EOR: peds random pearls

top 5 causes of infant mortality

- birth defects

- preterm birth & low birth weight

- maternal pregnancy complications

- SIDS

- injuries

1 umbilical artery think....

congenital anomalies → renal

APGAR scoring

tanner stages

erythematous grouped papules/pustules that classically SPARES the vermillion border

perioral derm → topical pimecrolimus, metro, erythro or clinda

**PO abx if extensive

perioral derm risk factors

- women 20-45 y/o

- h/o topical steroid use

- fluoride toothpaste

- lip licking

- hormonal changes (OCPs)

- cinnamon gum

gradual progressive loss of terminal hairs on the scalp in a characteristic distribution

↓ anagen to telogen ratio

dermoscopy: miniaturized hair & brown perihilar casts

androgenic alopecia → MC type of hair loss in M&F

- males: bitemporal thinning & vertex scalp

- females: vertex scalp (doesn't affect frontal hairline)

DHT (key androgen) shortens the anagen phase

anagen = growth phase

telogen = resting phase

tx = topical minoxidil, PO finasteride, spiro

MOA of finasteride

5-a-reductase inhibitor → inhibits conversion of testosterone to DHT

category X med

disruption of the skin barrier due to filaggrin gene mutation & disordered immune response

atopic dermatitis

MC locations of atopic derm

infantile → scalp, cheeks, neck, extensor surfaces (crawling)

childhood → flexural areas (ACF, popliteal)

adolescence → flexural areas, hands/feet

sharply defined erythematous, edematous coin-shaped crusted patches on the dorsal of the hands/feet and extensor surfaces (knees, elbows)

nummular (discoid) eczema

tx for eczema that is alternative to topical steroids and DO NOT cause skin atrophy

topical calcineurin inhibitors → pimecrolimus, tacrolimus

irritant vs allergic contact dermatitis

irritant (MC type) → non-immunologic reaction (immediate)

allergic → type 4 hypersensitivity reaction (delayed)

MCC of allergic contact derm

nickel MC worldwide

poison ivy is also a big cause

erythematous papules or vesicles in a linear or geometric pattern + localized pruritus, stinging & burning

+/- lichenification

contact dermatitis → patch testing to identify etio

lichenification seen in chronic cases

secondary infections associated with diaper dermatitis

- candidiasis

- impetigo

- HSV → child sexual abuse

beefy red plaques +/- maceration or erosion in the groin area, involving the inguinal folds w papular satellite lesions

cutaneous candidiasis (secondary infection from diaper rash)

**regular diaper dermatitis SPARES skin folds

most accurate method for estimating TBSA

Lund-Browder

degree of burn:

- confined to epidermis

- red, DRY

- painful

- blanches w pressure

superficial (1st degree) → do not calculate TBSA%

degree of burn:

- epidermis + papillary dermis

- pink-red; weeping/MOIST

- BLISTERING

- painful; INTACT cap refill

- blanches w pressure

superficial partial-thickness (2nd degree) → may heal with pigment changes

degree of burn:

- epidermis + reticular dermis

- mottled color variation from cheesy white to red

- WET or WAXY

- BLISTERING

- pain ONLY w pressure; ABSENT cap refill

- does NOT blanch w pressure

deep partial-thickness (2nd degree) → heals w hypertrophic scarring

degree of burn:

- epidermis + dermis + SQ

- waxy white to leathery gray to charred/black

- DRY, inelastic

- NO BLISTERING

- lack of sensation (painless)

- does NOT blanch w pressure

full-thickness (3rd degree) → requires surgery for healing

degree of burn:

- epidermis + dermis + SQ + fascia/muscle/bone

- black, CHARRED, dry

- no blistering

- no sensation, no cap refill

- does not blanch w pressure

4th degree → requires surgery

what BSA in children warrants fluid resuscitation?

