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Clerkship (CC3) > Paediatrics > Flashcards

Paediatrics Flashcards

1
Q

Describe how you weigh infants and children properly

A

Infants - nude in a warm room, kids who can stand on a scale—record weight to 2 sig digs

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2
Q

Describe how you measure height in infants and children

A

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

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3
Q

What are important things to ask on nutrition history for an infant

A

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?

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4
Q

What are some paeds specific questions to ask on FH in the setting on Down syndrome.

A

Ask about childhood illness, sudden childhood deaths, developmental delay, autism. University, parents employment,

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5
Q

On social history what are some helpful questions?

A

Food insecurity, benefits, disability or child tax credit. Who lives in the home?

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6
Q

What are some good questions for neuro ROS

A

Ask about seizures

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7
Q

How do you address cradle cap?

A

They don’t have to but you can do it aesthetically

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8
Q

For testicles what’s the difference between undescended and retracted

A

If you can milk it down then it’s retracted and doesn’t need surgical management.

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9
Q

For the red reflex after you check each eye, what should you do?

A

Back up and check both at once

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10
Q

Kids sleeping in really odd positions should be screened for what?

A

obstructive sleep apnea (ask about snoring, apneic episodes)

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11
Q

What are some important phrases not to use in SCAN notes

A

Evidence, denies, consistent with… Also make it clear who is saying it or reporting something rather than saying x has a cut

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12
Q

How do you measure head circumference?

A

Tape above the ears and around the head over he occipital prominence

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13
Q

What do you need to ask to confirm secondary enuresis?

A

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.

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14
Q

What should you do at the end of the adolescent history?

A

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.

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15
Q

What should you include in your first line when you present a paediatric patient?

A

Age, Immunization status, general appearance

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16
Q

What non-nutritional factors can change weight?

A

Dehydration, edema, tumor growth or organomegaly or hydrocephalus, medical equipment or devices (don’t forget casts / braces!)

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17
Q

What are the key milestones for weight after birth, at 6 months and by 1 year of age?

A

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

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18
Q

What is a good rule of thumb for maintenance fluid and calories for growth for infants?

A

100mL/kg/day 100 kcal/kg/day

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19
Q

When should moms breastfeed?

A

Exclusively first 6 mos, then supplemented by foods for the first 1-2 years

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20
Q

What vitamin must all breastfed infants receive?

A

Vitamin D (400 IU /day)

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21
Q

What are some advantages to breastfeeding?

A

Bonding, convenience, ideal nutrition composition and passive immunity, decreased SIDS, allergies and childhood obesity, maternal health benefits

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22
Q

What are some contraindications to breastfeeding?

A

Galactosemia, maternal HIV, breast herpetic lesions or untreated TB, some meds

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23
Q

What is the WHO definition for diarrhea? If a child doesn’t meet it, what else should arouse suspicion?

A

>= 3 loose or watery stools per day, but any change from a child’s routine is worth investigating

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24
Q

What is chronic diarrhea?

A

Any diarrhea lasting more than 14 days

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25
Q

What does the onset of diarrhea suggest about its etiology?

A

Since birth = congenital Sudden = likely infectious Gradual = chronic nonspecific diarrhea of childhood in the absence of any other explanation/symptoms Food related = intolerance??

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26
Q

What are the red flags for diarrhea?

A

Fever, anorexia, nausea, blood, nocturnal diarrhea, vomiting, abdo distention, poor weight gain or weight loss, poor growth.

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27
Q

How do you calculate the stool osmotic gap? What is the relevance for diarrhea?

A

290- 2(Na+K); if >100 mOsm/kg this is osmotic diarrhea

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28
Q

What’s the differential for osmotic diarrhea?

A

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

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29
Q

What’s the differential for secretory diarrhea?

A

Increased secretion into the lumen (so bigger stool volume): congenital Cl/Na, Microvilli Inclusion Disease, Autoeimmune enteropathy / IPEX, enteric hormone secretion, and also infections

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30
Q

What is the cause and treatment for toddler’s diarrhea / nonspecific diarrhea of childhood?

