general pediatrics lmcc review presented by marc e. zucker md, frcpc division of pediatric medicine...
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GENERAL PEDIATRICSLMCC Review
Presented by Marc E. Zucker MD, FRCPC
Division of Pediatric Medicine
CHEO
March 22, 2010
Feeding & Growth
Breastfeeding CPS recommends exclusive breastfeeding
for babies up to 6 months (when possible) Breast milk has a caloric content of ~20 Kcal/oz (0.67 Kcal/ml) Babies need 100-130 Kcal/Kg/day in 1st 3
months Feeding/growth spurts occur at 8-12 days,
3-4 wks, 3 mo, variably after that
Nutritionally, how does breast milk compare to cow’s milk?
Lower protein content - decreased solute load Greater whey:casein (70/30 vs 18/82, formula
60/40) CHO - both are lactose based (6.5% vs 4.5%) Fat - 30-50% vs 3.5-4% Vitamins - richer in A,C,E, lower in D & K Minerals - lower Fe but better absorbed
Breast Feeding Benefits for Baby
Immunological benefit secretory IgA, lactoferrin, lysozyme as GI
defence Lower rate OM, LRTI, gastro, possibly UTIs,
Hib Less allergenic Less constipating Better jaw/mandible development Attachment and ?Improved cognitive
functioning
Breast Feeding Benefits for Mother Postpartum weight loss & uterine involution Delayed return of fertility Bonding Pre-menopausal breast & ovarian Ca
reduced Economical benefit
“Disadvantages” To Breast Feeding Takes 3-7 days for milk supply to come in
risk of dehydration/ “breastfeeding jaundice” Jaundice is more common
Breastmilk jaundice “Mom/baby team”
ineffective latch/sore nipples/engorgement Infections
thrush , mastitis/abscess Reduced levels vitamin D & K
Vitamin D Supplementation Rickets is still a problem in Canada! 400 IU per day
All Breastfed infants Pregnant and nursing mothers in northern Canada Formula Fed infants living in northern Canada
800 IU per day - < 2 yrs breastfed babies with a risk factor
Home above 55 degree latitude, darker skin, sun avoidance Community with high prevalence Vit D deficiency
Vitamin D is found in milk, margarine, salmon, tuna, liver, kidney & from the sun
Contraindications to Breast Feeding Maternal infections
HIV, AIDS, active TB, malaria, herpes on breast, hepatitis
Maternal sepsis Psychotropic meds or others crossing Chemo/radiation Alcohol/drug abuse Infant Galactosemia (lactose) *May breastfeed even with VZV
Cow’s Milk Formula Always Fe fortified
Many choices!
Specialty formulas soy, lactose free, increased calories Protein hydrolysate formulas (eg.Alimentum, Nutramigen, Progestemil) Amino-acid based formulas (Neocate)
Introduction of Solids cereals 4-6 months vegetables fruits meats
cow’s milk should be postponed until at least 10-12 months of age (renal load)
2% or 1% milk should be postponed until after second birthday (inadequate fat content)
Rest gradually in this order
Infant Growth: Rules of Thumb Weight gain:
Regain birth weight by 10-14 days (max 10% loss)
Double birth weight by 5 months Triple birth weight by 1 year Quadruple birth weight by 2 years Increase by 5 lbs/year for rest of childhood
Growth - Height Average length at birth 50 cm (20 inches) Increases by 50% by 1 yr Doubles by 4 yrs Triples by 13 yrs
Ave growth 5-6 cm / yr (4 yrs-puberty)
Growth- Body Mass Index (BMI) BMI helps to quantify the weight to height
relationship BMI = weight(kg)/height (m)2 BMI of 20-25 is acceptable BMI > 30 indicates obesity BMI < 18 suggest severe anorexia or
Failure to thrive
Growth- Head Circumference
2 cm/month 1-3 months 1cm/month 3-6 months 0.5cm/month 6-12 months
Most of growth is in first yr! 12 cm in first yr, 2 cm in 2nd yr, 6-8 cm rest of life
Growth Monitoring Routinely recommended
Height, weight, head circumference Plot on appropriate chart considering ethnicity, genetic
syndromes (eg. Tri 21, Turner’s), and prematurity Prematurity, correct hc (18 mo), wt (24 mo),
