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GENERAL PEDIATRICS LMCC Review. April 14, 2011. Feeding & Growth. Breastfeeding. CPS recommends exclusive breastfeeding for babies up to 6 months (when possible) Breast milk has a caloric content of ~20 Kcal/oz (0.67 Kcal/ml) Babies need 100-130 Kcal/Kg/day in 1 st 3 months

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General pediatrics lmcc review


April 14, 2011

Feeding growth

Feeding & Growth



  • CPS recommends exclusive breastfeeding for babies up to 6 months (when possible)

  • Breast milk has a caloric content of

    ~20 Kcal/oz (0.67 Kcal/ml)

  • Babies need 100-130 Kcal/Kg/day in 1st 3 months

  • Feeding/growth spurts occur at 8-12 days, 3-4 wks, 3 mo, variably after that

When comparing human breastmilk and cow s milk the following is correct

When comparing human breastmilk and cow’s milk the following is correct

  • The ratio of whey:casein is higher in human milk

  • Cow’s milk has a lower solute load

  • Human milk has higher iron content

  • Cow’s milk has lactose, human milk does not

  • Human milk has sufficient vit D

Nutritionally how does breast milk compare to cow s milk

Nutritionally, how does breast milk compare to cow’s milk?

  • Lower protein content - decreased solute load

  • Greater whey:casein (70/30 vs 18/82, formula 60/40)

  • CHO - both are lactose based (6.5% vs 4.5%)

  • Fat - 30-50% vs 3.5-4%

  • Vitamins - richer in A,C,E, lower in D & K

  • Minerals - lower Fe but better absorbed

Breast feeding benefits for baby

Breast Feeding Benefits for Baby

  • Immunological benefit

    • secretory IgA, lactoferrin, lysozyme as GI defence

    • Lower rate OM, LRTI, gastro, possibly UTIs, Hib

  • Less allergenic

  • Less constipating

  • Better jaw/mandible development

  • Attachment and ?Improved cognitive functioning

Breast feeding benefits for mother

Breast Feeding Benefits for Mother

  • Postpartum weight loss & uterine involution

  • Delayed return of fertility

  • Bonding

  • Pre-menopausal breast & ovarian Ca reduced

  • Economical benefit

Breast feeding issues

Breast Feeding Issues

  • Takes 3-7 days for milk supply to come in

    • risk of dehydration/ “breastfeeding jaundice”

  • Jaundice is more common

    • Breastmilk jaundice

  • “Mom/baby team”

    • ineffective latch/sore nipples/engorgement

  • Infections

    • thrush , mastitis/abscess

  • Reduced levels vitamin D & K

Vitamin d supplementation

Vitamin D Supplementation

  • Rickets is still a problem in Canada!

  • 400 IU per day

    • All Breastfed infants

    • Pregnant and nursing mothers in northern Canada

    • Formula Fed infants living in northern Canada

  • 800 IU per day - < 2 yrs breastfed babies with a risk factor

    • Home above 55 degree latitude, darker skin, sun avoidance

    • Community with high prevalence Vit D deficiency

  • Vitamin D is found in milk, margarine, salmon, tuna, liver, kidney & from the sun

  • Contraindications to breast feeding

    Contraindications to Breast Feeding

    • Maternal infections

      • HIV, AIDS, active TB, malaria, herpes on breast, hepatitis

    • Maternal sepsis

    • Psychotropic meds or others crossing

    • Chemo/radiation

    • Alcohol/drug abuse

    • Infant Galactosemia (lactose)

    • *May breastfeed even with VZV

    Cow s milk formula

    Cow’s Milk Formula

    • Always Fe fortified

    • Many choices!

    • Specialty formulas

      • soy, lactose free, increased calories

      • Protein hydrolysate formulas

        (eg.Alimentum, Nutramigen, Progestemil)

      • Amino-acid based formulas (Neocate)

    Introduction of solids

    Introduction of Solids

    • cereals 4-6 months

    • vegetables

    • fruits

    • meats

    • cow’s milk should be postponed until at least 10-12 months of age (renal load)

    • 2% or 1% milk should be postponed until after second birthday (inadequate fat content)

    Rest gradually in this order

    Infant growth rules of thumb

    Infant Growth: Rules of Thumb

    • Weight gain:

      • Regain birth weight by 10-14 days (max 10% loss)

      • Double birth weight by 5 months

      • Triple birth weight by 1 year

      • Quadruple birth weight by 2 years

      • Increase by 5 lbs/year for rest of childhood

    Growth height

    Growth - Height

    • Average length at birth 50 cm (20 inches)

    • Increases by 50% by 1 yr

    • Doubles by 4 yrs

    • Triples by 13 yrs

    • Ave growth 5-6 cm / yr (4 yrs-puberty)

    Growth body mass index bmi

    Growth- Body Mass Index (BMI)

    • BMI helps to quantify the weight to height relationship

    • BMI = weight(kg)/height (m)2

    • BMI of 20-25 is acceptable

    • BMI > 30 indicates obesity

    • BMI < 18 suggest severe anorexia or Failure to thrive

    Growth head circumference

    Growth- Head Circumference

    • 2 cm/month 1-3 months

    • 1cm/month 3-6 months

    • 0.5cm/month 6-12 months

    • Most of growth is in first yr!

    • 12 cm in first yr, 2 cm in 2nd yr, 6-8 cm rest of life

    Growth monitoring

    Growth Monitoring

    • Routinely recommended

      • Height, weight, head circumference

      • Plot on appropriate chart considering ethnicity, genetic syndromes (eg. Tri 21, Turner’s), and prematurity

      • Prematurity, correct hc (18 mo), wt (24 mo),

        ht (40 mo)

    • Only way to detect FTT

      • Also detects chronic illness, feeding difficulties

    What is failure to thrive

    What is Failure to Thrive?

    • US National Center for Health Statistics defines FTT for children < 2 yrs of age as:

      • Weight <3rd-5th centile for age on more than one occasion

      • Weight <80% of ideal body weight for age

      • Weight crosses 2 major centile curves downwards on a standardized growth curve

      • Exceptions: genetic/familial short stature, constitutional growth delay, SGA infants & preterm infants

    Caloric needs

    Caloric needs

    • 0-10 kg: 100 kcal/kg/day

    • 10-20 kg: 1000 + 50 kcal/kg/day

    • >20 kg: 1500 + 20 kcal/kg/day

    Which growth curve demonstrates a growth pattern of ftt

    Which growth curve demonstrates a growth pattern of FTT?

    • A

    • B

    • C

    Which growth curve demonstrates a pattern of genetic short stature

    Which growth curve demonstrates a pattern of genetic short stature?

