Pediatrics clerkship

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Study topics for 3rd year Clerkship in Pediatrics.

HEEADSSS

Home, Education & Employment, Eating disorder screening, Activities, Drugs, Sexuality, Suicide risk and depression, Safety

Nikolsky sign

pealing of the epidermis in response to shearing forces

Ritter's disease

staphylococcal scalded skin syndrome, usually children < 5y/o, high fever, rash, irritability, extraordinary tenderness, peeling of epidermis

Roseola

caused by herpesvirus 6 & 7, usually <3y/o, high fever 3-5days, pink rash that BEGINS ON THE TRUNK and spreads outward. APPEARS WITHIN 24hrs OF FEVER RESOLUTION.

Criteria for physiologic jaundice

(1)bilirubin < 14 (2) bilirubin increases by <5mg/dL per day (3) 1st 3 days the bilirubin is <5mg/dL (4) jaundice resolved by 7d in term infant and 14d in pre-me. (5) conjugated bilirubin is always normal.

When is jaundice always pathologic?

during the first day of life.

Cause of physiologic jaundice?

defective hepatic uptake coupled with decreased UDP-glucuronyl-transferase activity. (increased RBC load may also play a role)

Bilirubin over what level is always pathologic?

>15mg/mL

What are some causes of pathologic jaundice?

ABO/Rh incompatibility, drug reactions, RBC defects (sickle cell, thal)

What are the two inborn disorders of bilirubin metabolism that lead to a CONJUGATED bilirubinemia?

Dubin-Johnson, Rotor syndrome, (Biliary atresia and alpha1 antitrypsin def. can present this way also)

What are the two inborn disorders of metabolism that lead to an UNCOJUGATED hyperbilirubinemia?

Gilbert's and Crigler-Najjar

What are the signs of biliary atresia?

lack of gallbladder and triangular cord sign on ultrasound.

When should children be screened for autism

18 months and 2 years

The AAP mandates a formal developmental screen should occur when?

9mo 18mo and 30mo checkups, but it is recommended that surveillance occur at all well-child visits!

Newborns lose weight right after birth, when do they regain their birth weight?

by 2 wks of age.

What is the PALMAR GRASP and when does it disappear?

anything placed in the palm the child tries to grasp. Disappears by 2-3 months

What is the MORO reflex and when does it disappear?

abrupt change in position causes symmetric arm abduction followed by adduction and sometimes a cry. Disappears by 4 MONTHS

What is the Asymmetric Tonic Neck Reflex, when does it disappear?

passively turning the child's head to one side causes the ipsilateral arm to extend and the contralateral arm to flex at the elbow (schwarzeneggar pose) think future hand eye coordination. Disappears by 6 months.

What is the PLANTAR GRASP reflex?

palpation of the ball of the foot causes flexion of the toes. Disappears by 8 months. (must disappear before walking possible.

What is the BABINSKI and when does it disappear?

Dorsiflexion of the great toe with fanning of the other digits in response to stroking the plantar surface of the foot. It persists up to 1-2 years.

What is the most sensitive test for detecting developmental dysplasia of the hip?

Ultrasound

What age groups are covered by the DENVER II developmental screen?

ages 0-6years

How much VitD should children get?

Children should get 400units of VitD per day. Supplement if necessary.

Why should you introduce foods one at a time several days apart?

to identify possible allergic reactions.

What age do most children start sleeping through the night?

4 to 6 MONTHS

What ages and weights correspond to what car seat positions?

rear seat/rear facing until 1YEAR AND 22lbs. 4 years and 40lbs = booster seat, 8 years back seat with seat belt, 12years front or back seat with seat belt.

How many HepB shots does a child need on the regular schedule?

3 (usually birth, 2mo, 6-18mo)

How many DTaP shots does a child need on the regular schedule?

5 (2mo,4mo,6mo, 15-18mo, 4-6yrs)

How many IPV (inactivated polio) shots does a child need?

