Peds Final Exam

What age group has highest mortality rate?

- 15-19: 45.5%

What age group has lowest mortality rate?

- 5-14 - 5-9: 11.5% - 10-14: 14%

Gastroschisis

- Bowel herniates through a defect in the abdominal wall to the right of umbilical cord - cover with transparent plastic bag and non adherent dressing - treat with primary closure (SILO) then surgery once bowel is reduced

Lyme disease

- caused by the spirochete Borrelia burgdorferi and is transmitted to humans by the bite of an infected deer tick - common in ages 5-15 years - stage 1 s/s: 3-30 days, erythema migraines at bite, enlarge rapidly up to 30 cm over days-weeks, bulls eye appearance, burning sensation/warm to touch, fever, myalgia, HA, malaise - stage 2 s/s: 2-10 weeks, occurs anywhere except palms and soles, fever, HA, malaise, anorexia, stiff neck, lymphadenopathy, splenomegaly, conjunctivitis, sore throat, abd pain, cranial nerve palsy, ophthalmic conditions - stage 3 s/s: most serious stage, 2-12 months, involves neuro/cardiac/msk, lyme arthritis (most common) with pain/swelling/effusion, intermittently painful swollen joints mostly in knees in children - dx: serologic testing - Tx: oral doxycycline (>8 y/o), oral amoxicillin (<8 y/o), cefuroxime/erythromycin (if allergic to penicillin), tx usually lasts 14-21 days - follow up care is important

Umbilical hernia

- common in newborn - typically resolves in 1st years of life - if surgery needed, restrict activity 2-3 wks

Top 3 causes of death per age group

- 1-4: injuries, congenital anomalies, homicide - 5-9: injuries, cancer, congenital anomalies - 10-14: injuries, suicide, cancer - 15-19: injuries, suicide, homicide

Toddler G&D

- 12-36 months (1-3 years) - intense period of exploration - temper tantrums, strong wills, stubbornness are frequent - clear guidance from adults assist with successful transition - growth is step like rather than linear - gains 4-6 pounds/year - birth weight quadrupled by 2.5 years - grows 3 inches/year in height - adult height around 2x 2 year old child's height - head circumference increases by 1 inch during 2nd year then slows until 5 years - anterior fontanel closes at 12-18 months - chest circumference continues to increase and exceeds abd circumference during toddler years - 20/40 vision acceptable - full binocular vision - hearing/smell/taste/touch become well developed - uses all senses to explore environment - defending development of spinal tract allows for increases sensation in lower extremities, pleasant tactile sensation soothe and comfort toddler - play is the work of childhood - parallel play, imitation, tactile play - increased locomotive skills

Burn degrees

- 1st: intact epidermis/no blisters, red and painful, blanches, pain for 48-72 hrs, peeling in 3-7 days - 2nd: partial thickness/into the dermis, wet/shiny with blisters, superficial heals < 21 days, deep heals > 21 days - 3rd: full thickness, down to subq level, no pain, skin graft - 4th: full thickness to the bone, no pain, amputation likely

Preschool G&D

- 3-5 years - time to prepare child for school - refine tasks mastered in toddlerhood - biologic changes are proportional - wt gain 4.5-6.5 pounds/year - ht 2.5-3.5 inches/year - bodies appear slender, graceful, and postural upright - muscle development and bone growth continue - most organ systems are well developed and able to adjust to moderate stress/change - play: associative play, play should provide physical/social/mental development, imaginary playmates, mutual play with parents

School age G&D

- 6-12 years - physiologically begins with shedding of first baby teeth and ends at puberty with final permanent teeth - 4.4-6.6 pounds/year - 2 inches/year, 1-2 feet total during school age - males and females differ in size until end of school age - females usually start puberty first - increased stomach capacity/better maintenance of blood sugar, increased urinary capacity - heart grows more slowly and is smaller in relation to body - HR and RR decrease, BP increases - antibody-antigen response increases - bones resist more pressure and muscles pull less

Pertussis

- Bordetella pertussis - transmitted by direct contact with droplets of infected person, indirect contact with freshly contaminated articles - 6-20 day incubation (usually 7-10 days) - Catarrhal s/s: begins with upper respiratory infection symptoms for 1-2 weeks when dry hacking cough becomes more severe - Paroxysmal s/s: cough most common at night, short rapid coughs followed by sudden inspiration with high pitched whoop, flushed cheeks/cyanosis, bulging eyes, protruding tongue, paroxysm may continue until thick mucous plus is dislodged, vomiting follows coughing attack, usually lasts 4-6 weeks followed by convalescent stage - infant <6 months s/s: difficulty maintaining adequate oxygen, frequent vomiting of mucous, formula, or breast milk - cough may last up to 10 weeks and also have trouble breathing and post tussle vomiting - tx: erythromycin, clarithromycin, azithromycin - increased oxygen intake/humidity, adequate fluids - intensive care/mechanical ventilation for infants < 6 months - Isolation during catarrhal stage (standard/droplet) - observe for airway obstruction - immunization booster for adolescents

Rocky Mountain Spotted Fever

- Caused by Rickettsia rickettsii - transmitted by ticks - 2-14 day incubation - s/s: fever, malaise, anorexia, vomiting, HA, myalgia, maculopapular or petechia rash on extremities (ankles/wrists), characteristically on palms and soles - tx: tetracycline and chloramphenicol

Diptheria

- Corynebacterium diptheriae - direct contact with infected person, a carrier, or contaminated articles - 2-5 incubation - s/s: cold symptoms, serosanguinous mucopurulent discharge, malaise, anorexia, increased pulse, BULL'S NECK, hoarseness, airway obstruction, cyanosis - tx: IV equine antitoxin, penicillin G/procaine/eryhtromycin, comlete bed rest - droplet precautions until 2 cultures are negative - have epi available, monitor for airway obstruction

3 years

- Fine motor: 9-10 block tower, 3 cube bridge - Gross motor: rides tricycle, jumps off bottom step, balance on 1 foot for few seconds, walks on tip toes, broad jumps, go UPSTAIRS with alternate footing - Language: 3 word sentences - Personal-social: trusted to obey warning of danger but exceed boundaries (3-4 years)

5 years

- Fine motor: ties shoelaces, uses scissors/simple tools/pencil well, shape stage 3, early pictorial stage 4-5, late pictorial stage 5-6 - Gross motor: skips and hops on alternating feet, jumps rope, begins to skate and swim, walks backwards with heel to toe, throws and catches ball well - Language: 5 word sentences, 2100 words - Personal-social: little assistance needed with dressing, eating or toileting (4-5 years)

4 years

- Fine motor: uses scissors to cut out picture with outline, can lace shoes but may not be able to tie bow - Gross motor: skips and hops on 1 foot, catches ball reliably, throws overhead, walks DOWNSTAIRS with alternate footing - Language: 4 word sentences - Personal-social:

Toddler Cognitive Development

- Freud: Anal, gratification from control over excretions, expect regression with illness, have potty chair available - Erickson: Autonomy vs Shame/Doubt, increasingly independent, allow self feeding/dressing/hygiene, provide explanations - Piaget: Sensorimotor/Pre-operational, increasing curiosity and exploration, language improves, name objects and give simple explanations

Adolescent Cognitive Development

- Freud: Genital, focus on genital function and relationships, ensure OBGYN care and testicular exams, provide info on sex, provide privacy - Erickson: Identity vs Role Confusion, searches for self identity and independence from parents and reliance on peers, provide separate for teens, perform exams without parents present - Piaget: Formal Operational, child is capable of mature abstract thought, give clear compete info about care, provide continued education about disease

School age Cognitive Development

- Freud: Latency, places importance on privacy and understanding the body, provide privacy and explain treatments - Erickson: Industry vs Inferiority, gains a sense of self worth from involvement in activities and mastering tasks, encourage child to continue school work - Piaget: Concrete Operational, child is capable of mature thought when allowed to manipulate/see objects, give clear instructions about treatment, show child equipment that will be used

Infant Cognitive Development

- Freud: Oral, pleasure through mouth (sucking), use pacifier or breast feeding - Erickson: Trust vs Mistrust, establishes a sense of trust when basic needs are met, comfort child and encourage parents to stay in room - Piaget: Sensorimotor, learned from movement and sensory input, use toys and stimuli to distract infant during procedures

Preschooler: Cognitive Development

- Freud: Phallic, initially identifies with parent of opposite sex then with same sex, encourage parental involvement, plan play time - Erickson: Initiative vs Guilt, initiates play activities and develops sense of accomplishment, offer medical equipment for play, accept child's choices - Piaget: Pre-operational, increasingly verbal with limitations in thought process, confused about causes, clearly explain child is not responsible for causing illness

Scarlet fever

- Group A hemolytic streptococci - Transmitted by direct contact with infected person/droplets, indirectly by contact with contaminated articles or ingestion of contaminated milk/food - 2-5 day incubation (1-7 days) - s/s: beefy and red edematous pharynx, STRAWBERRY TONGUE, red pinhead sized rash appears on body, sloughing on palms/soles of feet, abrupt high fever, increased pulse, halitosis, malaise, enlarged reddened tonsils covered with patches of exudate - tx: penicillin (erythromycin if allergic) or oral cephalosporin, abs for newly dx carriers, rest during febrile phase, analgesics for sore throat, antipruritic for rash - standard and droplet until 24 hrs after initiation of tx - soft diet, non irritation fluids - discard toothbrush and avoid sharing drinks/eating utensils

Erthema Infectiosum (5th Disease)

- HPV B19 - transmuted by blood/blood products - 4-21 day incubation (normally 4-14) - stage 1 s/s: erythema on face, chiefly on cheeks (slapped face appearance), disappears in 1-4 days - stage 2 s/s: 1 day after rash appears on face, maculopapular red spots appear, symmetrical on upper and lower extremities, progresses from proximal to distal surface, may last more than 1 week - stage 3 s/s: rash subsides but skin appears irritated/traumatized (sun, heat, cold, friction) - aplastic crisis: rash usually absent, fever, myalgia, lethargy, N/V, abd pain - tx: antipyretics, analgesics, anti-inflammatories, blood transfusions for transient aplastic anemia - isolation only for immunosuppressed/aplastic crisis during hospitalization suspected of Parvo virus infection (standard and droplet precautions) - routine urine samples for pregnant women

Fungal infections

- Invades the stratum corneum, hair, and nails - live on the skin - transmitted from person to person and from infected animals to humans - examine all household pets for disorder - 2% ketoconazole and 1% selenium sulfide shampoo may reduce colony counts (5-10 mins 3x/.week) - Griseofulvin for weeks-months, stop/decrease meds when s/s subside - SE: HA, GI upset, fatigue, insomnia, photosensitivity - meds: terbinafine, itraconazole, fluconazole

Acute Laryngotracheobronchitis (LTB)

- Most common croup syndrome - usually < 5 - caused by RSV, parainfluenza, mycoplasma pneumoniae, flu A/B - s/s: slowly progressive onset, URI symptoms, BARKING COUGH/CROWING SOUNDS, hoarseness, restlessness, low fever - tx: corticosteroids (PO/IM dexamethosone), fluids, nebulizer epi, humidified air, heliox if severe - occurs at night

5 months

- Physical: birth weight doubles between 5-6 months - fine motor: uses palmar grasp, plays with toes, able to grasp objects voluntarily, takes objects directly to mouth - gross motor: rolls from front to back, no head lag, can sit longer supported - sensory: visually pursues dropped objects, localizes sounds below ear - vocalization: cooing vowel sounds with consonant sounds - socialization/cognition: smiles at self in mirror, enthusiastically playful, can tell strangers from family, discovers body parts

