Peds Flashcards
1
Q
ASA in children should be avoided because risk of…
A
Reye’s syndrome
2
Q
Tissue that grows primarily in first 2 years
A
CNS
3
Q
Tissue that grows primarily in mid-childhood
A
Lymphoid tissue
4
Q
Tissue that grows primarily in puberty
A
Gonads
5
Q
Premature infants (<37wk) use corrected GA until age…
A
2yo
6
Q
Birth weight
A
Average is 3.25kg (7lb)
20-30d/g in term neonate
Up to 10% weight loss in first 7d of life is normal
Should regain birth weight by 10-14d of age
2x birth weight by 4-5mo
3x birth weight by 1yr
4x birth weight by 2yr
7
Q
Length/height
A
Average is 50cm (20in) 25cm in 1st yr 12cm in 2nd yr 8cm in 3rd then 4-7cm/yr until puberty 1/2 adult height at 2yo Measure supine lenght until 2yo then measure standing height
8
Q
Head circumference
A
Average is 35cm (14in)
2cm/mo for first 3mo
1cm/mo at 3-6mo
0.5cm/mo at 6-12mo
9
Q
Moro reflex
A
Abduction/extension of arms, opening of hands, followed by flexion/adduction of arms
Disappears by 4-6mo
10
Q
Galant
A
Pelvis moves in direction of side that back is stroked along paravertebral line
Disappears by 2-3mo
11
Q
Grasp
A
Disappears by 3-4mo
12
Q
ATNR (asymmetric tonic neck reflex)
A
Fencing posture when you turn infant’s head to one side
Disappears by 4-6mo
13
Q
Rooting
A
Disappears by 2-3mo
14
Q
Parachute reflex
A
Ipsilateral arm extension to side infant is tilted toward while sitting
Present by 6-8mo
Does not disappear
15
Q
Gross motor: 1mo
A
Turns head side to side when supine
16
Q
Gross motor: 2mo
A
Briefly raises head when prone
Holds head erect when upright
17
Q
Gross motor: 4mo
A
Lifts head and chest when prone
Holds head steady when supported sitting
Rolls prone to supine
18
Q
Gross motor: 6mo
A
Tripod sit
Pivots in prone position
19
Q
Gross motor: 9mo
A
Sits well without support, crawls, pulls to stand, stands with support
20
Q
Gross motor: 12mo
A
Gets into sitting position without help
Stands without support
Walks while holding on
21
Q
Gross motor: 15mo
A
Walks without support, crawls up stairs/steps
22
Q
Gross motor: 18mo
A
Runs, walks forward pulling toys or carrying objects
23
Q
Gross motor: 24mo
A
Climbs ups and down steps with 2 feet per step, runs, kicks ball
24
Q
Gross motor: 3yr
A
Rides tricycle
Climbs up 1 foot per step, down 2 feet per step
Stands on one foot briefly
25
Gross motor: 4yr
Hops on 1 foot
| Climbs down 1 foot per step
26
Gross motor: 5yr
Skips
| Rides bicycle
27
Fine motor: 1mo
Fist with thumb in fist
28
Fine motor: 2mo
Pulls at clothes
29
Fine motor: 4mo
Briefly holds object when placed in hand
| Reached midline objects
30
Fine motor: 6mo
Ulnar or raking grasp
Transfers objects from hand to hand
brings objects to mouth
31
Fine motor: 9mo
Early pincer grasp with straight wrist
32
Fine motor: 12mo
Neat pincer grasp
| Releases ball with throw
33
Fine motor: 15mo
Picks up and eats finger foods
Scribbles
Stacks 2 blocks
34
Fine motor: 18mo
Tower of 3 cubes
Scribbling
Eats with spoon
35
Fine motor: 24mo
Tower of 6 cubes
| Undresses
36
Fine motor: 3yr
Copies circle
Turns pages one at a time
Puts on shoes
Dress/undress fully except buttons
37
Fine motor: 4yr
Copies cross
Uses scissors
Buttons clothes
38
Fine motor: 5yr
Copies a triangle and square
Prints name
Ties shoelaces
39
Gross motor red flag
Not walking at 18mo
| Rolling too early at <3mo
40
Fine motor red flag
Hand preference at <18mo
41
Speech: 1mo
Cries, startles to loud noises
42
Speech: 2mo
Variety of sounds (coos)
43
Speech: 4mo
Turns head towards sounds
44
Speech: 6mo
Babbles
45
Speech: 9mo
Mama, dada
Imitates 1 word
Responds to no regardless of tone
46
Speech: 12mo
```
2 words
Follows 1 step command
Uses facial expression
Sounds
Actions to make needs known
```
47
Speech: 15mo
4-5 words
| Points to needs/wants
48
Speech: 18mo
10 words
| Follows simple commands
49
Speech: 24mo
2-3 word phrases
50% intelligible
Understands 2 step commands
50
Speech: 3yr
Combines 3 or more words in a sentence
Recognizes colours, preopositions, plurals, counts to 10
75% intelligble
51
Speech: 4yr
Speech 100% intelligble
Uses past tense
Understands 3 part directions
52
Speech: 5yr
Fluent speech, future tense, alphabet
| Retells sequence of story
53
Babinski sign
Present up to 2yo
| Upgoing plantar reflex
54
Social: 1mo
Calms when comforted
55
Social: 2mo
Smiles responsiveley
Recognizes and calms down to familiar voice
Follows movement with eyes
56
Social: 4mo
Laughs responsively
Follows moving toy or person with eyes
Responds to ppl with excitement
57
Social: 6mo
Stranger anxiety
| Beginning of object permanence
58
Social: 9mo
Plays games
| preaches to be picked up
59
Social: 12mo
Responds to own name
| Separation anxiety begins
60
Social: 15mo
Looks to see how other react (ie. after falling)
61
Social: 18mo
Shows affection towards other
| Points to show interest in something
62
Social: 24mo
Parallel play
| Helps to dress
63
Social: 3yo
Knows sex and age
Shares some of time
Playes make believe games
64
Social: 4yo
Cooperative play
Fully toilet trained by day
Tries to comfort someone who is upset
65
Social: 5yo
Cooperates with adult request most of the time
| Separates easily from caregiver
66
Speech red flag
<10 words at 18mo
67
Social red flag
Not smiling at 3mo
| Not pointing at 15-18mo
68
Breastfed infants require supplements
Vitamin D 400IU/d
Fluoride after 6mo if not sufficient in water
Iron at 6-12mo if not receiving fortified cereals/meat/meat alternatives
69
Foods to avoid in early infancy
Honey until past 12mo (botulism)
Added sugar, salt
Excessive milk (no more than 750mL per day after 1y)
Limit juice intake (1/2 cup daily)
70
Milk
Breastfeeding recommended
9-24mo: homo milk
2-6yr: 2% milk
71
C/I to breastfeeding
Medications known to cross into breast milk (chemo)
HIV/AIDS
Active untreated TB
Herpes in breast region
>0.5g/kg/d of EtOH or illicit drugs
OCPs are NOT a C/I to breastfeeding (estrogen may decrease lactation but is safe for baby)
72
Meds that cross into breast milk
```
Bromocrimptine
High dose diazepam
Gold
Metronidazole
Tetracycline
Lithium
Cyclophosphamide
```
73
Wet diaper amount
1 wet diaper per day of age for first wk
1-2 black or dark green stools/d on day 1 and 2
3+ brown/green/yellow stools per day on day 3 and 4
3+ yellow, seedy stools per day on day 5
74
Infantile colic
Unexplained paroxysms of irritability and crying for >3h/d, >3d/wk for >3wk in an other wise healthy, well-fed baby (rule of 3s)
Peaks at 6-8wk
Usually resolves by 3mo
75
When to see dentist
6mo after eruption of first tooth and definitely by 1yo
| First tooth typically at 5-9mo
76
Enuresis
Involuntary urinary incontinence by day and/or night in child >5yo
77
Secondary enuresis
Involuntary loss of urine at night after child had sustained period of bladder control (>6mo)
78
Pharmaco treatment for enuresis
Don't do before age 7 because often resolves spontaneously
| Consider DDAVP oral tablets (antidiuretic)
79
Encopresis
Fecal incontinence in child >4yo at least once per mo for 3mo
80
Failure to thrive
Weight <3rd percentile
| Falls across two major percentile curves or <80% of expected weight for height and age
81
Decreased weight, normal ht, normal HC
Caloric insufficiency
Decreased intake
Hypermetabolic state
Increased losses
82
Decreased wt, ht and normal HC
Structural dystrophies
Endocrine d/o
Constitutitional growth delay (BA < CA)
Familial short stature (Bone age = chronological age)
83
Decreased wt, ht, hc
Intrauterine insult
| Genetic abnormality
84
Overweight BMI
>85th percentile
85
Obesity BMI
>95th percentile for age and height
86
Risk factors for SIDS
```
Prematurity <37wk
Early bed sharing <12wk
Alcohol use during pregnancy
Soft bedding
