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Toronto Notes > Pediatrics > Flashcards

Pediatrics Flashcards

1
Q

When is the most rapid growth during development?

A

During first 2 year and at puberty

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2
Q

How early is considered a premature infant?

A

> 37 week

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3
Q

What age should you use for premature infants measurement of growth?

A

Gestational Age until age 2

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4
Q

What is the normal Birth weight?

A

3.25 kg (7 lbs)

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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

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6
Q

Do neonates experience weight loss?

A

Weight loss (up to 10% of BW) in first 7 days of life is normal

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7
Q

When do neonates regain their birth weight?

A

By 10-14 days of age

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8
Q

What is the normal length/Height at birth?

A

50 cm (20 in)

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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

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10
Q

How do you measure height of baby as they age?

A

Supine length until 2 years

After, measure standing height

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11
Q

What is the normal head circumference at birth?

A

35 cm (14 inches)

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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

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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

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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

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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

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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

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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

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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)

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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)

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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

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21
Q

Wha are common allergens?

A

Eggs
Milk
Mustard
Peanuts
Seafood
Sesame
Soy
Tree nut
Wheat

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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
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23
Q

Medications that cross into Breast Milk?

A
  • Antimetabolites
  • Bromocriptine
  • Chloramphenicol
  • High dose diazepam
  • Ergots
  • Gold
  • Metronidazole
  • Tetracycline
  • Lithium
  • Cyclophosphamide
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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
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25
Q

What is the content of breast milk?

A

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

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26
Q

What are the advantages of breastfeeding?

A
  • Easily digested, low renal solute load
  • Immunologic
  • Parent-child bonding
  • Economical, Convenient
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27
Q

What are the Immunologic benefits from breast milk?

A
  • 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
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28
Q

What are the maternal contraindications for breast feeding?

A
  • 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

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29
Q

What to consider if poor weight gain with breast feeding?

A
  • Consider dehydration or FTT
  • Consider formula supplementation if insufficient milk production or intake
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30
Q

How to treat Oral Candidiasis (Thrush) in babies? How does it occur?

A

Antifungal i.e., Nystatin

Can occur in breast or bottle-fed infants

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31
Q

What are the benefits of Circumcision?

A

-Prevention of phimosis
- Reduced risk of:
- UTI
- STI
- Balanitis
- Cancer of the penis

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32
Q

What are the complications of Circumcision (<1%)?

A
  • Local Infection
  • Bleeding
  • Urethral injury
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33
Q

What are the contraindications of Circumcision?

A

Presence of genital abnormalities (i.e., Hypospadias)
Known bleeding disorder

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34
Q

What are the types of Breath-holding spells?

A

Cyanotic (more common)
- Usually associated with anger/frustration

Pallid
- Usually associated with pain/surprise

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35
Q

What is the etiology of Breath Holding Spells?

A

Child provoked (Usually by anger, injury, or fear) –> Holds breath and becomes silent –> Spontaneously resolves or loses consciousness

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36
Q

What is the management of Breath holding Spells?

A
  • 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
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37
Q

What are the causes of Crying/Fussing Child?

A
  • Functional (i.e., Hungry, Irritable)
  • Colic
  • Trauma
  • Illness
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38
Q

What information would you want for crying/fussing child?

A
  • 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)
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39
Q

What would raise concerns of maltreatment on history?

A
  • Inconsistent history
  • Pattern of numerous ED visits
  • High-risk social situations
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40
Q

What is Infantile Colic?

A
  • Unexplained paroxysms of irritability and crying for >3h/d, >3d/wk, >3 wk in an otherwise healthy, well-fed baby (RULE OF 3s)
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41
Q

What is the management for Infantile Colic?

A
  • 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)
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42
Q

When do primary dentition occur?

A

First tooth at 5-9 months (lower incisor), then 1/month

6-8 central teeth by 1 year

43
Q

When should children first be assessed by dentists?

A

6 month after ruption of 1st tooth

Certainly by 1 year of age

44
Q

When does Secondary Dentition (32 teeth) occur?

