Pediatrics Exam 2 - HAVE NOT REVIEWED YET
What is a safe temp for bathing children?
100 degrees F
What is the recommended hours of sleep for a newborn - 12 months?
12-16 hours
At what temp water can a child get burned if they sit for 5 minutes and also the max temp that a water heater should be set at?
120 degrees F
How many onces per day of milk/formula should an infant recieve for up to 10-12 months? How does the frequency of feeding and serving sizes change as the infant gets older? How often should a 0 to 4 month old be fed?
20-32 ounces per day decrease in frequency of feedings increase in ounces per feeding 0-4 months: 8-12 feedings per day
What are three distinct time periods where constipation may become evident in children?
3 distinct times: ◦After the introduction of cereals and solid food into the infant's diet, ◦With toilet training, ◦During the start of school. ◦Other common triggers are psychosocial stressors such as separation from parents or schedule changes.
What is recommended for a one year old and beyond: How many meals/ day? % of carbs per meal? Simple sugars? % fat per meal? Cholesterol intake?
3 meal/day with 2-3 healthful snacks complex cabs should represent 55-60% of caloric intake simple sugars should represent < 10% of daily calories <30% of total calories should come from dietary fat cholesterol intake: about 100 mg/ 1000 Kcal/day avoid fat restriction - can lead to growth restriction!
What are the 3 types of Juvenile Idiopathic Arthritis?
3 types (based symptoms within first 6 months of disease) Oligoarticular - Most common (2-3 yrs.. of age) 4 or less joints Large joints (knee most common) Anterior uveitis (25%) Polyarticular 5 or more joints Small joints Symmetrical Systemic Fever, rash, lymphadenopathy, hepatosplenomegaly, serositis Koebner phenomenon Greatest mortality and morbidity Lacks autoantibody, sex, age and HLA associations seen with other forms Requires different therapy
Surfactant is Produced by alveolar cells after _____ weeks gestations
32 wks
Enuresis: involuntary or intentional urination in children whose age and development suggest achievement of bladder control, ~_____yrs. of age (bedwetting). Is it more common in males or females? What medication can be used but it not the first choice for treatment?
4 yrs MC in males Family counseling, reward system, conditioning therapy (70-85% cure rate), bed alarms, pharmacologic-anti-depressants or desmopressin (Ddavp) (drugs are not first choice)
What are the symptoms of bronchiolitis (RSV)? When is hospitalization indicated?
A clinical syndrome of respiratory distress that occurs in children <2 years of age Characterized by upper respiratory symptoms (e.g., rhinorrhea) Followed by lower respiratory (e.g., small airway/bronchiole) infection with inflammation, which results in wheezing and or crackles (rales). Infants and children with moderate to severe respiratory distress (e.g., nasal flaring, retractions, grunting, respiratory rate >70 breaths per minute, dyspnea, cyanosis) usually require hospitalization for supportive care and monitoring. Additional indications for hospitalization include toxic appearance, poor feeding, lethargy, apnea, and/or hypoxemia.
What is intestinal/ Duodenal atresia? What are the symptoms? How is it treated? How is the prognosis?
A congenital defect of a hollow viscus that results in complete obstruction of the lumen with ~ 50% cases involving the duodenum Symptoms and signs of intestinal obstruction, including abdominal distension and vomiting (may be bilious). Many patients fail to pass meconium Treatment Consists of initial preoperative management (NPO, NG/OG suction, IV hydration & electrolyte correction) followed by surgical correction. Prognosis - good Complications & increased mortality associated with infants with medical conditions such as prematurity or RDS, associated anomalies, or complications such as short gut syndrome
What is Sandifer syndrome?
A type of GERD where infants arch and become tonic to protect airway from refluxing gastric contents.
Explain each type of esophageal atresia: A: B: C: D: E: Which one is most common?
A: isolated esophageal atresia (8%) B: proximal fistula with distal atresia (1%) C: proximal atresia with distal fistula (85%) - Most common type D: double fistula with intervening atresia (1%) E: isolated fistula (H-type) (4%)
AAP suggests that acetaminophen not be administered to infants < ____ mos. & that ibuprofen not be administered to children < ___ mos. without evaluation by a clinician.
AAP suggests that acetaminophen not be administered to infants <3 mos. & that ibuprofen not be administered to children <6 mos. without evaluation by a clinician.
What is gastroschisis? How can it be diagnosed? Is it associated with other anomalies? How is it managed? When should the baby be delivered and how? What should happen immediately after birth? Then what?
Abdominal wall defect that occurs to the right of the umbilicus Defect usually smaller than omphalocele; not covered by a sac Umbilical insertion site is normal Together, U/S and ↑ maternal AFP screening detects >90% ●Increased risk of fetal demise in late pregnancy ○Attempt vaginal delivery at 37-38 weeks gestation in tertiary care center ●Immediately following delivery: ○Bowel is wrapped to preserve heat, minimize insensible fluid loss ○Insertion of an orogastric tube ●Emergent surgery replace abdominal contents ○Silo if unable to immediately replace abdominal contents due to bowel edema or distension ●Prognosis: survival >90%
An infant had a heel stick after birth and had a glucose of 35 mg/dl. Is this normal for 3 hours of age? What range is considered normal? What is considered abnormal? What should be done to confirm hypoglycemia after an abnormal heel stick?
Abnormal results should be confirmed with whole-blood testing Normal glucose = 50 - 80 mg/dl at 3 hours of age Abnormal is <40 - 45 mg/dL
What is the leading cause of morality and morbidity for physical abuse in children?
Abusive Head Trauma ○Shaking, blunt trauma or both ●Perpetrators are most commonly fathers or boyfriends of mom ○Usually occurs in the context of an intolerance to fussiness or incessant crying.
What are common symptoms of gastroenteritis in children? Is there blood and mucus in the stool? How long does it usually last? How is it treated?
Acute gastroenteritis -increased stool frequency with loose consistency with or without vomiting, fever, or abdominal pain; examples of increased stool frequency include: ≥3 loose or watery stools in 24 hours # of loose/watery bowel movements that exceeds the child's usual # of daily bowel movements by 2 or more Absence of visible blood and mucus in the stool Usually lasts less than one week and not longer than two weeks.
What criteria must be met for a BRUE to be considered low risk?
All of the following must be present: Age >60 days Postconceptional age >45 weeks Occurrence of only one event Duration < 1 minute No CPR by a trained medical provider needed No concerning historical features No concerning physical exam findings Infants meets low-risk criteria require minimal additional evaluation or observation
When should females start to get screened for cervical dysplasia?
All young women at 21 year visit
What are febrile seizures? How long do they last? Do they recur? What are the risk factors? On what day of the illness do febrile seizures usually occur? What are the characteristics of a febrile seizure? What will NOT be present?
An event in infancy or childhood associated with fever but without evidence of intracranial infection or a defined cause Majority are generalized (simple) seizures, lasting <15 minutes and NOT recurring during a 24-hr period Risk factors: the max height of the fever, viral infections > bacterial, admin of certain vaccines (DTP, MMR), genetic susceptibility Febrile seizure usually occurs on the 1st day of the illness A convulsion associated with an elevated temperature greater than 38°C A child > 6 mos. & younger than 5 years of age Absence of CNS infection or inflammation Absence of acute systemic metabolic abnormality that may produce convulsions No history of previous afebrile seizures
What are the criteria for epilepsy?
An individual is considered to have epilepsy when any of the following exists: At least two unprovoked (or reflex) seizures occurring more than 24 hours apart. Reflex seizures are seizures evoked by specific external (e.g. light flashes) or internal (e.g., emotion, thoughts) stimuli. One unprovoked (or reflex) seizure and a probability of further seizures that is similar to the general recurrence risk after two unprovoked seizures (e.g., ≥60%), occurring over the next 10 years. Diagnosis of an epilepsy syndrome.
