to 6mo
Warm milk by placing in warm water
Switch from formula to homogenized milk at 500-750 mL/day at 12 months
Discontinue bottle by 18 months
Transition to 1-2% milk (500mL/day) at 2-3 years
Counselling for introducing food to babies
No evidence to delay food beyond 6-12 months
Introduce foods one at a time q3d (monitor for reactions)
Avoid solid round smooth dry/sticky foods risk of choking
Avoid sugary food/drinks
No beets, carrots, spinach, turnips before 6 months (nitrates)
No honey in first year
Inquire about vegetarian diets
Iron-containing foods should be encouraged when introducing solids
Iron-fortified cereals and grain products
Consider screen at 6-12mo for anemia in at-risk (eg. low SES)
Counselling for safe sleep
Safe crib (no soft objects/loose items, firm mattress)
On Back
Room sharing for <6 months
Pacifier if <6 months
Avoid bed sharing (consider bed box)
Counselling for swaddling
Avoid beyond 2 months
Hip safe swaddling
Counselling about car seats
Rear-facing car seat
Infant must use rear-facing car seat
Use a larger seat once baby outgrows infant seat, and keep rear facing until at least 2 years of age or reaches the maximum weight or height limit of the rear-facing seat, as stated by the manufacturer
Forward-facing car seat with a 5-point harness
Once child outgrows larger rear-facing seat and is at least 2 years old, use 5-point harness seat until at least 18kg (40lbs) and can sit straight/tall without moving out of position or unbuckling (this may be 4-6 years old)
Booster seats with belt-positioning
When child has outgrown forward-facing car seat with a 5-point harness, use a booster seat until 145cm (4’9”) tall and they safely fit in adult seat belt without slouching (for most children this is 9-12 years old)
Rear seat with adult seatbelt until 13 years old
Signs of NAI
Bruises (uncommonly injured areas)
Hand Marks
Bite Marks
Multiple Injuries (different stages of healing)
Circumferential Immersion Burns
Blunt Instrument Marks or Burns
Retinal Hemorrhages (unexplained)
Evidence of poor care or failure to thrive
Sx of depression in kids
change in school performance, change in friend groups, somatic complaints, change in extracurricular activities
What is the PHQ-A ?
used for 11-17y/o kids to screen for depression
UTI sx for newborns, infants, school aged kids
Newborn: jaundice, sepsis, FTT, vomiting, fever
Infants: fever, strong smelling urine, hematuria, abdo pain, new onset urinary incontinence
School age: frequency, urgency, dysuria
What is PAS?
pediatric appendicitis score:
CHAPMEN F
cough
hopping
anorexia
percussion
mid abdo pain migrates to RLQ
elevated WBC
nausea
fever
What is in a HEEADSSSS hx?
home
education
employment
activities
dieting/ body image
sexuality (romantic or sexual relationship) + gender identity
suicide/ depression
safety (injuries, seatbelts, violence)
social media
supports
sex
Signs of resp distress in kids
Increased breathing rate.
Increased heart rate.
Bluish pallor/Color
Grunting.
Nose flaring.
Retractions.
Sweating.
Wheezing.
Stridor.
Accessory muscle use.
Changes in alertness/Fatigue/Sleepiness.
Leaning forward/ tripoding
What to use for teething
teeth rings, not numbing gel
When to NOT use soy formula
not if preterm or cows milk protein allergy
Nut advice for kids
don’t delay eggs or nuts, start around 6mo, feed a few times a week
Screen time advice for kids
monitor, model meaningful screen use, video chat ok, more screen time = more conduct problems + depression
Pediatric limps causes
LIMPSS (Legg Calve Perthes, infection/ inflammation, malignancies (Ewing’s sarcoma, osteosarcoma), pain from fractures (NAI?), SCFE, something above or below (knee/ hip/ ankle)
Unconjugated causes of hyperbilirubinemia
hemolysis, breast milk, Gilbert’s, blood loss, physiologic, dehydration
Conjugated causes of hyperbilirubinemia
biliary atresia, CF, duct stenosis
NAI signs
bruises, post rib fracture, bucket handle fracture, bites, behaviour changes
Rx for constipation in kids
osmotic laxative (PEG 3350, lactulose), behavioural mod, dietary mod, disimpaction, parental education, refer to GI if refractory
Rx for reflux in INFANTS
modify frequency, timing and thickness of feeds, trial hydrolyzed or amino formula, NO PPIs
Rx for reflux in KIDS
PPI for short term
Red flags for puberty
before 8 in girls, before 9 in boys - REFER
MIS-C sx
fever, abdo pain, vomiting, diarrhea, rash, mucocutaneous lesions
Best rx for kids w/ UTI
cefixime
Dose of dex for croup
dex 0.6mg.kg
Complication of croup
bacterial tracheitis
Fractures of abuse
femur <18mo, humerus <18mo, skull, metaphyseal, posterior rib
Ways of getting urine sample to diagnose UTI in kids
midstream urine, quick wee method, bag, catheter, bladder tap technique
DDx for stridor
influenza, RSV, adenovirus, tracheomalacia, FB
Options for formula for cows milk protein allergy
hydrolyzed cows milk, hydrolyzed rice milk, soy milk, amino acid based formula
What is a shuddering attack?
Shivering movements of head and upper body, last several seconds
What to do for workup of ?sz in kids?
EEG and neuro exam
Virus causing mono
EBV
