Last semester Flashcards
Newborn Infant Toddler Young Children Older Children Adolescents
Newborn --> birth to 1 month Infant --> 1 month to 1 year Toddler --> 1 year to 2 years Young Children --> 2 years to 5 years Older Children --> 5 years to 12 years Adolescents
Normal gestation Pre term infants Post term infants Low birth weight Very low birth weight
Normal gestation --> 38 to 42 weeks Pre term infants --> before the end of 37th week Post term infants --> 42 weeks Low birth weight --> under 2500g Very low birth weight --> under 1500g
Gross motor physical development of a child
When does child understand name?
Newborn: flexed posture 7 mo: sits without support 1 year: stands independently 15-18 months: walks independently and steadily 2 1/2 years: rund and jumps
Child understands name at 1 year
3 endocrine levels
Primary: gonads, thyroid gland
Secondary: anterior pituitary
Tertiary: Hypothalamus
Goitre - causes
Non-toxic:
- dietary deficiency, hashimotos, neoplasm, genetics
Toxic:
- graves, hashimotos, neoplasm, TSH-secreting pituitary gland tumor
In hyperthyroidism, TSH levels are…
…decreased
Calcium daily balance
- 1 g Ca per day!
- Total calcium is twice as high as ionic calcium
- decreased ca levels –> PTH released
Growth hormone - IGF-1 axis
- produced at anterior pituitary
- released into blood stream
- action via its mediator IGF-1
- directly on traget tissue
- ghrelin is secreted in stomach and increases the release of growth hormone
Puberty
- hormones involved
- Stages
- Anterior pituitary: LH and FSH
- LH: stimulates testes –> testosterone
- FSH: stimulates ovaries
- puberty starts at 11 in boys, 10 in girls (LH is a good marker for beginning)
1- Adrenarche: implement of adrenal androgen which could give some pubic/ axillary hair –> not conencted to gonadarche
2- Gonadarche: maturation of gonads
Window of opportunity
- mini-puberty at 3-6 months of age
- increased LH and FSH levels
What should we ask in history taking of urinary tract?
ANTENATAL HISTORY:
- amniotic fluid volume
- alpha-fetoprotein level
- presence of fetal distress
- maternal drug history and diabetes
BIRTH HISTORY:
- delivery, apgar, weight…
- low weight –> low nephron number; high weight –> Beckwith-Wiedemann syndrome
- number of umbilical vessels
- weight of placenta
Kidneys are enlarged/ palpable with…(7)
- autosomal recessive polycystic kidney disease
- autosomal dominant polycystic kidney disease
- tuberous sclerosis
- multicystic dysplastic kidney
- severly obstructed kidneys
- renal venous thrombosis
- renal tumor
Evidence of renal osteodystophy
- thickened wrists
- ricekty rosary
- lower limb deformities
Red Urine can be due to:
- macroscopic hematuria: the longer the contact and the more acidic the urine, the darker the color
- certain foods (beetroot)
- Hemoglobinuria
- myoglobinuria
- urate crystals
- drugs
- inborn errors of metabolism
Causes of cloudy urine
secondary to the presence of:
- pyuria (white blood cells)
- Calcium phosphate crystals
- combination of calcium salts, uric acid, cysteine or struvite
What does a dipstick urine test look for: (6)
- pH
- Blood
- Protein
- Glucose
- Leukocytes
- nitrites
Urine pH
- from 5 to 8
- important in diagnosing renal tubular acidosis
- important in treating and preventing urinary stones
Specific gravity
- 1.001 to 1.035
- reflects concentrating and diluting ability of kidney
- reflets persons hydration status
Causes of false positive and false negative proteinuria
FALSE POSITIVE:
- concentrated urine
- alkaline urine
- gross hematuria
- dipstick was left in too long
- contamination with secretions from urinary tract or vagina
- contamination with antiseptics, chlorhexidine, benzalkonium
FALSE NEGATIVE:
- diluted urine
- acidic urine
GLUCOSE on urine dipstick
- lower limit of detection is 4-5 mmol/l
- appears when serum glucose is >8.910 mmol/l
Nitrites of urine dipstick
- majority of pathogenic bacteria produce nitrite
- high specificity and low sensitivity for UTI
Casts in urine
- Hyaline casts –> in proteinuria
- Cellular casts
