Pediatrics Flashcards
At what point should an infant have regained her birthweight after initial weight loss?
What about at 4 months, 12 months, and 24 months?
2 weeks
double by 4 months
triples at 12 months
quaduples at 24 months
How much weight should a child gain per year?
from 2-13 years, weight gain is about 5 pounds per year
inadequate weight gain
poor food intake chronic vomiting or diarrhea malabsorption neoplasm congenital diseases
failure to thrive
weight
Complications of obesity
rapid growth sleep apnea HTN SCFE precocious puberty increased incidence of skin infections social dysfunction earlier development of 2DM
Height, or birth length at 1 year, 4 years, 13 years
1 year: increased by 50%
4 years: double
13 years: triple
2-13year: 2 inches/year
Greater-than-normal height
familial tall stature precocious puberty gigantism hyperthyroidism klinefelter syndrome Marfan syndrome obesity
lower-than-normal height
familial short stature neglect constitutional growth delay asthma CF TUrner IBD immunologic disease growth hormone deficiency hypothyroidism glucocorticoid excess skeletal dysplasia neoplasm
Macrocephaly
Cerebral metabolic diseases:
- Tay-Sachs
- Maple syrup urine disease
Neurocutaneous syndromes
- neurofibromatosis
- tuberous sclerosis
Hydrocephalus increased intracranial pressure skeletal dysplasia acromegaly intracranial hemorrhage
Microcephaly
fetal toxin exposure- fetal alcohol syndrome
chromosomal trisomies congenital infections cranial anatomic abnormalities metabolic disorders neural tube defects
how to address growth defects
treat underlying disorder
intervention in abuse cases
parent education
thorough family history
developmental milestones during childhood: 2 months
social smile
lefts head 45 degrees
eyes follow object to midline
isn’t talking but can coo
developmental milestones during childhood: 4 months
laughs is aware of caregiver localizes sound lifts head to 90 degrees when on stomach fine motor- can follow an object with eyes past midline
developmental milestones during childhood: 6 months
differentiates parents for others stranger anxiety grasps objects, or rakes objects toward self attempts to feed self babbles
developmental milestones during childhood: 9 months
interactive games
separation anxiety
crawling, pulls to stand
developmental milestones during childhood: 12 months
taking first steps
pincer grasp
makes 2-block tower
5-10 word vocabulary
developmental milestones during childhood: 18 months
parallel play walks well walks backward tower of 4 blocks can use a cup and spoon
developmental milestones during childhood: 2 years
dresses self with help
runs
climbs stairs
gender identity around 2-3 years old (around time of potty training)
6 block tower
50-75 words; 3-word sentences
developmental milestones during childhood: 3 years
magical thinking
climbs/descends stairs
makes a tower of 9 blocks
draws a circle
developmental milestones during childhood: 4 years
plays with others hop on 2 foot draws a line image and a closed figure (triangle, square) 250 or more words
developmental milestones during childhood: 6 years
skips
can draw a stick figure person
When do infant reflexes disappear?
by 6 months
after this, suggestive of CNS abnormalities esp in context of
perinatal complications
rooting reflex
rubbing the cheek causes turning the cheek towards the stim
Tonic reflex
face turns, arm on face side extends and other arm flexes
placing reflex
rubbing dorsum of foot causes that foot to step up
Anticipatory guidance:
newborn to 1 week
sleep on back to prevent SIDS
“back to sleep” campaign
baby does not need to bath every day
Anticipatory guidance:
4-6 months
begin feeding solid foods
usually first food is iron- fortified cereal
Anticipatory guidance:
12 months
can introduce cow’s milk
before 12 months, hemorrhage in the gut is more likely
When do kids start seeing the dentist?
2-3 yo
if cavities have begun, then go to the dentist with six months of first tooth eruption
unless there are risk factors (brushing less than once a day, caregivers with lots of cavities, etc.)
Anticipatory guidance:
2-3YO
can start seeing dentist
Anticipatory guidance:
3yo
regular sleep schedule
television limitation
when do you see kids for wellchilld visits?
2 days 2 weeks 1 month 2 months 4 months 6 months
every 3 months from 6-18 months
every year after 2 years old
how many DTaP vaccines does a kid get?
5
how many Hib vaccines does a kid get?
4
how many PCV vaccines does a kid get?