A

Too much juice intake (or hyperosmolar fluid). Decrease fructose / sorbitol intake.

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31
Q

What is the incidence of celiac disease in the population?

A

0.5-1%

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32
Q

What is the classic presentation of celiac disease?

A

Age 6-24 months, chronic diarrhea, abdo distension, anorexia, failure to thrive or weight loss.

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33
Q

What are some non-GI symptoms of celiac disease?

A

Dermatitis herpetiformis, dental enamel hypoplasia (permanent teeth), osteopenia or osteoporosis, short stature, delayed puberty, refractory iron-deficiency anemia

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34
Q

What tests are useful for diagnosing celiac disease?

A

Anti-endomyseal (EMA) or tissue transglutaminase (TTG), or IgA level. Gold standard is biopsy of mucosa via scope.

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35
Q

What are some key points for the diagnosis of IBD?

A

Exclude infectious etiology. Clinical history, labs (CBC, ESR, albumin), radiologic or endoscopic lesions, histology

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36
Q

Distinguish between Crohn’s and UC

A

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.

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37
Q

What are the top 3 non-infectious diagnoses that must be considered for persistent diarrhea in infants?

A

Formula intolerance (e.g. milk protein allergy), CF, immunodeficiency

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38
Q

What are the top 3 non-infectious diagnoses that must be considered for persistent diarrhea in toddlers?

A

Post-infectious enteritis, toddler’s diarrhea, celiac

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39
Q

What are the top 3 non-infectious diagnoses that must be considered for persistent diarrhea in older children and teens?

A

Celiac, lactose intolerance and IBD

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40
Q

What are the rome III criteria for a diagnosis of constipation?

A

>= 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).

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41
Q

How do you treat constipation?

A

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.

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42
Q

What are the 5 areas of development?

A

Gross motor Fine motor Speech/language Cognitive Social/emotional

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43
Q

What are key things to ascertain on development history?

A

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)

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44
Q

What are some developmental “red flags”?

A

No pincer grip by 12 mo Not walking by 18 mos Less than 15 words by 18 mos

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45
Q

What are some specific things you’ll want to look for on physical exam?

A

Head circumference Hearing & vision Facial abnormalities Spine / chest abnormalities. Organomegaly Genital abnormalities Limb deformity

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46
Q

What is the diagnostic criteria for global developmental delay?

A

2/5 categories significantly delayed Child < 5 yo

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47
Q

What are some causes of global developmental delay?

A

Prenatal intrinsic : genetic/metabolic disorder, CNS malformation Prenatal extrinsic : psychosocial

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48
Q

What are some key gross motor milestones in an infant?

A

6mo sits unsupported 9mo pull to stand 12mo walking/cruising

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49
Q

What are some key social milestones in an infant?

A

6 weeks: smiling 9 mo: babbling, develops stranger anxiety 1 yr: knows name and says a few words

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50
Q

What are some key milestones for toddlers?

A

Walking by 12-18mo Stairs by 2 years 2 word sentences temper tantrums

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51
Q

Name the components of the 3-minute exam.

A

Airway Breathing Circulation Disability (pupils, limb tone, GCS) Exposure / ENT (rashes, injury, bruises) Temperature/Tummy Glucose

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52
Q

What are the “red flags” you’re looking out for in the sick child

A

Respiratory distress Quiet (as opposed to crying), lethargic infants Delayed cap refil Dehydrated Less wet diapers Poor feeding Abnormal vitals Non-immunized

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53
Q

What is the glass test?

A

Pressing a glass over a rash -> nonblanchable purpura could be disseminated meningococcemia, a medical emergency.

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54
Q

Unconscious 8m.o. presenting to ER after fall from mom’s arms. What is the diagnosis?

A

SDH (extra-axial hyperdense collection on R frontal area), signs of mass effect

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55
Q

What type of fracture is this? What should you worry about with this type of fracture?

A

Metaphyseal corner fracture; child abuse

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56
Q

What are the findings on this CXR? What follow-up imaging is required?

