Pediatrics Flashcards
What two things should be provided to the newborn at birth and why?
Erythromycin ointment (ward off bacterial infection) Vitamin K (prevent hemorrhagic disease)
Before discharging the newborn and mother what additional tests should you complete?
Hearing screen
Give mom HBV vaccine if HBsAg negative (admin HBV vaccine and HBV Ig if positive)
Neonatal screening tests
APGAR at 1 minute tells about _______
at 5 minutes tells about ______
1 minute: labor and delivery
5 minute: response to therapy
What should you rule out when seeing Mongolian spots?
Child abuse
Newborn presents on second day of life with firm papules on an erythematous base. What are these and what is mgmt?
Erythema toxicum
Self-limited
What constellation of symptoms may be seen in Sturge-Weber syndrome?
Port wine stain
AVM resulting in seizures
Mental retardation
Glaucoma
Mgmt of Sturge-Weber Syndrome?
Pulsed laser therapy, AEDs, and evaluate for glaucoma
Treatment for large hemangiomas which are at risk for causing organ dysfunction to shifting cardiac output in a newborn?
Steroids or pulsed laser
Preauricular tags in newborn assd with …
Hearing loss
GU anomalies
Iris defect in newborn should raise suspicion for what syndrome?
CHARGE
Coloboma Heart defects Atresia of nasal choanae Retardatioon of growth GU anomalies Ear abnormalities
Absence of iris is red flag for …?
Wilms tumor
What type of surveillance should Wilm’s tumor patients undergo?
Abdominal US every 3 months until the age of 8
Newborn presenting with neck mass lateral to the midline is …
Branchial cleft cyst
Distinguish omphalocele vs gastroschisis
Omphalocele: GI organs outside of body but covered by peritoneum
Gastroschisis: GI organs outside of body with no covering
Umbilical hernia in newborn raises concern for …
Hypothyroidism
In newborns with undescended testes what is mgmt?
No treatment until 1 year of age
At that time either hormone injections or orchiopexy
Should you circumcise hypospadias?
No
What abnormalities are seen in infants of diabetic mothers?
Hypoglycemia Hypocalcemia Hypomagnesia Hyperbilirubinemia Polycythemia
Cardiac anomalies
Small left colon syndrome
What causes transient tachypnea of the newborn and how long does it generally last?
Retained lung fluid in newborns delivered by C-section or with a rapid second stage of labor
What medicine do you provide to prevent respiratory distress in a potentially premature newborn?
Antenatal betamethasone when
What are ventilator settings you would use in a newborn with meconium aspiration?
High frequency ventilation
PEEP
What is mgmt of diaphragmatic hernia?
Immediate intubation and surgical correction
How do you treat meconium plugs and meconium ileus?
Get abd xray and give gastrografin enema
What is part of the VACTERL syndrome?
Vertebral defects Anal atresia Cardiac anomalies TEF with ... Esophageal atresia Radial and Renal anomalies Limb Syndrome
What is treatment of newborn born with duodenal atresia (double bubble on xray)?
NG decompression and surgical correction
Greatest risk factor of NEC …
Premature delivery
Mgmt of NEC
Stop feeding
Decompress gut
Broad spectrum antibiotics
Evaluate for surgical resection
Your patient fails to pass stool early in course and upon digital exam a large volume passes. Dx?
What is the next part of the work-up?
What is a confirmatory test?
Hirschsprung disease
Barium enema
Rectal biopsy (absence of ganglionic cells)
Mgmt of kernicterus
Immediate transfusion exchange
If a newborn presents with jaundice and elevated conjugated bilirubin then what should you consider and the tests you should order?
Cholestasis
Get LFTs and consider US and liver biopsy
Early onset sepsis in a newborn is most often from ….
PNA (GBS, E. coli, H. influenzae, L. monocytogenes)
Late onset sepsis in newborn is most often from ….
Meningitis or bacteremia (S. aureus, E. coli, Klebsiella, Pseudomonas?
What is empiric treatment of sepsis in newborn?
Ampicillin and gentamicin
If meningitis possible consider adding cefotaxime
Buzzwords
Hydrocephalus with generalized intracranial calcifications and chorioretinitis
Toxo in newborn
What is the best initial test for Herpes dx in newborn? Most accurate?
Initial: Tzanck
Accurate: HSV PCR
Best initial test for syphilis in newborn?
Most accurate?
Initial: VDRL
Accurate: IgM-FTA-ABS
What tests should be ordered in working up seizures in the newborn?
