Pediatrics

birth weight

-Extremely low birth weight <1,000 g (ELBW) -Very low birth weight <1,500 g (VLBW) -Low birth weight <2,500 g -Normal birth weight ≥2,500 g

patent ductus arteriosus

-60% of FT infants have a murmur at birth -Closing of the duct: birth is responsible for its closure, nl closure occurs ~15 hours of life, highly sensitive to O2 tension, the increase in O2 tension that normally occurs, withdrawal prostaglandins, Prematurity, respiratory distress and hypoxia can delay closure -Incidence: 10-20% of premies with RDS, 30% of infants <1.5kg -cardiomegaly, pulmonary congestion, and haziness -Signs and symptoms: hyperdynamic precordium, bounding pulses, widened pulse pressures, loud systolic murmur, tachycardia and increased O2 requirement -CXR: cardiomegaly, increased pulm vasc markings -Diagnosis: ECHO -Treatment: fluid restriction, furosemide, indomethacin (only medication indicated for closure of ductus), surgical ligation

newborn exam

-"opportunistic exam", start swaddled, perform as much of exam in parents lap as possible -length, weight, head circumference, BP, HR, RR, temp -head circumference (macrocephaly or Microcephaly) -head shape: Plagiocephaly (flattening of one side of head); Dolichocephaly (common in premature infants where head is long in occipitofrontal diameter and narrow at bitemporal diameter -frontanelles: anterior: closes betwn 4-26 months; posterior closes by 2 months; need to assess for sunkenness, molding, bulging, overriding sutures -assess symmetry of face and look for congenital anomalies -asses eyes, visual milestones, conjunctivitis -assess that infant can hear, or any congenital anomalies -looks at nose, nose breathers, listen for upper airway congestion, nasal flaring could indicate resp distress -mouth, assess hydration, palpate palate, macroglossia, natal teeth (most need removal), epstein pearls (small white cysts with keratin) -neck: palpate lymph nodes, torticollis, webbed neck (Turner's and Noonan's syndrome), short neck (trisomy 21) -chest: assess nipples (wide spaced or extra), observe respiratory pattern, auscultate -CV: assess pulses (femoral and brachial), assess precordium, assess rhythm, rate, murmurs -Abd: shape, auscultate, palpate liver, spleen, assess for hernias or other abd wall defects -extremities: perfustion/capillary refill, tone -back: assess spine, look for sacral defects -Female GU exam: prominant labia minora/clitoris common, vaginal skin tag, mucoid/whitish dischage, may have small amount of vaginal bleeding -male GU exam: palpate testes, hypospadias, chordee, hydroceles, inguinal hernias -GU/Recal (VATERAL: Vertebral anomalies, Anal atresia, Cardiovascular anomalies, Tracheoesophageal fistula, Esophageal atresia, Renal and/or radial anomalies, Limb defects) -skin exam: acrocyanosis, polycythemia, jaundice -neuro exam: neuro development begins centrally to peripherally, assess tone, mental status , jitteriness, clonus, reflexes -CN tests -Hips: Barlow maneuver: done first, ADDuct hip while applying downward pressure on knee (may hear pop); Ortolani maneuver: confirms + above finding- flex knee and hips to 90 degrees and with index finger place ant pressure on greater trochanters ABDucting with thumbs (pos finding is a clunk as femoral head relocates -development: wt should double by 6 months and triple by a year; height is doubled by 1 year of life -breastfeeding: BF 8-12 feeds/day, formula 8 feeds/day; at least 8 wet diapers a day and 1 stool, multivitamin with iron, vit D oral drops -car seat is REAR facing

cleft palate

-1 in 2500 births (Caucasian) -Usually starts at uvula -Can involve soft & hard palate -Repair by 1 year

cleft lip

-1 in 750 births (Caucasian) -With or without cleft palate -Common in Trisomy 13 -Repair by 3 months of age

breast feeding

-10 steps to successful breastfeeding: 1. have written breastfeeding policy that is routinely communicated to all health care staff, 2. train all health care staff in skills necessary to implement this policy, 3. inform all pregnant women about the benefits and management of breastfeeding, 4. help mothers initiate breastfeeding within one hour of birth, 5. show mothers how to breastfeed and how to maintain lactation, even if separated from their infants, 6. give infants no food or drink other than breast-milk, unless medically indicated, 7. practice rooming, allow mothers and infants to remain together 24 hrs a day, 8. encourage breastfeeding on demand, 9. give no pacifiers or artificial nipples to breastfeeding infants, 10. foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center -human milk is gold standard recommended as exclusive food for all term infants for the first 6 months of life -advantages: mother-infant bonding, ideal nutritional composition, contains immune factors (IgA), reduces GI and resp infections, less feeding intolerance, reduces risk of NEC in preterm infants, promotes keytone production as alternate energy to substrate to glucose, protects against: bacteremia, diarrhea, resp tract infections, necrotizing enterocolitis, otitis media, UTI, late-onset sepsis in preterm infants, type 1 and type 2 DM, lymphoma, leukemia, and hodgkins disease, childhood overweight and obesity -maternal benefits: decreased postpartum bleeding and more rapid uterine involution, decreased menstrual blood loss and increased child spacing (lactational amenorrhea), earlier return to pre-pregnancy wt, decreased risk of breast and ovarian cancers -lower health care costs, higher work productivity, environmentally friendly -two true C/I: infants with galactosemia and mothers who are infected with HIV -other poss C/I: active TB, infant with PKU, active herpes lesions -NOT C/I in hep B pos mothers, Hep C pos mom, febrile mothers, mothers exposed to low-level environmental chemical agents, CMV pos mothers, mothers who use tobacco products, jaundice mothers, COVID pos mothers, marijuana -comps: assessing intake, dehydration or hypoglycemia, breast feeding jaundice, low vit K in BM, maternal discomfort (breast engorgement, mastitis, emotional issues, infant cannot latch) -colostrum: sticky, yellow fluid full of IgA Abs and WBCs help baby pass meconium full of vitamins, adequate in first few newborn days, supplement only if medically necessary (hypoglycemia) -immediate skin-to-skin, establish latch early (first feed within 30 mins of birth), use of lactation consultants, demand feeding is preferable, should pump to keep milk supply every 3 hrs -making sure mother and baby are comfortable and lots of support for mom when BF (cradle, cross-cradle, football, side-lying) -initially feed every 3 hrs, feed until baby is content, at least 8 times every 24 hrs, infants may only take 10-15 ml in first few days and then start to take 2-4 oz per feed -BF should continue with addition of complementary food throughout second half of first year of life -should have child led weaning, start by substituting one feed at a time -formula: no anti-infective properties, can be used when infants have varying nutritional needs based on their history (Similac pro advance, Gentle formulas, Lactose free)

milestones

-6 month milestones: rolls over, reaches for objects, raking grasp, responds to own name, holds bottle, imitates speech sounds -9 month milestones: stands while holding on, passes object from hand to hand, feeds self, waves, understands no, uses one or two words (mama, dada) -1-year milestones: can stand alone for 2 seconds, bangs 2 objects together, hugs stuffed animals, points and gestures needs -15 month: falls and picks self up, walks, starts to use spoon, waves bye-bye, uses 4-5 words -18 month: starts to run, scribbles, turns pages of book, can drink from cup, feeds self with spoon, follows simple commands, 20-50 words -2 year: jumps, throws ball overhead, can turn doorknob, can wash hands, combines words into simple sentences -36 month: stands on 1 foot for 2 seconds, toilet training, uses pronouns, gives names -4 year milestones: hops on one foot, dresses self, knows colors, asks questions -5 year: skips using alternate feet, holds a pencil correctly, brushes teeth independently, can carry out a conversation, knows alphabet

Thiamine deficiency

-AKA Beri Beri -In infants, presents in babies who are breastfed by B1 deficiency moms -Can be a complication of long term TPN -Presents at 2-3 months -Cardiomegaly, tachycardia, loud piercing cry, cyanosis, dyspnea, emesis -Older kids: signs of meningitis, aphonic cry, emesis, nystagmus, altered consciousness, seizures -Adults: "dry" or "wet" -Dry beriberi - symmetrical peripheral neuropathy -Wet beriberi - cardiac involvement in addition to neuropathy (cardiomegaly, cardiomyopathy, heart failure, tachycardia, peripheral edema) -Tx: parenteral or oral thiamine replacement

vitamin B12 deficiency

-AKA Cobalamin -Water-soluble -Important for hematopoiesis and neurologic function -Vegetarians and vegans are at risk -Causes megaloblastic anemia -Severe deficiency can lead to impaired brain function and elevated homocysteine levels

Niacin deficiency

-AKA Pellagra -Pellagra = raw skin -Often seen in resource limited countries -Photosensitive pigmented dermatitis (often symmetric) -Diarrhea -Dementia

atrial septal defect/PFO

-Abnormal connection between the left and right atrium -PFO is an incomplete closure of a fetal shunt -ASD refers to an absence of cardiac tissue between the atrium -ASDs > PFO: hemodynamically significant shunts -PFOs > ASD: paradoxical emboli/cryptogenic strokes -Blood follows path of least resistance -Oxygenated blood travels from left atrium to right atrium -Results in Increased right sided output and pulmonary blood flow -Shunting in ASD > PFO -Most often asymptomatic until middle age -Presents with exercise intolerance, DOE, fatigue -Mild-systolic ejection murmur at 2nd left sternal boarder -Wide, fixed splitting of S2 -Afib common secondary to RA enlargement -Paradoxical emboli do occur -dx: TEE w/ "bubble study" often used for diagnosis, CXR w/ large pulmonary artery, ECG w/ R-axis deviation, RBBB is present in nearly all cases -ASD Management: Small shunts do not require surgical intervention; Surgery if shunt ratio >1.5; Open or percutaneous surgical closure -PFO Management: Surgical intervention indicated for pts w/ stroke, TIA, & hypoxemia; Open or percutaneous surgical closure

cyanotic lesions

-About 1/3 of potentially fatal forms of CHD -Involves R 🡪 L SHUNT -"BLUE BABY" -Patho: Venous blood is shunted from the R to L side of the heart bypassing the lungs, Deoxygenated blood is pumped and circulates to the rest of the body via arteries, Causes hypoxia and central cyanosis -includes: Tetralogy of Fallot, Transposition of the Great Arteries, Truncus Arteriosus, Hypoplastic Left Heart Syndrome, Total Anomalous Pulmonary Venous Return, Tricuspid Atresia, Pulmonary Atresia

tricuspid atresia

-Absence of tricuspid valve -Subtypes include: Muscular, Membranous, Valvular, & Epstein -Muscular is most common (80%) & has muscular floor to RA w/ dimple in place of TV -ASD & VSD also present -No connection between right atrium and right ventricle -Blood exists right to left atrium via ASD -Blood that reaches pulmonary circulation for oxygenation is received via VSD (LV to RV) or PDA (aorta to pulmonary artery) -sxs: Cyanosis, Holosystolic murmur at LLSB, Tachypnea -dx: echo -tx: Prostaglandin E1; Cardiorespiratory support (mechanical ventilation, inotropes, ect.) -3-stage surgical correction: Stage 1: Blalock-Taussig Shunt; Stage 2: Glenn Procedure; Stage 3: Fontan Procedure

necrotizing enterocolitis (NEC)

