Pediatrics 2
Terms
undefined, object
copy deck
- Bronchiolitis
-
acute inflammatory illness of small airways
mostly affects <2y/o
RSV most common
RF for severe RSV
<6m old
prematurity
heart/lung dz
immunodeficiency - Bronchiolitis S/S
-
low grade T
rhinorrhea
cough
apnea (in young infants)
tachypnea
wheezing, crackles
prolonged expiration
hyperresonance to percussion - Bronchiolitis eval
-
CXR
- hyperinflation
- interstitial infiltrates
- atelectasis
ELISA of nasal washings (high sens/spec) - Bronchiolitis Rx
-
Mild
Outpt - fluids, nebulizers, O2
Admit if marked resp distress
O2<95%
toxic appearance
hx prematurity (<34wks)
age <3m
underlying cardiopulm dz
dehydration/poor oral feeding
Need contact isolation, hydration, O2
Ribavirin aerosol may shorten symptoms - RSV prophylaxis
- poly/monoclonal Ab in winter for high risk pts
- Croup (laryngotracheobronchitis)
-
Acute inflam disease of larynx especially subglottic space
3m-3y/o
PIV-1 (most common)
PIV-2,3
RSV
influenza
rubeola
adenovirus
M. pneumoniae - Croup S/S
-
typical prodrome URI symp followed by:
low grade T
mild dyspnea
insp stridor (88% present with stridor)
hoarseness
characteristic barking cough usually at night - Croup Dx, Rx
-
Dx - clinical
AP neck film - "steeple sign" (subglottic narrowing)
Rx
Mild
outpt - cool mist therapy and fluids
Moderate
+/- steroids
Severe
Admit
nebulized racemic epi - Epiglottitis
-
3-7y/o
serious and rapidly progressive infection of supraglottic structures (epiglottis, arytenoids)
Common causes
Strep species
non-typable H. flu
viral - epiglottitis S/S
-
sudden onset (4-12h) high fever (39-40°C)
dysphagia
drooling
muffled voice
insp retractions
cyanosis
soft stridor (8% present with stridor)
"sniffing dog" position (neck hyperextended and chin protruding)
"tripod" position (sitting, leaning fwd) - Epiglottits Dx
-
Dx - clinical
DO NOT examine throad unless anaesthesiologist present
Definitive Dx - direct fiberoptic visualization of cherry red, swollen epiglottitis and arytenoids
Lat C/S Xray - "thumbprint sign"
(swollen epiglottis obliterating valleculae) - Epiglottits Rx
-
Emergency!
call anaesthesia, transfer to OR
ETT or trach
IV abx - ceftriaxone or cefuroxime - Tracheitis
-
3m-2y/o
S. aureus
prodrome 3d (acute decompensation 10h)
intermediate grade T
variable resp distress
CXR - subglottic narrowing - Otitis Media
-
S.pneumo
H. flu
M. catarrhalis
children predisposed d/t shorter more horizontal eustachian tube
RF
viral URIs
Down's
CF
immunodeficiencies
smoke exposure
day-care
bottle feeding
cleft palate
prior OM - OM S/S
-
fever
ear tugging
hearing loss
irritability
crying/feeding difficulties
vomiting
O/E
erythema, opacity
TM bulging, ↓mobility
loss of light reflex and bony landmarks - OM Dx and Rx
-
Dx - clinical
erythema alone is insufficient
Rx
amoxicillin x 10d
if Rx failure after 3d - amox/clavulinic acid or ceftriaxone or cefuroxime - OM complications
-
mastoiditis
meiningitis
hearing loss
cholesteatoma
tympanosclerosis
chronic suppurative OM - Neonatal jaundice
-
↑serum bili >5mg/dL d/t ↑production/↓excretion
Conjugated/direct - ALWAYS pathologic
Unconjugated - path or phys - Kernicterus
-
Cx of unconjugated/indirect
D/t irreversible bili deposition in BG, pons, CB
occurs with >20mg/dL
can be fatal
RF
prematurity
asphyxia
sepsis - Neontal jaundice S/S
-
hx - breast or bottle?
