Pediatrics: Block 1 Flashcards
What two phases is the prenatal period divided into?
What period overlaps the Prenatal and Postnatal periods?
Embryonic- first 8wks
Fetal- after 8wks of gestation
Perinatal- 20-28wks of gestation through 1-4 weeks after birth
Define Perinatal Mortality
What are the two most common causes of it?
Fetal death between 20wks EGA through 28 day pos-delivery
Congenital abnormalities
Prematurity <37wks
What is the range for normal respiration for newborns?
What is the range for normal heart rates? What ranges are indicative of necessary interventions needed?
30-60/min
120-160
>100: routine care
60-99: ventilation
<60: ventilation and chest compressions
What is the correlation between pediatric age, HR, BP and R?
How many chest compression and compression/breath ratio during NRP?
As they get older HR and RR decreases, BP increases. “Adult-like” around 12 y/o
120bpm
3 compression : 1 respiration w/ two thumbs method (preferred) or two finger method
When placed supine on tables, what breathing position do babies take?
When administering O2 to newborns by blow by, how much is used?
Sniffing position
Blow by= 10L/min @ < 1/2” from face
BVM= sniffing position @ 40-60/min
Intubated= done if no chest rise/fall w/ BVM and allows for med delivery and preferred for transport
What is done for neonatal HOTN?
What drugs are given for HR?
What drugs are given for opioid use/abuse?
10mL/kg NS or LR
Epi 0.1-0.3mL/kg or 1 : 10,000 for IV/ETT for Asystole/Brady and unresponsive to O2
Narcan- narcotic/opioid reversal 0.1mg/kg IV/IM/ET
DONT if mom is addict/methadone, leads to withdrawal seizures
USE if mom received opioids/short term use during delivery
What type of issues are seen in Hemorrhagic Disease of Newborns?
Generalized echymosis
GI bleeds
Umbilical stump bleeding
Circumcision bleeding
If baby is bottle fed, what does the formula need to contain when 4-6mon of age is reached?
Fe- deficiency risk starts at 4mon,
Starting @6mon: 1mg/kg/day, max 15mg
Vit D- 400 IU/day for first days of life; deficiency= rickets, most common in first 2yrs of life
What are the results of rickets in babies?
Craniotabes- thin skull, fells like ping pong ball
Thickened wrists/ankles
Rachitic Rosary- costochondral junction enlargement
Enlarged anterior fontanelle/delayed closure
Bow leg/knock knees
During a newborn exam, what does an enlarged anterior fontanelle greater than 5cm suggests ? issue
Define Craniosynostosis
Hypothyroidism
Closed fontanelles
Define Leukocoria
During newborn exams, how would congenital heart d/os present?
White reflex in the eye
Can be cataract, retinoblastoma, chorioretinits, hyperplastic primary vitreous, retinopathy of prematurity
Systemic Sxs, murmur may not be heard
What are the negative, false result and positive screenings for pulse oximetry for newborn screening and what are the next steps?
All 3 done at 24hrs of life or shortly before discharge
95% or more on R hand/foot w/ 3% difference= negative screening, plan for discharge
90-94% and 3% or less difference= repeat screening in 1hr. If repeat results are in low range, repeat again in 1hr. 3 readings in this range need echo
<90% in R hand or foot= positive screening result, Echo
What do each of the following findings during a newborn exam indicate? Weak pulse Bounding pulse Single second heart sound Continuous harsh holosystolic murmur Grade 3 or higher murmur Hepatomegaly
Poor CO- aortic stenosis High CO- PDA Cyanotic HDz- truncus arteriosus, hypoplastic left heart Pathologic Pathologic Pathologic L HF
Newborn exam should show a soft and round abdomen, what does a scaphoid shape mean?
Define Barlow and Ortolani maneuvers
Diaphragm hernia
Hip dysplasia indicator test
Ortalani- clunk of hip relocating anteriorly
What are the risk factors of congenital hip dysplasia
How is it evaluated?
Female, FamHx, Breech, First born, Oligohydramnios, Post natal swaddling
US suspicious findings or risk factors @ 4-6wks old
When are the following reflexes gone by Fencer/Asymmetric neck reflex Trunk Incurvature/Galant Placing Rooting- turns cheek to stimulus Moro Grasp Babinski
3mon 4mon 4-6mon 4-6mon 6mon 6mon 12-28mon
Define Caput Succedaneum
Define Cephalohematoma
Common boggy edematous swelling of scalp that crosses suture lines and resolved in 3 days
Less common swelling that doesn’t cross suture lines and resolves in wks/mon but can lead to jaundice
Define Subgaleal Hemorrhage
Rare subaponeurotic bleeding result of vacuum delivery that crosses suture lines and pushes ears anteriorly and increases risk of jandice; Tx by compression and resuscitation
Define Epstein Pearls
Define Vernix Caseosa
Keratin cysts, resolve in first weeks
Salivary tissue- Bohn nodules
Chalky white/gray mixture of epithelial cells, sebum, keratin and hair
Common in pre-terms
Thought to be protective/lubricant in womb
Define Milia
Define Milia Rubra
White smooth papules on face/scalp from epidermal occlusion of pores
Self limited and resolving
Overheated/febrile heat rash as erythematous papules
Tx by correcting over heating
Define Mongolian Spot
Define Cafe Au Lait Macules
Blue/black pigments on lower back/butt in AfAm/Asian/Indian infants that fades in life
Must be documented
Sharply defined oval macules/patches
6cm or larger Cafe or 5cm or larger diameter need further eval of neurofibromatosis, tuberous sclerosis, McCune-Albright Syndrome
Define Nevus Simplex
Define Nevus Flameus
AKA Salmon Patch
Stork bite- nape of neck
Angel kiss- forehead/eyelid
Transient and benign
Port wine stain from malformed capillary bed
Must consider Sturge-Weber Syndrome on face (trigeminal nerve distribution)
Define Erythema Toxicum Neonatorum
Define Neonatal Acne
Pustules w/ erythematous base appearing on back and trunk 24-48hrs after birth that lab results will show eosinophils and resolves in 2wks
Acne on cheeks/scalps in first few weeks of life from maternal estrogen
Define Cutis Marmorata
Define Cradle Cap
Mottling
Physiologic response to cold, resolves w/ warmth that decreases w/ age
If persistent: hypothyroid, vascular/congenital issue
Seborrheic Dermatitis
First sign of atopic dermatitis
Can treat resistant/persistant cases w/ mineral oil, white petrolatum emollient or medicated shampoo
Define Umbilical Granuloma
Red papule from umbilical stumps and resolved w/ silver nitrate Distinguish from: Urachus- urinary d/c Meckels Vitelline Duct Talc granulomas
Define Metatarsus Adductus
Most common foot disorder in infants
Medial deviation of mid and forefoot, can lead to hip dysplasia
Dx- mid-heel bisector line should go between toe 2 and 3; V-finger should not gap at 5th MT
Tx- most spontaneous, serial casting, bracing, surgery
Define Talipes Equinovarus
Clubfoot, Limp Hypoplasia Calf atrophy and foot shortening, half are bilateral Congenital- 75% of cases Teratological- myelomeningocele Positional from in utero Tx w/ serial cast or surgery
Define Spina Bifida
Lumbosacral neural tube defect, Cleft Spine
Dx during 2nd trimester from maternal AFP and US
Rachischisis- hair tuft
Meningocele- meninges through neural arch
Meningomyelocele- meninges and cord through arch
Myeloschisis- open skin, cord exposed
How can spina bifida be prevented during pregnancy?
