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What is erythema toxicum?

—Common rash-first few days after birth

—Small blotchy erythematous areas with a raised yellow/white center

—May be anywhere, including palms and soles, esp. on trunk

—Usually in first week to ten days of life; up to 4 weeks


How long does erythema toxicum stick around? What causes it?

—Usually in first week to ten days of life; up to 4 weeks

—Dissipate without treatment in 5-7 days

—Cause is unknown



What are milia? Are they pathological?

—Tiny white bumps occur in 40% of newborns

—Most often on the nose and cheek

—Not pimples although they look like them

—Blocked skin pores & disappear by 1-2 months of age

—Benign lesions


What are the 2 forms of miliaria?

2 forms:

Miliaria crystallina

Small clear fluid filled vesicles that rupture and leave scale


Miliaria rubra

Clear fluid filled vesicles that are surrounded by red areas


What causes miliaria? Where does it happen?

Usually found on head, neck, trunk and in skin folds

Blocked sweat gland ducts

Resolves on its own

Reoccurs w/ increased heat/humidity/bundling in warm clothing


What is neonatal acne? How long does it last and what causes it?

—>30% of newborns

—Begins at 3-4 weeks of age & lasts to 4-6 months of age

—Cause is maternal androgens prior to birth

—No treatment needed


What is seborrheic dermatitis? How is it treated?

Seborrheic dermatitis (cradle cap, aka baby dandruff)

◦Scaling of scalp or eyebrows

◦Treatment: Nizoral shampoo or cream, Selsun shampoo, frequent hairwashing with baby shampoo


What does transient neonatal pustular melanosis look like? How long does it stick around?

—Present at birth

—Cause unknown

—Tiny 1-2mm pustules on face, neck, ext, palms & soles

—Can have scale around them

—No erythema or inflammation

—Rupture in first few days of life & leave behind freckles which fade in 3 weeks to 3 months

—No treatment needed


What are the types of diaper rashes?

irritant diaper dermatitis

moniliasis/monilial diaper dermatitis


What is irritant diaper dermatitis caused by? Tx?

—Irritant diaper dermatitis

◦Reddish area in groin from urine or heat

◦Treatment: barrier ointment (zinc oxide), air dry, frequent changes


What does moniliasis look like? Tx?

—Moniliasis (monilial diaper dermatitis)

◦Classically described as “beefy red with satellite lesions”

◦Nystatin ointment


What do Mongolian spots look like? What causes them?

—Blue-gray flat birthmark (plaque) that is most often found in dark skinned infants

—Usually over the back and buttocks but can be anywhere

—Big variation in size

—Most fade by 2-3 years of age; they may persist into adulthood


—Entrapment of melanocytes in dermis during migration from neural crest cells into the epidermis


What does atopic derm look like? Acute v chronic?

Atopic Dermatitis (eczema)
”the itch that rashes”

—3-5% of children 6 mo to 10 yr

—Ill-defined, red, pruritic, papules/plaques

—Diaper area spared

—Acute: erythema, scaly, vesicles, crusts

—Chronic: scaly, lichenified, pigment changes


How is atopic derm treated?


Antihistamines for itching

After showers, moisturize with thick ointments QUICKLY afterwards, don’t wipe completely dry

Vaseline,  Aquaphor, Cetaphil, Eucerin, Vanicream

Dove unscented


What is the general distribution of atopic derm rash for infants, kids, & adults?


What is the difference between alopecia areata v tinea capitis?

—Alopecia areata may have associated nail changes

—R/o hypothyroidism

—No broken hairs


—Tinea capitis: black dots

—Kerion: inflammatory reaction


What are the general characteristics of acne? Cause? Tx?

—Common condition characterized by the inflammation of the pilosebaceous units of the face & trunk

◦Black heads (open comedones)

◦White heads (closed comedones)



—Propionibacterium acnes


◦Topical antibiotic or benzyl peroxide based solutions, clean with antibacterial soap and water


What causes molluscum contagiosum? What is the Tx?


