who is genreally the historian for children
parents
what are considered in addition to usual medical history
details of pregnancy/birth history
developmental history
immunization history
growth chart
what should you know about each of the common outpatient conditions
epidemiology (who gets it: age group, risk factors)
clinical features (key history physical)
diagnostic (labs and imaging)
managment (meds, interventions, natural history)
are fevers common in kids
yep
what in addition to a fever must be considered
appearance of child, age, and underlying medical conditions
what does fever do to heart and respiratory rate and vasoconstriction
increases them all
does fever cause brain damage
no
does heigh of fever predict severity of illness
no
should you treat the child or fever
child
what are the standard options in treating fever
acetaminophen or ibuprofen
are tepid baths recommended for fever
no
is aspirin recommended for fever
no
how many kids have febrile seiqures
2-4% in children under 5 years
what age group most often get febrile seizures
12-18 months
what is usually associated with febrile seizures
family history
what is the etiology like in febrile seizreus
certain interleukens be proconvulsant in susceptible patients
are febrile seizures a big deal
no, usually benign
what are the conditions in which febrile seizures usually have an excellent prognosis
generally tonic/clonic, non focal, last less than 15 minutes
no evidence of IC infection or neurologic signs
clear history of fever before seizure; more often at beginning of illness often at awakening or going to sleep
neurologcally and developmentally normal before and after the seizure
how many upper respiratory infections do kids have a year
6-7 epidosdes
what is the most common human illness
"cold"
what age group is URI most common in
infants and school age children
how many URIs are caused by rhinovirus
over half
besides rhinovirus what cuases colds
RSV
adenovirus
parainfluenze virus
influenza
what are the clinical manifestations of URIs
low grade fever (2-3 days) with sore throat, rhinorrhea, cough
how long do URIs last
7-14 days
are antibiotics indicated for URIs
no
what are recommended for URIs
humidifiers, nasal saline, adequate hydration
what are medications for symptom management in older children only given if
benefits outweigh side effects (minimal evidence for using antihistamines, cough suppressants, decongestants, or expectorants)
are OTC cold meds recoemmended for chilcren over 6
no
what % of kids have acute otitis media
70% by age 5
how many kids who have an acute otitis media will have more than 6 episodes
1/3
is AOM more common in males or females
males
is there a familial predisposition to AOM
yes
what increases risk of AOM
bottle feeding and daycare attendance
when does incidence for AOM increase
when the kid is under one year old
what is often concurrent or preceding with AOM
viral URI
what is AOM
acute otitis media is a bacterial infection of middle ear fluid
what is OME
otitis media with effusion (fluid pressent but not infected)
how can cultures for AOM be obtained
tympanocentesis
how many cultures of AOM are positive for bacteria
2/3
how many cultres of AOM are viral or sterile
1/3
is a canal drainage culture reliable or useful
unreliable but useful for chronic otorrhea
what accounts for 1/3 of AOM
strep pneumo
what accounts for 1/4 of AOM
haemophius influenza
are most H. flu AOMs typable
no
what accounts for 15% of AOM
moraxella catarrhalis
what are some low commonality AOM causes
staph aureus, miscellaneous strep
will young kids with AOM be able to localize the pain
young children will not localize pain well
what are the clincal presentation possibilities of AOM
irritiability
fever
not sleeping
pulling at ear or complaints of ear pain
vomiting and/or diarrhea
dizziness/balance problems
how would you diagnose AOM by otoscopy
bulging
dull/cloudy
ruptured
bullous
air fluid level
red
mobility
what is the most reliable AOM finding in otoscopy
bulging
what is a dull/cloudy TM mean
lack of light reflex
in a ruptured TM in AOM what does the canal often look like
purulent fluid, cant visualize perforation
what would a bullous TM have on it
blisters/bullae
what is the least reliable finding of AOM by otoscopy
red (injection from crying/staining/fever is common)
when wouuld a pneumatic otoscope be useful for AOM
espeiclly if ear "just red"
what is the most commmon diagnosis for antibiotic use in pediatrics
AOM
what does treatment reduce in terms of symptom duration of AOM
1 day of symptoms
how many AOMs resolve spontaneously
50%
what types of things are placed for recalcitrant cases
ventilation tubes
what is happening among AOM pathogens
increasing resistance
what types of AOM antibiotic options are there
amoxicillin
cephalosporin oral (cefinir, cefuroxime)
amoxicllin and clavulanate OR
ceftriaxone IM
if the child has had amoxil recently or you suspect h. flu what should you give
give 2nd/3rd generation cephalosporin (oral) like cefdinir or cefuroxime OR
how is ceftriaxone IM given
single dose and repeat in 48 hours if needed
what is an alternative to antibiotics for AOM
observation
what age group is observation appropriate for AOMs
over 2 yeras old, not ill appearing, unilateral disease and not prone to recurrent or frequent AOM
what would you encourage to someone who you wanted to observe with AOM
topical analgesic and oral NSAID
safey net prescritpion for antibiotics to increase parental comfort
what does acute bacterial sinusitis follo
5-15% of viral URIs in kids
what causes 30-43% of acute bacterial sinusitis
s. pneumo
what causes 20-28% of acute bacterial sinusitis
h. influ and moraxella
what causes 5-7% of acute bacterial sinusitis in kids
s. pyogenes and anaerobes
are there common complications in acute bacterial sinusitis
rarely
what will be considered in the acute bacterial sinusitis differential
nasal foreign body and allergic rhinitis
is there a definitive test based on acute bacterial sinusitis
no
what is usually how acute bacterial sinusitis works
initial improvement of URI symptoms then worsening of symptoms and high fever
persistant or prolonged URI symptoms (10 days), night cough, purulent nasal discharge, bad breath, variable facial pain/headache
severe symptosm over 3 days (high fever and purulent discharge)
how many acute bacterial sinusitises resolve spontaneously
505 at least
are antibiotics conclusively beneficial in acute bacterial sinusitis
no
what is the first line offense of acute bacterial sinusitis
amozil
what are some second options for acute bacterial sinusitis
amoxacillin/clavunate
2nd/3rd generation cephalosporins, clindamycin, macrolides, TMP/SMX
how long do you treat acute bacterial sinusitis
10-14 days or until no symptoms ofr 7 days
what is the most commmon cause of exudative pharyngitis in childhood
strep
is strep common in children under 3
no
what is strep pharyngitis a risk factor for
immune mediate rheumatic fever and post strep glomerulonerphitis
is s. pharyngtitis a clinical call
no, lab call
what is the test used for strep test
rapid strep (RS) antigen, tested in 5 minutes in office
what is specificity of RS being positive
95%
what is sensitivity of RS antigen
below 90%
how do you confirom RS
throat culture
what are the symptoms of s. pharyngitis
sudden onselt sore throat
swollen LNs
pain on swallowing
fever
headache
abdominal pain
nausea and vomiting
no URI symptoms
what are the signs of s. pharyngitis
tonsillopharyngeal erythema
tonsillopharyngeal exudate
soft palate petechiae
beefy red, swollen uvula
anterior cerivcal adenitis
scarlitiniform rash
left and right
left: soft palate petechiae
right: tonsillar exudates
what is this a picture of
scarlet fever
what is this a picture of
post scarlet fever desquamation
what is the use in treating s. pharyngitis
prevents rheumatic fever and PSGN
shortens duratin of symptoms by a day and prevents transmission
what is given in s. pharyngitis treatment
amoxicllin first line, BID better compliance than penicllin QID
what is given in s. pharyngitis if someone has penicillin allergies
azithromycin
what is given if recent antibiotic failure for strep
cephalosporins or clindamycin
what is acute gastritis most common and severe in
children under 5 (avg 2 episodes a year)
when (season) is AGE most common
winter
is AGE contagious
yes
where does AGE spread
crowded areas
what are the symptoms of AGE
vomintg 12-24 hours and diarrhea for 3-5 days
what is the most common etiology of AGE
rotavirus
adenovirus
norovirus
what are the lses frequent causes of AGE
enteric pathogens
c diff
parasites
what are the ocmplciatins of AGE
dehydration, hospitalization in less than on percent
how can AGE be prevented
rotavirus vaccine but initial product puled for increased intusseception risk
what is the clinical eval for AGE
estimate degree of dehydration and risk for less common pathologies
what should you record for AGE
vital signs
weight change
temperature
respirations (deep breathing=metabolic acidosi)
pulse (elevated=anxiety and fear)
BP (postural changes in older kids, overall BP is late indicator of hypovolemia in kids)
history of bloody stools, ill contacts, antibiotics, travel
what will AGE look like on physcial exam
lethary in general appearance
skin turgor: check abdominal wall above umbilicus