- intrauterine drug exposure
FHx - hemoglobinopathies, enzyme deficiencies, RBC defects
Symp
abd distension
delayed passage meconium
light coloured stools
dark urine
low APGAR
wt loss
vomiting
Sign
cephalopedal progression - Kernicterus S/S
-
lethargy
poor feeding
high pitched cry
hypertonicity
seizures
cephalopedal progression of jaundice - neonatal jaundice conjugated vs unconjugated
-
Direct
extrahepatic cholestasis
- biliary atresia
- choledochal cysts
intraheptic cholestasis
- neonatal hepatitis
- inborn errors of metabolism
- TPN cholestasis
- ToRCHeS
Indirect
physiologic
hemolysis
breast milk jaundice
↑enterohepatic circulation (eg GI obstuction)
disorders of bili metabolism
sepsis - Neonatal jaundice eval
-
CBC with periph smear
blood type of mom and baby
Coomb's test
bili levels
Direct
LFTs
bile acids
blood cultures
sweat test
tests for aminoacidopathies and α1AT↓
septic w/u as indicated - Neonatal jaundice Rx
-
Rx underlying cause
unconjugated - phototherapy (mild↑) or exchange transfusion (severe)
start phototherapy earlier in preterm - Physiologic jaundice
-
physiologic
presents ≥72h after birth
bili ↑<5mg/dL/d
bili peaks at <14-15mg/dL
Direct bili <10% total
resolves by 1wk in term babies, 2wks in preterm - Pathologic jaundice
-
present in first 24h of life
bili ↑>0.5mg/dL/h (>6mg/dL/d)
bili ↑>15mg/dL
direct bili >10% total
persists beyond 1wk in term, 2wks in preterm - Erythema infectiosum
-
5th disease
Parvovirus B19
prodrome - none (fever Ø/↓gr)
Rash
"slapped cheeks" erythematous
pruritic
maculopapular
starts on arms → trunks, legs
worse with fever, sun exposure - Erythema infectiosum Cx
-
arthritis
hemolytic anemia
encephalopathy
congenital infection associated with fetal hydrops, death - Measles
-
paramyxovirus
Prodrome
- ↓gr T
- cough, coryza, conjunctivitis
Koplik spots
(small irregular red spots with central grey specks) on buccal mucosa afer 1-2d
Rash
erythematous
maculopapular
head→feet - Measles Cx
-
common
OM
pneumonia
laryngotracheitis
Rare
Subacute sclerosising panencephalitis - Rubella
-
rubella virus
prodrome
asymp or tender, generalized lymphadenopathy (post auricular and suboccipital)
Rash
erythematous, tender rose-pink maculopapular rash, slight fever
+/- polyarthritis in adolescents
eye pain on lateral and upwd eye mvts
conjunctivitis
sore throat
h/a - Rubella complications
-
encephalitis
TCP (rare Cx of post-natal infection)
congenital infection associated with congenital anomalies - Roseola infantum
-
HHV6
prodrome
acute onset ↑fever (>40°C)
no other symp for 3-4d
Rash
maculopapular rash appears as fever breaks
trunk → face & extremities
often <24h - Roseola infantum Cx
- febrile sz d/t rapid fever onset
- Varicella
-
VZV
prodrome
mild fever, malaise, & anorexia precede rash by 24h
Rash
generalized, pruritic "teardrop vesicular rash"
trunk → periphery
lesions at different stages
infectious from 24h before eruption until lesions crust over - Varicella Cx
-
progressive varicella with
meningoencephalitis and hepatitis in immunocompromised
Congenital infection associted with congenital anomalies - Congenital rubella
-
triad
sensorineural hearing loss (most common)
ocular abnormalities (cataracts, infantile glaucoma, pigmentary retinopathy)
congenital heart dz
(PDA, PA stenosis)
Also:
IUGR
blueberry muffin spots
hepatosplenomegaly, jaundice - Varicella Zoster Cx (reactivation Cx)
-
encephalopathy
aseptic meningitis
pneumonitis
TTP
Guillain-Barre
cellulitis
arthritis - Hand-foot-and-mouth disease
-
Coxsackie A
prodrome
fever, anorexia, oral pain
Rash
oral ulcers
maculopapular or vesicular on hands, feet +/- buttocks - Tracheoesophageal Fistula associations
-
