•••••• • acofp••••••• INTENSIVE
UPDATE & BOARD REVIEW
AUGUST 25 - 27, 2017 Loews Chicago O'Hare Hotel
Rosemont, IL
INNOVATIVE • COMPREHENSIVE • HANDS-ON
acofp Am eric an College of
Osteopathi c
Family Physicians
The American College of Osteopathic Family Physicians is accredited by the
American Osteopathic Association Council to sponsor continuing medical
education for osteopathic physicians.
The American College of Osteopathic Family Physicians designates the lectures
and workshops for Category 1-A credits on an hour-for-hour basis, pending
approval by the AOA CCME, ACOFP is not responsible for the content.
Baby Basics
Sarah Hall, DO
8/7/2017
1
Sarah Hall, D.O.
August 25, 2017
ACOFP Intensive Board Review
Jaundice of the newborn
Ill appearing newborn
Failure to thrive
Respiratory Distress
Vaccination Schedule
Overview
Presentation
Differential Diagnosis
Risk factors
Work up
Treatment
Medication
8/7/2017
2
You are seeing a newborn at 72 hours for an initial newborn visit in your office. The baby was born at 37 weeks after a prolonged spontaneous vaginal delivery and is exclusivelybreastfeeding. APGARS were 7/9. Discharge papers indicate that at 24 hours, the baby’s Total bilirubin level was 8 mg/dL and the direct bilirubin level was 0.2 mg/dL. The baby is urinating and sleeping well. Baby is nursing every 3-4 hours for 10 minutes but falls asleep at the breast. +3 stools in the last 24 hours. On exam, the infant is afebrile and has lost 13 percent of birth weight. The baby’s eyes, tongue, and skin appear yellow down to the umbilicus. Anterior fontanelle is open and flat. The infant is alert and has a 3 cm cephalhematoma located on the left parietal area. A STAT Total serum bilirubin level is 17 mg/dL at 72 hours.
A. Reassure parents that this is normal. And follow up in 2 days.
B. Repeat total and direct bilirubin levels in 24 hours.
C. Admit the infant and initiate exchange transfusion.
D. Initiate home phototherapy and follow up in 24 hours.
E. Admit the infant and start IVIG and phenobarbital.
Overview
Presentation
Differential Diagnosis
Risk factors
Work up
Treatment
Medication
8/7/2017
3
Defined as total serum bilirubin > 95th % on the Bhutani nomogram
Almost all newborns will have values over 1 mg/dL
Yellowish discoloration of skin and conjunctiva caused by bilirubin deposition
Normal neonatal changes lead to increased bilirubin, decreased bilirubin clearance, and increased enterohepatic circulation
Unconjugated hyperbilirubinemia
Peak values occur at 48-96 hours
Resolves within 1-2 weeks after birth
Pathologic if noted in the first 24 hours of life
Different nomograms for determination of risk, phototherapy treatment and exchange transfusion
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4
Bryon J. Lauer, and Nancy D. Spector
Pediatrics in Review 2011;32:341-349
Bryon J. Lauer, and Nancy D. Spector
Pediatrics in Review 2011;32:341-349
8/7/2017
5
Bryon J. Lauer, and Nancy D. Spector
Pediatrics in Review 2011;32:341-349
Increased production
ABO incompatibility
Red blood cell membrane defects
Erythrocyte enzymatic defects
Polycythemia (delayed cord clamping)
Sepsis
Criggler-Najjar syndrome
Gilbert Syndrome
Maternal Diabetes
Congenital hypothyroidism
Galactosemia
Decreased clearance
