Transcript Pediatric Potpourri

Pediatric Potpourri
Barb Bancroft RN,
MSN, PNP
[email protected]
The approach—newborn-- first 28-30
days of life
• Newborn vision is the only special sense that
is not mature at birth—visual acuity for a
newborn is 20/100 to 20/200
• Bladder capacity is only 15 ml (1-2 ml per hour
per kg of body weight)—lots of diaper
changes –6 to 8 wet diapers per day (weigh
their diapers for I & O)
The approach—infant-- 30 days to first
birthday
• Infant—consistency of care is essential for an
infant to develop trust; attend to expressed
needs immediately and consistently;
observing your facial expressions and moods
at one month
• Causes of depression
Mirror neurons
• Monkey see, monkey do
Learning, learning, learning…from
their environment
• Synapses are forming in the newborn and
infant brain at the incredible rate of 3
billion/second
• 28 week old fetus—124 million connections
• Newborn—253 million
• 8 months—572 million
The approach—toddler– One to 3
years old
• Toddler—autonomy; 300 words; begin to
tolerate some separation from primary
caregiver; temper tantrums are normal;
negativism is common; enjoy rituals,
consistency, learning toileting skills and
locomotion; egocentricity—don’t ever ASK if
you can do something…can I look in your
ears? NOOOOOOO
Which ear would you like me to look in
first?
• How do you look at the back of a toddler’s
throat?
• Open your mouth and pant like a doggie…
• Turn them upside down if they won’t open
their mouth…
Life revolves around their “head”…
DON’T go to the head first
The approach—the preschooler–
Three-years old to fifth birthday
• Preschooler—may talk incessantly (900 words); evolving
from “me, me, me” to seeing other’s viewpoints; use
magical thinking to solve problems and make sense of their
environment; may deny pain or other problems through
magical thinking (KENDRA)
May be dependent on security objects and items…HANDLE
WITH CARE AND DO NOT LOSE!! “ my bankie, my teddie”
• Preschoolers are also very aware of surroundings; always
include the child in conversations
• Don’t forget that hearing is the LAST special sense to go in
patients in a coma (STACY)
• CONCRETE thinking
The approach—school-age—Early: 6 to 10
Late: 10 to 12 years
• Acquisition of skills achieves a sense on
competency; failure to do this may lead to a
sense of inferiority
• Conscience is forming and peer group
interactions are highly influential
• Concrete thinking (early)
• Early—engage about schoolwork/sports/art
projects; encourage, praise efforts
• Late—computer games, sports
The approach—adolescence—
13 to 18 years
• Think beyond the present, are logical and use
reasoning (HAHAHA…)
• Abstract thinking
• Group identity is paramount and risk-taking is
common secondary to peer pressures
• The teen-age brain
The prime real estate of the brain—the
frontal lobe
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The prefrontal cortex
The motor association area
The motor cortex
Broca’s area—voluntary speech and
communication
• (the last 2 areas are well-developed in early
adolescence, however the prefrontal cortex
and the association areas are immature in
teenagers and continue to develop into the
early 20s)
So, what is the prefrontal cortex?
• It’s the center for judgment, insight, reasoning,
organization, future planning and problem solving,
and it has extensive connections with the emotional
and instinctual centers in the limbic system,
especially the amygdala.
• These levels are critical for emotional learning and
high-level self regulation.
• This is the pathway that is immature in the
adolescent brain
An easier way to put it—the prefrontal
cortex is your MOTHER
• And MOM is inhibitory---what’s the only word a
MOM needs to know? NO.NO.NO.NO.NO.
• Judgment and insight
• Socialization
• She puts the checks and balances on behavior—
especially on the amygdala—the wild beast within
(the instinctual nucleus of the brain)
• Parents, who act like parents, do this for teenagers;
parents who act like teenagers, do not
The anterior cingulate gyrus of the
prefrontal cortex
• Weighs options, makes decisions
• Girls brains mature faster; pruning starts
earlier than boys; girls move more quickly
toward maturation of all brain circuits and
mature 2-3 years earlier than boys
Neuronal dropout over the first 21 years—
inverse relationship to brain development
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PRUNING
# of neurons at birth ~ 4000 per mm³
# at age 21 ~ 2100 per mm³
#at age 75 ~ 1050 per mm³
While they’re pruning neurons, the
pathways are continuing to mature
• In addition, the pathways continue to
develop, gradually improving the precision
and efficiency of normal communication—
completed in the early 20s
• Especially the large bundle connecting the two
hemispheres with the limbic system—the
corpus callosum
• And the pathways connecting the prefrontal
cortex with the limbic system
The teenage limbic system
• The limbic areas mature earlier than those
involved in judgment, organization, and
reasoning
• DISCONNECT BETWEEN THE TWO
• This discrepancy between expressing feeling
vs. thoughtful evaluation accounts for many of
the teen behaviors that dismay parents and
teachers…
• “but he was such a sweet little boy…”
The Teenage Brain
• “I just don’t understand what
happened…”
The biggest MISCONCEPTION: Looking like an
adult means they act like an adult…
• Even though they may “look like adults”
adolescents find it more difficult to:
Think before acting…
• Difficult to interrupt an action under way—
ramming the back of the car in front of
you…for example
• The teenager freezes and screams (the limbic
system--emotions)
• The adult brakes hard and steers out of the
way (the prefrontal cortex)
• Back to the prefontal lobe that underlies
planning and voluntary behavior
Adolescents find it more difficult to:
• Choose between safer and riskier alternatives
• Difficulty resisting peer pressure
• It’s that prefrontal cortex again—they’re using
it somewhat, but it’s overtaxed…throw in peer
pressure…”Aw c’mon, just once…” the
stressful situation on an already taxed
prefrontal lobe may give in to better
judgment--
General Assessment--observation
• The most useful information is often acquired
by watching the child move and play.
