Pediatrics 3 Flashcards
Peak age of Infectious mononucleosis
15-19 yr
EBV transmission
Infected saliva
Sexual
Incubation: 1-2 mo
Sx of Infectious mononucleosis
Infants/young children:
Often asymptomatic or mild
Older children and adolescents:
Malaise, fatigue, fever, sore throat, abd pain (LUQ)
Periorbital edema
Any -itis
Triad of IM
Fever
Generalized LAP
Pharyngitis/tonsillitis (exudative)
IM Dx
Monospot test:
Sensitivity increases with age
Tests heterophil ab
False positive in: HIV, SLE, Lymphoma, rubella, parvovirus
EBV titres
CBC, diff, blood smear
Throat culture to R/O streptococcal pharyngitis
Mx of IM
Supportive: Adequate rest Hydration Saline gargles Analgesics
All pts should avoid contact sports for 6-8 wk
If airway obstruction:
Admit
CS
Neurologic complication of IM
Guillain-Barré
Etiology of infectious pharyngitis
80% viral
20% bacterial:
Mainly GAS
M. Pneumoniae
N. Gonorrhea
Fungal: candida
GAS pharyngitis is uncommon in age:
<3 yr
Peak: 5-12 yr
Late winter, early spring
If suspected GAS pharyngitis, next step?
Rapid streptococcal Ag test
If negative:
Throat culture
Mx of streptococcal pharyngitis
Penicillin V Or Amoxicillin Or Erythromycin
Given within 9 d of Sx
x 10 d
Hydration
Acetaminophen
Indication of tonsillectomy for GAS pharyngitis
If proven recurrent strep pharyngitis
Role of antibiotic therapy and prevention of PSGN or rheumatic fever
Prevents rheumatic fever but not PSGN
PANDAS is a complication of
Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci
When and where does the rash of scarlet fever start
24-48 h after pharyngitis
Starts in folds
Within 24 h, sandpaper rash begins to generalize
No pain, No pruritus
Blanchable
Fades after 3-4 d
Tx if scarlet fever
Penicillin
Amoxicillin
Erythromycin
x10 d
Peak incidence of rheumatic fever
5-15 y
Criteria for diagnosis of rheumatic fever
Jones Criteria
2 major
Or
1 major + 2 minor + evidence of preceding strep infection
Tx of RF
Acute course:
Penicillin/erythromycin x 10 d
+ prednisone if severe carditis
Secondary prophylaxis:
Daily penicillin or erythromycin
PSGN peak age
4-8 yr
M> F
How long after strep pharyngitis does PSGN develop?
1-3 wk
Dx of PSGN
U/A
ASOT/anti-DNAseB
Low C3
Mx of PSGN
If symptomatic:
If HTN/edema:
Loop diuretics, Fluid/Na restriction
+/- dialysis
If evidence of persistent infection:
Penicillin, erythromycin
Peak age of meningitis in children
6-12 mo
Meningitis risk factors
Unvaccinated
Immunocompromised
Recent or current infections
Neuroanatomical defects/surgery/cochlear implant/dermal sinus, recent trauma
Daycare
Household contact
Recent travel
Inv for meningitis
CBC, diff Lytes BUN, Cr Glucose, Blood C&S LP(gram stain, C&S, WBC, diff, RBC, glucose, protein, acid fast if suspect TB, PCR esp if treated with AB)
Urinalysis, S/C
Gram stain/culture of petechial/purpuric lesions
HSV/enterovirus PCR
CSF WBC count in normal newborn/infant
Infant: 0-6 (no PMN)
Newborn 0-30 (2-3 PMNs)
CSF WBC count in meningitis
Bacterial:
>1000, >50% PMN
Viral:
100-500, <40% PMN
HSV:
10-1000, <50% PMN
CSF Glucose in meningitis
Bacterial:
< 1.66
Viral/HSV > 1.66
CSF protein in meningitis
Bacterial:
> 1
Viral:
0.5-1
HSV:
> 0.75
CSF RBC in meningitis
Bacterial:
0-10
Viral:
0-2
HSV:
10-50
Mx of meningitis
Supportive: Normal BP Mx ICP rise Fluid Lytes Acid-base Glucose Coagulopathies
Start AB if suspect bacterial meningitis
Isolation
Mx SAIDH (fluid restriction)
Hearing test
Reportable
Prophylactic AB for close contacts (HI, N. Meningitis)
How long should isolation continue for meningitis
Until 24 h after culture-sensitive AB therapy
Opistotonos seen in
Meningitus
Teranus
Empiric AB for meningitis in newborn
Ampicillin + cefotaxime
Empiric AB for meningitis in 1-3 mo infants
Vanco + cefotaxime + ampicillin if immunocompromised
Empiric AB for meningitis in infant > 3 mo
Ceftriaxone + vanco
If penicillin allergy:
Vanco + rifampin
Mx of viral meningitis
Supportive
Acyclovir for HSV
Report to public health
Meningitis with which organism causes higher mortality rates
Pneumococcus > N. Meningitis > HiB
Age of mumps
5-10 yr
Mumps transmission
Respiratory droplets
Direct contact fomites
Mumps communicability
7 d before to 5 d after parotitis
Dx of mumps
Clinical
But also: IgM PCR (oral secretions, blood, CSF) Viral culture CBC Amylase
Mx of mumps
Analgesics Antipyretics Warm/cold pack to parotid Admit if meningitis/pancreatitis... Droplet precaution
Px: vaccine
Transmission of pertuss
Respiratory deoplermts
Communicability of pertussis
Mostly during catarrhal phase
But may remain contagious for weeks
Post-tussive apnea
In infents < 6 mo in paroxysmal phase of pertussis
Age of greatest incidence of pertussis
<1 yr
Duration of pertussis phases
Catarrhal: 1-7 d
Paroxysmal: 4-6 wk
Convalescenct: 1-2 wk (non-contagious)
Cough may last up to 6 mo
Inv for pertussis
Gold: culture of NP specimen
PCR to detect Ag
CBC (lymphocytosis)
Serology
Mx of pertussis
Admit if: apnea, cyanosis : O2
Supportive care
AB if:
B. Pertussis isolated,
Or
Sx < 21 d
AB: macrolide
Droplet isolation
Reportable
Duration of droplet isolation for pertussis
Until 5 d of treatment
