Pediatrics Flashcards
Most frequently diagnosed neoplasm in infants
Neuroblastoma
2nd most common abdominal tumour in kids
Wilm’s Tumour (aka nephroblastoma)
Anaphylaxis definition
- Need any ONE of the following
- Acute onset (min-hrs) involving skin/mucosa and at least 1 of respiratory compromise and/or drop in blood pressure
- 2 or more organ systems – skin/mucosa, respiratory, CVS, or GI rapidly after exposure
- Drop in BP after exposure to a known allergen
Age limit of asthma dx
18 months (not enough smooth muscle yet to cause airway constriction)
Common bacteria for meningitis in newborns
K-LEG GBS E. Coli L. monocytogenes Klebsiella
Common bacteria for meningitis in toddlers
SN-EG S. pneumo N. meningitidis E. Coli GBS
Bacterial meningitis LP findings
Low glucose High protein Very high WBC Nitrites Positive or neg gram stain
Viral meningitis LP findings
Normal glucose Normal or slightly elevated protein High WBC Lymphocytes Neg gram stain
Pyruria definition
> 5 WBCs/hpf in centrifuged urine
Gram neg bacteria that cause nitrites
E. Coli
Klebsiella
proteus
Most common organism causing pyelonephritis
E.coli
Follow-up study for first episode of pyelo
Kidney and bladder U/S
Third generation cephalosporins good for broad spectrum antibiotic treatment
Cefiixime
Cefotaxime
Ceftriaxone
Epiglottitis typically caused by
H. influenza type B
Croup most commonly caused by
Parainfluenza Type 1
Most common cause of bronchiolitis
RSV
Top 2 most common bacterial causes of otitis media
- Strep pneumo
2. Haemophilus influenza
Buccal mucosa lesions in initial stage of measles
Koplik spots (red lesions with bluish white spots in centre)
Another name for 5th disease
Erythema infectiosum
Cause of 5th disease
Parvovirus B19
Causes of strawberry tongue (3)
Strep pharyngitis
Kawasaki
Toxic shock syndrome
Most common type of congenital diaphragmatic hernia
Bochdalek
Insulin sensitive organs
Heart, liver, muscle
Most common cause of respiratory distress in premature infants
Respiratory distress syndrome
Respiratory distress syndrome
♣ Deficiency of lung surfactant and delayed lung maturation
♣ Can occur as late as 37 weeks’ gestation
♣ Increased risk in infants of diabetic mothers
Transient tachypnea of newborn
♣ Result of delayed clearance of fluid from lungs following birth
♣ Much more common in infants born to diabetic mothers and in infants born by c-section
CXR findings in RDS
Diffuse reticulogranular appearance of lung fields (ground glass) and air bronchograms
CXR findings in TTN
Wet looking lungs, no consolidation, no air bronchograms
TORCH infections
Toxoplasmosis Other (syphillis, varicella, parvo) Rubella CMV Herpes
X-ray finding for croup
Steeple sign (tapering of upper trachea)
X-ray finding for epiglottis
Thumb-print sign
Treatment for severe dehydration
Lactated Ringer’s solution or normal saline (isotonic) in 20 mL/kg boluses until urine output is established and mental status improves, then 100 mL/kg oral rehydration solutions over next 4 hours. ntravenous hydration with 5% dextrose ½ normal saline at twice maintenance fluid rates may be substituted for the oral rehydration solution if the child is not tolerating PO intake. To replace ongoing losses, the CDC recommends 60-120mL of oral rehydration solution per diarrheal/emetic episode (through a nasogastric tube, if necessary).
Cushing’s triad
Symptoms related to increased ICP
- Increased BP
- Low HR
- Irregular respirations (Cheyne-Stokes)
Most likely pathogens in sepsis <4wk old
Streptococcus agalactieae (GBS)
E. coli
Listeria monocytogenes
HSV
First choice abx for sepsis in <4 weeks
Ampicillin + Gentamicin or Cefotaxime +/- Acyclovir
Most likely pathogens in sepsis >/= 4 wk old
Neisseria meningitides
Strep pneumo
H. influenzae
First choice abx for sepsis in <4 wk old
Amp + Gent +/- Acyclovir
Most likely pathogens for meningitis in <4 wk old
Streptococcus agalactiae (GBS)
E. coli
Listeria monocytogenes
HSV
First choice abx for meningitis in <4wk old
Ampicillin + Cefotaxime + Acyclovir
First choice abx for meningitis in >/= 4 wk old
Cefotaxime +Vancomycin +/- Acyclovir
Most likely pathogens for meningitis in >4wk old
N. meningitides
Strep penumo
H. influenza
Most likely pathogen for encephalitis
HSV
Abx for strep pharyngitis/tonsillitis
Penicillin V PO
or Amoxicillin PO
or Penicillin G
Bacterial acute otitis media common pathogens
H. influenza
Strep pneumo
Moraxella catarrhalis
Bacterial acute otitis media first line tx
Amoxicillin 80-90mg/kg/d PO
or Amox-Clav PO
Sinusitis common pathogens
H. influenzae Strep pneumo Moraxella catarrhalis Staph aureus GAS Anaerobic organisms
Sinusitis first line tx
Amox PO
Amox-clav PO
Community-acquired PNA <1mo most likely pathogens
GBS
E. coli
Listeria monocytogenes
Community acquired PNA <1mo first line tx
Ampicillin + Gentamicin or Cefotaxime
Community-acquired pneumonia (1-3 mo) first line tx
Cefotaxime +/- Vanco +/- Clarithomycin PO
Obstructive lung disease spirometry
Low FEV1/FVC ratio d/t reduction in FEV1
Restrictive lung disease spirometry
Normal FEV1/FVC ratio d/t proportionate reduction in FEV1 and FVC
Most commonly heard innocent murmur
Still’s murmur, best heard at LLSB in supine position
Most likely pathogen for UTI
E. coli
First line empiric abx for <2mo UTI
Amp + Gentamicin
First line empiric abx for >/=2mo mild UTI
Cephalexin PO
First line empiric abx for >/=2mo severe UTI
Cefotaxime OR Gentamicin
Requirements for renal U/S in UTI
<2yo first febrile UTI Any age with recurrent UTI Any age with fam hx of renal dz Any age with poor growth, HTN Any age with no response to abx
Requirements for voiding cystourethrogram in UTI
Any age with >/= 2 febrile UTI
Any age with first febrile UTI and abnormal U/S
Any age with >/= 39C and pathogen other than E. Coli
Any age with poor growth, HTN
Vesicoureteral reflux grades
Grade 1: Half way up ureter
Grade 2: All the way up ureter
Grade 3: Up ureter and some dilation of ureter & calyces
Grade 4: Marked dilation of ureter and calyces
Grade 5: Massive reflux, dilated ureter, calyces dilation and loss of renal cortex
VUR grade tx
Grade 1/2 - spontaneous resolution (2-5yrs), follow by GP
Grade 3/5 - referred to urologist
Roseola
HHV6