What is the hallmark finding of laryngotracheitis (croup)? What does the cough sound like? What other signs and symptoms might they have?
Anatomic hallmark is narrowing of the subglottic airway Characterized by barking/seal-like cough, inspiratory stridor, hoarseness, and fever Stridor: Harsh, high-pitched sound, typically inspiratory May be preceded by nasal discharge, congestion, and coryza Drooling and sore throat are uncommon Exam may demonstrate signs of upper airway obstruction Labored breathing or tachypnea Suprasternal, intercostal, and subcostal retractions Wheezing uncommon unless there is also lower airway involvement
What is the most common indication for emergency abdominal surgery in children?
Appendicitis
How is RDS treated? When would steroids be given?
Appropriate steps to avoid preterm birth Cervical cerclage, bed rest, treatment of infections, tocolytic Antenatal administration of steroids if delivery will occur between 24-34 wks. Gestation Stimulates fetal lung development Intratracheal administration of exogenous surfactant Immediately after birth or within hours of deliver Early application of nasal CPAP
What type of burns are usually associated with abuse?
Approximately 10% of children hospitalized with burns are victims of abuse Usually, thermal burns due to scalding or contact with hot object Immersion pattern: sharply demarcated and symmetric Esp. lower extremities and anogenital regions Common during toilet training Don't forget to check hair/scalp
Where is the most common locations for a neuroblastoma? Where do they often originate from?
Arise from neurons of the sympathetic nervous system → Most common location is in the retroperitoneum Often originate from the adrenal gland (40%) Other sites Sympathetic ganglia in the abdomen (25%), thorax (15%) cervical region (5%) and pelvis (5%), other Most common extracranial solid tumor in children <5 years of age Incidence 1/7,000 live births; 800 new cases annually 60% occur before age 2
What is the average age of menarche?
Average age of menarche is 12-13 years old
Hypoglycemia Blood glucose < ________ mg/dL What infants is this most common in? What are some signs and symptoms?
Blood glucose < 40 - 45 mg/dL Most common infants → Mother with diabetes, Restricted intrauterine growth Asymptomatic Poor feeding, lethargy, jitteriness, tremulousness, irritability, apnea, or seizures Cases with hyperinsulinemia - cardiac failure may develop
At what age does breast development start to occur? What about for AA and Mexican American girls? When does testicular enlargement start to occur?
Breast development age 9-10 → ~1 yr earlier for AA and Mexican-American girls Testicular enlargement ~ age 11
Breastfeeding exclusively for about the first _____ months of life. When should a mom stop breastfeeding?
Breastfeeding exclusively for about the first 6 months of life Continue to breastfeed for as long as the mother & baby want.
What is the most common of abusive injury?
Bruising
What should a one year old be able to do with the following? A cup or A bottle? Cows milk or formula? high chair or sitting at the table? Finger food or being fed with spoon?
By 12 months, the following should be established: Drinking from a cup and getting rid of the bottle Transition to cow's milk; stopping formula (too many calories!) Regular, scheduled meals with the family (@ the table); scheduled snacks Encourage to self-feed with finger foods
Who should be screened for chlamydia and gonorrhea?
Chlamydia and gonorrhea testing recommended for all sexually active females Wh(USPSTF Grade B) STI testing in sexually active boys if any of the following risk factors are present: Males who have sex with males (MSM) multiple/ anonymous partners Sex and illicit drug use Sex with partners who use illicit drugs Consider in males who have sex with females Racial and neighborhood disparities Number of partners
Circadian rhythm changes in early puberty makes it easiest for adolescents to sleep from ______ PM - ________ AM. ______ hours recommended for adolescents and young adults
Circadian rhythm changes in early puberty makes it easiest for adolescents to sleep from 11:00 PM - 8:00 AM
What is talipes equinovarus? What characteristics of the foot can make the diagnosis? How is it treated?
Clubfoot Pathologic deformity of the foot at birth → Talus is small and abnormal in all of its relationships May be isolated or associated with other systemic anomalies Diagnosis on 3 conditions: Forefoot varus Heel varus Ankle equinus Treatment: Refer to orthopedic surgeon trained in pediatrics/clubfoot Typically includes PT/OT, bracing, or surgical intervention
What are some complications of RDS?
Complications Severe RDS characterized by pulmonary edema, apnea, and respiratory failure Complications PDA → Hypoxemia in RDS may lead to persistent PDA Pneumothorax Bronchopulmonary dysplasia Retinopathy Others: Acute/Therapeutic Interventions Chronic Lung Disease Retinopathy of Prematurity
What is considered a concerning bruise?
Concerning bruises: Any bruising in infants < 6 months of age >1 bruise in a pre-mobile infant; >2 bruises in a crawling child Bruises located on the torso, ear, neck, or buttocks Bruises with a pattern of the striking object (slap, belt loop, spoons/spatulas, or other objects) Human bite marks
What is TORCH? Can you name them?
Congenital infections - TORCH - infection of developing fetus or newborn Toxoplasmosis Others (syphilis, Zika, varicella-zoster virus, +????) Rubella Cytomegalovirus Herpes Simplex
Conjugated Hyperbilirubinemia ●Direct bilirubin > ____ mg/dL What can this be due to? How is it treated?
Conjugated Hyperbilirubinemia Direct bilirubin > 2.0 mg/dL Pathophysiology Too much bilirubin ( ↑ RBC) Unable to excrete (intestinal or urinary obstruction) Liver dysfunction (hepatitis, sepsis, TORCH infections) Conjugation still occurs, conjugated bilirubin leaks out of the hepatocytes Management Treat underlying condition Will not respond to phototherapy or exchange transfusions
What is the most common food allergy in young children?
Cow's Milk Allergy
What are some benefits of breastfeeding?
Decreased incidence and severity of infectious illnesses, including diarrhea, respiratory infections, otitis media, bacterial meningitis, and urinary tract infections. Lower rates of hospitalization and mortality Reduces incidence of atopy, allergies, asthma, childhood obesity, T2DM, and even childhood cancer. Decreased rates of sudden infant death syndrome (SIDS).
Respiratory Distress Syndrome - RDS (Hyaline Membrane Disease) Deficiency of _____________.
Deficiency of pulmonary surfactant Surfactant: phospholipid protein mixture that decreases surface tension and prevents alveolar collapse Produced by alveolar cells after 32 weeks gestations
What is the gold standard for diagnosis of Hirschsprung disease?
Definitive diagnosis (gold standard) via rectal biopsy with absence of ganglia
Universal Screenings: When should the following occur? Depression Dyslipidemia Hearing Tabacco, alcohol, drug use Vision
Depression → beginning at 12 years visit Dyslipidemia → once between 9-11 years Hearing → once between 11-14 years Tobacco alcohol, drug use → every visit Vision → 12 year visit
How is a neuroblastoma diagnosed? What is the best imaging? What is required for definitive diagnosis?
Diagnosis CT scan of abdomen → Tumor w/ calcifications in abdomen in kids ⭐MRI scan of abdomen is better; ability to see vessel involvement Biopsy required for definitive diagnosis Secrete high levels of catecholamines which can be seen in urine in 90%
What lab is indicated in the work up of colic?
Diagnostics: urinalysis, others as indicated
How is appendicitis treated in children? What type of IV fluids are given?
