Pediatric Quick Notes
Table of Contents
1 PEDIATRIC CARDIOLOGY 6
1.1 Atrial Septal Defect 6
1.2 Coarctation of the
... [Show More] Aorta 6
1.3 Patent Ductus Arteriosus 7
1.4 Tetralogy of Fallot 7
1.5 Transposition of the Great Vessels 7
1.6 Ventricular Septal Defect 8
2 PEDIATRIC PULMONOLOGY 9
2.1 Acute Bronchiolitis 9
2.2 Acute Epiglottitis 9
2.3 Croup 10
2.4 Pneumonia 10
2.5 Respiratory Syncytial Virus 12
2.6 Asthma 12
2.7 Cystic Fibrosis 14
2.8 Neonatal Respiratory Distress Syndrome (Hyaline Membrane Disease) 15
2.9 Foreign Body Aspiration 15
3 PEDIATRIC ENDOCRINOLOGY 17
3.1 Dwarfism 17
3.2 Type I Diabetes Mellitus 17
3.3 Type II Diabetes Mellitus 18
3.4 Obesity 18
4 PEDIATRIC EENT 20
4.1 Conjunctivitis 20
4.2 Dacryoadenitis 20
4.3 Strabismus (Tropia) 21
4.4 Otitis Media 21
4.5 Otitis Externa 22
4.6 Oral Candidiasis 22
4.7 Nasal Polyps 23
4.8 Pharyngitis & Tonsillitis 23
4.9 Dental Caries 26
5 Pediatric GI 28
5.1 Gastritis 28
5.2 Pyloric Stenosis 28
5.3 Constipation 28
5.4 Intussusception 31
5.5 Umbilical Hernia 32
5.6 Childhood Nutritional Deficiencies 32
5.7 Phenylketonuria 33
5.8 Lactose Intolerance 34
5.9 Abdominal Pain 34
5.10 Acute Abdominal Pain 36
5.11 Diarrhea 39
5.12 Hyperbilirubinemia 43
6 PEDIATRIC GU 44
6.1 Cryptorchidism 44
6.2 Cystitis 45
6.3 Orchitis 46
6.4 Wilms Tumor 46
6.5 Male Circumcision 46
6.6 Vesicoureteral Reflux 47
6.7 Vaginitis 47
6.8 Dysmenorrhea 48
6.9 Amenorrhea 48
7 PEDIATRIC MSK 50
7.1 Nursemaid’s Elbow (Radial Head Subluxation) 50
7.2 Slipped Capital Femoral Epiphysis 50
7.3 Osteosarcoma 51
7.4 Juvenile Rheumatoid Arthritis 51
7.5 Osgood-Schlatter Disease 55
7.6 Scoliosis 55
7.7 Pediatric Fractures 56
8 PEDIATRIC NEUROLOGY 61
8.1 Febrile Seizures 61
8.2 Cerebral Palsy 62
8.3 Headache 63
8.4 Migraine Headaches 64
8.5 Tension Headaches 64
8.6 Cluster Headaches 65
9 PEDIATRIC PSYCHIATRY 66
9.1 ADHD 66
9.2 Autism 67
9.3 Eating Disorders 68
9.4 Adjustment Disorder 69
9.5 Child Abuse 69
10 PEDIATRIC DERMATOLOGY 71
10.1 Dermatitis 71
10.2 Childhood Exanthems 72
10.3 Dermatophytoses 75
10.4 Acne Vulgaris 81
10.5 Molluscum Contagiosum 81
10.6 Verrucae 82
10.7 Impetigo 82
10.8 Lice 83
11 PEDIATRIC HEMATOLOGY 84
11.1 Sickle Cell Anemia 84
11.2 Acute Lymphocytic Leukemia 85
12 PEDIATRIC INFECTIOUS DISEASE 86
12.1 Diphtheria 86
12.2 Pinworms 86
12.3 Mumps 87
12.4 Pertussis 87
13 Pediatrics Exam Notes 88
13.1 The Newborn Infant 88
13.2 Pediatric Oral Health 92
13.3 Pediatric Physical Exam & Health Maintenance Exams 95
13.4 Immunizations 99
13.5 Child Development 102
13.6 Common Behavior Problems 106
13.7 Pediatric Nutrition 108
13.8 Lactation Overview 109
13.9 Childhood Obesity 111
13.10 Adolescent Medicine 113
13.11 Sports Pre-Participation Physical 116
13.12 Pediatric Fever 119
13.13 Pediatric UTI 120
14 Pediatrics Exam II TRP 123
14.1 ADHD 123
14.2 Pediatric Imaging 125
14.3 Pediatric Asthma 129
14.4 Pediatric Snoring and Obstructive Sleep Apnea 131
14.5 Pediatric GI Problems 132
14.6 Pediatric Labs 134
14.7 Medical Evaluation for Child Abuse and Neglect 136
14.8 Pediatric Infectious Disease 139
14.9 Autism 149
14.10 The Allergic Child 152
14.11 Dehydration 155
14.12 Heart Disease in Childhood 157
14.13 Pediatric Pharmacology 164
14.14 Pediatric Hematology 166
14.15 Pediatric Oncology 170
14.16 Common Pediatric Musculoskeletal Disorders 174
1 PEDIATRIC CARDIOLOGY
• Acyanotic = left-to-right
• Cyanotic = right-to-left
NOTE: All left-to-right shunts have the potential to revert to right-to-left shunts due to increasing pulmonary congestion (Eisenmenger’s syndrome).
