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Other Common Pediatric Medical Problems Flashcards

1
Q

Normal Growth

  1. Newborns gain how much in three months?
  2. Infants gain how much in 3-6 months?
  3. They gain___ g/day between 6-12 months?
  4. Infants _____ their birth weight by 4 months
  5. They _____ their birth weight by 1 year
  6. Children gain __ kg/year between 2 yrs & puberty
A
  1. 30 g/day (1 oz/day) up to 3 months
  2. 20 g/day (.67 0z/day) between 3-6 months
  3. 10
  4. double
  5. triple
  6. 2
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2
Q

Pyloric Stenosis
Clinical presentation?
5

A
  1. 3-5 weeks
  2. “Projectile” nonbilious vomiting (FORCEFUL VOMITING)
  3. Infant immediately hungry (Hungry vomiter”)
  4. May be dehydrated
  5. May be jaundiced
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3
Q

Pyloric Stenosis
PE? 3

Labs?
Imaging?

Treatment?

If there is bile what would we think the problem is?

A
  1. Check hydration status
  2. Check for jaundice
  3. Palpate abdomen for “olive”—present 50-90%

Evaluation:
Labs- CMP
US

Treatment: pyloramyotamy

Obstruction

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4
Q
  1. Newborns with persistent emesis often have what?
  2. Toddlers comprise the age group that most commonly presents with what?
  3. Pyloric stenosis often presents around what?
A
  1. intestinal atresias’
  2. intussusecption
  3. 3-6 weeks of age
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5
Q
  1. Abdominal pain DDx for newborn? 3

2. Infancy to 2 yrs? 3

A
  1. GERD
  2. Necrotizing colitis*
  3. Vovulus
  4. Intussusception
  5. Meckel’s diverticulum
  6. Bacterial enteritis
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6
Q

What is is VERY common in healthy infants (“Happy spitters”)?

A

GERD

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7
Q

Warning signs of underlying pathology?

  1. GI? 2
  2. Neuro? 3
  3. Nonspecific? 4
A
  1. GI:
    - Bilious vomiting, GI bleeding, forceful vomiting
    - Prolonged constipation, diarrhea or abdominal distension
  2. Neurologic:
    - HSM, bulging fontanelle, seizures
    - Microcephaly or macrocephaly; hypertonia or hypotonia
    - Stigmata of genetic disease or chronic infections
  3. Nonspecific—
    - fever,
    - pneumonia,
    - lethargy,
    - failure to thrive
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8
Q

What is pathogonomic for necrotizing enterocolitis?

A

Pneumotosis instestinalis

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9
Q

GERD: IF warning signs are absent and the infant has any of the following symptoms?
4

Then a work-up can be considered**?

A
  1. Poor weight gain
  2. Irritability
  3. Feeding refusal
  4. Gross blood in stool
  5. Esophageal pH monitoring
  6. Endoscopy
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10
Q

GERD Lifestyle changes:

3

A
  1. Avoid ALL exposure to tobacco smoke (lowers the pressure of LES)
  2. Smaller feedings—most relevant for infants that are bottle fed
  3. Trial of a diet where ALL cow’s milk is removed**
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11
Q

GERD: Positioning therapy?

A
  1. Keep infant upright (on parent’s shoulder) for 10-20 minutes after a feed
  2. NOT in a semi-supine position (promotes reflux)
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12
Q

What US signs do you get from intussaception?

A
  1. Target sign

2. pseudokidney

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13
Q

1-2. GERD Treatment Options: Indications for pharmacotherapy
2

  1. Timeline for therapy?
  2. What kind of drug preferred?
  3. What is not useful for treatment?
A
  1. Infants w/ mild esophagitis on endoscopic biopsies
  2. Infants w/ significant symptoms*** AND in whom conservative measures have failed
  3. 3-6 months of therapy w/ a repeat endoscopy if erosive esophagitis is present
  4. PPI is preferred as it is a better acid suppressor; SE include increased risk for pneumonia and diarrhea
  5. Antacids are not useful for treatment
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14
Q

Colic is a diagnosis of what?

A

Diagnosis of exclusion

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15
Q

Colic: Rules of three?

4

A

1, Greater then 3/= hours a day of crying

  1. Greater then 3/= days a week
  2. Lasts at least 3/= weeks
  3. And infant less than 3 months old
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16
Q
  1. When does Colic start?

2. When does it end?

A
  1. Starts 3-6wks

2. Ends at 3-4 months

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17
Q

Colic: Associated characteristics?