—Usually no treatment recommended when less than 50 lesions or not on face


How is verruca vulgaris treated?

Pare, pare, pare!

Benign neglect (may go away in 2 yrs)

Salicylic acid topically



What is Henoch-Schonlein purpura? What does it look like?

—Systemic vasculitis of small vessels of skin, GI tract, kidneys, joints

—Abdominal pain, rash on legs, arthritis in ankles

"anaphylactoid purpura" characterized by 2- to 10-mm erythematous hemorrhagic papules in a symmetric acral distribution, over the buttocks, and extremities  à palpable purpura



How is Henoch-Schonlein prupura Dx'ed? What are some DDx?

—Urinalysis, which may be positive for blood or protein in 50% of the patients (other labs usually normal)

DDx: drug reactions, erythema multiforme, urticaria, and even physical abuse, other causes of purpura such as bleeding disorders, and/or infection (meningococcemia)



What are some complications of Henoch-Schonlein purpura? How are these patients managed?

Renal involvement is the most frequent and serious complication, usually acute glomerulonephritis. Hypertension is uncommon

Usually managed as outpatients. Severe abdominal pain, gastrointestinal hemorrhage, intussusception, and severe renal involvement are indications for admission.


Name 11 different structural pathologies/murmurs in kids, and where to auscultate for them.


What are some normal variants of heart rhythms in pedes? Name ages, correlation with respiration, effect of exercise on tachycardia, rhythm characteristics, and severity.


What is a closing ductus murmur? Where is it located, and what ages get them?

Common benign murmurs in children

Low pitched (non-turbulent, not high velocity)


Transient, soft, ejection

Location: upper left sternal border




Explain the characteristics of a periphery pulmonary flow murmur.

Newborn to 1 year

Soft, slightly ejectile, systolic

Location: to the left of upper left sternal border & in lung fields & axillae upper left sternal border.

High pitched - best heard with the diaphragm

Also seen in adolescents or in children with pectus excavatum.

Prominent in high-flow situations, such as when a child has a fever or is anemic


What is a Still's murmur? What are the characteristics?

Older child

Still’s: low-pitched sounds heard at the lower left sternal area, “musical.” These most commonly occur between age 3 and adolescence.

Low pitched - best heard with the bell of the stethoscope.

Can change with alteration of position and then can decrease or disappear with the Valsalva maneuver.

No clicks are present


What is a venous hum?

Low pitched (non-turbulent, not high velocity)

Venous hum: low-pitched continuous murmurs made by blood returning from the great veins to the heart - bell


What is a PDA? What types of patients are they more common in?

—Failure of closure of ductus arteriosus within a few days after birth


—More common in premature infants, neonatal respiratory distress, infants w/ genetic d/o (such as Down syndrome) & those w/ congenital heart lesions

Premature infants closure up to 2 years

Full term infants closure rarely after first week of life w/o intervention


What are the symptoms of a PDA? How is it treated?

—Small PDAs usu. asymptomatic

—Large PDAs:

◦Bounding pulse, murmur


◦Poor feeding habits

◦Shortness of breath

◦Sweating while feeding

◦Tiring very easily

◦Poor growth

Tx: Indomethacin or surgery



What is the physiology behind pathological heart murmurs in kids?

Changes in pulm vascular resistance

Obstructive lesions

Pressure gradient differences

Changes associated with growht


What types of murmurs cause a change in pulm vascular resistance? When do they become audible?

—Changes in pulmonary vascular resistance


◦Audible 7-10 days after birth


What murmurs can cause an obstructive lesion? When are they audible?

—Obstructive lesions

◦Pulmonic & aortic stenosis

◦Coarctation of the aorta

◦Audible at birth


What murmurs can cause pressure gradient differences? When are they audible?

—Pressure gradient differences

◦Atrioventricular valve regurgitation

Audible at birth


What structural problems can manifest as murmurs? Why are they associated with growth?

