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Questions and Answers
What is the primary psychosocial challenge faced by toddlers according to Erikson's theory?
In Piaget's theory, at what stage do toddlers complete their sensorimotor development?
Which type of play is commonly observed in toddlers?
How should caregivers respond to a toddler’s quest for autonomy?
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What type of thinking do preschoolers exhibit according to Piaget's preoperational stage?
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Which typical growth pattern is observed in preschoolers?
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What is an effective nutritional guideline for toddlers regarding milk consumption?
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What communication skill tends to develop in toddlers?
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During which stage do preschoolers primarily assert power and control over their environment according to Erikson?
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What is the recommended approach to feeding toddlers?
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What developmental characteristic is typical in toddlers when engaging in play?
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What is a key aspect of safety for toddlers as they explore their environment?
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What language skills are well developed by preschoolers?
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How do preschoolers typically engage in interactive play?
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What is the primary method of treatment for seborrheic dermatitis in infants?
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What is a characteristic symptom of slipped capital femoral epiphysis (SCFE)?
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Which of the following is a risk factor for Legg-Calve-Perthes disease?
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What is a common characteristic found during the assessment of developmental dysplasia of the hip?
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What is one crucial step in assessing a child with a suspected fracture?
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Which stage is NOT part of the progression in Legg-Calve-Perthes disease?
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What is a recommended intervention for children with fractures?
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In cases of scoliosis, what is a significant consequence of untreated progressive lateral curvature?
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Which intervention may be necessary for severe developmental dysplasia of the hip?
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What is a primary treatment goal for children diagnosed with SCFE?
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Which of the following signs might indicate compartment syndrome?
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What most accurately describes the process of managing a fracture in a child?
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Which symptom is NOT typically associated with seborrheic dermatitis?
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What is a significant long-term complication of a fracture involving the growth plate?
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What is the most common type of muscle impairment found in children?
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Which condition is characterized by the failure of the neural tube to fuse, leading to potential neurological impairments?
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What is a common clinical manifestation of Duchenne muscular dystrophy (DMD)?
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What is one of the treatment goals for children with spastic disorders?
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Which of the following is true regarding muscle weakness in muscular dystrophy?
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What type of intervention is most beneficial for achieving better outcomes in children with developmental delays?
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Which medication is commonly used to manage muscle spasms in children with spastic disorders?
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What significant risk is associated with surgical procedures in patients with muscular dystrophy?
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What is the primary characteristic of ataxic cerebral palsy?
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Which type of spina bifida is defined by an obvious protrusion containing both meninges and the spinal cord?
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What is a potential complication during gestation and birth for spina bifida?
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Which symptom is primarily associated with coarctation of the aorta?
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What is a primary focus in the management of feeding for children with muscular dystrophy?
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What kind of support is essential for families dealing with a child who has spina bifida?
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What should be monitored in children with cardiac conditions to ensure optimal health?
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What is a required component for the diagnosis of rheumatic fever using the modified Jones criteria?
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What type of defect is Tetralogy of Fallot primarily classified as?
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What clinical manifestation may occur due to prolonged hypoxia in patients with Tetralogy of Fallot?
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Which of the following is NOT a major criterion for diagnosing rheumatic fever?
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What management strategy is crucial for patients with Tetralogy of Fallot during acute episodes of hypoxia (TET spells)?
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What is the main consequence of pulmonary stenosis in Tetralogy of Fallot?
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Which of these treatments is specifically mentioned for managing rheumatic fever?
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How does the presence of a Ventricular Septal Defect (VSD) impact the blood flow in Tetralogy of Fallot?
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Which symptom is characteristic of Sydenham chorea as a major criterion for rheumatic fever?
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What is the role of Prostaglandin E infusion in tetralogy of Fallot management?
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What diagnostic test is commonly associated with identifying elevated ASO antibody titers in rheumatic fever?
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What is a common effect of exertional dyspnea in patients with Tetralogy of Fallot?
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Which of the following is considered a minor criterion for rheumatic fever?
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What is a potential complication of untreated rheumatic fever?
