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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

GENERAL PEDIATRICSLMCC Review

April 14, 2011



Breastfeeding
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 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? following is correct

  • 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 following is correct

  • 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 following is correct

  • Postpartum weight loss & uterine involution

  • Delayed return of fertility

  • Bonding

  • Pre-menopausal breast & ovarian Ca reduced

  • Economical benefit


Breast feeding issues
Breast Feeding Issues following is correct

  • 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 following is correct

  • 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 following is correctBreast 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 following is correct

    • 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 following is correct

    • 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 following is correct

    • 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 following is correct

    • 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) following is correct

    • 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 following is correct

    • 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 following is correct

    • 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? following is correct

    • 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 following is correct

    • 0-10 kg: 100 kcal/kg/day

    • 10-20 kg: 1000 + 50 kcal/kg/day

    • >20 kg: 1500 + 20 kcal/kg/day




    Ftt infant growth
    FTT- Infant Growth stature?

    • 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 stature?

    • 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 stature?

    • Grading of malnutrition:


    Ftt assessment1
    FTT- Assessment stature?

    • “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 stature?

    • 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 stature?

    • 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 stature?

    • 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 stature?

    • Increased Caloric Losses cont’d

      • Renal

        • Protein loss

        • Carbohydrate loss

      • Inability to use nutrients

        • Diabetes Mellitus

        • Metabolic dz


    Ftt investigations
    FTT- Investigations stature?

    • 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 stature?

    • 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 stature?

    • 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 stature?

    • 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 stature?

    • 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 stature?

    • 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 stature?

    • 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 stature?

    • Persistent growth deficits

    • Cognitive impairment

    • Behaviour problems


    Immunizations

    IMMUNIZATIONS stature?


    Immunization schedule recommended by the canadian immunization guide

    Age stature?

    2 mos

    4 mos

    6 mos

    12 mos

    18 mos

    4-6 year

    q10 years

    Vaccine

    DaPTP-HIB, Pneum, Men

    DaPTP-HIB, Pneum,Men

    DaPTP-HIB, Pneum,Men

    MMR, Varicella, Pneum

    DaPTP-HIB, MMR

    DaPTP

    dTaP/dT

    Immunization Schedule(Recommended by the Canadian Immunization Guide)


    Contraindications to vaccines
    Contraindications to Vaccines stature?

    • Strict

      - anaphylaxic or anaphylactic shock

      - encephalopathy

    • Precautions

      - febrile reaction > 40.5

      - shock collapse or hypotonia

      - hyporesponsive collapse

      - seizures


    Contraindications to vaccines1
    Contraindications to vaccines stature?

    • 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 stature?

    • DaPTP/Hib

      • reactions occur within 72 hrs

    • MMR

      • reactions occur 5-12 days


    Delayed immunization

    Age 1-6 years stature?

    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 stature?

    • Hepatitis A & B

    • Influenza

    • HPV

    • Rotavirus



    Fever
    Fever stature?

    • 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 stature?

    • 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 stature?

    • Risk Factors

      • mid-face hypoplasia (Down Syndrome)

      • daycare attendance

      • Inuit/Aboriginal

      • low SES

      • 2nd hand smoke


    Otitis media2
    Otitis Media stature?

    • 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


    Sinusitis
    Sinusitis stature?

    • 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)


    Meningitis
    Meningitis stature?

    • Newborn period (LEG)

      • Listeria

      • E. Coli

      • Group B strep

    • 2 months - 12 years (SHIN)

      • Strep pneumonia, N. meningitides

      • Less common Hib with immunization


    Meningitis1
    Meningitis stature?

    • 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 stature?

    • 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 stature?

    • 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


    Osteomyelitis
    Osteomyelitis stature?

    • 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 stature?

    • 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 stature?


    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


    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) 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:

    • 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) 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:

    • 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) 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:

    • 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 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:(Fourth Disease)

    • HHV6

    • High fever  rash maculopapular with cessation of fever

    • High WBC  low WBC

    • Febrile convulsions


    Erythema infectiosum fifth disease
    Erythema Infectiosum 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:(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

    ALTE/SIDS and 1 year of age is:


    Apparent life threatening event definition
    Apparent Life Threatening Event: Definition and 1 year of age is:

    • 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


    ALTE and 1 year of age is:

    • Detailed Hx and Px

    • Talk to person witnessing event

    • Significant event?


    ALTE and 1 year of age is:

    • Differential

      • Neuro- seizure

      • GI- reflux

      • Pulmonary- aspiration, apnea

      • CV- arrhythmia

      • Infection- sepsis, pertussis, RSV

      • Metabolic

      • Abuse


    ALTE and 1 year of age is:

    • Investigations

    • Labwork +/- infectious workup

    • EEG

    • ECG/Echo

    • UGI/pH probe

    • CT head

    • Monitor


    SIDS and 1 year of age is:

    • Unexpected death by Hx and Postmortem

    • most common cause of death 1mo-1yr

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


    Infant Risk Factors: and 1 year of age is:

    prematurity

    age, sex

    prone sleeping

    bottle fed

    smoke environ.

