Pediatrics Exam 1 NYU

Infancy

1 - 12 months

(first year)

Toddlerhood

1 - 3 years

Preschool

3 - 6 years

School-Aged

6 - 12 years

Adolescence

13 - 21 years

Piaget (INFANT)

cognitive development

sensorimotor period

respond reflexively then form focused responses

OBJECT PERMANENCE

("P is for permanence")

Erikson (INFANT)

psychosocial development

sense of self and world

TRUST vs. MISTRUST

("never trust an Erik or his son")

Early Intervention

birth - 36 months (3 yrs)

if developmental delay is suspected

Temperments

flexible

feisty

fearful

Infant growth expectations

WEIGHT

- 6 mo = double birth weight

- 12 mo = triple birth weight

LENGTH

- 6 mo = 1 in/mo

- 12 mo = 1/2 in/mo

(until can stand then height)

+ HEAD CIRCUMFERENCE

Premie age calculation

subtract how many weeks early they were from their out-of-uterus age then assess them by the calculated age

4 mo old? 32 wk GA?

assess as 2 mo old

Nutrition

if breastfeeding add in foods at 6 mo

loss of extrusion reflex at 4 mo - solid foods

PURPLE Crying

peak of crying

unexpected

resists soothing

pain like face

long lasting

evening

3 - 5 mos

NORMAL

Attachment Styles

SECURE (social)

AMBIVALENT (torn)

AVOIDANT (antisocial)

Infant Sleep

on back, no pillows, not near AC, no toys (SIDs)

can sleep thru night at 4 mo

first home - eating every 3 hrs

2 mo milestones

- smiles

- coos

- notes faces

- responds to sounds

- brings hands to mouth

- hold head up and push when prone

- NOT YET tracking 180

- DO tummy time

4 mo milestones

- smiles

- plays

- copies faces

- babbling

- brings toys to mouth

- different cries for different needs

- communicates mood

- reaches for toys

- recognizes faces

- NO head lag

- YES roll tummy to back

6 mo milestones

- saying mm, da, bb

- stranger danger

- responds to emotions

- looks at self in mirror

- copies sounds

- responds to own name

- joyful noises

- looks around

- passes objects btwn hands

- YES sits without support

- YES stands with help

9 mo milestones

- height of stranger danger (until 3 yrs)

- favorite toy

- understands "no"

- first words

- points at things

- obey simple command

- YES hide n seek

- YES pulls to stand

12 mo milestones

- shy w strangers, cries

- hands book to hear story

- helps dress themselves

- TWO or more WORDS

- signs of walking by 15 mo

- pincer grasp (spoon at 9 mo) can feed self

- YES cruising/crawling

leading cause of death for children under age of 19

unintentional injury

motor vehicle accidents

drowning + choking (1 yr)

poison (2 yrs)

fires and burns (3 yrs)

Toddler (1 - 3 yrs)

- birth weight tripled in 1st yr

- stranger danger over by 3 usually

- physical growth slows

- 3-5 lb/yr and 3in/yr

- two word sentences

- eat less than infants

PARALLEL PLAY

Piaget (TODDLER)

preoperational thought (through pre-school)

EGOCENTRIC THINKING - can only see own view

MAGICAL THINKING - animism

("preoperationals can't perform surgery, they are too selfish and they believe in magic!")

Erikson (TODDLER)

autonomy vs. shame and doubt

potty training, dressing

("CAN DO, CAN'T DO")

18 mo milestones (1 1/2 yrs)

- hands things to others

- temper tantrums

- simple play pretend

- explores along near parent

- several single words

- says "no" shakes head

- can scribble

- points to a body part

- CAN WALK

24 mo milestones (2 yrs)

- independent, social

- defiant, copies

- 2-4 word sentences

- follows 2 step instructions

- sorts by shape, color

- builds 4+ blocks

- kicks ball, climbs, runs

Toddler health

- 1-2 naps / day

- small frequent meals

- ROUTINE

- assist with self-care

- don't rush their thoughts

- normal negativism

- positive reinforcement

- give limited choices

- SAFETY IS KEY

(lead poisoning test 12-14 mo)

Preschooler (3-6 yrs) + Erikson

- physical growth slowed, personality and language growth FAST

- 5lb/yr, 3 in/yr

INITIATIVE vs. GUILT

3 yr milestones

- takes turns in a game

- separates easily from caregiver

- dresses themselves

- 2 or 3 step instructions

- understands location words

- strangers can understand

- 2 or 3 word sentences

- CIRCLE

- 6 tower block

5 yr milestones

- aware of gender

- real vs. pretend

- friend oriented

- counts to 10

- draws a person

- draws shapes

- independently toilets

School Age (6-12) milestones + Erikson

- 6 lb/yr, 2in/yr

- girls puberty 10-12

- fewer UR sicknesses

INDUSTRY vs. INFERIORITY

(school = first job, first time in the hierarchy)

tie shoelaces, draw,

Sexual Maturation

Girls 12 - 18

Menarche 12, early as 8

Boys 14 - 20

boys mature later

TANNER STAGES

Teenagers (Erikson vs. Piaget)

