Pediatrics Flashcards
Child abuse
Neglect; physic/sex/psych malttt
Story not consistent w/ PE
RF: parent w/ alcoh/drug use; child w/ complex med prob; repeated hospit
Dg: X-ray/CT (fx diff stages); tests for STDs; ophthalmo exam; noncontr head CT/MRI
ttt: document injuries + notify Child Protect* +/- hospit
Common presentations and mimics of child abuse
Bruises: mongolian spots
Burns: scalded skin sd; sev contact dermatitis
Fractures: osteogenesis imperfecta
Abusive head trauma: accidental head trauma
Congenital heart disease
RF: maternal: drug use, inf, illness
- Acyanotic: L-R shunt (VSD, ASD, PDA) are acyanotic unless develop of Eisenmenger (shunt reversal + pulm HTN)
- Cyanotic: R-L shunt; 5Ts (Truncus arteriosus, transposit* of great Vx, Tricuspid atresia, Tetralogy of Fallot, Total anomalous pulmonary venous return)
Septal defects (PE, dg)
ASD: small asympt; large fatig/fqt resp inf/FTT
Wide fix split S2; syst ejec murm LUSB; RVH, RA enlarg, PR prolong
VSD: small asympt; large fqt resp inf/FTT/CHF/dyspn
Narrow S2 w/ ↑P2; harsh holosyt murm LLSB (louder if small); LVH
Septal defects (ttt)
- Most ASD/VSD close spont; no ttt
- Follow-up echo based on size + PE
- No AB prophyl needed
- Surg repair in sympt if failure of meds; if <1yo w/ pulm HTN; >1yo w/ large defects; early surg prevents compl
- ttt CHF w/ diuretics, inotrop ⊕, ACEI
Septal defects (associated syndromes)
ASD: FAS, tris 21
VSD: FAS, tris 21, TORCH inf, cri du chat sd, tri 13, tri 18
Patent ductus arteriosus (PE)
Acyanotic L-R shunt
Asympt; if large then FTT; recurr LRT inf; clubbing; CHF
Continuous murmur at 2nd left intercost space
Loud S2; wide pulse pressure
Bounding periph pulses
Patent ductus arteriosus (dg, ttt)
Dg: echo + Doppler; if large then LA+LV enlargement
ECG (LVH); CXR (cardiomegaly)
ttt: indomethacin (NSAID) unless PDA needed for survival or if CI (intraventr hge)
If it fails or if >6-8mo, surg
4 #dg for infant in shocklike state in first few weeks
Sepsis
Inborn errors of metabolism
Ductal-dependent congenital heart ds
Congenital adrenal hyperplasia
Coarctation of the aorta (RF)
Esp distal to left subclav art
↑flow proximal, ↓flow distal
Ass w/ Turner sd, berry aneurysms, male
Bicuspid AV in >2/3
Coarctation of the aorta (PE)
Asympt upper extrem HTN
If collaterals present, continuous murmur in all torso
Lower extrem claudicat*, syncope, epistaxis, headac
Weak femoral pulses, radiofemoral delay
If critical, PDA for survival (poor feed, lethargy, tachypn)
Coarctation of the aorta (dg, ttt)
Dg: echo + Doppler; CXR (cardiomeg, pulm congest*, rib notch); ECG (LVH)
ttt: if severe, keep PDA open w/ PGE1; surg/balloon angioplasty
Monitor for restenosis, aneurysm, Ao dissect*
Transposition of great vessels (RF)
Cyanotic; Ao to RV; PA to LV
Incompat w/ life if no ASD/VSD + PDA
PDA alone not sufficient
RF: DM in mom; DiGeorge sd
Transposition of great vessels (PE, dg, ttt)
Cyanosis first few hours, tachypn, hypoxemia
CHF; single loud S2
No murmur if no VSD assoc
Dg: echo; CXR (narrow heart base, egg-shape)
ttt: IV PGE1; surg (if cannot be done emerg, balloon atrial septostomy)
Tetralogy of Fallot (RF, dg)
Cyanotic (early R-L shunt in VSD then L-R))
RV outflow obstruct*, overrid Ao, RVH, VSD
RF: maternal PKU; DiGeorge sd
Dg: echo and cath; CXR (boot shaped); ↑pulm vasc markings; ECG (right-axis deviat* + RVH)
Tetralogy of Fallot (PE)
Asympt till 4-6mo then CHF + tachypn/dyspn, fatigue
Cyanosis (not at birth, dev over 2y), FTT
Child squat for relief when hypoxemia (↑SVR, ↑bld flow to pulm, ↑oxygenat)
Systolic eject murmur at left upper sternum, RV heave, single S2
Tetralogy of Fallot (ttt)
Severe RV obstruct* or atresia: immed PGE1 + urgent surg
Hypercyanotic tet spells: O2, proprano, phenyleph, knee-chest posit, fluids, morphine
Temporary palliat: balloon atrial septostomy then surg
Major milestones in language development
12mo: 1 word, 1-step command
15mo: 5 words
18mo: 8 words
2yo: 2-word phrases, 2-step command, 50% intelligible
3yo: 3-word phrases, 75% intelligible
4yo: 100% intelligible
Growth (head circumf, height, weight)
- Head circumf: routinely till 2yo; ↑hydroceph/tumor; ↓microceph
- Height/Weight: routinely till adult; check pattern; NN may ↓10%BW in first days but ↑in 14d; double BW at4-5mo; triple at 1yo; quadruple at 2yo