    Thermal stress

    ethnicity

    prior illness

    winter months

    low birthweight

    Maternal Risk Factors

    low age

    low SES

    low education

    smoker

    drug use

    poor nutrition

    SIDS


    Gastroenterology pediatric surgery

    Gastroenterology/ and 1 year of age is:Pediatric Surgery


    Colic
    Colic and 1 year of age is:

    • 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


    Colic1
    Colic and 1 year of age is:

    • ++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 and 1 year of age is:

    • 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 and 1 year of age is:

    • 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 and 1 year of age is:

    • Diagnosis

      • pH probe

      • Ba swallow

      • nuclear scan

      • endoscopy


    Gastroesophageal reflux2
    Gastroesophageal Reflux and 1 year of age is:

    • 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


    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 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:

    • boy > girl

    • 3 weeks - 3 months

    • projectile vomiting (nonbilious)

    • hungry infant feeds vigorously


    Pyloric stenosis1
    Pyloric Stenosis 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:

    • 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


    Intussusception
    Intussusception 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:

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

    • 5% anatomic abnormality found

      • Meckel’s polyp

      • duplication

    • more frequent ileocolic or ileoileocolic


    Intussusception1
    Intussusception 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:

    • Clinical

      • severe paroxysmal pain

      • lethargy  shock

      • sausage shaped mass RUQ

      • vomiting

      • currant jelly stool


    Intussusception2
    Intussusception 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:

    • Lab

      • x-ray

        • density or gasless right side

      • barium enema

        • coil-spring sign

    • Treatment

      • reduction by barium enema

      • surgical reduction


    Meckel diverticulum
    Meckel Diverticulum 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:

    • 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


    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


    Constipation
    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:

    • 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 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:

    • Dietary

    • Behavioral

    • Obstruction

    • Dehydration

    • Structural defects (fissures)

    • Metabolic (hypothyroid,hypoparaT, hyperCa)

    • Neuromuscular ( MMC, MD, spinal cord)

    • Hirshsprungs


    Constipation treatment
    Constipation- Treatment 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:

    • Dietary: increased fluid/fibre

    • Stool softeners or laxatives

      • Lactulose

      • Lansoyl

      • PEG powder

    • Bowel evacuation (enemas)

    • Bowel/toileting regimen


    Hirshsprung s disease
    Hirshsprung’s Disease 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:

    • Absence of ganglion cells in the bowel

      wall

    • Most common cause of neonatal GI obstruction

    • Aganglionic segment

    • NB: failure to pass meconium within 48 hrs


    Hirshsprung s disease1

    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:

    onset after 2 yr

    encopresis

    large caliber stool

    normal growth

    normal nutrition

    normal anal tone

    stool in ampulla

    Hirshsprung’s

    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 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:

    Diagnosis:

    • rectal biopsy

      • shows absence of ganglion cells

      • rectal manometry

      • barium enema ->transition zone

        Treatment:

    • resection aganglionic bowel

    • colostomy, then pull through at

      6 to 12 months of age


    Umbilical hernia
    Umbilical hernia 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:

    • 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 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:

    • 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

    UROLOGY / 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:NEPHROLOGY


    Cryptorchidism
    Cryptorchidism 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:

    • 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


    Hypospadius
    Hypospadius 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:

    • Sibling risk - 10%

    • Undescended testes - 10-15%

    • Not associated with UT anomalies

    • Do not circumcise


    Enuresis
    Enuresis 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:

    • 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


    Enuresis1
    Enuresis 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:

    • 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: 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:

    • Hypoalbuminemia, proteinuria, edema, hyperlipidemia

    • Proteinuria, hematuria, hypertension, edema

    • hyperglycemia, glucosuria, ketonuria, weight loss

    • Proteinuria, hematuria, arthritis, purpura


    Proteinuria
    Proteinuria 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:

    • 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
    Proteinuria 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:

    • Tubular:

      • Hereditary- cystinosis, Wilson dis., RTA

      • Acquired- antibiotics, ATN, cystic diseases,

        heavy metal

    • Glomerular:

      • Nephrotic syndrome

      • Glomerulonephritis, tumour, drug, congenital


    Nephrotic syndrome
    Nephrotic Syndrome 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:

    • 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 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:

    • Treatment

      • prednisone

    • Renal biopsy

      • Unusual age (<1yr, adol.)

      • Steroid resistant/ frequent relapse

      • HTN, decreased renal function

    • Complications

      • hypercoagulability

      • infections

      • Drug side effect- steroids, immunosuppressants




    Hematuria
    Hematuria syndrome.

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

    • Approach based on anatomy:

      • Kidney

      • Ureter

      • Bladder

      • Urethra


    Hematuria1
    Hematuria syndrome.

    • 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 syndrome.

    • 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


    Glomerulonephritis
    Glomerulonephritis syndrome.

    • 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 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 syndrome.

    • Treatment

      • supportive

      • lasix infusion

      • Dialysis

    • No role for antibiotics, steroids

    • Prognosis:

      • 10-30% morbidity

      • 5-10% mortality


    Rheumatology

    RHEUMATOLOGY syndrome.


    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


    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 situation?

    • 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 situation?

    • 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%)


    Slide 1 situation?


    Hsp gastrointestinal
    HSP - Gastrointestinal situation?

    • 45 to 85% of children with HSP

      • major hemorrhage (5%)

      • intussusception (2%)

      • occult bleeding (33%)


    HSP situation?

    • 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 situation?

    Criteria

    • 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 situation?

    • 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

    Uveitis situation?

    Hydropic gallbladder

    Carditis

    Pancreatitis

    arthritis

    Sterile pyuria (urethritis)

    Diarrhea

    Aseptic meningitis

    Kawasaki DiseaseAssociated Features


    Kawasaki disease2
    Kawasaki Disease situation?

    • Treatment

      • IVIG

      • