quiz 2 s Flashcards
feeding
-<6mo- exclusively breast feeding
-6mo-2yrs- continue breast feeding + complementary foods
-cereals, fruits, veggies, meat
->2yrs- 3 meals- meat, poultry, fish, low fat milk
-peanut puree @ 4-6mo
-whole milk and honey @ 1 yr
vitamin A deficiency
-xerophthalmia
-Night blindness, followed by xerosis of conjunctiva and cornea
-Clinical/subclinical signs: Immunodeficiency (measles)
Niacin (B3) deficiency
-Pellagra (niacin deficiency):
-Weakness
-lassitude
-photosensitivity
-inflammation of mucous membranes
-4 Ds:
-dermatitis
-diarrhea
-dysphagia
-dementia (severe cases)
vitamin C deficiency
-Scurvy:
-Irritability
-bone tenderness/swelling
-pseudoparalysis of legs
-Progression:
-Subperiosteal hemorrhage
-bleeding gums/petechiae
-hyperkeratosis of hair follicles
-mental changes
-anemia
-decreased iron absorption
-abnormal folate metabolism
Vitamin D deficiency
-RICKETS:
-Craniotabes: Thinning of outer skull (when compressed feels like ping-pong ball)
-Enlargement of costochondral junction (rachitic rosary) and thickening of wrists and ankles
-Enlarged anterior fontanelle
-Scoliosis, exaggerated lordosis, bow-legs/knock knees, greenstick fractures
-Dx:
-Hx
-Low-normal calcium, low phosphorus, alk phos activity increased
-Best measure is level of 25(OH)D
-Imaging:
-Distal ulna/radius: Widening, concave cupping, frayed/poorly demarcated ends
pyloric stenosis
-hypertrophy
-gastric outlet obstruction
-projectile postprandial vomit (not bilious but may be blood streaked)
-2-4wks yrs old
-babys will be hungry
-distended abdomen after eating
-peristaltic waves from L to R
-oval mass- 5-15mm in RUQ
-Dx- hypochloremic alkalosis with low K
-dehydration- high Hmg/Hct
-Imaging:
-US- hypoechoic muscle ring >4mm and pyloric channel length >15mm
-Barium upper GI- retention of contrast in stomach and long narrow pyloric channel with double track of braium
-Tx:
-pyloromyotomy
-tx dehydration before
duodenal obstruction/atresia
-obstruction is intrinsic (atresia, stenosis, mucosal webs) or extrinsic (malrotation, annular pancreas, duodenal duplication)
-Imaging:
-Double bubble- distention of stomach and proximal duodenum
-Atresia -> absence of distal intestinal gas
-Duodenal atresia:
-maternal polyhydramnios
-bilious emesis and epigastric distention first few hrs of birth
-assoc with preterm and down
-Tx:
-duodenoduodenostomy to bypass
intestinal malrotation
-occludes SMA
-volvulus
-1st 3 wks of life- bilious emesis or SBO
-Later signs- intermittent obstruction, malabsorption, protein losing enteropathy, or diarrhea
-older kids- chronic GI sx of N/V/D, abd pain, dyspepsia, bloating, early satiety
-Imaging:
-upper GI series- Gold standard- corkscrew sign
-barium enema- mobile cecum
-US/CT- whirlpool sign- midgut vulvulus
-Tx:
-Ladd procedure
-Midgut volvulus -> surgical emergency
intussusception
-usually proximal to ileocecal valve
-MCC Of obstruction in first 2yrs of life (3x in males)
-causes: polyp, meckel diverticulum, omphalomesenteric remnant, duplication, lymphoma (MC >6yo), lipoma, parasites, FB, viral enteritis w/ hypertrophy of peyer patches (MC)
-paroxysms of abd pain with screaming and drawing up of knees
-V/D
-blood stool (current jelly)
-febrile
-sausage shaped mass palpated
-Dx:
-US- target sign
-Barium and air enema = dx and tx
-if ischemia or perf -> surgery
acute appendicitis
-15-30yrs MC
-WBCs seldom >15
-pyuria, fecal leukocytes, guaiac +
-high CRP and leukocytosis
-radio-opaque fecalith
-US- thickened appendix
-CT- with rectal contrast
-Tx:
-laparotomy or laparoscopy
congenital aganglionic megacolon/hirschsprung ds
-MC chromosomal abnormality assoc is downs
-colon cant relax in certain areas
-contracted parts are narrow -> proximal parts are dilated/thin
-newborn wont pass meconium within 24hrs -> vomiting, distention
-enterocolitis, fever, dehydration, explosive diarrhea
-ischemia, perf, sepsis
-Later infant- alternating obstipation and diarrhea
-Older kid- constipation
-foul smell, ribbon like, distended abd, hypoproteinemia, FTT