Changes associated with growth

Due to alterations in normal blood flow & occur or change w/ growth

Aortic stenosis (obstructive) but not often seen until considerable growth has occurred

Pulmonary flow murmur of ASD


When is aortic stenosis often noticed?

Often not seen until adulthood; despite congenital cause


Why does ASD cause a murmur? When is it usually heard?

Pulmonary flow murmur of ASD

Right ventricular compliance gradually increases & shunt becomes larger 

Resulting in too much blood flow across normal pulmonary valve


May not be heard for a year or more


What is hypertrophic cardiomyopathy? 

—Asymmetrical thickening of left ventricle

◦Causing increase work on heart to pump


—Younger people are likely to have a more severe form


What are the SSXs of hypertrophic cardiomyopathy?

◦Chest pain


◦Fainting, especially during exercise

◦Heart failure (in some patients)

◦High blood pressure

◦Light-headedness, especially with or after activity or exercise


◦Shortness of breath

Sudden collapse/death occurs due to arrhythmia or blockage of blood flow


What makes up the tetralogy of fallot?

—5 T’s:  

◦Tetralogy of Fallot

  1. VSD

  2. Overriding aorta

  3. RV outflow obstruction

  4. RV hypertrophy


In addition to ToF, what else causes 'blue babies'?

Cyanotic Congenital Heart Disease

—5 T’s:  

◦Tetralogy of Fallot

◦Transposition of the Great Arteries


◦Truncus arteriosus

◦Tricuspid Atresia


What are the SSXs of Neonatal Respiratory Distress Syndrome?

—Sx: (seen within minutes to a few hours after birth)



◦Decreased urine output

◦Grunting, nasal flaring

◦Puffy or swollen arms or legs

◦Rapid breathing &/or shortness of breath


What is the cause of RDS in neonates?

Most common complication seen in premature infants that affects breathing

Due to lack of surfactant

Most cases seen in premies <28 weeks



What increases the risk of neonatal RDS?

Increased risks of RDS:

A brother or sister who had RDS

Diabetes in the mother

Cesarean delivery

Delivery complications that lead to acidosis in the newborn at birth

Multiple pregnancy (twins or more)

Rapid labor


What does neonatal RDS look like on CXR? Tx?

—CXR: ground glass appearance

—Tx: surfactant, intubation or CPAP


How many colds do children get a year, on average? What is the role of daycare?

—Children younger than six years have an average of six to eight colds per year (up to one per month, September through April), with a typical symptom duration of 14 days

—Young children in daycare appear to have more colds than children cared for at home. However, when they enter primary school, children who attended daycare are less vulnerable to colds than those who did not.

—Older children and adults have an average of two to four colds per year, with a typical symptom duration of five to seven days

—Acute, self-limiting viral syndrome of the upper respiratory tract


What are the Sx of an average URI?

—Symptoms: rhinorrhea, congestion, sneezing, and may include fever


What are the Sx's of acute OM? What causes it?

Fever, otalgia, cough, rhinorrhea

May be a complication of URI



  Bacterial: Strep pneumoniae, Moraxella catarrhalis, H. flu nontypables


What is the Tx of acute OM?

First line: amoxicillin (high dose = 80-90 mg/kg/day)

  Second line: amoxicillin-clavulinic acid (Augmentin) or second generation cephalosporin


How is sinusitis dx'ed?

—Diagnosis is based on:

  1. Persistence of nasal discharge: if the child has a very congested and/or runny nose for 10 days without improvement, especially when it is associated with a daytime cough (may also have a night cough)

2. Severe symptoms: if the child has a high fever (over 39 C, which is 102.2 F) for 72 hours or has a high fever and is not eating or drinking and is difficult to calm

3. Worsening symptoms: A child's cold got better and then in a day or two the child is suddenly much more ill with a fever and/or pus-filled nasal discharge


What is croup? What is it the most common cause of?

