Pediatrics Flashcards
Pediatric Weight loss/gain
Term neonates may lose up to 10% of their birth weight in the first few days of life and typically regain their birth weight by 2 weeks of age.
Infants double their birth weight by 4 - 6 months of age and triple their birth weight by 1 years old.
Developmental milestones - 2 months
Looks at caregiver’s face
Reacts to loud sounds
Holds head up when on tummy
Developmental milestones - 4 months
Cooing occurs
Hold head steady without support while being held
Developmental milestones - 6 months
Knows familiar people
Laughs
Puts things in their mouth
Rolls from stomach to back
Leans on hands to support themselves if sat up
Developmental milestones - 9 months
May be shy or fearful around strangers
Makes various sounds such as mama/papa
Looks for objects when dropped out of sight
Bangs 2 objects together
Sits without support
Rakes food towards themselves
Transfers object from one hand to another
Developmental milestones - 12 months
Plays pat-a-cake
Waves “bye”
Says mama and dada
Puts object in a container
Looks for hidden objects
Pulls up to stand
“Cruising”
Drinks from a cup
Pincer grasp
Developmental milestones - 15 months
Mimics other children
1 or 2 words in addition to mama or dada
Stacks at least 2 objects (blocks)
Takes at least a few steps on their own
Developmental milestones - 18 months
Points to interesting things
Looks at book pages
3 or more words in addition to mama or dada
Copies caregiver
Pushes a toy car
Walks independently
Tries to use a spoon
Developmental milestones - 24 months
Notices other’s emotions
Says at least 2 words together
Runs
Kicks a ball
Puberty and development
Mean age for the first signs of puberty varies from 8.8 to 9.9 years old
Mean age of a females first menstrual cycle is 12.2 years old
Precocious puberty: Onset of puberty at an age two or more standard deviations below the mean age of onset
Male Genitalia - Stage 1
Prepubertal, without public hair
Male Genitalia - Stage 2
Sparse, straight public hair, enlargement of testes and scrotum
Male Genitalia - Stage 3
Pubic hair is darker, coarser, and curlier
Enlargement of penis
Male Genitalia - Stage 4
Pubic hair is adult-like in appearance but does not extend to thighs
Increased penis, testers and scrotum size
Scrotal skin appears darker
Male Genitalia - Stage 5
Adult genitalia
Hair is adult in appearance extending from thigh to thigh
Female breast development - Stage 1
Prepubertal
No palpable breast tissue
Female breast development - Stage 2
Breast buds
Enlarged areola
Female breast development - Stage 3
Enlargement of breasts without areola changing the counter of the breast mound
Female breast development - Stage 4
The areola projects outward from the breast forming a second mound
Female breast development - Stage 5
Recession of areola to line up with the contour of the breast shape
Adolescent Idiopathic Scoliosis
Lateral curvature of the spine
Most common type of adolescent idiopathic scoliosis and it occurs after 10 years of age
Presentation:
- Uneven shoulder heights and appears asymmetrical in the waist
- Adam’s forward bend test shows rib prominence due to rotation of the spine
Diagnosis:
- MAde both using clinical exam and radiographs
- Criteria that indicates likely AIS include onset of 10 years or older and a > 10 degree Cobb angle (Measures curvature of the spine)
Osgood-Schlatter Disease
Osteochondritis of the tibial tubercle
Overuse/repetitive use injury, generally seen in children and adolescents
Presentation:
- Anterior knee pain that is exacerbated with trauma and use and is relieved with rest
Diagnosis:
- Clinically
- Tenderness at the bony prominence of the tibial tubercle
Treatment:
- Icing, NSAIDs for short term pain relief
- No return to sports restrictions if the patient is able to tolerate continued activity.
