Pediatric Medicine: Exam 1
what is the most common cause of short stature?
constitutional (delayed bone age) *know this
what is the result of the absence of the tricuspid valve in tricuspid atresia?
hypoplastic right ventricle
what is the most common cause of both congenital and acquired GH deficiency?
idiopathic GH deficiency
what is the initial treatment of a distal radial greenstick fracture?
immobilize with sugar-tong splint
when is the risk of undernutrition the greatest?
in utero through 2 years of age
what is the purpose of instilling silver nitrate (1%) into both eyes of neonates?
indicated effective therapy for the prevention of neonatal gonococcal ophthalmia, which can result in severe panophthalmitis and subsequent blindness
what is the most common cause of anemia worldwide?
iron deficiency
what is the most common rheumatological disease of childhood?
juvenile idiopathic arthritis (JIA)
what is the most common location for coarctation of the aorta?
juxta-ductal (occurring opposite the entry of the ductus arteriosus)
acyanotic congenital heart diseases are ________________ to _______________ shunts cyanotic congenital heart diseases are ________________ to _______________ shunts
left to right right to left
how do you treat RF?
long-term penicillin prophylaxis
firm, fixed and nontender masses should raise your suspicion for ...
malignancy *inflammatory or infectious tumors are typically tender
what physical characteristics are a clue of endocrine causes of growth failure?
markedly reduced height velocity and usually marked by excessive weight for height
why does nutritional rehabilitation need to be initiated and advanced slowly?
minimize complications of refeeding syndrome *changes in serum electrolyte concentrations --> cardiac issues/ arrhythmias
what murmur is most commonly associated with RF?
mitral stenosis
do infants need water?
no *breast milk and formula provide all the fluids needed. However, with the introduction of solid foods, water can be added to the infant's diet
what is the cornerstone of treating FTT?
nutritional management *children with FTT may require more than 1.5 times the expected calorie and protein intake for their age for catch-up growth: -increase caloric density of foods -high-calorie oral supplement -vitamin and mineral supplementation needed
what are the most common cyanotic congenital heart defecets?
the 5 T's: 1. Truncus arteriosus 2. Transposition of the great arteries 3. Tricuspid atresia 4. Tetralogy of Fallot 5. Total Anomalous Pulmonary Venous Return
what is a nursemaids elbow?
radial head subluxation *most common elbow injury in children younger <5 years old due to annular ligament laxity
what is the AAP's recommendation on giving parenteral vitamin K after birth?
recommends that parenteral vitamin K (0.5-1 mg) be given to all newborns shortly after birth
how do you treat "psychosocial short stature" (ie: deprivation dwarfism)?
remove the child from the adverse environment is of paramount importance
what should you suspect in newborns with supernumerary nipples?
renal anomalies *order ultrasound to inspect kidneys
why should you avoid honey before 1 year of age?
risk of botulism
why should infants NOT receive fluoride supplements before 6 months of age?
risk of fluorosis
don't miss a _______________ fracture
scaphoid - can lead to avascular necrosis !!! *if you see a kid with a hand injury this needs to be ruled out
growth parameters should be measured _____________ and plotted on growth charts
serially *at one, two, four, six, nine, 12, 18 and 24 months
when you see an obese 14 year old male patient with a CC of "knee pain" that walks with an antalgic gait, out-toeing and some shortening of the affected limb what should you suspect...
slipped capital femoral epiphysis (SCFE)
micrognathia:
small jaw
vernix caseosa:
soft, white, creamy layer covering the skin in preterm infants, disappears by term
Growth failure denotes a slow growth rate regardless of _________________
stature
what medication is given when a mother is going into premature labor? why?
steroids and surfactant *help infant lungs produce surfactant
energy needs increase with _____________
stress
what does a bifid uvula suggest?
submucosal cleft
what should you suspect when you see an anterior and posterior fat pad sign?
supracondylar fracture *anterior fat pad / "sail sign" - can be normal *posterior fat pad - almost always pathologic
which fontanelle is larger?
the anterior is larger than the posterior *both should be soft and non-bulging in newborns
which infant is at higher risk of developing hemorrhagic disease - a breast fed infant or a formula fed infant?
the breast fed infant
what are the 3 causes of in-toeing?