-Accounts for 7.5% of neonatal deaths -m/c GI medical /surgical emergency in the neonate -Disease of the premature GI tract which represents an injury to the intestinal mucosa and vasculature -Incidence increases with decrease in gestational age -Cause is unknown: multifactorial and includes some predisposing factors: Bacteria (infection), vascular compromise -Other r/f include prematurity**, polycythemia, in utero cocaine exposure, sepsis, PDA, hypoxia, hypotension, early aggressive feeding, blood transfusion and UAC lines -Onset 2 weeks to several months after birth -Signs and Symptoms: glucose intolerance, prefeeding gastric residuals, increase in apnea episodes, abdominal distention, edema , poor perfusion, lethargy, abdominal tenderness, bloody stools, and frank apnea -Workup: guaiac +, CBC (leukocytosis, neutropenia, or thrombocytopenia), blood cx, CSF cx, lytes, ABG (met acidosis), **AXR-distended loops with fixed loops, gasless abdomen, pneumatosis** (pathognomonic although late finding) -Pneumatosis intestinalis, gas in submucosal layer, m/c affects right colon and distal ileum -Treatment: Bowel rest (NPO), Monitoring (lytes q6h, AXRq8h, ABG, CBC), Antibiotics x 14 days (Amp/Gent & Clinda or Flagyl), TPN, Surgery for those with evidence of necrotic bowel or perforation -Complications include short gut syndrome, adhesions and bowel strictures

APGAR scores

-Activity (muscle tone) -Pulse -Grimace (reflex irritability) -Appearance (skin color) -Respiration -0-3= severely depressed -4-6= moderately depressed -7-10= excellent condition

Reye Syndrome

-Acute non-inflammatory encephalopathy with altered level of consciousness and one of the following -Microvascular fatty changes of the liver -Serum AST, ALT or ammonia levels >3 times normal -CSF with < 8 leukocytes per cubic mm -Diagnosis of exclusion -Adenovirus, coxsackie virus, echovirus, EBV, parainfluenza virus, rubella, rubeola, type I poliomyelitis virus and HSV all appear to be linked with Reye syndrome -Occurs most commonly in children 5-14 yo -Hepatic mitochondrial dysfunction leads to hyperammonemia which leads to increased ICP -Liver - hepatocyte cytoplasmic fatty vacuolization -Brain - astrocyte edema leads to loss of neurons -Kidney- edema, fatty degeneration of proximal tubules -sxs: viral prodrome, child recovering, then repetitive vomiting, 24-48 hrs later becomes agitated, combative, disoriented, may develop seizures, 85% have hepatomegaly, may recover spontaneously or progress to a comatose state -dx: ALT/AST and ammonia >3 times nml, PT/PTT 1.5 times normal, hypoglycemia, increased amylase/lipase, decreased clotting factors, CT shows cerebral edema -Hurwitz staging 1-5 (1 being vomiting, sleepy, lethargy and 5 being seizures, paralysis, do DTRs, no pupillary response -tx: hospitalize in PICU setting, frequent neurological checks, 10% dextrose IVF solution, strict I's and O's, Dilantin for seizures, Mannitol for cerebral edema

total anomalous pulmonary venous return

-All 4 pulmonary veins are connected to systemic venous circulation -Oxygen-rich blood returns to the right side of the heart 1.Supracardiac--innominate vein or SVC 2.Cardiac --coronary sinus or RA 3.Infradiaphragmatic --portal or hepatic v. 4.Mixed -Oxygen-rich blood carried via pulmonary veins mixes w/ deoxygenated blood from systemic circulation -Blood is then shunted from R Atrium to L Atrium via PFO/ASD -This partially oxygenated blood is then sent into systemic circulation -RA and RV become dilated secondary to large volume load -Presentation: Cyanosis, Tachypnea, Poor feeding/FTT, Resp. Failure & Shock if severe obstruction, Fixed split S2 secondary to RV overload, Systolic Ejection Murmur (pulmonic valve), Hepatomegaly -Diagnosis: Echo - m/c, CXR- "snow man" sign, Angio - gold standard -Supplemental O2, mechanical ventilation, or ECMO -Inotropic support -Diuretics -Prostaglandin therapy to maintain PDA -Palliative cardiac cath w/ atrial septostomy or pulmonary vein stents -Surgical correction

introduction of solid foods

-Begin introduction of solid foods at 4-6 months -Signs that the infant is ready to take solids: -Can hold head upright -Can sit with support -Mouthing hands or toys -Shows interest in what others are eating -Continue feeding breastmilk/formula -Supplement with one single-ingredient food at a time -3-5 days for each new food -Offer baby cereal with spoon -By 8-10 months, many babies can handle finely chopped finger foods -By 1 years old - offer baby 3 meals/day plus snacks in addition to breastmilk and formula

nutrition

-CHALLENGE! -high energy requirement- high growth rate and heat loss increases energy needs -expend 60-75kcals/kg/day and require 100kcals/kg/day to achieve desired growth rate of 15g/kg/day -common to give total parenteral nutrition (TPN) in the first few days of life -enteral feeding is begun when medically stable -small volume trophic feeds to stimulate gut and prevent muscle atrophy -breast milk is considered to be the best

pneumothorax

-Definition: occurs in 1% of deliveries, risk is increased by positive pressure ventilation in DR -Signs and Symptoms: decreased breath sounds, grunting, tachypnea, cyanosis, retractions, respiratory distress, shift of mediastinum or heart tones (if tension) -Diagnosis: transillumination of chest, CXR (gold standard) -Treatment: if not clinically significant in TERM infant-watchful waiting-- 100% FiO2; Preterm-- needle decompression and chest tube insertion

sepsis

-Can present at anytime in the clinical course, early onset- maternal; late onset - environmental -Risk Factors: ROM >24 hours prior to delivery, mom GBS positive, ROM with chorioamnionitis -Signs and Symptoms: Resp distress due to pneumonia m/c, temp instability, tachycardia, decreased activity, low Apgars without fetal distress, hypotension, poor perfusion, apnea, feeding intolerance, increase need for O2, increase vent settings, metabolic acidosis , neutropenia, elevated immature to total WBC counts, thrombocytopenia, hyper/hypoglycemia, in early sepsis CXR may show infiltrates -Early onset m/c causes: Group B Streptococcus (m/c), Escherichia coli, Listeria monocytogenes. -Nosocomial infections: coagulase negative staphylococcus (especially if indwelling catheters), Klebsiella, Pseudomonas, and Candida albicans -Labs: CBC with diff, blood culture, CSF culture, urine culture (later), catheter culture (central lines, ETT) -Treatment: broad spectrum antibiotics for 48-72 hours pending negative blood cultures, supportive treatment -Early onset sepsis treat with Ampicillin and either a 3rd gen Cephalosporin or an Aminoglycoside-- Gentamycin -Late onset sepsis: Vancomycin and a 3rd generation cephalosporin (Cefotaxime) -Fungal-Amphoteracin B -Cultures should dictate antibiotics whenever possible -For proven sepsis treatment usually 10-14 days

transient tachypnea of the newborn

-Cause: retained fetal lung fluid -Etiology: unknown -Incidence: 11/1000 births -Signs and Symptoms: Respiratory distress (grunting, tachypnea and retractions) present from birth requiring a mild-moderate O2 requirement, term or near term non-asphyxiated, short labor or via c-section without labor; CXR: perihilar streaking and fluid in the interlobar fissures -Treatment: supplemental O2 prn; usually resolves within 12-24 hours

kernicterus

-Chronic and permanent complication of hyperbilirubinemia -Movement disorder (chorea, tremor) -Gaze abnormality -Auditory abnormalities -Cognitive function is normally spared

bronchopulmonary dysplasia/chronic lung disease

-Chronic lung disease occurring in premature infants with RDS who were treated with mechanical ventilation and oxygen -Definition: unclear* varies--O2 dependence at one month of age with persistent radiographic changes. Also defined as an abnormal pulmonary outcome with the need for supplemental O2 beyond 36 weeks PCA -Incidence: 5% of all NICU babies, 20-30% of infants with RDS, 20-70% with BW <1000 grams -Role of surfactant and antenatal steroids improved survival and decrease need for mechanical ventilation -The exact mechanisms that lead to BPD are not fully understood. BPD represents injury resulting from barotrauma, oxygen toxicity and inflammation of an immature lung -Clinical Course: ranges from mild O2 requirement that resolves to severe disease requiring a tracheostomy and mechanical ventilation -Severe diffuse bilateral atelectasis with pockets of trapped air, "Swiss cheese" appearance, Hazy heart border, ET tube at T3 -Treatment: inhaled glucocorticosteroids with occasional use of B agonists, chronic or intermittent diuretics, Lasix or HCTZ and Aldactone, Some require O2 and monitor at d/c

large for gestational age

-Common in infants of diabetic mothers -Beckwith-Wiedemann Syndrome: macroglossia, visceromegaly, macrosomia, neonatal hypoglycemia, omphaloceles