• Mood and behavior
• Level of activity
• Toddlers usually lie down when sick
School bullying
• Schoolyard bullies are at increased risk to
grow up as abusive adults
• 4 x greater risk of striking or threatening an
intimate partner
• (Falb K, et al. Arch Pediatr Adoles 2011)
The order of the exam is not carved in stone…
• Try to do everything you can with infants and
toddlers sitting on their parent’s ankles or on
their lap
• Lying the child on the examination table
increases vulnerability
The order of the exam is NOT carved in stone…
• Take advantage of all opportunities
• If the diaper needs changing, check the
external genitalia
• If they offer…GO for it…
If they are relaxed, check their belly…
• “Ms. Bancroft, can I ask you a question?
• Have you ever….?”
Facial expressions and the cranial nerve exam…
• Frown, smile
• Facial nerve (VII)
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Cross your eyes… Make a face
Raspberry
CN III (oculomotor) – eyes
Facial expression (VII)
• Stick your tongue out (XII)
Don’t go to the painful area first..
• Compare the good side with the bad side—
looking at the good side first
• Good ear, bad ear
• Good ankle, bad ankle
State of hydration..
• Does this infant continue to feed?
• Quality of cry—tears (+ or -) grunting
• Drooling in kids can lead to dehydration
quickly
DIGRESSION ON HYDRATION I KIDS:
What 3 individual clinical features are the most
accurate for predicting 5% dehydration?
• Abnormal capillary refill
• Abnormal skin turgor
• Abnormal respiratory pattern
• What conditions can lead to dehydration?
Vomiting, diarrhea, diabetic ketoacidosis
(DKA)
Clinical findings to estimate the degree
of dehydration—mild dehydration
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Body fluid lost (mL/kg) -- < 50
Weight loss -- < 5%
State of shock--impending
General appearance—thirsty, alert, restless
Systolic blood pressure -- normal
HR -- normal
Respiration -- normal
Radial pulse – normal rate and strength
Clinical findings to estimate the degree
of dehydration—mild dehydration
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Capillary refill -- < 2 seconds
Skin elasticity – retracts immediately
Anterior fontanel -- flat
Mucous membranes – normal to dry
Tears – present
Skin color -- pale
Clinical findings —moderate
dehydration
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Body fluid lost (mL/kg) – 50-100
Weight loss – 5-10%
State of shock -- compensated
General appearance – thirsty, restless or
lethargic; irritable to touch
SBP – normal (orthostatic)
HR – slight elevation (orthostatic)
Respiration – deep, may be rapid
Radial pulse – rapid and weak
Clinical findings —moderate
dehydration
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Capillary refill –2-3 seconds
Skin elasticity – retracts slowly (> 3 seconds)
Anterior fontanel -- depressed
Mucous membranes – very dry
Tears – absent
Skin color -- gray
Clinical findings to estimate the degree
of dehydration—severe dehydration
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Body fluid lost (mL/kg) -- >100
Weight loss -- >10%
State of shock -- uncompensated
General appearance –drowsy, limp, cold, sweaty,
older may appear apprehensive, younger may be
comatose
SBP – very low or absent
HR – very elevated
Respiration – deep and rapid (hyperpnea)
Radial pulse – feeble, rapid, may be impalpable
Clinical findings to estimate the degree
of dehydration—severe dehydration
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Capillary refill -- > 3 seconds
Skin elasticity – retracts very slowly
Anterior fontanel -- sunken
Mucous membranes—very dry to cracked
Tears -- absent
Skin color -- mottled
Dehydration and urine
volume/osmolarity/specific gravity
• Mild less than 2-3 mL/kg/h; 600 mOsm/L;
1.010
• Moderate (oliguric) less than 1 mL/kg/h; 800
mOsm/L; 1.25
• Severe=anuric; maximal osmolarity; maximal
Assessment of pain
Vital signs in kids
• Weight (always!!! Basis for fluid replacement,
doses of medication, fluid and electrolyte
balance)
• Temperature—rectal, oral, axillary, tympanic
membrane
• Pulse (apical heart rate is best for young kids)
• Respirations—place your hand on the infant chest
to determine RR
• Blood Pressure—proper cuff size!!
• Pulse oximetry
Weight …
• Best index for a healthy child is appropriate weight
gain
• ALARM SIGN: Failure to gain weight is the first
indication of a serious problem
• Weights are essential for determining fluid
requirements and medication dosages
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Breast-fed babies gain weight more slowly
Benefits of breast feeding?
Teeth alignment
Immune system
Response to vaccines
IQ
Reduction in IgE-mediated allergies
Obesity in kids…33%
• Complications of obesity—the first generation
to NOT outlive their parents at the rate we’re
going
• Type 2 diabetes—50% of all kids with newly
diagnosed diabetes have type 2 diabetes
Is it any wonder?
• French fries are addicting (as are illicit drugs
and nicotine)
• The earlier you start…
• Areas of the brain that have to do with
addiction—the nucleus accumbens and the
ventral tegmentum
• Why isn’t anyone addicted to??
ALARM…rapid weight gain in girls
• RAPID weight gain in young girls or teenage
girls
• Sexual abuse ?
• PCOS (polycystic ovary syndrome)
Height/length
• Growth occurs in a step-wise pattern
• Spurts and lulls
• Vertical growth occurs during sleep when GH
is released during the late stages of SWS
• Do kids have growing pains at night?
• Adenoiditis, sleep apnea, and growth
• How about tonsillectomies for hyperactive
kids? ADHD?
Vertical growth and Iron
• Iron is essential for growth
• Iron deficiency anemia in kids usually due to dietary
deficiency OR
• Consider celiac disease
• (may also have a bleed somewhere, but most iron deficiency
in kids is due to a lack of adequate iron in their diet)
• Ulcerative colitis causes bleeding in GI tract
• Teenage girls? Menstrual blood loss…
Temperatures
• Temperature-regulating mechanisms are not well
developed in infants and young children, so
temperature may fluctuate as much as 3° F in one
day
• Young infants do not shiver and lack adequate
adipose tissue to insulate against heat loss
• Exercise, stress, crying, ambient temperature,
and diurnal variations all influence body
temperature
• Always document route (po, axilla, rectal,
tympanic)
Temperature
• The diagnosis of fever is a rectal temperature of at
least 38.0º C (100.4º F).
