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
What are the three categories of formula
Cow milk based:
Fortified w/ Fe, no sterilization needed
Soy based:
Lactose free alternative w/ possible isoflavone effect
Casein hydrolysate:
Used when absorption/digestion problem exists, $$
Do not feed infants honey/canned goods until ? age
Begin solid foods at ? age
Avoid cows milk until ? age
Avoid whole milk until ? age
12mon
6mon
12mon d/t risk for GI bleed/anemia
24mon
Do not substitute formula w/ soy milk for infants under ? age d/t ? risks
Toddlers 1-12y/o need to avoid ingesting more than ? muck cows milk/day
Over weight children don’t need to be on diets before ? age
<12mon; Scurvy Anemia Malnutrition
> 24oz
3y/o
What age groups should WHO growth charts be used
? age should CDC growth charts be used
When/How is autism screened for
Birth - 2y/o
2y/o - 20y/o
M-CHAT-R at 18, 24mon
>2 predictive or >3 total behavior= further work up
What is the ASQ
How is it adjusted for pre-mature born infatns
What 5 areas are surveyed
21 age specific surveys about developmental skills
3wks premature for up to 2y/o
Problem solving
Communication
Motor
Personal/Social
What are the red flags for Gross Motor
What are the red flags for Language
Rolling <3mon old= inc tone
Poor head control at 5mon= dec tone
Lack of sitting at 7mon= dec tone
Hand dominance <18mon= contralateral motor abnormality
Vary pitch by 4mon Lack of babble by 6mon No word/gesture by 15mon No pointing by 18mon Less than 50% intelligible speech at 24mon
All children w/ speech delay need ? tests
When do Well Child Exams take place
BP is not a standard part of VS until ? age and how is it calculated
Ear exam
Hearing eval w/ tympanometry and audiometry
Auditory Brain Stem Response- r/o peripheral loss
Day 3-5
Week 2
Mon 2 4 6 9 12 15 18 24 30, then annual
After 3y/o
SBP= 80 + Age x 2
DBP= 2/3 of SBP
How is newborn metabolic screening conducted
? metabolic issue is screened for at every visit
Guidelines for newborn exams when 0-6mon, 6-36mon and >36mon old
Hgb electrophresis
Obesity
0-6: no fear, easily comforted/distracted
6-36: fear of stranger/doctor, harder to restrain; moody
>36mon: less fear, more interaction
When are anemia screenings conducted
How much lead accumulation can cause irreversible developmental/behavior abnormalities
When does cholesterol screening begin
12mon if healthy
4mon if high risk
5-10ug/dL; screen at 12mon
Non fasting 9-11y/o and 17-21y/o
Overweight/Obese- fasting
Parent cholesterol >240= high risk, start at 2y/o
What are the accepted cholesterol limits in kids
? populations are considered high risk for TB and when do screenings begin
Borderline: <170
High: >200
Acceptable LDL: <110; Border: 110-129; High: >130
HDL should be >40
12mon/>:
Close contact; w/ high risk adults
Health care workers
Foreign born in high TB areas
Define Active Immunity
Define Passive Immunity
Define Primary Prophylaxis
Define Secondary Prophylaxis
Immunity from vaccine/toxoid
Maternal Ab transfer/administration of Abs
Prevent infection before first occurrence
Prevent recurrence after first infective episode
How are premature infants immunized
What is the exception to this schedule
When is DTaP given
Regardless of birth weight, same chronological age/schedule
Hep B vaccine if <2000g w/ HBsAg negative mother- give first dose at 1mon
5 doses at 2, 4, 6, 15, 48mon
One adult dose at 12
When is Hep B vaccine given
Why his HIB vaccine given
When is MCV4 Meningococcal given
First of three at <24hrs old if healthy term
Protection from meningitis/epiglottitis
11-12y/o or prior to college
When is Hep A given
When can influenza be given
Prevnar vaccine is given to protect from ?
