Pediatrics Flashcards
What are risk factors for severe respiratory disease in children?
Premature birth
Age < 6-12 weeks
Low birth weight
Hemodynamically significant cardiac disease
Hx of Immune deficiency, neuromuscular disorder, lung disease, or anatomical defects of the airway
Family history of wheezing
Household contacts who are cigarette smokers
Indigenous peoples
Breastfeeding is protective
Ref: iLearn Peds case 3 month old with cough
What questions on history are relevant to assess hydration status in an infant ?
History of emesis - volume and frequency
Number of wet diapers
Milk intake
Solid intake
Ref: iLearn peds three month with cough
What are the 3 most common causes of bronchiolitis?
Respiratory Syncytial Virus (64%)
Rhinovirus (16%)
Human metapneumovirus
What surgical conditions commonly present with abdominal pain in children?
Appendicitis
Intestinal obstruction
Testicular torsion
Intussusception
Ref: iLearn Peds Module 2
- Examine genitalia in younger male children c/o Abdo pain
A pediatric patient presents with perforated appendicitis. What is the management?
Admission
IV antibiotics, then oral
Repeat ultrasound to ensure resolution of collection, inflammatory mass, or phelgmon
Delayed or interval appendectomy in 4-6 weeks from initial presentation
In pediatric patients with abdominal pain, what are red flags that point to a possible surgical cause?
Children less than 5 years Previous abdominal surgery Progression of pain Pain far away from umbilicus Bilious vomiting Vomiting without diarrhea No pain like this before Disturbance in gait Return visit for same pain within 72 hours
When is a diagnosis of epilepsy made?
After 2 or more unprovoked seizures
Name 4 immediate management steps for a patient having an actute seizure episode. (Not including medications)
ABCs!! And G
Support the airway
100% oxygen
Monitor (record vitals and BP)
Get a glucose reading
Febrile seizures happen in what age group?
5 months to 5 years
Less than 5 years old
Peak between 12 and 18 months of age
Seizures are treated acutely when they last longer than 3-5 minutes. What can you give (dose and route for pediatrics) if there is no IV access? If there is IV access?
Lorazepam 0.1 mg/kg buccal or PR (max 4 mg/dose)
Diazepam 0.5 mg/kg PR (max 20 mg/dose)
If IV available:
Lorazepam 0.1 mg/kg IV (max 4 mg/dose) administer over 30 to 60 seconds slow push to minimize risk of respiratory depression
Midazolam 0.1 mg/kg IV (max 10 mg/dose)
What is Todd’s paralysis?
Post ictal paralysis or weakness
Should only last a few hours, and by definition resolve by 24 hours
What are red flags with bruising or injury in pediatrics?
Any unexplained bruising in an infant younger than 6 months
No history of trauma or a vague history
A changing story
A different story from different caregivers
An injury not compatible with history or developmental stage
A delay in seeking medical attention
When considering the possibility of non accidental trauma, what details do you need to elicit on history?
Developmental stage (is the child rolling, cruising, walking)
Any developmental regression?
Temperament (irritable or excessive crying)
More information about caregivers
Prior involvement of CAS or police
Domestic violence or caregiver hx of abuse
Mental health and substance abuse problems
Other children
FHx - bleeding disorders
What is the most common cause of serious head injury in children less than 1 year of age?
Child abuse
You’ve admitted an infant (6 week old) with a subdural hemorrhage and unexplained bruising which are suspicious for non accidental trauma. What additional investigations are you going to order as part of your evaluation for physical abuse?
- Additional blood work to rule out an underlying bleeding disorder
- CBCD, INR, PTT, fibrinogen, vWD screen - Screening labs for abdominal trauma
- AST, ALT, lipase and u/a
- consider imaging if Abdo bruising, distension, or tenderness (CT with contrast modality of choice) - Ophthalmology consult to assess for retinal hemorrhage
- Skeletal survey
- recommended in all cases of suspected physical abuse in children less than 2
+/- bone scan
What finding on fundoscopy is specific for abuse?
DIFFUSE retinal hemorrhages (multilayer)
In children less than a year, what percentage of rib fractures are from abuse?
70%
Rib fractures are often posterior and bilateral in inflicted trauma. But any rib fractures without a clear mechanism should raise concerns for inflicted trauma.