• For every one degree F increase in temp above
normal, the basal metabolic rate increases by 10%
• Increased BMR = increased insensible water loss
• SKIN: proportionally larger body surface area in kids
leads to greater amounts of body fluid loss and less
temperature regulation
• Dehydration occurs much sooner in kids with fever
• Drooling kids
Temperatures
• Rectal temps for mouth breathers, infants and
toddlers (0.9º F or 0.5º C higher than p.o.)
• Not a core temp
• Axillary temps most difficult to interpret but if
necessary add 1º C or 1.8º F
• Tympanic membrane temps are highly
variable and therefore can be inaccurate
(otitis, screaming kids, ear variation)
“I have a sore throat and I can’t
swallow…”
• Group A Beta Hemolytic Strep (peritonsilar
abscesses)
• 60% of 5-15 year olds with exudative
pharyngitis and fever above 101.8º, anterior
cervical nodes, NO cough, coryza, hoarseness
• PCN x 10 days
• Prednisone to reduce the inflammation
More strep notes
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40% of kids with sore throats have GABHS
10% of adults and teenagers
Rapid Ag test 80% accurate
10% of EBV will be + on rapid Ag test
#1 cause of recurrent strep is non-compliance; #2
cause is starting Rx too early—wait 48-72 hours
unless really sick or M13 or M18 strains; #3 cause is
retreating with same AB after failure of 1st Tx; #4
tooth brushes and dental devices re-infecting
Guidelines for Pre- and
Peritonsillectomy decisions
• Recurrent pharyngitis—some benefits for children with > 7
in past year; 5 per year in past 2 years; 3 infections per year
for past 3 years (documented w/ fever, cervical adenopathy,
tonsillar exudate, positive ASO titers
• Tonsillectomy for sleep-disordered breathing—might
benefit from tonsillectomy, particularly children with
growth retardation, enuresis, poor school performance or
behavioral problems, or tonsillar hypertrophy on physical
exam
• Baugh RF et al. Clinical practice guideline: tonsillectomy in
childrenn. Otolaryngol Head Neck Surg 2010 Dec 31;144:S1.
Fever
• Children with temps over 40º C or 104º F
• Only 1 in 4 have a bacterial infection
• Moral of the story—all high fevers are NOT associated with
bacterial infections
• Acute pyelonephritis (could follow an untreated strep
throat—APSGN0
• Fever, nausea, vomiting, back pain (CVA tenderness)--girls
The treatment of fever
• 50% of Primary Care Practitioner’s alternate
acetaminophen with Ibuprofen to reduce fever
• This is NOT condoned by the American Academy of
Pediatrics; the most common cause of overdose
deaths in the US is acetaminophen, owing to its
widespread availability and frequency of use in
accidental and suicidal intoxications.
• Use one or the other
• Acetaminophen is preferable for any viral illness
Fever
• Aspirin can be used with Kawasaki’s disease and
Juvenile Rheumatoid Arthritis
• Aspirin should NOT be given to a child with a viral
syndrome
• Reye’s syndrome (rare today) due to parents
using acetaminophen or ibuprofen for fever in
kids with infections
• If it looks like Reye’s syndrome (liver dysfunction
and brain dysfunction) and there is NO history of
aspirin ingestion—consider another diagnosis
Fever
• Factitious fever—uncommon in kids unless the
caretaker is causing the fever (Munchausen’s
by proxy)—single spikes of temperature
cannot be documented by the HCW and only
occur when the caretaker is present (distant
spouse, M.D. shopping, knowledge of health
care, history of sibling death such as SIDS)
How many infections are too many infections in
kids?
• Consider age: in an infant, 3-4 infections in 6
months is too many
• During the second year of life, toddlers
experience an average of 8 respiratory
infections
• Double that number if they are in day care
• After age 2, 3-4 infections per year; should
gradually decrease until they enter school
Hypothermia and infections
• Is a fever good for you?
• Immune system mounts an response to boost the
WBC function
• Also fever inhibits the ability of bacteria to use
iron (no iron? No growth)
• But…hypothermia is an ALARM sign in a child
with an infection (sepsis)
• Salmonella sepsis
• NO REPTILES FOR KIDS UNDER 6
Simple febrile seizures
• Common—observed in 2-5% of children
• DEFINITION: a seizure accompanied by fever, but not central
nervous system infection or electrolyte imbalance; simple
febrile seizures are primary generalized seizures that last for
less than 15 minutes and do not recur within 24 hours
• Usually observed with viral infections of the upper respiratory
or GI tract (usually occurs within the first 24 hours of the
illness); after a vaccination (6x greater on the day of DPT up to
72 h after (6-9 per 100,000); 8-14 days after MMR vaccine 2534/100,000)
Simple febrile seizures
• Most common between the ages of 18 months to 3 years
range is 6 months to 60 months)
• Family history is common; M > F (pathway maturity)
• Treatment? Rectal diazepam if needed…most of the kids have
finished seizing by the time they arrive at the ER
• ALARM: COMPLEX febrile seizures: focal, lasting longer than
15 minutes or recurrence within 24 hours; potential long-term
complications with complex although the risk is low;
developing subsequent seizures WITHOUT FEVER may cause
impaired cognition long-term
Inquiring minds want to know…what is the risk of
developing a seizure disorder after a simple febrile
seizure?
• In otherwise normal children, the risk of developing a
seizure disorder is 2% after a simple febrile seizure
• HOWEVER: if any of the following is present…
1) close family history of nonfebrile seizures
2) prior neurologic or developmental abnormalities
3) atypical or complex seizures occurred
1 risk factor? 3% All three? 5 to 10%
(Waruiru C, Appleton R: Febrile seizures: an update. Arch
Dis Child 2004; 89:751-756.
To LP or not to LP?