—Aka laryngotracheobronchitis

—Steeple sign ◦ Subglottic narrowing of trachea

—Most common cause of inspiratory stridor in peds

—Viral in origin


What are the Sx and Tx of croup?


◦Coryza 1-2d prior to croupy cough, hoarseness, & stridor

—Tx: if severe, inhaled epinephrine & oral steroids


What is bacterial tracheitis?

—Invasive exudative bacterial infection of the soft tissues of the trachea

—“Acute bacterial laryngotracheobronchitis” – with similarities to croup but worse


What are the pathogens that cause bacterial tracheitis?

◦Bacterial: Staphylococcus aureus, Streptococcus pneumoniae, gram-negative enteric bacteria, Pseudomonas aeruginosa

◦Predisposing viral infections with: influenza A, influenza B, respiratory syncytial virus (RSV), parainfluenza virus, measles, and enterovirus


What viruses can cause acute pharyngitis?

◦CMV, adenoviruses, HSV, influenza viruses, and enterovirus, EBV


How is EBV pharyngitis treated? tested for?


–Monospot testing is not accurate under 4-5 years of age or before 2nd week of illness

–remember it has a really long incubation period

–Exudative pharyngitis is accompanied by fever, generalized adenopathy, hepatosplenomegaly, heterophile antibodies

–Sometimes treated with steroids


What bacteria cause acute pharyngitis in kids? How common is it?

—Group A beta hemolytic streptococcus

15 to 30 percent of all cases of pharyngitis in children between the ages of 5 and 15 years

◦Peaks during the winter and early spring

◦Rapid strep in office, back up culture


—Other bacterial pathogens

◦Group C and group G strep: acute rheumatic fever is not a complication of infection due to these organisms

Arcanobacterium hemolyticum

◦Corynebacterium diphtheriae



What is the typical Hx of strep pharyngitis?


◦Typically has an abrupt onset of symptoms

◦Typically the school aged child

Sore throat



GI symptoms: abdominal pain, nausea, and vomiting

◦Poor oral intake

NO cough or rhinorrhea!!  Aka, no viral symptoms ( coryza, conjunctivitis, hoarseness, anterior stomatitis, discrete ulcerative lesions or vesicles).


What are the typical PE findings for strep pharyngitis?


Exudative pharyngitis or erythema of posterior orophayngeal mucosa

◦Enlarged tender anterior cervical lymph nodes

◦Palatal petechiae

◦Inflamed uvula

Scarlatiniform rash

◦Pastia’s lines


How is strep pharyngitis worked up?

Work Up:

Rapid strep with back up culture if negative

-How can you possibly get a sample?? 

-Use two swabs at once; double tongue depressor for stronger kids, have smaller child pant like a puppy dog

-Wear a mask because you’ll probably get coughed on


What is the most common deep neck infection in kids?

◦Peritonsillar abscess

–Most common deep neck infection in children and adolescents, accounting for at least 50 percent of cases – can be a complication of strep pharyngitis


What are the Sxs of peritonsillar abscess?


–Severe sore throat (usually unilateral)


–“Hot potato" or muffled voice

–Pooling of saliva or drooling may be present


–neck swelling and pain


What is the Tx of peritonsillar abscess?

needle aspiration:

antimicrobial therapy (amoxicillin/clavulinic, cephalosporins, and clindamycin),

and supportive care (hydration, analgesia)


What population are retropharyngeal abscesses more common in?

◦Retropharyngeal abscess

  Most commonly in young children between the ages of two and four years


What are the Sxs of retropharyngeal abscess?

–Difficulty swallowing (dysphagia)

–pain with swallowing (odynophagia)

–drooling with decreased oral intake

–Unwillingness to move the neck secondary to pain (torticollis), particularly unwillingness to extend the neck

–"hot potato" quality [dysphonia]

–Gurgling sound, or stertor (snoring sound)

–Respiratory distress (stridor, tachypnea, or both); stridor develops as disease progresses

–Neck swelling, mass, or lymphadenopathy

Trismus (in approximately 20 percent


What is RSV? Who does it affect?

