Pediatrics Flashcards
What two therapies should be given to a newborn at the time of delivery?
- 0.5% erythromycin ophthalmic ointment
2. 1 mg vitamin K intramuscular injection (prevent hemorrhagic disease)
What are the clotting factors and anticoagulant factors that are vitamin K dependent? (6)
- factor II (2)
- factor VII (7)
- factor IX (9)
- factor X (10)
- protein C
- protein S
What steps in management should occur in a newborn after delivery prior to discharge from hospital?
1a. hep B vaccine if mom Hep B negative
1b. hep B vaccine with hep IVIG if mom Hep B positive
2. hearing test (congenital sensorineural hearing loss)
3. neonatal screening test (after 48 hours; tests for PKU, galactosemia, hypothyroidism)
What is the purpose of APGAR scores?
measure need (1-minute) and effectiveness (5-minute) of resuscitation/ therapy
A newborn who has blue/ gray macules on presacral back or posterior thigh most likely suffers from …. and the next step in management is ….
Monoglian Spots (fade after first few years); rule out abuse
A newborn presents with firm yellow-white papules/ pustules with an erythematous base which peaks on the second day of life most likely suffers from …
Erythema Toxicum
tx: none bc self limited
A newborn presents with a permanent unilateral vascular discoloration/ malformation on their head and neck most likely suffers from … and the best treatment is ….
Port Wine Stain (nevus flammeus); pulsed laser therapy
What disease is associated with the presence of a port wine stain?
Sturge-Weber syndrome
AV malformation resulting in seizures, mental retardation, glaucoma and port wine stain
What is the next best step in management of a infant/ child with a port wine stain after pulsed laser therapy?
evaluate for glaucoma and start anticonvulsants
A newborn presents with red, sharply demarcated raised lesions appearing in the first 2 months, rapidly expanding and then involuting by age 5-9 years old most likely suffers from …
Hemangioma
Can involve internal organs and result in high output cardiac failure
What is the best treatment for hemangioma?
Steroids or pulsed laser therapy (if large or interferes with organ function)
What is the next best step in management for an infant who presents with preauricular tags/ pits? (2)
- Hearing test ( assess for hearing loss)
2. Kidney ultrasound (assess for genitourinary abnormalities)
What disorder is associated with a defect in the iris known as coloboma of the iris?
CHARGE syndrome (coloboma, heart defects, atresia of nasal choanae, growth retardation, genitourinary abnormalities, ear abnormalities)
What disorder is associated with an absence of the iris known as aniridia?
Wilma tumor (WAGR syndrome- wilms tumor, aniridia, genitourinary anomalies, mental retardation)
What is the next best step in management of an infant presenting with an absence of the iris/ aniridia?
Abdominal ultrasound every 3 months until age 8 (to assess for Wilms tumor)
An infant presenting with a neck mass that is lateral to the midline most likely suffers from …
Branchial cleft cyst (remnant of embryonic development associated with infections)
An infant presenting it with a neck mass that is midline and moves with swallowing or tongue protrusion most likely suffers from ….
Thyroglossal duct cyst (occurs anywhere along Thyroglossal tract which forms form descent of primordial thyroid gland)
What is the next best step in management of an infant presenting with a Thyroglossal duct cyst?
Thyroid scan and thyroid function test (to assess for thyroid ectopia) followed by surgical removal (associated with infections)
An infant presents with GI tract protrusion through the umbilicus with a sac covering the intestinal content most likely suffers from …
Omphalocele (failure of GI tract to retract at 10-12 weeks gestation)
(associated with chromosomal abnormalities)
What is the next best step in management for an infant presenting with an omphalocele after specifically treating the omphalocele with a silo, TPN and antibiotics?
screen for trisomy 13, 18 and 21
An infant presenting with abdominal defect in which intestinal content are protruding lateral to the midline without a sac covering most likely suffers from … and is associated with …
Gastroschisis; intestinal atresia
What is the next best step in management of an infant presenting with an umbilical hernia (congenital weakness where vessels of the fetal and infant umbilical cord exited thru the rectus abdominis muscle)?
obtain TSH level (screen for associated congenital hypothyroidism)
A male infant presenting with scrotal swelling that transilluminates most likely suffers from …
Hydrocele (must differentiate from inguinal hernia)
What is the next best step in management of an infant presenting with undescended testes (unilateral absence of testes in scrotal sac)?