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What are the goals for ambulation post-treatment?
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Which is the least severe type of curvature based on the given classification?
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What complication is NOT a long-term goal of treatment for the conditions described?
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Cerebral palsy primarily affects which area of development in children?
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What should be monitored to prevent complications after treatment?
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What factor is primarily responsible for the increasing incidence of cerebral palsy?
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Which assessment sign is NOT associated with the complications listed in the content?
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What type of incidents can mimic signs of the conditions discussed in the content?
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Which approach should be taken when addressing body image concerns?
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What is a primary characteristic of cerebral palsy?
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Study Notes
Toddler Development (1-3 Years)
-
Erikson's Stage: Autonomy vs. Shame and Doubt
- Toddlers strive to gain autonomy by controlling their environment, particularly through self-control over toileting and food preferences.
- Successful development leads to self-confidence, self-control, and a sense of independence.
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Piaget's Stage: Transition from Sensorimotor to Preoperational
- Object permanence is well-developed, meaning toddlers understand that objects continue to exist even when hidden.
- Magical thinking emerges, representing the belief that inanimate objects can think or feel like humans.
- Gross motor skills develop rapidly.
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Social Development: Parallel Play
- Toddlers engage in parallel play where they play alongside each other without direct interaction.
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Safety:
- Constant supervision is crucial due to their increasing mobility and curiosity.
- Toddlers explore their surroundings extensively, so ensure safety measures are in place to prevent accidents.
- Consistent discipline is essential as they test boundaries.
Preschool Development (3-6 Years)
-
Erikson's Stage: Initiative vs. Guilt
- Preschoolers assert their power and control over their surroundings, taking initiative in their actions.
- Success fosters a sense of purpose and direction, while failure can lead to guilt and a lack of confidence.
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Piaget's Stage: Preoperational Stage Continues
- Magical thinking progresses.
- Egocentrism is prominent, making it difficult for preschoolers to see things from another person's perspective.
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Physical Growth: Slow and Steady
- Preschoolers exhibit steady growth with shape changes.
- Physical skills continue to develop.
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Language Development: Well-Developed
- Preschoolers have well-developed language skills and can engage in sophisticated conversations.
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Social Development: Associative Play
- Preschoolers participate in associative play, interacting and sharing ideas with peers while playing together.
Nutrition
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Meals vs. Snacks:
- Toddlers and preschoolers typically eat seven times a day, consuming more meals than snacks.
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Milk:
- Whole milk is recommended until the age of two.
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Choking Hazards:
- Continue to avoid foods that can pose choking hazards.
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Grazing:
- Toddlers and preschoolers often graze, consuming small amounts of food throughout the day.
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Forcing Food:
- Avoid forcing children to eat.
Hydration
- Provide frequent water throughout the day to ensure adequate hydration.
Communication/Interaction
- Toddlers and preschoolers use expressive language, imitating sounds and words.
- Expect frequent "no's!" and "why's!" as they explore and question their world.
Seborrheic Dermatitis
- Also known as cradle cap
- It is caused by an overgrowth of yeast.
- Characterized by mild, non-itchy erythema, waxy scaling, and yellow and red patches with greasy scaling.
- It typically affects infants between 0 and 3 months old and adolescents.
- Daily washing of the hair with baby shampoo is recommended for treatment, along with using a soft baby hairbrush or soft toothbrush to loosen the plaques.
- Apply a warm compress to the scalp for 15 minutes while shampooing and then brushing the scalp gently.
- Avoid vigorously scrubbing the scalp.
- For adolescents, shampoos containing selenium (such as Head and Shoulders) can be used.
Legg-Calve-Perthes Disease
- Also known as Perthes disease.
- It is characterized by temporary disruption of blood supply to the femoral head, causing avascular necrosis (death of bone cells).
- Progressive, but slow.
- Affects children between 4 and 8 years old, with boys being more common.
- Exact cause is unknown, but suspected risk factors exist.
- Treatment involves a long recovery time, lasting several years.
- Clinical manifestations depend on the age of the child at the time of diagnosis.