Increased enterohepatic circulation Intestinal obstruction
Breastmilk jaundice
Breastfeeding failure
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Severe neonatal bilirubinemia TB> 25 mg/ dLBilirubin induced neurologic dysfunction (BIND) Acute bilirubin encephalopathy (ABE)
Chronic and permanent sequela of BIND=kernicterus
***Treated with exchange transfusion
Transcutaneous bilirubin level
Serum total and direct bilirubin
CBC
Blood type
Continuation of breastfeeding, increase frequency, formula supplementation
Phototherapy
Exchange transfusion
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Phototherapy
24 hrs-bilirubin > 12 mg/dL
48 hrs-bilirubin>15 mg/dL
72 hrs-bilirubin>18 mg/dL
24 hrs-bilirubin >19 mg/dL
48 hrs-bilirubin > 22 mg/dL
72 hrs- bilirubin>24 mg/ dL
Exchange transfusion
Phototherapy
24 hrs-bilirubin > 10 mg/dL
48 hrs-bilirubin>13 mg/dL
72 hrs-bilirubin>15 mg/dL
24 hrs-bilirubin >16.5 mg/dL
48 hrs-bilirubin > 19 mg/dL
72 hrs- bilirubin> 21 mg/ dL
Exchange transfusion
IV Immune globulin (IVIG) if isoimmune hemolytic disease
Ursodeoxycholic acid Cholestatic jaundice
No longer routinely used Phenobarbital
Metalloporphyrins
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8
You are seeing a newborn at 72 hours for an initial newborn visit in your office. The baby was born at 37 weeks after a prolonged spontaneous vaginal delivery and is exclusively breastfeeding. APGARS were 7/9. Discharge papers indicate that at 24 hours, the baby’s Total bilirubin level was 8 mg/dL and the direct bilirubin level was 0.2 mg/dL. The baby is urinating and sleeping well. Baby is nursing every 3-4 hours for 10 minutes but falls asleep at the breast. +3 stools in the last 24 hours. On exam, the infant is afebrile and has lost 13 percent of birth weight. The baby’s eyes, tongue, and skin appear yellow down to the umbilicus. Anterior fontanelle is open and flat. The infant is alert and has a 3 cm cephalhematoma located on the left parietal area. A STAT Total serum bilirubin level is 17 mg/dL at 72 hours.
A. Reassure parents that this is normal. And follow up in 2 days.
B. Repeat total and direct bilirubin levels in 24 hours.
C. Admit the infant and initiate exchange transfusion.
D. Initiate home phototherapy and follow up in 24 hours.
E. Admit the infant and start IVIG and phenobarbital.
A. Reassure parents that this is normal. And follow up in 24 hours.
B. Repeat total and direct bilirubin levels in 48 hours.
C. Admit the infant and initiate exchange transfusion.
D. Initiate home phototherapy and follow up in 24 hours.
E. Admit the infant and start IVIG and phenobarbital.
8/7/2017
9
A 2 week old infant presents to the office with mom and complaint of poor feeding for the last 2 days. She has noted that the infant has been more fussy and has been sleeping more. The baby has been formula feeding 2 ounces/ 3-4 hours until 2 days ago at which time the infant would only take 1 ounce every 6-8 hours. Urine output has decreased from 8 wet diapers to 3 wet diapers/ day. Vitals-T101 ° F, HR-167, RR-60-fontanelle is sunken and MM dry. Heart is tachycardic without Murmurs. Lungs are clear without wheezes or rhonchi. Abdomen is soft, no masses or erythema noted at umbilicus. Decreased bowel sounds in all quadrants.