4
When do you give HepB vaccine?
at birth
When do you give Tdap vaccine?
11-12 yo
When do you give meningococcal vaccine (MCV4)
at 11-12 years, with a booster at 16yo
when do you give HPV vaccines? there are 3
11-12 yo to males and females both
when do you give flu vaccines?
annually
>6 months
appropriate use of car seats
How many calories are present in an ounce of breast milk? How many calories are present in an ounce of formula?
20 kcal/ounce
breast milk is designed to be this way
What are the caloric needs for an infant younger than 6 months?
100-120 kcal/kg/day
What work-up should be performed on a newborn with a single umbilical arter?
occurs in about 0.5% of births and 20-30% of these infants have major structural anomalias
Work this up with renal ultrasound, as 7% will have clinically significant (but asymptomatic) renal anomalies
What are the most common problems that arise in premature infants?
respiratory distress syndrome (RDS) hypoglycemia persistent PDA infection/sepsis retinopathy of prematurity intraventricular hemorrhage necrotizing enterocolitis
in a NICU, these are the things you would try to treat and prevent
caput succedaneum
edema in the scalp
crosses the midline and diminishes after a few days
cephalohematoma
subperiosteal hemorrhage
edema does not cross suture lines
resolves in weeks to months
more likely with vacuum deliveries, increased risk of jaundice as blood breaks down
bloody vaginal discharge in a the first few days of life
withdrawl of hormones leads to menstruation. there is nothing to do about this
cutis marmorata
spider webbing or marbling of the skin
not concerning
erythema toxicum neonatorum
2-3 mm yellow pustule with red base
similar in appearance to a whitehead
arising in the first 24-72 hours of life, microscopic examination of the pustular contents (not necessarily for diagnosis), reveals numerous eosinophils, that are usually gone by 3 weeks.
Tell the parents to leave this alone
Harlequin color change
intense reddening of gravity- dependent side and blanching of the nondependent side with a line of demarcation between the two, lasts a few seconds-minutes, affects 10% of newborns (more common in newborns), most common in first few days of life, may be due to immaturity of autonomic innervation to skin vessels. Completely benign and will resolve in days to 3 weeks.
macular stains (stork bites)
permanent vascular malformations, commonly at the nape of the neck, but also at upper eyelids and middle forehead
Benign but permanent.
Milia (or miliaria)
sweat accumulated beneath eccrine sweat ducts
obstructed by keritin at stratum corneum
usually develops in the first week after birth, with excess clothing or fever
Mongolian spots
benign,
will fade in 1-2 years
Neonatal acne
20% of infants
onset around 3 weeks of age
mild lesions should be left alone and will resolve in about 4 months
severe inflammation managed with retinoids, or benzoyl peroxide
infantile acne
different than neonatal acne, onset usually at 3-4 months of age, yellow papules around nose and cheeks, usually clear by age 1, but may persis until age 3. Severe inflammation can be managed with benzoyl peroxide or topical retinoids
transient neonatal pustular melanosis
Superficial pustules overlying hyperpigmented macules.
Tell parents to leave these alone
what medications can be used to treat thrush in infants?
you can’t swab it off (unlike milk)
Treat:
nystatin oral suspension for a couple of weeks
What are the risk factors for sudden infant death syndrome (SIDS)?
Usually occurs at 2-4 months old
Usually occurs while infant is sleeping
Maternal risk factors: low socioeconomic status, age
Anterior fontanelle- when should it close? what would you suspect if it did not close?
closed in 1% by age 3 months
38% by 12 months
96% by 24 months
If closure is delayed, consider Down syndrome, achondroplasia, rickets, congenital hypothyroidism, and increased intracranial pressure
If closure
Adolescence
a period of rapid, physical, psychosocial, and sexual growth and maturity leading into adulthood
from 10-19 yo
before this, would be considered precocious puberty
Early adolescence: age 10-13
psychosocial
concrete thinking
early independent behavior
middle adolescence: 14-16
psychosocial
emergency of sexuality
increased desire for independence
self- absorption
development of abstract thought
late adolescence (age 17-21)
increased self awareness
increased confidence in own abilities
open relationship with parents
cognitive maturity
Adolescents are more likely to exhibit…
risk-taking behavior:
- drug use
- unprotected sexual activity
- violence
accidents are the number cause of death in teenagers
depression
suicidal ideation
homicide
eating disorders
What should you ask an adolescent?