Indications for CT for sinusitis
Surgery
Complications
Persistent/recurrent disease
Indication of AB therapy for sinusitis
All children
UTI in boys and girls
< 4-6 wk old, more prevalent in boys
> 1yr, more prevalent in girls
RFs fir URI
Female Caucasian Previous UTI FHx VUR Neurogenic bladder Obstructive uropathy Posterior urethral valve Dysfunctional voiding Repeated bladder cath Uncircumcised males Labial adhesion Sexually active Constipation Toilet training
Inv for UTI
Sterile urine specimen
U/A, microscopy, C/S
Dx if: suggestive U/A + > 50,000 CFU/ml in U/C
Bagged urine value for UTI Dx
Not useful for Ruling in, but iseful for ruling out UTI
Mx of UTI
Admit if indicated
Supportive care:
Hydration
Pain control
AB:
Neonates: IV ampicillin and gentamycin
Infants and older children:
If outpt: oral AB
If inpt: IV ampicillin + genta
x7-10 d
Imaging
Indications for admission of child with UTI
<2 mo Urosepsis Persistent vomiting Inability to tolerate oral medications Moderate to severe dehydration Immunocompromised Complex urologic pathology Inadequate follow-up Failure to respond to outpatient therapy
Indications for imaging in UTI
U/S for all febrile infants (<2yr) with UTI
VCUG: Not recommended after 1st episode of febrile UTI Unless: Signs suggestive of high-grade VUR: Hydronephrosis on U/S Obstructive uropathy on U/S
Definition of SGA
2 SD < mean wt for GA
Or
< 10th percentile
Definition of LGA
2SD > mean wt for GA
Or
> 90th percentile
Ca, BS, Hb in premature infant?
Hypocalcemia
Hypoglycemia
Anemia
Ca, BS, Hb in SGA
Hypocalcemia
Hypoglycemia
Polycythemia
Ca, BS, Hb in LGA
Hypocalcemia
Hypoglycemia
Polycythemia
Routine neonatal care
Ophthalmic erythro oint
Vit K IM
Screening tests: Metabolic disorders Blood disorders Endocrine disorders Other genetic diseases Congenital hearing loss
If mother Rh - : send cord blood for BG and direct anti-globulin test
Screening tests for neonates:
Amino acid disorders Organic acid disorders Fatty acid oxidation defects Biotinidase deficiency Galactosemia SCD Hb-pathies CAH Hypothyroidism CF SCID Hearing loss
Neonatal care for neonate with HBsAg + mother
HBIg
+ Hep B vaccine series
Neonate with APGAR < 7 at 5 min, next step?
Assess APGAR q 5 min until above 7
Steps to take immediately after birth
Warm and dry
Put in sniffing position and clear airway
Stimulate: rub lower back, flick soles
Assess breathing and heart rate
NO STIMULATION IF MECONIUM PRESENT ( tracheal suction first)
If neonate HR < 60 in delivery room
Epinephrine
IV, ET
If evidence of hypovolemia in neonate
Fluid bolus
NS, RL, Blood
Definition of depressed newborne
I depressed newborn lacks one or more of that following characteristics:
Pulse > 100
Cries when stimulated
Actively moves all extremities
Good strong cry
Inv for depressed newborn
Detailed Hx
CBC, ABG, blood type, glucose
Transillumination of chest
CXR
Periodic breathing in newborn. Definition, significance
Periods of rapid respiration alternating with pauses lasting 5 to 10 seconds
Normal
Definition of apnea in neonate:
absence of air flow for > 20 s
Or
Less if bradycardia or desaturation
Apnea of prematurity
< 34 wk
Resolves by 36 wk
CNS immaturity and obstructive apnea
Dx of exclusion
Mx of newborn apnea
Full workup
O2,
ventilation support,
maintain normal blood gases
Tactile stimulation
Correct underlying cause
Methyxanthines (caffeine): for apnea of prematurity (stimulates CNS/diaphragm)
Pathophysiology of neonatal alloimmune thrombocytopenia
Mother is negative for HPA, fetus is positive
Sx of neonatal alloimmune thrombocytopenia
Petechia, purpura, intracranial bleeding
Dx of neonatal alloimmune thrombocytopenia
Maternal and paternal platelet typing
Identification of platelet alloantibodies
Tx of neonatal alloimmune thrombocytopenia
IVIg to mother starts in 2nd trimester
+/- steroids
+/- fetal plt transfusion
IVIg to neonate
Transfusion with washed maternal plt or donor HPA negative plt if required
Neonatal AI thrombocytopenia
Caused by: antiplatelet Ab from maternal ITP or SLE
Sx less severe than neonatal alloimmune thrombocytopenia
Tx of Neonatal AI thrombocytopenia
Steroid to mother for 10-14 d prior to delivery
Or
IVIg to mother before delivery
IVIg to neonate if plt < 60,000
Transfusion of infant with maternal/donor plt only in severe cases
Hemorrhagic diseases of the newborn
Vitamin k deficiency
Both PT and PTT increase
RFs for vitamin k deficiency in neonate
Poor placenta transfer
Insufficient bacterial colonization of colon
Breastfeeding
Mother taking AED
definition of bronchopulmonary dysplasia (chronic lung disease)
O2 requirement for > 28 d
Plus
Persistent need for oxygen/ventilatory support at 36 wk corrected GA
Etilogy of BOD
Prolonged intubation/ventilation/O2
Infection
CXR in BPD
Decreased lung volumes
Areas of atelectasis
Signs of inflammation
Signs of hyperinflation
Tx for BPD
Gradual wean from ventilator
Optimize nutrition
Dexa (decrease inflammation, encourage weaning)
Dexa associated with increased risk of adverse neurodevelopmental outcome
Prognosis of BOD
pHTN
Poor growth
Right-sided heart failure
May persist into adulthood:
Airway obstruction