Dictated by whether appendix is intact, perforated or abscess has formed IV fluids (isotonic crystalloids) IV Abx (e.g., Cephalosporins) Analgesia (e.g., IV opioids) Determine early OR delayed Surgery status based on acuity (laparoscopic preferred) vs. Non-operative mgmt. (Abx, SDM w/caregivers, child old enough to describe sx)
A 5 year old girl comes to the clinic with a fever and nausea and diarrhea. She has a rash on her cheeks that developed 4 days after her fever started (2 days ago). Just today she developed an erythematous symmetric, maculopapular rash on her abdomen. What is the most likely diagnosis? What do you think her rash will progress to?
Erythema Infectiosum (Fifth Disease) Clinical Manifestations Nonspecific prodrome: fever, coryza, headache, nausea, and diarrhea Constitutional symptoms coincide with onset of viremia Erythematous malar rash with circumoral pallor → "Slapped cheek" appearance 3-5 days after prodrome; no longer infectious THEN erythematous symmetric, maculopapular, truncal rash appears 1-4 days later THEN lacy/reticular appearance due to central clearing Duration of 2-40 days (mean: 11 days)
Describe the rash of Head-Foot-Mouth Disease. Where is it primarily located? Is it itchy? Painful? What is the difference between exanthem and enanthem? Describe enanthem.
Exanthem: macular, maculopapular, or vesicular rash Primarily on the extremities including the palms and soles, May have lesions on buttocks All three may occur in the same patient Nonpruritic though may be painful Oral enanthem: small ulcerations with erythematous halo
What is colic? When does it usually begin, peak, and resolve? At what time of day does it usually occur?
Excessive crying without an apparent cause → Poorly understood
What causes retinopathy or prematurity? How is it managed?
Exposure of immature retina to high oxygen concentrations → vasoconstriction and obliteration of retinal capillary network, followed by vasoproliferation Management Monitoring ABG in all infants receiving oxygen → < 50-70 mmHg Screening in very low birth weight (<1,500 gm) and those born before 28 weeks' gestation
_______________ is a Descriptive term given to infants & young children with malnourishment resulting in inadequate growth. What is the unofficial criteria? What is ALWAYS the cause?
Failure to Thrive Frequently used (but not official) definitions: Weight < 2nd percentile for gestation-corrected age and sex (some use 3rd or 5th) Decreased velocity of weight gain that is disproportionate to growth in length Other measures - suggest using WHO calculator The cause is always inadequate nutrition but there are many organic and psychosocial causes
A child has a hematoma. What other characteristics could be present that would make you suspect abuse as the cause?
Features predictive of abuse: Subdural Hematoma AND any one of the following: Inadequate history Apnea or seizures on presentation Asso. fractures of ribs, metaphyseal region, or long bones Retinal hemorrhage(s) Any skull fracture other than an isolated, unilateral, nondiastatic, linear, parietal skull fracture Any bruising of the child's face, ears, neck, or torso
How is fever treated in an infant that is 29-60 days old?
Fever and Age 29-60 Days - Evaluation & Management Well-appearing without focal bacterial infection should be managed based upon level of risk for IBI Considerations are made based on UA, blood culture and inflammatory markers If any are (+), proceed with next step testing such as urine culture and/or LP If IMs are (-), infant may be observed closely at home with f/u in 24-36 hrs. +/- Abx for urinary infection
How is fever treated in an infant that is 61 - 90 days old?
Fever and Age 61-90 Days - Evaluation & Management Previously healthy and well-appearing with no risk factors for IBI and who have normal preliminary urine testing, we suggest outpatient observation with close follow-up with their primary care provider. Ill-appearing - require hospitalization and full sepsis evaluation, treatment for sepsis and shock.
How is a FUO in pediatrics defined? How is Fever without localizing source defined?
Fever of unknown origin (FUO): fever lasting >/= 8 days without identifiable source Fever without localizing source: fever </= 1 week without explanation
Formula Feeding - Cow's Milk - Based Formulas Iron-fortified Add fluoride after ____ months if not using a fluoridated water supply Caloric density ____ Kcal/ounce → Approximately the same as breast milk. Which one is the cheapest? powder, liquid concentrate, or ready to feed?
Formula Feeding - Cow's Milk - Based Formulas Iron-fortified Add fluoride after 6 months if not using a fluoridated water supply Caloric density 20 Kcal/ounce → Approximately the same as breast milk.
Define functional fecal incontinence (encopresis). What are the 2 types?
Functional fecal incontinence — the involuntary passage of stool in the underwear after the acquisition of toileting skills, in the absence of overt neuromuscular anorectal dysfunction. Retentive — associated with functional constipation (hx of retentive posturing or excessive volitional stool retention, hx of hard or painful bowel movements, presence of large fecal mass in the rectum, or hx of passing large-diameter stool). Non-retentive — occurs in the absence of S/Sx of functional constipation. The Dx criteria for a child with a developmental age >4 years and at least 1-month hx of the following: Defecation in locations inappropriate to the social context No evidence of fecal retention After appropriate medical evaluation, the fecal incontinence cannot be explained by another medical condition
Gender identity becomes apparent at ____ years of age → Often presents in adolescence
Gender identity becomes apparent at 2-4 years of age → Often presents in adolescence
Generally, the neonate should nurse at least ____ times a day. Urine and stool output can be a reliable indicator of the success of breastfeeding. A successful breastfeeding neonate should urinate ___ times a day and pass stool ______ times a day by 3 to 5 days of age.
Generally, the neonate should nurse at least 8 times a day. Urine and stool output can be a reliable indicator of the success of breastfeeding. A successful breastfeeding neonate should urinate 3 times a day and pass stool 3 to 4 times a day by 3 to 5 days of age.
What are the pre-op guidelines for pediatric surgery?
Guidelines for interval between eating and drinking differ In general- adults NPO 8-12 hours prior to surgery In kids < 36 months - miss 1 meal before surgery ( NPO = 2-4 hours for infants, 2-8 hours 6-36 months) Guidelines differ amongst facilities, follow your specific policy and check with the anesthesiologist Hemoglobin > 10 g/dL; check with anesthesia about limits If blood loss is anticipated, your patient should have a type & cross with matched
An infant has unconjugated hyperbilirubinemia. What could be the cause if hemolysis is present? What is hemolysis is absent?
Hemolysis present: blood group incompatibility Hemolysis absent: breast milk jaundice, internal hemorrhage, polycythemia, infant of diabetic mother
___________is the congenital absence of ganglion cells in the distal rectum. Who is it more common in?
Hirschsprung Disease More common in individuals with Trisomy 21
What does HEEADSSS stand for?
Home, Education, Eating, Activities, Drugs, Sexuality, Suicide, Safety
Breast Feeding Basics: How often should a mom breastfeed per day? How many diapers should be soaked per day? How many loose, yellow stools should an infant have per day? When should a newborn regain their birth weight? What type of supplementation should be started at few days after birth? What supplementation should be started after 4 months?
How often to feed? → 8-12 times per day initially (see chart) Output → 6-8 soaked diapers per day By 5-7 days should have at least 4 loose, yellow stools per day This will decrease, infant may go several days without passing a stool by 6-8 weeks of age Weight gain → should regain birth weight 7-10 days Vitamin supplementation Vit D supplementation starting a few days after birth Iron supplementation after 4 months (via foods or prescribed)
What is human milk made of? What should a mom increase in their diet when breastfeeding?
Human milk is made of water, fat, lactose-containing carbohydrates, and protein, as well as vitamins, immunoglobulins, prebiotics, enzymes, hormones, and even phagocytes and lymphocytes. Mothers should be educated on proper nutrition and supplements such as folic acid and omega fatty acids. Increase iodine & choline Iodine - found in dairy, eggs, seafood or in iodized table salt. Choline - dairy, proteins (e.g.gs, meat, beans, peas, lentils)
What is the Hyperoxia challenge test?
