Pediatric Medical Disorders Flashcards
infants double their birth weight in how many months? triple?
how much weight do children gain between 2 years and puberty?
infants double their birth weight by 4mo and triple their birth weight in one year.
children gain 2kg/years between 2 years and puberty.
Pyloric Stenosis
- occurs at what age?
- clinical presentation
- PE
- labs/evaluation
- Tx
Occurs at 3-5weeks
Clinical Presentation:
- projectile nonbilious vomitting*
- infant immediately hungry (Hungry vomitter)*
- dehydrated
- jaundice
PE:
- check hydration status
- check for jaundice
- palpate abdomen for “olive”* (50-90%)
Labs: CMP, Bilirubin
Eval: US
Tx: Pyloramyotamy (insicion and cut pylorus)
differential diagnosis of a newborn infant with vomiting can be divided into what two categories? WHat are the etiologies of these?
Bilious:
- partial or complete bowel obstruction
- malrotation, volvulus, Hirschsprung dz, incarcerated hernia, intussusception, intestinal atresia
Nonbilious:
- GERD
- cow or soy milk protein intolerance
- pyloric stenosis
- gastritis
WHat is the MC etiology behind persistent emesis in newborns?
Which age group MC presents with intussusception?
What age range does pyloric stenosis often present?
Newborns with persistent emesis often have intestinal atresia
Toddlers comprise the age group that most commonly presents with intussusception
Pyloric stenosis often presents around 3-6weeks of age.
MC etiology behind abdominal pain in:
- newborn
- infancy to 2yrs
Newborn:
- GERD
- Necrotizing colitis
- vovulus
Infancy to 2 years;
- intussusception
- Meckels diverticulum
- bacterial enteritis
Necrotizing enterocolitis:
- what is this?
- who gets this?
What: inflamed & infected bowel d/t poor immune system of baby.
Pneumatosis intestinalis is pathopneumonic for this dz. (gas cysts in bowel wall from bacteria)
Who: complication after premature birth.
What is vovulus? seen up to what age? sx? Tx?
twisting of the gut, presents with bloody stools, bile, vomiting. Seen up to 1 year of age.
Tx: surgery to untwist the bowel
What is meckels diverticulum? Sx? Tx?
slight bulge in the small intestine present at birth.
Sx: painless rectal bleeding
Tx: surgical removal.
What is Hirschsprungs dz?
- aka
- Tx
what: occurs when part or all of the large intestine has no ganglion cells and therefore cannot function. The affected segment cannot contract or relax to pass stool through the colon leading to an obstruction
aka: congenital megacolon
Tx: if just one segment they can sometimes remove it, possible colostomy.
GERD:
- infants aka
- warning signs of underlying pathology
happy spitters
Warning signs:
- GI: bilious vomiting, GI bleeding, forceful vomiting, prolong consstipation, diarrhea, or abd distention
- Neurologic: bulging fontanelle, seizures, micro/macrocephaly, hyper/hypotonia,
- nonspecific: fever, pneumonia, lethargy, failure to thrive.
GERD:
- if warning signs are absent and the infant has any of the following sx then you consider GI specialist to do work up, what are theses sx?
- work up
- tx
- indications for pharmocotherapy
poor weight gain, irritability, feeding refusal, gross blood in stool
Work up:
- esophageal pH monitoring
- endoscopy
Tx:
- lifestyle changes; avoid ALL exposure to tobacco smoke, smaller feedings, trial of a diet where ALL cows milk is removed**
- positioning therapy: keep infant upright for 10-20mins after feed
- PPI
Indications for pharm:
- infant with mild esophagitis on endoscopic bx
- infant w/ significant sx AND whom conservative measures have failed then do 3-6mo of therapy w/ repeat endoscopy
- PPI
Colic:
- what are important questions to ask?
- what is the rule of threes?
- what age does this usually occur? stop?
Questions:
-feeding habits, when do they cry, how long do they cry, how long do they sleep?
Rule of threes:
- greater than/= 3 hrs of day crying
- greater than/= 3days a week
- lasts at least 3 weeks
- infant less than 3mo old
Ususally starts 3-6weeks and ends at 3-4 mo.