pulmonary atresia

-Complete obstruction of RVOT -Related to varying degrees of hypoplasia of tricuspid valve and right ventricle -No connection between RVOT and pulmonary arteries -No connection between RVOT and pulmonary artery -PAIVS blood leaves the RV via tricuspid regurgitation or via fistulas/sinusoids of coronary artery circulation -PAIVS will have an obligate R🡪L atrial shunt (PFO/ASD) -Pulmonary blood flow depends on PDA -PA w/ VSD blood can leave RV via shunt to LV -sxs: Cyanosis, Tachypnea, Systolic murmur, Single second heart sound, PDA closure, metabolic acidosis, hypoxia, cardiogenic shock, cardiac arrest & death -dx: Echo, EKG w/ absent normal right axis deviation of newborn & right atrial enlargement -Maintain PDA w/ prostaglandin infusion -Cardiopulmonary support -Surgical repair: Univentricular; Biventricular; Hybrid

retinopathy of prematurity

-Complication of oxygen therapy in premature infants -Can lead to retinal detachment and blindness -Most common in infants born before 31 weeks of age -Screen all pre-term infants -Treatment -Cryotherapy, Laser therapy

fever

-Definition - elevation of body temperature -30% of all pediatrician and ED visits with chief complaint of fever -In fever, internal "thermostat" has been reset at a higher set point -Primary substance for elevating set point is IL-1 -Other substances include IL-6, TNF and interferon alpha -Infections, antigen-antibody mediated reactions and tumors all release IL-1 -IL-1 stimulates production of prostaglandins, prostacyclins and thromboxanes that increase the set point of the hypothalamic thermostat -Rectal- most widely accepted measurement of core body temperature, Is preferred route of measurement unless contraindicated; oral acceptable in cooperative kids >5 y/, tympanic is easy, quick, painless -An elevated temperature is any measurement higher than 100.4°F or 38°C -causes: Infections, Collagen vascular disease, Neoplasia, Hematological disease, Metabolic disease, Poisoning, CNS abnormalities, Chronic inflammatory disease, Factitious fever -sxs: Irritability, Anorexia, Flushed cheeks, Glittery eyes, Shivering/sweating, Elevated pulse, Increased respiratory rate, Lethargy -Intermittent - high temperature spikes with rapid drop -Remittent - fluctuating temperature peaks, with no return to baseline -Sustained - persistent temperature with little or no fluctuation -Relapsing - afebrile for days in-between temperature spikes -Recurrent - temperature for greater than 1 year -Infant <1 month with fever >100.4 F: must be admitted, full sepsis work up, pt must be placed on empiric IV abxs until cx results -infants 1-2 months >100.4 F: nml lab workup and lumbar puncture for toxic appearing pts, can give ceftriaxone for outpt and empiric abxs for inpt -toxic child 2-36 months with F >100.4- admit to hospital for full sepsis workup and parenteral antibiotics; non toxic: tylenol for F -children >3 years old: sore throat, ear pain, abd pain -Tx of F: tylenol or motrin

apnea of prematurity

-Definition: cessation of inspiratory activity for >20 seconds or for a shorter period if accompanied by bradycardia (<100bpm), cyanosis or pallor (can be central, obstructive or mixed) -Diagnosis of exclusion -Usually presents after the 1st DOL and resolves between 34 and 36 weeks post conceptional age -Inversely proportional to gestational age, 90% of infants <1000 grams -Differential Dx: sepsis, CNS, metabolic, respiratory, other (anemia, GERD, withdrawal) -Pathophysiology: abnormal breathing control due to neuronal immaturity of the brainstem, breathing control improves as the brain matures and AOP tends to resolve @ 34-35 weeks PCA -Diagnosis: usually clinical - but must R/O other causes of apnea -Treatment: supportive (lytes, CBC, sepsis W/U): tactile stimuli, respiratory support (O2, CPAP, ETT), caffeine or theophylline, apnea monitor

persistent pulmonary hypertension

-Failure of the normal circulatory transition that occurs after birth -In utero high pulmonary vascular resistance, after birth PVR decreases blood flow increase and allows gas exchange -Characterized by marked pulmonary hypertension that causes hypoxemia and right-to-left extrapulmonary shunting of blood -Inadequate pulmonary perfusion -Develop refractory hypoxemia, respiratory distress, and acidosis -Causes: Unknown in healthy infant; Stress (maternal DM, HTN, anemia >40 wks gestation); MAS, anemia, pneumonia, infection, hypoglycemia; Drugs- SSRI's -Presentation: hypoxemia disproportionate to pulm dz, usually at gestation age or near term -S&S: respiratory distress, tachypnea, cyanosis -Prognosis: 50% mortality -Treatment: 100% FiO2 and mechanical ventilation; Alkalinization - bicarb or hyperventilation; Pulmonary vasodilitation; Nitric Oxide

meconium

-First intestinal discharge -Formed after 34 weeks gestation -Dark green- thick made up of intestinal mucosal cells, lanugo, mucosal cells, intestinal secretions, water -Intrauterine fetal hypoxia causes passage in utero- mature GI tract -Reduces antibacterial activity - increase risk for bacterial infection -Irritates skin - erythema toxicum -Pneumonia -aspiration

respiratory distress syndrome

-Formerly known as Hyaline Membrane Disease -Early complication of preterm birth caused by surfactant deficiency -Pathophysiology: surfactant deficiency, alveoli collapse causing worsening atelectasis, edema and decrease in total lung compliance -Incidence: inversely proportional to gestational age. 90% of infants less than 26 weeks have RDS -Signs and Symptoms: tachypnea (>60bpm), cyanosis, retractions, nasal flaring and grunting in the first 6 hours of life -CXR-- reticulogranular appearance, air bronchograms (ground glass appearance), small lung volume -Exogenous surfactant as well as oxygen &/or vent support -Antibiotics pending negative cultures -Close monitoring -Prevention: antenatal use of steroids, tocolytics, tx of maternal dz and surfactant

unconjugated hyperbilirubinemia

-Hazardous in neonates because of potential for deposition of free bilirubin in neuronal tissue with associated brain damage •BIND - bilirubin induced neurologic dysfunction -Total bilirubin level of 14mg/dl or higher may be associated with deafness in preterm infants whose birth weight is less than 1500 grams -Moderate hyperbilirubinemia in full term infants affect auditory and cry production pathways -Must be prevented, recognized and treated -Persistent unconjugated hyperbilirubinemia suggests: Excessive production of bilirubin, Block in bilirubin transport, uptake or conjugation, Abnormal extrahepatic circulation of bilirubin •Physiologic Jaundice: appears on the 5th to 7th day of life and disappears by the 14th day of life •Pathologic Jaundice: Jaundice within the 1st 24hrs of life, Total bilirubin >12mg/dl, Jaundice beyond the 8th day in full term infants, Direct bilirubin >1.5mg/dl, caused by sepsis, hemolytic states, hereditary spherocytosis, G6PD deficiency, meds, gilbert syndrome, hypothyroidism, breast milk jaundice -crigler Najjar syndrome: UGT deficiency, must be treated with phototherapy/exchange transfusion

tests done in newborn nursery

-Hepatitis B vaccine #1 -Vitamin K -EES -Hearing screen -CCHD -Bilirubin screenings: Transcutaneous vs serum -Newborn screen (aka PKU), Sent at 24-48 hours of life (Phenylketonuria, hypothyroidism, sickle cell disease, thalassemia, MCADD, maple syrup urine disease, galactossemia, homocystenirua, and more), State dependent -CF screen (measures IRT or immunoreactive typsinogen) -Car seat test; < 37 weeks; < 2000 g -ask about any issues in the nursery: feeding, voiding/stooling, temp instability, hypoglycemia, tx for maternal intra-amniotic infection (IAI) -discharge criteria: feeding is established, no concerns about parental handling of baby, bilirubin levels downtrending, FU in place, newborn visit in 1-2 days after discharge

substance abuse

-High risk behavior that affects social & emotional development -Should address substance abuse at every adolescent visit -Identify low and high risk substance abuse using the CRAFFT screening tool -Should also identify if there is any substance use disorders in the household -Health supervision for children should always include monitoring the emotional health or parents/caregivers -Interfering with neurotransmitters and damaging connections within the brain -Reducing the ability to experience pleasure -Creating problems with memory -Causing missed opportunities during a period of heightened learning potential -Ingraining expectations of unhealthy habits into brain circuitry -Inhibiting development of perceptual abilities -CRAFFT screening tool: been in Car with someone high or drunk, ever use alc/drugs to Relax, ever do it Alone, ever Forget things while drinking, Friends/Family tell you should cut down, ever gotten in Trouble while using alc/drugs -DSM-IV dx for substance abuse: 1 or more of following: use causes failure to fulfill obligations at work, school, or home, recurrent use in hazardous situations, recurrent legal problems, continued use despite recurrent problems -DSM-IV dx for substance dependence: 3 or more following: tolerance, withdrawl, substance taken in larger amount or over longer period of time than planned, unsuccessful efforts to cut down or quit, great deal of time spent to obtain substance or recover from effect, important activities given up because of substance, continued use despite harmful consequences

feeding difficulties

-Neonatal suck & swallow disorders -Craniofacial birth defects (i.e. Pierre Robin sequence) -Cleft lip & palate -GI anomalies: Short gut syndrome: Long term nutrition and GI support needed, Often benefit from continuous feedings, Enteral feeds slowly introduced, Reducing dependence on TPN is a main goal -G tube: Many infants go home from the hospital with G tubes while they are learning to feed

ADHD

-Hyperactivity & impulsivity -m/c developmental disorder -Other symptoms: emotional immaturity and lability, poor social skills, motor incoordination, disruptive behavior -2-5x more common in boys -Symptoms manifest by 7 years of age; Must occur in 2 settings (home & school) -sxs: impulsivity; experiences difficulty waiting for his/her turn, has trouble waiting until a question is finished before answering, often interrupts; Inattention: easily distracted, has trouble following directions and finishing tasks, displays organizational problems, experiences difficulty listening while others are speaking, forgets about daily activities, often loses things, has tendency to day dream; hyperactivity: squirms or fidgets when sitting, doesn't stay seated, has trouble playing quietly, is restless and always on the move, talks excessively

calcium deficiency

-Important for mineralizing bone and teeth -Common in young females and elderly women -Most common symptom is osteoporosis in adult and rickets in children -Dietary sources of calcium: -Boned fish, dairy, dark green vegetables -Food is the best source!

