Pediatrics Flashcards
1
Q
When is the most rapid growth during development?
A
During first 2 year and at puberty
2
Q
How early is considered a premature infant?
A
> 37 week
3
Q
What age should you use for premature infants measurement of growth?
A
Gestational Age until age 2
4
Q
What is the normal Birth weight?
A
3.25 kg (7 lbs)
5
Q
What is the weight growth pattern babies?
A
Gain 20-30 g/d (term neonate)
2x birth weight by 4-5 months
3x birth weight by 1 year
4x birth weight by 2 year
6
Q
Do neonates experience weight loss?
A
Weight loss (up to 10% of BW) in first 7 days of life is normal
7
Q
When do neonates regain their birth weight?
A
By 10-14 days of age
8
Q
What is the normal length/Height at birth?
A
50 cm (20 in)
9
Q
What is the Length/Height growth pattern babies?
A
25 cm in 1st year
12 cm in 2nd year
8 cm in 3rd year then
4-7 cm/year until puberty
1/2 adult height at 2 year
10
Q
How do you measure height of baby as they age?
A
Supine length until 2 years
After, measure standing height
11
Q
What is the normal head circumference at birth?
A
35 cm (14 inches)
12
Q
What is the Moro reflex and when does it disappear?
A
An infant placed semi-upright, head supported
by examiner’s hand, the sudden withdrawal of
supported head with immediate return of
support
Response: Abduction and extension of the arms, opening of the hands, followed by flexion and adduction of arms
4-6 months
13
Q
What is the Galant Reflex and when does it disappear?
A
Infant held in ventral suspension and one side
of back is stroked along paravertebral line
Response: Pelvis will move in the direction of the stimulated side
2-3 months
14
Q
What is the Asymmetric Tonic Neck Reflex and when does it disappear?
A
Turn infant’s head to one side
Response: “Fencing” posture (extension of ipsilateral arm and leg and flexion of the contralateral arm and leg)
4-6 months
15
Q
What is the placing reflex and when does it disappear?
A
Dorsal surface of infant’s foot placed touching
edge of table
Response: Flexion followed by extension of ipsilateral limb up onto table (resembles primitive walking)
Variable
16
Q
What is the Rooting reflex and when does it disappear?
A
Tactile stimulus near mouth
Response: Infant turns head and opens mouth to suck on same side that cheek was stroked
2-3 months
17
Q
What is the parachute reflex and when does it disappear?
A
tilt infant to side while in a sitting position
Response: Ipsilateral arm extension, present by 6-8 mo
Does not disappear
18
Q
What are the dietary recommendations for 0 to 6 months?
A
Breast milk or formula
Exclusive breast milk during the first 6 months is recommended (unless contraindicated)
19
Q
What supplements are required for 0 to 6 months?
A
Breastfed children.
Vitamin D (400 IU/D)
Fluoride (after 6 months if not sufficient in water)
Iron (6-12 months, only if not receiving fortified cereals/meat/meat alternatives)
20
Q
What are the dietary recommendations for those >6 months?
A
2-3 new foods per week (wait at least 2 days to identify adverse reactions)
Early introduction of highly allergenic foods is recommended
Offer lumpy, soft-cooked, pureed, mashed textured foods.
Provide 3 large feedings (meals) with 1-2 smaller
21
Q
Wha are common allergens?
A
Eggs
Milk
Mustard
Peanuts
Seafood
Sesame
Soy
Tree nut
Wheat
22
Q
What are foods to avoid in the first year?
A
- Honey (until past 12 months) - the risk of botulism
- Added sugar, salt
- Excessive milk (i.e., no more than 750 mL)
- Limit juice intake (max 4-6 oz daily)
- Anything that is a choking hazard (i.e., chunks, round food like grapes)
- 2 to 6 years: switch to 2% milk (500 mL/d)
- Can maintain breastfeeding during this time complementary to solids
23
Q
Medications that cross into Breast Milk?
A
- Antimetabolites
- Bromocriptine
- Chloramphenicol
- High dose diazepam
- Ergots
- Gold
- Metronidazole
- Tetracycline
- Lithium
- Cyclophosphamide
24
Q
Signs of inadequate intake?
A
- <6 wet diapers/d after first week
- <7 feeds/d
- Sleepy or lethargic, sleeping throughout the night <6 weeks
- Weight loss >10% of birth weight
- Jaundice
25
What is the content of breast milk?
