Peds Exam 2

growth hormone deficiency

• inhibits growth

• primary site of dysfunction→ hypothalamus

diagnostic evaluation for growth hormone deficiency

• family history 

• physical exam 

• growth patterns and health history 

• bone age films: 

  • looking at the wrist 

• endocrine studies to detect deficiences 

  • thyroid

  • growth hormones 

• GH stimulation 

• CT, MRI, Skull xray 

  • looks for tumors that can impact growth 

growth hormone deficiency- therapeutic management

• biosynthetic growth hormone

  • somatropin (SQ injection)

• other hormones replacements as needed- given at bedtimes daily 

  • Thyroid hormone 

  • Cortisone 

  • Testosterone or estrogen and progesterone

GH deficiency: prognosis

• GH replacement successful in 80% of affected children 

• Growth rate of 3.5 to 4 cm/ year before treatment and increase to 8-9 cm after treatment 

• Response varies based on

  • Age 

  • Length of treatment 

  • Frequency of doses 

  • Dosages 

  • Wt 

  • GH receptors amount

GH deficiency: if untreated

• Decreased growth 

• Delayed epiphyseal closure 

• Delayed bone age and sexual development 

• Premature aging

Pituitary Hyperfunction

• Excess GH before closure of the epiphyseal shafts results in overgrowth of long bones

Pituitary Hyperfunction growth changes

• Reach heights of 8 feet or more

• Vertical growth and increased muscle 

• Weight is generally in proportion to height

Pituitary Hyperfunction: acromegaly 

• Excess GH after epiphyseal closure is called acromegaly

• Typical facial features

Precocious puberty:

• Secondary sexual development before age of 9 in boys and 7 ½ - 8 in girls 

• Occurs more in girls (breast development and growth in ht ) 

Precocious puberty: potential causes 

• Disorder of the gonads, adrenal glands, hypothalamic- pituitary gondadal axis 

• No causative factors in 80% to 90% of girls and 50% boys

precocious puberty treatments

treatment of specific cause is unknown

• May be treated with Lupron

  • Slows prepubertal growth to normal rates

  • Treatment is discontinued at age for normal pubertal changes to resume

• Psychologic support for child and family

Degree of dehydration 

• compare to weight before they’re sick to determine extent (% of body weight dehydrated)

  • Mild = 3-5% infant, 3-4% child

  • Moderate = 6-9% infant, 6-8% child

  • Severe = > 10% infant and child

dehydration: fluid loss in mL/kg/body wt (need to wt before sickness to compare

• Mild = loss of 50 mL/kg 

• Severe = loss of 100 mL/kg

dehydration risks

electrolyte imbalance

dehydration causes

• insensible water loss

  • urine 

  • stool 

  • vomiting 

  • sweating 

  • skin/ respiratory tract 

dehydration symptoms

• LOC,

• irritability,

• lethargy/lack of activity,

• decreased response to stimulation,

• decreased skin turgor/elasticity (wrinkles),

• increased cap refill > 2 seconds,

• increased HR,

• sunken fontanelles in infants,

• dry skin or mucous membranes,

• coolness or mottling of extremities

mild dehydration symptoms

•  increased thirst,

• dry mucous membranes (tacky – not a lot of saliva)

moderate dehydration symptoms

• decreased tears,

• loss of skin turgor,

• dry mucous membrane,

• normal-moderate to sunken fontanel,

• cap refill 2-4 seconds

severe dehydration symptoms 

• weight loss (moderate),

• tachycardia,

• decreased BP,

• extreme thirst,

• tenting,

• no tears and sunken eyes,

• decreased urine output,

• lethargy (decreased activity is a big issue)

diagnostic test for dehydration

• Degree of dehydration – VS, cap refill, I&Os, BS

• Type of illness

• Clinical signs

• Body weight

dehydration treatment 

• Oral rehydration first (PO or IV)

• Ondansetron (Zofran) 🡪 decrease vomiting

  • Less expensive

• Tylenol 🡪 break fever; ibuprofen only in 6 months+ (harder on the stomach though)

• IV fluids if severe enough

• Need education

Oral rehydration first (PO or IV) for dehydration 

• correct fluid imbalance, treat the cause

  • Only if alert/awake

  • Clear fluids first (ex. Pedialyte – recommended ratio for electrolytes OR Gatorade – for older kids)

IV fluids if severe enough-for dehydration 

• if severely dehydrated; unable to drink or drink enough to replace losses

  • Give small, frequent sips (want them to keep it down for a couple hours)

    • Via syringe or medicine cup – children may refuse to drink b/c of fear of vomiting again

  • If tolerating 🡪 progress to bland foods like crackers, bread, etc.