A. Administer acetaminophen and obtain labs.
B. Administer ceftriaxone and follow up in 24 hours.
C. Admit the infant for work up and empiric antibiotics.
D. Arrange for home health to assist with improved feeding.
E. Obtain prenatal history and birth history.
Overview
Presentation
Differential Diagnosis
Risk factors
Work up
Treatment
Medication
8/7/2017
10
Fever is the prominent symptom of many different conditions
May be the only symptom on presentation
Fever is a rectal temperature over 100. 4°F or 38 ° C
Type of Infection Prevalence
Urinary tract infection 72
Bacteremia 20
Soft tissue infection/ cellulitis 13
Meningitis 6
Pneumonia 4
Temperature over 100. 4°F or 38 ° C
Lethargy
Poor tone
Poor feeding
Respiratory distress
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Infections Bacterial sepsis
UTI
Bacteremia
Pneumonia
Cellulitis
Meningitis
Omphalitis
Osteomyelitis
Pyelonephritis
Pertussis
Viral infection HSV
Enterovirus
Influenza
Varicella
Adenovirus
RSV
Bronchiolitis
Myocarditis
Trauma Inflicted Head injury Unintentional injury
Neurological Seizures
Surgical/ GI Pyloric stenosis Malrotation with
volvulus Incarcerated hernia NEC
Cardiac Congenital heart
Disease SVT
Endocrine Congenital Adrenal
hyperplasia
Metabolic Hypoglycemia Inborn errors of
metabolism
Hematologic Acute bilirubin encephalopathy
Toxic exposure Methemoglobinemia
Carbon monoxide poisoning
Medication overdose
Apparent life threatening event (ALTE)
Kawasaki Disease
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Age younger than 28 days
Maternal infection in pregnancy or labor
Temperature over 40° C (104 F)
Unimmunized
Prematurity
Chronic illness
Antibiotic administration with in 7 days
Social barriers to follow up
History and Physical
CBC and CMP
Blood culture
Urine culture
CSF culture
Total and direct bilirubin if jaundiced
HSV culture of vesicles if present
CXR
Abdominal xray and ultrasound
CT head and skeletal survey if trauma or abuse
EKG if CHD suspected
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Age Organism Empiric treatment
Neonate (<28 days) GBSE.ColiListeriaEnterococcusS. AureusHSV
Ampicillin + Cefotaxime OrAmpicillin + Aminoglycoside and Acyclovir
Infant (29-90 days) S. PneumoniaH. InfluenzaN. MeningiditisGBSE.ColiListeriaEnterococcusS. AureusPseudomona
Well appearing, no CSFpleocytosisCeftriaxone or cefotaxime
CSF pleocytosis or ill appearingVancomycin + Ampicillin and Ceftriaxone or cefotaxime
A 2 week old infant presents to the office with mom and complaint of poor feeding for the last 2 days. She has noted that the infant has been more fussy and has been sleeping more. The baby has been formula feeding 2 ounces/ 3-4 hours until 2 days ago at which time the infant would only take 1 ounce every 6-8 hours. Urine output has decreased from 8 wet diapers to 3 wet diapers/ day. Vitals-T101 ° F, HR-167, RR-60-fontanelle is sunken and MM dry. Heart is tachycardic without Murmurs. Lungs are clear without wheezes or rhonchi. Abdomen is soft, no masses or erythema noted at umbilicus. Decreased bowel sounds in all quadrants.
A. Administer acetaminophen and obtain labs.
B. Administer ceftriaxone and follow up in 24 hours.
C. Admit the infant for work up and empiric antibiotics.
D. Arrange for home health to assist with improved feeding.
E. Obtain prenatal history and birth history.
8/7/2017
14
A. Administer acetaminophen and obtain labs.
B. Administer ceftriaxone and follow up in 24 hours.
C. Admit the infant for work up and empiric antibiotics.
D. Arrange for home health to assist with improved feeding.
E. Obtain prenatal history and birth history.
An 18 month old male presents to your office for well child check. His weight has dropped from 30th
percentile to 5th percentile since his last well check 6 months ago. Father reports that he is a picky eater and mainly consumes apple juice and rice cereal. He has refused milk and his mother believes he is lactose intolerant and therefore has not been receiving any. He has 6 wet diapers/ day and 4-5 loose stools/ day. On physical exam you note symmetric bruising on the upper arms and healed circular burns on the buttocks and lower back.
