Peds Clinical Prep (KS)
Mongolian Spots
(Slate Grey Patches or Congenital dermal melanocytosis) These dark blue-grey lesions are most commonly seen in darker-skinned infants. - The sacrum is the most commonly affected area. - These lesions tend to fade over several years but may not completely disappear. - No evaluation is needed. They can be easily differentiated from bruises by the absence of other colors associated with bruises -- red, purple, green, brown or yellow.
Hirschsprung's disease
(also called congenital aganglionic megacolon) occurs when some of your baby's intestinal nerve cells (ganglion cells) don't develop properly, delaying the progression of stool through the intestines. The intestine becomes blocked with stool, and your baby or child will be constipated (unable to have normal bowel movements).
Cradle Cap (Seborrheic dermatitis)
*Seborrheic Dermatitis*-Typically seen on the scalp, but may spread to the ears, neck, and diaper area of infants. Tx: -Baby oil, small brush -Frequent shampooing -Hydrocortisone
Ballard Gestational Age Assessment is accurate within about
+/- 2 weeks
Gestational Age Assessment - Later OB ultrasound, accurate within approximately ____
+/- 2 weeks
Gonococcal Conjunctivitis
- Conjunctival injection - eye discharge - swollen eyelids 2-5 days after birth
2 common overwhelming viral infx in infants
- HSV - enterovirus
meningocele vs myelomeningocele
- Meningocele sac-like protrusion contains meninges and cerebrospinal cord - Myelomeningocele *contains meninges, cerebrospinal fluid, and NERVES - THEY BOTH PROTRUDE - They can cause bowel and bladder incontinence despite surgery
Common causes of bacterial meningitis in infants & young adults
- Neisseria meningitidis - h. influenzae - Streptococcus pneumoniae
Neonatal Jaundice Treatment
- Phototherapy - IVIG: inhibits hemolysis by blocking antibody receptors on red blood cells Decreases rate of exchange transfusions - Exchange blood transfusion: Reserved for refractory, severe hyperbilirubinemia Withdrawing small amounts of blood, removing both the bilirubin and maternal antibodies Double-volume exchange
Ballard Exam Neuromuscular Maturity Criteria
- Posture - Square window - Arm recoil - Popliteal angle - Scarf sign - Heel-to-ear
Pre-term infants are at higher risk for:
- Respiratory distress syndrome - necrotizing enterocolitis - patent ductus arteriosis - apnea
Ballard Exam Physical Maturity Criteria
- Skin - Lanugo - Plantar surface - Breast - Eye/Ear - Genitals
Bacterial meningitis treatment
- Vaccination (preventative) - Corticosteroids (Dexamethasone - before abx) - Abx (Beta Lactam & Macrolide/Aminoglycoside) - Fluids - Tx of close contacts
Post-term infants are at higher risk for:
- asphyxia (body is deprived of oxygen) - meconium aspiration - trisomies and other syndromes
Common causes of bacterial meningitis in neonates
- e. coli - group b strep - liisteria monocytogenes often come from mom during delivery
jittery movements in a newborn can be associated with:
- hypoglycemia - hypocalcemia - neonatal abstinence syndrome - it can also be normal
What newborns need a glucose check?
- infants of a diabetic mother - infants large for gestational age (LGA) - infants small for gestational age (SGA) - jittery infants - mom is septic
Sequelae of overwhelming viral infection of enterovirus in infant
- myocarditis - hepatitis (jaundice) - hypotension - perfuse bleeding
Viral causes of gastroenteritis
- rotovirus - norovirus - adenovirus
bacterial causes of gastroenteritis
- shigella - e. coli - salmonella
MC organisms to cause endocarditis
- streptococci (group A) - staphylococci
hyaline membrane disease (HMD)
-AKA as respiratory distress syndrome (RDS) of the newborn -often associated with prematurity and low birth weight. -caused by a lack of surfactant: small air sacs within the lungs collapse because of increased tension, a problem indicated by the baby's labored breathing. Tx: maintain adequate oxygenation.
Colostrum
-breast milk produced during the last part of pregnancy & the first few days after delivery - typical feeding of colostrum is only a tsp (5ml) or less, it contains a large amount of protective Ig that give the baby his/her first protection against infection. - More yellow than mature milk with thick, sticky consistency.
Myocarditis sxs
-signs of heart failure -fatigue -chest pain
Normal passage of meconium should include at least one stool in the first _______ hours after birth and end with the onset of transitional stools by day _______.
1) 48 hours 2) 4
What are the top 3 organisms to cause sepsis in a newborn?
1) GBS 2) E. coli 3) Listeria
3 stages of pertussis
1. Catarrhal stage (2 weeks) - highly contagious - sxs similar to URI 2. Paroxysmal stage (week 2-8) - worsening cough 3. Convalescent stage (week 8 and onward) - subsiding cough
Direct Coombs test vs Indirect Coombs Test
1. Direct: Detects antibodies on the RBC surface - Anti-Ig antibody (Coombs reagent) added to patient's blood. RBCs agglutinate if RBCs are coated with Ig. 2. Indirect: Detects antibodies in the plasma - Normal RBCs added to patient's serum. If serum has anti-RBC surface Ig, RBCs agglutinate when Coombs reagent added. https://www.youtube.com/watch?v=4MJA8Wzp2XM
Most newborns have _______ major creases on the palm
2 - neither of which completely extend from one side of the palm to the other
When does the fencer reflex appear and disappear?
2-4 wks; 6 mos
Term babies AGA weight should fall between ______ kg & _____ kg
2.5 - 4 kg (5 lbs 12 oz - 8 lbs 12 oz)
Neonatal Acne
20% of newborns, week 1-2 of life, comedones + pustules/papules, no tx ~ comes from maternal hormone transmission
how long does acrocyanosis typically take to resolve in a newborn?
24-48 hours
If a newborn is hypoglycemic, how many normal glucose test need to be read before they do not need to monitored for hypoglycemia?
3 consecutive blood sugars > 45 without the use of glucose gel or other interventions
Gestational Age Assessment - Early OB ultrasound is best, accurate within approximately ____
3 days
The 50th percentile for Occipital Frontal Circumference (OFC) of a term newborn is ________.
34 cm
Term baby
37-41 6/7 weeks
Normal vaginal withdrawal bleeding that occurs in some female infants. Similar to withdrawal bleeding in adolescents, this typically occurs on the ________ day after birth, continues for a few days, then stops.
3rd day
Post-term baby
42 or more weeks
When does the plantar grasp disappear?
9-12 months
What is the cut off for a cord pH?
< 7.15 is acidotic
Dacrostenosis
A blocked tear duct
Clinodactyly
A slight medial incurvation of the fifth finger is a frequent finding on the newborn exam. - It is often inherited as a familial trait
Congenital Glaucoma
Abnormal development of the anterior chamber before birth leading to improper aqueous outflow system. Causes intra-ocular pressure resulting in vision loss. - Glaucoma is a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve (most common cause high pressure inside your eyes)
ear pit
Abnormality of the pinna characterized by a small hole typically located about the tragus
Epstein Pearl
Accumulations of epithelial cells also called a retention cyst located at the juncture of the hard and soft palates - benign
Salmon Patch
Also called a stork bite or capillary hemangioma or nevus simplex - May appear on the nape of the neck, eyelids, forehead, or upper lip - They are distended capillaries and not nevi and should disappear
Sandal Gap Deformity
Another physical finding in many infants with Down's syndrome is an increased gap between the great and first toes. - While this finding can occur as a familial trait, when it occurs in constellation with other features of Down's, it supports the dx..
Apgar scale
Appearance Pulse Grimace Activity Respiration (a standard measurement system that looks for a variety of indications of good health in newborns)
Undescended Testicles
At times, a testicle is not palpable at all in the scrotum. - In the photo, the scrotum appears asymmetric with the right side flatter than the left. - Palpation confirmed that a testicle was present on the left, but not on the right. - Unilateral undescended testicle is fairly frequent finding in term newborns and does not require further evaluation at birth or preclude circumcision. - With time (weeks to several months) the testicle is expected to descend spontaneously. - Bilateral undescended testicles, on the other hand, are quite unusual at term and should be considered as ambiguous genitalia (with circumcision contraindicated) until proven otherwise.
Milia
Benign, keratin-filled cysts that can appear just under the epidermis and have no visible opening - The white papules on this baby's chin and cheeks are milia. - Milia are keratin filled epithethial cysts which occur in up to 40% of newborns. - Spontaneous exfoliation and resolution is expected within a few weeks. - Parents will occasionally mistake these lesion for neonatal acne, but milia are present at birth and have no inflammatory component. - Acne, even though caused by maternal hormones, does not generally appear until after 2 weeks of age.
what bacteria causes pertussis?
Bordetella pertussis
Clinical presentation - MC in breastfed infant ( ~4 mo (median age) - diminished muscle activity - poor feeding - lethargy - constipation - hypotonia (decreased muscle tone) - respiratory failure - ptosis - decreased eye movements
Botulism - A rare poisoning caused by toxins produced by Clostridium botulinum bacteria
caput succedaneum vs cephalohematoma
Caput Succedaneum- soft tissue swelling, that can cross suture lines Cephalohematoma- subperiosteal hemorrhage that does NOT cross suture lines.
congenital adrenal hyperplasia
Genetic disease in which the adrenal gland is overdeveloped, resulting in a deficiency of certain hormones and an overproduction of others A form of intersexualism in which a genetic female has internal female sexual structures but masculinized external genitals
Gravida/Para
Gravida (gravidity): # of Pregnancies Para (parady): # of live births WOMAN HAS TWO KIDS, ONE ABORTION, AND IS CURRENTLY PREGNANT: Gravida = 4; Para = 2
What is the Hepatitis B test for new mothers?
HepBsAg
Galeazzi Sign
Hips can also be assessed by looking at the symmetry of the height of the knees when the infant is supine. - A positive galeazzi sign (unequal knee heights) suggests a unilaterally dislocated hip. - It is important to remember that bilateral dislocations will likely appear symmetric, so this assessment should only be used in combination with the Ortolani and Barlow maneuvers. - This finding is usually caused by a dislocated femoral head which is situated posterior to the acetabulum, instead of in the acetabular fossa. This creates a shortened appearance of the thigh on the affected side.
Delayed passage of meconium should prompt consideration of ________________ or conditions associated with meconium plugs.
Hirschsprung's disease
MC cause of respiratory distress in a preterm infant?
Hyaline membrane disease
What is given to newborns with sepsis caused by GBS in their mother?
IV ampicillin
Sebaceous Hyperplasia
In contrast to milia, the raised lesions on the nose in this newborn are sebaceous hyperplasia. The lesions are more yellow than milia and are the result of maternal androgen exposure in utero. - Sometimes referred to as "the miniature puberty of the newborn," maternal hormone exposure may also cause vaginal withdrawl bleeding in infant girls and neonatal acne. - Sebaceous hyperplasia is a benign finding and spontaneously resolves with time. No evaluation is needed.
"LGA"
Large for gestational age [above 90th percentile]
What must be completed in a newborn with a cord pH of < 7.15?
Neuro exams
Meconium Plug
Obstruction of left colon and rectum by dense and dehydrated meconium
"100 day cough"
Pertussis (whooping cough)
Transient pustular melanosis
Pustules with pigmented bases are present at birth, microscopic evaluation will reveal neutrophils but the lesions will be sterile. They are more common in black people and pustules resolve in about 24-48 hours, macules 1-3 months.