hypoglycemia

-In utero euglycemia is maintained by mom via placenta -Hypoglycemia-neonate serum glucose <40mg/dL -Monitoring- D-sticks are done every few hours or if symptomatic -S+S-may not be obvious: seizures, jitteriness, lethargy, apnea, poor feeding -Tx: immediate IV dextrose 2cc/kg 10% Dextrose in water, followed by continuous infusion of dextrose

meconium aspiration

-Incidence: Meconium stained fluid 10-20% of deliveries, 2-5% develop MAS; Rare in fetus <34 weeks -Pathophysiology: acute mechanical obstruction resulting in air trapping , chemical irritation, surfactant dysfunction, pulmonary hypertension -Signs and symptoms: respiratory distress; tachypnea, grunting, retractions, hypoxia -CXR-- patchy infiltrates -MAS associated with persistent pulmonary hypertension which has a mortality rate of 50% -Prevention: OB Diagnose fetal distress and be prepared; Suctioning of the oropharynx and airway which could significantly decrease incidence of MAS. -Intubation for infants with cardiorespiratory depression, respiratory distress, thick mec or those that require positive pressure ventilation in the delivery room -Treatment: oxygen (CPAP/mechanical ventilation)to keep saturation >95%. Oxygen is the best pulmonary vasodilator; If severe, inhaled nitric oxide or ECMO (extra-corporal membrane oxygenation)

thermoregulation

-Infants are susceptible to heat loss after birth due to: -high body surface area to body weight ratio -decrease fat stores -decreased glycogen supply -thin skin -Temp control is PARAMOUNT!! -radiant warmers and double walled incubators -transport to NICU-wrapped in warm blankets or cellophane to help retain body heat -delivery room and NICU kept warm

acyanotic lesions

-Involves L-- R Shunt -"Pink Baby" -Patho: Oxygenated blood from L shunts to R side of the heart; Increases workload of R ventricle causing R ventricular hypertrophy and respiratory distress; Babies are not cyanotic, but present with CHF and respiratory distress -include: Patent Ductus Arteriosus, Ventricular Septal Defect, Atrial Septal Defect, Coarctation of the Aorta

language and speech screenings

-Isolated speech delay - usually environmental and can be alleviated -True language delay - combined expressive and receptive problem, pathologic -Most common cause is conductive hearing loss -Should assess hearing!!!! -Signs of delay - omitted sounds, difficulty with certain letters, failure to have appropriate language skills by 2-3 yrs -Referral to speech & language specialists often necessary

rickets

-Main presentation of Vit D deficiency in infants and young children -Failure of mineralization of growing bone and cartilage -May be asymptomatic -If severe: Pain, irritability, motor delays, poor growth; Delayed closure of fontanelles, frontal bossing, widening of wrists and ankles, bow legs or knock knees

childhood food allergies

-Rapidly growing public health concern -Prevalence in USA increased by 50% between 1997-2011 -Peanut allergies have tripled since 1997 -For true food allergies (IgE-mediated), not intolerances, child must have been exposed to the food once before -Second exposure = allergic reaction -Common allergy symptoms: Hives, asthma, itching, respiratory distress, abd pain, vomiting, diarrhea -Most common allergens: Milk, eggs, wheat, soy, tree nuts, peanuts, fish, shellfish; Nut & shellfish allergies = most severe reaction

childhood obesity

-Major public health concern in the US -1/3 of children are either overweight or obese -5% of children in the US have SEVERE obesity -Diagnose with BMI -Many environmental factors: Sedentary lifestyle, Excessive caloric intake, Sugar-containing beverages, Availability & affordability of fast food, Decreasing structured physical activity, Increased television, Increasing of computer-based activity -Genetics -Metabolism -Lack of sleep -Endocrine disorders -Hx of prematurity of SGA, LGA -BMI = weight (kg) / m2 -Overweight = 85-95th percentile -Obese = 95th percentile -Start encouraging weight loss -Severely obese = 99th percentile -Asses BMI-for-age on growth chart -RED FLAGS ON GROWTH CHART - increased BMI percentiles crossing major percentile lines -Short and long term effects of physical, social, and emotional health -Higher risk for chronic health conditions: asthma, sleep apnea, bone & joint problems, diabetes, heart disease -Children with obesity experience bullying & teasing more than normal BMI peers -This leads to social isolation, depression, and low self esteem -More likely to have obesity as an adult nPerform thorough nutritional & activity assessment -Behavioral strategies -Self-monitoring, Food and activity logs; Stimulus control, Removing environmental cues for unhealthy behaviors; Goal setting; Positive reinforcement for target behaviors -Family involvement -Motivational interviewing -Must ask about food insecurity -Ask about family's living conditions -Ask about income assistance -Provide resources such as WIC

hyperbilirubinemia

-Most (80%) preterm infants have significant indirect hyperbilirubinemia requiring treatment -Normal peak -3-5 days -Causes: increase in RBC turnover and destruction, immature liver impaired in conjugation, decreased bowel motility, Rh disease, ABO incompatibility, sepsis -Kernicterus-unconjugated bili crosses BBB and stains the basal ganglia, pons and cerebellum resulting in death, MR, CP and deafness -Tx: phototherapy, exchange transfusion

cows milk allergies

-Most common food allergy in babies -Affects 2% of children under 4 years old -3rd most common food responsible for anaphylaxis in pediatric population -IgE mediated or non IgE mediated -Many patients with CMA are sensitive to multiple milk proteins -Many are also sensitive to soy -Symptoms present days-weeks after introduction of cow's milk based formula -Most children eventually develop tolerance to cow's milk IgE mediated: symptoms occur immediately -Skin, oropharyngeal, resp tract, GI tract -Can cause mild to life threatening anaphylaxis -Can persistent into adulthood Mixed IgE/Non-IgE mediated: -Atopic dermatitis -GERD -Enterocolitis - severe vomiting or diarrhea -Infantile colic -Constipation -Often resolves by early childhood -Exclusive breast feeding, Mom's should avoid cow's milk -Hydrolyzed formula, Extensive vs partial, Similac Alimentum, Enfamil Nutramigen, Enfamil Pregestimil -Free Amino Acid Base Formulas: Elecare, Enfamil Nutramigen AA

Iron deficiency

-Most common nutritional deficiency in children -Global prevalence of 33% in kids < 5 years old -Common in resource-limited areas -Diagnosing: Assess for ID risk factors at all well-child evals from 4-36 months; For kids 6 months-5 years: Ferritin < 12 mg/L and Hemoglobin < 11 g/dL; For kids 5-12 yrs: Ferritin < 15 mg/L and Hemoglobin < 11.5 -Dietary issues are the primary cause of IDA in infancy and early childhood -Heme iron: This type of iron is very well absorbed. It is only found in animal foods, and red meat -Non-heme iron: This type of iron is more common, and is found in both animal and plant foods. It is not absorbed as easily as heme iron. -Common factors: Insufficient intake, In infants, often due to exclusive BF without supplementation, NO LOW IRON FORMULAS!, Inefficient absorption due to low bioavailability of available iron, Introduction of unmodified cow's milk, Occult blood loss, Obesity -Often asymptomatic, well-nourished child -Mild-moderate microcytic, hypochromic anemia -Severe anemia: Lethargy, pallor, irritability, cardiomegaly, poor feeding, tachypnea, Pica, Pagophagia -Associated with impaired neurocognitive development -Recommended intake: Infants: Full term: 1mg/kg daily, Start supplementation at 4 months if BFing; Premature: 2-4 mg/kg daily: Start supplementation at 2 weeks of age -Children: 6 months - at least 1 feeding/day of vit C rich foods, No non-formula cow's milk under 1 yr, Limit cow's milk to 20z/day in kids, At least 3 servings of iron containing food, 1-3 yrs: 7mg daily, 4-8 yrs: 10 mg daily, 9-13 yrs: 8 mg daily

fluids and electrolytes

-Must be closely monitored!!! -Compared with FT infants Preterm have more fluids in the extracellular compartment and a larger proportion of total body weight composed of water -in the 1st few days of life a diuresis occurs--10-20% weight loss that can be exacerbated by phototherapy and warmers -premature infants have immature kidneys decrease in GFR and decreased ability to reabsorb bicarb, secrete potassium and other ions, and inability to concentrate urine -Management: strict ins and outs, daily or twice daily weights, monitoring electrolytes frequently, in the 1st few days of life in preterm usually q6h

guidelines for infant nutrition

-NO cow's milk before 12 months: Poor source of iron -NO honey before 12 months: Can cause infant botulism -Do not offer solids unless they are cut up into small pieces: Caution with hot dogs, meat, cheese, grapes, raw veggies -NO hard foods: Like seeds, nuts, popcorn, or hard candy -Introduce a variety of solid foods -Keep trying - can take 10-15 tries for child to get used to new flavor -Do not force feed -New trend: Baby led weaning -Work fruits and vegetables into the daily routine -Make it easy for kids to choose healthy snacks -Serve lean meats and other good sources of protein, such as fish, eggs, beans, and nuts. -Choose whole-grain breads and cereals -Limit fat intake by avoiding fried foods and choosing healthier cooking methods, such as broiling, grilling, roasting, and steaming. Choose low-fat or nonfat dairy products. -Limit fast food and low-nutrient snacks -Limit sugary drinks. Serve water and low-fat milk instead. -Juice: 0-6 months: no juice; 6-12 months less than 1 cup a day; 1-6 years less than 1 cup a day; 7-18 less than 2 cups a day

coarctation of the aorta

-Narrowing of the descending aorta -Most commonly just distal to left subclavian artery near the site of the ductus arteriosus -After birth, DA and foramen ovale close and blood needs to cross the narrowed segment to perfuse lower extremity -Increased afterload results in increased SBP in LV & proximal aorta -LV undergoes hypertrophy to maintain adequate CO -Collateral blood flow can develop via internal mammary, intercostal, and scapular vessels -May be asymptomatic -Systolic hypertension in upper extremities -Low or unobtainable BP in lower extremities (>10mmHg BP diff from UE) -Diminished or absent femoral pulse -Radial to femoral artery pulse delay -Well-developed upper body w/ underdeveloped lower body -Headache -Cold extremities & claudication w/ exertion -Bicuspid aortic valve (50-80%) -Heart Failure & Shock may occur w/ closure of PDA -dx: Most commonly via Echo, EKG w/ LVH, CXR w/ "3" sign -Conservative management if asymptomatic -HTN management -Surgical resection via L thoracotomy -Angioplasty w/ stent graft -Genetic testing for Turner's syndrome in girls -Surveillance for cerebral berry aneurysms

jaundice

-Occurs in about 60% of healthy term infants and 80% of those born early. -Bilirubin concentration >5 mg/dL, the face takes on a yellow appearance ->15 mg/dL, the yellow tint is visible from the head down to the midabdomen ->20 mg/dL soles of the feet are yellow ->20-25 mg/dL, caution -kernicterus -Yellowish discoloration of the skin and mucous membranes -Direct indication of hyperbilirubinemia -Excessive conjugated and/or unconjugated bilirubin -Nearly all infants have total bilirubin level >1mg/dL -Jaundice appears first on the face and forehead, then the trunk and extremities, Blanches -physiologic jaundice in healthy baby, total serum bilirubin levels should not exceed: 12 at 24 hrs, 15 at 48 hrs, 18 at 72 hrs, and 20 at 96 hrs -tx: phototherapy: mainstay of tx for neonatal jaundice, infant naked except diaper and eye shields, blue light most effects, SE: Insensible water loss, retinal damage, bronzing of skin, loose stools -exchange transfusion: When direct bilirubin is greater than 20mg/dl in full term infant, greater than 10mg/dl in a preterm infant or is rising rapidly -albumin transfusion: Increases bilirubin binding sites

late adolescence (18-21)

