Module 17 common issues with toddlers

Question 1

vomiting

Answer 1

forceful emptying of gastric contents coordinated by the medullary vomiting center and/or chemoreceptor trigger zone of the brain

• Bilious vomiting: obstructive lesion
• Bloody vomit: active bleed in upper GI

Question 2

potential dx for newborn if vomiting

Answer 2

infectious process
congenital GI anomaly
CNS abnormality
inborn errors of metabolism

Question 3

potential dx for infants and young children with vomiting

Answer 3

gastroenteritis
GERD
milk/soy allergies
pyloric stenosis
obstructive lesion
inborn errors of metabolism 
intussusception
abuse
intracranial mass

Question 4

potential dx for older children and adolescents with vomiting

Answer 4

gastroenteritis
systemic illness
CNS: cyclic vomiting syndrome, abdominal migraine 
intussusception
rumination
superior mesenteric artery syndrome
pregnancy

Question 5

Vomiting in the early morning

Answer 5

indicative of increased intracranial pressure

Question 6

encopersis

Answer 6

fecal soiling or fecal incontinence
- repetitive, voluntary, or involuntary passage of stool in the underwear or inappropriate places after the age of 4
Dx: occurs at least once per month x 2 months

Question 7

primary encopresis

Answer 7

continuous

in children who have never been toilet trained

Question 8

secondary encopresis

Answer 8

discontinuous

in those who were previously trained but who begin to soil

Question 9

encopresis with constipation

Answer 9

associated with stool retention, constipation, and incontinence overflow
Cycle of constipation
- constipation -> painful defecation -> stool retention -> more severe constipation -> continues
This leads to:
- distention of the colon and stretching. of the rectum, ineffective peristalsis, ddec. sensory threshold in rectum, weakened rectal and sphincter muscles
- soft or semi-formed, or liquid stool from higher in colon leaks around retained stool and passes uncontrollably through the rectum

Question 10

encopresis without consitpation

Answer 10

functional non-retentive fecal incontinence

- more behavioral problems

Question 11

physiologic factors related to encopresis

Answer 11

inadequate fluid intake
dehydration
change in diet
secondary stool retention

Question 12

psychosocial factors related to encopresis

Answer 12

major family or life adjustments
inappropriate toilet training -> power struggle
irregular toilet patterns
physical and sexual abuse
children absorbed in play or activity 
behavioral and attention problems 
anxiety and depressive s/s
social structure

Question 13

encopresis physical exam

Answer 13

overflow soiling
abd distention
abd tenderness 
mass felt midline suprapubic 
anal fissures
sacral dimple or hair tuft
neurological signs
- absent/diminished reflexes, DRT in lower extremities

Question 14

encopresis management

Answer 14

establish regular bowel routine
miralax
ongoing maintenance with meds as needed 
normal physical activity
regular toileting hygiene

Question 15

enuresis

Answer 15

voluntary or involuntary urination at an age when there should be control
Dx: minimum age of 5, one episode/month x 3 months

Question 16

primary enuresis

Answer 16

children who have never had control

Question 17

secondary enuresis

Answer 17

children have been dry for more than 6-12 months and then begin wetting

Question 18

nocturnal enuresis

Answer 18

incontinence during sleep

Question 19

potential causes of enuresis

Answer 19

constipation
familial disposition
neurologic developmental delay
behavioral comorbidities 
functional small bladder capacity 
sleep disorders
stress and family disruptions
polyuria
inappropriate toilet training

Question 20

enuresis physical exam

Answer 20

assess genitalia: s/s of irritation, infection, labial fusion, or meatal stenosis
abd: masses
lower back: dimples, hair tufts
Neuro: DTR

Question 21

enuresis management

Answer 21

behavioral modification
medication
tx of comorbid or organic conditions
combo

Question 22

Genu varum

Answer 22

bowing of the legs

• can be physiologic or developmental variation or normal or a pathologic condition that involves a rotational deformity
• Normal until 2-3 years of age
• persists after 30months: blount disease, rickets, tumor, neurologic problems, infection, other conditions

Question 23

genu varum clinical findings

Answer 23

Family Hx: 
- marfan, OI, vit. D- resistant rickets 
Exam: 
- tibial-femoral angle > 15
- internal tibial torsion
- lower extremity length discrepancy 
- knee distance with ankles together greater than 4-5 inches -> referral 
- joint laxity of lateral collateral ligaments

Question 24

genu valgum

Answer 24

knock knees

• lower extremity alignment goes through a predictable progression from varus to valus over the first 6 years of life
• improves between 4-6 years of age
• Pathologic: rickets, renal osteodystrophy, skeletal dysplasia, posttraumatic physeal arrest, tumors, infection

Question 25

genu valgum clinical findings

Answer 25

Hx: 
- progression of deformity
- joint pains or stiff gait
Exam: 
- tibial-femoral angle greater than 15 
- unilateral deformity
- awkwardness of gait
- sublaxating patella
- ankles distance with knees together greater than 4-5 inches: referral 
- short stature

Question 26

in-toeing

Answer 26

typically physiologic, age-related, and resolve as child grows
Referral considered if:
- thigh-foot angle > -10 or -20 degrees
- > 70 degree medial/less than 10 degree lateral hip rotation

Question 27

Picky eating

Answer 27

• common
• require less food (growth rate slowed)
• encouraging children to eat when they are not hungry -> excess caloric consumptions
• set established meal times 3/day with snacks between

Question 28

terrible twos

Answer 28

balance between dependence and independence

- toddler attempting to master multiple new social tasks

Question 29

terrible twos parental advice

Answer 29

• provide creative toys
• allow toddler to explore
• structure time for “natural play”
• allow choices when possible, avoid when - there are none
• help to identify, name, and express feelings
• teach anger management and conflict resolution
• take trips to places of interest
• play dates
• cooperative play
• reinforce positive behavior
• differentiate discipline and teaching from punishment