Facial pasly after birth is indicative of ?
Folate
Forcep delivery
Define Erb-Duchenne Palso
C5-6 and Phrenic nerve lesion \+ Grasp reflex - Bicep reflex Waiter tip palsy From difficulty delivery- shoulder dystocia Resolves w/ PT and observation
Define Klumpke’s Palsy
C8-T1 lesion - Grasp reflex \+ bicep reflex Claw hand Ipsilateral Horner's Syndrome
What are the two types of hydrocephalus
Communicating- w/ subarachnoid
Non-communicating- obstructed
Tx w/ Ventriculoperitoneal shunt
What are the risk factors of neonatal sepsis
Prematurity- 6x greater Prolonged membrane rupture GBS Maternal fever Amnionitis Fetal tachycardia
What are the common etiologies of early onset neonatal sepsis
What are the causes of late onset?
GBS, E Coli, Klebsiella, Listeria M., Salmonella, Mycoplasma
H Influenzae, Staph, HSV, CMV, Enterovirus, S Pneumo, N. Meningitis
What is early onset neonatal sepsis
What is late onset?
0-7 days old; fast onset and quick progression to severe Sxs: fever, hypothermia, HOTN, Resp Distress
8-28 days old; isidious onset w/ fever, poor feeding, lethargy, bulging fontanelle, poor muscle tone, seizures, direct hyperbilirubinemia; more likely associated w/ meningitis
What labs are ordered to evaluate neonatal sepsis?
CBC, Cultures x 2, UA, Urine culture, Blood glucose
CXR
LP for culture, stain, protein and glucose
How is neonatal sepsis treated?
IV Ampicillin and Gentamicin or; Ampicillin and Cefotaxamine Draw labs and continue until: - culture results Sepsis confirmed- 14 day Tx Meningitis confirmed= 21 days Tx
What two ABX can be added to neonatal sepsis treatment
Vancomycin- if late onset of miningitis is present
Acyclovir- concern for HSV infection
Support- IV fluid, nutrition
What are the 3 steps for GBS treatment of the mother?
1- infant Sxs; yes= full eval and empiric Tx
2- child <35wks EGA; yes= limited eval and 48hr observation
3- mother receive 2 ABX doses prior to delivery; yes= no eval or therapy, observe 48hrs
RDS is AKA and is what issue?
Hyaline Membraine Dz Insufficient surfactant production by Type 2 Pneumatocytes Commonly seen <34 wks EGA Ends w/ End-Expiration Atelectasis CXR shows bilateral ground glass
How can RDS be prevented prior to birth?
How is it treated after birth?
Steroids at 32-34wks
Intubation and respiratory support by artificial surfactants via ET tube
Define PDA and what type of issue is it
How is it treated?
L to R shunting from high to low press that becomes apparent 2-4 days of life but can result in HF, pulmonary edema or hepatomegaly
Fluid restriction and diuretics
Indomethacin or Ibuprofen
What causes Bronchopulmonary Dysplasis and how is it treated?
O2 toxicity/barotrauma Presents as required O2, Poor Growth, Hypercapnea, PHTN, R HF Inc risk in those who: O2 dependence at 36wks RDS fails to improve after 2wks Prolonged mechanical ventilation
What causes Retinopathy of Prematurity
Acute and Chronic effects of O2 toxicity
Leads to neovascularization, retinal detachments or fibrous proliferation behind lens
What are the 2 types and causes of Premature Apnea
How is it treated
Central- medulla and pons don’t stimulate phrenic nerve (majority but usually has peripheral component too)
Peripheal- airway obstruction
O2, Caffeine/Theophylline, Anemia Tx
Define Tracheomalacia
Weak/floppy tracheal cartilages
Worsens: cry, cough, feed or URIs
Possible high pitch/rattling noise
What 4 issues can develop into Meconium Aspiration Syndrome
What delivery airway interventions are done?
Respiratory distress, Pneumonia, Pneumonitis, Pneumothorax
Nonvigorous child= intubate and suction
Vigorous- no routine intubation or suction
How does MAS look on CXR?
Coarse irregular infiltrates
Predisposed to chemical/bacterial pneumonia and pneumothorax
What causes Transient Tachypnea of Newborns?
Retained amniotic fluid causing mild hypoxia and resolves in 24hrs
CXR shows fluid in fissures
More common in C-Section or LGA infants since they don’t get squeezed during delivery
What are the two types of PHTN
Primary- hypoxia w/out cardiac/pulmonary dz; normal CXR; inherited/autoimmune, drugs
Non-Primary- result of other process PFO, PDA
What is the most common cause of neonatal anemia
What test is done to assess anemia from maternal-fetal hemorrhage?