12 months

- Physical: birth weight tripled, birth length increased by 50%, 6-8 teeth, anterior fontanel closed (12-18 months) - fine motor: fails at building 2 block tower, can turn pages in book, places cube in cup, fails at placing pellet into narrow neck bottle - gross motor: sits from standing without help, may try to stand or take steps alone - sensory: begins to discriminate against geometric shapes, can follow fast moving objects - vocalization: 3-5 words besides mama/dada, recognizes objects by name, imitates animal sounds, understands simple commands - socialization/cognition: searches for object where it was last seen, may have security blanket/toy

30 months

- Physical: birth wt quadrupled, 20 teeth - fine motor: draws circles, good hand/finer combination, 8 block tower - gross motor: jumps across floor and off steps with both feet, stand on one foot momentarily, takes a few steps on tip toe - vocalization: knows first and last name, refers to self with correct pronoun, uses plurals, can name 1 color - socialization/cognition: can help with putting toys away, can be trusted to carry breakable items, pushes and steers toys well, notices gender differences, emotions expand including pride/shame/guilt/embrarrassment

4 months

- Physical: drooling begins, moro/tonic neck/rooting reflexes disappear - fine motor: insects hands and grasps objects with both hands, pulls blanket over face, tries to reach for objects, plays with rattle when placed in hand - gross motor: almost no head lag, able to balance head, back less curved when sitting, rolls from back to side, raises head and chest 90 degrees when prone - sensory: begins to have hand eye coordination - vocalization: laughs aloud, makes consonant sounds - socialization/cognition: enjoys social interaction, may fuss when alone or bored, shows excitement with whole body, begins to show memory

11 months

- Physical: eruption of lower lateral incisors - fine motor: neat pincher grasp, places and removes object from container, explores objects, drops objects for them to be picked up - gross motor: walks while holding onto object/with one hand held - vocalization: imitates speech/animal sounds - socialization/cognition: joy when mastering task, restrictions cause frustration, anticipates body gestures when reading books, shake head "no"

9 months

- Physical: eruption of upper lateral incisors - fine motor: uses crude pincer grasp, dominant hand preference evident - gross motor: pulls to standing position, creeps on hands and knee's instead of crawling (army crawl) - sensory: localizes sounds by turning head directly toward sound, increased depth perception - vocalization: responds to simple commands, comprehends no - socialization/cognition: increasing interest to please parent, begins to show fears of going to bed/being left alone, puts arms in front of face to avoid being washed

7 months

- Physical: eruptions of 2 upper central incisors, parachute reflex appears - fine motor: moves objects from hand to hand, unidextrous approach and grasp, holds 2 cubes and can bang on counter, rakes at small objects - gross motor: bears full weight on feet when standing and bounces, sits leaning forward on both hands - sensory: can fixate on small objects, responds to name, begins depth/space awareness - vocalization: produces vowel sounds chained to syllables such as baba/dada with no meaning, can vocalize 4 vowel sounds - socialization/cognition: increasing fear of strangers, plays peek a book, biting and mouthing

10 months

- Physical: labyrinth righting reflex strongest in prone/supine, able to raise head - fine motor: grasps rattle by handle - gross motor: changes from prone to sitting, standing holding onto furniture - vocalization: says mama/dada with meaning, may say hi/no/bye - socialization/cognition: object permanence, stops behavior if name or no no is stated, waves bye, imitates facial expressions, repeats actions for attention/laughter, patty cake, follows pictures in books, likes animal sounds, begins to dress/feed self

24 months

- Physical: may be ready for daytime bowel/bladder control, 16 teeth - fine motor: builds 6-7 block tower, turn pages one at a time, aligns 2 or more block train, turns doorknob and unscrews lid - gross motor: walks up and down stairs with BOTH feet on each step, runs well with wide stance, kicks ball forward without falling - vocalization: 300 words, 2-3 word sentences/phrases, uses pronouns, understands directional commands, knows and refers to self by name, able tor remember and imitate gestures/actions - socialization/cognition: parallel play, sustained attention sign, temper tantrums decrease, dresses self, develops awareness of others emotions

18 months

- Physical: physiologic anorexia, able to control sphincters, all fontanels closed - fine motor: manages a spoon without rotation, turns pages 2-3 at a time, builds 3-4 block tower - gross motor: runs clumsily and falls often, throws ball overhand, jumps in place with BOTH feet, pulls/pushes toys - vocalization: 10 or more words, points to common objects such as shirt and 2-3 body parts, forms word combinations, uses gesture word combinations - socialization/cognition: takes off gloves/socks/shoes, unzips zippers, begins awareness of ownership

2 months

- Physical: posterior fontanel closes at 6-8 weeks - fine motor: hands open more - gross motor: extends legs and arms, able to lift head 45 degrees when prone, less head lag - sensory: visually searches for sounds - vocalization: vocalizes noises that is different from crying, coo's - socialization/cognition: social smile

3 months

- Physical: primitive reflexes fading - fine motor: hands loosely open, actively holds rattle, clutches own hands and objects such as clothing - gross motor: light head lag, bears weight on forearms when prone, able to hold head more erect the. sitting but still bobs - sensory: follows objects, locates sounds by turning head and looking in direction of sound - vocalization: squeals to show pleasure, coo's, babbles, and chuckles when spoken to - socialization/cognition: shows interest in environment, recognizes familiar faces and objects

8 months

- Physical: regular bowel and bladder patterns - fine motor: begins using pincer grasp, reaches persistently for toys out of reach - gross motor: sits unsupported, may stand holding onto furniture - vocalization: listens selectively to familiar words - socialization/cognition: increasing anxiety over parental absence and fear of strangers, bad time to start day care (start earlier), responds to no

15 months

- Physical: steady growth of ht and wt - fine motor: builds 2 block tower, places pellet in narrow neck bottle, scribbles spontaneously, uses cup well - gross motor: walks without help, creep upstairs, cannot throw ball without falling - sensory: identifies geometric objects and can place in correct hole, binocular vision - vocalization: 4-6 words, asks for items by pointing, understands commands - socialization/cognition: tolerates parental separation, decreasing stranger fear, imitates house hold chores, expresses emotions

