Professional Documents
Culture Documents
Dengue Fever
Dengue NS-1 Ag Day 1 and Day 4 of the illness
Rickets
Disease of growing bone which occurs in children only before fusion of the epiphyses Due to unmineralized matrix at the growth Increase in the circumference of the growth plate and the metaphyses --> widening of the wrists & ankles General softening of the bones
Rickets
Craniotabes or softening of the cranial bones Widening of the costochondral junctions leads to rachitic rosary Harrison groove is a horizontal depression along the lower anterior chest due to pulling of the softened ribs by the diaphragm during inspiration
LLLI
3. In a freezer (-18- -20 C) for 6 months (ideal), up to 12 months (acceptable) . What type of container should be used? 1. Glass or hard-sided plastic containers with well-fitting tops 2. Containers not made with the controversial chemical bisphenol A (BPA) 3. Containers which have been washed in hot, soapy water, rinsed well, and air-dried
LLLI
4. Containers should not be filled to the top leave one inch of space to allow for expansion 5. Put only 2-4 ozs of milk in the container to reduce waste. 6. Disposable plastic bags are not recommended as it leads to greater risk of contamination.
Febrile Seizures
Most common seizure disorder in childhood Rare before 9 months and after 5 yrs old Peak age of onset: 14-18 months old Normal neurologic exam Normal EEG (+) family history
Comparison:
Simple: Lasts a few secs & rarely >15 mins. Initially generalized and tonic-clonic Followed by a brief period of post-ictal drowsiness Occurs only once in 24 hrs Complex: Duration is >15 mins. Repeated convulsions occur within 24 hrs Focal seizure activity
Status Epilepticus
One seizure lasting 30 mins or multiple seizures during 30 mins without regaining consciousness Usual cause: breakthrough seizures missed doses of anti-epileptic drug/s May be due to CNS infection
PPHN
Most common cause is meconium aspiration syndrome about 13% of all live births are complicated by meconium-stained fluid but only 5% who had this complication subsequently develop MAS Coarse streaking granular pattern in both lung fields Irregularly aerated lungs Flattened diaphragm, increased AP diameter
PPHN
2nd most common cause is idiopathic black-lung Significant remodeling of pulmonary vasculature with vascular wall thickening and smooth muscle hyperplasia Contributory factor: use of NSAIDs during 3rd trimester leading to constriction of the fetal ductus arteriosus in utero
SMR in Boys
SMR Stage PUBIC HAIR 1 None 2 Scanty, long, slightly pigmented
PENIS Preadolescent
Slight enlargement
TESTES Preadolescent
Enlarged scrotum, pink, texture altered Larger
Darker, starts to curl, small amount Longer 4 Resembles adult type but less in quantity; coarse, curly Larger; glans and breadth increase in size 5 Adult distribution, spread to medial surface of thighs Adult size
SMR in Girls
SMR STAGE PUBIC HAIR BREASTS
1
2
Preadolescent
Sparse, lightly pigmented, straight, medial border of labia
Preadolescent
Breast and papilla elevated as small mound; areolar diameter increased
4 5
Social development
Expanding social world
Identification and reliance on peer groups 7 years attachment to parents decrease and to peers increase 9 years tightly knit groups are formed;
APGAR Score
What is the order of disappearance in a sick baby? Color Respiration Muscle tone Reflex Cardiac rate
APGAR Score
What is the order of appearance in a resuscitated baby? Cardiac rate Color Respiration Reflex Muscle tone
Newborn Care
Eye prophylaxis Erythromycin ointment 0.5% or tetracycline ointment 1% Vitamin K: 1 mg IM Vaccine: Hepatitis B and BCG
Congenital Hypothyroidism
Normal birth weight & length Delayed physical, mental & sexual development Sluggish, feeding difficulties, hypothermia Edema of scrotum / genitals Prolonged physiologic jaundice
Galactosemia