Calculation of maintenance fluid requirements in children

• Purpose

  • Keep children hydrated and nourished, especially if child is NPO

• Calculate child’s weight in kg

• Allow 100 mL/kg for first 10 kg of body weight (in 24 hr period)

• Allow 50 mL/kg for second 10 kg of body weight (additional)

• Allow 20 mL/kg for remaining body weight (anything over 20 kg they need 20 mL more)

• Add up totals and divide by 24 hrs to determine mL/hr

fluid balance- replacement

• Insensible water losses- through skin, respiratory tract, urinating, defecating

  • If kids have high fever they will loss more fluid (12%)→ more intake of fluids  

• Urine and stool 

fluid balance- increased requirements

• Fever, tachypnea

  • need fluid to bring temperature down

    • 12% increase per degree C

• radiant warmer, phototherapy (preterm infants)--> increase fluids 

• Vomiting and diarrhea, DI, acidosis

• Shock, burns, postoperative bowel surgery (have to wait/ listen for bowel sounds before eating to drinking)

fluid balance: decreased fluid requirements

• Heart failure

  • Restrictions because they have too much fluids in the body 

• Increased ICP

  • Minimize excess fluid on the brain 

• Renal failure

• Postop- you already get fluids through IV

GI assessment: history

• pattern of elimination

  • What is normal for them 

    • When did you last poops and what does it look like 

      • round, skinny, loose and watery, hard and round 

GI assessment: clinical exam and observation 

• Activity 

• Skin moisture

• Mucous membranes 

• Lips 

• Do eyes appear sunken 

• Sunk frontalles 

GI assessment: I and O

• fluid balance is important, vomiting, diarrhea, breast milk not sufficient which causes decreased activity

  • First concern is are they dehydrated

GI assessment: wt and ht

• Can’t grow properly if they have a malabsorption disorder (ex. pts with CF are short and skinny)

GI assessment: abdominal assessment

• Inspect 🡪 are they distended, is it flat, does it appear enlarged, observe guarding behaviors

• Circumference recorded if concerned about a potential tumor

• Listen

• Palpate  

GI assessment: Lab tests

• Stool exam

  • Color, amount, frequency, consistencies 

• O and P (ova & parasites)- look for infection 

• Stool Culture- looks for bacterial infections 

• Occult Blood Guaiac- look for blood (blue ring- blood in stool) 

GI assessment: diagnositic procedures

• Xray

• Upper/lower GI (barium or air swallowed enema 

  • Assess structure and function

  • Identify masses

  • May be given via NGT 

• Ultrasound- at invasive 

• MRI/CT- if there a mass 

• Endoscopy- in from the top 

• Colonoscopy- in from the bottom 

Consequences of GI Dysfunction in Children:

malabsorption,

fluid and electrolyte disturbances,

malnutrition,

poor growth

vomiting causes

• Acute infection, increased ICP (if they have a shunt 🡪 could be malfunction of the shunt), ingestions, food allergy/intolerance, GI obstruction, UTI, etc.

  • May be protective, stress induced, or learned behavior

vomiting symptoms

• Forceful expulsion of stomach contents

vomiting assessment

hydration status (most important)

vomiting evaluation

• Clinical evaluation

• Urine analysis for ketones, specific gravity (would be elevated)

• Labs – CO2 (would be elevated)

  • Metabolic acidosis

vomiting treatment

• Give ondansetron (Zofran) to settle their stomach

• Prevent complications with poisoning

• Rehydration

• Support of the child and family

diarrhea is caused by

• abnormal intestinal water and electrolyte transport

  • Fecal-oral spread

  • Rotavirus, norovirus

  • Bacteria 

  • Might be drinking too much 🡪 cut out milk to see if it’s a lactose issue

bacteria that cause diarrhea

• E coli, salmonella, yersinia, C diff, clostridium, shigella, staph

  • Spread through food (contaminated or undercooked), contaminated water, pets

acute diarrhea

•  < 14 days, usually due to infection or antibiotics

chronic diarrhea

•  > 14 days, can be due to IBD, lactose intolerance, food allergy

• Higher mortality and morbidity < 5 years

• Higher incidence in low income houses and communities worldwide

diarrhea treatment

• Understand and initiate appropriate treatment for mild, moderate, or severe dehydration