ABO incompatibility
Kleihauer-Betke test
What is the most common cause of neonatal jaundice?
Define Breastfeeding Jaundice
Define Breast Milk Jaundice
Hemolytic Dz of newborns
Insufficient milk production/ingestion
Unknown milk factor that inhibits bilirubin conjugation or enzyme that enhances bilirubin absorption
Characteristics of Physiologic Pattern Jaundice
Characteristics of Pathologic Patter
Evidence of jaundice starting when Bili levels get to 5-10; starts on face and moved to trunk, concerning if past umbilicus
Term= 12 or less on day 3
Pre= 15 or less on day 5
Early /fast, >13mg/dl on day 1 (always pathologic), jaundice set in within 24hrs
Hepatosplenomegaly and Anemia
Inc of >0.5mg/dl/hr, onset within first 24hrs and peak over 12= abnormal
What can cause Physiologic Jaundice
Insufficient UDPGT activity= no conjugation Insufficient intestine bacteria Dec intestine motility Altitude- +3100m Race- Asian, Greek Premature Breast feeding
What causes Breast Milk Jaundice
Adequate intake
Fatty acids displace bilirubin from albumin (unconjugates)
Factor enhances intestinal bilirubin
Occurs 7-10 days after birth
Unconjugated hyperbilirubinemia w/out hemolysis
Bilirubin rarely rises above 20mg/dL
What labs are ordered for Neonatal Jaundice
Total bili CBC, Blood type Coombs- tests for Abs on RBCs Peripheral smear Retic count Test G6PD deficiency
Define Kernicterus
Bilirubin Encephalopathy
Lipid solube, unconjugated indirect bilirubin that accumulate and are CNS toxic
Usually does NOT develop in term infants but are predisposed if other issues are present
How does Kernicterus manifest clinically
Early: Lethargy, Hypotonia, Irritable, Poor Moro response, Poor feeding, High pitch cry usually seen on day 4 of life
Late: bulging fontanelle, opisthotonic posturing, pulmonary hemorrhage, fever, hypertonicicty, paralysis of upward gaze, seizure
How are different severity of neonatal jaudince treated?
Mild- lifestyle changes, increase feeding, sunlight
Moderate- phototherapy
Severe- transfusion (indirect Bili @ 20 in infants w/ hemolysis and weight +2000g; indirect Bili >25 in ASx infants w/ physiologic or breast milk jaundice
What are the adverse effects of neonatal phototherapy?
Short: Diarrhea, interfered bonding, intestinal hypomotility, temp instability
Long: Childhood asthma, Type 1 DM
What are the timing intervals for jaundice evaluation of healthy term neonates post-hospital discharge
Discharged before:
24= 72hrs
24-47.9= 96hrs
48-72= 120hrs
What are the age ranges for Neonate, Infant, Toddler, Pre-Schooler, Child, and Adolescent?
N 0-28 days I 29-1y T 1-3y P 2-5y C 1-12y A 13-18y
What are the criteria for underweight, normal, overweight and obese
Under= <5th percentile
Normal= 5-85th
Over= 85-95th
Obese- >95th
During childhood, what part of growth typically doesn’t cross percentile lines?
When does sigmoid shaped growth occur?
Height
Adolescence, accounts for 15% of adult height
How does weight change from day of birth to first year of life
5-10% of birth weight lost in first few days
Return to weight by day 14
Double 4-5mon
Triple- 1yr
Daily gain- 20-30g first 3-4mon; 15-20g for rest of first year
Average baby length is _in at birth and _in by 1st year and _in by 4yrs
What is the average head circumference
20, 30; double birth length or 40in
35cm at birth
Inc 1cm/mon for first year; 2cm/mon for first 3mon then dec
How long are head circumference serial measurements taken?
When do abnormal growth patterns require action to be taken?
Until 2yrs old
Infant <5% w/ no obvious cause
Infant crosses two percentiles or major channels w/out cause
Large discrepancy between head circumference, height, weight
In general, half of a child’s growth occurs during ?
Babies that are small for gestational age or are premature do catch up growth when?
First 2yrs of life and usually remains in the same channel
First 6mon
What is the mid parental method of height prediction equations?
What is the 2 year x 2 method equation:
What is the most accurate method
Male: Dad + Mon/2 + 2.5
Female: same but -2.5
Inches at 2 x 2
Bone age- xray of hand
What are the 5 developmental areas assessed during ASQs?
When is DDST-II used?
Communication, Gross motor, Fine motor, Problem solving, Personal-Social
0-6yrs, assesses 4 areas: Personal-Social, Fine motor-adaptive, Language, Gross motor
What is the M-CHAT
Modified Checklist for Autism in Toddlers
Autism Screening done at 18-24mon that checks 23 behaviors
> 2 predictive or >3 total behaviors require additional assessment
What milestones are seen at 2wks old?
Gross motor: moves head side to side
Personal social: regards face
Language: alerts to bell
What milestones are seen at 2mon old?
Gross motor: lifts shoulder when prone
Fine motor: tracks past midline
Personal social: smiles responsively
Language: cooing, searches w/ eyes
What milestones are seen at 4mon old?
Gross motor: lifts up on hands, rolls f-to-b, no head lag
Fine motor: reaches, raking grasping
Personal social: looks at hands, works towards toys
Language: laughs and squeals
What milestones are seen at 6mon?
Gross motor: sits alone
Fine motor: transfers objects in hands
Personal social: feeds self,
Language: babbles
What milestones are seen at 9mon?
Gross motor: pulls to stand, seating postion
Fine motor: pincer grab, bangs blocks together
Personal social: waves by, plays patty cake
Language: says non-specific two syllable words
What milestones are seen at 12mon?
Gross motor: walks, stoops and stands
Fine motor: puts blocks into cups
Personal social: drinks from cups, initiates others
Language: says mom/dad and one/two other words
What milestones are seen at 15mon?
Gross motor: walks backwards
Fine motor: scribbles, stacks blocks
Personal social: uses spoon/fork, helps in housework
Language: says 3-6 words, follows commands
What milestones are seen at 18mon?