Birth - 1 month

- Physical: strong primitive reflexes, nose breathers - fine motor: holds hand in fist, strong grasp reflex - gross motor: may lift head briefly in prone position and turn head to side, marked head lag, flexed position with pelvis high when prone - sensory: prefers black and white with geometric designs, follows object in line of vision - vocalization: cries to express displeasure, makes small throaty sounds - socialization/cognition: watches parent face intently as they talk to infant

6 months

- Physical: teething with eruption of 2 lower central incisors, may begin to chew/bite - fine motor: holds bottle, rescues dropped objects, drops object when another is given to them - gross motor: rolls from back to front, begins bearing weight on hands when prone, bears almost all weight on feet when held in standing position - sensory: can localize sounds above ear, adjust posture to see objects, turns head to side and looks up and down - vocalization: start to imitate sounds/actions, babbling in 1 syllable such as ma/da/hi with no meaning, talks to toys and self in mirror - socialization/cognition: recognizes parents, stranger anxiety starts, briefly searches for dropped objects, frequent mood swings

Questionares

- SCOFF questionare (anorexia/bulemia) - CRAFFT (substance abuse) - SLAP (suicide): Specificity, lethality, accessibility, proximity)

Asthma

- a chronic inflammatory disorder of the airways that causes air passages to become narrow or blocked, making breathing difficult - most common chronic disease in childhood, primary cause of school absences, 3rd leading cause of hospitalization in children < 15 - risk factors: age, atopy, heredity, male, young maternal age, smoking, African American, allergies - s/s: dyspnea, wheeze, cough - dx: PFT, PEF, allergy skin test, chest x ray, CBC - maintenance meds: inhaled corticosteroids/bronchodilators, theophylline - rescue meds: albuterol, anticholinergics, systemic corticosteroids, epi, magnesium sulfate

Acute Hepatitis

- acute/chronic inflammation of the liver that leads to alteration in liver function - usually self limiting, complete recovery is possible - causes: virus, chemical reaction/drugs - 4 stage progression: Mononuclear inflammatory cells surrounds small bile ducts, Proliferation of small bile ducts, Fibrosis and scarring, Cirrhosis - types: A (fecal oral), B (blood/perinatally), C (parenteral exposure to virus), D (only with Hep B), E (contaminated water/fecal oral, worst in pregnancy) - prodromal s/s: anorexia, malaise, lethargy, fatigue - icteric s/s: disappearance of prodromal s/s, jaundice/itching - active s/s: usually asymptomatic, can have fatigue, lethargy, wt loss, vague abd pain - dx: serologic markers for A,.B,C, liver biopsy

Resp Failure

- as child tires due to prolonged effort of breathing, rate will decrease - initial s/s: restlessness, tachypnea, tachycardia, diaphoresis - early decompensation s/s: nasal flaring, retractions, grunting, wheezing, anxiety/irritability/mood changes, HA, confusion - imminent resp arrest s/s: severe hypoxia, dyspnea, bradycardia, cyanosis, stupor, coma

Inguinal hernia

- asymptomatic inguinal swelling that disappears at rest or can be reduced with gentle compression - normal: elective surgery - incarcerated: emergency surgery bc blood flow is being cut off, pale at first then turns grey

Parenting styles

- authoritarian: parent control behavior through mandates, "do it because I say so", stern punishment, children are shy, self conscious, fearful, associated with defiant and antisocial behavior, males tend to be rebellious and females dependent - permissive: parent exert little to no control on childs actions, not role models for child, parent explain reason for rules and consult children in decision making, lax and inconsistent discipline, child may be rebellious, socially inept or outgoing - authoritative: direct child's behavior by emphasizing reason for rules and using negative reinforcement, respects individuality and allows child to voice objections, control is focused on problem, child adjusts well, has high self esteem and is highly interactive with others - indifferent: no limit setting, lack of affection for child, parent focuses on own life, child has destructive impulses and bad behavior

Cystic Fibrosis

- autosomal recessive genetic disease - abnormal gene on long arm of chromosome 7 - 95% white - most common lethal genetic illness among white kids - major dysfunction of exocrine glands characterized by several unrelated s/s - effects respiratory tract and pancreas - s/s: increased viscosity of mucous secretions causing mechanical obstruction, sweat gland dysfunction, FTT, wt loss, resp deterioration, wheezing/dry cough/cyanosis, clubbing of fingers/toes, frothy foul smelling stool, rectum prolapse, sterility in males, SALTY TASTING SKIN, dehydration - dx: early infant screening, DNA testing, sweat chloride test, chest x ray - tx: remove excess secretions, treat infections with steroids/NSAIDS, lung transplant, high protein/high calorie diet, decreased lift expectancy

Phenylketonuria (PKU)

- autosomal recessive trait - causes absence of phenylalanine hydroxylase - increased amounts of phenylalanine leads to musty smelling urine - decreased tyrosine leads to hypopigmintation due to decreased melanin - can cause cognitive impairment - severe can lead to profound CI - s/s: FTT, irritability, vomiting, erratic behavior, hyperactivity, cognitive delays, brain damage, seizures - symptoms can look like schizo - Guthrie test/newborn screening test (#1 after 24 hrs after eating, 0.5-1mg/dl normal)(#2 at 1-2 week check up) - Diet: lifelong high protein foods starting no later than 3 weeks old, 20-30 mg/kg/day of phenyl, mom on low phenyl diet - Levels: <12 y/o = 8mg/dl, >12 y/o = 2-10 mg/dl, 11-15 mg/dl = severe

Omphalocele

- bowel covered with peritoneal sac, seen at birth or on ultrasound - cover with non adhering dressing if sac is intact - IVF/ABX - primary closure of stage reduction surgery - silver sulfadiazine or pressure dressing

Enterobiasis (Pinworms)