>10% BSA → LR via 2 large bore

*can add 5% dextrose for children < 5 y/o or < 20 kg to prevent hypoglycemia

Parkland formula for children

3 mL x TBSA% x wt (kg)

***adults is 4 mL

4-2-1 rule for maintenance fluids

4 mL for first 10kg + 2 mL for next 10kg + 1 mL for each remaining kg

MC lab abnormality seen in burns

hyperkalemia

criteria for burn center admission

- > 10% BSA or ANY deep partial/full-thickness burns

- burns to hands, feet, face, genitalia

- chemical, electrical or inhalation injury

- circumferential burns

- underlying comorbidity

- abuse

cutaneous drug reaction types

type 1 → IgE mediated; urticaria, angioedema; immediate

type 2 → antibody-mediated, cytotoxic

type 3 → antibody-antigen complex; vasculitis, serum sickness

type 4 → delayed cell-mediated; erythema multiforme, ACD

type 5 → non-immunologic; genetic incapability to detox meds (anticonvulsants, sulfa)

MC drugs assoc w an exanthematous drug eruption

abx → aminopenicillins, sulfonamides, Bactrim

anticonvulsants → carbamazepine

CCBs

NSAIDs

causes morbilliform rash primarily on trunk/proximal extremities after drug initiation; NO mucosal involvement

type IV hypersensitivity rxn

mast-cell mediated vs bradykinin-mediated angioedema

mast cell → has assoc allergic sxs (flushing, pruritus, urticaria, etc)

- d/t histamine release

bradykinin → NO associated allergic sxs

- hereditary deficiency or ACE-induced

edema of the superficial layers of the skin → sudden onset transient well-circumscribed hives or wheals with central pallor

urticaria → lesions are blanchable

histamine release from mast cells & basophils in dermis = ↑ vascular permeability

MCC of erythema multiforme

HSV

target lesions MC on extremities (hands/feet) with 3 zones → dusty central blister, ring of pallor and surrounding peripheral ring of erythema

(-) Nikolsky sign

erythema multiforme

EM minor → mild/no mucosal involvement; no system sxs

EM major → widespread, severe mucosal involvement + systemic sxs (fever, arthralgia)

both erythema multiforme and SJS/TEN have target-like lesions, what differentiates them?

EM → - Nikolsky; +/- mucous membrane involvement

SJS/TEN → + Nikolsky; always has mucous membrane involvement

**SJS/TEN can also have a flu-like prodrome

SJS < 10% BSA

TEN > 30% BSA

prodrome: high fever + 3Cs (cough, coryza, conjunctivitis)

morbilliform dark brick red rash starting at the hairline

small pale white/blue papules w a red base on the buccal mucosa

rubeola (1st disease) → koplik spot pathognomonic

*etio = measles virus from paramyxovirus

give vit A for young/severely malnourished children to ↓ risk of complications/death

complications of rubeola

- severe diarrhea → MC

- pneumonia → MCC of measles-related death

- AOM, conjunctivitis

- sclerosing panencephalitis

- diffuse erythema (resembling a sunburn) that blanches with pressure + small papular elevations giving a sandpaper texture → desquamation

- red tongue with enlarged papillae (strawberry tongue)

- linear petechial lesions in skin folds (pastia lines)

scarlet fever → GAS type IV hypersensitivity rxn

typically occurs w/in 1-2 days of strep infxn

tx = PCN or amox (preferred in kids)

complications of scarlet fever

rheumatic fever and post-strep glomerulonephritis

single phase lasting 3 days (NO PRODROME) → low-grade fever, postauricular/post-cervical LAD

arthritis/arthralgias → teens/adult women

light red/pink non confluent rash starting on face & generalizes w/in 24 hrs

pinpoint red macules & petechiae on the soft palate & uvula

rubella (aka "3 day measles") → forchheimer spots

*etio = togavirus family → MC in African regions

TERATOGENIC IN 1ST TRIMESTER!!!

patho of erythema infectiosum

parvo B19 → infects & destroys reticulocytes = transient halt in erythropoiesis

leads to aplastic crisis in sickle cell, G6PD, IDA, hereditary blood d/o pts → do NAAT & give RBC transfusion

erythematous malar rash w circumoral pallor → develops into lacy reticular blanching rash on trunk/ext sparing palms/soles

symmetric arthlagias/arthritis in small joints common in older children/adults

erythema infectiosum (5th disease) → slapped cheek

can cause hydrops fetalis/fetal demise if infected during pregnancy

~3 days of HIGH fever (> 104F) in an otherwise healthy appearing child

fever resolves → rash starting on trunk/neck

Nagayama spots → red papules/ulcers on the soft palate & uvula

roseola (HHV-6) → only exanthem that starts on the trunk

major cause of febrile seizures!!

etio of HFMD

coxsackie type A16 → MC in summer months; fecal-oral transmission

prodrome: mild URI sxs, mouth/throat pain, ↓ or no appetite/refusal to eat

enanthem: small red macules → vesicles → ulcers w/ gray base & erythematous on buccal mucosa & tongue

exanthem: gray-yellow nonpruritic nontender vesiculopapular lesions on distal extremities