Airway hyperreactivity
Emphysema
Adverse neurodevelopmental outcome
DDx of peripheral cyanosis
Transient (typical)
Sepsis
Temperature instability
Causes of central cyanosis
Deoxygenated Hb
Or
Abn Hb
DDx of abn Hb causing cyanosis
Methemoglobinemia:
Reads higher on pulse oximetry than the true level. Alters absorption of red light
Carboxyhemoglobinemia:
CO-Hb, may not be evident clinically and may not register on pulse oximetry
DDx if deoxyhemoglobin
Respiratory Cardiovascular Neurogenic Hematologic Sepsis
Mx of cyanosis
ABG
Elevated CO2: respiratory causes
Hyperoxia test:
If < 150 (cyanotic CHD, possible PPHN)
If > 150: likely respiratory/non cardiac cause
CXR
Diaphragmatic hernia
Often associated with other anomalies
Pulmonary hypoplasia
PPHT
Tx of diaphragmatic hernia
DO NOT BAG MASK VENTILATE
Large bore orogastric tube to decompress bowel
Stabilization
Mx pulmonary hypoplasia
Hemodynamic support
Surgery when stable
Hypoglycemia definition
Glucose <2.6
Mx of hypoglycemia
Identify and monitor infants at risk (pre-feed Glucose check)
Begin oral feed as soon as possible
Ensure regular feeds
If significant/symptomatic hypoglycemia: IV glucose
If persistent or if no predisposing cause:
Sent critical blood work during an episode:
ABG, Ammonia, Betahydroxybutorate, Cortisol, FFA, GH, Insulin, Lactate, Urine dipstick for ketones
Hypoglycemia RFs
Prematurity SGA RDS Maternal HTN GH/Cortisol/EN deficiency Insulin excess HPA axis suppression FFA oxidation defects Galactosemia Sepsis Hypothermia Polycytemia
RFs for IVH
Prematurity (<32 wk) BW < 1500 Need for vigorous resuscitation at birth Pneumothorax Ventilation in preterm Hemodynamic instability RDS Coagulopathy
IVH screening
Routine head U/S of all preterm infants < 32wk or < 1500
MRI for term, extremely LBW infant
Mx of IVH
Supportive:
Maintain blood volume
Maintain acid-base status
Avoid BP fluctuation or CBF fluctuation
F/U: serial imaging
At which bil level would jaundice be visible?
85-120
Factors increasing jaundice severity and duration
Prematurity Acidosis Hypoalbuminemia Dehydration Hemolysis
Disorders causing both conjugated and unconjugated hyperbilirubinemia
Hyperthyroidism
Sepsis
Physiologic jaundice in term infant
Onset: 3-4d
Resolution by 10 d of life
Physiology Jaundice in preterm infants
Higher pick
Longer duration
Breast-feeding jaundice
Physiologic
Due to dehydration
Common
Breast milk jaundice
Physiologic
Onset: 7d of life
Peak: 2-3 wk
Resolution:
By 6 wk
RFs for jaundice
Asian Native american GDM ABO/Rh incompatibility BF FHx Previous child required phototherapy Birth trauma Prematurity Difficulty establishing breast-feeding Infection Genetic factors Polycythemia Drugs TPN
Causes of conjugated hyperbil
Sepsis Hep B TORCH Galactosemia Tyrosinemia a-1-antitrypsin deficiency Hypothyroidism CF Drugs TPN Idiopathic neonatal hepatitis Biliary/choledochal problems
Jaundice needing evaluation:
First 24 h of life (always pathologic)
Conjugated hyperbil (always pathologic)
Rapid rise of unconjugated hyperbil
Excessive hyperbil for age/wt
Persistent beyond 1-2 wk of age
Inv for unconjugated hyperbil
Hemolytic w/u:
CBC, Retic, PBS, Blood group (mother/infant), Coombs
If unwell baby:
Septic workup
Also:
G6PD, TSH
Inv for conjugated hyperbil
AST, ALT PTT,PT Alb Ammonia TSH TORCH Septic W/U Erythrocyte Galactose-1PUT Metabolic screen Abd U/S HIDA Sweat chloride
Predicting occurrence of severe hyperBil
TSB or TCB in all infants between 24-72 hr of life
Results should be ploted on predictive normogram
Tx of HyperBil
Continue BF, ensure adequate feeds and hydration
Pump after feeds
Treat underlying
Phototherapy (not UV)
Exchange transfusion
IVIg
Contraindication to phototherapy
Conjugated hyoerBil
Indications of exchange transfusion for hyperbil
High bil levels
Mostly for:
Hemolytic disease
G6PD deficiency
Indication for IVIg in hyperBil
Severe hyperbil, DAT+
Level of bil able tu cause kernicterus
340<
Lower if:
Sepsis, meningitis, hemolysis, hypoxia, acidosis, hypothermia, hypoglycemia, prematurity
Sx of kernicterus
15% asymptomatic
Early stage:
Lethargy, hypotonia, poor feeding, emesis
Mid stage:
Hypertonia, high-pitched cry, opistotonos, bulging fontanelle, seizures, pulmonary hemorrhage
Late stage:
Hypotonia, delayed motor skills, extrapyramidal abn (choreoathetoid), gaze palsy, mitral regurgitation, SNHL
Biliary atresia presentation
After first week of life
Dark urine, pale stool, jaundice
Persists > 2 weeks
Dx of biliary atresia
Conjugated hyperBil
Abd U/S
Operative cholangiogram
HIDA (bypass if time is critical)
Liver Bx
Tx of biliary atresia
Surgical drainage
Hepato-porto-enterostomy
Liver transplantation required in most cases
Diet enriched with medium-chain TG
Vitamin ADEK
Site of involvement in NEC
Terminal ileum and colon
RFs for NEC
Prematurity Asphyxia Shock Hyperosmolar feeds Enteral feeding with formula Sepsis
Protective factor: breast milk, early full enteral feeding
Sx of NEC
Onset: 2-3 wk of age
Distended abd
Increased gastric aspirate/vomitus with bile staining
Frank/occult blood in stool
Feeding intolerance
Diminished bowel sounds
