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Pediatrics

Links

• local: ADHD, Beta Strep Management, Infectious Disease, Paraphimosis, Radial Head Dislocation, Slipped Capital Femoral Epiphysis, Therapeutics
• MD Consult texts: Harriet-Lane Handbook, Red Book, Nelson

Abdominal pain

Red Flags

1. pain not central, peri-umbilical
2. noctural pain that awakens child **
3. onset related to meals
4. child not a “high achiever”, no school absenteeism
5. emesis, or hematemesis
6. diarrhea, with or without blood
7. no stressful life events
8. loss of weight, or failure to gain
9. anal tags, perianal disease, anemia, fever, etc.
10. keeps eyes open during abdominal exam (attention not internalized)

See also: Distinguishing. Features (FPH).

Bronchiolitis/RSV

• FPH: Stridor and Dyspnea
• Peds in Rev Feb 98 $

RSV bronchiolitis/pneumonia

• 50% infect < 12 mo, 100% < 2 y
• reinfection declines with age, from 60% to 20%. Immunity increase with recurrent infection.
• high infectivity in families, very hardy virus
• incub 5 days, shed virus 14 days (longer immunosuppressed)
• major cause of wheezing in children, including asthmatic exacerbations
• secondary bact infection is rare
• RSV immune globulin available for prevention in high-risk popn (premie), may prevent other vaccines from working

Therapy

• Steroids not helpful
• bronchodilators worth a try
• culture for RSV (also adenovirus, influenza B) or rapid test if available. Rapid tests somewhat problematic.

Croup

FPH: Stridor and Dyspnea

Steroid Therapy

• Decadron .6 mg/kg IM single dose then oral 0.5-2.0 mg/kg qD. Most use Pedia-Pred for oral instead. Decadron must be ground up and put in food — awful taste.
• Geelhoed study: Decadron 0.15 mg/kg one time dose for mild to moderate croup not requiring hospitalization.
• Klassen '98: oral decadron 0.6mg/kg

Developmental Dysplasia of the Hip (DDH)

• formerly congenital dislocation of the hip (CDH)
• dislocation tests are not useful after about 10 weeks of age, best exam is then limitation of abduction
• physical exam is not perfect test (I suspect it's actually pretty crummy, but this is not a polite thing to say)
• ultrasound and x-ray similar value at 5 months, but ultrasound better prior to 5 months
• incidence in girls is 1/50, reexamine females at 2 weeks of age (so need a 2 week visit)
• ultrasound screening at 6 weeks if*
  • breech delivery and female (1/10 risk of DDH)
  • family history and female (1/20 risk DDH)

Development

Red Flags - should have

• responsive smile by 2-3 months
• some head lag allowed at 6 months
• speech by 12 months (mama, dada)
• walking by 15 months

Diarrhea, Pede

Child

Pepto-Bismol??: 100mg/kg/day in 4 doses. (liquid is 262mg/15ml, max strength is 525 mg/15ml, also available 262mg chewable tabs. Dark tongue and stool) (ref: #1230)

• standard dosage is 100mg/kg/day in q4h doses. If give QID then: 1.5ml/kg/dose (15ml=1tbsp).
• 44 lb child (4 yo): 1 tbsp QID of max strength, or 2 tbsp QID of regular.
• 22 lb child (1 yo): 1 tbsp QID of regular strength
• 2 months between treatments to prevent accumulation of Bismuth

Diarrhea, Infant

• see also: Diarrhea
• PediaLyte mixed with sugar-free Kool-Aid powder: 1/4 tsp per 8 oz, or 1 tsp per quart. Add to chilled liquid. Can also freeze as "freezer pops".
• Kao-pectate: available for age 3 or over. Consider use if severe dermatitis or to allow some nighttime sleep. Avoid regular use.

Factlets

• occult renal tumors may present with polycythemia
• pulmonary hypertention in neonates (PFC): inhaled nitric oxide
• children with acute or chronic arthralgia: human parvovirus B19
• tuberculous meningitis: PCR of CSF
• cat scratch disease
• warts: rx with oral cimetidine
• downs syndrome: may have coexistent Celiac Disease
• neonatal Vitamin K: IM injection at birth, repeat at 3-4weeks if exclusively breast fed.
• syllables by 11 months: da, na, bee or yaya. If not, screen for infantile hearing loss or communication disorder/autism
• clindamycin is superior to other abs for chronic sinusitis in children, but there is considerable toxicity (Brook et al, Dec. 1995)

Fever w/o Source

The history and physical assessments of the febrile infant. Bonadio WA - Pediatr Clin North Am - 1998 Feb; 45(1): 65-77 (MD Consult)

Evaluation

1. confirm with a rectal temp
2. urine culture for boys < 6 mo, girls < 2 y (no prior UTI)
3. UTIs may have little or no findings
4. antipyretics don't improve affect much with meningitis, but can improve with less serious conditons.
5. good signs (esp > 2 w old, doesn't help with UTI)
   • social smile
   • if asleep, stays asleep but is easily roused. if awake, stays awake.
   • easy respiration