Fever 3-5d –> maculopapular rash that starts on trunk and spreads to face/extremities
Tx = Reassurance
Asthma X-ray findings
Hyperinflation
Increased interstitial markings
Patchy atelectasis
Pertussis stages
Catarrhal (1-2wks) - URTI symptoms
Paroxysmal (4-6wks) - whooping cough
Convalescent - decrease in severity/freq of cough
Pertussis treatment
Azithromycin
Clarithromycin
Erythromycin
Turner syndrome
45XO
Klinefelter Syndrome
47 XXY
Trisomy 13
AKA Patau Syndrome
Trisomy 18
Edward Syndrome
Fragile X syndrome
Expansion of CGG repeats on FMR1 gene on X chromosome
Febrile seizures simple vs complex
Simple: - More common - <15min - Generalized - Once in 24h period Complex: - Less common - >15min - Focal - More than once in 24h period
Recurrence rate of febrile seizures
<12mo: 50%
>12mo: 30%
Risk of epilepsy after febrile seizure
Slightly increased above 0.5-1% baseline population risk
Most common cause of recurrent headache in children
Migraine without aura (more common than classic with aura)
Tx for headaches in children
TCAs for migraine
NSAIDs for tension
Dx criteria for idiopathic intracranial HTN
- Increased ICP with associated symptoms
- Normal brain anatomy
- Normal CSF
Infratentorial brain tumour findings
Cerebellar signs and increased ICP
Cerebellar brain tumour findings
Change in muscle tone, deep tendon reflexes = hypotonia, hypOreflexia
Supratentorial brain tumour findings
Focal motor and sensory abnormalities on side OPPOSITE to lesion
Brain stem brain tumour findings
CN and gaze palsies
Most common location for brain tumour
Posterior fossa
Most common brain tumours in peds
Medulloblastoma, juvenile pilocytic astrocytoma
Measles rash
Maculopapular, starts on neck/face then spreads down to feet in 2-3d
Initial Koplik spots in buccal mucosa
Tx: supportive
Rocky mountain spotted fever
Tick-borne bacterial infection
Rash on ankles and wrists –> spreads centraly and to palms and soles
Maculopapular –> petechial
Cat scratch disease
Bartonella henselae
Axilla > cervical, submandibular, inguinal areas
Subacute/chronic unilateral lymphadenitis
Self-limited
Start empiric abx if suspected coverage for S. aureus and GAS (cephalexin, clinda, septra, amox-clav, etc.) + coverage for cat scratch (azithromycin, rifampin, septra, doxy)
Bacterial cervical adenines most common causes
Staph aureus Strep pyogenes (GAS)
Kawasaki disease dx
Fever >5d
4/5 of the following:
- Conjunctivitis (bilateral, non purulent)
- Rash
- Extremity changes (redness/swelling)
- Adenopathy (unilateral cervical lymphadenopathy)
- Mucosa (strawberry tongue)
Kawasaki stages
Acute Onset-10d (fever, clinical findings, serologic evidence of inflamm)
Subacute 10d-3wk (Fever resolves and clinical findings subside, ongoing serologic evidence) coronary artery aneurysm formation
Convalescent 3wk - 6-8wk (clinical findings resolved, cont serologic evidence of inflammation)
Drug to avoid in kawasaki
Ibuprofen
Use corrected age in premature babes until age…
2yo
Developmental screening tests recommended at…
9, 18 and 30 months
Common risk factors for developmental delay in premature infant
- Chronic lung dz
- Periventricular leukomalacia (damage/necrosis to white matter around ventricles)
- Retinopathy of prematurity
- Hyperbilirubinemia
Babinski reflex gone by…
Time child is walking
Up to 2yrs
Types of cerebral palsy
Spastic hemiplegia Spastic diplegia Spastic quadriplegia Ataxic Dyskinetic
Spastic hemiplegia CP
Leg and arm on one side
Etiology - unilateral UMN abnormalities
Clinical - stroke
Spastic diplegia CP
Most common
Legs > arms
Etiology - periventricular white matter abnormality
Clinical - premature
Spastic quadriplegia CP
Whole body
Etiology - global brain involvement
Dyskinetic CP
AKA Athetoid dystonic
Variable, often entire body
Basal ganglia, cerebellum and/or thalamus
Clinical - perinatal asphyxia, kernicterus
Ataxic CP
Entire body
Etiology - Cerebellum
Clinical - Cerebellar hypoplasia, pontocerebllar hypoplasia
Screening tool for ASD
M-CHAT
Language milestone at 2yo
50+ words 2 word phrases 50% intelligible Follows 2-3 commands Points to pictures when asked
Language milestone at 3yo
200+ words
3 word phrases
75% intelligible
Knows age and gender
Language milestone at 4yo
Tells stories, 100% intelligible
400-1500 words
Numbers 1-4
Knows full name
Language milestone at 9-10mo
Single words “mama” “dada”
Language milestone at 18mo
10-25 words
Names body parts
Follows 1 step commands
Risk factor for speech delay
Sex (boys > girls)
Fencing reflex
Should be gone by 6mo
Most common primitive reflex that persists in CP
Dx of Trisomy 21
Lymphocyte karyotype
Most common familial cause of intellectual disability
Fragile X syndrome
Turner syndrome
45XO
Physical differences at birth
Webbed neck, edema of hands/feet, low ears, shield chest with wide nipples, coarctation of the aorta
Most have NORMAL IQ
Klinefelter Syndrome
47 XXY (male)
Normal at birth
Infertility, gynecomastia, small testicles
Other less obvious symptoms: weaker muscles, greater height, poor coordination, less body hair, decreased libido (most noticeable at puberty)
Typical random mutation
IQ low-normal range
Fragile X clinical
Females - asymptomatic (ID, behavioural), may suffer from infertility
Males - large testes, flat feet, long face with large mandible, high-arched palate, hypotonia, connective tissue abnormalities (joint laxity, pectus excavatum)
~1/3 have features of autism (co-occur), usually fertile
Hyperactivity common
Normal-severe IQ
Normal weight gain in newborn
20-30g/d average weight gain during first 4mo of life
Weight should double by…
Weight should triple by…
4mo of age
1 yo
FTT definition
Weight <3rd percentile
Weight for height/length <3rd percentile
Rate of weight gain slows compared with previous growth, crossing 2 more major percentiles in downward direction
Child CPR
100-120 compressions/minute 1/3 AP diameter Infants = 1.5inches Children = 2inches Teens = 5cm (adult recommendation)
Neimann-Pick disease
Neurodegenerative disorder
6mo-2yrs
GDD, milestone regression, hepatosplenomegaly, interstitial lung dz, macular cherry red spot
Palmar grasp persists until
2-3mo
Plantar grasp persists until
8mo
Fencing reflex persists until
6mo