Gross motor: runs
Fine motor: kicks ball, stacks 4 blocks
Personal social: removes clothes, feeds dolls
Language: says 6 words
What milestones are seen at 24mon?
Gross motor: goes up and down stairs Fine motor: stacks 6 blocks Personal social: washes/dries hands Language: puts two words together Other cognitive: understands concept of 'today'
What are the red flags of gross motors are concerning if seen at certain time frames?
Rolling prior to 3mon= increased tone
Poor head control by 5mon= hypotonia
Lack of sitting by 7mon= hypotonia
Hand dominance before 18mon= contralateral neuromotor abnormality
What are the red flags of language development?
1st think hearing Failure to vary voice pitch by 4mon Lack of babble/localizing sound by 6mon No true words/gestures by 15mon No protodeclarative pointing by 18mon Less that 50% intelligible speech by 2yrs
All kids with speech delay get what series of exams?
Visual exams are performed at every visit until what age?
Tympanometry, Audiometry- Auditory Brain Stem Response to r/o peripheral hearing loss
2y/o
When do general exams occur in peds lives?
Normal development should show what type of BP by 3yrs old?
3-5 days, 2wks
Mon= 2 4 6 9 12 1 5 18 24 then annual
SBP= 80 + (age x 2) DBP= 2/3 of SBP
What is one growth marker/assessment that is conducted at every appointment?
What screening tests are performed on kids?
Obesity
Metabolic, Hgb Electrophoresis, Hearing eval
When are anemia screenings conducted?
How much lead does it take to cause learning issues?
12mon if healthy, 4mons if at high risk
5-10 ug/dL, screened at 12 and 24mon
Screening questions from 6mon-6yrs, may be required prior to starting Kindergarten
When is TB screening conducted?
When are kids lipid panels assessed?
After 12mon
9-11yrs and 17-21yrs
If parents have Cholesterol >240 or premature CAD, start at 2y/o
Normal total cholesterol <170
How often are STI screenings done and what is tested for?
When are Paps and HPV done?
Annually after any form of intercourse
G/C, syphilis, Hep B and HIV
21y/o
Define Active Immunity
Define Passive Immunity
Induces immunity from vaccine/toxoid (inactivated toxin)
Induces transplacental transfer of maternal Abs and administration of Ab (immunoglobulin or monoclonal Ab)- breast feeding
How often are premature babies vaccinated?
Regardless of weight, same chronologic age/schedule as full term kids
ONE exception- Hep B for <2000g; if mother is Hep B surgace Ag negative then give at 1mon instead of birth
When are adolescents given vaccines?
Which vaccine has mercury and why is it of concern?
11-12yrs of age w/ completion of series by 13-18yrs
N Meningitides booster at 16yrs
Thimerosal- trace amounts found in flu vaccine but was banned in 2001 and autism cases have increased
What is the Hep B series
3 doses, 1st dose at birth/within 24hrs
Exception, underweight <2000gm
What is the DTap Series
5 doses given at 2 4 6 and 15-18mon and 4-6yrs old
1 adult dose at 11-12y/o
What does the HIB series prevent?
What was the IPV series discontinued?
Reduces risk of meningitis and epiglottis
Only known cases of vax-induced polio in US
What is MMR given?
When is MCV4 (Menactra) given?
Mumps- resurgence in adolescents
Rubella- prevent fetal malformation
Measles- from overseas
Meningococcal, given 11-2y/o or prior to college
Consider at 2-10 if splenc disfunction/immunocompromised
When is Hep A given?
How old do kids need to be before influenza vaccine is given?
2 shots between 1-2yrs
6mons or more
What does Prevnar vaccine prevent?
Why is Varicella used?
Pneumoccocal
Secondary cellulitis and pneumonia, reduces shingles
When is the HPV series given?
Facts of Rotavirus
9-26y/o
Given prior to exposure, protects 75% from cervical CA and 90% of genital warts
Live attentuated cow rotavirus; first dose MUST be at 15wks, final dose NLT 8mon
When are vaccines contraindicated?
Which vaccines are ‘live” vaccines?
Anaphylaxis
No live vaccines in immunocompromised or pregnant PTs
MMR, Rota, Smallpox, Varicella/Chicken Pox, Yellow fever and Nasal influenza
What are the basic guidelines for doing Peds exams when they’re from birth to 6mon?
What about 6-36mon?
36mon and older?
No stranger fear, easily comforted by parents, easily distracted
Fearful of adults/strangers
Harder to restrain
Moody
Less fear, more interaction
What recommendations are offered to providers when examining Peds that may be difficult?
How long are kids recommended to sit in car seats?
Sit at distance, observe interaction w/ parents, start w/ heart/lungs and save ears/mouth for last
Until 2yrs or reach weight/height limit of seat
How long are kids recommended to sit in booster seats?
Define SIDS
Until 4’ 9” and 8-12yrs
<13 should be in back seat and w/ seat belts
Unexpected death of infant under 1y/o after autopsy, investigation and review of clinical Hx- Dx of Exclusion
What are the stats associated w/ SIDS?
What position do babies sleep in and what can be offered that are beneficial
3rd leading cause of infant death in US, most common cause of death in ages 1mon-1yr
On back, Pacifier
Kids exposed to tobacco smoke are at risk for ?
How does tobacco cessation rank among quitting?
LBW, SIDS, Respiratory illness, Otitis media, Asthma
Harder than alcohol, heroin or cocaine
Define Plagiocephaly
Asymmetric head shape
Risks: first born, premature, limited tummy time, no position changes during sleep
If normal= no x-ray, improves in 2-3mon
Tx: supervised tummy time, treat torticollis
If unresolved after 4-6mon, refer
What predicts adult stature and some health outcomes for Peds?
What are the major risk periods for growth stunting?
Nutrition and growth in first 3 yrs
4-24mon
Mothers taking anti-thyroid drugs are recommended to take ? ones if breast feeding?
What pediatric issues are contraindications of breast feeding?
Pumped breast milk needs to be refrigerated and used with ? hrs
Propylithiouracil preferred over methimazole
Galactosemia, PKU
48hrs or frozen and stored for up to 6mon
Once thawed, use in 24hrs
NEVER microwave
What type of formula is used when absorption/digestion is a medical problem?
