Paediatrics Flashcards
Describe how you weigh infants and children properly
Infants - nude in a warm room, kids who can stand on a scale—record weight to 2 sig digs
Describe how you measure height in infants and children
For infants, measure with the guardian holding their head against the headboard and bring the footboard up. If they can stand use a statiometer. Record height to nearest 0.1 cm
What are important things to ask on nutrition history for an infant
When asking nutrition history, make sure you get a sense of the timing of their meals, their bottles per day, what size bottle, what’s in the bottle. What are the pees and poops like?
What are some paeds specific questions to ask on FH in the setting on Down syndrome.
Ask about childhood illness, sudden childhood deaths, developmental delay, autism. University, parents employment,
On social history what are some helpful questions?
Food insecurity, benefits, disability or child tax credit. Who lives in the home?
What are some good questions for neuro ROS
Ask about seizures
How do you address cradle cap?
They don’t have to but you can do it aesthetically
For testicles what’s the difference between undescended and retracted
If you can milk it down then it’s retracted and doesn’t need surgical management.
For the red reflex after you check each eye, what should you do?
Back up and check both at once
Kids sleeping in really odd positions should be screened for what?
obstructive sleep apnea (ask about snoring, apneic episodes)
What are some important phrases not to use in SCAN notes
Evidence, denies, consistent with… Also make it clear who is saying it or reporting something rather than saying x has a cut
How do you measure head circumference?
Tape above the ears and around the head over he occipital prominence
What do you need to ask to confirm secondary enuresis?
If they say they were dry, are they still wetting the bed at all? Even once a month? If they say that they are still wetting the bed, even if it’s only occasionally, then it’s still primary enuresis.
What should you do at the end of the adolescent history?
Ask them if there’s any remaining concerns and if there’s anything that they do not want to share with their family. This lets you know how open they are and offers an opportunity to counsel/explore if they are not.
What should you include in your first line when you present a paediatric patient?
Age, Immunization status, general appearance
What non-nutritional factors can change weight?
Dehydration, edema, tumor growth or organomegaly or hydrocephalus, medical equipment or devices (don’t forget casts / braces!)
What are the key milestones for weight after birth, at 6 months and by 1 year of age?
Return to birth weight by 10-14 days (may lose up to 10% initially) Double by 6 months (20-30g/day) Triple by 1 y
What is a good rule of thumb for maintenance fluid and calories for growth for infants?
100mL/kg/day 100 kcal/kg/day
When should moms breastfeed?
Exclusively first 6 mos, then supplemented by foods for the first 1-2 years
What vitamin must all breastfed infants receive?
Vitamin D (400 IU /day)
What are some advantages to breastfeeding?
Bonding, convenience, ideal nutrition composition and passive immunity, decreased SIDS, allergies and childhood obesity, maternal health benefits
What are some contraindications to breastfeeding?
Galactosemia, maternal HIV, breast herpetic lesions or untreated TB, some meds
What is the WHO definition for diarrhea? If a child doesn’t meet it, what else should arouse suspicion?
>= 3 loose or watery stools per day, but any change from a child’s routine is worth investigating
What is chronic diarrhea?
Any diarrhea lasting more than 14 days
What does the onset of diarrhea suggest about its etiology?
Since birth = congenital Sudden = likely infectious Gradual = chronic nonspecific diarrhea of childhood in the absence of any other explanation/symptoms Food related = intolerance??
What are the red flags for diarrhea?
Fever, anorexia, nausea, blood, nocturnal diarrhea, vomiting, abdo distention, poor weight gain or weight loss, poor growth.
How do you calculate the stool osmotic gap? What is the relevance for diarrhea?
290- 2(Na+K); if >100 mOsm/kg this is osmotic diarrhea
What’s the differential for osmotic diarrhea?
Osmotic diarrhea = malabsorption/indigestion. Could be fat (CF, pancreatic insufficiency, bile acid malabsorption), protein (lymphangiectasia, protease deficiency), or carbohydrate malabsorption (can be congenital, but more often secondary to some other process involving mucosal damage), or combined due to short gut, IBD, food intolerance or celiac. Osmotic diarrhea can also be caused by infections
What’s the differential for secretory diarrhea?
Increased secretion into the lumen (so bigger stool volume): congenital Cl/Na, Microvilli Inclusion Disease, Autoeimmune enteropathy / IPEX, enteric hormone secretion, and also infections
What is the cause and treatment for toddler’s diarrhea / nonspecific diarrhea of childhood?
Too much juice intake (or hyperosmolar fluid). Decrease fructose / sorbitol intake.
What is the incidence of celiac disease in the population?
0.5-1%
What is the classic presentation of celiac disease?
Age 6-24 months, chronic diarrhea, abdo distension, anorexia, failure to thrive or weight loss.
What are some non-GI symptoms of celiac disease?
Dermatitis herpetiformis, dental enamel hypoplasia (permanent teeth), osteopenia or osteoporosis, short stature, delayed puberty, refractory iron-deficiency anemia
What tests are useful for diagnosing celiac disease?