HFMD → typically resolves in 1 wk

complications of HFMD

aseptic (aka viral) meningitis

GBS

type A → herpangina

type B → myocarditis, pericarditis

HFMD vs herpangia

HFMD → ulcers of anterior oral cavity (buccal mucosa, tongue)

*mild URI sxs, assoc skin lesions on hands/feet

herpangina → ulcers of posterior oral cavity (soft palate, uvula, tonsils)

*sudden onset HIGH fever, no skin lesions

etio of mumps

paramyxovirus → MC in unvaxxed (2-9y), crowded settings (college, schools), boys > girls

~48 hrs of low-grade fever, HA, otalgia, malaise then U/L (possibly B/L) parotitis with facial edema that obscures the angle of the mandible

stensen duct orifice enlarged, red & edematous

mumps → isolate for 5 days!!

↑ amylase, leukopenia on labs

complications of mumps

- orchitis → MC in adult men

- oophoritis → post pubertal females

- encephalitis → incidence ↓ with vaccine

- acute pancreatitis → MCC of pancreatitis in kids

- deafness

URI sxs + pruritic asynchronous maculopapular rash appearing in successive crops that form vesicles & eventually crust over

rash starts on face → spreads caudally

varicella (HHV-3) → confirm w PCR

antivirals if >13 y/o, unvaxxed or immunocompromised (< 13 is supportive)

VZIG if high-risk

complications of varicella

bacterial superinfection → MC in kids

pneumonia → MC in adults

encephalitis

reye syndrome → if use of aspirin

MC bacterial skin infection in children

impetigo → highest incidence 2-6y; HIGHLY contagious

pruritic, nontender vesicles → dry with a honey-colored crust

occur at sites of superficial skin trauma & MC around nose/mouth

non-bullous impetigo (MC type) → S. aureus, GAS

vesicles rapidly enlarging to flaccid bullae with sharp margins & no surrounding edema → rupture and leave varnish-like crust

MC occurs on trunk

**associated fever & diarrhea

bullous impetigo → S. aureus; seen in NB & young kids

punched out ulcers with yellow crusts & violaceous margins

aka deep form of impetigo

ecthyma → GAS; heals w scarring

complications of impetigo

cellulitis (MC)

post-strep GN

***DOES NOT lead to rheumatic fever!!

intense itching esp occipital area + papular urticaria

white, oval-shaped egg capsules at base of hair shafts

pediculosis capitis (head lice) → outbreaks MC in warm & humid weather

permethrin 1st line

6Ps: purple, polygonal, planar, pruritic, papules & plaques

(+) koebner's phenomenon

Wickham striae: fine gray-white lines on skin lesions or oral mucosa

biopsy → saw-tooth lymphocyte infiltration, hypergranulosis, hyperkeratosis, degeneration of basal cell layer

lichen planus → MC involves volar (flexor) surfaces of wrist & ankles

↑ incidence assoc w HCV infection, meds (thiazides, sulfa, penicillamine), lymphoma

Herald patch followed by smaller, very pruritic round papules w collarette scaling at the edges & central clearing

oriented along the skin cleavage lines on the trunk & proximal extremities

commonly follows a viral infection

pityriasis rosea → get RPR in YAs to r/o syphilis

PAINFUL diffuse cutaneous blanching erythroderma that is more accentuated in skin folds → sterile, flaccid bullae in areas of mechanical stress with a (+) Nikolsky sign → sheet-like desquamation and thick perioral crusting (resembling oatmeal)

**mucous membranes NOT involved

SSSS (Ritter disease) → MC < 5y

oatmeal = "SSSS sad face"

tx = nafcillin or oxacillin (vanco if MRSA); steroids are CI!!

diffuse red maculopapular rash with desquamation of the palms & soles

toxic appearing

TSS → admit, IVFs & abx

severe pruritus worse at night or after a hot shower/bath

serpiginous burrows in intertriginous zones

erythematous papules +/- excoriations

scabies → permethrin (> 2 mo); sulfur (< 2 mo)

- patches of alopecia on the scalp w black dots (distal broken hair shafts)

