Transcript PEDIATRICS REVIEW

PEDIATRICS REVIEW
Jennifer K. Bell MHS, PA-C
TOPICS
The newborn assessment
 Newborn Problems
 Development
 Immunizations
 Specific Pediatric problems by
system
 Genetic Disorders
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THE NEWBORN ASSESSMENT
Apgar score
Exam
•SKIN: Erythema toxicum, mongolian spots
•HEENT: fontanelles
•CARDIAC: PDA
•ABD/GU: hypospadias, hydrocele
•MS: hip dislocation
•NEURO: babinski is normal
APGARS
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Done at 1 min and 5 min (may be repeated at 5
minute intervals for infants with 5 min scores <7)
Score
0
1
2
Heart Rate
Absent
<100
>100
Respiratory
effort
Absent,
irregular
Slow, crying
Good
Muscle tone
Limp
Some flexion
of extremities
Active motion
Reflex
Irritability
No response
Grimace
Cough or
sneeze
Color
Blue, pale
Acrocyanosis
Completely
pink
Erythema Toxicum neonatorum
(the rash of the newborn)
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COMMON skin condition in newborns, BENIGN
Appears in 50% of newborns
Usually between day 3 or life and 2 weeks of life
Rash: small, yellow to white papules surrounded by
red skin, usually on face, chest, back, upper arms,
sometimes on thighs.
Palms and soles are not involved
No treatment needed.
Usually fade and disappear over 2 weeks or more
Erythema
Toxicum
neonatorum
Acrocyanosis
Mongolian Spots
Benign Infantile Hemangioma
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Common
3 stages: Growth, Stabilization, Disappearance
Most common complication is ULCERATION
Usually no treatment required and a simple BIH resolves
on its own.
Further evaluation needed for :
Very large or segmented hemangiomas (>5cm)
 Multiple hemangiomas
 Located over sacral spine or at the midline
 Located near the eye
 Ulceration
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Physical Exam of head, face, and neck
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Asses head for its shape, symmetry, and fontanelles.
Caput succedaneum: It is subcutaneous and does cross suture
lines
Cephalhematoma: It is subperiosteal and does not cross suture
lines
Cephalohematomas, go away over the course of
a few weeks.
Caput succadaneum, goes away in a few days
CARDIAC
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Patent Ductus Arteriosus (PDA)
 Failure
of the ductus arteriosus to close in the first few days of
life OR reopening after functional closure.
 Up to 60% in preterm infants weighing < 1500 grams
 Female to male ratio= 2:1
 Systolic murmur that may be continuous, and is heard best at
the upper left sternal border.
 MANAGEMENT:
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Indomethacin: a prostaglandin synthetase inhibitor, 80% CLOSURE
RATE
SURGICAL closure.
The Abdomen
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Palpate the kidneys.
Anus is visualized, but digital examination is not
recommended unless obstruction is suspected. Meconium is
usually passed in the first 12-24 hours. An absence of the
passage of meconium by 24 hours may suggest either cystic
fibrosis or Hirschsprung’s Disease.
imperforate anus
Genitals : Inspect the external genitalia for ambiguity
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Inspect the glans for the location of the external urethral meatus. In Hypospadias, the
meatus is located in an abnormal ventral position. The presence of Hypospadias in
the newborn indicates a contra-indication for circumcision.
Genitals
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Testes should be descended into the Scrotum or in
the inguinal canals. You can ultrasound the area to
“find them” if you cannot feel them.
Hydroceles or hernias are not uncommon in
newborns.
After a breech delivery, the external genitalia are
often erythematous and edematous.
Musculoskeletal
The purpose of this examination is to detect gross abnormalities.
The appearance of the extremities at birth usually reflects the positioning of the child within the uterus.
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Examine the hips for the possibility of dislocation. The presence of asymmetric skin
folds on the medial aspect of the thigh, a positive galeazzi sign, and positive
ortolani and barlow maneuvers are suggestive of a dislocated femur. There are
risk factors associated with hip dysplasia, but one to remember is breech position.
(ALL breech babies get an ultrasound of their hips done to rule out dysplasia)
Positive galeazzi sign
Ortolani
Barlow
Babinski sign is normal in newborns
(> 2 years of age is abnormal)
NEWBORN ISSUES
Hypoglycemia
Jaundice
Hearing
Hypoglycemia<40mg/dL
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Differential
 Insufficient
glucose delivery
 Decreased glycogen stores
 Increased circulating insulin (infant of a diabetic mother,
maternal drugs)
 Endocrine and Metabolic disorders
 Sepsis
 Hypothermia
 Polycythemia
 Asphyxia
 Shock
Hyperbilirubinemia
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Total Serum Bilirubin
Bilirubin peaks at age 5-6 days, then normally stabilizes and drops.