Anti-endomyseal (EMA) or tissue transglutaminase (TTG), or IgA level. Gold standard is biopsy of mucosa via scope.
What are some key points for the diagnosis of IBD?
Exclude infectious etiology. Clinical history, labs (CBC, ESR, albumin), radiologic or endoscopic lesions, histology
Distinguish between Crohn’s and UC
Crohn’s: any part of GI tract, but discontinuous inflammation that is transmural with granulomata. Ulcerative colitis is all or part of the colon with continuous mucosal inflammation from rectum up.
What are the top 3 non-infectious diagnoses that must be considered for persistent diarrhea in infants?
Formula intolerance (e.g. milk protein allergy), CF, immunodeficiency
What are the top 3 non-infectious diagnoses that must be considered for persistent diarrhea in toddlers?
Post-infectious enteritis, toddler’s diarrhea, celiac
What are the top 3 non-infectious diagnoses that must be considered for persistent diarrhea in older children and teens?
Celiac, lactose intolerance and IBD
What are the rome III criteria for a diagnosis of constipation?
>= 2 criteria per week for at least 2 months: > 4 years old <= 2 poops per week >= 1 episode of fecal incontinence Retentive posturing or volitional stool retention Painful bowel movements Fecal mass in rectum Big poops that block the toilet (+r/o structural, endocrine or metabolic disease).
How do you treat constipation?
Reassurance, then first disimpact and then maintain (typically use PEG 3350 0.8-1g / kg/ day, well-tolerated by children. Once disimpacted, then you can maintain the PEG and have a toileting routine + rewards. Encourage hydration + continue therapy as it will take many months for the bowel to return to normal.
What are the 5 areas of development?
Gross motor Fine motor Speech/language Cognitive Social/emotional
What are key things to ascertain on development history?
Characterize both trajectory and current functioning. If delay, is it isolated/specific or generalized? Prenatal history & birth history & consanguinity FH (developmental delay, genetic disorders, learning difficulties, neuro, infant deaths, recurrent miscarriages) SH (family structure, social support, parental education, where is the child spending most of the time in, neglect/abuse)
What are some developmental “red flags”?
No pincer grip by 12 mo Not walking by 18 mos Less than 15 words by 18 mos
What are some specific things you’ll want to look for on physical exam?
Head circumference Hearing & vision Facial abnormalities Spine / chest abnormalities. Organomegaly Genital abnormalities Limb deformity
What is the diagnostic criteria for global developmental delay?
2/5 categories significantly delayed Child < 5 yo
What are some causes of global developmental delay?
Prenatal intrinsic : genetic/metabolic disorder, CNS malformation Prenatal extrinsic : psychosocial
What are some key gross motor milestones in an infant?
6mo sits unsupported 9mo pull to stand 12mo walking/cruising
What are some key social milestones in an infant?
6 weeks: smiling 9 mo: babbling, develops stranger anxiety 1 yr: knows name and says a few words
What are some key milestones for toddlers?
Walking by 12-18mo Stairs by 2 years 2 word sentences temper tantrums
Name the components of the 3-minute exam.
Airway Breathing Circulation Disability (pupils, limb tone, GCS) Exposure / ENT (rashes, injury, bruises) Temperature/Tummy Glucose
What are the “red flags” you’re looking out for in the sick child
Respiratory distress Quiet (as opposed to crying), lethargic infants Delayed cap refil Dehydrated Less wet diapers Poor feeding Abnormal vitals Non-immunized
What is the glass test?
Pressing a glass over a rash -> nonblanchable purpura could be disseminated meningococcemia, a medical emergency.
Unconscious 8m.o. presenting to ER after fall from mom’s arms. What is the diagnosis?
SDH (extra-axial hyperdense collection on R frontal area), signs of mass effect
What type of fracture is this? What should you worry about with this type of fracture?
Metaphyseal corner fracture; child abuse
What are the findings on this CXR? What follow-up imaging is required?
Anterior mediastinal mass; CT chest.
This is a lymphoma
What are the findings in this preterm infant? What is the most likely diagnosis
Small rounded lucencies (bubbles) along the wall of the colon; pneumatosis intestinalis. Necrotizing enterocolitis
What is the diagnosis in this newborn with severe cyanosis not improving with oxygen?
Transposition of the great arteries (TGA) suggested by the narrow mediastinum and cardiomegaly.
What is the name for this fracture? What is the cause?
Toddler’s fracture, believed to be caused by additional stress by new ambulation.
What does this abdo x-ray show?
Constipation (notice colon filled with poop)
What is this sign called? What is the most likely diagnosis?
Steeple sign; croup
What are the findings in this x-ray? What is the most likely diagnosis?
Epiglottal swelling; epiglottitis
The NG tube is stuck…why?
Congenital esophageal atresia. Given the absence of air in the bowel, this is likely complete atresia without tracheo-esophageal fistula
What are the findings on this xray?
RML consolidation, pneumonia
What are the findings in this xray suggestive of?