ht (40 mo)
Only way to detect FTT Also detects chronic illness, feeding difficulties
What is Failure to Thrive? US National Center for Health Statistics defines FTT
for children < 2 yrs of age as:
Weight <3rd-5th centile for age on more than one occasion
Weight <80% of ideal body weight for age Weight crosses 2 major centile curves downwards
on a standardized growth curve Exceptions: genetic/familial short stature,
constitutional growth delay, SGA infants & preterm infants
Caloric needs
0-10 kg: 100 kcal/kg/day
10-20 kg: 1000 + 50 kcal/kg/day >20 kg: 1500 + 20 kcal/kg/day
FTT- Infant Growth Caveats to normal growth velocity:
>50% of babies shift their growth parameters upwards between birth and 3 months
Nearly 30% of well babies shift their parameters downwards between 3 and 18 months
Exclusively breastfed babies plot higher for wt at 0-6 months and lower at 6-12 months5
Growth Velocity Average age to “settle” on a growth curve is 13
months6
Downward shift seen with constitutional growth delay downward shift between 6 & 24 months may have decreased weight for height re-establish normal growth velocities by 3 yrs
*Genetically Programmed curve is established by 18-24 months
FTT- Assessment Grading of malnutrition:
Grade Wt for Age (%)
Wt for Ht (%)
0-Normal >90 >90
1-Mild 75-90 81-90
2-Moderate 60-74 70-80
3-Severe <60 <70
FTT- Assessment “Organic” vs. “non-organic”
Historical way of viewing FTT Refers to presence/absence of diagnosis of
major disease process or organ dysfunction “Non-organic” accounts for >80% Now felt to be more of a continuum Multifactorial process
FTT- Assessment Under-nutrition results from:
1) Decreased caloric intake
2) Inadequate caloric absorption
3) Increased caloric losses
4) Increased caloric requirements
FTT- Differential Diagnosis Decreased caloric intake:
Inadvertent (decreased breast milk, improper formula preparation)
Neglect or abuse Behavioural (ex. Food refusal) Pain (GERD, injury to mouth or esophagus) Fatigue /anorexia (anemia, cardiac dz, resp dz, RTA) Impaired swallowing (neurologic dz) Craniofacial abnormalities (cleft lip/palate, choanal
atresia) Toxin (lead)
FTT- Differential Diagnosis Inadequate Caloric Absorption & Increased Caloric Losses
GI Pancreatic insufficiency (CF) Liver disease (biliary atresia, chronic cholestasis) Generalized malabsorption (CF, Celiac, short gut) Diarrheal state (infectious, post-infectious) Persistent vomiting (pyloric stenosis, GERD) Inflammatory disorders (IBD) Allergic gastroenteropathy Protein-losing enteropathy
FTT- Differential Diagnosis Increased Caloric Losses cont’d
Renal Protein loss Carbohydrate loss
Inability to use nutrients Diabetes Mellitus Metabolic dz
FTT- Investigations Careful and complete history taking and physical
examination are ESSENTIAL Unless an illness other than primary under-
nutrition is suspected on Hx or P/E the yield of lab investigations is almost nil!
Lab testing helps with diagnosis in 1.4%
FTT- Investigations Non-specific “screening”
CBCD, ESR, lytes, BUN, Cr, venous gas Urine R&M, C&S
Markers of nutritional status Total protein, albumin, glu, Ca, PO4, Iron studies Zinc, vitamin levels
Dependent on specific aspects of Hx & P/E Liver function tests Thyroid studies Stool OB, reducing substances, culture, O&P, trypsin Sweat test, immunoglobulins & celiac screen, viral
serology (incl HIV), TB testing, immune w/up, metabolic w/up, CXR, ECG, milk scan
FTT- Management Admit if :
Suspect enviro. deprivation/neglect/abuse Suspect chronic dz which needs stabilizing Severe under-nutrition (consider if moderate)
ie. <60% of median weight for age Failed out-patient management
With hospitalization: greater likelihood of catch-up growth no change in developmental outcomes
FTT- Management Inter-disciplinary approach!!
