Newman Flashcards
MC organisms causing acute bacterial meningitis in children of different ages:
1 mo-3 mo:
3 mo-3 yrs:
3 yrs-10 yrs:
10yrs-19yrs:
1 mo-3 mo: GBS
3 mo-3 yrs: S. pneumoniae
3 yrs-10 yrs: S. pneumoniae
10yrs-19yrs: N. meningitidis
What is the difference in acquisition between early-onset (7 days) Group B Strep in neonates?
EARLY-onset GBS reflects vertical transmission from maternal vaginal flora.
LATE-onset GBS suggests community or nosocomial acquisition, although the maternal flora now colonizing the neonate may still be a source of infection.
TQ Mainstay of therapy for tx of MRSA in the pediatric pt:
Vancomycin
classic signs and sx of pediatric bacterial meningitis: (3)
- Fever
- Headache (less likely in younger children)
- Meningeal signs (less likely in younger children)
- Brudzinski and Kernig signs
Signs and sx of pediatric bacterial meningitis in neonates:
- Fever, hypothermia
- Poor feeding, listlessness, hypotonia, pallor, lethargy
- Irritability, shrill cry
- Apnea, seizures
- Jaundice, bulging fontanelle
- Hypoglycemia, intractable metabolic acidosis, shock
Signs and sx of pediatric bacterial meningitis in older infants and children:
Definitive diagnosis is based on:
- Fever, hypothermia (if severely ill)
- Nuchal rigidity, opisthotonos, Kernig sign, Brudzinski sign
- Headache, irritability, lethargy, photophobia, alteration of the sensorium
- Vomiting, nausea, anorexia Definitive diagnosis is based on:
- Bacteria isolated from CSF obtained via lumbar puncture
- Evidence of meningeal irritation demonstrated by increased pleocytosis, elevated protein level, and low glucose level in the CSF
TQ
Bacterial meningitis
- Appearance:
- Pressure:
- WBC count:
- Differential count (predominance):
- Protein:
- Glucose:
- Gram stain:
Bacterial meningitis
- Appearance: Turbid
- Pressure: Elevated
- WBC count: >1000
- Differential count (predominance): PMNs
- Protein: Elevated
- Glucose: Low
- Gram stain: G+
Pathophysiology of pediatric bacterial meningitis:
- Bacteria enter the ____________ _____ hematogenously (across the blood brain barrier)
- Bacteria reach the meninges directly from a parameningeal infection (eg, sinusitis, mastoiditis, otitis media, brain abscess, spinal epidural abscess)
- Intense host inflammatory response (cytokines, ___, ____)
- Ultimate damage to neuron/apoptosis
Pathophysiology of pediatric bacterial meningitis:
- Bacteria enter the SUBARACHNOID SPACE hematogenously (across the blood brain barrier)
- Bacteria reach the meninges directly from a parameningeal infection (eg, sinusitis, mastoiditis, otitis media, brain abscess, spinal epidural abscess)
- Intense host inflammatory response (cytokines, IL-1, TNF-a)
- Ultimate damage to neuron/apoptosis
TQ
What is Cushing’s Triad associated with increased ICP and brain edema?
- BP increases
- HR decreases
- Respirations become irregular (signifies brainstem involvement)
List the organisms responsible for neonatal bacterial meningitis. (6)
Bacteria acquired from the maternal vaginal flora:
- Gram negative enteric flora
- Group B streptococcus (Streptococcus agalactiae) – Early onset (7 days of life)
- Staphylococcus epidermidis (coag negative Staph)
- Candida
- Listeria monocytogenes (well known but uncommon)
- Citrobacter (uncommon but associated with brain abscesses)
List the organisms responsible for bacterial meningitis in infants (>3 mo) and children: (2)
- S pneumoniae (leading cause)
- N meningitidis
TQ What would you see on LP in viral meningitis?
- WBC diff count:
- RBCs:
- Protein: Rx?
- WBC diff count: Lymphocytes
- RBCs: Increased
- Protein: Increased
Rx acyclovir
- Fever
- Racing heart
- Rapid or labored breathing
- Cool extremities
- Color changes
Sepsis in pediatric pt
Explain the pathophysiology of sepsis.