- ->RBCs (in glomerular bleeding) –> >5 RBC/mcl
- ->WBCs (renal inflammation) –> > 10 WBC/mcl
- ->epithelial cells
- can be a normal finding
- centrifugation can damage casts
Diagnostic tools in urinary system
- Ultrasound
- Intravenous urogram
- voiding cysturethrogram (to detect VUR)
- DMSA scan
- Dynamic renography (to asses renal blood flow)
- CT
- MRI
Hematopoiesis in children
- by birth, all bone marrow cavities are actively hematopoietic
- in childhood, hematopoiesis moves to central bones
Causes of an increase and decrease in WBCs
Normal levels
Normal: 5.0-10
INCREASE:
infection, tissue necrosis, bone marrow malignancies, inflammation
DECREASE:
- infection, conditions that suppress immune system or exhaust bone marrow
WBCs precentages of different types
prcentages of total WBC count
- Neutrophils 40-60% (elevated in bacterial infection)
- Monocytes 2-10% (viral infectio)
- Lymphocytes 20-40% (viral infection)
- Eosinophils 0-5% (allergic and parasitic disorder)
- Basophils 0-1% (systemic allergic reaction)
Physiologic WBC changes
- newborn has high WBC count (falls within 2 weeks)
- until 8 years, lymphocytes are more dominant than neutrophils
Causes of increase and decrease of RBC
INCREASE
- congenital heart disease, chronic hypoxia, high altitudes, polycythemia vera
DECREASE
- renal disease, RBC destruction, iron deficiency, vit. B12 deficiency, blood loss, bone marrow depression
MCV
MCH
MCHC
RDW
- Mean corpuscular volume: average size of RBCs
- Mean corpuscular hemoglobin: average weight of Hb per RBC
- Mean corpuscular hemoglobin concentration: average concentration of Hb (normo-, hyper- and hypochromic)
- Red Cell Distribution Width: uniformity of RBDs
Hemoglobin
Causes for increase and decrease
- 115-145 g/l)
- Hgb F (fetal hemoglobin)
- Hgb A (adult hemoglobin)
INCREASE:
- congenital heart disease, chronic hypoxia, high altitudes, polycythemia vera, fluid loss
DECREASE
- decreased production(anemia, renal disease, iron deficiency, bone marrow depression)
- Increased destruction (sickel cell, shperocytosis)
- blood loss
- fluid volume overload
Reticulocytes
causes of increase and decrease
- immature RBC (0.5%-1.5%)
INCREASE
- anemia, chronic hemolytic anemia
DECREASE
- bone marriw failure syndrome, iron deficiency anemia, vit. B 12 anemia, folate deficiency anemia
Physiologic anemia of the newborn
at one week postnatal –> all RBC indices begin declinign to a minimum
Platelets
causes of increase and decrease
- 150-450
INCREASE
- acute blood loss, myeloproliferative disease, polycythemia vera
DECREASE
- decreased production (leukemias, bone marrow failure syndromes)
- increased destruction (ITP, certain drugs)
- Abnormal pooling (splenic sequestration, splenomegaly)
Lymph node exam
- size: insignificant if 2cm or less
- consistency: soft (hard –> malignancy, rubber –> lymphoma)
- tender: no
- Mobility: yes, should not be fused together
- Patient’s age: 2-12 years -> always palpable head and neck
Examination of fontanelles
- anterior fontanel closes until 1-2 y
- posteiror fontanel closes into 2 months
- anterior fontanel is felt for bulging (raised intracranial pressure) or depression (dehydration)
Macrocephaly and Microcephaly
Macrocephaly: OFC > 2 standard devations (SD) above the mean
Microcephaly: OFC > 2 SD below the mean
Severe Microcephaly: OFC > 5 SG below the mean
Meningeal signs
- Neck muscle (Nuchal) rigidity
- Kernig sign: pain or resistance to straightening leg from flexed position
- Brudzinsky signs: involuntary flexion of knees when lyign supine
- Lasegue sign: pain or resistance to lift extended leg
Munich functional Deelopmental Diagnostics
–> 8 most important psychomotor functions
- crawling
- sitting down
- walking
- gripping
- perception
- speaking
- understanding speech (from 10 mo)
- social skills
Iron deficiency anemia
- Hb < 110g/l in children younger than 2
- Hb < 120 g/l in children older than 2
Fe metabolism after birth
- mothers Fe keeps Fe level of infant until 1 year
- postnatal high Hb - high iron storage
- during first 4 months Fe storage increases only 10%