Investigation of suspected heart defect
• Most cases are diagnosed prenatally by US screening @ 16-20 weeks
• Some defects don’t emerge until several days or weeks have passed since birth due to transition of circulation → adult levels of pulmonary vascular resistance
• Neonate will usually have symptoms within 24 hours
1.1 Atrial Septal Defect
• Acyanotic
Signs & symptoms
• May be asymptomatic unless there are other defects
• R heart failure
• Pulmonary edema
• Increased pulmonary vasculature
• Midsystolic pulmonary flow or ejection murmur accompanied by a fixed split S2
Management
• Refer to pediatric cards for echo
• Surgical repair at age 2-3 for most
• Small defects in boys don’t need closure if RV size is normal.
1.2 Coarctation of the Aorta
• Obstructive
Signs & symptoms
• Poor perfusion to LEs → diminished femoral pulses, cyanosis, cardiogenic shock, cold extremities, claudication
• Association with Turner’s syndrome, Shone’s syndrome, and bicuspid aortic valve
Workup
• Measure BPs on all 4 extremities → HTN in UEs with low or unattainable BP in LEs
• Refer for echo
Management
• Reopen truncus arteriosus within 4 days of birth with prostaglandins
1.3 Patent Ductus Arteriosus
• Acyanotic
Signs & symptoms
• Harsh continuous machine murmur
• Usually asymptomatic
• May have exertional dyspnea or heart failure
Management
• Refer to pediatric cards for echo and for meds to make ductal tissue regress or surgical repair
1.4 Tetralogy of Fallot
• The most common cyanotic heart defect
• Pulmonary stenosis → RV hypertrophy, overriding aorta, VSD
• VSD may be right-to-left or left-to-right
Signs & symptoms
• Progressive
• May appear healthy and pink at birth
• Cyanotic “tet spells” where child turns blue,
squats to valsalva
• Harsh systolic ejection murmur
• May also have right aortic arch, Down’s or DeGeorge’s syndrome
Management
• Surgical correction in early infancy
Complications
• Brain abscess
• Stroke
• CNS injury
1.5 Transposition of the Great Vessels
• Cyanotic
• Aorta and pulmonary trunk are switched so that deoxygenated blood gets pumped through the aorta to systemic circulation while the oxygenated blood gets pumped through the pulmonary artery back through the lungs
• Coexisting left-to-right shunt must also be present for life ex utero
Signs & symptoms
• Severe cyanosis at birth
• Loud S2
Management
• Requires arterial switch for long-term survival
1.6 Ventricular Septal Defect
• The most commonly diagnosed congenital heart defect
• May be single or multiple
• May be associated with other lesions
Signs & symptoms
• Holosystolic murmur
• May have thrill or diastolic rumble
• Heart failure
• Down’s syndrome association
Management
• Most will get smaller and disappear on their own
• Surgical repair indicated for intractable CHF, failure to thrive
2 PEDIATRIC PULMONOLOGY
2.1 Acute Bronchiolitis
• Reserach definition = first episode of wheezing in a child younger than 12 to 24 months who has physical findings of a viral respiratory infection and has no other explanation for the wheezing, such as pneumonia or atopy
• Broader definition = an illness in children <2 years of age characterized by wheezing and airway obstruction due to primary infection or reinfection with a viral or bacterial pathogen, resulting in inflammation of the small airways/bronchioles
• Mostly in infants < 2 months
• Prophylaxis with Synagis given to high risk infants during first RSV season
Agents
• Usually RSV
• Rhinovirus
• Human metapneumovirus
