PedsExam(short).docx

Intro to Peds Pregnancy *Women are given folic acid (0.4-0.8mg/day) started 1 month prior to pregnancy and continued through 12 weeks gestation to help prevent neural tube defects Test for Group B Streptococcus (GBS) at 35-37 weeks; if positive, mother is given abx DURING labor to reduce transmissio...

Intro to Peds Pregnancy *Women are given folic acid (0.4-0.8mg/day) started 1 month prior to pregnancy and continued through 12 weeks gestation to help prevent neural tube defects Test for Group B Streptococcus (GBS) at 35-37 weeks; if positive, mother is given abx DURING labor to reduce transmission from mother to baby. Ampicillin is most commonly used. *Ampicillin is given to newborns suspected of having sepsis, pneumonia or meningitis. GBS is primarily the reason for choosing Ampicillin. Tdap is given with each pregnancy between 27-36 weeks to protect newborn from Pertussis. *Infants below the age of 6 months are at highest risk for pertussis. *IM betamethasone 2 doses separated by 24h is given to mothers in labor to help mature the baby’s lungs *Complications of premature birth include: respiratory distress, apnea, cerebral palsy, vision problems, developmental delays and learning disabilities. *The most common cause of neonatal distress is respiratory distress. Tocolytics are used to prolong labor for 2-7 days Magnesium sulfate (neuroprotective effect) Will make the newborn CNS-depressed until Mg level drops Indomethacin is used more often in 24-32 weeks EGA CCB (Nifedipine) 32-34 weeks EGA Terbutaline Neonates APGAR is performed at 1 and 5 minutes after birth for all infants then every 5 minutes as needed; measures appearance, grimace, activity/muscle tone, and respiration (each have 0-2 pts each); Higher = better *Start chest compressions when HR is <60 *Surfactant is given to the baby shortly after birth to help babies better oxygenate and minimize effects of prematurity on the lungs. Surfactant lowers the surface tension on the alveoli and allows better gas exchange and less trauma from artificial ventilation. The Ductus Arteriosus is a connection between aorta and pulmonary artery; if it does not close, leads to left-to-right shunting of blood into the lungs which can lead to respiratory distress, low cardiac output, pulmonary edema, and pulmonary hypertension. We can close PDA with APAP (IV or PO), Indomethacin IV, or Ibuprofen IV *To keep the PDA open in the case of a severe heart defect, use Prostaglandin E1. *Bronchopulmonary dysplasia/chronic lung disease of prematurity: is treated with diuretics like HCTZ or chlorothiazide along with spironolactone and sometimes furosemide For inflammation: inhaled CS (budesonide) and beta agonists Newborns can get infections from mom (early/first 7 days) or can be acquired from the caregiving environment (late/up to 90 days). Early infections are usually GBS (tx: Ampicillin), E. Coli (Gent/AG), H. flu., Listeria; tx: Cefepime, Cefotaxime, Flagyl Late infections are usually from Coagulase negative staph aureus, GBS, E. coli, Klebsiella, PSA, Enterobacter, Serratia, H. flu, Listeria, Candida Tx: Cefepime or Meropenem + Vancomycin Never use Ceftriaxone ins neonates IM Vitamin K is given to newborns to prevent late-onset bleeding/hemorrhagic disease (VKDB) Every baby is given eye care 0.5% erythromycin ointment to prevent neonatal gonococcal ophthalmia. Chlamydia might be present and should be treated systemically (Azithromycin). Apnea of prematurity: caffeine citrate (Cafcit) 20mg/kg loading dose then 5mg/kg/day Redness around the umbilicus should be referred because it is suggestive of necrotizing fasciitis or staph infections. Newborn screen includes screening for things like: amino acid disorders (PKU), organic acid conditions, fatty acid oxidation disorders, endocrine disorders, hemoglobin disorders, cystic fibrosis. These are important tests for conditions not evident on physical exam that if not diagnosed and treated, result in disability, disease, or death. Calories in breastmilk and formula: 20 calories per ounce *Decogexanoic acid (DHA) and arachidonic acid (AA) are additives thought to be beneficial in brain development/future intellectual accomplishments, but not proven to be beneficial and are more expensive *Infant formula does NOT have immunoglobulins in it. Yes, can mix infant formula to higher concentration (22, 24, or 26 per ounce; standard is 20 cals per ounce) Pediatric Assessment *ABCs: Appearance, Breathing, Circulation Children are more vulnerable when it comes to medication safety because: Every calculation is a chance for error Limited drug info available Lack of commercially-available dosage forms Developmental differences Less margin for errors Oral extemporaneous preparations have limitations Quaid twins received 1000x the recommended dose of heparin. They were supposed to receive 10 units but instead got 10,000 units because pediatric and adult doses have the same labels PK variables that are more specific to infants and children: Children have a larger surface area per unit of mass than adults, greater degree of skin hydration, thinner skin, and higher rates of perfusion, leading to more drug absorption Infants lack significant stomach acid, so acid-labile drugs are better absorbed in the small intestine (reaches adult values at 6-8 months of life) Premature newborns have the slowest drug elimination (longer half-lives) *Neonates and infants usually have a higher percent body water, therefore a larger volume of distribution than older children and adults. 