Treat any underlying illness and provide nutritional support: Increase caloric intake
1.5-2 X RDA (120 kcal/kg/day x ideal wt)/current wt Estimate 150-200 kcal/kg/day
FTT- Management Mild under-nutrition
Ensure frequent feedings (q 3 hrs) Increase formula concentration (eg. 24 kcal/oz) Add calorie-rich foods to diet (butter, PB, oils) Provide dietary counseling Prescribe multivitamin with zinc and iron Follow-up frequently (?public health nurse) Expect catch-up growth at 2-3x regular rate in first
month
FTT- Management Moderate under-nutrition
Determine caloric intake Consider whether investigations are necessary Increase caloric intake (150-200 kcal/kg/day) Ensure adequate protein (3-4 g/kg/day) Consider meal supplements (eg. Pediasure) Add Multivitamin Consider therapeutic doses of iron Monitor weight gain
FTT- Management Severe under-nutrition
Admit Initiate re-feeding slowly Consider using elemental formula Consider diluting formula May need ng continuous feeds or tpn Follow fluid and lytes status closely
FTT- Long-term implications
Persistent growth deficits
Cognitive impairment
Behaviour problems
IMMUNIZATIONS
Immunization Schedule(Recommended by the Canadian Immunization Guide)
Age 2 mos 4 mos 6 mos 12 mos 18 mos 4-6 year q10 years
Vaccine
DaPTP-HIB, Prevnar, Menj DaPTP-HIB, Prevnar,Menj DaPTP-HIB, Prevnar,Menj MMR, Varicella, Prevnar DaPTP-HIB, MMR DaPTP dTaP/dT
Contraindications to Vaccines Strict
- anaphylaxic or anaphylactic shock- encephalopathy
Precautions- febrile reaction > 40.5- shock collapse or hypotonia - hyporesponsive collapse- seizures
Contraindications to vaccines Anaphylaxis to eggs:
Influenza and yellow fever Severe immune deficiency:
All live vaccines (MMR, VZV, OPV, BCG, Yellow
fever, Oral cholera, Oral typhoid) Pregnancy:
MMR and Varicella Anaphylaxis to neomycin:
MMR and IPV
Immunization Reactions DaPTP/Hib
reactions occur within 72 hrs
MMR reactions occur 5-12 days
Delayed ImmunizationAge 1-6 years
0 mos:DPTP-Hib, MMR,HepB, P,V,MC
2 mos: Pentacel,MMR,HepB, Prevnar
4 mos: DPTP 12 mos:DPTP 4-6 yrs: DPTP 14-16 yrs: dTaP
> 7 Years Old 0 mos: TdaP,Polio,
MMR,V,Menj,HepB 2 mos: TdaP, Polio,
HepB,MMR, V 6-12 mos:
TdaP+Polio,HepB TdaP (no polio) q10
yrs thereafter
Other Immunizations
Hepatitis A & B Influenza HPV Rotavirus
INFECTIOUS DISEASE
Fever Temp > 38.3 Celsius rectal Occult bacteremia: most in 3-24 mos
3-5% febrile are bacteremic most common org. is Strep. Pneumo **
0-1 mos: FSWU 1-3 mos:
toxic = FSWU non-toxic and low risk (WBC 5-15,
bands <5%, urine neg, well-looking, reliable family): investigate and follow
Otitis Media Incidence:
15% to 20% Peak:
6 to 36 months 4 to 6 years decreases > 6 years old
Etiology: S. pneumoniae, M. catarrhalis, non-type H. Flu, GAS & viral
Otitis Media Risk Factors
mid-face hypoplasia (Down Syndrome) daycare attendance Inuit/Aboriginal low SES 2nd hand smoke
Otitis Media Treatment:
1st line: Amoxil 2nd line: High dose Amoxil, Clavulin,
Macrolides, Cephalosporin T-Tubes if recurrent or persistent effusion
Complications: hearing loss chronic effusion mastoiditis meningitis
Sinusitis Mainly ethmoid sinus Predisposed by viral URTI, allergy,
asthma, periodontal disease Same bugs as OM +/- anaerobes Presents with fever, purulent nasal
discharge (> 10 days), periorbital tenderness, halitosis
Treat with same Abx as OM, may need longer course (3 weeks)
Meningitis Newborn period (LEG)
Listeria E. Coli Group B strep
2 months - 12 years (SHIN) Strep pneumonia, N. meningitides Less common Hib with immunization
Meningitis in abnormal hosts or anatomic defects:
increased Pseudomonas, Staph, Salmonella, Serratia
Complications SIADH seizures subdural effusions transient joint effusions (Ag-Ab reaction) hearing loss
Urinary Tract Infection Newborn M › F (2) Children F › M (10) Schoolgirls - 5% Recurrence - 80% Vesicoureteral reflux - 35% Renal scarring - 50% All children ‹ 3 yrs
U/S VCUG
Urinary Tract Infections UTI
KEEPPSS Klebsiella, E. Coli, Enterococcus, Proteus, Pseudomonas,
Staph, Strep
Pyelonephritis ampicillin + gentamycin IV initially then Amoxil or Septra po
VUR prophylactic Septra or nitrofurantoin (or Amoxil) Higher grades may require surgery
Osteomyelitis Organism
neonate: Staph, GBS, E.Coli > 3mos.: Staph, Hib, Strep,Pseudomonas SS disease: Salmonella
Diagnosis bone scan x-ray 10-12 days
Septic Arthritis Monoarticular (trauma) Organism
neonate group B strep, staph, E.Coli
>3 mos Staph aureus Strep, Hib
most common site is knee (40%)
Fever and Rash
Measles (First Disease) Paramyxovirus Stages
incubation: 8-13 days prodrome: 4 C’s then fever with rash skin rash (erythematous, maculopapular, starts at
hairline and spreads to face, trunk and extremities)
Complications pneumonia encephalitis SSPE
Scarlet Fever (Second Disease) Fever, pharyngitis, exanthem (starts in
axilla, groin, neck, blanches,circumoral pallor, Pastias lines)
Age › 3 yrs; recurrence Group A strep: erythrogenic toxin (2-5
days postStrep throat or GN) Treatment with Penicillin Complications
cellulitis Rheumatic fever
Rubella (Third Disease) Togavirus Congenital Postnatal
mild disease suboccipital nodes maculopapular pink rash, starts on face, neck
to extremities, spreads quicker than measles
Roseola Infantum (Fourth Disease)
HHV6 High fever rash maculopapular with
cessation of fever High WBC low WBC Febrile convulsions
Erythema Infectiosum (Fifth Disease) Parvovirus B19 No prodrome: red flushed face/slapped
cheek, maculopapular rash with lacelike appearance
Complications miscarriage/SA aplastic crises
ALTE/SIDS
Apparent Life Threatening Event: Definition Clinical symptoms frightening to caregiver Combo of apnea, colour change, tone
change, choking, gagging
Apnea: 20 seconds of breathing cessation or shorter if associated with tone change, colour change, CV change
ALTE Detailed Hx and Px Talk to person witnessing event Significant event?