AKA asymmetric tonic neck reflex
Babinski reflex persists until
1-2yrs
Moro reflex persists until
4mo
Vitamin D recommendations
400IU per day within days of birth to 6 months if child is exclusively breasted or not receiving at least 1L via D fortified formula daily
Birth weight doubles by age…
4-5mo
Birth weight triples by age…
12mo
Birth length doubles by age…
4yo
New food may be added to the diet…
every 5-7 days
Wilms tumour often associated with this syndrome
Beckwith-Weidemann syndrome = genetic overgrowth (omphalocele, hemihypertrophy, hypoglycaemia, large for GA)
Neuroblastoma lab findings
Elevated Urine or serum VMA/HVA (measures metabolites of catecholamines)
Possible anemia/other cytopenias
Target glucose screen in neonate prior to feeds
2.6mmol/L
Preterm definitions
Extremely preterm <28wks
Very preterm 28-32 wks
Moderate preterm 32-34 wks
Late preterm 34-36wks
Replacement of losses for dehydration
<10kg: 60-120mL ORS to each diarrheal stool or vomiting episode
>10kg: 120-140mL ORS for each diarrheal stool or vomiting episode
Rehydration therapy for mild-moderate dehydration
ORS 50-100mL/kg over 3-4h
Rehydration therapy for severe dehydration
Lactate Ringer’s solution or NS in 20mL/kg until mental status improves THEN 100mL/kg body weight ORS over 4h or D5 1/2 NS IV at twice maintenance fluid rates
Replacement therapy for severe dehydation
D5 1/4 NS with 20mEq/L KCl
Surgical abdomen that has bilious vomiting
Malrotation with volvulus
Surgical abdomen that has projectile, non-bilious vomiting
Pyloric stenosis
Hallmark electrolytes in pyloric stenosis
Hypochloremic, hypokalemic metabolic alkalosis with dehydration
Radiological sign of pyloric stenosis via upper GI contrast study
String sign (narrow pyloric channel)
Intussusception symptoms
Bilious emesis and red current jelly stools
Duodenal intestinal atresia associated with…
Trisomy 21
Congenital heart disease
Xray imaging sign for duodenal intestinal atresia
Double bubble
Symptoms of intestinal atresia
Abdo distention
Bilious emesis
Hyperbilirubin –> jaundice
Possible polyhydramnios in utero
IV fluid bolus
Isotonic (0.9%) NS at 20mL/kg over 60min
DKA definition
Random glucose >11.1mmol/L AND
pH < 7.3 or bicarb <15mmol/L AND
Moderate or large ketonuria or ketonemia
Diagnosing DM in peds
Symptoms of diabetes (polyuria, polydipsia, unexplained weight loss) + random glucose >11.1 OR
Fasting glucose >7 OR
2h post-Oral glucose challenge >11.1
HbA1c not usually used in peds but >/= 6.5% in adult
Isotonic/isonatremic dehydration - time period for fluid replacement
Over 12h
Hypotonic/hyponatremic - time period for fluid replacement
Over 24h
Risk of central pontine myelinolysis
(ie. patient consumes diluted fluids/water when dehydrated)
Hypertonic/hypernatremic - time period for fluid replacement
Over 48h
Risk of cerebral edema
(ie. DKA)
Add dextrose to fluid maintenance once glucose levels drop below
16.7mmol/L
Cushing’s triad of increased ICP
High BP
Low HR
Irregular respiration
Most common AI diseases associated with DKA
AI thyroid disease
Celiac disease
Traditional regimen 2/3, 1/3 insulin
2/3 in AM - 1/3 rapid and 2/3 intermediate acting
1/3 in PM - 1/6 rapid with dinner, 1/6 intermediate acting at bedtime
Basal bolus regimen for T1DM
Half of total given at bedtime in long-acting form (insulin glargine)
other half split up into 3 doses with meals (rapid)
T2DM screening guidelines in peds
Screen all overweight children (BMI >85th percentile) PLUS any 2 of :
- Maternal hx of diabetes or GDD
- Fam hx of T2DM in 1st or 2nd degree relative
- Race/ethnicity
- Signs of insulin resistance (acanthosis nigricans, HTN, dyslipidemia, PCOS)
Screen by fasting plasma glucose starting at 10yo onset of puberty and 13yrs
T2DM treatment
Start treating right away if random glucose >13.9mmol/L or HbA1c >9%
Name of enzyme that conjugates bilirubin in liver
Glucuronsyl transferase
Kernicterus
Pathological consequence of elevated unconjugated bill –> bill staining the basal ganglia and CN nuclei
Physiologic jaundice
Total bili = 257umol/L in full term infants who are otherwise healthy
Seen in 2-3 d of life, peaks at 3-4d
Breastfeeding jaundice
Early in first week of life
Low breast milk –> slow gut motility –> beta glucuronidase in meconium
2nd most common cause of neonatal jaundice
Breastmilk jaundice
Presents after 1st week of life, can persist up to 12 wks
Beta-glucuronidase in breastmilk
2 diseases that are antibody negative hemolytic cause of anemia due to RBC enzyme deficiency
- G6PD deficiency
2. Pyruvate kinase deficiency
Crigler-Najjar Syndrome
Auto-recessive
Causes unconjungated hyperbili
Type 1 - glucuronosyl transferase absence (more severe)
–> Tx = lifelong phototherapy
Type 2 - glucuronosyl transfersation dysfunction
–> Tx = Phenobarbital
Gilbert Syndrom
Not as severe, usually presents in adolescence
Dysfunction of glucuronosyl transferase
Biliary atresia
Jaundice, dark urine and pale stools presenting at 3-6wks of age
Tx - Kasai procedure
Caput succadaneum
Swelling commonly from SVD in vertex position
Serum, crosses suture lines
Does not cause hyperbili
Cephalohematoma
Subperiosteal hemorrhage
Blood, does NOT cross suture lines
Causes hyperbili
Photherapy
For unconjugated hyperbili
Expect 30-40% decline in first 24h
If no decline, consider HEMOLYSIS as cause
MEC should no longer appear in stool by day…
3
Conjugated hyperbili
If >20% of TSB is conjugated Think obstruction (cholestasis), hepatitis or AI diseases
CPR in child
100-120 compressionsmin
Depress chest at least 1/3 AP diameter
Infant Colic
Crying for more than 3h/d, for at least 3 days/wk for 3wks
Typically starts after 2wks of age, peaks at 6 wks, lessens by 3-4mo
Brief resolved unexplained event (BRUE)
Occurs in infan <1yo when observer reports sudden, brief, now resolved episode that includes on or more of the following:
Cyanosis or pallor
Absent, irregular or decreased breathing
Marked change in tone (hyper or hypo)
Altered level of responsiveness
Distinguishing between restrictive and obstructive lung disease
Restrictive = normal FEV1/FVC ratio (both decrease) Obstructive = lower FEV1/FVC ratio
Spirometry finding for asthma dx
FEV1/FVC < 80% with 12% improvement in FEV1 after SABA