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Low risk zone: do nothing
Low intermediate risk: possibly supplement if breastfeeding, recheck in 24
hours. Encourage to put in sunlight.
High intermediate risk zone: consider bili-blanket (photo therapy) or a bililight. Ensure not dehydrated. May need IV fluids.
Physiologic jaundice: normal
Breastfeeding jaundice: lack of breastmilk
Breastmilk jaundice: persists in breastfed babies for 3 weeks to 4 months.
Normal.
Remember Kernicterus
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Bilirubin >20-25
Can lead to permanent brain damage, even death.
Hearing
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Routine hearing screening prior to discharge, using
 Auditory
brainstem responses (ABR)
 Otoacoustic emissions (OAE)
 *If a child fails, further audiologic testing needed.
Development
Primitive Reflexes
Milestones
Sucking Response, Rooting Response
Palmar Grasp, Plantar Grasp
Moro’s Reflex
Asymmetric Tonic Neck Reflex (Fencer)
Galant Reflex
Developmental Milestones
Five Major Areas of Normal
Development
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1. Gross motor skills
 overall
movements of large muscles
 e.g., sitting, walking, running
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2. Fine motor/adaptive skills
 involve
use of small muscles of the hands
 ability to manipulate small objects
 problem-solving skills
 eye-hand coordination
Five Major Areas of Normal
Development
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3. Language skills
 hearing
 understanding
language
 use of language
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4. Personal/social skills
 socialization
 ability
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to care for personal needs
5. Cognitive skills
 ability
to use higher mental processes including
comprehension, memory, and logical reasoning
Gross Motor Skills progression
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1 month: raises head while prone
2 month: holds head in midline, lifts chest off table
4 months: Rolls from front to back, sits with support
6 months: sits unsupported, puts feet in mouth
9 months: pivots when sitting, crawls, pulls to stand, cruises
12 months: walks alone
15 months: creeps up stairs, walks backwards
18 months: runs, throws objects without falling
2 years: walks up and down steps without help
3 years: alternates feet going up steps, pedals a tricycle
4 years: hops, skips, alternates feet going down stairs
5 years: skips, jumps over low obstacles
Fine motor/cognitive progression
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1 month: visually fixes, follows to midline, tight grasp
2 months: no longer clenches fists tightly, follows object past midline
4 months: holds hands open, responds to visual threat, follows 180 degrees,
reaches with arms in unison, brings hands to midline
6 months: unilateral reach, uses raking grasp, transfers objects
9 months: uses immature pincer grasp, holds bottle, throws objects
12 months: uses mature pincer grasp, can make a crayon mark, releases
voluntarily
15 months: scribbles in imitation, builds a tower of 2 blocks
18 months: scribbles spontaneously, builds a tower of 3 blocks, turns 2-3 pages at
a time
2 years: Imitates stroke with pencil, builds tower of 7 blocks, turns pages 1 at a
time, removes shoes and clothes
3 years: copies a circle, undresses completely, partially dresses, unbuttons
4 years: copies a square, buttons, dresses self, catches a ball
5 years: copies a triangle, ties shoes, spreads with a knife.
Language Progression
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1 month: alerts to sound
2 months: smiles socially
4 months: laughs, orients to voice
6 months: babbles, lateral orientation to bell
9 months: says “mama dada” indescriminately, gestures, understands “no”
12 months: uses 2 words besides mama and dada, follows a one step
command with a gesture, waves bye bye
15 months: uses 4-6 words, follows a one step command without a gesture
18 months: 15 words, knows 5 body parts
2 years: uses pronouns (I, you, me) inappropriately, follows 2 step commands,
>20 word vocabulary, uses 2 word sentences
3 years: uses 250 words, 3 word sentences
4 years: knows colors, says a song or poem from memory, asks questions
5 years: prints first name, asks what a word means, knows opposites, counts
Social Skills progression
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1 month: regards race
2 months: recognizes parent
4 months: enjoys looking around
6 months: recognizes that someone is a stranger
9 months: explores environment, plays pat-a cake or peek a boo
12 months: imitates actions, comes when called, cooperates with dressing
15 months: uses a spoon and a cup
18 months: copies parents in tasks (cleaning), plays in company of other
children
2 years: parallel play, possibly chase games
3 years: group play, shares toys, takes turns, knows full name, age, gender
4 years: tells “tall tales”, plays cooperatively with a group of children
5 years: plays competitive games, abides by rules, likes to help in household
tasks.