1. metatarsus adductus (most common <18 months old) 2. internal tibial torsion (most common 18 months - 3 YO) 3. femoral anteversion (most common 3 - 8 YO)
what are the 4 problems of Tetralogy of Fallot (TOF)?
1. "Malalignment" type of ventricular septal defect (VSD) 2. The aortic root overrides the ventricular septum 3. Pulmonic stenosis 4. Right ventricular hypertrophy
what does CBC of anemia look like?
-hypochromic -microcytic -serum iron low -serum ferritin low
miliaria:
(prickly heat), which is caused by obstructed sweat glands
what is characteristic of the subacute phase of KD?
-Desquamation of the skin -Reactive thrombocytosis -Development of coronary artery aneurysms
what is characteristic of the acute phase of KD?
-High, hectic fever, followed by: -Conjunctival erythema -Mucosal changes -Cervical lymphadenopathy -Swelling of the hands and feet -Elevated inflammatory parameters
what genetic disorders may cause short stature?
-Turner syndrome -Noonan syndrome -Down syndrome -Prader-Willi syndrome
how do you define failure to thrive (FTT)?
-Weight for height ratio less than 3rd- 5th percentile for age and gender or -Weight crossing 2 major percentiles on the growth curve
characteristics of innocent murmurs?
-the quality of the sound -lack of significant radiation -a significant alteration in the intensity of the murmur with positional changes -most important, the cardiovascular history and examination are otherwise normal
how do you treat transposition of the great arteries ?
1. Prostaglandin E1 to keep ductus arteriosus open (survival is not possible without a ASD, VSD or PDA) 2. Arterial switch surgery
what are the 3 causes of out-toeing?
1. external tibial torsion 2. hip contracture 3. femoral retroversion
When are APGAR scores done?
1 and 5 minutes after birth
Salter-Harris Classification:
1- straight (narrow growth plate) 2- above 3- below 4- through 5- crush (no growth plate visible)
how long should you wait between introducing solid foods?
2-3 days *watch for signs of allergic reactions such as diarrhea, rash, or vomiting
when does the pupillary response to light appear?
28 weeks of gestation
when does the rooting reflex appear?
32 weeks gestation *turning of the head toward light tactile stimulation of the perioral area --> helps with breast/bottle feeding
when does the palmar grasp reflex disappear?
4 months
when should you start introducing semisolid foods?
6 months
what APGAR is expected in a healthy term newborn?
7-10 *however, a high APGAR score cannot always predict a healthy newborn
APGAR scoring:
A= appearance, P= pulses, G= grimace, A= activity, R= reflexes (Done at 1 and 5 min with a score of 0 for absent, 1 for decreased, and 2 for strongly positive)
what is the most common form of cancer in children age 0-14 YO?
ALL
grade I or II systolic ejection murmur and fixed split S2 ...
ASD
what are the 2 diastolic murmurs?
Aortic regurgitation/insufficiency Mitral stenosis
what is the initial treatment of KD?
Aspirin at anti-inflammatory doses (80-100 mg/kg/day divided every 6 hours) in the acute phase
when do you need to start bracing scoliosis?
Cobb angle > 25 degrees *no need to refer for consult if < 20 and not progressing
erythema toxicum:
an erythematous, papular-vesicular rash common in neonates that develops after birth and involves eosinophils in the vesicular fluid
if you see a child with a "cherub" (ie: chubby, immature) appearance, high pitched voice, sparse thin hair and delayed dentition suspect ...
GH deficiency
what is the most common cause of hypothyroidism in the US? worldwide?
Hashimoto thyroiditis (associated with other autoimmune conditions) iodine deficiency
what test do you use to screen for GH deficiency after you have ruled out chronic disease or familial short stature?
IGF-1 •If IGF-1 low, do two GH stimulatory tests- L-Arginine & Clonidine, and Glucagon stimulation
what is the main treatment of KD?
IV Ig *shown to reduce the incidence of coronary artery aneurysms from 20-25% to <5%
red blood shot eyes, red cracked lips and red tongue, swollen hands and feet, high fever, and whole body rash are hallmarks of...
