MedU Clipp Cases 9 and 10 Flashcards
What age is an infant expected to regain his birth weight?
2 weeks
- Failure to regain Birth Weight by 3 weeks of age or continuous wieght loss after 10 days of life has been defined as Failure to Thrive
- Adequately nourished = 6 feedings/day
- and 6 wet diapers/day
What are (4) indications to initiate Breastfeeding?
- Increased Alertness
- Increased Physical Activity
- Mouthing
- Rooting
How often should an infant be feeding?
- Every 1 - 3 hours for 10 - 15 minutes per breast
- If > 4 hours between feedings –> inadequate
How much Vit. D should infants recieve?
- 400 iU of Supplemental Oral Vitamin D beginning with the first hours of life
Do Formula-fed Infants need Vit. D supplementation?
- Exclusive Formula-fed infants, 1 liter/day, DO NOT require Vitamin D supplementation
How can voiding (urinating) be used to assess Breast Milk feeding?
- Newborn –> 3 - 5 voids and 3 - 5 stools / day
- 5 - 7 days –> 4 - 6 voids and 3 - 6 stools / day
- From day one to end of week one the number of voids and stools onlyl goes up by one
- 5 voids –> 6 voids
- 5 stools –> 6 stools
What is the definition of Lethargy in a Newborn?
- A level of consciousness characterized by poor or absent eye movements
or - Failure of a Child to Recognize Parents or Objects in the Environment
(4) DDx of Lethargy in a 2 week old?
- Infection (Sepsis, Meningitis)
- Intracranial Pathology (Hemorrhage from Trauma, Hydrocephalus, Hydranencephaly)
- Metabolic disorder
- Chromosomal anomaly
Define Seizures in a Newborn?
- Different from adults
- Newborns rarely have organized, generalized, tonic-clonic seizures
- Often subtle
- Manifest as jerking or horizontal deviation of the eyes
- Blinking or Fluttering eyelids
- Drooling
- Sucking
- Lip smacking
- Tonic posturing of a Limb
- Apnea
Define Jitteriness in Newborns?
- Distinct from Seizure activity
- Movements are Stimulus-sensitive
- Generalized
- Symmetric
- Can be Diminshed by Gentle, Passive Flexion of the Limbs
Define Myoclonic Jerks in Newborns?
- Brief Myoclonic jerks in and of themselves
- Not abnormal in Infants
- Often noted when infant is falling asleep
Define Clonus in Newborns?
- Ankle clonus (spasmodic alternation of muscular contractions between antagonistic muscle groups caused by a Hyeractive stretch reflex from an Upper Motor Neuron Lesion
- Up to 10 Beats
- Disappears rapidly
- More than 3 Beats in a child 1 - 2 months old is abnormal
(3) Uncommon Risks a/w Home Deliveries?
- Neonatal Tetanus
- Omphalitis (serious infection of the umbilical stump)
- Hemorrhagic disease of the Newborn
- No Vit. K is administered
(11) DDx for a Neonate w/
Poor Feeding and Decreased Activity
- Congenital Hypothyroidism
- Shaken Baby Syndrome
- Down Syndrome
- Sepsis
- Congenital Adrenal Hyperplasia
- Inborn Error of Metabolism
- Hypoglycemia
- Botulism (Honey)
- Hypoxic-ischemic encephalopathy
- Polycythemia
- Hyperbilirubinemia
What is the mean fontanel size?
- 2.1 cm ( 0.6 - 3.6 cm)
What is an Abnormally Large Fontanel Size A/w?
- Skeletal Disorders (Rickets, Osteogenesis Imperfecta etc.)
- Chromosomal Abnormalities (Down Syndrome)
- Hypothyroidism
- Malnutrition
- Increased Intracranial pressure can also be a/w Large Fontanels and Splitting of the Sutures
What is a Small Fontanel A/w?
- Premature closure of a Small fontanel
- Microcephaly
- Craniosynostosis
- Hyperthyroidism
- ~ NORMAL variant
What is a Sunken Fontanel A/w?
- Dehydration
What is a Bulging Fontanel A/w?
- Bulging Fontanel is Generally regarded as a sign of Increased intracranial pressure
- Meningitis
- Hydrocephalus
- Subdural Hematoma
- Lead poisoning
What are Upslanted Palpebral Fissures A/w?
(Eliptical openings of the eyes, the Eye Slits)
- Down Syndrome
(6) What are the Signs of Fetal Alcohol Syndrome?
- Short Palpebral Fissures
- Thin upper lip
- Smooth Philtrum
- Growth Retardation
- Microcephaly (height and weight < 10th %)
- Cognitive deficits
Signs and Symptoms of Congenital Hypothyrodism?
- Feeding Problems
- Large Tongue
- Coarse Cry
- Hypotonia
- Large Fontanels
- Umbilical Hernia (common but a/w Cong. Hypothyroid)
- Jaundice
- Mottled Skin
- Hypothermia
A baby with virilization would indicate a possible?
- Congenital Adrenal Hyperplasia
Signs of Smnolence and Poor feeding,
followed by Vomiting and Lethargy?
- Inborn Error of Metabolism
Low Temperature, Irritiability, Tremors, and Jitteriness
are a/w with Newborn?
- Hypoglycemia
- sometimes Asymptomatic
- check blood sugars routinely if considered
A Newborn with Low Sodium and High Potassium suggest?
- Congential Adrenal Hyperplasia (CAH)
- Req’s further testing, 17-OH Progesterone analysis
Elevated Serum Ammonia in a Newborn?