    • A

    • B

    • C

    Ftt infant growth

    FTT- Infant Growth

    • Caveats to normal growth velocity:

      • >50% of babies shift their growth parameters upwards between birth and 3 months

      • Nearly 30% of well babies shift their parameters downwards between 3 and 18 months

      • Exclusively breastfed babies plot higher for wt at 0-6 months and lower at 6-12 months5

    Growth velocity

    Growth Velocity

    • Average age to “settle” on a growth curve is 13 months6

    • Downward shift seen with constitutional growth delay

      • downward shift between 6 & 24 months

      • may have decreased weight for height

      • re-establish normal growth velocities by 3 yrs

        *Genetically Programmed curve is established by 18-24 months

    Ftt assessment

    FTT- Assessment

    • Grading of malnutrition:

    Ftt assessment1

    FTT- Assessment

    • “Organic” vs. “non-organic”

      • Historical way of viewing FTT

      • Refers to presence/absence of diagnosis of major disease process or organ dysfunction

      • “Non-organic” accounts for >80%

      • Now felt to be more of a continuum

      • Multifactorial process

    Ftt assessment2

    FTT- Assessment

    • Under-nutrition results from:

      1)Decreased caloric intake

      2) Inadequate caloric absorption

      3)Increased caloric losses

      4)Increased caloric requirements

    Ftt differential diagnosis

    FTT- Differential Diagnosis

    • Decreased caloric intake:

      • Inadvertent (decreased breast milk, improper formula preparation)

      • Neglect or abuse

      • Behavioural (ex. Food refusal)

      • Pain (GERD, injury to mouth or esophagus)

      • Fatigue /anorexia (anemia, cardiac dz, resp dz, RTA)

      • Impaired swallowing (neurologic dz)

      • Craniofacial abnormalities (cleft lip/palate, choanal atresia)

      • Toxin (lead)

    Ftt differential diagnosis1

    FTT- Differential Diagnosis

    • Inadequate Caloric Absorption & Increased Caloric Losses

      • GI

        • Pancreatic insufficiency (CF)

        • Liver disease (biliary atresia, chronic cholestasis)

        • Generalized malabsorption (CF, Celiac, short gut)

        • Diarrheal state (infectious, post-infectious)

        • Persistent vomiting (pyloric stenosis, GERD)

        • Inflammatory disorders (IBD)

        • Allergic gastroenteropathy

        • Protein-losing enteropathy

    Ftt differential diagnosis2

    FTT- Differential Diagnosis

    • Increased Caloric Losses cont’d

      • Renal

        • Protein loss

        • Carbohydrate loss

      • Inability to use nutrients

        • Diabetes Mellitus

        • Metabolic dz

    Ftt investigations

    FTT- Investigations

    • Careful and complete history taking and physical examination are ESSENTIAL

    • Unless an illness other than primary under-nutrition is suspected on Hx or P/E the yield of lab investigations is almost nil!

    • Lab testing helps with diagnosis in 1.4%

    Ftt investigations1

    FTT- Investigations

    • Non-specific “screening”

      • CBCD, ESR, lytes, BUN, Cr, venous gas

      • Urine R&M, C&S

    • Markers of nutritional status

      • Total protein, albumin, glu, Ca, PO4, Iron studies

      • Zinc, vitamin levels

    • Dependent on specific aspects of Hx & P/E

      • Liver function tests

      • Thyroid studies

      • Stool OB, reducing substances, culture, O&P, trypsin

      • Sweat test, immunoglobulins & celiac screen, viral serology (incl HIV), TB testing, immune w/up, metabolic w/up, CXR, ECG, milk scan

    Ftt management

    FTT- Management

    • Admit if :

      • Suspect enviro. deprivation/neglect/abuse

      • Suspect chronic dz which needs stabilizing

      • Severe under-nutrition (consider if moderate)

        • ie. <60% of median weight for age

      • Failed out-patient management

    • With hospitalization:

      • greater likelihood of catch-up growth

      • no change in developmental outcomes

    Ftt management1

    FTT- Management

    • Inter-disciplinary approach!!

    • Treat any underlying illness and provide nutritional support:

      • Increase caloric intake

        • 1.5-2 X RDA

        • (120 kcal/kg/day x ideal wt)/current wt

        • Estimate 150-200 kcal/kg/day

    Ftt management2

    FTT- Management

    • Mild under-nutrition

      • Ensure frequent feedings (q 3 hrs)

      • Increase formula concentration (eg. 24 kcal/oz)

      • Add calorie-rich foods to diet (butter, PB, oils)

      • Provide dietary counseling

      • Prescribe multivitamin with zinc and iron

      • Follow-up frequently (?public health nurse)

      • Expect catch-up growth at 2-3x regular rate in first month

    Ftt management3

    FTT- Management

    • Moderate under-nutrition

      • Determine caloric intake

      • Consider whether investigations are necessary

      • Increase caloric intake (150-200 kcal/kg/day)

      • Ensure adequate protein (3-4 g/kg/day)

      • Consider meal supplements (eg. Pediasure)

      • Add Multivitamin

      • Consider therapeutic doses of iron

      • Monitor weight gain

    Ftt management4

    FTT- Management

    • Severe under-nutrition

      • Admit

      • Initiate re-feeding slowly

      • Consider using elemental formula

      • Consider diluting formula

      • May need ng continuous feeds or tpn

      • Follow fluid and lytes status closely

    Ftt long term implications

    FTT- Long-term implications

    • Persistent growth deficits

    • Cognitive impairment

    • Behaviour problems



    Immunization schedule recommended by the canadian immunization guide


    2 mos

    4 mos

    6 mos

    12 mos

    18 mos

    4-6 year

    q10 years


    DaPTP-HIB, Pneum, Men

    DaPTP-HIB, Pneum,Men

    DaPTP-HIB, Pneum,Men

    MMR, Varicella, Pneum




    Immunization Schedule(Recommended by the Canadian Immunization Guide)

    Contraindications to vaccines

    Contraindications to Vaccines

    • Strict

      - anaphylaxic or anaphylactic shock

      - encephalopathy

    • Precautions

      - febrile reaction > 40.5

      - shock collapse or hypotonia

      - hyporesponsive collapse

      - seizures

    Contraindications to vaccines1

    Contraindications to vaccines

    • Anaphylaxis to eggs:

      • Influenza and yellow fever

    • Severe immune deficiency:

      • All live vaccines (MMR, VZV, OPV, BCG, Yellow

        fever, Oral cholera, Oral typhoid)

