Pediatrics Flashcards
(301 cards)
1
Q
At delivery, give newborns…
A
- 1% silver nitrate or 0.5 erythromycin ophthalmic ointment
- 1mg of Vitamin K to prevent hemorrhagic disease
2
Q
Before discharge, one should do the following:
A
- Perform hearing tests to r/o congenital sensorineural hearing loss
- Order neonatal screening tests
3
Q
Neonatal screening tests
A
- Phenylketonuria
- Galactosemia
- Hypothyroidism
- best done after 48 hrs
4
Q
APGAR Score
A
- measure of the need and effectiveness of resuscitation
- 1 minute score gives idea of what was going on during labor and delivery
- 5 minute score gives an idea of response to therapy
5
Q
Mongolian Spots
A
- blue/gray macules on presacral back/posterior thighs
- usually fade in first few years
- must r/o child abuse
6
Q
Erythema toxicum
A
- firm, yellow white papules/pustules with erythematous base, which peak on 2nd day of life
- usually self limited
7
Q
Port wine stain (Nevus flamus)
A
- permament, unilateral vascular malformation on head and neck
- associated with Sturge Weber syndrome (AV malformation results in seizures, mental retardation and glaucoma
- can give pulsed labor therapy
- If Sturge Webser, evaluate for glaucoma and give anticonvulsives
8
Q
Hemangioma
A
- red sharply demarcated raised lesions appearing in first 2 months, rapidly expanding then involuting by 5-9 yrs
- consider underlying organ involvement with deep hemangiomas
- if it involves larynx, can cause obstruction
- may cause high cardiac output when large
9
Q
Tx of hemangioma
A
- treat with steroids or pulsed laser therapy if large or intereferes with organ function
10
Q
Periauricular tags/pits
A
- associated with hearing loss
- genitourinary abnormalities
- further evaluate with hearing test and U/S of kidneys
11
Q
Coloboma of the iris
A
- defect in the iris
- associated with CHARGE syndrome
- make sure to screen for CHARGE syndrome
12
Q
CHARGE syndrome
A
- Colonoma
- Heart defects
- Atresia of the nasal choanae, growth
- Retardation
- Genitourinary abnormalities
- Ear abnormalties
13
Q
Aniridia
A
- absence of the iris
- associated with Wilms’ tumor
- screen for Wilms’ tumor with abdominal U/S q3 months until age 8
14
Q
Branchial cleft cyst
A
- mass lateral to midline
- remnnt of embryonic development associated with infxns
- tx with surgical removal
15
Q
Thyroglossal duct cyst
A
- mass midline that moves with swallowing
- associated with infections
- may have thyroid ectopia
- tx with surgical removal
16
Q
Omphalocele
A
- GI tract protrusion through umbilicus WITH sac
- caused by failure of GI sac to retract at 10-12 weeks
- associated with malformations and chromosomal disorders
- screen for trisomies 13, 18, and 21
17
Q
Gastrochisis
A
- abdominal defect lateral to midline WITHOUT sac
- associated with intestinal atresia
18
Q
Umbilical hernia
A
- congenital weakness where vessels of fetal and infant umbilical cord exited through rectus abdominal muscle
- associated with congenital hypothyroidism
- screen with TSH
- may close spontaneously (usually by 2)
19
Q
Hydrocele
A
- scrotal swelling, transillumination
- associated with inguinal hernia
- must differentiate from inguinal hernia
20
Q
Undescended testes
A
- unilateral absences in scrotal sac
- associated with malignancy if > 1 yr of age
- tx with surgical removal
21
Q
Hypospadias
A
- urethral opening on ventral surface
- associated with other GU abnormalities (MCC is undescended testes and inguinal hernia)
- DO NOT CIRCUMCISE
22
Q
Epispadias
A
- urethral opening on DORSAL side of penis
- associated with urinary incontinence (form of urinary exstrophy)
- tx with surgical evaluation for bladder exstrophy
23
Q
Inguinal hernia
A
- usually indirect
- inguinal bulge or reducible scrotal swelling
- tx with surgery
24
Q
Pt is 9.5lb newborn who is jittery. Pregnancy complicated by prolonged delivery w/ shoulder dystocia. PE shows large plethoric infant who is tremulous. Pan-systolic murmur is heard. What’s most appropriate diagnostic test?
A
Blood glucose
- Child is likely infant of diabetic mother
25
Newborns of diabetic mothers
- Look for macrosomia (enlarged organs)
- Hx of birth trauma and cardiac abnormalities
- tx with glucose and small, frequent meals
26
Lab abnormalities: infant of diabetic mother (IODM)
- Hypoglycemia (after birth)
- Hypocalcemia
- Hypomagnesmia
- Hyperbilirubinemia
- Polycythemia
27
IODM associated with which cardiac and GI abnormalities?
- ASD
- VSD
- Truncus arteriosus
- Small left colon syndrome (abdominal distention)
28
IODM is associated with what risks for child?
Increased risk of developing diabetes and childhood obesity
29
Newborn is in respiratory distress. Best initial therapy?
Chest X-ray
30
Other diagnositic tests to consider in newborn in resp distress?
- ABG
- Blood cx (r/o sepsis)
- Blood glucose (r/o hypoglycemia)
- CBC (r/o anemia or polycythemia)
- Cranial U/S (intracranial hemorrhage)
31
Best initial treatment for newborn in respiratory distress?
- Oxygen: keep SpO2 > 95%
- Give nasal CPAP if high oxygen requirements to prevent barotrauma and bronchopulmonary dysplasia
- Consider empiric abx for suspected sepsis
32
If newborn in respiratory distress is still hypoxic with oxygen therapy, next cause?
Evaluate for cardiac causes
33
Clinical fx of premature neonate in respiratory distress
- Tachypnea
- Nasal grunting
- Intercostal retraction within hours of birth
- HYPOXEMIA
- Eventually hypercarbia and respiratory acidosis develop
34
Best initial diagnositc test for newborns in respiratory distress?
