Pediatrics - Exam 1

Term infants

delivery at or beyond 37 weeks

Preterm infants

delivery before 37 weeks

late: between 34-37

extreme: before 28

Newborn

first 28 days of life

Newborn medical history

maternal and paternal PMH/genetics

maternal obstetric history

Tool used to estimate gestational age

Ballard calculator

Birth weight classification

extremely low <1000 g

very low <1500 g

low < 2500 g

normal >= 2500

SGA

small for gestational age

symmetrical (ht, wt, and hc are all under 10%) - early pregnancy problem

asymmetrical (just wt under 10%) - late pregnancy problem

AGA

appropriate for gestational age

LGA

large for gestational age

IUGR

intrauterine growth restriction

Intrauterine growth curves

Asymmetrical SGA

event late in pregnancy

placental insufficiency

pregnancy induced HTN

maternal age over 35

poor weight gain during pregnancy

multiple gestations

Symmetrical SGA

event early in pregnancy

maternal drug/alcohol use

chromosomal abnormalities

congenital viral infections

Newborn exam

observation, chest auscultation, inspection

first look for airway/skin color

Cyanosis and pallor in newborn, concern about...

cardiac output

APGAR scoring system

done at 1 and 5 minutes

repeated at 20 if low

Nursery examination - vitals

HR: 120-160

RR: 30-60

SBP: 50-70 and increased during first week

Nursery examination - auscultation

cardiac murmurs are common in first few hours

MC heart disease presentation: cyanosis and CHF with abnormal pulses/perfusion

Hyperbilirubinemia

jaundice

caused by increased levels of bilirubin - byproduct of normal breakdown RBCs by liver

yellow color of skin and eyes

measured via total serum bilirubin

Unconjugated (indirect) hyperbilirubinemia

jaundice present to some degree in most newborns due to immature liver function

appears after 24 hrs between 2nd-5th day of life and clears by 2 weeks

Increased bilirubin production - hemolytic causes

antibody mediated hemolysis: Coombs+ with ABO incompatibility and/or Rh isoimmunization

non immune hemolysis: Coombs- with hereditary spherocytosis, G6PD deficiency or other enzymes, or infectious sepsis

Increased bilirubin production - nonhemolytic causes

enclosed hemorrhage (cephalohematoma)

polycythemia

bowel obstruction (increased enterohepatic circulation)

Unconjugated (indirect) hyperbilirubinemia - Decreased rate of conjugation

Crigler-Naijar: glucuronyl transferase deficiency

Gilbert syndrome: glucuronyl transferase deficiency

Unconjugated (indirect) hyperbilirubinemia - other/unknown causes

race

prematurity

breast-milk jaundice

breast-feeding jaundice

Breast milk jaundice

seen at 1 week and peaks during 2nd-3rd week

something in milk affecting infant liver function

resolves in 6-12 weeks

no evidence of hemolysis, hypothyroidism, etc

Breast feeding jaundice

occurs in first week of life

inadequate milk intake leading to dehydration/low caloric intake

supplementation/breast pump

2-3 day post discharge visit

Jaundice evaluation

predischarge TSB or transcutaneous bilirubin (TcB) measurement

follow up within 24-48 hrs for all infants before 72 hrs of age

feeding/elimination history

birth weight and changes

assessment of blood type, Coombs, CBC with smear, serum albumin, G6PD test, fractionated bilirubin level