FTT: ↓weight then height then head circumf
Weight<5th percentile for age or ↓2 major percentile lines
Failure to thrive
- Organic: medic ds
- Nonorganic: psychol (poverty, maternal depress*, neglect, abuse)
Hospit if neglect or sev malnourish
ttt: caloric count + supplements if breastfeed inadeq
Sexual development
Tanner staging: boys (testic, penis, pubic hair); girls (breast, pubic hair)
Puberty: boys ~11.5yo; girls ~10.5yo (menarche ~12.5yo)
Precocious puberty: boys ≤9yo; girls ≤8yo
Delayed puberty: boys ≥14yo; girls ≥13yo
Pathologic puberty delay
Systemic ds
Malnutrition
Gonadal dysgenesis (Klinefelter, Turner)
Endocrine abNl (hypopituit, hypothyroi, Kallmann, androg insensitivity, Prader-Willi)
Down syndrome
Esp meiotic nondisjunct*; Robertosian transloc; mosaicism
Ass w/ atlantoaxial instability; duodenal atresia; Hirschsprung ds; congen heart ds (esp AV canal def)
↑R of ALL; hypothyroidism; early Alzheimer
Edwards syndrome
Rocker-bottom feet; low-set ears; micrognathia; clenched hands; prominent occiput
Congen heart ds
Death in 1y
Patau syndrome
Microphthalmia; microceph; cleft lip/palate; holoprosencephaly; polydactyly; omphalocele
Congen heart ds
Death in 1y
Klinefelter syndrome
47,XXY; inactivated X (Barr body)
Ass w/ ↑mat age
Hypogonadism
ttt: testosterone (prevent gynecoma; ↑2* sex charact)
Turner syndrome
45,XO; missing X (no Barr)
Ovarian dysgenesis
Coarct Ao, bicuspid AV
ttt: estrogen
Double Y males
47,XYY
↑fqcy in inmates of penal institutions
Often look Nl; some ptts very tall w/ severe acne
Phenylketonuria
↓phenylalanine hydroxylase or ↓tetrahydrobiopterin cofactor; AR; in first few months
↑phenylalanine but ↓↓tyrosine
Intellect disab; fair hair/skin; eczema; blond; blue eyes; musty odor; ↑R heart ds
ttt: ↓phenylal + ↑tyrosine
Fragile X syndrome
Defect in methylat/express of FMR1 gene
Triplet repeat disorder; X-link D
Large jaw, testes, ears
Intellect disability; autistic behav
Fabry disease
↓alpha-galactosidase A so ↑ceramide trihexoside
X-link R
Sev neuropath limb pain; angiokeratomas; telangiect
Renal failure; ↑R stroke/MI
Krabbe disease
↓galactosylceramide/galactoside so ↑galactocerebroside
AR
Progress CNS degenerat*; optic atrophy; spasticity
Death in 3y
Gaucher disease
↓glucocerebrosidase so ↑glucocerebroside
AR
Crinkled paper cells
Anemia, thrombocytopenia; rapid neuro decline
Niemann-Pick disease
↓sphingomyelinase so ↑sphingomyelin
AR
Cherry-red spot + HSMG
Tay-Sachs disease
↓hexosaminidase so ↑GM2 ganglioside AR Normal till 3-6mo, weakness + devel regress* Cherry-red spot but NO HSMG Death by 3yo
Metachromatic leukodystrophy
↓arylsulfatase A so ↑sulfatide
AR
Demyelination then progress ataxia + dementia
Hurler syndrome
↓alpha-L-iduronidase
AR
Corneal clouding, intellect disabil, gargoylism
Hunter syndrome
↓iduronate sulfatase
X-link R
Mild Hurler sd; NO corneal clouding
Mild intellect disabil
Cystic fibrosis (presentation)
AR; mutat* in CFTR gene; esp in white
Exocrine gland dysfct; chloride channel
Present w/ obstruct of distal ileum (abNl thick meconium)
<1yo: cough, wheez, recurr resp inf; steatorrhea; FTT
>1yo: FTT (pancreat insuff) or chronic sinopulm ds
Cystic fibrosis (PE)
- Recurr resp inf (Pseudo, staph aureus) w/ cyanosis, digital clubbing, chronic cough, dyspn, nasal polyposis
- Pancreat insuff: steatorrh, flatul, rectal prolapse, hypoprot, biliary cirrhosis
+ DM2; salty-tasting skin; male infertility; hyponatremia
Fat-soluble vitamin def (ADEK) w/ their manifest
Cystic fibrosis (dg, ttt)
Dg: sweat chloride test; confirm by genetic
!!! mandatory newborn screening
ttt: chest physical therapy, bronchodilators, CS, AB (cover Pseudo) + DNase Give pancreatic enzymes + vit ADEK High-calorie + high-protein diet Lung or pancreas transplants Death around 40yo
Intussusception (RF, PE)
#1 bowel obstruc in 6mo-3yo; esp boys Esp proximal to ileocecal valve RF: potential lead points (Meckel divert, intest lymphoma, submucosal hematoma, polyp, CF)
Triad: abrupt episodic abdo pain, vomit, bloody mucus in stool (currant jelly)
Palpable RUQ mass, empty RLQ
Intussusception (dg, ttt)
Dg: US (#1; target sign) during episode
AXR (later in ds, obstruct/perforat/mass)
ttt: correct volume/e- abNl; CBC; NG tube (decompress)
Air insufflat enema (dg+cure)
Surg: if peritoneal signs, unsuccess enema, pathol lead point