A

Anterior mediastinal mass; CT chest.

This is a lymphoma

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57
Q

What are the findings in this preterm infant? What is the most likely diagnosis

A

Small rounded lucencies (bubbles) along the wall of the colon; pneumatosis intestinalis. Necrotizing enterocolitis

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58
Q

What is the diagnosis in this newborn with severe cyanosis not improving with oxygen?

A

Transposition of the great arteries (TGA) suggested by the narrow mediastinum and cardiomegaly.

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59
Q

What is the name for this fracture? What is the cause?

A

Toddler’s fracture, believed to be caused by additional stress by new ambulation.

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60
Q

What does this abdo x-ray show?

A

Constipation (notice colon filled with poop)

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61
Q

What is this sign called? What is the most likely diagnosis?

A

Steeple sign; croup

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62
Q

What are the findings in this x-ray? What is the most likely diagnosis?

A

Epiglottal swelling; epiglottitis

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63
Q

The NG tube is stuck…why?

A

Congenital esophageal atresia. Given the absence of air in the bowel, this is likely complete atresia without tracheo-esophageal fistula

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64
Q

What are the findings on this xray?

A

RML consolidation, pneumonia

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65
Q

What are the findings in this xray suggestive of?

A

R femoral epiphyseal widening due to hyperemia, soft tissue swelling of R knee, suggesting JIA

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66
Q

This infant has a palpable abdo mass and this U/S. What is the diagnosis?

A

Donut sign; intusseception

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67
Q

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?

A

Lucency in the femoral epiphysis, osteomyelitis.

Should have MRI knee.

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68
Q

What are the key differences between the between the adult and pediatric airway?

A

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.

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69
Q

What are some signs of airway obstruction in a child?

A

Nasal flaring, wheeze or stridor, cyanosis, tracheal tug, SCM or scalene use, inter/subcostal and substernal indrawing

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70
Q

What features on exam are characteristic of lower airway obstruction?

A

Prolonged expiratory phase

Wheeze

History of atopy

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71
Q

What features on exam are characteristic of upper airway obstruction?

A

increased drooling/secretions

Face, lip, or neck swelling or mass

Stridor, snoring, horseness or barking cough

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72
Q

What is the peak age of incident for croup?

A

7-36 months

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73
Q

How do you manage/treat croup?

A

Dexamethasone 0.6mg/kg

If moderate, add epinephrine via nebulizer + observe for 2-4 hrs

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74
Q

Sudden onset difficulty breathing, no viral/infectious symptoms, biphasic stridor, decreased breath sounds, drooling…what’s this kid have?

A

Foreign body aspiration

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75
Q

What do you do when you suspect foreign body aspiration?

A

Call ENT for a scope to remove it. Hook him up to monitors and make sure the intubation equipment is available.

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76
Q

What is bronchiolitis? What is its most common cause?

A

Viral LRTI (RSV usually), starts as a URTI followed by resp distress with edema, inflammation and mucous clogging smaller airways.

Children <2yo

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77
Q

How to you manage bronchiolitis?

A

Supportive care. Admission if needs O2 to maintain sats, dehydrated, high-risk population, apnea history, cyanosis.

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78
Q

How do you manage an asthma exacerbation?

A

Mild (0-3 PRAM) inhaled salbutamol

Moderate (4-7) Salbutamol + oral steroid

Severe (8+) inhaled salbutamol and ipratropium q20min x3 + steroid PO or IV.

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79
Q

What are the risk factors for development of recurrent febrile seizures?

A

Shorter duration of fever before seizure

Younger age at first seizure

FH of febrile seizure

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80
Q

What are the characteristics of typical febrile seizures?

A

age 6mo-6yo

Associated with fevers without other cause (can’t have had previous afebrile seizure), brief, generalized, 1 in 24hr.

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81
Q

Atypical febrile seizures have what characteristics?

A

>15 min duration

focal fetures

recurrent (multiple in 24 hr)

increased risk of epilepsy

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82
Q

When should you do an LP on a kid with febrile seizure?