Bilirubin toxicity

neurotoxic

acute bilirubin encephalopathy

kernicterus - staining of basal ganglia and nuclei

Bilirubin toxicity treatment

phototherapy

exchange transfusion

Conjugated (direct) hyperbilirubinemia - anatomic causes

biliary atresia

choledochal cyst

Conjugated (direct) hyperbilirubinemia - metabolic causes

alpha 1 anti-trypsin deficiency

neonatal hemochromatosis

cystic fibrosis

hypothyroidism

hypopituitarism

Conjugated (direct) hyperbilirubinemia - infectious causes

TORCH

sepsis

UTI

Conjugated (direct) hyperbilirubinemia - toxic causes

parenteral nutrition

drugs

Respiratory distress in the newborn

meconium aspiration

hyaline membrane disease

persistent pulmonary HTN

pneumothorax

transient tachypnea

bronchopulmonary dysplasia

apnea of prematurity

Respiratory distress treatment

supplemental oxygen - PaO2 60-70mmHg

umbilical or arterial blood line with frequent blood gas

pulse ox monitoring

CXR, CBC, and blood glucose

Meconium aspiration

fetal aspiration of meconium and amniotic fluid with period of stress

respiratory distress, limpness, and cyanosis

Meconium aspiration risk factors

aging placenta past due date

hypoxia in utero

diabetic mother

difficult delivery

prolonged labor

preeclampsia/HTN

Meconium aspiration treatment

immediate suctioning

O2/ventilator support

ABX

Spontaneous pneumothorax

increased risk with positive pressure ventilation in delivery room

tachypnea at birth

confirmed with CXR

Spontaneous pneumothorax treatment

supplemental oxygen

needle thoracentesis or thoracostomy tube

Persistent pulmonary hypertension

respiratory distress day one of life

no decreased in pulmonary vascular resistance after birth

vasoconstriction post perinatal hypoxia

R--> L shunting through patent ductus arteriosus and/or foramen ovale

Persistent pulmonary hypertension treatment

oxygen and ventilatory support

correct underlying problems

Transient tachypnea

respiratory distress at birth

mild-mod O2 requirement

full or late term

non asphyxiated

short labor or C section

delayed clearance of fetal lung fluid

usual resolution in 12-24 hrs

Bronchopulmonary dysplasia

newborn needs breathing support 28 days after birth

chronic lung disease

infants with RDS

structural immaturity of lung - surfactant deficiency, atelectasis, pulmonary edema, barotrauma from ventilation, oxygen toxicity

Apnea of prematurity

respiratory pause more than 20 sec or any pause with cyanosis and bradycardia

diagnosis of exclusion

Mixed apnea

immaturity of central regulation

airway obstruction-patency

Apnea of prematurity treatment

caffeine citrate and home monitoring

resolves within 2 weeks of life

Hyaline membrane disease

MCC of respiratory distress

especially in infants 26-28 weeks

deficiency of surfactant --> poor lung compliance and atelectasis --> increased work of breathing --> respiratory failure

Patent ductus arteriosus

persistent connection between aorta and pulmonary artery (L-->R shunting)

usually closes within minutes to days after birth

if persistent, can damage lungs and heart or lead to CHF

Patent ductus arteriosus S&S

continuous murmur, wide pulse pressure, increased peripheral pulses

respiratory distress

poor feeding/growth

sweating with feeding

Patent ductus arteriosus diagnosis

echo/doppler color flow

Patent ductus arteriosus (treatment)

indomethacin

surgery/catheterization

Necrotizing enterocolitis (NEC)

MC acquired GI emergency

abdominal distention, vomiting, heme+ stool

pneumatosis intestinalis on abd XR

Necrotizing enterocolitis (NEC) treatment

bowel rest +/- NG tube

supportive care with IVF, +/-abx

surgery to remove necrotic bowel if perforation

Intraventricular hemorrhage

occurs in infants before 31 weeks by 4 days of life

subependymal germinal matrix by lateral ventricles

results from ischemia with reperfusion injury

Intraventricular hemorrhage S&S

CNS deterioration - ranging from rapid-gradual

Intraventricular hemorrhage diagnostics

routine cranial US on infants born before 32 weeks

Intraventricular hemorrhage treatment

supportive care

shunt

Vitamin K deficiency bleeding

aka hemorrhagic disease of newborn

low levels of vit K in newborn is common --> normally rise within a month after birth

Vitamin K deficiency bleeding pathophysiology

immature liver does not efficiently utilize vitamin K

low vit K stores since low content in breast milk, sterile gut, poor placental transport

Vitamin K deficiency bleeding preventative treatment

IM 1mg of vit K

bleeding risk is over 80x greater in those that do not receive it

Vitamin K deficiency risk factors

did not receive vit K injection at birth

exclusively breastfed

maternal use of anticoagulants, certain abx (cephalosporins), and sum anti-convulsant meds

Vitamin K deficiency bleeding S&S

bleeding post circumcision, at umbilical cord, GI bleed, mucus membranes, site of injections, hematuria, bruising, hematomas of the skull, intracranial

Classic onset of vitamin K deficiency bleeding

in breastfed babies between 2-7 day of life

Vitamin K deficiency bleeding evaluation

PT

INR

CBC

neuroimaging

Vitamin K deficiency bleeding treatment

parenteral vitamin K - 1-2mg IV or subq

FFP or prothrombin complex concentration

Esophageal atresia and tracheoesophageal fistula

blind esophageal pouch +/- fistula to trachea

hx of polyhydramnios

presents with copious secretions/drooling, choking with feeding, cyanosis and respiratory distress

Esophageal atresia and tracheoesophageal fistula diagnosis

CXR after NG tube placement

tube seen in blind pouch

with a fistula --> gas in bowel

Esophageal atresia and tracheoesophageal fistula treatment

supportive care with NG tube in proximal pouch low intermittent suction

surgery

r/o associated congenital abnormalities (VACTERL)