R femoral epiphyseal widening due to hyperemia, soft tissue swelling of R knee, suggesting JIA
This infant has a palpable abdo mass and this U/S. What is the diagnosis?
Donut sign; intusseception
What are the findings on this x-ray of a 5 yo with knee pain and swelling and new onset fever? Do you need to order any additional imaging?
Lucency in the femoral epiphysis, osteomyelitis.
Should have MRI knee.
What are the key differences between the between the adult and pediatric airway?
The pediatric airway is: cone-shaped, narrowed at cricoid cartilage. Tongue, adenoids and tonsils and epiglottis larger whlch makes obstruction by these structures more likely. The larynx is higher and more anterior which means overextension of the neck can cause airway obstruction.
What are some signs of airway obstruction in a child?
Nasal flaring, wheeze or stridor, cyanosis, tracheal tug, SCM or scalene use, inter/subcostal and substernal indrawing
What features on exam are characteristic of lower airway obstruction?
Prolonged expiratory phase
Wheeze
History of atopy
What features on exam are characteristic of upper airway obstruction?
increased drooling/secretions
Face, lip, or neck swelling or mass
Stridor, snoring, horseness or barking cough
What is the peak age of incident for croup?
7-36 months
How do you manage/treat croup?
Dexamethasone 0.6mg/kg
If moderate, add epinephrine via nebulizer + observe for 2-4 hrs
Sudden onset difficulty breathing, no viral/infectious symptoms, biphasic stridor, decreased breath sounds, drooling…what’s this kid have?
Foreign body aspiration
What do you do when you suspect foreign body aspiration?
Call ENT for a scope to remove it. Hook him up to monitors and make sure the intubation equipment is available.
What is bronchiolitis? What is its most common cause?
Viral LRTI (RSV usually), starts as a URTI followed by resp distress with edema, inflammation and mucous clogging smaller airways.
Children <2yo
How to you manage bronchiolitis?
Supportive care. Admission if needs O2 to maintain sats, dehydrated, high-risk population, apnea history, cyanosis.
How do you manage an asthma exacerbation?
Mild (0-3 PRAM) inhaled salbutamol
Moderate (4-7) Salbutamol + oral steroid
Severe (8+) inhaled salbutamol and ipratropium q20min x3 + steroid PO or IV.
What are the risk factors for development of recurrent febrile seizures?
Shorter duration of fever before seizure
Younger age at first seizure
FH of febrile seizure
What are the characteristics of typical febrile seizures?
age 6mo-6yo
Associated with fevers without other cause (can’t have had previous afebrile seizure), brief, generalized, 1 in 24hr.
Atypical febrile seizures have what characteristics?
>15 min duration
focal fetures
recurrent (multiple in 24 hr)
increased risk of epilepsy
When should you do an LP on a kid with febrile seizure?
If you are concerned about meningitis or intracraneal infection.
Optionally: if the child was not immunized against strep pneumo and h flu, or the child is pretreated with antibiotics (bc it may mask symptoms
Does vaccination increase risk of febrile seizure?
Yes, DPTP on the day of vaccination and MMR 8-14 days post vaccination.
What is the likelihood of seizure recurrence following febrile seizure? Are there any treatments that can reduce the risk of recurrence?
1/3 will have recurrences, most within 1 year.
Treatment does not reduce epilepsy risk, antiepileptic side effects outweigh benefits here.
What are the adverse effects of prenatal use of tobacco, alcohol, heroin, and cocaine?
Tobacco = risk of low birth weight
Alcohol = FAS, no safe amount
Heroin = fetal growth restriction, placental abruption, fetal death, preterm labour and intrauterine passage of meconium (+ NAS)
Cocaine = vasoconstriction leading to placental insufficiency and low birth weight.
What are the risk factors for GBS in the newborn?
Prolonged ROM
Prematuity
Intrapartum fever
Previous delivery of infant who got GBS
What are the components of the APGAR score?
Appearance
Pulse
Grimace (reflex irritability)
Activity (muscle tone)
Respiration
What causes symmetric vs asymmetric intrauterine growth restriction?
Symmetric typically due to congenital infections (affects brain growth)
Asymmetric = head-sparing, often due to poor delivery of nutrition to fetus (e.g. smoking).
How is “small for gestiational age” defined? What are such infants at increased risk for?
SGA = <10th percentile birth weight for dates (but keep in mind 70% of such infants are simply that way due to parents).
Increased risk for hypoglycemia, hypothermia and polycythemia.
Which medications are routinely given to newborns?
IM vit K
Hep B vaccine
Erythromycin or Tetracycline topical eyedrops
Why would you be concerned about tachycardia in a teenager?
Teens can compensate really well, so tachy may be a sign that there may be something more concerning going on.
What is a physiological reason for low hgb in an 8-10 wk old infant?
They are transitioning from fetal to adult hemoglobin.
How are gram-positive cocci classified?