A

First adult tooth is 1st molar at 6 year, then lower incisors

45
Q

How to prevent caries in babies?

A
  • 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
Q

What is Enuresis?

A

Involuntary urinary incontinence by day and/or night in child >5 year

47
Q

What is the general approach for Enuresis?

A

Evaluate if:
- Dysuria
- Change in colour
- Odour
- Stream
- Secondary or diurnal
- change in gait or stool incontinence are present

48
Q

What is the clinical feature for Primary Nocturnal Enuresis?

A

Involuntary loss of urine at night, bladder control has never been attained

49
Q

What is the etiology of Primary Nocturnal Enuresis?

A
  • Developmental disorder OR
  • Maturational lag in bladder control while asleep
50
Q

What is the management for Primary Nocturnal Enuresis?

A
  • 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
Q

What medications can be used for Primary Nocturnal Enuriesis?

A
  • DDAVP oral Tablets
  • Imipramine (Tofranil) - Rarely used due to Overdose Risk (S/E: Cardiac Toxicity, Anticholinergic effects)
52
Q

What are the clinical feature of Secondary Enuresis?

A

Involuntary loss of urine at night, develops after a child has sustained a period of bladder control (>6 month).

53
Q

What are the causes of Secondary Enuresis?

A
  • Inorganic regression due to stress or anxiety (i.e., the birth of a sibling, significant loss, family discord, sexual abuse)
54
Q

What is the management of Secondary Enuresis?

A

Treat underlying cause

55
Q

What is Diurnal Enuresis?

A

Daytime wetting (60-80% also wet at night)

56
Q

What is the etiology of Diurnal Enuresis?

A

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
Q

What is the management of Diurnal Enuresis?

A
  • Treat underlying cause
  • Behaviour (i.e., Scheduled toileting, double voiding, good bowel program, etc.)
  • Good constipation management
  • Pharmacotherapy
58
Q

What is Encopresis?

A

Fecal incontinence in a child >4 year old, at least once per month for 3 month

59
Q

What are the causes of Encopresis?

A
  • Chronic Constipation
  • Hirschsprung disease
  • Hypothyroidism
  • Hypercalcemia
  • Spinal cord lesions
  • Anorectal malformations
  • Bowel obstruction
60
Q

What is Retentive Encopresis?

A

The child holds bowel movement, and develops constipation, leading to fecal impaction and seepage of soft or liquid stool

Overflow incontinence

61
Q

What are the causes of Retentive Encopresis?

A

Physical
- Painful stooling often secondary to constipation

Emotional
- Disturbed parent-child relationship, coercive toilet training, social stressors

62
Q

What are the clinical features of Retentive Encopresis?

A
  • 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
Q

What will Retentive Encopresis show on investigations?

A
  • Abdo x-ray/ DRE - will show a large fecal mass in the rectal vault
  • Anal fissures (from hard stools)
  • Palpable stool in LLQ
64
Q

What is the management of Retentive Encopresis?

A
  • 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
Q

What is Failure to Thrive?

A
  • Weight <3rd percentile
  • Falls across two major percentile curves
  • <80% of expected weight for height and age
66
Q

What is the most common facture in poor weight gain?

A

Inadequate caloric intake

67
Q

What factors affect physical growth?

A
  • Genetics
  • Intrauterine factors
  • Nutrition
  • Endocrine hormones
  • Chronic infection/disease
  • Psychosocial factors
68
Q

What is the equation for Mid-Parental height?

A

Boys = (Father ht + Mother ht +13)/2
Girls = (Fathher ht + Mother ht - 13)/2

Height in cm

69
Q

What clinical features are important to assess for Failure to Thrive patients?

A

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
Q

What investigations should be ordered for patients suspected for ‘failure to thrive’?

A
  • 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
Q

Clinical Signs of Failure to Thrive?

A

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
Q

How many children will have heart murmurs?

A

80%

1-2% have CHD

73
Q

What are some causes of failure to thrive?

A

Inadequate Caloric intake
Inadequate Absorption
Increased Metabolism

74
Q

What are examples of inadequate caloric intake?