ALTE Differential
Neuro- seizure GI- reflux Pulmonary- aspiration, apnea CV- arrhythmia Infection- sepsis, pertussis, RSV Metabolic Abuse
ALTE Investigations Labwork +/- infectious workup EEG ECG/Echo UGI/pH probe CT head Monitor
SIDS Unexpected death by Hx and Postmortem most common cause of death 1mo-1yr peak 2-4 months, 95% <6 months old
SIDS Infant Risk Factors:
prematurity age, sex prone sleeping bottle fed smoke environ. Thermal stress ethnicity prior illness winter months low birthweight
Maternal Risk Factors low age low SES low education smoker drug use poor nutrition
Gastroenterology/Pediatric Surgery
Colic Unexplained irritability/crying 2-3 wks to 3 mos At least 3 hrs/day > 3 days/week > 3 weeks duration ? Secondary to immature gut development
Colic ++Gas/legs drawn up; otherwise well No proven treatment - rhythmic
motion/sounds Ovol/Tylenol- no proven benefit Parental support and reassurance
Abdominal Pain Acute: Ddx includes gastro, hernia, UTI,
appendicitis, intussusception, malrotation, volvulus, HSP, SC Crisis, pneumonia, mesenteric adenitis,
Chronic: > 3 episodes affecting activities > 3 months Organic (<10%): constipation, IBD, mass, PUD,
GU, lactose intolerance Functional (90%): 8-10 yo peak, girls
predominate, vague crampy periumbilical pain with no awakening, ppting or alleviating factors. Normal growth.
Gastroesophageal RefluxGastroesophageal Reflux Incompetence of lower esophageal
sphincter improves by one year of age in most infants
Complications apnea in infants aspiration pneumonia chronic cough/wheeze esophagitis- dysphagia,hemetemesis, Fe
deficiency anemia
Gastroesophageal RefluxGastroesophageal Reflux Diagnosis
pH probe Ba swallow nuclear scan endoscopy
Gastroesophageal RefluxGastroesophageal Reflux
Treatment chalasia routine - attention to burping, small
frequent feeds, 300 prone
thickening feeds Medications:
H2 blockers or PPI if esophagitis or gastritis present
Domperidone for decreased gastric emptying
Pyloric StenosisPyloric Stenosis
boy > girl 3 weeks - 3 months projectile vomiting (nonbilious) hungry infant feeds vigorously
Pyloric StenosisPyloric Stenosis O/E:- dehydration, lethargy, weight loss,
peristaltic waves L R, palpable “olive”
Lab- hypochloremic alkalosis
Investigation- U/S, UGI Rx: rehydrate and restore electrolyte
balance
- myotomy of pyloric muscle
IntussusceptionIntussusception
3 months - 3 years (up to 6 years) 5% anatomic abnormality found
Meckel’s polyp duplication
more frequent ileocolic or ileoileocolic
IntussusceptionIntussusception
Clinical severe paroxysmal pain lethargy shock sausage shaped mass RUQ vomiting currant jelly stool
IntussusceptionIntussusception
Lab x-ray
density or gasless right side
barium enema coil-spring sign
Treatment reduction by barium enema surgical reduction
Meckel Diverticulum 2% population year peak incidence 2 feet from ileocecal junction 35% ectopic gastric or pancreatic tissue painless rectal bleeding (typically bright red) 99Tc scan confirms diagnosis treatment: excision
Constipation Def’n: passage of bulky or hard stool at
infrequent intervals Retention of stool in rectum leads to
encopresis in up to 60% Most causes are not organic but due to
voluntary or involuntary retentive behavior