If kids are allergic to cows milk they may also be allergic to ?
Casein Hydrolysate
Protein in soy formula
Why are no formulation substitutions before 12mon old recommended?
What are the criteria of peanut/food allergy?
Scurvy, anemia or nutritional deficits
1= severe eczema, egg allergy or both, earliest attempt at 4-6mon 2= mild/mod, attempt at 6mon 3= no eczema or allergy, attempt as age appropriate
Limit cow milk intake in toddlers to what amount?
What is defined as child obesity?
<24oz/day, can reduce intake of food diversity
95th percentile or higher
Fluffy kids don’t need to be on diets before what age
When are mother’s screened for post-partum
3yrs
Edinburgh Post natal scale for 1st 6mon; increase activity, decrease sedentary life
How much TV/day?
When should toilet training occur?
Home water heaters should max out at what temp?
Nothing before 2yrs, no more than 2hrs/day
Between 2-3y/o
120*
If kids have delayed teeth eruption, what needs to be checked?
When do permanent teeth show?
TSH and Ca (hypo thyroid, hypo pituitary, rickets) Osteoporosis Gaucher Dz Down Syndrome Celidocranial dysplasia
Begin 6yrs, end 12yrs
3rd molar @ 18y/o
Sequence of primary teeth eruption
Slide 98 Lect 2
How is infant oral hygience accomplished
Don’t use fluoride toothpaste before what age?
When are dental visits started?
Rubbing gums w/ wet washcloth/infant toothbrush
2y/o, community water w/ 2ppm is effective
1y/o, cleanings q6mon
What are the most psychological damaging comments parents can make to kids?
What kinds of disciplines threats are appropriate
Leave/give up kids
Mild loss of privileges
Define Extinction discipline
How much time out is used?
Eliminates frequent/annoying and harmless behavior through ignoring the kids actions
One minute per year of life
What is the definition of FTT
Weight <3rd percentile
Weight decreases, crosses two major percentile lines
Weight <80% of median weight for height
What are the 3 types of FTT
Wasting- deficient weight gain from malnutrition
Shunting- deficiency in linear growth but head circumference is spared
Symmetric- proportional weight, height and head from long malnutrition, chromosome abnormalities, infections/exposures
What is the cause of FTT
What do patterns of FTT mean?
Insufficient usable nutrition at the cell level
Dec weight after certain age= infection, endocrine, environment
Body asymmetry= epiphyseal, chromosome issue
If a Peds PT is hospitalized for FTT, what results can be seen and what do they mean?
Feeds fine/gains weight= poor home feeding
Feeds normal, doesn’t gain weight= malabsorption, endocrine, metabolic dz
Infants that feed poorly in hospital= neuromuscluar, poor intake or frequent regurg
What Hx ?s are asked during a FTT issue?
What are the parts of a FTT physical?
Hx on prenatal, birth, medical, family, nutritional/stool and social
VS, Ht, Wt, HC
Impression
Full head to toe exam
What labs are ordered in FTT visit?
How is premature FTT weight calculated?
CBC, Fe, UA w/ culture, Serum E+, PPD, LFTs, HIV, Stool culture, lead and TSH
Adjusted until 24mon
HT correction until 40mon
HC correction until 18mon
Birth age - # of wks premature
Bone age > chronological age is seen in ? issues
Bone < chronological age can mean ?
If bone age = chronological age and no other abnormal findings are seen then ?
CAH, Premature adrenarche, excess sex steroids, overweight
insufficient GH, hypo thyroid or constitutional growth delay
Probably hereditary short stature
How is FTT treated?
When are FTT PTs admitted for in patient care?
Increase calorie/protein intake by >1.5x
Severe, underlying Dx requiring hospitalization, safety is jeopardized or failed out patient
Why does Refeeding Sydrome cause death?
New food sitmulates glycogen/fat/protein synthesis which requires E+ that are already depleted leading to deficiencies:
Loss of fluid/E+ homeostasis causing loss of phosphorous, Mg, and K and causing fluid retention leading to cardiac, pulmonary and neurological p
What type of genetic issues are most common at birth?
What are examples of autosomal dominant inheritance issues
Multifactorial defect
Achodroplasia, Neurofibromatosis, Huntington,s Marfans, Polycystic Kidney
What are examples of autosomal recessive Dzs?
What are X-linked issues?
CF, PKU, CAH, SS,
Fragile X, Muscular Dystrophy, Hemophilia A, G6PD, Color blindness
Autosomal dominant= ?
Autosomal recessive= ?
Hetero or homozygous expression from one gene, both sexes equally effected
Homozygous expression from two genes, usually born to unaffected parents
X chromo carries ? genes while Y carries ? genes
X= 500
Y= 50
Males more common, all daughters of affected males will be affected, no father-son transmission and may skip genes
Define Genotype
Define Phenotype
Type of genes
Physical characteristics
These AKAs are for ? Dz Trisomy 21 Excessive base repeats 45XO 47XXY Autosomal dominant CT d/o
Downs- mongoloid previous term no longer used Fragile X Turner Klinefelter Marfan
Facts of Downs Syndrome
Method of inheritance= Increased risk w/ maternal age and parents genetics (maternal nondisjunction)
All kids need genetic studies, if translocation is present= parents need screening
What are the 3 types of TS21?
3 copies- mos common, from maternal nondisjunction
Translocation- carrier state w/ higher baseline maternal nondisjunction rate
Mosaicism- phenotypically normal
What is the take away from Down’s maternal age and incidence?
Incidence higher in older women
Downs kids are born more commonly to younger women due to more births
What are the phenotypical features of Downs
Hypotonia, decreased Moro reflex Small head Up slanting fissures- opening between eye lids Epicanthal folds Midface hypoplasia Dyspastic pinna- small ears Macroglossia
What are the phenotypical features of Down’s extremities
Single palmar crease- don’t use term ‘simian”
Shortened 5th finger
Widened firs toe space
Shortened/stubby fingers
What medical conditions are Down’s PTs more susceptible to?
