Pediatrics is a specialty of what?
Promise, Education, Advocacy, & Medical Care
The major problem in obtaining a history
Kids are unable to give good histories so you must rely on the parents
Name the order of physical exam
Observe, Listen, Examine
An opisthotonic position may indicate what?
CNS infection, tetanus, or phenothiazide intoxication
What would you suspect if the child is on its side with knees drawn up?
What would you suspect if child's head is deviated to one side?
acute myositis, cerebellar tumors, congenital asymmetry
What would you suspect if the nature of the cry was hoarse?
stridor, laryngitis, epiglottitits, FB, croup
What would you suspect with a high pitched cry?
What would you suspect with moaning?
meningitis or toxic infant
Grunting usually indicated?
55% resp distress and cardiac failure
25% invasive bacterial disease w/ fever
Infrequent crying indicates?
Colic is defined as?
crying for 3 hours/ day >3X a week for 3 wks-3 months
The average baby cries?
The most important part of the exam for children
a dynamic sequential pattern w/ a varying timetable in both normal & abnormal kids
What is the pattern & progression of function?
Cephalocaudal w/ a proximodistal progression consistent with myelinization
Socioenvironmental factors that lead to decreased development
decreased in put ie. deafness, decreased mobility, chaotic environment ie. emotional or sensory deprivation
High parental goals can shape...
linguistic, intellectual, emotional, and social function and skills
What correlates well with intelligence?
acquiring fine motor skills
Weight increases by how much in 3- 5 months of age?
It will double (and then triple by a year)
Who does not follow standard weight gains?
The most important assessment of growth
Head circumference increases by how much?
2cm/mo for 3 months
1cm/mo for 3 months
0.5cm/mo for 6 months
When do the fontanelles close?
Anterior: 12-15 months
Posterior: 3-4 months
Length increases by how much?
Same as head circumference but in inches
What is the growth velocity?
With a 20 in baby:
1st year= 1/2 birth weight= 10 in
2nd year= 1/2 first year= 5 in
3rd year= 1/2 the 2nd year= 2.5 in
4th year-puberty= 2.5in/year
The moro reflex disappears by when?
Rooting disappears by when?
The palmer grasp is gone by when?
Asymmetric Tonic neck disappears by when?
Babinski disappears by when?
When child starts standing
The leading reason of injury deaths is what?
Motor vehicle accidents
Drowning peaks in what ages?
Preschoolers and adolescents
Why is homicide is the leading cause of injury death in kids under 1 yo?
Why is homicide also prevalent in adolescents?
Suicide is most common in what population?
What are the 2 goals of fluid therapy?
Restore intravascular volume and raise blood pressure
When do you add K+ to the fluid therapy?
When urine output has been established
>15% weight loss is considered what and how would you treat?
SHOCK! Administer 20 mL/Kg over 20 minutes.
Why do we want to correct hypernatremia slowly?
To avoid cerebral edema
If patient presents with high BUN and creatinine, what fluid therapy is incorrect and how would you treat?
Maintenance is incorrect due to renal failure. Oliguric regimen, half the maintenance and match the urine output.
Hyponatremia in an MVA can be due to what and which test would you order?
Head trauma can cause inappropriate ADH secretion, order a serum osmolality.
10% dehydration symptoms with hypertension and no weight loss may indicate what disease?
Post streptococcal pyelonephritis
What is the best way to treat mild dehydration?
equal to serum
sodium and osmolarity < serum (130)
sodium and osmolality > serum (145)
Define isotonic dehydration.
loss of salt/water is equal, most common
Define hypotonic dehydration.
loss of salt>water
Define hypertonic dehydration.
loss of water > salt, elevated serum sodium
pathological water and electrolyte loss in excess of fluid intake
Insensible fluid loss includes what?
Loss through the skin and lungs
Sensible fluid loss includes what?
Loss through urine, diarrhea, vomit, and sweat.
Define maintenance fluid.
fluid required to replace normal losses
Define replacement fluid.
fluid required to replace the nature of losses
3-5% loss is defined as what and presents how?