Low birthweight
Bed sharing
Aboriginals
Male
No prenatal care
Smoking in household
Prone sleeping
Poverty
```
87
Prevwntion of SIDS
Back for sleeping
Avoid sharing bed, overheating, overdressing
Appropriate infant bedding
Exclusive BF in first month and no smoking
Pacifiers appear to have a protective effect
Do not reinsert if falls out during sleep
Infant monitors do not reduce incidence
88
Tests to order to R/O pathologic causes of fractures
```
Ca2+
Mg2+
PO4
ALP
PTH
Vit D
Albumin
```
89
Tests to order to R/O pathologic causes of bruising
```
CBC
INR
PTT
vWF
Factors VIII/IX
```
90
Sexual assault examination kit
Within 24h if prepubertal
| Within 72h if pubertal
91
Ductus arteriosus
Connection btwn pulmonary artery and aorta
92
Ductus venosus
Connection btwn umbilical vein and IVC
93
Prenatal circulation of oxygenated blood
Oxygenated blood from placenta --> umbilical vein --> IVC --> RA --> foramen ovale --> LA --> LV --> aorta --> brain/myocardium/upper extremties
94
Prenatal circulation of deoxygenated blood
Deoxygenated blood returns via SVC to RA --> 1/3 of blood goes to RV --> pulmonary arteries --> ductus arteriosus --> arota --> systemic circulation --> placenta
95
Ductus venosus closure
Separation of low resistance placenta --> systemic circulation becomes high resistance system
96
Foramen ovale closure
Increased pulmonic flow --> increased LA pressures
97
Ductus arteriosus closure
Increased oxygen concentration in first breath --> decreased prostaglandins --> ductus arterosus closure
98
Acyanotic heart disease
L to R shunt
| Obstructive
99
Cyanotic heart disease
R to L shunt
100
L to R shunt
ASD
VSD
PDA
Atrioventricular spetal defect
101
Obstructive causes of acyanotic CHD
Coarctation of aorta
Aortic stenosis
Pulmonic stenosis
102
R to L shunt
Tetralogy of Fallot
| Ebstein's anomaly
103
5Ts of cyanotic CHD
```
Tetralogy of Fallot
Transposition of the great arteries
Truncus arteriosus
Total anomalous pulmonary venous drainage
Tricuspid atresia
Hypoplastic left heart syndrome
```
104
Boot shaped heart on CXR
Tetralogy of Fallot
| Tricuspid atresia
105
Egg-shaped heart
Transposition of great arteries
106
Left to right shunts
ASD
VSD
PDA
107
3 types of Atrial Septal Defects
Ostium primum
Ostium secundum
Sinus venosus (located at entry of SVC into right atrium)
108
Ostium primum
AKA endocardial cushion defect
Defect in atrial septum at level of tricuspid and mitral valves
Common in DS
109
Ostium secundum
Most common type, 50-70%
| Foramen in septum primum
110
Foramen ovale
Foramen in septum secundum
| Normally closes at birth when pulmonary vascular pressure decreases and the LA > RA
111
Mgmt of ASDs
80-100% spontaneously close if ASD diameter is <8mm
| Elective surgical or catheter closure btwn 2-5yo
112
ASD heart murmur
Grade 2-3/6 pulmonic outflow murmur, widely split, and fixed S2
113
ECG for ASD
RAD
Mild RVH
RBBB
114
Most common congenital heart defect
VSD (30-50%)
| Majority are small and close spontaneously
115
ECG for VSD
LVH
LAH
RVH
116
VSD heart murmur
The size of the VSD is inversely related to the intensity of the mumur
Holosystolic murmur at LLSB
117
Treatment of VSD
If small --> most close spontaneously
| If mod/large --> tx CHF and surgical closure by 1yo
118
PDA
Patent vessel btwn descending aorta and the left pulmonary artery
Normal functional closure is at 15h
Normal anatomical closure within first days of life
119
Treatment for PDA
Premature infants have higher rates of spontaneous closure
Indomethacin (antagonizes prostaglandin E2, only effective in preterm)
Catheter or surgical closure if PDA causes resp compromise, FTT or persists beyond 3mo
120
PDA heart murmur
Machinery murmur continuous through systolic and diastolic at L infraclavicular area
121
Coarctation of the aorta
Narrowing of aorta almost always at level of ductus arteriosus
122
Syndrome often a/w coarctation of aorta
Turner syndrome (15-35%)
123
Obstructive lesions
Coarctation of the aorta
Aortic stenosis
Pulmonary stenosis
124
Coarctation of the aorta tx
Give prostaglandins to kep ductus arteriosus patent
Surgical correction in neonates
Balloon arterioplasty may be considered for older children
125
Test to differentiate btwn cardiac and other causes of cyanosis
Hyperoxic test
Obtain preductal, right radial ABG in room air, then repeat after pt inspires 100% O2
If PaO2 improves to >150mmHg --> less likely cardiac cause
126
Preductal and post ductal oximetry
>5% difference suggests R to L shunt
127
Tetrology of fallot
VSD
Pulmonary stenosis
Aortic root overriding VSD
RVH
128
Most common cyanotic heart defect dx beyond infancy
Tetrology of fallot
129
ToF murmur
Single loud S2 due to severe pulmonary stenosis, systolic ejection murmur at LSB
130
ToF ECG
RAD, RVH
131
ToF CXR
Boot shaped heart
Decreased pulmonary vasculature
Right aortic arch in 20%
132
ToF mgmt
Surgical repair at 4-6mo of age
133
Most common cyanotic CHD in neonates
TGA
134
Transposition of the Great Arteries
Parallel systemic and pulmonary vasculature
Systemic: Body --> RA --> RV --> aorta --> body
Resp: Lungs --> LA --> LV --> pulmonary artery --> lungs
Survival dependent on mixing through PDA, ASD, VSD
135
TGA mgmt
Prostaglandin E1 infusion to keep ductus open until surgical mgmt
136
Total anomalous pulmonary venous return
All pulmonary veins drain into right sided circulation
| ASD must be present to mix oxygenated blood to LA
137
Total anomalous pulmonary venous return mgmt
Surgical repair
138
Ebstein's anomaly
Septal and posterior leaflets of tricuspid valve are malformed and displaced into RV
--> RV dysfunction, tricuspid dysfunction
Often A/W ASD and/or patent foramen ovale causing R-->L shunt
A/W maternal benzo and lithium use in 1st trimester
139
Ebstein's anomaly mgmt
Newborn: consider closure of tricuspid valve and aortopulmonary shunt, or transplant
Older: Tricuspid valve repair or replacement
140
Truncus arteriosus
Single great vessel giving rise to aorta, pulmonary and coronary arteries
Requires surgical repair within first 6wk of life
141
Hypoplastic left heart syndrome
Hypoplastic LV
Narrow mitral/aortic valves
Small ascending aorta
Coarctation of aorta
142
Most common cause of death from CHD in first mo of life
Hypoplastic left heart syndrome
143
Hypoplastic left heart tx
Surgical palliation or heart transplant
144
4 key features of CHF in peds
```
2 tachys and 2 megalys
Tachycardia
Tachypnea
Hepatomegaly
Cardiomegaly
```
145
PVCs
Common in teens
| Benign if single, uniform, disappear with exercise and no associated structural lesions
146
Most frequent sustained dysrhythmia in children
SVT
147
Still's murmur
Innocent
3-6yo
High-pitched, vibratory, LLSB or apex, SEM
Flow across pulmonic valve leaflets
148
Global developmental delay
Performance significantly below average in 2 or more domains of development in a child <5yo
149
Intellectual disability
Historically defined as IQ<70
| Limitations in both intelligence and adaptive skills
150
Bilingual exposure and language delay
Bilingual exposure generally does NOT explain frank delay in language development
151
Developmental disorder with high incidence of psychiatric comorbidity
Specific learning disorder
152
Most common preventable cause of intellectual disability
Fetal alcohol spectrum disorder
153
Fetal alcohol spectrum disorder diseases
FAS
Partial FAS
ARBD (Alcohol related brain damage)
ARND (Alcohol related neurodevelopmental disorder)
154
Criteria for dx of FAS
1. Growth deficiency not due to nutrition
2. Characteristic pattern of facial anomalies (short palpebral fissures, flattened philtrum, thin upper lip)