- Release of pro-inflammatory mediators exceeds the boundaries of the local infection
- Generalized inflammatory response (SIRS: Systemic Inflammatory Immune Response)
- Cytokines (tumor necrosis factor-alpha, interleukin-1)
- Complement activation
- Genetic susceptibility
Earliest and mildest manifestation of sepsis: (3)
- Hyperthermia (or hypothermia)
- Tachypnea
- Tachycardia
- Increased cardiac output
- Peripheral vasodilation
- Increased tissue oxygen consumption
- Hypermetabolic state
Warm shock
- Cardiac output falls
- Peripheral vascular resistance increases
- Shunting of blood
Cold shock
Bacterial etiologies of early-onset neonatal sepsis: (4)
- Group B streptococcus (Streptococcus agalactiae)*
- Escherichia coli
- Haemophilus influenzae
- Listeria monocytogenes
Bacterial etiologies of late-onset neonatal sepsis: (6)
- Coagulase-negative Staphylococcus (S epidermidis)
- Staphylococcus aureus
- E. coli
- Klebsiella species
- Candida species
- GBS
MC bacterial etiology of infantile meningitis worldwide:
H influenzae type b (Hib)
MC bacterial etiologies in infants and children in the United States and developed world: (5)
- E coli
- S aureus
- S pneumoniae
- N meningitides
- S pyogenes
TQ
Intrapartum antibiotic prophylaxis
- When in labor, __________ or __________ is given IV every 4 hours until delivery with at least one dose given 4 hours before birth
- Due to IAP, the rate of (early/late) onset GBS dz has decreased significantly
Intrapartum antibiotic prophylaxis
- When in labor, PENICILLIN or AMPICILLIN is given IV every 4 hours until delivery with at least one dose given 4 hours before birth
- Due to IAP, the rate of EARLY onset GBS dz has decreased significantly (IAP has no affected the rate of late onset dz)*
Occurs within the first 24 hours up to 1 week of age
Signs and symptoms
- Tachypnea
- Grunting
- Flaring
- Apnea
- Cyanosis
- Hypotension (25% of cases)
- Temperature instability
- Poor feeding
- Tachycardia
- Jaundice
- Lethargy
* Dx: (early/late) onset GBS dz
EARLY onset GBS dz Risk factors for EOD
- Maternal colonization at birth
- Preterm birth
- ROM >18 hours prior to delivery
- Lack of maternal antibodies to type specific capsular polysaccharides and protein antigens
- Chorioamnionitis
- Multiple gestation
- Nonwhite maternal race
- Intrapartum fever >38 C
- Intrauterine monitoring
- Postpartum maternal bacteremia
- Having had a previous infant with invasive GBS disease
TQ
- Generally more mildly ill upon presentation
- 65% present as bacteremia without a defined focus
- 25% to 30% present with meningitis
- Septic arthritis (hip, knee, ankle)
- Osteomyelitis (humerus most common, femur, tibia)***
- Cellulitis and adenitis
Dx: (early/late) onset GBS dz
LATE onset GBS dz
- Lack of antibodies to the TSST-1 toxin
- Compromise in mucosal or skin integrity
- Often the presence of a foreign body (Tampon*, surgical implant)
- Can occur in children with pneumonia or skeletal infection
- Blood cultures positive in
Toxic Shock Syndrome
Recurrent Staph skin infections:
- Usually MRSA (obtaining a culture is important)
- Treat everyone in family with a co-existing infection
Rx?
What Rx is still the go-to choice for therapy in children with infections due to MRSA?
Rx nasal mupirocin and bleach baths MRSA
Rx vancomycin
TQ
- Multisystem inflammatory dz that mostly affects infants and children
- Vasculitis of medium-sized extraparenchymal arteries
- MC cause of acquired heart dz in North America, Japan, and Europe
- Development of coronary artery aneurysms***
Lab findings:
- Elevated acute phase reactants (CRP, ESR, thrombocytosis, leukocytosis)
- Normochromic normocytic anemia
- Sterile pyuria
- Mild elevation of liver enzymes and bilirubin
- Mononuclear cells in the CSF
Kawasaki dz
TQ
Explain the “C.R.A.S.H.” mnemonic for diagnosis of Kawasaki dz.
