Module 17 common issues with toddlers Flashcards
vomiting
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
potential dx for newborn if vomiting
infectious process
congenital GI anomaly
CNS abnormality
inborn errors of metabolism
potential dx for infants and young children with vomiting
gastroenteritis GERD milk/soy allergies pyloric stenosis obstructive lesion inborn errors of metabolism intussusception abuse intracranial mass
potential dx for older children and adolescents with vomiting
gastroenteritis systemic illness CNS: cyclic vomiting syndrome, abdominal migraine intussusception rumination superior mesenteric artery syndrome pregnancy
Vomiting in the early morning
indicative of increased intracranial pressure
encopersis
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
primary encopresis
continuous
in children who have never been toilet trained
secondary encopresis
discontinuous
in those who were previously trained but who begin to soil
encopresis with constipation
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
encopresis without consitpation
functional non-retentive fecal incontinence
- more behavioral problems
physiologic factors related to encopresis
inadequate fluid intake
dehydration
change in diet
secondary stool retention
psychosocial factors related to encopresis
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
encopresis physical exam
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
encopresis management
establish regular bowel routine miralax ongoing maintenance with meds as needed normal physical activity regular toileting hygiene
enuresis
voluntary or involuntary urination at an age when there should be control
Dx: minimum age of 5, one episode/month x 3 months
primary enuresis
children who have never had control
secondary enuresis
children have been dry for more than 6-12 months and then begin wetting
nocturnal enuresis
incontinence during sleep
potential causes of enuresis
constipation familial disposition neurologic developmental delay behavioral comorbidities functional small bladder capacity sleep disorders stress and family disruptions polyuria inappropriate toilet training
enuresis physical exam
assess genitalia: s/s of irritation, infection, labial fusion, or meatal stenosis
abd: masses
lower back: dimples, hair tufts
Neuro: DTR
enuresis management
behavioral modification
medication
tx of comorbid or organic conditions
combo
Genu varum
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
genu varum clinical findings
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
genu valgum
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
genu valgum clinical findings
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
in-toeing
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
Picky eating
- 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
terrible twos
balance between dependence and independence
- toddler attempting to master multiple new social tasks
terrible twos parental advice
- 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
