Peds Flashcards
Define the two parts of the prenatal period
When do the most critical stages of development occur
What are TORCH infections
Embryonic: through 8wks EGA
Fetal: 9wks EGA +
First trimester
Toxoplasmosis Rubella CMV HSV
Rh incompatibility can lead to ? OB complication
Define APGAR
Why are the timings of this score different
Hydrops fetalis
Appearance Pulse Grimace Activity Respiration:
0-10pts w/ 5 features, done at 1min and 5min-
Rpt q5min if score <8
1min: tolerance of birthing process
5min: tolerance to life
What are the APGAR scores made
Appearance:
0- cyanotic 1- Acrocyanosis/blue extremities 2- all pink
Pulse:
0- none 1- <100bpm 2- >100bpm
Grimace w/ bulb suction to nares:
0- none 1- grimace/cry w/ stimulation 2- sneeze/cough/withdrawal w/ stimulation
Activity:
0- limp/none 1- some flexion 2- active
Respiration:
0- none 1- weak/slow/irregular 2- strong cry
Newborn respiratory rate
Newborn HR
What are the next steps taken for abnormal HR ranges
30-60/min w/ inc number if premature
120-160
> 100: routine care
60-99: ventilation support
<60: ventilation w/ compressions
Neonatal Resuscitation Protocol flow chart
Compressions at 120bpm w/ two thumbs > two fingers
3 compression : 1 respiration
BVM sniffing position (neck w/ slight extension) w/ 40-60 bpm
How do premature/neonates respond to hypoxia
What fluids are used during NRP
What is the next step for asystole/bradycardia unresponsive to O2
Apnea rather than tachypnea
10mL/kg NS for hypo-volemia/tension
IV Epinephrine
Rules for Narcan usage in newborns
? care is routine for all infants and w/ ? goal
What are the two categories of this care and what is done during each
Yes- opiates used during labor
No- maternal addict/methadone d/t withdrawal seizures
Nursing- prevent illness/complications w/ high level of morbidity/mortality
A) Shortly after:
Erythromycin ointment- prevent G/C conjunctivitis
Vit K injection- prevents Hemorrhagic Dz of Newborn
HBV- only vaccine given at birth
B) 24hr Routine Care: Bilirubin screen Congenital heart screening Genetic/Metabolic screen (AKA- newborn screen) Hearing
Infants receive Vit K injections into their thigh at birth to prevent HDzoN which is more common in ? population and will present as ?
? genetic/metabolic tests are included in the Newborn Screen
Infant length is done in ? position until ? time frame and when are inaccurate measurements most likely to occur
MC in breast fed infants in first few weeks of life;
Generalized ecchymosis
GI bleeds
Umbilical/Circumcision bleeding
CF CAH PKU Sickle TSH
Laying down until 2yrs old;
First week d/t positioning
Congenital heart dz screening is done at 24hrs of life/before d/c and is interpreted how
Spo2 95% or higher w/ 3% or less difference between right hand/foot= negative screening, plan for d/c
SpO2 90-94% in right hand/foot or 3% difference= repeat in one hour; same results- repeat again in one hour; 3 readings in same range= echo
SpO2 <90% in right hand/foot= +screen- order Echo
? is the number one cause of LBW
Criteria for Low/Very Low birth weights
What are the RFs for LBW
Prematurity
Low: <2500gm; Very: <1500gm
Previous LBW baby Age <16, >35 Socioeconomic status Tobacco/ETOH/Drugs Poor weight gain during pregnancy Education Antenatal care
Normal sutures and two abnormal findings possibly seen in newborn HEENT exam
Define Caput Seccedaneum
Define Cephalohematoma
Normal: open/flat sutures
Anterior suture >5cm suggests hypothyroidism
Closed sutures: craniosynostosis
Boggy, edematous swelling crossing lines, self resolves
RBC breakdown/jaundice causing swelling w/out crossing suture lines
? head malformation is associated w/ vacuum deliveries and how is it Tx
Define Hydrocephalus, the two types, and Tx
Subgleal hemorrhage- swelling crosses suture lines pushing ears anteriorly;
Tx: Compression w/ resuscitation PRN
Inc CSF volume- macrocephaly, bulging fontanelle, ‘setting sun’ gaze;
Communicating w/ subarachnoid
Non-Communicating= obstructed
Tx: ventriculoperitoneal shunt
What can cause an abnormal red reflex on newborn eye exam
What optic abnormality can be normal until 4mon old
How is normal ear positioning verified
Leukocoria: cataract, tumor, retinopathy of prematurity
Disconjugate gaze: eyes fail to move in same direction; alignment achieved at 4mon old