3. CNS dysfunction, need >/= 3 (motor skills, neuroanatomy/neurophysiology, cognition, language, academic achievement, memory, attention, executive function, affect regulation, adaptive behaviour, social skills or social communication OR microcephaly in infant/young children)
155
Criteria for dx of ARBD
Congenital anomalies (malformations and dysplasias of cardiac, skeletal, renal, ocular and auditory systems)
156
Criteria for dx of ARND
CNS dysfunction
Complex pattern of behavioural or cognitive abnormalities inconsistent with developmental level that can't be explained by familial background or environment alone
157
Dx criteria for DM (Types 1 and 2) in children
1. Symptoms (polyuria, polydipsia, weight loss) and hyperglycemia (random glucose >/= 11.1)
OR 2. 2 of the following on one occasion: fasting glucose >/= 7, 2h plasma glucose during OGTT >/=11.1, Random glucose >/= 11.1
OR 3. One of the following on 2 separate occasions: fasting glucose >/= 7, 2h plasma glucose during OGTT >/= 11.1, random glucose >/= 11.1
158
T1DM
Most common form of DM in children
M=F
Bimodal, peaks at 5-7yo and at puberty
159
Major negative outcome of DKA in children
Cerebral edema
160
Tx for cerebral edema
Mannitol
Decrease fluids
Elevate head of bed
Intubate
161
Kussmaul breathing from DKA
Deep laboured breathing for respiratory compensation of metabolic acidosis
162
DKA management
ABCs
100% O2
Correct fluid losses first (NS + 40mEQ/L KCl)
Insulin 0.05-0.1U/kg/h after fluids running for 1-2h
Add glucose once glucose levels drop to keep in 8-12 range
Can replace fluids with D10NS + 40mEq KCl
DON'T GIVE BICARB
163
Cushing's Triad of cerebral edema
HR low
High BP
Irregular respirations (Cheyne-Stokes)
164
T2DM
F > M
Less common in children but increasing rates due to child obesity
Glycemic taret HbA1c = 7%
Metformin first line
Can start on insulin if A1c > 9% at dx
Screening: Add annual screening for PCOS and NAFLD
165
Short stature
Height <3rd percentile
| Poor growth evidenced by growth deceleration (height crosses major percentile lines, growth velocity <25th percentile)
166
Short stature ddx
```
ABCDEFS
Alone (neglect)
Bone dysplasias (rickets, scoliosis, mucopolysaccharidoses)
Chromosomal (turner, down)
Delayed growth (constitutional)
Endocrine (low GH, Cushing, hypothyroid)
Familial
GI malabsorption (Celiac, Crohn's)
```
167
Investigations for short stature
Calculate mid-parental height Boys: (mother + father's height in cm + 13)/2
Girls: (mother + father's height in cm - 13)/2
AP xray of left hand and wrist fot bone age
GH testing
Other tests based on hx/pe
168
GH therapy for GH deficiency
May help reach adult height if given at an early age AND
1. GH shown to be deficient by 2 diff stimulation tests (arginine, glucagon, insulin)
2. Growth velocity <3rd percentile or height <3rd perventile
Bone age xrays show unfused epiphyses/delayed bone age
169
Measure proportionality
```
Calculate Upper/lower segment ratio using pubic symphysis as landmark
Normal newborn: 1.7
Normal child: 1.4
Normal adult: 0.9
Normal female: 1
```
170
Proportionate short stature with slow growth velocity
```
Endocrine (height more affected than weight)
Chronic disease (weight affected more than height)
Psychosocial neglect
```
171
Tall stature
Height greater than 2 SD above the mean for a given age, sex and race
172
Beckwith-Wiedemann Syndrome
Overgrowth syndrome
Growth slows by ~8yo and adults are not unusually tall
May grow asymmetrically (hemihyperplasia)
A/w omphalocele, umbilical hernia, macroglossia, visceromegaly, creases near ears, hypoglycemia, renal abnormalities
Increased risk of cancerous and noncancerous tumours (esp Wilms tumour and hepatoblastoma) - 10%
Normal life expectancy
173
Tall stature etiology
Constitutional/familial
Endocrine: Beckwith-wiedemann syndrome, hyperthyroidism, hypophyseal gigantims, precocious puberty
Genetic: homocystinuria, klinefelter syndrome, Marfan syndrome, sotos syndrome
174
Homocystinuria
Disorder of methionine metabolism causing abnormal accumulation of homocysteine
Characterized by myopia, dislocation of lens, bloot clotting, osteoporosis, developmental delay
175
Sotos syndrome
Genetic disorder
Distinctive facial appearance (long, narrow face, high forehead, flushed cheeks, pointed chin, down-slanting palpebral fissures), overgrowth in childhood, learning delay
Adult height usually normal
A/W ADHD, phobias, OCD, impulsivity
Scoliosis, sz, heart or kidney defects, hearing loss, vision problems
176
Neonatal grave's disease/Congenital hyperthyroidism
Typically caused by transplacental transfer of TSH receptor antibody
A/w low birthweight, IUGR, microcephaly, prematureity, tachy, frontal bossing, triangular facies, hepatosplenomeg, goiter
177
Neonatal grave's investigations
TSH receptor antibody levels during 3rd trim or in cord blood
Neonatal TSH, T3, free T4
178
Neonatal grave's mgmt
Methimazole and beta adrenergic blocker (ie. propranolol)
| Should resolve within a few weeks
179
Congenital hypothyroidism epidemiology
F:M = 2:1
| One of the most common preventable cause of intellectual disability
180
Congenital hypothyroidism clinical manifestations
Usually asymptomatic in neonatal period b/c maternal T4 crosses placenta
Prolonged jaundice, feeding difficulty, lethargy, constipation, umbilical hernia, macroglossia, large fontanelles, puffy face, swollen eyes
181
Congenital hypothyroidism investigations
Most commonly detected at newborn screen of TSH
Rpt screening at 2wks in high risk infants (preterm, very low birth weight, NICU, specimen collection <24h
Abnormal results confirmed with serum levels from venipuncture
182
Primary congenital hypothyroidism lab results
Increased TSH, low free T4
183
Secondary congenital hypothyroidism lab results
Low TSH, low free T4
184
CH treatment
Thyroxine replacement within 2wk to avoid cognitive imapirment
If tx started after 3-6mo, may result n permanent developmental delay
185
Congenital adrenal hyperplasia
Autosomal recessive disorder characterized by partial or total defect of various synthetic enzymes required for cortisol and aldo production in adrenal cortex
186
Most common cause of ambiguous genitalia in genotypically normal females (46XX)
Congenital adrenal hyperplasia
187
Enzyme responsible for CAH 95% of the time and function
21-hydroxylase mutation
Leads to decrease in cortisol and aldosterone production --> increased shunting of precursors to androgens
Cortisol deficiency leads to elevated ACTH = adrenal hyperplasia
188
Classic 21-OH deficiency with salt wasting
Inadequate aldosterone resulting in FTT, hyper kalemia, hyponatremia, hypoglycemia, acidosis (majority of classic type_
189
Classic 21-OH deficiency without salt wasting
Simple virilization with adequate aldosterone
Females: Amenorrhea, precocious puberty, polycystic ovaries, hirsutism
Males: Typically asymptomatic at birth, may have hyperpigmentation, penile enlargement, rapid growth and accelerated skeletal maturation, virilization later in life
190
Non-classic CAH
Mild androgen excess, sometimes asymptomatic, virilization present later in life
191
CAH investigation
High serum levels of 17-OH progesterone
Newborn screening
Assess plasma ACTH, serum electrolytes, plasma glucose, plasma aldo, plasma renin, blood gas
U/S to look for enlared adrenal gland and presence of uterus
192
CAH treatment
Glucocorticoids (ie. hydrocortisone); more in times of stress
Mineralocorticoids (ie. fludrocordisone) as necessary to reduce ACTH levels
193
HPG axis during puberty
Pulsatile release of GnRH --> increased release of LH and FSH --> maturation of gonads, release of sex steroids --> secondary sexual characteristics
194
Female puberty