• Influenza
• Parainfluenza
• Adenovirus
Signs & symptoms
• Concomitant URI
• Conjunctivitis or OM
• Wheezing, tachypnea, retractions, crackles
Differential
• Asthma
• Foreign body
Workup
• Diagnosis is usually clinical
• CXR showing hyperinflation, interstitial pneumonitis, infiltrates
• ELISA for RSV available
Management
• Supportive
• Humidifier
• Oxygen if needed for severe disease
• Bronchodilators or steroids for select patients
2.2 Acute Epiglottitis
Agents
• H. flu
• Strep pneumo or Strep pyogenes
• Staph aureus
• Trauma
Signs & symptoms
• Abrupt onset of high fever, sore throat, stridor, dysphagia, drooling, trismus
• Sitting child that won’t lie down, head leaning forward (sniffing or tripod position)
Differential
• Croup
• Peritonsillar abscess
• Foreign body
• Diptheria
Workup
• Lateral x-ray for “thumb sign”
Management
• Send to ED for inpatient management and antibiotics as any manipulation of glottis could result in airway obstruction
2.3 Croup
Agents
• Usually parainfluenza virus
• RSV
• Human metapneumovirus
Signs & symptoms
• Average child is 18 months of age
• Stridor, hoarseness, barking seal cough, low-grade fever
• Rales, rhonchi, wheezing
• Symptoms worse at night Differential
• Epiglottitis
• Neoplasm
• Bacterial tracheitis
• Pharyngeal abscess
• Foreign body
Workup
• CXR showing “steeple sign”
Management
• Supportive: cool mist humidifier
• Send to ED for inhaled epinephrine if severe or if there is stridor at rest
• Steroids
2.4 Pneumonia
Agents
• Kids under 5: mostly viruses, also Strep pneumo, Staph aureus, and Strep pyogenes
• Kids over 5: Strep pneumo, Mycosplasma, Chlamydophila
Signs & symptoms
• Fever
• Cough
• Tachypnea
• Increased work of breathing: retractions, nasal flaring, grunting, accessory muscle use
• Hypoxia
• Adventitious lung sounds
Severity of community acquired pneumonia in infants and children
Clinical features of mild pneumonia Clinical features of severe pneumonia
Temperature <38.5°C (101.3°F) Temperature>=38.5°C (101.3°F)
Mild or absent respiratory distress: Increased RR, but less than the age-specific
RR that defines moderate to severe respiratory distress
Mild or absent retractions No grunting
No nasal flaring No apnea
Mild shortness of breath
Moderate to severe respiratory distress: RR >70 breaths/minute for infants; RR >50 breaths/minute for older children
Moderate/severe suprasternal, intercostal, or subcostal retractions (<12 months)
Severe difficulty breathing (>=12 months) Grunting Nasal flaring Apnea
Significant shortness of breath
Normal color Cyanosis
Normal mental status Altered mental status
Normoxemia (oxygen saturation>=92 percent in room air) Hypoxemia (sustained oxygen saturation <90 percent in room air at sea level)
Normal feeding (infants); no vomiting Not feeding (infants) or signs of dehydration (older children)
Normal heart rate Tachycardia
Capillary refill <2 seconds Capillary refill >=2 seconds
Workup
• No clinic or radiologic features can reliably distinguish between bacterial, atypical bacterial, and viral pneumonia
• CXR if disease is severe
Management
• Send to ED for admission with severe disease, failure of outpatient antibiotics, toxic appearance, dehydration, or younger than 3-6 months
• Empiric antibiotics for 6 months-5 years → amoxicillin, cefdinir, or macrolide
• Empiric antibiotics for > 5 years → macrolide, doxycycline
• F/u outpatient treatment in 24-48 hours
Sequelae
• Postinfectious cough for up to 4 months [Show Less]