• Rehydration*; monitor hydration (ORS guidelines)

• Replace ongoing stool losses 1:1 ORS

• Give in small amounts frequently (tsp, cup, syringe, NGT)

• I&Os

• Skin care

• Maintenance fluid

• Medications

  • Probiotics to restore good bacteria and provides bulk

  • Sometimes antibiotics

• Education 🡪 prevention

• Family support

diarrhea nutrition

• Reintroduce normal diet after rehydration

• Continue use of breast milk

constipation

symptom rather than a disease

constipation causes

• Alteration in frequency, consistency, or ease of passage of stool

constipation is secondary to

• Systemic disorders associated with it = 

  • structural anomalies of intestine, 

  • ectopic anus, 

  • Hirschsprung disease, 

  • lead poisoning, 

  • children with spinal cord lesions (lose sensation and tone of rectum 🡪 prone to fecal retention/incontinence)

constipation is a associated with

• antacids, diuretics, antiepileptics, antihistamines, opioids, iron supplements

idiopathic constipation

functional, not known cause

chronic constipation

• may be due to environmental or psychosocial factors

  • Hard stool can cause anal fissures 🡪 pain causes stool withholding behaviors

constipation symptoms

• Less than 3 stools/week, painful BMs, retained stool/stool incontinence (encopresis)

constipation symptoms in newborn

• first meconium should be passed within 24-36 hrs of life, otherwise assess for…

  • Hirschsprung disease,

  • hypothyroidism,

  • meconium plug,

  • meconium ileus (CF)

constipation symptoms in infancy

• Often related to diet

• Constipation in exclusively BF infants is almost unknown

  • Infrequent stool may occur b/c of minimal residue from digested breast milk

• Formula fed infants may develop constipation

constipation treatment

• Increase fruit, vegetables, fluids (might use prune juice, Miralax, etc.)

constipation nutrition

• Increase fiber, fluids, fruits/vegetables, exercise

Hirschsprung

• Absence of ganglion cells in colon, causes decreased motility

• stool accumulates, sphincter won’t relax- leads to obstruction

Hirschsprung s/s newborn 

• delayed meconium passage

• bilious vomiting

• refusing PO feeds

• Abdominal distention

Hirschsprung s/s infant

• FTT

• Constipation

• Diarrhea

• vomiting

Hirschsprung s/s child

• poor growth

• abdominal distention

• foul smelling

• ribbon like stool

• palpable mass (stool)

Hirschsprung diagnostic testing

• CBC, Electrolytes

  • Rectal biopsy

    • determine whether ganglion cells are absent

  • Check for dehydrations

Hirschsprung surgery to correct

• May need Daily anal dilations in future

Hirschsprung therapeutic management 

• Assist family with improving nutritional status

  • Low Fiber, High protein & calorie diet

  • TPN if needed

• Surgery

  • Preoperative care- 

    • saline enemas, antibiotics, Abdominal Circ

  • Postoperative care- 

    • Daily anal dilations

  • Discharge planning and care

Hirschsprung two stages

• Temporary ostomy

• Second stage is the pull-through procedure

GER

• gastric contents back up into the esophagus

• Usually resolved during the first year of life

GER at risk

• Preemies

• CF

• Chronic lung disease

• neuro problems

GER diagnositic testing

• UGI- checks for abnormal anatomy

• 24 hour PH probe- amount of reflux

• Endoscopy-checks for narrowing in esophagus

GER presentation

• vomiting/spitting up

• Crying

• Arching

• Difficulty breathing/Apnea

• FTT in infancy

GER children presentation

•  chronic cough, abdominal pain, chest pain

Therapeutic Management of GER/GERD: feeding alteration

• Thickening feedings (1 tsp-TBSP rice cereal/oz formula)

  • AR formula= added rice (weigh it down to keep it int the cold stomach)

• Upright positioning after 

• Frequent burping during feeds

• Avoid overfeeding- small, frequent meals

• Avoid offending foods

• Maintain normal weight

Therapeutic Management of GER/GERD: meds

• H2 receptor antagonists:  

  • cimetidine (Tagamet), ranitidine (zantac), or famotidine (Pepcid)

• Proton pump inhibitors: 

  • esomeprazole (Nexium)

  • lansoprazole (Prevacid)

  • omeprazole (Prilosec)- reduce acid secretion, increase sphincter tone

Therapeutic Management of GER/GERD: surgery

Nissen fundoplication

Pyloric stenosis-

Constriction of the pyloric sphincter with obstruction of the gastric outlet

Pyloric stenosis- when does it occur

•  first few weeks of life

  • When baby is eating, food isn’t going to their stomach 🡪 they get hungry, they eat, they vomit, repeat (always hungry)