Colostrum (First few days)
- Clear
- Rich in nutrients (i.e., High Protein, Low Fat), Immunoglobulin
Mature Milk:
- Whey: Casein ratio (70:30)
- Fat from dietary butterfat
- Carbohydrates from lactose
26
What are the advantages of breastfeeding?
- Easily digested, low renal solute load
- Immunologic
- Parent-child bonding
- Economical, Convenient
27
What are the Immunologic benefits from breast milk?
- Reduction of acute illness
- Contains IgA, Macrophages, active lymphocytes, lysozymes, lactoferrin (inhibits E. Coli growth in Intestine)
- Lower pH promotes growth of Lactobacillus in GI tract
28
What are the maternal contraindications for breast feeding?
- Chemotherapy, radioactive compounds, and medications known to cross into breast milk
- HIV/AIDS, active untreated TB, herpes in the breast region
- >0.5 g/kg/d of alcohol or illicit drugs
OCPs are not a contraindication to breast feeding
- estrogen may decrease lactation; but not dangerous to infant
29
What to consider if poor weight gain with breast feeding?
- Consider dehydration or FTT
- Consider formula supplementation if insufficient milk production or intake
30
How to treat Oral Candidiasis (Thrush) in babies? How does it occur?
Antifungal i.e., Nystatin
Can occur in breast or bottle-fed infants
31
What are the benefits of Circumcision?
-Prevention of phimosis
- Reduced risk of:
- UTI
- STI
- Balanitis
- Cancer of the penis
32
What are the complications of Circumcision (<1%)?
- Local Infection
- Bleeding
- Urethral injury
33
What are the contraindications of Circumcision?
Presence of genital abnormalities (i.e., Hypospadias)
Known bleeding disorder
34
What are the types of Breath-holding spells?
Cyanotic (more common)
- Usually associated with anger/frustration
Pallid
- Usually associated with pain/surprise
35
What is the etiology of Breath Holding Spells?
Child provoked (Usually by anger, injury, or fear) --> Holds breath and becomes silent --> Spontaneously resolves or loses consciousness
36
What is the management of Breath holding Spells?
- Usually resolves spontaneously and rarely progresses to seizure
- Help child control response to frustration and avoid drawing attention to spells
- Maybe associated with iron deficiency, improves with supplemental iron
37
What are the causes of Crying/Fussing Child?
- Functional (i.e., Hungry, Irritable)
- Colic
- Trauma
- Illness
38
What information would you want for crying/fussing child?
- Baseline feeding, sleeping, and crying patterns
- Infectious symptoms (i.e., Fever, Tachypnea, rhinorrhea, Ill contacts)
- Feeding intolerance: GERD w/ esophagitis, N/V, Diarrhea, Constipation
- Trauma
- Recent immunizations (vaccine reaction) or medications (drug reactions - including maternal drugs during pregnancy)
39
What would raise concerns of maltreatment on history?
- Inconsistent history
- Pattern of numerous ED visits
- High-risk social situations
40
What is Infantile Colic?
- Unexplained paroxysms of irritability and crying for >3h/d, >3d/wk, >3 wk in an otherwise healthy, well-fed baby (RULE OF 3s)
41
What is the management for Infantile Colic?
- Parental Relief, rest, and reassurance
- Hold baby, soother, car ride, music, vacuum, check the diaper
- Probiotics (some evidence)
- Maintain breastfeeding but eliminate allergens (i.e., cow's milk protein, eggs, wheat, and nuts) from the mother's diet
- Time-limited (2 wk) trial of protein hydrolsate formula (i.e., Nutramigen)
- Time (All resolve, most in the first 3-6 month of life, no long-term adverse effects)
42
When do primary dentition occur?
First tooth at 5-9 months (lower incisor), then 1/month
6-8 central teeth by 1 year
43
When should children first be assessed by dentists?
6 month after ruption of 1st tooth
Certainly by 1 year of age
44
When does Secondary Dentition (32 teeth) occur?
First adult tooth is 1st molar at 6 year, then lower incisors
45
How to prevent caries in babies?
- No bottle at bedtime, clean teeth after last feed
- Minimize juice and sweetened pacifier
- Clean teeth with a soft damp cloth or toothbrush and water
- water fluoridation
- ensure every child has a dentist by 1 year of age
46
What is Enuresis?