ERIKSON - Identity vs. Role Confusion

SELF UNDERSTANDING

PIAGET - formal operational thought

WORLD UNDERSTANDING

1st wk review

object permanence = 7-8 mo

sleeps through night = 3-6 mo

stranger danger peaks = 6-12 mo

toilet training begins = 2-3 yr

ABDCE!

airway

breathing

circulation

disability

exposure

pediatric airway

- tongue is larger

- airway is narrower

(edema = 50% obstruction)

- infants obligate nose- breathers

- more susceptible to respiratory infections

pediatric breathing

- nasal flaring

- RR higher

- weaker chest muscles

- higher metabolic rate

- increased 02 demand

pediatric circulation

- cap refill <2 sec

- hydration = tenting

- blood loss more severe

pediatric disability

- pupillary reactivity

- LOC

(basic first assessment = alert, voice, pain, unresponsive)

full consciousness, confusion (difficulty following commands), delirium (disoriented x3, hallucinations), lethargy (severely drowsy), obtundation (slow response, sleepy), stupor (vigorous shaking to arouse), coma (unarousable)

THINNER SKULL, WEAK NECK MUSCLES, BIG HEAD TO BODY RATIO

pediatric exposure

remove clothing to see

pediatric hx (S.A.M.P.L.E.)

Signs and symptoms

Allergies

Medications

Prior Illness

Last Meal

Events around injury

general shock protocol

BP -, HR +

give fluids!

HYPOTENSION is a LATE SIGN in kids

kids more at risk for fluid loss/fluid overload

septic shock peds early/late

EARLY

(BP -, HR +, extremeties warm, RR+)

LATE

(HR+, cyanosis, cold skin, narrow pulse pressure, anuria, purple lesions)

peds normal vitals

HR = 65-110

RR = younger is higher

(toddler 30, teen norm)

BP = younger is lower

(toddler 95/53, teen norm)

FLACC scale

FLACC (non-verbal)

face, legs, activity, cry, consolability (2 pts each) 10 = most pain

not good for intubated (or paralyzed) children who are sedated - mobility is altered, won't show pain this way

FACES scale

shows faces

Wong-Baker

10 hurts the most

signs of peds IV fluid overload

HR+

BP+ then BP-

Edema

use electronic infusion pump to prevent free flow of IV meds

peds integumentary

- rashes (systemic sign)

- lesions can co-occur

- skin is thinner + more sensitive

- less able to regulate temperature

- greater absorption area

contact dermatitis

irritants

avoid itching

oatmeal baths topical/oral steroids antihistamines protective ointments: A D zinc

cool compress

change soap

atopic dermatitis (eczema)

chronic

maculopapular rash

pruitic

infants - hands face arms legs

older children - folds of arms and legs

associated with allergy

remove irritants

protect from infection

Seborrheic diaper dermatitis

DIAPER RASH

Seborrheic dermatitis

CRADLE CAP

gone by 12 mo

Impetigo

- contagious

- BACTERIAL

- often secondary

- HONEY EXUDATE

- pruritic

- antibiotics

- hand washing

- keep nails short

- often around nose and mouth

- don't share utensils

diaper candidiasis

oral candidiasis (THRUSH)

- treat with NYSTATIN

- FUNGAL

- common

- affects swallow

Tinea (capitis, corporis, cruris, pedis, unguium)

RINGWORM

(tinned = "ringing")

capitis = scalp

corporis = trunk, face, extremeties

cruris = groin, butt, scrotum

pedis = feet

unguium = nails

ORAL ANTIFUNGAL

herpes simplex

episodic

oral acyclovir

no cure

pediculosis (capitis, corporis, pubis)

LICE ("how

head, body, public (crabs)

mite infestation - SCABIES (lesions)

complications of electrical injury

- cardiac arrest/dysrhythmia

- tissue damage

- myoglobinuria

- metabolic acidosis

- loss of short term memory

- altered emotional state

wk 2 review

- unintentional injury leading cause of death

- pain scales = FLACC, wong, visual analog

- burns = airway, fluid loss, heat regulation

- injury not symmetrical = RED FLAG, abuse

- head lag gone by 4mo

- 6 mo = ma/da/ba vocalization

- 12 mo = parallel play

- 18 mo = stranger danger

- 2 yr old = help w self-care, 2 word sentences

- 3 yr old = dressing, circles

- 4 yr old = ride a bike

fetal circulation review

placenta = oxygenation

foramen ovale = between atria

ductus arteriosus = between pulmonary artery and aorta

(away from pulmonary circulation)