The presence of unexplained fever for 5 days or more and the presence of 4 of the following 5 findings:
C - Conjunctival injections, generally B/L and bulbar w/o discharge and with sparing of the limbus
R - Rash, polymorphous and generalized, may have perineal desquamation
A - Adenopathy, non-suppurative, generally cervical, and ≥1.5 cm in size
S - Strawberry tongue, or other mucous membrane changes such as dryness and fissuring of the lips, erythema of the oral mucosa
H - Hand and feet changes, generally with swelling, periungal desquamation of the fingers and toes, erythema of palms and soles
- Fever >5 days
- 2-3 of the CRASH criteria
Incomplete or Atypical Kawasaki dz
Management of Kawasaki dz: (2)
IVIG
aspirin
What happens during a well child check?
- Check ht, wt, head circumference
- BMI @ 2yr
- BP and Sensory screening- vision @3yo (hearing @4yo)
- Develop/Behavioral Assessment- 9mo, 18mo, 30mo.
- Alcohol and Drug use @ 11yo
TQ
When do we screen children for autism and what do we use?
- 18mo and 24mo when kids start socializing and communicating
- M-CHAT: 10Q questionnaire
TQ
What do we do at EVERY well child check?
Full physical exam!!!
Labs:
- Newborn Screening: birth and w/in 1 mo (metabolic and hgb)
- Immunizations
- Hgb/Hct @ 12 mo (iron def!)
- Lead screening: 12 mo, 24 mo
- TB test
- Dyslipidemia (risk @ yo, actual 20yo)
- STI @11yo
- Cervical Dysplasia @???
11yo
Def: Inform parents what to expect developmentally and advise them accordingly (developmental changes, diet, injury prevention)
Anticipatory Guidance
TQ
T/F Growth parameters don’t have to plot out at 50% percentile for age to be normal! Instead, PICK a line on the curve and make sure they grow along that curve (even if at 3%)
TRUE
Grow at normal rate, regardless if small or big
TQ
If WEIGHT falls off first, think…(.eg, 90th percentile–>60th–>30th)
nutritional!
not getting enough calories (reflux), not absorbing calories (malab), or incr metabolic demands (CHD, Hyperthyroid)
TQ
If HEIGHT falls off first, think….
Endocrine abnormalities
TQ
If head circumference falls off first, think…
failure of primary brain growth
For nutritional deprivation, what is the 1st growth parameter to be affected? 2nd? 3rd?
Wt=1st
Lgth/Ht=2nd
Head circum=3rd (ominous)
TQ
Daily caloric requirements for a term neonate-1 yo? (kcal/kg/d)
Preterm neonate: 120-240
1-7yo: 75-90
7-12yo: 60-75
12-18yo: 30-60
>18yo: 25-30
100 (90-120)kcal/kg/day
TQ
How many kcal/ounce are in newborn formula and breast milk?
20 kcal/ounce!
TQ
Daily wt gain in gms/day?
Birth-4mo: ?
4mo-8mo: ?
8mo-12mo: ?
**Birth-4mo: 30gms/day (1 ounce)
4mo-8mo: 20gms/day
8mo-12mo: 10gms/day
TQ
Newborns may lose up to 10% of their birth wt during the first week of life…usually regain birth wt by when?
2 wks of age
If fails a screening…
repeat, further, more specific screening/testing…screen isn’t diagnostic!
TQ
What are the speech milestones?
1/4, 2/4, 3/4, 4/4 rule!
- at 1 yr age, strangers understand 1/4
- at 2 yr age, strangers understand 2/4 of what the baby says
- at 3 yr age, strangers understand 3/4
- at 4 yrs of age, should understand all speech
TQ
What is a normal BMI?
18.5-24.9
BMI or equal to 30=obese
TQ
What is the normal linear growth rate for ages 6-11 yo?