    • Pregnancy:

      • MMR and Varicella

    • Anaphylaxis to neomycin:

      • MMR and IPV

    Immunization reactions

    Immunization Reactions

    • DaPTP/Hib

      • reactions occur within 72 hrs

    • MMR

      • reactions occur 5-12 days

    Delayed immunization

    Age 1-6 years

    0 mos:DPTP-Hib, MMR,HepB, P,V,MC

    2 mos: Pentacel,MMR,HepB, Prevnar

    4 mos: DPTP

    12 mos:DPTP

    4-6 yrs: DPTP

    14-16 yrs: dTaP

    > 7 Years Old

    0 mos: TdaP,Polio, MMR,V,Menj,HepB

    2 mos: TdaP, Polio, HepB,MMR, V

    6-12 mos: TdaP+Polio,HepB

    TdaP (no polio) q10 yrs thereafter

    Delayed Immunization

    Other immunizations

    Other Immunizations

    • Hepatitis A & B

    • Influenza

    • HPV

    • Rotavirus

    Infectious disease




    • Temp > 38.3 Celsius rectal

    • 0-1 mos: FSWU

    • 1-3 mos:

      • toxic = FSWU

      • non-toxic and low risk (WBC 5-15, bands <5%, urine neg, well-looking, reliable family): investigate and follow

    Otitis media

    Otitis Media

    • Incidence:

      • 15% to 20%

    • Peak:

      • 6 to 36 months

      • 4 to 6 years

      • decreases > 6 years old

    • Etiology: S. pneumoniae, M. catarrhalis, non-type H. Flu, GAS & viral

    Otitis media1

    Otitis Media

    • Risk Factors

      • mid-face hypoplasia (Down Syndrome)

      • daycare attendance

      • Inuit/Aboriginal

      • low SES

      • 2nd hand smoke

    Otitis media2

    Otitis Media

    • Treatment:

      • 1st line: Amoxil

      • 2nd line: High dose Amoxil, Clavulin, Macrolides, Cephalosporin

      • T-Tubes if recurrent or persistent effusion

    • Complications:

      • hearing loss

      • chronic effusion

      • mastoiditis

      • meningitis



    • Mainly ethmoid sinus

    • Predisposed by viral URTI, allergy, asthma, periodontal disease

    • Same bugs as OM +/- anaerobes

    • Presents with fever, purulent nasal discharge (> 10 days), periorbital tenderness, halitosis

    • Treat with same Abx as OM, may need longer course (3 weeks)



    • Newborn period (LEG)

      • Listeria

      • E. Coli

      • Group B strep

    • 2 months - 12 years (SHIN)

      • Strep pneumonia, N. meningitides

      • Less common Hib with immunization



    • in abnormal hosts or anatomic defects:

      • increased Pseudomonas, Staph, Salmonella, Serratia

  • Complications

    • SIADH

    • seizures

    • subdural effusions

    • transient joint effusions (Ag-Ab reaction)

    • hearing loss

  • Urinary tract infection

    Urinary Tract Infection

    • Newborn M › F (2)

    • Children F › M (10)

    • Schoolgirls - 5%

    • Recurrence - 80%

    • Vesicoureteral reflux - 35%

    • Renal scarring - 50%

    • All children ‹ 3 yrs

      • U/S

      • VCUG

    Urinary tract infections

    Urinary Tract Infections

    • UTI

      • KEEPPSS

      • Klebsiella, E. Coli, Enterococcus, Proteus, Pseudomonas, Staph, Strep

    • Pyelonephritis

      • ampicillin + gentamycin IV initially

      • then Amoxil or Septra po

    • VUR

      • prophylactic Septra or nitrofurantoin (or Amoxil)

      • Higher grades may require surgery



    • Organism

      • neonate: Staph, GBS, E.Coli

      • > 3mos.: Staph, Hib, Strep,Pseudomonas

      • SS disease: Salmonella

    • Diagnosis

      • bone scan

      • x-ray 10-12 days

    Septic arthritis

    Septic Arthritis

    • Monoarticular (trauma)

    • Organism

      • neonate

        • group B strep, staph, E.Coli

      • >3 mos

        • Staph aureus

        • Strep, Hib

      • most common site is knee (40%)

    Fever and rash

    Fever and Rash

    General pediatrics lmcc review

    A 14 year old male comes to you with a fever and rash for 2 days. He states that before the fever and rash he had started with red eyes, coryza, and cough. He has now developed a maculopapular rash starting at the head and moving to his toes. You look in his mouth and see little white ‘spots’. You are most concerned he has:

    • Kawasaki disease

    • Measles

    • Rubella

    • Scarlet Fever

    • Erythema Infectiosum

    General pediatrics lmcc review

    A 1 year old presents to your office with a new rash. Mum reports the baby had a high fever for two days with no associated symptoms. The fever has now disappeared as the rash appeared. The most likely organism causing the illness is:

    • HHV-1

    • HHV-2

    • HHV-6

    • Group A Strep

    • Mycoplasma

    Measles first disease

    Measles (First Disease)

    • Paramyxovirus

    • Stages

      • incubation: 8-13 days

      • prodrome: 4 C’s then fever with rash

      • skin rash (erythematous, maculopapular, starts at hairline and spreads to face, trunk and extremities)

    • Complications

      • pneumonia

      • encephalitis

      • SSPE

    Scarlet fever second disease

    Scarlet Fever (Second Disease)

    • Fever, pharyngitis, exanthem (starts in axilla, groin, neck, blanches,circumoral pallor, Pastias lines)

    • Age › 3 yrs; recurrence

    • Group A strep:  erythrogenic toxin (2-5 days postStrep throat or GN)

    • Treatment with Penicillin

    • Complications

      • cellulitis

      • Rheumatic fever

    Rubella third disease

    Rubella (Third Disease)

    • Togavirus

    • Congenital

    • Postnatal

      • mild disease

      • suboccipital nodes

      • maculopapular pink rash, starts on face, neck to extremities, spreads quicker than measles

    Roseola infantum fourth disease

    Roseola Infantum (Fourth Disease)

    • HHV6

    • High fever  rash maculopapular with cessation of fever

    • High WBC  low WBC

    • Febrile convulsions

    Erythema infectiosum fifth disease

    Erythema Infectiosum (Fifth Disease)

    • Parvovirus B19

    • No prodrome: red flushed face/slapped cheek, maculopapular rash with lacelike appearance

    • Complications

      • miscarriage/SA

      • aplastic crises

    The number one cause of death in children between 1 month and 1 year of age is

    The number one cause of death in children between 1 month and 1 year of age is:

    • Child abuse

    • Sudden infant death syndrome

    • Apparent life threatening events

    • Drowning

    • Sepsis

    Alte sids


    Apparent life threatening event definition

    Apparent Life Threatening Event: Definition

    • Clinical symptoms frightening to caregiver

    • Combo of apnea, colour change, tone change, choking, gagging

    • Apnea: 20 seconds of breathing cessation or shorter if associated with tone change, colour change, CV change

    General pediatrics lmcc review


    • Detailed Hx and Px

    • Talk to person witnessing event

    • Significant event?