Pediatric Fractures - Buckle
Compression/FOOSH injury
Often occurs in the distal radius
Stable: requires splinting and only 1 visit follow up
Pediatric Fractures - Greenstick
Fracture line does not extend completely through the affected bone
Splint; followed by casting
Pediatric Fractures - Bowing
Longitudinal force directed along the shaft of the bone exceeds the bone’s ability to recoiled to its normal position
If the curvature is less than than 20 degrees or if the injury occurs in children < 4 years of age, these fractures typically spontaneously resolve
Pediatric Fractures - Salter-Harris
Classification system grades fractures
Severity increases as the grade scale increases
S: Type I; straight across the growth plate
A: Type II; above the growth plate
L: Type III; lower or below the growth plate
T: Type IV; through the growth plate
ER: Type V; erasure of the growth plate or crush
Fractures associated with abuse
Long bone fractures in non-ambulatory children
Metaphyseal corner and bucket-handle fractures
Rib fractures
Fractures of the sternum, scapula or spinous processes
Multiple fractures in various stages of healing
Bilateral acute long-bone fractures
Vertebral fractures and subluxations in the absence of a history of high force trauma
Digital fractures in children younger than 36 months of age or without a corresponding history
Displaced physeal fractures, especially transphyseal distal humerus fractures in non-ambulatory children
Complex skull fractures in children
Gastroesophageal Reflux (“Happy spitter”)
Presentation:
- Effortless regurgitation in an otherwise healthy infant
- Typically resolves over the first year of life
- Can trial removing cows milk as this may mimic GER
- Symptoms of cows milk protea in are intolerance, poor weight gain (Family history of atopy increases risk)
Treatment:
- Keep infant upright after feedings
- Avoid smoking around infant
Pyloric stenosis (“hungry vomiter”)
Hypertrophy of the pyloric sphincter causes an obstruction
Occurs between 3 and 6 weeks
Presentation:
- Projectile, non-billous vomiting, that occurs immediately after being fed followed by an infant demanding to be fed again as they lost all their nutrients
- May see dehydration and weight loss
- May be able to palpate and “olive-shaped mass” in the RUQ, easier to palpitate immediately after infant vomits.
Diagnosis:
- Made by Ultrasound
- Refer for surgical correction
Treatment:
- Refer to ER if the symptoms of dehydration are present
Intussusception
Intestine “telescopes” in on itself causing sudden, intermittent and severed abdominal cramping
Most commonly occurs between 6 and 36 months
Presentation:
- Inconsolable crying, may suddenly draw legs towards abdomen.
- “Jelly like stools”
- As obstruction worsens vomiting may occur, that can turn bilious
Diagnosis:
- Confirm with ultrasound (may show “coiled spring” appearance)
Cryptorchidism (Undescended testes)
A testes that does not descend by 4 months of age
Presentation:
- Empty, poorly righted scrotum
- If testes does not descend by 4 months, this generally requires surgical intervention
- Cryptorchidism increases the risk for testicular cancer in the future if not corrected early on
Diagnosis:
- Refer to pediatric urology
Wilms Tumor
Most common renal malignancy in children and one of the most common malignancies in childhood
Occurs < 10 years old… 75% before 5 years old
Presentation:
- Abdominal mass palpated that rarely crosses the midline. May be asymptomatic, may also present with abdominal pain, hematuria and hypertension.
- Once a Wilms tumor is suspected, do NOT palpate as it may result in rupturing the capsule and spilling contents from the tumor
Diagnosis:
- Ultrasound is the initial diagnostic tool… Biopsy to confirm
Treatment:
- Refer to pediatric cancer center
Pediatric murmurs
Heart murmurs are common findings in infants and children and are generally benign
- Murmurs detected in the first 6 hours of life are typically a result from a valve complication
- Murmurs auscultated after 6 hours of life are more likely to represent shunt lesions (atrial or ventricular septal defects, patent dictum arteriosus or peripheral pulmonary stenosis.
- Murmurs identified after 1 year of age are typically benign.
Characteristics of pathological murmurs
Grade 3 or higher
Holosystolic timing
Maximum intensity at the left upper sternal border
Harsh or blowing qualities
Systolic click
Diastolic murmur
Increases in intensity with upright position
Most benign murmurs decrease in intensity in the upright position
Gallop rhythm
Friction rub (Occurs with pericarditis)
Characteristics associated with cardiac disease
Parent or sibling with congenital heart disease
Abnormal prenatal ultrasound or fetal echocardiogram
Age < 1 year old
Symptoms of heart disease
Abnormal vital signs
Abnormal pulses
Abnormal ECG
Congenital Heart Disease (CHD)
Most common congenital anomaly
Risk Factors:
- Prematurity, pregnant with multiples, in-utero infection with rubella or influenza, preeclampsia, phenylketonuria, diabetes, HTN, obesity, thyroid dysfunction, 40 years and older, alcohol or substance abuse, tobacco smoking in the first trimester, use of NSAIDs or lithium during pregnancy, family history of CHD.