Stress right to confidentiality
SHADESSS
Strengths (you are an advocate) Home environment Activities Drugs and alcohol Education and employment Sexual activity Suicide (or depression) Safety
focus the exam on derm issues, sexual maturation,
height and weight growth, and examine boys for scrotal masses, HTN, HLD, obesity, DM
2-3 mm yellow pustule with red base, looks like a whitehead, arising in the first 24-72 hours, microscopic examination of the pustular contents (not necessary for diagnosis) reveals numerous eosinophils, usually gone by 3 weeks
erythema toxicum neonatorum
spider-webbing/marbling of skin
cutis marmorata
intense gravity- dependant reddening and blanching of nondependent side with a line of demarcation lasting a few seconds- minutes
Harlequin color change
Due to accumulation of sweat beneath eccrine sweat ducts that are obstructed by keratin at the stratum corneum
milia
What do you give to enhance fetal lung maturity? How long do you give it for? at what age do you no longer need to give it?
Corticosteroids:
betamethasone
dexamethasone
given for 48 hours
recommended up to 34 weeks gestation
clinical features of measels infection?
Prodrome for 2-3 days: fever, malaise, anorexia, and 3 C’s (cough, coryza, conjunctivitis)
coryza is nasal congestion and inflammation
Then, after 1-2 days you’ll see Koplik spots on the buccal mucosa and palate, that appear 48 hours before the rash
Rash begins 5 days after onset of prodrome, starting at the head and spreading to the feet, lasts 4-5 days, then resolves from the head down
Treat: supportive therapy and vitamin A
ribavirin
What is the treatment for measles in detail?
Supportive therapy (antipyretics, fluids) Monitoring and treating bacterial superinfections such as pneumonia or otitis media
Vitamin A
-100,000 IU PO x1 in 6-12 mo
200,000 IU PO x1 if older than 12 months
- WHO recommends vitamin A to all children with measles in areas where vitamin A deficiency is prevalent and measles mortality exceeds 1%
- AAP recommends vitamin A given as above to children 6 months-12 years hospitalized for measles or its complications, or if immunodeficient or high likelihood of vitamin A deficiency (opthalmoplegic evidence, intestinal malabsorption, malnutrition or recent immigration from an area with high measles mortality)
Ribavirin is not well studied and not currently standard of care for measles, despite that it harms measles virus in vitro
What are the classic features of rubella virus (German measles)?
- low-grade fever, lymphadenopathy, and rash
- prodromal malaise, fever, anorexia for 1-5 days prior to rash
- lymphadenopathy involving suboccipital and posterior cervical nodes
The rash, about 5 days, is erythematous, tender, maculopapular,
unlike measles, it does not darken or coalesce
The fever is milder and shorter (only 1 day) than measles
polyarthritis may be seen for up to a month in women and adolscents
What are the characteristic features of Coxsackie hand, foot, and mouth disease
- constitutional fever and anorexia
- oral vesicles on the buccal mucosa and tongue
- small, tender, maculopapular/vesicular rash on the hands, feet, and sometimes buttocks
duration is typically 3-5 days without complications
what are the signs and symptoms of scarlet fever cause by strep. pyogenes?
rash that is
-coarse (“sandpaper-like”), erythematous and blanching (“sunburn-like”)
- starts on the trunk then generalizes but spares the palms and soles
- most prominent in the skin creases of axilla and groin (Pastia’s lines/sign)
- strawberry tongue, beefy-red pharynx, cervical LAD
- fever/chills
later, desquamation of hands and feet
distinguished from Kawasaki bu positive throat culture or rapid strep test
Roseola infantum- characteristic symptoms
sudden, high fever (exceeding 102 F) for 3-4 days
child has no other signs of infection and often acts/plays normally
Then as the fever starts to dissipate, the patient gets a rash on the trunk/ entire body, that is usually gone within 24 hours
Other common findings: erythematous papules on soft palate and uvula, mild cervical LAD, edematous eyelids, bulding anterior fontanelle in infants.