- caused by enterobius vernicularis - transmitted by crowded conditions/classrooms/daycares - s/s: general irritability, restlessness, poor sleep, bed wetting, short attention span, perianal dermatitis, excoriation secondary to itching, possible vulvovaginitis and urethral infection - tx: pyrantel pamoate (pin-rid, antiminth), albendazole - mebendazole not recommended for children < 2 - treat all household members - anti parasitic meds repeated in 2 weeks to prevent infection - Tape test performed in morning as soon as child awakes and before bowel mvmt/bathing - wash all clothes/bedding in hot water, vacuum

Lead Poisoning

- caused by lead based paint or lead in soil - most common type is ingestion/inhalation from toys, paint, renovations - can cause behavioral/cognitive deficit, encephalopathy, brain injuries, paralysis, seizures - usually asymptomatic but can cause N/V, constipation, anorexia, abd pain - dx: venipuncture test (acceptable is < 10) - tx: calcium disodium edetave, british antilewisite, succimer - refer for treatment if 20-44, > 70 treat immediately

Mumps

- caused by paramyxovirus - transmitted by direct contact or droplet, contagious right before swelling starts and immediately after - s/s: fever, HA, fatigue, and anorexia for 24 hrs, followed by earache, parotitis (puffy cheeks/jawbone) - Tx: symptomatic/supportive - Droplet and contact

Seborrheic dermatitis

- chronic recurrent inflammatory reaction of the skin - occurs on scalp, eyelids, external ear, nasolabial folds, and inguinal region - unknown cause, more common in early infancy/right after puberty - tx: scalp hygiene, topical corticosteroids if > 2 y/o

Acute Appendicitis

- classic early signs: periumbilical pain followed by nauseas and RLQ pain, rebound tenderness - epigastric = McBurney's point - s/s: fever, N/V - dx: ultrasound - tx: laparoscopic for unruptured, open surgery for ruptured

Autistic spectrum disorder (ASD)

- complex neurodevelopment disorder characterized by abnormalities in social behavior, language, communication, and unusual behaviors/interests - autistic disorders, aspergers syndrome, persuasive developmental disorder - dx between 18-36 months using MCHAT - get tested if no speech, no babbling/gesture by 12 months, no words by 16 months, no 2 word phrases by 2 years - likely caused by a link between hereditary, genetic, and medical problems - familial tendency - s/s: Failure of social interaction, no eye contact, early language/play/motor impairment, constipation, some form of CI - tx: highly structured routines, behavior modification, private room/low stimuli, introduce to new environments slowly

Hirschsprung disease

- congenital anomaly resulting in mechanical obstruction from inadequate motility of intestine - absence of ganglion cells in colon - more common in males/down syndrome - effects the internal sphincter, rectum, and small amount of sigmoid colon (short segment disease) - failure of internal sphincter to relax causing accumulation of stool and possible enterocolitis - newborn s/s: failure to pass meconium by 48 hrs, abd distention, bilious vomit, refusal to eat - infant s/s: FTT, V/D, abd distention, enterocolitis - childhood s/s: ribbon-like/foul smelling stool, abd distention, visible peristalsis, palpable fecal mass, looks malnourished - dx: x ray, barium enema, anorectal manometric exam, confirm with rectal biopsy - surgery: First stage (temporary ostomy), second stage (pull through procedure) - preop: GI prep, oral ABX, monitor for shock/bowel perf - post op: monitor for irregular stool, VS, wound infection - discharge: ostomy care and daily dilations

Pyloric Stenosis

- constriction of pyloric sphincter with obstruction of gastric outlet - risk factors: full term, prior sibling/offspring of affected person - s/s: develop in first wks of life, NON BILIOUS PROJECTILE VOMITING AFTER FEEDINGS, visible peristalsis, FTT but always hungry, dehydration, metabolic alkalosis - dx: olive-like mass, ultrasound, upper GI series, rule out other causes of vomiting - labs: CBC CMP - tx: laparoscopic surgery (pyloromyotomy) - preop: NPO, strict I&O, number of vomiting/stools - postop: begin feeding after 4-6 hrs, monitor for apnea for 24 hrs

Preadolescence

- end of middle childhood until 13 years old - first signs usually appear around 9 and evident by 11-12 - puberty occurs around 12 for females and 14 for males - fine motor: enjoys craft projects, plays card and board games - gross motor: rides bike without training wheels, jumps rope, roller skates/ice skates - social: less intense emotions, peer groups are important, forms groups/clubs, begin to incorporate family values into own values, sibling relationships become more difficult and conflict increases - language: use more complex grammatical forms, narrative skills improve - play: competitive and cooperative, rules and rituals are important, quiet games and activities

Infant Growth and Development

- growth occurs in a cephalocaudal and proximodistal sequence - weight: 1.5/month for 1st 6 months, double weight by 5 months, triple by 1 year - height: 1 inch/month for 1st 6 months, 0.5 inches/month from 6 months - 1 year, occurs in spurts, more in trunk than legs - head: 0.75 inch/month until 3 months, 0.4 inch/month until 6 months, 0.2 inch/month until 1 year - chest: = to head circumference in 1st year - vision: binocular fixation by 4 months, doth perception starts by 7-9 months - auditory: begin to locate sounds - resp: predisposed to issues due to structure/immaturity - cardiac: sinus arrhythmia - kidney and liver: able to excrete drugs/toxins better by 1st year, presupposed to dehydration until renal system matures at 2nd year - hematopoietic: physiologic anemia due to fetal hgb present in 1st 5 months, RBCs lifespan short, maternal iron used up by 5 months - GI: little digestive enzyme activity until 5 months - immune: can't produce IgA in mucosal lining, maternal IgA present 1st 3 months to fight things mom was exposed to, adult levels of IgM by 9-12 months - thermoregulation: increases with age during 1st year - endocrine: fully developed at birth with immature function makes infant vulnerable for imbalances - brain/cognitive: increases in complexity during 1st year, increased control over body movements and able to go from general to specific skills - birth-3months play: responds to environment - 3-6 month play: solitary play - 6-12 months play: sensory motor skills - birth to 6 month toys: mobiles, rattle, texture toys, infant swings - 7-12 month toys: colored blocks, picture books, cups/spoons, toys with lights/music, teething toys, push/pull toys