Scoring system used to assess severity of acute asthma exacerbation
PRAM Score O2 sat Suprasternal retractions Scale muscle contractions Air entry Wheezing
Mild acute asthma exacerbation
PRAM score of 0-3
Salbutamol q20min x 1-2 doses in first hour
Moderate acute asthma exacerbation
PRAM score of 4-7
Salbutamol q20min x 3 doses AND
Ipratropium q20min x 3 doses in first hour
Mild persistent asthma
Symptoms >2d/wk but not daily
PM awakenings 1-2x/mo if <4yrs, 3-4x/month if >/= 5mo
SABA use >2d/k but not daily and not more than 1x/day
Minimal limitation of normal activity
FEV1 >80%
FEV1/FVC 80%
Moderate persistent asthma
Symptoms daily PM awakenings 3-4x/mo if <4yrs, >1x/wk but not nightly if >/= 5yrs SABA use daily Some limitation of normal activity FEV1 60-80% FEV1/FVC 75-80%
Severe asthma
Symptoms daily PM awakenings >1x/wk if <4 yrs, >7x/wk if >/=5yrs SABA use several times per day Extreme limitation of normal activity FEV1 <60% FEV1/FVC <75%
Mild persistent asthma tx
Daily low dose ICS
SABA reliever med as needed
Mod persistent asthma tx
Daily med dose ICS
If >12yrs, add LABA (affair, symbicort, salmeterol)
SABA reliever med as needed
Severe asthma tx
Refer to specialist
AND/OR Leukotriene receptor antagonist or LABA in combo with med dose inhaled steroids
Vitamin K given to newborns to prevent
Hemorrhagic disease of the newborn
Erythromycin eye ointment given to newborns to prevent
Ophthalmia neonatarum caused by N. gonorrhoea
Causes globe rupture and blindness
No protection against chlamydia trachoma’s conjunctivitis which is more common
Hearing screen
Should be done before 1mo of age (usually as newborn before d/c)
if failed, then repeat at 3mo
If failed twice then needs more formal assessment
Repeat at 4yo
Tx for congenital hypothyroid
Levothyroxine ASAP 10-15mcg/kg/d
Juvenile idiopathic arthritis
<16yo, arthritis in at least 1 joint for >6wks
Fleeting salmon-coloured rash of discrete macule on trunk and extremities
A/W Iridocyclitis
Oligoarthritis
Typically affects knee, onset of arthritis is acute a/w asymptomatic iridocyclitis
Affects = 4 joints for >/= 6 weeks
Slipped capital femoral epiphysis
Most common hip d/o in adolescents (boys > girls)
Affected leg is shortened and externally rotated
Months of vague hip or knee symptoms and limp
Tx: Internal reduction of femoral head
Legg-Calve-Perthes Disease
Most commonly affects boys btwn 4-10
Avascular necrosis of femoral head
Typically self-resolving, casting and crutches to keep joint ABducted and internally rotated to keep head in acetabulum
Complications - femoral head deformity, degenerative arthritis
Developmental dysplasia of the hip
Infants where femoral head is not properly aligned with acetabulum
Common in females born by breech with fam hx of DDH
Tx: Newborn wears pavlik harness –> closed reduction and spica cast at 6mo-2yrs
Ortolani maneuver
Assesses for dislocated hip by abduction of flexed hip with gentle anterior force
Barlow maneuver
Assesses for dislocatable hip by adduction of flexed hip with gentle posterior force
Holosystolic murmur ddx
VSD (starting with S1, blowing)
Mitral insufficiency
Tricuspid insufficiency
Continuous murmur
Patent ductus arteriosus
Most common murmur
Still’s murmur
3-7 yo
Musical or vibratory
Best heard at LLSB in supine position
Atrial septal defect murmur
First detected at age 3-5
Systolic murmur caused by increased flow through pulmonic valve
Widely split, fixed S2
Best heard at ULSB
Coarctation of the aorta
Systolic murmur with loud S2 bet heard at ULSB, L axilla and L unterscapular area
Presents in infancy
Check BPs
Ventricular septal defect murmur
Most common in infancy
Holosystolic murmur with possible wide split S2
Best heard at LLSB
Meds for CHF due to VSD
Furosemide
Digoxin
Enalapril (ACEi causes after load reduction –> more bloodflow out to systemic vasculature than through VSD)
Eisenmenger syndrome
Pulmonary HTN gets so severe that pulmonary pressure > systemic pressure –> R to L shunting –> RV hypertrophy –> cyanosis –> polycythemia –> HF –> death
Aortic stenosis murmur
Systolic ejection murmur followed by early diastolic murmur of aortic insufficiency
Pulmonic stenosis
Prominent systolic ejection click just after S1
Tetralogy of Fallot
R –> L shunt
- VSD
- RV out flow tract obstruction
- Overriding aorta
- RVH
Henoch-Schonlein Purpurs (HSP)
NON-thrombocytopenic purpura
Self-limited, IgA-mediated small vessel vasculitis that typically involves tetrad of RASH, ARTHRALGIAS, ABDO PAIN, RENAL INVOLVEMENT
A/W hematuria (possible progression to renal failure), arthralgias, colicky abdomen pain, intestinal bleeding with FOBT, possible intussusception
Tx: supportive management, steroids controversial
Most common cause of isolated thrombocytopenia in otherwise healthy child
idiopathic thrombocytopenic purpura
Idiopathic thrombocytopenic purpura
Most cases follow non-specific viral illness
NOT a/w splenomegaly and hepatomegaly
Isolated thrombocytopenia with normal plt morphology
Tx depends on severity
Ranges from watchful waiting to methylprednisilone (1st line), IVIG (2nd line) and platelet transfusions
HEEADSSS
Home Education Eating Activities Drugs Sexuality Safety Suicide
First and most subtle sign of possible inadequate perfusion
Tachycardia
Pediatric sepsis treatment
20cc/kg NS boluses over 5-20 min to a max of 60cc/kg
Give bolus even in its with relative C/I to receiving large amounts of fluids (ie. meningitis, SIADH)
Once reached max and pt’s perfusion still inadequate, give inotropic support (epinephrine, norepinephrine, dopamine)
Leading cause of bacterial meningitis in children
Neisseria meningitides
Definitive tx for meningococcal disease
Pen-G
Tx for carrier status of meningococcal disease
Adults: Ciprofloxacin
Peds: Ceftriaxone, azithromycin or rifampin
Antibiotic choice for Rocky Mountain Spotted Fever
Doxy
Toddler fracture
Subtle, non-displaced oblique fracture of distal tibia in young walking children (9mo-3yrs)
Tests to order post-strep
Anti-streptolysin-O (ASO)
Low C3
Causes or primary nephrotic syndrome from most to least common
Minimal change disease
Focal segmental glomerulonephritis
Membranoproliferative glomerulonephritis