- gray scaly patches of hair loss

- kerion: painful edematous plaque w pustules & thick crusting

- favus: cup-shaped yellow crusts

tinea capitis → T. tonsurans; MC in prepubescent children

tx = PO griseofulvin

*ADRs: hepatitis, GI upset, HA, disulfiram rxn

MC dermatophyte infection

tinea pedis → T. rubrum; MC in teens & young males

interdigital → MC type

hyperkeratotic → soles/lateral foot surfaces; "moccasin" pattern

annular patches/plaques & diffuse erythema to inner thighs or groin w sharply demarcated raised border

spares scrotum

ținea cruris (jock itch) → T. rubrum; tinea pedis may be source of infxn

asymmetrically distributed pruritic red scaly annuals plaques/patches w central clearing & well-defined raised borders

often have h/o exposure to pet with same infection

tinea corporis → T. rubrum

segmented hyphae on KOH; cx definitive

tx for tinea infections

capitis → PO griseofulvin (alt terbinafine)

pedis, cruris, corporis → topical azoles (PO if extensive)

hypo- or hyper pigmented well-demarcated round macules w fine scaling on upper trunk, neck & proximal extremities

KOH: hyphae & spores (spagetti and meatballs)

woods lamp: yellow-green fluorescence

tinea versicolor → Malasssezia furfur

topical selenium or azoles 1st line

MC opportunistic infection

Candidiasis → C. albicans

types of warts

plantar → painful, hyperkeratotic papules w central depression on bottom of foot; HPV 1

common (verruca vulgaris) → skin-colored papillomatous papules; distorts skin lines; HPV 2 & 4

flat (verruca plana) → skin-colored papules w smooth surface

anogenital (condyloma) → cauliflower-like; HPV 6 & 11

**HPV vax only protects against anogenital HPV types, not any of the others

multiple blotchy red macules & papules that rapidly progress to yellow-white pustules on the trunk & proximal extremities

typically seen w/in first 72hrs of life; MC in fat babies with higher gestational age (>40wks)

Wright-stain smear → numerous eosinophils

erythema toxicum neonatorum → resolves spontaneously

irregularly shaped bluish-gray macule on the sacrococcygeal area/butt/shoulders

usually found at birth

slate gray nevus (aka congenital dermal melanocytosis) → benign; can disappear in a few yrs

bacterial infection of middle ear, temporal bone & mastoid air cells commonly preceded by a viral URI

acute otitis media (AOM) → peak age 6-24 months (d/t more short/horizontal E tube)

RFs: daycare, bottle fed, 2nd hand smoke exposure

**being breastfed is a protective factor

etios of AOM

S. pneumo (MC), H. flu, M. catarrhalis

less common in kids → GAS (most likely to cause TM perforation)

rapid onset otalgia, ear tugging/rubbing, low-grade fever

conductive hearing loss in affected ear

bulging red TM, loss of landmarks, ↓ TM mobility on pneumatic otoscopy

AOM → amox or augmentin

comps: mastoiditis (MC), bullous myringitis, TM perforation

pain, erythema & pruritus in ear canal; ear pressure/fullness; malodorous otorrhea

+/- hearing loss d/t debris & discharge

PE: pain with traction/palpation of tragus or pinna, canal may be edematous & blocking view of TM

normal TM mobility on pneumatic otoscopy

otitis externa ("swimmer's ear") → pseudomonas MCC; S. aureus (digital trauma)

if fungal cause → moist, wet appearance

pt will have h/o water immersion (swimming), mechanical trauma (Q-tips), occlusive devices (hearing air, ear plugs, headphones)

exquisite tenderness & swelling of external ear structures; pain worse @ night → radiates to TMJ (pain w chewing)

persistent purulent otorrhea unresponsive to treatment

macerated granulation tissue at bony cartilaginous junction of ear canal

CN involvement → CN 6, 7, 9

malignant (necrotizing) otitis externa → AOE sxs + CN involvement from osteomyelitis of skull base

MCC pseudomonas

complication of otitis externa seen in immunocompromised pts (DM, malignancy, steroids, HIV)

complication of untreated AOM → MC in children < 2y

deep otalgia (worse at night), tugging/pulling ear, fever, lethargy

fussiness, +/- CN palsies

PE: bulging red TM, erythema/tenderness posterior to ear, forward protrusion of ear, narrowed auditory canal

mastoiditis → confirm w CT w contrast

same bugs as AOM → S. pneumo (MC), S. pyogenes, H. flu, M. cat

acute otalgia & conductive hearing loss → sudden pain relief w bloody otorrhea

+/- transient tinnitus, vertigo

MC d/t penetrating or noise trauma, barotrauma or otitis media

TM perforation → MC at pars tensa; DO NOT perform pneumatic otoscopy!!