Two doses: 1-2y/o
6mon
Pneumococcal
When is HPV vaccine given
Describe the Rotavirus vaccine and when it’s given
How long should rear facing car seats be used and how long should kids ride in back seat
Early as 9
Target of 11
Two doses if completed by 15y/o
Live attenuated cow virus;
First dose- 15wks old, final dose NLT 8mon
2y/o;
Back seat until 13y/o
Risks of tobacco smoke
Sequence of teeth eruptions at ? ages
What labs are ordered if delayed tooth eruption is present
LBW
SIDS
Respiratory illness- asthma
Otitis media
Deciduous: lower central incisors to upper central incisors to lateral incisors;
Permanent 6-12y/o w/ 3rd molars by 18y/o
TSH, Ca for Hypothyroid/Hypopituitary, Rickets
Sequence of deciduous teeth eruptions
Sequence of permanent teeth eruprtions
Lower central incisor Upper central incisor Lower lateral incisor Upper lateral incisor Lower first molar Upper first molar Lower second molar Upper second molar
L central incisor First molars U central incisor L lateral incisor U lateral incisor L cuspid U cuspid U second cuspid L second cuspid L second molars U second molars Third molars
Avoid fluoride tooth past until ?
When do dental visits/cleanings begin
What is the ultimate goal of discipline
24mon
12mon w/ cleanings q6mon
Child’s self control
Define SIDS
What stats belong to this Dx of exclusion
What therapy may be beneficial in prevention during the first year
Unexpected death <1y/o unexplained by autopsy/CSI and review of clinical history
Third leading cause of US infant mortality
MCC of death 1mon-12mon old
Pacifiers
What is the risk of Back-To-Sleep position
When does this Dx require no further eval
When is further eval warranted
Pagiocephaly
Normal then Dx develops w/ improvement in 2-3mon
No improvement in 4-6mons- craniofacial specialist
Gross Motor Skills at 4mon old
Gross Motor Skills at 9mon old
Minimum age for child to be forward facing in car seat
Rolls front to back, no head lag w/ pull from supine
Pulls to stand, gets into seated position
2y/o that outgrew rear facing weight/height limits
Criteria for FTT Dx
What are the three classifications of FTT
What are the two patterns and their meaning
Weight <3rd percentile
Weight decreases by two major percentile lines
Weight <80% of median weight for heigt
Type 1: Wasting; deficient weight gain d/t malnutrition
Type 2: Shunting; deficient linear growth w/ head circumference spared d/t malnutrition x months
Type 3: Symmetric; proportional loss weight, height and circumference d/t long standing malnutrition, chromosome abnormalities or infection/exposures
Dec weight after certain age: infection, endocrine, environment
Body asymmetry: epiphyseal, chromosomal
Basically FTT is d/t ? and 1/3 of organic causes are ?
How is FTT corrected
Why is Refeeding Syndrome deadly
Insufficient nutrition at cellular level;
GI causes
Inc calories/protein <>1.5x
During starvation- dec metabolism to force storage for homeostasis
Rapid feeding- loss of fluid/E+; fluid retention, Hypo-Phos/Mg/K/Ca
Autosomal dominant congenital malformations
Autosomal recessive congenital malformations
X-linked congenital malformations
Achondroplasia Neurofibromatosis Huntingtons Marfans Polycystic kidney
CF PKU CAH SS
Fragile X- excessive gene base repeats Muscular dystrophy Hemophilia A G6PD deficiency Color blindness
RFs for Downs Syndrome
What do all Pts w/ Downs need to have ordered
What are the three forms of Trisomy 21
Inc maternal age, Parental genetics
Chromsomal analysis, + translocation= parental analysis
MC- maternal non-disjunction
Translocation- part of #21 is stuck on another chromosome prior to replication
Mosaicism- rarest; pehnotypical normal Pt
What will be seen on PE of Down Syndrome
What are the face characteristics
What are the extremity characteristics
Generalized hypotonia- dec Moro reflex
Small head
Flat bridge d/t midface hypoplasia Up slanting fissures Macroglossia Epicanthal folds Dysplastic pinna
Single palmar crease
Shortened mid-5th phalanx
Wide first toe interspace
All Down Syndrome Pts will have ?, two-thirds have ? and half will have ?