Involuntary urinary incontinence by day and/or night in child >5 year
47
What is the general approach for Enuresis?
Evaluate if:
- Dysuria
- Change in colour
- Odour
- Stream
- Secondary or diurnal
- change in gait or stool incontinence are present
48
What is the clinical feature for Primary Nocturnal Enuresis?
Involuntary loss of urine at night, bladder control has never been attained
49
What is the etiology of Primary Nocturnal Enuresis?
- Developmental disorder OR
- Maturational lag in bladder control while asleep
50
What is the management for Primary Nocturnal Enuresis?
- Time, and reassurance (~20% resolve spontaneously each year)
- Avoidance of punishment or humiliation to maintain self-esteem
- Behavioural modification
- Limiting fluids and avoiding caffeine-containing
food before bedtime
- Void prior to sleep
- Ensure access to the toilet
- Take out of diapers
- Conditioning ("wet" alarm wakes child upon voiding - 70% success rate)
- Medications (For Children >7 year)
51
What medications can be used for Primary Nocturnal Enuriesis?
- DDAVP oral Tablets
- Imipramine (Tofranil) - Rarely used due to Overdose Risk (S/E: Cardiac Toxicity, Anticholinergic effects)
52
What are the clinical feature of Secondary Enuresis?
Involuntary loss of urine at night, develops after a child has sustained a period of bladder control (>6 month).
53
What are the causes of Secondary Enuresis?
- Inorganic regression due to stress or anxiety (i.e., the birth of a sibling, significant loss, family discord, sexual abuse)
54
What is the management of Secondary Enuresis?
Treat underlying cause
55
What is Diurnal Enuresis?
Daytime wetting (60-80% also wet at night)
56
What is the etiology of Diurnal Enuresis?
Micturition deferral (holding urine until last minute)
- Due to psychosocial stressor (i.e., Shy)
- Structural anomalies (i.e., neurogenic bladder)
- UTI
- Constipation
- CNS disorders
- DM
57
What is the management of Diurnal Enuresis?
- Treat underlying cause
- Behaviour (i.e., Scheduled toileting, double voiding, good bowel program, etc.)
- Good constipation management
- Pharmacotherapy
58
What is Encopresis?
Fecal incontinence in a child >4 year old, at least once per month for 3 month
59
What are the causes of Encopresis?
- Chronic Constipation
- Hirschsprung disease
- Hypothyroidism
- Hypercalcemia
- Spinal cord lesions
- Anorectal malformations
- Bowel obstruction
60
What is Retentive Encopresis?
The child holds bowel movement, and develops constipation, leading to fecal impaction and seepage of soft or liquid stool
Overflow incontinence
61
What are the causes of Retentive Encopresis?
Physical
- Painful stooling often secondary to constipation
Emotional
- Disturbed parent-child relationship, coercive toilet training, social stressors
62
What are the clinical features of Retentive Encopresis?
- Crosses legs or stands on toes to resist the urge to defecate
- Distressed by symptoms, soiling of clothes
- Toilet training coercive or lacking motivation
- May show oppositional behaviour
- Abdominal pain
63
What will Retentive Encopresis show on investigations?
- Abdo x-ray/ DRE - will show a large fecal mass in the rectal vault
- Anal fissures (from hard stools)
- Palpable stool in LLQ
64
What is the management of Retentive Encopresis?
- Complete clean-out of bowel
- PEG 3350 is the most effective
- Enemas and suppositories may be the second line
(but more invasive and often less effective)
- Maintenance of regular movements
- assessment and guidance regarding psychosocial stressors
- behavioural modification
65
What is Failure to Thrive?
- Weight <3rd percentile
- Falls across two major percentile curves
- <80% of expected weight for height and age
66
What is the most common facture in poor weight gain?
Inadequate caloric intake
67
What factors affect physical growth?
- Genetics
- Intrauterine factors
- Nutrition
- Endocrine hormones
- Chronic infection/disease
- Psychosocial factors
68
What is the equation for Mid-Parental height?
Boys = (Father ht + Mother ht +13)/2
Girls = (Fathher ht + Mother ht - 13)/2
Height in cm
69
What clinical features are important to assess for Failure to Thrive patients?