CXR: ground glass appearance, atelectasisa, air bronchograms
35
Most accurate test for respiratory distress :
Lecithin-sphingomyelin (L/S) ration on amniotic fluid prior to birth
36
Best initial treatments for newborn in respiratory distress?
Oxygen and nasal CPAP
37
Most effective treatment for newborn in respiratory distress?
Exogenous surfactant adminitstration (proven to decrease mortality)
38
Primary prevention of newborn RDS
- Antenatal betamethasone: most effective if > 24 hrs before delivery and < 34 gestations
- Avoid prematurity: give tocolytics
- Postnatal corticosteroids do not help and are not indicated
39
Complications of newborn RDS
- Retinopathy of prematurity 2/2 hypoxemia
- Bronchopulmonary dysplasia 2/2 prolonged high-concentration oxygen
- Intraventricular hemorrhage
40
If fetus is in danger of preterm delivery < 34 weeks, next step?
Give corticosteroids
41
Transient Tachypnea of the Newborn (TTN)
- presents as tachypnea after a term birth of infant delivered by Cesarean section or rapid second stage of labor
42
Diagnostic test for TTN
Perform CXR to look for:
- air trapping
- fluid in fissurs
- perihilar streaking
43
Best initial treatment for TTN
Oxygen (minimal requirements need) results in rapid imporovement within hours to days
44
Birth weight
- normally doubles by 6 months
| - triples by 1 year
45
Height percentile
- at 2 years of age normally correlates with final adult height
46
Best indicator for acute malnutrition
Weight/height < 5th percentile
47
Best indicator for under- or overweight
BMI
48
Skeletal maturity
- correlates with sexual maturity (less related to chronological age)
49
Most common cause of failure to thrive in all age groups
Psychosocial deprivation
50
Ddx: Low weight gain >> Low length/height
- Undernutririon
- Inadequate digestion
- Malabsorption (infxn, celiac disease, cystic fibrosis, disaccharide deficiency, protein-losing enteropathy)
51
Workup: low weight gain >> decreased length height
- Assess caloric intake
- Perform stool studies for fat
- Perform sweat chloride test
52
Ddx:
| Normal weight Low length/height
- Growth hormone or thyroid hormone deficiency
- Excessive cortisol secretion
- Skeletal dysplasia
53
Workup: for normal weight, low length/height
-Growth hormone deficiency
- IGF-1 and IGF-binding protein
Thyroid hormone
- TSH, free T4, free T3
Cushings
- 24 hr urinary cortisol or free cortisol
Bone age (X-ray of hand and wrist)
- Skeletal dysplasia: no delay in bone age and disproportionate bone length on exam
54
Meconium aspiration
- severe respiratory distress and hypotexmia and TERM neonate with hypoxia or fetal distress in utero
55
Meconium aspiration: Diagnosis
```
Chest X Ray
Look for:
- patchy infiltrates
- increased AP diameter
- flattening of diaphragm
```
56
Meconium aspiration: treatment
- Positive pressure ventilation
- High frequency ventilation
- Nitric oxide therapy
- Extracorporeal membrane oxygenation
57
Meconium aspiration: prevention
Endotracheal intubation and airway suction for depressed infants
58
Possible complictations of meconium aspiration
- Pulmonary artery hypertension
- Air leak (pneumothorax, pneumomediastinum)
- Aspiration pneumonitis
59
Diaphragmatic Hernia
severe respiatory distress and scaphoid abdomen (distress related to pulmonary hypoplasia)
60
Diaphragmatic Hernia: Diagnostic Testing
Chest X-ray
| - look for loops of bowel visible in the chest
61
Diagphramatic Hernia: Treatment
Immediate intubation (may require extramembrane corporeal oxygenation), followed by surgical correction
62
Meconium plugs
presents initially as intestial obstruction
63
Meconium plugs associated with the following conditions
- Small left colon in IODM
- Hirschsprung disease
- Cystic fibrosis
- Maternal drug abuse
64
Meconium ileus: associated w/ which conditions?
Cystic fibrosis
65
Best diagnotic test for meconium plug or meconium ileus
Abdominal X-ray
66
Meconium plug/ileus: treatment
Gastrografin enema
67
Newborn is born by normal vaginal delivery w/o complications. There is no RDS. Upon first feed, he is noted to have prominent drooling: he gags and develops RDS. CXR shows infiltrate on the lung. Which of the following best confirms the diagnosis?
Nasogastric tube placement
| - Pt has tracheoesophageal fistula
68
Premature infant is born by normal vaginal delivery w/o complications. There is no RDS. Upon her first feed, she begins vomiting gastric and bilious material. CXR show "double bubble. Most likely diagnosis?
Duodenal atresia
- associated w/ Downs syndrome
- treat w/ nasogastric decompression and surgical correction
69
VACTERL abnormalities
```
Vertebral defects
Anal atresia
Cardiac abnormalities
Tracheoesophageal fistula
Radial and renal anomalities
Limb Syndrome
```
70
Ddx: Double bouble seen on CXR
- Duodenal atresia
- Annular pancreas
- Malrotation
- Volvulus
71
Necrotizing Enterocolitis
- premature infant with low APGAR scores, bloody stools, apnea, and lethargy when feeding is started
- abdominal wall erythema and distention are signs of ischema
72
Best initial test for necrotizing enterocolitis?
Abdominal X-ray
| ** pneumatosis intestinalis is pathognomonic
73
Intial therapy for necrotizing enterocolitis
- Stop all feeds
- Decompress the gut
- Begin broad spectrum abx
- Evaluate for surgical resection
74
Best initial test if infant fails to pass meconium
Rectal exam
75
Newborn fails to pass meconium on own however with DRE, patient passes large volume of stool. Suspected dx?