• LP should be performed only in a child with a seizure, fever and signs of
meningitis
• LP is an option in any child aged 6 to 12 months with a simple febrile
seizure if immunization status is unknown or insufficient for H. flu type b
or strep pneumoniae
• LP is an option for a child with a simple febrile seizure who has received
antibiotics
• An EEG should not be performed in an otherwise neurologically healthy
child with a simple febrile seizure
• Serum electrolytes, calcium, phosphorus, magnesium, blood glucose, and
a CBC should not be performed routinely to identify the cause of a simple
febrile seizure
• Subcommittee on Febrile Seizures. Clinical Practice Guideline—
Neurodiagnostic evaluation of the child with a simple febrile seizure.
Pediatrics 2011 Feb;127:389)
Febrile seizures and meningitis
• Seizures occur in 30% of patients with meningitis; kids who
have seizures within the first 48-72 hours of illness generally
have a better prognosis are and less likely to require longterm anticonvulsant therapy than those that occur later in the
course of the disease
• Focal seizures are more likely to occur in this group with
localized infection or with subdural effusions
• Generalized seizures are due to diffuse irritation of cerebral
tissue, diffuse ischemia, and hyponatremia
Status epilepticus in kids
• 0-5 minutes: Airway, O2, suction as needed
• Vital signs, pulse oximetry, ECG
• IV, draw blood for glucose, electrolytes, CBC, toxicology, blood
culture, anticonvulsant levels
• Antipyretics as needed
• 5 to 10 minutes: if hypoglycemic, administer 2 mL/kg of D25W
or 5mL/kg of D10W; monitor O2 with pulse oximetry
• IV lorazepam 0.1 mg/kg (up to 4 mg) OR rectal diazepam, 0.5
mg/kg rectally
• 10 to 20 minutes—re-administer lorazepam if seizures persist
• If seizures persist, fosphenytoin is the anti-convulsant of
choice for kids
• (see BIB: Abend, Goldstein, and Yoong)
Heart rate
• Very labile in kids; more sensitive to the
effects of illness, exercise, medication, pain
and emotions
• Check for a full minute; use apical rate
• Check radial with femoral for coarctation of
the aorta (more valuable in older infants and
toddlers; in infants a PDA may shunt blood to
the lower extremities, bypassing a severe
coarctation (M>F)
Heart rate
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Newborn (100-180)
Infant (80-120)
Toddler (80-110)
School age (70-110)
Adolescent (55-90)
Heart rate
• Beta-2 agonists for bronchodilation in
asthmatics may cause tachycardia even tho’
they are beta-2 specific
• Tremor and saturation of B-2 receptor sites
• An extremely rapid heart rate occurs before
notable alterations in blood pressure in infants
and young children
Respirations
• Newborn (35+) (obligate nose breathers for
the first 8 to 12 weeks)
• Infant (30+)
Place your hand on the chest of a
neonate/infant to assess respirations; count
for a full minute, especially with a resp. illness
• Toddler (23-25)
• School-age (17-21)
• Adolescent (17-18)
Respirations
• The respiratory tract of a young child has a
narrow lumen until age 5—makes the child more
prone to airway obstruction and respiratory
distress from inflammation
• Aspiration and obstruction of airway by a foreign
object is the number 1 cause of death children
less than a year old
• Sudden onset of acute respiratory distress in an
infant crawling on floor—consider foreign object!
• ALARM SIGN: tripod breathing position (jaw
thrusted out, leaning forward, drooling)
• Acute epiglottitis (rare today except in kids
who have NOT been vaccinated, kids coming
from foreign countries without vaccinations
• Hemophilus influenzae B
• Peritonsillar abscess
Respirations
• ALARM: Respiratory rates greater than 70 in
infants—consider lower respiratory tract
infection; under one year consider Respiratory
Syncytial Virus (RSV), bronchiolitis*
*underdeveloped intercostal muscles—severe
retractions
• HEAD INJURY: Hyperventilating a child with
increased ICP reduces the PaCO2 from 40 mmHg
to 25-30 mmHg and decreases the cerebral blood
volume by 50% and increases CPP (cerebral
perfusion pressure)—and that’s
GOOD…decreases cerebral edema
Acidosis
• Kussmaul respirations (deep, regular, rapid)
and acidosis—the physical findings of acidosis
are primarily respiratory—tachypnea,
hyperpnea, hyperventilation
• Mnemonic K U S M A L
• Ketones, Uremia, Salicylates, Metabolic,
Alcohol, Lactic
Digression—Type 1A diabetes
• 25% of all kids with type 1 diabetes present with
diabetic ketoacidosis
• Autoimmune disease—inability to recognize self vs.
non-self
• Antibodies formed against pancreatic beta cells or
components of pancreatic beta cells
• Genetic susceptibility with an exogenous trigger-Type 1 diabetes—HLA-DR3, HLA-DR4
Type 1 diabetes—how many triggers?
• genes that have been found mediate the
immune response to viruses (explains the viral
hypothesis as a possible trigger)
Too little dirt
• The hygiene hypothesis—back to the
GUT bacteria and priming the immune
system
• Germphobic (mysophobic) *moms
• Triclosan/antibiotic soap maniac moms
• LET THEM EAT DIRT!
• (*irrational fear of DIRT)
Too little sun
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Sunphobia
Sunscreen maniac moms
Kids playing inside (the “thumb tribe”)
Pushes the immune system in the wrong direction—
2 pathways—TH1 and TH2
Taking the TH2 pathway increases the risk of allergies
and autoimmune disease
Too much cow’s milk…
• Decreased risk in babies who are breast fed
• Increased risk in drinking cow’s milk—is there
a protein that aggravates the immune system
and triggers diabetes in genetically susceptible
individuals?