-Physiologic growth is completed -Cognitive: Future orientation, Emotional independence, Capacity for empathy, intimacy, and reciprocity in interpersonal relationships. Legally capable of providing consent -Social: individual over peer relationships, transition in parent-child relationship, may transition to college or out of home, -Potential problems: eating disorders, depression, suicide, MVA, substance abuse

early adolescence (11-14)

-Physiologic: Onset of puberty & growth spurt -Cognitive: Develop concrete thought, preoccupation with body changes, sexual identity, questioning independence, parental controls remain strong -Social: search for same-sex peer affiliation, good parental relationships, see adults as role models, transition to middle school, extracurricular activities, sensitivity towards differences between home culture and culture of others -Potential problems: Delayed puberty, acne, orthopedic issues, school problems (ADHD), psychosomatic concerns, depression, initiation of drug and alcohol use

middle adolescence (15-17 years)

-Physiologic: Ovulation (girls), growth spurt (boys) -Cognitive: Competence in abstract and future thought, idealism, narcissism, invincibility, sexual identity, beginning of cognitive capacity to provide legal consent -Social: beginning emotional emancipation, increased power of peer group, conflict over parental control, interest in sexual relationships, driving, more risk-taking behaviors, transition to high school, cultural conflicts -Potential problems: risk taking behaviors (sex, alcohol, tobacco, drug use), unwanted pregnancy, acne, obesity, physical inactivity, poor eating habits, eating disorders

newborn skin conditions

-Pigment and texture changes -Lanugo -Vernix -Desquamation -Jaundice- blanching -Vascular markings -Acrocyanosis: hands and feet blue -Flame nevi: salmon patch, port wine stain -Cafe-au-lait spot -hemangioma -mila -erythema toxicum -neonatal acne -seborrheic dermatitis "cradle cap" -mongolian spot

patent ductus arteriosus

-Prematurity is important risk factor -More common in infants born at altitude & those w/ congenital rubella -Failure of Ductus Arteriosus to close after birth creating a left-to-right shunt -Often defined as DA that persists 6 weeks after delivery -Dx excluded in pts w/ obligatory shunt lesions (CHD) or those who received prostaglandin therapy -In utero, ductus arteriosus allows oxygenated blood to shunt from the PA to the aorta -Typically after birth - PVR drops, DA closes, & blood flows to PA -If patent ductus fails to close, a persistent shunt develops between PA & aorta -Persistent L-to-R can result in heart failure and pulmonary HTN -If severe enough, can result in Eisenmenger physiology Degree of shunt is determined by Pulmonary to Systemic Flow Ratio (Qp:Qs): Small = Qp:Qs <1.5 to 1; Moderate = Qp:Qs 1.5-2.2 to 1; Large = Qp:Qs >2.2 to 1 -sxs: May be asymptomatic, Continuous "machinery murmur" at left 2nd intercostal space, Heart Failure, Left ventricular dilation, Right ventricular hypertrophy, Differential cyanosis, Exercise intolerance -Complications: Heart Failure, Pulmonary HTN, Eisenmenger Syndrome (R-L Shunt), Infective Endocarditis -Diagnosis: Echo, EKG w/ hypertrophy, Cardiac cath -Depends if there is a PDA dependent cardiac lesion -Small lesions can be monitored as outpatient -Indomethacin for non-surgical closure of PDA -Endovascular repair w/ coil or closure device -Surgical ligation via open heart sx -Spontaneous closure in PDA prior to 3mo is 72-75% -Spontaneous close in PDA after 3mo is rare =Closure following conservative tx w/ NSAID is 80-92% -Untreated PDA has mortality rate of 20% by 20yo -Morality rate of surgical correction low except in extremely premature infant

gestational age

-Preterm <34 wks -Late preterm 34-36 wks -Term 37-42 wks Post-term >42 wks

puberty

-Puberty includes cognitive, psychosocial, and physical maturation -Most visible changes: growth in stature (peak height velocity - 2 inches) and development of secondary sexual characteristics -Increase in fat mass -Onset for girls: 12-13 yrs -Onset for boys: 13-14 yrs -Precocious puberty - pubertal onset at an age 2-3 SDs below mean age of onset of puberty -Delayed puberty - absence of signs of puberty by an age 2-3 SD above the mean onset of puberty -Tanner staging- development of external genitalia in boys, breast development in girls, and boys and girls pubic hair -issues arising with puberty: anemia, gynecomastia, acne, psychological changes, sports-related injuries (can injure epiphyseal growth plates), myopia, scoliosis, dysfunctional uterine bleeding, STIs, increased risk-taking behaviors -importance of regular exercise (60 mins/day), may require more calories to complement growth, first signs girls breast budding, menstruation begins 1.5-2 years after; boys testicular enlargement, safe sex practices, HPV vaccine, emotional well being, sleep, stress management, safety

Preterm labor

-RF: Dehydration, PROM, Incompetent cervix, Infections, Excessive uterine enlargement, Uterine distortion, Placental abnormalities, Maternal smoking, Substance abuse, Iatrogenic-induction of labor -acute challenges/comps: Thermoregulation, Hypoglycemia, Fluid and electrolytes, Nutrition, Hyperbilirubinemia, Respiratory distress, Apnea of prematurity, Patent Ductus Arteriosis, Infection/Meningitis, Necrotizing enterocolitis

choanal atresia

-bone blocking nasal passage -unable to pass NG tube -if bilateral this is emergency -cyanosis relieved with crying

transposition of the great arteries

-Right Ventricle --Aorta --Left Ventricle --Pulmonary Artery Circulation: -Deoxygenated systemic venous blood --Right Atrium --Right Ventricle-- Aorta-- Systemic Circulation -Oxygenated pulmonary venous blood-- Left Atrium-- Left Ventricle -- Pulmonary Artery -- Lungs -NEED a shunt to be compatible with life 1. Intracardiac Shunt (FO, VSD, ASD) 2. Extracardiac Shunt (PDA, Bronchopulmonary collateral circulation) -Degree of hypoxia in infant is dependent on degree of mixing that occurs via these shunts -Mixing most efficient in the lower-pressure atria which allows bidirectional flow -Without treatment, most will die within 1st year -Most cases diagnosed after delivery -Postnatal dx made on clinical suspicion in cyanotic infant -Confirmed with echo -Cardiac Cath gold standard, but rarely done -Usually presents before 30 days of age -CYANOSIS not affected by use of supplemental O2 -Tachypnea (RR: >60) -Murmurs -Failed pulse oximetry screening -Prostaglandins to prevent PDA from closing -Cardiac Cath to perform balloon septostomy to maintain shunt -Arterial Switch (Jatene procedure) is preferred/most common sx

autism and autism screening

-Screening at 18 and 24 months -No set screening tool -Follow bright futures guidelines for each appointment -Be aware of signs/symptoms of autism nInvolve the parents and listen to their concerns -Refer those identified with being at risk to a specialist -1 in 59 children 8 years of age have the diagnosis of ASD -sxs: Defined by impaired social interaction, impaired communication, repetitive behavior, Abnormal language development (may include muteness), Echolalia, unusual rhythm of speech, non-speech like vocalizations, difficulty with conversations, Reduced or atypical non verbal communication, Poor response to name, Preference for aloneness, Difficulty making friends at school, Rigid routine, Restricted patterns of interest, Inability to cope with change, Repetitive motor mannerisms, Atypical play -Autism Spectrum Disorders referrals: developmental/behavioral services, early intervention programs, supervised community play groups, parent training programs

febrile seizures

-Seizures that occur with an elevated body temperature: >38C (100.4 F), Occurs in 2-4 % of kids, Classified as either simple or complex -Dx: Seizure occurs with elevated body temperature (100.4 F/38C), Child must be younger than 6 yo, No CNS infection /inflammation, No acute systemic metabolic abnormality, No prior history of afebrile seizures -RF: Infections, immunizations, family history -simple: generalized, less than 15 mins, 1 in 24 hr period -complex: last longer than 15 mins, more than 1 seizure in 24g period, focal features -manifestations: usually tonic-clonic, staring, stiffening, often occurs at beginning of an illness, post-ictal period -Ct scan and EEG not routinely recommended for 1st episode -Any seizure that lasts > 5 minutes should be treated, Monitor airway, breathing and circulation, Lorazepam (0.05-0.1mg/kg) IV, Phenytoin -Recurrence - 30-35% will have another febrile seizure; Neurologic sequelae - extremely rare; Ensuing diagnosis of epilepsy - slightly increased risk