VACTERL association

V - vertebral defects

A - imperforate anus or anal atresia

C - cardiac anomalies (VSD)

TE - transesophageal fistula

R - renal anomalies

L - limb anomalies (radial agenesis)

babies with VACTERL have at least 3 or more of these

Intestinal obstruction

MC surgical emergency in neonates

MC caused by bowel atresias often caused by ischemic event during development

Duodenal atresia

congenital

higher the obstruction --> earlier presentation

emesis +/- bile

defects in vacuolization or ischemic event

often associated with Down Syndrome

Duodenal atresia diagnostics

Double Bubble on XR - dilated stomach and proximal duodenum and no air distally

Meconium ileus

at level of terminal ileum

failure to pass meconium in first 12-24 hrs

abdominal distention and bilious vomiting

high association with CF

Meconium ileus imaging

XR with multiple dilated loops of bowel, intra-abdominal calcification if in utero perforation occurred (meconium peritonitis)

barium enema shows microcolon

Meconium ileus treatment

radiographic contrast enema

surgery

Omphalocele

membrane covered herniation of abdominal contents in the base of the umbilical cord

most have abnormal karyotype or associated syndrome

Omphalocele treatment

keep it covered and moist at delivery

keep stalk free from vascular compromise

NG decompression and supportive care with IVF/glucose

rapid surgical correction

Gastroschisis

herniation of uncovered abdominal viscera through a defect in the abdominal wall

associated with IUGR and intestinal atresia

Gastroschisis treatment

place bowel or infant in silastic bowel bag

rapid surgical correction

Diaphragmatic hernia

herniation of abdominal organs into the hemi-thorax (left)

posterolateral defects in diaphragm

presents with respiratory distress from birth, poor breath sounds, scaphoid abdomen, and associated anomalies

Diaphragmatic hernia diagnosis

bowel loops seen in chest with mediastinal shift to opposite side on chest

Diaphragmatic hernia treatment

intubation, mechanical ventilation, GI decompression

surgery

pulmonary HTN may need ECMO

Neonatal sepsis - early

first day of life in first 12 hrs

low APGAR scores

poor perfusion

hypotension

respiratory distress - MC

Neonatal sepsis - late

greater than 3 days of life

decreased level of activity

poor feeding

hypotonia

increased oxygen requirement/apnea

associated with meningitis or other local infections

Neonatal sepsis - early etiologies

MC - group B strep or E coli

enterococcus

S aureus

streptococci

listeria monocytogenes

H influenza

Neonatal sepsis - late etiologies

coagulase neg staph aureus

gram negatives

candida

Neonatal sepsis diagnostics

CBC with low WBC, absolute neutropenia, elevated ratio of immature to mature neutrophils, thrombocytopenia

hyper or hypoglycemia

metabolic acidosis

CRP

cultures of blood, CSF, or other

Neonatal sepsis treatment

broad spectrum abx - ampicillin + 3rd gen cephalosporin or aminoglycoside

10-14 days of IV abx

supportive therapy

TORCH infections

pre and post natal

toxoplasmosis

other: varicella, syphillis, HIV, parvovirus B19, hepatitis B

rubella

cytomegalovirus

herpes simplex

Toxoplasmosis

transmitted via raw-undercooked meat with infective cysts or contamination from feline feces

asymptomatic, developmental delay, visual impairment, and learning disabilities

Congenital rubella

infection during first 8 weeks of pregnancy

microcephaly, encephalitis, cataracts, retinopathy, cardiac defects, deafness

CMV

MC virus transmitted in utero

hepatosplenomegaly

thrombocytopenia

microcephaly

intracranial calcifications-periventricualr

chorioretinitis

sensorineural hearing loss

treated with oral valganciclovir

Herpes simplex

perinatal infection transmitted from birth canal

localized, disseminated, or CNS disease

treated with acyclovir

Varicella

acquired in 1st 20 weeks of pregnancy

perinatal exposure

treated with varicella zoster immune globulin

Syphilis

transplacental passage

can lead to stillbirth or prematurity

asymptomatic newborns, hepatosplenomegaly, bony changes, hydrops, mucocutaneous lesions

Zika

can cause congenital anomalies

HIV

can be acquired in utero, perinatal, and via breast milk

treated with zidovudine

Parvovirus B19

erythema infectiosum - fifth disease

transmitted by respiratory secretions

anemia, hydrops, myocarditis, and fetal death

Hepatitis B

infants infected at birth

can develop chronic active hepatitis

born to HBsAg positive mothers