Kawasaki Disease
what is the second most common vasculitis of childhood?
Kawasaki Disease (KD)
Inadequate protein intake in the presence of adequate caloric intake causes ...
Kwashiorkor -abdomen is distended with hypoactive bowel sounds -weight is near normal -pitting edema -marked atrophy of muscle mass -skin changes -moon facies
when you see a patient that has pain when running and tenderness over the tibial tubercle suspect ...
Osgood-Schlatter disease
what is the most common abnormal continuous murmur?
PDA *can also be heard with coarctation of the aorta when collateral vessels are present
continuous machine-like murmur heard at the upper left sternal border...
PDA *systolic-diastolic murmur (continuous)
primary protein-energy malnutrition (PEM) vs. secondary PEM:
Primary PEM: a lack of food Secondary PEM: -increased caloric requirements -increased caloric loss -reduced caloric intake -or a combination of these three
when you see erythema marginatum suspect ...
Rheumatic fever
when you see a child that has a history of squatting while playing and a boot shaped heart on CXR suspect ...
TOF
high-pitched and holosystolic murmur and is best heard at the left sternal border or apex ...
VSD *small VSDs may be louder than large ones due to the higher flow velocity across smaller defects
what is the most common congenital cardiac malformation?
VSD (42%)
what is a buckle fracture?
a common pediatric fracture with no fracture line and only cortical deformation and angulation *aka Torus fracture
what is a patent ductus arteriosus (PDA)?
a persistent communication between the aorta & pulmonary artery that lasts beyond the immediate postpartum period *more common in infants born before 28 weeks GA or those weighing <1500 g at birth *more common in females
What is Kawasaki disease?
a vasculitis that typically affects children under the age of seven *characterized by multisystem involvement and inflammation of small- to medium-sized arteries with resulting aneurysm formation *runs a triphasic course: acute, subacute, and convalescent
scaphoid fractures will present with tenderness to the __________________
anatomic snuff box *if patient presents with tenderness to this area with no radiological evidence of fracture still treat it like a fracture
what is the most important manifestation of KD?
aneurysmal involvement of the coronary arteries
what is the most common major manifestation of RF?
arthritis *it usually involves the large joints and is migratory. *arthralgia cannot be used as a minor manifestation if arthritis is used as a major manifestation.
when should children be referred to the dentist?
at their first birthday
how do you treat GH deficiency? what is the risk associated with this treatment?
biosynthetic recombinant DNA-derived GH (dosage is titrated to the growth rate, weight of the patient, and IGF-1 levels) slipped capital femoral epiphysis (SCFE) and pseudotumor cerebri
what 2 vital signs signify severe and life-threatening malnutrition?
bradycardia and hypothermia *know this
when does the fetal heart develop?
by 6 weeks gestation
capillary hemangiomas:
capillary hemangiomas are raised, red lesions *increase in size after birth then resolve when the child is 1-4 years of age
what could leukocoria (white reflex of the retina) indicate?
cataracts, ocular tumor, severe chorioretinitis, persistent hyperplastic primary vitreous, or retinopathy of prematurity
cavernous hemangiomas:
cavernous hemangiomas are deeper, blue masses *increase in size after birth then resolve when the child is 1-4 years of age
what is the 1st line treatment for ALL?
chemotherapy
how do you diagnose Rheumatic fever?
clinical and laboratory findings of the revised Jones criteria -polyarthritis -carditis -chorea -erythema marginatum -subcutaneous nodules
what murmurs are transient, common in the delivery room and during the 1st day of life?
closure of the ductus arteriosus, peripheral pulmonary artery stenosis, or a small ventral septal defect
what congenital heart defect should be suspected in an adult patient with unexplained hypertension, heart failure, exercise intolerance, or underdeveloped lower extremities?
coarctation of aorta
what signs suggest pulmonary disease in newborns?
cyanosis, nasal flaring, intercostal retractions, and grunting
what are signs of malnutrition on PE?
decreased subcutaneous fat, decreased muscle mass, dermatitis, hepatomegaly, cheilitis (vitamin B12 deficiency), or edema
define low birth weight:
defined as infants having birth weights of less than 2,500 g (about 1 lb) *accounts for more than 70% of neonatal deaths
how do you determine gestational age?