Constipation DDx Dietary Behavioral Obstruction Dehydration Structural defects (fissures) Metabolic (hypothyroid,hypoparaT,
hyperCa) Neuromuscular ( MMC, MD, spinal cord) Hirshsprungs
Constipation- Treatment Dietary: increased fluid/fibre Stool softeners or laxatives
Lactulose Lansoyl PEG powder
Bowel evacuation (enemas) Bowel/toileting regimen
Hirshsprung’s Disease Absence of ganglion cells in the bowel wall Most common cause of neonatal GI
obstruction Aganglionic segment NB: failure to pass meconium within 48
hrs
Hirshsprung’s Disease Constipation
onset after 2 yr encopresis large caliber stool normal growth normal nutrition normal anal tone stool in ampulla
Hirshsprung’s onset at birth no encopresis small stools assoc. FTT/poor
nutrition abdominal distension normal anal tone ampulla empty
Hirshsprung’s DiseaseHirshsprung’s Disease
Diagnosis: rectal biopsy
shows absence of ganglion cells rectal manometry barium enema ->transition zone
Treatment: resection aganglionic bowel colostomy, then pull through at
6 to 12 months of age
Umbilical hernia Defect of central fascia beneath umbilicus Most common condition of abdominal wall Almost never incarcerate Strong family history and racial propensity Medical risk factors:
Congenital hypothyroidism Prematurity
Umbilical hernia DDx:
Small omphalocele (looks like fixed hernia) Supra-umbilical hernia
Refer to surgery if: Ring defect > 1.5 - 2 cm in diameter “elephant’s trunk” appearance Incarceration Not closing by 2 years of age
UROLOGY / NEPHROLOGY
Cryptorchidism 3.4% of NB, 0.7% of children > 1 year of age Bilateral in 20% Consequences- tumour, infertility, torsion,hernia Differential diagnosis
Ectopic testes Retractile testes Absent testes
surgical correction <2 year of age
Hypospadius Sibling risk - 10% Undescended testes - 10-15% Not associated with UT anomalies Do not circumcise
Enuresis Nocturnal , Diurnal, both Primary vs. Secondary 10% 5yr old, 5% 10 yr old, 1% 18 yr old Male > Female Familial maturational defect in bladder control
Enuresis Treatment
Rule out underlying cause (UTI, constipation, IDDM)
Motivational maneuvers- star charts Alarm Medication- DDAVP, TCA
Proteinuria Def”n: >150mg/24 hr (>4mg/m2/hr) Nonpathologic:
Postural- incr. in upright position 10x Collection done in supine and upright
positions Febrile Exercise
Proteinuria Tubular:
Hereditary- cystinosis, Wilson dis., RTA Acquired- antibiotics, ATN, cystic diseases,
heavy metal Glomerular:
Nephrotic syndrome Glomerulonephritis, tumour, drug, congenital
Nephrotic Syndrome Minimal change disease the most common
(76%) Membranous (8%), Focal Segmental (7%) Diagnosis
proteinuria(>40 mg/m2/hr) hypoalbuminemia hyperlipidemia edema
Nephrotic Syndrome Treatment
prednisone Renal biopsy
Unusual age (<1yr, adol.) Steroid resistant/ frequent relapse HTN, decreased renal function
Complications hypercoagulability infections Drug side effect- steroids, immunosuppressants
Marked eyelid edema in a 2-year-old boy with minimal change disease and nephrotic syndrome. Eyelid edema in any child should prompt the performance of urinalysis, rather than the presumption of allergy.
Severe scrotal edema in a 6-year-old boy with nephrotic syndrome.