truncus arteriosis

-Single arterial trunk & ventricle that supplies blood to the pulmonary and systemic circulation -No separate Right Ventricle & Left Ventricle or Pulmonic Valve & Aortic Valve -Mixing of pulmonary & systemic blood flow in ventricles connected via VSD -Blood is pumped to a single trunk -At birth, higher PVR restricts pulmonary blood flow resulting in mild to moderate cyanosis -PVR decreases after birth, blood flow increases, and pulmonary fluid overload/heart failure occurs -sxs: Cyanosis, Tachypnea, grunting, nasal flaring, costal-sternal retractions, Poor feeding, Lethargy, Hepatomegaly, Tachycardia, Loud/Single second heart sound, Systolic ejection click & murmur -dx: Most often by echo, CXR w/ large cardiac silhouette and increased PVC -Tx heart failure: Diuretics, inotropes, afterload reducers and NIPPV -Primary Surgical Repair: Pulmonary Arteries mobilized & anastomosed to RV, Patch repair of the truncus, Patch closure of VSD

hypoplastic left heart syndrome

-Small left ventricle incapable of supporting systemic circulation -Accompanied by atresia, stenosis, or hypoplasia of aortic and/or mitral valve -Small LV unable to meet demands of the body -RV is responsible for perfusion to pulmonary & systemic circulation -Requires a PDA and ASD -At birth, PDA open & high PVR = asymptomatic period -PDA closes & PVR declines = cardiogenic shock -Restrictive ASD causes cyanosis & pulmonary venous congestion -Dx: Echo, CXR w/ "white out" -Presentation: Cyanosis that can worsen w/ oxygen, Diminished peripheral pulses & cool extremities, Hypotension, Acidosis, Respiratory Distress, Heart Failure & Cardiogenic Shock, If restrictive ASD/no ASD, immediate shock/death -Initial: Prostaglandin (Alprostadil) infusion to maintain PDA; Balloon Atrial Septostomy to create adequate ASD; Inotropes, Diuretic, & mechanical ventilation if needed -Staged Palliative Surgery: Stage 1: Norwood Procedure; Stage 2: Bidirectional Glenn Procedure (3-6mo); Stage 3: Fontan Procedure (18-30mo)

bilirubin encephalopathy

-Stage I: First few days, lethargy, hypotonia, poor sucking -Stage II: Later in first week, Irritable, high pitched cry, hypotonia, Retrocollis, opisthotonus, Fever -Stage III: After the first week, Hypertonia, shrill cry, marked retrocollis, opisthotonus, Stupor/coma

Congenital heart defects

-Structural problems that result from the abnormal formation of the heart or major blood vessels -International classification of diseases (ICD) lists 25 congenital heart defects -Most defects are compatible with intrauterine life, but term birth brings along physiologic changes in a newborn -Range from tiny lesions that will go undiagnosed and close spontaneously -Others, are major malformations that may result in death in utero, infancy or childhood -Ideally, diagnosis made on prenatal sonograms -If not, it's a clinical diagnosis that will be aided by your history & physical exam -Left to right shunts usually don't give overt symptoms, but often present with murmur -Cyanotic disease will present with obvious clinical cyanosis or borderline oxygen saturation with no response to oxygen -Echo will confirm diagnosis -Ancillary tests to aid diagnosis: ECG, CXR, ABG, Hyperoxia test -cardinal signs: cyanosis, pathologic murmur, tachypnea, decreased systemic perfusion -hyperoxia test: used to help confirm cyanosis secondary to R-to-L shunt using ABG draws -Duct-dependent pulmonary circulation often presents with cyanosis (Aorta --Ductus Arteriosus -- Pulmonary blood flow) -Duct-dependent systemic circulation often presents with shock (Pulmonary artery -- Ductus Arteriosus-- Systemic Circulation) -IV prostaglandins can be administered if need to keep ductus open for duct-dependent lesions

Juvenile Idiopathic Arthritis

-characterized by chronic arthritis in one or more joints for at least 6 weeks. -Chronic arthritis can be: Joint swelling, Pain with functional limitation, Warmth, Morning stiffness,, Decreased ROM, Unknown cause, Starts before 16 years of age -Articular: joint swelling, joint pain, joint stiffness/gelling after periods of inactivity, joint warmth, restricted joint movements, limping gait in older children, refusal to wt bear in younger children -Extra-articular: general, growth disturbances, skin, others, enethesitis (inflammation of the entheses: the sites of insertion of tendon, ligament, or joint capsule into bone) -sxs of extra-articular: F, pallor, anorexia, loss of wt, anemia, fatigue, growth failure, delayed puberty, limb length/size discrepancy, subcutaneous nodules, rash-systemic, psoriasis, vasculitis, hepatomegaly, splenomegale, lymphadenopathy, muscle atrophy/weakness, uveitis, enthesitis -no dx test -pts with systemic JIA have sig elevated markers of inflammation: ESR, C-reactive protein, WBC, Platelets, RF, Anti-cyclic citrullinated peptide antibody= high specificity for IRA, ANA + a/w increase of uveitis with oligoarticular dz and late onset of RF and form of dz -joint fluid analysis for joint aspiration and synovial fluid analysis to r/o infxn (JIA usually 5,000-60,000 white cells mostly neutrophils; glucose usually normal or slightly low) -MRI with no contrast to see involved joints-early joint damage and with contrast to see presence of synovitis -US useful for detection of synovitis, tenosynovitis, and bony erosions -Tx goals: restore function, relieve pain, maintain joint motion, prevent damage to cartilage and bone -Tx: NSAIDs (Naproxen, Ibuprofen, Meloxicam) , disease modifying (Methotrexate) and biologic agents (Etanercept, Infliximab, Adalimunab), corticosteroids (Triamcinolone acetonide), rehabilitation (PT and OT) -pts with uveitis: needs monitoring by ophthalmologist, corticosteroid eye drops

fever of unknown origin

-Temperature greater than 101°F (38.3°C), lasting greater than 8 days -Cause not elicited by simple diagnostic testing -Must have careful documentation of fever before labeling a patient with FUO -60% infectious, collagen vascular diseases, malignancies -look for new murmur, swelling of joints, rashes, petechiae/purpura -may need bone marrow aspiration -tx fever with conventional modalities and underlying cause once determined

definitions of normal pregnancies

-Term-normal pregnancy lasts 38-42 weeks -Pre-term-less than 36 weeks gestation -Post-term-greater than 42 weeks gestation -Low Birth Weight-(LBW) <2500 grams -Extremely Low Birth Weight Infant-(ELBW) <1000 grams: youngest of premature infants, usually less than <=27 weeks

meningitis

-The newborn is at increased risk for meningitis -Signs and Symptoms: lethargy, irritability, late onset impaired consciousness, coma, bulging fontanel, focal cerebral signs and nuchal rigidity -Diagnosis: spinal tap with positive gram stain, CSF high protein, low glucose, more than 25 leukocytes /uL -m/c organisms are Group B Streptococcus and gram negative enteric organisms -Treatment MUST be for 21 days -Mortality rate is 25%with neurologic sequelae in 1/3

lead poisoning

-The number one environmental health problem for children in the US -Toxic blood lead level (BLL) > 10mcg/dl -Prevalence has decreased secondary to pre-school screening programs and increased public awareness -Approximately 1 million children in the US have toxic BLL's: NO level is safe -Children less than 6 years old are more susceptible to leads toxic effects -Increased prevalence in inner city children -sources: can be inhaled, ingested or absorbed transdermally, Paint chips, Lead dust, Lead containing soil, Drinking water,Parental occupations, Canned food/beverages, Lead glazed pottery, Imported cosmetics, Imported crayons, Lead based plumbing, Imported toys -Lead is not metabolized in the body; it is absorbed, distributed and excreted -Factors affecting absorption: Age, Nutritional status, Route -Lead absorbed via the GI and respiratory tract is distributed to the blood, soft tissues and mineralized tissues -½ life of lead in the body compartments; Blood - 28-36 days, Soft tissue - 40 days, Mineralized tissue - > 25 years -Lead that is not retained is excreted by the kidneys and biliary clearance via the GI tract -Lead interferes with interactions of divalent cations and sulfhydryl groups -Can uncouple mitochondrial oxidative phosphorylation in the CNS: Affects cerebral metabolism -Important to realize that even children with extremely high BLL's may be entirely asymptomatic -Neurological - developmental delay (cognitive and behavioral), hearing loss, peripheral neuropathy, acute encephalopathy -GI - sporadic vomiting, abdominal pain, constipation -Endocrine - decreases vitamin D metabolism -Hematological - rarely causes anemia -Renal - impairment of proximal tubular function -effects: >10mcg/dL - decreased IQ, growth and hearing, 20mcg/dL - decrease in nerve conduction velocity, 30mcg/dL - vitamin D metabolism decreases, 40mcg/dL - Hgb synthesis decreases, 100mcg/dL - encephalopathy, anemia, colic, neuropathy, 140mcg/dL - DEATH -sxs: Anorexia, Decreased activity, Insomnia, Irritability, Abdominal pain, vomiting, Language delay, Hearing loss; (late) Encephalopathic patient with seizures and possibly coma -dx: Usually made via screening program, If you suspect lead poisoning, you must obtain a detailed history: Onset of symptoms, Pica, Assessment of potential sources, Family history of lead poisoning -Physical exam generally normal; Except in acutely encephalopathic patients -labs: Increased capillary lead level, Increased blood lead level, Basophilic stippling on RBC, Increased FEP concentration, Lead flecks on AXR or lead lines on x-ray of long bones, However long bone radiography is not part of work-up for lead poisoning -Assess all children for exposure beginning at 6 months yearly until 6yo -Children should be tested at one and two years of age -Testing should be continued yearly up to 6 years of age for children who are determined to be at high risk for lead exposure -See chart for guidelines on how to treat specific lead levels -chelating agents: Dimercaprol - increases urinary excretion of heavy metals; CaNa2EDTA (Calcium sodium ethylenediaminetetracetate) increases urinary excretion of lead; DMSA (Succimer) - water soluble analog of dimercaprol -minimize lead toxicity: Wet mopping floors and other surfaces in home, Wash children's hands frequently, wash toys and pacifiers frequently, A diet rich in calcium and iron, Use cold, not hot tap water