Treatment: antipyretics as needed to lower the fever
What is the differential diagnosis for cervical lymphadenitis in a child?
if acute and bilateral- usually viral
-URIs rhinovirus, adenovirus, influenza, group A streptococcus
Mono: EBV, CMV, mycoplasma
Other viruses: HIV, HSV
If acute and unilateral- usually bacterial (s. aureus, group A strep > anaerobes, GBS)
If chronic and unilateral:
- bartonella henselae- cat scratch fever
- toxoplamosis
- TB- scrofula
- actinomyces israelii- sinuses drain pus
Noninfectious causes (much less common): Kawasaki disease, Hodgkin lymphoma
PFAPA syndrome
benign, recurrent 4-5 day syndrome consisting of Periodic Fever, Aphthous ulcers, Pharyngitis, and Adenitis
- occurs monthly (every 28 days)
- exclusion criteria include neutropenia, cough, coryza, diarrhea, severe abdominal pain, rash, arthritis, neuro defects
usually affects preschool- aged children (2-5 yo), usulaly goes away before age 10
benign, self- limiting disease
treatment:
-glucocorticoids relieve symptoms in a matter of hours
-cimetidine may be used for prevention of episodes, but is of questionable efficacy
-average duration of recurring symptoms is 4.5 years
Pertussis (whooping cough)
- Incubation (7-10 days)
- Catarrhal stage (7-10 days): mild URI symptoms
- Paroxysmal stage (1-6 weeks): paroxysms of cough with inspiratory whoop that is worse at night and often with post-tussive emesis and exhaustion
- often confused with acute bronchitis - Convalescent stage (2-3 weeks): waning symptoms
Treatment: supportive care antibiotics -azithromycin (5 days) shorter course, and erythromycin/clarithromycin contraindicated before 2 months
-erythromycin (14 days)
-clarithromycin (7 days)
TMP-SMX (14 days)
prophylaxis for close contacts (full course of one of the above antibiotics)
isolation from school/day care until 5 days of antibiotics have been completed, or 3 weeks after onset of symptoms in untreated patients
hospital admission (with isolation) indications for children with pertussis:
- respiratory distress
- PNA
- inability to feed
- cyanosis or apnea (with or without coughing)
- seizures
what additional work-up is needed in a child diagnosed with UTI?
renal and bladder ultrasound (RBUS)
- child 2 febrile UTIs
- child any age with first febrile UTI and family history of urologic disease, poor growth, or HTN
Immunodeficiency disorders- overall clues
recurrent infections after 3 mos
Thymic aplasia (DiGeorge syndrome)
3rd and 4th pouches fail to develop
-no thymus means no mature T cells
no parathyroids means hypocalcemia, leading to tetany
Recurrent viral, fungal, and protozoal infections
Congenital defects in heart/great vessels
90% have a chromosome 22q11 deletion (detect with FISH)
Chronic mucocutaneous candidiasis
T cell dysfunction vs c. albicans
Treatment: antifungals (ketoconazole, fluconazole)
Bruton agammaglobulinemia
- X- linked (boys)
- B-cell deficiency- defective tyrosine kinase gene- low levels of all immunoglobulins
- Recurrent bacterial infections after 6 months
- No B cells on peripheral smear
Selective IgA deficiency
MC selective immunoglobulin deficiency. IgA is found in mucus to protect the respiratory tract
- most appear healthy
- recurrent sinus infections
- recurrent lung infections
- 1/600 people of European descent
- associated with atopy and asthma
- There isn’t much you can do but provide antibiotics when there is an infection. It is important to diagnose this condition, as there is possible anaphylaxis to blood transfusions and blood products.