Neonates with fever less than or equal to 1 month of age should receive a full septic workup. What investigations does this include?
CBCD Blood culture Urinalysis and urine culture Lumbar puncture (protein, glucose, cell count, gram stain, viral, and bacterial culture) Peripheral blood glucose
Infants 28 to 90 days old with fever without a source who meet low risk criteria should have a partial septic workup. What investigations are included in this?
CBCD
Blood culture
U/a and culture
+/- stool culture if diarrhea and greater than 5 WBC/hpf
If you suspect ITP, what tests should you order?
CBC
Peripheral smear
Retics
INR, PTT, fibrinogen
Ref: iLearn Peds Module
A 2 year old has gastroenteritis. When can she return to daycare?
48 hours of no symptoms with normal stools
Ref: iLearn peds
For a term, healthy infant, what is a normal caloric intake?
100-120 kcal/kg/day
To ensure appropriate catch up growth in the setting of FTT, what percent of baseline caloric intake is required?
150%
What 3 infectious agents most commonly cause sepsis in healthy children?
Staphylococcus sp
streptococcus sp
Escherichia coli
Ref: iLearn Peds
What volume (cc/kg) and type of fluid should be used in pediatrics for a bolus?
20 cc/kg
Crystalloid
Normal saline or ringers lactate
If a child remains in shock, how much fluids should be given (ml/kg) over what time frame?
60 ml/kg total fluid in the first 60 minutes
Ref: iLearn Peds Module
How does a fluid bolus need to be administered in pediatrics? Over what duration?
Rapidly over 5-10 minutes manually via syringe or through specialized rapid infuser.
Pediatric patients should receive what antibiotics for presumed sepsis? (Not including infants < 3 months old)
Third generation cephalosporins (e.g. ceftriaxone)
+/- vancomycin
You have given 3 boluses of fluid (60 cc/kg) in 60 minutes for hypovolemic shock. The patient is not responding. What is your next step?
Inotropic/vasoactive therapy (fluid refractory shock)
Eg. Dopamine infusion
How can you distinguish between a benign and a pathological murmur? List 4 features of a benign murmur.
Grade < 3
Soft quality
Absent thrill
No associated click
S2 splitting only associated with inspiration (no fixed splitting)
Intensity changes with position and with respiration
Ref: iLearn Peds Module
How do you do a hyperoxic test in an infant? What is a positive hyperoxic test? What is the significance of a positive test?
Performed by doing an ABG in the right arm on 100% oxygen.
When the partial pressure of oxygen is < 150 mmHg
Suggestive of cyanotic congenital heart disease.
What are the cyanotic congenital heart lesions? List 3
Transposition of the great arteries Tetralogy of Fallot Total anomalous pulmonary drainage Truncus arteriousus Tricuspid atresia
Ref: iLearn Peds Modules
What is the most common cyanotic heart lesion in infancy?
Tetralogy of Fallot
Ref: iLearn Peds Modules
What should the target oxygen saturation be for a child with suspected congenital heart disease?
75-85%
Ref: iLearn Peds Modules
What are the 4 domains of health used to stage obesity in children?
Four Ms Mental health Mechanical health Metabolic Health Milieu (Social)
Edmonton Obesity Staging System
What findings on history/physical exam of a unilateral swollen eye are suggestive of orbital cellulitis until proven otherwise?
Vision changes (blurred vision or diplopia)
Pain with EOM
Proptosis (abnormal protrusion of the eye)
Ophthalmoplegia (restriction in EOM)
Relative afferent pupillary defect (not present in all cases)
NB. The above should not be present in periorbital cellulitis
Ref: iLearn Peds
Pediatric patient in DKA are at an increased risk of cerebral edema. Therefore, if you are required to give a fluid bolus, what amount should you give? (cc/hr)
NS at 10 cc/kg bolus
Ref: iLearn Peds modules
You suspect DKA. What investigations should you order?
Glucose Venous blood gas Sodium and potassium Urea/Creatinine Urine ketones
Ref: iLearn Peds Modules
What lab findings are consistent with DKA?
Hyperglycemia
Elevated urinary ketones
Bicarb < 18 mmol/L (with pH < 7.3)
Metabolic anion gap acidosis
Ref: iLearn Peds Module
ALL children with T1DM should be screened for what autoimmune disease? What bw should be ordered? How frequently?