Hirschsprung
76
If newborn fails to pass meconium. How should one proceed?q
1. Digital rectal exam
2. Barium enema (look for megacolon proximal to obstruction)
3. Rectal biopsy
77
Best confirmatory test for Hirschsprung disease
Rectal biopsy ( tlook for absent ganglionic cells)
78
Hirschsprung disease: treatment
Surgical resection
79
If newborn fails to pass meconium and DRE shows absent anal opening. What's the treatment?
Imperforate anus
| - surgical treatment is best treatment
80
When is hyperbilirubinemia considered pathological ?
1. On the first day of life
2. Bilirubin > 5mg/dL/day
3. Bilirubin > 12mg/dL in term infant
4. Direct bilirubin > 2 mg/dL at any time
5. Hyperbilirubinemia is present after 2nd week of life
81
Hyperbilirubinemia in 3 week old infant
- Total and direct bilirubin
- Blood type of infant and mother: Look for ABO or Rh incompatibility
- Direct Coombs'test
- CBC, reticulocyte count, and blood smears: Assess for hemolysis
- Urinalysis and UCx if elevated direct bilirubin: assess for sepsis
82
Most feared complication of jaundice (2/2 to elevated indirect bilirubin)
Kernicterus
- Indirect bilirubin can cross BBB, deposit in basal ganglia and brainstem nuclei
-
83
Kernicterus: Sx
- Jaundice
- Hypotonia
- Seizures
- Opisthotonos
- Delayed motor skills
- Choreaoathetosis
- Sensineural hearing loss
84
Kernicterus: Treatment
Immediate exchange transfusion
85
If prolonged jaundice (> 2 weeks) workup w/ no elevated of indirect bilirubin, consider the following diagnoses:
- UTI or other infxn
- Bilirubin conjugation syndromes (e.g. Gilbert, Crigler-Najjar)
- Hemolysis
- Intrinsic red cell membrane or enzyme defects (e.g. spherocytosis, G6PD deficiency)
86
If patient has prolonged jaundiced with elevation of conjugated bilirubinemia. What's most likely diagnosis?
Cholestasis
87
Best initial test for suspected cholestasis
Liver function tests
88
Most specific test for cholestasis
Ultrasound and liver biopsy
89
Hyperbilirubinemia: Treatment
Phototherapy: when bilirubin > 10-12 mg/dL (normally decreases by 2 mg/dL every 4-6 hrs)
Exchange transfusion in any infant with suspected bilirubin encephalopathy or failure of phototherapy to reduce total bilirubin
90
5 week old infant is brought into the clinic with irritability, weight loss of 3 lbs over the past week and "grunting. PE reveals temperature of 102.5F. There is a bulging anterior fontanel delayed capillary refill. What is the next step of management?
Transfer patient to ER and initiate full sepsis workup
91
Most common cause of early onset sepsis (< 24 hrs) is..
Pneumonia
92
Organisms seen in early onset neonatal sepsis
Group B Strep
E.coli
H. influenxa
Listeria monocytogenes
93
Organisms seen late onset neonatal sepsis
S. aureus
E. coli
Klebsiella
Pseudomonas
94
Neonatal Sepsis: Treatment
If no evidence of meningitis, ampicillin and aminoglycoside until 48 to 72 hr cx are negative
If meningitis is possible, ampicillin and 3rd generation cephalosporin (NOT ceftriaxone)
95
General features of TORCH infections
- intrauterine growth retardation
- hepatosplenomegaly
- jaundice
- mental retardation
96
Diagnostic workup of TORCH infections
Elevated total cord blood IgM
97
Toxoplasmosis
hydrocephalus with generalized intracranial calcifications and chorioretinitis
98
Toxoplasmosis: Diagnostic Workup
IgM against toxoplasmosis
99
Rubella
- cataracts, deafness, and heart defects
| - blueberry muffin spits (extramedullary hematopoeisis)
100
Rubella: Diagnostic Workup
Maternal rubella immune status negative or unknown -- obtain IgM against rubella
101
CMV
microcephaly with periventricular calcifications
| - petechiae with thrombocytopenia, sensorineural hearing loss
102
CMV: Diagnostic workup
Urine CMV Cx - if negative, excludes CMV
103
Herpes
First week: pneumonia/shock
Second week: skin vesicles, keratoconjunctivitis
Third to Fourth week: acute meningoencephalitis
104
Herpes: Diagnostic Workup
Best initial tests: Tzanck smear/ culture (doesn't exclude disease if negative)
Most specific test: PCR
105
Syphillis
osteochondritis and periostitis
desquamating skin rash of palms and soles, snuffles (mucopurulent rhinitis)
106
Syphillis: Diagnostic Workup
Best initial test: VDRL screening
Most specific test: IgM-FTA-ABS
107
Varicella
Neonatal: pneumonia
Congenital: Limb hypoplasia, cutaneous scars
108
Varicella: Diagnostic workup
Best initial test: IgM serology
Most specific test: PCR of amniotic fluid
109
In newborn ICU, an infant is noted to be "jittery" and has repetitive sucking movements, tongue thrusting, and brief apneic spells. Blood counts and chemistries are within normal limits. What is the initial workup of this patient?
Ocular deviation and failure of jitteriness to subside with stimulus
This is a seizure (with subtle repetitive movements)
110
Seizure: Diagnostic Workup
1. EKG
2. CBC, electrolytes
3. Amino assay and urine organic acids
4. Look for infectious causes
- TORCH infection studies
- Blood and urine cx
- Lumbar puncture
5. U/S of head in preterms
111
Seizures: Treatment
Phenobarbital (initial drug of choice)
| If seizures persist, use phenytoin
112
Neonatal Withdrawal
Presents with
- hyperactivity, irritability
- diarrhea,
- poor feeding
- tachypnea
- high pitched crying
113
Withdrawal timing: heroin, amphetamine, cocaine, and alcohol
Presents within the first 48 hrs of life
114
Withdrawal timing: methadone
Presents within the first 96 hrs (up to 2 weeks). Drug associated with higher risk of seizures
115
Infants of addicted mother are at higher risk of following complications
- Low birth weight
- Intrauterine growth restriction (IUGR)
- Congenital anomalies (alcohol, cocaine)
- Sudden infant death syndrome (SIDS)
116
Complications of mother's conditions
- Sexually transmitted diseases
- Toxemia
- Breech
- Abruption
- Intraventricular hemorrhage (cocaine use)
117
Neonatal withdrawal: Treatment
Best initial treatment: opioids (esp if specific prenatal opioid use was known) and phenobarbital
118
Why do you never give naloxone to an infant born from mother with known narcotics use?