4 (2mo,4mo,6-16mo, 4-6yrs)

What shots are not required until 1 yr?

MMR, Varicella, HepA ...happy birthday ;- (

When do kids get immunized to ROTAVIRUS?

2mo, 4mo, 6mo

By what ages do children double and triple their birthweight?

double at 5mo, triple at 12mo.

When do most children reach double their birth length?

4 years

What are some possibilities when you cannot elicit the red reflex on eye exam?

abnormalities such as cataracts, glaucoma, retinoblastoma and chorioretinitis

How do you assess pallor in children with darker complexions?

in the conjunctiva, nail beds and mucous membranes

What is the most frequently Dx neoplasm of infancy?

neuroblastoma, usually presenting before age to with fever, pallor, weight loss. Often asymptomatic abdominal mass.

What labs do you want to get if you suspect neuroblastoma? What is the Sn ?

Urine vanillylmandelic acid (VMA) and urine homovanillic acid (HVA). Sensitivity = 90-95% (small cell rosettes (homer-wright) on Bone marrow aspirate are highly suggestive)

What are the favorable prognostic factors of neuroblastoma?

non-amplification of the n-myc oncogene, DNA index greater than 1, favorable histology (Shimada classification), and age less than 1.

What are the teratogenic effects of maternal diabetes?

sacral agenesis (pathognomonic), cardiac defects, renal defects, anencephaly

What are the teratogenic effects of phenytoin?

fetal hydantoin syndrome: pre/postnatal growth retardation, hypoplasia of the distal phalanges, and defects alteration of CNS performance. Can also interfere with folate metabolism (give folate)

What are the teratogenic effects of valproate?

neural tube defects

Describe fetal EtOH syndrome?

growth retardation, developmental delay, characteristic facies: microcephaly, microphthalmia, flattened philtrum. Also may have skeletal, joint, cardiac abnormalities

In testing for immunodeficiencies what test would you order to look for chronic granulomatous dz?

Nitroblue tetrazolium (NTB) a respiratory burst assay to look for phagocyte defects

In testing for immunodeficiencies what test would you order to look for wiscott-aldrich?

platelet count, if it is normal wiscott-aldrich is unlikely

When might you consider wiscott Aldrich?

severe eczema, thrombocytopenia, and unusual infections

In testing for immunodeficiencies what might intradermal skin testing with candida reveal?

no response in a patient with T-cell deficiency (DiGeorges)

In testing for immunodeficiencies what test might you check if a patient has repeated infections with encapsulated organisms?

peripheral smear (look for howell-jolly bodies as evidence of asplenia)

What are the Danger Signs in Jaundiced Infants?

(1) Family history of significant hemolytic disease, (2) Vomiting, (3) Lethargy, (4) Poor feeding, (5) Fever, (6) Onset of jaundice after the third day, (7) High-pitched cry

MCC of jaundice?

physiologic and breastfeeding associated

Physiologic jaundice of the newborn

bili <15, no other cause for jaundice, child healthy, transient unconjugated hyperbilirubinemia due to multiple factors (decreased liver enzymes (UDPGT), increased RBC, lack of intestinal flora

How often/day and for how long do babies typically nurse

Babies usually nurse 8-12 times in 24 hours, and the feedings may initially range from 20 to 60 minutes (although consistently lengthy feeds may indicate a problem)

When should stool switch from meconium and to what do they switch?

By the 3rd day of life, they should begin to appear yellow.

How many stools/day are normal by the 6th-7th day?

there are usually 3-4 stools per day (some have stools with every feeding).

How often should the baby void by the 3rd day?

The baby should void 3 to 4 times a day by the third day

When should the baby urinate pale yellow urine at least 6 times a day?

by the 6th day

how might Biliary atresia appear in a healthy-appearing infant?

with jaundice and gradually acholic (pale) stools at 3 to 6 weeks.

How is G-6-PD inherited

X linked

Why might G6PD cause jaundice even if there is no anemia?