-no stool in anal canal/rectum even though obvious retained stool on imaging
meckel diverticulum
-bleeding due to ileal ulcers adjacent to diverticulum
-cased by acid secreted by heterotopic gastric tissue
-can cause obstruction / intussusception
-imaging:
-Meckel scan
-Technetium-99m-pertechnetate take up by heterotopic gastric mucosa in the diverticulum and outlines diverticulum on a nuclear scan
-Tx: Surgical with good prognosis
dehydration
-higher SA to volume ratio
-vitals (orthostatic BP too)
-urine- high SG, ketonuria, BMP, serum bicarb (metabolic acidosis), BUN
-Classified by % of total body water lost (mild, moderate, severe)
-Tx:
-Mild-moderate- oral rehydration therpay (ORT) (pedialyte/gatorage), BRAT diet (diarrhea)
-1 mL/kg q 5-10 mins or 0.5 ounces q 5-10 mins
-Ondansetron if needed to tolerate ORT (for vomiting)
-Severe: IV fluids
-Initial bolus of 20 mL/kg normal saline over 20-30 mins
-Ongoing tx: fluid deficit (FD) = % dehydration x weight (kg)
-½ fluid deficit over first 8 hours, second ½ over next 16 hours
normal short stature: familial short stature
-takes on average of mom and dad
-normal birth wt and length
-normal growth curve -> decelerates -> normal growth curve -> just shorter than average
-puberty = normal age
normal short stature: constitutional growth delay
-late bloomers
-normal birth wt and ht
-lower growth based on parents, delayed skeletal maturation compared to age, late puberty
-growth continues beyond average child stops
-final ht is normal
-growth spirt at 17-18yo
growth hormone deficiency
-Decreased growth velocity and delayed skeletal maturation in absence of other explanations
-May be congenital, genetic, or acquired
-Idiopathic is MC
-Infantile GHD: Normal birthweight and slightly reduced length, hypoglycemia (with adrenal insufficiency), micropenis (with gonadotropin deficiency), and conjugated hyperbilirubinemia
-Dx- clinical and lab evidence
-Labs: Serum IGF-1 gives reasonable estimations of GH secretion and action
-MRI of hypothalamus/pituitary gland to evaluate for tumor
disproportionate short stature: achondroplasia
-dwarfism
-Autosomal dominant transmission
-Upper arms and thighs are proportionately shorter than forearms/legs
-Skeletal dysplasia
-Height measurements for screening
-Bowing of extremities, waddling gait, limited ROM, relaxation of ligaments, short stubby fingers, frontal bossing, midface hypoplasia, otolaryngeal dysfunction, moderate hydrocephalus, depressed nasal bridge, lumbar lordosis
-Imaging:
-Short, thick, tubular bones and irregular epiphyseal plates
-Ends of bones are thick, with broadening and cupping
-Delayed epiphyseal ossification
-Narrowed spinal canal (diminished growth of pedicles)
-Tx: Growth hormone
DMT1
-Polyuria, polydipsia, and wt loss
-Heavy diaper in a dehydrated child w/o diarrhea -> alarm
-Labs:
-HbA1c does not rule out dx (less sensitive than blood glucose)
-Tx:
-Aim for lowest HbA1c w/o severe hypoglycemia or frequent, moderate hypoglycemia
-Diet/exercise: At least 60 mins of daily aerobic exercise with bone/muscle strength training at least 3 days/week
DMT1 management
-Monitor glucose at least 4x/day -> 7-10 for optimal management
-CGM- Subcutaneous glucose measured q 1-5 mins
-Subcutaneous may lag behind blood glucose if rapid change, so finger sticks still recommended for tx and monitoring of recovery from hypoglycemia
-New onset- long acting insulin for basal level // rapid acting analog for mealtime dosing
-peak dose @ 1 wk and then decrease it slightly
–Pre-pubertal: Higher rate early in night
-Post-pubertal: Higher rates early in morning – “dawn phenomenon”
precocious puberty in girls
-onset of 2ndary sexual characteristics before 8yo in Caucasian girls
-7yo for African American and Hispanic girls
-Central PP: Idiopathic or 2ndary to a CNS abnormality that disrupts prepubertal restraint on the GnRH pulse generator
-Abnormalities include hypothalamic hamartomas, CNS tumors, cranial irradiation, hydrocephalus, and trauma
-Peripheral PP (GnRH-independent): Ovarian/adrenal tumors, ovarian cysts, late-onset congenital adrenal hyperplasia, McCune-Albright syndrome, or exposure to exogenous estrogen