EEG CBC, glucose, calcium, magnesium Amino acid and urine organic acids for inborn errors of metabolism IgM levels Blood and urine cultures LP Ultrasound head - look for IVH
Tx of seizure in newborn?
Lorazepam or diazepam (rectally)
Ethosuximide if absence
Of the following: heroin, methadone, cocaine, amphetamines, and alochol which presents with withdrawal in newborns at 48 hrs and which at 96 hrs to up to 2 weeks?
48 hrs: cocaine, heroin, alcohol amphetamines
96 hrs to 2 weeks: methadone
Is it acceptable to give narcan to a newborn?
No it may trigger withdrawal. It is acceptable to give small doses of opiates and phenobarbital
Effect on newborn
Phenobarbital
Vitamin K deficiency
Effect on newborn
Sulfonamides
Displaces bilirubin from albumin and increases risk of kernicterus
Effect on newborn
NSAIDS
Premature closure of ductus arteriosus
Effect on newborn
ACEi
Craniofacial abnormalities
Effect on newborn
Isoretinoin
Facial and ear anomalies, congenital heart disease
Effect on newborn
Phenytoin
Hypoplastic nails, typical facies, IUGR
Effect on newborn
Diethylstilbestrol (DES)
Vaginal adenocarcinoma
Effect on newborn
Lithium
Ebstein’s anomaly (atrialization of RV due to ineffective tricuspid valve leaflets)
Effect on newborn
Warfarin
Facial dysmorphism and chondrodysplasia
Effect on newborn
Valproate/Carbamazepine
Mental retardation, neural tube defects
Buzzwords
Trisomy with rocker bottom feet and hammer toe; micrognathia; microcephaly
Trisomy 18 Edwards Syndrome
Buzzwords
Trisomy with holoproencephaly, cleft lip/palate
Trisomy 13 Patau Syndrome
What kind of regular surveillance should you complete in patients with Beckwith-Weideman Syndrome and to look for what?
Ultrasound and serum AFP every 6 weeks to look for Wilm’s tumor and hepatoblastoma
What are features of Robin (Pierre Robin) sequence and what complication should you watch for over the first 4 weeks of life?
Mandibular hypoplasia and cleft palate
(Assd with Edwards syndrome and fetal alcohol syndrome)
*Watch for airway obstruction in first 4 weeks of life
Height percentile at which age correlates with final adult height percentile?
2 years old
Advantages of breastfeeding
Passive immunity via T-cell transfer which reduces risk of allergy and GI/respiratory infection
Emotional bonding with mother
Contraindications to breast feeding
HIV Galactosemia Active drug use (e.g. cocaine, opiates, heroin) Systemic illness (e.g. TB) HSV (if lesions on breast) Maternal cancer receiving treatment
Until what age is enuresis normal?
5 years old
Until which age is encopresis normal?
4 years old
For retentive encopresis what are appropriate therapies to use in mgmt?
Stool softeners
Disimpaction
Behavioral modifications
Patients with a known egg allergy should receive which form of influenza vaccine?
Trivalent inactivates influenza vaccine
Newborn is exposed to Measles in mother. Is 5 months old. What is tx?
Just give Ig
If 6-12 months when exposed then give Ig and vaccine
Neck Xray showing steeple sign is positive for what disease?
Croup (caused by parainflulenza)
Mgmt of croup
Humidified oxygen
Nebulized epinephrine and corticosteroids
Patient presents with drooling and muffled voice. Neck Xray shows ‘thumbprint’ sign. Dx and mgmt?
Epiglottitis (often Hib)
Emergency - get anesthesia and ENT
Intubate if needed
Ceftriaxone and steroids
Rifampin ppx to household contacts
3 yo patient presents after having a URI last week with fever, cough, and respiratory distress. He is not drooling or has a changed voice. CXR shows subglottic narrowing. Dx, cause, and mgmt?
Bacterial tracheitis
S. aureus
Antistaph Antibx
What mediates the development of angioedema?
Bradykinin
Where are the most common sites for foreign body aspiration in kids older and younger than 1 year of age?
> 1 yo: larynx
Causes of bronchiolitis
RSV
Parainfluenza
Adenovirus
Most specific test for bronchiolitis dx
Viral antigen testing (IFA or ELISA)
What is a routine way to prevent bronchiolitis development in young children?
What is used to prevent it in high risk patients?
Routine: Breastfeeding which provides IgA which helps prevent respiratory illnesses (disease occurring across mucosal linings)
High Risk: Palivizumab (against RSV F protein)
What is the most common pathogen causing PNA in children
Viral - RSV
What are the most common pathogens causing PNA in children > 5 yo?