A. Contact a pediatric dietician for outpatient consultation
B. Inpatient admission for work up and initiation of nutritional support
C. Notify local authorities to escort the father out of the clinic
D. Perform labs to screen for underlying medical disorder
E. Perform skeletal survey for inherited bone disease
8/7/2017
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Overview
Presentation
Differential Diagnosis
Risk factors
Work up
Treatment
Medication
FTT is a sign not a diagnosis
Occurs in 5-10 % of children in primary care
Also called weight faltering, or failure to gain weight appropriately Weight loss across two standard deviations on the
growth chart
Weight less than 80 percent ideal weight for age
Weight below the 2nd percentile
Rate of daily weight gain less than expected
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Thorough History and Physical with basic labs Birth history
Prenatal history
Past Medical History
Family History
Review of Systems
Diet and feeding Food preferences, length of feeding
HIV
Primary immunodeficiency
Intestinal malabsorption
Congenital heart disease
Kidney disease
Liver disease
Chronic lung disease
Malignancy
Prematurity
Developmental delay
Congenital anomalies
Intrauterine exposures
Lead poisoning
Anemia
Inadequate intake **
Increased metabolic rate
Maldigestion
Malabsorption
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Poverty
Health and nutrition beliefs
Social isolation
Life stressors
Poor parenting
Disordered feeding techniques
Substance abuse, mental health disorder
Violence or abuse
History Possible Diagnosis
Diarrhea Malabsorption
Chronic constipation Decreased appetite
Recent travel Infectious diarrhea
Chronic OM Immune deficiency/ structural defect
Snoring Adenoidal hypertrophy
Wheezing Mechanical obstruction or ILD
Vomiting GERD or obstruction
Gagging or prolonged time Oral motor dysfunction
Polyuria, polydipsia, polyphagia Diabetes
Frequent infections Immune deficiency
Examination Potential Diagnosis
Vital signs Adrenal, thyroid, renal, increased metabolic demands
General appearance Anemia, malnutrition, genetic syndrome
Head and neck: Microcephaly Neurologic disorder, Fetal alcohol syndrome
Delayed closure of fontanelle Vit D deficiency, low thyroid
Thyroid enlargement Thyroid disease
Chest: wheezing Cystic fibrosis, asthma
Cardiac murmur Congenital or acquired heart disease
Abdomen: Distention, increased BS Malabsorption
Hepatosplenomegaly Liver disease, glycogen storage disease, malignancy
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Examination Potential Diagnosis
Genitourinary: Abnormalities Endocrinopathy
Rectal fistulae Crohn disease
Musculoskeletal: Clubbing Cardiac or pulmonary disease with low O2
Bony deformities Rickets
Edema Protein deficiency
Neurologic: Abnormal DTR’s Cerebral palsy
Hypotonia, weakness, spasticity Cerebral palsy
Skin and Mucus Membranes: Scaling Zinc deficiency
Bruises, rashes Possible abuse or neglect
Lab evaluation
CBC
UA
CMP
Lead testing
Phosphorus
Albumin level
Upper GI
SBFT
Swallow study
Gastric emptying scan
Diagnostic imaging
Nutritional
Medical
Developmental/behavioral
Psychosocial factors
Interdisciplinary approach is critical to success
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Indication for Hospitalization Severe malnutrition
Dehydration
Serious illness
Child at risk for harm
Failed OP management
Severe parental mental health disorders
Loss of follow up due to location or transportation
Finding Mild Moderate Severe
Pulse Normal Rapid Rapid, weak, orabsent
Systolic pressure Normal Normal to low Low
Respirations Normal Deep, may be ↑ Deep, ↑ or ↓
Buccal mucosa Normal Sunken Markedly sunken
Anterior fontanelle
Normal Sunken Markedly sunken
Eyes Normal Sunken Markedly sunken
Skin turgor Normal Reduced Tenting
Skin Normal Cool Cool, mottled, acrocyanosis
Urine output Normal Markedly reduced
Anuria
Systemic signs Increased thirst Listlessness, irritability
Grunting, lethargy, coma
Outpatient management generally successful
Dietary advice by PCP or pediatric dietician
Changes to feeding environment
Home based support (visiting nurse)
Referral to community, state or federal assistance programs
Regular follow up to monitor weight
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Frequent small volume feedings
Calorie dense formulas progressed slowly
Monitor for refeeding syndrome or “nutritional recovery syndrome”
Involve an interdisciplinary team
Daily multivitamin with iron and zinc
Cyprohepatidine 0.12 mg/ kg twice daily
Appetite stimulant used only in children that have not had catch up weight in 3-6 months of fortification of food of formula/ breast milk
Supplementation of oral feedings with nasogastric feedings during the daytime or nighttime
8/7/2017
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An 18 month old male presents to your office for well child check. His weight has dropped from 30th
percentile to 5th percentile since his last well check 6 months ago. Father reports that he is a picky eater and mainly consumes apple juice and rice cereal. He has refused milk and his mother believes he is lactose intolerant and therefore has not been receiving any. He has 6 wet diapers/ day and 4-5 loose stools/ day. On physical exam you note symmetric bruising on the upper arms and healed circular burns on the buttocks and lower back.