6-7cm/year (2.5 inches)
TQ
How do you estimate the adult height of a child? (2 ways)
-Double the height of the child at 2 yo
OR
-Using “mid-parental height”:
For boys…using inches
• [(dad’s ht + mom’s ht)+5] / 2
For girls…using inches
• [(dad’s ht + mom’s ht) – 5] / 2
TQ
When weight falls off first think…
nutrition
- Not enough in (emesis, no food)
- Not enough absorbed (mal-absorptive conditions)
- Higher than average caloric requirements
TQ
When length falls off first think…
endocrine
- GH deficiency
- Hypothyroidism
- Cushing’s syndrome (iatrogenic?)
TQ
When head circumference falls off first think…
- Primary failure of the brain to grow
- Severe craniosynostosis
TQ
How do you estimate a child’s skeletal maturation/bone age?
By assessing the ossification of the epiphyseal centers
Helps estimate a child’s growth potential!>> X-ray of the left hand and wrist (Compared against Gruelich and Pyle atlas standards)
TQ
What is considered delayed skeletal maturation?
Two standard deviations below the chronologic age
TQ
When does catch-up or catch-down growth occur?
1st 18 mo of life
corrections are due to the child trying to reach their genetically determined percentile
TQ Some kids make up to a __% downward correction on the growth curve, often due to table/solid food
25%
TQ
If <36 mo, using 0-36 mo curve, how do you measure the child?
If >24 mo, may use the 2-20 yo curve, but then how do you measure the child?
Measure length when child supine (length)
Height when standing up (stature)
TQ
What is the defintion of short stature?
- Height 2 std dev below mean ht for age and sex
- Ht >2 std dev below mid-parental ht
TQ
Short stature differential?
- **Constitutional delay (late bloomer)
- GH defic
- Neglect
- Turners
- Noonan
- Hypothyroid.
TQ
GH-def from hypopit.
What lab findings?
- IGF-1, IGF binding protein 3
- Ancillary test: GH stimulation test (GHRF-arginine)
TQ
- Obesity
- Moon facies
- Violaceous striae
- Cessation of linear growth
What do you measure?
Cushing syn
Measure cortisol
TQ
- Short stature
- Webbed neck
- Shield shaped chest
- Low posterior hairline
- Mosaic? May have no stigmata
What is the karyotype? What tests do you run?
Turner Syndrome
- Karyotype (45 XO)
- Ancillary tests:
- Echocardiography
- Renal ultrasonography (horseshoe)
TQ
- Craniotabes (softening or thinning of skull)
- Bulbous, flared wrists
- Bowing of extremities
What impt lab do you draw?
Rickets
**25-hydroxyvitamin D
Also: -1,25-dihydroxyvitamin D -PTH -ALP
TQ
- low birth wt
- short stature
- poor wt gain
- microcephaly
- epicanthal folds
- smooth philtrum
- flat nasal bridge
- thin upper lip
Fetal Alcohol Syndrome
TQ
- big head, big/tall when young, normal adult height
- Incr Insulin-like growth factor 2
- Hypoglycemia
Beckwith-Wiedemann syndrome
- Incr LH, FSH
- Decr testoserone
- 47XXY
Klinefelter syndrome
TQ
- Clinical diagnosis using Ghent nosology
- abnormality of connective tissue
- Ancillary tests
- Fibrillin-1 gene mutation
- Genetic consultation
What inheritance pattern???
Autosomal dominant
- Due to either central (GnRH) or peripheral (GnRH indep) causes leading to overgrowth
- incr tanner staging
- tall stature
Precocious puberty
Children may have up to 11 respiratory infxs in infancy, each lasting 8-14 days. Therefore, children w/ recurrent infxs is a common reason for doc visits.
What is the definition of recurrent infx?