G6PD deficiency may cause a gene interaction with the promoter variant of the gene for UDPGT causing a deficiency similar to Gilbert's disease

What must you exclude in a infant/child with cataracts?

galactosemia

Increased circulating levels of alpha melanocyte stimulating hormone

addisons disease

Maternal infection with toxoplasmosis produces what in the neonate?

microcephaly, hydrocephalus, chorioretinitis, seizures, intracranial calcifications.

Maternal infection with rubella causes what in the neonate?

cataracts, sensorineural hearing loss, and congenital heart disease (PDA, and pulm art stenosis)

Clinical features of CMV infection in neonates?

IUGR, low birth weight, petechiae and purpura, jaundice and hepatosplenomegaly, microcephaly, chorioretinitis, and intracranial calcifications.

What aer the characteristics of fetal hydantoin syndrome?

IUGR, Mental retardation, dysmorphic facies, hypoplasia of the nails and distal phalanges.

Side effects of tetracycline in the neonate?

tooth discoloration, inhibition of bone formation.

Maternal LUPUS (SLE) might lead to what in the neonate?

FIRST degree AV block

Why perform APGAR assessment?

to determine need for neonatal resuscitation

What does APGAR stand for?

Activity (none,arms/legs,active), Pulse (none, <100,>100), Grimace (none, grimace, sneeze/cough/pull away), Appearance (Blue, extremities blue, pink), Respirations (none, slow irregular, crying)

TORCHES?

Toxoplasmosis, Other (HepB, Varicella), Rubella, CMV, HERPES/ HIV, Syphilis

When does the anterior fontanelle close?

9 to 12 months

What might a large fontanelle imply?

hypothyroidism, Osteogenesis imperfecta, chromosomal anomalies

What might miacrogolossia imply?

Downs, hypothyroidism, beckwidth-wiedemann

What are brushfield spots?

"salt and pepper" speckling (white spots) on the iris seen in downs

How many blood vessels are in a normal umbilical cord? What are they?

2 arteries, 1 vein

What is considered Small for Gestational Age (SGA)?

birth weight < 10th percentile

Infants above how many Kg are considered Macrosomic?

4kg

Most common cause of abdominal mass in a newborn?

enlarged kidney

What is ERB's palsy?

congenital brachial plexus injury involving the 5th and 6th cervical roots: arm adducted, internally rotated, but grasp reflex intact

How can you differentiate caput succedaneum and cephalohematoma?

caput succedaneum occurs external to the periosteum and therefore crosses suture lines.

What are the 3 bacteria causing neonatal infections?

GBS, E coli, Listeria

What is the main cause of Gram (-) sepsis and meningitis in the newborn?

e.coli

What might make you think meconium aspiration?

postdates, grunting respirations, meconium staining, signs of air trapping, RR>100.

What is the Barlow test?

adduct hips push back used w/ Ortolani's to check for Developmental dysplasia of the hip.

What is Ortolani's test?

abduction of the hip with upward pressure used with Barlow's to test for DDH

What is the cushings triad?

HTN, bradycardia, and respiratory depression (these are late findings of intracranial pressure)

How does lead poisoning manifest as neurological effects?

lead has an affinity for the SH amino groups and inhibits delta-aminolevulinic acid dehydratase which catalyzes the formation of the porphobilinogen ring. (needed for heme synthesis) Aminolevulinic acid (a neurotoxin) builds up because this dehydratase is inhibited

What are the treatment options for lead poisoning?

succimer (45-70mcg) or Dimercaprol followed by Calcium EDTA for higher levels. Laxative can help with removal of paint chips or large ingestions.

What are the Five F's of febrile seizure?

Fever, Five months to Five years, less than Fifteen minutes, non-Focal, and + Family history (if they don't fit this pattern, look for another cause!)

Classic characteristics of roseola?

xanthum subitum, caused by HHV-6: 3-5 days of hi fever followed by maculopapular rash.

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