What is a normal growth rate for kids between 3 yo and puberty?
2 inches per year
What are two subsets of pathologic short stature?
Proportionate (normal U/L ratio) and disproportionate (abnormal U/L ratio)
What are the two main causes of disproportionate short stature?
Ricket’s and congenital skeletal dysplasias
What tests should be initiated for pathologic short stature?
CBC, ESR, T4, serum Ca/PO4, IGF-1. X-ray imaging.
What are some causes of growth hormone deficiency?
Brain tumors (craniopharyngioma), autoimmune, trauma, CNS defects
How is precocious puberty defined?
Girls: breast development/pubic hair before 7 yrs, menarche before 9 yrs
Boys: testicular changes, penile enlargement, pubic hair before 9 yrs
What are the two main categories of precocicous puberty and how are they different?
Central: early activation of hypothalamus, leads to high FSH/LH, high sex steroids
Peripheral: high sex steroids w/o activation of hypothalamus, no response to GnRH stimulation testing, INDEPENDENT OF HPGA
What are two categories of delayed puberty?
Hypogonadotropic hypogonadism (low LH/FSH) Hypergonadotropic hypogonadism (high LH/FSH)
How do the two male fetal hormones cause male sexual differentiation?
Testosterone (by Leydig): development of wolffian ducts, DHT stimulates masculinization of male genitalia
Anti-mullerian hormone (by Sertoli): inhibits development of the mullerian (female) structure
What is the difference between Cushing syndrome and Cushing disease?
Both are causes of hypercortisolism. Cushing syndrome occurs with adrenal tumors. Cushing disease occurs with pituitary tumors (excessive ACTH). Test with a dexamethasone suppresion test.
What distinguishes hypercortisolism from obesity?
Hypercortisolism has growth impairment and delayed bone age, whereas obesity has normal to fast growth and advanced bone age.
What two haplotypes and what antibody are associated with Type I diabetes?
DR3 or DR4 and Islet cell antibodies
Why do Type 1 diabetics see a “honeymoon” period (reduction in insulin reqs)?
Transient recovery of residual islet cell function, resulting in endogenous release of insulin
How is the Somogyi phenomenon treated with Type 1 diabetics?
Somogyi - large nighttime dose of insulin causes AM hypoglycemia and subsequent endogenous AM glucose production/release, leading to high blood glucose.
Tx: REDUCE nighttime dose of insulin
How is diabetic ketoacidosis (DKA) defined?
Hyperglycemia > 200mg/dL, serum bicarbonate level < 7.30
What are common lab findings in DKA, and how is it treated?
Anion gap metabolic acidosis, hyperglycemia/glucosuria, ketonemia/ketonuria, hyperkalemia
Tx: fluid/electrolyte therapy w/ isotonic saline, gradual decline in osmolarity (to prevent cerebral edema), potassium repletion, regular insulin
What are three signs of hypothyroidism?
- ) Subotimal growth velocity
- ) Goiter
- ) Myxedema
What are four etiologies of congenital hypothyroidism?
- ) Thyroid dysgenesis
- ) Thyroid dyshormonogenesis
- ) PTU during pregnancy
- ) Maternal AI thyroid disease
What are two lab tests conducted for the two autoimmune thyroid disorders?
TSH/T4
Hashimoto’s: high TSH, low T4
Graves: low TSH, high T4
Tetany and seizures along with a prolonged QT interval can signal what endocrine disorder?
Hypocalcemia
What are risk factors for the disease that is caused by a deficiency of Vitamin D?
Rickets. Risk factors include exclusively breast-fed infants with minimal sunlight, anticonvulsants, renal/hepatic failure
What are three forms of Rickets and what is the most common form?
Vitamin-D dependent (enzyme deficiency)
Vitamin-D resistant (most common, renal tubular phosphorus leak, typical bowing of legs)
Oncogenous (bone pain/myopathy)
Diabetes insipidus is characterized by an insufficiency or unresponsiveness to what hormone? And how does it present?
Anti-diuretic hormone. Central DI = lack of ADH. Peripheral DI = unresponsiveness.
Hypernatremic dehydration and inappropriately dilute urine (remember, DI = inability to concentrate urine). Give DDAVP.
What four etiologies must be considered on the differential for hypoglycemia
Ketotic hypoglycemia, ingestions, inborn errors of metabolism, hyperinsulism
What is the epidemiology of fever in infants <3 months?
3-10% of well-appearing infants, 17% of toxic-appearing infants have serious bacterial infections
What criteria are used to hospitalize infants between 1 and 3 months that present with a fever?