Pyloric stenosis (RF, PE)
Hypertrophy of pyloric sphincter
Esp 1st born male
Ass w/ TE fistula; formula feed; matern erythromycin
Nonbilious projectile emesis; at 3-5wks
After meals, bb stays hungry; dehydrat* + malnutrit*
Palpable olive mobile nontender epigastric mass
Pyloric stenosis (dg, ttt)
Dg: abdo US; hypochloremic hypokalemic metabolic alkalosis; RAAS activat*; barium study (narrow pylor)
ttt: NPO + IV access (dehydrat* + e- correct*)
Surg (pyloromyotomy)
Meckel diverticulum (PE)
Failure of omphalomes/vitelline duct to obliterate True divertic (3 layers); esp boys
2 inches long; 2 feet of ileocecal valve
Gastric or pancreatic tissue
Asympt; painless rectal bleed
Meckel diverticulum (complications, dg, ttt)
Compl: intest perforat/obstruct; diverticulitis (#dg w/ appendicitis); intussuscept*
Dg: Meckel scintigraphy scan (Tc99m for ectopic gastric tissue); AXR (perforat/obstruct)
ttt: surg excis; emergent if hge, diverticulitis, perforat, obstruct, intussuscept
Hirschsprung disease (RF, PE)
Congen lack of gg cells distally
Ass w/ male; Down sd; MEN2
Failure to pass meconium in 48h; bilious vomit; FTT
If mild: chronic constip later in life
Abdo distens*; explosive discharge of stool after DRE
Hirschsprung disease (dg, ttt)
Dg: barium enema (#1; narrow dist colon + prox dilat*)
AXR (paucity of air in rectum); anorectal manometry (failure of internal sphincter to relax)
!!! Rectal biopsy confirms dg (No Auerbach+Meissner plexuses + hypertrophied nerves)
ttt: 2-stage rectal surg
Malrotation with volvulus (PE)
Congen malrotat* of midgut
Cecum in RUQ + fibrous (Ladd) bands
↑R of obstruct, constrict of bld
Esp 1st month of life w/ bilious emesis
Abdo cramps, distenst, bld/mucus stool
Later in life: postsurg adhes lead to volvulus
Malrotation with volvulus (dg, ttt)
Dg: AXR (bird-beak; air-fluid levels)
Upper GI series (#1 if ptt stable)
ttt: NG tube + IV hydrat* Emergent surg (if gastric V); or endoscop (if intest V)
Necrotizing enterocolitis (PE, complications)
Necrosis of bowel (term ileum/prox colon)
#1 GI emergency in NN; esp premature infants
RF: low birth weight; hypoTN; enteral feeding
1st few days/wks of life; feeding intoler; delayed gastric emptying; abdo distens*; bld stool
Rapidly intest perfor, peritonitis, shock
Compl: intest strictures; short-bowel sd
Necrotizing enterocolitis (dg, ttt)
Dg: hyponatremia; metab acidosis; ↑WBCs w/ left shift; ↓plts; coagulop
AXR (#1; dilated bowel loops; pneumatosis intestinalis; portal venous gas; abdo free air=perfor) every 6h
ttt: NPO + orogastric tube + correct dehydrat* and e- + TPN and IV AB
Surg: if perforat* or worsening AXR
Immunodeficiency disorders
Congen
Chronic or recurr inf; unusual or opportun microorg
Incomplete ttt resp or FTT
Bruton agammaglobulinemia
X-linked R; B-cell def; only in boys
>6mo age when No maternal IgG
Encapsul org inf; life-threat
Dg: qtty of Ig, if low confirm that B-cell def; absent tonsils/lymphoid tissue
ttt: prophyl AB + IVIG
Common variable immunodeficiency
B-cell + T-cell def; all Ig levels low; at 15-35yo
Normal B-cell nb but ↓plasma cells
↑pyogenic up/low resp inf; ↑lymphoma/autoimm ds
Dg: qtty of Ig; confirm w/ B+T cell nb
ttt: IVIG
IgA deficiency
1 immunodef; mild; only ↓IgA
Asympt or recurr resp or GI inf
Anaphylactic transfus* react* (anti-IgA Ab)
Dg: qtty of IgA; ttt inf
ttt: IgA-depleted IVIG
Thymic aplasia (DiGeorge syndrome)
AD; CATCH22; tetany (hypoCa) first few days of life
↑↑↑↑inf w/ viruses, fungi, PCP
Absent thymic shadow (CXR)
Dg: absolute T-cell count; delayed hypersens skin test
ttt: bone marrow tranplant + IVIG; PCP prophyl
Ataxia-telangiectasia
AR; mut in gene for repair of dsDNA breaks
Cerebellar ataxia + oculocutan telangiect
↑NHL/leukemia/gastr carcinoma
ttt: IVIG dep on severity of Ig def
SCID
X-linked R; severe lack of B+T cells
Confine to isolated sterile environment
Severe fqt bact inf, chron candida, opportun inf
ttt: BM or SCT + IVIG; PCP prophyl
Wiskott-Aldrich syndrome
X-linked R; only in male
At birth; ↑IgE/IgA, ↓IgM and ↓plts
Bleeding, eczema, recurr otitis media
↑↑R of atopic dso; lymphoma/leuk; encaps org inf
ttt: IVIG + AB; if sev inf then BMT
Rare survival to adult
Chronic granulomatous disease
X-linked R or AR; def superoxide by PMNs/macroph
↓RBCs, LNpathy, hypergammaglob
Chronic skin, LN, pulm, GI, UTI infect*, osteomyelitis, hepatitis
