Exam 3: PEDS-1

What happens to the infant after the umbilical cord is cut?

- with mother skin-skin (if there are no concerns with baby)

- in a radiant warmer (if resuscitation measures are needed)

What temperature is considered a fever?

>100.4°F

What bacterial infection is most common 0-3 months? 3-36 months?

0-3 months: GBS

3-36 months: S. pyogenes

ALL febrile infants <28 days should have what?

Sepsis evaluation (CBC, BG, CSF, UA)

When is fever a concern for 3-36 months?

>102.2°f

What should you work up in fully immunized infants with a fever?

UTI

When can a child take ibuprofen?

>6 months of age

What is a simple febrile seizure?

generalized tonic-conic seizure lasting <15 minutes that occurs only

once in a 24 hour period

What is a complex febrile seizure?

seizures that are focal (shaking limited to one limb or one side of the body), lasting

longer than 15 minutes or occur more than once in 24 hours

What illness is a main cause of febrile seizures in children?

HHV-6 (Roseola)

What can be given if a febrile seizure lasts >5 min?

Benzodiazepines

What are the risk factors for UTIs in children?

female infants <4 y/o and male infants <1 y/o

lack of circumcision

Vesicoureteral reflux

Treatment for UTIs children <2 y/o

1st gen. Cephalosporin (Cephalexin)

Treatment for UTIs children >2 y/o

3rd gen. Cephalosporin (Cefixime or Cefdinir)

What is Human Metapneumovirus?

Children <1 y/o

Contaminated secretions

Upper respiratory track infection (can progress to lower respiratory tract)

Mistaken for RSV

What is seborrheic dermatitis?

“cradle cap”

Self-limiting eruption of erythematous plaques

Around sebaceous glands

What is the diagnostic criteria for pediculosis capitis?

>5 nits within ¼ inch of the scalp

What can be used for refractory pediculosis capitis?

Cetaphil treatment on hair

Treatment for tinea capitis in children

Oral Griseofulvin 20-25 mg/kg/day x 6-12 weeks

What is Infantile colic?

Crying for no apparent reason in an otherwise healthy infant (usually multi factorial) that resolves by 3-4 months of age

What is the “rule of 3’s” for Infantile colic?

Crying…

≥3 hours per day,

≥3 days per week

<3 months of age

What should be encouraged for plagiocephaly?

Tummy time

What are the two main indications for tonsillectomy?

Airway obstruction (apnea)

Recurrent infections

What is the initial newborn exam?

1. Check for evidence of meconium

2. Clear mouth & nares

3. Dry with pre-warmed towels

4. Apply knit hat

5. APGAR scoring at 1 & 5 minutes

If the baby has poor respiratory effect OR HR <100 bpm, what is the initial management?

resuscitate

What is the single most reliable indication of the need for resuscitation in an infant?

decreased HR

What is used for infant resuscitation?

positive pressure ventilation (PPV)

What are the s/sxs of respiratory distress in the term newborn infant?

grunting, nasal flaring intercostal retractions, bradycardia (<100bpm), central cyanosis, tachypnea, apnea, feeding intolerance

When should APGAR scoring be recorded?

- 1 minute

- 5 minutes

- +/- 10 min, 15 min, 20 min

What does the APGAR score reflect?

reflects cardiopulmonary and neurologic status at that point in time

What does APGAR stand for?

- appearance (color)

- pulse (HR)

- grimace (reflex irritability)

- activity (muscle tone, movement)

- respiratory effort

What is a normal 1/5 min APGAR score?

8-10

What is considered abnormal APGAR scores for 1 min?

5-7

What is considered abnormal APGAR scores for 5 min?

<7

What is considered a low APGAR score for 1 min?

- 0-4

- Needs immediate resuscitation

What is considered a low APGAR score for 5 min?

- 0-6

- High-risk for CNS &/or other organ dysfunction

What does an infant need if there 5 min APGARD is <7?

score again every 5 min until

a score ≥ 7 is reached or reach 20 minutes of life

What are other items initially assessed in a newborn?

- patency of nares: choanal atresia

- chest: heart/lungs

- skin color: indicator of cardiac output

- abdomen: umbillical stump --> 2 arteries/1 vein

- genitalia

- neuromuscular/skeletal: clavicular fractures or nerve palsies

What is choanal atresia?

obliteration or blockage of the posterior nasal aperture

What are other components of newborn infant care?

- 0.5% erythromycin ophth. ointment (preventative against gonococcal infections)

- Vitamin K 1 mg IM (prophylaxis for vit K def bleeding)

- Umbilical cord blood collection (COOMBs)

- Birth measurements

- Beside blood glucose testing (if concern for hypoglycemia)

- H/H (if risk for anemia/polycythemia)

- Idenity documentation

When is a complete nursery exam completed?

24 hours of birth

What is a hyperthermia/fever in a newborn?

> 38.0 o C (100.4 oF)

What is HTN for a newborn?

≥ 90/60 mmHg

What do you ALWAYS need to check when doing vitals during a complete newborn nursery exam?

check all 4 limbs if suspicious of cardiac disease (FEMORAL PULSES ARE VERY IMPORTANT)

What are the three parameters for the growth and development of a newborn?

- weight

- length

- head circumference

What is considered small for gestational age?

<10th percentile

What is considered large for gestational age?

>90th percentile

What is Ballard scoring?

neuromuscular & physical "maturity" for gestational age

What is macrosomia?