Colic:
- associated characteristics
- soothing maneuvers
Characteristics:
- paroxysmal
- occurs more in evening
- qualitatively different from normal crying
- associated w/ hypertonia*
- inconsolability
- infant is normal when not colicky
- first few weeks of life are unremarkable.
Soothing maneuvers:
- pacifier
- car or stroller ride
- hold/rock infant
- change scenery/minimize visual stimuli
- place child in infant swing
- rub infant abd
- provide white noise or play CD of heartbeats
- sing to infant
- give baby quite time in crib for 5-10 minutes
Colic Tx
- trial of elemental formula for 1 week (predigested so they are easy to eat)
- if breast feeding try hypoallergenic diet
- trial of probiotic – Lactobacillus reuteri
NOT a trial of soy milk, simethacone, infant massage, homeopathic remedies
***most important to provide parenteral support
- never shake the baby
- ok to take break and let someone else take care of the baby**
- stay positive, dont feel guilty, colic is not a sign of bad parenting
Oral Rehydration Therapy
- what is this?
- first choice fluid?
- technique?
What: small amounts of liquid taken orally to replace fluids and electrolytes
-Pedialyte is first choice fluid
Technique: 5ml every 2-3 minutes, just enough to coat the esophagus WITHOUT causing a large enough bolus in the stomach to induce emesis.
WHat are the antiemetics approved in the pediatric patient?
Odansetrom (Zofran)
-available in oral dissolving tablets and IV
Physical findings of volume depletion in infants and children:
- mild
- moderate
- severe
- Pulse:
- SBP:
- Resp:
- Buccal mucosa:
- Anterior fontenelle:
- Eyes:
- skin turgor:
- skin:
- urine output:
- systemic sings:
Mild:
- Pulse: normal
- SBP: normal
- Resp: normal
- Buccal mucosa: tacky/slight dry
- Anterior fontenelle: normal
- Eyes: normal
- skin turgor: normal
- skin: normal
- urine output: normal/mild reduced
- systemic sings: increased thirst.
Moderate;
- Pulse: rapid
- SBP: normal to low
- Resp: deep, may be increased
- Buccal mucosa: dry
- Anterior fontenelle: sunken
- Eyes: sunken
- skin turgor: reduced
- skin: cool
- urine output: markedly reduced
- systemic signs: listlessness, irritability
Severe:
- Pulse: rapid & weak
- SBP: low
- Resp: deep, tachypnea
- Buccal mucosa: parched
- Anterior fontenelle: markedly sunken
- Eyes: markedly sunken
- skin turgor: tenting
- skin: cool, mottled, acrocyanosis
- urine output: anuria
- systemic sings: grunting, lethargy, coma
What is the preferred treatment of fluid and electrolyte losses caused by diarrhea in children with mild to moderate dehydration?
Tx of severe hypovolemia
Oral rehdyration therapy!!!
Severe:
-rapid infusion of isotonic saline & then oral rehydration therapy.
Constipation
- definition
- 3 main causes
def: a decrease in a persons normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard dry stool.
causes:
- lack of fiber
- inadequate consumption of fluids
- sedentary lifestyle
What is gastrocolic reflux?
peristalsis occurring 5-15mins after eating meal that stimulates you to have a BM.
What is encopresis?
paradoxical diarrhea…aka fecal leakage. :)
*this is basically diarrhea in the presence of constipation.
What are some causes of functional retention leading to constipation?
- traumatic events:
- -painful passage of hard stools
- -painful diarrhea
- physical or sexual abuse
- Psychosocial situations/environmental changes:
- difficulty with potty training
- -divorce.
Encopresis:
-often results from what?
often the result of functional retention causing stretching of rectum and decreased sensation to empty bowel. liquid stool leaks around a retained stool mass and is involuntarily passed.
Organic causes of constipation?
- hirschsprungs dz (aganglionic colon)
- anatomic abnormalities of anus or colon
- meds: antacids, opiates, phenobarbitol
- spinal cord abnormalties
- infant botulism
- hypothyroidism
- celiac dz
- DM
- CF
- cows milk intolerance
Concerning PE findings (when investigating constipation?)