What type of hearing loss will majority have
What eye defects will they have
All- developmental delay
2/3: polycythemia
Half- cardiac anomalies
SNHL
Cataracts Refractive error Ectopic lens Brushfield spots Strabismus
? x-ray finding in Down Syndrome needs immediate surgical Tx
What is the routine health care check list for all Down Syndrome Pts
Duodenal atresia; seen as “double-bubble” sign
Hearing screening q3mon until 3y/o, then annual
Cards for Echo
Optho by 6mon then annual
Annual TSH/CBC, Celiac screen
? is the most preventable cause of developmental delay/intellectual disability
What are the classic facial features
What hand feature is seen
Fetal Alcohol Spectrum D/o
Short palpebral fissures
Smooth philtrum
Thin upper lip
Clinodactyly- hockey stick crease
What developmental abnormalities are seen in FASD
How much ingestion puts fetus at risk for developing this
What multidisciplinary team is assigned to these Pts
Fine motor delay
ADHD
Retardation
> 7/wk or >3 drinks per period
ADHD
Anxiety therapy
Speech
SpEd
Developmental/Neuro problems seen win Fragile X Syndrome
What physical attributes will be seen
How is this definitively Dx
Hyperarousal Anxiety Mood lability Epilepsy Sterotypy
Joint laxity
Oblong face
Hypotonia
Macro-orchidism
DNA amplification w/ direct analysis
Define 45XO
Majority of defects arise from ? side
What may be seen shortly after birth if infant survives to delivery
Turner Syndrome d/t no/abnormal X
2/3 of X are maternal
Extremity edema
What type of mental development is seen w/ Turner Syndrome
What CV issues are usually seen
What endocrine d/os are seen
Poor visual-spacial skills
Superior verbal skills
Coarctation
Early onset HTN
Bicuspid aorta
Hypothyroidism
Osteoporosis
DMT1
How is Turner’s Dx
What Dx method is not recommended
How are these Pts Tx/managed
Direct karytotyping
Barr body analysis
Annual TSH, Chem-7, UA
Cards- Echo, MRI, EKG
Endo- GH initiation
Define Klinefelter Syndrome
What issue can present
How is this screened, Dx and what would be seen on lab results
How are these Pts Tx and what are they at risk for
47XXY: phenotypically normal prior to puberty
Result of testosterone deficiency:
Irregular features
Violent tendencies
Severe MR
Screen: Barr body
Dx: direct karytopying
Inc LH/FSH w/ low T
T replacement
16-30x inc risk for breast Ca
What type of genetic defect leads to Marfans
What three systems are affected
Crying from an infant can signal ? possible issues
Fibrillin 1 gene on Chrom #15
Ortho: arachnodactyly
CV: AV insufficiency/dissection
Ocular: dislocation
Pain Distress Fatigue Hunger
Pain > Hunger= higher pitch/intensity
What is the correlation to crying if infant is preterm
When is the diurnal variation more common
How loud can these reach
Little before 40wks old
More than term infant at corrected 6wks
Late afternoon/evening
80dB
What findings suggest a crying infant has colic
What is the Wessel’s Rule of 3 for Colic
When does the Dx of exclusion begin to risk maternal health
Paroxysmal crying w/ grimace, leg flexion and flatus
Starting at 3wks: Crying >3hrs/day Crying 3d/wk Crying longer than 3wks Resolves around 3mon old
Inc PPD risk if crying episodes >20min
? is the MC reported behavior problem in kids 2-3y/o
When does this MC become an abnormal
How can these be prevented
Temper tantrum
Past 4y/o Injury to self/others Lasting >15min >5/day Negative mood swings w/ tantrum
Parental education at 12-18mon
Define Intellectual Disability
What type of testing results aids w/ Dx