A. Contact a pediatric dietician for outpatient consultation
B. Inpatient admission for work up and initiation of nutritional support
C. Notify local authorities to escort the father out of the clinic
D. Perform labs to screen for underlying medical disorder
E. Perform skeletal survey for inherited bone disease
A. Contact a pediatric dietician for outpatient consultation
B. Inpatient admission for work up and initiation of nutritional support
C. Notify local authorities to escort the father out of the clinic
D. Perform labs to screen for underlying medical disorder
E. Perform skeletal survey for inherited bone disease
8/7/2017
22
A 3 year old female presents with her mother with a complaint of productive cough over the last 3 days. The sputum is described as copious and is yellowish white in color. She does go to day care and there have been several kids out due to some respiratory illness. Vitals T 102°F, HR 150, RR 65. She is ill appearing and clinging to her mother. Heart is tachycardic without murmur. Lungs reveal rhonchi in the right lower lung field. Retractions are noted.
A. Group B streptococcus
B. Klebsiella pneumonia
C. Listeria monocytogenes
D. Pseudomonas aeruginosa
E. Streptococcus pneumonia
Overview
Presentation
Differential Diagnosis
Risk factors
Work up
Treatment
Medication
8/7/2017
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10 % of pediatric emergencies
20 % of hospitalization
Respiratory arrest is the most common cause of cardiac arrest in pediatric patients
Tachypnea *
Retractions-sternal and intercostal *
Nasal flaring
May be agitated, restless or combative
May have wheezing or stridor
May have accessory muscle use
Sniffing or tripod position may be assumed
Cyanosis may be present
Age Respiratory rate
0-3 month 43
3-6 month 41
6-9 month 39
9-12 month 37
12-18 month 35
18-24 month 31
2-3 year 28
3-4 year 25
4-6 year 23
6-8 year 21
8-12 year 19
12-15 year 18
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Respiratory
Infection
Asthma
Anaphylaxis, inhalation, chemical exposure
Foreign body
Airway anomalies
Chest wall trauma or abnormalities
Pulmonary conditions or trauma
Congenital heart disease
Acute decompensated heart failure
Myocarditis
Pericarditis
Arrhythmia
Shock
Cardiac tamponade
Myocardial infarction
Cardiovascular
Nervous system
Depressed ventilation Ingestion
CNS trauma
Seizures
CNS infections
Hypotonia
Pulmonary aspiration
Hypoventilation due to abdominal pain or distention
Gastroesophageal reflux with pulmonary aspiration
Gastrointestinal
Metabolic or Endocrine
Metabolic acidosis
Hyperthyroidism
Hypothyroidism
Hyperammonemia
Hypocalcemia
Acute severe anemia
Methemoglobinemia
Carbon monoxide poisoning
Acute chest syndrome
Hematologic
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Chronic health problems