Most frequent infectious complication associated with nephrotic syndrome
Spontaneous peritonitis
HTN defined as
Systolic OR diastolic >95th percentile measured on 3 or more occasions, preferably several weeks apart
Urine protein:creatinine ratio
<0.2 = normal in children >2yo
< 0.5 = normal in children <2yo
>1 = suspicious for nephrotic syndrome
>2.5 = dx for nephrotic syndrome
Streptococcal infection rash
Scarlet fever rash Erythematous, sand-paper rash Accentuated at skin creases Starts on face/neck --> trunk, arms, legs Blanchable
Erythema multiforme
`Symmetrical rash that starts as dusky macule and forms target lesions
Often triggered by infections (HSV)
1-3 wks
Conservative maanagement
Erythema migrant
A/W early localized Lyme disease
Head lice
AKA pediculosis capitis
Tx: 1% permethrin lotion, 2-3 repeated applications in weekly intervals
Scabies
5-10mm curvilinear thread-like lesion (burrow)
TxL 2 applications of permethrin 5% cream, 1 wk apart
Tinea capitis treatment
Systemic therapy required
Griseofulvin (oral anti fungal )
Diaper rash common causes
Irritant dermatitis
Diaper candidiasis
Bacterial infection (perianal GAS)
Irritant dermatitis diaper rash
Most common cause of diaper rash
Typically spares intertriginous creases
Tx: Barrier cream with Zinc-oxide
Diaper candidiasis
Erythematous papule that become confluent plaques with satellite lesions
Tx: Antifungal nystatin, imidazole antifungals (miconazole, ketoconazole)
Bacterial infection causing diaper rash tx
Oral abx
Neonatal acne associated with…
Malassezia species
Erythema toxicum
Idiopathic benign self-limiting cutaneous eruption of full-term newborns
Blotchy, macular erythema
Progresses to 1-3mm yellow/white papule and pustules
Day 2-10 of life
No tx needed
Neurofibromatosis Type 1
Need at least 2 of 7:
- Cafe au last spots (>/=6, 0.5cm if pre-puberty and >1.5cm if post-puberty)
- Axillary/groin freckling
- Auto dominant (first-degree relative affected)
- Neurofibromas present
- 2 or more Lisch nodules (iris hamartomas) - no clinical significance –> seen later in dz
- Optic nerve gliomas
- Patognomonic skeletal dysplasia
Risk associated with tobacco use during pregnancy
Low birth weight
SGA
Diagnosed at birth
<3rd or <5th percentile
IUGR
Dx during pregnancy
Height and weight <2SD mean for GA
Usually catch-up
Symmetric IUGR
Growth pattern in which head, length, weight are decreased proportionately
Can be caused by congenital infections
Early pregnancy
Asymmetric IUGR
Growth pattern in which decrease in size of length and/or weight without affecting head circumference
Can be caused by poor fetal nutrition (i.e. maternal smoking), placental insufficiency
More favourable than symmetric
Risk factors for early onset GBS
Prolonged rupture of membranes
Prematurity
Intrapartum fever
Previous delivery of infant with GBS disease
Prophylaxis against GBS administered if ONE of the following is present and mother is in labour with ruptured membranes
Prev infant with GBS dx
GBS bacteriuria during any trimester of current pregnancy
+ve GBS vag-rectal screening culture in late gestation
Unknown GBS status and any of the following:
- <37 wks GA
- Amniotic membrane rupture >/= 18h
- Intrapartum temp >/= 38C
- Intrapartum NAAT +ve for GBS
Rubella
Prodrome of low grade fever, headache, mild pink eye, myalgia, swollen/enlarged lymph nodes, cough, runny nose
Rash on face that spreads to rest of body, lasts ~3d
Caloric requirements for term infant
100-120 cal/kg/d
Caloric requirements for pre-term infant
115-130cal/kg/d
Caloric requirements for very low birth weight infant
Up to 150cal/kg/d
First line imaging for abdo mass
U/S
Preventing dental caries
No bottle use by the time child is 12-15mo
Supplement with fluoride
Intoeing in toddlers
Caused by tibial torsion
Resolves by ~4yo
Intoeing in school-aged children
Caused by femoral ante version
Resolves by 8-12yo
Common cause of normocytic anemia in children
Transient erythoblastopenia of childhood
Post-viral in school-aged children, recovers in 2mo
Vision screening begins at
3yo
Psych condition with highest comorbidity rate with ADHD
Oppositional defiant disorder
Empiric abx of choice for UTI
Cephalexin (Keflex)
Antibiotic to be avoided in neonates
Ceftriaxone (knocks off bill from Albumin –> risk of kernicterus; also avoid in pregnant women 48h before delivery)
Tetracycline avoid <8yo (teeth staining)
Nitrofuratnoin (hemolytic anemia)
Septra <2mo (risk of G6PD)
Abx choice for PNA PO step-down
Cefprozil
Only cephalosporin with pseudomonas activity
Ceftazidime
PNA treatment in >3mo (mild)
Amoxicillin
PNA treatment in >3mo (moderate)
Amp +/- Clarithromycin +/- Oseltmavir
PNA treatment in >3mo (severe)
Cefotax +/- Vanco +/- Clarithro PO +/- Oseltmavir PO
GBS treatment
Penicillin G mono therapy
Most likely pathogens for cervical lymphadenitis
Staph aureus Strep pyogenes (GAS)
Most likely pathogens for preseptal cellulitis
Strep pneumo
Staph aureus
Most likely pathogens for orbital cellulitis
Staph aureus
Strep pneumo
Other strep spp
Haemophilus influenza
Most likely pathogens for community acquired pneumonia in 1-3 months
Strep pneumo Strep agalactiae (GBS) Staph aureus E. coli Chlamydia trachoma's
Most likely pathogens for community acquired pneumonia >3mo
Viruses Strep pneumo Haemophilus influenza Staph aureus Strep pyogenes Mycoplasma pneumonia Chlamydia pneumonia
Most likely pathogens for infective endocarditis
Viridans strep
Staph aureus
Most likely pathogens for PID
Neisseria gonorrhoea
CHlamydia trachoma’s
Anaerobic organisms
PID tx
Cefixime PO Or ceftriaxone IM
+ Doxycycline PO or Azithro PO
+/- Metronidazole PO
Most likely pathogens for bacterial gastroenteritis
Salmonella Shigella Campylobacter E. coli Plesiomonas shigelloides Aeromonas hydrophily
Tx for bacterial gastroenteritis
Not routinely required
If severe then tx according to susceptibilities
Most likely pathogens for cellulitis
GAS
Staph aureus
Tx for mild cellulitis
Cephelexin PO or Septra PO
Tx for severe cellulitis
Cefazolin or Vancouver (if MRSA)
Dog/cat/human bites most likely pathogens
Staph aureus Strep spp Eikenella corrodens (human) Pasteurella spp (dog/cat) Capnocytophaga cynodegmi (dog/cat) Anaerobic organisms Usually polymicrobial
