peds3 Flashcards
prophylactis for RSV bronchiolitis?
RSV monoclonal antibody called palivizumab
difference in sx of viral and bacterial pneumonia
viral sx begin with URI, whereas bacterial pneumonia has a more rapid onset with greater severity and not preceded by URI symptoms
difference in lab values between viral and bacterial pneumonia
for viral, WBC count is less than 20,000 cells/mm3 and for bacterial is more than that
common cause of afebrile pneumonia in 1-3 months of age
chlamydia
clinical clues that an infant with pneumonia has a chlamydia infection
a staccato-type cough, absence of fever, eosinophilia on WBC
management of chlamydia pneumonia
erythromycin or azithromycin
most common cause of bacterial pneumonia in older kids/adolescents
mycoplasma pneumonia and chlamydia
definitive dx of mycoplasma pneumonia
serum igM titers for mycoplasma
managmeent of mycoplasma pneumonia
oral erythromycin or azithromycin
pertussis aka
whooping cough
immunization for pertussis
beginning at 2 months
who is at greatest risk for pertussis?
infants less than 6 months
major source of pertussis
adolescents and adults whose immunity has waned
pertussis is characterized by what three stages
catarrhal stage, paroxysmal stage, convalescent stage
describe the cararrhal stage of pertussis
lasts 1-2 weeks; characterized by URI sx and low grade fever
describe the paroxysmal stage of pertussis
lasts 2-4 weeks; characterized by fits of forceful coughing; whoop= inspir gasp head at the very end of a coughing fit; post-tussive vomitting is common; between the fits, kids appear well and are afebrile
describe the convalescent stage of whooping cough
lasts weeks to months; recovery stage in which paroxysmal cough becomes less freq and less severe over time
definitive diagnosis of pertussis
direct fluorescent antibody tests of nasopharyngeal secretions
antibiotics and pertussis?
they don’t alter the course of the disease but they are given to help prevent the spread; azithromycin and erythromycin are options; respiratory isolation is required until antibiotics have been given for 5 days!
how common is asthma?
50% of kids by 1 year and 90% by 5 years of age; 30-50% have remission by puberty
what may be the only sx of asthma?
chronic or recurrent cough
what does cxr show in an asthma patient?
hyperinflation, peribronchial thickening, and patchy atelectasis
what do PFTs show in a patient with asthma
obstructive disease, increased lung volumes, decreaed expiratory flow rate
differential for acute wheezing
asthma, hypersensitivity reaction, bronchiolitis, pneumonia, foreign body aspiration, acute aspiration of stomach contents, environmental irritants
6 types of drugs for asthma
sympathomimetics, cromolyn sodium and nedocromil sodium; corticosteroids; anticholinergic agents; leukotriene modifiers; methylxanthines (theophylline)
examples of sympathomimetics
b2 adrenergic agonists, short acting bronchodilators (albuterol), long acting bronchodilators
what are cromolyn sodium and nedocromil sodium?
anti-inflamm prophylaxis by inhibiting release of inflamm mediators
corticosteroids in asthma patient
can be systemic (for 5-10 days after acute exacerbation) or inhaled
good and bad of theophylline
has both anti-inflamm and bronchodilator properties but narrow therapeutic window
diff between intermittent, mild, moderate, and severe asthma
intermittent is daytime less than twice a week and nighttime less than twice a month; mild is less than once a day and nighttime greater than 2x per month; moderate is daily symptoms and nighttime greater than once per week; severe is continuous symptoms and frequent nighttime sx
how common is CF?
one in 2500 caucasians
what percent of caucasians are carriers?
five percent
what chrom is CF mutation on?
chrom 7
common infectious agents in CF
staph aureus and then pseudomonas
what nose thing is common in CF?
nasal polyps
what does dx of CF require?
one or more phenotypic features OR pos fam hx OR increased immunoreactive trypsinogen on newborn screen; AS WELL AS lab evidence of abnormal CFTR (two CF mutations or sweat chloride over 60 or characteristic ion transport abnormality across the nasal epithelium
chronic lung disease
aka bronchopulmonary dysplasia; it is defined as oxygen dependency past 28 days of life; causes both obstructive and restrictive lung disease
what causes CLD?
acute lung injury followed by not good healing; often in children born prematurely with RDS
what does cxr show for CLD?
atelectasis, hyperinflation, linear or cystic radiodensities
foreign body aspiration- what kids are at greatest risk?