1/3 of ear above canthus/occipital protuberance line
20* from anterior of lobe to superior helix
Define Epstein Pearls and Bohn Nodules
What parent education goes w/ Dx
When conducting new born exams, how do neck bulge locations hint at Dx
EP: Keratin cysts on gums/palate
BN: Keratin cysts on salivary tissues
Harmless, resolve in first week of life
Anterior midline: thyroid d/o
Anterior to SCM: brachial cleft cyst
Posterior to SCM: cystic hygroma
What do each of the following suggest for cardiac d/o/dz
Weak pulse
Bounding pulse
Single second sound
Holosystolic, continuous, harsh
Grade 3/>
Diastolic murmur
Hempatomegaly
Weak: poor CO/AS
Bounding: high CO, PDA
Second sound: cyanotic dz- truncus/hypoplastic heart
Holosystolic, continuous, harsh- pathologic
Grade 3/>: pathologic
Diastolic: pathologic
Hempatomegaly: left sided HF
How are lower extremity pulses assessed during newborn exam
? abdomen shape suggests diaphragmatic hernia
? umbilical finding suggests need for detailed exam
Brachial and femoral together:
Pulse pressure >40mm= r/o PDA
LE < UE pulse= r/o coarctation
Scaphoid
Two vessels: 1 artery, 1 vein instead of normal 2A/1V
Umbilical cord stump remaining longer than ? needs further work up
? DDxs need to be r/o
1mon
Umbilical polp: sticky surface
Patent Urachas: urinary d/c
Meckels: proximal end of vitelline duct
Vitelline duct: odorous d/c
What is the main concern w/ hip exam
Since all infants are born w/ limited laxity, what are the three concerns if this persists
RFs for Congenital Hip Dysplasia
Congenital Hip Dysplasia- spontaneous dislocation and reduction of femoral heads; L > R
Flat acetabulum
Muscle contraction limiting ROM
Capsule tightening
Female First FamHx
Breech
Oligohydramnios
Postnatal swaddling position
What are the two maneuvers done for hip stability during newborn exam
If ‘clunk’ is heard, ? is the next step
What populations should received this next step
Barlow
Ortolani- clunk from hip relocating anteriorly
Hip US at 4-6wks to avoid confusion w/ normal laxity
Clunk or persistant click x 2wks of age
+ RFs- US after 4-6wks old
Congenital Hip Dysplasia referred to Peds Ortho will be placed in ? device for ? age groups
? is the MC foot d/o in infants
Infants w/ this MC are at risk for developing ? later in life
Pavlik harness- up to 6mon old
Metatarsus adductus- medial deviation of mid and forefoot
Developmental hip dysplasia
How is Metatarsus Adductus Dx
How are these Tx
Define Talipes Equinovarus
What is the next step after Dx Talipes Equinovarus
Mid-heel bisector line- should go between toes 2-3
V-finger- should not gap at base of 5th MT (styloid)
Most self-resolve
If not w/in 2yrs= Ortho referral cast/brace/surgery
Clubfoot- entire leg involved d/t hypoplastic tarsals and limb muscles
MC affected- talus, causes foot shortening/calf atrophy
Refer to Ortho: casting/tenotomy to correct deformity, preserve mobility
? testi/female genitalia abnormalities can be seen on newborn exam
Define Spina Bifida
When/How is this normally identified during pregnancy
Testi: retractile
Female: hypertrophy d/t maternal estrogen
Cleft Spine; Lumbosacral tube defect d/t incomplete brain/cord/meninge development
2nd-Tri Quad screen- maternal A-fetoprotein/US
Define Rachischisis and ? risk needs to be r/o
Spina Bifida Occulta- hair tuft/minor defect w/out neuro S/Sxs; r/o connecting sinus d/t inc risk for meningitis
What are the categories of Spina Bifida
How is this Tx and avoided
Meningocele- meninges herniates through neural arch
Meningomyelocele- meninges and cord herniate through neural arch
Myeloschisis- open skin w/ cord exposed
Neurosurgery;
Folate prior to tube closure at 4-6wks EGA
What are the primitive reflexes tested for on newborn exam
What do these reflexes evaluate
When do these normally disappear
What could cause an asymmetric/persistent response
Suck Moro Grasp
Brain stem, Basal ganglia
4-6mon d/t increased cerebral inhibition of
Focal brain/peripheral nerve lesion
Only reflex not present at birth and never disappears
What reflexes disappear at 3, 4, 6 or 12mon
Parachute- appears at 8-10mon; suspended face down, move towards table causes arm extension for protection
3: Asymmetric tonic neck
4: Rooting, Gallant, Placing
6: Moro, Grasp
12: Babinski
Facial palsy in newborn is associated w/ ?
