MedU Clipp Cases 9 and 10 Flashcards
1
Q
What age is an infant expected to regain his birth weight?
A
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
2
Q
What are (4) indications to initiate Breastfeeding?
A
- Increased Alertness
- Increased Physical Activity
- Mouthing
- Rooting
3
Q
How often should an infant be feeding?
A
- Every 1 - 3 hours for 10 - 15 minutes per breast
- If > 4 hours between feedings –> inadequate
4
Q
How much Vit. D should infants recieve?
A
- 400 iU of Supplemental Oral Vitamin D beginning with the first hours of life
5
Q
Do Formula-fed Infants need Vit. D supplementation?
A
- Exclusive Formula-fed infants, 1 liter/day, DO NOT require Vitamin D supplementation
6
Q
How can voiding (urinating) be used to assess Breast Milk feeding?
A
- 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
7
Q
What is the definition of Lethargy in a Newborn?
A
- A level of consciousness characterized by poor or absent eye movements
or - Failure of a Child to Recognize Parents or Objects in the Environment
8
Q
(4) DDx of Lethargy in a 2 week old?
A
- Infection (Sepsis, Meningitis)
- Intracranial Pathology (Hemorrhage from Trauma, Hydrocephalus, Hydranencephaly)
- Metabolic disorder
- Chromosomal anomaly
9
Q
Define Seizures in a Newborn?
A
- 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
10
Q
Define Jitteriness in Newborns?
A
- Distinct from Seizure activity
- Movements are Stimulus-sensitive
- Generalized
- Symmetric
- Can be Diminshed by Gentle, Passive Flexion of the Limbs
11
Q
Define Myoclonic Jerks in Newborns?
A
- Brief Myoclonic jerks in and of themselves
- Not abnormal in Infants
- Often noted when infant is falling asleep
12
Q
Define Clonus in Newborns?
A
- 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
13
Q
(3) Uncommon Risks a/w Home Deliveries?
A
- Neonatal Tetanus
- Omphalitis (serious infection of the umbilical stump)
- Hemorrhagic disease of the Newborn
- No Vit. K is administered
14
Q
(11) DDx for a Neonate w/
Poor Feeding and Decreased Activity
A
- Congenital Hypothyroidism
- Shaken Baby Syndrome
- Down Syndrome
- Sepsis
- Congenital Adrenal Hyperplasia
- Inborn Error of Metabolism
- Hypoglycemia
- Botulism (Honey)
- Hypoxic-ischemic encephalopathy
- Polycythemia
- Hyperbilirubinemia
15
Q
What is the mean fontanel size?
A
- 2.1 cm ( 0.6 - 3.6 cm)
16
Q
What is an Abnormally Large Fontanel Size A/w?
A
- 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
17
Q
What is a Small Fontanel A/w?
A
- Premature closure of a Small fontanel
- Microcephaly
- Craniosynostosis
- Hyperthyroidism
- ~ NORMAL variant
18
Q
What is a Sunken Fontanel A/w?
A
- Dehydration
19
Q
What is a Bulging Fontanel A/w?
A
- Bulging Fontanel is Generally regarded as a sign of Increased intracranial pressure
- Meningitis
- Hydrocephalus
- Subdural Hematoma
- Lead poisoning
20
Q
What are Upslanted Palpebral Fissures A/w?
(Eliptical openings of the eyes, the Eye Slits)
A
- Down Syndrome
21
Q
(6) What are the Signs of Fetal Alcohol Syndrome?
A
- Short Palpebral Fissures
- Thin upper lip
- Smooth Philtrum
- Growth Retardation
- Microcephaly (height and weight < 10th %)
- Cognitive deficits
22
Q
Signs and Symptoms of Congenital Hypothyrodism?
A
- Feeding Problems
- Large Tongue
- Coarse Cry
- Hypotonia
- Large Fontanels
- Umbilical Hernia (common but a/w Cong. Hypothyroid)
- Jaundice
- Mottled Skin
- Hypothermia
23
Q
A baby with virilization would indicate a possible?
A
- Congenital Adrenal Hyperplasia
24
Q
Signs of Smnolence and Poor feeding,
followed by Vomiting and Lethargy?
A
- Inborn Error of Metabolism
25
Low Temperature, Irritiability, Tremors, and Jitteriness
are a/w with Newborn?
* Hypoglycemia
* sometimes Asymptomatic
* check blood sugars routinely if considered
26
A Newborn with Low Sodium and High Potassium suggest?
* Congential Adrenal Hyperplasia (CAH)
* Req's further testing, 17-OH Progesterone analysis
27
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
* Organic Acidemias
* Fatty Acid Oxidation Disorders
* Ornithine Transcarbamylase Deficiency (OTC)
* X-linked
28
An infant with Hypotonia? Critical to check?
* Glucose
29
How are T4 and TSH changed in an Infant w/
Congenital Hypothyrodism?
* Low T4
* High TSH
30
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
31
(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
32
Primary Hypothyroidism vs. Secondary/Tertiary?
* Primary
* Hypothalamic-pituitary axis is functioning
- -\> High TSH
- -\> Low T4
* Secondary/Tertiary
* Low TSH
* Low T4
33
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
34
Signs and Symptoms of Infant Botulism?
* Hypotonia
* Lethargy
* Constipation
* Weak cry
* **Absent Deep Tendon Reflexes**
* Can eventually lead to Respiratory Failure
35
Which Test is diagnostic for an
Ornithin Transcarbamylase Deficiency?
( OTC deficiency )
* **Hyperammonemia**
* Elevated **Urine Orotic Acid**
* X-linked condition
* Most common Urea Cycle disorder
36
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
37
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
38
(8) Bacterial Infections in Newborns?
* UTI
* Meningitis
* Sepsis
* Pneumonia
* Bacterial gastroenteritis
* Osteomyelitis
* Septic arthritis
* Occult Bacteremia
39
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
40
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
41
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
42
```
(2) Most common bacteria for Bacterial Meningitis
in Children (3 - 36 months)?
```
* *S. pneumoniae*
* *N. meningitidis*
43
Common cause of Viral Meningitis in Children?
* Enterovirus
44
(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
45
Define Pyuria?
46
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
47
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
48
What does a Positive Nitrite and Leukocyte Esterase Test mean?
* UTI
49
(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.
50
What study should be ordered after
First Episode of Pyelonephritis?
Renal and Bladder Ultrasound
51
```
When do you order a
Voiding Cystourethrogram (VCUG)?
```
* After a Second Febrile UTI
* Demonstrates Vesicoureteral reflux