Signs of bowel perforation: sepsis, shock, peritonitis, DIC
Inv for NEC
AXR CBC ABG Lactate Blood culture Lytes
AXR in NEC
Pneumonitis intestinalis (intramural air)
Free air
Fixed loops
Ileus
Thickened bowel wall
Portal venous gas
Tx of NEC
NPO (7-10d)
Vigorous IV fluid
Decompression with NGT
Supportive therapy
TPN
AB (ampi, genta+metro if risk of perforation x7-10d)
Serial AXR
If perforation: peritoneal drain/surgery
Surgical resection of necrotic bowel/complications
Presentation of Persistent pHTN of the newborn
Within 12 h of life
Severe hypoxemia, cyanosis
RFs for PPHTN
Asphyxia MAS RDS Sepsis Pneumonia Structural abn
More common in term/post-term infants
Inv for PPHTN
Pre- and post-ductal O2 levels
Hyperoxia test
ECG
Echo
Tx of PPHTN
Maintain good oxygenation (SaO2 > 95%)
O2 given early and tapered slowly
Minimize stress and metabolic demands
Maintain nl blood gases
Circulatory support
Mechanical ventilation
NO, surfactant
Extracorporeal membrane oxygenation
Tachypnea and tachycardia in newborn
RR> 60
HR> 160
Inv for respiratory distress in newborn
CXR
ABG
CBC, BG, B/C
ECG
RF for newborn pneumonia
Maternal fever
Prolonged/premature ROM
GBS positive mother
RDS RFs
Maternal DM PTB Male LBW Acidosis Sepsis Hypothermia Second born twin
Onset of RDS
First few hours
Worsens iver next 24-48 h
CXR of RDS
Homogenous infiltrates
Airbronchogram
Decreased lung volumes
May resemble pneumonia
Without lungs if severe
Prevention of RDS
Prenatal CS if risk of PTB <34 wk
Monitor L/S with AC (> 2: lung maturity)
Tx of RDS
Resuscitation
O2
Vent
Surfactant
TTN gestational age
Term, late preterm
RFs fir TTN
GDM
Maternal asthma
Male
Macrosomia (> 4500)
Elective cesarian
Short labor
Late PTB
Onset of Sx in TTN
First few hours of life
NO CYANOSIS
Retraction, nasal flaring, grunting
CXR in TTN
Perihilar infiltrates
Wet silhouette
Fluid in fissures
Prevention from TTN
Avoid elective Cesarian delivery, esp before 38 week GA
Tx of TTN
O2 if hypoxic
Vent
If too tachypneic to feed orally:
IV fluid
NGT feeding
In TTN when is recovery expected?
In 24-72 h
Meconium aspiration syndrome GA
Term, post-term
RFs for MAS
Meconium stained AF
Post-term delivery
Onset of MAS Sx
Within hours of life
Barrel chest in neonate
Diaphragmatic hernia
MAS
CXR in MAS
Hyperinflation
Patchy atelectasis
Patchy/coarse infiltrates
Pneumothorax
Prevention
If depressed at birth:
Intubate and suction below vocal cords
Avoidance of factors associated with in utero meconium passage
Tx of MAS
Resuscitate
Vent
O2
Surfavtant
Inhaled NO
ECMO if PPHN
Early onset sepsis in neonate, Definition, transmission
Within 72 h of birth
Vertical
Early onset sepsis in neonate, RFs
Maternal UTI, GBS+, previous child with GBS infection
Maternal fever/leukocytosis/chorioamnionitis
Prolonged ROM >18 h
PTB
Pathogens of Early onset sepsis in neonate,
E.Coli, GBS, Listeria
Most common infection in early onset neonatal sepsis
Pneumonia
Late onset neonatal sepsis definition
Onset at: 72h-28d
Acquired after birth
Most common pathogen in Late onset neonatal sepsis
Coagulase negative staph
Others:
GBS, anaerobes, E.Coli, Klebsiella
Most specific lab in sepsis?
WBC < 5
Degree of hypovolemia based on age
<2 yr:
Mild: 5% (of preloss body wt)
Mod: 10%
Sev: 15%
> 2yr:
Mild: 3%
Mod: 6%
Sev: 9%
Pulse changes in different levels of hypovolemia
Mild: Nl, full
Mod: rapid
Sev: rapid, weak
BP changes in different levels of hypovolemia
Mild: Nl
Mod: Nl-Decreased
Sev: decreased, shock (very late finding)
U/O changes in different levels of hypovolemia
Mild: decreased
Mod: markedly decreased
Sev: anuria
Oral mucosa changes in different levels of hypovolemia
Mild: slightly dry
Mod: dry
Sev: parched
Anterior fontanelle changes in different levels of hypovolemia
Mild: normal
Mod: sunken
Sev: markedly sunken
Eyes changes in different levels of hypovolemia
Mild: normal
Mod: sunken
Sev: markedly sunken
Skin turgor changes in different levels of hypovolemia
Mild: nl
Mod: decreased
Sev: tenting
Capillary refill changes in different levels of hypovolemia
Mild: Nl (<3s)
Mod: Nl-increased
Sev: increased (>3 s)
Inv for hypovolemia
If mod-sev: Urinalysis Lytes BUN, Cr ABG
Indications of IV rehydration
Severe dehydration
Inability to tolerate ORT: Vomiting Altered mental status Ileus Monosaccharide malabsorption Inability to provide ORT Failure of ORT in providing adequate rehydration
Tx of mild dehydration
ORT 50 ml/kg over 4 h
+ ORT for ongoing loss
+ age appropriate diet after rehydration
Tx of moderate dehydration
ORT 100 ml/kg over 4 h
+ ORT for ongoing loss
+ age appropriate diet after rehydration
Tx of severe dehydration
IV NS or RL, 20-40 ml/ kg bolus over 1 h
Repeat if necessary
Continue with ORT when stable
Replace ongoing loss
Age-appropriate diet after rehydration
Calculation of maintenance fluid
Per day: 100:50:20
Or
Per hour: 4:2:1
Common maintenance fluids for children
Should contain dextrose
Newborn:
D10W
First month of life:
D5W/0.45 NS + KCl 20mEq/L(if voiding well)
Children: D5W/NS + KCl 20 Or D5W/0.45NS + KCl 20 Bolus NS for dehydration
Na adjustment rate
12 mmol/L/d
When to monitor lytes daily in a child being treated for dehydration?