Sacral Dimple
Sacral dimples are a commonly encountered finding on the physical exam. - Most of these dimples are "simple dimples" and require no further evaluation. - A simple dimple is one that is located within 2.5 cm of the anus, has a base that can be visualized and is not associated with other abnormalities on exam.
MC of myocarditis
Secondary to a recent infx in the last 2 weeks - Respiratory infection (Adenovirus) - Gastrointestinal infection (Coxsackie - enterovirus)
"SGA"
Small for gestational age [below 10th percentile]
Barlow vs Ortolani Tests
The Barlow maneuver is a test used to identify an unstable hip that can be passively dislocated. The infant is placed in a supine position with the hip flexed to 90º and in neutral rotation. The examiner adducts the hip while applying a posterior force on the knee to cause the head of the femur to dislocate posteriorly from the acetabulum. A palpable clunk may be detected as the femoral head exits the acetabulum. The Ortolani maneuver identifies a dislocated hip that can be reduced. The infant is positioned in the same manner as for the Barlow maneuver, in a supine position with the hip flexed to 90º. From an adducted position, the hip is gently abducted while lifting or pushing the femoral trochanter anteriorly. In a positive finding, there is a palpable clunk as the hip reduces back into position. Hip examination should occur soon after birth and at every visit until the child is walking normally.
Galant Reflex
The galant reflex is elicited by suspending the infant in a prone position -- the feet should not be touching the bed. - The side of the back is then stroked in a cephalocaudal direction. - The infant will respond by moving the hips towards the side that was stimulated.
Junctional Melanocytic Nevus
The lesion is completely flat and is medium to dark brown in color. It may become slightly raised as the infant grows and may become a compound nevus if intradermal melanocytes develop. It is considered a benign lesion.
Acute Testicular Torsion
The right testicle was torsed and the baby was taken emergently to surgery - Because of the pathology that is occuring in the right testicle, the right scrotum does not transilluminate equally with the left.
T/F Phimosis is normal in a newborn
True!!! - do NOT attempt to retract the foreskin over the glans
Edematous hands and feet in infancy is often associated with:
Turner's syndrome - a condition that affects only females, results when one of the X chromosomes (sex chromosomes) is missing or partially missing
Is acute gastroenteritis more often viral or bacterial?
VIRAL
Chordee
Ventral (downward) curvature of the penis due to a fibrous band along the corpus spongiosum, often associated with hypospadias
Appropriate for gestational age (AGA)
Weight, length, and head circumference are between the 10th and 90th percentiles for gestational age
protective reflex
When eyes and nose are covered with cloth the baby makes effort to push it away. Enables baby to breath while breastfeeding.
Asymmetric Tonic Neck Reflex
While lying supine, extremities are extended on the side of the body to which the head is turned and opposite extremities are flexed - also called the "fencing" position.
Pectus Excavatum
a chest that is hollowed out (funnel chest)
imperforate anus
a congenital defect in which the rectal opening is missing or blocked
linea nigra
a dark line appearing on the abdomen and extending from the pubis toward the umbilicus - the presence of linea nigra seems to be impacted by hormonal levels, as this finding is often seen is pregnant women as well
club feet
a deformity in which an infant's foot is turned inward, often so severely that the bottom of the foot faces sideways or even upward
Peters Anomaly
a disorder of the eye which involves thinning and clouding of the cornea and attachment of the iris to the cornea, which causes blurred vision - It may also be associated with clouding of the lens of the eye (cataracts) or other lens abnormalities.
port-wine stain
a flat vascular birthmark made up of dilated blood capillaries, creating a large, reddish-purple discoloration on the face or neck - Port wine stains are always present at birth. In an infant, they are flat, pink, vascular lesions. - Common locations include the face and neck, but they may be present anywhere on the body. - They do NOT go away.