A

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

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83
Q

Does vaccination increase risk of febrile seizure?

A

Yes, DPTP on the day of vaccination and MMR 8-14 days post vaccination.

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84
Q

What is the likelihood of seizure recurrence following febrile seizure? Are there any treatments that can reduce the risk of recurrence?

A

1/3 will have recurrences, most within 1 year.

Treatment does not reduce epilepsy risk, antiepileptic side effects outweigh benefits here.

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85
Q

What are the adverse effects of prenatal use of tobacco, alcohol, heroin, and cocaine?

A

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.

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86
Q

What are the risk factors for GBS in the newborn?

A

Prolonged ROM

Prematuity

Intrapartum fever

Previous delivery of infant who got GBS

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87
Q

What are the components of the APGAR score?

A

Appearance

Pulse

Grimace (reflex irritability)

Activity (muscle tone)

Respiration

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88
Q

What causes symmetric vs asymmetric intrauterine growth restriction?

A

Symmetric typically due to congenital infections (affects brain growth)

Asymmetric = head-sparing, often due to poor delivery of nutrition to fetus (e.g. smoking).

89
Q

How is “small for gestiational age” defined? What are such infants at increased risk for?

A

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.

90
Q

Which medications are routinely given to newborns?

A

IM vit K

Hep B vaccine

Erythromycin or Tetracycline topical eyedrops

91
Q

Why would you be concerned about tachycardia in a teenager?

A

Teens can compensate really well, so tachy may be a sign that there may be something more concerning going on.

92
Q

What is a physiological reason for low hgb in an 8-10 wk old infant?

A

They are transitioning from fetal to adult hemoglobin.

93
Q

How are gram-positive cocci classified?

A
  • Pairs & Chains = Strep species
  • Clusters = Staph
    • Coagulase +ve = Staph aureus
    • Coagulase -ve = everything else Staph
94
Q

How are gram positive rods classified?

A
  • Aerobic /or facultative anaerobes including Listeria + Corynebacteria
  • Anaerobes = Clostridium, Bacillus, Lactobacillus
95
Q

Name some clinically important gram -ve cocci

A

Neisseria gonorrhea, N. meningitidis, Moraxella catarrhalis

96
Q

Describe the spectrum of activity of penicillin?

A

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)

97
Q

What does Amoxicillin cover beyond the basic spectrum of activity of penicillin?

A

H. influenzae, some gram negative coverage including E. coli, K pleumoniae, Salmonella

Listeria & enterococci.

98
Q

What are the 1st generation cephalosporins? What is their coverage?

A

IV Cefazolin or PO Cephalexin

Best against gram +ve orgs (streptococci & staphylococci).

99
Q

What are the 2nd generation cephalosporins? What is their coverage? What are they useful for clinically?

A

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

100
Q

What is ceftazidime used for?

A

Pseudomonas aerugenosa

101
Q

What are the 3rd generation cephalosporins? What are they used for?

A

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.

102
Q

What are the exceptions to coverage of meropenem (carbapenems)?

A

MRSA

Ampicillin-resistant enterococci

some very resistant gram -ves.

atypical organisms (chlamydia, rickettsia, mycoplasma, mycobacteria)

103
Q

What is the mechanism of action of vancomycin? What is the coverage? What are the side-effects?

A

Glycopeptide binds terminal D-ala-D-ala

Gram positive bugs (except vancomycin resistant enterococci)

Adverse effects include “red man syndrome”, nephrotoxicity and ototoxicity

104
Q

What is the spectrum of activity of clindamycin?

A

Good coverage against gram +ves and oral anaerobes

Used for skin, soft tissue and MSK infections

lots of GI side-efects

105
Q

What are macrolides used for?

A

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

106
Q

What are the fluoroquinolones? What is their coverage?

A
  1. Ciprofloxacin (good for gram-negative infections esp. enteric bacteria e.g. UTI, Pseudomonas)
  2. Levofloxacin also a good choice for community acquired pneumonia
  3. Moxifloxacin -> broad GI infections, atypical infections.

Fluoroquinolone side effects previously worried about cartilage/tendon disruption in children, but that hasn’t occured.

107
Q

Gentamicins–what are they & what are they used for?

What are the adverse effects you have to watch out for?

A

Gentamicin, tobramycin, amikacin

Poor penetration in CNS

Gram -ve coverage including pseudomonas, mycobacteria

Ototoxicity, nephrotoxicity (if used for seveal weeks)

108
Q

What are the 3 things you must think about when selecting an antibiotic?

A

Bug (likely pathogen, likelihood of resistance)

Drug (can it get to the site of infection, drug interactions, bactericidal/static

host (allergies, conditions, immunocompromise)

109
Q

What is the most likely organism? How do you confirm your diagnosis? What is the best antibiotic?

A

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.

110
Q

Acute otitis media, 2yo girl fever 39.3 and ear ache 24hrs.

What are the organisms which cause acute otitis media?

A

S pneumo, H flu, Moraxella, or viral infection. 80% will resolve on it’s own.

High dose 80mg/kg amoxcillin (to overcome resistance).

111
Q

What signs are concerning for meningitis? What would you worry about on LP?

A

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

112
Q

What are the most common pathogens which cause meningitis? What empiric therapy will you go for?

A

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)

113
Q

How would you distingish between bacterial and viral meningitis with CSF?

A

Bacterial, very high white count vs viral

Higher neutrophils with bacterial

higher protein in viral

Low glucose in bacterial

114
Q

What are the causitive organisms in a lobar pneumonia?

A
115
Q

How do you manage acute bacterial pneumonia?

A

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

116
Q

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…

A

Atypical pneumonia

Think: M. pneumoniae, Chlamydophila pneumo (babies) / psittaci (birds), Legionella pneumophilia or Coxiella burnetii

117
Q

What pathogen causes impetigo? How do you treat?

A

Group A strep or Staph arueus.

Topical mupirocin or fucidin or systemic Cloxacillin or cephalexin.

118
Q

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?

A

Likely: E coli or Klebsiella,

If complicated, acutely ill, young, vomiting…admit + ampicillin and gentamicin

uncomplicated UTI -> cefalexin, TMP-SMX

Get a urine culture

119
Q

How do you treat toxic appearing infants (concern for sepsis)?

A

<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

120
Q

What are the low risk criteria for febrile infants aged 29-90?

A

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

121
Q

What should you do in a febrile child < 30 day old child

A

Full septic workup

(consider full septic workup if high risk between 30-90 days of life)

122
Q

At what age does precocious puberty gets defined (wlth any secondary sexual characteristic development)

A

Girls <8 y.o., everyone under 7 gets a full evaluation

Boys <9y.o,

123
Q

What determines the timing of puberty?

A
124
Q

How do we define delayed puberty?

A

Girls >13 no breast development

Boy > 14 with no testicular enlargement

125
Q

When considering precocious puberty, what percentage have pathology?

A

Girls 10-20%

Boys 60-80%

126
Q

What percentage of delayed puberty is pathologic?

A

60-80% of girls and 10-20% of boys

127
Q

What is the differential of precocious puberty?

A

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.)

128
Q

What are beningn causes of puberty

A

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)

129
Q

How do you categorize delayed puberty?

A

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)

130
Q

Why would treatment be indicated for idiopathic central precocious puberty?

A

Psychosocial <6, treat but > 8 don’t treat

Growth/height <6 treat for sure

131
Q

What is the treatment for central precocious puberty?

A

Use a GnRH agonist (gets rid of pusatile GnRH and shuts down HPG)

132
Q

How do you treat delayed puberty in a boy or girl?

A

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.

133
Q

What are some important questions on history for fetuses that are SGA?

A

maternal factors - substance use, smoking

pregnancy factors - chronic HTN or pre-eclampsia

fetal factors - genetic disorders?

134
Q

What kinds of symptoms would you see with symptomatic hypoglycemia in the newborn?