- Elevated in Inborn errors of Metabolism
- Urea Cycle Disorders
- Ornithine Transcarbamylase Deficiency (OTC)
- X-linked
- and Elevated Urine Orotic Acid
- Ornithine Transcarbamylase Deficiency (OTC)
- Organic Acidemias
- Fatty Acid Oxidation Disorders
- Ornithine Transcarbamylase Deficiency (OTC)
- X-linked
- Urea Cycle Disorders
An infant with Hypotonia? Critical to check?
- Glucose
How are T4 and TSH changed in an Infant w/
Congenital Hypothyrodism?
- Low T4
- High TSH
A deficiency in 21-OH in Congenital Adrenal Hyperplasia?
- Decreased production of:
- Cortisol
- Aldosterone
- Elevated 17-OH Progesterone
- -> diverted to Androgen formation
- Females –> Virilized
- Males –> Virilization presents w/ Increased Penile Length and Darker Pigmentation of Scrotum
- Also consider Salt-wasting form too
(4) Hypothyroidism in Newborn caused by?
Transient Hypothyrodism?
- Aplasia
- Hypoplasia
- Ectopic Gland (2/3 of cases)
- Iodine Deficiency
- Transient Hypothyoridism
- Mother’s with
- Autoimmune Thyroiditis
- Grave’s Disease
- Mother’s with
Primary Hypothyroidism vs. Secondary/Tertiary?
- Primary
- Hypothalamic-pituitary axis is functioning
- -> High TSH
- -> Low T4
- Secondary/Tertiary
- Low TSH
- Low T4
Treatment of Hypothyoridism in a Newborn?
- Levothyroxine
- Maintain TSH - 1 mlU/L
- T4 - upper half of Normal range for age
- Follow-up is Key
- every 1 - 2 months until 1 y.o.
- every 2 - 3 months until 3 y.o.
- every 3 - 12 months until growth is completed
Signs and Symptoms of Infant Botulism?
- Hypotonia
- Lethargy
- Constipation
- Weak cry
- Absent Deep Tendon Reflexes
- Can eventually lead to Respiratory Failure
Which Test is diagnostic for an
Ornithin Transcarbamylase Deficiency?
( OTC deficiency )
- Hyperammonemia
- Elevated Urine Orotic Acid
- X-linked condition
- Most common Urea Cycle disorder
Adverse reactions to Vaccines in Newborns?
- Most Adverse rxns occur w/in first 24 to 48 hrs after the First Dose of Innoculation
- Rotavirus (live virus) –> Fever in some infants (several days)
- MMR and Varicella (live virus) –> Fever w/in 1 week
Define Fever Without Source?
- Used when a Complete history has been obtained and a Detailed physical examination performed
- No identified Source of Child’s Fever
- Most are Viral in origin
- Small Percentile are Bacterial
(8) Bacterial Infections in Newborns?
- UTI
- Meningitis
- Sepsis
- Pneumonia
- Bacterial gastroenteritis
- Osteomyelitis
- Septic arthritis
- Occult Bacteremia
What are Kernig’s and Brudzinski’s Sign
used for in Neonates?
- Kernig’s sign is resistance to extension of the Knee
- Brudzinski’s sign is flexion of the hip and knee in response to flexion of the Neck by the examiner
- Bacterial Meningitis
- -> Lumbar Puncture
Other Sign’s of Bacterial Meningitis?
- Fever
- Hypothermia
- Bulging Fontanelles
- Lethargy
- Irritability
- Restlessness
- Nunchal Rigidity - Opisthotonos
- Paroxysmal crying (crying when picked up)
- Poor feeding
- Vomiting
- Diarrhea
Risk for UTI in Infants?
- Uncircumscised Male under 6 mo.
- Any Female < 24 mo.
- Signs and Symptoms
- Suprapubic tenderness
- History of UTI
- Foul-smelling Urine
- Temp > 39 C (102.2 F)
- Fever > 24 hours w/out source
(2) Most common bacteria for Bacterial Meningitis in Children (3 - 36 months)?
- S. pneumoniae
- N. meningitidis
Common cause of Viral Meningitis in Children?
- Enterovirus
(4) What tests do you order for testing a child w/
Fever Without Source?
- UA w/ culture
- most likely UTI
- Suprapubic aspiration > Bagged Urine
- CBC w/ differential
- “Left-shift”
- Blood culture
- Lumbar punture
- Additional considder: Stool Guaiac, Fecal Leukocytes, Stool culture, CXR, Rapid Viral Resp. Pathogens, Inflammatory markers: CRP, Procalcitonin, IL-6
Define Pyuria?
What does a Positive Nitrite Test of Urine mean?
- Occurs when a G- bacteria can reduce
Urinary nitrate –> nitrite - E. coli
- Klebsiella
- Proteus spp
- Good Sensitivity
- Poor Specificity
What does a Positive Leukocyte Esterase Urine test mean?
- Detcts Esterases released from Broken-down Leukocytes
- -> presence of WBCs in Urine
- A positive Leukocyte Esterase Test alone is insufficient to make a diagnosis of UTI
What does a Positive Nitrite and Leukocyte Esterase Test mean?
- UTI
(4) Parenteral ABX treatments of Pyelonephritis?
- Ampicillin / Gentamicin
- Ceftriaxone
- cannot give Ca2+ meds through same IV –> precip.
- not Pseudomonas aeruginosa
- Piperacillin / Tazobactam
- not optimal for enterococci
- Ciprofloxacin
- cost
- adverse rxns in children, used in > 1 y.o.
What study should be ordered after
First Episode of Pyelonephritis?
Renal and Bladder Ultrasound
When do you order a Voiding Cystourethrogram (VCUG)?
- After a Second Febrile UTI
- Demonstrates Vesicoureteral reflux