    General pediatrics lmcc review


    • Differential

      • Neuro- seizure

      • GI- reflux

      • Pulmonary- aspiration, apnea

      • CV- arrhythmia

      • Infection- sepsis, pertussis, RSV

      • Metabolic

      • Abuse

    General pediatrics lmcc review


    • Investigations

    • Labwork +/- infectious workup

    • EEG

    • ECG/Echo

    • UGI/pH probe

    • CT head

    • Monitor

    General pediatrics lmcc review


    • Unexpected death by Hx and Postmortem

    • most common cause of death 1mo-1yr

    • peak 2-4 months, 95% <6 months old

    General pediatrics lmcc review

    Infant Risk Factors:


    age, sex

    prone sleeping

    bottle fed

    smoke environ.

    Thermal stress


    prior illness

    winter months

    low birthweight

    Maternal Risk Factors

    low age

    low SES

    low education


    drug use

    poor nutrition


    Gastroenterology pediatric surgery

    Gastroenterology/Pediatric Surgery



    • Unexplained irritability/crying

    • 2-3 wks to 3 mos

    • At least 3 hrs/day

    • > 3 days/week

    • > 3 weeks duration

    • ? Secondary to immature gut development



    • ++Gas/legs drawn up; otherwise well

    • No proven treatment - rhythmic motion/sounds

    • Ovol/Tylenol- no proven benefit

    • Parental support and reassurance

    Abdominal pain

    Abdominal Pain

    • Acute: Ddx includes gastro, hernia, UTI, appendicitis, intussusception, malrotation, volvulus, HSP, SC Crisis, pneumonia, mesenteric adenitis,

    • Chronic: > 3 episodes affecting activities > 3 months

      • Organic (<10%): constipation, IBD, mass, PUD, GU, lactose intolerance

      • Functional (90%): 8-10 yo peak, girls predominate, vague crampy periumbilical pain with no awakening, ppting or alleviating factors. Normal growth.

    Gastroesophageal reflux

    Gastroesophageal Reflux

    • Incompetence of lower esophageal sphincter

      • improves by one year of age in most infants

    • Complications

      • apnea in infants

      • aspiration pneumonia

      • chronic cough/wheeze

      • esophagitis- dysphagia,hemetemesis, Fe deficiency anemia

    Gastroesophageal reflux1

    Gastroesophageal Reflux

    • Diagnosis

      • pH probe

      • Ba swallow

      • nuclear scan

      • endoscopy

    Gastroesophageal reflux2

    Gastroesophageal Reflux

    • Treatment

      • chalasia routine - attention to burping, small frequent feeds, 300 prone

      • thickening feeds

      • Medications:

        • H2 blockers or PPI if esophagitis or gastritis present

        • Domperidone for decreased gastric emptying

    General pediatrics lmcc review

    A 6 week old male infant presents with a one day history of increasing severity of vomiting. Mum notes he is very hungry but appears to forcefully vomit all that he has eaten in a ‘projectile’ fashion. She now worries he is becoming more lethargic and dehydrated. The typical abnormality on laboratory investigations would be:

    • Anemia

    • Eosinophilia

    • Hyperchloremic metabolic acidosis

    • Hypochloremic metabolic alkalosis

    • Respiratory alkalosis

    Pyloric stenosis

    Pyloric Stenosis

    • boy > girl

    • 3 weeks - 3 months

    • projectile vomiting (nonbilious)

    • hungry infant feeds vigorously

    Pyloric stenosis1

    Pyloric Stenosis

    • O/E:- dehydration, lethargy, weight loss, peristaltic waves L R, palpable “olive”

    • Lab- hypochloremic alkalosis

    • Investigation- U/S, UGI

    • Rx: rehydrate and restore electrolyte balance

      - myotomy of pyloric muscle



    • 3 months - 3 years (up to 6 years)

    • 5% anatomic abnormality found

      • Meckel’s polyp

      • duplication

    • more frequent ileocolic or ileoileocolic



    • Clinical

      • severe paroxysmal pain

      • lethargy  shock

      • sausage shaped mass RUQ

      • vomiting

      • currant jelly stool



    • Lab

      • x-ray

        • density or gasless right side

      • barium enema

        • coil-spring sign

    • Treatment

      • reduction by barium enema

      • surgical reduction

    Meckel diverticulum

    Meckel Diverticulum

    • 2% population

    • year peak incidence

    • 2 feet from ileocecal junction

    • 35% ectopic gastric or pancreatic tissue

    • painless rectal bleeding (typically bright red)

    • 99Tc scan confirms diagnosis

    • treatment: excision

    General pediatrics lmcc review

    A 4 year old girl presents with longstanding constipation. The mother reports her daughter has always been constipated and has been challenging to treat with many different therapeutic interventions being tried. They describe her stools as long and thin. She is noted to not be growing well when plotted on a growth curve. He neurological exam is normal. She appears to have good anal tone with the absence of stool in the rectum. The best test to pursue for confirmation of the diagnosis is:

    • MRI of the spine

    • Contrast enema

    • Colonoscopy with proximal large bowel biopsy

    • Rectal biopsy

    • No investigation required



    • Def’n: passage of bulky or hard stool at infrequent intervals

    • Retention of stool in rectum leads to encopresis in up to 60%

    • Most causes are not organic but due to voluntary or involuntary retentive behavior

    Constipation ddx

    Constipation DDx

    • Dietary

    • Behavioral

    • Obstruction

    • Dehydration

    • Structural defects (fissures)

    • Metabolic (hypothyroid,hypoparaT, hyperCa)

    • Neuromuscular ( MMC, MD, spinal cord)

    • Hirshsprungs

    Constipation treatment

    Constipation- Treatment

    • Dietary: increased fluid/fibre

    • Stool softeners or laxatives

      • Lactulose

      • Lansoyl

      • PEG powder

    • Bowel evacuation (enemas)