Dog/cat/human bites tx for mild and severe cases
Mild: Amox-clav PO
Severe: Pip-Tazo
OM or septic arthritis tx
Cefazolin or Vanco
Gross motor milestone at 4mo
Rolls prone to supine
Able to lie prone and push up onto elbows
Moro reflex may/maynot be present
Gross motor milestone at 6mo
Sits unsupported
Fencing reflex should disappear
Gross motor milestone at 5mo
Rolls supine to prone
Gross motor milestone at 8mo
Crawling
Gross motor milestone at 9-10mo
Cruising
Gross motor milestone at 12mo
Walks
Extensor plantar response seen until 12mo
Drinks from a cup
Gross motor milestone at 15mo
Runs
Gross motor milestone at 18 mo
Goes up stairs holding adult’s hand
Feeds self
Gross motor milestone at 3yo
Rides tricycle
Goes up and down stairs with alternating feet
Gross motor milestone at 4yo
Hops on one foot
Balances on one foot
Gross motor milestone at 5yo
Skips with alternating feet
Rides 2 wheeler
Plays games with rules
balances for 10s on one foot
Fine motor milestone at 1 mo
Visual fixation
Fine motor milestone at 3mo
Brings hands to midline
Fine motor milestone at 6mo
Puts toys in mouth
Transfers objects hand to hand
Ability to follow object visually at age
3mo
Fine motor milestone at 8mo
Pincer grasp
Fine motor milestone at 6mo
Trying to get things that are out of reach
Fine motor milestone at 12mo
Copy gestures such as clapping
Fine motor milestone at 18mo
Handing things to others as play
Stacks 3-4 cubes
Emergence of hand preference
Kicks ball, throws ball
Fine motor milestone at 2 yrs
Copies a line
Stacks 6 cubes
Fine motor milestone at 3yo
Buttons and zippers
Copies a circle
Fine motor milestone at 4yo
Copies a square, uses scissors, chopsticks, brush teeth
Fine motor milestone at 5yo
Copies a triangle, prints first name, starts tying shoelaces, mature tripod grasp of pencil, cuts along line, copies triangle
Fine motor milestone at 6yo
Draws man with fingers, 2D arms and legs
Ties shoelaces
Cognitive milestone at 4mo
Out of sight, out of mind
Cognitive milestone at 8mo
Aware that if object is out of sight, may still exist and have fallen to ground
Cognitive milestone at 12mo
Child will search for completely hidden object
Toilet training
Start at 18mo
Most are toilet-rained by 3yo
Independent with ADLs by age
5yo
Social milestone at 1mo
Social smile
Social milestone at 5mo
Clear preference for primary caretakers
Social milestone at 9mo
Stranger anxiety develops
Social milestone at 18-20mo
Starts to pretend
Galactogogues
Metoclopramide, Domperidone
= DA antagonists
Lactational mastitis
Most common in first 6wks postpartum
Tx: Cold compresses, anti-inflammatories, good breastfeeding techniques
Abx : No MRSA –> Cephalexin, MRSA risk –> Septra or Clinda
Tx for low risk febrile neutropenia
IV mono therapy: Ceftriaxone Pip-Tazo Cefepime Carbapenems
Tx for high risk febrile neutropenia
Pip-Tazo, add gentamicin if unstable
Tx for septic shock febrile neutropenia
Vanco + Gentamicin + Meropenem
Meds that requires therapeutic drug levels
Gentamicin, Vancomycin
Anticonvulsants
Immunosuppresants (tac, cyclosporine)
Drugs to avoid with EBV
Amoxicillin, Ampicillin
Can cause nonallergic morbilliform rash
Oral thrush
Most commonly caused by Candida albicans
Pseudomembranous oropharyngeal candidiasis
Tx: Nystatin suspension
All pulses poor
Myocardial problem
Palpable paradoxus
Pericardial effusion
Bounding pulses
PDA, truncus arteriosus, AI, AVM, sepsis
Femorals < brachial
Coarctation
Right racial only pulse palpable
Interrupted aortic arch
Medication used to keep ductus arterioles open
Prostin 0.05mcg/kg/min
Transposition of the great arteries
Most common heart defect presenting with cyanosis in newborn
Aorta comes off RV, Pulmonry artery comes off LV
Requires ASD, VSD, PDA to survive
Needs intervention right away
Features of innocent murmur
Never a/w thrill Normal hx Normal peripheral exam Never in diastole normal S2 Usually low-pitched ejection Changes with position
Common ECG finding in new born
Right Axis Deviation
Trisomy 21 with LAD
AVSD
Syndromal look with LAD
Noonan’s
Normal child with LAD and cyanosis
TGA
Tricuspid atresia ECG finding
LAD (no right AV connection –> uses ASD to send blood to left side and VSD to send blood to pulmonary arteries = LV has to pump blood to pulmonary and systemic systems –> LV hypertrophy –> LAD)
Familial short stature
Appropriate for mid-parental height
Bone age = chronological age
normal growth velocity
Constitutional growth delay
Delay at 18mo-3yrs
After 3yrs grow at normal rate –> catch up
May have delayed puberty
Clue to chondrodystrophies causing abnormalities of cartilage or bone dz
Height:arm span ratio (should be within 3cm of each other)
GH and IGF1 levels in malnutrition cases
GH levels vary
IGF1 levels low (esp in protein shortage diets)
Tx for boys with constitutional growth delay
Testosterone 1x/month for 3 months –> induces puberty and increases growth rate –> primes pituitary gland to take over once completed
Does NOT affect end adult height
No tx for girls
Tx for child with hypothyroid (ie. Hashimoto’s Thyroiditis)
Adolescent/older child –> start low and go slow, if you correct too fast can cause hyperthyroid
Neonate –> load first then work down to maintenance (thyroid hormone necessary for brain myelination)
Febrile seizure management
Benzo at 5min, 10min
If still seizing, then give phenobarbital at 15min over 20min
If still seizing, call ICU and secure airway
Goal SBP
(2 x age in years) + 70
Inotrope for warm shock
Norepinephrine
Inotrope for cold shock
Epinephrine
Parkland formula for burn rehydration
Volume of Ringer’s Lactate = 4mL x %BSA x weight (kg) –> half in first 8 h, then half in next 16h
IV tx for hypoglycaemia in newborn
10% dextrose in 80mg/kg/d
Adjust pen to keep glucose >2.6mmol/L
IDM/LGA –> stop testing glucose when >/- 2.6mmol/L for 12h
Preterm/SGA –> stop testing when >36h of stable glucose and intake achieved
Bucket handle fracture
Metaphyseal fracture/corner fracture
Caused by torsional/shearing force on limb or violent shaking
Pathognomic for abuse
Most common form of child maltreatment
Neglect
TEN-4
Bruising clinical decision rule
TEN = Torso, Ears, Neck (bruising in TEN region?)
Child <4mo?