Autoimmune thyroid disease
TSH, thyroid antibodies
At diagnosis and q 2 years (if positive antibodies, then needs TSH and antibodies q6 months)
Ref: CDA guidelines
In children with type 1 diabetes, what are the A1C targets?
Less than 6 years old = < 8.0%
6-12 = = 7.5%
13 or older = = 7.0% (same as adults)
Ref: CDA Guidelines
How do you calculate the total daily insulin dose? If adjustments need to be made in the insulin, approximately what percent do you adjust?
0.5 units/kg/day
10% up or down
In instances of severe hypoglycemia in children with type 1 diabetes when oral treatment is not an option, what dose of glucagon do you give?
Children less than or equal to 5 years old = 0.5 mg of glucagon SQ or IM
Children greater than 5 years old = 1 mg (same as adults
REf: CDA guidelines
How is arthritis defined? (i.e. and inflamed or active joint)
A joint with obvious swelling or effusion OR At least two of the following: Limitation of ROM Joint line tenderness Pain on motion
Ref: iLearn Peds Modules
What is the most common extra-articular manifestation of juvenile idiopathic arthritis?
uveitis
Ref: iLearn Peds
A child presents with concerns for precocious puberty. What should you ask to obtain a comprehensive history? List 4. (hint: think of the differential diagnosis)
Headaches
Visual Changes
Polyuria/Polydipsia
Symptoms of hypothyroidism (weight gain, cold intolerance, constipation, skin changes)
Access to exogenous estrogens
Family history of pubertal onset
Symptoms of androgenization (deep voice, hirsutism, clitoromegaly)
Ref: iLearn Peds Modules
Central precocious puberty is associated with what other findings (unrelated to development of secondary sex characteristics)
Advanced bone age compared to chronological age
Acceleration in linear growth
Ref: iLearn Peds Modules
What is the gold standard test for assessing central precocious puberty?
GnRH stimulation test
(give GnRH and measure LH and FSH levels, in central precocious puberty, LH and FSH levels will rise in response).
Ref: iLearn Peds Modules
You see a 6 year old female with premature isolated adrenarche. What tests should you order to rule out CAH or an androgen secreting tumor?
17-hydroxyprogesterone (17-OHP)
Dehydroepiandrosterone -sulfate (DHEAS)
Testosterone profile
Ref: iLearn Peds
What is the definition of systemic inflammatory response syndrome (SIRS)?
At least 2 of the following:
- Core temperature >38.5 or <36
- Tachycardia (in children less than 1 year, bradycardia)
- Tachypnea
- Elevated or depressed WBC or greater than 10% immature neutrophils
What does APGAR stand for?
A - Appearance P - Pulse G - Grimace A - Activity R - Respirations
SECTIONS
APGAR Score
The Apgar score is used as a part of early assessment of a newborn.[1]
A score of 0, 1, or 2 is assigned to each of the 5 physical signs at 1 and 5 minutes after birth. The maximum score that can be assigned is 10. Scores ranging from 7-10 are considered normal. If the 5-minute Apgar score is abnormal (< 7), appropriate measures should be taken. Apgar scores should be assigned every 5 minutes until the infant is stabilized.
Heart rate
2 points = ≥100 beats/min
1 point = < 100 beats/min
0 points = Absent
Respirations
2 points = Regular breathing/strong cry
1 point = Irregular/weak/slow breathing/gasping
0 points = Absent
Muscle tone and movement
2 points = Good flexion/action motion
1 point = Some flexion
0 points = None/limp
Skin color / oxygenation
2 points = Body and extremities pink
1 point = Blue at extremities; pink body
0 points = Completely blue
Reflex irritability to tactile stimulation
2 points = Cry/cough/sneeze
1 point = Grimace/feeble cry when stimulated
0 points = Silence; no response to stimulation
What are the cyanotic congenital heart diseases? (Right to left shunts). List 3.
Cyanotic Congenital Heart Disease (5 T’s, with 1-5 mnemonic)
Truncus Arteriosus(1 vessel)
Transposition of the Great Vessels(2 vessels switched)
Tricuspid valve atresia (3 valve cusps)
Tetralogy of Fallot(4 components)
Total Anomalous Pulmonary Venous Return(5 words)