- Pairs & Chains = Strep species
- Clusters = Staph
- Coagulase +ve = Staph aureus
- Coagulase -ve = everything else Staph
How are gram positive rods classified?
- Aerobic /or facultative anaerobes including Listeria + Corynebacteria
- Anaerobes = Clostridium, Bacillus, Lactobacillus
Name some clinically important gram -ve cocci
Neisseria gonorrhea, N. meningitidis, Moraxella catarrhalis
Describe the spectrum of activity of penicillin?
Gram +ve cocci, especially Strep species
Gram -ve cocci and rods, Neisseria gonorrhea / meningitidis, Pasteurella multocida
Syphillis
Some gram+ve bacilli (Clostridium, Actinomyces, Bacillus, Corynebacterium)
What does Amoxicillin cover beyond the basic spectrum of activity of penicillin?
H. influenzae, some gram negative coverage including E. coli, K pleumoniae, Salmonella
Listeria & enterococci.
What are the 1st generation cephalosporins? What is their coverage?
IV Cefazolin or PO Cephalexin
Best against gram +ve orgs (streptococci & staphylococci).
What are the 2nd generation cephalosporins? What is their coverage? What are they useful for clinically?
IV or PO cefuroxime, PO cefprozil
good (but not as good as 1st gen) against gram +ve strep/staph
Coverage for H flu and M catarrhalis
Useful for pneumonia
What is ceftazidime used for?
Pseudomonas aerugenosa
What are the 3rd generation cephalosporins? What are they used for?
IV ceftriaxone or cefotaxime
PO cefixime
Good against gram -ve orgs, decend coverage against S pneumoniae and GAS/GBS.
Clinically useful for menigitis because of good penetration into CNS + broad spectrum coverage.
What are the exceptions to coverage of meropenem (carbapenems)?
MRSA
Ampicillin-resistant enterococci
some very resistant gram -ves.
atypical organisms (chlamydia, rickettsia, mycoplasma, mycobacteria)
What is the mechanism of action of vancomycin? What is the coverage? What are the side-effects?
Glycopeptide binds terminal D-ala-D-ala
Gram positive bugs (except vancomycin resistant enterococci)
Adverse effects include “red man syndrome”, nephrotoxicity and ototoxicity
What is the spectrum of activity of clindamycin?
Good coverage against gram +ves and oral anaerobes
Used for skin, soft tissue and MSK infections
lots of GI side-efects
What are macrolides used for?
Good for community-acquired pneumonia
Staph, strep & other gram positives
H flu and M catarrhalis
Bordatella, Legionella, Mycoplasma, Chlamydia and Rickettsia
Campylobacter
Side effects: GI symptoms, stevens-johnson, drug interactions with CYP3A4
What are the fluoroquinolones? What is their coverage?
- Ciprofloxacin (good for gram-negative infections esp. enteric bacteria e.g. UTI, Pseudomonas)
- Levofloxacin also a good choice for community acquired pneumonia
- Moxifloxacin -> broad GI infections, atypical infections.
Fluoroquinolone side effects previously worried about cartilage/tendon disruption in children, but that hasn’t occured.
Gentamicins–what are they & what are they used for?
What are the adverse effects you have to watch out for?
Gentamicin, tobramycin, amikacin
Poor penetration in CNS
Gram -ve coverage including pseudomonas, mycobacteria
Ototoxicity, nephrotoxicity (if used for seveal weeks)
What are the 3 things you must think about when selecting an antibiotic?
Bug (likely pathogen, likelihood of resistance)
Drug (can it get to the site of infection, drug interactions, bactericidal/static
host (allergies, conditions, immunocompromise)
What is the most likely organism? How do you confirm your diagnosis? What is the best antibiotic?
Likely group a strep (note strawberry tongue, “sandpaper” fine rash)
Should do a throat swab for culture
Treatment is penicillin V or amoxicillin for 10 days, or macrolides if allergic to pen.
Acute otitis media, 2yo girl fever 39.3 and ear ache 24hrs.
What are the organisms which cause acute otitis media?
S pneumo, H flu, Moraxella, or viral infection. 80% will resolve on it’s own.
High dose 80mg/kg amoxcillin (to overcome resistance).
What signs are concerning for meningitis? What would you worry about on LP?
In an infant, often nonspecific fever, poor feeding, irritability, lethargy, inconsolable crying with bulging anterior fontanelle, septic appearance and petechial rash
in a child, fever, headache, vomiting, altered level of consciousness, nuchal rigidity (Kernig, Brudzinsky), focal neuro findings, petechial rash.
High white count, RBCs, low glucose
What are the most common pathogens which cause meningitis? What empiric therapy will you go for?
Neonates -> Listeria, Group B strep, Gram negative enteric bacteria (Ampicillin + cefotaxime in the neonate + vancomycin if 1-3 mo)
>3m.o. -> Strep pneumo, N. meningitidis, H. flu type B very rare (ceftriaxone + vancomycin)
How would you distingish between bacterial and viral meningitis with CSF?