Mild dehydration. Pulse normal or increased, increased thirst, decreased urine output, some loss of weight, normal physical exam
How does Moderate dehydration (7-10%) present?
tachycardia, little or no urine output, irritable or lethargic, sunken eyes, depressed anterior fontanelle, decreased tears, dry mucous membranes, mild loss of skin turgor, delayed capillary filling, and pale/cool skin
Rapid and weak pulse, decreased blood pressure, no urine output, very sunken eyes, markedly sunken anterior fontanelle, absence of tears, parched and dry mucous membranes, marked loss of skin turgor, very delayed cap filling, and cold mottled skin describes what?
Severe dehydration (10-15%)
What does breast milk provide?
Bacterial and viral antibodies including IgA that presents bacterial adherence to GI mucosa and macrophages that secrete complement, lysozymes, and lactoferrin.
When does vitamin supplementation begin?
At 6 months with vitamin D, iron (1mg/kg/day, up to 15), and fluoride.
Contraindications for breast feeding include what?
CMV, HIV, septicemia, TB, malaria, typhoid fever, breast cancer, or substance abuse.
If you are allergic to cows milk protein, you are most likely also allergic to?
Formula contains what 3 things?
Protein source, fat source, and carbohydrate source.
Children's caloric requirements
Infants 150-200 cal/kg/day
>1 year 60-100 cal/kg/day
Older 1000 cal + age x 100 cal
Inadequate caloric intake
Emaciation, abdomen distended or flat, muscle atrophy, hypotonia, edema, & hypothermia
Inadequate protein intake with normal caloric intake.
Lethargy, hyperactivity, distended abdomen, edema, diarrhea, rash, decreased hair color, anemia, and secondary immunodeficiency.
Failure of mineralization of growing bones due to deficiency of vitamin D due to lack of sun, darker skin, and genetic/hepatic/renal abnormalities.
Craniotabes, costochondral junction enalrgement, and kyphoscoliosis.
Define obesity and it's greatest correlating factor.
BMI >95 percentile for gender/age
TV in kid's bedroom
What would you test for when evaluating jaundice?
Coombs, Hemoglobin, and Reticulocyte
What are the hematologic centers in neonates?
Connective tissue, then liver and spleen, and finally bone marrow.
Why does maternal febrile illness lead to fetal brain damage?
An illness like the flu leading to fever causes an increase in cytokines that can cross the placenta and cause lekomalacia.
At what week is the neural tube developed and what maternal factor increases risk?
What would you suspect with PROM?
>12 hours suspect infection and if >24 hours kid is septic till proven otherwise
Why is precipitous delivery dangerous?
meninges can tear because of quick expansion of sutures
The APGAR score is based on what and when is it performed?
appearance, pulse, grimace, activity, and respirations
at 1 minute and at 5
Why do we ween a large for gestational age off glucose?
To prevent seizures
What is a common auscultatory finding in the first 24 hours?
How many vessels are in the umbilical cord?
3 (2 arteries and 1 vein)
Imperforate rectum may indicate what?
Neural tube defects
When would you do a sepsis work up?
<1 month >101 degrees
<2 months >102 degrees
What bilirubin is usually increased?
What has the same symptoms as sepsis?
direct hyperbilirubinemia, tachypnea, grunting, flaring, cyanosis, and apnea
What differentiates between sepsis and meningitis?
T or F: Transplacental bacterial infections are common.
False, rare except for syphilis
What is the number 1 organism to cause sepsis?
Group B Strep
What does the sepsis work up inlcude?
Blood, urine and CSF cultures, immunoassay for bacterial antigens, CBC, ESR, and CRP. Administer antibiotics.
What percent of sepsis cases may develop neurological handicaps?
Which Group B strep serotype has a late onset of infection and how does it present?
serotype III, pneumonia at 2-10 weeks of life
What disease or progressive atelectasis forms a hyaline membrane in the alveolar ducts?
When does RDS most often occur and what are the symptoms?
In infants <36 weeks gestation due to insufficient surfactant
retractions, grunting, decreased breath sounds bilaterally, ground glass on CXR
How does the etiology differ in RDS verse Transient Tachypnea?