Onset: age 8-13 (7 in African descent), earlier common
1. thelarche (breast budding)
2. pubarche (axillary hair, body odour, mild acne)
3. growth spurt
4. menarche (mean age 12.5)
195
Male puberty
```
Onset: age 9-14yo, earlier uncommon
1. Testicular enlargement
2. Penile enlargement
3. Pubarche (axillary and facial hair, body odour, mild acne)
4. Growth spurt (occurs later in boys)
Gynecomastia common and self limited
```
196
Female breast tanner staging
1: papilla elevation
2: breast and papilla elevated as small mound, areola enlarging
3: Enlarging breast and areola, no contour separation
4: areola and papilla form secondary mound
5: mature, nipple projects, no secondary mound
197
Female genital tanner staging
1: no hair, prepubertal
2: small amount of long, straight or curled, slighlty pigmented along labia majora
3: Darker, coarser, curlier hair distributed sparsely over pubis
4: adult-type hair; no extension to medial thighs
5: mature distribution with spread to medial thighs
198
Male genital tanner staging
1: no hair, prepubertal
2: small amount of long, straight or curled slightly pigmented hair along base of penis. enlargement of testes and scrotum, reddening of scrotal skin
3: darker, coarser, curlier hair distributed sparsely over pubis. lengthening of penis, further enlargement of testes and scrotum
4: adult type hair, no extension to medial thighs. Increasing penile circumference and length, development of glands, further enlargement of testes and scrotum, darkening of scrotal skin
5: mature distribution with spread to medial thighs. Adult size
199
Precocious puberty in females
<8yo
200
Precocious puberty in male
<9yo
201
Central cause of precocious puberty
GnRH dependent
hypergonadotropic hypergonadism
Hormone levels as in normal puberty
Premature activation of HPG axis
May be normal, CNS disturbance (tumours, hamartomas, post-meningitis, increased ICP, radiotherapy), NF, primary severe hypothyroidism
If proven central cause, get MRI of brain
202
Peripheral cause of precocious puberty
GnRH independent
Hypogonadotropic hypergonadism
Adrenal d/o (CAH), testicular/oavarian tumour, gonadotropic/hCG secreting tumour (ie. hepatoblastoma, intracranial teratoma, germinoma), exogenous steroid administration, McCune-Albright syndrome, primary severe hypothyroidism
203
McCune-Albright Syndrome
Genetic disorder
Develop fibrous tissue in bones (polyostic fibrous dysplasia) --> asymmetric growth
Cafe au lait spots w/ irregular borders
Precocious puberty (menstrual bleeding at very young age)
Goiter
Hyperthyroidism
Acromegaly
204
Tx of central precocious puberty
GnRH agonists (ie. leuprolide)
205
Tx of peripheral precocious puberty
Meds that decrease production of specific sex steroid or block its effects (ie. ketoconazole, spironolactone, tamoxifen, anastrozole)
Surgery
206
Delayed puberty in males
Lack of testicular enlargement by 14yo
207
Delayed puberty in females
Lack of breast development by 13yo or absence of menarche by 16yo or within 5yr of pubertal onset
208
Central causes of delayed puberty
Constitutional delay in HPG axis activation (most common)
| Hypogonadotropic hypogodanism
209
Peripheral causes of delayed puberty
Hypergonadotropic hypogonadism (ie. primary gonadal failure, gonadal damae, Turner's syndrome, hormone deficiency, androgen insensitivity syndrome)
210
Tx of delayed puberty
Hormone replacement
Cyclic estradiol and progesterone for females
Testosterone for males
211
Mild degree of dehydration
```
5% in <2yo, 3% in >2yo
Normal pulse
Normal BP
Decreased UO
Slightly dry oral mucosa
Normal ant fontanelle
Normal eyes
Normal skin turgor
Normal cap refill
```
212
Moderate degree of dehydration
```
10% in <2yo, 6% in >2yo
Rapid pulse
Low to normal BP
Markedly decreased UO
Dry oral mucosa
Sunken anterior fontanelle
Sunken eyes
Decreased skin turgor
Normal to increased cap refill
```
213
Severe degree of dehydration
```
15% in <2yo, 9% in >2yo
Rapid, weak pulse
Decreased in shock (very late finding in peds and very dangerous)
Anuria
Parched oral mucosa
Markedly sunken anterior fontanelle
Markedly sunken eyes
Tenting
Increased cap refill
```
214
Mild dehydration tx
Rehydrate with ORT at 50cc/kg over 4h
215
Moderate dehydration tx
Rehydrate with ORT at 100cc/kg over 4h
216
Severe dehydration tx
IV resuscitation with NS or RL at 20-40cc/kg over 1h
| Begin ORT when pt stable
217
IV fluid for newborn
D10W
218
IV fluids for first month of life
D5W/0.45 NS + KCL 20mEq/L (only add KCl if voiding well)
219
IV fluids for children
D5W/NS + KCl 20mEq/L or D5W/0.45NS + KCl 20 mEq/L
220
Pyloric stenosis - 3Ps
Peristalsis
Pyloric mass
Projectile vomiting (2-4wk after birth)
221
Fussiness after feeds, spit ups, arching of back, poor weight gain
GERD
222
GERD investigations
Empiric trial of acid suppression
pH monitoring study
Upper GI study
Endoscopy
223
Bilious emesis ddx
Malrotation with volvulus
Meconium ileus
Duoenal atresia/stenosis
Hirschsprung's disease
224
Upper GI series sign for duodenal atresia
Double bubble sign
225
Triad of intussusception
1. colicky progressive abdo pain
2. bilious vomiting
3. red currant jelly stool
226
Gastroesophageal reflux vs GERD
Reflux is vomiting typically soon after feeding, non-bilious, very common, rarely progresses to GERD
GERD = reflux when it causes troublesome symptoms (ie. poor weight gain, heart burn, asthma, URTIs, OMs)
227
Sigmoid volvulus AXR sign
Coffee bean sign
228
Diarrhea
Infants = increase in stool frequency to 2x as often per day
Older children = 3+ loose or watery stools/day
Acute: <2 wk
Chronic: >2wk
229
Most common virus causing gastroenteritis
Rotavirus
230
Stool analysis (bacterial vs viral)
Leukocytes/erythocytes --> bacterial/parasitic
| pH <6 and presnece of reducing substances --> viral
231
Most common cause of chronic diarrhea in thriving child
Toddler's diarrhea
232
Toddler's diarrhea
Onset at 6-36mo
Ceases spontanesouly btwn 2-4yo
4-6 BM/d
Dx of exclusion in thriving child
233
Toddler's diarrhea tx
```
4Fs
Fibre
Normal fluid intake
35-40% fat
Discourage excess fruit juice
```
234
Skin rash a/w celiac disease
Dermatitis herpetiformis
235
Diagnosing celiac disease
Serum anti-tTG antibody (type of IgA antibody)
IgA deficient pts have false negative anti-tTG
MUST measure IgA concomitantly
Small bowel mucosal biopsy (usually duodenum) is dx with increased intraepithelial lymphocytes (earlist path finding)
236
Milk allergy
IgE mediated
| Skin, upper and lower respiratory symptoms within hours of milk exposure
237
Cow's milk protein allergy
Non-IgE mediated, more common
238
Most common cause of acute abdo after 5yo
Appendicitis
239
Common site for intussusception
Ileocecal junction
240
Intussusception tx
Air enema or hydrastatic pressure
| Sugery rarely needed
241
Physiologic anemia
Normal to fall to as low as 100g/L at 8-12wk of age due to shorter fetal RBC lifespan
Usually no tx required
242
Most common cause of childhood anemia
Iron deficiency anemia
243
Mentzer index
MCV/RBC
Helps distinguish Fe def anemia vs thalassemia
Ratio < 13 = thalassemia
Ratio > 13 = iron deficiency
244
Blood smear indicative of fe-def anemia
Hypochromic, microcytic RBCs
Pencil shaped cells
Poikylocytosis
245
Iron studies in iron-def anemia
```
Low ferritin
Low Fe
High TIBC
High transferrrin
Low TSat
```
246
Fe def anemia tx
Oral iron therapy: 4-6mg/kg/d elemental iron divided BID to TID for 3 mo
Repeat Hb after 1mo of treatment
247
Most common cause of thrombocytopenia in childhood
Immune thrombocytopenic purpura
248
Immune thrombocytopenic purpura
Binding of antiplatelet antibody to platelet surface, leading to removal and destruction of platelets in spleen and liver