no treatment until 1 year of age, treatment can be:
- hormone injections (beta HCG or testosterone)
- orchiopexy (surgery)
A male infant presents with urethral opening on the ventral surface of the penis most likely suffers from …. and … should be avoided
hypospadias; circumcision
A male infant presents with urethral opening on the dorsal surface of the penis most likely suffers from … and the next best step in management is…
epispadias; surgical evaluation for bladder exstrophy (associated with urinary incontinence)
A male infant presenting with an inguinal bulge or reducible scrotal sac swelling most likely suffers from …
Inguinal hernia
tx surgically
What is the best initial diagnostic test for an infant that presents large for gestation, plethora, jitteriness, prolonged delivery with birth trauma (shoulder dystocia), macrosomia and cardiac abnormalities?
blood glucose
likely infant of diabetic mother
What is the best treatment for a symptomatic infant of a diabetic mother?
glucose and small, frequent meals
What are the five lab abnormalities associated with an infant of a diabetic mother?
- hypoglycemia (bc hyperinsulinemic)
- hypocalcemia
- hypomagnesemia
- hyperbulirubinemia
- polycythemia
What is the best initial diagnostic test for an infant with respiratory distress?
Chest X-ray
(other tests are ABG, blood cultures, blood glucose for hypoglycemia, CBC for anemia/ polycythemia, cranial ultrasound for intracranial hemorrhage)
What is the best initial treatment for an infant with respiratory distress?
- oxygen to keep SaO2 > 95%
- nasal CPAP if high O2 requirement (prevents barotrauma and bronchopulmonary dysplasia)
- empiric antibiotics (if suspected sepsis)
On the CCS, if an infant presents with respiratory distress and doe not improve with oxygen, what is the next best step in management?
evaluate for cardiac causes of hypoxia (ECHO for congenital heart defects)
A premature infant develops tachypnea, nasal grunting, and intercostal retractions within hours of birth with associated hypoxemia, hypercarbia and respiratory acidosis most likely suffers from…
Respiratory Distress Syndrome
What is the best predictive test for respiratory distress syndrome in an infant and what is the most effective treatment for respiratory distress syndrome in an infant?
lecithin-sphingomyelin (L/S) ratio on amniotic fluid prior to birth; exogenous surfactant administration
(best initial test: chest X-ray; best initial tx: oxygen & nasal CPAP)
At what point in pregnancy do type II pneumocytes start to produce surfactant and at what point is there sufficient amount of surfactant?
24 weeks gestation; 35 weeks gestation
What are three steps of management that can be done as primary prevention for respiratory distress syndrome in an infant?
- antenatal bethamethasone (if >24 hours before delivery and
What are the three possible complications associated with respiratory distress syndrome in infant?
- retinopathy of prematurity (due to hypoxemia)
- bronchopulmonary dysplasia (due to prolonged high concentration oxygen)
- intraventricular hemmorhage
A term infant presents with tachypnea after being delivered by cesarean section or after a rapid second stage of labor most likely suffers from …. which is due to …
Transient Tachypnea of the Newborn (TTN); retained lung fluid
What is the diagnostic test for transient tachypnea of the newborn and its associated findings?
Chest X-ray showing air trapping, fluid in fissures, perihilar streaking
What is the best initial treatment for transient tachypnea of the newbown?
oxygen (improvement within hours or days)
A full term neonate presents with severe respiratory distress, hypoxemia, hypoxia/ fetal distress in utero, and chest X-ray findings of patchy infiltrates, increased A-P diameter (barrel chest) and flattening of diaphragm most likely suffers from …
Meconium Aspiration
complications: pulmonary artery hypertension, air leak (pneumothorax, pneumomediastinum), aspiration pneumonitis
What is the treatment for meconium aspiration?
- positive pressure ventilation
- high frequency ventilation
- nitric oxide therapy
- extracorporeal membrane oxygenation
What is the best step in management to prevent meconium aspiration?
endotracheal intubation and airway suction of depressed infants
An infant presents with respiratory distress and scaphoid abdomen most likely suffers from …
Diaphragmatic hernia
What is the best initial diagnostic test for suspected diaphragmatic hernia and what is the associated finding?
Chest X-ray showing loops of bowel in chest
What is the best initial treatment for diaphragmatic hernia?
immediate intubation followed by surgical intubation
What disorders are associated with meconium plugs (meconium stuck in lower colon resulting in intestinal obstruction)? (4)
- small left colon in infant of diabetic mother
- hirschsprung disease
- cystic fibrosis
- maternal drug abuse
What disorder is associated with meconium ileus (meconium stuck in lower ileum resulting in intestinal obstruction)?