DSM-5 requires impaired behavior across ? areas
D/o w/ common deficits of adaptive/intellectual function and an onset before maturity is reached
<2SD, IQ <70
Practical/conceptual/social behavior
Define Global Developmental Delay
Possible environmental RFs for Autism
What screening form is used for this Dx and when
Children <5y/o w/ >2SD delay in multiple milestones
Infections- Rubella, CMV Maternal obesity Advanced parent age Premature Short interval from prior pregnancy
M-CHAT-R at 18-24mon
Two predictive- hearing concern, finger movement near eye, noise sensitivity or,
Three total
Define Cerebral Palsy
What are 3 potential RFs
Two PE findings suggestive of Dx
Non-progressive motor impairment syndromes; static encephalopathy
Intrauterine infection
Multiple pregnancies
Infertility Tx
Athetosis, Chorea
What are the 6 classifications of Cerebral Palsy
Mixed- catch all for Pts that don’t fit other patterns
Ataxic- cerebellar injury causing abnormal posture/coordination
Dyskinetic- involuntary, repetitive movements
Dystonic- rare; stiff/dec movements
Spastic- MAJORITY; pyramidal tract injury to upper neurons w/ two: abnormal movement, inc tone, pathologic reflexes
Choreoathetotic- hyperkinesia, hypotonia; rare now that bilirubin is Tx
How is ADHD Dx if Pt is 16y/o or <
How is ADHD Dx if PT is 17y/o or older
What genetic d/os are associated w/ this condition
16y/o or :
5 Sxs of inattention or hyperactive impulsitivity
x 6mon in two environments
Fragile X
22a11.2 deletion syndrome
NF-1
What is at the core of all ADHD Tx
What meds are used first line
What SNRI can be used
What A-agonists can be used
Behavior management
Methylphenidate
Amphetamine
Atomoxetine
Clinidine, Guanfacine
Define Oppositional Defiant D/o
Define Conduct D/o
What screening tool is used for OCD
Moody, defiant, vindictive behavior
Pattern of behavior where basic rights/norms are violated:
Aggression Destruction Deceit Violation
Vanderbilt
What is the mnemonic for interviewing adolescent Pts
HEADDSS: Home/Friends Education Alcohol Drugs Diet Sex Suicide/Depression
Average age for female puberty is ? but preccocious puberty is defined as ?
Tanner stages associated w/ TAPuPMe
Completion of Tanner stages takes ? amount of time for male and female
11y/o;
6y/o in AfAm; 7 y/o in Caucasian
Thelarche: Tanner 2
Ad/Pub: Tanner 2
Peak: one year after thelarche, tanner 3-4
Female: 4-5yrs
Male: 2.5-5yrs
Once female starts menarche, ? much expected height growth is expected remaining
Tanner Stages Mnemonics from OBGYN
Sexual Maturity Rating for female for pubic hair/breast
2-5cm
Deck
1: preadolescent/preadolescent
2: sparse/elevations
3: darker curls/enlargement w/out contour separation
4: abundant and coarse/secondary mound
5: adult triangle/adult contours
When do boys going through puberty pass through Tanner 1 to 2
How does onset of adrenarche present
Both male and female Pts going through puberty will have ? elevated lab result and ? previous issue may worsen
9-11y/o
Pubic, axillary <12mon later
inc ALP d/t rapid bone turnover;
Scoliosis worsens
Male tanner stages
1: childhood
2: testicle enlargement w/ scrotal reddening
3: all 3 grow in size; length
4: all 3 grow; width
5: adult
2: sparse hair at base
3: dark/coarse/curled hair
4: adult hair not on thighs
5: adult hair including thighs
Male Sexual Maturity Ratings
Normal male puberty growth sequence
Table
Testicular growth SMR 2
Pubarche
Penile growth SMR 3
Peak height velocity SMR 4
Breast mass in adolescent females are usually ? type and evaluated by ?