It may precipitate sudden withdrawal, including seizures
119
Fetal defects: Anesthetics
Respiratory, CNS depression
120
Neonate: Barbituates
Respiratory, CNS depression
121
Neonate effects: Magnesium sulfate
Respiratory depression
122
Phenobarbital neonate effect
Vitamin K deficiency
123
Sulfonamides neonate effect
Displaces bilirubin from albumin
124
NSAIDs neonate effect
Premature closure of the ductus arteriosus
125
ACE inhibitors neonate effect
Craniofacial abnormalities
126
Isotretinoin neonatal effects
Facial and ear anomalies
| Congenital heart disease
127
Phenytoin neonatal effects
Hypoplastic nails
Typical facies
IUGR
128
Diesthylstillbestrol (DES) neonate effects
Vaginal adenocarcinoma (clear cell)
129
Tetracycline neonate effect
Enamel hypoplasia
| Discolored teeth
130
Lithium neonate effect
Ebstein's anomaly
131
Warfarin neonate effect
Facial dysmorphism and chrondrodysplasia
132
Valproate/ Carbamezepine neonate effect
Mental retardation
| Neural tube defects
133
Trisomy 21: Down syndrome
- associated with advanced maternal age (> 35)
- upward slanting palpebral fissues
- speckling of iris (Brushfield spots)
- inner epicanthal folds
- small stature
- late fontanel closure
- mental retardation
134
Trisomy 21: Down syndrome Diagnostic workup
- Hearing exam
- Echocardiogram: endocardial cushion defect > VSD > PDA, ASD; MVP
- Gastrointestinal: TEF , duodenal atresia
- TSH: hypothyroidism
- With advancing age, risk of ALL and early onset Alzheimer
135
Trisomy 18: Edward syndrome
- low-set, malformed ears
- microcephaly
- micrognathia
- clenched hand: index over 3rd, fifth over 4th
- rocker bottom fee and hammer te
- omphalocele
136
Trisomy 18: Edward syndrome - Diagnostic workup
- Echocardiogram: VSD, ASD, PDA
- Renal U/S: polycystic kidneys, ectopic or double ureter
- Most patients don't survive past 1st year
137
Trisomy 13 - Patau syndrome
- defect of midface, eye, and forebrain development
- holoprosencephaly
- microcephaly
- microphthalmia
- cleft lip/palate
138
Trisomy 13 - Patau syndrome: diagnostic workup
- Echocardiogram: VSD, PDA, ASD
- Renal U/S: polycystic kidneys
- Single umbilical artery
139
Aniridia-Wilms' tumor association (WAGR syndrome)
- Wilms'
- Aniridia
- GU anomalies
- Retardation (mental)
140
WAGR syndrome: diagnostic workup
When you see an infant with aniridia, do a complete workup of WAGR syndrome
141
Klinefelter syndrome (XXY) - 1:500 males
- low IQ
- behavioral problems
- slim with long limbs
- gynecomastia
142
Klinefelter syndrome: diagnostic workup
- Testosterone levels: hypogonadism and hypogenitalism
| - Replace testosterone at 11 - 12 years of age
143
Turner syndrome (XO)
- sporadic no association with maternal age
- small stature female
- gonadal dysgenesis
- low IQ
- congenital lympheema
- webbed posterior neck
- broad chest, wide spaced nipples
144
Turner syndrome (XO): Diagnostic workup
- Renal U/S: horseshoe kidney, double renal pelvis
- Cardiac: bicuspid aortic valve, coarctation of aorta
- Thyroid fxn: primary hypothyroidism
- Can give estrogen, growth hormone, and anabolic steroid steroid replacement
145
Fragile X syndrome
- fragile site on long arm of X
- molecular diagnosis: variable # of repeat CGG
- macrocephaly in early childhood
- large ears, large testes
- most common cause of mental retardation in boys
146
Fragile X syndrome: disease association
attention deficit hyperactivity syndrome
147
Beckwith-Wiederman syndrome
- IGF-2 disrupted at 11p11.5
- multiorgan enlargement:
- macrosomia, macroglossia,
- pancreatic beta cell hyperplasia (hypoglycemia)
- large kidneys
- neonatal polycythemia
148
Beckwith-Wiederman syndrome: disease association
- Increased risk of abdominal tumors
| - Obtain ultrasounds and serum AFP every 6 months through 6 years of age to look for Wilms' tumor and hepatoblastoma
149
Prader-Willi syndrome
- deletion at 15q11q13 paternal chromosome responsible
- obesity
- mental retardation
- binge eating
- small genitalia
150
Prader-Willi syndrome: disease association
decreased life expectancy related to morbid obesity
151
Angelmann syndrome (happy puppet syndrome)
- deletion of 15q11q13 - maternal chromosome
- mental retardation
- inappropriate laughter
- absent speech or < 6 words
- ataxia and jerky arm movements resembling puppet gait, recurrent seizures
152
Angelmann syndrome: disease association
Epilepsy
153
Robin sequence (Pierre Robin)
- associated with fetal alcohol syndrome, Edwards syndrome
| - mandibular hypoplasia, cleft palate
154
Robin sequence: diagnostic workup
Monitor airway: obstruction possible over 1st 4 weeks of life