249
ITP presentation
50% present 1-3wk after viral illness
No lymphadenopathy
No hepatosplenomegaly
Sudden onset petechiae, prupura, epistaxis in otherwise well child
250
ITP management
Spontaneous recovery in >70% of cases within 3mo
IVIg or prednisone if significant bleeding, plt <10 or at risk of significant bleeding
avoid contact sports
avoid ASA/NSAIDs
251
Most common type of pediatric malignancy
Leukemia
252
Leukemia classification
ALL (80%)
AML (15%)
CML (<5%)
253
Most common presentation of Hodgkin lymphoma
Persistent, painless, firm, cervical or supraclavicular lymphadenopathy
254
Hodgkin lymphoma treatment
Combo chemotherapy and radiation
255
Non-Hodgkin lymphoma treatment
Combo chemotherapy
| No added benefit of radiation in peds protocols
256
Most common primary renal neoplasm of childhood
Nephroblastoma (Wilm's Tumour)
257
Most common cancer occurring in first year of life
Neuroblastoma
258
Nephroblastoma prognosis
90% long term survival
259
Neuroblastoma prognosis
Poor
| Often late detection
260
Fever without a source
Acute febrile illness (typically <10d) with no cause discerned even after careful hx and physical
261
Fever of unknown origin
Daily or intermittent fevers for at least 2 consecutive wk of uncertain cause after careful hx and P/E and initial lab assessment
262
More common bacterial causes of AOM
S. pneumoniae
H. influenza
M. catarrhalis
GAS
263
AOM tx
Watchful waiting if appropriate
| Abx if <6mo or moderately/severely ill (Amoxicillin 75-90mg/kg/d dosed BID x10d for 6mo-2y and 5d if >/2 yr)
264
Most common cause of pediatric hearing loss
OM with effusion
265
Erythema infectiosum
AKA Fifth disease/slapped cheek
Parvovirus B19
Flu-like illness for 7-10d then rash appears ~10-17d after
Erythematous maculopapular rash, lacy on cheeks, may affect trunk/extremities
Supportive mgmt
266
Giannoti-Crosti Syndrome
EBV and Hep B
* Asymptomatic symmetric papules
* On face, cheeks, extensor surfaces of extremities, spares trunk
* Viral prodrome
* May have lymphadenopathy, hepatosplenomegaly
* Asymptomatic symmetric papules
* On face, cheeks, extensor surfaces of extremities, spares trunk
* Viral prodrome
* May have lymphadenopathy, hepatosplenomegaly
Supportive mgmt
Pain control
Resolves in 3-12wk
267
Hand, foot, mouth dz
Coxsackie group A
* Vesicles and pustules on erythematous base
* Extremities
* May have vesicles in posterior oral cavity
Supportive mgmt
268
Measles
Morbillivirus
* Airborne transmission
* Prodrome of fever, cough, coryza, conjunctivitis
* Maculopapular rash starts on neck, behind ears and along hairline 3d after start of symptoms
* Rash spreads downward, reaching feet in in 2-3d
* Initial rash on buccal mucosa as red lesions with bluish white spots in center (Koplik spots)
Supportive
Unimmunized contacts: measures vaccine within 72h of exposure or IgG within 6d of exposure
269
Roseola
HHV6
* Exanthem subitum = blanching, erythematous macules start on neck and trunk —> spread to arms (less commonly face and legs)
* Rash typically preceded by 3-4d of high fevers --> end as rash appears
* Usually in children <2yrs
Supportive tx
270
Rubella
* Droplet transmission
* Prodrome of low grade fever, sore throat, arthritis
* Pink, maculopapular rash appears 1-5d after start of symptoms
* Starts on face and spreads to neck and trunk
Supportive
MMR vaccine for prevention (caution with pregnant women)
271
Varicella
```
Varicella zoster virus
Mainly airborne transmission
Groups of polymorphic lesions (macules, papules, vesicles, crusts)
Generalized distribution
Significant pruritus
Supportive
Consider antiviral
```
272
Mono classic triad
Febrile
Generalized non-tender lymphadenopathy
Pharyngitis/tonsillitis
273
Coarctation of the aorta often associated with...
Bicuspid aortic valve (75-85%)
274
CXR findings of coarctation of the aorta
Upper left mediastinal shadow
Cardiomegaly may be seen in older children
Dilated intercostal collateral arteries may erode 3rd to 8th ribs causing rib notching (years to develop)
275
Coarctation of the aorta murmur
Grade 2-3/6 ejection systolic murmur best heard in left interscapular area
Ejection click may be aduible when associated with bicuspid aortic valve
276
Treatment for GAS pharyngitis
Penicillin V
Amoxicillin
or Erythromycin x 10d
Tx prevents rheumatic fever but does NOT alter risk of post-strep GN
277
PANDAS
Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci
278
Scarlet fever
Hypersensitivity rxn to exotoxin produced by GAS
Fever, sore throat, strawberry tongue
Sandpaper rash ~24-48h after pharyngitis (blanchable, perioral sparing, non-pruritic, non-painful)
Tx: Penicillin, amoxicillin, or erythromycin x 10d
279
Rheumatic fever
Due to antibody cross-reactivity following GAS
| Tx: Penicillin or erythromycin for acute course x 10d, prednisone if severe carditis
280
Post-strep GN
Occurs 1-3wk after initial GAS infection
Dx confirmed with elevated serum antibody titres against strep antigens (ASOT, anti-DNAse B), low serum complement (C3)
Tx: fluids, Na+ restriction, loop diuretics for HTN and edema
Tx: Penicillin or erythromycin if evidence of persistent GAS infection
Prognosis: 95% children recover completely within 1-2 wk
281
Bacterial meningitis CSF findings
```
WBC < 100x10^5
Neutrophils 100-10000 x 10^5 (may be normal)
Glucose <0.4 (CSF:Blood), may be normal
Protein > 1 (may be normal)
RBC 0-10
```
282
Viral meningitis CSF findings
```
WBC 10-1000 x 10^5 (may be normal)
Neutrophils usually <100 x 10^5
Glucose level usually normal
Protein 0.4-1 ( can be normal)
RBC 0-2
```
283
Herpest meningitis CSF findings
```
WBC 50-1000 (can be normal)
Neut <100
Glucose <0.3
Protein 1-5
RBC 10-50
```
284
Common culprits of bacterial meningitis in 0-4wks
```
KLEG
Klebsiella (-)
L. monocytogenes (+)
E. coli (-)
GBS (+)
```
285
Common culprits of bacterial meningitis in 1-23mo
```
H. SN-EG
GBS
E. coli
S. pneumoniae
N. meningitidis
H. influenzae
```
286
Common culprits of bacterial meningitis in >2yo
SNL
S. pneumo
N. meningitis
L. monocytogenes
287
Empiric abx for 0-28d suspected meningitis
Ampicillin + Cefotaxime
288
Empiric abx for 28-90d suspected meningitis
Cefotax + Vancomycin (+ Amp if immunocompromised)
289
Empiric abx for >90d
Ceftriaxone +/- vancomycin
290
HSV meningitis tx
Acyclovir
291
Pertussis bacteria
Bordtella pertussis
| Gram negative pleomorphic rod
292
Stages of pertussis
Prodromal catarrhal stage: 1-7d, URTI symptoms, no or low-grade fever
Paroxysmal stage: 4-6 wk, whooping cough
Convalescent stage: 1-2wk, decreased frequency of coughing episodes, may last up to 6mo
293
Pertussis treatment
Macrolide (azithro, erythromycin, clarithromycin) if B. pertussis isolated or symptoms present <21d
Droplet isolation until 5d of tx
Report to Public Health
Macrolide abx for all household contacts
Vaccine
294
Common bacterial culprit of preseptal cellulitis in children
H. influenza
295
Common bacterial culprits of preseptal cellulitis in adults
S. aureus
| Streptococcus
296
Treatment for preseptal cellulits
Amox-clav
297
Treatment for orbital cellulitis
Admit
Blood cultures x 2
Orbital CT
Ceftriaxone + Vancomycin IV x 7d
298
Cardinal signs of orbital cellulitis
* Ophthalmoplegia/diplopia
* Decreased VA
* Pain with extra ocular eye movement
299
Common bacterial culprits for UTIs
```
KEEP (Gram neg)
Klebsiella
E. Coli
Enterobacter
Pseudomonas
and
S. saprophyticus (+)
Enterococcus (+)
```
300
Empiric abx for UTI in neonate
IV amp and gent
| Abx ourse: 7-10d
301
Empiric abx for infant/older children
Oral abx (based on local E. coli sensitivity
If requiring IV: IV amp and gent
Abx course: 7-10d
302
UTI imaging for neonates