- 4-12 months: Fe storage increases 50%
Impaired absorption of Iron
- Malabsorption syndrome
- Celiac disease
- Prolonged diarrhea
- Anatomic gut lesions
- Allergic gastroenteropathy
- intestinla parasites
- colonisation of H. pylori
Stages of Iron Deficiency
1- Prelatent Stage: decrease in ferritin, no symtpoms
- Latent stage: decrease of MCV, MCH, reticulocytes, ferritin
- Iron deficiency anemia: decrease of Hb
Consequences of IDA in pregnant women and children
PREGNANT WOMEN
- pre-eclampsia
- abortion
- peripartal bleeding complications
- Premature delivery
- low birth weight
CHILDREN
- impaired motor development
- impaired language development
- psychological and behavioural effects
- decreased physical activity
- mild to moderate mental retardation
Stages of IDA and their treatment
- mild: Hb 110-90 g/l (1-3 mg/kg/day to normal Hb + 1-2mo)
- moderate: 90-70 (3-5 mg(kg/day to normal Hb + 2-3 mo)
- severe: < 70 (5-7 mg/kg/day), tapering 5-6 mo
give premature babies 1-4mg of Fe/kg to prevent
four baby miracles after birth
- Physical growth
- Cognitive development
- Immature maturation
- Digestive maturation
Celiac disease oral manifestations
Enamel defects Delayed eruption recurrent aphthous ulcers Cheilosis Oral lichen planus Atrophic glossitis
Etiology of halithosis
- mouth (gingivitis, aphta, ulcer)
- Nasopharynx (tonsils, adenoids)
- Esophagus (GERD)
- Stomach (gastritis, peptic ulcer disease)
- Liver
- Other: lungs, renal, metabolic disease
Peutz-Jager syndrome
- autosomal dominant disorder characterized by the development of benign hamartomatous polyps in the GI tract and hyperpigmented macules on the lips and oromucosa
What does parotid gland produce?
- amylase
- growth hormone
- lipase
Stomach functions
- Chief cells: pepsinogen
- lipase
- Parietal cells: HCl
- G cells: gastrin
- D cells: somatostatine
- horomones: ghrelin
- mucous production
less acidic the younger the child
Importane of HCL
- Activation of pepsinogens 1-5
- Protein digestion
- Food sterilization
Stomach pH and pepsin relation
the higher the pH, the lower the pepsin activity
Maturing of digestive system
- enzyme activities develop throughout the digestive system during the first year of life
- first 4-6 mo: infants gut is more open and antibodies from breast milk can enter
- 6 mo: gut barrier is closed, infant produces antibodies
Human pancreatic exocrine enzymes
PROTEASES
LIPASES (low during first months of life)
GLYCOSIDASES (amylase; is low at birth)
NUCLEASES
Protein digestion
- Stomach: pepsin
2. Intestine: pancreatic proteases
Exocrine pancreas secreted enzymes during:
- fasting
- interdigestive period
- after eating
Clinical symtpoms of exocrine pancreatic insufficiency
- poor growth
- diarrhea
- lipid soluble vitamins deficiency
Development of skeletal system
- 3rd week: formation of notochord
- 4th week: first signs of arms and legs
- 5th to 8th week: limbs begin to extend
- ossification of most bony nuclei of long and rouhnd bones does not complete until after birth
Bone formation
- Intramembranous ossification: flat bones of the skull and mandible
- Endochondral ossification: replacement of cartilage by bone, most bones of the body
Factors affecting bone growth
- lack of calcium, protein and other nutrients
- vitamin D needed to absorption of calcium(lack –> ricketts in childhood and osteomalacia in adults)
- vitamin C needed for collagen synthesis (lack –> scurvy, teeth fall out, wounds do not heal)
Gait in children
- Toddler who begins to walk: wide and unstable gait
- 18 mo: wide base narrows and more stable
- 4 years: child can hop on one foot and arm swing occurs
- 6 years: gait and arm swing similar to adult
Joint hypermobility is assessed by the …
Beighton score
- one point for each thumb
- one point for each finger + 90°
- one point for each elbow + 10°
- one point for each knee + 10°
- one point with straight legs
Causes of Rickets
- Vit D disorders
- Calcium deficiency
- Phosphorus deficiency
10 importatn clinical features in Rickets
- delayed closure of fontanelles
- frontal bossing
- dental hypoplasia
