PEDS PEARLS - ROYAL COLLEGE REVIEW 1-75.pptx

Peds Pearls: Royal College Review Notes By: Alon Coret Winter/Spring 2023 [email protected] 1 How these slides work Someone once told me that yellow backgrounds help with memory and information retention; I don...

Peds Pearls: Royal College Review Notes By: Alon Coret Winter/Spring 2023 [email protected] 1 How these slides work Someone once told me that yellow backgrounds help with memory and information retention; I don’t know how true that is, but I am going with it anyway. Main slides = high-yield pearls ○ Sources = CPRP 2023 (AKA ‘Hamilton Review’) and CPS position statements/practice points Slide notes = further elaboration and details ○ Sources = CPRP 2023, CPS, study group discussions, my personal notes ○ If you see the CPS logo - there is usually a statement summary in the notes! This is not an exhaustive guide that addresses all the Objectives of Training in Pediatrics, but I did my best Use at your own discretion; if you spot an error, please let me know YOU GOT THIS! :) 2 Table of Contents General Pediatrics = 4-14 GI, Hepatology, Nutrition = 130-138 Allergy = 15-20 Orthopedics = 139-142 Toxicology, Burns, Submersion = 21-29 Development/Behavior = 143-148 Child Maltreatment = 30-34 Nephrology = 149-157 Endocrinology = 35-44 Surgery = 158-164 Metabolics = 45-49 Urology = 165-171 Hematology = 50-57 Cardiology = 172-183 ENT = 58-62 Neurology = 184-192 Rheumatology = 63-69 Critical Care = 193-203 Random CPS Lecture = 70 Mental Health = 204-207 Ophthalmology = 71-75 Respirology = 208-210 Adolescent Medicine = 76-86 Dermatology = 211-223 Neonatology = 87-100 Genetics = 224-232 Infectious Disease/Vaccines = 101-124 Immunology = 233-238 Oncology = 125-129 3 General Pediatrics Breast is best: ○ Benefits to mother = improved PP weight loss, delayed onset of menses, decreased breast +/- ovarian ca, cheaper. ○ Benefits to baby = immune protection, cognitive development, ↓ SIDS, ↓ obesity risk; ? ↓ risk of DM, atopy, ALL/AML ○ Prevalence has been increasing (~88% initiation), but risk of discontinuation remains ○ Composition: 20 kcal/oz (0.67 kcal/mL), lots of IgA in colostrum, lots of fat in hind milk, 60:40 whey-to-casein ratio. Milk for preterm infants is lower in CHO but more caloric. ○ Contraindications = mother HIV+, mother receiving cytotoxic chemo/rads, infant galactosemia. PKU is not an absolute contraindication. ○ Exclusively until 6 months of life + 400 IU/day vitamin D; continue along with solids until age 2 years and beyond ○ Tongue ties are common (5-10%); need for tx is controversial; +minor complications ○ If not breastfed, use cow’s milk-based, iron-fortified formula; avoid homemade formulas 4 General Pediatrics Infant nutrition: ○ First complementary foods should be iron-rich. Introduce lumpy textures no later than 9 months to avoid aversions. ○ Responsive feeding to the child’s cues is good; promote finger feeding, open cups ○ Homogenized cow’s milk can be introduced ~9-12 months; max 750 mL/24 oz daily ○ No honey until 12 months (botulism risk); avoid added salt/sugar/juice; high-fat = good energy source; have parents role model healthy eating habits with a regular schedule. ○ For infants at high risk of allergy (i.e. 1st degree relative w/ allergic condition), earlier introduction (age 4-6 months) of common allergens (e.g. peanuts, eggs) is a good idea. Appropriate texture, offered one at a time, and maintained a few times/week for tolerance. No evidence for restrictions on maternal diet. ○ Pacifiers are generally fine once breastfeeding has been established; consider d/c by 6 months and DEFS by 2-4 years. Benefits = ↓ SIDS, ↑ comfort/oromotor skill development (mostly in prems). Risks = ?AOM, ?dental arch/occlusion issues. ○ Vitamin D = 400 IU daily is standard; 800 IU daily in northern/Indigenous populations. If formula-fed infant and at high risk, still give 400 IU daily. If formula-fed and drinking enough formula/cow’s milk (800+ mL daily), no need to supplement if low-risk. One risk factor = high risk! 5 General Pediatrics Pediatric Growth, Obesity, Screens: ○ Use the WHO growth curves; BMI age ≥2 years; weight-for-length 97th= overweight; >99.9th = obesity Age 2-5 years: BMI >85th = risk of overweight; >97th= overweight; >99.9th = obesity Age 5-19 years: BMI >85th = overweight; >97th = obesity; >99.9th = severe obesity ○ Obesity management should be multi-D. “5-2-1-0” rule = 5+ fruits/veggies per day; max 2 hours recreational screens/day; 1+ hours physical activity/day; 0 sugar drinks. Optimize sleep. ○ Kids are exposed to too much screen time; may have some benefits re: language, learning, prosocial behavior, friendships (older kids), but generally outweighed by various risks. Recommendations = avoid in kids 48h, early/severe constipation (age F; 10-15% of 5-year-olds, 1-2% of 15-year-olds. If new onset, obtain a urinalysis! R/O infection, DM1, DI, etc. Treat if it poses a significant problem for the child Prevention = avoid caffeine/excess fluids before bed; empty bladder before bed Enuresis alarms may be helpful for highly motivated kids/families; can take 1-2 months to see improvement; success rate 6 weeks. Often non-allergic - e.g. viral infections. Raised, indurated, +/- pruritic, migrate ~q24h. Non-sedating antihistamines are key to treatment. 17 Allergy Non-IgE food allergy: ○ FPIES = profuse/repetitive vomiting, pallor, lethargy, hypotension +/- shock-like state; 1- 4 hours post-ingestion of trigger food, diarrhea 5-10 hours post. Peaks age 2-7 months, but can occur in adults, too. Can occur with first exposure or following period of tolerance. Treat with fluids and ondansetron; eliminate the trigger foods (usually grains, eggs, veggies, meats, cow’s milk). Maternal elimination generally not needed. Most resolve by age 5; trigger foods should be reintroduced under medical supervision. ○ FPIAP (previously CMPA) = intermittent mucous/bloody stools in otherwise well infant; generally first 4 weeks but anytime in first 6 months. Usual trigger is cow’s milk (76%), but can also be soy, egg, and corn. Strict elimination from baby AND mother required; if nil response, may need extensively hydrolyzed or AA-based formula. Outgrown by 12 months; food challenge can be safely done at home. 18 Allergy Potpourri: ○ Mastocytosis (see top two photos) is a rare condition whereby excessive mast cells accumulate in one or more tissues. Darier’s sign = ‘urtication’ of these lesions with pressure/irritation. Will see ↑↑↑ tryptase (found in mast cells). Generally managed with avoidance and antihistamines; epinephrine IM if significant anaphylaxis-like reaction. ○ Vaccine allergy is rare, but large local reactions can be seen. MMR and influenza no longer contain egg derivatives! ○ Allergic rhinitis is generally due to environmental allergies; can be seasonal or perennial; +conjunctivitis, sinus symptoms, cough, ‘allergic shiners,’ allergic salute, pale/bluish turbinates, Dennie-Morgan lines (extra creases under the eyelid from irritation/itching - third photo). Treatment is generally with antihistamines + nasal steroid sprays; Montelukast also an option; newly available SL immunotherapies (e.g. Grastek, Ragwitek - for grass and ragweed, respectively). 19 Allergy Potpourri (cont.): ○ Pollen-food allergy syndrome (AKA oral allergy syndrome) refers to cross-reactivity between fruit/vegetable proteins and pollen proteins, causing a localized - and extremely rare, systemic - IgE-mediated reaction. Usual ssx = itching/burning in the lips, mouth, ear canal, or pharynx; +/- swelling or tightening sensation. Cooking denatures the allergenic epitope. No need to prescribe an Epipen! Just avoid the raw food. ○ Poison Ivy causes a type IV (delayed) hypersensitivity reaction in ~50% of people; onset usually within 4-96 hours. Usual ssx = pruritus, erythema, +/- papules/plaques/vesicles, usually in a linear or streak-like distribution. Treat with high-potency topical steroids (PO prednisone if very severe); antihistamines will not help. ○ Hereditary angioedema is episodic angioedema without itch or urticaria; affects skin and mucosa, typically of the upper respiratory and GI tracts → beware: airway compromise! F>M (slightly); can be de novo or AD mutation → deficient/dysfunctional C1 inhibitor protein → increased bradykinin → swelling with minor physiologic stress (or nil trigger). Investigate by checking C1 esterase inhibitor levels (should be LOW) and function; treat with C1 inhibitor replacement; avoid Rx that cause bradykinin accumulation (e.g. ACEi, cOCP). 