determined by an assessment of various physical signs and neuromuscular characteristics that vary according to fetal age and maturity
Classic GH-deficient patients ___________ show an increase in serum GH levels after stimulation
do not
what is the next best step if you're concerned about a murmur?
echo
what is the preferred method to diagnose VSD?
echo *will give you information about size/location, relationship to the pulmonary, aortic, and tricuspid valves, presence of obstruction to outflow of the left or right ventricles and/or prolapse of the aortic valve, right ventricular pressure and function, and evaluation for additional congenital heart disease
what is the atopic triad?
eczema, allergic rhinitis, asthma *highest risk for persistence as a child/adult
what is the moro relfex?
elicited by sudden, slight dropping of the supported head from a slightly raised supine position, which should elicit opening of the hands and extension and abduction of the arms, followed by upper extremity flexion and a cry *present at birth and gone in 3-6 months, one of the primary newborn reflexes
skin lesions associated with Kwashiorkor:
erosions and scaling
what are risk factors for vitamin D deficiency?
exclusive breast feeding, malabsorption, certain medications
what is the most common cause of Cushing's syndrome?
exogenous steroids for other medical conditions
T/F: APGAR score at 1 minute has a relationship to neonatal morbidity and mortality
false *Apgar score at 1 minute of age is used to determine level of resuscitation required *Apgar score at 5 minute of age has a relationship to neonatal morbidity and mortality
T/F: Pure dietary iron deficiency is common especially in children 1-3 years of age
false *IDA is rare except in children 1-3 YO
T/F: infants need to drink juices
false *infants do not need juices, but if juice is given, it should be started only after 12 months of age, given in a cup (as opposed to a bottle), and limited to 4 oz
T/F: constipation is very common in the first month of life
false *unusual --> if infant is truly constipated this may indicate insufficient milk intake --> requires further evaluation !!!
T/F: club foot commonly corrects on its own
false - WILL NOT correct on its own *Ponseti method (stretching, casting, bracing) and surgery (for severe cases not responding to Ponseti method)
T/F: iron supplements are recommended for all children during acute nutritional rehabilitation phase
false - iron supplements are not recommended during the acute rehabilitation phase, especially for children with kwashiorkor *associated with higher morbidity and mortality
meconium staining of the umbilical cord, nails and skin suggests ...
fetal distress and the possibility of aspiration pneumonia
what is the concern for newborns with torticollis?
flat spots on the skull due to lack of movement of head
what is the #1 cause of chronic disease in childhood?
fluoride deficiency *contributes to early childhood caries
what are the goals of treatment for malnutrition?
gain weight at greater than 50th percentile for age *≥150% or more of the recommended calories for an age-matched, well-nourished child
what is the flag sign?
hair is sparse, easily plucked, appears dull brown, red, or yellow-white *associated with Kwashiorkor
what should you suspect in infants that exhibit poor growth, with weight being more significantly affected than height and head circumference, fatigue or diaphoresis with feeding?
heart failure
how do you define idiopathic short stature?
height below 2 standard deviations of the mean for age without any endocrine, metabolic, or other diagnosis
what vaccine should neonates receive before being discharged?
hepatitis B vaccine *they are also screened for various disease
gluteal fold asymmetry or leg length discrepancy is suggestive of ...
hip dysplasia *perform Barlow and Ortolani maneuver to evaluate the stability of the hip joint
what is the most common cause of death from cardiac defect in the first month of life?
hypoplastic left heart syndrome *occurs when there is failure of development of the mitral or aortic valve *a small left ventricle that is unable to support normal systemic circulation is a central finding
what is characteristic of the convalescent phase of KD?
occurs 6-8 weeks into the illness, is characterized by the resolution of symptoms and the development of dystrophic nail changes
which has better prognosis - omphalocele or gastroschisis?
omphalocele (sealed by peritoneal layer)
what is a common presentation of Legg-Calve Perthes disease?