- growth beyond a specific threshold (weight of 4000g) (8lbs 13oz)

- does not take into account gestational age

What are the normal findings of the skin in a newborn?

- appears pink in color

What is acrocyanosis in an newborn?

bluish appearance of the hands, feet, and perioral area

What are abnormal findings of skin in a newborn?

- central/persistent cyanosis (best seen on tongue and mucous membranes)

- pallor (anemia)

What does persistent pallor/cyanosis suggest in an infant?

inadequate cardiac output

What is plethora in newborns?

may indicate neonatal polycythemia

Is jaundice in the first 24 hours a normal finding in an newborn?

NEVER (indicates hemolysis or congenital liver disease)

Is neonatal jaundice beyond the 24 hour mark normal in a newborn?

extremely common (physiologic jaundice)

How is neonatal jaundice diagnosed in newborns?

- check serum total bilirubin

- >5-6mg/dL = elevated

What does elevated indirect bilirubin indicate in newborns?

physiologic

What does elevated direct bilirubin indicate in newborns?

biliary/GI atresia/obstruction

How do you treat neonatal jaundice in newborns?

- monitor total serum bilirubin levels

- phototherapy: induces conjugation to a water soluble form

- exchange transfusion

What are the complications of neonatal jaundice?

- acute bilirubin encephalopathy (brain damage due to elevated bilirubin)

- chronic bilirubin encephalopathy (irreversible brain injury characterized by cerebral palsy and hearing impairment)

What is congenital ichthyosis in newborns?

hereditary d/o characterized by hyperkeratosis, scaling, and underlying inflammation

If you see petechiae/purpurae above the nipple line, what is this indicative of in newborns?

nuchal cord (cord wrapped during birth)

If you see petechiae/purpurae below the nipple line, what is this indicative of in newborns?

platelet issues/sepsis

What is erythema toxicum in newborns?

- most common "rash" in newborn nursery

- presents 24-28 hours after birth

- pustules on an erythematous base

What is transient neonatal pustular melanosis in newborns?

- small pustules/vesicles present at birth

- leave pigmented macules upon resolution

What are milia in newborns?

keratin, white, and firm

What is sebaceous hyperplasia in newborns?

sebum, yellow/oily

What is neonatal cephalic pustulosis?

neonatal acne limited to the face and scalp

What is congenital dermal melanocytosis in newborns?

- mongolian spots

- blue/gray pigmented patch

- usually on the sacrum and fade within the first two years of life

What are Café au lait macules in a newborn?

- Hyperpigmented macules, usually benign

- Presence of 6 or more that are >1.5 cm in adults or >0.5 cm in prepubertal children may be indicative of neurofibromatosis I

What is nervus simplex in a newborn?

- type of capillary malformation

- blanchable, pink/red macular patches

- gradually fade over time

What is a port wine stain in a newborn?

- another type of capillary malformation

- more intense, purple-red compared to nevus simplex

What can a port-wine stain indicate in a newborn?

- Face: Sturge-Weber Syndrome

- Back/extremities: Klippel-Trénaunay Syndrome

What is the treatment for a port wine stain in a newborn?

pulse dye laser treatment

What is cutis marmorata in a newborn?

- transient vasomotor mottling

- most visible if cold

- disappears with warming

What is cutis marmorata telangiectasia congenita in a newborn?

- type of vascular malformation

- deep purple, marble or net like

- does NOT fluctuate with temperature changes

What are congenital hemangiomas?

- benign vascular tumor

- most involute without therapy

- require intervention if excessive growth occurs or they compromise vision or airway

Suture lines in the baby's head should not be fused, what is it called if they are?

craniosynostosis

When does the anterior fontanelle close?

10-24 months

When does the posterior fontanelle close?

around 2 month

What is caput succedaneum in a newborn?

- Superficial scalp edema

- crosses suture lines

- soft/boggy

- resolves on own

What is a cephalohematoma in a newborn?

- collection of blood under the periosteum

- does NOT cross suture lines

- more fluctuant

What is a facial nerve palsy in a newborn?

- pressure against maternal sacrum

- forceps injury?

- most prevalent during crying

- usualy resolves

What is a micrognathia?

- small recessed jaw

- Many chromosomal conditions associated with this finding (pierre-Robin syndrome)

What is associated with webbing on the neck?

Turner syndrome

What is a normal RR of an newborn?

30-60/min

What is considered abnormal breathing for an infant?

grunting or retractions

What is considered a normal findings on auscultation of a newborn?

rales/crackles

What do you need to do if you have any suspicious/concerning findings in a newborn during a chest/lung exam?

CXR

What are widely spaced nipples indicative of in a newborn?

turner syndrome

What is a normal HR for newborns?

120-160 bpm

What is coarctation in a newborn?

narrowing of the aorta

Are murmurs concerning in a newborn?

- can be very common initially, often innocent

- related to closure of ductus and/or foramen ovale

What is the most common innocent murmur in the neonate?

Peripheral pulmonary stenosis (PPS)

Do infants with congenital heart disease always have a murmur on the initial exam?

No, often asymptomatic at birth

What are the more obvious presentations of CHD?

1. Cyanosis (central)

2. CHF with abnormal pulses/perfusion

If you hear anything suspicious on auscultation of the heart, what do you do?

ECHO

What is congenital heart disease screening?

- screening completed via pulse ox on day of life 2

- failed: any O2 < 90% or <95% in 3 separate measures

- failed --> ECHO

What are normal bowel sounds in neonates?

tinkling