• Large scale clinical trial called TRIGR, testing
this hypothesis and is scheduled for
completion in 2017
Ketoacidosis (DKA) in Type 1 diabetes
• Type 1 ketoacidosis is a prolonged fasting state
with an absolute deficiency of insulin;
• Accounts for 8-29% of all hospital admissions in
kids with T1DM; usually precipitated by an
infection
• Glucagon is working overtime—glycogenolysis;
lipolysis; and gluconeogenesis
• Weight loss; hyperglycemia; osmotic diuresis;
fatty acid release (ketones)—DKA
• A young girl presenting with alternating
hypoglycemia and DKA – consider an eating
disorder
Diabetic Ketoacidosis (DKA)
• Dehydration (assess based on clinical signs
mentioned earlier)
• Abdominal pain (may mimic acute appendicitis)
• Anorexia, weight loss
• Kussmaul’s respirations (acidosis)
• Tachycardia
• Weakness, fatigue
• Fruity breath odor
• hypotension
• N or V
• Confusion, decreased reflexes, coma
Lab tests
• Severe hyperglycemia (greater than 250 mg/dl) and
glycosuria
• Acidosis less than 7.30 with PCO2 less than 40 mm Hg
• Ketonuria (ketonemia) and glycosuria
• Serum bicarb (HCO- 3) is usually less than 15 mEq/L
• Serum potassium may be low, nl, high (remember there is
always significant K+ depletion regardless of initial level)
• Serum sodium is usually decreased as a result of
hyperglycemia; if elevated initially it may be due to
dehydration
• AG = Na+ - (Cl- + HCO- 3) (usually greater than 10)
Lab tests
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CBC, UA, cultures to R/O infection
Ca+, Mg+, Ph+
BUN, Creatinine
Amylase and liver enzymes for patients with
abdominal pain
• CXR to R/O pneumonia (may initially be
negative due to dehydration)
Diabetic Ketoacidosis (DKA)
• Dehydration is your biggest concern
initially (usually 6-8 L fluid deficit – 100
ml/kg)
• GIVE FLUIDS…what kind? NS or RL
• Not too fast—should not exceed
4L/m2/24 hours to avoid cerebral edema
Then what?
• Then what? Regular insulin IV (0.15 to 0.3
U/kg as an initial bolus (controversial about
the bolus) and then 0.1 U/kg / hour (make
sure the serum K+ is greater than 3.3 mEq/L
to prevent life-threatening hypokalemia
Then what?
• Potassium replacement: average total potassium loss in
DKA is 300 to 500 mEq
• Amount varies with the patient’s serum K+ level, degree of
acidosis, and renal function
• As a ROT (rule of thumb) potassium replacement may be
started when there is no ECG evidence of hyperkalemia
(tall, narrow T waves; decreased or absent P waves; short
QT intervals; widening of the QRS complex)
• Monitor serum K+ every hour for first 2 hours and then
every 2-4 hours
• Should bicarb be given? Routine use is contraindicated;
only consider if pH is less than 6.9 and HCO-3 is less than 5
DKA
• Average mortality rate is 5-10%
• In kids less than 10, DKA causes 70% of
diabetes-related deaths
• Cerebral edema occurs in 1% of episodes of
DKA I children and is associated with a
mortality rate of 40-90%
• (Ferri’s Clinical Advisor 2011)
Blood pressure
• Recommend at age 3;
• Ages 1 to 5
90 + age in years/56
4 yr- old? 94/56
• Ages 6 to 18
83 + 2 x age in years/52 + age in years
8-yr old? 83 + 16/52+8 = 99/60
• Proper cuff size (no less than ½ to no more than
2/3 of the length of the upper arm or upper leg)
Hypertension in kids
• Consider family history and the size of the child
• Most hypertension in kids is due to primary kidney disease
(80%); renal artery stenosis (12%); coarctation of the aorta
(2%)
• APSGN (1-2 weeks after strep throat; 2-4 weeks after strep
pyoderma)
• Cola-colored urine, BP 150/100; pulse 100
• 1-2+ protein
• Nephritis vs nephrotic syndrome (3+-4+)
Acute renal failure in kids
• #1 cause
• E. Coli O157:H7
Common Skin Conditions
• Is it a macule, papule, vesicle, bullae?
• Skin color—gray or mottled, jaundice (best
observed in natural light)
Common skin conditions…
• Petechiae—what are the causes in kids?
• Platelet type bleeding? Mucous membrane
bleeding, oozing around IV sites, hematuria,
purpura, petechiae due to low platelets
• Causes of thrombocytopenia?
Infectious diseases associated with low
platelets…
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N. meningitidis
H. influenzae B
N. gonorrhea
S. pneumoniae
S. pyogenes
Y. pestis
Enteroviruses
Rubella
Rickettsiae
EBV, CMV
Kawasaki’s
HIV
Child abuse and bruises
• “The skin and the bones tell a story that the
child is either too young or too frightened to
tell.”
• Normal bruises are facial scratches, one bruise
on forehead (toddler), knee and chins
Age of bruise
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Is it red, purple, blue?
Green, yellow, brown?
Reddish/blue less than 1 day, immediate
Blue/purple 1-5 days
Green 5-7 days
Yellow 7-10 days
Brown 10-14 days
Resolution 2-4 weeks
Bite marks
• From another child? Adult? Animal? A
diameter of greater than 3 cm between
cuspids is human
• Human bites—crescent
• Dogs—tear and triangular
• Cats--puncture
French proverb: The mother of a child who elects to
re-wed, has taken the enemy into her bed.
•
“A child living with a stepparent is 100 times as
likely to suffer fatal abuse.”
•
(Daly M, Wilson M. The Truth About Cinderella: A Darwinian View of
Parental Love, Yale University Press, 1999)
•
A stepparent can also be an opposite –sex partner
who lives with the parent, like a boyfriend.
Eating disorders
Pet abuse/spousal abuse/child abuse
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•Report child
abuse!!
•It’s the LAW!!
Head and neck—facial features
• Head circumference—measure as a vital sign in
infants; measure heads daily (paper tape measure) in
infants with meningitis
• Rapid head growth in first year, suspect autism
• Head size—small head circumference at birth
followed by a sudden excessive increase in head size
the first year
• The most severely autistic children were those
whose heads grew the fastest--especially the frontal
lobe
• (Courchesne E. JAMA July 16, 2004)
Autism--what do we know?
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Exposure to toxins during pregnancy?
Gene(s) malfunction?
Older parents?
The “GEEK” theory
Broken Mirror Neurons?
Clues to early diagnosis of autism?