Cystic fibrosis
What is the best initial diagnostic test for suspected meconium plugs/ ileus causing intestinal obstruction?
Abdominal X-ray
What is the best treatment for meconium ileus?
gastrograffin enema
An infant born term with no complications presnts with choking, drooling and gagging with the first feeding followed by developing respiratory distress with an infiltrate on chest x-ray most likely suffers from …
Tracheoesophageal fistula
incomplete division of cranial part of foregut into respiratory and esophageal parts at 4 weeks gestation
What is the best diagnostic test for suspected tracheoesophageal fistula?
nasogastric tube placement resulting in tube coiling in chest
What are the disorders are included in VACTERL syndrome?
- vertebral defects
- anal atresia
- cardiac defect
- tracheoesophageal fistula with esophageal atresia
- radial and renal abnormalities
- limb syndrome
A premature infant born via normal vaginal delivery develops vomiting of gastric and bilious material with initial feed, has a history of polyhydramnios on prenatal exam and is found to have a double bubble on abdominal x-ray most likely suffers from …
duodenal atresia
failure to re-form lumen during duodenal development
What is the treatment for duodenal atresia?
nasogastric decompression and surgical correction
What disorder is associated with duodenal atresia?
Down Syndrome
What are the four disorders associated with a double bubble sign on abdominal x-ray?
- duodenal atresia
- annular pancreas
- malrotation
- volvulus
A premature infant who had low APGAR scores at birth develops bloddy stools, apnea, and lethargy when feeding is started and may have associated with abdominal wall erythema and distension most likely suffers from ..
Necrotizing Enterocolitis
increased risk with formula feeding; greatest risk factor is prematurity
What is the best initial diagnostic test for suspected necrotizing enterocolitis?
abdominal x-ray showing pneumatosis intestinalis (gas cysts in bowel wall instead of lumen)
What is the best initial therapy for necrotizing enterocolitis?
- stop all feeds
- decompress gut
- broad spectrum antibiotics
- surgical resection if needed
What is the best initial test for an infant who fails to pass meconium?
rectal examination
For an infant who fails to pass meconium in the initial 24-48 hours. a patent rectum with passage of a large voluminous stool after digital exam suggests that the infant most likley suffers from …
Hirschsprung disease
absence of ganglionic cells in intestine
What is the best confirmatory test for hirschsprung disease and the treatment for hirschsprung disease?
rectal biopsy (absent ganglionic cells); surgical recontruction
What is the next best step in management of an infant who fails to pass meconium after performing a rectal examinaton?
barium enema
assess for megacolon proximal to obstruction
An infant who fails to pass meconium and has an absent anal opening on rectal examination most likely suffers from… and treatment is ….
Imperforate anus; surgical reconstruction
What are five indications that suggest that hyperbilirubinemia in a newborn is pathologic instead of physiologic?
- appears in first day of life
- bilirubin rises > 5 mg/dL/ day
- bilirubin > 12 mg/dL at any time
- direct bilirubin > 2mg/dL at any time
- present after 2nd week of life
What are the two main reasons for physiologic jaundice in a newborn?
- low levels of glucuronosyltransferase (unable to conjugate for excretion)
- shorter life span of RBCs
What diagnostic tests should be performed in a newborn with jaundice present in the first 24 hours?
- bilirubin level (total and direct)
- blood type of infant and mother (assess for ABO or Rh incompatibility)
- direct coombs test
- CBC, reticulocyte count, blood smear (assess for hemolysis)
- urinalysis and urine culture if elevated direct bilirubin (assess for sepsis)
What diseases should be considered if there is prolonged jaundice (> 2 weeks) with no elevation in conjugated bilirubin in a neonate?
- UTI or other infection
- bilirubin conjugation abnormality (Gilbert’s syndrome, Criglre-Najjar syndrome)
- hemolysis
- intrinsic red cell membrane or enzyme defects (G6PD deficiency, pyruvate kinase deficiency, spherocytosis)
What is the likely cause of prolonged jaundice (> 2 weeks) with elevation in conjugated bilirubin in a neonate?
cholestasis
What is the best initial diagnostic test for prolonged jaundice (> 2 weeks) with elevation in conjugated bilirubin in a neonate?
liver function tests
What is the most specific test for prolonged jaundice (> 2 weeks) with elevation in conjugated bilirubin in a neonate?
ultrasound and liver biopsy
A neonate with jaundice develops hypotonia, seizures, opisthotonos, delayed motor skills, choreoathetosis and sensorineural hearing loss most likely suffers from …
Kernicterus (due to elevated indirect bilirubin crossing BBB and depositing in basal ganglia and brainstem nuclei)
What is the treatment for kernicterus?
immediate exchange transfusion
What is the treatment for hyperbilirubinemia?