History:
- nutritional intake
- current symptoms
- past illness
- family history (i.e., growth, puberty, parental height and weight + mid-parental height)
- psychosocial history
Physical Exam:
- Growth parameters, plotted:
- <2 year: height, weight, head circumference
- >2 year: height, weight, BMI
- Vital signs
- Complete head-to-toe exam
- Dysmorphic features/evidence of chronic disease
- Upper to lower segment ratio
- Sexual maturity staging
- Signs of maltreatment
70
What investigations should be ordered for patients suspected for 'failure to thrive'?
- CBC, Blood smear, electrolytes, T4, TSH
- Bone age X-ray
- Chromosomes/Karyotype
- Chronic illness:
- Chest: CXR, Sweat Cl
- Cardiac: CXR, ECG, ECHO
- GI: Celiac screen, inflammatory markers,
malabsorption
- Renal: Urinalysis
- Liver: Enzymes, Albumin
71
Clinical Signs of Failure to Thrive?
SMALL KID
Subcutaneous Fat Loss
Muscle Atrophy
Alopecia
Lethargy
Lagging behind normal
Kwashiorkor (a form of malnutrition caused by protein deficiency in the diet)
Infection (recurrent)
Dermatitis
72
How many children will have heart murmurs?
80%
1-2% have CHD
73
What are some causes of failure to thrive?
Inadequate Caloric intake
Inadequate Absorption
Increased Metabolism
74
What are examples of inadequate caloric intake?
- Inadequate milk supply/latching
- Mechanical feeding difficulty (i.e., cleft palate)
- Oromotor dysfunction
- toxin-induced anorexia
75
What are examples of inadequate absorption?
- Biliary Atresia
- Celiac disease
- IBD
- Cystic Fibrosis
- Inborn errors of metabolism
- Milk protein allergy
- Pancreatic Cholestatic conditions
76
What are examples of increased metabolism?
- Chronic infection
- Cystic fibrosis
- Lung disease from prematurity
- Hyperthyroidism
- Asthma
- IBD
- Malignancy
- Renal Failure
77
What is the medical management for failure to thrive?
- Oromotor problems
- Iron-deficiency anemia
- GERD
78
What are the nutritional management plans for failure to thrive?
- Goal to reach 90-110% of IBW
- Educate about age-appropriate food
- Calorie boosting
- Mealtime schedules
- Correct nutritional deficiencies
- Promote catch-up growth/development
79
What is behavioural management of failure to thrive?
- Positive reinforcement
- No distractions during mealtime
80
What is the definition of obesity in Pediatrics?
Overweight:
- BMI >85%
Obesity:
- >95% for height and age
81
What are the risk factors for childhood obesity?
- Genetic predisposition (i.e., both parents are obese)
- Psychosocial/environmental contributors
82
What are the complications of childhood obesity?
- HTN
- Dyslipidemia
- Slipped capital femoral epiphysis
- Type 2 DM
- Asthma
- Obstructive Sleep Apnea
- Gynecomastia
- PCOS
- Early menarche
- irregular menses
- Psychological trauma (i.e., bullying, decreased self-esteem)
83
What investigations for children with obesity?
- BP
- Pulse
Screen for:
- Dyslipidemia
- Fatty Liver Disease (ALT)
- Type 2 DM (Based on risk factors)
84
What is Asthma?
- Inflammatory disorder of the airways characterized by recurrent episodes of reversible small airway obstruction
- due to hyperresponsiveness to endogenous and exogenous stimuli
85
What are the clinical features of Asthma?
- Episodic
- Wheezing
- Dyspnea
- Tachypnea
- Cough (usually at night/early morning, with activity, or cold exposure)
Physical exam:
- hyper-resonant chest
- prolonged expiration
- wheeze
86
What are triggers of Asthma?
- URTI (Viral or Mycoplasma)
- Weather (i.e., cold exposure, humidity changes)
- Allergens (pets)
- Irritants (i.e., cigarette smoke)
- exercise
- emotional stress
- drugs (i.e., ASA, B-blockers)
87
What are the classifications for Asthma?
A
Mild:
- Occasional attacks of wheezing or coughing (<2/week)
- symptoms respond quickly to inhaled bronchodilator
- Never needs systemic corticosteroids
Moderate
- More frequent episodes with symptoms persisting and chronic cough
- Decreased exercise tolerance
- sometimes needs corticosteroids
Severe:
- Daily and nocturnal symptoms
- Frequent ED visits and hospitalizations
- usually needs systemic corticosteroids
88
What is the acute management of Asthma?