Define the MC brachial plexus lesion
What reflex is present/absent in this MC
Forcep delivery
Erb-Duchenne palsy- C5/6 lesion, association w/ phrenic nerve lesion d/t shoulder dystocia
+ grasp
- bicep
Define Klumpke Palsy
What syndrome is this associated w/ if a cervical sympathetic nerve root was injured
Define Vernix Caseosa
C8-T1 lesion: - grasp +bicep w/ claw hand
Ipsilateral Horner’s Syndrome
Chalky white mixture of shed epithelials cells, sebum, keratin and hair; common in preterms for suspected fetal protection
When is term infant desquamation typically seen
Define Milia
Define Milia Rubra
24-48hrs of life
Smooth, white papules on face/scalp d/t trapped keratin; self limited/resolves 1-4wks
Heat rash d/t overheated/febrile infant w/ erythematous papules; Tx/correct overheating
Define Cutis Marmorata
Define Slate Gray Nevi
Define Cafe Au Lait macules and when are further work ups indicated
Mottling- cold response; persistent suggests hypothyroidism/vascular malformation
Transient dark macule on lower back/buttocks that fade w/ time
Sharply defined, pigmented macules;
6 or more/ 5cm or bigger to r/o NF-1, TB, McCune Albright Syndrome
Nevus Simplexes are AKA ?
Define Nevus Flameus
? syndrome needs to be r/o depending on location
Salmon patches
Stork bite- nape of neck
Angel kiss- forehead/eyelids
Port Wine Stain; d/t capillary bed malformation
Sturge Weber Syndrome if trigeminal nerve distribution
Define Erythema Toxicum Neonatorum
Wat would be seen on microscopy results
What causes neonatal acne
Pustules w/ erythematous base on back/trunk appearing 1-2 days after birth, resolves in 14days
Eosinophils
Maternal estrogen
Primitive reflexes are usually gone by ? age
RFs for neonatal sepsis
4-6mon
Prematurity PROM Fetal tachy Amnionitis Maternal fever GBS
Neonatal sepsis etiologies w/ early onsets
Neonatal sepsis etiologies w/ late onsets
Mycoplasma GBS- MC/#1 E coli Klebsiella Listeria Salmonella
Hflu Neisseria meningitidis CMV HSV Enterovirus Strep pneumo Staph
Early onset neonatal sepsis begins on ? day and presents w/ ?
Late onset neonatal sepsis begins on ? day and is more likely associated w/ ?
What orders are needed
0-7d old;
Fast onset, Hypo-thermia/tone/tension
8-28d old;
Insidious onset, Dec feeding/tone, Bulging fontanelle; associated w/ meningitis
CBC CXR if + resp Sxs Blood culture x2 UA w/ culture Blood glucose LP
How is Neonatal Sepsis Tx
Why would Vanc be added to Tx regiment
Three steps for GBS mother
Draw labs then:
IV Ampicillin+Gentamicin
IV Amp+Cefotaxime if >3wks d/t liver function
Late onset, + meningitis, MRSA coverage
1: infant have S/Sxs?