Microorg catalase⊕; granulomas of skin/GI/GU
Dg: ANC; dihydrorhodamine + nitroblue tetrazolium tests
ttt: daily TMP-SMX; AB when inf; IFN-gamma; BMT and gene therapy
Leukocyte adhesion deficiency
Def leukocyte chemotaxis
Recurr skin, mucosal, pulm infect*
NN: omphalitis + delayed separ of umb cord (>14d)
Dg: No pus + minimal infl in wounds; ↑WBCs
ttt: BMT
Chediak-Higashi syndrome
AR; def neutrophil chemotaxis, microtub polymeriz
Partial oculocut albinism, periph neurop, neutropenia
↑pyogenic inf w/ strep pyog, S aureus, Pseudo
Dg: giant granules in neutrophils
ttt: BMT
Job syndrome (Hyperimmunoglobulin E syndrome)
Def neutrophil chemotaxis
Coarse facies, abscesses (S aureus), retained 1* teeth, hyperIgE (eosino), sev eczema
ttt: penicillinase-resistant AB + IVIG
C1 esterase inhibitor deficiency (hereditary angioedema)
AD; recurr angioedema for 2-72h provoked by stress/trauma
Life-threat airway edema
Dg: total hemolytic complement (qtty+fct* of complem)
ttt: C1 esterase + FFP prior to surg
Terminal complement deficiency (C5-C9)
Inability to form MAC
Recurr Neisseria infect*
ttt: meningococcal vaccine; AB
Kawasaki disease (3 phases)
Vasculitis; esp <5yo and Asian; 3 phases
- Acute ph: 1-2wks; 5d of fever + ≥4 of criteria
- Subacute ph: 2-8wks; coronary aneury if not ttt, do echocardio
- Chronic ph: >8wks till ESR is Nl; sympt disapp; unttt at R of aneury expans* + MI
Kawasaki disease (dg, ttt)
Dg: 5d of fever + ≥4 of these criteria (bilat conjunct, oral mucos changes, rash, periph extrem changes, cervical LN >1.5cm)
-Acute: normochrom An; ↑WBCs; ↑ESR; ↑CRP
-Subac: ↑plts; ESR and CRP gradual ↓
Echo: at dg + follow-up
Kawasaki disease (ttt, #dg)
dg: scarlet fever (same presentat* but normal lips and no conjunctivitis)
ttt: high-dose ASA + IVIG; continue low-dose ASA for 6wks. If coro aneury, chronic anticoag w/ ASA or other antiplt.
!Reye sd
Juvenile idiopathic arthritis (PE, ttt)
AI ds; <16yo; girls>boys
Arthritis + morning stiff; gradual ↓mot* for ≥6wks
3 subtypes; 95% resolut* by puberty
ttt: NSAIDs + strength exo; CS/methotrexate/etanercept (carditis)
Juvenile idiopathic arthritis (subtypes)
- Oligoarthritis (#1): ≤4 joints; uveitis; ANA⊕, RF⊖
- Polyarthritis: ≥5 joints, symm; ANA⊕; if RF⊕ then severe w/ rheumatoid nodules
- Still ds (systemic): recurr >39*C, HSMG, salmon-col macular rash; ANA⊖, RF⊖; joint infl after mo-ys of systemic sympt
Acute otitis media (causes, PE)
75% of children have ≥3 by 2yo
S pneumo; nontype H influ; M catarrh; influ A; RSV; parainflu
Ear pain, fever, cry, irritab, diff feed/sleep, vomit, diarrh
Acute otitis media (dg, ttt, complications)
Dg: otoscopy (erythem tympanic memb, bulging/retract* of TM, ↓TM mobility)
ttt: high-dose amoxicillin (80-90mg/kg/d) x10d
If resistant, amoxi-clav; if recurr, tympanostomy
Complic: TM perforat*, mastoiditis, meningitis, cholesteatoma, chronic OM; if recurr then ↓hearing + speech/language delay
Bronchiolitis (RF, PE, complications)
Esp <2yo; fall/winter
RSV (#1), parainflu, influ, metapneumoV
RF for sev: <6mo; prematur; heart/lung ds; neuromusc ds; immunodef
First ↑RR; D1-3 (low fev; rhinorr; cough +/- apnea); D4-6 (resp distress; tachypn; hypoxia)
Compl: respir failure
Bronchiolitis (dg, ttt)
Dg: crackles or coarse breath sounds +/- wheezing
If sev, CXR (r/o pneumonia); nasopharyng aspirate (RSV)
ttt: hydrat*, suctioning, O2
If Hx asthma, bronchodilat; if sev ds, hospit
If underl ds (heart/lung/immuno), ribavirin
If ↑R ptt (lung/heart ds, prematur), RSV prophyl w/ palivizumab inj
Croup (laryngotracheobronchitis)
Parainflu V (#1); RSV; influ; adenoV \+/- bact superinf URI sympt then low fev, mild dyspn, inspiratory stridor, hoarse voice, barking cough
Neck X-ray (steeple sign of subglottic narrowing)
ttt: mild (cool mist + fluids); mod (+O2, PO/IM CS, inhal epineph); sev (hospit, inhal epineph, +/- intubat*)
Epiglottitis (causes, PE)
Serious + rapidly progress supraglott inf
Before vaccine, H.influ type B was #1
Now esp strep, nontyp H.influ, virus
Acute high fev (39-40), dysphagia, drooling, muffled voice, inspirat retract*, cyanosis, inspir stridor
Sit neck hyperextended + lean forward (tripod)
Epiglottitis (complications, dg, ttt)
Compl: if unttt, life-threat airway obstr; resp arrest
Dg: clinic; secure airway before defin dg!!!