If > 50 % of daily fluid intake is via IV
Most common cause of ARF in children
HUS
Inv for HUS
CBC PBS BUN, Cr Lytes U/A S/C, verotoxin/shiga toxin assay
Mx of HUS
Mainly supportive: Nutrition Ventilation If symptomatic anemia: blood transfusion Dialysis if indicated
Hematuria definition
RBC > 5
Most common cause of GN in children
PSGN
GNs with decreased C3
PSGN
MPGN
SLE
Bacterial endocarditis
Abscess, Shunt nephritis
Cryoglobulinemia
GN with normal C3
IgA nephropathy
RPGN
Anti-GBM disease
HSP
PAN
GPA
Goodposture
Inv for GN
Urine R&M
First morning urine protein/creatinine ratio (nl < 200 mg/mmol)
BUN, Cr Lytes ABG CBC Alb C3/C4 ASOT/anti-hyaluronidase/anti-SK/anti-NAD/anti-DNAse B) ANA Anti-DNA ANCA IgA level Anti-GBM Renal Bx
Indications for renal Bx in GN
Acute renal failure
No evidence of strep infection
Normal C3,C4
Mx of GN
Treat underlying
Supportive:
Dialysis
Proper hydration
HTN:
Water/salt restriction (watch renal function)
Chronic persistent HTN:
ACEI, ARB
Edema:
Salt/fluid restriction
+/- Diuretics
CS if indicated:
IgA nephropathy
Lupus nephritis
…
Most common cause of nephrotic syndrome
Primary
Nephrotic definition
Proteinuria > 50 mg/kg/d
Inv for nephrotic
U/A: 3-4+ proteinuria
Urine microscopy
First morning urine alb/Cr ratio
Alb Lipid profile Lytes BUN, Cr Coagulation profile
CBC PBS C3/C4 ANA Hep B/C ASOT HIV Renal Bx
Indications of renal Bx in nephrotic
HTN
Gross hematuria
Decreased renal function
Low C3/C4
No response to CS after 4 wk
Frequent relapse (>2/6mo)
Presentation before first year of life
Presentation after 12 yr
PTT in nephrotic
Decreased
Mx of nephrotic
Varicella status should be known
Oral prednisone 2mg/kg/d up to 12 wk
If resistant:
Cytotoxic agents
Immunomodulators
High-dose CS pulse
Tx of nephrotic edema
Salt/fluid restriction
+/- diuretics
If anasarca:
Furosemide + alb
Tx of nephrotic hyperlipidemia
Resolves with remission
Limit fat intake
Statin if persistently nephrotic
Abn BP
If intravascular depletion: fluid
If persistent HTN: ACEI, ARB
Diet in nephrotic
No added salt
Monitor caloric intake
Ca, Vit D if on CS
Vaccines for nephrotic
Pneumococcal: at diagnosis
Varicella: after remission
Child with nephrotic, on CS, exposed to varicella
VZIG + acyclovir
Mx of hypercoagulability state in child with nephrotic
Mobilization
Avoid intravascular volume depletion and hemoconcentration
Prompt sepsis Tx
Heparin if thrombi
Relapse rate in nephrotic
2/3
Definition of HTN
sBP or dBP > 95th percentile on 3 or more occasions
Definition of preHTN
sBP or dBP > 90th percentile
Or > 120/80 at any age
Primary vs secondary HTN
Primary: 90% of adolescent (> 10yr) cases (esp if obese, positive FHx, mild)
Secondary: majority of childhood cases
RFs for primary HTN
Male FHx Obesity OSA African American Prematurity/LBW
RFs for secondary HTN
Hx of renal
Abd trauma
FHx of AI dis
Umbilical artery cath
Signs of secondary hypertentiin
Edema Abd bruit Differential 4 limb BP/ diminished femoral pulses Abd mass Goiter Skin changes Ambiguous genitalia
Inv for HTN
Urine dipstick Urine catecholamines Lytes BUN, Cr Renin, aldosterone levels
Echo
Abd U/S
Renal radionuclide scarring
Other tests based on findings
Mx of HTN
Tx underlying
LSM: Wt reduction Exercise Salt restriction Smoking cessation
Thiazides
Mx of EOD
Cosider referral to specialist
Mx of hypertensive emergencies
Hydralazine
Labetalol
Sodium nitroprusside
Pediatric BP calculation
sBP: Age x 2 + 90
dBP: 2/3 x sBP
Inv for epilepsy
CBC,diff
Na, K, Cl, Mg, Ca,
BG
Toxicology
EEG
CT/MRI (if FND, not returned to baseline several hours after seizures)
LP (if first-time, non-febrile)
Cardiac disorders often misdiagnosed as seizures
Hypertrophic CMP
Long QT syndrome
Infantile spasm
Brief flex/ext
10-30 sec
In clusters
Developmental delay
Onset: 4-8 mo
EEG: hypsarrhythmia
Tx of infantile spasm
ACTH
Vigabatrin
BDZ
Prognosis of infantile spasm
20% idiopathic with good Tx response
80% metabolic/encephalopathic/neurocutaneous/developmental abn reasons with poor response to Tx
Lennox-Gastaut triad
Multiple seizure types
Diffuse cognitive dysfunction
Slow generalized spikes and slow wave EEG
Other features:
Onset: 3-5 y
Underlying encephalopathy/brain malformation
Tx of Lennox-Gastaut
Valp
BDZ
Ketogenic diet
Juvenile myoclonic epilepsy
Onset: 12-16 y
AD
Esp in morning
Frequently presents as GTC
EEG: 3.5-6 Hz, irregular spike and wave, increased with photic stimulation
Mx of juvenile myoclonic seizure
Lifetime Valp
Childhood absence seizure
<30 sec
No post-ictal
Onset: 6-7 yr
Strong genetic predisposition
F>M
EEG: 3 Hz spike and wave
Mx of absent seizures
Valp
Ethosuximide
Benign focal epilepsy of childhood with Rolandic/Centrotemporal spikes
Focal motor (tongue, mouth, face, upper ext)
Usually in sleep-wake transition state
Conscious but aphasic post-ictally
Onset: 5-10 y
EEG: spikes in centrotemporal area, normal background
Prognosis of Rolandic seizure
Spontaneous remission in adolescence without sequla
Prognosis of absence seizure
Spontaneously resolves or becomes generalized
Mx of rolandic seizures
If infrequent: none
If frequent: carba
Mx of seizures
Education (precautions: buddy system, shower instead of bath…)
Indication for meds:
> 2 unprovoked, afebrile seizures within 6-12 mo
Start with 1 drug and increase dose
Switch over to another if not controlled
Add a second if not controlled
When to D/C AED?