1) 2+ severe infections in 1 yr
- Persistent fever or confinement to bed for 1wk+
- Failure to respond to oral antibiotics and/or the need for IV antibiotics or hospitalization
- Infections with an unusual pathogen
- Unusual complications (mastoiditis, pleural effusion, abscesses)
- Persistent laboratory/radiologic abnormalities
2) 3+ respiratory infections in 1 yr
3) Need for antibiotics for 2 months/year
TQ
Children w/ primary immuno-def are more likely to have what?
hint “SPUR”
- Serious infx (meningitis, peritonsillar abscess)
- Persistent infx (does not improve)
- Unusual infx (burkholderia cepacia, pneumocystitis jiroveci)
- Recurrent infx
TQ
Osteomyelitis in kids? infants?
Kids=staph
Infants=kingella
3 most impt factors in dx of PID?
- FH
- Need for IV antibx
- Failture to thrive
-Family history of immunodeficiency or unexplained early death
Suggestive of a primary immunodeficiency
TQ
Inheritance pattern?
Chronic granulomatous disease (CGD) and agammaglobulinemia 
X-linked
TQ
Inheritance pattern?
Ataxia-telangiectasia
AR
TQ
Umbilical cord does fall off…think
Leukocyte‐Adhesion defects
TQ
Absence of T cells? think
Complete DiGeorge syndrome
no thymus
TQ
Signature organism in chronic granulomatous dz?
Staphylococcus aureus
Also: aspergillus
TQ
-Petechiae, easy bleeding, eczema, and chronic draining ears
Wiskott-Aldrich syn
TQ
Oral ulcers, gingivitis, and impetigo
leukocyte‐adhesion defects
chronic granulomatous disease
TQ -
**Developmental delay
- Cerebellar defects
- Spider angiomas
- AR
- Ataxia + infx
Ataxia-telangiectasia
TQ
- Coarse features, chronic‐infected eczema, and deep‐seated abscesses
- recurrent staphylococcal skin infections, abscesses, lung cysts, or pneumonia
hyperimmunoglobulin E syndrome
TQ
- Growth retardation w/ infection
- Short stature
- chondrodystrophy
- fine hair
cartilage‐hair hypoplasia
TQ
- Congenital heart disease
- developmental delay
- hypocalcemia (no parathyroid)
- dysmorphic facies with low‐set ears
- hypertelorism
- downturning eyes
- micrognathia
DiGeorge syndrome
No thymus or T cells
TQ
- Oculocutaneous albinism
- progressive neurologic dysfunction in young adults
Chediak‐Higashi disease
TQ
- Appears b/t birth-6 mo
- Pneumocystis jiroveci (carinii) pneumonia
- seborrheic dermatitis and alopecia
SCID
TQ
Autosomal recessive form of severe combined immunodeficiency (SCID) characterized by erythroderma, desquamation, alopecia, chronic diarrhea, failure to thrive, lymphadenopathy, and hepatosplenomegaly
Omenn syndrome
Supraclavicular LN enlarged is NOT good. How about cervical?
Normal
TQ Most impt component of the work up for lymphadenopathy?
H and P
Supraclavicular LN enlarged?
Never normal. BAD
LN
Tender, warm, red, fluctuant?
Soft, mobile, smooth?
Firm and rubbery?
Fixed and matted?
Tender, warm, red, fluctuant? Lymphadenitis
Soft, mobile, smooth? Benign
Firm and rubbery? Possible lymphoma
Fixed and matted? Possible malignant or TB
TQ
LDH=marker for?
hematologic malignancy
TQ
4 yo presents w/ diffuse lymphadenopathy, sore throat, can you do a mono spot on her?
NO
5-6 yo cut off…before that don’t form heterophile Ab May be negative
Diffuse lymphadenopathy + respiratory symptoms what do you order?
CXR
Diffuse lymphadenopathy + failure to thrive?
HIV considered
LN swollen in axilla, knicked when shaved, tender, warm LN, fever, Dx?
MC staph aureus
also: strep pyogenes
Animal related causes of lymphadenitis:
- Tularemia
- TQ Cat scratch dz (?????)
- Yersinia pestis (plague)
Bartonella henselae
TQ
Pt presents w/ fever, swollen LN in axilla
- sore on left hand recently
- sister has a cat
Cat scratch dz (Bartonella henselae)
Tx: Azithromycin
TQ
- Parinaud’s triad: conjunctivitis, preauricular adenitis, conjunctival granuloma
- Neuroretinitis (macular star)
Dx?