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The failure to mimic a mother sticking out her tongue
Failure to respond to name being called
Quieter, more passive
Lag behind in motor skills like sitting up/reaching for
objects
• Show extreme reactivity—either getting upset with a
new toy or activity or barely noticing it at all
• May exhibit repetitive behaviors—rocking, fixation,
less responsive to playful interactions with others
Speech development and autism
• In speech development, the best results are
achieved when deliberate exercises are
instituted prior to the age of two. By the time
the child is 3 or 4, deficits can be reduced but
fundamental changes are no longer possible,
because the critical period for speech
development has passed.
Microcephaly
• Slowed brain growth
• Hair patterns
• Neurologic “soft-signs”
Microcephaly and fetal alcohol syndrome
• Alcohol is the most prevalent teratogen
in Western society
• Microcephaly; short palpebral fissures,
hypoplastic maxilla and midface with a
short upturned nose, thin upper lip,
hypoplastic philtrum
• Average IQ of 68? Where will that get
you?
Down syndrome
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Flat facies
Frontal upsweep
Low-set ears
Cerebellar immaturity
Small oral cavity giving the appearance of a
large tongue
FLK and COUP syndrome
• Hmmm…
Lymph nodes
• Note local drainage patterns
• Local lymphadenopathy?
• Generalized lymphadenopathy?—2 or more
contiguous node groups
• Check liver, spleen, joints, thyroid
• Consider hematologic malignancies
• Connective tissue disorders
Neck mobility
• Nuchal rigidity and meningitis
• The sucker sign
• Brudzinski’s sign—flexion of the thighs results when
the patients neck is passively stretched (meningeal
irritation)
• Kernig’s sign—flex the hip to 90 degrees and attempt
to extend the knee. The limitation of the knee
extension results from painful resistance (meningeal
irritation)
• The extraordinary success of the H. flu and
pneumococcal vaccines
Cranial nerves
• CN II and III (Optic and
Oculomotor)(congenital ptosis)
• Head injury and pupil size (hippus)
• Anisocoria and pupil size
• EOMs
• Fundoscopic exam
Shaken impact or shaken baby
syndrome
• Shaken impact or shaken baby syndrome—
injury more likely to occur from severe shaking
and/or impact
• Retinal hemorrhages may be the only sign in
an infant of a nonaccidental shaking injury
• Almost never caused by seizures alone
ALARM:
• The prevalence of retinal hemorrhages with a
seizure of only about 3 per 10,000 – an extremely
small likelihood
• If retinal hemorrhages are found in a child with
seizures, the possibility of nonaccidental injury
must be explored
• Curcoy AL, Trencha V, Morales M, et al: Do retinal
hemorrhages occur in infants with convulsions?
Arch Dis Child 94:873-875, 2009.
Shaken impact or shaken baby
syndrome—retinal hemorrhages
• Should always be assessed in an infant whose
presenting symptoms include excessive irritability,
lethargy, apnea, respiratory stress, sepsis-like
appearance, seizures, or coma
• The symptoms may be mild and nonspecific and may
mimic symptoms of viral illness, feeding disorder or
dysfunction or even colic; may have a history of poor
feeding, vomiting, lethargy, and/or irritability that may
have gone on for days or months
• If suspicious, should be followed by a skeletal series
and cranial neuroimaging (CT or MRI)
Skeletal survey up to 2 years of age
• Yield diminishes after age 2 and is of little value after
age 5
• About 30% of child abuse cases involve bone
fractures
• Anterior and posterior rib fractures from squeezing;
humerus, femur are most common broken bones
• Total skeletal x-ray
(AAP, Radiology: Diagnostic imaging of child abuse.
Pediatrics 123:1432, 2009
Corneal reflex (CN V and CN VII)
• Extensive area of brainstem
• Absence of corneal reflex in a comatose child
is indicative of a brainstem injury
• Bell’s palsy—Herpes simplex; Borrelia
burgdorferi
• Racoon eyes—basilar skull fracture
Raccoon eyes
• Kids with disabilities have a higher risk of child
abuse
Ear exam
• Favorite hiding place for foreign objects
• Kids vs. adults hiding places
• Don’t ask if you can do something—if an ear
hurts, ask “which ear can I look in first”?
• Clean ‘em out. 1 mL of Colace liquid (not
Colace syrup); wait 10-15 minutes and irrigate
with saline or H2O
Another sign of child abuse—
“boxing ears”
• By virtue of their location, kids ears don’t get
bruised with the normal rough and tumble
play
• If they fall on their side, either their shoulder
protects them or their head hits first
Some notes on acute otitis media…
• To treat or not to treat?
• Children who are treated with
amoxicillin fare significantly
better and achieve symptom
resolution much quicker
• However, some pediatricians still
advocate watchful waiting in kids
over 2 who look well, are old
enough to easily evaluate, and
can be comforted with supportive
care
• UNDER 2? Always treat with AB
• 2/3 Strep. pneumonia, moraxella,
H. flu
• (Tahtinen PA, Hoberman, Klein)
• Bilateral otitis = bacterial
infection (H. flu)
Embryologic development
• Ears and kidneys
Nose and Throat
• One airway theory—sinuses, nose, throat,
airway
• Sinusitis, allergic rhinitis and asthma
• Kiesselbach’s triangle and nose bleeds
The belly
• Ticklish? How to relax the abdomen…
• Inspection…scars, bruises, distention
• The 6 F’s (fat, flatus, feces, fibroid [tumor],
fluid, fetus)
• Auscultation—are the bowel sounds present
or absent; does it matter where you place the
stethoscope?
• Palpation for lumps, bumps, growths, tumors,
pain
Selected conditions
• Gastroenteritis—peri-umbilical pain
• Acute diarrhea—watery—think viral? Bloody—think
more invasive, bacterial?