Family history of asthma or cardiac disease
Immune compromise
Prematurity
Tobacco exposure
Poor nutrition
Lack of vaccinations
HISTORY
Trauma
Change in voice
Onset and duration of symptoms
Associated symptoms
Exposures
Previous episodes
Underlying medical problems
Mental status
Position
Cyanosis
drooling, dysphagia
Vitals
Pulmonary Tracheal deviation
Accessory muscle use
Auscultation
Palpation/ Percussion
CNS
Cardiac Gallop, murmur, rales
JVD, hepatomegaly
GI
Metabolic Kussmaul breathing
Endocrine
Allergy
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Upper Airway
Sniffing position
Nasal flaring
Prolonged inspiration
Retractions
Abnormal Voice
Stridor
Barking cough
Transmitted upper airway sounds
Retractions
Nasal flaring
Prolonged expiration
Wheezing
Grunting
Rales
Pleural rub
Bronchophony
Pulsus paradoxus
Lower Airway
Pulse oximetry
ABG
Chest Xray
CBC
CMP
Blood cultures, UA, CSF If infection with CNS
signs
EKG
Echocardiography and ultrasound
Lateral neck X-ray
Abdominal X-ray
CT head and chest
Airway management (PALS or NRP)
Needle decompression if indicated
Disease specific management: Croup: racemic epinephrine and decadron
Tracheitis: intubation and antibiotic until cultures return
Retropharyngeal abscess: ENT consultation with antibiotics and steroids
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Age Organism Treatment
<1mo Group B strep, E. Coli, Klebsiella, Pseudomonas, Listeria
Amp + Aminoglycoside OR Amp + Cefotaxime
1-3 moH. influ, S. pneumonia, Grp A or B strep, pertussis
Amp + Cefotax
3mo- 5 yrS. pneumonia, H. influ, Staph aureus, Grp A Strep, pertussis
Cephalosporin + anti-staph or pertussis if indicated
>5yo S. pneumonia, H. influ, Grp A Strep
PCN OR Amp OR Cephalosporin + anti-staph or pertussis if indicated
Bronchodilators may be helpful
Supplemental oxygen
IV hydration
Nebulized hypertonic saline
Antibiotics are not indicated
Chest physiotherapy and OMT
8/7/2017
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Oxygen
IV hydration
Nebulized albuterol
Steroids-IV or oral
IV Magnesium
A 3 year old female presents with her mother with a complaint of productive cough over the last 3 days. The sputum is described as copious and is yellowishwhite in color. She does go to day care and there have been several kids out due to some respiratory illness. Vitals T 102°F, HR 150, RR 65. She is ill appearing and clinging to her mother. Heart is tachycardic without murmur. Lungs reveal rhonchi in the right lower lung field. Retractions are noted.
A. Group B streptococcus
B. Klebsiella pneumonia
C. Listeria monocytogenes
D. Pseudomonas aeruginosa
E. Streptococcus pneumonia
8/7/2017
29
A. Group B streptococcus
B. Klebsiella pneumonia
C. Listeria monocytogenes
D. Pseudomonas aeruginosa
E. Streptococcus pneumonia
Questions:
Sarah Hall, D.O.