3 distinct enzyme deficiencies: 1. galactose-1-phosphate uridyltransferase deficiency (GALT) - classic form 2. Galactokinase deficiency (GALK) 3. Galactose-4-epimerase deficiency (GALE) Injury to parenychymal cells of the kidneys, liver & brain Feeding intolerance, vomiting, jaundice, convulsions, lethargy, hypotonia, mental retardation
G6PD deficiency
Episodic or chronic hemolytic anemia Episodic: symptoms develop 1-2 days after exposure to a substance with oxidant properties: sulfonamides, nalidixic acid, nitrofurantoin, chloramphenicol, antimalarials, vitamin K analogs, ASA, benzene, naphthalene
G6PD deficiency
Onset of hemolysis results in precipitous fall in Hgb & Hct Heinz bodies Reticulocytosis Jaundice, anemia, hemolysis, acute renal failure
Phenylketonuria
Deficiency of the enzyme phenylalanine hydroxylase causes accumulation of pheynylalanine in body fluids (hyperphenylalaninemia) Excess phenylalanine is transaminated to phenylpyruvic acid or decarboxylated to phenylethylamine & disrupts normal metabolism & cause brain damage
Phenylketonuria
Affected infant is normal at birth Most common manifestation without treatment is developmental delay MR develop gradually Infant: severe vomiting, hypertonic, hyperactive DTRs, seizures; older: hyperactive with purposeless movements, rhythmic rocking & athetosis unpleasant musty odor
Neonatal Jaundice
Physiologic
presents after the 48th hour of life TB increases not > 5 mg/dL/day TB peaks at 14-15 mg/dL DB < 10% of TB resolves in 1 week (term), 2 weeks (preterm)
Pathologic
presents in the 1st 24 hours of life TB increases by > 0.5 mg/dL/hr TB increases to > 15 mg/dL DB > 10% of TB persists beyond 1 week (term), 2 weeks (preterm)
Breast milk jaundice: If breastfeeding is continued, bilirubin gradually decreases but may persist for 3-10 weeks at lower levels. If discontinued, serum bilirubin level falls rapidly. Phototherapy may be of benefit.
IUGR
Symmetric - earlier onset & associated with diseases that seriously affect fetal cell number like chromosomal, genetic, malformation, teratogenic, infectious, or severe maternal hypertensive etiologies Asymmetric - late onset & associated with poor maternal nutrition or with late onset or exacerbation of maternal vascular disease
Post-term infants
Born after 42 wks of gestation regardless of birth weight Unknown cause Their appearance & behavior suggest those of an infant 1-3 wks of age Absence of lanugo & vernix caseosa, long nails, abundant scalp hair, desquamating skin & increased alertness CS may be indicated for older primigravidas who go more than 2-4 wks beyond term
seen in preterms incidence is inversely proportional to gestational age (60-80% in <28 wks of gestation) SSx: respiratory distress soon after birth CXR: ground-glass pattern, air bronchograms prevention: reach term, maternal steroids at least 48 hrs prior to delivery
RDS
Tx: supportive (most are self-limited), mechanical ventilation for severe RDS & persistent apnea (to improve oxygenation & elimination of CO2 without causing pulmonary barotrauma or 02 toxicity), exogenous surfactant complications: pneumothorax
IVH persistent PDA bronchopulmonary dysplasia (bubbly lungs or cystic lucencies, irregularly aerated lung)
ABO incompatibility
Most common cause of hemolytic disease of the newborn Occurs in 20-25% of pregnancies but hemolysis develops in only 10% of such offspring Mother is type O and baby is either A or B Most cases are mild; jaundice Mild hepatosplenomegaly Phototherapy
RH incompatibility
Rh antigenic determinants are genetically transmitted from each parent & direct the production of blood group factors (C, c, D, d, E, e). Each factor can elicit a specific antibody response where 90% are due to D antigen. Rarely occurs during the 1st pregnancy because transfusion of Rh+ fetal blood into an Rh- mother occurs near the time of delivery, too late for the mother to become sensitized & transmit antibody to her infant before delivery.