If > 2 yr seizure free, taper over 4-6 mo
Indication for ketogenic diet in seizure control
If no response to polytherapy
Or
Who do not wish to take meds
VALP IS CONTRAINDICATED IN CONJUNCTION WITH KETOGENIC DIET: increased hepatotixicity
Age of febrile seizure
6mo - 6 yr
Features of febrile seizures
M> F
Associated illness/fever
FHx
No Hx of afebrile srizure
No evidence of CNS infection/inglammation
Typical febrile seizures?
Duration < 15 min
GTC
No recurrence in 24 h
No neurological impairment/developmental delay before/after seizures
Atypical/complex febrile seizures?
Duration > 15 min
Focal onset or focal features
> 1 seizures/24 h
Previous neurological impairment or neurological deficit after seizure
W/U for febrile seizure
If typical febrile seizures, only determine source of fever
Septic W/U:
Including LP: Strongly consider if child < 12 mo, Consider if 12-18 mo, only if meningeal signs in child > 18 mo
EEG/CT/MRI: only if atypical febrile seizure, or abn neurologic findings
Mx of febrile seizures
Counsel and reassure
Antipyretics
Fluids
If high risk of recurrence or prolonged seizure: have rectal or sublingual lorazepam at home
Treat underlying cause of fever
Prognosis of febrile seizures
No brain damage
Very small risk of developing epilepsy
33% chance of recurrence
Px with AED NOT RECOMMENDED
Seizures with positive family Hx
Juvenile myoclobic epilepsy (AD)
Febrile seizures
Absence
Headache red flags
First and worst headache of their life
Sudden onset
FND
Constitutional Sx
Worse in morning
Worse with bending over, coughing, straining
Change in LOC
Sudden mood change
Pain wakes pt
Fatigue
Affecting school attendance
Inv for headache
If red flags: CT, MRI
Postural movements showing hypotonia
Traction response
Axillary suspension
Ventral suspention
Inv for hypotonia
Lytes ABG Blood glucose CK Serum/urine investigations for metabolic etiologies MRI/MRA if indicated EMG, muscle Bx/NCS Chromosomal analysis, genetic testing, Metabolic testing Neuromuscular testing
Cerebral palsy
Non progressive
Central motor impairment
Insult to/anomaly of immature CNS
10% intrapartum asphyxia
10% post natal insult
Associated with LBW
No etiology in 1/3
Sx of CP
Delay in motor milestone
Developmental delay
Learning disability
Visual/hearing impairment
Seizure
Microcephaly
Uncoordinated swallow (aspiration)
Inv for CP
Metabolic screen
Chromosome studies
Serology
Neuroimaging
EMG, EEG
Ophthalmology assessment
Audiology
Mx of CP
Multidisciplinary
Orthopedic
Symptomatic
Signs of URT disease, above thoracic inlet
Inspiratory stridor
Suprasternal retraction
Croup location
Subglottic laryngitis
Croup age
<6 yr
Peak 7-36 mo
Croup virus
Mostly Parainfluenza
Inv for croup
Clinical Dx
If atypical presentation: CXR: steeple sign
Emergency in croup
Stridor at rest
Tx of croup
Dexa, PO 1 dose
Racemic epinephrine: nebulized, 1-3 dose, q 1-3 h
If unresponsive: intubate
The most common pathogen of tracheitis
S. Aureus
Dx of bacterial tracheitis
Clinical
Definitive Dx: endoscopy
Tx of bacterial traceitis
Intubation
IV AB
Most common pathogen of epiglottitis
H. Influenza
Age of bacterial traceitis
All ages
Age of epiglotitis
2-6 y
Tripod position
Epiglotitis
Inv for epiglotitis
Clinical
AVOID EXAMINING THROAT
Tx of epiglotitis
Intubation
AB
Sign of airway obstruction below thoracic outlet
More expiratory sounds
Wheezing
DDx of wheezing
Asthma:
Recurrent wheezing
> 6 y
Identifiable trigger
Bronchiolitis:
First episode of wheezing
Usually <1 y
Recurrent aspiration
Pneumonia
Foreign body:
Acute
Unilateral
CF:
Prolonged
Unresponsive to therapy
BPD CHF Mediastinal mass Bronchiolitis obliterans Tracheobronchial anomalies
Most common age for pneumonia
< 1y
Pneumonia pathogens
<5 yr : viral
CXR of viral pneumonua
Diffuse streaky infiltrates bilaterally
CXR of bacterial pneumonia
Lobar consolidation
Pleural effusion
Mx of pneumonia
Hydration
Antipyretics
Humidified O2
Peak incidence of bronchiolitis
At 6 mo
Bronchiolitis and risk if asthms
Increases incidence of asthma
Most common etiology of bronchiolitis
RSV
Sx of bronchiolitis
Prodrome of URTI
Wheezing, crackles, respiratory distress
Peak: at 3-4 d
Inv for bronchiolitis
CXR if:
Severe
Poor responsive to treatment
Chronic
NP swab: IF for viral Ag
WBC
CXR of bronchiolitis
Air trapping
Peribronchial thickening
Atelectasis
Increased linear markings
Tx of bronchiolitis
Self limiting
Mild-mod: Supportive: PO/IV hydration Antipyretic Regular/humidified high-flow O2
Sev:
Supportive
+/- intubation/ventilation
+/- ribavirin
Indication for ribavirin in bronchiolitis
BPD
CHD
Congenital lung disease
ImmDef
Px against RSV