Yes: eval w/ empiric Tx
No: step 2
2: infant <35wks EGS?
yes; limited eval w/ 48hr observation
no: step 3
3: Two maternal ABX doses prior to delivery?
Yes: no eval/therapy, observe x48hrs
No: limited eval w/ 48hr observation
? PE finding is a sign of neonatal respiratory distress
What Dzs make this finding MC found
Respiratory Distress Syndrome is AKA ? and caused by ?
Grunting (can sound like meowing)
Dec functional residual capacity:
Pneumonia
Pulmonary edema
Peripheral airway obstruction
Hyaline Membrane Dz: dec surfactant from Type 2 pneumatocytes in <34wks EGA
RDS results in ? and looks like ? on CXR
How is RDS Tx prior to birth
How is RDS Tx after birth
End expiration atelectasis; Ground glass
Maternal steroids 32-34wks EGA
Intubation w/ surfactant/support via ET tube
What complications can arise from RDS
Which one appears on day 2-4 of life and what does this look like
How is this Tx
PDA PTX
Bronchopulmonary dysplasia
Retinopathy of prematurity
PDA: L to R shunt (systemic to pulm) as pulmonary edema/hepatomegaly
Fluid restriction w/ diuretic
Indomethacin/Ibuprofen
How is RDS induced PTX Tx
What causes the Bronchopulmonary Dysplasia after RDS
What are the 3 RFs for this dysplasia
Sxs= chest tube
O2 toxicity/barotrauma
O2 dependence at 36wks old
RDS persists >14days
Prolong mechanical ventilation
How does RDS cause Retinopathy of Prematurity
Criteria for Apnea of Prematurity
What are the two types and causes
O2 toxicity causes vasoconstriction in developing vessels= obliteration/blindness (term infant eyes fully vascularized- no risk)
10-20sec w/out pulmonary airflow
Central: medulla/pons don’t stimulate phrenic nerve (more common in premature infants)
Obstructive: malformation/positional
How is Apnea of Prematurity Tx
When does this usually correct itself by?
? is the MC congenital tracheal abnormality
O2, Stimulants: caffeine/theophylline
36-40wks post-conceptual age
Tracheomalacia- weak/floppy tracheal wall worse during expiration (harsh, monophonic wheeze/normal voice/inspiration)
Four possible outcomes from Meconium Aspiration Syndrome
How are non-vigorous babies w/ aspiration managed
How does aspiration appear on CXRs
Respiratory distress
Pneumo-nia/nitis/thorax
Suction mouth/trachia
Unsuccessful: BVM w/ PPV
Coarse, irregular infiltrates
What causes Transient Tachypnea of the Newborn
How would this appear on CXR
When is this type of issue more commonly seen
Retained amniotic fluid causes hypoxia that resolves <24hrs
Fluid in fissures
C-section, LGA d/t no ‘squeeze’ during birth
How does P-HTN in term infant present
MCC of Hemolytic Dz of newborn
What are the three reasons all newborn have an elevated bili
Primary: Hypoxia w/out cardiac/pulm dz and normal CXR
Non-Primary: induced L to R shunt
ABO incompatibility
Inc RBC turnover
Dec hepatic clearance/gut motility
Neontal hyperbilirubinemia is ? levels
? is the MCC of neonatal jaundice
Define Kernicterus
Total Bili >5mg/dL
Hemolytic Dz of the newborn- ABO incompatability is MCC
Bilirubin Encephalopathy- indirect bili deposits in brain, disrupts neuron metabolism/function
Early signs of Kernicterus
Late signs of Kernicterus
Day 4 of life w/: Lethargy Emesis Hypotonia High pitch cry Irritable Poor Moro/feeding
Fever Hypertone Bulging fontanelle Opisthotonic posture Pulmonary hemorrhage Paralysis of upward gaze Seizures
What are the two classifications of hyperbilirubinemia
What is a common cause of jaundice in first time mothers
What causes Adequate Intake Breast Milk Jaundice
Unconjugated: estimated w/ indirect (MC)
Conjugated: direct; rare but more serious
Breastfeeding jaundice- lack of adequate feeds causes dec gut motility on day 2-3 of life
Defected milk w/ conjugation inhibitor, increased hepatic recirculation d/t glucuronidase; seen on day 7-10 w/ bili rarely above 20mg