- Goals of treatment include pain control, maintaining hip movement, restoring the shape of the femoral head, and preserving bone density.
Stages of Legg-Calve-Perthes Disease
- Prenecrosis: before the blood supply to the femoral head is disrupted.
- Necrosis: blood supply is interrupted, causing death of bone cells.
- Revascularization: blood supply is restored.
- Remodeling: the bone begins to heal and reshape.
Slipped Capital Femoral Epiphysis (SCFE)
- It is a hip deformity that affects children in their late childhood or early adolescence.
- Symptoms include intermittent hip, knee, or groin pain on the affected side, and limping.
- It can be classified as stable or unstable with either a gradual or acute onset.
- Any child who is limping and reports pain to the groin, hip, thigh, or knee should be evaluated for SCFE.
- Limping and pain worsen after activity, the affected leg turns outward, and the child experiences decreased range of motion.
- Diagnosis is confirmed through an X-ray.
- Treatment involves stabilizing the hip joint, promoting healing, and preventing further injury to the growth plate.
Developmental Dysplasia of the Hip (DDH)
- It involves dislocation of the hip, often originating from in utero positioning or a congenital anomaly.
- Most commonly diagnosed during the newborn exam, but may be missed until later.
- Clinical presentations vary but include limited hip abduction, absence of knee flexion contractures, differences in leg lengths, asymmetrical thigh skinfolds, palpable and audible clicks when the femoral head moves out of the acetabulum, and Trendelenburg gait in older children.
- Assessments utilize the Ortolani test to reduce the hip joint and the Barlow test to promote dislocation.
- Treatment can involve positioning devices, slings, surgery, or bracing.
Fractures/Cast Care in Children
- Children's bones are more porous and therefore more likely to buckle or bow than break.
- The periosteum, a sheath covering the bones, is thicker and stronger in children, promoting faster healing and providing stability.
- Involvement of the physeal plate (growth plate) increases the risk of complications with healing and deformity.
- Clinical manifestations include pain, swelling, and inability to move the affected extremity.
- Assessment involves obtaining a history, reviewing neurovascular status, and conducting radiological studies.
- Fractures may require reduction (open or closed) and immobilization with a spica cast, often accompanied by pain medication for pain control and constipation prevention.
- Cast care includes elevation of the cast above the heart, ice to prevent swelling, monitoring for potential infection, and ensuring skin integrity.
- Educating the patient and family about cast management and infection prevention is crucial.
The Five P's of Tissue Ischemia
- Pain: Assessing the location, duration, and quality of the pain.
- Pulses: Checking the quality of peripheral pulses distal to the casted extremity.
- Pallor: Observing for pallor, cyanosis, and capillary refill distal to the cast.
- Paresthesia: Assessing for numbness or tingling and the ability to feel tactile stimuli distal to the cast.
- Paralysis: Evaluating the ability to move the area distal to the casted extremity.
Compartment Syndrome
- Assessing neurovascular status (the five P's) is crucial.
- Signs of compartment syndrome include pain out of proportion to the injury and unrelieved by opioids, pain with passive movement, and persistent deep aching pain.
Scoliosis
- It is a progressive lateral curvature of the spine, resulting in an S-shaped appearance.
- Classified by location (thoracic or lumbar) and cause (congential, neuromuscular, idiopathic).
- Severity is categorized into types I-IV.
- Assessment includes examining for fractures, muscle weakness, bone deformities, short stature, hearing loss, and blue tinting of the sclera.
- Treatment is palliative, focusing on prevention of complications such as contractures, deformities, muscle weakness, osteoporosis, and misalignment of the lower extremities.
Cerebral Palsy
- It affects motor development in children, affecting muscle movement and coordination.
- It is the most common physical disability in childhood.
- Caused by a hypoxic event to the brain during development.
- It is multifactorial, non-progressive, and permanent.
- Varying degrees of disability exist.
- The incidence is increasing due to improved survival rates for low birthweight and premature infants.
- Etiology involves a developing brain that fails to form correctly or experiences an insult.