capillary refill time (1.5-2 second normal)
dry mucus membranes, loss of tears, sunken eyes, sunken fontanelle
urine output and oral intake history
do you need diagnostics in AGE
no not usually unless looks ill
what will dehydration labs look like
BUN/creatinine elevated
sodium high or low
potassium low (lost in stool)
bicarbonate low (lost in stool)
urine specific gravity high (concentrated to preserve water)
stool studies rarely needed
is AGE self-limited
yes with supportive care
what is treatment if no or mild dehydration
small amounts of fluids frequently to prevent dehydration: increase volume as tolerate
pedialyte is good choice but probably doesnt matter what they drinnk
resume normal diet as soon as possible with exception of lactose and high sugar/fructose drinks (can worsen diarrhea)
avoid antidiarrheal agents
what do you use for moderate dehydration of AGE
oral rehydration solution with salt and no more than 3% sugar solutinons
pedialyte tast a problem, popsicle form better sometimes
should you give kids anti-emetics
no because of sedation and extra-pyramidal reactions
what is a beneficial kid anti emetic
zofran/odansetron (but expensive)
if moderate to severe dehydration fails oral hydration, what should be the next course
hospitalization for IV fluids
what is pyelonephritis
kidney infection (upper UTI)
what is cystitis
bladder infection (lower UTI)
what do you have to watch for in UTIs
increased potential for renal damage in infants and young children
why is UTI more difficult to diagnose in young children/infants
nonspecific symptoms or asymptomatic
what is the usually only symptom of UTI
unexplained fever
what kids have a higher risk of UTI
uncircumcised males and females
do clinical UTI manifestations vary with age
yes
what do newborns show in UTIs
sepsis, jaundice, diarrhea, vomiting, FTT (failure to thrive)
what do infants show in UTIs
fever, ab pain, FTT, irritability
what do older children show in UTI
similar to adults (urgency, frequency, dysuria), ab pain, incontinence
does the physcial exam show much in UTI
fever
flank mass (hydronephrotic kidney with urine flow obstructed)
costovertebral angle tenderness (kidney pain)
what are the diagnostics of UTI
urinarlysis/urine culture
what are the screening tests for urinalysis
leukocyte esterase and nitrate are indicatros
is bag urine good for culture
no it is contaminated with skin flora
what is a main diagnostic for UTI suspicion
urinalysis/urine culture
what are bag specimens for infants and toddlers used for and what indicates UTIs
screening test for urinalysis
leukocyte esterase and nitrate are the most useful indicators of UTI
do you use bag urine from infants/toddlers for culture
no (skin flora)
if a toddler is toilet trained how do you get a urine culture
midstream catch
what would indicate a UTI in a clean catch
more than 100,000 colonies/mL of a single bacterial pathogen
how would you get a urine culture from a kid who is under two years old or not toilet trained
bladder catherization (more than 100 colonies/mL is UTI)
bladder aspiration (rare, any growth suggests UTI)
how many of utis are E. coli
80%
how are UTIs treated normally
2nd or 3rd generation cephalosporins
address hygeiene (antibact soap, bubble bath, bowel habits)
if male and recurrent UTIs what should you think about
underlying anatomic issues like obstruction and reflux
if you have reflux causing UTIs what might be in order
preventive meds long term or surgery (controversial)
what is constiipation
hard, large, or infrequent stools
how does constipation present
abdominal pain
is frequency of stooling variant in kids
yes, maybe after every feeding, usually daily BM by 4 years
is infant dyschezia constipation
no
what should you do to diet if the infant passes hard, painful stool
higher fiber diet
what should you do if child has fear/anxiety related to defecation
toilet train
what must be done to rule out serious underlying disorder instead of constipation
abdominal exam
neurological exam
rectal exam
what are some reasons that child can be constipated
structural disorders of rectum, colon
metabolic disorders like thyroid disase, lead poisoning, hypokalemia, CF
is the typical american diet high fiber
low fiber
what are some constipation treatments
high fiber
fiber supplement
osmotic laxatives
enemas
behavioral changes
what is roseola cause by
HHV6
how many roseola cases are in kids younger than 2
90%
what is roseola characterized by
high fever 3-5 days then sudden appearance of transient blanching papular rash on trunk
is there a roseola seasonal pattern
no
is roseola self limiting
yes
what is this rash
roseola
what causes erythema infectiosum