ventricular septal defects

-VSD is the most common congenital cardiac lesion -Abnormal connection between the left and right ventricle -Results in left-to-right shunt -Blood flows from high pressure LV into RV via hole in the septum -Pulmonary blood flow is increased resulting in right sided volume overload -Shunt remains left-to-right as long as SVR is greater than PVR -If pulmonary HTN develops and PVR>SVR a shunt reversal can occur -Types: I: supracristal Infundibular or Conal; II: Paramembranous; III: Artrioventricular canal or inlet -IV: Muscular -May be asymptomatic; depends on size/shunt ratio -Harsh, blowing holosystolic murmur w/ thrill at 4th intercostal space -Murmur increased w/ handgrip -CHF, growth failure, & recurrent lower respiratory infections -Can progress to Eisenmenger's syndrome w/ SOB, DOE, CP, syncope, & cyanosis -Diagnosis: CXR w/ enlargement of pulmonary artery, Echo -Management: No sx indicated if asymptomatic/small defect; Sx if pulmonary:systemic flow is >1.5:1; Sx indicated for pts w/ endocarditis; Endocarditis ppx NOT currently recommended for pts w/ uncomplicated VSD & no h/o endocarditis

vitamin D deficiency

-Vitamin D is fat soluble -Important in calcium homeostasis and bone health -Deficiency causes rickets in young children and osteomalacia in older adolescents -Very few foods naturally contain vit D -Low Vit D in breastmilk -Main food source: oil rich fish, organ meat, egg yolk -Milk, formulas, and breakfast cereals are often fortified with Vit D -Infants - 400 IU daily; Want to maintain Vit D levels > 20 -Children 1-18 yrs - 600 IU daily -Consider skin pigmentation

murmurs

-a "swooshing" sound created by turbulent blood flow across a heart valve -Incidence of murmurs in children can be as high as 90% -Prevalence of structural heart disease is about 0.8% -Therefore, most children with murmurs DO NOT have CHD -Should be evaluated for: timing, pitch, location, Intensity (Graded I-VI), radiation, quality, contour and effect of respiration/position -Important to determine Innocent vs Pathologic murmurs

Febrile seizure

-affects 6 months to 5 yrs with peak btwn 12-18 months (most likely due to vulnerability in developing nervous sytem) -are at higher risk of recurrent febrile seizures during early childhoos -risk of developing epilepsy only slightly higher than the general population -epilepsy: multiple seizures that continue beyond six years of age or are a/w afebrile tonic-clonic seizures -meningitis- lack of meningeal signs. do not return to a normal baseline (mental status) -complex febrile seizure: are characterized y episodes that have a focal onset (shaking limited to one limb of one side of the body, last longer than 15 mins or occur more than once in 24 hrs) -diagnostic testing is unnecessary -get meds to reduce fever such as acetaminophen followed by period of observation and re-evalutation -if pt actively seizing or seizures last more than 5 mins- need IV benzos to abort seizure in many cases

trigeminal autonomic cephalagia (cluster headache)

-always unilateral, usually begins around the eye or temple -depp continuous pain -pain begins quickly, reaches a crescendo within mins, pain is deep, continuous, excruciating, and explosive in quality -pt remains active -30 mins- 3 hrs in duration -sxs: ipsilateral lacrimation and redness of the eye, stuffy nose, rhinorrhea, pallor, sweating, horner syndrome, focal neurologic sxs rare, sens to alc -typically occur two to three times per day for several months -may worsen with lying down or resting

tension HA

-bilateral -pressure or tightness that waxes and wanes -pt may remain active or may rest -duration varies -may worsen with stress, bright lights, noise, strenuous activity -may respond to sleep

migraine HA

-commonly bilateral in young children but unilateral in adolescents and young adults -gradual onset, crescendo pattern, pulsating, mod-severe intensity, aggravated by routine and physical activity -throbbing/pulsating quality -pt prfers to rest in a dark, quiet room -2-72 hrs in duration -sxs: N, V, photophobia, phonophobia, may have aura -usually begin in first decade of life -typically occur two to four times per month -can be triggered by certain foods, odors, bright lights, noise, lack of sleep, menses, and strenuous activity -typically respond to analgesic meds, dark, quiet room, cool compress, or sleep

concussion

-complex process involving a decline in neurologic or cognitive fx that is induced by traumatic mechanical force to the person's head, neck, or body -type of traumatic brain injury -a concussion is a functional brain injury definced by the presence of a symptom in any of the following categories: somatic, cognitive, emotional, or sleep -syncope: a/w exercise is concerning for cardiac etiology (arrhythmia, cardiomyopathy, or structural heart dz) -constitutional findings often seen in pts with concussion, such as confusion, memory deficits, nausea, and headache are relatively uncommon in pts with syncope -history and neuro exam, CT scan and MRI are usually normal -physical and cognitive rest -if letting him return to play immediately which could lead to second impact syndrome-- increased cerebral vascular congestion and edema may occur which can lead to death -individually judge the return to play time for each concussion state -need symptom free intervals for 24 hrs at each level w/o any medication before advancing -most resolve within 7-10 day period

growth

-continuous dynamic process which comes from conception to maturity -quantitative -measurements -assessed by length, height, weight, BMI, head circumference -growth charts: pre-mature infants (Olsen'd or Fenton's charts), WHO ages 0-2 (establishes growth of breastfed infant as the norm for growth), CDC children above 2 (statures and weight-for-age, BMI for age -BMI for age: can track from 2 years through adulthood, examines wt, height, sex, and age, screening tool for health and nutrition status (BMI does not take into account stress, poverty, access to healthcare, or genetics- blanket measurement) -at birth, head is 1/3 of body; once fully grown head is 1/8 of body

poor weight gain

-formerly failure to thrive -child 2 years or younger with wt plotting below 2nd percentile for corrected gestational age and sex plotted on appropriate growth chart on more than one occasion AND decreased velocity of wt gain that is disproportionate to grow in length -z-scores are most useful -RF: prematurity/IUGR, developmental delays, congenital anomalies (cleft palate, chromosomal disorders), IUD exposure, lead poisoning, anemia, any medical condition that results in decreased intake, increased metabolic rate, malabsorption, pyschosocial factors -long term effects: persistent short stature, secondary immune deficiency, permanent damage to brain/CNS -psychosocial factors: poverty and food insecurity, parenting skills and nutrition knowledge, psychosocial stressors, maternal factors, child neglect -severity of malnutrition: z-scores for weight-for-length and length-for-age, mid-upper arm circumference if only one data point available, weight gain velocity (severe is z-score <-3, wt gain velocity <25 percent of expected norm) -full PE and check labs -early tx necessary, multidisciplinary, tx underlying cause -dietary advice, feeding times, feeding behavior, feeding environment -refeeding: often require supplementation, may need multivitamin, CaPhos, iron, or zinc supplements- if no wt gain in 4-6 weeks, may require NG feeds

cystic fibrosis

-is a hereditary disorder characterized by lung congestion and infection and malabsorption of nutrients by the pancreas -The most common lethal genetic disease of Caucasians: Autosomal recessive mode of transmission, Main characteristics of disease are, Pulmonary infection, Pancreatic insufficiency, Increased sodium loss through sweat, Male infertility -results from a defect in a gene on the long arm of chromosome 7 -Defect in protein product of cystic fibrosis transmembrane conductance regulator (CFTR) -This defect cause abnormal electrolyte transport which leads to the buildup of thick secretions -Secretions become more viscous -Normally thin and slippery now thick and sticky -Instead of lubricating act as a plug -Cells more susceptible to infection -increased bacterial adherence to cell surface prior to invasion -In lung airways dehydrate and secretions thicken & difficult to clear -Thick secretions inhibit ciliary clearance of foreign bodies -In pancreas the secretions thicken in ductal lumen, lead to obstruction & tissue destruction -Ducts become dilated, obstructed and replaced by fibrotic tissue and fat (origin of name) -Resulting pancreatic enzyme deficiency leads to maldigestion and malnutrition -excretion of fat in stool -In addition to pulmonary/pancreatic manifestations see increase in NaCl of sweat -sxs: Chronic cough, recurrent pulmonary infections, Steatorrhea, Failure to thrive, Salty taste to skin, "Woe is the child who tastes salty from a kiss on the brow, for he is cursed and soon must die", Meconium ileus -dx: Now part of NYS Newborn Screen, Test for elevation of immunoreactive trypsin (IRT), However, many false positives, Must confirm with sweat chloride test -Sweat chloride test: Should be done at a CF center to avoid erroneous results, Sweat chloride levels >60meq/L in the presence of signs and symptoms of CF confirms the diagnosis -Chronic bronchopulmonary infection leads to progressive lung damage, lung dysfunction and death -Most common lung pathogens are staphylococcus aureus and pseudomonas aeuruginosa -Recurrent respiratory tract infections leads to chronic cough, bronchiectasis, hemoptysis and clubbing -Nasal polyps -85-90% of patients have pancreatic exocrine deficiency -Dehydrated pancreatic secretions lead to pancreatic duct obstruction and poor secretion of digestive enzymes -Malabsorption of fat and fat soluble vitamins -Leads to frequent, bulky foul smelling stools -Pancreatic fibrosis leads to glucose intolerance and DM -Meconium ileus -98% of males with CF are sterile -Decreased fertility in females -Once patient is diagnosed with CF, siblings should be tested -If result is negative, still a 2/3 risk of being a carrier -All patients diagnosed with CF need to be followed by their general pediatrician and at a CF center -Treatment: CFTR Modulator Therapies, Aimed to correct defective protein made by CF gene, 2 therapies FDA approved: Kalydeco (Ivacaftor) - patients 2 and up with specific mutations; Orakambi (Lumacaftor/Ivacaftor) - patients 2 and up with homozygous F508 delta mutation; Trikafta (elexacaftor/ivacaftor/tezacaftor) - patients 6 and up with at least 1 copy of F508 delta mutation (90% of patients) -Pulmonary manifestations treated with: Chest physiotherapy, Bronchodilators, Dornase alfa (Pulmozyme) via nebulizer to help clear secretions, Antibiotics control progression of lung disease, Specifically Azithromycin, Inhaled antiobiotics aimed at p. aeuruginosa, Additional antibiotics added during acute infection, Lung transplant is the final option for chronic respiratory failure -Gastrointestinal manifestations treated with, Replacement therapy with pancreatic enzymes in the form of enteric coated microspheres, Enzymes taken with meals and snacks, Supplementation of vitamins A, D, E and K; Importance of a diet with sufficient calories and protein cannot be over emphasized, HCM - influenza vaccination -Improve quality of life - increase periods of stability and decrease exacerbations -Improve airflow, keep lungs free of sputum, treat infection when present -Maintain adequate caloric & liquid intake -Team approach with CF specialist, nurse, SW, nutritionist, PT, geneticist -Provide emotional and family support