Mnemonics:
For infants < 6 months old: Wt in grams = age in months x 600 + birth weight For infants 6-12 months old: Wt in grams = age in months x 500 + birth weight For 1-6 years old: Wt in kilos = age in years x 2 + 8
Length / Height:
Birth to 3 months 4-6 months 7-9 months 10-12 months 9 cm 8 cm 5 cm 3 cm
Length / Height:
At 1 year
2 years
30 inches
1/2 of mature height
3 years
4 years 13 years
3 feet tall
40 inches or 2x the birth length 3x the birth length
Head circumference:
at birth = 14 inches (13.5-14.5) 33-35 cm
- routinely taken up to 3 years old - approximates adult head circumference at 6 years old - measured over the glabella and supraorbital ridges anteriorly and part of the occiput which gives the maximal circumference posteriorly
Chest circumference:
- measured at mid-respiration at the level of the xiphoid cartilage or substernal notch - measured in recumbent position for infants
More mnemonics:
1st part of infancy Chest circumference < Head circumference
- Middle part of infancy CC = HC - Latter part CC > HC Number of teeth = Age in months - 6
Growth characteristics:
First Year - 10% decrease in birth weight in the 1st week - Birth weight regained or exceeded by 2 weeks - Gain of 30 g/(1 oz) day in the 1st month - Gain of 20 g/day beginning the 3rd or 4th month - Eruption of 1st tooth - mandibular central incisors
Water requirements
Normal infants absolute water requirement is 75-100 ml/kg/24 hrs 0-6 mo: 700 ml/24 hrs 7-12 mo: 800 ml/24 hrs 1-3 yrs old: 1,300 ml/24 hrs 4-8 yrs old: 1,700 ml/24 hrs
Scurvy
Vitamin C deficiency early symptoms: lowgrade fever, irritability, tachypnea, anorexia, generalized tenderness esp. in the legs Pseudoparalysis with hips & knees semiflexed & the feet rotated outward scorbutic rosary at the costochondral junction & depression of the sternum Angulation of the scorbutic beads is sharper than the rachitic rosary
Scurvy
Bluish, purple spongy swellings of the mucous membranes esp. over the upper incisors Other symptoms: swollen joints, purpura and ecchymoses, poor wound & fracture healing, perifollicular hemorrhages X ray changes: distal ends of long bones with a ground-glass appearance Plasma ascorbate of <0.2 mg/dL is deficient
Larger doses (>2 grams) may produce abdominal pain and osmotic diarrhea
Contraindications to Breastfeeding
1. 2. 3. 4. 5. 6. 7. Infants with galactosemia Mothers with: Septicemia Active TB Breast cancer Malaria Typhoid fever Substance abuse Severe neurosis or psychosis
Breastfeeding
Acute maternal infection may contraindicate breastfeeding IF the infant does not have the same infection. When the infant is unaffected, the breast may be emptied and the milk be given by cup or bottle. Mastitis usually can be alleviated by continued and frequent nursing on the affected breast to keep it from becoming engorged (warm compress).
Breastfeeding
Transmission of HIV by breastfeeding is well documented. If safe alternatives are available, breastfeeding by HIV-infected mothers is not recommended. In many developing countries, breastfeeding may be crucial for infant survival. WHO recommends that breastfeeding be continued unless safe infant formula is readily available.
Breastfeeding
CMV, rubella virus, hepatitis B virus, human T-cell lymphotropic virus type 1, & herpes simplex virus have been demonstrated in breast milk. Evidence of breast milk transmission of other viruses is rare. Although hep B virus has been isolated from breast milk, the predominant means of mother-infant transmission appears to be through delivery.