Cerebral Palsy
- Four types of cerebral palsy: spastic, dyskinetic, ataxic, and mixed
- Spastic cerebral palsy is the most common type.
- Cerebral palsy is a disorder that affects muscle movement and coordination.
- Cerebral palsy is caused by damage to the brain during development.
- Symptoms of cerebral palsy can include developmental delay, feeding difficulties, seizures, and cognitive delay.
- There's no cure for cerebral palsy.
- Early intervention is essential for the best possible outcomes.
- Management involves a multidisciplinary team approach.
- Goals include optimizing mobility, maximizing physical abilities, supporting growth and development, promoting successful communication, ensuring adequate nutrition, and promoting social, academic, and recreational activities suitable for development.
Muscular Dystrophy
- Muscular dystrophy is an inherited disease that causes progressive muscle weakness, degeneration of muscle fibers, and muscle wasting.
- Duchenne muscular dystrophy is an X-linked form of muscular dystrophy that affects males only.
- The disease may also happen due to spontaneous genetic mutations.
- Clinical manifestations include Gower's sign, gross motor delay, muscle weakness, difficulty or inability to navigate stairs, clumsiness, and elevated creatine kinase (CK) levels.
- Diagnosis is typically made through genetic testing.
- Muscle biopsy may still be used in some cases.
- Treatment focuses on slowing the disease progression, maintaining function, and improving quality of life.
Spina Bifida
- Spina bifida is a neural tube defect that results from the failure of the neural tube to fuse in the lower spinal area.
- It can lead to an open vertebral arch, a sac protruding from the spinal area, a lesion covered with skin, or a combination of these features.
- Spina bifida can increase the risk of infection and trauma during gestation and childbirth.
- Neurological impairment is common, including paralysis below the level of the defect, orthopedic difficulties, and potential cognitive disabilities.
- Complications include Chiari II malformation and hydrocephalus.
- Three types of spina bifida: spina bifida occulta, spina bifida with meningocele, and spina bifida with myelomeningocele.
- Management involves providing support at birth, covering the lesion with sterile gauze, preventing heat and fluid loss, surgically closing the spine, monitoring head circumference for hydrocephalus, and taking latex-free precautions.
- Long-term management requires a multidisciplinary team and focuses on providing support, promoting emotional well-being, and addressing education and developmental needs.
Pediatric Cardiac Assessment and Interventions
- Do not cluster care for infants with cardiac conditions.
- Monitor apical pulse closely.
- Conduct thorough skin assessments to assess for cyanosis.
- Promote rest and comfort.
Medications for Heart Defects and Disorders
- Vasoactive medications like epinephrine and norepinephrine are used to treat shock.
- Prostaglandin E drip is used to keep the patent ductus arteriosus (PDA) open.
- Digoxin is used to improve myocardial contractility and is administered every 12 hrs.
- Digoxin toxicity presents with lethargy, nausea, vomiting, diarrhea, anorexia, and bradycardia.
Coarctation of the Aorta (COA)
- COA is a narrowing of the aorta that obstructs blood flow to the lower part of the body.
- The narrowing can lead to increased pressure and blood flow in the heart and upper body, and decreased pressure and blood flow in the lower extremities.
- This condition leads to backup of blood and increased workload of the heart and results in elevated renin levels, causing hypertension.
- Clinical manifestations include:
- Differences in blood pressure and pulses between the upper and lower extremities.
- Acyanotic.
- Tachypnea and dyspnea.
- Diaphoresis.
- Poor growth.
- Profound shock.
- Metabolic acidosis.
- End-organ ischemia.
- Systolic murmur.
- Headache.
- Management involves treating CHF, repairing the coarctation, improving blood flow, and monitoring perfusion.
- Education for families includes prevention of bacterial endocarditis.
Patent Ductus Arteriosus (PDA)
- PDA is an acyanotic defect where the ductus arteriosus, a blood vessel connecting the pulmonary artery to the aorta outside the heart, remains open.
- Blood flow is diverted from the left ventricle and aorta to the pulmonary artery, resulting in increased pulmonary blood flow.