patients often develop a noticeable limp, stiffness of the hip or complain of mild pain in the groin area, thigh or knee *pain is usually worse with activity and improves with rest
define post-maturity:
post-maturity is defined as a pregnancy lasting ≥ 42 weeks (294 days) from the last menstrual period
define late-term:
pregnancies lasting between 41 and 41 and 6/7 weeks
define prematurity:
prematurity is defined as a birth that occurs before 37 completed weeks (less than 259 days) of gestation
what is the initial management to maintain or reopen the ductus arteriosus? what is the initial management to induce ductal closure?
prostaglandin E1 Indomethacin or ibuprofen (NSAIDs)
what is the biggest risk factor for early childhood caries (ECCs)?
putting infants to sleep with a bottle or sippy cup filled with milk, formula or juice
what is the best diagnostic study for iron deciency?
therapeutic trial of oral iron •Reticulocytosis (48-72 hours) •Increase in hemoglobin levels (4-30 days) •Repletion of iron stores (in 1-3 months) •The usual therapeutic dose of 4-6 mg/day of elemental iron induces an increase in hemoglobin of 0.25-0.4 g/dL per day
how do you immobilize a scaphoid fracture?
thumb spica splint - NO THUMB MOVEMENT
what congenital heart defect do the pulmonary veins fail to connect to the left atrium?
total anomalous pulmonary venous return
Mongolian spots:
transient, dark blue to black pigmented macules seen over the lower back and buttocks in 90% of African American, Indian, and Asian infants
what is the most common cyanotic lesion to present in the newborn period?
transposition of the great arteries
T/F: White, shiny, multiple transient epidermal inclusion cysts (Epstein pearls) on the hard palate are normal
true
T/F: a Babinski sign is normal in newborns
true
T/F: a normal linear growth pattern is good evidence of overall health
true
T/F: scoliosis is typically painless
true
T/F: vitamin K deficiency in humans with normal intestinal function is rare
true
what cyanotic congenital heart defect is associated with DiGeorge syndrome and diabetic mothers?
truncus arteriosus
what needs to be ruled out in late-onset growth failure (ie: acquired GH deficiency)?
tumor of the hypothalamus or pituitary
what is SIDS?
unexpected death of an infant (<12 months old) during sleep who was well prior to death and whose cause of death remains unexplained even after a clinical history, case investigation, complete autopsy, and death-scene investigation
what does constitutional delay of bone age usually lead to?
usually leads to a delay in secondary sexual development
if you see an irritable infant with a protruding belly, frequent respiratory infections, and Rickets suspect ...
vitamin D deficiency
what is one of the most common causes of bleeding in healthy infants?
vitamin K deficiency
what should be given to all infants to prevent hemorrhagic disease of the newborn?
vitamin K prophylaxis IM
milia:
yellow-white epidermal cysts of the pilosebaceous follicles that are noted on the nose
can you get pregnant while breast feeding?
yes
what are general signs of readiness for solid foods in infants?
•Ability to hold the head up •Big enough (around double the birth weight) •Opening their mouths wide showing eager anticipation of eating food and interest in foods •Sitting unassisted •Bringing objects to the mouth •Ability to track a spoon and take food from the spoon •Stopping when they are full
what is included in the neurological examination of a newborn?
•Assessment of active and passive tone •Level of alertness •Primary neonatal (primitive) reflexes •Deep tendon reflexes •Spontaneous motor activity •Cranial nerves (involving retinal examination, extraocular muscle movement, masseter power as in sucking, facial motility, hearing, and tongue function)
Risk factors for late-term or post-term pregnancy include:
•Nulliparity •Obesity •Older maternal age •Previous post-term pregnancy •Male fetus
vital signs for newborns:
•heart rate (normal rate, 120-160 beats/min) •respiratory rate (normal rate, 30-60 breaths/min) •temperature (usually done per rectum and later as an axillary measurement) •blood pressure (often reserved for sick infants)
what are risk factors for SIDS?
•male gender (3:2 ratio) •prone and side sleeping position (BACK TO SLEEP) •bed sharing •maternal smoking during pregnancy or environmental tobacco smoke •crib and bedding accessories, such as soft bedding, pillows, and loose blankets •overheating/overdressing/over-bundling •inadequate prenatal care •young maternal age •prematurity or low birth weight •African American or American Indian/Alaska Native heritage