Hematuria Microscopic (> 5 rbc/hpf) vs. Macroscopic Approach based on anatomy:
Kidney Ureter Bladder Urethra
Hematuria Glomerular Tubulointerstitial
ATN Infections Hypercalciuria Drugs
Hematologic causes platelets, SS disease, renal vein thombosis
Anatomic abnormalities Tumour, trauma, cysts, vascular
Exercise
Hematuria: Work-up STEP 1:
CBC, urine culture, Cr, C3, U/S 24 hr urine- Cr, protein, calcium
STEP 2: ASOT/antiDNase-B, T/S, ANA, coags, urine RBC
morphology, SS screen, VCUG (if infection/lower tract suspect)
STEP 3: biopsy
Glomerulonephritis Proteinuria, hematuria, hypertension, edema Etiology: Acute post Strep GN, IgA Nephropathy,
HSP, SLE Nephritis, RPGN, MPGN Acute Post Strep GN:
school-aged, mean age 7, 2:1(M:F), 1-2 wks between infection and presentation, dark urine, edema
Dx: UA, ASOT, anti DNAase B, low C3 (and in 6-8 wks) Management: fluid/Na restriction, diuretics +/- antiHTN 98% recover completely, sx resolve in 3-4 wks
Hemolytic Uremic Syndrome Diarrheal and non-diarrheal causes E. Coli 0157:H7 verotoxin Present with diarrhea followed by bloody
diarrhea 5-7 days later- Triad
microangiopathic hemolytic anemia thrombocytopenia renal failure
Hemolytic Uremic Syndrome Treatment
supportive lasix infusion Dialysis
No role for antibiotics, steroids Prognosis:
10-30% morbidity 5-10% mortality
RHEUMATOLOGY
Henoch Schonlein Purpura Immune-mediated systemic vasculitis of small
vessels Often preceding URTI Ages 4-10yr; recurs in 1/3 Classically involves,
skin GI joints (75% have arthralgias) kidney (20% develop gross hematuria)
HSP - Skin Palpable nonthrombocytopenic
purpura May be presenting sign in only 50%
of patients. Purpura involves dependent areas of
the body. Edema of the hands, feet, and scalp
often an early finding (20-40%)
Slide 1
HSP - Gastrointestinal 45 to 85% of children with HSP
major hemorrhage (5%) intussusception (2%) occult bleeding (33%)
HSP Treatment
Steroids used if severe/life-threatening GI involvement
Doesn’t affect renal outcome Must monitor for renal involvement- may
occur late Watch for recurrence education
Kawasaki DiseaseCriteria F ever for 5 days Plus 4 of 5:
E xanthem E xtremities L ymph nodes (>1.5 cm) M ucosal changes C onjunctivits
“feel my conjunctivitis”
Kawasaki Disease CVS
coronary aneurysms- 20% of cases Risk < 5% if treated
Phases Acute- febrile 1-10 days Subacute (peeling, afebrile, high
platelets/ESR) 10-21 days Convalescent (normalize plt/ESR) >21 days
Kawasaki DiseaseAssociated Features Uveitis Hydropic gallbladder Carditis Pancreatitis arthritis
Sterile pyuria (urethritis)
Diarrhea Aseptic meningitis
Kawasaki Disease Treatment
IVIG Aspirin- high followed by low dose Echo at baseline and at 6-8 weeks for
coronary aneurysms
ONCOLOGY
Acute Lymphocytic Leukemia Most prevalent malignancy under 15 yo-
immature lymphoid cells accumulate in the BM (lymphoblasts)
80% of all cases of acute leukemias : peak 2-6yo
Poor prognosis if < 2yrs or > 10yrs, WBC > 50,000, CNS or testicular involvement at diagnosis, T-Cell or B-Cell, Pseudodiploidy (presence of translocations within leukemic cells), and hypodiploidy (< 46 chr. in leukemic cells), L3 morphology of blasts
ALL- Clinical Features Bone marrow failure: anemia, low plts,
neutropenia Lymphadenopathy Hepatosplenomegaly Bone pain
Acute Lymphocytic Leukemia Relapse 30 - 40%
bone marrow CNS testes
Long term problems secondary tumours infertility learning disability
Neuroblastoma Malignancy of neural crest cells Most common neoplasm in infants Most in first 4 yrs (mean=2yo) Most common site of primary tumor is abdomen (abd.
mass ,abd. pain ,HTN ) Thoracic tumors: resp. distress H & N-Horner syn. Constitutional s/sx Metastases common to bone, BM, liver lung (50%) High catecholamines in 90%
Wilms’ Tumor 5-6% of childhood Ca: 75% before 5yo Palpable abdominal mass, HTN, hematuria Bilateral in 5% Association with aniridia,
hemihypertrophy, and Beckwith Wiedmann Syndrome in 12-15%
Retinoblastoma Bilateral (40%)
hereditary - AD osteogeneic carcinoma
Unilateral (60%) sporadic
Slide 3
Brain Tumors Second most common tumor-most common
solid tumor cerebellum 40%, brainstem and 4th ventricle
15%, suprasellar 15% Presentation depends on location Common signs: vomiting, papilledema,
lethargy, headache, personality change, ataxia, loss of vision, seizures, focal neurologic signs, nystagmus
HEMATOLOGY
Anemia Low Retics (underproduction)
MCV- Low- iron, thal,lead, chronic - Normal- renal, thyroid, infection
- High- B12, folate, fanconi High Retics (increased loss)
Blood Loss Hemolysis- intrinsic
- extrinsic
Iron Deficiency Anemia Decrease in RBC Hb due to inadequate Fe stores Etiology: poor dietary intake, early transition to
cow’s milk, high requirements with growth spurts, cow’s milk intolerance, chronic GI blood loss
Diagnosis: microcytic anemia, low serum iron, ferritin,
S/sx: irritability, anorexia, lethargy, pale, tachycardia, systolic murmur
Slide 1
.