Burn tx

- high protein/high calorie diet - acute phase: treat shock, manage pulmonary status, prevent complications - management/rehab phases: multidisciplinary team, comfort, nutrition, psychosocial - rehab begins when permanent wound closure happens

ADHD

- inattention, impulsiveness, hyperactivity - typical onset before age 7, more common In males - unknown cause - s/s: behavior issues at early age, learning problems, distracted, immature, selective attention, dont consider risks, inappropriate social skills - dx: multidisciplinary eval, medical/developmental eval - checklist: IQ, hand eye coordination, visual/auditory perception, comprehension/memory - tx: behavioral therapy, classroom structures - Stimulants: amphetamines (dexedrine/adderal), methylphenidate (ridilan/concerta/focalin), lisdexamphetamine (vyvanse) - non stimulants: atomextine (Strattera), guanfacine ER (intuniv) - tricyclic antidepressants, Effexor, Wellbutrin, clonidine extended release

Rubella (German Measles)

- incubations 4-14 days - s/s: absent in children and present in adults/adolescents during prodromal stage (low grade fever, headache, malaise, anorexia, conjunctivitis, coryza, sore throat, lymphadenopathy all go away 1 day after rash appears), rash first on face and rapidly spreads down body, discrete pinkish red maculopapular exanthema, disappears in same order it begins (face then body), usually gone by 3rd day - tx: antipyretics/analgesics PRN - MMR vaccine - droplet precautions - avoid contact with pregnant women

Mild dehydration

- infant wt loss: 3-5% - child wt loss: 3-4% - HR/RR/BP/behavior/mucous membranes/anterior fontanel = normal - slight thirst - present tears - visible external jugular vein when supine - cap refill > 2 sec - decreased urine - 50 ml/kg of pedialyte first 4 hrs, extra 10 ml for diarrhea

Moderate dehydration

- infant wt loss: 6-9% - child wt loss: 6-9% - HR/RR slightly increased - normal/ortho BP - irritable - moderate thirst - dry mucous membrane/decreased tears - normal to sunken fontanel - external jugular vein visible with supraclavicular pressure - cap refill = 2-4 sec - oliguria - 100 ml/kg pedialyte

Severe dehydration

- infant: < or = 10% - child: 10% - HR/RR very increased - orthostatic BP - hyperirritable/lethargic - intense thirst/parched membranes/absent tears - sunken fontanel - jugular not visible - cap refill > 4 sec/cool mottled skin - oliguria/anuria - normal saline/LR IV bolus 20 ml/kg over 5-20 min, maintenance fluids over 24 hrs, then oral feedings

Paroxysmal Abdominal Pain (Colic)

- infants < 3 months - abd pain/cramping accompanied by loud crying and drawing legs up to the abdomen - colic cry: > 3 hrs/day, > 3 days/week, lasts > 3 weeks

Otitis Media

- inflammation of the middle ear - OM: inflammation w/o reference to cause - OME: non purulent fluid in middle ear w/o symptoms of acute infection - AOM: purulent fluid in middle ear with symptoms of infection - children are at risk due to short eustachian tube and frequent lying position - caused by strep, flu, RSV - s/s: fever up tp 104, post auricular/cervical lymph nodes enlarged, irritability, ear pain, V/D, rhinorrhea, decreased appetite - OME dx: otoscopic exam shows obscured light reflex, hyperemia, visible bony landmarks, retracted membrane, impaired membrane mobility - AOM dx: obscured/absent light reflex, visible fluid meniscus, obscured bony landmarks, building membrane with no motility, erythema - can lead to speech delays - tx: ABX/topical relief - first line ABX: amoxicillin 80-90 mg/kg/day for 10 days - second line: Azythromicin, Cephalosporin, Augmentin - no steroids, antihistamine, decongestant or ABX ear drops

Atopic Dermatitis (Eczema)

- inflammatory skin disorder that causes itching/lesions - infantile: begins at 2-6 months, spontaneous remission by 3 years - Childhood: may follow infantile, occurs at 2-3 years, manifests by 5 - preadolescent-adolescent: begins around 12 years, may continue in to older adulthood - dx: hx and s/s - tx: hydrate skin, relieve pruritus, reduce flare ups/inflammation, prevent secondary infections, antihistamines/topical immunomodulators/topical steroids/mild sedatives if needed - tepid bath with mild or no soap followed by emollient (this traps moisture) - use lotions such as aquaphor, cetaphil, eucerin - Clean cut fingernails - long sleeves/pants

Types of discipline

- limit setting: setting rules and guidelines, clear limits allows them to be enforced easily - reasoning: explains why an act is wrong, better for older children - behavior modification: rewarded behavior will be repeated, uses reward system - positive/negative reinforcement - scolding: uses shame/criticism, child takes remarks personally - time out: offers child and parent time to cool off - corporal/physical punishment: spanking, teaches child violence is acceptable, child may get used to spanking and require more

Down syndrome (trisomy 21)

- most common chromosomal abnormality - genetic - normal life span - caused by old mother or family hx - dx: chromosomal analysis - s/s: oblique palpebral fissures, flat occiput, almond shaped eyes, large tongue, little nose, depressed nasal bridge, low set ears, funky toes, hyperflexability, delayed G&D, simian crease on hands - 50% have heart defects - tx: supportive, increase fiber/fluids, lube skin

Fragile X Syndrome

- most common inherited cause of impairment - 2nd most common genetic cause - 1 in 2000-5000 life births, mostly males - abnormal mutation of lower end of long arm on x chromosome - fragile site fails to condense during mitosis - prenatal dx - s/s: big head, long narrow face with prominent jaw, large ears/palpebral fissures, strabismus, high arched pallet, mitral valve prolapse, macro-orchidist (big balls), flexible fingers, flat feet, hypersensitivity to taste/sound/touch, CI, delayed speech, autistic like, aggressiveness - tx: speech therapy, normal classes at school, genetic counseling