- pectus carinatum
- swelling in wrist and ankle
- wide sutures (skull)
- Craniotabes
- Rachitic rosary
- Harrison’s sulcus
- Bowing of legs
Spasmophilia
- in malnutrition of vit D
- development of alkalosis and hypocalcemia
- laryngospasm, convulsions, increased neuromuscular tone
Grading of heart murmurs
I°: only listening very carefully
II°: audible, only in full contact of stetoscope with chest
III°: audible at once without full contact
IV°: audible thourgh the palm
V°: audible through the forearm
VI°: hear it without stetoscope
Innocent murmurs
- only systolic
- mostly under II°
- not audible from back
- vertical position decreases intensity
- temporary
Abnromal murmurs
- systolic and diastolic
- Mostly above II°
- audible from back and out of heart area
- Vertical position increases intensity
- permanent
Hypertension from 0-15 years (percentile)
over 95th percentile
CTI equation
(CD+DE)/AB (must be under 50%)
growth is controlled by
- genetics
- nutrition
- environment
- hormones
Endocrine regulation of grwoth
- GH
- growth factors (IGF-1)
- thyroid hormones
- insulin
- sex steroids (during puberty)
Growth hormone - IGF-1 axis (more detailed)
GH –> Liver –> IGF-1 –> bone, cartilage and others
Physical growth components
Infancy component: mostly nutrition
Childhood component: GH
Pubertal component: sex steoids and GH
Target height
girls: Father height - 13 + mother hieght / 2
boys: mother height + 13 + father height /2
maturation of the hypothalamic-pituitary gonadal axis in puberty
- development of gonads
- increased secretion of sex steroids
Breast milk protective effect from
1- Infections 2- Allergy 3- obesity 4- High blood pressure and total blood cholesterol 5- psychological and cognitive benefits 6- Higher intelligence 7- Crohns disease and ulcerative colitis
Recommendations on Breastfeeding
- 8-12 feedigns in 24 h
- no supplements
- begin daily vit D drops at hosptial discharge
- avoid routine pacifier use (no earlier than 3-4 weeks)
Milk secretion
- prolactin and oxytocin are secreted and released into the circulation
- prolactin stimulates milk synthesis
- oxytocin stimulates the myoepithelial cells to contract
domperidon could be given to induce mild secretion
Composition of human milk
- carbohydrates (lactose)
- protein
- lipids
- vitamins (influenced by mothers diet)
- Minerals
- HMOs
HMOs
Glucose Galactose N-acetyl-glucosamine Fucose Sialic acid
HMOs protective factors
- healthy intestinal microbiota
- support gut barrier
- reduce harmful bacteria
- promote the gut associated immune system
Contraindications of breast feeding
- baby has galactosemia
- mother has active untreated tuberculosis
- mother is receiving radioactive isotopes
- mother is receiving antimetabolites, chemotherapeutic agents
- mother is abusing drugs
- mother is HIV positive
- mother has herpes simplex lesions on breast
Fatty acids in formulas
- omega 6 and omega 3 is important for development of baby’s eyes, brain, nerves and immune system
Weaning from bottle
- infants are introduced to a cup at 6 months
- begin weaning from bottle around 1 year
- should be fully weaned by 15 months
Complementary feeding guidelines
- 6 mo: pureed, mashed and semi-solid food
- 8 mo: “finger food”
- 12 mo: same types of food eated by the rest of the family
Daily nutritional needs from complementary foods
6-8 mo: 130 kcal
9-11 mo: 310 kcal
12-23 mo: 580 kcal
what not to give as complementary food
- no sugar/ salt
- no whole nuts/ mushrooms
- no juices and honey
Gluten and milk as complementary food
- gluten between 4-12 months, large quantities should be avoided
- milk should not be used as the main drink before 11-12 months
When can the child eat what
Grain - porridge: 4-6 months Vegetables: 4-6 months Meat: 5-6 months Egg: 6-7 months Fish: 6-7 months Fruits: 6-7 months
Antenatal development of lungs
- embryonic
- pseudovascular
- canalicular
- saccular
Postnatal development of lungs
- alveolar maturation (up to 2 years)
- microvascular maturation (up to 3 years)
- Late alveolarization (3 years tp to adulthood)