- Oxygenated blood flows back to the lungs, leading to lung congestion and decreased lung compliance.
- PDA can be asymptomatic or lead to heart failure.
- The defect is common in preterm infants.
- Clinical manifestations include:
- Tachypnea.
- Dyspnea, including apnea.
- Tachycardia.
- Machine-sounding murmur.
- Fatigue.
- Poor feeding.
- Sweating with feeds.
- Bounding pulses.
- Widened pulse pressures.
- Management includes closing the ductus with medication (indomethacin or ibuprofen) or using a ductal occluder through catheterization, and surgical closure via thoracotomy.
Transposition of the Great Vessels
- The pulmonary artery and aorta are transposed, creating two separate circulatory systems.
- The aorta is connected to the right ventricle, and the pulmonary artery is connected to the left ventricle.
- Deoxygenated blood enters the right atrium, right ventricle, and aorta, circulating to the body. Oxygenated blood from the lungs enters the left atrium, left ventricle, and pulmonary artery, returning to the lungs. This results in significantly decreased systemic oxygenation.
- The condition causes profound hypoxia and cyanosis, decreased cardiac output, and heart failure.
- Clinical manifestations include:
- Profound cyanosis.
- Tachypnea.
- Tachycardia.
- Poor feeding.
- Poor growth.
- Signs of CHF.
- Management involves providing prostaglandin E, performing an atrial septostomy, and surgical reconstruction.
Ventricular Septal Defect (VSD)
- VSD is a defect in the septum between the right and left ventricles.
- It's one of the most common congenital heart defects.
- VSD is an acyanotic defect, allowing left-to-right shunting of blood from the left ventricle to the right ventricle.
- Increased pulmonary blood flow occurs, resulting in oxygenated blood flowing back to the lungs.
- The defect can be asymptomatic but can eventually lead to heart failure.
- The condition can also lead to increased work of breathing and pulmonary hypertension.
- Clinical manifestations include:
- Tachypnea.
- Dyspnea or apnea.
- Tachycardia.
- Fatigue.
- Poor feeding.
- Irritability.
- Sweating with feeds.
- Congestive heart failure.
- Management may include observation for spontaneous closure, surgical patch repair, closure with a valve occluder via catheterization, and a reduction in work of breathing.
Kawasaki Disease
- Kawasaki disease is an acute systemic vasculitis of unknown origin.
- It's a self-limiting inflammatory response, believed to be triggered by an infection, often viral.
- The disease is characterized by prolonged high fever, leading to coronary aneurysms and cardiomyopathy.
- Kawasaki disease is the leading cause of acquired heart disease in children.
- It affects children of Asian descent more frequently.
- The disease typically occurs in children between 6 months and 5 years of age.
- Kawasaki disease consists of three stages.
- Clinical manifestations include:
- High fever.
- Extreme irritability.
- Conjunctival hyperemia (redness of the eyes).
- Oral and pharyngeal erythema and inflammation.
- Cherry red, peeling lips.
- Strawberry tongue.
- Swollen hands and feet.
- Erythema on palms and soles.
- Erythematous/maculopapular rash.
- Erythema and desquamation in the perineum.
- Enlarged lymph nodes.
- Cardiac involvement.
- Diarrhea.
- Hepatic dysfunction.
- Vessel inflammation.
- Labs often show: anemia, elevated white blood cell count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), liver enzymes, and platelets.
- The sub-acute phase (2-4 weeks) shows: resolution of fever, worsening lip cracking and fissures, desquamation of palms, soles, and around the nail beds, joint pain, and cardiac disease.
- During the convalescent phase (6-8 weeks after the onset of the disease), patients tend to be normal but may have lingering effects.
- Management includes:
- Obtaining an echocardiogram.
- Hospitalization.
- Intravenous immunoglobulin (IVIG) infusions.
- Aspirin, which helps decrease clotting and joint pain.
- Clustered care to promote rest and comfort.
- Monitoring cardiac status, vital signs, and temperature frequently.