    • Bowel/toileting regimen

    Hirshsprung s disease

    Hirshsprung’s Disease

    • Absence of ganglion cells in the bowel


    • Most common cause of neonatal GI obstruction

    • Aganglionic segment

    • NB: failure to pass meconium within 48 hrs

    Hirshsprung s disease1


    onset after 2 yr


    large caliber stool

    normal growth

    normal nutrition

    normal anal tone

    stool in ampulla


    onset at birth

    no encopresis

    small stools

    assoc. FTT/poor nutrition

    abdominal distension

    normal anal tone

    ampulla empty

    Hirshsprung’s Disease

    Hirshsprung s disease2

    Hirshsprung’s Disease


    • rectal biopsy

      • shows absence of ganglion cells

      • rectal manometry

      • barium enema ->transition zone


    • resection aganglionic bowel

    • colostomy, then pull through at

      6 to 12 months of age

    Umbilical hernia

    Umbilical hernia

    • Defect of central fascia beneath umbilicus

    • Most common condition of abdominal wall

    • Almost never incarcerate

    • Strong family history and

      racial propensity

    • Medical risk factors:

      • Congenital hypothyroidism

      • Prematurity

    Umbilical hernia1

    Umbilical hernia

    • DDx:

      • Small omphalocele (looks like fixed hernia)

      • Supra-umbilical hernia

    • Refer to surgery if:

      • Ring defect > 1.5 - 2 cm in diameter

      • “elephant’s trunk” appearance

      • Incarceration

      • Not closing by 2 years of age

    Urology nephrology




    • 3.4% of NB, 0.7% of children > 1 year of age

    • Bilateral in 20%

    • Consequences- tumour, infertility, torsion,hernia

    • Differential diagnosis

      • Ectopic testes

      • Retractile testes

      • Absent testes

    • surgical correction <2 year of age



    • Sibling risk - 10%

    • Undescended testes - 10-15%

    • Not associated with UT anomalies

    • Do not circumcise



    • Nocturnal , Diurnal, both

    • Primary vs. Secondary

    • 10% 5yr old, 5% 10 yr old, 1% 18 yr old

    • Male > Female

    • Familial

    • maturational defect in bladder control



    • Treatment

      • Rule out underlying cause (UTI, constipation, IDDM)

      • Motivational maneuvers- star charts

      • Alarm

      • Medication- DDAVP, TCA

    The typical features of nephrotic syndrome include

    The typical features of nephrotic syndrome include:

    • Hypoalbuminemia, proteinuria, edema, hyperlipidemia

    • Proteinuria, hematuria, hypertension, edema

    • hyperglycemia, glucosuria, ketonuria, weight loss

    • Proteinuria, hematuria, arthritis, purpura



    • Def”n: >150mg/24 hr (>4mg/m2/hr)

    • Nonpathologic:

      • Postural- incr. in upright position 10x

        • Collection done in supine and upright positions

  • Febrile

  • Exercise

  • Proteinuria1


    • Tubular:

      • Hereditary- cystinosis, Wilson dis., RTA

      • Acquired- antibiotics, ATN, cystic diseases,

        heavy metal

    • Glomerular:

      • Nephrotic syndrome

      • Glomerulonephritis, tumour, drug, congenital

    Nephrotic syndrome

    Nephrotic Syndrome

    • Minimal change disease the most common (76%)

    • Membranous (8%), Focal Segmental (7%)

    • Diagnosis

      • proteinuria(>40 mg/m2/hr)

      • hypoalbuminemia

      • hyperlipidemia

      • edema

    Nephrotic syndrome1

    Nephrotic Syndrome

    • Treatment

      • prednisone

    • Renal biopsy

      • Unusual age (<1yr, adol.)

      • Steroid resistant/ frequent relapse

      • HTN, decreased renal function

    • Complications

      • hypercoagulability

      • infections

      • Drug side effect- steroids, immunosuppressants

    General pediatrics lmcc review

    • Marked eyelid edema in a 2-year-old boy with minimal change disease and nephrotic syndrome. Eyelid edema in any child should prompt the performance of urinalysis, rather than the presumption of allergy.

    General pediatrics lmcc review

    • Severe scrotal edema in a 6-year-old boy with nephrotic syndrome.



    • Microscopic (> 5 rbc/hpf) vs. Macroscopic

    • Approach based on anatomy:

      • Kidney

      • Ureter

      • Bladder

      • Urethra



    • Glomerular

    • Tubulointerstitial

      • ATN

      • Infections

      • Hypercalciuria

      • Drugs

    • Hematologic causes

      • platelets, SS disease, renal vein thombosis

    • Anatomic abnormalities

      • Tumour, trauma, cysts, vascular

    • Exercise

    Hematuria work up

    Hematuria: Work-up

    • STEP 1:

      • CBC, urine culture, Cr, C3, U/S

      • 24 hr urine- Cr, protein, calcium

    • STEP 2:

      • ASOT/antiDNase-B, T/S, ANA, coags, urine RBC morphology, SS screen, VCUG (if infection/lower tract suspect)

    • STEP 3:

      • biopsy



    • Proteinuria, hematuria, hypertension, edema

    • Etiology: Acute post Strep GN, IgA Nephropathy, HSP, SLE Nephritis, RPGN, MPGN

    • Acute Post Strep GN:

      • school-aged, mean age 7, 2:1(M:F), 1-2 wks between infection and presentation, dark urine, edema

      • Dx: UA, ASOT, anti DNAase B, low C3 (and in 6-8 wks)

      • Management: fluid/Na restriction, diuretics +/- antiHTN

      • 98% recover completely, sx resolve in 3-4 wks

    Hemolytic uremic syndrome

    Hemolytic Uremic Syndrome

    • Diarrheal and non-diarrheal causes

    • E. Coli 0157:H7 verotoxin

    • Present with diarrhea followed by bloody diarrhea

    • 5-7 days later- Triad

      • microangiopathic hemolytic anemia

      • thrombocytopenia

      • renal failure

    Hemolytic uremic syndrome1

    Hemolytic Uremic Syndrome

    • Treatment

      • supportive

      • lasix infusion

      • Dialysis

    • No role for antibiotics, steroids

    • Prognosis:

      • 10-30% morbidity

      • 5-10% mortality



    General pediatrics lmcc review

    A 5 year old female is admitted with acute abdominal for the past week. It is intermittent and severe. You are called to her bedside the next day for an evolving rash that is mainly on the lower limbs and appears to be raised bruising. At the same time she passes what appears to be a bloody stool. You note on review of the investigations from last night that she has 10-20 RBC/hpf on urinalysis.

    What is the best treatment option you can offer to provide her with the best long term prognosis

    What is the best treatment option you can offer to provide her with the best long term prognosis?