RDS is a lack of surfactant where TT is a delay in lymphatic absorption of lung fluid
Meconium aspiration occurs due to...
intrauterine stress and fetal hypoxia
TT is most common in what babies?
C-section, LGA, and IDM
RDS and Pneumonia present similarly but have the same treatment. What work up would you do for both?
Sepsis work up
What is the 3rd leading cause of birth defects associated with mental retardation?
Fetal alcohol syndrome
What are some associated findings with fetal alcohol syndrome?
CVS/VSD, cyanotic defects, renal malformations, neural tube defects, hydrocephalus, abnormal vertebral segmentation, or joint mobility abnormalities.
What would you suspect if a newborn presents lethargic, poorly responsive, hypertonic, has tremulous and disorganized feedings, not sleeping well, and has an abnormal EKG?
What if you had a more severe case where the newborn developed irritability, jitteriness, tremors, seizures, was poorly feeding, vomiting, diarrhea, a high pitched cry and tachypnea within 24-48 hours of delivery?
When do barbiturate withdrawals begin?
Rare to have symptoms but at 7 days due to the slow metabolism of their liver
To diagnose SIDS, what needs to be performed?
When is SIDS most common?
2-6 months of age
What has decreased SIDS cases by 50%?
Back to sleep campaign
What is the basic foundation underlying abuse?
Parental inability to maintain a developmentally appropriate and enriching environment
Who is more abusive, mom or dad?
But who tends to do more damage?
What is the average age of death due to abuse?
< 3 yo
What is the statistics for kids <1 yo with fractures?
50% are abused
What is the result of calling your kid stupid?
Emotional Abuse= low self esteem and a sense of incompetence for lifetime
What is the result of not loving your kid?
Emotional Neglect= convinces the child no one cares for him, that he is unlovable, bad, and worthless
What is physical neglect and in what population is it most seen in?
The inability or unwillingness to provide adequate food, shelter, clothing, and hygiene, most often seen in indigent populations.
What validates consideration of abuse or neglect?
If a child's appearance is leading to denigration by other children
What are the 4 rules of discipline?
1. infants should never be struck/shaken
2. inanimate objects or closed fist should never be used
3. slapping limited to extremities
4. slapping never severe enough to injure the skin
How long does a full thickness burn occur in 150' F?
What would you suspect if the parent is complaining of respiratory distress in their baby and you find retinal hemorrhages, bradycardia, and a bulging anterior fontanelle?
Shaken Baby Syndrome
Child may also be lethargic, hypothermic, seizing, or in a coma.
What is the most common form of sexual abuse?
What is sexual abuse until proven otherwise?
venereal disease before the age of 15
The body temperature is regulated by what part of the brain?
What are the 4 reasons for heat loss?
Endogenous pyrogens that reset the body's temperature include?
cytokines, interleukins (1 and 6), tumor necrosis factor, and inteferon
What is considered a fever in children?
>100.4 F or 38 C
When do proteins begin to denature?
How do you treat a fever?
tylenol, cover, avoid shivering, increase fluid intake, and warm bath
Who is at risk for harmful effects for fever?
kids with heart disease or anemia, chronic lung disease, and metabolic disorders
When do febrile seizures occur?
Between 6 mo and 5 years but rare after 3 yo
What are 3 danger signs of febrile seizures?
Focal seizure, apnea with cyanosis, or prolonged (>20min)
Define fever of unknown origin.
10 days of unremitting fever >38 C w/o a focus OR a fever at least 2x/wk for 21 days or longer with normal history and exam
Most common infection causing FUO
EB virus in < 3 yo
Screen for what in the case of FUO?
What would you include in your history for FUO?
Animal contact, pica, travel, meds, & fam Hx.
What labs would you order for FUO?
CBC, ESR, CRP, LDH, uric acid, UA, LP
(no ANA in kids <12 yo)
cultures (blood, urine, CSF), PPD, Xrays, and bact/viral serology
An APGAR score of a depressed baby would be what #?
less than or equal to 6, send to NICU
Jaundice is considered at a bilirubin of what?
Which disease in neonates presents with a ground glass appearance on CXR?