7

A
  1. Paroxysmal
  2. Occurs more in the evening
  3. Qualitatively different from normal crying
  4. Associated with hypertonia*
  5. Inconsolability
  6. Infant is normal when not colicky
  7. First few weeks of life are unremarkable
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18
Q

Colic Soothing Maneuvers

12

A
  1. Use a pacifier
  2. Take the infant for a car or stroller ride
  3. Hold the infant or placing them in a front carrier
    4, Rock the infant
    5, Change the scenery or minimize visual stimuli
    6, Place the child in an infant swing
    7, Give the infant a warm bath
  4. Gently rub the infant’s abdomen
  5. Provide “white” noise
  6. Play a CD of heartbeats
  7. Sing to baby
  8. Give baby quiet time in crib for 5-10 minutes
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19
Q

Colic Treatment Suggestions 3

What cannot we NOT use as treatment? 4

What is the most important treatment?

A
  1. Trial of an elemental formula for one week
  2. If breast-feeding a trial of hypoallergenic diet
  3. Trial of the probiotic—Lactobacillus reuteri (especially in formula fed infants)
  4. NOT a trial of soy milk
  5. NOT simethacone
  6. NOT infant massage
  7. NOT homeopathic remedies

MOST important—parenteral support!!!

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20
Q

Other Suggestions to Give Parents for Colic?

6

A
  1. NEVER shake the baby
  2. It’s okay to take a break and let someone else take care of the baby.** It’s OK to take a break
  3. Talk to someone and express your feelings
  4. Try to stay positive—don’t feel guilty, colic is not a sign of bad parenting
  5. Take care of yourselves as parents
  6. Remember that it’s only temporary!
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21
Q

Oral Rehydration Therapy
1. How should we administer the fluid and electrolytes?

  1. What is our first choice?
  2. What do homemade solutions consist of?
  3. What is the goal of this therapy?
  4. Good technique to accomplish this?
A
  1. Small amounts of liquid taken orally to replace fluids and electrolytes
  2. Pedialyte first choice (Remember, where sodium goes, water follows)
  3. Homemade solution consists of 8 level teaspoons of sugar, 1 level teaspoon of salt, mixed with one liter of water
  4. Idea is to coat the esophagus WITHOUT causing a large enough bolus in the stomach (which will irritate the stomach and induce emesis)
    - -Increase as tolerated.
  5. A great technique is to use a syringe (5ml) every 2 – 3 minutes
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22
Q

What type of education would be given in this circumstance?
When would you recommend that mom bring Suzy back for IV therapy?
2

A

Tachycardyic or her BP is low

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23
Q

Use of an antiemetic recommended in the pediatric patient?

A
  1. Odansetron (Zofran) is safe and effective

- -Available in ODT (oral dissolving tablets) and IV

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24
Q

Describe the following for Mild (3-5%) dehydration:

  1. Pulse
  2. Systolic pressure
  3. Respirations
  4. Buccal mucosa
  5. Anterior fontanelle
  6. Eyes
  7. Skin turgor
  8. Skin
  9. Urine output
  10. Systemic signs
A 
Mild (3-5 percent)
1, Full, normal rate
2. Normal
3. Normal
4. Tacky or slightly dry
5. Normal
6. Normal
7. Normal
8. Normal
9. Normal or mildly reduced
10. Increased thirst
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25
Describe the following for Moderate (6-9%) dehydration: 1. Pulse 2. Systolic pressure 3. Respirations 4. Buccal mucosa 5. Anterior fontanelle 6. Eyes 7. Skin turgor 8. Skin 9. Urine output 10. Systemic signs
Moderate (6-9 percent) 1. Rapid 2. Normal to low 3. Deep, rate may be increased 4. Dry 5. Sunken 6. Sunken 7. Reduced 8. Cool 9. Markedly reduced 10. Listlessness, irritability
26
Describe the following for Severe (>10%) dehydration: 1. Pulse 2. Systolic pressure 3. Respirations 4. Buccal mucosa 5. Anterior fontanelle 6. Eyes 7. Skin turgor 8. Skin 9. Urine output 10. Systemic signs
Severe ( >10 percent) 1. Rapid and weak 2. Low 3. Deep, tachypnea 4. Parched 5. Markedly sunken 6. Markedly sunken 7. Tenting 8. Cool, mottled, acrocyanosis 9. Anuria 10. Grunting, lethargy, coma
27
Recommended by the American Academy of Pediatrics (AAP) as “the preferred treatment of fluid and electrolyte losses caused by diarrhea in children with mild to moderate dehydration”?
Oral rehydration therapy (ORT)
28
Severe hypovolemia treatment? | 2
1. rapid infusion of 20 mL/kg of isotonic saline 2. The patient should then be reassessed and the saline bolus repeated as needed until adequate perfusion is restored - ---Conversion to ORT can take place once the patient is adequately hydrated
29
Reasons to Hospitalize a Child w/ Diarrhea | 5
1. Diagnosis or strong clinical suspicion of life-threatening diarrhea 2. Severe dehydration or electrolyte abnormality 3. Lack of improvement w/ rehydration 4. Continues copious diarrhea that will lead to recurrent dehydration if ongoing IV rehydration is not continued 5. Inability to drink
30
Diarrhea—Acutely Ill Child | 1. If you have peritonitis or abdominal mass what possibilities could be on your diff? 3
1. Apendicitis 2. Intussusception 3. Toxic megacolon
31
Diarrhea—Acutely Ill Child 1. If you have bloody diarrhea what possibilities could be on your diff? 4 2. If there is no blood? 5
1. Sepsis 2. Hemolyitc uremic syndrome 3. Intussusception 4. Toxic megacolon 1. Sepsis 2. Apendicitis 3. Intussusception 4. Toxic megacolon 5. Organophosphate poisoning
32
Reasons to Hospitalize a Child w/ Diarrhea | 5
1. Diagnosis or strong clinical suspicion of life-threatening diarrhea 2. Severe dehydration or electrolyte abnormality 3. Lack of improvement w/ rehydration 4. Continues copious diarrhea that will lead to recurrent dehydration if ongoing IV rehydration is not continued 5. Inability to drink
33
Look at slides 52
52
34
The definition of constipation?
A decrease in a person’s normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.
35
Big three reasons people in the US are constipated: | 3
1. Lack of fiber 2. Inadequate consumption of fluids 3. Sedentary lifestyle
36
Defined in children > 4YO as what?
abnormally reduced defecation
37
Differential for constipation includes functional retention (the great majority of cases) which can result from: 1. Traumatic events? 3 2. Difficult psychosocial situations or environmental changes? 2
1. Traumatic events: - Painful passage of hard stools - Painful diarrhea - Physical or Sexual abuse 2. Difficult psychosocial situations or environmental changes: - Difficulty with potty training - Divorce
38
Functional Retention Cycle | What two things make the problem keep intensifying?
1. Painful passage of hard stools 2. Withholding of stool
39
Encopresis: Definition
1. Often the result of functional retention causes stretching of rectum and decreased sensation to empty bowel 2. Liquid stool leaks around a retained stool mass and is involuntarily passed
40
Other Causes of Constipation: Organic causes of constipation | 10
Organic causes of constipation
41
Warning Signs of constipation? | 10
1. Weight loss or poor weight gain 2. Anorexia 3. Delayed growth 4. Delayed passage of meconium (> 48 hours after birth) 5. Urinary incontinence or bladder disease 6. Blood in the stool (unless anal fissure present) 7. Constipation present from birth or infancy 8. Acute constipation 9. Associated fever, vomiting or diarrhea 10. Extraintestinal symptoms
42
Constipation Concerning Findings on PE | 9
1. Failure to thrive 2. Abdominal distension 3. Lower spine abnormalities 4. Anteriorly displaced anus 5. Tight, empty rectum in the presence of a palpable fecal mass 6. Absent anal wink 7. Absent cremasteric reflex 8. Decreased lower extremity tone or strength 9. Absence of delay in relaxation phase of lower extremity DTRs
43
Findings That support a Functional Etiology: Onset of constipation coincides with? 3
1. Dietary change 2. Toilet training 3. Painful bowel movement
44
Laxatives | 4
1. Stool softeners 2. Osmotic agents 3. Bulking/Fiber agents 4. Peristalic inducers
45
Name the meds in each category: 1. Stool softeners 1 2. Osmotic agents 3 3. Bulking/Fiber agents 2 4. Peristalic inducers 2
1. Docusate sodium (Colace) 2. - *Polyethylene glycol (Miralax) - Mineral Oil - *Lactulose 3. - Psyllium (Metamucil) - Methylcellulose (Citrucel) 4. - Senna (Ex-Lax) - Bisacodyl (Dulcolax)
46
Treatment of Encopresis | Begins with clearing the child’s bowel: HOw?
1. Use of a osmotic laxative for 3 days | - Child will usually have diarrhea then bowel is clear
47
Education of the parents: start a toilet training process: | 6