- phototherapy when bilirubin > 10-12 mg/dL (reduces by 2 mg/dL every 4-6 hours)
- exchange transfusion if suspected bilirubin encephalopathy or failure of phototherapy
What are the 5 steps in management included in a sepsis workup?
- CBC with differential
- blood culture
- urinalysis and urine culture
- chest x-ray
- followed by antibiotics
What is the most common cause of early onset sepsis (within the first 24 hours) in a newborn and the likely organisms that cause it?
pneumonia
- group B strep (beta hemolytic gram positive)
- E. coli (gram negative rod)
- Haemophilus influenza (gram negative coccobacillus)
- listeria (gram positive, motile with flagella)
What are the most common cause of late-onset sepsis (after first 24 hours) in a newborn and the likely organism that cause it?
meningitis and bacteremia
- Staph aureus (gram positive coccus)
- E. Coli (gram negative rod)
- Klebsiella (gram negative, oxidase negative rod)
- Pseudomonas (gram negative aerobic)
What antibiotics are given as empiric therapy for neonatal sepsis until 48-72 hours cultures are negative?
ampicillin and gentamicin
add cefotaxime if meningitis
An infant presents with intrauterine growth retardation, hepatosplenomegaly, jaundice, mental retardation, and hydrocephalus with generalized intracranial calcifications and chorioretinitis most likely suffers from …
Toxoplasmosis congenital infection
dx: IgM against toxoplasmosis
An infant presents with intrauterine growth retardation, hepatosplenomegaly, jaundice, mental retardation, cataracts, deafness, heart defects, and extramedullary hematopoiesis (blueberry muffin spots) most likely suffers from …
Rubella congenital infection
dx: IgM against rubella if mother’s status negative or unknown
An infant presents with intrauterine growth retardation, hepatosplenomegaly, jaundice, mental retardation, microcephaly with periventricular calcification, petechiae with thrombocytopenia, and sensorineural hearing loss most likely suffers from …
CMV congenital infection
dx: serum CMV IgM antibodies; urine/saliva CMV culture
An infant presents with intrauterine growth retardation, hepatosplenomegaly, jaundice, mental retardation, pneumonia/ shock in the first week, skin vesicles and keratoconjunctivitis in the second week, and acute meningoencephalitis during the 3rd to 4th week most likely suffers from …
Herpes congenital infection
What is the best initial test and the most specific test for herpes congenital infection?
Tzanck smear/ culture; HSV PCR
An infant presents with intrauterine growth retardation, hepatosplenomegaly, jaundice, mental retardation, osteochondritis, periostitis, desquamating skin rash of palms and soles, and snuffles (mucopurulent rhinitis) most likely suffers from …
Syphillis congenital infection
What is the best initial test and the most specific test for syphillis congenital infection?
VDRL screening; IgM-FTA-ABS
An infant presents with intrauterine growth retardation, hepatosplenomegaly, jaundice, mental retardation, limb hypoplasia, cutaneous scars, and seizures most likely suffers from…
Varicella congenital infection
What is the best initial test and the most specific test for varicella congenital infection?
IgM serology; PCR of amniotic fluid
An infant presenting with subtle repetitive movements (chewing, tongue thrusting, apnea, staring, blinking, desaturations), ocular deviations and failure of jitteriness to subside with stimulus (such as passive movement of limb) most likely suffers from …
Seizures
tonic-clonic movements uncommon in neonates
What is the best treatment for an acute seizure in a neonate?
lorazepam or diazepam rectally
What is the diagnostic work-up for neonatal seizures?
- EEG (likely normal)
- metabolic testing (CBC, electrolytes, calcium, magnesium, glucose)
- amino acid assay and urine organic acids (inborn errors of metabolism and pyridoxine deficiency)
- infectious (total cord blood IgM screening for TORCH, blood and urine cultures, lumbar puncture if meningitis)
- head ultrasound in premature (intraventricular hemorrhage cause seizures 2-7 days after birth)
What is the best initial treatment for absence seizures?
ethosuximide
What are the four substances used by a mother during pregnancy that results in withdrawal symptoms (hyperactivity, irritability, fever, diarrhea, tremors, jitters, high pitched crying, sneezing, restlessness, vomiting, nasal stuffiness, poor feeding, seizures, tachypnea) within the first 48 hours of life?
- heroin
- cocaine
- amphetamine
- alcohol