Acne

- most common skin disorder in adolescence - caused by testosterone, excess sebum production - peak age 16-18 years - tx: facial cleansing, Retin -A, benzoyl peroxide (best), topical antibacterial agents, systemic abx therapy - avoid picking/squeezing/manual expression/abrasive cleansing products

Tonsilitis

- occurs with pharyngitis, viral or bacterial - s/s: kissing tonsil, difficult swallowing/breathing, mouth breathing, foul breath, muffled voice - meds are same as pharyngitis - surgery: tonsillectomy/adenoidectomy - postop: soft/liquid diet, no suctioning, no clearing throat, resume normal in 2 wks

UTI

- one of the most common renal conditions in childhood - most important host factor is urinary stasis - caused by: E. coli (85%), streptococci, staphylococcus saprophyticus, fungal/parasitic pathogens - physical causes: short urethra in girls, uncircumcised males - upper uti includes: renal parenchyma, pelvis, and urteters, usually cause fever, chills and flank pain - lower uti includes: lower urinary tract, no systemic s/s, can cause cystitis and urethritis - dx: dipstick, microscopic UA, culture, IVP/CT - asymptomatic bacteriuria: bacteriuria with no s/s - symptomatic bacteriuria: dysuria, suprapubic pain, hematuria, fever - recurrent - persistent: doesn't respond to ABX - febrile: fever, indicates pyelonephritis - urosepsis: febrile UTI with systemic signs of bacterial illness, pathogens in blood - newborn s/s: fever, hypothermia, jaundice, tachypnea, cyanosis, ill - < 2 years s/s: fever, irritability, lethargy, poor feeding, V/D - > 2 years s/s: classic symptoms - tx: short term ABX for uncomplicated, long term ABX for complicated - meds: Bactrim, nitrofurantoin (Macrobid), amoxicillin, cephalexin (keflex), Pyridium for discomfort

Acute Pharyngitis (Viral)

- onset: gradual - temp: low grade fever - s/s: sore throat, mild erythema, hoarseness, cough, rhinitis, conjunctivitis - labs: normal to high leukocytes - self limiting and resolves 4-10 days - meds: decongestants (Phenyephrine > 6 y/o), saline nose drops, antihistamines, OTC antitussives - adequate fluid intake, elevate HOB, suctioning, vaporizer

Acute Pharyngitis (streptococcal)

- onset: sudden - temp: 103-104 - s/s: sore throat, exudate, erythema, petechial mottling, swollen tonsils, abd pain, vomiting and HA - labs: leukocytosis - dx: throat swab for culture - meds: PO penicillin for 10 days, PO amoxicillin for 10 days, IM penicillin G (PO erythromycin if allergic to penicillin) - cold/warm compresses to neck, warm saline gargle, adequate fluid intake, complete course of ABX, throw away tooth brush after 24hrs of ABX

Diaper Dermatitis

- peak age 9-12 months - Prolonged contact with urine/feces/soaps/detergents/ointments/friction - s/s: lesions on butt/inner thigh/mons pubis/ scrotum, Candida albicans produces perianal inflammation and a maculopapular rash with satellite lesions - tx: use superabsorbant diapers, change when soiled, expose skin to dry by air, zinc oxide/petroleum ointment, avoid removing ointment with every diaper change, avoid over washing skin, use neutral/mild soaps and wipes - no talcum powder

child maltreatment

- physical neglect: deprivation of food, clothing, shelter, supervision, medical care, education - emotional neglect: lack of affection, attention, and emotional nurturance - emotional abuse: destroy/impair child's self esteem - physical abuse - sexual abuse

Nephrotic Syndrome

- preschool children (peak = 2-3) - rare < 6 months and > 8 years - caused by: metabolic, biochemical, physiochemical, immune mediated - classifications: MINIMAL CHANGE - s/s: generalized edema, proteinuria, hypoalbuminemia, hyperlipidemia, pallor, anorexia, diarrhea, DARK FROTHY SCANT URINE, MUEHRCKE lines on nails, malaise, irritability - tx: steroids (first line): prednisone (drug of choice) 60 mg/m2/day for 4-6 wks then 40 mg/m2/day, immunosuppressants, furosemide - taper off steroids to prevent renal crisis - low to moderate protein diet

Acute Glomerulonephritis (AGN)

- primary event or evidence of systemic disorder (SLE or SC) - usually 5-12 days after strep - most common in early school age (peak = 5-7), uncommon < 3 - non infectious renal disease (autoimmune) - s/s: oliguria/hematuria/proteinuria, circulatory congestion, periorybital edema/HTN, increased WBC/BSR/BUN/creatinine/ESR, decreased GFR, HA - can cause hypertensive encephalopathy, acute cardiac decompensation and acute renal failure - tx: ace inhibitors, diuretics, penicillin, corticosteroids - low sodium/low to moderate protein diet

Brief Resolved Unexplained Event (BRUE)

- related ALTE - sudden and frightening event when infant has apnea, change in color/muscle tone, choking, gagging or coughing - tx: 24 hr observation - less than 1 year of age - event lasts less than 1 min including at least one: cyanosis/pallor, absent/decreased/irregular breathing, change in muscle tone, altered responsiveness

Bulimia nervosa

- repeated binge eating followed by purging - eat large amounts of high calorie food then purge with laxative or vomiting - binge eating disorder: binge eating w/o purging - peak onset 16-17 years - normal weight (pithing 5-15 lbs) or overweight - more common in females - monitor for Russels sign (hand lesions/scarring) - erosion of enamel of anterior teeth duet to vomiting - may have long QT interval, mitral valve prolapse, chronic constipation - SCOFF questionare

Encopresis

- repeated voluntary/involuntary passage of feces of normal consistency in non appropriate places - most common cause is constipation - more common in males - s/s: painful pooping, pellet like poop, abd pain, poor appetite, soiled underwear - tx: avoid dairy, increase fiber/fluid, manage constipation, psychotherapeutic interventions

Congenital Diaphragmatic Hernia (CDH)