Monthly palivizumab (RSV-Ig) for high-risk group:
Infants born before 29 wk GA
Infant born before 32 wk with chronic lung disease of maturity
Infant with hemodynamically significant heart disease
Children with pulmonary abn
Neuromuscular disease (impaired ability to clear secretions)
Children < 2 yr who are profoundly ImComp
Recommended for the 1st year of life. Up to 5 monthly doses. (Nov-Apr)
Tx with no benefit in bronchiolitis
CS
Bronchodilators
Ipratropium bromide
Indications for hospitalization of bronchiolitis
O2 sat < 92%
Persistent resting tachypnea (>60) and retraction after several salbutamol masks
PMHx if: chronic long disease, hemodynamically significant cardiac disease, neuromuscular problem, immunocompromised
<6mo unless extremely mild
Significant feeding problem
Social problem
Common causes of pneumonia in neonates
Viral: CMV, HSV
Bacterial: GBS, E.Coli, Listeria
Tx of pneumonia in neonates
Ampicillin + genta/tobra
+ erythro if suspect chlamydia
Common causes of pneumonia in 1-3 mo
S. Aureus
H. Influenza
S. Pneumonia
B. Pertussis
Viral: CMV, RSV
Pneumonia Tx in 1-3 mo
Cefuroxime/ampicillin
+/- erythromycin or clarythro
Common causes of pneumonia in 3mo-5yr
S. Pneumoniae
S. Aureus
H. Influenza
GAS
Viral: RSV, adeno, inf
Tx of pneumonia in 3mo-5y
Amoxi Or Ampi Or Cefuroxime
Common causes of pneumonia in >5y
S. Pneumonia
H. Inf
S. Aureus
Viral: influenza, varicella
Tx of pneumonia in > 5y
Erythromycin
Clarythro
Ampi
Cefuroxime
Acute asthma Mx
O2 (keep O2sat > 94%)
Fluid if dehydrated
Salbutamol q20 min
Ipratropium bromide if severe q20 min
Steroid x 5d PO (IV if severe)
Chronic asthma Mx (LSM)
Education
Emotional support
Avoid allergens or irritants
Develop action plan
Exercise program
Monitoring with peak flow meter
PFT for > 6 yr
Chronic asthma meds:
Reliever therapy: SABA
First line controller therapy: low dose of daily ICS
Second line controller therapy:
<12 yr: mod dose of ICS
>12 yr: add Leukotriene receptor antagonist Or LABA
If no response to 1st and 2nd line Tx:
Injection
Immunotherapy
SABA dosage in acute Mx of asthma
<20 kg: 5 puff q 20 min x 1 hr
> 20 kg: 10 puff q 20 min x 1 hr
Ipratropium bromide dosage in acute Mx of asthma
<20 kg: 3 puff
> 20 kg: 6 puff
q 20 min
Indications for hospitalization of asthma
Ongoing need for supplemental O2
Persistently increased work of breathing
B2-agonist needed > q4h after 4-8 h of conventional therapy
Pt deteriorates while on systemic CS
Acute asthma attack discharge
If pt asymptomatic for 2-4 h after last dose
Adequate control of asthma?
Daytime symptoms < 4 d/wk
Night time symptoms < 1 n/wk
Normal physical activity
Mild and infrequent exacerbations
No work/school absenteeism
Need for B-agonist < 4 doses/wk
FEV1 or PEF > 90% of personal best
PEF diurnal variation < 10-15%
Antenatal bowel perforation
CF
Microorganisms causing recurrent chest infection in CF
S. Aureus
P.aeroginosa
H. Influenza
Inv for CF
Sweat chloride test x2 (abn: >60 mEq/L)
3d fecal fat collection
Genetic testing if sweat chloride test was equivocal
Sputum S/C
CXR
False negative sweat chloride test
Technical problem
Malnutrition
Skin edema
Mineralocorticoids
False positive sweet chloride test
Malnutrition
Atopic dermatitis
Hypothyroidism
Hypopara
Glycogen storage diseases
Adrenal insufficiency
G6PD
Kleinfelter Sx
Technical issues
Autonomic dysfunction
Familial cholestasis syndrome
Mx of CF
High calorie diet
Pancreatic enzymes
Fat soluble vitamins supplementation
Chest disease: Chest physio Postural drainage Exercise Bronchodilators Aerosolized DNAase Inhaled hypertonic saline AB (depending on sputum C&S) Lung transplantation
Genetic counseling
Inv for rheumatologic diseases
CBC, diff Blood smear ESR, CRP Xray ANA RF B/C Viral/bacterial serology CK PTT SCD screening Igs Complement U/A Synovial fluid (cell count, gram stain, culture) TB test Imaging BMA Slit lamp exam
Growing pain age
2-12 yr
M=F
Dx of exclusion
Characteristics of growing pain
Intermittent
Non-articular
Normal PEx
Pain at night
Often bilateral
Calf, shin, thigh
Short-lived
Relieved by heat, massage, mild analgesics
Asymptomatic during day
Well
No functional limitation
Possible FHx
Mx of growing pain
No lab if typical presentation
Supportive
Reassurance
Red flags for limb pain
Fever
Pinpoint pain/tenderness
Pain out of proportion to degree of inflammation
Night pain
Wt loss
Erythema
Age of transient synovitis of the hip
3-10 yr
M> F
Rt> Lt
Sx of transient synovitis of hip
Afebrile/low fever. Not toxic
Pain in hip, knee (referral)
Painful limp
Full ROM
Pain not disabling
Gradually worsens over few days
Can be sudden
Resolves over 7-10
Inv for transient synovitis