Presentation:
- Early presentation usually involves symptoms of shock, cyanosis, and/or respiratory symptoms.
- Late presentation may occur and usually presents with symptoms such as poor feeding, irritability, excessive sweating, poor weight gain and delayed milestones.
Diagnosis:
- Evidence shows that universal screening with pulse oximetry improves the detection of critical CHD and should be done after the first 24 hours of life, before discharge.
- Positive screening test results:
- SpO2 < 90% in either extremity.
- SpO2 90 - 94% in both the right hand and a lower extremity on two to three measurements, each separated by one hour.
- SpO2 difference >4% between the upper and lower extremities on two to three measurements, each separate by one hour.
Treatment:
- Infants with a positive pulse oximetry screening should have an echo and be referred to cardiology if CHD is identified on the echo or if clinical suspicion for CHD.
Community Acquired Pneumonia
Streptococcus pneumonia is the most common cause for a typical bacterial pneumonia
Presentation:
- Bacterial pneumonia: Fever (>101.3), tachypnea, non-productive cough, malaise, anorexia, decrease in breath sounds or crackles.
- Viral pneumonia: Gradual onset, preceded by URI symptoms (Nasal congestion), non toxic appearing, diffuse auscultation findings.
Diagnosis:
- Radiographs are not required for diagnosis, for mild cases of pneumonia that will be managed outpatient
- Lack of tachypnea helps to rule out pneumonia
Treatment for BACTERIAL PNEUMONIA: High dose amoxicillin (90mg/kg/day)
Indications for hospitalization:
- Presence of severe illness, confirming or excluding a pneumonia diagnosis when clinical findings are inconclusive, if the patient is hospitalized, if they have a history of recurrent pneumonia, excluding an alternative diagnosis and assessing for complications.
- Hypoxemia, dehydration, signs of respiratory distress, toxic appearing, immunocompromised, failure of outpatient treatment
- Signs of respiratory distress: Nasal flaring, intercostal retractions, head bobbing, abdominal breathing, tachypnea, decrease respirations.
Cystic Fibrosis
Life shortening, autosomal recessive disease caused by mutations in the CFTR Gene
Thick, viscous secretions accumulate in the lungs, pancreas, liver, intestines and reproductive tract.
Presentation:
- Productive cough, wheezing, or breathing difficulties, a meconium ileus (which is a blockage of the small intestine d/t an abnormally thick and sticky first meconium BM), failure to thrice.
- CF patients often suffer from many health complications as a result of the build up of thick mucus through out the body.
Diagnosis:
- A: Symptoms consistent with CF, or a positive newborn screen, or patient has a sibilig who has CF.
- B: Evidence of CFTR dysfunction by one of the following
- Elevated sweat chloride test of >60 mmol/L (most important diagnostic test)
- Presence of 2 disease causing mutations in the CFTR gene, one from each parental allele
- Abnormal nasal potential difference
Treatment:
- Managed by CF specialist/Pulmonologist
- CFTR Modulators
- Chest physiotherapy
Croup
A respiratory illness that occurs from inflammation to the larynx and subglottic airway
Presentation:
- Inspiratory strider, cough (“bark-like”), and hoarseness
- Generally viral, occurring mostly in children <6 years of age, however predominately between 6 months and 3 years of age.
Diagnosis:
- Made clinically in the presence of cough and strider
Treatment:
- Mild croup treated in clinical setting should be given a single dose of dexamethasone or prednisone
- Moderate to severe croup should be managed in the ER (Stridor at rest, retraction, distress)
- Nebulized epinephrine and a single dose of dexamethasone (Preferred glucocorticoid)
Asthma
Presentation:
- Cough and wheeze are the most common asthmatic symptoms in pediatrics.
- Precipitating factors are animals, tobacco smoke, perfume, physical activity
Diagnosis:
- Symptoms of asthma and wheezing on exam strongly suggest asthma
- Demonstration of reversible airflow obstruction, with spirometers after administration of a bronchodilator, confirms the diagnosis of asthma and helps define the severity of the disease.
- FEV1/FVC <0.85 indicates airflow obstruction
- Reversibility is indicated by an increase in FEV! Of 12% or greater (However, some studies suggest a smaller number of an 8% increase in FEV1 is a better indicator for children)
- If unable to perform spirometers, appropriate to treat with asthma medications if patient has symptoms of asthma and evaluate for improvement.