Severe combined immunodeficiency (SCID)
- Defect in early stem cell differentiation
- Can be caused by at least seven different gene defects:
- adenosine deaminase deficiency is the most high- yield one to know
Last defense is NK cells
Presentation triad:
- Severe recurrent infections
- chronic mucocutaneous candidiasis
- fatal or recurrent RSV, VZV, HZV, measles, flu, parainfluenza - pneumocystis jirovecii (PCP) pneumonia
- chronic diarrhea
- failure to thrive
Radiology:
no thymic shadow on newborn chest x-ray
Do not give these patients live attenuated vaccines
Ataxia- telangiectasis
IgA deficiency and T cell deficiency- sinus and lung infections
Cerebellar ataxia and poor smooth pursuit of moving target with eyes
Talengiectasias on the face (after 5 years old)
Radiation sensitivity (try to avoid x-days)
Increased risk: lymphoma and acute leukemias
+/- elevated AFP (After 8 months of age)
average age of death: 25 years
ATAXIA: Ataxia Telangiectasia Acute leukemia/lymphoma X-ray sensitivity IgA deficiency AFP
Wiskott-Aldrich Syndrome
WAITER Wiskott Aldrich Immunodeficiency Thrombocytopenia and purpura Eczema Recurrent pyogenic infections
X- linked
Chronic granulomatous disease (CGD)
X-linked inheritance (65-70%)
Lack of NADPH oxidase- phagocytes cannot destroy catalase-positive microbes
Especially susceptible to
S. aureus and
aspergillus infections
Diagnosis: negative nitroblue tetrazolium (NBT) test:
-NO yellow to blue-black oxidation (phagocytes don’t generate oxygen free- radicals)
Treatment:
- prophylactic TMP-SMX and itraconazole
- IFN-gamma also helpful
Chediak- Higashi syndrome
defective LYST gene (lysosomal transport)- can’t get enzymes int olysozomes
defective phagocyte lysosomes- giant cytoplasmic granules in PMNs are diagnostic
presentation triad:
- partial albinism
- recurrent respiratory tract and skin infections
- neurologic disorders
Hyper IgE syndrome (Job syndrome)
Mutation in the gene for STAT2 signaling protein, leading to
- impaired differentiation of Th17 cells
- impaired recruitment of neutrophils
High levels of IgE and eosinophils
Presentation triad:
- eczema
- recurrent cold S. aureus abscesses (think of biblical Job with boils)- normal inflammation would make it warm
- coarse facial features: broad nose, prominent forehead (“frontal bossing”), deep-set eyes, and “doughy” skin
- common to have retained primary teeth, resulting in 2 rows of teeth
Leukocyte adhesion deficiency syndrome
abnormal integrins- inability of phagocytes to exit circulation
recurrent bacterial infections
delayed separation of umbilical cord
desquamation of hands and feet
scarlet fever Kawasaki disease toxic shock syndrome SJS acrodynia (2/2 mercury poisoning)
congenital heart defect+ low calcium+ recurrent infections
DiGeorge syndrome
chronic mucocutaneous candidiasis+ chronic diarrhea+ failure to thrive
SCID
negative nitroblue tetrazolium test
chronic granulomatous disease
poor smooth pursuit of eyes + elevated AFP after 8 months
ataxia telangiectasis
partial albinism+ recurrent URIs+ neurological disorders
Chediak-Higashi syndrome
best choice for septic shock
NE
best choice for cardiogenic shock
dobutamine
causes vasoconstriction but with bradycardia
phenylephrine
4 most common brain tumors in adults
Mets glioblastoma meningioma schwannoma (MGM studies)
3 most common brain tumors in children
Astrocytoma
Medulloblastoma
Ependymoma
Turner syndrome
webbed neck short stature infertility abnormal genital formation renal defects cardiac defects- coarctation of aorta craniofacial abnormalities 45XO karyotype MCC primary amenorrhea
Labs: karyotype
Treatment:
- CV assessment
- Estrogen and progestin replacement
- growth hormone
Labs for sex chromosome disorders
karyotype
many end in 1st trimester abortions (MCC 1st trimester abortion)
Klinefelter syndrome
47,XXY males with an extra X testicular atrophy tall, thin body gynecomastia infertility mild intellectual disability psychosocial adjustment abnormalities
47, XYY male
tall body
significant acne
mild intellectual disability (sometimes)
47, XXX syndrome
intellectual disability
menstrual abnormalities
80th percentile for height
25th percentile for head circumference
Trisomy 21
autosomal nondisjunction
Tri21 is most common
craniofacial abnormalities includinf protruding tongue, flat nose, small ears, vision and hearing loss, broad hands with simian crease, intellectual disability, cervical instability, increased space between first and second toes,
GI abnormalities: duodenal atresia, Hirschprung disease (inital failure to pass meconium), annular pancreas, celiac disease, early Alzheimer (30’s), cardiac defects