Hyperoxia challenge test - Supp O2 resolves cyanosis and supports pulmonary or non-cardiovascular cause (no cardiac)
What symptoms are associated with each type of esophageal atresia? If esophagus end in blind pouch: If esophagus fistulizes to trachea:
If esophagus end in blind pouch: excess salivation; early difficulty with feedings If esophagus fistulizes to trachea: coughing with feedings, respiratory distress
What is the criteria for gender dysphoria in children?
In Children: Diagnosis involves at least six of the following AND associated significant distress or impairment in function, lasting at least six months: A strong desire to be of the other gender or an insistence that one is the other gender A strong preference for wearing clothes typical of the opposite gender A strong preference for cross-gender roles in make-believe play or fantasy play A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender A strong preference for playmates of the other gender A strong rejection of toys, games and activities typical of one's assigned gender A strong dislike of one's sexual anatomy A strong desire for the physical sex characteristics that match one's experienced gender
What type of rib fracture is suspicious for abuse?
In violent shaking the child is held very tightly around the chest and squeezed while being shaken. Compresses the ribs front to back and tends to break them next to their attachment to vertebrae and laterally These fractures WILL NOT occur from CPR/ attempts at resuscitation
What infections are malnourished children at higher risk for? Do most remain small for their age? What about cognitive problems?
Increased risk for infections → Particularly AOM, respiratory infections and GI infections. Approximately 40% of children with FTT remain small for age (<20th%percentile) Possible increased risk of cognitive problems Behavioral and learning problems are common.
What is a "fever of concern" for the following ages? Infant = Child, 3-36 mos. = Older Children = •Greatest risk for bacterial infection is in infants < ____months.
Infant = Rectal* T > 38°C (100.4°F) Child, 3-36 mos. = Rectal T > 38°- 39°C (100.4° - 102.2°F) Older Children = Oral T >37.8° - 39.4°C (100.0 - 103.0° F) •Greatest risk for bacterial infection is in infants < 3 months
Who is pyloric stenosis more common in? Males or females? first born or after? older moms? What could cause this?
Infantile Hypertrophic Pyloric Stenosis (IHPS) Incidence: 3/1,000 live births, Male: female: 4:1 More common in first born infants and preterm Less common in infants born to older mothers Etiology likely multifactorial: Genetic predisposition Macrolide antibiotics during first two weeks of life or during late third trimester/breast feeding
What is Meckel's Diverticulum? What is the rule of twos? How will an infant present? How is it treated?
Intestinal diverticulum mid-to-distal ileum; failure of vitelline duct to obliterate Most common congenital anomaly of GI tract Rule of Twos: 2% of the population Male-to-female ratio of 2:1 Found ~ 2 feet from the ileocecal valve and ~ 2 inches long 2% develop complications, typically before age 2 yrs... Often clinically silent, but may present with abdominal pain, dark red/maroon stools, obstruction, or GI bleeding Resection if symptomatic
What are the 2 etiologies of jaundice and examples of each?
Jaundice etiologies - 2 categories 1. Overproduction of bilirubin Reticulocyte counts elevated Hemolysis (ABO, Rh), Hereditary Spherocytosis, G6PD 2. Decreased rate of conjugation Reticulocyte counts normal Gilbert or Crigler-Najar syndrom
What is the most common cause of stridor in children?
Laryngotracheitis (Croup)
At what time of year does laryngotracheitis peak? At what ages does it peak? What is the most common pathogen?
Laryngotracheitis (Croup) Most common cause of stridor in children Peak ages - 6 months to 3 years Peaks in fall and early winter
What will show up on labs in a infant with necrotizing enterocolitis? What will show on xrays?
Leukocytosis OR leukopenia Thrombocytopenia is common Various other abnormalities depending on disease severity Coagulopathy (DIC), metabolic acidosis (sepsis), electrolyte imbalance (sepsis, perforation), hypo-/hyperglycemia Abdominal radiograph with thickened bowel loops and air-fluid levels Pneumatosis intestinalis: air/gas present in the bowel wall
What are the signs and symptoms of cerebral palsy?
Major signs and symptoms are weakness and spasticity due to upper motor neuron damage Damage to the brain's motor system or basal ganglia, in utero, during the birth process, or in infancy Non-progressive in nature Generally, the more severe the weakness, the higher the likelihood of damage to other parts of the brain and other organ systems along with it. 25-50% of patients with CP have seizures
How is HFMD treated?
Management Diagnosis based upon the typical appearance & location of the oral enanthem and exanthem Present in ~75% of patients Management is supportive Antipyretics and analgesics Hospitalization may be required for dehydration or severe complications (encephalitis, meningitis, myocarditis) Palmar and plantar desquamation may occur one to three weeks after
How is fifth disease treated? What is a complication of fifth disease?
Management Supportive! → Antipyretics and fluid Complications include transient aplastic crisis Due to RBC destruction, ineffective erythroid production (7-10 days) Especially common in sickle cell disease, thalassemia, etc.. Extremely low reticulocyte count; hemoglobin level lower than usual for the patient Transfusions of IgG may be required
How is a neuroblastoma treated?
Management and Prognosis Surgery and likely chemotherapy and radiation therapy Referral to tertiary care center Worse outcomes if older or metastatic disease present → 50% will have recurrence Represents only 8% of cases of childhood cancer; responsible for 15% of cancer deaths in children
How is fever treated in an infant that is 28 days of age or younger? If ill-appearing? If well appearing? What if you are suspicion of HSV infection?
Management: 28 days of age or younger Ill-appearing: require tx for sepsis & septic shock in ICU Well-appearing: Broad spectrum antibiotics Ampicillin + gentamicin (or cefotaxime) Clinical suspicion for HSV infection should receive Acyclovir
What is marasmus? What clinical manifestations are present? What is their HR and temp like?
Marasmus: Severe pediatric malnutrition due to inadequate calories Clinical features: Weight is <60% of median for age or <70% of ideal weight for height Emaciation with loss of muscle mass and subcutaneous fat Head may appear large for the body Bradycardia and hypothermia may be Present
What are the contraindications for breastfeeding?
Maternal abuse of street drugs or alcohol HIV Untreated military TB Chemotherapy or ongoing radiation therapy Active herpetic breast lesions Infant galactosemia Many drugs are not recommended during breastfeeding but are not absolutely contraindicated and can be checked on the NIH website, Drugs and Lactation Database (LactMed®) a
What is the most common congenital anomaly of the GI tract?
Meckel's Diverticulum
How is jaundice treated?
Medical management: Phototherapy - most commonly used IV immune globulin - Rh, ABO, or other blood group incompatibilities that cause significant neonatal jaundice Exchange transfusion is indicated for avoiding bilirubin neurotoxicity when other therapeutic modalities have failed or are not sufficient.
Most babies lose about __________ of their birth weight during the first five days. When should they gain this back?
Most babies lose about one-tenth of their birth weight during the first five days. Within the first week, they should gain weight.
What is the most common presenting sign of retinoblastoma? What should be done if you see this sign?
Most common presenting sign is leukocoria (white pupillary reflex) Strabismus, nystagmus, red and inflamed eye Presence of leukocoria requires urgent referral to ophthalmology Treatment includes chemotherapy, cryotherapy, laser photocoagulation, and enucleation > 95% five-year survival rate for children in U.S. Recurrence free for five years is considered cured Vision prognosis depends on extent of tumor involvement Untreated, retinoblastoma grows to fill the eye and destroys the internal architecture of the globe
What is necrotizing enterocolitis (NEC)? Who is it most common in? What are some risk factors associated with this?