No throat exam unless anesth/ORL doctor present
Defin dg: fiberoptic (cherry-red swoll epiglott/arytenoids)
Lateral X-ray (thumbprint sign)
ttt: emergent!!! ABC (#1); intubat*/tracheostomy then IV AB (ceftriaxone, cefuroxime)
Meningitis (causes)
-NN: grpB strep; E coli; Listeria
-Infant/child: S pneumo; N mening; H influ
-Ado: N mening; S pneumo
Enteroviruses
RF: sinofacial inf; trauma; immunodef; sepsis
Meningitis (PE, dg, ttt)
Bact: triad of headac, high fev, nuchal rigidity
Viral: prodrom (fev, sore throat, fatig)
Kernig/Brudzinski signs
+/- ↑ICP; petech rash (N.men)
NN: may not have meningeal signs but ↑/↓ thermia; poor tone; bulging fontanelle; vomit
Meningitis (dg, ttt)
Dg: head CT (r/o ↑ICP) if ↑R of herniat*
LP (count+diff; glu; prot; Gram; Cx)
ttt: NN (ampi ⊕ cefotaxime or genta) No ceftriax in NN
Add acyclovir if susp herpes encephalitis (mom has HSV les*)
Older child (ceftriax ⊕ vanco)
Retropharyngeal abscess
6mo-6yo
Acute high fev, sore throat, hot potato voice, trismus, drooling, cerv LNpathy; unilat post mass
GrpA strep (#1); S aureus; Bacteroides
Supine + neck extended
Dg: lateral X-ray; contrast CT
ttt: aspirat* or drain + AB
Peritonsillar abscess
> 10yo
Sore throat, hot potato voice, trismus, drooling, uvula to opposite side
GrpA strep (#1); S aureus; S pneumo; anaerobes
Dg: clinic
ttt: drain +/- tonsillectomy + AB
Ocular infections of the neonate (causes)
- C trachomatis: 1-2wks of life; eyelid swell, scant watery disch
- HSV-2: 2wks of life; conjunct, watery/serosg disch, vesic erupt* around eye
- N gonorrh: 1wk of life; bilat purulent conjunct + eyelid edema; sev; now silver nitrate for prophyl
Ocular infections of the neonate (dg, ttt)
Dg: bact Cx and Gram (gono, chlam)
HSV PCR (if corneal ulcerat* or vesic erupt*)
Cervical Gram+Cx for STI in mom
ttt: empiric before Cx; topical and PO erythrom for chlam
IV/IM C3G for gono; if cause unknown always cover gono
14-21d systemic acyclovir + topical vidarabine for HSV
Pertussis (Whooping cough) (vaccine, PE)
Esp <6mo
DTaP vaccine (5 doses early childhood)
Immunity ↓ at ado (ado becomes reservoir)
Life-threat in young infants but mild in older
3 stages: catarrhal (mild URI, 1-2wks) then paroxysmal (cough + insp whoop + posttussive emesis, 2-3mo) then convalescent (↓sympt)
Highly infectious bronchitis (esp in stage 1)
Pertussis (Whooping cough) (dg, ttt)
Dg: ↑WBCs and lymphocytosis Nasophar Cx (#1)
ttt: hospit if <6mo; azithromycin x10d
Exposed NN at ↑R
Close contacts: prophyl azithrom x5d
Erythema infectiosum (5th disease)
ParvoB19
-No prodrome or low fev
-Rash (slapped cheek), prurit, maculopap, erythem; worse w/ fever + sun expo
Arms then spread to trunk/legs
Compl: arthropathy (child/adult); hydrops fetalis; aplastic crisis (SCD, hered spheroc, sev iron def An)
Measles
Paramyxovirus
- Prodrome: low fev + Cough, Coryza, Conjunctivitis; Koplik spots (1-2d)
- Rash: erythem maculopap from head to toe
Compl: otitis media, pneumonia, laryngotracheitis
Subacute sclerosing panencephalitis
Rubella
Rubella virus
- Prodrome: asympt or tender generalized LNpathy (esp post auricular), low fev
- Rash: erythem maculopap from head to toe
Compl: encephalitis, ↓plts, congen inf
Roseola infantum
HHV-6 and 7
- Prodrome: acute high fev (>40*C), no sympt for 3-4d
- Rash: maculopap when fev breaks, on trunk then face/extremities; for <24h
Compl: febrile seizures
Varicella (chickenpox)
VZV
-Prodrome: mild fev, anorex, mal; 24h before rash
-Rash: general, prurit, vesicles on red base; diff stages of healing; face then body; Spare palms/soles
!! infectious 24h before erupt* till crust
Compl: meningoencephalitis, pneumonia, hepatitis in immunocompr; 2* bact inf of skin les*; Reye sd if ASA
Varicella zoster
VZV
- Prodrome: reactivat* of varicella; pain along 1 sensory N
- Rash: prurit vesic, dermatomal; esp in immcompr
Compl: encephalopathy, aseptic meningitis, pneumonitis, TTP, Guillain-Barre sd, cellulitis, arthritis
Hand-foot-and-mouth disease
Coxsackie A
- Prodrome: fev, anorex, oral pain
- Rash: oral ulcers, maculopap vesic (hands, feet, buttocks)
Compl: none
Toxoplasma gondii
TOrches
Mom: asympt; LNpathy
NN: triad (chorioretinitis, hydrocephalus, intracranial calcifications) +/- blueberry muffin rash
Rubella
toRches
Mom: rash, LNpathy, arthritis
NN: triad (PDA, cataract, deafness) +/- blueberry muffin rash
CMV
torChes
Mom: asympt; mononucleosis-like ds
NN: hearing loss, seizures, petechial rash, blueberry muffin rash, periventricular calcifications
HIV
torcHes
Mom: depends on CD4+ count
NN: recurrent inf, chronic diarrhea
HSV-2
torcHes
Mom: asympt; herpetic les*
NN: encephalitis, herpetic les*
Syphilis