What do you do if you see symptoms?

A

Remember that symptoms are non-specific (so you have to screen for it)

apnea, cyanosis, lethargy, jitteryness, seizures

Start dex infusion.

135
Q

What is the management of hypoglycemia in the newborn?

A

Give dextrose gel (facilitates breatsfeeding)

Feed

Establish IV access

Check glucose q3h

136
Q

What groups of neonates are at risk for hypoglycemia?

A

Infants of diabetic mothers

Large for gestational age

Prematurity

Small for gestational age

137
Q

At what point do you need to intervene for hypoglycemia in the newborn?

A

or 1 Critical low <1.8

or 3 lows in a row <2.6

138
Q

How do you calculate glucose infusion rate?

A

(%dex x mL/Kg/day)/144

139
Q

When glucose stays low despite gel/feeding what do you do?

A

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)

140
Q

What is the workup for the cyanotic baby?

A

4 limb BP

SpO2 - pre-ductus (R arm) and post ductus (leg)

ABG + lactate

Hyperoxia test

CXR

141
Q

What is the difference between cyanosis and hypoxia?

A

Hypoxia = insufficient O2 reaching cells

Cyanosis = blue discolouration due to desat hemoglobin (so not a specific indication of hypoxia)

142
Q

What is the diferential for cyanosis in a neonate?

A

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)

143
Q

How do you perform a hyperoxia test? What’s the interpretation?

A

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

144
Q

Describe the transition after birth.

A

Cord clamp (removal of placenta (low pressure system)

Lungs inflate - > small vessels unkink release of PGI2

PO2 rises

145
Q

What are the risk factors for neonatal jaundice?

A

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

146
Q

What is Kramer’s rule?

A

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)

147
Q

How do you manage jaundice?

A

Plot on normogram, but if symptoms of kernicterus move to #3

  1. Phototherapy
  2. IVIG (over 2 hours)
  3. exchange transfusion
148
Q

When do you need to work up jaundice?

A
149
Q

What is the normal pattern of weight loss and gain post birth?

A

Weight loss <7% BW by day 3

< 10% BW by day 7

Return to birth weight by 2 weeks

150
Q

Define preterm, term and posterm?

How do you stratify preterm babies?

A

Preterm < 37 weeks Term 37-41

Late preterm

151
Q

What are the limits of viability?

A

Low survival and high risk of neurodevelopmental impairment 22-24 weeks, discuss whether to offer intensive care.

152
Q

What is necrotizing enterocolitis? What are the risk factors

A

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.

153
Q

What are the deformities classic for Patau’s (Trisomy 13)

A

Cutis aplasia and cleft palate

154
Q

When you are evaluating fever without a clear infectious focus in a child, what must you always consider on your differential?

A

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.

155
Q

What is stevens-johnson syndrome?

A

Hypersensitivity reaction to infections, medication or other illness. Charaterized by fever, macular rash with subsequent vesicles/bullae + mucosal changes (stomatitis) and conjuctivitis.

156
Q

What are the diagnostic crlteria for Kawasaki Disease?

A

Fever >=5 days

Cervical adenopathy

Nonpurulent conjunctivitis

Rash (nonspecific)

Swelling/erythema of extremities

Mucosal inflammation (classic strawberrry tongue)

157
Q

What are some causes of unilateral cervical lymphadenopathy in children?

A

Reactive (in response to oral infectious/inflammatory process)

KD

Bacterial adenitis (staph/strep)

Cat scratch disease

Mycobacterial infection.

158
Q

What investigations are helpful in the context of suspected Kawasaki disease?

A

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

159
Q

What complication of KD requires an additional testing during the acute phase of the illness?

A

Coronary artery aneurysm (do an echo, repeat in 2wks and 6wks).

160
Q

What is the treatment for Kawasaki Disease?

A

IVIG + Aspirin

161
Q

What is the differential for vomiting?

A

Gastroenteritis, GI obstruction, pyelonephritis, DKA (esp in the context of polydipsia + enuresis), increased ICP or appendicitis.