3 months to 5 years
aspirated object usually ends up in which bronchus?
right
definition of apnea of infancy
unexplained cessation of breathing for at least 20 seconds or a shorter pause that leads to bad things like cyanosis
what is short central apnea?
less than 15 sec; interestingly, this is normal at all ages
definition of periodic breathing
three or more episodes of apnea lasting 3 sec each with no more than 20 sec in between
what is ALTE?
loss of breathing and tone and choking or gagging and baby needs to be resussitated
SIDS
death of an infant less than 1 year that cannot be explained
when is peak SIDS age
2-4 months, with like 95% happening before 6 months of age
drooling and neck hyperextension
think retropharyngeal abscess or croup (caused by staph or strep in a vaccinated infant)
how do you treat moderate exacerbation (10 days) of asthma?
systemic corticosteroids for 5 days
management of intermittent asthma
no daily medication; SA beta ag for sx
management of mild persistent asthma
SABA, low dose inhaled corticosteroid
management of moderate persistent asthma
SABA, medium dose inhaled corticosteroid
management of severe persistent asthma
SABA, high dose inhaled steroid and LABA, long term systemic if needed
difference between essential and non-essential nutrients
essential cannot be synthesized by the body so must be taken in
of the 20 Aas, how many are essential?
9
vit E def can cause
anemia/hemolysis, neuro deficits, altered prostaglandin synthesis
vit K def can cause
coagulopathy/prolonged prothrombin time, abnormal bone matrix synthesis
vit B1 (thiamine) def can cause
beriberi (cardiac failure, peripheral neuropathy, hoarseness, or aphonia, wenicke’s encephalopathy)
vit B6 (pyroxidine) def can cause
dermatitis, cheilosis, glossitis, microcytic anemia, peripheral neuritis
vit B12 (cobalamin) def can cause
megaloblastic anemia, demyelination, methylmalonic acidemia
Vit c def can cause
scurvy
sx of scurvy
hematologic abnormalities, edema, spongy swelling of the gums, poor wound healing, impaired collagen synthesis
niacin def
pellagra (diarrhea, dermatitis, dementia), glossitis, stomatitis
zince def
skin lesions, poor wound healing, immune dysfunction, diarrhea, growth failure
marasmus
the most common energy depletion state; characterized by near starvation; patient is typically very thin from loss of bone and muscle
kwashiorkor
less common than marasmus; seen in parts of the world where starches are the main dietary staple; protein-deficient state; characterized by edema, abdominal distension, changes in skin pigmentation and thin sparse hair
how is malabsorption characterized
diarrhea, abdominal distension, and impaired growth
carbohydrate malabsorption
unabsorbed sugars draw water into the lumen; result is watery stool that is acidic (pH below 5.6); the unabsorbed sugars are detected as reducing agents by a positive Clinitin test
pos Clinitin test
unabsorbed sugars
congenital enterokinase def
rare cause of protein malabsorption; hypoproteinemia causes edema and growth impairment
inflamm disorders of the GI tract (crohn’s disease) cause what kind of malabsorption
protein
how do you measure protein loss in the stool
fecal alpha 1 antitrypsin levels
steatorrhea
fat in stool
causes of exocrine pancreatic insuff (leads to decr lipid absorpt)
CF, Schwachman-Diamond syndrome, chronic pancreatitis
acanthocytosis of erythrocytes
seen in abetalipoproteinemia
Schwachman-Diamond syndrome
AR disorder characterized by pancreatic exocrine insufficiency, FTT, short stuature, neutropenia and sometimes pancytopenia
infection with what can caue malabsorption
Giardia; can be x with stool studies
most protein intolerance is caused by what protein?
cow’s milk protein
what to expect in a kid with protein intolerance?
usually resolve by 1-2 years of age
celiac disease pathology?
intolerance to gluten, which causes mucosal damage
gold standard for dx of celiac
small bowel biopsy showing short, flat villi, deep crypts, and vacuolated epithelium with lymphocytes
serum screens for celiac disease
serum igA endomysial and serum tissue transglutaminase antibody testing (in patients with igA deficiency, check serum antigliadin igG)
what can non-compliance to a gluten free diet in adolescence in patients with celiac lead to?
growth failure and delayed sexual maturity
distal small bowel resecstion (ileum resection) leads to what?
vitamin b12 and bile acid absorption deficiency
predominant cause of GERD during childhood
transient lower esophageal sphincter relaxation
another cause of GERD in kids
gastric emptying delay
what to tell parents about their kid with emesis?
it is benign and usually resolves by a year old
most common sx of GERD in infants
emesis
Sandifer syndrome
torticollis with arching of the back caused by painful esophagitis
how does GERD present in older kids?
midepigastric pain (“heart burn”)
how does GERD lead to airway disease?
acid refluxate causes bronchopulm constriction and can also lead to aspriation
who requires long term medical manaement of GERD
when infants have GERD past one year of age
scintigraphy
uses radioactive marker (technetium 99m) mixed into food to measure the rate of gastric emptyng. Radioactive tracer detected in the lung confirms aspiration
gold standard for diagnosis of GERD
pH probe in esophagus for 18 hours
metoclopramide
motility agents increase LES tone or increase gastric emptying;though metoclopramide has side effects
Nissen fundoplication
wraps the fundus of the stomach around the distal esophagus to reduce transient LES relaxation; works in 90% of kids; need gastrostomy tube for a short amt of time after this procedure
pyloric stenosis results in what sx?