    • Supportive care

    • IVIG

    • Aspirin

    • Antibiotics to cover Group A strep

    • IV steroids

    With this condition what will you tell the family with regards to necessary followup

    With this condition, what will you tell the family with regards to necessary followup?

    • She will need an echocardiogram as there is a risk of coronary aneurysms

    • She will need regular renal monitoring as there is a risk of long term renal impairment

    • There is no need for regular monitoring after the illness resolves as there are no long term sequelae

    • She will need long term antibiotic prophylaxis

    General pediatrics lmcc review

    A 2 year old male was seen three days ago for a three day history of fever and neck swelling. He was sent home with antibiotics to treat a cervical adenitis that measures 2x2cm. He now returns 3 days into the antibiotics with persistent fever and no improvement in his neck swelling. You note he has red conjunctiva and his lips are red and cracked. The mother is worried he is reacting to the medication as he has a new rash.

    What would be the next best step in managing this child s situation

    What would be the next best step in managing this child’s situation?

    • Admit for IV antibiotics

    • Change his oral antibiotics and follow up in 2 days to ensure good response

    • Send off serology for EBV infection and discontinue the antibiotics

    • Admit for IVIG

    • Perform an echo and if abnormal initiate IVIG

    Henoch schonlein purpura

    Henoch Schonlein Purpura

    • Immune-mediated systemic vasculitis of small vessels

    • Often preceding URTI

    • Ages 4-10yr; recurs in 1/3

    • Classically involves,

      • skin

      • GI

      • joints (75% have arthralgias)

      • kidney (20% develop gross hematuria)

    Hsp skin

    HSP - Skin

    • Palpable nonthrombocytopenic purpura

    • May be presenting sign in only 50% of patients.

    • Purpura involves dependent areas of the body.

    • Edema of the hands, feet, and scalp often an early finding (20-40%)

    General pediatrics lmcc review

    Slide 1

    Hsp gastrointestinal

    HSP - Gastrointestinal

    • 45 to 85% of children with HSP

      • major hemorrhage (5%)

      • intussusception (2%)

      • occult bleeding (33%)

    General pediatrics lmcc review


    • Treatment

      • Steroids used if severe/life-threatening GI involvement

      • Doesn’t affect renal outcome

      • Must monitor for renal involvement- may occur late

      • Watch for recurrence

      • education

    Kawasaki disease

    Kawasaki Disease


    • F ever for 5 days

    • Plus 4 of 5:

      • E xanthem

      • E xtremities

      • L ymph nodes (>1.5 cm)

      • M ucosal changes

      • C onjunctivits

        “feel my conjunctivitis”

    Kawasaki disease1

    Kawasaki Disease

    • CVS

      • coronary aneurysms- 20% of cases

      • Risk < 5% if treated

    • Phases

      • Acute- febrile 1-10 days

      • Subacute (peeling, afebrile, high platelets/ESR) 10-21 days

      • Convalescent (normalize plt/ESR) >21 days

    Kawasaki disease associated features


    Hydropic gallbladder




    Sterile pyuria (urethritis)


    Aseptic meningitis

    Kawasaki DiseaseAssociated Features

    Kawasaki disease2

    Kawasaki Disease

    • Treatment

      • IVIG

      • Aspirin- high followed by low dose

      • Echo at baseline and at 6-8 weeks for coronary aneurysms



    Acute lymphocytic leukemia

    Acute Lymphocytic Leukemia

    • Most prevalent malignancy under 15 yo- immature lymphoid cells accumulate in the BM (lymphoblasts)

    • 80% of all cases of acute leukemias : peak 2-6yo

    • Poor prognosis if < 2yrs or > 10yrs, WBC > 50,000, CNS or testicular involvement at diagnosis, T-Cell or B-Cell, Pseudodiploidy (presence of translocations within leukemic cells), and hypodiploidy (< 46 chr. in leukemic cells), L3 morphology of blasts

    All clinical features

    ALL- Clinical Features

    • Bone marrow failure: anemia, low plts, neutropenia

    • Lymphadenopathy

    • Hepatosplenomegaly

    • Bone pain

    Acute lymphocytic leukemia1

    Acute Lymphocytic Leukemia

    • Relapse 30 - 40%

      • bone marrow

      • CNS

      • testes

    • Long term problems

      • secondary tumours

      • infertility

      • learning disability



    • Malignancy of neural crest cells

    • Most common neoplasm in infants

    • Most in first 4 yrs (mean=2yo)

    • Most common site of primary tumor is abdomen (abd. mass ,abd. pain ,HTN )

    • Thoracic tumors: resp. distress

    • H & N-Horner syn.

    • Constitutional s/sx

    • Metastases common to bone, BM, liver lung (50%)

    • High catecholamines in 90%

    Wilms tumor

    Wilms’ Tumor

    • 5-6% of childhood Ca: 75% before 5yo

    • Palpable abdominal mass, HTN, hematuria

    • Bilateral in 5%

    • Association with aniridia, hemihypertrophy, and Beckwith Wiedmann Syndrome in 12-15%



    • Bilateral (40%)

      • hereditary - AD

      • osteogeneic carcinoma

    • Unilateral (60%)

      • sporadic

    General pediatrics lmcc review

    Slide 3

    Brain tumors

    Brain Tumors

    • Second most common tumor-most common solid tumor

      • cerebellum 40%, brainstem and 4th ventricle 15%, suprasellar 15%

    • Presentation depends on location

    • Common signs: vomiting, papilledema, lethargy, headache, personality change, ataxia, loss of vision, seizures, focal neurologic signs, nystagmus



    This child is at risk for

    This child is at risk for:

    • Overwhelming sepsis

    • Bone pain

    • Hypersplenism

    • Stroke

    • Growth failure

    With this blood smear you would expect the cbc to show

    With this blood smear, you would expect the CBC to show:

    • Low Hgb, low MCV, high retics, high RDW

    • Low Hgb, low MCV, low retics, high RDW

    • Low Hgb, high MCV, low retics, normal RDW

    • Low Hgb, normal MCV, normal retics

    With this blood smear which statement is most accurate

    With this blood smear, which statement is most accurate

    • This condition is autosomal recessive

    • Hemolysis is not a feature of this disease

    • Bony crises are a common sequelae

    • The osmotic fragility test is a diagnostic test

    • Hemoglobin electrophoresis is a diagnostic test



    • Low Retics (underproduction)

      • MCV- Low- iron, thal,lead, chronic

        - Normal- renal, thyroid, infection

        - High- B12, folate, fanconi

    • High Retics (increased loss)