Mucosal or transmural ischemia and subsequent necrosis of the intestine Most common intestinal emergency in the newborn period 90% of cases occur in preterm infants Mortality rates of 20-30% Risk factors: Prematurity Bacterial colonization of gut Formula feeding (often enteral)
What is the most common intestinal emergency in a newborn?
Necrotizing Enterocolitis (NEC)
What is the most common form of child maltreatment?
Neglect Accounts for >50% of reports to child protective services
How many days are the following? Neonatal period: Post neonatal period: Postnatal period: Newborn: Infant: Perinatal mortality: Neonatal mortality: Infant mortality:
Neonatal period: 0 - 27 days of life Post neonatal period: 28 days - 1 year of life Postnatal period: first 6 weeks after birth Newborn: birth to 2 months Infant: 1 - 12 months Perinatal mortality: fetal deaths from 28 wks. gestation until 7 days after birth Neonatal mortality: deaths of infants under 28 days Infant mortality: all deaths of infants to 1st birthday
What is an Omphalocele? What are the two types? How is it managed? How is the prognosis?
Omphalocele Abdominal wall defect in which one or more organs protrude outside the body through the umbilicus. Types: non-liver-containing (containing bowel loops) or liver-containing Management Immediately following delivery: Bowel is wrapped to preserve heat, minimize insensible fluid loss Insertion of an orogastric tube to decompress the stomach Small defect can be replaced and repaired immediately Larger defects require silo or delayed closure once infant has grown, abdominal wall repair Prognosis Survival of live born infants is approximately 90%, Prognosis depends on associated anomalies
When should adolescence get screened for HIV?
Once between 15-18 years
What are some characteristic features of Osteogenesis imperfecta? What causes this?
Osteogenesis Imperfecta → "Brittle bone disease" Genetic disorder that produces decreased amounts of collagen or abnormal collagen Several different forms of the disorder → Most (80%) are autosomal dominant Consider in patients with multiple fractures and any of the following: Short stature Scoliosis Basilar skull abnormalities Blue sclerae 🔵 Hearing loss 👂 Teeth that wear quickly Increased laxity of ligaments and skin Wormian bones in the cranial sutures Easy burisability 🔵
What do the following PAS scores mean? PAS ≤3 PAS ≥7 In isolation - PAS is inadequate to stratify risk level
PAS ≤3 suggests a low risk for appendicitis. PAS ≥7 or 8 indicates a high risk for appendicitis. PAS of 3 to 6 or 7 is indeterminate for appendicitis and the best approach is not clear. In isolation - PAS is inadequate to stratify risk level
What is found on physical exam in an infant with pyloric stenosis?
Palpable "olive-like" mass at lateral edge of rectus abdominis Palpable only when infant is relaxed Present in 50-90% → pathognomonic if present Peristaltic waves may be seen just before emesis
What pathogen most commonly causes Head-Foot-Mouth Disease? How is it transmitted? What time of year does it usually occur?
Pathogen: Coxsackievirus A (most common), Also Enterovirus Transmission: commonly fecal-oral route Incubation period: 3-5 days Occurs in summer ☀️and early fall 🍂
What pathogen causes firth disease or erythema infectiosum? How is it transmitted? What is a common age group? What time of year is it common?
Pathogen: human parvovirus B19 → DNA virus with affinity for RBCs Transmission: Respiratory secretions; blood products (less common) → Incubation period:1-2 weeks, rarely up to 21 day Age: 3-12 years old → Spring outbreaks in school-aged children
When does a majority of SIDS occur? Is incidence higher in males or females?
Peaks incidence between 2-3 months of age → 90% occur before 6 months of age Incidence is slightly higher in males
What is considered physiologic jaundice?
Physiologic jaundice - after 24 hours and peaks 3 - 5 days
Post-OP circumcision: What may the penis look like? How often should the bandage be changed? What can be used to keep the bandage from sticking? How long does it take for it to fully heal?
Post-op care: the tip of the penis may seem raw or yellowish. If there is a bandage, it should be changed with each diapering to reduce the risk of infection. Use petroleum jelly to keep the bandage from sticking. Sometimes a plastic ring is used instead of a bandage. This should drop off within 5 to 8 days. The penis should be fully healed in about 7 - 10 days after circumcision.
What are some risk factors of cerebral palsy? What are some known causes of Cerebral Palsy?
Prematurity, Low birth weight/IUGR Multiple pregnancy → Esp. if one of the fetuses die Maternal toxin exposure Rh disease Maternal hemorrhage Problems during labor and delivery (rarely a cause) Causes: Fetal strokes → Embolic and thrombotic HIE Cerebral malformations Intracranial hemorrhages Intrauterine infections → TORCH In many cases no specific association or cause is identified OR there may be more than one.
How will a patient with a volvulus present? What is the gold standard for diagnosis? What should be done first if the patient is stable? What if unstable? How is it treated?
Presentation - typical signs Vomiting , typically bilious (green or fluorescent yellow) but can be nonbilious, especially in neonates and young infants Abdominal pain (most common sx in older children; may be out of proportion to the examination) Hemodynamic instability from hypovolemia and/or septic shock Abdominal distension (not always present, especially in young infants) Abdominal tenderness (can be difficult to elicit, especially in infants and young children) Upper GI series (xray) = gold standard for diagnosing malrotation but do US first if stable! If unstable send straight to surgery! Treatment - surgical approach (Ladd procedure - better long-term outcomes over laparotomy due to decreased risk of recurrent volvulus)
What medical interventions can be used for the following? Puberty suppression gender-affirming hormones gender-affirming surgery
Puberty suppression → GnRH analogues, spironolactone, and oral contraceptive pills Gender-affirming hormones → Testosterone and estrogen Gender-affirming surgery → Top and bottom surgeries
What is the imaging of choice for pyloric stenosis? What will be seen? How is it treated?
Pyloric ultrasound is imaging of choice, but requires capable sonographer "Target sign" on transverse view Management: Pyloromyotomy: laparoscopic or open
When does uncomplicated GERD resolve by? If symptoms still worsen or no improvement by what age should they get referred to pediatric gastroenterologist? What are some lifestyle modifications that can be helpful with uncomplicated GERD?
Reassure parents! → Resolves by 12 months of age If symptoms worsen or no improvement by 18-24 months, refer to pediatric gastroenterologist Keep infant upright for 20-30 minutes after feeding → Putting in an infant seat is not helpful Avoid tobacco smoke exposure → It lowers LES tone Smaller-sized feedings Trial of milk-free diet (2 weeks) Especially if the child has eczema and rectal bleeding (indicates food protein-induced proctocolitis) Breastfed: mom should not consume milk products or beef Formula-fed: Hydrolyzed (hypoallergenic) = milk and soy-free Treatment only necessary if symptoms are distressing to family
What is transient tachypnea of Newborn? Who is it more common in?
Respiratory distress shortly after delivery (few hours after birth) → Fast (> 60 bpm) and harder breathing to get O2 Extra fluid in lungs that clears slower AKA - "wet lungs" More common Preemies - lungs not fully developed Rapid births or C-sections - don't get hormonal changes for lungs to absorb fluid Babies of mothers with asthma or diabetes
What are the risk factors for RDS?
Risk Factors Occurs in 25-60% of infants born <34 weeks gestation ↑ incidence with ↓ gestational age Antepartum steroid administration reduces risk → 35% for infants <30 wks., 10% for infants 30-34 wks. Other risk factors: Maternal diabetes Perinatal asphyxia Second twin Previous infant with RDS
How can cerebral palsy be prevented?