Kidney/bladder U/S for:
* Children < 2y.o. with first febrile UTI
* Children of any age with recurrent febrile UTIs
* Children of any age with UTI who have fam hxof renal or urologic disease, poor growth, hypertension
* Children who do not respond as expected to appropriate antimicrobial therapy
303
Voiding cystourethrogram
X-rays to take pictures of urinary system
* Children of any age with ≥ 2 febrile UTIs OR
* Children of any age with first febrile UTI AND abnormality on renal U/S OR
* Fever ≥ 39C and pathogen other than E. coli OR
* Poor growth or hypertension
304
Small for gestational age
2 SD < mean weight for GA or <10th percentile
305
Large for gestational age
2 SD > mean weight for GA or >90th percentile
306
Low birthweight
<2500g
307
Very low birthweight
<1500g
308
Extremely low birthweight
<1000g
309
APGAR
```
Appearance (colour)
Pulse
Grimace (irritability)
Activity (tone)
Respirations
```
If <7 at 5min, then reassess q5min until <7
310
APGAR scores of 1
```
HR <100/min
Slow, irregular resps
Grimace
Some flexion of extremities
Body pink, extremities blue
```
311
APGAR scores of 2
```
HR > 100/min
Good, crying resps
Cough/cry
Active motion
Completely pink
```
312
HR at which to start chest compressions in neonate
HR < 60
313
Treatment for apnea of prematurity (<34wk)
Methylxanthines (caffeine) to stimulate CNS and diaphragm
| Not for term infants
314
Hemorrhagic disease of the newborn
Vitamin K deficiency
| Both PT and PTT are abnormal since factors X, IX, VII, II are affected
315
Hypoglcyemia in newborn
Glucose <2.6mmol/L
316
Preferred imaging modality to investigate intraventricular hemorrhage
Head U/S
317
Neonatal hyperbilirubinemia
Total serum bili >95th percentile (high risk zone) on Butani nomogram in infants >3wks GA
318
Jaundice is pathological if
- It occurs within 24h of birth
- Conjugated hyperbilirubinemia is present (>35)
- Unconjugated bilirubin rises rapidly or is excessive for pt's age and weight (>257 in full term)
- Persistent jaundice lasts beyond 1-2 wk of age
319
Enzyme used to conjugate bilirubin
Glucoronyl transferase (Immature in neonates)
320
Enzyme in meconium used to hydrolyze conjugated bili back to unconjugated bili
Beta glucuronidase
| Causes increased enterohepatic circulation
321
Physiologic jaundice
Total bili = 257umol/L
| Peaks at 3-4d of life, resolves by 10d of life
322
Breastfeeding jaundice
Lack of milk production --> dehydration --> exaggerated physiologic jaundice
Early in first week of life
323
Breast milk jaundice
Onset at 7d of life, peaks at 2-3wk, usually resolved by 6wk
| Glucoronyl transferase inhibitor in breast milk
324
Galactosemia
Genetic disorder (GALT gene) causing inability to properly process galactose
A/W jaundice, cataracts, lethargy, repro problems in females
Decreased level of erythrocyte galactose-1-phosphate uridyltransferase
325
Criggler Najjar Syndrome
* RARE auto recessive conditions that causes severe unconjugated hyperbilirubinemia starting in first few days of life
* Results from decreased bili clearance caused by deficient (type 2) or completely absent (type 1) UDPGT = kernicterus
326
Gilbert Syndrome
* UGT1A1 gene (auto recessive): Decreased enzyme function interferes with gluronidation àconjugation of bili is slowed
* Intermittent, self-resolving epis of unconjugated hyperbilirubinemia
* Usually STARTS in adolescence
327
Kernicterus
Unconjugated bili concentrations exceed albumin binding capacity --> bili deposited in brain = tissue necrosis and permanent damage to basal ganglia or brainstem
Incidence increases as bili > 340umol/L
328
Unconjugated hyperbilirubinemia tx
1. Phototherapy
2. Exchange transfusion (mostly for hemolytic or G6PD)
3. IVIg if severe (DAT+)
329
Biliary atresia
Atresia of extrahepatic bile ducts which leads to cholestasis and increased conjugated bili after 1st week of life
Tx: Kasai procedure (anastomosis to allow bile to drain directly into intestine); 2/3 require liver transplantation
330
Necrotizing enterocolitis
Primarily affects terminal ileum and colon
| Internal inflammation a/w focal or diffuse ulceration and necrosis
331
Necrotizing enterocolitis AXR hallmark
```
Pneumonitis intestinalis
(intramural air)
```
332
Persistent Pulmonary Hypertension of the Newborn
Persistence of fetal circulation due to persistent elevation of pulmonary vascular resistance (ongoing R-->L shunt through PDA, foramen ovale --> decreased pulmonary blood flow and hypoxemia --> further pulmonary vasoconstriction)
333
Respiratory distress syndrome
Deficiency of lung surfactant —> poor lung compliance due to high alveolar surface tension —> atelectasis —> decreased SA for gas exchange —> hypoxia + acidosis —> respiratory distress
* Resp distress within first few hours of life, worsens over next 24-72h
* Hypoxia
* Cyanosis
334
Most common cause of respiratory distress in premature infants
Respiratory distress syndrome
335
RDS treatment
Resuscitation, oxygen, ventilation
| Surfactant (decreases alveolar surface tensions, improves lung compliance and maintains functional residual capacity)
336
RDS CXR findings
Ground glass
Air bronchograms
Decreased lung volume
337
Transient tachypnea of the newborn
Delayed clearance of fluid from lungs following birth
Usually in late and late preterm babes born via C/S to diabetic moms
Tachypnea with no hypoxia or cyanosis
338
TTN Tx
Supportive
O2 if hypoxic
Ventilator support
Recovery expected in 24-72h
339
TTN CXR
Perihilar infiltrates
| No consolidation/air bronchograms
340
Snowman heart on CXR
Total anomalous pulmonary venous return
341
Tricuspid atresia murmur
Single S2 with 2-3/6 systolic regurg murmur at LLSB if VSD is present
342
Hirschprung disease
Absence of myenteric plexus in distal colon
40% of children with this do not pass mec in first 24h
Dx via full-tickness rectal bx
Tx: remove aganglionic bowel and restore continuity of healthy bowel with distal rectum
343
Most commonly used diuretic for CHF edema in children
Lasix
| then thiazide diuretic as second line/in combo
344
Mongolian spots
Congenital dermal melanocytosis
345
Hemolytic uremic syndrome
Simultaneous occurrence of triad of:
Non immune MAHA
Thrombocytopenia
Acute renal injury
346
Most common cause of acute renal failure in children
Hemolytic Uremic Syndrome
347
Most common cause of HUS in peds
E. coli O157:H7, shiga toxin
348
Tx of HUS
* Mainly supportive (nutrition. hydration, ventilation if needed, blood transfusion for symptomatic anemia
* Steroids not helpful
* Abx are C/I as death of bacteria leads to increased toxin release and worse clinical course
349
Nephritic syndrome
```
PHAROH:
Proteinuria (>50mg/kg/d)
Hematuria (>5 RBCs/hpf)
Azotemia
RBC casts
Oliguria
HTN
```
Most common in 5-15yo
350
Most common cause of acute GN in pediatrics
Post-infectious GN
351
Causes of nephritic syndrome
```
Post-infectious GN
Membranoproliferative
IgA nephropathy
Idiopathic rapidly progressive GN
Anti-GBM disease
HSP
Granulomatosis with polyangitis
Goodpasture's syndrome
Polyarteritis nodosa
SLE
Bacterial endocarditis
Abscess or shunt nephritis
Cryoglobuminemia
```
352
Nephrotic syndrome
```
PALE
Proteinuria (>50mg/kg/d)
HypoAlbumoinemia (<20g/L)
HyperLipidemia
Edema
Most common in 2-6yo, M>F
```
353
Most common cause of nephrotic syndrome in peds
Primary idiopathic
354
Nephrotic syndrome etiology, glomerular inflammation absent on renal biopsy
Minimal change disease (85%)
| Focal segmental glomerular sclerosis
355
Nephrotic syndrome etiology, glomerular inflammation present on renal biopsy
Membranoproliferative GN
| IGA neprhopathy
356
Causes of nephrotic syndrome
AI (SLE, DM, rheumatoid arthritis)
Genetic (sickle cell dz, alport)