Development delay Hearing/eye loss GI/Cardiac abnormalities- ASD, VSD, Eisenmengers Hypothyroidism- life long issue Polycythemia Leukemia
What types of hearing losses do Down’s suffer from?
Sensorinueral- issues w/ CN8
Conductive from dysplasia of ossicles and scarring from ear infections
Hearing screening q6mon until 3y/o then annual
What eye defects are seen in Down’s
Ophthalmology exam by 6mon Brushfield spots- white/gray spots on periphery of iris Cataracts Ectopic lens Refractice errors Strabismus- cross eyed
What is the first Sx to be seen suggesting Down’s PT is suffering from R sided HF?
What is the ‘double bubble’ sign seen in these PTs?
Clubbing, cyanosis in lips
Echo done routinely
Esophageal/duodenal atresia
What type of cervical issues do Down’s have?
What labs are drawn/tested annually?
Atlantoaxial instability
C-spine x-ray by 3-5y/o
TSH, CBC, Celiac
Fetal alcohol syndrome is the severe manifestation of ?
Fetal Alcohol Spectrum D/o
What is the most common cause of preventable development and intellectual delays?
Kids living in what 3 areas are more susceptible?
FASDs
Poverty, American Indian, Foster care
What are the common physical characteristics of FAS?
What are the less common features
Short palpebral fissures
Smooth philtrum
Thin upper lip
Rail road track ears
Ptosis
Microcephaly
Epicanthal folds
What extremity, cardiac and developmental abnormalities are seen in FAS PTs?
Clinodactyly
Hockey stick crease
VSD, ASD
Retardation, fine motor delay, ADHD
Mothers are referred to therapy to prevent FAS if how much is consumed?
FAS Tx is a multi-specialty team effort including?
> 7 drinks/wk
Multiple periods of >3 drinks/wk
ADHD, Anxiety, Speech, SpecEd
What chromosomal issue causes Fragile X Syndrome
What neurological problems appear?
Excess CGG base triplet repeats at 5’ end of FMR1 gene on the X chromosome
Hyper arousal/anxiety
Epilepsy
Autism spectrum d/o
What physical attributes are related w/ Fragile X
How is it officially Dx?
Large head, oblong face
Macro-orchidism
Joint laxity
Hypotonia
DNA amplification w/ direct analysis
How is Fragile X treated?
Genetic counseling, Spec Ed
Autism eval
Neuro referral
What are the 3 variants of Turner Syndrome
50% lack X
25% have abnormal X
25% are mosaic
Phenotypic female w/ absent/dysfunctional X chromosome
What mental development issue and increase is seen in Turner’s?
What cardiac issues are seen?
Normal development, poor visual/spacial skills
Superior verbal skills
Coarctation, bicuspid aorta, early HTN
What endocrine issues are seen in Turners
How is Turners Dx
Amenorrhea/infertile
Hypo thyroid
DM Type 1
Osteoporosis
Direct Karyotyping Barr body (inactive X chrom) analysis not recommended due to high % of mosaics
How is Turner’s treated?
What labs are tested annually?
Cardio consult at Dx for Echo, MRI and ECG
Endo referral for GH
Start estrogen replacement at 14y/o
TSH, Chem 7, UA
What d/o is phenotypically normal prior to puberty
What dangerous issue can be seen rarely?
Klinefelter Synd
15% have mosaic variants- multi-X or multi-Yx= irregular features, violence, retardation
Klinefelter Barr Test is same as ?
Klinefeltor Sxs are related to an issue of ?
XX Female
Testosterone deficiency
How is Klinefelter Dx
How is it Tx?
Direct karyotyping
Inc LH and FSH w/ dec testosterone
Testosterone replacement to treat hypogonadism and cause virulization
Marfan Synd is an issue at what molecular level?
What pos thumb/wrist sign is seen?
AutoDom mutation in Fibrilin 1 gene on Chrom 15
Arachnodactyly
Thumb AKA Steinberg Sign
Wrist AKA Walker-Murdoch
Both needed for Arach. Dx
Marfans manifests in what 3 body systems?
How is it Dx?
Cardiac, skeletal, Ophthalamic
Clinical criteria but confirmed w/ FISH (Fluorescent In-Situ Hybridization)
When are infant crying louder and more intense?
Premature infants cry little before __wks but cry more than term infants at _wks
Hunger and Pain
40wks; 6wks
How much crying should babies be crying at 2wks, 6wks, 12wks
How much fussing is seen?
2: little
6: 2/hrs day
12: 1hr/day
6wks: 10 episodes/24hrs
Corrected age equation
How long is it used for?
Chron age - wks premature
Until 24mon
Define Colic
What is Wessels rule of 3
Difficult/fussy child that has paroxysmal crying w/ facial grimace, leg flexion and flatus
Crying >3hrs/day
Crying 3 days/wk
Crying more than 3wks
Usually resolves around 3mon
What has been shown to be an excellent soother of colic babies?
What is more likely to be seen when colic babies are present?
Car rides
White noise- vacuums
Post Partum depression in mother
What is the most commonly reported pediatric behavioral problem
What are triggers?
Temper tantrum- terrible twos
Tired, Hungry, Ill, Transition
How can temper tantrums be prevented?
How are breath holding spells treated
Parent education at 12-18mon
Ignore
What is the goal of therapy in special needs Peds
What do parents experience after child is Dx w/ Special Needs
Maximize potential for adult function
Kubler Ross stages of grief
How are special needs kids best managed?
Define Intellectual Disability
Medical Home
D/os with common deficits of adaptive and intellectual function and an age onset before maturity is reached
IQ <70
Criteria of Mild ID
Criteria of Severe ID
IQ 50-70, higher association w/ environment and highest risk among low socioeconomic status
IQ <50, linked to biological/genetic causes
What developmental delay is common in PTs w/ ID?
What needs to be considered if abnormal facial features, hypotonia, FTT are seen at birth?
Hearing and Speech delays
Syndromes or Genetic Abnormalities
What labs are ordered for ID PTs?
What is the school screening used to ID students needing help?