Routine prenatal care - prevent prematurity Increasing evidence that magnesium sulfate for women with preterm labor decreases incidence and severity of CP Delayed cord clamping → Lowers risk of IVH → improved neurodevelopmental outcomes Supportive, neuroprotective measures for neonates at risk of neurologic injury I.e.: preterm very low birth weight infants and infants with neonatal asphyxia and/or encephalopathy
What is the criteria for SIRS in children?
SIRS is a widespread inflammatory response that may or may not be associated with infection. Need to have the presence of two or more of the following criteria (one of which must be abnormal temperature or leukocyte count): - Core temperature (measured by rectal, bladder, oral, or central probe) of >38.5°C or <36°C - Tachycardia, defined as a mean HR >2 standard deviations above normal for age, or for children younger than one year of age, bradycardia defined as a mean HR <10th % for age - Mean respiratory rate > 2 standard deviations above normal for age or mechanical ventilation for an acute pulmonary process - Leukocyte count elevated or depressed for age, or >10% immature neutrophils
What is the work up for sepsis evaluation in children?
Sepsis Evaluation PoC glucose - stat ABG (or VBG) & pulse ox CBC with diff & smear Complete metabolic panel (CMP) - serum lytes, BUN, creat, Ca++, bili, ALT ESR, CRP, procalcitonin Blood lactate Blood cultures PT, PTT, INR, Fibrinogen and D-dimer UA, micro-urinalysis, and urine culture CSF cell count with diff, protein, and glucose CSF meningitis/encephalitis panel (includes gram stain and bacterial culture) Other specific dx testing (e.g. respiratory viral testing and CXR if respiratory symptoms present
How is severe bronchiolitis treated? What should be avoided?
Severe - require assessment & usually require IP care Provide supportive cares as above Bronchodilators (albuterol or epi) with 1st episode Avoid glucocorticoids Provide nebulized hypertonic saline or heliox Median LOS = 2 days, wheezing may persist for a week or longer
What is Kwashiorkor? What are some clinical features? Is weight a reliable indicator of this disease?
Severe protein malnutrition Clinical features: Leads to hypoalbuminemia Pitting edema develops in the LE and ascends with increasing severity → Ascites often present. Maintains subQ fat tissue with marked atrophy of muscle mass (if adequate calories otherwise provided) Discolored hair Weight is 60-80% of expected for age but not a reliable indicator because of the edema.
What are some signs of respiratory distress in a newborn?
Signs and Symptoms: Infant appears cyanotic on room air Respiratory rate > 60 bpm Grunting with intercostal and sternal retractions
What type of foods should be initiated first? When can fruit juice start to be introduced? At least one feeding per day should be rich in Vit. ____.
Single-ingredient foods should be introduced first Infant cereals and pureed meats offered first Offer only one kind at a time to identify allergies or intolerances Prepare cereals with human milk, infant formula, or water These contain iron and zinc, hence the reason to use first Then, pureed fruits and/or vegetables → NO fruit juice until after 12 months → Eat pureed fruit instead
What is a BRUE?
Sudden, brief, and now resolved episode in an infant (< 1 yr.) that includes one or more of the following: Cyanosis or pallor Absent, decreased or irregular breathing Marked change in muscle tone (hyper- or hypotonia) Altered level of responsiveness Average duration of event is typically <20 to 30 seconds Usually < 1 min Term applied only when infant is asymptomatic on presentation AND no explanation for the episode after a focused history and physical examination
Why 3 movements of an infant along with regurgitation would be suggestive of irritability due to GERD?
Suggestive of irritability due to GERD Regurgitation PLUS Arching of the back Turning of the head Lifting up of the chin
Fill in the blanks: Term: > _____ weeks Preterm/premature: < _______ weeks Very preterm/premature: < ________weeks Low birthweight (LBW): < ________ gm Very low birth weight (VLBW): < ______ gm
Term: > 37 weeks Preterm/premature: < 37 weeks Very preterm/premature: < 32 weeks Low birthweight (LBW): < 2500 gm Very low birth weight (VLBW): < 1500 gm
The avg newborn gains weight at a rate of _______ grams per day and by one-month weighs ~ _____ lb.
The avg newborn gains weight at a rate of 2⁄3 of an ounce (20-30 grams) per day and by one-month weighs ~ 10 lb. (4.5 kg).
What is the squirt sign?
The explosive release of gas and feaces from a spastic anus of a patient with hirshsprung disease when the sphinchter is forcefully opened by a finger.
Asymptomatic infants generally are not screened for congenital infections,. What are the two exceptions?
Toxoplasmosis - some states in the US have adopted universal screening Cytomegalovirus (CMV) - Targeted newborn screening for congenital CMV infection (i.e., testing infants who fail the newborn hearing screen) is performed in some institutions. Universal screening has been proposed
How is hypoglycemia treated in a newborn?
Treatment Bolus of dextrose and water (D10W) and IV glucose as needed Infant feeding is also option Monitor with resolution usually by 5th day of life → Failure to resolve indicates possible alternate cause
How are febrile seizures treated? What is the seizure lasts longer than 15 minutes?
Treatment: most febrile seizures end spontaneously - benzos typically not indicated, tx the fever symptomatically. If seizure last >5 min, treat w/benzodiazepines Discharge: most do not require hospitalization and can be d/c home Recurrence rate: 30-35%
True or False: BRUE and ALTEs are not a risk factor for SIDS.
True!
True or false: Jaundice on the first day of life is always pathological.
True!
True or False: Newborns tend to waken about equally, day and night.
True! May lack a day or night schedule. Patterns may vary from day to day
What are the 2 guiding principles of management of FTT?
Two guiding principles: Children with FTT need a high-calorie diet for catch-up growth → 50% greater than maintenance requirements All children need close follow-up (monthly until catch-up growth is demonstrated and positive trend is sustained)
When should the first follow up occur after birth?
Typically, a follow up visit should occur within 48-72 hrs. of discharge.
When is Breast milk jaundice typically seen? What are bilirubin level usually? Why does this occur? How is it managed?
Unconjugated Hyperbilirubinemia - Breast Milk Jaundice Breast milk contains glucuronidase - inhibitor of enzyme required for conjugation or increase enterohepatic recirculation Clinical manifestations Typically seen in 1-2 week of life Bilirubin levels usually < 20 mg/dL Management Interruption of breastfeeding for 1-2 days Bilirubin will NOT significantly increase when breastfeeding resumes
What is spastic quadriparesis? What causes it?
Upper motor neuron damage with → head, arms, and legs equally affected → weakness Occurs in both premature and full-term infants Why does this pattern occur? Severe, prolonged impairment of blood flow and/or oxygen to the baby's brain → Upper motor neurons are more sensitive to hypoxia than other types of neurons Often evidence of damage to other organs in addition to widespread CNS dysfunction Severe cognitive impairment (no speech) Often blind or deaf due to ischemic damage of retina and cochlea Most need G-tube for feedings Typically, non-ambulatory
What is the MC cause of a fever without localizing source in children?
Urinary tract infection (MCC)
At what time of day do growing pains usually occur? What age is most common to have growing pains? How is it managed?
Used to describe children with limb pain (most commonly LE & bilateral) that occurs primarily late in the day or at night who are otherwise without any manifestation of MSK problems. Most commonly occur in children 4-14 yrs... Management: Reassurance, RICE vs. heat, PT/massage, NSAIDs, monitoring
When does transient tachypnea of newborn usually resolve?
Usually resolves < 24 hours Monitor for O2 needs
How may an infant with meconium aspiration syndrome present? How is it treated?