20 Toxicology There are four main toxidromes, or toxic syndromes, to know: ○ Cholinergic (think: organophosphates (pesticides), neostigmine, donepezil) Classic ssx = DUMBBELLS = diaphoresis, urination, miosis, bronchorrhea, bradycardia, emesis, lacrimation, lethargy, salivation. Basically, “excretions from every orifice.” Treatment = 100% O2, early ETT (avoid succinylcholine!), remove clothing/irrigate skin, atropine q5 mins, inhaled ipratropium, pralidoxime. ○ Anticholinergic (think: atropine, antihistamines, TCAs, glycopyrrolate, Jimson Weed) Classic ssx = “mad as a hatter, hot as a hare, blind as a bat, dry as a bone, red as a beet” → confusion, hyperthermia, mydriasis, dry mouth, urinary retention, flushed skin Treatment = NaHCO3 if prolonged QRS (TCA antidote), lorazepam for agitation, water spray and cooling fans, +/- activated charcoal, +/- physostigmine ○ Sympathomimetic (think: cocaine, amphetamines, MDMA, ephedrine, PCP) Classic ssx = up and wet = mydriasis, diaphoresis, HTN, tachyHR, hyperthermia, psychosis, (hypoNa) PCP → nystagmus while awake! Treatment = phentolamine (reduce BP), lorazepam, cool water spray/fans, activated charcoal if ≤1 h ○ Opioid Classic ssx = bradycardia, hypotension, respiratory depression, pinpoint pupils, coma Treatment = naloxone (IV/IN) can help within seconds! 21 Toxicology Decontamination: Drug/substance Antidote ○ Activated charcoal: 1 g/kg, given as a slurry (semi Acetaminophen N-acetylcysteine liquid mixture); typically ≤1 hour of ingestion, but can be given later if slowed motility (e.g. anticholinergic); Iron Deferoxamine avoid in caustic ingestions or compromised airway. Will not work in “PHAILS” - potassium, hydrocarbons, Benzodiazepines Flumazenil alcohols, iron, lithium, solvents. B2 agonists, CCB Glucagon ○ Intravenous lipids (Intralipid) may be used in the setting of local anesthetic systemic toxicity (LAST) MetHgb, cyanide Methylene blue and life-threatening overdoses of bupropion or Heparin Protamine sulfate amitriptyline. Risks = pancreatitis, ARDS, fat embolism. Salicylates, TCAs Sodium bicarb Warfarin Vitamin K 22 Toxicology Other toxins and toxicities to know about: ○ Hydrocarbons (e.g. gasoline, nail polish remover, lighter fluid) - if aspirated - can cause pulmonary toxicity, with findings of perihilar infiltrates and pneumatoceles. ○ Diabetes medications - glyburide (sulfonylurea), insulin, rosiglitazone (SGLT2i) - will cause hypoglycemia. Metformin will not, however, it can cause a lactic acidosis in overdose. Other agents that will cause hypoglycemia = beta blockers, ethanol, salicylates ○ Acetaminophen → NAPQI → hepatotoxic in overdose (~150 mg/kg or ~7 g in adults). Will see AGMA. Maximal toxicity at 72-96 hours. Can give activated charcoal within 1-2 hours. Start NAC within 8 hours of ingestion; if unknown time, START IMMEDIATELY. Follow Rumack-Matthew nomogram (starts at 4 hours); trend transaminases, coags, RFTs, lipase. ○ Salicylates can be toxic in small quantities; ssx = respiratory alkalosis, N/V, GIB, tinnitus, hypoglycemia, hypokalemia, seizures. Order acetaminophen level, because often co-ingested/mixed up. Can give charcoal up to 6 hours; give glucose regardless. Hemodialysis if severe (e.g. seizure). ○ Iron overdose can be fatal due to shock or liver failure. Think about ordering an AXR, which could show opacities! Initial N/V/D → quiescent → multi-organ failure, metabolic acidosis. Treated with fluids, IV deferoxamine (do it early!) +/- whole bowel irrigation if 10) +/- acidosis OG = measured serum osmolality - calculated osmolality Calculation of osmolality = 2xNa + glucose + urea Pitfalls: won’t tell you type of alcohol; insensitive in late presentations; insensitive to small ingestions - thus, normal OG ≠ ingestion ruled out. Isopropyl alcohol (isopropanol) will cause ketosis without acidosis! No toxic organic acids → thus, no antidote necessary. Supportive care. Others - ethylene glycol, ethanol, methanol, will additionally cause acidosis. Methanol (e.g. solvents) ingestion can be toxic in tiny quantities; can cause retinal injury. Antidotes = fomepizole or ethanol. Ethylene glycol (e.g. antifreeze, brake fluid) can cause a significant acidosis with cardiac decompensation; ++QTc. Antidotes = fomepizole or ethanol. 