1. Continued daily use of chosen laxative to keep stools soft 2. REGULAR toilet sitting time for 5-10 minutes after a meal 2-3 x a day 3. Stool by toilet so child can put his/her feet on and not let legs dangle 4. Rewards for sitting on the toilet NOT just for results 5. Note times when BM occurs and when it happens in the toilet 6. May need to take laxatives for several months before weaning off
48
1. What is Enuresis? 2 Control by what age usually? 3. Familial? 4. What exacerbates this? 2
1. Involuntary discharge of urine after the age at which bladder control should have been established 2. Control usually established by 5yo 3. Significant genetic component 4. Exacerbated with stress and emotional problems
49
Monosymptomatic enuresis: 1. Happens in children without a history of? 2. Daytime sympotms? 3. Describe primary enuresis? 4. Describe secondary?
1. Children without any h/o of urinary tract symptoms or bladder dysfunction 2. Nocturnal—no daytime symptoms 3. Primary—80% have this/have never had a nighttime dry period 4. Secondary—child develops enuresis after a dry period of at least 6 months
50
Enuresis: Small percentage have an underlying neurologic or anatomic problem: such as? 5
1. Urinary tract abnormality/UTI/Kidney disease 2. Trauma or disease of the spinal cord 3. Diseases: seizures, hyperthyroidism, DM 4. Sleep apnea 5. Pinworms
51
Evaluate with the following for enuresis: Ddx? | 9
1. Overactive bladder or dysfunctional voiding 2. Cystitis 3. Constipation 4. Neurogenic bladder 5. Sleep disordered breathing 6. Urethral obstruction 7. Major motor seizure 8. Ectopic ureter 9. Diabetes mellitus or Diabetes Insipidus
52
PE for enuresis? 6 Labs? 1
1 Measure BP 2. Perianal area 3. Lumbosacral spine/neurologic exam 4. Genitalia exam 5. Palpate abdomen 6. Palpation of renal and suprapubic areas 1. LAB: urinalysis**
53
Enuresis: pharmological treatment considerations? | 2
1. Desmopressin acetate** orally (works ONLY while on it) | 2. Anticholinergic agents such as oxybutynin
54
For visual development to proceed normally a child needs: 4 What do we have to remember about vision in developing children?
1. Normal visual environment 2. Well-aligned eyes 3. Freedom from visually threatening disease 4. Freedom from significant refractive errors ***In the normally developing child, if one eye is dominating visual acuity, blindness can occur in the opposite eye
55
Amlyopia definition?
unilateral or bilateral reduction in central visual acuity due to the sensory deprivation of a well-formed retinal image that occurs with or without a visible organic lesion commensurate with the degree of visual loss
56
Amlyopia 1. Can only occur during critical period of visual development when? 2. Best screening test?
1. In the first decade of life | 2. Best screening test is obtaining visual acuity in each eye
57
Amlyopia Types: | 3
1. Strabismic amblyopia (occurs in nondominant eye of strabismic patient) 2. Refractive amblyopia (results from refractive errors, can be unilateral or bilateral) 3. Deprivation amblyopia [rarest] (occurs with congenital cataracts, unilateral ptosis, corneal opacities or vitriol hemorrhage
58
When testing the nonverbal child what is the differential occlusion test and why do we do it?
1. Fixation test (occluding the not-tested eye) 2. Differential Occlusion test: - Monitoring infant’s response to the occlusion of vision in each eye - Normal sight in both eyes won’t bother an infant - If one occludes the eye with poor vision the infant will get fussy
59
1. What is strabismus? 2. What is esotropia? 3. What is exotropia? 4. A child may be intermittently esotropic over the first few months of life but ***should be well aligned by when? 5. 20% of patients with ______________ have strabismus 6. Other disorders that may cause this include what? 2 7. Treatment ranges from what to what? 3
1. Definition: misalignment of the visual axes of the two eyes 2. Esotropia: Inward turning misalignment of the eyes 3. Exotropia: Outward turning misalignment of the eyes 4. 5-6 months of age 5. retinoblastoma 6. hydrocephalus and a space-occupying lesion 7. - glasses, - to patches, to - surgical correction
60
Carefully look at the what to identify Strabismus!
corneal light | reflex
61
1. _____________ indicates a complete or partial obstructive process and almost always warrants corrective or exploratory surgical intervention. 2. The most important thing to assess initially with a CC of vomiting and/or diarrhea is what? 3. Understanding ORT is critical for treating the child with _________________ who is mildly to moderately dehydrated
1. Bilious vomiting 2. hydration status 3. viral gastroenteritis
62
1. The great majority of the time constipation is a what kind of problem? 2. what things are extremely helpful for functional constipation? 3 3. _________ is not diarrhea, but the result of functional retention constipation. 4. Give the kid an _______, then use __________________ to normalize, then follow with the standard therapies plus rewarding the kid for number two 5. _________ is generally thought to be from developmental lag, it’s important to educate parents about this
1. functional problem, not organic. 2. - High fiber, - increased water intake, - utilizing the gastrocolic reflex 3. Encopresis 4. enema, polyethylene glycol or lactulose 5. Enuresis
63
1. ***In the normally developing child, if one eye is dominating visual acuity, _________ can occur in the opposite eye 2. A child may be intermittently __________ over the first few months of life but ***should be well aligned by 5-6 months of age If unsure, refer (the earlier treatment is begun, the better chance of improving visual acuity)
1. blindness | 2. esotropic

Pediatrics (18 decks)

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