UA, Metabolism (PKU, TSH), Hypo thyroid, EEG, Chromosomes
Parent’s Evaluation of Developmental Status
ID Tx is dependent on ?
What environmental risk factors increase chances of autism?
Stanford Binet scores, IQ doesn’t equal functional ability
Advanced age Premature birth Maternal obesity Short interval from prior pregnancy Infections
Autism often coexists w/ what other issue?
How does Autism clinically present?
ID
Deficit in social communication/interaction
Restricted/repetitive actions of behavior/activities
Inflexible adherence to routines
Hyper/hypo reactive to sensory input
Most Autism PTs have what comorbid condition
What meds are used?
Sleeping problem
Antipsychotic SSRIs Antiepileptics Gi meds- esp constipation Sleep hygiene
Define Cerebral Palsy
What is a huge risk for CP?
D/o of movement and posture limiting activity
80% antenatal factors leading to abnormal brain development
Multiple pregnancy
Infertility treatments
If child only walks on tip toes they have?
What other neuro S/Sxs may be seen
Spastic Hemiplegia
Ankle Clonus, Babinski, Inc DTRs
What is the imaging modality preferred for CP?
MRI, inc sensitivity
If child is continuously army crawling, they have ?
What other Neuro S/Sxs are seen?
Spastic diplegia
Damage to immature white matter
Brisk reflexes, ankle clonus and bilateral Babinksi
What is the most common neuropathic finding in spastic diplegia?
Periventricular leukomalacia
Define Spastic Quadriplegia
What will be seen on neuro exam?
Motor impairment of all extremities
High risk of ID and seizure, pneumonia and growth failure
Inc spasticity, dec spontaneous movement, brisk reflexes, plantar extensor responses
Athetosis is common
Define Athetoid CP
Choreoathetoid, Extrapyrimidal, Dyskinetic
Hoptonic, poor head control, head lag and isolated more to upper extremeties
Slurred speech
What causes Athetoid CP
What labs/rads are ordered?
Birth asphyxia Kernicterus Lesion in basal ganglia/thalmus Genetic metabolic d/o Mitochondrial d/o
MRI and metabolic panel
What labs/rads are ordered to Dx Cerebral Palsy
What meds can be used for spasticity
Hx, Clinical, MRI, Vision/Hearing, EEG, UA
Genetics
Botox, Benzo, PO MRs, Baclofen
Difference in ADHD appearance in m/f
How is it Dx?
M- hyper active and impulsive
F- inattentive
<16= 6 inattention or 6 hyperactive/impulse Sxs
>17= 5 inattention or 5 hyperactive/impulse Sxs
For 6mon
In 2 or more environments
How is ADHD Tx?
Behavior management- core
Stimulants- first line
NE reuptake inhibitor- Atomoxatine
A-agonist- Clonidine/Guanfacine
Signs of ODD
Signs of CD/o
Angry/irritable
Argumentative and vindictiveness
Aggression, destruction and deceitfulness/theft
Serious violations of rules
How are ODD/CD/o screened for
What meds are used for both?
Vanderbilt
Stimulants
Atypical antipsychotics
Define Early, Mid and Late Adolescence
Early- Concrete, body/attention focused, ambivalent to independence
Mid- abstract, concern w/ identity, risky behavior, independence
Late- formal operational, marriage/job, commitments, re-emergence of unresolved separation anxiety
Failure to launch
Define identity confusion
Define Role Confusion
Search for commitment before identity roles are formed- experimentation
Reluctant to make commitment and develops avoidance
What is the acronym for doing adolescent interviews
HEADDSS Home/friends Education Alcohol Drugs Diet Sex Suicide/depression
Series of events that lead to sex hormone production
Interference with this process can be caused by ? and lead to early puberty
Hypothalamus inc GnRH
Ant Pit releases FSH/LH (pulse generator)
Hormones triggered
CNS d/o, tumor
First part of female development is ?
What is second?
Estrogen, Breasts
Adrenal- androgen
What are the Tanner stages of breast development
1- preadolescent 2- buds 3- enlargement of breast/areola 4- areola and papilla mound 5- mature
What are the Tanner stages of female pubic hair?
1- none 2- sparse along labia 3- dark/coarse over pubes 4- covers but not to thighs 5- covers to thighs Peak growth 3-4
When do female menarche begin?
2.5-3yrs after breast development
Tanner 4 breast Physiologic leukorrhea 3-6mon prior
2-3yrs post-thelarche
Avg- 4/2yrs
What is the first part of male development?
Testosterone, inc testes size
SMR 2
What are the Tanner stages for male pubic hair
1- childhood 2-testes enlarge 3- penile length 4- penile breadth 5- adult
What are the Tanner stages of
1- none 2- sparse, base of penis 3- darker, coarse, curled 4- covered but not thighs 5- thighs Avg- 2.5-5yrs
Define Leukorrhea
When do gynecomastia cases need to be referred to Endo?
Tanner stage 3 event- vaginal discharge of clear/non-odorous due to estrogen stimulation of uterus/vagina
> 3cm
Persists after 2yrs
Past age 16yrs
Tanner 1, 2, 5
DDx of premature Thelarche
Male testes should not enlarge before ? age, and if the do ?
Estrogen excess- soy, legumes, flax seed, tofu
Prior to 9, brain MRI
Define Adrenarche
What are DDx
Odor, hair, acne
F: <8 M: <9
Cushings, Tumor, Adrenal hyperplasia
What can be given for obvious gynecomastia?
How long are female cycles?
How long does each last?
How much is normal flow?
Androgens, Aromatase inhibitors, Estrogen antagonists
Past 18-24mon- surgery
21-45 for first 3yrs
21-35 after
Lasts 7 days or less
6 or fewer pads/tampons
What type of abnormal cycle needs further eval?
What are the two types of Amenorrhea
What are the 3 caveats
2 or more abnormal cycles or skipped period for more than 3 consecutive cycles
Primary- 15y/o or no period 3yrs after puberty onset
Secondary- no menstruation for 3 cycles in post-menarchal PT
Lacks puberty signs by 13
Sexually active
Early breast development
What are the first line evaluations for amenorrhea?