Usually term or post-term Clinical manifestations Respiratory distress (tachypnea, hypoxia, cyanosis, etc.) Patchy infiltrates on CXR ●Management ○Supportive care and ventilation
What is the second leading cause of death from physical abuse in children?
Visceral Injury
_______ is the consequence of acute malnutrition associated with high risk of mortality. ____________ is the consequence of chronic malnutrition and affects physical and cognitive potential.
Wasting: Inadequate weight/height The consequence of acute malnutrition, Associated with high risk of mortality Stunting: Low height/age The consequence of chronic malnutrition, Affects physical & cognitive potential
What type of cows milk should be given until 2 years of age? When what type of cows milk should they switch to?
Whole or 2% milk until age 2 years; then SKIM MILK
What is a Wilms tumor? How is the definitive diagnosis made? How is it treated?
Wilms Tumor Most common malignant renal tumor of childhood → Two-thirds of cases diagnosed <5 yrs.. of age Typically presents as painless abdominal mass or swelling +/- abdominal pain, hematuria, constipation, hypertension U/S or CT can identify intrarenal mass vs. adrenal mass (neuroblastoma) → Definitive diagnosis with tissue biopsy Referral to tertiary pediatric center Nephrectomy, Adjuvant chemotherapy +/- radiation Overall survival rate is 90% → Many will develop chronic health conditions
What are some recommendations and preventions for obeisty?
consume 5+ serving of frutis and veggies per day minimize consumption of suger-sweetened drinks prepare meals at home when possible eat at table as family at least 5-6x /wk consume healthy breakfast every day avoid overly restrictive feeding behaviors allow child to self-regulate meals limit screen time t 2 hrs der day, no TV if less than 2 years old no TV in room be physically active at least 1 hr per day dont force a child to eat if not willing avoid overemphasis of food as a reward
Well-Child Visits in Middle Adolescence (15-17 years) When should the following be screened for? Depression Dyslipidemia HIV Tobacco, alcohol, drug use Vision and hearing
depression --> continuing throughout adolescence dyslipidemia --> once between 17-21 year visit HIV --. once between 15-18 years Tabacco, alcohol, drug use --> every visit vision and hearing --> 15 years visit
A 4 year old is diagnosed with laryngotracheitis. The have a frequent barky cough and a stridor at rest with mild retraction. How should they be treated?
dexamethasone and nebulized racemic epinephrine
What are the clinical manifestations of Necrotizing Enterocolitis?
ec - Clinical Presentation SIRS/Sepsis-like syndrome Abdominal distension Feeding intolerance → Increased gastric residuals if enteral feedings Emesis Severe disease → Fever, Sepsis, DIC, Bilious emesis, Abdominal wall erythema
What are some warning signs with reflux?
oBilious vomiting or hematemesis oForceful vomiting oAbdominal tenderness or distension oConstipation/diarrhea oHematochezia oOnset after 6 months of age oRecurrent pneumonia oSystemic symptoms: fever, lethargy oDysmorphic appearance (e.g. Down syndrome) oAbnormal neurologic exam
What are the 4 basic types of seizures?
our basic groups: Focal (partial) - limited to one hemisphere. May be discretely localized or widely distributed. The individual may or may not have awareness of seizure activity. MOST COMMON type (>50% of all seizures in children) Generalized - bilateral; awareness may be impaired. Absence seizures - sudden & profound impairment of consciousness without loss of body tone Unknown Unclassified There are over 30 epilepsy syndromes!
What are the screening recommendations for childhood obesity?
should measure height and weigth, calculate BMI, and asess BMI percentile using age-and sex specific CDC growth charts for ALL chilrdern 2-18 years repeat annually if < 85% If > 85% --> diagnose, get labs, check BP, treat --> motivational interviewing, lifestyle, weight loss drugs, bariatric surgery
What are the clinical manifestations of a neuroblastoma?
•Abdominal mass (retroperitoneal or hepatic) •Abdominal pain or constipation •Proptosis •Periorbital ecchymosis ("raccoon eyes") •Horner syndrome (miosis, ptosis, anhidrosis) •Involvement of sympathetic chain at superior cervical ganglion •Localized back pain, weakness •Scoliosis, bladder dysfunction •Otherwise unexplained secretory diarrhea Hypertension (catecholamine release)
What is Juvenile Idiopathic Arthritis? Is it more common in males or females? What race is it most common in? When it the age of onset?
•Characterized by: •Chronic idiopathic inflammation of a joint space •Formerly Juvenile Rheumatoid Arthritis (name changed as Rheumatoid Factor is absent in most children) •Most common rheumatologic disease in children •Females > Males •Caucasians > other •Age of onset < 16 y/o (>16 considered as adult RA); peak = 1-5 yrs.. of age •Etiologies: unclear •Risk factors - •Family history HLA predisposition
What developmental readiness skills should an infant have in order to initiate complementary foods?
•Developmental readiness •Ability to hold the head up and sit up with support •No extrusion reflex •Indicate a desire for food (by opening the mouth and leaning forward) •Indicate satiety (by leaning back or turning away) •Food should be offered via spoon or infant feeds
How is NEC managed?
•Discontinue enteral feedings (NPO) •IV fluids •Electrolyte replacement •Total parenteral nutrition (TPN) •Gastric decompression with nasogastric suction (NG tube) •Broad-spectrum Abx for 7-14 days •Immediate surgical consultation •Laparotomy with removal of necrotic bowel
What are the most common pediatric surgeries?
•Elective: •Hernia repair (inguinal, umbilical) •Cyst excisions •Urgent/Emergent: •Appendectomy •Pyloromyotomy (pyloric stenosis repair) •Intussusception reduction
What is hypermobility syndrome? Is it common? Who is it most common in? How does it progress with age?
•Includes those individuals with a hypermobility-related condition who do not fulfill either the more stringent criteria for hEDS or criteria for another of the hereditary disorders of connective tissue •Common cause of leg pain in children, up to 1 in 5 individuals •Present either in isolated joints or be more generalized throughout the body •More common in childhood and adolescence, in females, and in Asians and West Africans. •Joint hypermobility tends to lessen with age and has strong heritability •Benign trait, rather than a true disorder
Who is more likely to have seizures males or females?
•Males > Females
What is radial Head subluxation? How will a child present? How will an xray present? How is it treated?
•Occurs after forearm or wrist is jerked with longitudinal/pronational forces ("airplane") - pull injury •Most common joint injury in kids •Common presentation: child holds arm in pronated and flexed position and resists extension •Diagnosis: •History and exam •Radiographs are normal •Treatment: •Reduction by hyperpronation •Splint if recurrent Prevention
Why is reflux normal in infants?
•Reflux is common in infants because the lower esophageal sphincter is still developing tone - "spitting up"
What are the risk factors for jaundice?
•Risk factors: •Race - incidence is higher in East Asians and American Indians and is lower in Africans/African Americans •Higher in BF infants & those that are undernourished •Maternal factors (e.g. diabetes) •Birthweight and gestational age - incidence is higher in premature infants and in infants with low birthweight. •Congenital infection
•Semisolid food should be introduced at ____ months of age
•Semisolid food should be introduced at 6 months of age
What is the Rochester, Philadelphia, and Boston criteria used for?
•Set of risk stratifiers used in the context of a well-appearing child, developed in the early 1990s
How is Juvenile Idiopathic Arthritis treated?
•Treatment: NSAIDS, DMARDs (methotrexate), biologics, JAK inhibitor, oral or joint steroids, PT/OT •Prognosis varies - 75% report remission, 13% continue into adult RA, do not administer live vaccines (while on systemic suppression)
What is the criteria for the following in children older than 2 years: Overweight: Obese: Severe obesity:
○> 2 years: BMI > 95th percentile ■Overweight: 85th-95th for age and sex ■Obese: >95th percentile for age and sex ■Severe obesity: >120% of the 95th percentile for age and sex
What are some popular methods for predicting height?