24 Toxicology Other toxins and toxicities to know about: ○ TCAs (e.g. amitriptyline, imipramine) can be especially toxic in overdose, and will lead to ECG changes (QT prolongation, QRS widening, tachycardia), sedation, hypotension, and seizures. Will often require intubation for decreased LOC. Give NaHCO3 if QRS >100. ○ Cannabinoid hyperemesis syndrome presents with abdominal pain and intractable vomiting - relieved by hot showers - generally in heavy cannabis users. Standard antiemetics will not help; what might work is topical capsaicin, ?haloperidol, supportive care, and abstinence. ○ Synthetic cannabinoids can be very potent and toxic; often packaged as gummies, chocolates, and other things that kids may inadvertently ingest. From yours truly. ○ Calcium channel blockers (e.g. verapamil) - in overdose - can lead to bradycardia, hypotension, and hyperglycemia (block pancreatic Ca channels; induce cellular resistance to insulin). Often precipitous deterioration; don’t be fooled by reassuring mental status. Treat with atropine, calcium gluconate, and high-dose insulin euglycemic therapy → help feed the starved myocardium! ○ Amyl nitrite is a vasodilator, and when inhaled, can have a euphoric effect. This has led to its recreational use (“poppers”), often as a sexual enhancer. High doses → methemoglobinemia = cyanosis, hypoxemia, dyspnea, decreased LOC. Treated with IV methylene blue +/- hyperbaric O2 +/- exchange transfusion. ○ Bath salts are bad; can cause hallucinations, seizures, suicidality. Don’t do them. ○ Laundry detergent capsules, if ingested, can cause caustic injury and esophageal perforations. 25 Burns & Submersion Injuries Submersion injuries: ○ One of the most common preventable causes of death; M>F; kids age 9; for younger kids - child’s palm = 1% BSA. Only count superficial partial thickness burns (or more severe). Give NS/RL per Parkland formula = 4 cc/kg/BSA over 24 hours - 50% in first 8 hours, 50% in next 16 hours. Head (front + back) = 9%; total of each arm = 9%, total of each leg = 18%; total of chest and back = 36%; genital region = 1% Admit to hospital if: suspected NAI, >10% PT, >2% FT, >1% involving hands/feet/face/perineum, circumferential burn, enclosed space/inhalation injury, high-tension electrical wire, associated trauma Infection is the leading cause of morbidity and mortality! 28 Burns & Submersion Injuries Electrical Injuries: ○ 110V household circuits usually cause limited injury, but beware risk of arrhythmia/seizure if contact near chest or head; rule out rhabdomyolysis if exit wound or tender compartment. ○ High-tension wires can cause extensive damage, albeit masked by a small wound; beware rhabdomyolysis → AKI; CNS injuries; fatal arrhythmias. ○ Lightning strikes often associated with CNS injury (cerebral edema, hemorrhage, seizures), with deep injuries and burns being less common. May see an “arborescent” burn pattern on the skin (looks like branches of a tree; “feathering” is the other name for it). A bit more on inhalational injuries: ○ Again, suspect in the setting of singed nasal hairs; soot in the airway; hoarseness. Need to worry about other toxins as well, including CO, CN-, HCl, SO2. CO = tasteless, odorless, non-irritating; 240x higher affinity for Hb than O2 → hypoxemia (but with normal pulse oximetry and arterial pO2, because the machine can’t distinguish CO-Hb and O-Hb) - thus, measure CO-Hb levels! Tx = 100% FiO2. Beware as well of possible CN- poisoning in the setting of house fires! Be especially suspicious if decreased LOC and/or metabolic acidosis! Tx = cyanocobalamin kit STAT. 29 Child Maltreatment There are various child-specific, caregiver-specific, and household-specific factors that can lead to child maltreatment. ○ Greatest risk factor = having a caregiver who is a victim of intimate partner violence! FNIM/Black children are significantly overrepresented in the child welfare system Child maltreatment/ACEs predispose to significantly worse health outcomes. The physical examination in cases of sexual abuse is often normal or nonspecific. ○ The ones they seem to keep getting at are hymenal injuries. Hymenal notches can be NORMAL if ABOVE 3 and 9 o’clock or below these positions but WITHOUT extending all the way to the base of the hymen. Any lacerations of the hymen or notches below 3 and 9 o’clock that EXTEND ALL THE WAY to the base are ABNORMAL. ○ Also keep in mind the possibility of infections. Vaginitis and genital ulcers could be related to circulating viruses, candida, or noninfectious causes. Molluscum, HSV1/2, and HPV (especially age