What are the S/Sxs of PCOS
TSH, Prolactin, FSH, HCG, US if primary
Hperandrogenism, obesity, insulin resistance
PCOS can be Dx with two of what findings?
Infrequent bleeding
Secondary amenorrhea
Hyperandrogenism
US showing morphology
How is PCOS anovulation manages?
How is hypothalamic amenorrhea treated?
Cyclic Prog/PO OCs
Est/prog combo
What drugs are used for androgen excess in PCOS PTs?
What is the most common cause of abnormal uterine bleeding in adolescents?
Combo Est/Prog
Sprinolactone helps hirsutism
Metformin
Anovulation
Why are combo Est/Prog used for abnormal uterine bleeding cases?
Regulates menstruation
Allow hypothalamic-pituitary-gonad axis maturity
Pts w/ bleeding d/o (Von Willebrand)
What causes the pain of 1* Dysmenorrhea
Prostaglandins/Leukotriens from declining progesterone levels increase uterine tone and contractions
Menstruation pain w/ pelvic pathology is most frequently caused by ?
If outlet obstruction is suspected, what imaging is used?
Endometriosis or PID
US
When are MRIs used for dysmenorrhea evals?
How is endometriosis Dx?
Complex reproductive tract abnormalities
Laparoscopy
PID in Tx failure
What are the red flags of Enometriosis/Adenomyosis, Mullerian, and PID
E/Ad- increasing dsymenorrhea despite therapy
M= pain at/shortly after menses w/ known renal tract abnormality
PID- vaginal d/c
How is dysmenorrhea treated?
Prevent/dec prostaglandins w/ NSAIDs
If unsuccessful, hormones
If hormones fail after 4mon, re-eval and reconsider Dx
Sex identity is self perceived with what 4 components
Define Gender Identity
Sex at birth, Gender Identity, Expression, Orientation
Basic sense of man/woman (PRESENTATION)
Define Gender Expression
Define Gender Non-Conforming
Characteristics, need to distinguish from gender identity
Fem boy/masculine girl
Define sexual orientation
Define Sexual behavior
Attraction/attachments to men/women
Activity for pleasure
What is the difference between trans, cross dresser and drag?
Trans- live in other gender
Cross- crosses over but reverts back to assigned
Drag- impersonator
Define nonbinary
Define Gender Fluid
Neither
Not fixed but changing
When is gender identity formed?
Whats the difference between Gender Constancy and Consistency
2-3yrs
Const- stable over time
Consis- permanent
What part of gender identity is normal and part of life?
Define Gender Dysphoria
Nonconformity
Distress from inconsistency on thoughts/feelings of gender
More often in male kids but even in adolescence
Can medical professionals tell coaches a Ped PT isn’t cleared for sports and not violate HIPPA?
What two cardiac findings during sports physicals are bad?
Yes, but can’t tell why
Murmur that gets louder w/ Valsalva or standin
Can kids play sports with seizure history?
What is a disqualifier?
Yes as long as it’s controlled
Stage 2 HTN or poorly controoled (S/DP >99 percentile for age +5mmHg)
Can kids play sports w/ Mono?
How many calories do male/female adolescents need?
Restricted for 28 days to dec risk of spleen trauma
F: 1800-2400
M: 2000-3200
What is the Ca+ requirement for adolescents
How is adolescent BMI calculated?
What is over, obese
1300mg/day
BMI= kgs/height in meters^2 >120% IBW obese >200 IBW morbid 85-95% BMI= overweight >95% BMI= obese
Define SCFE
Define Blount’s Dz
Most common hip d/o in obese PTs when rapid femur growth weakens plate and causes slipage backward off of epiphysis
Growth issue causing tibia to angle inward
Define NASH
What is the SMART acronym for obesity?
Non-Alcoholic Steatohepatitis
Severe form of fatty liver
Specific Measurable Achievable Relevant Timely
What are diet goals for Peds at 7y/o
<7- maintain weight, let linear growth catch up
>7= 1lb/mon until <85% BMI
What appears first, anorexia or bulemia?
What neonatal sign may be seen in anorexia?
Anorexia, bulemia presents w/ BPD/o
Lanugo
How is Anorexia treated?
When do they need to be hospitalized?
Feeding program to restore weight
>25% loss of ideal weight Suicide risk Bradycardia/Hypothermia Dehydrate/hypo-K/dysarrhythmia Failed OutPT
Dx criteria for bulemia
How is it treated?
2x/wk x 3mon Discrete eating Loss of control Compensatory over reactions Self eval of unwanted size
Anti-Depressants
Define Female Athelete Triad
What happens to the brain during this d/o
Too much exercise dec estrogen
Attempted weight loss to inc performance
Low bone density, inc Fx risk
BF% dec and stops hypothal/pit/gonad system
What meds can be used for Female Athlete Triad
What is the SIGECAPS acronym for Dep/Suicide
OCPs to restore menses, won’t correct bone loss
Ca, K Vit D supplements
Mainstay= life modification
Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Safety/Suicide
What is a leading cause of death in teens that surpasses MVAs?
What med is used for depressed/suicidal adolescents?
Suicide
Fluoxetine or Escitalopram
Risk- SSRIs, inc suicide risk
Define Anxiety
What is the difference between Anxiety and anxiety d/o
Dread or Apprehension
Anxiety= not pathologic D/o= pathologic, most common psych d/o of childhood
When does Separation Anxiety D/o develop
10-18mon
By age 3, can accept temporary absence
When does Schizo frquency increase?
What are the 4 Sx categories for Schizo?
13-18y/o
Higher risk in monozygotic twins (identical) and 1* relatives
Pos Sxs= hallucinations and delusions
Neg Sxs= lack of motivation/social interaction
Disorganization of thought/behavior
Cognitive impairment- most common/disabling
What are the 5 sub-types of Schizo
Paranoid- delusion persecutory
Disorganized
Catatonic- rare in kids/adolescents
Undifferentiated- doesn’t fit other types
Residual- previous Dx, no current Pos Sxs
What is the Substance Abuse Screening acronym
CRAFT
Car, Relax, Alone, Forgetting, Fam/Friends, Trouble