Bacterial, very high white count vs viral
Higher neutrophils with bacterial
higher protein in viral
Low glucose in bacterial
What are the causitive organisms in a lobar pneumonia?
How do you manage acute bacterial pneumonia?
Start supportive care (check if you need to protect airway, provide supplemental oxygen, get IV access)
Blood culture and sputum if possible
Start cefuroxime or Ampicillin if strong suspicion of strep pneumo
Atypical / severe disease add a macrolide
What is the diagnosis in this 16 year old male with a 4-day history of fever and dry cough who is tachypneic and presents with bilateral crackles…
Atypical pneumonia
Think: M. pneumoniae, Chlamydophila pneumo (babies) / psittaci (birds), Legionella pneumophilia or Coxiella burnetii
What pathogen causes impetigo? How do you treat?
Group A strep or Staph arueus.
Topical mupirocin or fucidin or systemic Cloxacillin or cephalexin.
18-month old previously healthy F presents with fever and pain with urination, 3+ leukocytes and +ve nitrite on urinalysis.
What are the most likely pathogens?
How would you treat it?
What other investigations do you do?
Likely: E coli or Klebsiella,
If complicated, acutely ill, young, vomiting…admit + ampicillin and gentamicin
uncomplicated UTI -> cefalexin, TMP-SMX
Get a urine culture
How do you treat toxic appearing infants (concern for sepsis)?
<28 days, Ampicillin + cefotaxime
29-90 days, Amp + cefotaxime + vanco if concerned about meningitis
3mo - 3 yo, cefuroxime or cefotaxime, again +vanco if you are worried about meningitis
What are the low risk criteria for febrile infants aged 29-90?
Previously healthy term infant
Not toxic appearing
No focal infection (other than otitis media)
Peripheral white count 5-15 x 109/I
Band count <1.5 x 109
Urine < 10 WBC per field or Stool < 5 WBC per field
What should you do in a febrile child < 30 day old child
Full septic workup
(consider full septic workup if high risk between 30-90 days of life)
At what age does precocious puberty gets defined (wlth any secondary sexual characteristic development)
Girls <8 y.o., everyone under 7 gets a full evaluation
Boys <9y.o,
What determines the timing of puberty?
How do we define delayed puberty?
Girls >13 no breast development
Boy > 14 with no testicular enlargement
When considering precocious puberty, what percentage have pathology?
Girls 10-20%
Boys 60-80%
What percentage of delayed puberty is pathologic?
60-80% of girls and 10-20% of boys
What is the differential of precocious puberty?
Central (high LH/FSH)
Peripheral (low LH/FSH)
If concerned for central process -> MRI
If concerned abourt peripheral process (could have gonadal tumor, CAH, etc.)
What are beningn causes of puberty
Premature adrenarche (could be CAH, but sometimes it just resolves on its own)
Premature thelarche (estrogen effects with no androgens, some breast development, typically before age 2)
How do you categorize delayed puberty?
Hypogonadotropic hypogonadism (low FSH/LH) -> permanent (brain tumor or injury, genetic defect, kaulmann’s syndrome), functional (temporary delay due to underlying illness), constitutional (FHx of delayed puberty, no underlying disorder)
Hyergonadotrophic hypogonadism (high FSH/LH)
Why would treatment be indicated for idiopathic central precocious puberty?
Psychosocial <6, treat but > 8 don’t treat
Growth/height <6 treat for sure
What is the treatment for central precocious puberty?
Use a GnRH agonist (gets rid of pusatile GnRH and shuts down HPG)
How do you treat delayed puberty in a boy or girl?
Start with testosterone / estrogen (+ progestin, eventually then OCP), stop to see if the development continues on its own (functional vs constitutional) and restart at a higher dose if need be.
What are some important questions on history for fetuses that are SGA?
maternal factors - substance use, smoking
pregnancy factors - chronic HTN or pre-eclampsia
fetal factors - genetic disorders?
What kinds of symptoms would you see with symptomatic hypoglycemia in the newborn?
What do you do if you see symptoms?
Remember that symptoms are non-specific (so you have to screen for it)
apnea, cyanosis, lethargy, jitteryness, seizures
Start dex infusion.
What is the management of hypoglycemia in the newborn?
Give dextrose gel (facilitates breatsfeeding)
Feed
Establish IV access
Check glucose q3h
What groups of neonates are at risk for hypoglycemia?
Infants of diabetic mothers
Large for gestational age
Prematurity
Small for gestational age
At what point do you need to intervene for hypoglycemia in the newborn?
or 1 Critical low <1.8
or 3 lows in a row <2.6
How do you calculate glucose infusion rate?
(%dex x mL/Kg/day)/144
When glucose stays low despite gel/feeding what do you do?
Start D10W (can increase to D12.5 or D15 (via umbilical cath or central line))
If still not working, start glucagon infusion.
Wean down GIR as feeds introduced
Do labs when glucose <2.2 (check insulin / glucagon + Cpep, metabolites)
What is the workup for the cyanotic baby?