Immunizations
Hep B
Rotavirus
Influenza
Pneumococcal
HIB
Polio
Dtap
Hep A
Varicella
MMR
HPV
Meningococcus
The schedule and also details about the conditions
FIRST A HINT
If you memorize a typical schedule of
immunizations at well child visits, you will
probably have a hard time missing a vaccine
question regarding timing of vaccinations.
Hep B
Transmission: percutaneous or mucosal
exposure to blood or body fluids, including
contact with contaminated surfaces
 Chronic HBV infection: 25% die prematurely
from cirrhosis or liver cancer
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Recommended: birth, 1-2 months, 6-18 months
3 dose schedule for adolescents and adults
Tetanus Diptheria and Pertussis
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DTaP, Tdap, Td
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2 months, 4 months, 6 months of age completes initial series
with boosters recommended at 18 months and between 4&6
years of age
Adults should have tetanus booster (Td) every 10 yrs
Tdap age 11 and older
NEW MOMS!!
Diptheria
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Bacterial infection spread by respiratory droplets
Sore throat, low-grade fever
Obstructive grayish membrane
Pertussis
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Whooping cough
Bordetella pertussis
Spread by respiratory droplets
Treat with Erythromycin, and treat close contacts
Tetanus
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Lockjaw
Clostridium tetani (anaerobic bacteria found in soil)
Toxin proliferates in wounds
Treatment with antitoxin
Signs: severe muscle spasm, trismus
Rotavirus
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Most common cause of severe gastroenteritis in
infants and young children
Near universal infection by age 5 years
U.S. – vaccine saves baby severe dehydration,
hospitalization
2-3 doses at 2/4/6 months
Influenza
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Yearly dose
Starts at age 6 months
Avoid if allergy to eggs
Inactivated and Live are available. Do not give live
vaccine to pregnant women.
Pneumococcal
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All children
4 doses: 2,4,6, 12-15 months
After age 2 in certain populations: asplenics, sickle
cell, complement deficiency
HIB
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Prevents Meningitis, Epiglottitis, Pneumonia
HIB: bacterial infection spread by respiratory
droplets
4 doses: 2, 4, 6, and 12-15 months
IPV-Poliovirus
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Fecal-oral transmission
Up to 95% of infections are
asymptomatic
Maintain high immunization rates
 Infections
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in Amish, 2005
29 countries reported wild poliovirus to WHO in
2009 or 2010 (plane ride away)
IPV schedule: 2, 4, 6-18 months, 4-6 years
Hep A
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Fecal-oral transmission
Food-borne outbreaks
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PA, 2003 (Chi-Chi’s, green onions)
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601 cases, 124 hospitalizations, 3 deaths
Risk factors include child or employee in day care,
travel
2 doses at least 6 months apart
Recommended at 12-23 months
MMR
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Live vaccine
First dose at 1 year, second dose at 4-6 years of
age.
Measles
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Begins behind the ears, and in 24-36 hours it spreads to the
trunk and extremities
In 3 days it reaches its maximum intensity and fades after 510 days.
Koplik spots
VITAMIN A
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Reduce morbidity and mortality in measles
Mumps
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Paramyxovirus
Spread by respiratory droplets
Signs and symptoms:
 Fever
with inflammation and swelling of Parotid glands,
Orchitis is possible
Rubella
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Most important consequences are to the unborn:
miscarriages, stillbirths, fetal anomalies (congenital
rubella syndrome).
Varivax
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Varicella Zoster
2 doses: 1 year of age and a booster at 4-6 years
of age
Spread by respiratory droplets
Signs: fever, flue-like symptoms, blistery itchy rash
that crusts over
Contagious until the rash becomes crusted
Reactivations later in life are possible (shingles)
HPV
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Approved for girls and boys ages 9-26 years of
age.
3 doses
 Dose
1
 Dose 2, in 2 months
 Dose 3, in 6 months from first dose
Meningococcus
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Protects against Neisseria meningitidis
 Meningitis
 septicemia
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High risk groups
 Dormatory
living
 Military
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Booster dose now approved, so 1 dose at age 11,
then 5 years later a booster dose.
Some Select Pediatric Problems
•Nasolacrimal duct obstruction
•Strep Throat
•Coarctation of the Aorta
•Tetrology of Fallot
•Pyloric Stenosis
•Intussusception
•Cryptorchidism
•Cradle Cap
•Diaper Rash
•Fifths disease: Erythema Infectiosum
•Roseola infantum (sixth disease)
•Kawasaki’s Disease
Nasolacrimal Duct Obstruction
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1st few weeks of life
Eye drainage and crusting
Treatment: you can clean the crusts, local massage, if
becomes infected tx that infection.