155
Ddx: Decreased weight gain = decreased length/height
Systemic illness
- Heart failure
- Inflammation (e.g. inflammatory bowel disease)
- Renal insufficiency
- Hepatic insuficiency
Genetic short stature
Constitutional delay in growth and development
156
Decreased weight gain = decreased length/height: workup
* Inflammatory markers (CRP, ESR, CBC w/ diff)
* Organ dysfunction
- LFT, creatinine, BUN
- electrolytes
* Bone age
- Genetic short stature: bone age ~ chrono age
- Constitutional growth delay: bone age is delayed and puberty occurs later
157
Breastfeeding advantages
- Passive transfer of T cell immunity: decreased risk of allergies and GI and respiratory infections
- Psycho/emotional: maternal- infant bonding
158
Contraindications to breastfeeding
- HIV
- CMV
- HSV if lesions on breast
- Acute maternal disease if absent on infant
- Breast cancer
- Substance abuse
- Drugs
159
Newborn milestones
- Moro, grap, rooting, tonic neck, and placing reflexes: Appear at birth and disappear at 4-6 months
- Parachute reflex (extension of arms when fall is simulated): Present at 6-8 months and persists
160
9 month milestones:
Has pincer grasp
Creeps and crawls
Knows own name
161
12 month milestones
Cruises
Says one or more words
Plays ball
162
15 month milestones
Builds 3 cube tower
Walks alone
Makes line and scribbles
163
18 month milestones
Builds 4 cube tower
Walks down stairs
Says 10 words
Feeds self
164
24 month milestones
```
Builds 7 cube tower
Runs well
Goes up and down stairs
Jumps with 2 feet
Threads shoelaces
Handles spoon
Says 2-3 sentences
```
165
36 month milestones
- Walks downstaires alternating feet
- Rides tricycle
- Knows age and sex
- Understands taking turns
166
48 month milestones
- Hops on one foot
- Throws ball overhead
- Tells stories
- Participates in group play
167
4 yr old bory has problems with bedwetting. The mother says that during the day, he has no problems but is usually wet 6 of 7 mornings. He does not report dysuria or frequency and has not increased thirst. the mother also says that he is a deep sleeper. Which of the following is the most appropriate next step in management?
Reassure mother bedwetting is normal
| - bedwetting before age 5 (before bladder control is anticipated) is normal
168
Enuresis
- involuntary voiding of urine, occurring at least 2x week for at least 3 months in children > 5 years
- daytime enuresis is more common in girls
- nocturnal enuresis is more common in boys
169
Best initial diagnostic test for enuresis
Urinalysis
170
Enuresis: Diagnostic tests
- Urinalysis
- Signs of infection: Urine Cx
- If recurrent UTIs: Bladder/renal U/S or voiding cystourethogram
171
Best initial treatment for enuresis
Behavior and motivational therapy
172
Enuresis: Treatment
1. Behavior modification
| 2. If behavior mods fail, try TCAs, imipramine and desmopression (to decrease urine volume)
173
Encopresis
- intentional or involuntary passage of feces in inappropriate settings (e.g. clothing, onto floor) in children > 4 years
174
Best initial test for encopresis
Abdominal X-ray
| - distinguishes between retentive and nonretentive
175
Distinguishes between retentive and nonretentive
Retentive: associated w/ constipation and overflow incontinence
Nonretentive: associated w/ abuse
176
Encopresis: Treatment
Best initial therapies:
- Retentive encopresis: disimpaction, stool softeners, and behavior intervention
- Nonretentive encopresis: Behavior modification alone
177
Ddx: low weight gain & low length/height
```
Systemic illness:
- Heart illness
- Inflammation (e.g. IBS or arthritis)
- Renal insufficiency
- Hepatic insufficiency
Genetic short stature
Constitutional delay in growth and development
```
178
Workup: low weight gain & low length/height
```
Inflammatory markers:
- CRP, ESR, CBC with differece
Organ dysfunction
- LFT, Creatinine, BUN
- Creatinine
Bone age
- Constitutional delay of growth
- Genetic short stature
```
179
Bone age: genetic short stature
Bone age is close to chrono age
| Puberty occurs at normal age
180
Constitutional delay of growth: bone age
Bone age is delayed, and puberty occurs later than most children
181
Immunizations in premature infants or low birth weight
- Don't delay immunizations - immunize at chrono age
| - Don't dose adjust immunizations
182
Contraindications to live vaccines
Immunocompromized patients
183
Non-contraindications to vaccines
- Rxn to previous DPT of temp < 105F, redness, soreness and swelling
- Mild acute illness in otherwise well child
- Fam hxof seizures or SIDS
184
Is egg allergy contraindication to MMR?