Hydrocele
a fluid-filled sac in the scrotum along the spermatic cord leading from the testicles - Spontaneous resolution is expected - the fluid-filled hydroceles transilluminate
spinal dysraphism
a group of neural tube defects that describe some manifestation of incomplete closure of the spine
Erb's Palsy
a paralysis of the arm that most often occurs as an infant's head and neck are pulled toward the side at the same time as the shoulders pass through the birth canal - Most brachial plexus injuries of this type resolve spontaneously. - Improvement in movement can often be noted within the first 24 hours. - If improvement does not occur, referral to a pediatric neurologist, and possibly a physical therapist, is warranted.
What is the Direct Coombs test?
a serum blood test used to differentiate among types of hemolytic anemia Any Rh negative mother that has been previously pregnant has her plasma mixed with known Rh+ RBCs A positive test (agglutination) indicates she has already been sensitized
simian crease
a single straight palmar crease; an abnormal finding that is associated with Down Syndrome
Transverse Palmar Crease
a transverse palmar crease is frequently inherited as a familial trait - Although single palmar creases are also associated with Down's syndrome and other genetic disorders
Icthyosis
abnormal condition of dry, scaly skin
hypospadias
abnormal congenital opening of the male urethra on the undersurface of the penis
In the 2nd day of life, what should the glucose be?
aiming for 35 or greater
In the first 4 hrs of life, what should the glucose be?
aiming for 35 or greater
"AGA"
appropriate for gestational age
Corioamnionitis
bacteria infects the chorion and amnion (the membranes that surround the fetus) and the amniotic fluid.
Clinical presentation: infant - fever - poor feeding - seizures - lethargy - irritability - high pitch cry - bulging of the fontenelles (increased ICP) - apnea - vomiting
bacterial meningitis
When is the Ballard Exam best done?
between 12 and 20 hrs of life
inguinal hernia
bilateral inguinal hernias - In contrast to hydrocele, inguinal hernias are typically associated with a fullness in the inguinal area. - This infant is preterm, a risk factor for the presence of hernias. - While the scrotum may transilluminate with hernias, the masses can frequently be reduced with digital pressure. - At times bowel sounds may also be appreciated over the area of the mass.
How does phototherapy work?
bilirubin in skin absorbs light and is converted to a urobilinogen which is water soluble and excreted in bile (stool) and urine without conjugation
Subconjunctival Hemorrhage
bleeding between the conjunctiva and the sclera - caused by ruptured blood vessels
what should you do if bacterial meningitis is suspected?
blood culture and LP
What is something to closely monitor for babies who are SGA or LGA?
blood sugar - both are at risk for hypoglycemia
acryocyanosis
blue hands and feet
When hair whorls are multiple or in unusual locations, abnormal _______ growth may be a causative factor.
brain - Normally, because the growth of the brain occurs in a predictable fashion, there is one primary hair whorl over the vertex of the head.
discordant size
checking to see if twins are similar or differ in size
Vernix caseosa
cheesy substance covering the skin of the fetus - Vernix coating on the neonatal skin protects the newborn skin and facilitates extra-uterine adaptation of skin in the first postnatal week if not washed away after birth.
cataract
clouding of the lens of the eye
Epispadias
congenital defect in which the urinary meatus is located on the upper surface of the penis - With epispadias, the urethral meatus is dorsally displaced. - This condition is much less common than hypospadias, but also presents a contraindication to routine circumcision. - In it's severe forms, epispadias is often associated with exstrophy of the bladder.