If not resolved on its own by one year-refer
Strep Throat: Group A (GABHS)
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Strawberry tongue
Scarletina rash: fine reddish sandpaper like rash
sparing the palms and soles
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Symptoms:
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 Exudative
tonsilitis
 Ant cervical lymphadenopathy
 Fever > 101F
 Absence of URI symptoms
 Abdominal Symptoms
Cardiac stuff
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Coarctation of the aorta
 Narrowing
of aorta causing systolic murmur and
differential in pulses in upper and lower extremities
 Tx: surgery
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Tetralogy of Fallot
 VSD,
RVH, Pulmonic Stenosis, Overriding Aorta
 Tx: complete surgical repair
Pyloric Stenosis
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In first month of life
More common in first born males
PROJECTILE VOMITTING
Palpable “olive mass”
Dx: ultrasound, barium swallow
Tx: surgery
Intussusception
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Telescoping of the bowel
Triad: vomiting, abd pain, CURRANT JELLY STOOL
DX and TX: barium or air enema
Cryptorchidism
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Increased risk of testicular cancer later in life
Undescended testes
Tx: surgery
Seborrheic Dermatitis (cradle cap)
Seborrheic Dermatitis (Cradle cap)
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Very common rash characterized by erythema and
greasy scales
Can affect the face, ears, and neck
Usually self limiting, but can be treated:
 White
petroleum
 Ketoconazole
 Hydrocortisone cream
Diaper Dermatitis
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Causes:
 Candida
(satelite lesions)
 Treatment:
antifungal (lotrimin)
 Prolonged
contact with urine or stool causes skin
breakdown
 Barrier
(desitin otc cream)
 Bacterial
 Strep
causes
B, “Perianal streptococcal infection” (Amoxil)
Diaper Rash
Prolonged Contact with
urine/feces
Candida=SATELLITE
LESIONS
Erythema Infectiosum-AKA Parvovirus
B19 or Fifth disease
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Common, Mildly contagious
Appears in epidemics, children between 5-14 years
of age
Transmitted via respiratory route and infected
blood
Can be asymptomatic
Prodromal symptoms
 Mild,
pruritus, low-grade fever, malaise, sore throat
(asymptomatic)
Erythema infectiosum-3 phases
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Stage 1: facial erythema (slapped cheeks)
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Stage 2: Net pattern erythema
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Red papules coalesce forming fiery red, slightly edematous, warm
plaques that are symmetric on both cheeks and spare the nasolabial
fold and circumoral region.
Fades in 4 days
Erythema in a fishnet-like pattern begins on the extremities 2 days after
the facial erythema. Extends to the trunk and buttocks fading in 6-14
days
Stage 3: recurrent phase
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The eruption fades and then reappears in previously affected sites on
the face and body during the next 2-3 weeks.
Triggers: emotional upsets, sunlight, temperature.
Roseola
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80% of all children by age 1, 90% by age 2
Most cases are asymptomatic OR occur with a fever of
unknown origin and NO rash
Most cases between 6 months and 4 years
Typically: very high fever, fever subsides and the rash
appears.
Febrile seizures common
Kawasaki Disease:
AKA Mucocutaneous lymph node syndrome
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Children: 7 weeks-12 years of age. (rare in adults)
An acute multisystem vasculitis of unknown
etiology (likely infectious cause)
Cardiovascular manifestations are the main cause
of morbidity
Genetic Disorders
Down Syndrome
Klinefelter Syndrome
Turners Syndrome
Marfan Syndrome
Down Syndrome-Trisomy 21
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Mental retardation
Single palmar crease
Hypothyroidism
Flat occiput, epicanthal folds, large tongue
Congenital heart disease
Turner Syndrome (XO)
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1/2500 affected
Physical characteristics
 Short
stature
 Broad chest with widely placed nipples
 Low hairline
 Low set ears
 Webbed neck
 Amenorrhea
 Sterility
 Congenital heart disease, DM, vision problems,
hypothyroidism, autoimmune diseases
Turner Syndrome
Kleinfelter Syndrome (XXY)
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Most common sex chromosome disorder
1/500
 Long legs
 small, firm testes and gynecomastia
 Osteoporosis
 Motor delay or dysfunction
 Language and speech problems
 Attention deficits
 Behavioral and psychosocial problems
 Dyslexia or reading dysfunction
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Decreased fertility (thought to be the cause of 2-3% of
male infertility)
Kleinfelter Syndrome
Marfan Syndrome
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Autosomal dominant, chromosome
15
Systemic connective tissue disease
Tall stature, long arms and fingers
Commonly scoliosis and pectus
excavatum
Displaced ocular lens
Mitral valve prolapse
Aortic root dilation-aortic
regurgitation
Aortic dissection and rupture
The Last time you will likely ever
endure a lecture with me 
GOOD LUCK TO YOU ALL!!!