Asthma - Step 1
Daytime symptoms < or = 2days/week without nocturnal waking. No interference with daily activities and 1 or less exacerbations treated with glucocorticoids per year.
Treatment:
- SABA PRN or Low-dose ICS whenever SABA is used
Asthma - Step 2
Daytime asthma symptoms 3 to 6 days a week, up to 4 nocturnal wakings per month / but not more than 1x a week, Minimal interference with daily activities and 2 or more exacerbations requiring glucocorticoids per year.
Treatment:
- Daily low-dose ICS with SABA PRN or
- Daily low-dose ICS with a low-dose ICS anytime a SABA is used.
Asthma - Step 3
Daily symptoms of asthma, nocturnal wakings more than 1x a week but not every nights. Some limitations to normal activities and evidence of airway obstruction are not d/t an exacerbation (as evidence by an FEV1 between 60% - 80%)
Treatment:
- Daily lo-dose ICS-Formoterol as a reliever and maintenance therapy OR
- Daily low-dose ICS-LABA with SABA PRN or
- Daily medium dose ICS with SABA PRN
Asthma - Step 4
Severe asthma restricted by their symptoms, nightly wakings, FEV1 <60%
Treatment:
- Daily medium-dose ICS-Formoterol as reliever and maintenance therapy
- Daily medium-dose ICS-LABA with SABA PRN or
- Daily High-dose ICS with SABA PRN
Roseola Infantum
Most cases occur in individuals who are younger than 2 years old (peak between 7 months to 13 months)
Presentation:
- 3 to 5 days of high fever
- As the fever resolved a non pruritic, blanch able, macular/maculopapular rash develops
- Rash typically begins on the neck and trunk and then spreads t o face and limbs
Treatment:
- Supportive case and manage fever
***Remember: RoSeola causes a super high fever, Secondary rash Starting on the Stem (neck) and Stomach before the Second year.
Scarlet Fever
Complication of streptococcal tonsillopharyngitis
Presentation:
- The rash is diffusely erythematous and blanchable with popular elevations usually beginning in ancillary or pelvic region
- Papular elevations may cause skin to have “sandpaper” quality
- other symptoms include circumoral pallor and a strawberry tongue
Treatment:
- Antibiotics for strep infection and antipyretics for fevers
Erythema Infectiosum (Fifths disease)
This viral exanthema normally affects school aged children, though adults can be affected
Caused by the Parvovirus B19
Presentation:
- Generally presents as a mild fever and nonspecific prodromal symptoms followed by a rash 2-5 days later that is often described as a “slapped cheek” rash
- Several days after the “slapped cheek” rash develops a “lace-like” rash on the trunk and limbs
Remember: Fifths disease = 5 fingers on a hand = slapped cheek rash
Rubeola (Measles)
Highly contagious virus
Approximately 90% of susceptible indicates who have been exposed to measles with contract measles
Person believed to be contagious from 5 days before the development of the rash and 4 days afterwards
Presentation:
- Prodrome includes 2 to 4 days of fatigue, cough, coryza and conjunctivitis
- Rash typically presents 2 to 4 days after onset of fever and is an erythematous maculopapular rash
- Rash typically begins on the head and spreads downward (cephalocaudally), palms and soles rarely involved.
- Initially rash is blanchable, however at the end rash is not blanchable
- “Koplik spots” are seen (small white/blueish/grayish dots) in the mouth approximately 48 hours before the rash appears
Treatment:
- Supportive
- All children with acute measles may be treated with Vitamin ! As a deficiency in Vitamin A can delay recovery
Remember: RuBeola = Bad virus, with Blueish/white Bumps on the Buccal mucosa, then rash Begins at the Ball cap (head)
Vaccine Key points
Any questions regarding vaccine administration - REFER TO CDC
Administration of a vaccine 4 days before a dose is due is acceptable… >4 days before it is due is considered invalid
Live vaccines must be either given on the same day or a minimum of 28 days apart
No live vaccines before 12 months old, in pregnant patients or the immunocompromised (Varicella and MMR)
Monitor minimum 15 minutes after administering a vaccine to observe for allergic reaction
Egg allergy is NOT a contraindication to the influenza vaccine