What is seen on lab results to aid w/ Dx of Breast milk Jaundice
Jaundice seen at ? point in time is always pathologic
Un/Conjugated DDxs
Unconjugated hyperbilirubinemia w/out hemolysis
1st day of life
Indirect: Hemolysis, Insufficient conjugation
Direct: Biliary atresia, Unresponsive to phototherapy or transfusions
Characteristic clues of Physiological Jaundice
Characteristic clues of Pathological Jaundice
When evaluating jaundice, ? is the first location that needs to be assessed
Evidence starts w/ bili at 5-6 or,
Preterm w/ bili <15 on day 5 of life:
Yellow skin started on face, moves down
Very early, very fast: Peak bili w/in 24hrs of life in term infant Bili rises 0.5/hr or 5mg/dl/day Jaundice w/in 24hrs of life Hepatosplenomegaly and anemia
Under tongue THEN sclera
? is first line test ordered for evaluation of neonatal jaundice
How are these Tx if Mild, Mod or Severe
What are the short and long term adverse effects of neonatal phototherapy
Transcutaneous then serum bili
Mild: lifestyle, breast feed, sunlight
Mod: phototherapy
Sev: exchange transfusion if levels >20
Short:
Diarrhea, Dec bonding, GI hypermotility
Temp instability
Long:
Inc risk for asthma and DMT1
What is included in a standard well visit
Define Neonate
Define Infant
Growth Development Imms Guidance Screenings
0-28d old
29d-1y/o
Define Toddler
Define Pre-Schooler
Define Child
1-3y/o
2-5y/o
1-12y/o
Define Adolescent
Define Growth
Define Development
13-18y/o
Increase in body size
Increase in function/process
Developmental Scales are AKA ? and use ? as more more detailed screening
Define Developmental Milestones
What is the MCC of abnormal growth chart results
Ages and Stages;
Denver Developmental Screening Test 2
Observable traits/actions that present/fade at predictable ages
Operator error
Weight loss expected during first few days of life
Time frame to return to birth weight, double and triple their weight
What is considered normal daily weight gain
5-10% of birth weight
Return by day 14
Double 4-5mon
Tripled birth weight by 12mon
20-30g x first 3-4mon
15-20g x remainder of first year
Average length at birth is ?
By 4y/o, average child length has increased by ? much
Average head circumference at birth is ? and increases by ? much
20” at birth
30” at first year
Double birth length or, 40”
35cm at birth
Inc 1cm/mon x first 12mon (2cm/mon first 3mon)
How long are head circumferences taken at child appointments
Pediatric weight percentiles/categories
How are heights predicted for fe/males
Until 2y/o
<5th: underweight
5-85th: normal
85-95th: over weight
>95th: obese
M: Paternal + Maternal/2 + 2.5
W: Paternal + Maternal/2 - 2.5
What is the 2 Year x 2 Method for predicting height
What is the most accurate method for predicting height
MC factor affecting growth
Height inches at 2y/o x 2
Bone age w/ hand x-ray
Hereditary factors
Babies born small/premature can be expected to go through ‘catch up’ growth during ? frame
When is medical interventions indicated for deficient growth patterns
When is it normal to see a decline in growth rate
First 6mon
<5% w/out cause
Crosses two percentile lines w/out cause
Discrepancy between Circumference/Weight/Length
After 2y/o
Nutrition/growth during ? pat of life predict adult stature and health outcomes
When is the biggest risk for stunted growth
It is recommended breast milk as sole nutrition source for premature infants d/t ? benefits
First 3yrs
4-24mon
6mon;
Lower readmission rates
Long term IQ development
What can be used for Vit D/Fe supplementation for breast feeding mothers
Absolute c/is to breast feeding
Mothers should limit alcohol consumption to ? much
Polyvisol
HIV Active TB Varicella H1N1 HSV on breast
<0.5mg/kg