Pyloric stenosis- incidence

1 in 500 infants

Pyloric stenosis- diagnostic evaluation

• Serum electrolytes

• ABD ultrasound

Pyloric stenosis- clinical manifestations

• Non-bilious projectile vomiting after eating

• Constant hunger- eat and throwing up, never gets to their stomach 

• Olive shaped abd mass in RUQ & poss peristaltic movements

• Failure to gain wt  and S& S of dehydration

Pyloric stenosis- therapeutic management 

• surgery pylorotomy

Pyloric stenosis- nursing management

• Surgery – pylorotomy (opens up pylorus/stomach to correct passage)

• Preop care – correct dehydration

• Postop care – feeding starts gradually

pyloric stenosis nutrition

• Usually ravenous b/c they eat and then puke so it never makes it all the way down to satisfy their hunger needs

Intussusception Pathophysiology

• Telescoping or invagination of one portion of intestine into another

• Usually Toddlers

Intussusception classic triad of symptoms 

• Sudden onset of abdominal pain w/fever, vomiting and typically in toddlers 

• Abdominal mass “sausage like, RUQ”

• Blood/mucous in stool- “currant-jelly stools” (late sign) 

Intussusception Diagnostic evaluation:

• US,

• air enema

  • Can cure the issue so we don’t always know if this was the issue because air goes into the bowel and reinflates it 

Intussusception therapeutic management

• often cured by enema

  • Conservative treatment first

    • Air enema – usually cures it (radiologist guided; with or without contrast)

    • Hydrostatic (saline) enema (US guided)

    • Barium enema

  • Might surgically go in to see if bowel needs repair 🡪 surgical reduction and fixation or excision of nonviable segment of colon

Intussusception nutrition

• Might not be eating b/c of pain and vomiting

Appendicitis 

• Inflammation due to obstruction of the lumen of the appendix by burdened stool, swollen lymph tissues or a parasite 

Appendicitis clincial manifestations

• Referred pain/ RLQ

• Epigastric McBurney’s point

• Fever, nausea, vomiting

Appendicitis diagnostic test

• Detailed physical exam, history

• Labs 🡪 CBC, electrolyte, UA

• US of abdomen

• Abdominal XR

• CT (GOLD STANDARD**)

Appendicitis treatment sugery

• Nonruptured 🡪 appendix is removed (laparoscopic, open surgery)

• Ruptured 🡪 treat infection, clear them up, and schedule removal at a later time

Appendicitis surgery preop

• NPO, IVF (fluid and electrolyte assessment), pain medications, support

Appendicitis postop

• early ambulation, 

• pain management, 

• monitor temperature and surgical site (wound care), 

• start with clear liquids and advance as tolerated once NGT removed, 

• deep breathing, 

• assessment of BS, 

• supportive care

• Discharge once having gas

Appendicitis treatment: perforation

•  IV antibiotics, NG to suction until BS return, surgical incision care

• Family support; emotional support of child

Appendicitis nutrition

• NPO

• Clear liquids and advance as tolerated 

GU physical assessment

• Palpation, percussion

• Not much to inspect besides urine sample

GU health history

• Previous UTIs (on our radar if they’re recurrent), calculi (kidney stones), urinary stasis (not emptying bladder all the way), retention, pregnancy (have to urinate more frequently), STIs

  • Tea and soda can make kids more likely to have kidney stones (oscillate drinks) 🡪 need water and lemonade to decrease risk

• Family history of enuresis/bed wetting (at least 2x a week for at least 3 months and at least 5 years old)

• Urologic instrumentation

GU health history- medication list

• Medications = antibiotics, anticholinergics, antispasmodics (decrease function of the bladder by relaxing muscles)

  • Desmopressin acetate = decreases urine volume

  • Imipramine hydrochloride = inhibits urination

  • Oxybutynin chloride = reduces bladder contractions

GU hygiene 

• harder for females if not wiping front to back

  • Need education on assisting females in keeping their perineal area clean

GU health history- pattern of elimination

• voiding

  • In middle school/high school kids tend to hold their pee b/c they don’t want to leave their class

  • In elementary school the teachers do joint bathroom breaks at certain intervals

  • Expect kids to empty their bladder about 6x a day 🡪 need to tell kids this and potentially create a schedule