What is a normal variant of puberty seen in peripubertal females and
What causes this variant
How is is evaluated
Fibroadenoma, cyst; eval w/ US
Physiologic leukorrhea- clear vaginal d/c w/out odor/pruritus;
Estrogen from ovary stimulating uterus/vagina
Vaginal culture w/out speculum
Menarche usually presents ? long after thelarche
How long are these classified as irregular after onset
How do Pts know when ovulation has set in
2-3yrs after
1-2yrs
Cycle length 21-45 days
Define Premature Thelarche
What can cause this
What labs/rads need to be ordered
Isolated breast development in 6-7y/o female
Estrogen exposure to phytoestrogens in soy, legumes, flax seed, tofu
Estradiol, LH, FSH, bone age
Head MRI, Pelvic US, GNRH stimulation test
Define Premature Adrenarche
What are two etiologies for this variant
What labs/rads need to be ordered
Body odor, pubic/axillary hair, acne in females <8y/o/males <9y/o
Obesity, CNS injury
DHEAS, Androstenedione, Testosterone, 17-OH, Bone age
ACTH stimulation test, Adrenal/Pelvic imaging
Define Premature Testelarche
What is the next step
Why is this next step so important
Enlarged testis >3cc/2.5cm in male <9y/o
Endocrine emergency
50% have brain tumor
How is Male Gynecomastia evaluated
When is further work up needed
What medication may be used
Round, freely mobile, tender mass under areola in Tanner Stage 3
Large, Hard, Fixed or w/ d/c
Bromocriptine
When does irregular bleeding suggest organic abnormality may exist
When is further evaluation needed for irregular menses
Define Primary Amenorrhea and the MCC
1yr of regular cycles followed by irregular bleeds
Two or more cycles that are not 21-35d, 7d/
Menses frequency
Menses regularity
Menses duration
Menses flow
Frequent: <21d/cycle
Infrequent: >35d/cycle
Amenorrhea: absent x 6mon/>
Irregular: >20 day variation in cycle length
Prolonged: >8 days
Shortened: <2 days
Heavy: >80cc loss
Light: <5cc loss
Define Secondary Amenorrhea
Criteria to Dx PCOS
MCC of abnormal uterine bleeding in adolescents
Menses that have stopped x 3mon after menarche
Two of:
Hyperandrogenism
Infrequent bleed/Secondary amenorrhea
Polycystic morphology on ovary US
Anovulation
How is AUB Tx
What is the mainstay of Tx for Pts w/ bleeding d/o such as Von Willebrand Dz
Define Primary Dysmenorrhea
Fe therapy
Combo E/P to regulate cycle and allow HPO axis to mature
Combo E/P
Pelvic pain DURING menstruation w/out pelvic pathology;
Feature of ovulation developing 1-3yrs after menarche
What causes the pain associated w/ dysmenorrhea
MCC of Secondary Dysmenorrhea
What is the initial screening study for Dysmenorrhea Evaluation
Prostaglandins and leukotrienes from degenerating endometrium after progesterone declines causing increased uterine tone; inc pain fiber sensitivity to bradykinin
Endometriosis or PID
Outlet obstruction w/ US
How is Dysmenorrhea Tx
When is referral/second opinion warranted
What is the most important part of a Sports Physical
NSAIDs- first line therapy
Failure= hormones
Combo OCPs >4mon w/ persistence
Hx
What is an example of a disqualifying and non-disqualifying finding on sports physical
How long are Peds disqualified from sports for Mono
How many calories do boys/girls 14-18y/o need per day
MedHx of seizures that are controlled- not
Stage 2 HTN/poorly controlled- dq’d
28d d/t risk for spleen injury
B: 2000-3200
G: 1800-2400
How much Ca/day do teens need
When is a teen considered Obese and Morbidly Obese
How is Obesity managed in Pts <7y/o and >7y/o
1300mg/day
> 120% ideal body weight
200% ideal body weight
<7y/o: goal of weight maintenance to let linear height catch up
>7y/o: goal is 1lb/mon until BMI is <85%
What are the SMART Goals when managing Peds w/ obesity
One in five adolescents are depressed and are at risk for developing ?