      • Blood Loss

      • Hemolysis- intrinsic

        - extrinsic

    Iron deficiency anemia

    Iron Deficiency Anemia

    • Decrease in RBC Hb due to inadequate Fe stores

    • Etiology: poor dietary intake, early transition to cow’s milk, high requirements with growth spurts, cow’s milk intolerance, chronic GI blood loss

    • Diagnosis: microcytic anemia, low serum iron, ferritin,

    • S/sx: irritability, anorexia, lethargy, pale, tachycardia, systolic murmur

    General pediatrics lmcc review

    Slide 1




    • Autosomal Dominant, northern European

    • abnormal membrane protein- Spectrin

    • leads to hemolysis- less flexible

    • newborn- jaundice < 24 hr

    • disease can be mild, moderate or severe

    • mild- mod. Anemia, reticulocytosis and splenomegaly

    • Dx- osmotic fragility test

    • Rx.- support, splenectomy

    From cd atlas mccqe toronto notes 2003

    From CD Atlas, MCCQE Toronto Notes, 2003

    General pediatrics lmcc review


    • Most common RBC enzyme defect

    • X-linked, African, Mediterranean

    • susceptible to oxidation stress--> Hgb precip.--> membrane damage

    • Precipitating agents-

      • infection, vit. C, fava bean, benzene, Medications (nitrofurantoin, antimalarial, sulfa, nalidixic acid, vit. K analog)

    • intermittent hemolysis, chronic hemolysis, incidental with anemia and retics

    • smear- bite cells

    Sickle cell disease

    Sickle Cell Disease

    • Newborn asymptomatic

      • first sign (6 mos) - hand-foot syndrome

    • Crises

      • sequestration

      • vaso-occlusive

      • aplastic(Parvovirus)

      • hyperhemolytic

      • infections

    • Prevent infections (considered asplenic)

    From cd atlas mccqe toronto notes 20031

    From CD Atlas, MCCQE Toronto Notes, 2003

    General pediatrics lmcc review

    Slide 2

    Classic hemophilia

    Classic Hemophilia

    • Factor VIII deficiency:

      • X-linked ie asymptomatic female carriers transmit to sons

    • Symptoms:

      • excessive bruising with ambulation

      • intramuscular hematomas from minor trauma

      • hemarthrosis: often spontaneous

      • hematuria

      • risk for intracranial hemorrhage & bleeding into the neck

    Classic hemophilia1

    Classic Hemophilia

    Severity depends on level FVIII in plasma

    • mild 6% to 30%

    • moderate 1% to 5%

    • severe < 1%

  • Pts with mild FVIII deficiency experience only prolonged bleeding following tooth extraction, surgery or bleeding

  • Lab: PT normal, PTT greatly prolonged

  • Classic hemophilia2

    Classic Hemophilia

    • Treatment:

      - prevention of trauma

      - FVIII concentrates

      - strict avoidance of drugs that affect platelet function

    Immune thrombocytopenic purpura itp

    Immune Thrombocytopenic Purpura (ITP)

    • Thrombocytopenia mediated by auto antibodies causing destruction

    • Peak age 2-6yo: associated with antecedent viral infection

    • Most resolve in 4-6wks: 20% duration > 6mos

    • Clinical Features: purpura, petechiae, bleeding from mouth, gums, kidney, GIT, no hepatosplenomegaly

    • Treatment- IVIG, steroids

    General pediatrics lmcc review

    Slide 5

    Child abuse


    Child abuse1

    Child Abuse

    • Physical - 80%

    • Sexual - 15%

    • Physical and emotional neglect

    • Munchausen by proxy

    • 2nd cause of death in 1-6mos

    • 1/3:1/3:1/3- <1yo:1-6yo:>6yo

    • Premature and developmentally impaired have 3x risk

    Red flags

    Red Flags

    • Recurrent injury/ingestion

    • Injury poorly explained/ out of proportion

    • High risk injuries: scald, cigarette,spiral fracture, retinal hemorrhage

    • Injury pattern/site

    • High risk environment

      • preterm, neurologic impairment

      • single parent

      • family stress

      • psychiatric illness

    General pediatrics lmcc review

    Slide 4

    General pediatrics lmcc review

    Slide 1

    General pediatrics lmcc review

    Slide 2

    General pediatrics lmcc review

    Slide 6

    General pediatrics lmcc review

    Slide 7

    General pediatrics lmcc review

    Slide 3



    Adolescence heeadss

    Adolescence- HEEADSS

    • Home

    • Education

    • Eating

    • Activities

    • Drugs

    • Sexuality

    • Suicide

    Adolescent suicide warning signs

    Adolescent SuicideWarning Signs

    • Depression

    • Psychosomatic complaints

    • Acting out

    • Previous attempt

    • Family history



    Growing pains

    Growing Pains

    • 3 - 6 years

    • Night time: poorly localized

    • Pain in shins, calves, thighs

    • Heat, massage, Tylenol

    • Normal physical exam

    Congenital dislocation hip developmental dislocation hip

    Congenital Dislocation Hip(Developmental Dislocation Hip)

    • Age: 2 months to 2 years

    • Signs:

      • limitation of abduction

      • tight adductors

      • shortening of leg

      • asymmetric skin folds

      • + Galeazzi sign (one knee lower than other)

    Congenital dislocation hip

    Congenital Dislocation Hip

    Assess stability: Ortolani(reduce) & Barlow(dislocate) signs


    • triple diaper first for mild cases of subluxation (x 6 to 8 weeks)

    • < 6 to 8 months, Pavlik harness

    • > 8 months, traction

       closed reduction  spica cast

    General pediatrics lmcc review

    Slide 2

    Metatarsus adductus

    Metatarsus Adductus

    • Forefoot faces in rather than lining up with 2nd metatarsal

    • May be secondary to intrauterine positioning

    • Early treatment is stretching

    • If rigid may require casting to correct

    General pediatrics lmcc review

    An 8 year old male comes to clinic with a 5 day history of limp together with pain in the right hip and upper thigh. He is otherwise healthy and has been on no medications. Exam demonstrates limited ROM in the hip and a normal knee exam. An xray has been taken . The most likely diagnosis is.