parvovirus B19
what are the prodromal symptoms of EI
fever
coryza
headache
nausea
diarrhea
what happens 2-5 days after EI nonspecific symptoms start
classic erythematous malar rash (slapped cheek rash)
facial rash followed by reticulated or lacelike rash on trunk and extremities
is EI slef limiting
yes in healthy person
who is EI dangerous in
pregnancy of 1st or 2nd trimester
whats this kid have
EI
what causes herpangina and hand foot mouth disease
coxsackie virus
is herpangina contagious
yes, direct contact with secretions
where do people get ulcers in HFM
soft palate
hands
feet
buttocks
when is herpangia not herpangina anymore
when it is not limited to mmouth
who is most affected by herpangina/HFM
kids ages 3-10
is herpangina/HFM self limiting
yes
what is this typical of
herpangina
what is this typical of
HFM
what type of virus is mulloscum
pox virus
how is molluscum spread
direct contact and fomites, autoinoculation from scratching, sexually transmitted
where can mulloscum be present
anywhere except palms/soles
is molluscum self-limiting
yes but can take months/years to resolve
what helps to destroy molluscum lesions
cryotheraphy
currette
chemical blistering agents
what is the most common cause of intestinal obstruction in infants between 6 and 36 months of age
intussesception
how many people who get intuss are younger than 2
80-90%
what is incidence of intuss
30 per 100000 live births
what is the cause of most intussecption
idiopathic
miniority due to structural variation
where are intuss most seen anatomically
near ileocecal junction
what is the mechanics of the msot seen intuss
proximal segment of bowel telescopes into distal segment taking mesentery with it
what is the "lead ponit" associated with
lymph node enlargement dragged by peristalsis into distal segment of instesting in intuss
how does the proximal segment get dragged into the distal one
venous and lymphatc congestion leads to intestinal edema trapping the distal segment
what does intuss lead to if left untreated
obstruction
ischemia
performatioon
peritointis
how does intuss present
sudden onset of intermittent, severe, progressive ab pain
inconsolable crying and drawing up of legs toward abdomen at 15-20 minute intervales
vomiting and bloody currant jelly stools, lethergy
sausage shaped mass in right side of abdomen
what will stools look like in intuss
currant jelly
where will there be a mass in intuss and what will it look like
sausage shaped right side of abdomen
how would you diagnose intuss
US: target sign
enema under fluoroscopy: filling defect
what is the non operative treatment of intuss
hydrostatic or pneumatic pressure by enema
when would you operate with intuss
if long duration of symptoms and/or suspected bowel perforation
how do pyloric stenoses come along
hypertrophy of pylorus with elongation and thickening, eventually progressing to the near complete obsrcution of gastric outlet
how common is pyloric stenosis
2-3.5 in 1000 live births
when do symptoms of pyloric stenosis begin
3-5 weeks of age, rarely after 12 weeks
what is the predisposition of pylori stenosis patients
"hungry vomiter"
describe the "hungry vomiter"
postprandial, non bilious vomit, often projectil vomiting in infant that demands to be refed soon after
what is the mass felt in pyloric stenosis
olive like mass at lateral edge of rectua abdominus in RUQ of abdomen
what usually results from pyloric stenosis (physiologically)
hypochorelmic, metabolic alkhalosis resulting from loss of large amounts of gastric hydrochloric acid
how can pyloric stenosis be diagnosed when oliver or peristaltic waves cant be detected
when "oliver" and/or peristaltic waves cannot be detected, confirm by imaging
what types of imaging could help diagnose pyloric stenosis
upper GI contrast study: STRING SIGN
abdominal ultrasound: measure of pyloric dimensions
how do you treat pyloric stenosis
pyloromyotomy
what does a pyloromyotomy involve
longitudinal incision of hypertrophic pylorus with blunt dissection to level of submucosa
what usually needs to be treated first before surgery in pyloric stenosis
electrolytes and dehydration
what is NEC from
unknown etiology: ischemic necrosis of intestinal mucosa
how common is NEC
1-3 /1000 live births
how many of the NEC cases are in premature infants
90%
what is mortality and long term morbidiy in NEC in survivors of neonatal intensive care
5-10%
how many of the low birth weight infants get NEC
6-7%
what are the risk factors of NEC
prematurity
microbial bowel overgrowth
milk feeding (relative to IV)
impaired mucosal defense
circulatory instability of intestinal tract