torcheS
Mom: chancre (1), dissem rash (2)
NN: stillbirth, hydrops fetalis; if survives then notched teeth, saddle nose, short maxilla; saber shins, CNVIII deafness
APGAR scoring
Evaluate need for NN resuscitat*
At 1 + 5 minutes; 5 parameters (Activity, Pulse, Grimace, Appearance, Respirations)
8-10: good cardiopulm adaptat*
4-7: possible need for resuscitat, observ/stimulat/possible ventilatory support
0-3: immediate resuscitat
Tracheoesophageal fistula
Ass w/ defects as esoph atresia and VACTERL
Polyhydramnios, ↑oral secret, inabil to feed, gag, aspirat pneumonia, resp distress
Dg: CXR (NG tube coiled; air in GI); confirm by bronchoscopy
ttt: surg
Congenital diaphragmatic hernia
GI in thorax; 90% post left (Bochdalek) Respirat distress (pulm hypopl + pulm HTN); sunken abdo; bowel sounds in left hemithorax
Dg: US in utero; confirm by postnatal CXR
ttt: high fqcy ventilat* or extracorporeal oxygenat*; surg
Gastroschisis
Herniat* of intest next to umbilicus (esp R) w/o sac
Polyhydramn; esp premature
Ass w/ GI stenosis/atresia; erythem bowel
ttt: wrap bowel till surg
Omphalocele
Herniat* of viscera at umbilicus into a sac (peritoneum + amniotic membrane)
Polyhydramnios; esp premature
Ass w/ other GI/cardiac defects
In Beckwith-Wiedemann sd; trisomies
ttt: C-sect*; keep covered and stable till surg
Duodenal atresia
Complete/partial failure of duod recanalizat* in gestat* wks 8-10
Polyhydramnios; bilious emesis in hours of first feeding
Ass w/ Down sd; other cardiac/GI anomalies
Dg: AXR (double bubble)
ttt: surg
Neonatal jaundice (types)
↑bili >5
- Conj/direct: always pathologic
- Unconj/indirect: physiol or pathol
-Kernicterus: complic of unconj hyperbili; irreversible bili deposit* in basal gg, pons, cerebellum; at >25-30; can be fatal; RF (premature, asphyxia, sepsis)
Neonatal jaundice (PE)
Check diet (breast/formula), intrauterine drug expo, fam Hx (RBC defects) Signs of hepatic/GI dysfct* (abdo distent*, delayed meconium, light-col stools, dark urine); inf; birth trauma
Kernicterus: lethargy, poor feed, high-pitched cry, hypertonicity, seizures, jaundice in cephalopedal progr
Neonatal jaundice (dg, ttt)
-Direct: LFTs, bile acids, bld Cx, sweat test, aminoacidopathies, alpha1-antitrypsin def; US; HIDA scan
-Indirect: CBC, periph bld smear, bld typing (mom+bb), Coombs, bili level
Sepsis workup + ICU adm if jaundiced NN + fever + hypoTN +/- tachypn
ttt: underl cause; if unconj do phototherapy (mild) or exchange transfus* (sev >20); CI of photottt if conj
Physiologic vs pathologic jaundice
Physiol: not in 24h of term; bili ↑<0.5mg/dL/day; bili <14-15; direct <10%; resolves in 1wk (in term) or 2wks (in preterm)
Pathol: in 24h of term; bili ↑>0.5mg/dL/hr; bili >15; direct >10%; persists after 1wk (in term) or 2wks (in preterm)
Mechanisms of neonatal jaundice
- ↑bili product* (↑unconj): hemolysis, RBC enz def, RBC struct def, ineffect erythropoiesis, sepsis+DIC
- Impaired hep bili uptake (↑unconj): Gilbert, Crigler-Najjar
- Impaired bili conj (↑conj): Dubin-Johnson, Rotor, NN physiologic jaundice
- ↑enterohepatic circulat* (↑unconj): poor feeding, breast milk jaundice, pyloric stenosis
Respiratory distress syndrome (hyaline membrane ds) (RF, PE, complications)
#1 resp failure in preterm Surfactant def → poor lung compliance, alv collapse, atelectasis RF: mat DM, male, second bb of twins
First 48-72h w/ RR>60, progress hypoxia, cyanosis, nasal flaring, intercostal retract*
Compl: persistent PDA, bronchopulm dysplasia, retinopathy of prematurity, barotrauma, intraventric hge, NEC
Respiratory distress syndrome (hyaline membrane ds) (dg, ttt)
Dg: ABGs, CBC, bld Cx (r/o inf); confirm w/ CXR
ttt: CPAP or intubat* + mechanical ventilat* Artificial surfactant (↓morta) Prettt mom at risk for preterm (<30wks) w/ CS; if >30wks monitor fetal lung maturity by L/S ratio (if <2:1 give GC to mom)
Cerebral palsy (RF, types)
Nonhereditary, nonprogressive disorders of mvt+posture
From prenatal neuro insult or idiopathic
RF: low birth weight, intraut expo to mat inf, premature, perinat asphyxia, trauma, brain malfo, NN cerebral hge
Pyramidal: 75%; spastic paresis, any limb; intellect disab
Extrapyramidal: dyskinetic; 3 subtypes (ataxic/choreoathetoid/dystonic)
Cerebral palsy (PE)
Ass w/ seizure, behav disord, hear/vis* impair, learning disab, speech def
Affected limb: hyperreflexia, ↑tone/contracture, weak, underdev
!!! if hand preference at <1yo
Toe walking, hip dislocat*, scoliosis
Cerebral palsy (dg, ttt)
Dg: clinic, US (r/o intracran hge, sturctural malfo), MRI (older child); EEG
ttt: No cure; special educat*, physical therapy, braces, surg release of contractures