Leukemias
Most common malignant neoplasm in childhood (41% of all malignancies that occur in <15 years old) ALL (77%) AML (11%) CML (2-3%) - Philadelphia chromosomal translocation JCML (1-2%)
Leukemias
Group of malignant diseases in which genetic abnormalities in a hematopoietic cell give rise to an unregulated clonal proliferation of cells Increased rate of proliferation & decreased rate of spontaneous apoptosis Result: disruption of normal marrow function
ALL
SSx: (acute onset < 4 wks duration of Sx) non-specific (anorexia, irritability, lethargy)
signs of marrow failure (anemia, bleeding, purpuric/petechial lesions, low-grade fever) signs of infiltration (bone pain, lymphadenopathy,
splenomegaly > hepatomegaly)
ALL
Dx: bone marrow aspiration
anemia, thrombocytopenia (75%), lymphoblasts in the PBS & bone marrow, median WBC count is 33,000 CXR may show a mediastinal mass CSF may contain lymphoblasts (10-20%)
Diagnosis
ALL is diagnosed by a bone marrow evaluation that shows >25% of the BM cells as a homogenous population of lymphoblasts Differential dx: infectious mononucleosis (acute onset of fever and lymphadenopathy) and JRA (fever and joint swelling)
1. 2. 3.
ALL
no anatomic staging system because usually disseminated at the time of Dx Tx:
remission induction (vincristine, prednisone, Lasparaginase x 4 wks + CNS prophylactic irradiation or chemotherapy) to eradicate leukemic cells from BM consolidation phase: 14-28 wks to prevent later CNS relapse maintenance phase x 2-3 years (Mercaptopurine daily and Methotrexate weekly)
Treatment
Remission defined as <5% blasts in the BM and a return of neutrophil and platelet count to near-normal levels after 4-5 wks of tx RELAPSE occurs in the BM in 15-20% of patients with ALL -- BAD! esp. if it occurs during or shortly after the tx Options: intensive tx with agents not previously used followed by allogenic stem cell transplantation results in long-term survival rate for a few patients
ALL
sites of relapse: bone marrow, CNS (increased ICP and isolated cranial nerve palsies), testes (painless swelling of one or both testes in 1-2% of males) poor prognostic factors:
< 2 yrs or > 10 yrs male WBC > 100,000 u/L on presentation presence of CNS leukemia presence of a mediastinal mass
Comparison:
Osteosarcoma: 2nd decade; M>F All races Spindle-cell producing osteoid Metaphysis of long bones Local pain & swelling, often history of injury Sunburst pattern Spreads to lungs, bones Chemotx and ablative surgery of primary tumor Ewing tumor: 2nd decade: M>F Primarily whites Undifferentiated small round cell of neural origin Diaphysis of long bones Local pain & swelling with fever Onion-skinning Spreads to lungs, bones Chemotx, radiation and/or surgery of primary tumor
Type
Description
Cause
Obstructive or Obstruction Abnormality of the noncommuni- within the ventri- aqueduct or a lesion in cating cular sytem the 4th ventricle (aqueductal stenosis) Nonobstruc- Obliteration of Follows a tive or the subarachsubarachnoid hemorrcommunica- noid cisterns hage ting Malfunction of the arachnoid villi Leukemic infiltrates
Febrile Seizure
Most common seizure disorder in childhood Rare before 9 months and after 5 yrs old Peak age of onset: 14-18 months old Normal neurologic exam Normal EEG (+) family history
Comparison:
Simple: Lasts a few secs & rarely >15 mins. Initially generalized and tonic-clonic Followed by a brief period of post-ictal drowsiness Occurs only once in 24 hrs
Complex: Duration is >15 mins. Repeated convulsions occur within 24 hrs Focal seizure activity
PEDIATRIC PULMONOLOGY
Bronchial Asthma
a reversible obstructive airway disease involving both the small & large airways
increased residual lung volumes decreased FEV1/FVC ratio