No
185
Contraindication to yellow fever vaccine
Egg allergy
186
Influenza vaccine concerns
- Egg allergy is no longer contraindication
187
Influenza vaccine protocol in child > 6 months with egg allergy
```
Give TIV (trivalent inactivated influenzae vaccine) followed by 30 minute observation period in place to recognize and treat anaphylaxis
- those with severe egg allergy should referred to allergy specialist
```
188
Hep B vaccine: concerns
- doesn't cause demyelinating neuro disorders
189
Meningococcal vaccination concerns
- doesnt cause development of Guillain Barre
190
Active immunizations after exposure: Measles
0-6 mths: immunoglobulins (Ig)
6-12 mths: Ig plus vaccine
> 12 mths: vaccine only within 72 hrs of exposure
Pregnant or immunocompromised: Ig only
191
Varicella immunization after exposure:
| at risk children and household contacts
VZIG and vaccine
192
Varicella immunization after exposure: pregnant women and women who had varicella (5 days before delivery and 48 hrs after delivery)
VZIG
193
Hepatitis B immunization after exposure
Ig plus vaccine: given at birth, 1 month, and 6 months
194
Mumps and rubella immunization after exposure
No post-exposure protection available
195
Hepatitis B vaccine routine w/ HBsAg negative mom
1st dose: birth
| Total of 3 doses by 18 months
196
Hepatitis B vaccine routine w/ HBsAg positive mom
1st dose of hepatitis B vaccine plus HBIg at 2 different sites within 12 hrs of birth. Total of 3 doses by SIX MONTHS
197
DTAP vaccine routine
Total of 5 doses is recommeneded before school entry (last dose 4-6 years)
- pertussis booster given at adolescence
- Td is given at 11-12 years, then every 10 years
198
HiB conjugated vaccine rotutine
Does not cover nontypeable Haemophilus
- not given after age 5
- invasive disease does not confirm immunity, patients still require vaccine if < 5
199
Varicella routine
associated with development herpes zoster after immunization
200
Meningococcal conjugate vaccine
- given at age 11 - 12 or age 15
- indicated for all college freshmen living in dorms
- MPSV4 (menomune) indicated in children aged 2- 10
201
Child Abuse: Dx Test
```
LAB TESTS: PT, PTT, platelets, bleeding time, CBC
SKELETAL SURVEY:
- Head CT scan +/- MRI
- Ophthalmologic exam
ABDOMINAL TRAUMA:
- Urine and stool for blood
- Liver and pancreatic enzymes
- Abdominal CT Scan
AMS:
- urine toxicology screen
```
202
Child Abuse: Treatment
1. Always first address medical and/or surgical issues
| 2. Report issues to CPS
203
Indications for hospitalization in suspected child abuse
- Medical condition requires it
- Diagnosis unclear
- No alternative safe place
** if parents refuse, then get emergency court artery
204
Croup: organismss
Parainfluenza 1 or 3
| Influenza A or B
205
Croup: classic presentation
Child age 3 mths to 5 yrs with URTI symptoms
Rhinorrhea, sore throat, hoarseness, BARKING COUGH
INSPIRATORY STRIDOR, tachypnea
symptoms are worse at night
206
Croup: Diagnosis
Neck X-ray (not needed for diagnosis)
207
Croup: Management
1. Humidified oxygen
2. Nebulized epinepherine and corticosteroids
** Antitussives, decongestants, sedatives or abx are NOT used to treat croup ***
208
Croup: Complications
Spontaneous resolution in 1 week
| - Always suspect diagnosis of epiglottis
209
Epiglottitis: Bugs
- H. influenzae type B (now less common)
- S. pyogenes
- S. pneumoniae
- S. aureus
- Mycoplasma
210
Epiglottitis: Classic Presentation
Sudden onset, MUFFLED voice, DROOLING, dysphagia, high fever, and inspiratory stridor
** Patient prefers to sit in tripod position. Patient has toxic appearance***
211
Epiglottitis: Diagnosis
MEDICAL EMERGENCY!! TX IMPORTANT BEFORE DX!
After stabilization:
- Neck X-ray (thumb print sign)
- Blood Cx
- Nasopharyngoscopy in OR
- Epiglottic swab cx
212
Epiglottitis: Management
1. Tx to hospital/OR
2. Consult ENT and anasthesia
3. Intubate
4. Give ceftriaxone and steroids
5. Give rifampin prophylaxis to household contacts if H. influenzae positive
213
Epiglottitis: Complications
Airway obstruction and death
214
Bacterial tracheitis: Bugs
S. aureus
215
Bacterial tracheitis: Presentation
Brassy cough, high fever, respiratory distress, but no drooling or dysphagia
Child < 3 years after viral URTI
216
Bacterial tracheitis: Diagnosis
Clinical plus laryngoscopy
- CXR: subglottic narrowing plus ragged tracheal air column
- Blood cx
- Throat cx
217
Bacterial tracheitis: Management
Antistaphylococcus abx
| - may require intubation if severe
218
Bacterial tracheitis: complicaitons
Airway obstruction
219
Epiglottitis vs croup
NO BARKING COUGH with Epiglottitis
220
Diphtheric croup
- rare in North America
- presents with gray-white pharyngeal membrane
- may cover soft palate; bleeds easily!
- Don't forget that diphtheria is notifiable!
221
Foreign body aspiration
look for sudden choking/coughing w/out warning
222
Retropharyngeal abscess
patient has drooling and difficulty swallowing
223
Extrinsic compression
- vascular ring
- patient has continued symptoms and does not improve w/ treatment
- see similar symptoms with INTRALUMINAL OBSTRUCTION (masses)
224
Angioedema
- due to sudden allergic reaction
- manage with steroids and epinepherine
- if severe, intubate for airway protection
225
Pertussis
severe cough develops after 1-2 weeks w/ characteristic whoop and spell of cough (paroxysm)
- look for child for incomplete immunization hx
226
Most common site for foreign aspiration: > 1 years
Larynx
227
Most common site for foreign aspiration < 1 years
Trachea or right mainstream bronchus
228
Toddler presents to ER w sudden onset respiratory distress. Mother reports child was w/o symptoms, playing with LEGOS in room w siblings. On exam, patient is drooling and in moderate respiratory distress. Decreased BS on right and intercostal retraction. Next step?
Bronchoscopy
- to visualize suspected foreign body and foreign body retrieval
** If significant respiratory distress, then emergency cricothyroidotomy**
229
Bronchiolitis
- RSV (50% of cases)
- Parainfluenza
- Adenovirus
- Other viruses
** results in inflamation, which results ball-valve obstruction results in air trapping and overinflation
230
Bronchiolitis: presentation
child < 2 years of age (most severe in children 1-2 months old)
- mild URI
- fever
- paroxysmal wheezing cough
- wheezing and prolonged expiration
- dyspnea
- tachypnea
- apnea (in young infants)
231
Bronchiolitis: Diagnosis
Most clinical
- CXR
- Viral antigen testing (IFA or ELISA)
232
Best initial test for bronchiolitis
CXR: shows hyperinflation w patchy atelectasis (looks like early pneumonia)
233
Most specific test for bronchiolitis
Viral antigen testing (IFA or ELISA) of nasopharyngeal secretions
234
Bronchiolitis: Treatment
Supportive only:
- hospitalize if severe tachypnea (> 60/min), pyrexia, and intercostal retractions are present. Give trial of B-agonists
** Steroids are NOT indicated **
235
Bronchiolitis: Prevention
In high risk patients, give hyperimmune RSV IVIG or monoclonal Ab to RSV F protein (palivizumab)
** High risk pts: bronchiopulmonary dysplasia and preterm**
236
Best prevention against bronchiolitis:
Breastfeeding
| - colostrum is particularly rich in IgA and protects against bronchiolitis
237
Viral pneumonia
Most common cause in < 5 years. Most commonly RSV
- URI symptoms
- Low grade fever
- Tachypnea (most consistent finding)
238
Bacterial pneumonia
```
Most common cause in > 5 years.