Diazepam/dantrolene/baclofen or post rhizotomy (↓contractures)
Febrile seizures (RF, types)
6mo to 5yo
No evidence of intracranial infect* or other cause
RF: rapid ↑temp, ⊕fam Hx
- Simple: short (<15min), generalized tonic-clonic, one/24h, return to baseline shortly; high fev (>39*C) within hours
- Complex: long (>15min) or focal or multiple in 24h or no return to baseline; low fev several days before
Febrile seizures (dg, ttt)
Dg: find inf; LP after r/o ↑ICP (if signs of CNS inf)
First simple seiz or clear dg in >18mo (no workup)
If <6mo do sepsis workup (all Cx)
Atypical: e-, glu, Cx, …
ttt: antipyretic (acetam; CI ASA) + ttt underl cause
If complex, complete neuro eval (EEG, MRI) +/- chronic anticonvulsant
Febrile seizures (complications)
R of recurr <30%; highest within 1y of first episode
RF for dev of epilepsy: complex febrile seiz (Not simple); ⊕fam Hx of epilepsy; abNl neuro exam; dev delay
Leukemia (RF)
1 child malignancy; esp ALL (97%)
ALL: esp white boy 2-5yo
AML: esp black boy
Ass w/ trisomy 21; Fanconi An; prior radiat*; SCID; congen BM failure
Leukemia (PE)
Abrupt onset, nonspecif (anorex, fatig) then bone pain w/ limp or refuse to bear weight; fev (neutrop); An; ecchymos; petech; HSMG
CNS meta: headac, vomit, papilledema
AML: can present w/ chloroma
Leukemia (dg, ttt)
Dg: coag study, bld smear, ↑blasts, WBCs ↓/Nl/↑
Confirm w/ BM aspir/biopsy + genetic analysis
BM hypercell + ↑lymphoblasts
CXR (r/o mediastinal mass)
ttt: chemoth (induct*/consolid/mainten); !!!tumor lysis sd (hyper K/P/uric, hypoCa) (ttt w/ fluids, diuretics, allopur)
Neuroblastoma (RF, PE)
Tumor of neural crest origin; esp <2yo
70% meta at presentat*
Ass w/ neurofibromatosis, Hirschsprung ds, N-myc oncog
Mass in abdo > thorax > neck
Nontender abdo mass (may cross midline), Horner sd, HTN, cord compress*; anemia, FTT, fev
BM suppr, proptosis, HMG, subcut nodules, opsoclonus/myoclonus
Neuroblastoma (dg, ttt)
Dg: FNA (small blue cells w/ rosette); ↑24h VMA +HVA
Stage by CT, bone scan, BM aspir
ttt: local excis* + postsurg chemoth +/or radiat*
Wilms tumor (RF, PE)
Renal tumor; esp 2-5yo
Ass w/ Beckwith-Wiedmann sd, neurofibromatosis, WAGR sd
Asympt nontender abdo mass; Not cross midline
Abdo pain, fev, HTN, hematuria
Wilms tumor (dg, ttt)
Dg: biopsy/FNA (defin); abdo US; CT chest/abdo (meta)
ttt: local resect* + nephrectomy + postsurg chemoth+radiat* (dep on stage)
Ewing sarcoma
From neuroectoderm; ass w/ t(11:22)
Esp white male ado
Midshaft of long bones
Local pain+swell; fev, anorex, fatig
Dg: ↑WBCs, ↑ESR, X-ray (lytic bone les* w/ onion skin)
ttt: local excis, chemoth, radiat
Osteosarcoma
Osteoblasts
Esp male ado
Metaphyses of long bones (dist fem, prox tib, prox hum)
Local pain+swell
Dg: ↑ALP; sunburst lytic bone les; chest CT (r/o meta)
ttt: local excis, chemoth
Clavicular fracture
1 fx in child
Birth related or not
Ass w/ brachial plexus palsies, subclav art injury
Esp middle 1/3 fx w/ proximal end displaced superiorly by SCM
ttt: sling
Greenstick fracture
Incomplete fx: cortex + 1 side of bone
ttt: reduct* + cast
X-ray at 10-14d
Nursemaid’s elbow
Radial head subluxat*
Pain, pronat*, refuse to bend elbow
ttt: reduct* by supination at 90* of flexion
Torus fracture
Buckling of compress* side of cortex
Esp distal radius or ulna (after fall)
ttt: cast immobil 3-5wks
Supracondylar humerus fracture
1 elbow fx in child; 5-8yo
↑R of Volkmann contracture
!!! brachial artery entrapment
ttt: closed reduct* w/ percutan pinning; cast immobil
Osgood-Schlatter disease
Overuse apophysitis of tibial tubercle
Active young boy
Local pain, esp quadriceps contract*
ttt: ↓activity for 2-3mo or until asympt
Salter-Harris fracture
Fx of growth plate: I (physis); II (metaph+phys); III (epiph+phys); IV (epiph+metaph+phys); V (crush of phys)
ttt: closed/open reduct* (align) then immobil
Duchenne muscular dystrophy (PE)
X-linked R; dystrophin def; esp 3-5yo
Axial + prox muscles
Progress clumsy, fatig, diff stand/walk, Gowers maneuver, waddling gait
Pseudohypertrophy + shortening of gastrocnemius
+/- intellect disab
Duchenne muscular dystrophy (dg, ttt, complications)
Dg: muscle biopsy (necrosis, absent dystrophin); ↑CK
EMG
ttt: physical therapy (prevent contractures) +/- tendon release surgery
Compl: mortality in teens (high-output cardiac failure from cardiac fibrosis)
Becker muscular dystrophy
X-linked R; dystrophin level Nl but abNl proteine
Esp 5-15yo
No intellect disab
Death in 30s-40s
Developmental dysplasia of the hip (PE)
= Congenital hip dislocation
Subluxed or dislocated femoral head → early degenerative joint ds
Esp firstborn girls; in breech posit*
Barlow (dislocat) and Ortolani (reduct) maneuvers