vomitting of non-billious milky fluid during the 2nd or 3rd week of life; jaundice can occur in 5% of patients
who is affected most commonly by pyloric stenosi
caucasians and first born males
“olive” on physical exam
hypertrophied pyloric muscle palpable up and to right of umbilicus
what is acid/base and salt status of kid who has been vomitting due to pyloric stenosis
hypocalcemic, hypokalemic, metabolic alkalosis
diagnosis of pyloric stenosis
u/s that measures the pyloris muscle length and thickness
string sign on UGI
elongated, narrow pyloric channel due to stenosis
tx for pyloric steonosis
partial pyloromyotomy
malrotation
midgut twists around the mesenteric vessels (volvulus). Causes obstruction and infarction of the bowel
maltrotation more common in what gender
2:1 male predominance
Ladd’s bands
peritoneal bands that result from the small bowel compressing the duodenum; happens in malrotation
presentation of malrotation/volvulis
billous vomitting and sudden onset of abdominal pain in an otherwise healthy infant; older kids might have crampy abdominal pain and vomitting
diagnosis of volvulus
upper intestinal contrast imaging; shows abnormal position of the ligament of treitz to the right of midline, partial or complete duodenal obstruction, jejunum to the right of the midline
management of volvulus
surgical emergency for the untwisting and removing any bowel that is dead; you also want to give fluid resuscitation (due to all the vomitting), and broad spectrum parenteral antibiotics
how does duodenal atresia happen?
failure of the duodenum to recanalize at 8-10 weeks gestation
most common cause of obstruction in the neonatal period
intestinal atresia
duod atresia more common in who?
males and babies with down syndrome
scaphoid abdomen with epigastric distension
duodenal atresia
double bubble on abdominal radiography
duodenal atresia
cause of jejunoileal atresia
caused by mesenteric vascular accident during fetal life
intussusception
proximal portion into distal
peak age of intussusception
5-9 months
most common cause of bowel obstruction after the neonatal period in infants less than 2
intussusception
most common location for intussuception
ileocolic
Meckel’s diverticulum
diverticulum in the distal ileum
how does intussception present?
sudden onset of crampy pain that comes in intervals followed by periods of calm
currant jelly stools
intestinal ischemia and mucosal sloughing
sausage shaped mass in the RUQ
intussusception
gold standard dx for intussusception
air or contrast enema; both to reduce and diagnose the enema
“coil spring” sign on contrast enema
intussusception
management of intususception
contrast enema with air or hydrostatic pressure
risk of recurrence after contrast reduction and surgical repair of intussception
5% after contrast and 1% after surgical
acute abdomen
sudden onset of abdominal pain that requires urgent eval
most common pediatric surgery
appendectomy, peak age 10-12 years
appendix usually perforates by when
36 to 48 hours after onset of sx
tenderness at mcburney’s point
appendicitis
most common cause of acute pancreatitis
blunt trauma, then idiopathic, then infection
presentation of acute pancreatitis
pain is periumbilical or epigastic and radiates to the back
gray-turner sigh
bluish discoloration of the flanks, sign of severe pancreatitis
cullen sign
bluish discoloration of of the periumbilica area, sign of pancreatitis
most specific blood sign of acute pancreatiits
serum lipase, but serum amylase is also elevated
other lab abnormalities in acute pancreatitis
interestingly, you see liver things go up; leukocytosis, hyperglycemia, hypocalcemia, elevated transaminases, and coagulopathy
most common method for diagnosis pancreatitis
u/s
management of pancreatitis
supportive care, TPN, antibiotics, and possibly surgery if there is lots of necrotic tissue around the pancreas
complications of acute pancreatitis
ARDS, renal failure, shock, GI bleeding; also a pseudocyst (collection of fluid rich in pancreatic enzymes that arises from pancreatic tissue) may develop
management of pseudocyst
small resolves on its own and large needs to be surgically removed
acute acalculous cholecystitis
cholecystitis that is not associated with gall stones (note that cholecystitis is usually associated with gall stones)
acute cholecystitis is uncommon in kids (as is pancreatitis), so if you see cholecystits, what should you think of?
sickle cell disease, or possibly CF or prolonged TPN
murphy’s sign
palpation of RUQ during inspiraton elicits pain; sign of cholecystitis
gold standard dx for cholecystitis
u/s, can detect stones and thickened gall bladder wall
cholescintography
radioactive tracer goes through the biliary system; basically if it takes longer for the gall bladder to be visualized then there is inflamm