common bugs: S. pneumoniae, M. pneumoniae, C. pneumoniae
- Acute onset, sudden, shaking chills
- High fever
- Prominent cough
- Pleuritic chest pain
- Markedly inflated diminished breath sounfs
- Dullness to percussion
```
239
Chlamydia trachomatis
- infants 1-3 months of age w/ insidious onset (usually > 3 weeks)
- no fever or wheezing (distinguishes from RSV +/- conjunctivitis at birth
- Classic findings: STACCATO COUGH and PERIPHERAL EOSINOPHILS
240
Pneumonia: Diagnostic Tests
- CXR
- CBC with differential
- Viral antigens: IgM titers for mycoplasma
- Blood cx
241
Viral pneumonia: diagnosis
- CXR: hyperinflation w/ b/l interstitial infiltrates and peribronchial cuffinnd
- CBC w/ differential has WBC < 20,000
- viral antigens: IgM titers for mycoplasma
- Blood cx
242
Bacterial pneumonia: diagnosis
CXR: confluent lobar consolidation
CBC has WBC 15,000 - 40,000
Blood cx
243
Mycoplasma/Chlamydia pneumonia findings on CXR
Unilateral lower-lobe interstitial pneumonia; looks worse than presentation
244
Mild pneumonia (outpatient): treatment
Amoxicillin
| - alternatives: cefuroxime and amoxicillin/clavulanic acid
245
Pneumonia (hospitalized): treatment
IV cefuroxime
| - If S. aureus, add vancomycin
246
Viral pneumonia:
Withhold antibotics unless child deteriorates (as may have co-existing bacterial infection)
247
Chlamydia/mycoplasma: treatment
Erythromycin or other macrolide
248
3 y.o white female presents with rectal prolapse. Noted to be
Sweat chloride test
| - best initial test for cystic fibrosis
249
Most common initial presentation for cystic fibrosis
Meconium ileus
| - look for abdominal distention at birth, failure to pass meconium, and bilious vomiting
250
Cystic fibrosis: presentation
- Meconium ileus
- Failure to thrive (from malabsorption, steatorrhea)
- Rectal prolapse
- Persistent cough in 1st year of lige
251
Conditions associated with cystic fibrosis
- Infertility (absent vas deferens)
| - Allergic bronchopulmonary aspergillosis
252
Conditions associated with cystic fibrosis
- Infertility (absent vas deferens)
| - Allergic bronchopulmonary aspergillosis
253
Cystic fibrosis: diagnostic testing
- 2 elevated sweat chloride concentrations (> 60 mEq/L) obtained on separate days
- Genetic testing
- Newborn screening (immunoreactive trypsinogen in blood spots and then confirm w/ DNA or sweat testing)
- CXR shows course and exacerbation
- PFTs (done > 5 yrs to eval disease progression)
254
Cystic fibrosis
Supportive treatment includes:
- aerosol treatment
- albuterol/saline
- chest physical therapy w/ postural drainage
- pancrelipase (aids digestion in patients w/ pancreatic dyfynction)
255
Ivacaftor (VX-770)
- restores function of mutant CF protein
- recommended for patients > 6 years who have at least one copy of the G551D mutation
- decreases sweat chloride levels, improve FEV1, pulmonary symotoms and exacerbation and improve weight gain
256
Cystic fibrosis treatments: shown to improve survival
- Ibuprofen: reduces inflammatory lung response
- Azithromycin: slow rate of decline in FEV1 in pts < 13 yrs
- Antibiotics: during exacerbations delay progression of lung fisease
257
Cystic fibrosis management considerations
- Give routine vaccine PLUS pneumococcal and yearly flu vaccine
- Never delay abx
- Steroids improve PFTs in short term, but no persistent benefit when steroids are stopped
- Expectorants (guaifenesin or iodides) are not effective in removal of respiratory secretions
258
Abx to treat mild CF
Give macrolide, trimethoprim-sulfamethoxaxole (TMP-SMX) or ciprofloxacin
259
Abx to treat CF with documented infection w/ Pseudomonas or S. aureus
Treat aggressively w/
| piperacillin plus tobramycin or ceftazidime
260
Abx to treat CF with resistant pathogen:
Use inhaled tobramycin
261
Most common symptom of acyanotic defect
Congestive heart failure
262
Most common acyanotic lesions are these:
- VSD, ASD
- AV canal
- Pulmonary stenosis
- PDA
- Aortic stenosis
- Coarctation of aorta
263
Primary concern for infants w/ cyanotic defects
Hypoxia
264
Common defects associated cyanosis in infants
Tetralogy of Fallot
| Transposition of great arteries
265
Congenital heart disease: common presentation
Shock, tachypnea, and cyanosis (esp if fever is absent)
| - do not respond to oxygen
266
Congenital heart disease: infants
- Feeding difficulty
- Sweating while feeding
- Rapid respiration
- Easy fatigue
267
Congenital heart disease presentation in older children
Dyspnea on exertion
Shortness of breath
Failure to thrive
268
Congenital heart disease: abnormalities on exam
- Upper exam HTN or decreased lower extremity blood pressures
- Decreased femoral pulses ( obstructive lesions on left heart)
- Facial edema, hepatomegaly
- Heart sounds: Pansystolic murmur, grade 3/6 murmur, PMI at upper left sternal border, harsh murmur, early midsystolic click, abnormal S2
269
When is murmur innocent?