? has a higher rate of adolescent death than MVCs
Specific Measurable Attainable Realistic Timely
Bipolar d/o
Suicide
What are the only two meds approved for depression Tx in children
How often are Pts f/u w/ after starting meds
? is the MC psychiatric d/o of childhood
Fluoxetine, Escitalopram
Weekly x 2mon
Anxiety
Substance abuse screening acronym
Done w/
CRAFFT: Car- driving under influence Relax- using drugs to relax/fit in Alone- alcohol/drug use while alone Forget- d/t consumption Fam/Friend- tell teen to stop/cut down Trouble- d/t substance abuse
Slide deck 7
How does Post-Strep Glomerulonephritis present
How are these Pts managed
Hematuria, Periorbital edema, and HTN two weeks after strep pharyngitis or 3-6wks after strep skin infection Dx/Tx
ABX if active infection
Volume overload w/ Furosemide/fluid restriction
Dialysis if severe renal impairment
How does Henoch Schnelein Purpura/IgA Vasculitis present
What will lab results show
Purpuric rash, Abdominal pain, Arthralgia, Arthritis 1-3wks after URI
Normal platelet counts
Heme-pos stool
Proteinuria w/ elevated BUN/Cr
? is the MC solid renal tumor in kids <15y/o
? is the imaging method of choice
What medication can be used to help reduce the cosmetic effect of Acanthosis Nigricans
Wilms tumor
US then CT w/ contrast
Topical retinoids
Name of microbe causing pinworms
How is this Tx
E. vermicularis
Me/Al-bendazole and w/ repeat dose at 2wks
Pyrantel pamoate
How does acute urticaria present
What is first line therapy
Raised, erythematous plaques w/ central pallor w/ intense pruritus
Second generation H1 antihistamine:
Levo-Cetirizine- citrus magazine
Des-Loratadine- low-riding jeans
Fexofenadine- fox fencing
? is the MC abnormality of male GU tract
What is the MC location of this MC abnormality
When is surgical intervention indicated
Cryptorchidism
High scrotal > Inguinal canal > abdominal
Undescended at 6mon= orchopexy
Define Rumpel Leede phenomenon seen w/ RMSF
Name of tick carrier
How is it Tx
Petechiae formation after BP cuff
Dermacentor
Doxy
Chloramphenicol if preg/allergic to tetracyclines
Criteria for Kawasaki Dz Dx
What will lab results show
What inflammatory markers will be elevated or normal
How is this Tx
What unique GI finding is associated w/ this Dx
Fever 5d or more w/ 4 of the following: Bilateral conjunctival injections Oral mucus membrane changes Peripheral extremity erythema/edema/desquamation Polymorphous rash Cervical lymphadenopathy
Thrombocytosis
Leukocytosis
Normocytic anemia
+: CRP, ESR, A-1 antitrypsin
-: ANA, RF
High dose ASA and IVIG w/ f/u at Cards for Echo
Hydrops of Gallbladder: pain, jaundice, boggy on US
Testicular torsion is corrected w/ in ? time frame and w/ ? procedure
How is pain described
Stopped on
<6hrs w/ bilateral orchiopexy
Radiating towards abdomen
Rosh #10
? is most frequently reported as perpetrator of child abuse
Who is more likely to inflict serious head/abdominal trauma
? is the MC type of abuse that is also ?
Mother
Father/Maternal boyfriend
Neglect- failure to provide for child’s needs; also hardest to document/prove
? is the 2nd MC type of abuse
? is the MC type of emotional abuse
? are six complications that can arise from abuse
Physical, non-accidental trauma; MC perp is primary care giver
Verbal
Aggression Relationships Language Depression Substance abuse Sleep/Anxiety d/os
What would be seen on PE if child was experiencing neglect
? types of Fxs have high abuse suspicion
Abdominal injuries are more common in ? populations
Type 1 growth deficiency: normal head/length, low weight
Metaphyseal Scapula Rib Spiral Vertebral
Infant/Toddler
? type of abuse is the leading cause of morbidity/mortality
How does the color of a bruise correlate to age
Head injuries- shaking or blunt/force trauma
Red: 0-2d Blue/Purple: 2-5d Green: 5-7d Yellow: 7-10d Brown: 10-14d Hbg to Biliverdin to Bilirubin
What image is done for suspected abuse in kids <3y/o
Sequence of events for Fxs to heal
Skeletal surveys
7-14d: new bone/callus
14-21d: loss of Fx line, callus matures
3-6wks: dense callus
>6wks: sclerotic thickening
? is the Shaken Baby Triad
Sexual assault kits can be collected w/in ? time frame
Diabetes is characterized by ? and ?