***CLOSE within 42 hrs

parent teaching post cardiac surgery

- increase calories (start at 20 cal/oz, go up slowly)

- anatomy

- surgery details

- post care

Cardiovascular conditions of childhood

congestive heart failure

congenital heart defects

acquired heart disease

arrhythmias

cadiomyopathies

congenital vs. acquired heart disease

CONGENITAL = structural anomaly, present at birth, most common

ACQUIRED = occur after birth, long-term effect of CHD

increased pulmonary flow (congenital)

- patent ductus arteriosus (PDA)

- atrial septal defect (ASD)

- ventricular septal defect

NON-CYANOTIC

decreased pulmonary flow (congenital)

- tetralogy of fallot

- tricuspid atresia

CYANOSIS

obstructive heart disease (congenital)

- coarctation of aorta

- aortic stenosis

- pulmonary stenosis

mixed heart disease (congenital)

- transposition of great vessels

- trunks arteriosus

- hypo plastic left heart syndrome

atrial septal defect (+PF)

NON-CYANOTIC

most common

could be asymptomatic

- ATRIAL opening (left to right shunting)

- increased flow to lungs > pulmonary HTN, right sided heart failure

- right-sided hypertrophy

ventricular septal defect (+PF)

NON-CYANOTIC

blood is reoxygenated

- VENTRICULAR opening (increased pressure in right ventricle > right sided hypertrophy, pulmonary HTN, HF, fatigue, tachypnea)

- often close by 2 or 3

- patch repair

- left to right shunting

patent ductus arteriosus (PDA) (+PF)

NON-CYANOTIC

- in utero pathway between pulmonary artery and aorta

- if doesn't close in 1st. 72 hours of life

- mixes oxygenated with deoxygenated

signs of decreased pulmonary flow

- cyanosis (bluish)

- exacerbated by crying

- polycythemia (+ RBCs to carry 02 but lack 02)

- SOB

- clubbing (as in CF)

- tiring easily

- dehydration life threatening (closure of shunt needs for pulmonary blood flow)

RIGHT TO LEFT = BLUE

LEFT TO RIGHT = PINK

tetralogy of fallot (-PF)

CYANOTIC

- 4 defects:

1. ventricular septal defect

2. pulmonic stenosis (worst part, others are compensations - narrowing)

3. overriding aorta

4. right ventricular hypertrophy (happens quickly

DEOXY blood to body!

right to left shunting

(bypassing lungs)

TET symptoms

- TET spells (cyanosis increases while crying - increased R>L shunting)

- hypoxia

- pallor

- tachypnea

- give prostaglandins to keep PDA open! (it increases oxygenation, not permanent fix)

- make them sit in ball to increase BP

- document pulse ox

tricuspid atresia (-PF)

CYANOTIC

- valve btwn right atrium and ventricle fails to develop

1. atrial septal defect

2. tricuspid valve missing ***

3. hypo plastic right ventricle

4. pulmonary stenosis

5. ventricular septal defect (VSD)

6. patent ductus arteriosus (PDA) - prostaglandins

coarctation of aorta (obstructive)

- depending aorta is narrowed (i.e. story)

- decreased PERIPHERAL blood flow (lower pulses weak)

- often near ductus arteriosus

- leads to CHF > death

- BP differs on upper and lower extremeties**

aortic stenosis (obstructive, -PF)

- obstruction of blood flow out of left ventricle to the aorta (periphery)

- left sided BACKUP into LUNGS (CHF), LEFT side has to work HARDER to pump blood to BODY

- open PDA is good here! (pulm artery to aorta)

pulmonary stenosis (obstructive)

- obstructs blood flow btwn right ventricle and pulmonary arteries (to lungs)

- RIGHT ventricle must work HARDER to pump blood to the LUNGS

- PDA good here too

- RS HF, peripheral edema (BACK UP into BODY)

transposition of great vessels (mixed)

- aorta and pulm artery are swapped

- left to right mixing

- L and R side are closed circuits

- needs atrial septal defect, ventricular septal defect, and/or patent ductus arteriosus to survive (PROSTAs)

trunks arteriosus (mixed) *?

- one artery leaves heart to lungs and other to body

- all blood is mixed

- pressure in lungs lower than in body

- needs to have VSD

hypo plastic left heart syndrome (mixed)

- small left ventricle (can't pump blood to aorta)

1. stenotic mitral valve (LS, into)

2. stenotic aortic valve (LS, out of)

3. hypo plastic left ventricle

4. hypoplastic ascending aorta

5. coarctation of aorta

6. atrial septal defect

PROSTAs for PDA

acquired heart disorders

CHF

infective endocarditis

acute rheumatic fever

cardiomyopathy

kawasaki disease

CHF

- heart not filling/pumping well

- 80% of peds cases before 1 yr = congenital

- also from fluid overload, drugs, viral, dysrhythmias, organ failures

- SOB: asthma/viral?

not resolved = check heart

- LIVER + SPLEEN ENLARGEMENT

- falling off weight curve?