4 limb BP
SpO2 - pre-ductus (R arm) and post ductus (leg)
ABG + lactate
Hyperoxia test
CXR
What is the difference between cyanosis and hypoxia?
Hypoxia = insufficient O2 reaching cells
Cyanosis = blue discolouration due to desat hemoglobin (so not a specific indication of hypoxia)
What is the diferential for cyanosis in a neonate?
Sepsis
Neurometabolic
Resp (RDS, TTN, pneumonia, meconium aspiration, chronic lung disease)
Cardiac causes (5Ts Transposition of the Great Vessels, Tetralogy of Fallot, Tricuspid valve atresia, Truncus Arteriosus, Total anomalous pulmonary venous return)
How do you perform a hyperoxia test? What’s the interpretation?
Check ABGs before and after (gold standard is R radial artery, preductal)
Baby on 100% O2 CPAP 15 minutes.
100-150 -> parenchymal lung disease
50-100 - > congential heart defect or persistent pulmonary hypertension of the newborn
<50 - duct dependent pulmonary circulation
Describe the transition after birth.
Cord clamp (removal of placenta (low pressure system)
Lungs inflate - > small vessels unkink release of PGI2
PO2 rises
What are the risk factors for neonatal jaundice?
Maternal: ethnicity (asian, native american, mediterranean),complications during pregnancy (diabetes, Rh or ABO incompatibility), breastfeeding
Perinatal - birth trauma (cephalohematoma), infection
Neonatal - prematurity, genetic causes (gilbert, crigler-najjar), G6PD deficiency, pyruvate kinase deficiency, erythrocyte defects (spherocytosis or elliptoscytosis), a-thalassemia, polycythemia, hypothyroidism, low intake of breast milk
What is Kramer’s rule?
Jauncdice visible at 85+, head first, then down to chest, abdo/thigh, lower leg/arm, hands and feet.
(increases by 50 umol/L for each “step” down the body)
How do you manage jaundice?
Plot on normogram, but if symptoms of kernicterus move to #3
- Phototherapy
- IVIG (over 2 hours)
- exchange transfusion
When do you need to work up jaundice?
What is the normal pattern of weight loss and gain post birth?
Weight loss <7% BW by day 3
< 10% BW by day 7
Return to birth weight by 2 weeks
Define preterm, term and posterm?
How do you stratify preterm babies?
Preterm < 37 weeks Term 37-41
Late preterm
What are the limits of viability?
Low survival and high risk of neurodevelopmental impairment 22-24 weeks, discuss whether to offer intensive care.
What is necrotizing enterocolitis? What are the risk factors
Bacterial invasion of ischemic bowel. Presents with not feeding, bowel distension, loops /gas on abdo xray.
risk factors: prematurity, formula (vs breastmilk), asphyxia in delivery, shock, hyperosmolar feeds, sepsis
Amp, gentamicin, and metronidazole. Surgical resection of bowel if perforated.
What are the deformities classic for Patau’s (Trisomy 13)
Cutis aplasia and cleft palate
When you are evaluating fever without a clear infectious focus in a child, what must you always consider on your differential?
Meningitis. Often presents without “classic” headache or neck pain; young children esp. may not be able to verbalize or localize the pain in this way.
What is stevens-johnson syndrome?
Hypersensitivity reaction to infections, medication or other illness. Charaterized by fever, macular rash with subsequent vesicles/bullae + mucosal changes (stomatitis) and conjuctivitis.
What are the diagnostic crlteria for Kawasaki Disease?
Fever >=5 days
Cervical adenopathy
Nonpurulent conjunctivitis
Rash (nonspecific)
Swelling/erythema of extremities
Mucosal inflammation (classic strawberrry tongue)
What are some causes of unilateral cervical lymphadenopathy in children?
Reactive (in response to oral infectious/inflammatory process)
KD
Bacterial adenitis (staph/strep)
Cat scratch disease
Mycobacterial infection.
What investigations are helpful in the context of suspected Kawasaki disease?
CBC+diff: elevated WBCs, normochroic normocytic anemia, thrombocytosis (week 2)
Elevated liver enzymes, low albumin
ESR or CRP (not specific, but fairly sensitive)
UA: sterile pyuria
What complication of KD requires an additional testing during the acute phase of the illness?
Coronary artery aneurysm (do an echo, repeat in 2wks and 6wks).
What is the treatment for Kawasaki Disease?
IVIG + Aspirin
What is the differential for vomiting?
Gastroenteritis, GI obstruction, pyelonephritis, DKA (esp in the context of polydipsia + enuresis), increased ICP or appendicitis.
What complication of DKA management must you look out for? What are some signs?
Cerebral edema (high mortality / morbidity) before or up to 24 hrs after treatment.
Headache (A), recurrent vomiting (B), restlessness/irritability (H), lethargy (I) are concerning for cerebral edema. Inappropriate slowing of heart rate (D), a rising blood pressure (F), and irregular respirations (G) are signs of cerebral edema and increased intracranial pressure (Cushing’s Triad). On physical exam, cranial nerve palsies (J) or abnormal pupillary responses (K) are suspicious for cerebral edema
What are kussmaul respirations?