—Respiratory virus affecting nasal passages and lungs

—Almost all children will be infected by 2 years of age

—Recovery within 1-2 weeks of infection

—May be severe in premature or very young infants


What are the risk factors for severe RSV disease?

–young age

–preterm birth (specific guidelines for immunization with Synagis = palivizumab)

–low birth weight

–chronic pulmonary disease

–cyanotic or complicated cardiac disease

–neurologic disease

–immunodeficiency or immunosuppression

–congenital defects of the airway


What is the most common cause of bronchiolitis? What are some additional causes?

—RSV is the most common cause of bronchiolitis

◦Inflammation of small airways of lung

◦Other causes of bronchiolitis include: rhinovirus, parainfluenza, influenza, human metapneumovirus, and adenovirus

◦Seen most often in fall, winter & early spring


What is an important cause of chronic cough in toddlers? What are the SSXs associated with it?

Foreign Body

—Important cause of chronic cough in toddler



–Unilateral purulent drainage

–Foul smelling


◦Lower respiratory tract

–DDx: recurrent viral infections and asthma

–PE and CXR may be unrevealing


When does gastroesophageal reflux (GER) often begin? What are the Sx's?

—Often begins in infancy



◦Poor weight gain

◦Substernal CP

◦Abd pain




How can GER be dx'ed? What is the Tx?

—Dx often based on clinic sx only


◦Upper GI (r/o other abn.)

◦24 hr esophageal pH probe



◦Dec. feedings, positioning

◦Acid suppressive meds



What does rotavirus cause? What is the course of the disease like?

—Rotavirus causes viral gastroenteritis

◦Most common cause of diarrhea in young children throughout the world

◦Normally self-limiting but can cause severe dehydration

◦Sx: fever, vomiting, diarrhea

◦Highly contagious, lasting 3-9 days


How is diarrhea in infants prevented?

Usually, it's a sisyphean effort 


—Rotavirus vaccination in early infancy

◦Rotateq 3 dose series

◦Rotarix 2 dose series


What are the potential dangers of esophageal foreign bodies?

aspiration or ingestion


When are esophageal foreign bodies an emergency?

Tracheal or esophageal – how can you tell?

Urgent or emergent intervention:

When the object is sharp, long, or consists of magnets  

When the object is a disk battery in the esophagus

If airway compromise, such as tracheal compression, is present

If there is evidence of esophageal obstruction (eg, the patient is unable to swallow secretions)

If there are signs or symptoms suggesting inflammation or intestinal obstruction (fever, abdominal pain, or vomiting)

If the object is in the esophagus and the suspected ingestion occurred 24 or more hours prior to the evaluation, or if the time of ingestion is unknown


What is a buried penis in neonates?


Result of thick suprapubic fat

Resolve as infant grows


How common is hypospadias? When should it be treated?

—1:250 male births

—Infants should not be circumcised

◦Dorsal preputial skin may be need repair

—Repair usu.  at 6 months of age


What are labial adhesions? What problems can it cause?

—Common in prepubertal age group

—Fusion of labia minora

—inflammation of thin labial mucosa that adheres in midline

—Severe fusion may result in dysuria& urinary problems including UTIs


How are labial adhesions Tx'ed?


—Tx: mechanical separation then petroleum ointment to diminish irritation

◦estrogen creams (Premarin)


What is vesicoureteral reflux (VUR)?


—Normal valve mechanics of uretervesicular jxn is impaired

—Reflux from bladder to ureter or kidney


How are VURs graded? Treated?

—Grades I to III high rate of spontaneous resolution, grades go up to 5

—Suppressive Abx



How are UTIs dx'ed in children?


—Don’t trust a culture from a bag urine sample!!

—Catheterized sample only in infants

—Clean catch if potty trained