Allis sign; asymm inguin skin folds
Developmental dysplasia of the hip (dg, ttt, complications)
Dg: critical early detect*; US (<6mo), X-ray (>4-6mo) ttt: early; may self-resolv <2wks age <6mo: Pavlik harness (flex/abduct hips) 6-15mo: spica cast 15-24mo: open reduct* then spica cast
Compl: joint contractures, AVN of fem head; if unttt signif defect <2yo
Legg-Calve-Perthes disease (PE)
Idiopathic AVN + osteonecrosis of femoral head
Esp boys, 4-10yo, unilateral
Self-limited ds, sympt last <18mo
Asympt first then painless limp, antalgic gait, thigh muscle atrophy; limited abduct/internal rotat
Legg-Calve-Perthes disease (dg, ttt)
Dg: X-ray Nl first then flat/fragmented femoral head
Good pg if <6yo + full ROM, limited involv, stable joint
ttt: observ if limited involv or if full ROM
Extensive involv or ↓ROM: bracing, Petrie cast or osteotomy
Slipped capital femoral epiphysis (PE)
Displacement at growth plate
Epiph stays; metaph moves anterior+superior
Esp obese, 10-16yo; bilateral
Ass w/ hypothyr or endocrinopathies
Dull hip pain (referred knee pain), painful limp
Restricted ROM, inability to bear weight
Limited abduct/internal rotat
Slipped capital femoral epiphysis (dg, ttt, complications)
Dg: X-ray in AP + frog-leg lateral (post+inf displacement of fem heads)
+/- TSH
ttt: immediate surg fixat* (↓R AVN); no weight bearing until stabiliz post-surg
Compl: chondrolysis, AVN, premature osteoarthritis
Scoliosis (PE)
Lateral curv of spine >10*
Male/Female = 1:7
Esp idiopathic in early ado (by screening)
Or congen; ass w/ neuromusc, verteb, spinal cord ds
Vertebral+rib rotat* (Adams test)
Scoliosis (dg, ttt, complication)
Dg: X-ray spine (all views)
ttt: close observ if <20; bracing if 20-49 w/ remaining growth (may progress); surg if >50*
Compl: severe ds create restrictive lund ds
Anticipatory guidance
Water heater <48.8C
Baby sleep on back w/o stuffed animals/toys
Car safety: rear facing in back of car; face forward if >2yo or >40pounds
No solid food at <6mo; gradual introduct one at a time
No cow mild at <12mo
Contact poison control immediately
Sudden Infant Death Syndrome (SIDS)
1 cause of unexplained death in <1yo
Apparent Life-Threatening Event (ALTE)
Unexpected + frightening change in appearance or behavior
Not a precursor of SIDS
Hearing screening
Otoacoustic emissions +/or auditory brainstem response
Newborn before discharge
In child w/ Hx of meningitis, TORCHES, measles, mumps, recurr otitis media
Vision screening
Red reflex at birth
Leukocoria (=absent red refl): retinoblastoma; cataracts; retinopathy of prematurity
Strabismus Nl till 3mo
Evaluate if >3mo; corrective lenses, occlus* +/or surg to prevent amblyopia
Contraindications of childhood vaccinations
Severe allergy to vaccine components
Life-threat allergy to eggs: No MMR
Encephalopathy in 7d of prior pertussis vacc
No live vacc: immcompr and pgnt mom
Except HIV mom: receive MMR and varicella
Precautions of childhood vaccinations
Current mod-sev illness (+/- fever)
Prior >40.5*C to pertussis vacc; shocklike state; persist crying for >3h in 48h of vacc; seiz in 3d of vacc
Hx of IVIG
Can give vaccine if: mild illness; low fever; current AB ttt; prematurity
Lead poisoning (RF, PE)
Esp lead-contam house dust from lead paint
Routine screen at 12 and 24mo if ↑R child
Irritab, headac, hyperactiv/apathy, anorex, interm abdo pain, constip, vomit, periph neuropathy
Sev: acute encephalopathy (confus*, seiz, coma)
!!! impaired intellig/neurodev even if 10ug/dL
Lead poisoning (dg, ttt)
Dg: finger test then serum level
CBC + periph smear (microcytic hypochromic anemia + basophilic stippling) +/- sideroblastic anemia
ttt: if <45ug/dL + asympt (retest in 1-3mo + remove lead source)
If 45-60: chelate (inptt EDTA or outptt oral succimer
If ≥70: chelate (inptt EDTA + BAL; IM dimercaprol)
Vesicoureteral reflux (RF, grades)
By post urethral valves (boys); urethral or meatal stenosis; neurogenic bladder
Mild (I-II): no dilat; resolv spont
Mod-sev (III-IV): ureteral dilat w/ caliceal blunting if sev
Vesicoureteral reflux (PE, dg, ttt)
Recurr UTIs; prenatal US (hydronephrosis/oligohydramnios)
Dg: first US, if suspicious then Voiding CystoUrethroGram
ttt: aggressive ttt of inf
Mild: daily prophyl AB until resolut* (amoxi if <2mo; TMP-SMX or nitrofur if >2mo)
Mod-sev: surg
Inadeq ttt can lead to progr renal scarring + ESRD
Cryptorchidism
RF: low birth weight
Bilat cryptor ass w/ prematurity, oligospermia, infertility, congen malfo sd (Prader-Willi, Noonan)
Dg: testes not in scrotum, palpated along inguinal canal or abdo
ttt: orchiopexy (if prepub); orchiectomy (if postpub; !!testic cancer)