162
Q

What complication of DKA management must you look out for? What are some signs?

A

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

163
Q

What are kussmaul respirations?

A

Rapid + deep breathing (as opposed to shallow breaths) as a patient attemptts to blow of excesss CO2 from metabolic acidosis.

164
Q

what is appropriate management for DKA?

A

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.

165
Q

What is a typical fluid bolus for volume resus in a child?

A

20mL/kg of NS (or other isotonic crystalloid like RL)

166
Q

What are the diagnostic criteria for DKA & diabetes?

A

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.

167
Q

What is the differential of a limp or refusal to ambulate in a child?

A

Legg-calve-perthes (avascular necrosis of the femur), SCFE (think obese teenagers), septic arthritis, osteomyelitis, leukemia, bone tumor, JIA, transient synovitis, reactive arthritis,

168
Q

How would you differentiate transient synovitis of the hip from a septic arthritis?

A

Suspicious of septic arthritis if there is a fever with 2 or more of the following

++CRP, ++ESR, refusal to weight-bear, or ++WBC

169
Q

How would you treat a septic arthritis? What are the most common bugs?

A

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).

170
Q

What is transient synovitis of the hip? How do you treat it?

A

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.

171
Q

What is the expected weight gain for an neonate?

A

gain back to birth weight by 14 days.

Afterwards 20-30g/day 6/7 days per week.

172
Q

What is suggestive of failure to thrive?

A

<5th percentile weight or weight-for-length

Crossing 2 or more lines on the growth curve.

173
Q

What are some causes of failure to thrive?

A

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

174
Q

What is the ddx for hepatomegaly in an infant?

A

CHF, hepatitis, congenital infections, inborn errors of metabolism, anemia, tumor (uncommon)

175
Q

What are some signs of CHF in an infant

A

dyspnea with feeds, diaphoresis, poor growth, active precordium, hepatomegaly.

176
Q
A
177
Q

What is a Still’s murmur?

A

musical/vibratory and best appreciated in the LLSB while supine.

178
Q

What are some acyanotic heart defects? What are some cyanotic ones?

A

Acyanotic: VSD, aortic stenosis, coarctation of the aorta, large PDA

Cyanotic, TOF, TGA, Truncus arteriosus, TAPVC and Triscupid valve abnromality

179
Q

How would you treat CHF in an infant?

A

Furosemide, elanapril or captopril

Fortify feeds to increase caloric intake

Surgical repair if defect isn’t fixing itself by 6mos

180
Q

What are some causes for petechiae / purpura?

A

Trauma, platelet deficiency, coagulopathy, vascular fragility eg. immune-mediated vasculitis.

181
Q

What is Henoch-Schônlein purpura?

A

HSP is an IgA mediated small-vessel vasculitis

Presents in an otherwise well child with bruising and leg pain, associated with URI

182
Q

What investigations would you order for HSP?

A

CBC+diff

UA

BUN + Creatinine

183
Q

What is the classic presentation, diagnosis and treatment for intussesception?

A

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.

184
Q

What is a good rule of thumb for assessing language in infants / toddlers?

A

Sentence length = age in years

1 = several single words

2 = two-word sentences

3 = too many words to count, 3+ word sentences.

185
Q

At what age does handedness usually develop?

A

18-24 months.

186
Q

An infant that prefers to stand than sit should raise your suspicion of?

A

Neuromuscular disorder or abnormally tight muscles.

187
Q

What condtions cause specific developmental delays vs global developmental delay?

A

Autism spectrum = social & communication delay

CP = motor dysfunction, some impact on other domains

Genetic / metabolic syndromes = global developmental delay.

188
Q

At what age and with what instrument/tool should you screen for ASD?

A

18 and 24 months; M-CHAT

(modified checklist for autism in toddlers)

189
Q

At what age do children start imitating adults and “helping” around the house?

A

18 months

190
Q

What are the developmental “red flags”?

A

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

191
Q

How would you distinguish between progressive and non-progressive disorders as potential causes for developmental delay?