Bronchial Asthma
SSx: family Hx of asthma or atopy, recurrent cough & wheezing with exposure to certain triggers (viral infection, weather changes, exercise, allergens, emotions), responds to Tx with bronchodilators CXR: hyperinflation; helps to exclude structural abnormalities of the airway or chronic infection
Bronchial Asthma
Pulmonary function tests: increased residual lung volumes, decreased FEV1/FVC ratio Not routinely done esp. for <5 yrs old due to inability of these children to perform reproducible expiratory maneuvers
Exacerbation of asthma:
Acute or subacute deterioration in symptom control that is sufficient to cause distress or risk to health Any of the following: Increase in wheeze or shortness of breath Increase in coughing, esp. at night Lethargy or reduced exercise tolerance Impairment of daily activities Poor response to reliever medication
Management:
Management of acute attacks:
short-acting inhaled beta2-agonist oral or IV steroids (Prednisolone) anticholinergics (ipratropium bromide) never used alone methylxanthines (theophylline, aminophylline) - NOT first line
Uncontrolled (3 or more
of features of partly controlled asthma in any week)
More than 2x/wk (last minutes or hours or recur) Any (may cough, wheeze during exercise, vigorous play, or laughing)
Limitation of activities
Uncontrolled (3 or more
of features of partly controlled asthma in any week)
Any (typically coughs during sleep or wakes with cough, wheezing, and/or dyspnea) > 2 days/week
Any (typically coughs during sleep or wakes with cough, wheezing, and/or dyspnea)
2 days/week
> 2 days/week
Mild
No
Severe
Agitated, confused, or drowsy Less than 90%
words
Mild
< 100 bpm
Severe
>200 bpm (0-3 yrs) >180 bpm (4-5 yrs) Likely to be present
Central cyanosis
absent
Wheeze intensity
variable
May be quiet
Pulmonary Tuberculosis
Mycobacterium tuberculosis Most specific confirmation is isolation of the organism! Sputum specimens for culture for those who can expectorate Induce sputum with a jet nebulizer & chest percussion followed by nasopharyngeal suctioning: for culture and smear staining
PTB
Gastric aspirates: cultured Young children: early AM gastric acid obtained before the child has arisen & peristalsis has emptied the stomach of the pooled secretions 3 consecutive AM gastric aspirates yield the organism in <50% of cases
Pulmonary Tuberculosis
1. 2. 3. 4. Primary complex (Ghon complex): Primary pulmonary focus Regional lymph nodes Peritracheal lymph nodes Localized pleurisy between the middle & lower lobes
Classification:
Class I: TB exposure: (+) exposure to and adult/adolescent with active disease, (-) PPD, no signs/symptoms, negative chest x ray findings
Class II: TB infection: +/- exposure, (+) PPD, no signs/symptoms, negative chest x ray findings
Classification:
1. 2. 3. 4. 5.
Class III: TB disease: 3 or more of the ff criteria: Exposure to an adult/adolescent with active TB disease (+)PPD Signs/symptoms suggestive of TB Abnormal chest x ray findings Laboratory findings
Classification:
1. 2. 3. 4. 5. 6. Class IV: TB inactive: w/ or w/o history of previous TB w/ or w/o previous chemotherapy has radiographic evidence of healed/calcified TB (+)PPD no signs & symptoms (-) smear or culture for TB
PPD interpretation:
Equal or >10 mm is (+)
Equal or >5 mm is (+) in the presence of any or all of the ff: 1. history of close contact with a known or suspected case of TB 2. clinical findings suggestive of TB 3. chest X ray findings suggestive of TB 4. immunocompromised condition
Management:
INH 10 mg/kg/day (6 months) Rif 15 mg/kg/day (6 months) PZA 25 mg/kg/day (2 months) Ethambutol 15-25 mg/kg/day (>6 y/o) Streptomycin 20-30 mg/kg/day