- Keep SpO2 >94% and fluids if dehydrated
- B2-agonists: (Salbutamol) - MDI + Spacer
- 5 puffs (<20kg) q20min
- 10 puffs (>20kg) q20min
- Ipratropium bromide (Atrovent) if severe: MDI + spacer
- 3 puffs (<20kg) or 6 puffs (>20 kg) q20min with salbutamol
OR add to first 3 salbutamol masks
(0.25mg <20kg, 0.5mg >20kg)
- Steroids: Prednisone (1-2 mg/kg x 5d) or dexamethasone (0.3 mg/kg/d x 5 d or 0.6 mg/kg/d x 2d); in severe disease - use IV steroids
If no response, add magnesium sulphate
Can discharge after 2-4 hours after last dose
89
What is the Chronic management of Asthma?
- Education & Exercise program
- PFTs for children >6 year
- reliever therapy: Short acting B2-agonist
- Controller therapy: (1st line for all children) Low dose daily inhaled Steroids
- Second line <12 year: Moderate dose of daily inhaled corticosteroids
- Second line >12 year: Leukotriene receptor antagonist OR long acting B2-agonist w/ low dose ICS
- Severe asthma unresponsive to 1st and 2nd line treatments: injection immunotherapy
90
What are the indications for hospitalizations in Asthma?
- Ongoing need for supplemental oxygen
- Persistently increased work of breathing
- B2- agonists are needed more than q4h
- Patient deteriorates while on systemic steroids
91
What is HSP Rash?
[Google It]
92
What is Bronchiolitis?
- Lower Respiratory Tract Infection
- Usually in children <2 years
- Has wheezing and signs of respiratory distress
93
What is the cause of Bronchiolitis?
- Respiratory Syncytial Virus (RSV)
- Parainfluenza
- Influenza
- Rhinovirus
- Adenovirus
- M. pneumoniae (rare)
94
What are the clinical features of Bronchiolitis?
- Cough and/or rhinorrhea possible fever
- feeding difficulties, irritability
- Wheezing, crackles
- respiratory distress
- tachypnea
- tachycardia
- retractions
- poor air entry
- symptom peak from 3-4 days
95
What orders should be made for Bronchiolitis?
- Routine investigations are not required when suspected
- CXR (only for poor response to therapy or atypical disease):
- Air trapping
- Peribronchial thickening
- Atelectasis
- Increased linear markings
96
What is the management for Bronchiolitis?
- Self-limiting disease usually lasting 2-3 weeks
Mild to moderate distress:
- supportive:
-PO or IV hydration
- antipyretics for fever
- Regular or humidified high flow O2
Severe distress:
- As above +/- intubation and ventilation as needed
- consider Rebetol (Ribavirin) in high risk groups:
- bronchopulmonary dysplasia
- CHD
- Congenital lung disease
- immunodeficient
97
What is protective for severe disease in patients with Bronchiolitis?
- RSV-Ig
- Palivizumab (monoclonal antibody against F-glycoprotein of RSV)
98
Are Bronchodilators, Corticosteroids, and antibiotics helpful in Bronchiolitis?
No
Unless there is a secondary bacterial pneumonia
99
What are the indications for hospitalization for patients with Bronchiolitis?
- Hypoxia (SpO2 <92%) on initial presentation
- Resting Tachpnea (>60/min) retractions after several salbutamol masks
- Hx of:
- Chronic lung disease
- Hemodynamically significant cardiac disease
- Neuromuscular problem
- Immunocompromised
- Young infants <6 months old (unless EXTREMELY mild)
- Significant feeding problems
- Social problem (i.e., inadequate care at home)
100
What is Choanal atresia?
Obliteration or blockage of the posterior nasal aperture
associated with bony abnormalities of the pterygoid plates and midfacial growth abnormalities
101
What causes Cystic Fibrosis?
CFTR gene found on Chromosome 7
102
What does cystic fibrosis cause?
relative dehydration of airway secretions
Impaired mucociliary transport
AIrway obstruction
103
What are the clinical features of Cystic Fibrosis?
Neonatal: Meconium ileus, prolonged jaundice, antenatal bowel perforation
Infancy: pancreatic insufficiency with steatorrhea and FTT (despite voracious appetite), anemia, hypoproteinemia, hyponatremia
Childhood: Heat intolerance, wheezing or chronic cough, recurrent