Retinal hemorrhage
Brain swelling
Subdural hematoma
<72hrs from attack
Hyperglycemia and glycosuria
What are the two type of DM in Peds
Criteria for Pre-Diabetic and Diabetic
DMT1: MC type in childhood d/t autoimmune destruction of B-islet cells leading to permanent insulin deficiency
DMT2: MC in adulthood d/t insulin resistance and obesity
Pre: A1c 5.7-6.4
DM: Fasting 126 or higher
2hr OGTT 200 or higher
A1c 6.5% or higher
? is first line medical therapy for DMT2 Tx
What are the 4 phases of DMT1
What are the 3 Ps of DMT1 presentation
Metformin
Pre-clinical B-cell destruction
Clinical onset
Transient remission w/ honeymoon
Established diabetes
Poly-dipsia/uria/phagia
Potential fatal outcome from undetected/poorly acknowledged DMT1
What are the 3 classifications of this outcome
DKA: glucose >300, pH <7.3, BiCarb <15
Mild: Co2 16-20, pH 7.25-7.35
Mod: Co2 10-15, pH 7.15-7.25
Sev: Co2 <10, pH <7.15
How is DKA Tx
What is the most serious complication from this Dx and how is it Tx
What RF places Pt highest risk for developing this outcome
Admit for insulin/fluid w/ E+ therapy
Switch D5W when glucose 250-300
10% once glucose <200
Cerebral edema; IV Mannitol w/ HOB raised
Dec in glucose >100mg/hr
How is DKA Tx
What is the most serious complication from this Dx and how is it Tx
What RF places Pt highest risk for developing this outcome
Admit for insulin/fluid w/ E+ therapy
Switch D5W when glucose 250-300
10% once glucose <200
Cerebral edema; IV Mannitol w/ HOB raised
Dec in glucose >100mg/hr
What should DM diet compose of
What are the A1c goals for Peds
What are the blood glucose goals
55% carbs
15% protein
<30% fat
<300mg/24hrs cholesterol
<6y/o: 7.5-8.5%
6-13y/o: <8%
13-18y/o: <7.5%
<5y/o: 80-180
School aged: 80-150
Adolescent: 70-130
Define Honeymoon Period seen in DMT1
Define Dawn Phenomenon
Define Somogyi Phenomenon
Residual B-cell function, measured w/ C-peptide
Inc morning glucose d/t GH release and fading insulin levels; Tx w/ inc bedtime insulin
Hypoglycemic level at 0300 d/t counter regulatory effect; Tx w/ lower bedtime insulin
MC complication of DMT1 and when is it most likely to occur
How are Mild or Sev complications Tx
What f/u do these Pts need
Hypoglycemia; after hypoglycemic episode d/t reduce autonomic responses
Mild: PO glucose
Sev w/ seizure/LOC: glucagon
Annual Ophth for Pts w/ dx >3yrs
Annual UA for microalbuminuria
Annual cholesterol/BP checks
Annual thyroid
Sick Day Rules for DMT1
What is the rule used for insulin insensitivity and establishing sliding scale
BG >240= check for ketones w/ fluid/insulin management
Insulin pump- change site, give correction dose via injection
Re-check BG/mental status q3hrs
Re-check ketones qVoid
Min 8oz sugar free fluid/hr
15g carbs/hr
Rule of 1500:
1500/total insulin= amount 1unit of insulin will lower glucose
? is the most sensitive test of thyroid function in Peds
? is the MC cause for this most sensitive to be elevated if on corrective meds
Only indication to US thyroid in Peds
TSH
Non-compliance
Nodular; No if symmetrical