meds that cause intestinal mucosal injury or enhance microbial overgrowth
what are the general/nonspecific signs of NEC
apnea and lethargy
change in feeding tolerance
what are some gastric signs of NEC
gastric retention
abdominal distension, discoloration
vomiting
what are some fecal signs of NEC
rectal bleeding
bilious drainign from feeding tubs
what are some more serious signs of NEC
hypotension and shock
how would you diagnose NEC
heme positive stools
abdominal X ray
what would show up in NEC abdominal xray
pneumatosis intestinalis (air in bowel wall)
dilated bowel loops
free intraperitoneal air
portal venous gas
what are the "easier" treatments ofr NEC
bowel rest
parenteral feedings
antibiotic therapy (ampicillin, gentamicin, metronidazole)
what indicates surgery in NEC
peritonitis
pneumoperitoneum
what are some complications of NEC
strictures
short bowel syndrome
impiared neurodevelopmental and growth outcomes
when does meconium ileus present
first 3 days of life with ab distention or without vomiting and failure to pass meconium
what causes meconium ileus
meconium pellets that cause intestinal obstrcution at level of terminal ileum
how many people who have CF have meconium ileus
10%
how many meconium ileus patients have CF
80-90%
how would you diagnose meconium ileus
image with water soluble contrast enema
find: small caliber colon (microcolon); meconium pellets in terminal ileum, ileum proximal to obstrcution is dilated
how do yo utreat meconium ileus
enema of hyperosmolar constrast breaks up the plug
REMEMBER TO TEST FOR CF
what type of defect is congenital agang megacolon
defect in craniocaudal migration of neuroblasts originating fro neural crest that occurs during the first 12 weeks of gestatino
how common is congenital agang megacolon
1/5000 live births
how does agang megacolon present
neonatl period as failure to pass meconium within 48 hours of birth: bilious emesis, abdominal distention, and delay in passage of first meconium
what will be obstructed in congenital aganglioinc megacolon
distal intestinal obstruction
what is the "sign" associated with congenital agang megacolon
squirt sign or blast sign: explosive expulsion of gas and stool after digital rectal examination
how would you diagnose agang megacolon
suction biopsy of rectal mucosa
abdominal radiograph
contrast enema
anorectal manometry
what types of children could you use anorectal manometry to diagnose agang megacolon
older
what would you find on congental agang megacolon with contrast enema
transition zone in rectosigmoid area, residual barium in colon over 24 hours
what would you fine with cong agang megacolon with abdominal radiograph
dilated proximal loops
what would you find in cong. agang megacolon with suction biopsy of rectal mucsa
no ganglion cells
how do you treat agang megacolon
resect affected segment
what is VUR
incompetent or inadequate closure of the UVJ, a short segment of the ureter within the bladder wall (intravesical ureter)
how is VUR usually prevented
fully compressing intravesical ureter and sealing it off with surrounding bladder muscles
what else is VUR a risk factor for
pyelonephritis
renal scarring
chronic damage
how many kids with UTIs ahve VUR
30-45%
when would you look for VUR
recrurrnt UTI or personal history of renal anomalies
what test would demonstrate reflux of urine from bladder to upper UT
voiding contrast cystourethrogram (VCUG)
how can spontaneous resolution of primary VUR occur
growth of intravesical ureter length
when are antibiotics used in VUR
high grade reflux
what could severe VUR cases require
surgical reimplantation
what is the most commmon renal malignancy in children
wilms tumor
what is the fourth most common childhood cancer
wilms tumor
how many cases of wilms tumor are there per million under 15 years old
8
how many wilms tumors are diagnosed before age 5
2/3
how many wilms tumor cases are diagnosed before age 10
95%
where does wilms tumor arise from
foci of persistent metanephric cells referred to as nephrogenic rests or nephroblastomatosis
how does wilms tumor present
asymptomatic abdominal meas/swelling
abdominal pain
hematuria
fever
HTN
how will wilms tumor be on physical exam
firm
nontender
smooth mass eccentrically located and rarely crosses midline
how would you diagnose wilms tumor
abdomnal injury: US and CT
how would you proceed once you found wilms tumor
biopsy and surgical staging (dont spill tumor, could lead to further spread)
what would you do treatment wise for wilms tumor
nephrectomy
chemo and radiation before or after surgery
what is the 5 year survival rate for wilms tumor
90%
what are the long term risks for wilms tumor
renal insufficieny and failure