WBC
ESR, CRP
Joint U/S (to see effusion)
If suspicious for septic arthritis: aspirate joint
If suspicious for osteomyelitis/periarticular pyomyositis: MRI
Dx of exclusion
Tx of transient synovitis of hip
Symptomatic
Anti-inflammatory meds
Usually resolves within 24-48 h
Complication of transient synovitis of hip
Legg-calve-perthes
Septic arthritis pathogen in neonates
GBS, GNB, S. Aureus
Septic arthritis pathogen in 1-3mo
Strep Staph H. Inf GBS GNB
Septic arthritis pathogen in child
S. Aureus
S. Pneumoniae
GAS
Septic arthritis pathogen in adolescents
S. Aureus
S. Pneumoniae
GAS
N. Gonorrhea
Septic arthritis pathogen in SCD
S. Aureus
S. Pneumoniae
GAS
Salmonella
Tx of septic arthritis in neonate
Cloxa + genta
Or
Cloxa + cefotaxime
Tx of septic arthritis in 1-3mo
Cloxacillin + cefotaxime/cefuroxime
Tx of septic arthritis in child
Cefazolin OR cloxa OR clinda
Tx of septic arthritis in adolescent
Ceftriaxone/cefixime + azithro
Tx of septic arthritis in SCD
Cefotaxime
JIA Dx
At least 1 joint
At least 6 wk
Age < 16 yr
Exclusion of other causes
Classification by features in the 1st 6 mo of disease
Still’s disease (systemic arthritis)
M=F
Fever spikes:
Once/twice daily
>38.5
At least 2 d/wk
Unwell during fever episodes
Rash:
Erythematous salmon-colored
LAP
HSM
Leukocytosis
Thrombocytosis
Anemia
Serositis
Arthritis:
May occur weeks to month later
High ESR, CRP
Oligoarticular arthritis
1-4 joints
Onset < 5 yr
F>M
Large joints: knee(most common), elbow, wrists
ANA+ (60-80%)
RF-
Asymptomatic anterior uveitis
Most common type of JIA
Oligo
Complications of oligoarticular JIA
Knee flexion contracture
Quadriceps atrophy
Leg length discrepancy
Growth disturbance
Uveitis
Polyarticular arthritis
ANA+ in 50%
Uveitis in 10%
RF negative (usually negative): Onset: 2-4 yr, 6-12 y F>M Symmetrical involvement Large to small joints of hands and feet, TMJ, cervical spine
RF positive: Late childhood/early adolescence F>M Severe Rapidly destructive Symmetrical Large and small joints Reumatoid nodules Unremitting Persists into adulthood
Enthesitis-related arthritis
Late childhood/adolescence
M>F
Enthesitis/arthritis
Wt-bearing joints (esp hip, intertarsals)
Risk of ankylosing spondylitis in adulthood
Psoriatic arthritis
Onset: 2-4 yr, 9-11 yr
F>M
Dactylitis
Nail pitting
FHx of pso in 1st degree
Asymmetric/symmetric small/large joints involvement
Mx of JIA
Exercise:
To maintain ROM, muscle strength
OT/PT Social work Orthopedics Ophthalmology Rheumatology
1st line meds:
NSAIDs
Intra-articular CS
2nd line:
DMARDs (MTX, Sulfasalazine, leflunamide)
CS (acute Mx of severe arthritis, systemic symptoms, topical for eye)
Biologics
Reactive arthritis
Typically the knee
Following salmonella/shigella/yersinia/campylo/chlamydia
Or
Following Strep
Highest incidence of lyme in children at age?
5-10 yr
SLE
F>M
More commonly Age>10
Children have: More active disease More likely to have renal disease More intensive drug therapy Poorer prognosis
Most common vasculitis of childhood
HSP
Peak incidence of HSP
4-10 yr
M>F
How long after URT infection does HSP happen?
1-3 wk
HSP clinical triad
Palpable purpura
Abd pain
Arthritis
Scrotal swelling
HSP
HSP arthritis
Large joints
Renal involvement in HSP
Microscopic hematuria
Proteinuria
HTN
RF (<5%)
IgA nephropathy
Inv for HSP
U/A (blood, ACR)
Urea, Cr
Lytes
Alb
IgA (elevated)
Skin/renal Bx
U/S (intussusception, scrotal pain/swelling)
R/O other AI conditions
Mx of HSP
Mainly supportive:
Elevation for edema…
Monitor proteinuria, BP q mo x 6 mo
Check for renal disease
Anti-inflammatory meds for joint pain
CS for selected pts
Immunosuppressive therapy if severe renal disease
Prognosis of HSP
Self-limited
Resolution within 4 wk
Recurrence in 1/3
Long-term prognosis depends on severity of nephritis
Most common cause of acquired heart disease in children in developing countries
Kawasaki
Size of vessels involved by Kawasaki
Medium
Peak age of kawasaki
3mo-5yr
Asian>Black>Caucasians
Dx criteria of Kawasaki
Fever persisting 5 d or more
And 4 of:
Bilateral, non-exudative conjunctival injection
Oral mucous membrane changes
Changes of peripheral ext
Polymorphous rash
Cervical LAP > 1.5 cm USUALLY UNILATERAL
Atypical Kawasaki
Fever at least 5 d
Plus 2-3 of symptoms
ESR, CRP
Mx of Kawasaki
Initial therapy:
IVIg + high dose ASA
Once afebrile > 48h:
Low-dose of ASA until plt normalize. Longer if coronary artery involvement
Baseline echo and F/U echo at 2,6 wk
Time of IVIg treatment to prevent coronary artery disease in Kawasaki
10 d
RFs for coronary artery disease in Kawasaki
Male
Age<1 yr, > 9yr
Fever > 10d
Asian or hispanic
Thrombocytopenia
Hyponatremia