If yes to one of these, workup for child abuse unless clear accidental cause of bruise
Humerus fracture
Always concerning for abuse, esp in young infant
Rib fracture
If abuse, usually in posterior at transverse process articulation (levering from shaking baby)
Pittsburg Infant Brain Injury Score
Any skin abnormality –> 2pts
Age >/= 3mo –> 1pt
Head circumference >85th percentile –> 1pt
Hemoglobin <112 –>1pt
Cyanotic baby ddx
1,2,3,4,5 Truncus arteriosus TGA Tricuspid atresia, pulmonary atresia Tetralogy of ballot Total anomalous pulmonary venous return
Poor pulses and LVH
Aortic stenosis
Poor femoral and RVH
Coarctation of the aorta
Normal ECG with cyanotic babe
TGA
Ebstein’s anomaly
Tricuspid valve sits low and leaflets displaced towards apex of RV –> RA hypertrophy
5 features that make it an epileptic event
o Post-ictal o Not suppressible o Reproducible o Stereotyped o Eyes open
Tx for idiopathic intracranial HTN
Acetazolamide
Optic nerve sheath fenestration
Therapeutic LP
Ability to follow object at age
3mo
Orbital cellulitis features not seen in periorbital cellulitis
Pain with eye movements Diplopia Proptosis Vision impairment Chemosis
Orbital cellulitis treatment
IV ceftriaxone + Vanco
OR Cefotaxime
OR Amp-sulbactam
OR Pip-Tazo
Switch to PO once afebrile and symptoms resolved (3-5d)
PO tx: Clindamycin mono, OR Clindamycin or Septra + amox or amox-clav (continue for 2-3 more wks)
Periorbital cellulitis treatment
Oral output abx - clinda mono OR septa +amox or amox-clav
Tx for 5-7d
Serious ddx to rule out for conjunctivitis
Acute angle glaucoma
Iritis
Keratitis
Nocturnal enuresis
Episodes of urinary incontinence in children >/= 5yo
Phimosis
Inability to retract foreskin
Balanopothitis/Balantis
Inflammation of glans penis and foreskin vs Inflammation of glans penis only
Phimosis tx
Physiological - no tx needed
Pathological (non retractable secondary to distal scarring) –> stretching exercises (gentle retraction), topical corticosteroids (betamethasone), circumcision
Balanopothitis tx
Proper hygiene
Abx ointment (polysporin, bactrian)
Should resolve in 3-5d
Vulvovaginitis abx tx if needed
10d amox PO or amox-clav
OR topical metronidazole
OR topical clindamycin
Benefits of circumcision
Lower rates of STIs, penile cancer, UTI
Major complication in circumcised males
Meatal stenosis (urine from wet diaper irritates meatus –> chemical dermatitis –> scarring)
Most common CFTR gene mutation a/w Cystic Fibrosis
Delta F508
Physiologic anemia
Mean hemoglobin in healthy 2mo = 112g/L
Marrow only stimulated to make new RBCs once 110g/L at 7-9wks of age
Fetal RBCs have short half life –> physiological nadir
GERD
Peak onset at 1-4mo
Usually resolves by 1yo (more upright)
Test to rule out malrotation
Barium swallow
Major gene a/w celiac disease
HLA-DQ2
Major complication of untreated celiac disease
Osteoporosis secondary to poor calcium and vitamin D absorption
Intussusception classic triad
Inconsolable pain
Red currant jelly stool
Sausage on palpation
Intussusception treatment
Barium or air enema
Surgery if failed
Antibiotic associated with diarrhea
Erythromycin (promotability)
Osmotic diarrhea
High stool osmolality compared to serum
Problem with absorption
Responds to NPO
Secretory diarrhea
Stool osmolality equal to serum
Problem with secretion
Does not respond to NPO
Think Cholera
Crohn’s disease
Regional enteritis - SI, LI, or both
Less likely to cause bloody stool
More likely to cause FTT
Dx: Upper and lower GI endoscopy with biopsy
Tx: Corticosteroids for acute, immunomodulators for maintenance (thiopurines, MTX, anti-TNF), surgery
Ulcerative colitis
Colon only Diarrhea usually bloody FTT less common Dx: MRI of SI, fecal calprotectin Tx: Corticosteroids for acute, immunomodulators for maintenance (thiopurines, MTX, anti-TNF), surgery
Ulcerative colitis antibody marker
ANCA
Crohn’s disease antibody marker
ASCA
Stool assay for IBD protein marker
Fecal calprotectin
Derm condition a/w IBD
Erythema nodosum
Most common cause of anemia in childhood
Fe-deficiency anemia
Low Fe, low retics, high iron binding capacity
HTN, oliguria, AKI, edema indicates
Acute Nephritic syndrome
HTN med choice for child with HTN and edema secondary to acute nephritic syndrome
Diuretic (ie. high dose lasix 1mg/kg TID and titrate up)
Nephritic vs nephrotic a/w HTN
Nephritic
Hematuria definition
> /= 5 RBCs/hpf on urine microscopy
Non-glomerular causes of hematuria
Hypercalciuria, stones, sickle cell, cystic disease
Glomerular causes of hematuria
Post-infectious glomerulonephritis, IgA nephropathy, HSP, HUS, SLE, Familial thin basement membrane dz, Alports
Nephrotic syndrome definition
Proteinuria (>50mg/kg/d)
Hypoalbuminemia (<25g/L)
Hyperlipidemia
Edema
Proteinuria definition
> 100mg/m2/d or >22g protein/mol creatinine
Treatment for nephrotic syndrome
Most likely minimal change disease which responds to steroids
Oral prednisone 2mg/kg to max 60-80mg for 6 wks, then alternate day dosing a 1mg/kg –> wean off over 6mo
na+ restrict
If edema, treat with IV lasix and 25% albumin
Seborrheic dermatitis
AKA cradle cap
Older patients caused by Malassezia fungus
Tx:
Baby oil and small brush
Frequent shampooing with baby shampoo, if resistant get rx shampoo with ketoconazole or pyrithione zinc
Low potency topical steroid (hydro)
Ketoconazole cream in older children
Parvo B19 rash
Stage 1 (2-3d after prodrome): Fiery red facial eruption Stage 2 (1-4d after facial rash): Lacy reticulated eruption on extremities and trunk Stage 3: intermittent waxing and waning of reticular rash Not infectious anymore once rash develops
Complication of Parvovirus B19
In pregnant women can cause fetal hydrous
Test solution for nickel
Dimethylglyoxime in 10% aqueous solution of ammonia
Sturge-Webber Syndrome
Port-wine stain on face
Neuro symptoms - seizures, glaucoma
Newborn milia
Resolves within 3-4 wks
No tx needed
Tuberosclerosis
Hypopigmented macule (ash-leaf) spots Angiofibromas often in malaria region Cardiac rhabdomyoma Renal angiomyolipomas --> HTN, CKD Seizures
Pityriasis alba
Asymptomatic hypo pigmented scaly patches
Commonly in atopic dermatitis patients
Esp noticeable after summer b/c don’t tan as well
Supportive tx
Ataxia telangiectasia
Truncal ataxia –> axial ataxia in infancy
Conjunctival telangiectasias
Immunodeficiencies
Predisposition to malignancy
Phenylketonuria (PKU)
Auto recessive disorder of AA metabolism caused by deficiency in phenylalanine hydroxylase
Detected by newborn screen
Vomiting, hypotonia, musty odor, developmental delay, decreased pigmentation of hair/eyes
Tx: Phenylalanine-restricted diet
Sleep through the night by age
4-6mo
5-2-1-0 Rule
5 servings of fruits/veggies per day
= 2h screen time/d (no screen time <2yo)
>/= 1h of physical activity per day
0 sugar sweetened drinks per day
ADHD subtypes
Inattention
Hyperactive/Impulsive
Combined
ADHD Screening Test
Vanderbilt Assessment Scale
von Willebrand disease treatment
Intranasal or IV desmopressin
Female puberty stages by age
Puberty during 8-13yo 10-11: breast buds, pubic hair 12: growth spurt 12-13: periods begin 15: adult height