• Acute appendicitis—no more than a 5-day disease;
periumbilical pain followed by pain in the RLQ;
increased WBC with left shift; fever; psoas sign; “the
walk”
• ULTRASOUND
• Other causes of abdominal pain in kids
Selected conditions
• Child abuse injuries
• The second most common cause of death from child
abuse is injury to abdominal organs
• Small intestine, especially the duodenum, followed
by mesenteric hemorrhage and liver lacerations
• Accidental abdominal injury—spleen, kidney
• Liver damage and coagulopathies
The lungs…
• Pearls for listening
• Warm the stethoscope
• Bell for low pitched sounds; diaphragm for high-pitched
sounds; Use a pediatric stethoscope for young kids and infants
• Right mainstem bronchus is more vertical than left; foreign
objects down the right
• Sudden onset of acute respiratory distress especially if they
are crawling
The lungs
• Rule of finger—the trachea of the child is approximately the
diameter of the child’s little finger
• Drinking straw 4mm—adult trachea is 20 mm
• Obligate nose breathers up to 6 months of age; listen over the
nose with stethoscope
• 6 months to 6 years—abdominal breathers—feel abdomen
• After 6 they use the intercostals; (intercostal retractions are
prominent as the flexible rib cage is pulled inward)
The lungs
• Inspection—shape of thorax, AP/lateral diameter;
deformities? Retraction of interspaces?; tracheal tug;
Rate and rhythm?
• Respiratory excursion
• Auscultation—where should you place your
stethoscope? Remember that the base of the lungs is
POSTERIOR; mainstem bronchii are in the 2nd
intercostal spaces; trachea over the suprasternal
notch
The lungs…
• Crackles—popping, crackling sounds produced by fluid in the
alveolar spaces or small airways; re-opening of closed alveoli
on inspiration
• Early inspiratory crackles? Late?
• Rhonchi—coarse, rumbling, low-pitched produced by airflow
over secretions in the larger airways
• Wheezes—mostly high-pitched sounds heard during
expiration or inspiration
The lung…
• Vagal input to the bronchii—increased input during sleep
causing bronchoconstriction; 8% bronchoconstriction in the
healthy lung vs. 56% in the asthmatic lung
• Peak bronchoconstriction between 4-6 a.m.
• Compare PEFRs at 3 p.m. and 3 a.m. to assess nocturnal
respiratory function
• The ONE AIRWAY hypothesis—allergic rhinitis and asthma
Asthma…IgE mediated disease
• Mast cell release of primary and secondary
granules
• Histamine causes the first wave of symptoms
• Triggers—dust mites; cat, dog, cockroach
dander; ragweed, pollen
Criteria for assessing the severity of an
acute asthma attack--mild
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PEFR –70-90% of predicted personal best
RR, resting or sleeping – nl to 30% above mean
Alertness--normal
Dyspnea—absent or mild; speaks in complete
sentences
Pulsus paradoxus--< 10 mm Hg
Accessory muscle use—none to mild
Color--good
Auscultation—end-expiratory wheeze only
O2 saturation 95%
PCO2--< 35
Criteria for assessing the severity of an
acute asthma attack--moderate
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PEFR – 50-70% of predicted personal best
RR, resting or sleeping – 30-50% increase above mean
Alertness--normal
Dyspnea—moderate; speaks in partial phrases
Pulsus paradoxus—10-20 mm Hg
Accessory muscle use—moderate intercostal retraction s;
use of SCM; chest hyperinflation
Color--pale
Auscultation—wheeze during entire inspiration and
expiration
O2 saturation—90-95%
PCO2--< 40
Criteria for assessing the severity of an
acute asthma attack--severe
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PEFR –< 50% predicted of personal best
RR, resting or sleeping – increase > 50% above the mean
Alertness—may be decreased
Dyspnea—severe; speaks only in single words or short phrases
Pulsus paradoxus—20-40 mm Hg
Accessory muscle use—severe intercostal retractions,
tracheosternal retractions with nasal flaring during inspiration
Color—possibly cyanotic
Auscultation—breath sounds becoming inaudible
O2 saturation--< 90%
PCO2 40
Treatment of an acute asthmatic
episode
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•
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Coffee is a potent bronchodilator if in a pinch
Beta-2 agonists
Corticosteroids
Epinephrine if severe
May see magnesium sulfate added for smooth
muscle relaxation and additional
bronchodilation
RSV…respiratory syncytial virus
• Fusion protein protein that results in cells
forming a syncytium; Jan/Feb/March; RR=70;
rhonchi, crackles, wheezes; rhinorrhea;
pharyngitis
• Monoclonal antibody—palivizumab (Synergis)
targets the fusion protein
• Pneumonia—place child on the good side;
gravity increases perfusion to the good lung
facilitating optimal CO2 and O2 exchange
CV exam
• Auscultation—4th L ICS medial to MCL in kids under 7
• Lub
dub
Lub
dub
systole
diastole
sys
diastole
Remember: Significant heart disease is infrequent in the absence
of a murmur
Remember: Almost all (99.9%) of diastolic murmurs are
pathologic;
Functional murmurs—systolic; grade 1 or 2; low-pitch; 3rd to 4th
ICS @ L parasternal border; no thrills, clicks; increases with
fever and increased with sitting up
Non-innocent or organic murmurs before the age of 3, consider a
congenital heart defect; after age 3, consider rheumatic
valvulitis
Pathologic systolic murmurs
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Harsh with thrill
Pansystolic or late systole
Murmur at upper L sternal border
Grade 3 or greater
Early or mid-systolic click
Abnormal second heart sound
Non-cardiac factors that indicate a murmur is
pathologic
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Growth retardation
Dysmorphic features
Exertional blueness, pallor, dyspnea with minor exertion
Short feeding times and volumes in infants
Syncopal or presyncopal episodes
IV drug use
Maternal history of DM (VSD, transposition, septal
hypertrophy)
• FH
• Fetal alcohol syndrome—pulmonic stenosis, VSD
Neuro exam
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Age related for mental status exam
Observation
Developmental tests
Major components—mental status, Cranial
nerves (see head and neck exam), motor
exam, cerebellar function, sensory exam
Motor exam
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Gait
Deep tendon reflexes
Babinski sign (always positive prior to walking)
Cerebellum—muscle tone, synergy, widebased gait
• Abnormal (involuntary) movements—
kernicterus
Sensory testing
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Dermatomes
Touch
Pain
Temperature
Proprioception
Symmetry is the RULE!!