Management

• when in doubt: blood culture, rocephin, recheck

Fifth Disease, erythema infectiosum, Parvovirus B19

• Slapped cheeks then “fishnet” rash, minimal fever, ages 5-14. Contagious 7-10 days before rash appears, not contagious after appears. Rash may persist for weeks. Sickle Cell crisis.
• If pregnant woman infected (migratory polyarthritis), then 1% risk Ab esp < 24 w GA. Mgt/test per Ob.
• adult parvovirus infection: suspect if occupational exposure with fever, malaise, arthralgia, small joint synovitis, faint maculopapular reticular rash on thighs, inner aspects of arms.

Fluoride

1. limit dosing, start at age 6 months. Not needed if > .6 ppm in water.

2. beware fluoridated toothpaste (pea-sized only). Avoid Beech Nut’s ‘Spring Water with Fluoride’

GI foreign bodies (coin/battery swallowing)

coin (AP chest)

• if past gastro-duodenal junction is likely to pass. Recheck in 3 days if not found in stool. If signs/symptoms obstruction, refer.
• if lodged in esophagus, refer to ER for extraction or boogie into stomach.

button battery

• PA/lateral chest and abdomen
  • esophagus: remove immediately
  • stomach: OK unless > 15 mm in child < 6 years

Headache & Brain Tumor

see imaging indications

Onset of Neurologic Findings

• 50% ataxia 2 weeks after h/a onset
• 85% ataxia 2 months after onset
• 88% ataxia 4 months after onset

Henoch-Schonlein Purpura (HSP)

• AFP 1998 Review. Generally benign and self-limited, but renal injury can occur. Peak age 5 yo.
• starts with red papular rash (100%). Variable: purpuric rash (often leg), abdominal pain (65%), renal (50%), arthritis (transient, 70%)
• associated with Group A Strep, mycoplasma, esp spring and fall
• renal involvement resemble's Berger's Disease lesions, within 3 months of rash -> hematuria
• D/Dx: RMSF, SBE (purpuric rashes), SLE, acute abdomen, Rheum Fever, sepsis, menigococcemia, ITP
• don't confuse with the similarly acronym of a d/o that also impacts the kidney --

Human Herpesvirus 6, Exanthum Subitum, Roseola Infantum, Sixth disease

• HHV-6
• 6mo - 2 yrs, almost all seropositve by age 4 years, 94% by 1 year, often first fever in a child
• high fever (105) for 2-5 days, irritable, non-toxic, palpebral edema, suboccipital adenopathy, late leukopenia, 50% cough
• faint pink macular rash at day 4 with defervescence (resembles rubella, measles)

Intoeing

Dietz FR. Intoeing -- fact, fiction, and opinion. Am Fam Physician 1994 Nov 1;50(6):1249-1264. #1771

metatarsus adductus

• C shaped forefoot, reducible, 95% resolve
• stretch if stiff, refer if not resolved by 4-8 mo and rigid or “cosmetically unacceptable”. Treatment -- casting, best before 8 months.

internal tibial torsion

• with patella facing forward, entire foot points inwards
• presents at walking age, 95% resolve by age 7-8 years
• bracing and therapy (incl osteotomy) very controversial.

excessive femoral anteversion

• patella and feet face inwards, present age 4 with history of 2 years of “worsening”
• lie on stomach, ankles can go “out” so far as to almost touch ground (internal rotation of 70-90 degrees), external rotation is only 10-30 degrees
• only therapy is surgical, very controversial, high rate of complication. Consider if persists > age 8-10, cosmetically unacceptable, functional gait problems. Only do at a “super-center”.

Iron deficiency anemia (infant)

1. Hematocrit [mean (-2SD)]

• 2 mo 35 (28)
• 6 mo 36 (31)
• 6 mo-2 y 36(33)

2. Evaluation

• Hematocrit (screening)
• lead level if anemia
• CBC?
• ferritin
• response to replacement: expect 1 gm Hg increase after 3 month therapy

3. Therapy: elemental iron 3 mg/kg/day

• test for response at one month, treat 3 months to replace stores
• give 30 minutes before mealtime, with citrus juice (vitamin C). May eat 30 minutes later. Cows milk interferes with absorption.
• Fer-In-Sol: (75 mg iron (15 mg elemental iron) /0.6 ml)

Kawasaki

• “scarlet fever” + conjunctivitis + swollen hands/feet + persistent fever
• initially looks like strep/enterovirus, then more edema of mucosa then rash hands/feet
• fever > 5 days; conjunctivitis; lip fissuring/strawberry tongue; palmar erythema/edema/peeling; nonvesicular polymorphous trunk rash; big cervical nodes
• probably infections, but agent unknown
• response to immunoglobulin can be very dramatic but cardiac aneurysms may still develop
• see: d/dx fever and rash in sick person

Misc

• lateral neck
  • must have slight extension else false negative for epiglottitis and false positive for retropharyngeal abscess
  • 20% false negative rate for epiglottitis
  • should this test be replaced by CT?