Rapid + deep breathing (as opposed to shallow breaths) as a patient attemptts to blow of excesss CO2 from metabolic acidosis.
what is appropriate management for DKA?
NPO, monitor ins/outs, On continuous vitals monitor with Q1 neuro checks for cerebral edema, IV fluid ressuscitation. Q1H Fingerstick glucose, extended lytes, VBG and UA + ketone dipstick. Start insulin drip 0.1 units/kg/hr. Consult endocrinology.
Consider blood/urine cultures if altered mental status, hypotension or tachycardia.
What is a typical fluid bolus for volume resus in a child?
20mL/kg of NS (or other isotonic crystalloid like RL)
What are the diagnostic criteria for DKA & diabetes?
DKA if random glucose >11.1mmol/L AND
venous pH < 7.3 or bicarb < 15 mmol/L AND
moderate ++ ketonuria or ketonemia.
DM if any of the following (with repeat testing
HbA1C >= 6.5
or fasting glucose >7
or 2-hour plasma glucose > 11.1 during an OGTT
OR with symptomatic hyperglycemia and a random glucose >11.1, no repeats required.
What is the differential of a limp or refusal to ambulate in a child?
Legg-calve-perthes (avascular necrosis of the femur), SCFE (think obese teenagers), septic arthritis, osteomyelitis, leukemia, bone tumor, JIA, transient synovitis, reactive arthritis,
How would you differentiate transient synovitis of the hip from a septic arthritis?
Suspicious of septic arthritis if there is a fever with 2 or more of the following
++CRP, ++ESR, refusal to weight-bear, or ++WBC
How would you treat a septic arthritis? What are the most common bugs?
U/S hip + joint aspirate and culture. Start empiric antibiotics; surgical incision and drainage if necessary.
Bugs: staph aureus, Strep (GBS in neonate otherwise GAS or strep pneumo), H flu (non-immunized), Neisseria gonorrhea (sexually active), Kingella (<4yo).
What is transient synovitis of the hip? How do you treat it?
fairly common inflammation of tissues surrounding the hip joint in younger children, treatable with ibuprofen 10mg/kg q6h; pain typically resolves on its own in 3-10 days.
What is the expected weight gain for an neonate?
gain back to birth weight by 14 days.
Afterwards 20-30g/day 6/7 days per week.
What is suggestive of failure to thrive?
<5th percentile weight or weight-for-length
Crossing 2 or more lines on the growth curve.
What are some causes of failure to thrive?
Medical causes: heart defect, CF, GERD, metabolic/genetic disease
Nutrition: are they getting adequate calories & macros?
Feeding skills: developmental delay, poor suck/swallow coordination
Psychosocial: food insecurity, feeding routines, food aversion
What is the ddx for hepatomegaly in an infant?
CHF, hepatitis, congenital infections, inborn errors of metabolism, anemia, tumor (uncommon)
What are some signs of CHF in an infant
dyspnea with feeds, diaphoresis, poor growth, active precordium, hepatomegaly.
What is a Still’s murmur?
musical/vibratory and best appreciated in the LLSB while supine.
What are some acyanotic heart defects? What are some cyanotic ones?
Acyanotic: VSD, aortic stenosis, coarctation of the aorta, large PDA
Cyanotic, TOF, TGA, Truncus arteriosus, TAPVC and Triscupid valve abnromality
How would you treat CHF in an infant?
Furosemide, elanapril or captopril
Fortify feeds to increase caloric intake
Surgical repair if defect isn’t fixing itself by 6mos
What are some causes for petechiae / purpura?
Trauma, platelet deficiency, coagulopathy, vascular fragility eg. immune-mediated vasculitis.
What is Henoch-Schônlein purpura?
HSP is an IgA mediated small-vessel vasculitis
Presents in an otherwise well child with bruising and leg pain, associated with URI
What investigations would you order for HSP?
CBC+diff
UA
BUN + Creatinine
What is the classic presentation, diagnosis and treatment for intussesception?
Presentation: Severe abdo pain, incolsolable crying, with current jelly stool and a palpable mass.
Diagnosis: U/S or barium enema
Treatment: reduction by air/hydrostatic pressure or surgery.
What is a good rule of thumb for assessing language in infants / toddlers?
Sentence length = age in years
1 = several single words
2 = two-word sentences
3 = too many words to count, 3+ word sentences.
At what age does handedness usually develop?
18-24 months.
An infant that prefers to stand than sit should raise your suspicion of?
Neuromuscular disorder or abnormally tight muscles.
What condtions cause specific developmental delays vs global developmental delay?
Autism spectrum = social & communication delay
CP = motor dysfunction, some impact on other domains
Genetic / metabolic syndromes = global developmental delay.
At what age and with what instrument/tool should you screen for ASD?
18 and 24 months; M-CHAT
(modified checklist for autism in toddlers)
At what age do children start imitating adults and “helping” around the house?