○A child's height at age 2 years generally predicts their adult height potential. ○Girl: (mom height inches + dad height inches) - 5/2 ○Boy: (mom height inches + dad height inches) + 5/2
How do you calculate corrected age? ■Weight should be corrected until age _____ months ■Length should be corrected until age _____ months ■Head circumference should be corrected until _____ months
○Corrected age= actual age in weeks - # weeks preterm ■Weight should be corrected until age 24 months ■Length should be corrected until age 40 months ■Head circumference should be corrected until 18 months
Human milk as the sole source of nutrition for the first ____ months of life, then supplemented with foods but with continued intake of human milk for ______ year(s).
○Human milk as the sole source of nutrition for the first 6 months of life, then supplemented with foods but with continued intake of human milk for the first year.
A baby is has GERD associated with poor weight gain. So you put them on a two week trial of hydrolyzed formula and the mother is told to eliminate all dairy and beef if breastfeeding. If that showed improvement she would continue this until 1 year of age. However, the infant did not show improvement even with lifestyle modifications for GERD. Now what can she try?
○If no improvement... two-week trial of acid suppression with PPIs ■Omeprazole 30 minutes before first meal of the day ■If improvement, continue PPI for 2-3 months ○If no improvement with PPIs, further evaluation is indicated
What are the advantages of breastfeeding?
●Decreased incidence of the following: ○Bacteremia ○Diarrhea ○Respiratory tract infections ○Necrotizing enterocolitis ○Otitis media ○Urinary tract infections ○Late-onset sepsis in preterm infants ○Type I and Type II DM ○Lymphoma, leukemia and Hodgkin's disease ○Childhood overweight and obesity
What is constitutional growth delay? How will menarche usually be affected? How is skeletal age determined? Is it a type of FTT?
●Def: global delay in development affecting every organ system of the body ○Growth and development are appropriate for skeletal age instead of chronological age = "Late Bloomers" ○Menarche/secondary sex characteristics are also delayed. ●Skeletal age is determined by left wrist and left hand radiographic evaluations NOT a disease state!!!
Why shouldn't you give cows milk to infants younger than 1 year?
●Do not feed cow's milk to infants <1 year of age ●Low iron content and high calcium and casein concentration impair iron absorption ●Occult intestinal blood loss ○Causes inflammation in the intestines → blood loss which can be significant- ■E.g. >1 cc/day and contribute to iron deficiency ●High renal solute load which can lead to dehydration
What are some early clinical manifestations of cerebral palsy?
●Excessive docility or irritability ○Irritable, sleep poorly, vomit frequently, be difficult to handle and cuddle, and demonstrate poor visual attention ●Delayed disappearance OR exaggeration of developmental reflex ●Tone may be normal, decreased, OR increased ○ Persistent or asymmetric fisting ○ Abnormal oromotor patterns (tongue thrusting, grimacing) ●Delayed motor milestones (corrected for GA) ○Not sitting by 8 months ○Not walking by 18 months Early hand preference before one year
Is Familial Short Stature also FTT?
●Not a disease state! ●NO proven way to predict height - determined by genetics! ●In familial short stature, bone age is equivalent to chronologic age.
How is malnutrition treated? Are IV fluids used? ○Start calories at _____% above the child's recent intake or _________% of estimated requirements and increase by ~______% per day. ○Eventually, will need caloric intake at ~_____% of requirements with multivitamin supplementation. Are iron supplements recommended for acute rehabilitation? What else should be monitored?
●Nutritional rehabilitation is initiated and advanced slowly. ○IV fluids avoided → can lead to fluid overload and/or worsening edema. ○Start calories at 20% above the child's recent intake or 50-70% of estimated requirements and increase by ~10% per day. ○Eventually, will need caloric intake at ~150% of requirements with multivitamin supplementation ○Iron supplements not recommended during acute rehabilitation ○Cow's milk formulas as well as other easily digested foods are used ●Monitor for heart failure, edema, electrolyte imbalances (refeeding syndrome), or feeding intolerances (diarrhea, vomiting)
What is cerebral palsy? More is preterm or term infants? How is it associated with birth weight?
●Permanent, nonprogressive disorder of movement and posture that results from lesion of the immature brain ○Affects muscle tone, posture, and/or movement ●Most common movement disorder in children (2/1000 live term births) ○Higher prevalence in preterm compared with term infants ○Increases with decreasing gestational age and birth weight
What does SSHADESS stand for?
●Strengths, Schools, Home, Activities, Drugs, Emotions/Eating, Sexulity, Safety
How is Hirschsprung Disease treated?
●Surgical resection of the aganglionic segment of bowel with transanal pull-through ○Normal ganglionic bowel is brought down and anastomosed just proximal to the anus; injury to the anal sphincter is avoided ●Abnormalities of bowel function are common after definitive surgery ○Constipation and fecal incontinence ○Postoperative enterocolitis may occur →emergency!
What are the symptoms of Abusive head trauma?
●Symptoms range from lethargy and irritability to seizures, apnea and coma ○30% are misdiagnosed at initial evaluations 25% are reinjured before diagnosis is made.
Cow's milk allergy: When do symptoms start to show? What are the symptoms for the following? IgE mediated: Non-IgE mediated: Are they likely going to develop tolerance?
●Symptoms within days-weeks of initiating cow's milk-based formulas ○IgE-mediated: urticaria/angioedema and anaphylaxis ○Non-IgE-mediated: delayed gastrointestinal manifestations ○Mixed: atopic dermatitis, eosinophilic esophagitis ●Tolerance is achieved by the majority of children with cow's milk allergy
What is recommended for children and highly allergenic foods?
●The most common highly allergenic foods include cow's milk, hen's egg, soy, wheat, peanut, tree nuts, sesame, shellfish, and fish. ●High-risk: family or personal history of atopy ○Recommend early introduction of highly allergenic solid foods ○Introduction of peanut- and egg-containing foods into the diet of all infants regardless of allergic risk, starting around 6 mos. but not before 4 mos. of age ●Once introduced and tolerated, highly allergenic foods should be consumed on a regular basis
What is considered increased bilirubin at the following times? ●Total bilirubin ○> ______ mg/dL on first day of life ○> _______ mg/dL at any other time
●Total bilirubin ○> 5 mg/dL on first day of life ○> 13 mg/dL at any other time
How does phototherapy work in the treatment for unconjugated hyperbilirubinemia?
●Transforms unconjugated bilirubin into water-soluble isomer that can be easily excreted ●Indications for use: ○Indirect (unconjugated) bilirubin 16-18 mg/dL in term infants ○Earlier use in preterm infants for prevention
What are the clinical manifestations of kernicterus? What causes it? Is it conjugated or unconjugated hyperbilirubinemia?
●Unconjugated bilirubin is lipid-soluble and easily crosses blood-brain barrier ○Basal ganglia deposition ●Clinical manifestations: ○Lethargy and hypotonia ○Poor Moro response and feeding ○Characteristic high-pitched cry ●Management ○Phototherapy? ○Early exchange transfusions
A vitamins and supplements recommended for healthy children older than 1 year?
●Vitamins/mineral supplementation ○Not necessary for healthy children who are growing normally, consume a varied diet, and have adequate exposure to sunlight
What will show on CXR in an infant with RDS?
●reticulonodular pattern on CXR ●Air bronchograms may be present ●Heart borders may be obscured