Associated with:
esophageal atresia
VACTERL anomalies
Vertebral
Anal
Cardiac
Tracheal
Esophageal
Renal
Limb
Presentation - TEF presentation
-
polyhydramnios in utero
↑oral secretions
inability to feed
gagging
resp distress - TEF Dx and Rx
-
CXR after NGT identifies esophageal atresia
presence of air in GIT suggestive
Confirm Dx - bronchoscopy
Rx - Sx repair - Congenital Diaphragmatic Hernia
-
GIT segement protrudes thru diaphragm into thorax
90% posterior L
Presentation
resp distress (from pulm hypoplasia & PHTN)
sunken abdomen
bowel sounds over L hemithorax
Dx - U/S in utero
Confirm - CXR postnatal - Congenital Diaphragmatic hernia Rx
-
HF vent or ECMO to manage PHTN
Sx - Gastroschisis
-
Herniation of intestine thru abd wall next to umbilicus (R>L)with NO sac
Presentation
polyhydramnios in utero
prematurity
associated with GI stenosis/atresia
Rx - Sx emergency - Omphalocele
-
herniation of abd viscera thru abd wall at umbilicus into sac covered by peritoneum and amniotic memb
= - Omphalocele presentation and Rx
-
polyhydramnios in utero
prematurity
associated with other GI, cardiac defects
Rx
C/S to prevent sac rupture
if sac intact delay Sx until baby fully resuscitated
Keep sac covered/stable w petroleum jelly and gauze
intermittent NG suction to prevent abd distension - Duodenal atresia
- complete/partial failure of duodenal lumen to recanulize during GA 8-10wks
- Duodenal atesia presentation and Rx
-
polyhydramnios in utero
bilious emesis within hours of 1st feeding
associated with:
Down's
other cardiac/GI anomalies (annular pancreas, imperforate anus, malrotation)
Dx: "double-bubble" on AXR proximal to site of atresia
Rx - Sx repair - Meckel's diverticulum
-
vestigial remnant of omphalomesenteric duct
most common congenital GIT anomaly
"rule of 2's"
2x ♂:♀
2 feet from ileocecal valve (most common)
2 types of mucosa (gastric, pancreatic)
2% of people affected - Hirschsprung's disease
-
congenital aganglionic megacolon
absence of autonomic innervation of bowel wall; inadequate relaxation and peristalsis → obstruction - Meckel's diverticulum presentation and Dx
-
painless rectal bleeding (most common)
obstruction from intussusception/volvulus
painful diverticulitis (often misDx as appendicitis)
Dx - Meckel's scan (for ectopic mucosa - IV technetium pertechnetate - preferentially taken up by gastric mucosa) - Hirchsprung's disease presentation and Rx
-
abd distension
bilious emesis
failure to pass meconium in 1st 24h
Dx
barium enema - dilated prox segment, narrow distal seg
Rectal Bx - lack of ganglion cells confirms dx
Rx
colostomy prior to corrective Sx allows for pelvic growth and normalization of dilated bowel - hypospadias
-
abnormal urethral opening on ventral surface of penis d/t incomplete dvt of distal urethra
presentation
curved penis (chordee)
associate with herias, cryptorchidism
Rx
circumcision contraindicated
Sx repair with preputial tissue - RDS
-
most common cause resp failure in preterm (>70% of babies born 29-40wks GA)
surfactant deficiency → poor lung compliance & atelectasis - RDS risk factors
-
maternal DM
♂
second born of twins - RDS S/S
-
presents in 1st 48-72h
RR>60
progressive hypoxemia
cyanosis
nasal flaring
intercostal retractions
expiratory grunting - RDS DDx
-
TTN
meconium aspiration
congenital pneumonia
spontaneous pneumothorax
diaphragmatic hernia
cyanotic heart disease - RDS evaluation
-
ABG, CBC, blood cultures
CXR
b/l diffuse atelectasis causes "ground-glass" appearance, air bronchograms - TTN CXR findings
- retained amniotic fluid causes prominent perihilar streaking in interlobular fissures
- Meconium aspiration CXR findings
-
coarse, irregular infiltrates