18 months
What are the developmental “red flags”?
Gross motor: Not sitting independently by 9 mos, not walking by 18 mos
Fine motor: no pincer by 12 mos, early handedness < 18mos
Language: not responding to name by 12 mos, <15 words by 18 mos, no 2-word sentences by 2 years
Cognitive: no prentend play by 3 years
Emotional: not pointing to desired object by 15 mos
How would you distinguish between progressive and non-progressive disorders as potential causes for developmental delay?
A progressive disorder will most likely manifest with regression of previous milestones.
What is the biggest risk factor for CP? What are other contributory risk factors?
1 = Prematurity
IUGR, chorioamnionitis, and prenatal asphyxia
What are some common features of Down Syndrome infants?
Upslanting palpebral fissures, small ears < 34mm, flattened midface, epicanthal folds, nuchal skin, hypotonia
When should you do a chromosomal study in a child?
Clinical features consistent with known chromosomal disorder,
or with other unrecognized findings e.g. intellectual disability, short stature or dysmorphisms.
or with a known genetic condition, but additional/more severe findings than expected.
What conditions occur most often in neonates with Down syndrome?
Congenital hearing loss & cataracts
Congenital heard disease
GI atresia
Hip dysplasia
What additional surveillance is recommended for children with down syndrome?
Screening for thyroid, CBC+diff at 1 month, vision/hearing screening, pediatric cardiology referral, annual Hgb (screening for iron deficiency anemia) and referral for early intervention services
What is the most common inherited cause of intellectual disability?
Fragile X syndrome.
What are some findings in neonates with Turner syndrome?
Webbed neck, low-set ears, hand/foot edema, shield chest (widely spaced nipples).
Watch out for coarctation of the aorta (20% of cases)
What are some contrasting features of Patau and Edwards
Patau (trisomy 13)O micropthalmia and microcephaly, polydactily with cleft lip and palate, umbilical hernias and cutis aplasia
Edwards (trisomy 18) prominent occiput, micrognathia, low-set ears, short neck, overlapping fingers, rocker-bottom feat
Common to both: severe ID, heart / renal defects.
What surgeries are common in individuals with sickle cell disease?
Tonsillectomy (due to hypertrophy), cholecystectomy (due to increased bilirubin gallstones)
What prophylaxis is given to infants and young children with sickle cell disease?
Pennicilin to prevent sepsis. Decreased spleen function increases risk of bacteremia from encapsulated organisms including Strep pneumo, H flu and N meningitidis
What complications happen in children with SCD?
Jaundice and anemia (due to increased breakdown of red cells)
Stroke
Respiratory problems, pneumonia, and acute chest syndrome (vaso-occlusion of lung parenchyma)
What are indications for transfusion in sickle cell pts with acute chest syndrome?
Fall in Hgb from baseline
Increasing RR
Worsening chest symptoms
Falling SpO2
Progressive infiltrates on CXRs
Name the exanthem
Coryza, cough and conjunctivitis + genrealized morbiliform “painbucket” rash = measles
A 12yo previously healthy girl presents with low-grade fever, .Name the exanthem. What are the accompanying findings?
Rubella (3-day measles, 3rd disease)
Often accomapanied by Sore Throat, Arthritis and Rash
+ unilateral cervical adenopathy
A macular, salmon-pink rash appears after on the upper body after resolution of a high-grade fever and URTI. Nagayama spots (pink) are found on the palate. Name the exanthem?
Exanthem subitum = Roseola
A blueberry muffin baby with deafness, cataracts or congenital heart diease most likely has….
Congenital rubella
This boy has an acral, reticulated rash and a classic presentation on his face
Parvo!
What is this rash characteristic of?
Chicken pox (rash at different stages: macule > papule > vesicle > crust)
What is the characteristic rash of HSV-1 /2 infection?
grouped vesicles on an erythematous base
GI symptoms and a rash involving the hands and feet…what is the causative organism?
Coxsackie A virus (hand foot and mouth)
Papular acrodermatitis with truncal sparing is….
Gianotti-Crosti syndrome
(multiple possible viral etiologies: EBV, HBV, coxsackie or parvo)
A “statue of liberty” exanthem is concerning for?
Not concerning, unknown cause.
This generalized sandpaper rash is accompanied by fever, headache and a sore throat. What is the exanthem and causative organism?
Scarlet fever (2nd disease) caused by Strep pyogenes (GAS)
Other symptoms -> desquamation of finger tips, toes and groin, white strawberry tongue -> red strawberry tongue
You see a child with chapped lips, a 5-day fever history, dry conjunctivitis with perilimbic sparing and a generalized rash with perineal desquamation. What do you think it is?
Kawasaki disease.
What neonatal condition is associated with jaundice, vomiting / FTT and E. coli sepsis?
Galactosemia
What is the rule of 5s for estimating growth velocity?
25cm 1st year then 10cm/y 2-4 then 5cm/y until puberty (Avg birth length is 50cm
What is this?
Rose!