usually survive into 4th decade of life or possibly longer
associated with ALL
small risk of AML as well
US: increased nuchal translucency
Quadruple screen: decreased AFP increased beta HCG decreased estriol increased inhibin A
trisomy 18 (Edwards syndrome)
severe intellectual disability micrognathia (small mouth) limb abnormalities (rocker bottom feet, overlapping fingers)
cardiac defects, GI abnormalities, frequently fatal within 1 year of life
Trisomy 13 (Parau syndrome)
cleft lip and palate cardiac defects CNS defects severe intellectual disability rounded nose polydactyly frequently fatal wihin first year
labs: karyotyping
quadruple screen
amniocentesis to confirm diagnosis
Deletion syndrome: Cris du chat
low birth weight
failure to thrive
intellectual disability
small head
high-pitched cat-like cry
Wolf- Hirschhorn syndrome
intellectual disability
multiple cranial abnormalities
seizures
Prader-Willi syndrome
- overeating and obesity
- decreased muscle tone in -infancy
- intellectual disability
- small hands and feet
- obesity- related complications
inherited from the father
Angelman syndrome
inherited from the mother
“happy puppet syndrome”
deletion or inactivation of genes on the maternally inherited chromosome 15, while the paternal copy, which may be of normal sequence, is imprinted and therefore silenced
happy mood
intellectual disability
inappropriate laughter
ataxic gait
Velocardiofacial syndrome (22q11 deletion)
associated with DiGeorge syndrome Cleft palate Cardiac defects Mild intellectual disability Overbite Speech disorders
T cell deficiency and hypocalcemia
Williams syndrome
cheerful
cardiac defects
intellectual disability
Fragile X syndrome
X- linked
trinucleotide repeat disorder (CGG) with anticipation in successive generations
occurs earlier and is more severe with each successive generation
H and P: large face with prominent jaw, large ears mild hand/foot abnormalities macroorchidism intellectual disability hyperactivity seizures
common cause of intellectual disability in men
screening, education, and monitoring needed
Congenital malformations- most common
unilateral cleft lip, with or without cleft palate
prevent with folate supplementation
Congenital malformations- what features are characteristic of fetal alcohol syndrome?
facial features: short palpebral fissures, thin upper lip, smooth philtrum, flattened midface
deficient brain growth: structural brain abnormalities,
Ebstein anomoly (6 key features)
- tricuspid leaflets displaced inferiorly
- RV hypoplasia
- tricuspid regurgication or stenosis
- 80% have a patent foramen ovale
- dilated right atrium, leading to increased risk of SVT and WPW
- physical exam: widely split S2, tricupid regurgitation
Branchial cleft cyst versus thyroglossal duct cyst
Branchial cleft cyst:
- lateral neck
- dose not move with swallowing
Thyroglossal duct cyst
- midline neck
- moves with swallowing
- often associated with ectopic thyroid tissue
Common presenting features of tuberous sclerosis
distinctive brown, fibrous plaque on the forehead seen in infancy
ash-leaf spots (hypopigmented macules most easily identified by wood’s lamp)
Shagreen patch (leathery cutaneous thickening usually on the lower trunk)
facial angiofibromas (adenoma sebaceum)
seizures
intellectual disability
subependymal nodules in the brain
lactic acidosis, hyperlipidemia, hyperuricemia (gout)
Type 1 (von Gierke), where liver cells can’t undergo gluconeogenesis
diaphragm weakness- respiratory failure
Type II (Pompe disease)
Increased glycogen in liver, severe fasting hypoglycemia
Type 1 (von Gierke disease) where liver cells can't undergo gluconeogenesis
Hypatomegaly, hypoglycemia, hyperlipidemia (normal kidneys, lactate, and uric acid)
Type III (Cori disease)
Painful muscle cramps, myoglobunuria with strenuous exercise
Type V McArdle disease
severe hepatosplenomegaly, enlarged kidneys
Type 1 (von Gierke disease) where liver cells can't undergo gluconeogenesis
Cleft lip/palate, life expectancy
TRisomy 13 (Patau)
high- pitched cat-like cry
cri du chat
Elfin facial features, cardiac fects
Williams syndrome
Tall, thin man with gynecomastia and testicular atrophy
Kleinfelter syndrome
Large ears, intellectual disability, macroorchidism
Fragile X syndrome
Obesity and overeating
Prader-Willi syndrome
Micrognathia, life expectancy
trisomy 18
happy mood, inappropriate laughter, ataxic gait
angelman syndrome
intellectual disability, simian crease, GI and cardiac defects
Trisomy 21
short stature, infertility, coarctation of aorta
Turner syndrome
How to prevent flushing with niacin administration?
pre-treat with aspirin, half an hour ahead,
extended-release formulation, may improve with time