Infections (hep B/C, post-strep, infective endocarditis, HUS, HIV)
Malignancies
Meds (NSAIDs, antiepileptics)
Vasculitides (HSP, granuloamtosis with polyangiitis)
Congenital
357
Often first sign of nephrotic syndrome
Edema (periorbital, pretibial)
358
Urine findings of nephrotic syndrome
3-4+ proteinuria, microscopic hematuria
Microscopy (oval fat bodies, hyaline casts)
First morning urine protein/creatinine ratio (>200mg/mmol)
359
Tx for nephrotic syndrome
Often corticosteroids
Furosemide + albumin for generalized edema
May need statin therapy
ACEI/ARBs for persistent HTN
360
HTN in childhood
sBP and/or dBP >/= 95th percentile for sex, age and height on >/= 3 occasions
361
Treatment of HTN in peds
Gradual BP lowering using thiazide diuretics
| If HTN emergency, use hydralazine, labetalol, sodium nitroprusside
362
Cerebral palsy
Non-progressive central motor impairment syndrome due to insult to or anomaly of immautre CNS
363
Types of cerebral palsy
Spastic (70-80%) -- UMN of pyramidal tract affected
Athetoid/dyskinetic (10-15%) -- Basal ganglia
Ataxic (<5%) -- cerebellum
Mixed
364
Simple febrile seizure
```
ALL of:
<15min
Generalized tonic-clonic
No recurrence in 24h period
No neuro impairment or developmental delay before or after seizure
```
365
Complex febrile seizure
```
At least 1 of:
Duration >15min
Focal onset or focal features
Recurrent (>1 in 24h period)
Previous neuro impairment or neuro deficit after sz
```
366
Neurofibromatosis type I
Autosomal dominant
Dx requires 2 or more of:
>/= 6 cafe au lait spots (>5mm if prepuberal, >1.5cm if postpubertal)
>/=2 neurofibromas of any type or one plexiform NF
>/=2 Lisch nodules (hamartomas of iris)
Optic glioma
Freckling in axillary or inguinal region
Distinctive bony lesion
First degree relative with confimed NF-1
367
Neurofibromatosis type II
Autosomal dominant
Bilateral vestibular schwannomas or 1st degree relative with NF2 and either unilat vestibular schwannoma OR any 2 of: meningioma, glioma, schwannoma, NF, posterior subcapsular lenticular opacities
368
Infantile spasms
Brief repeated symmetric contractions of neck, trunk, extremities lasting 10-30s, often a/w developmental delay
369
Infantile spasm EEG
Hypsarrhythmia (high voltage slow waves, spikes and polyspikes, background disorganization)
370
West syndrome
Infantile spasms
Psychomotor developmental arrest
Hypsarrhythmia
371
Infantile spasm tx
ACTH injections
Vigabatrin (GABA inhibitor)
Benzo
372
Lennox Gastaut
Triad of:
Multiple seizure types
Diffuse cognitive dysfunction
Slow generalized spike and slow wave EEG
Seen with underlying encephalopathy and brain malformations
373
Lennox-Gastaut tx
Valproic acid
Benzos
Ketogenic diet
374
Juvenile Myoclonic epilepsy (Janz Syndrome)
Generalized tonic clonic sz
| Autosomal dominant with variable penetrance
375
Juvenile myoclonic epilepsy EEG
3.5-6Hz irregular spike and wave, increased with photic stimulation
376
Juvenile myoclonic epilepsy mgmt
Lifelong treatment with valproic acid
377
Childhood absence epilepsy
Multiple absence sz per day lasting <30s without post-ictal state
May resolve spontaneously or become generalized in adolescence
378
Childhood absence epilepsy EEG
3Hz spike and wave
379
Childhood absence epilepsy mgmt
Valproic acid or ethosuximide
380
benign focal epilepsy of childhood with rolandic/centrotemporal spikes
Focal motor sz involving tongue, mouth, face, upper extremity usually in sleep-wake transition states
Remains conscious but aphasic post-ictally
381
Benign focal epilepsy with rolandic spikes EEG
Repetitive spikes in centrotemporal area with normal background
382
Benign focal epilepsy tx
If frequent sz: carbamapazemine
| If infrequent sz: no tx needed
383
When to initiate tx for sz
Often if >2 unprovoked afebrile sz within 6-12mo
384
When to discontinue tx for sz
Until pt free of sz for >2yr then wean over 4-6mo
385
Chronic asthma management
```
Rescue ventolin (SABA)
1st line: low dose ICS
2nd line <12yo: moderate dose of daily ICS
2nd line >12yo: leukotriene receptor antagonist OR LABA + low dose ICS or Leukotrine antagonist monotherapy
```
386
Age to start PFTs
>6yo
| self-monitor with peak flows to improve self-awareness of status
387
Bronchiolitis
LRTI usually in children <2yo
| Leads to increased incidence of asthma in later life
388
Most common viral etiology of bronchiolitis
RSV
389
Time course of bronchiolitis
Peaks at 3-4d, lasts 2-3wk
390
Cystic fibrosis presenting signs
CF PANCREAS
Chronic cough and wheeze
FTT
Pancreatic insufficiency (ie. steatorrhea)
Alkalosis and hypotonic dehydration
Neonatal intestinal obstruction (ie. mec ileus), Nasal polyps
Clubbing, CXR findings
Rectal prolapse
Electrolyte elevation in sweat, salty skin
Absence or congenital atresia of vas deferens
Sputum with S. aureus or P. aeruginosa
391
Testing for CF
Sweat chloride test x 2
| CFTR gene mutation analysis
392
Croup
Laryngotracheobronchitis
Subglottic laryngitis
Barking cough, stridor, worse at night
Most commmon in 6mo-3yo
393
Croup etiology
Parainfluenza (75%)
Influenza A and B
RSV
Adenovirus
394
Croup CXR
Steeple sign from subglottic narrowing
| Not needed for dx
395
Croup tx
```
Stridor at rest is emergency
No evidence for humidifed O2
Dexamethasone PO 1 dose
Racemic epi neb 1-3 doses, q-12h
Intubation if unresponsive to tx
```
396
Bacterial tracheitis
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Subglottic tracheitis
Rare
Caused by S. aureus, H. influenza, pneumococcus, M. catarrhalis
Rapid deterioration
IV abx and intubation
```
397
Epiglottitis
Supraglottic laryngitis
4Ds: Drooling, dysphagia, dysphonia, distress
Avoid examining throat to prevent further exacerbation
398
Epiglottitis etiology
H. influenzae
| beta-hemolytic strep
399
Juvenile idiopathic arthritis
Arthritis in >/=1 joint(s) for >/= 6wk, onset age <16yo
Exclusion of other causes of arthritis
Classification defined by features/numbers of joints affected in first 6mo of onset
400
Still's disease/systemic arthritis
Onset at any age
1-2x/d fever spikes (>38.5C) >/= 2d/wk with temps returning below baseline
Erythematous salmon-coloured maculopapular rash, lymphadenopathy, hepatosplenomegaly, leuk, thrombocytosis, anemia, serositis
401
Oligoarticular arthritis
```
1-4 joints
Most common type of JIA
Typically large joints (knees, elbows, wrists)
ANA + in 60-80%
RF neg
```
402
Polyarticular arthritis
```
>/=5 joints
RF neg (usually) - symmetrical, large and small joints of hands and feet, TMJ, cervical spine
RF pos - severe, rapidly destructive, symmetrical, large and small joints
```
403
Enthesitis-related arthritis
Weight-bearing joints, esp hip and intertarsal joints
| Risk of developing ank spond
404
Psoriatic arthritis
Arthritis + psoriasis OR
arthritis and at least 2 of dactylytis, nail pitting or other abnormalities, or fam hx of psoriasis in a 1st degree relative
Asymmetric or symmetric small or large joint involvement
405
Juvenile idiopathic arthritis tx
1st line: NSAIDs, intra-articular corticosteroids
2nd line: DMARDs (MTX, sulfasalazine), corticosteroids, biologics (IL1, IL6 inhibition for systemic arthritis, TNF antagonist for polyarticular JIA)
406
Lyme arthritis
Caused by spirochete Borrelia burgdorferi
| Do not treat children <8yo with doxycycline (may cause permanent tooth discolouration)
407
Reactive arthritis
Salmonella, Shigella, Yersinia, Campylobacter, Chlamydia, Streptococcus
408
Reiter's syndrome
Conjunctivitis
Urethritis
Arthritis
Occuring after an infection
409
Transient synovitis of the hip
```
Benign, self-limited inflammatory joint disorder usually after URTI, pharyngitis, AOM
More common on right side