Neonatal Jaundice

• pathologic: occurs in 1st 24 hours, usually hemolytic, r/o sepsis.
• physiologic (unconjugated, immature liver): day 2-3, peak total bilirubin < 12 mg/dl on day 4-5, rise < 5mg/dl/day, conjugated < 1 mg/dl.
• biliary atresia and neonatal hepatitis usually present after 1 week

Neonatal resuscitation

Suction Catheter

• NeoVac meconium suction catheter
  • 3.5 mm and 3.0 mm (use mainly 3.0)
  • Concord/Portex Cat # 430035

Orogastric catheter

• use if must ventilate for > 2 minutes.

Useful Numbers

• Bag pressure (pop-off valve at 35mm)
  • opening: 30-40 mm
  • standard: 15-20 mm
• TC of newborn: 7 ml/kg (25-30 ml typical)
• Ventilation rate: 40-60, 30 if doing chest compressions at 120/min (3:1)
• ET sizing
  • 3.0 F for most
  • trachea 5-6 cm (term), 3 cm (preterm)
  • cut to 13 cm length
  • use 0 blade

Drugs (old)

Pubertal and Growth Disorders

• AFP July 1999 - includes Tanner Stages.
• Girls: breast buds and skeletal growth -> pubic hair, axillary hair -> menarche.
• Boys: testicular enlargement -> pubic hair -> enlargement of penis -> spermarche.
• precocious puberty in boys: often serious pathology. In girls 90% benign.
• delayed sexual devpt
  • girls: lack of any breast development by 14 years of age or when more than five years pass between initial growth of breast tissue and menarche.
  • boys: no testicular enlargement (length > 2.5 or volume > 3.0 cc) by 14 years of age or the passing of five years between the initial and complete development of the genitalia.
  • evaluation male if NO enlargement: hCG will cause testes to produce testosterone, hence assess function without pituitary CT or testicular biopsy. If enlargement is present this is not needed.
• short stature
  • constitutional with delayed pubertal maturation: height age = bone age < chronological age
  • familial: height age = bone age < chronological age

Disorders of body proportion

• achondroplasia: most common, limbs are short
• hypothyroid: immature proportions
• upper-to-lower body segment ratio
  • use if assessing for a alteration of proportional growth
  • equals crown to pubis/pubis to heel ratio
  • birth: 1.7, age 10 or greater: 1.0

Rhinitis

• if rhinitis in first year then tend to allergic rhinitis by age 6
• maternal hx of allergic rhinitis much more predictive of rhinits in children than paternal inheritance
• nasal polyp - cystic fibrosis, aspirin sensitivity
• hormonal nasal congestion in girls age 12-15
• pre-school rhinitis: adenoid, infection, non-allergic. With rhinitis > 3 mo resolve symptoms with antibiotics in about 1/3? (? any data)
• secondary enuresis: consider sleep disturbance due to allergic rhinitis
• blue mucosa: vasomotor rhinitis - smoking in house
• pale mucosa: allergic rhinitis

Allergic rhinitis

• see allergies (therapy)
• allergic rhinitis in age < 3 y usually indoor allergen
• management: therapeutic trial, skin test if > age 7
• cromolyn not effective
• Zyrtec/cetirizine (pediatric advantage) most effective non-sedating anti-histamine for use in children
• nasal steroids: Flonase has low systemic absoprtion

Sedation

Under 1 year

Chloral hydrate soln 250gm/5 ml and 500 mg/5 ml

• 50 mg/kg, if no effect after 45 minutes may give half of original dose (do not exceed 1000 mg max dose total)
• NPO 4 hours prior to procedure

Sudden cardiac death

• Hypertrophic cardiomyopathy: most common cause, autosomal dominant, all family members must be evaluated
  • Subaortic stenosis in 25%
• Long QT syndrome
• aortic stenosis

Tachypnea and pneumonia

Auscultation in infants and children is rarely useful. High negative predictive values of respiratory rate (measured for 1 min with scope) less than:

• 60 (age 0 -6 mo)
• 53 (6 - 11 mo)
• 43 (1 -2 yrs)

Topical Anesthesia

• LET: repairs
• EMLA cream: procedures, intact skin
• add .5 ml HCO3 to 2.0 ml lidocaine

UTI

• UTI 4/1/98 AFP
• some argue against differential management of 1st UTI in boys vs. girls (both vcug, u/s?)

Vaccination

The live virus attenuated vaccines are:

• Varicella
• Smallpox (no longer used)
• Polio (oral, no longer used)
• Measles
• Mumps
• Rubella