Infants 1-3 months should be hospitalized if they have any of the following:
- ) toxic appearance
- ) suspected meningitis
- ) pneumonia, pyelonephritis, bone/soft tissue infections
- ) uncertain outpatient care and follow-up
What are two common causes of fever in children 3-36 months?
- ) Strep pneumoniae (most common)
2. ) H. flu type B (HIB)
When is the highest incidence of bacterial meningitis?
During the first month of life
What are some clinical features of bacterial meningitis?
Bulging fontanelle (infants), alteration in consciousness, nichal rigidity (Kernig and Brudzinski signs), seizures, photophobia, emesis
What is the empiric treatment of bacterial meningitis?
Antibiotics, corticosteroids (to reduce risk of hearing loss)\
A patient that presents with low-grade fever, rhinorrhea, cough and sore throat likely has…
Viral URI
What are the three most common etiologies of sinusitis? (3 bugs)
Strep pneumoniae, H. flu, M. catrrhalis (look for nasal discharge AND cough, with headache and low-grade fever)
What are common viral and bacterial etiologies of pharyngitis?
Viral: similar as URI (rhino, parainflu, corona, RSV)
Bacterial: Group A strep (STREP THROAT)
What distinguishes bacterial from viral pharyngitis?
Lack of URI symptoms, fever, scarlatiniform rash (scarlet fever)
What are the three cardinal symptoms of otitis media? And the one sign needed to dx?
Fever, ear pain, decreased hearing. Identification on fluid in the middle ear space. Treat with amoxicillin
What is the difference between unilateral and bilateral parotitis?
Unilateral: bacterial (staph, strep, myco tuber)
Bilateral: MUMPS
What are four complications of GABHS infections?
- ) glomerulonephritis
- ) rheuamatic fever
- ) post-streptococcal arthritis
- ) PANDAS
What are some classic symptoms of infectious mono?
Fever, malaise, pharyngitis, posterior cervical lymphadenopathy, hepatosplenomegaly
What are some compications to be aware of for infectious mono?
Neurologic complications Upper airway obstruction Amoxicillin-associated rash (GABHS mis-diagnosis) Splenic rupture Malignancy
I say measles. You think:
3 C's: cough, coryza, conjunctivitis Koplik spot (gray papules on buccal mucosa)
There are three common innocent heart murmurs. What are they, where are they heard and what are their characteristics?
- ) Still’s murmur: LLSB, thought to be LVOF, twanging/vibratory
- ) Pulmonic systolic murmur: ULSB, blowing, high-pitched
- ) Venous hum: turbulence at junction of R jugular and subclavian veins, disappears if supine, changes with neck flexion/extension
How and why is acyanotic congenital heart disease treated?
Closure by heart surgery to prevent right-sided heart failure, pulmonary HTN, atrial dysrhythmia and paradoxic embolism.
Why are ASDs, VSDs, PDAs, coarctations and aortic and pulmonic stenoses considered acyanotic?
There is left to right blood flow, so there is no admixture of deoxygenated blood into the systemic circulation.
What providees perfusion of the lower abdomen and descending aorta in the setting of severe coarctation?
A patent PDA. Symptoms of CHF develop and progress as the PDA closes. The PDA can be maintained with prostaglandin E (PGE).
Where are peripheral and central cyanosis visualized?
Peripheral = vasomotor instability, vasoconstriction (cold temperature) Central = tongue and inner mucous membranes, cardiac and non-cardiac causes
What are the five most common causes of central cyanotic congential heart disease?
Tetralogy of Fallot (look for a squat)
Transposition (requires site of mixing)
Tricuspid atresia (ASD/PFO is always present, tx with Fontan procedure)
Truncus arteriosus
Total anomalous pulmonary venous connection (PV goes to systemic circulation, O2 blood is just recycled)
What group of bacteria are most commonly responsible for bacterial endocarditis?
Gram-positive cocci
What is the most common cause of pericarditis in children?
Viral infection
However, purulent pericarditis is most commonly caused by bacterial infection and can lead to tamponade
What are the three types of cardiomyopathy in children?
Dilated Hypertrophic (assymetric hypertrophic septum, autosomal dominant) Restrictive (amyloidosis, infiltrative disorders)
What are the two types of SVT, which is the most common dysrhythmia of childhood?
AVRT: retrograde conduction through an accessory pathway leads to SVT
AVNRT: cyclical conduction within the AV node itself
What are the five categories of chest pain etiologies?
Cardiac (pericarditis) Gastrointestinal (GERD) Respiratory Musculoskeletal Psychological
How will a case of HIB or GABHS epiglottitis present?
High fever
Muffled speech
Dysphagia
Sitting forward in tripod position
What are the two forms of croup (inflammation and edema of subglottic space)?