Painful limp but full ROM
Symptomatic and anti-inflammatory meds
Usually resolves in 24-48h
```
410
Most common vasculitis of childhood
Henoch-Schonlein Purpura
411
Henoch-Schonlein Purpura
Vasculitis of small vessels, often following 1-3wk of URTI
Clinical triad:
Palpable purpura (non-thrombocytopenic purpura in lower extremities, scrotal swelling)
Abdo pain (GI bleed, intussusception)
Arthritis (large joints)
412
HSP tx
Mainly supportive
Anti-inflammatory meds for joint pain, corticosteroids for select pts
Self-limited, resolves within 4wk
413
Most common cause of acquired heart disease in children in developed countries
Kawasaki disease
414
Kawasaki disease
Medium-sized vasculitis with predilection for coronary arteries
Likely triggered by infection
415
Kawasaki dx criteria
HOT CREAM
Fever persisting >/= 5d AND >/=4 of:
Conjunctival injection (bilateral, non exudative)
Rash (polymorphous)
Edema/erythema of hands and feet
Adenopathy (cervical >1.5cm in diameter, usually unilateral)
Mucosal changes (fissured lips, strawberry tongue, injected pharynx)
416
Kawasaki tx
IVIG and high dose ASA
Once afebrile >48h, low dose ASA until plts normalize
Baseline echo and follow up periodic echo usually at 2 and 6wk
417
Risk a/w kawasaki
Coronary aneurysm
| If receive IVIg within 10d onset, reduces risk
418
Most common organisms a/w septic arthritis
```
Staph aureus
Streptococcus (neonate --> group B, infant/older child --> group A and strep pneumo)
H. influenza type B
N. gonorrhea
Kingella kingae
```
419
Slipped capital femoral epiphysis
Posterior displacement of capital femoral ephiphysis from femoral neck through cartilage growth plate
Causes limp and impaired internal rotation
Common in adolescents
Tx: Internal reduction of femoral head
420
Legg-Calve Perthes dz
Most commonly affects boys btwn 4-10yo
Avascular necrosis of capital femoral ephiphysis
Refer to ortho
421
Developmental dysplasia of hip
Most common in females born breech
| Femoral head not properly aligned with acetabulum
422
Most common cause of neonatal and antenatal hydronephrosis
Ureteropelvic junction obstruction
423
Potter's syndrome
Bilateral renal agenesis
424
Cryptorchidism
Most common genital progrem
| Presents with empty and hypoplastic or poorly rugated scrotum or hemiscrotum
425
DiGeorge Syndrome
CATCH-22
Congenital heart abnormalities
Abnormal facies
Thymic aplasia
Hypocalcemia from hypoparathyroidism Failure of 3rd and 4th branchial pouch development
--> poorly developed thymus and parathyroid
HypoPTH --> HypoCa --> Tetany
Low T-cell maturation --> recurrent infections (esp candida)
Gene deletion in chromosome 22q11
Tx: Ca supplement and thymus tissue transplant
426
Suggestion of impending respiratory failure in asthma attack
PaCO2 > 43
427
3 most common bacterial infections in cystic fibrosis patients
Staph aureus
H. influenza
Pseudomonas aeruginosa (most common in pts >10)
428
Bacterial infection in CF a/w multiple antibiotic resistance
Burkholderia cepacia
429
Most beneficial agent for long-term mucus clearance in cystic fibrosis patient
Aerosolized dornase alfa (DNAse to help break down polymerized DNA dervied from degraded neutrophils in viscous mucus)
430
Bilirubin induced neurologic dysfunction
Caused by indirect hyperbilirubinemia
Kernicterus, opisthotonus , delayed motor skills, choreoathetosis, sensorineural hearing loss
Tx: Immediate exchange transfusion
431
Epiphora
Overflow tearing in neonates
432
Congenital nasolacrimal duct obstruction
Occurs in 5% normal newborns
Blockage commonly at valve of Hasner at distal end of duct
Blockage can be unilateral or bilateral
Spontaneous resolution is estimated to be 90% within first year of life
Test with dye disappearance test -- should drain into nose within 5 minutes if no obstruction
If obstructed, dye remains in eye and is seen as bright green tear meniscus or dye escapes over eyelid and drains down cheek
433
Car seats (stage 1)
Rear-facing seats should be used until children weigh at least 10kg and are at least 1y of age and able to walk
No more than 2.5cm/1in of movement in either direction
434
Car seat (stage 2)
Forward- facing infant/child car seat
| 10-18kg
435
Car seat (stage 3)
Child booster seat
| 18-36kg
436
Car seat (stage 4)
Seatbelt
| At least 36kg or 145cm or 8yrs ago
437
Fragile X Syndrome
```
X-linked disorder (expansion of CGG trinucleotide repeat)
Most common inherited cause of intellectual disability
Prominent jaw, forehead, nasal bridge
Long thin face with large ears
Macroorgchidism
Hyperextensibility
High arched palate
May have sz, scoliosis, MV prolapse
```
438
Botulism symptoms
```
Poor ability to suck pooled secretions
Poor head control
Hypotonia
Weak cry
Constipation
Lethargy
Facial weakness
Extraocular muscle paralysis
Irritability
Hyporeflexia
Sluggish pupils
Resp difficulty
```
439
Type of NTD that is not compatible with life
Anencephaly
440
AFP trend in maternal serum consistent with NTD
Increased at 16-18wks
441
What to test in amniotic fluid to dx NTD
AFP
| Acetylcholinesterase
442
PECARN >2yo
```
CT Head if one of:
AMS (altered mental status)
GCS <15
Signs of basal skull fracture
Observe or CT head if:
History of LOC
History of vomiting
Severe headache
Severe mechanism (>5 feet fall)
If none of the above, no CT head required
```
443
PECARN <2yo
```
CT Head if one of:
AMS
GCS <15
Palpable skull fracture
Observe or CT head if:
LOC > 5 seconds
Nonfrontal hematoma
Not acting normally
Severe mechanism (>3 feet fall)
If none of the above, no CT head required
```
444
CXR for inspiratory body
Deviates away from side of obstruction
445
Most common locations for foreign body obstruction
Upper esophageal sphincter
Middle of esophagus where it crosses over aortic arch
Lower esophageal sphincter
446
Tx for developmental dysplasia of the hip
<6mo: Pavlik harness
| >6mo: Closed reduction with spica cast
447
Most common cause of painless hematochezia
Meckel's diverticulum
448
Juvenile Idiopathic Arthritis
<16yo, for at least 6 wks
Morning stiffness at least 1h in the morning, decreased ROM, swelling, fevers, rash, post-exercise pain
ANA+ (a/w uveitis --> most examine with slit lamp for inflammatory cells/increased protein in anterior chamber of eye within 1mo of dx)
Anti-cyclic citrullinated peptide antibody (specific)
449
Abdo pain in DKA can be a/w...
Hypokalemia causing skeletal muscle weakness and ileus
| Order ECG --> flattening of T- waves and prolonged QRS
450
Klinefelter features
Tall
Small testicles
Infertile
451
Osgood Schlatter
```
Common
Begins at onset of teen growth spurt, resolves in 18-24mo
Clinical dx
Pain confined to tibial tubercle of knee
Worse with activity
Conservative mgmt
```
452
Most common neuro sequelae after meningitis
Sensorineural hearing loss
| Test hearing 4-6wk post tx
453
Respiratory distress syndrome long-term complication
Bronchopulmonary dysplasia
454
Respiratory distress syndrome acute complication
Alveolar rupture
455
Hypothyroidism and bone/height age relative to chronological age
Delayed bone age relative to height age and chronological age
456
CF and bone/height age relative to chronological age
Bone and height age are equivalent and both lag behind chronological age
457
Chromosomal abnormalities and maternal substance abuse and bone/height age relative to chronological age
Height age delayed relative to bone age
458
ITP purpura vs vasculitic purpura (ie. HSP)
ITP purpura is non pruritic and non palpable in dependent areas of body
459
Most common congenital abnormality causing primary hypogonadism
Klinefelter
460
Physiologic genu varum
Resolves by 2 yo
| Xrays would show normal mineralization of growth plates