Cat scratch fever
- Supraclavicular LN + lump in scrotum (not painful)
- tired
- cough
- nose bleeds
Cancer loves the mediastinum!!
TQ
Testicular mass, esp painless w/o hx of trauma/injury>>order???
chest radiograph indicated (likely malig.)
TQ What must you do if you find a supraclavicular LN?
work it up! have to know where its coming from
TQ
Generalized LAD + respiratory s/s what must you do?
Order a chest x-ray
What are the 2 categories of tumor like lesions?
heterotopia (normal cells in abn location)
hamartoma (overgrowth natives)
What are the 4 types benign tumors?
1) Hemangioma: MC tumor of infancy (ex: port wine stain)
2) lymphatic tumors
3) Fibrous tumors
4) Teratomas
TQ
- Benign, well-diff cystic lesions (cells with teeth, hair, etc)
- sacrococcygeal MC
teratoma
Where do most frequent childhood cancers arise from?
Hematopoietic system
TQ Why do we always check for red reflex in kids?
Retinoblastoma!
TQ Age group for wilms tumor?
0-4 yrs
TQ Age group for retinoblastoma?
6 to 9 yrs
TQ MC extracranial solid tumor of childhood
Neuroblastoma
TQ
Older child presents w/ **bone pain, resp s/s, GI complaints, no red reflex
Where is the mets?
Periorbital region
TQ 90% of neuroblastomas produce what?
Catecholamines (VMA, HMA)
TQ
MC primary renal tumor of childhood?
Big mass is abdomen
Wilms tumor
TQ
what chromosome is wilm’s tumor assoc w/?
Chrom 11 (deletions)
TQ
Pt w/ Beckwith-Wiedemann syn now presents with a tumor. What type of tumor is it?
Beckwith-Wiedemann: enlargement of body organs, macroglossia, hemihypertrophy, omphalocele, chrom 11
Wilms tumor!!!
TQ
- large abd mass
- hematuria
- pain in abd
- intestinal obstruc
- HTN
Wilm’s tumor
Intentional harm or threat of harm to a child by whomever is taking care of child
Child Maltreatment
TQ T/F All care providers=mandated reporters. Must report cases of child abuse or neglect to local Child Protective Services.
True!
Any non-accidental physical injury to child.
Physical abuse
Any activity w/ child before age of legal consent or beyond child’s comprehension (eg. Retarded) that is for sexual gratification
Sexual abuse
Repeated damaging interactions stating child is flawed, unloved, unwanted
Emotional abuse
TQ MC form of child abuse
Caretaker omissions in care that result in actual or potential harm to child. Child’s basic needs not adequately met.
Neglect
Omissions in medical care that result in actual or potential harm to child
chronic illnesses or failure to f/u
failure to be compliant w/ meds
Medical neglect
MC perpetrators of maltreatment?
Parents
Role of medical provider in suspected maltx
- Needs of child=primary concern
- The parents have the right to know if a report has been or is going to be made, but only after child safety is ensured!!
TQ Open and good-faith exchange w/ child abuse agencies and care providers is legal and protected. What is generally trumped?
HIPPA
TQ Most important when identifying child maltreatment?
History! Use quotes when possible
Easy bruising? FHx of fx. Hx of bleeding disorders (Did pt bleed a lot during circumcision).
DO COAG STUDIES.
TQ
- Developmntally inapprop hx (2 mo old was walking and fell down the stairs— can’t walk at 2mo old!).
- No hx- “no idea what could have happened.”
- **Hx INCONSISTENT W/ INJURY (serious injuries following supposedly minor incidents).
- Serious injuries- esp claimed to have been inflicted by other small children.
- Genital injuries.
- Changing hx.
- Delay in seeking medical care.
Red flags!
TQ When suspect child maltreatment, order labs/rad, and a skeletal survey. What is a red flag on the skeletal survey?
Multiple fractures at different stages of healing
A reduction of the hemoglobin concentration or red blood cell (RBC) volume below the range of values occurring in healthy persons
Anemia