Hypertension in Pediatrics
- Blood pressure should not be checked in infants under 3 years of age.
Rheumatic Fever
-
Diagnosis:
- Jones Criteria: Requires two major OR one major and two minor criteria AND a positive anti-streptolysin O (ASO) antibody titer.
-
Major criteria:
- Carditis: Inflammation of the heart.
- Migratory Polyarthritis: Type of arthritis where pain or inflammation moves from one joint to another.
- Subcutaneous Nodules: Firm, raised bumps that form under the skin.
- Erythema Marginatum: Bright pink or red, circular lesions appearing on the arms, trunk, and legs.
- Sydenham Chorea: Jerky, purposeless, and uncontrollable movements of the hands, face, shoulders, arms, and legs.
-
Minor criteria:
- Arthralgia: Joint pain.
- Fever.
- Elevated Erythrocyte Sedimentation Rate (ESR) or C-reactive protein (CRP): These are indicators of inflammation in the body.
-
Treatment/Management:
- Penicillin (PCN): Administered for 10 to 14 days.
- Corticosteroids: Used to reduce inflammation.
- Non-steroidal anti-inflammatory drugs (NSAIDs): Used to manage pain.
- Antibiotic Prophylaxis: Involves taking regular antibiotics to prevent further strep infections.
- Ongoing Cardiac Follow-up: Necessary for patients with heart complications.
- Family Education: Families should be encouraged to ensure their child completes the full course of antibiotics, receive influenza prophylaxis, and attend annual immunization appointments. Antibiotic prophylaxis should also be administered for dental work.
Tetralogy of Fallot (TOF)
-
Description:
- Cyanotic heart defect (systemic cyanosis).
- Right-to-left shunting of blood.
- Typically involves a coinciding atrial septal defect (ASD) or ventricular septal defect (VSD) causing obstruction to blood flow.
- Deoxygenated blood returns to the body.
- Pulmonary blood flow is decreased due to obstruction.
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Four Components:
- Pulmonary Stenosis: Narrowing of the pulmonary valve.
- Overriding Aorta: The aorta is located above the ventricular septal defect (VSD) instead of directly above the left ventricle, causing more blood to flow to the systemic circulation.
- Right Ventricular Hypertrophy: Thickening of the muscle walls of the right ventricle due to increased workload.
- Ventricular Septal Defect (VSD): A hole in the septum between the right and left ventricles.
-
Clinical Manifestations:
- Cyanosis: Bluish discoloration of the skin and mucous membranes, especially around the mouth (perioral), hands and feet.
- Exertional Dyspnea or Apnea: Difficulty breathing or pauses in breathing during exertion.
- Polycythemia: Increased red blood cell count to compensate for low oxygen levels.
- Irritability: Infants may exhibit fussiness and increased restlessness.
- Poor Growth: Infants and children with TOF may experience slow weight gain.
- Fatigue: Low oxygen levels can lead to fatigue and lethargy.
- TET Spells: These are episodes of severe cyanosis, often accompanied by a drop in oxygen saturation, that are triggered by crying, feeding, or exertion.
- Irritability during feedings, crying, or bowel movements: These activities may exacerbate the cyanosis.
-
Treatment/Management:
- Prostaglandin E Infusion: Helps keeps patent ductus arteriosus (PDA) open.
-
Surgical Intervention: Typically required, may include:
- Pulmonary valve Repair or Replacement:
- Enlargement of the Pulmonary Artery:
- Closure of the VSD:
-
Increase Oxygenation:
- Providing supplemental oxygen helps to reduce vasoconstriction.
-
Decrease Oxygen Demand:
- Minimize activities that increase oxygen demand.
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Pre- and Post-Operative Care:
- Knee-to-chest position: Helps to increase pulmonary blood flow.
- Keep the baby calm and decrease stimulation: Promotes rest and better oxygenation.
- Frequent short interactions: Provides adequate periods of rest.
- Frequent small feeds: Promotes better absorption of nutrition.
- Strict intake and output monitoring: Vital for monitoring fluid balance.
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