- results from failure of closure of the pleuro-peritoneal canal allowing mid gut to herniate into the chest impairing lung development - can cause pulmonary HTN and malrotation - s/s: concave abdomen when born, bowel sounds in chest, cyanosis/resp distress, displaced heart sounds - tx: intubation/GI decompression, surgery

Acute Epiglottitis

- serious obstructive inflammatory process that affects the epiglottis or supraglottic area. - usually occurs 2-5 yrs. old. - PRIMARY ORGANISM- H. INFLUENZA. - abrupt onset & rapid progression. - MEDICAL EMERGENCY!!! - s/s: sore throat, pain, tripod position, retractions, inspiratory stridor, high fever, drooling, muffled voice - tx: emergency equipment at bedside, no tongue blade/clearing throat, use humidity/ABX/analgesics/antipyretics - prevention: HIB vaccine

Dehydration

- severe: IV fluids (1. IV bolus 20ml/kg over 5-20 min, 2. IV maintenance fluids over 24 hrs) - isotonic: grey/cold/dry skin with poor turgor, dry mucous membranes, absent tearing/salivation, sunken eyes/fontanels, low/high temp, rapid HR/RR, irritable/lethargic - hypotonic: grey/cold/clammy skin with very poor turgor, slightly moist mucous membranes, absent tearing/salivation, sunken eyeball/fontanels, low/high temp, very rapid HR/RR, lethargic/comatose/convulsions - hypertonic: grey/cold or hot/thick/doughy skin with fair skin turgor, parched mucous membranes, absent tearing/salivation, skunks eyeballs/fontanels, low/high temp, moderately rapid HR/RR, marked lethargy with extreme hyperirritability when stimulated

Puberty

- starts at 12 for females, 14 for males - dramatic change is secondary to sex characteristics - Females: breast development, pubic hair growth, axillary hair growth, menstruation - Males: testicular enlargement, pubic hair growth, penile enlargement, axillary hair growth, facial hair growth, vocal changes

Anorexia nervosa

- strong fear of being fat - progressive weight loss - significantly underweight (<85%) - peak onset 13-18 years - false image of being fat - overachievers/perfectionists - deny illness - assess: HR, temp, BP supine and standing, may have prolonged QT interval/mitral valve prolapse, chronic constipation - SCOFF questionare

sudden infant death syndrome (SIDS)

- sudden death of an infant < 1 year that remains unexplained after complete post mortem exam - risk factors: low birth weight, low APGAR scores, recent viral illness, siblings with SIDS, male, African American/Native American, preterm, tummy sleeping - complications: positional plagiocephaly

Intussusception

- telescoping of the intestines/invagination of one portion of the intestine into another - often follows viral illness, can be from intestinal lesions - potentially life-threatening - classic triad of symptoms in 30% of children: sudden onset abd pain, sausage like mass, bloody/currant jelly-like stools - dx: bulls eye on ultrasound - tx: pneumenema first line, hydrostatic enema 2nd line, surgery 3rd line - NPO/bowel decompression preop

Types of burns

- thermal: hot liquids, surfaces, flames, - chemical: acid, cleaning products and other chemicals - electrical: electrical currents - irradiation: radiation from x rays or radiation therapy

Family Structures

- traditional nuclear: married couple with biologic children - nuclear: 2 parents and child (child can be biologic, step, adoptive or foster) - blended: reconstituted family (at least 1 step parent, step sibling, or half sibling) - extended: at least 1 parent, I or more children, and 1 or more related/unrelated member - binuclear: joint custody/co parenting - single parent - polygamous: multiple wives/husbands (mothers and children share husband/father living in same or separate house) - communal: share common ownership of property - LGBT: may have biologic children from previous relationship

Adolescents

- transition period between childhood and adulthood - time of profound changes - Early adolescence: 11-14, changes of puberty and responses to those changes - middle adolescence: 15-17, transitions to peer dominant orientation - late adolescence: 18-22, takes on adult roles/relationships

Rubeola (measles)

- transmitted by direct contact with droplets of infected person usually in winter - s/s: fever/malaise followed in 24 hrs by coryza cough, conjunctivitis, and Koplik spots that subside on day 2, anorexia, abd pain, malaise, lymphadenopathy - tx: bed rest during febrile period/antipyretics, ABX to prevent secondary infection in high risk children - isolation until 5th day of rash (airborne precautions) - MMR vaccine - cool mist vapor for coryza cough - fluids and soft/bland foods - dim lights and provide eye care

Enuresis in school age

- unintentional urination in kids beyond age of bladder control - bed wetting - more common in boys, stops around 6-8 years - caused by structural defects, UTI, impaired kidney function, neuro deficits, endocrine disorders, sickle cell - s/s: immediate urge to pee with discomfort, restlessness and frequency - tx: bladder training, fluid restriction, desmopressin acetate, anticholinergic (oxybutynin), imipramine (tofranil) - dont get onto child for wetting bed

Chicken Pox

- varicella zoster - spreads by direct contact, droplet and contaminated objects - 2-3 weeks incubation - s/s: sight fever, malaise, anorexia, highly pyritic rash, macule then papule then vesicle - tx: Acylovir, Varicella zoster immunoglobulin or IVIG after exposure in high risk children, Diphenhydranine hydrochloride or antihistamine for itching - avoid aspirin - standard airborne and contact precautions until no new lesions are seen/vesicles have dried

Failure to thrive

- weight below 5th percentile and height within normal limits - caused by: incorrect formula prep, neglect, CF, celiac disease, hyperthyroidism, congenital heart defects, genetic anomalies

Tanner Stages: Female

1. Pre-pubertal 2. Pubertal 3. enlargement of breast with no separation of contour, pubic hair darkens and is sparse over entire pubis 4. secondary breast mound, pubic hair abundant in pubic area 5. adult size and shape, pubic hair spreads to inner thighs

Tanner Stages: Male

1. Pre-pubertal 2. Pubertal 3. enlargement of penis length, pubic hair darken and is sparse over entire pubis 4. increase size of penis and glans, pubic hair abundant on pubic area 5. adult size and shape, pubic hair spreads to inner thighs