Spherocytosis Autosomal Dominant, northern European abnormal membrane protein- Spectrin leads to hemolysis- less flexible newborn- jaundice < 24 hr disease can be mild, moderate or severe mild- mod. Anemia, reticulocytosis and
splenomegaly Dx- osmotic fragility test Rx.- support, splenectomy
From CD Atlas, MCCQE Toronto Notes, 2003
G6PD Most common RBC enzyme defect X-linked, African, Mediterranean susceptible to oxidation stress--> Hgb precip.-->
membrane damage Precipitating agents-
infection, vit. C, fava bean, benzene, Medications (nitrofurantoin, antimalarial, sulfa, nalidixic acid, vit. K analog)
intermittent hemolysis, chronic hemolysis, incidental with anemia and retics
smear- bite cells
Sickle Cell Disease Newborn asymptomatic
first sign (6 mos) - hand-foot syndrome Crises
sequestration vaso-occlusive aplastic(Parvovirus) hyperhemolytic infections
Prevent infections (considered asplenic)
From CD Atlas, MCCQE Toronto Notes, 2003
Slide 2
Classic HemophiliaClassic Hemophilia Factor VIII deficiency:
X-linked ie asymptomatic female carriers transmit to sons
Symptoms: excessive bruising with ambulation intramuscular hematomas from minor trauma hemarthrosis: often spontaneous hematuria risk for intracranial hemorrhage & bleeding into the
neck
Classic HemophiliaClassic Hemophilia
Severity depends on level FVIII in plasma mild 6% to 30% moderate 1% to 5% severe < 1%
Pts with mild FVIII deficiency experience only prolonged bleeding following tooth extraction, surgery or bleeding
Lab: PT normal, PTT greatly prolonged
Classic HemophiliaClassic Hemophilia
Treatment:
- prevention of trauma
- FVIII concentrates
- strict avoidance of drugs that affect platelet function
Immune Thrombocytopenic Purpura (ITP) Thrombocytopenia mediated by auto antibodies
causing destruction Peak age 2-6yo: associated with antecedent viral
infection Most resolve in 4-6wks: 20% duration > 6mos Clinical Features: purpura, petechiae, bleeding
from mouth, gums, kidney, GIT, no hepatosplenomegaly
Treatment- IVIG, steroids
Slide 5
CHILD ABUSE
Child Abuse Physical - 80% Sexual - 15% Physical and emotional neglect Munchausen by proxy 2nd cause of death in 1-6mos 1/3:1/3:1/3- <1yo:1-6yo:>6yo Premature and developmentally impaired have
3x risk
Red Flags Recurrent injury/ingestion Injury poorly explained/ out of proportion High risk injuries: scald, cigarette,spiral fracture, retinal
hemorrhage Injury pattern/site High risk environment
preterm, neurologic impairment single parent family stress psychiatric illness
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ADOLESCENCE
Adolescence- HEEADSS Home Education Eating Activities Drugs Sexuality Suicide
Adolescent SuicideWarning Signs Depression Psychosomatic complaints Acting out Previous attempt Family history
ORTHOPEDICS
Growing Pains 3 - 6 years Night time: poorly localized Pain in shins, calves, thighs Heat, massage, Tylenol Normal physical exam
Congenital Dislocation Hip(Developmental Dislocation Hip)
Age: 2 months to 2 years Signs:
limitation of abduction tight adductors shortening of leg asymmetric skin folds + Galeazzi sign (one knee lower than other)
Congenital Dislocation HipAssess stability: Ortolani(reduce) &
Barlow(dislocate) signsTreatment: triple diaper first for mild cases of
subluxation (x 6 to 8 weeks) < 6 to 8 months, Pavlik harness > 8 months, traction closed reduction spica cast
Slide 2
Metatarsus Adductus Forefoot faces in rather than lining up with
2nd metatarsal May be secondary to intrauterine
positioning Early treatment is stretching If rigid may require casting to correct
Legg Calve Perthes Disease Avascular necrosis femoral head males > females 5 to 9 year old:sx: painful hip, limp,
referred pain X-ray: lucency, widening of the distance
and eventual distortion of the femoral head Treatment: casts to keep hip in abduction
& medial rotation surgery
Slipped Capital FemoralEpiphysis Most common in obese boys in adolescence femoral epiphysis slips posteromedially off the
metaphysis unilateral or bilateral gradual or sudden causes pain & limitation of motion abduction & internal rotation are limited Klein’s line on xray
Treatment: pinning to prevent further slipping
Osgood-Schlatter’s Disease Common cause of knee pain Mostly in athletic or overweight kids Pain arises in tibial tuberosity (at site of
attachment of patellar tendon)after exercise or kneeling
Treatment mainly supportive: includes reduced physical activity +/- bracing
DERMATOLOGY
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Pityriasis rosea Prodrome rare: fever, malaise, arthralgia,
pharyngitis Herald patch: solitary 1-10cm annular
papular lesion anywhere on body 5-10 days later, widespread symmetrical
eruption involving trunk & proximal limbs < 1cm slightly raised pink/brown papules
eruption, fine scale, especially at periphery
Pityriasis Rosea Christmas tree pattern on back Duration: 2 to 12 weeks Mild to severe pruritus ? Viral trigger Treatment:
antipruritic/antihistamine lubricating lotion or topical cortosteroid if
moderate to severe pruritus
Impetigo + Prevalent during hot, humid months + Common in infants & children
Initiated by infection with Grp.A hem.strep Bullous impetigo 2o to Staph Aureus Grp.2
phase type Erythematous macule...vesicles & pustules
ImpetigoImpetigo
Bullae with erythematous halo...honey coloured crusts (non bullous form), superficial & rupture easily (bullous type
Spread by contact to other parts of body
Treatment: local measures...personal hygiene compresses to remove crusts systemic antibiotic
Atopic DermatitisAtopic Dermatitis
Inflammatory skin disorder
erythema...edema...intense pruritus...