5 things that kill under five: peanuts, hard candy, popcorn, hot dogs, grapes *If an item is small enough to slide through the center of a paper towel or toilet paper roll, it is small enough to be a choking hazard in a child. Acute Illnesses Dehydration Common causes -- Viral cause: rotavirus, adenovirus; Bacteria: Salmonella, E. coli, campylobacter, C. diff; Parasites: Giardia; New onset type 1 diabetes or DKA Baby should have about 6 wet diapers per day *Signs and Symptoms: Dry mucus membranes and sunken eyes Crying without tear production No urine output for 12 hours Blood in stool Polyuria Vomiting for >24, fever >103, lethargy Abdominal pain IV fluid replacement is done with 0.9% NS or LR; IV bolus 10-20mL/kg over 30-60 mins *Oral replacement (5mL at a time) is just as effective as IV replacement *Hypo- and hypernatremia should be corrected SLOWLY *Hypo- and hyperkalemia should be corrected QUICKLY Mild, moderate, and severe pain *Children with underlying airway obstruction (tonsillar hypertrophy, sleep apnea) are at higher risk of opioid-related AE. Migraine Headaches *Abortive: APAP, NSAIDs, Triptans, Ondansetron, water, rest *Preventive: Topiramate, gabapentin, verapamil UTI The only sign of UTI in an infant is fever Flank pain is usually pyelonephritis and would be treated with 24 hours IV The most common pathogen for UTI is E. coli IV medication for UTI: 3rd Gen Ceph – Cefotaxime or Cephalexin PO medication for UTI: Amox, Amox/Clav, Oral Ceph, Bactrim, etc. Chicken Pox Patient groups that are at greatest risk of severe complications from chicken pox: immunocompromised (leukemia, HIV, on oral steroids >2 weeks) Pathogen to consider if skin infection occurs in a child w/ chicken pox: MRSA *The varicella vaccine is 86%-90% effective in preventing infection after two doses. Tx for fever/discomfort: acetaminophen (AVOID NSAID due to possible link to secondary infection) Acyclovir for high-risk, use IV for immunocompromised Croup Barking cough caused by airway obstruction; almost always caused by a virus *Medications for croup include racemic epinephrine (reduces upper airway swelling, short lived and may need to be repeated) and dexamethasone 0.6mg/kg (max 16mg) single dose Meningitis Common signs and symptoms: irritability, impaired consciousness, vomiting and nuchal rigidity, poor feeding Bacterial causes: Strep pneumo, H. flu, Neisseria meningitides Infants (<2 months): GBS/Strep. Agalactiae, E. coli, Listeria, Monocytogenes Ampicillin+Gent, Cefotaxime *Infants (>2 months) and children: S. pneumo, H. flu, N meningitidis *Ceftriaxone or Cefotaxime +/- Vanc Adj therapies: dexamethasone, rifampin Chemoprophylaxis: H. flu (Rifamipin), Neisseria meningitidis (Rifampin, Ceftriaxone or Cipro) Ampicillin and Pen G is likely resistant to H flu Clindamycin is NOT for meningitis and it does not cover gram negatives Kawasaki Disease This is the main cause of acquired disease in children in the US Symptoms: fever for 5 days of unknown cause + four of the following Bilateral congestion of ocular conjunctivae Changes of lips and oral cavity Dryness, redness, fissuring of lips Protuberance of tongue papillae (strawberry tongue) Diffuse reddening of oral and pharyngeal mucosa Medications used to treat KD: *Aspirin 80-120 mg/kg/day in acute phase After fever subsides: 30-50 mg/kg/day After ESR returns to normal 3-5mg/kg/day STOP when platelets return to normal IVIG 2g/kg over 12 hrs IV CS if 2 doses of IVIG have failed; otherwise, *CS (ex. methylprednisolone) is NOT considered DOC for KD Infliximab in IVIG-resistant cases (risks include infection, aseptic meningitis, etc.) Cough and Colds *Codeine is contraindicated in children younger than 13 years of age Treatment goals: symptomatic relief Non-drug therapies: nasal saline, increased humidification, honey, vapor rub, suctioning FDA mandates medications NOT be given to children under age of 4 years because there is a severe lack of scientific data to support use, mistakes were common, overdose was common, and AE from drugs. Cough should be treated when coughing leads to consecutive nights of poor sleep and/or vomiting, cough leads to rib fractures, cough severe enough to lead to hypoxia Acceptable medications for an irritant cough: dextromethorphan, guaifenesin, benzonatate Fever Rectal, ear, and temporal artery temps are considered core temperatures. Fever when core temp is >100.4 Treat if: underlying medical problem, history of febrile seizures, child is uncomfortable Infants <3 months with core temp >104F Child >3mo with temp 100.4 for greater than 3 days or appears ill Children 3-36 months with temp >102F Any age with temp 104, febrile seizure, recurrent fever, chronic medical problem, fever and new skin rash Tylenol dose: 10-15mg/kg q4-6 hrs (max rectal dose 45mg) Advil dose: 5-10mg/kg q6-8 Can alternate if really bad fevers GER & GERD GER is the passage of gastric contents into the esophagus GERD is the symptoms and complications related to GER Keep baby upright, avoid overfeeding, take time to burp the baby, put baby to sleep on their back, experiment with your own diet. Medications for GERD include: H2RA, PPIs, prokinetic agents (metoclopramide, erythromycin, bethanechol) Conjunctivitis (Pink Eye) Allergic itchy Bacterial purulent Viral swollen Enuresis Enuresis alarm is more effective than any pharmacotherapy Desmopressin may take up to 2-3 months for full effect and relapse is common. Side effects include: N/V/HA, abdominal pain, facial flushing, increased BP, tachycardia, hyponatremia Oxybutinin is useful for daytime enuresis Otitis Media Pathogens that cause otitis media: viral is most common; strep pneumo (can be treated w/ plain amox), H.flu, Moraxella We use Amox 80-90 mg/kg/day as first line because most likely bug is strep pneumo Augmentin should be used for kids who have received plain Amoxicillin within the last 30 days Amoxicillin 80-90mg/kg/day + Clavulanate 6.4mg/kg/day Chronic Diseases Hypertension Most common cause of HTN in children is *kidney disease and heart disease Treatment for hypertension in children is generally the same: HCTZ, ACEi, ARBs (*ex DOC: Enalapril); Usually avoid BB due to exercise intolerance unless it is needed for rate control *Hypertension is defined as >95th to 99th percentile PLUS 5 mmHg when compared to children of the same sex, age, and height Not well studied in children, not many children are diagnosed/receive pharmacotherapy Cerebral Palsy Causes: prenatal (premature birth) problems, postnatal problems (meningitis, encephalitis, brain injury) Tx for spasticity (most common): Diazepam, clonazepam, or *baclofen (can be given via intrathecal pump; but use caution with abrupt withdrawal) Tx for drooling: glycopyrrolate and scopolamine Autism 2 core features: Lack of appropriate social body language, lack of empathy or interest in what others are saying; difficulty adjusting behavior to fit the social situation Restricted or repetitive patterns of behavior, interests, or activities; stereotyped or repetitive motor movements, insistence on sameness, highly fixated interests; increased or decrease reactivity to sensory input *Tx for insomnia: Melatonin Alt tx: omega-3 fatty acids, levocarnitine, N-acetylcysteine *Tx for aggression/irritability: aripiprazole and risperidone Tx for depression: SSRI (citalopram) Tx for symptoms of ADHD: atomoxetine, clonidine, guanfacine Anticoagulation *DVT/PE in children is uncommon and can originate in the upper or lower extremities *DVT is usually secondary to a central line (CVC) but can be due to sepsis, nephrotic syndrome, malignancy, use of L-asparaginase, heart disease or other factors *Enoxaparin is the DOC and dose is typically much higher in mg/kg Nephrotic syndrome *Tx for acute exacerbation (significant edema): albumin and furosemide Corticosteroids (2mg/kg/day, up to 60mg) to induce remission; may be continued QD or QOD If steroid resistant: Calcineurin inhibitor (but have significant AE) – cyclosporine, tacrolimus; also *mycophenolate mofetil which has the least effect on renal function AE of medications: Cyclosprorine HTN, hirsutism, electrolyte abnormalities, nephrotoxicity Tacrolimus HTN, AMS, electrolyte abnormalities, nephrotoxicity Mycophenolate mofetil dyspepsia, diarrhea, leukopenia, rarely lymphoma; *Mycophenolate mofetil has the least effect on renal function Cyclophosphamide and chlorambucil chemotherapy AE NEPHROTOXICITY *Bedside Schwartz Equation is used to estimate renal function in a child Irritable Bowel Syndrome Stress management Exercise helps IBS-C: use whatever works for the patient IBS-D: loperamide to decrease symptoms and pain Cystic fibrosis Common bacteria: PSA, MRSA, H. flu Antibiotic dosing in CF is a lot more Asthma exacerbations First line tx: inhaled corticosteroids and long-acting beta-agonists Montelukast: neuropsychiatric disorders are very uncommon, but there is a history of it so try to avoid Atopic dermatitis Atopic triad: AD + allergic rhinitis + asthma or food allergies Standard threapy: emollients, topical CS, topical calcineurin inhibitors, wet-wrap tx, antihistamines, antibiotics, antivirals, antifungals, oral CS Ulcerative Colitis and Crohn’s Disease Peaks in children between the ages of 10-20 Traditional tx: start therapy with lowest toxicity (step-up) that include CS, aminosalicylates and immunomodulators Top down therapy is starting with biologics like infliximab and adalimumab because it helps quickly health mucos to prevent structural damage Most concerning risk w/ the use of biologics is hepatosplenic T-cell lymphoma (this is very very very rare); but is reported in patients who have used a thiopurine immunomodulator