OSU Center for Health Sciences
Associate Professor of Family Medicine
8/7/2017
30
Gastroesophageal Reflux
Pyloric stenosis
Constipation
Overview
Presentation
Differential Diagnosis
Risk factors
Work up
Treatment
Medication
Physiologic
Passage of gastric contents into the esophagus
Brief therefore no symptoms
Often resolves by 1 year of life
GERD-symptoms with esophagitis, poor weight gain, and respiratory symptoms
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Frequent regurgitation
Present in 67 % of infants by 3-4 months
May be associated with periods of prolonged crying
Infant may draw the legs up with or soon after feeding
Sleep disturbances noted
Often not associated with weight loss
GI obstruction or disease
Bilious vomiting
GI bleed
Forceful vomiting
Onset of vomiting after 6 months
Constipation
Diarrhea
Abdominal tenderness
Recurrent pneumonia
Hepatosplenomegaly
Bulging fontanelle
Macrocephaly or microcephaly
Seizures
Hypotonia
Chronic infection
Systemic or Neurologic disease
Nonspecific symptoms Fever
Pneumonia
Lethargy
FTT
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Pyloric stenosis
Volvulus
Intussusception
Hirschsprung disease
Gastroenteritis
PUD
Gastroparesis
Pancreatitis
Mass lesion
Subdural hematoma
Intracranial hemorrhage
Hydrocephalus
Sepsis (UTI, pneumonia, meningitis)
Endocrinopathies
Renal insufiency
Prematurity
Neurodevelopmental disabilities
Supine position
Food allergies
Delayed gastric emptying
Medications that relax the LES
Thorough H and P
Esophageal manometry
Esophagogastroduodenoscopy (EGD)
Upper gastrointestinal imaging series
Gastric scintiscan study
Esophagography
Intraesophageal pH probe monitoring
Intraluminal esophageal electrical impedance
Sleep study
8/7/2017
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Conservative therapy Lifestyle changes
Upright position after feedings
Small frequent feedings
Thickening formula or breastmilk
Proton pump inhibitors
Omeprazole (Prilosec)
Lansoprazole (Prevacid)
Rabeprazole (Aciphex)
Esomeprazole (Nexium)
Hydrogen 2 blockers Ranitidine (Zantac)
Nizatidine (Axid)
Failure of medication therapy for over 12 weeks
Continued respiratory symptoms (Obstructive apnea with confirmed pH monitoring)
Patients with complications of gastroesophageal reflux
Neurologic impairment that requires feeding gastrostomy
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The parents of a 2 month old present with concerns that their daughter vomits at least 2 ounces of formula with every feed. There is no blood in the vomit and the baby appears to be hungry after she vomits. She has no respiratory symptoms. They burp her for 5-10 minutes after each feeding. She is at the 70th percentile for height, 50th percentile for weight, and 60th percentile for head circumference which is consistent with her growth measurements since birth. Physical exam reveals a cheerful infant otherwise unremarkable.
A. Order lab tests to rule out underlying medical condition
B. Counsel the parents regarding lifestyle modifications.
C. Refer the baby to a gastroenterologist
D. Prescribe ranitidine
E. Prescribe omeprazole
A. Order lab tests to rule out underlying medical condition
B. Counsel the parents regarding lifestyle modifications.
C. Refer the baby to a gastroenterologist
D. Prescribe ranitidine
E. Prescribe omeprazole
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Overview
Presentation
Differential Diagnosis
Risk factors
Work up
Treatment
Medication
Hypertrophy of the pylorus leading to gastric outlet obstruction
Occurs in 2-3.5/ 1000 live births
Occurs more commonly in male infants (4:1) and is associated with prematurity
Symptoms begin ~3-6 weeks of age
Infant age 3-6 weeks
Immediate post prandial “projectile” non bilious vomiting
Hungry vomiter
Palpable “olive” in the RUQ lateral to the rectus abdominus (present in 50-90%)
Dehydration may be present
Hypochloremic alkalosis may be present
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Gastroesophageal reflux
Gastroenteritis
Eosinophilic gastritis
Cow’s milk protein intolerance or feeding intolerance
Adrenal crisis
Intestinal obstruction
UTI
Toxic ingestion
Hepatobiliary disease
Male gender
Birth order
Maternal smoking
Premature birth
Bottle-feeding
Erythromycin and Azithromycin use
CBC
Venous pH
CMP Electrolytes
BUN/ Creatinine
Liver function
Bilirubin level
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Abdominal ultrasonography Operator dependent
Sensitivity and specificity over 95%
Pyloric muscle thickness >4 mm