Get this for your practice/ER/Pediatricians
in your community!
• Centers for Disease Control and Prevention.
Heads Up: Brain Injury in Your Practice: A Tool
Kit for Physicians.
(http://www.cdc.gov/ncipc/tbi/Physicians_Tool_Kit
The end.
• Barb Bancroft, RN, MSN, PNP
• [email protected]
• www.barbbancroft.com
Bibliography
• Abend NS, et al. Anticonvulsant medications in the pediatric emergency
room and ICU. Pediatr Emerg Care 24:705-718, 2008
• Bailey BN et al. Prenatal exposure to binge drinking and cognitive and
behavioral outcomes at age 7 years. Am J Obstet Gynecol 2004
Sep;191:1037-43.
• Briggs GG, Carson DS, Rayburn WF. Which medications are safe in
pregnancy? Patient Care 2000 (December 30): 19-44.
• Christensen D. Sobering work: unraveling alcohol’s effects on the
developing brain. Science News 2000 (158): 28-29.
• Fackelmann K. The birth of breast cancer: do adult diseases start in the
womb? Science News 1997 (151):108-109.
• Falb K, el al. School bullying perpetration and other childhood risk factors
as predictors of adult intimate partner violence perpetration.” Arch
Pediatr Adoles 2011; DOI: 10.1001/archpediatrics.2011.91
• .
Bibliography
• Goldstein J. Status epilepticus in the pediatric emergency
department. Clin Ed Emerg Med 9:96-100, 2008
• Hoberman A et al. Treatment of acute otitis media in children under
2 years of age. N Engl J Med 2011 Jan 13;364:105.
• Klein JO. Is acute otitis media a treatable disease? N Engl J Med
2011 Jan 13; 364:168.
• McCormick DP et al. Laterality of otitis media: Different clinical and
micorbiologic features. Pediatr Infect Dis J 2007 Jul;26:583-8.
• Nathanielsz, P. The Prenatal Prescription. HarperCollinsPublishers,
2001.
• Rodier PM. The early origins of autism. Scientific American:
February 2000; 56-63.
• Rosenberg, A. Brain damage caused by prenatal alcohol exposure.
SCIENCE & MEDICINE 1996 (July/August):42-52.
Bibliography
• Tahtinen PA et al. A placebo-controlled trial of antimicrobial
treatment for acute otitis media. N Engl J Med 2011 Jan
13;364:116.
• U.S. Food and Drug Administration. Antidepressant Use in Children,
Adolescents, and Adults. October 15, 2004.
http://www.fda.gov/cder/drug/antidepressants/default.htm
• Verstraeten T et al. Safety of thimerosal-containing vaccines: A twophased study of computerized health maintenance organization
databases. Pediatrics 2003 Nov; 112-1039-48.
• Advice on SSRIs in Children from the Committee on Safety in
Medicine. February 12, 2004.
http://medicines.mhra.gov.uk/aboutagency/regframework/csm/cs
mhome.htm
• Yoong M, Chin RFM. Management of convulsive status epilepticus
in children. Arch Dis Child Educ Pract 94:1-9; 2009.
When should the diagnosis of a seizure disorder be
considered rather than a breath-holding spell?
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•
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When the precipitating event is minor or non-existent
History of no or minimal crying or breath holding
Episode lasts longer than one minute
Period of post episode sleepiness is longer than 10 minutes
Convulsive component of episode is prominent and occurs
before cyanosis
• Occurs in a child less than 6 months or greater than four years
Maternal infections and schizophrenia
• (References for those interested in this hypothesis: Brown AS,
Biol Psychiatry, 49; 473-86, 2001. L. Shi et al., “Maternal
influenza infection causes marked behavioral and
pharmacological changes in the offspring.” J Neurosci, 23:297302. Gilmore JH, et al., “Maternal infection regulates BDNF
and NGF expression in fetal and neonatal brain and maternal
fetal unit of the rat,” J Neuroimmunol, 138; 49-55, May 2003
Karlson H et al, “Retroviral RNA identified in the cerebrospinal
fluids and brains of individuals with schizophrenia,” Proc Natl
Acad Sci, 98:4634-9, 2001. Baker HF, et al.Psychol Med,
19:325-9, 1989)
• Clinical Quips (Barb’s newsletter), January 2004.
Weights in critically ill infants…
• Factor in diaper weight, arm board weights,
bandages
• Daily weights and volume determinations
• Mild dehydration with less than 5% weight
loss; moderate dehydration with 5-10%;
severe dehydration greater than 15%
A brief digression on the WBC and differential
• Segs-- 57-63% of total (bacteria, acute necrosis)
Bands (precursor to the segs) – 0-4%
• Lymphs– 30% (viral infections; immune cells)(Young
kids with greater # of lymphs—immune system is
“learning”)—(acute lymphoblastic leukemia most
common in this age group)
• Monocytes– 4% (chronic inflammation; APC)
• Eosinophils– 3% (allergies, parasites, drug fever)
• Basophils– 1% or less (mast cells in tissues)
FINALLY! The teleologic explanation for nosepicking…
• Nose-picking and the immune system. Dr. Friedrich
Bischinger, a leading Austrian pediatrician, extols the virtues
of nose-picking. He states: “With the finger you can get to
places you just can’t reach with a handkerchief, keeping your
nose far cleaner.” He goes on to say, “And eating the dry
remains of what you pull out is a great way of strengthening
the body’s immune system.” Ingesting the bacteria from your
nose helps inoculate the body against illness, which may be
why this instinctual behavior evolved. Dr. Bischinger also
recommends that parents encourage children to pick their
nose; somewhat of a new approach to the habit wouldn’t you
agree? (The Week, April 9, 2004)
www.Mdcalc.com
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Answers on Pediatric ET cuff size
Fluid calculations
Absolute neutrophil counts
Pulmonary Expiratory Flow estimates per age
GREAT WEBSITE…