Viral croup (most common cause of stridor, M:F 2:1)
Spasmodic (caused by hypersensitivity to antigen)
tx: cool mist
What is the difference between bronchiolitis and pneumonia?
Bronchiolitis is inflammation of the bronchioles themselves, whereas pneumonia is inflammation of the lung parenchyma.
Pertussis is characterized by 3 stages. What are they?
- ) Catarrhal stage (1-2 wks)
- ) Paroxysmal stage (2-4 wks)
- ) Convalescent stage (wks to mos)
What long-term sequelae of RDS leads to oxygen dependency beyond 28 days of life?
Chronic Lung Disease (CLD) or Bronchopulmonary Dysplasia (BPD). Note that symptoms of CLD diminish over time.
What should always be considered for a child 3mo-5yrs with chronic respiratory problems?
Foreign body aspiration
Short gut syndrome, which can be caused congenitally or iatrogenically, manifests with what symptoms?
Steatorrhea, dehydration, hyponatremia, hypokalemia. Tx: TPN
What is the primary caused of GERD in childhood, and what else plays a role?
Transient Lower Esophagesal Sphincter Relaxation (TLESR) and gastric emptying delay.
What is the gold standard for diagnosis of GERD?
pH probe measurement. Continuous monitoring for at least 18 hours, and results are correlated with clinical presentation.
How can GERD be treated?
- ) Positioning, thickening of feeds, acid inhibition
- ) Motility agent (increase gastric emptying): metoclopramide
- ) Surgery
What are five obstructive GI disorders (which all have male predominance) that can result in vomiting?
Hypertrophic pyloric stenosis (first-born white males, nonbilious, PROJECTILE)
Malrotation (bilious, sudden onset of pain)
Atresia (duodenal = double bubble, jejunal)
Intussusception (ileocolic, coil spring on contrast enema)
Hirschsprung’s
What’s the difference between the two types of malnutrition, marasmus and kwashiorkor?
Marasmus - low-energy intake and all types of energy deficiency, occurs <1yo
Kwashiorkor - normal energy intake but low protein, leads to edema
What is the course of symptoms when a child of 10-12 years presents with acute abdominal pain?
Pain first (peri-umbilical then RLQ), then vomiting, then fever. Perforation occurs in 36-48 hours without treatment
Though pancreatitis is uncommon in children, what are the two most common causes?
1.) Trauma
2.) Idiopathic
Look for Gray-Turner or Cullen signs (bluish discolorations), elevated serum amylase/lipase
Acute cholecystitis, which presents with RUQ pain and Murphy’s sign, is predisposed by what three conditions?
Sickle cell disease, cystic fibrosis or prolonged TPN therapy.
When a child presents with constipation or encopresis, what should you think of first?
Functional causes.
Organic causes include Hirschsprung’s, low-fiber, systemic disease (dehydration, hypothyroidism, CF)
How are the two main types of IBD (UC and Crohn’s) diagnosed and managed?
- ) Dx: labs, stool studies, US/CT, biopsy
2. ) Tx: Sulfasalazine, corticosteroids, immunosuppressives, metronidazole
How is occult blood in the stool identified?
Positive guaiac testing, which tests for the peroxidase activity of hemoglobin
How does age help in diagnosing the etiology of newborns?
Newborn: necrotizing enterocolitis
Beyond infancy: juvenile polyps (most common!)
When evaluating hepatic injury/disease, what three hepatocellular and two biliary enzymes should you evaluate?
HC: 1.) AST, ALT, LDH
Biliary: 1.) alkaline phosphatase 2.) GGTP and 5NT
Elevation of what suggests cholestatic disease, and what differential is generated?
Prolonged elevation of direct bilirubin.
Etiologies: infections, metabolic derangements, extra/intrahepatic obstructions, A1AT
What are three common cholestatic diseases of infancy?
- ) neonatal hepatitis: idiopathic hepatic inflammation, tx: urso
- ) biliary atresia: progressive fibrosclerotic disease, polysplenia,tx: re-establish bile flow
- ) Alagille syndrome: paucity of intrahepatic bile ducts, pruritis, multiorgan involvement
What are the two most common viral hepatitis agents?
- ) HepA: fecal-oral, most common, 2-6 wk incubation, mostly asymptomatic, IgM and ALT rise first then IgG
- ) HepB: blood/vertical exposure, long incubation, rare symptoms, look at surface antigen/Ab, e antigen/Ab, core Ab IgM/IgG
How are the two types autoimmune hepatitis identified?
Type 1: ANA or ASMA (anti-smooth muscle antibody)
Type 2: anti-liver antibodies
In both cases, look for elevated serum transaminases, hyperIgG, circulating autoantibodies