    • Avascular necrosis of the head of the femur

    • Slipped Capital Femoral Epiphysis

    • Fractured femoral neck

    • Septic arthritis

    • Growing pains

    Legg calve perthes disease

    Legg Calve Perthes Disease

    • Avascular necrosis femoral head

    • males > females

    • 5 to 9 year old:sx: painful hip, limp, referred pain

    • X-ray:  lucency, widening of the distance and eventual distortion of the femoral head

    • Treatment: casts to keep hip in abduction & medial rotation surgery

    General pediatrics lmcc review

    This 12 year old child comes with a 2 week history of increasing pain in the right leg and limping. He has a hard time flexing his hip and prefers to keep it externally rotated when examined. He gives no history of trauma. There has been no illness. The best management of this child would be

    • Urgent consult with orthopedics

    • Semi-urgent referral to the ortho clinic

    • Routine referral to the ortho clinic

    • Expectant management, return if symptoms do not resolve in 2-4 weeks

    • Follow-up xrays in 2 weeks

    Slipped capital femoral epiphysis

    Slipped Capital FemoralEpiphysis

    • Most common in obese boys in adolescence

    • femoral epiphysis slips posteromedially off the metaphysis

      • unilateral or bilateral

      • gradual or sudden causes pain & limitation of motion

      • abduction & internal rotation are limited

      • Klein’s line on xray

        Treatment: pinning to prevent further slipping

    Osgood schlatter s disease

    Osgood-Schlatter’s Disease

    • Common cause of knee pain

    • Mostly in athletic or overweight kids

    • Pain arises in tibial tuberosity (at site of attachment of patellar tendon)after exercise or kneeling

    • Treatment mainly supportive: includes reduced physical activity +/- bracing



    General pediatrics lmcc review

    Slide 3

    Pityriasis rosea

    Pityriasis rosea

    • Prodrome rare: fever, malaise, arthralgia, pharyngitis

    • Herald patch: solitary 1-10cm annular papular lesion anywhere on body

    • 5-10 days later, widespread symmetrical eruption involving trunk & proximal limbs

    • < 1cm slightly raised pink/brown papules eruption, fine scale, especially at periphery

    Pityriasis rosea1

    Pityriasis Rosea

    • Christmas tree pattern on back

    • Duration: 2 to 12 weeks

    • Mild to severe pruritus

    • ? Viral trigger

    • Treatment:

      • antipruritic/antihistamine

      • lubricating lotion or topical cortosteroid if moderate to severe pruritus



    • + Prevalent during hot, humid months

    • + Common in infants & children

    • Initiated by infection with Grp.A hem.strep

    • Bullous impetigo 2o to Staph Aureus Grp.2 phase type

    • Erythematous macule...vesicles & pustules



    • Bullae with erythematous halo...honey coloured crusts (non bullous form), superficial & rupture easily (bullous type

    • Spread by contact to other parts of body


      • local measures...personal hygiene

      • compresses to remove crusts

      • systemic antibiotic

    Atopic dermatitis

    Atopic Dermatitis

    • Inflammatory skin disorder

    • erythema...edema...intense pruritus...

      exudation, crusting & scaling

    • > risk to develop allergies & asthma

    Atopic dermatitis1


    1st 2 to 3 months

    weepy patches on cheeks, neck, wrists, hands & extensor aspect extremities


    involvement of flexural areas, especially popliteal & antecubital fossae

    also, neck, wrist, behind ears, > with age; > drying & thickening of skin

    Atopic Dermatitis

    Atopic dermatitis2

    Atopic Dermatitis

    Other signs:

    “Mask of atopic dermatitis”

    • Hyperpigmentation of skin

    • Lichenification

    Atopic dermatitis3

    Atopic Dermatitis

    • Itch - scratch - itch cycle Rx:

      • antihistamines

      • topical corticosteroids

      • topical immune modulators (Protopic)

      • hydrating lotions

    General pediatrics lmcc review

    Slide 2

    General pediatrics lmcc review

    Slide 1

    Seborrheic dermatitis

    Seborrheic Dermatitis

    • Begins on scalp as “cradle cap”

    • Involvement behind ears, sides of nose & eyebrows

    • Greasy, brownish scales

    • Shorter course than atopic dermatitis

    • Responds more rapidly to treatment than atopic dermatitis

    General pediatrics lmcc review

    Treatment: General Guidelines

    • Keep bathing at minimum

    • Use of non-soap cleansers

    • Cotton garments/avoid wool

    • Keep nails cut short

    • Avoid environmental triggers

    • Treat superinfections with systemic antibiotics

    General pediatrics lmcc review

    • Staphylococcal diaper dermatitis. There are numerous thin-walled pustules surrounded by erythematous halos, as well as multiple areas in which pustules have ruptured, leaving a collarette of scale around a denuded erythematous base.

    General pediatrics lmcc review

    • Irritant or ammoniacal diaper dermatitis. Note the involvement of the convex surfaces and the sparing of the intertriginous creases.

    General pediatrics lmcc review

    • Candidal diaper dermatitis. The eruption is bright red with numerous pinpoint satellite papules and pustules. Intertriginous areas are prominently involved.

    General pediatrics lmcc review

    • Psoriatic diaper dermatitis. This child had a persistent diaper rash that did not respond to routine therapy. Note that scaling is not as intense as in psoriatic lesions seen elsewhere on the body.

    Erythema multiforme

    Erythema Multiforme

    • Erythema multiforme (EM minor). A, The characteristic target lesions are symmetrically distributed. B, In these typical target lesions with central dusky areas, the peripheral rims are beginning to vesiculate. C, In this case, the peripheral rims have become frankly bullous. (C, Courtesy of Michael Sherlock, MD, Lutherville, Md.)

    Stevens johnson syndrome

    Stevens-Johnson Syndrome

    • Stevens-Johnson syndrome (EM major). A, Severe bullous and erosive lesions cover the face, neck, upper trunk, and proximal extremities. Note the ocular and oral involvement. B, Typical bullae, target lesions, and erosions of the lips are seen in this boy. C, This child has numerous vesicles and bullae of the oral mucosa along with formation of a shaggy white membrane consisting of sloughed debris. (C, Courtesy of Michael Sherlock, MD, Lutherville, Md.)



    • White-yellow papules

    • Epidermal inclusion cysts

    • Face, gingivae, palate

      • Ebstein pearls

    • Neonates:

      • Occur spontaneously

      • Resolve spontaneously

        • (weeks-months)

    • Older children:

      • Occur at site of trauma

        • (blisters, abrasions)

      • May not resolve spontaneously

    Erythema toxicum neonatorum

    White papule/pustule (1-2mm)

    surrounded by red wheal

    Localized or generalized

    Palms and soles spared

    Usually starts ~ day 2

    New lesions continue to appear as rash waxes and wanes up to 10 days

    Less common & delayed presentation in prems

    Eosinophils on scraping


    Erythema Toxicum Neonatorum

    Class of 2011 faculty of medicine university of ottawa



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