vaccines

-live vaccines: MMR, varicella, rotavirus -NOT a/w autism -try to limit number of shots children need to receive (Comvax= Hep B, Hib; Pediarix= DTap, Hep B, IPV, TriHibIt= DTap, Hib, ProQuad (MMRV)= MMR, varicella) -at birth new borns get Vit K (to prevent Vit K Deficiency bleeding), Hep B, and erythromycin eye ointment to prevent neonatal ophthalmic infections m/c/c by gonorrhea/chlamydia -Hep B vaccine given at birth, 2 months, 6 months -DTap (Diphtheria, tetanus, and acellular pertussis vaccine)- 5 doses: 2, 4, 6, 15-18 months and 4-6 years- used for children under 7 y/o -HiB (Haemophilus influenza type B vaccine)- given at least 6 weeks of age- also available in combo form) -Rotavirus: 2 doses given at 2 and 4 months and optional 3rd dose at 6 months -pneumococcal conjugate vaccine (Prevnar 13)- 4 dose series: 2, 4, 6, 12-15 months -IPV (Inactivated polio): 4 dose series: 2, 4, 6-18 months, booster at 4 years- aval in combo -MMR (Measles, mumps, rubella), live vaccine, given at 12 months, booster at 4-6 years -varicella: live dose, 12-15 months, 4-6 years, combo vaccine -Hepatitis A: 2 dose series 12 months and 18 months, often needed when traveling to infected countries -influenza: 6 months and older need flu vaccine yearly -TDap: given as booster 11-12 years, follow up every 10 years, all pregnant women get it to prevent newborn pertussis; poss rare Arthus reaction type III hypersensitivity reaction -meningococcal vaccine: 2 vaccines available; Meningococcal Conjugate vaccines: 1 dose series 11-12 years; Serogroup B Vaccine; need booster every 5 years -HPV: inactivated vaccine, 2 available (Gardasil and Cervarix)- 2 doses if started prior to 15th birthday and 3 doses if started after 15th birthday -COVID-19 vaccine: Pfizer 12-15- increased risk of myocarditis -herd immunity protects those who cannot be vaccinated

oligoarticular JIA

-m/c, characterized by arthritis of four or fewer joints -often affects medium to large joints -arthritis is often asymmetrical -Affected limb may grow longer secondary to increased blood flow and growth factors =limb length descrepency -Systemic features are uncommon except for inflammation of the eye (uveitits)-- blindness-- need routine ophthalmalogic screening

well baby visit

-mother's pregnancy history, mother's nutritional history, family history, drug/toxin exposure, social issues -labor and delivery history -newborn history: gestational age, birth weight

development

-overall changes which includes growth -qualitative -maturation of organ systems -acquisition of skills -ability to perform tasks -Denver developmental screening test: m/c developmental screening, used in children aged 0-6 years, test covers 4 functions: gross motor, language, fine motor-adaptive, personal-social

nutrition

-premature: 100 kcal/day; newborns 120 kcal/day; infants 220-660 kcal/day; small kids 650-1400 kcal/day; older kids 1500-2000 kcal/day; teens 2000-2200 kcal/day -fats- main energy source for infants -carbs- main energy source for children > 2 y/o, COMPLEX carbs -fat soluble vitamins A, D, E, K -water soluble vitamins: B complex, Folic acid, vitamin C

headache

-primary= intrinsic to the nervous system ( Migraine, tension, cluster) •THE MOST COMMON PRIMARY HEADACHES ARE MIGRAINE & TENSION TYPE HEADACHE •Secondary=the headache is secondary to the underlying condition including the exacerbation of primary headaches •ACUTE FEBRILE ILLNESSES ARE THE MOST COMMON CAUSE OF SECONDARY HEADACHES IN CHILDREN (Influenza, URI, sinusitis) -headaches that wake child from sleep or occur on waking may indicated increased intracranial pressure/space occupying lesion -abrupt onset of severe headache/thunderclap headache or worst headache of my life may indicate intracranial hemorrhage -stiff neck may indicate meningitis -children with chronic non-progressive headaches have frequent school absences- impaired function may warrant referral -analgesics first (acetaminophen or ibuprofen or naproxen) -more serious attacks- could use triptans like rizatriptan, zolmitripan, and sumatriptan

BRUE: Brief, Resolved, Unexplained event

-replacing the term ALTE: apparent life threatening event -an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness -need to ask parents/caregivers all the specific questions about what happened -when infant arrives in ED or healthcare providers office, patient appears well -A complete head to toe physical exam is required -Patient may be placed on a cardiopulmonary monitor

initial neonate evaluation

-should take place at birth or shortly thereafter (12-24 hrs) -indications for pediatric presence: C-section, multiple births, prematurity, meconium staining, fetal distress, known anatomic anomaly

delivery and discharge

-suctioned by Ob at perineum -baby delivered, cord clamped & cut, baby handed to mother OR Peds providers OR Ob nurse -warmed, dried, mouth/oropharynx suctioned, weighed, footprints are made and ID bracelets, physical exam -Erythromycin ophthalmic ointment, prevents the development of ophthalmia neonatorum (caused by gonorrhea NOT chlamydia), Vitamin K given IM -Normal references: RR: 30-60, HR: 120-160, Urine: should make urine by 12 hrs, Meconium: should pass by 12 hrs, wt: lose 5-7% of birth wt in 1st few days of life, normal color pink, abnormal colors: cyanosis, pallor, jaundice -newborn screened for many metabolic and mitochondrial disorders -cleared for discharges: Urinates/passes 1 stool spontaneously, Vital signs stable for 12 hours, 2 successful feedings, Hearing screening, Hepatitis B vaccine given, Caretaker training, 1st physician office visit should be before 7 days of age (according to AAP), Cord care (for parents): Keep dry, exposed to air, don't submerse until umbilical cord falls off -breast milk is best -newborns sleep on avg 16-18 hrs of sleep per 24 hrs -any F in a newborn less than a month old requires a hospitalization, full sepsis work up and 2 days of IV abxs -BM: breast fed infants normally have BM after each feed

sudden infant death syndrome (SIDS)

-sudden death of an infant under 1 year of age that remains unexplained after a thorough case investigation, including the performance of a complete autopsy, examination of the death scene and a review of the clinical history" -SIDS is a diagnosis of exclusion -Autopsy must be done to r/o other causes of death -Developmental abnormalities secondary to prenatal/perinatal brain injury -Abnormalities in respiratory control (arousal and responsiveness) -Combination of coinciding factors -Autopsy findings: Well developed child; Intrathoracic petechiae, pulmonary congestion/edema -Investigating a case of SIDS involves not only an autopsy and death scene investigation but also an extensive questioning of witnesses and family members -Devastating - offer counseling immediately -Must proceed with caution and not allow family's emotional response alter your objectivity -Must rule out homicide/child abuse -RF: maternal smoking, prone sleeping, prolonged QT interval, wintertime, bed sharing, mother < 20yo, apnea, previous ALTE, poor prenatal care, multiple births, anemia, low 5 minute APGAR -Firm bedding - no stuffed animals, Sleeping supine, Breast feeding, Good prenatal care, Keep infants environment smoke free

tetralogy of fallor

1.Ventricular Septal Defect (VSD) 2.Pulmonary Artery or Valve Stenosis 3.Right Ventricular Hypertrophy 4.Overriding Aorta -Blood travels the path of least resistance -As RV outflow obstruction worsens and RV pressures increase, deoxygenated blood can shunt from the RV to the LV -RV outflow obstruction can fluctuate --"Tet Spells" -Cyanosis is m/c symptom -Tet Spells -Severe RVOTO: profound cyanosis at birth -Moderate RVOTO: murmur and hypercyanotic spells -Mild RVOTO: present as child w/ heart failure -RV impulse/thrill, crescendo-decrescendo w/ harsh systolic quality (RVOTO) -Hypercyanotic episodes that occur after sudden increase in right-to-left shunt -Pathophysiology: Thought to be related to sudden decrease in systemic vascular resistance; Often occurs with exertion - crying, BM, or exertion during feeding; Pt may respond by squatting to increase SVR and pulmonary blood flow -sxs: Cyanosis, tachypnea, & agitation; Loss of murmur, unconsciousness, seizure, or death -Place knee-to-chest position to increase SVR; Administer high-flow oxygen to decrease PVR; IVF, Morphine, Phenylephrine -Dx: Echo, ECG with right atrial enlargement & RVH, CXR w/ "boot-shaped" heart, Cardiac Cath -Tx: Heart Failure Management (Inotropes, Diuretics, No afterload reducers); Antibiotics for endocarditis ppx -Intracardiac Surgical Repair (Patch closure of VSD, RVOT enlargement (relief of pulmonary stenosis & resection of infundibular & subinfundibular muscle fibers, Valve sparing vs transanular patch) -Palliative Shunt: Ex: Blalock-Taussig Shunt; Reserved for premature infants, severe RVOT, medically refractive tet spell, & complicated coronary anatomy

neonatal conjunctivitis

Chemical -Erythromycin prophylaxis given at delivery -Requires no treatment -resolves within 48 hours Gonorrheal -24-48 hours old -Profound edema, purulent exudate -Tx - Penicillin G, Rocephin, or Claforan Chlamydial -Occurs within 7-10 days -Watery discharge changes to copious/purulent -Tx - Erythromycin HSV -Occurs within 2 weeks -Keratitis, cataracts, chorioretinitis -Tx - Topical and systemic antivirals

small for gestational age (SGA)

Infant's in the < 10th percentile of birth weight -Symmetric -HC, length, and weight all < 10th percentile -Caused by infection, chromosomal abnormalities, drugs Asymmetric -Weight is < 10th percentile -HC and length normal -Caused by UP insufficiency, PEC, gestational HTN, abruption, twins

innocent murmurs

Still's Murmur: -Created by pulmonic valve leaflet vibration -Low-pitched/intensity, vibratory systolic ejection murmur best heard at the lower left sternal boarder Peripheral Pulmonary Stenosis: -Created by the narrow pulmonary arteries of a newborn, which expands w/ increased blood flow -Mid-systolic, blowing, high-pitched, low-intensity murmur