A

A progressive disorder will most likely manifest with regression of previous milestones.

192
Q

What is the biggest risk factor for CP? What are other contributory risk factors?

A

1 = Prematurity

IUGR, chorioamnionitis, and prenatal asphyxia

193
Q

What are some common features of Down Syndrome infants?

A

Upslanting palpebral fissures, small ears < 34mm, flattened midface, epicanthal folds, nuchal skin, hypotonia

194
Q

When should you do a chromosomal study in a child?

A

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.

195
Q

What conditions occur most often in neonates with Down syndrome?

A

Congenital hearing loss & cataracts

Congenital heard disease

GI atresia

Hip dysplasia

196
Q

What additional surveillance is recommended for children with down syndrome?

A

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

197
Q

What is the most common inherited cause of intellectual disability?

A

Fragile X syndrome.

198
Q

What are some findings in neonates with Turner syndrome?

A

Webbed neck, low-set ears, hand/foot edema, shield chest (widely spaced nipples).

Watch out for coarctation of the aorta (20% of cases)

199
Q

What are some contrasting features of Patau and Edwards

A

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.

200
Q

What surgeries are common in individuals with sickle cell disease?

A

Tonsillectomy (due to hypertrophy), cholecystectomy (due to increased bilirubin gallstones)

201
Q

What prophylaxis is given to infants and young children with sickle cell disease?

A

Pennicilin to prevent sepsis. Decreased spleen function increases risk of bacteremia from encapsulated organisms including Strep pneumo, H flu and N meningitidis

202
Q

What complications happen in children with SCD?

A

Jaundice and anemia (due to increased breakdown of red cells)

Stroke

Respiratory problems, pneumonia, and acute chest syndrome (vaso-occlusion of lung parenchyma)

203
Q

What are indications for transfusion in sickle cell pts with acute chest syndrome?

A

Fall in Hgb from baseline

Increasing RR

Worsening chest symptoms

Falling SpO2

Progressive infiltrates on CXRs

204
Q

Name the exanthem

A

Coryza, cough and conjunctivitis + genrealized morbiliform “painbucket” rash = measles

205
Q

A 12yo previously healthy girl presents with low-grade fever, .Name the exanthem. What are the accompanying findings?

A

Rubella (3-day measles, 3rd disease)

Often accomapanied by Sore Throat, Arthritis and Rash

+ unilateral cervical adenopathy

206
Q

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?

A

Exanthem subitum = Roseola

207
Q

A blueberry muffin baby with deafness, cataracts or congenital heart diease most likely has….

A

Congenital rubella

208
Q

This boy has an acral, reticulated rash and a classic presentation on his face

A

Parvo!

209
Q

What is this rash characteristic of?

A

Chicken pox (rash at different stages: macule > papule > vesicle > crust)

210
Q

What is the characteristic rash of HSV-1 /2 infection?

A

grouped vesicles on an erythematous base

211
Q

GI symptoms and a rash involving the hands and feet…what is the causative organism?

A

Coxsackie A virus (hand foot and mouth)

212
Q

Papular acrodermatitis with truncal sparing is….

A

Gianotti-Crosti syndrome

(multiple possible viral etiologies: EBV, HBV, coxsackie or parvo)

213
Q

A “statue of liberty” exanthem is concerning for?

A

Not concerning, unknown cause.

214
Q

This generalized sandpaper rash is accompanied by fever, headache and a sore throat. What is the exanthem and causative organism?

A

Scarlet fever (2nd disease) caused by Strep pyogenes (GAS)

Other symptoms -> desquamation of finger tips, toes and groin, white strawberry tongue -> red strawberry tongue

215
Q

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?

A

Kawasaki disease.

216
Q

What neonatal condition is associated with jaundice, vomiting / FTT and E. coli sepsis?

A

Galactosemia

217
Q

What is the rule of 5s for estimating growth velocity?

A

25cm 1st year then 10cm/y 2-4 then 5cm/y until puberty (Avg birth length is 50cm

218
Q

What is this?

A

Rose!

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