Dacrocystoceles
cysts in nasolacrimal ducts. need optho consult
DDH
developmental dysplasia of the hip - abnormal development of the hip joint found that is congenital Sx: fat rolls asymmetrical, abnormal leg length, AROM limited Tx: Cast, surgery, PT Tests: US (ultrasonogram), x-ray of hips, AROM testing of hips
Lanugo
fine, soft hair, especially that which covers the body and limbs of a human fetus or newborn
Often mistaken for blood in the urine, urate crystals are a frequent intermittent finding in the ________.
first week
Bilious emesis
green or bright yellow color, indicating larger amounts of bile in the stomach - bilious vomiting is often associated with intestinal obstruction - NEVER normal
omphalocele
herniation at the umbilicus (a part of the intestine protrudes through the abdominal wall at birth)
Absent red reflex
indicates cataracts, retinal detachment, retinoblastoma
omphalitis
inflammation of the umbilicus
subgleal hemorrhage
injury to the head at birth that usually occurs from instrument use on the scalp; crosses the suture line
finger hypoplasia
is when a baby is born with a finger or thumb that is not developed completely (it is usually small in size). - often the nail is not developed
Cafe Au Lait Spot
large round or oval patch of light brown usually present at birth - Cafe au lait spots are lighter in color than melanocytic nevi, but they also may be congenital macules. - They are caused by an increased amount of melanin in both melanocytes and epidermal cells, and may increase in number with age. - Most children with cafe au lait spots do not have neurofibromatosis, but the presence of six or more of these spots that are larger than 0.5cm diameter is considered to be a major clue to the diagnosis.
What causes jaundice in newborns?
liver not functioning - Red blood cells die and release heme which is metabolized to bilirubin - Bilirubin is bound to albumin in the blood, carried to the liver where it is conjugated for excretion Babies have a high number of RBCs in their blood, which are broken down and replaced frequently. - A newborn baby's liver is not fully developed, so it's less effective at processing the bilirubin and removing it from the blood.
Diastasis Recti
midline longitudinal ridge in the abdomen, a separation of abdominal rectus muscles - spontaneous resolution is expected - caused by a relative weakness of the fascia between the two rectus abdominus muscles
digit aplasia
missing thumb, finger, or toe - Whenever digits are missing, underlying genetic or chromosomal diagnoses should be considered
Bright futures
national health promotion initiative with a goal to improve the health of our nations children - American Academy of Pediatrics - Theory based guidelines for health supervision of infants, children and adolescents - also talks about interventions - preventative medicine
Moro reflex
often called a startle reflex - That's because it usually occurs when a baby is startled by a loud sound or movement. - In response to the sound, the baby throws back his or her head, extends out his or her arms and legs, cries, then pulls the arms and legs back in
Cleft Palate vs Cleft Lip
palate = palatine shelves of maxillary prominence fail to fuse with one another or the primary palate lip = maxillary prominences fail to properly fuse with intermaxillary segment
Erythema Toxicum
pink rash that appears suddenly anywhere on the body of a term newborn during the first 3 weeks - This is the "rash" most commonly observed in the nursery. - Lesions generally start on day 1 or 2 and increase in number over the next several days, followed by spontaneous resolution in about a week. - Even newborns who have hundreds of spots are not symptomatic and need no further evaluation.
lop ear
pinna deformity, where the superior edge of the helix is folded down
Microtia
pinna is not well-formed and is smaller than a normal ear - Hearing evaluation is mandatory in these infants and referral to a pediatric ENT specialist is recommended
Stahl's ear
pinna not folded over. "spock" ear
meconium staining
presence of meconium in amniotic fluid - stains nails, skin, and/or umbilical cord - infant who was stressed prior to birth
umbilical hernia
protrusion of the intestine through a weakness in the abdominal wall around the umbilicus (navel)
Micrognathia
small jaw
Skin tags in the sacral area are also potential indicators of
spinal dysraphism
What organ are we most worried about in a newborn who is acidotic?
the brain - are they getting an adequate supply of oxygen
Pavlik Harness
used for hip dysplasia in infants - Remove only to take baths
Bohn's Nodules
white bumps present on the upper gum in this infant - The exact etiology is unknown, but they are thought to arise from remnants of the dental lamina or from heterotrophic salivary glands - Present either on the lateral aspect of the gum (as seen here) or on the periphery of the palate, these nodules are a benign finding and will disappear with time