- failure to thrive
- abd distension
- lower spinal abnormalities
- anteriorly displaced anus
- tight empty rectum in presence of palpable fecal mass.
- absent anal wink (expose anus and use cotton ball to induce reflex)
- absent cremasteric reflex
- decreased lower extremity tone or strength
- absence of delay in relaxation phase of lower extremity DTRs.
Findings that support a functional etiology of constipation?
onset of constipation coincides with:
- dietary change
- toilet training
- painful BM
stool withholding behavior
good response to conventional laxatives
Medications for constipation
Which medication class is the best way to clean out the colon?
Stool softeners:
-ducosate sodium (Colace)
Osmotic agents:
- Polyethylene glycol (Miralax)**
- Mineral Oil
- Lactulose**
Bulking/fiber agents:
- Psyllium (Metamucil)
- Methylcellulose (Citrucel)
Peristalic inducers:
- Senna (Ex-Lax)
- Bisacodyl (Dulcolax)
Osmotic agents are the best to clean out the colon.
Tx of Encopresis
-clearing the childs bowel: use of osmotic laxative for 3 days, usually have diarrhea then bowel is clear.
Educate parents to start toilet training process:
- continued daily use of chosen laxative to keep stools soft
- REGULAR toilet sitting time for 5-10minutes after a meal 2-3x/day
- stool by toilet so child legs dont dangle
- rewards for sitting on the toilet NOT just for results.
- may need to take laxative for several months before weaning off
Enuresis:
- what is this?
- when is bladder control usually established?
- MC in which gender
- Tx
What: involuntary* discharge of urine after the age at which bladder control should have been established.
Bladder control is usually established by 5 years of age
MC in boys; significant* genetic component
Tx: use bathroom before bed, minimize caffeinated and high sugar drinks, enuresis alarms, Desmopressin acetate, anticholinergic such as oxybutynin
Monosymptomatic enuresis
-definition
def: episodes of urinary incontinence during sleep in children greater than 5yrs who have never had a satisfactory period of nighttime dryness, no lower urinary tract sx, and have no hx of bladder dysfunction. (this is primary)
Secondary: child develops enuresis after a dry period of at least 6 months.
What are the neurological and/or anatomical problems that cause enuresis?
- Urinary tract abnormality/UTI/Kidney dz
- trauma or dz of spinal cord
- seizures, hyperthyroidism, DM
- sleep apnea
- pinworms
In the normally developing child, if one eye is dominating visual acuity, blindness can occur in the opposite eye, T/F?
True!
Amblyopia
- definition
- what is the best screening test for this?
- types
Def: unilateral of bilateral reduction in central visual acuity d/t sensory deprivation of well-informed retinal image that occurs with or without a visible organic lesion commensurate with the degree of visual loss. (AKA: developmental problem in the brain, the part of the brain recieving images from the affected eye is not stimulated properly and does not develop to its full visual potential.
Best screening test is visual acuity.
Types:
- strabismic amblyopia (occurs in nondominant oeye of strabismic pt)
- refractive amblyopia (results from refractive errors)
- deprivation amblyopia (rarest, results from congenital cataracts, unilateral ptosis, corneal opacities or vitriol hemorrhage)
Testing the nonverbal Childs vision
-how do we do this?
Fixation test; occluding the not-tested eye. if they cant see out of the eye youre not covering they should wiggle around trying to see & get fussy
Prism test
Strabismus
- definition
- what is esotropia and exotropia & hypertropia
- what other disorders may cause this?
- tx
misalignment of the visual axes of the two eyes. (muscle problem)
esotropia: inward turning misalignment of the eyes; this may be normal during first few months of life but SHOULD be well aligned by 5-6mo.
Exotropia: outward turning misalignment of the eyes.
hypertropia: vertical deviation, one eye higher than the other.
Other;
-hydrocephalus and space occupying lesions
Tx:
-glasses, patches, surgical correction.
The great majority of the time constipation is function or organic?
High fiber, increased water intake, utilizing the gastrocolic reflex is extremely helpful for treating what?
Enuresis is generally thought to be from what?
functional.
Treating functional constipation.
Enuresis is generally thought to be from developmental lag.