- If question includes: fever, infection, or anxiety
- When it is only systolic (never diastolic)
- When it is < grade 2/6
270
Best initial test for congenital heart disease
CxR and EKG
- increased pulmonary vascular markings suggest:
* Transposition of the great arteries
* Hypoplastic left heart syndrome
* Truncus ateriosus
271
Most specific test for congenital heart disease
Echocardiography
272
Ventricular septal defect
- harsh holosystolic murmur over LLSB +/- throll
- Loud pulmonic S2
- almost half of cases have spontaneous closure w/in the 6 months
- surgical repair if FTT, pulmonary HTN or right to left shunt > 2:1
273
Atrial septal defect
Loud S1, wide fixed splitting of S2, systolic ejection murmur along LUSB
- majority are asymptomatic, secundum types, and close by age 4
- primary and sinus types require surgery
- PFO needs to be closed if clot goes through it
274
Late complications of ASD
- Mitral valve prolapse
- Dysrhythmias
- Pulmonary hypertension
275
Atrioventricular canal
- combination of primum type of atrial septal defect, ventricular septal defect, and common atrioventricular valve
- presentation similar to VSD
- perform surgery in infancy BEFORE pulmonary hypertension develops
276
Pulmonary stenosis
- may be asymptomatic or may result in severe congestive heart failure
- give prostaglandin E1 influsion at birth
- attempt balloon valvuloplasty
277
Patent ductus arteriosus
- more common in girls (2:1), babies where maternal rubella infection was present and premature infants
- WIDE PULSE PRESSURE, bounding arterial pulses, and machinery sounds
- indomethacin-induced closure helpful in premies
- term infants require surgical closure
278
Aortic stenosis
early systolic ejection click at apex of LSB
| valve replacement and anticoagulation may be required
279
Coarctation of the aorta
- 98% occur at origin of left subclavian artery
- blood pressure higher in arms than legs, bounding pulses in arms and decreased pulses in legs
- Ductus dependent: give PGE1 infusion to maintain patent ductus
Surgery repair after stabilization
280
Tetralogy of Fallot
- most common CHD beyond infancy
- defects include pulmonary stenosis, RV hypertrophy, overiding aorta, VSD
- substernal RV impulse and systolic thriil along LSB
- intermittent hypernea, irritability, cyanosis w/ decreased intensity of murmur
281
Tetralogy of Fallot: Treatment
Give oxygen, B-blocker, PGE1 infusion for cyanosis present at birth
- Surgical repair at 4 - 12 months
282
Transposition of the great arteries
Most common cyanotic lesion presenting in immediate newborn
- more common in diabetic moms
- S2 usually single and loud, murmurs usually absent
- Ductus dependent: Give PGE1 to keep ductus open
- Definitive surgical switch of aorta and pulmonary artery ASAP
283
Abx prophylaxis and prevention of endocarditis
Abx is required prior to dental procedures if:
- prosthetic valves
- previous endocarditis
- congenital heart disease (unrepaired or repaired w/ persistent defect)
- cardiac transplantation pts w/ cardiac valve abnormalities
284
When to begin HTN checking in children
Start at age 3 (check all extremities)
285
Always workup for secondary HTN if newborn
- has umbilical artery catheters leads to renal artery/vein thrombosis
286
Always workup for secondary HTN in early childhood if
Renal parenchymal disease
Coarctation
Endocrine
Medications
287
Workup secondary HTN for adolescents if
Essential hypertension is associated w. obsesity
- evaluate for renal and renovascular hypertension
- majority of causes due to UTI (2/2 obstruction), acute glomerulonephritis, HSN, HUS, ATN, renal trauma
288
Hypertension: Diagnostic Testing
- CBC, UA, UCx, BMP
- Lipid panel w/ essential hypertension and positive family hx
- Echocardiogram
289
Kidney evaluation for hypertension
- Renal ultrasound
- Voiding cystourethrogram (if there is a hx of repeated UTIs esp < 5 years
- 24 hr urine colleciton for protein excretion and creatinine clearance
- Plasma renin activity (PRA) for renovascular and renal disordes
290
Endocrine causes of hypertension
- Urine and serum catecholamines (if pheochromocytoma suspected)
- Thyroid and adrenal hormone levels
- Drug screening (in adolescents), if drug abuse is suspected
291
Treatment: peds pt with HTN and is obese
Lifestyle modifications (e.g. weight control, aerobic exercise, no salt diet, monitoring BP)
** If no response to life mods, give anti-BP meds
292
Best initial HTN medications:
Diuretic or B-blocker
| - add calcium channel blocke and ACE inhibitor
293
Most common cause of acute diarrhea in peds patietns
Rotavirus
294
Most common causes of bloody diarrhea in peds patients
- Campylobacter
- Amoeba (E. histolytica)
- E. coli
- Salmonella
295
Best initial test for acute diarrhea
- Stool cultures: ( look for blood, leukocytes, HUS)
- C. diff toxin if recent hx of abx
- Ovum and parasites
296
Best initial therapy for acute diarrhea
- Hydration and fluid and electrolyte replacement
| * don't use antidiarrheals in children
297
Shigella: tx
TMP-SMX
298
Campylobacter: tx
Self limiting
- erythromycin speeds recovery and reduces carriet sates
- recommended for patietns w/ severe disease or dysentery
299
Salmonella: tx
Indicated only for patients < 3 months old, who are toxic, who have disseminated disease, or who have S. typhi
300
C. difficile: tx
Metronidazole (Flagyl) or PO vancomycin and discontinuation of other antibiotics
301
E. histolytica or Giardia: tx
Metronidazole