S. pneumoniae
M. pneumoniae
C. pneumoniae
A 2 month old infant presents with staccato cough and peripheral eosinophilia noticed on CBC. Had conjunctivitis at birth. What is Dx?
Chlamydia trachomatis pneumonia
Are sputum cultures helpful in the dx of PNA in children
No
For mild cases of PNA handled in outpatient setting what is an appropriate treatment?
Amoxicillin
Alternatives are cefuroxime and amoxicillin/clavulanic acid
In hospitalized patients with PNA what is appropriate tx?
IV cefuroxime
In Chlamydia or Mycoplasma pneumoniae what is appropriate tx?
Erythromycin
Absent vas deferens and allergic bronchopulmonary aspergillosis are assd with what genetic condition?
Cystic fibrosis
What is the first symptom cystic fibrosis often presents with?
Meconium ileus
What is the first approved therapy for CF which restores the function of the mutant CF protein given to patients > 6 yo with G551D mutations?
Ivacaftor (VX - 770)
What are common organisms causing infection in CF?
S. aureus
Pseudomonas
H. influenzae
For resistant pathogens in CF patients what antibiotics do you use?
Inhaled tobramycin
In CF patients infected with S. aureus or Pseudomonas what is appropriate treatment?
Piperacillin and tobramycin/ceftazidime
When is a surgical repair for VSD indicated?
Failure to thrive
R: L shunt > 2:1
Pulm HTN
How are primary and sinus type ASDs managed?
They are closed surgically
In newborn with pulmonary stenosis what should they be given at birth and how should they managed in the longterm?
Give prostaglandin E1 infusion at birth (keeps PDA open) and attempt balloon valvuloplasty later
What drug is used to close a PDA?
Indomethacin
What drug is used to maintain the ductus arteriosus?
Prostaglandin E1 infusion
When should you attempt surgical repair of tetralogy of Fallot?
4-12 months
*Before that give oxygen, beta blocker, PGE1 infusion
Which cyanotic congenital heart disease lesion presents immediately after birth? How is it managed?
Transposition of great vessels
Prostaglandin E1 to keep PDA open and attempt surgical repair ASAP
Gram negative spiral that is motile with flagella
Campylobacter (a cause of bloody diarrhea)
Antibx tx of:
Shigella
TMP/SMX
Antibx tx of:
Salmonella
Only treat those
What is treatment of HUS from suspected E. coli O157:H7?
Do NOT give antibiotics
Supportive, HTN control, aggressive nutrition, early dialysis
What is the best initial test for fat malabsorption?
Best confirmatory test?
Initial: Sudan black stain
Confirmatory: 72 hour stool for fecal fat
Best initial test for protein malabsorption
Spot stool alpha-1 antitrypsin level
What is the best initial test in pediatric GERD dx?
Esophageal pH monitoring
What are first line GERD meds in children?
H2 receptor blockers (e.g. ranitidine) are first line bc of an improved safety profile
Hypochloremic metabolic alkalosis is pathognomonic of what?
Pyloric stenosis
How can pyloric stenosis and duodenal atresia be distinguished on exam?
Pyloric stenosis presents with nonbilious vomitus
Duodenal aresia has bilious vomitus
What is both diagnostic and therapeutic in intussuception?
Air enema
Tx pediatric cystitis
Amoxicillin or SMP/TMX
Tx pediatric pyelonephritis
IV ceftriaxone or ampicillin/gentamicin
In patients with vesicoureteral reflux what is provided as ppx against renal scarring?
They get multiple UTIs so give TMP-SMX
What are the best initial tests in obstructive uropathy?
What is the most common cause in boys?
What is the most common cause in newborns?
Voiding cystourethrogram and renal scan
Boys: Posterior urethral valves
Newborns: Hydronephrosis and polycystic kidney disease
Acute post-strep glomerulonephritis occurs after what infections?
Post strep pharyngitis or impetigo
What unique test results are seen in APGN?
What is the most specific test?
Low C3 complement, anti-streptococcal antigens
Specific test: Anti-DNase antigen
Tx of APGN
Penicillin Supportive (diuresis, sodium restriction, electrolyte mgmt)
20 yo patients presents with hematuria after URI and has a normal complement level. Dx?
Berger’s nephropathy (IgA nephropathy)
What is tx of infantile (recessive type) polycystic kidney disease?
Dialysis and transplant
What benign cause of proteinuria should be ruled out before any additional work-up be completed?
For transient or orthostatic proteinuria
What are two complications of nephrotic syndrome in children?