Pyloric muscle length >19 mm
Pyloric diameter > 14 mm
If Abdominal US non diagnostic Upper GI (UGI)
If UGI non diagnostic Upper endoscopy with
biopsy
Conservative management
Continuous nasal duodenal feedings for several months to allow obstruction to resolve
Balloon Dilation Can be used when general anesthesia is contraindicated
Surgical approach to pylorus is not possible
Pyloromyotomy (preferred treatment) Dehydration and electrolyte abnormalities should be
corrected prior to surgery
• Oral or IV atropine- Relaxes the pyloric musculature
- Not typically preferred
- Small non randomized studies have shown this medication to be effective in ~75 % of infants
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Overview
Presentation
Differential Diagnosis
Risk factors
Work up
Treatment
Medication
Common problem in pediatric population
30 % of children affected
17-40 % of case begin in the first year of life
Painful, incomplete, or infrequent defection associated with fecal incontinence and abdominal pain
In the absence of organic pathology, 2 of the following must occurFor a child with a developmental age <4 years
1. 2 defecations per week2. At least 1 episode of incontinence per week after the acquisition of toileting skills3. History of excessive stool retention4. History of painful or hard bowel movements5. Presence of a large fecal mass in the rectum6. History of large-diameter stools that may obstruct the toilet
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Absence of stool in a bottle-fed infant over 3 days
Absence of stool in breastfed infant over 7 days
Small caliber hard stools
Crying with defecation
Straining with defecation
Irritability
Decreased appetite
Early satiety
Abdominal pain and fullness
Introduction of solid foods
Milk protein allergy or increased intake of dairy
Withholding
Toilet training
Changes in routine (i.e. travel)
School entry
Stressful life event
Celiac disease Hypothyroidism, hypercalcemia, hypokalemia Diabetes mellitus Dietary protein allergy Drugs, toxics Opiates, anticholinergics Antidepressants Chemotherapy Heavy metal ingestion (lead) Vitamin D intoxication Botulism Cystic fibrosis
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Hirschsprung Disease
Anal achalasia Colonic inertia
Anatomic malformations
Imperforate anus Anal stenosis
Pelvic mass (sacral teratoma) Spinal cord anomalies, trauma, tethered cord
Abnormal abdominal musculature (prune belly, gastroschisis, Down
syndrome) Pseudoobstruction (visceral neuropathies, myopathies,
mesenchymopathies) Multiple endocrine neoplasia type 2B
Constipation starting extremely early in life (<1 mo)
Passage of meconium >48 h
Family history of HD
Ribbon stools
Blood in the stools in the absence of anal fissures
Failure to thrive
Fever
Bilious vomiting
Abnormal thyroid gland
Severe abdominal distension Perianal fistula Abnormal position of anus Absent anal or cremasteric
reflex Decreased lower extremity
strength/tone/reflex Tuft of hair on spine Sacral dimple Gluteal cleft deviation Extreme fear during anal
inspection Anal scars
Sedentary lifestyle
Limited to no fiber intake
Decreased fluid intake (H20)
Medications
Medical condition affecting the anus or rectum
Family history of constipation
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History and physical
Digital rectal exam
Only Indicated in severe cases or directed by H&P
Abdominal radiography
Colonic manometry
Barium enema
Rectal Biopsy
Complete blood count
Celiac screening (IgA antibodies to tissue transglutaminase)
Urine analysis and culture
Thyroid stimulating hormone
Electrolytes and calcium
Blood lead level
Infants
Glycerin suppositories
Rectal stimulation
Apple, prune or pear juice 2-4 oz/day
Pureed Apples, prunes or pears
Multigrain or barley cereals
Pureed green peas
Foods high in fiber >3 g/ serving
Adequate water intake 32-64 ounces/day
Behavioral therapy for stool withholding
Toddler and Children
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Polyethelene glycol (Miralax) 0.4-0.8 g/ kg/ day, max 17 g/da
Lactulose 1 mL/kg po q day or bid, max 60 mL day
Sorbitol 1 mL/kg q day or bid, max 30 mL day
Senna
1.25-2.5 mL once or twice daily for 1-2 year olds
2.5-15 mL, from 2-12 and older
Bisacodyl ½ to 1 suppository once daily
Glycerin suppositories
1 suppository once daily
Metamucil ¼ to ½ teaspoon one to three times daily
Benefiber ¼ to ½ tablespoon one to three times daily
Citrucel ¼ to ½ tablespoon one to three times daily
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