comp: cholesteatoma

*sudden pain relief is a sign that TM has ruptured (release of pressure)

MCCs of conductive & sensorineural hearing loss

conductive → anything that ↓ transmission of sound from environment to cochlea

- otitis media, cerumen impaction, cholesteatoma, TM perf

SN → disruption of sound transmission after cochlea

- presbycusis (MC), noise-induced, drug-induced, rubella (MC congenital cause)

ototoxic drugs

loops, vanco, aminoglycosides, macrolides, ASA, NSAIDs, anti-malarials, chemo drugs, PDE5i

NB testing for hearing loss

auditory brainstem response or otoacoustic emissions

**all infants should have hearing screened by 1 month

conductive vs SNHL weber & rinne

conductive → weber: lateralizes to affected ear; rinne BC>AC

SN → weber: lateralizes to good ear; rinne: AC>BC

what is the ONLY surgical treatment for SNHL?

cochlear implants

MCC of acute pharyngitis

VIRAL → adenovirus

consider fungal in pts using inhaled steroids

cough, hoarseness, rhinorrhea, coryza, conjunctivitis, diarrhea

sore throat worse w swallowing or phonation + anterior stomatitis (ulcers on soft palate/tonsils

acute viral pharyngitis

these sxs suggest viral etio → no cough suggests bacterial

MCC of bacterial pharyngitis

GABHS → can lead to rheumatic fever if untreated

consider gonorrhea if sexually active & non-resolving pharyngitis

abrupt onset high fever, SEVERE sore throat + exudates

NO COUGH

scarlatiniform rash

anterior cervical LAD

strep pharyngitis → use Centor criteria to determine need for testing (need 3 out of 4 to do rapid strep)

complications of strep pharyngitis

acute rheumatic fever → prevented w abx

severe pharyngitis → give IM dexamethasone

post-strep GN

peritonsillar abscess

PANDAS → ped autoimmune neuropsych d/o assoc w strep

MCC of chronic rhinosinusitis

S. aureus

chronic = sxs > 12 wks

*get CT of sinuses & refer for allergy testing

nasal congestion, CLEAR rhinorrhea, hyposmia

HA, cough, malaise

maxillary tooth discomfort

red, engorged nasal mucosa

Eustachian tube dysfunction → ear pain/fullness/pressure, HL, tinnitus

SXS LAST < 10 DAYS!!!

acute viral rhinosinusitis → rhinovirus MCC (common cold)

SXS PRESENT > 10 DAYS

purulent yellow-green nasal d/c

facial pain/pressure worse when bending down/leaning forward

fever, HA, halitosis, cough

sinus TTP → maxillary (MC) > ethmoid > frontal > sphenoid

biphasic pattern ("double worsening") → sxs initially improve but then worsen ~5-6d later

acute bacterial rhinosinusitis → MC from viral URI (S. pneumo)

**maxillary tenderness = referred dental pain

samter's triad

asthma + allergic rhinitis + ASA/NSAID sensitivity

types of rhinitis

allergic (MC type) → IgE-mediated mast cell histamine release d/t allergens

infectious → rhinovirus MC (common cold)

vasomotor → nonallergic & noninfectious dilation of blood vessels d/t temp changes, smells, humidity

paroxysms of sneezing, nasal congestion & itching

clear watery rhinorrhea

allergic shiner → bluish discoloration around eyes

Dennie-Morgan lines → accentuated lower eyelid lines

salute sign → transverse nasal bridge crease

PE: pale blue edematous boggy turbinates, nasal polyps, cobblestone conjunctival mucosa

allergic rhinitis → MCC of nasal polyps

rhinitis sxs + erythematous ("beefy red") turbinates on PE

viral rhinitis (common cold)

what med can be used for allergic rhinitis and asthma?

leukotriene receptor antagonists → montelukast

anterior vs posterior epistaxis

anterior → Kiesselbach's plexus; MC d/t trauma (nose picking); bleeding usually only in one nare

posterior → sphenopalatine artery (Woodruff's plexus); MC in older pts w HTN; bleeding in both nares & posterior pharynx

painless thick mucopurulent eye discharge

LACK of itching

diffuse conjunctival erythema w no ciliary injection

bacterial conjunctivitis → S. pneumo & H. flu MC in children

S.aureus MC in adults