Increased risk of SBP (immunize against pneumococcus and varicella)
Increased VTE risk (prothrombotic)
How does 21-hydroxylase deficiency present on a BMP and vitals?
Hyperkalemia, hyponatremia, hypoglycemia
Hypotension
*Females will also have ambiguous genitalia
Tx of 21-hydroxylase deficiency
Hydrocortisone and fludrocortisone
Corrective surgery for females
How does Kawasaki disease present?
Fever Desquammating rash on hands Lymphadenitis (cervical) Conjunctivitis Strawberry tongue/cracked lips Erythema and swelling of hands/feet Nonvesicular rash
Tx of Kawasaki disease
Aspirin and IVIG
*May consider adding warfarin, especially if platelet count high
What are major complications of Kawasaki disease?
Coronary artery aneurysms
Intussusception, arthritis, and glomerulonephritis/nephrosis all may develop in what IgA and C3 mediated disease?
Henoch-Schonlein Purpura
Increased IgA and IgM
Antiphospholipid or anticardiolipin antibodies
The above may be seen in what disease?
HSP
What is tx of HSP?
If anticardiolipin or antiphospholipid are present then give ASA.
If there are intestinal or renal complications then give corticosteroids
When is there a physiological anemia in newborns and why does it occur?
At 12 weeks it nadirs at 9-11 mg/dL. This is due to progressive drop in EPO production until tissue oxygen needs are greater than they were at delivery
Infants only receiving cow’s milk are at increased risk of which anemia?
IDA
What types of bacteria are patients with sickle cell disease susceptible to and why?
Encapsulated abcteria bc they undergo autosplenectomy by age 5; Strep pneumo, Hib, N. meningitidis
What are the most common causes of death in sickle cell?
Sepsis and acute chest syndrome
Your patient with sickle cell anemia presents with SOB and chest pain. Do you do transfuse blood or do an exchange transfusion?
Transfuse
In what situations is an exchange transfusion indicated for sickle cell anemia?
Life-threatening complications (stroke, acute chest, splenic crisis)
Before high-risk surgery
What drug reduces number of recurrent painful crises and needs for exchange of transfusion?
Hydroxyurea
What is the only definitive treatment of sickle cell disease?
BM transplant (but carries a 10% mortality)
What ppx measures are taken in sickle cell disease pts?
Penicillin ppx from 6 mos until 5 years of age
Regular immunizations but with early pneumococcus and meningitis vaccines
When and how does Beta thalassemia major present?
At 2 months with severe anemia (Hb
What are findings on hemoglobin electrophoresis in a patient with Beta thalassemia major?
HbF is increased
HbA2 may be increased
Absent or reduced HbA
Low reticulocytes
Microcytosis
Hemolysis consistent labs
Elevated ferritin and transferrin saturation
Dx?
Beta thalassemia major
How is Beta thalassmeia managed?
Transfusion to maintain Hb > 9
Iron chelation (deferoxamine and vitamin C)
Splenectomy
Routine (folate, vaccine, growth hormone)
BM transplant is curative
How are mixing studies helpful in diagnosing hemorrhagic disorders?
Involves mixing normal plasma to the patient’s plasma and repeating PT/PTT/INR
If lab prolongation is not corrected in a mixing study what does that mean?
An inhibitor is present (e.g. heparin in hospitalized patients)
If a mixing study shows more prolonged bleeding with clinical bleeding what does that mean? What if there is no clinical bleeding?
w/ bleeding: an antibody against a clotting factor is present
w/o bleeding: possibly lupus anticoagulant
How is minor bleeding in hemophilia A treated?
Major bleeding?
Minor: desmopression, transexamic acid or aminocaproic acid
Major: Factor VIII supplemetation
What are treatment options in ITP?
1st: prednisone
2nd: IVIG
Chronic ITP may benefit from rituximab or splenectomy
In what situations is a child with a febrile seizure at higher risk for epilepsy?
Atypical seizure (>15mins)
Previous neurologic condition
Abnl development
FHx of epilepsy
15 yo has a seizure described as jerky movements in the morning. Dx? Mgmt?
Juvenille myoclonic epilepsy
Valproic acid
What is hypsarrhythmia? What epileptic syndrome is it seen in? Mgmt?
High voltage slow waves irregularly interespersed with spike and sharp waves. West syndrome (infantile spasms during 1st year of life) Tx: ACTH, prednisone, vigabatrin, pyridoxine
What is first line medication for generalized seizure in child?
Valproic acid
What are first line meds for partial seizure in pediatrics?
Valproic acid or carbamazepine
What is the most common long term complication of meningitis?
Hearing loss