exudation, crusting & scaling
> risk to develop allergies & asthma
Infancy: 1st 2 to 3 months weepy patches on
cheeks, neck, wrists, hands & extensor aspect extremities
Childhood: involvement of flexural
areas, especially popliteal & antecubital fossae
also, neck, wrist, behind ears, > with age; > drying & thickening of skin
Atopic Dermatitis
Atopic DermatitisAtopic Dermatitis
Other signs:
“Mask of atopic dermatitis” Hyperpigmentation of skin Lichenification
Atopic DermatitisAtopic Dermatitis
Itch - scratch - itch cycle Rx: antihistamines topical corticosteroids topical immune modulators (Protopic) hydrating lotions
Slide 2
Slide 1
Seborrheic DermatitisSeborrheic Dermatitis
Begins on scalp as “cradle cap” Involvement behind ears, sides of nose &
eyebrows Greasy, brownish scales Shorter course than atopic dermatitis Responds more rapidly to treatment than
atopic dermatitis
Treatment: General Guidelines
Keep bathing at minimum Use of non-soap cleansers Cotton garments/avoid wool Keep nails cut short Avoid environmental triggers Treat superinfections with systemic
antibiotics
Staphylococcal diaper dermatitis. There are numerous thin-walled pustules surrounded by erythematous halos, as well as multiple areas in which pustules have ruptured, leaving a collarette of scale around a denuded erythematous base.
Irritant or ammoniacal diaper dermatitis. Note the involvement of the convex surfaces and the sparing of the intertriginous creases.
Candidal diaper dermatitis. The eruption is bright red with numerous pinpoint satellite papules and pustules. Intertriginous areas are prominently involved.
Psoriatic diaper dermatitis. This child had a persistent diaper rash that did not respond to routine therapy. Note that scaling is not as intense as in psoriatic lesions seen elsewhere on the body.
Erythema Multiforme Erythema multiforme (EM
minor). A, The characteristic target lesions are symmetrically distributed. B, In these typical target lesions with central dusky areas, the peripheral rims are beginning to vesiculate. C, In this case, the peripheral rims have become frankly bullous. (C, Courtesy of Michael Sherlock, MD, Lutherville, Md.)
Stevens-Johnson Syndrome Stevens-Johnson syndrome (EM
major). A, Severe bullous and erosive lesions cover the face, neck, upper trunk, and proximal extremities. Note the ocular and oral involvement. B, Typical bullae, target lesions, and erosions of the lips are seen in this boy. C, This child has numerous vesicles and bullae of the oral mucosa along with formation of a shaggy white membrane consisting of sloughed debris. (C, Courtesy of Michael Sherlock, MD, Lutherville, Md.)
Milia White-yellow papules Epidermal inclusion cysts Face, gingivae, palate
Ebstein pearls Neonates:
Occur spontaneously Resolve spontaneously
(weeks-months) Older children:
Occur at site of trauma (blisters, abrasions)
May not resolve spontaneously
Erythema Toxicum Neonatorum White papule/pustule (1-2mm)
surrounded by red wheal Localized or generalized Palms and soles spared Usually starts ~ day 2 New lesions continue to
appear as rash waxes and wanes up to 10 days
Less common & delayed presentation in prems
Eosinophils on scraping BENIGN & SELF-LIMITING
CLASS OF 2010 FACULTY OF MEDICINE UNIVERSITY OF OTTAWA
GOOD LUCK!