Male puberty staged by age
Puberty during 10-15yo 12: testicles grow, pubic hair 13-14: Growth of penis/scrotum, first ejaculations 14: Growth spurt 17: Adult height
Sleep stage GHRH is released during
Stage 4
Thyroid hormones role in growth
Direct effect on growth of epiphyseal cartilage
Needed to release GH from pituitary
Needed for post-natal growth only
Sex steroids role in growth
Augments GH pulsatility
Does NOT play a role prior to puberty
Growth inhibitory peptides
Cytokines (ie. TNF) regulate programmed cell death
Cortisol affect on growth
High levels act on epiphyses to inhibit growth
Affect levels of GH, IGF-1, IGFBP3
In utero growth most dependent on
Nutrition
Insulin
IGF-2
Height deficiency but okay weight gain, think of…
Endocrinopathy
Graves’ disease
Anti TSHr
Hashimoto’s disease
Anti-TPO (Thyroperoxidase)
Thyroiditis
Anti-Thyroglobulin (Anti Tg)/Anti-TPO
Cortisol testing
If suspecting Cushing’s: Dexa suppresion
If suspecting deficiency: AM cortisol
Hypopituitarism tx order
CORTISOL FIRST > Thyroid > GH
Diabetes insipidus test
Water deprivation
Deprive water for 8h –> >3% weight loss, serum osmolality increase and UO < 600mosm/kg = DI
Nephrogenic vs central diabetes insipidus
ddAVP (synthetic ADH) –> if urine osm does NOT increase by much = nephrotic, if urine osm increases to >700mosm/kg = central DI
False results from heel stick blood test
Hb higher and platelets lower
Fe-def treatment
3-6mg/kg elemental iron daily for 3 months
Fe-def anemia lab work restyle
Low Fe Low ferritin Hb <110 Low MCV High TIBC High RDW Low relic count High transferrin
RDW to distinguish thalassemia from Fe-def
Thalassemia = small RDW Fe-deficiaency = High RDW
Diagnosing Fe-deficiency
6-24mo: Fe supplement trial
Older children: Bloodwork
Blast smear
Leukemia
Microcytic hypo chromic smear
Fe-deficiency
Spherocytes on smear
HS or AIHA
Schistocytes on smear
HUS, TTP, MAHA
Blister cells on smear
G6PD
Transient erythroblastopenia of childhood
Post-viral in school-aged children
Otherwise healthy
Recover in 2mo
Diamond blackfan
Bone marrow disorder where it fails to make enough RBCs
Bloodwork supporting hemolysis
Normocytic anemia High LDH High indirect bili Plasma free Hb Reduced haptoglobin
Hereditary spherocytosis
Inherited erythrocyte membrane defect that causes lifespan to be 10-30d instead of 120d
Anemia, jaundice, splenomegaly
Dx: Peripheral blood smear –> spherocytosis
Tx: Supportive, folic acid, possible splenectomy
HUS
Bloody diarrhea, thrombocytopenia, and microangiopathic hemolytic anemia, AKI
Shiga toxin, Strep pneumo
Tx: Support care
MAHA
TTP - Thrombotic thrombocytopenia purpura (severely reduced activity of vWF cleaving protease ADAMTS13)
DIC - Activation of coag system from sepsis, trauma, malignancy
Tx - PLEX if feeling unwell, severe anemia, thrombocytopenia, fragmented RBCs, renal failure; anti-complement, transfusion of RBCs/plts
Hemophilia A
Factor VIII deficiency
Hemophilia B
Factory IX deficiency
Hemophilia C
Factor XI deficiency
Anticonvulsants during pregnancy can lead to
Cardiac defects Dysmorphic cranial features Hypoplastic nails IUGR Microcephaly Mental retardation
Chorioretinitis of the newborn may be due to
Congenital toxoplasmosis and CMV infections
Cocaine use during pregnancy
Not typically a/w withdrawal symptoms
Linked to subtle deficits later in childhood - cognitive performance, attention
Fetal alcohol syndrome characteristic facial features
Thin upper lip
Smooth philtrum
Small palpebral fissures
Congenital rubella presentation
Sensorineural deafness
Eye abnormalities
PDA
Congenital CMV presentation
Microcephaly
Jaundice
Low birth weight
Petechiae
PKU
Auto recessive
Mutation in phenylalanine hydroxyls
Vomiting, hypotonia, musty odor, developmental delay, decrease pigmentation of hair and eyes
General ADHD dx requirements
6 or more symptoms in 2 or more settings for at least 6 months, several symptoms presenting before age 12
Overweight vs obesity definitions
Overweight = BMI 85-95th percentile Obese = BMI >95th percentile
Treatment for vWF disease
Desmopressin
Female puberty stages
Breast bud > pubic hair > growth spurt > menarche
Male puberty stages
Testicular enlargement > pubic hair appearance > growth of penis and scrotum > first ejaculations > growth spurt
Congenital hypothyroidism
Clinically evident at 6wks
Circulating maternal thyroid hormone transmitted from placenta
Feeding problems, large fontanels, hypotonia, large tongue, coarse cry, umbilical hernia
Picked up on neonatal screening
Most often due to aplasia or hypoplasia of thyroid gland
Congenital adrenal hyperplasia
Abnormal genitalia (females) Poor feeding Vomiting Dehydration Electrolyte changes Low Na, High K, low cortisol, low aldosterone Elevated 17-OH progesterone Presents at 1-2wks
Ornithine transcarbamylase (OTC) deficiency
Most common urea cycle d/o
Hyperammonemia
Elevated urine orotic acid
X-linked
Factors that decrease insensible losses
CHF
Renal failure
ADH release
Mechanical ventilation
NPO orders for children
- No solids after midnight
- May have formula until 2AM
- May have breastmilk until 4AM
- May have clear fluids until 6AM, complete NPO after
- Start IV fluids at 6AM
NPO orders for neonates
- Higher fluid requirements
- Term: 60cc/kg/d
- Pre-term: 80cc/kg/d
- Increase 20cc/kg/d until day 7 (150ml/kg/d)
- Ex. For 3kg newborn
- Day 1 - 180cc/24h = 7.5cc/h
- Day 4 - 60 —> 80 —> 100 —> 120: 120cc/kg/d x 3d = 360ml/24h = 15cc/h
Reasons to NOT add K+ to IV fluids
Hyperkalemic
Not voiding
Starting to tolerate PO
IV rate TKVO
Symptomatic hyponatremia treatment
3% NS at 2cc/kg bolus
ECG findings for hyperkalemia
- Peaked T-waves
- Short QT int
- Depressed ST segment
- Wide QRS
Hyperkalemia treatment
- Fluids
- Calcium gluconate to protect cardiac membranes
- Ventolin neb
- Beta-agonist role… not really sure how this works
- Always check K+ if pt is on ventolin!
- Insulin
- Bicarb
- Kayexalate
Encapsulated organisms
Strep pneumo
H. influenzae type B
N. meningitides
Pneumococcal vaccine
13-valent pneumococcal conjugate vaccine given in first year of life provides protection against 13 serotypes (all children)
23-valent pneumococcal polysaccharide vaccine given to sickle cell children at 2 and 5yo
Vaccines required in sickle cell children
H. influenza type b conjugate vaccine at 2, 4, 6 and mo
13-valent pneumo at 2, 4, and 6mo
23 valent pneumo at 2 and 5yo
Meningococcal vaccine at 2yo if functionally/anatomically splenic
Yearly flu shot
Esophagus begins at which spinal level
C4
Lateral neck X-ray rule
Pre-vertebral soft tissue should never be more than the AP diameter of the vertebrae behind them
Possible complications of retropharyngeal abscess
Mediastinitis
Jugular vein thrombosis
Most common congenital anomaly of nasal cavity
Bilateral choanal atresia
Most are BONY and BILATERAL
How to diagnose choanal atresia
CT
Most common lesion in young child at subglottic region of trachea
Hemangioma
Bronchial wall thickening with hyperinflation
<2yo: Bronchiolitis
>2yo: Reactive airway disease