A
  • Inadequate milk supply/latching
  • Mechanical feeding difficulty (i.e., cleft palate)
  • Oromotor dysfunction
  • toxin-induced anorexia
75
Q

What are examples of inadequate absorption?

A
  • Biliary Atresia
  • Celiac disease
  • IBD
  • Cystic Fibrosis
  • Inborn errors of metabolism
  • Milk protein allergy
  • Pancreatic Cholestatic conditions
76
Q

What are examples of increased metabolism?

A
  • Chronic infection
  • Cystic fibrosis
  • Lung disease from prematurity
  • Hyperthyroidism
  • Asthma
  • IBD
  • Malignancy
  • Renal Failure
77
Q

What is the medical management for failure to thrive?

A
  • Oromotor problems
  • Iron-deficiency anemia
  • GERD
78
Q

What are the nutritional management plans for failure to thrive?

A
  • 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
Q

What is behavioural management of failure to thrive?

A
  • Positive reinforcement
  • No distractions during mealtime
80
Q

What is the definition of obesity in Pediatrics?

A

Overweight:
- BMI >85%

Obesity:
- >95% for height and age

81
Q

What are the risk factors for childhood obesity?

A
  • Genetic predisposition (i.e., both parents are obese)
  • Psychosocial/environmental contributors
82
Q

What are the complications of childhood obesity?

A
  • 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
Q

What investigations for children with obesity?

A
  • BP
  • Pulse
    Screen for:
  • Dyslipidemia
  • Fatty Liver Disease (ALT)
  • Type 2 DM (Based on risk factors)
84
Q

What is Asthma?

A
  • Inflammatory disorder of the airways characterized by recurrent episodes of reversible small airway obstruction
  • due to hyperresponsiveness to endogenous and exogenous stimuli
85
Q

What are the clinical features of Asthma?

A
  • Episodic
  • Wheezing
  • Dyspnea
  • Tachypnea
  • Cough (usually at night/early morning, with activity, or cold exposure)

Physical exam:
- hyper-resonant chest
- prolonged expiration
- wheeze

86
Q

What are triggers of Asthma?

A
  • 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
Q

What are the classifications for Asthma?

A

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
Q

What is the acute management of Asthma?

A
  • 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
Q

What is the Chronic management of Asthma?

A
  • 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
Q

What are the indications for hospitalizations in Asthma?

A
  • Ongoing need for supplemental oxygen
  • Persistently increased work of breathing
  • B2- agonists are needed more than q4h
  • Patient deteriorates while on systemic steroids
91
Q

What is HSP Rash?

A

[Google It]

92
Q

What is Bronchiolitis?

A
  • Lower Respiratory Tract Infection
  • Usually in children <2 years
  • Has wheezing and signs of respiratory distress
93
Q

What is the cause of Bronchiolitis?

A
  • Respiratory Syncytial Virus (RSV)
  • Parainfluenza
  • Influenza
  • Rhinovirus
  • Adenovirus
  • M. pneumoniae (rare)
94
Q

What are the clinical features of Bronchiolitis?

A
  • 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
Q

What orders should be made for Bronchiolitis?

A
  • 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
Q

What is the management for Bronchiolitis?

A
  • 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
Q

What is protective for severe disease in patients with Bronchiolitis?

A
  • RSV-Ig
  • Palivizumab (monoclonal antibody against F-glycoprotein of RSV)
98
Q

Are Bronchodilators, Corticosteroids, and antibiotics helpful in Bronchiolitis?

A

No

Unless there is a secondary bacterial pneumonia

99
Q

What are the indications for hospitalization for patients with Bronchiolitis?

A
  • 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
Q

What is Choanal atresia?

A

Obliteration or blockage of the posterior nasal aperture

associated with bony abnormalities of the pterygoid plates and midfacial growth abnormalities

101
Q

What causes Cystic Fibrosis?

A

CFTR gene found on Chromosome 7

102
Q

What does cystic fibrosis cause?

A

relative dehydration of airway secretions
Impaired mucociliary transport
AIrway obstruction

103
Q

What are the clinical features of Cystic Fibrosis?

A

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

Toronto Notes (2 decks)

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