- galloping rhythm

infective endocarditis

microbial infection of heart

congenital defects or prosthetic valves increase risk

BACTERIAL ENDOCARDITIS = fatal

platelets stick > emboli

- nodes, lesions, spots

acute rheumatic fever

group A strep pharyngeal infection

- give antibiotics > clears

- if not > heart damage

- JONES criteria

JONES criteria (RF)

- Joint involvement (large joints = elbows, knees, wrists)

- O = heart, carditis (new murmur, EKG changes, tachy)

- Nodules (non-tender masses)

- Erythema marginatum (rash)

- Sydenham chorea (involuntary moves, slurred speech)

Also:

- FEVER

- CRP up first, then ESR

- long PR

- leukocytosis

THROAT CULTURE, STREP O TITERS + 2 major or 1 major 2 minor

Kawasaki's disease

most common cause of acquired heart disease

- systemic vasculitis, structural integrity of vessels impaired

- unknown etiology

- HIGH FEVER > 5 DAYS

- headache, chills, V/D

- IRRITABILITY

- JOINT PAIN

- PEELING FINGERS

- RED EYES

- SWOLLEN LYMPH NODES

- SYSTEMIC RASH

- STRAWBERRY MOUTH

ANEURYSM RISK, bleeding, clot risk

IVIG, aspirin, oral care

peds respiratory differences

- nose breathers

- less alveoli

- decompensated more quickly

- overt retractions

- tachy early, brady late

nasopharyngitis

COMMON COLD

- monitor hydration (diaper count)

- NO decongestants under 4 yrs old

- influenza positive? give antivirals (liquid)

- NO Motrin (ibuprofen) for less than 6 mo

- fever emergent <2 mo

acute otitis media

- viral or bacterial

- middle ear

- mucus back up

- pain, fever, irritability

- NO decongestants <4 yr old

- saline + suction

- recur = myringotomy tubes (wear ear plugs in pool)

- antibiotics for some

sinusitis

- BACTERIAL

- mucosal swelling

- decreased ciliary movement

- young = less space to fill

- antibiotics

pharyngitis & tonsillitis

- inflammation

- viral

- group A strep (concern = acute glomeruli nephritis)

- gonorrhea

- white drainage patch

- headache, stomach pain, fever, sore throat

post-tonsillectomy

- side-lying or prone

- NO coughing

- fluids YES, citrus/brown/red fluids NO

- ice collar, analgesics, narcotics maybe

- excessive bleeding = emergent!

pharyngitis & tonsillitis

testing and treating

- rapid strep test

- culture if rapid negative

- BACTERIAL = penicillin, antibiotics

(back to school after 24 hrs)

- VIRAL = wait until fever free for 24 hours

infectious mononucleosis

- self-limiting illness

- Epstein-Barr virus (EBV)

- transmitted by oral secretions

- swollen cervical lymph nodes

- splenomegaly

- hepatomegaly

NO CONTACT SPORTS

SALT WATER GARGLE

laryngotracheobroncitis (CROUP)

- inflammation of upper airway

- parainfluenza

- RSV (give Synagis)

- steeple sign = narrowing of trachea seen in x-ray

- barking cough, stridor

- suprasternal retractions

- humidified oxygen (tent, blowby)

- dexamethasone (PO/IM)

bronchiolitis

- inflammation of BRONCHIOLES

- RSV, adenovirus, parainfluenza

- NO antibiotics, NO cough suppressants

pneumonia

- inflammation of ALVEOLI

- viral, bacterial, aspiration

- one-sided chest pain

- fever, cough, tachypnea, decreased breath sounds, CRACKLES, difficulty feeding

- give antibiotics

- LAY ON AFFECTED SIDE

epiglottitis

- bacterial croup

- inflammation of epiglottis

- Hib (vaccine against!)

- tripod ding, muffled voice, difficulty swallowing, drooling, anxiety

- EMERGENT (DON'T look at throat, leave alone, or put supine, DO give oxygen, trach materials near)

asthma (chronic)

- hyper-responsiveness

- respiratory distress with treatment

- chest tightness sign of impending decompensation

- tachypnea, hypoxia, non-productive cough

treating asthma

- RESCUE = albuterol (short acting beta 2)

USE SPACER

- PREVENTION = inhaled or systemic corticosteroids

- peak flow meter (stand, blow into, 3 x, record highest)