-starts with breast development -> pubic hair -> menarche
-PPP:
-!Ovarian cysts/tumors usually with signs of estrogen excess: Breast development, vaginal discharge, vaginal bleeding
-!Adrenal tumors and CAH with signs of androgen excess: Pubic hair, axillary hair, acne, and increased body odor
-Accelerated growth/maturation; skeletal maturation quicker than linear growth = compromised adult stature
precious puberty in girls dx and tx
-Labs:
-CPP: Random FSH and LH may confirm dx
-PPP: LH response to GnRH is suppressed by autonomously secreted gonadal steroids
-Estradiol levels, androgen levels (testosterone, androstenedione, dehydroepiandosterone sulfate), and 17-hydroxyprogesterone should be measured
-Imaging:
-Bone age (L hand and wrist)
-CPP: MRI of brain for CNS lesions
-PPP: Imaging of ovaries and/or adrenal gland
-Tx:
-CPP: GnRH analogues that downregulate pituitary GnRH receptors
-Leuprolide (IM injections), histrelin subdermal implant (replaced annually)
-After stopping therapy, pubertal progression resumes, and ovulation and pregnancy have been documented
-PPP: Dependent on underlying cause
-Regardless of cause, attention to the psychological needs of the patient and family is essential
delayed puberty in girls
-Primary hypogonadism: Primary abnormality of ovaries
-!!!MCC is Turner syndrome
-Central hypogonadism: Hypothalamic or pituitary deficiency of GnRH or FSH/LH
-Functional (reversible): Stress, undernutrition, prolactinemia, excessive exercise, or chronic illness
-Permanent: Congenital hypopituitarism, CNS tumors, or cranial irradiation
-H&P, BONE AGE:
-Low bone age (< 12 years):
-abn growth rate!
-Bone age > 12 years:
-FSH/LH distinguishes between primary ovarian failure (elevated FSH/LH) and central hypogonadism (low FSH/LH)
-Cranial MRI for central
-GIRLS W/ ADEQUATE BREAST DEVELOPMENT AND AMENORRHEA:
-Progesterone challenge to determine if sufficient estrogen is being produced and to evaluate for anatomical defects
-Producing estrogen: Withdrawal bleeding 5-10 days of PO progesterone -> !!MCC of amenorrhea in this case is PCOS
-Estrogen-deficient/anatomical defect: No bleeding
-Tx:
-Replacement therapy in hypogonadal: Estrogen alone @ lowest available dosage
-increased slowly then 18-24 months later -> add progesterone
-Unopposed estrogen = endometrial hyperplasia
precocious puberty in boys
-2ndary sexual characteristics before 9yo
-Pubic hair -> penile enlargement -> scrotal maturation, axillary hair, voice deepening, increased growth velocity
-CPP: Testes enlarge
-PPP: Testes remain much smaller than expected for degree of virilization
-Labs:
-Elevated testosterone levels
-CPP: High LH/FSH
-PPP: Low LH/FSH -> CAH: Adrenal androgens and 17-hydroxyprogesterone will be elevated
-Imaging:
-Bone age
-CPP: Brain MRI
-PPP: Rule out hepatic, adrenal, and testicular tumors
-Tx:
-CPP: GnRH analogues/tx of underlying cause
-PPP: Steroid synthesis blockers (ketoconazole) or combination of antiandrogens (spironolactone) and aromatase inhibitors (anastrozole or letrozole) that block conversion of testosterone to estrogen
delayed puberty in boys
-No 2ndary sexual characteristics by 14yo or if >5 years since first signs of puberty w/o completion of genital growth
-!!!!MCC is constitutional growth delay
-Hypogonadism may be primary or central
-Primary: Testicular insufficiency/anorchia, Klinefelter syndrome/sex chromosome anomalies, enzymatic defects in testosterone synthesis, inflammation/destruction of tests following infection, autoimmune disorders, radiation, trauma
-Central: Deficiencies in pituitary/hypothalamic function (same as girls)
-H&P, bone age:
-Low bone age relative to chronological age + normal growth velocity (prepubertal) -> constitutional growth delay
-Bone age > 12 years
-Elevated LH/FSH: Primary hypogonadism or testicular failure
-Low LH/FSH: Central hypogonadism
-Tx:
-4-6-month course of low-dose depot testosterone to promote virilization and possibly “jump-start” endogenous development