hyperexpansion
PTXs - Congenital pneumonia CXR findings
-
nonspecific patchy infiltrates
neutropenia, tracheal aspirate, & gram stain suggest Dx - RDS Rx
-
CPAP/intubation
artificial surfactant (↓mortality)
PREVENTION
betamethasone to mom
monitor FLM - lecithin:sphyingomyelin and phosphotidylglycerol - Complications of RDS
-
persistent PDA
BPD
retinopathy of prematurity
IVH
necrotizing enterocolitis
==> Cx of Rx - Cerebral palsy
-
nonprogressive, nonhereditary disorders
most common mvt disorder in children
RF
prematurity
perinatal asphyxia
IUGR
early infection/trauma
brain malformation
neonatal ICH - Types of CP
-
Pyramidal (spastic)
spastic paresis of ≥1 limb
75% of cases
MR present in ≤90%
Extraparamidal (nonspastic)
result of damage to extrapyramidal tracts
subtypes:
Ataxic
choreoathetoid
dystonic (uncontrollable jerking, writhing, or posturing)
abnormal mvts ↑with stress, disappear during sleep - CP S/S
-
+/- associated with:
- seizure disorder
- behavioural disorder
- hearing/vision impairment
- learning disabilities
- speech deficits
- hyperreflexia
- ↑tone/contractures
- weakness/underdevelopment
- toe walking/scissor gait
- hip dislocations
- scoliosis - Rx of spasticity
-
diazepam
dantrolene
baclofen - febrile seizures
-
usually 6m-6yrs with no evidence of intracranial infection or other cause
RF
rapid ↑T
FHx - febrile seizures S/S
-
occur during onset of fever
may be 1st sign of underlying illness (OM, roseola)
Simple
<15min
generalized
1 in 24hrs
fever >39°C
fever onset within hrs of sz
Complex
>15min
focal sz
>1 in 24hrs
low grade fever/fever for several days before sz - Febile seizures Eval and Rx
-
find the source of infection
LP if signs CNS involvement
labs as indicated (none if obvious febrile sz)
Rx
antipyretics (not ASA)
Rx underlying illness
complex sz - thorough neuro eval
diazepam, phenobarb if needed
EEG, MRI controversial for complex febrile sz - Complications of febrile sz
-
recur in 30%
Ø ↑risk epilepsy or developmental, intellectual, growth abnormalities
pts with complex sz have 10% risk developing epilepsy - Top childhood cancers
-
1. leukemia (ALL)
2. CNS tumors
3. lymphoma
4. neuroblastoma - Neuroblastoma
-
embryonal tumor of neural crest cell origin
>50% are <2y/o
Associated with:
hircshprung's
NF
N-myc oncogene - Neuroblastoma S/S
-
lesions anywhere (abdomen, mediastium)
nontender abd mass
horner's
HTN
Spinal cord compression
anemia, FTT, fever
Site specific mets → proptosis & periorbital bruising (racoon eyes0
subcutaneous tumor nodules
bone pain with pancytopenia
opsoclonus/myoclonus ("dancing eyes/dancing feet") - DDx of neuroblastoma
-
Wilm's tumor
rhabdomyosarcoma
lymphoma
renal cell ca
PCKD - Neuroblastoma eval
-
abd CT
24h urine catecholamines for ↑VMA, HVA
Staging
CXR
bone scan
CBC, LFTs, BUN/Cr, coags - Neuroblastoma Rx
-
localized - cured with excision
Chemo
cyclophosphamide & doxorubicin
adjuvant XRT for mets
Px better in subtype in infants <1y/o - Wilm's tumor
-
renal tumor of embryonal origin
most common renal tumor in kids
2-4y/o
Associated with:
Beckwith-Wiedemann syndrome
NF
WAGR syndrome (esp aniridia, hemihypertrophy) - Beckwith-Wiedemann syndrome
-
hemihypertrophy
macroglossia
visceromegaly - WAGR syndrome
-
Wilms'
Aniridia
GU abnormalities
mental Retardation - Wilms' S/S
-
painless abdominal/flank mass (does NOT cross midline) -most common finding
hematuria (usually micro)
fever
HTN
N/V
bone pain
dysuria, polyuria
wt loss - Wilm's eval
-
abd CT, U/S → solid intrarenal mass
Ax for mets
CXR
chest CT
CBC, LFTs, BUN/Cr - Wilms' Rx
-
transabd nephrectomy
AND
post-Sx chemo - vincristine & dactinomycin
+/- flank XRT
Px - generally good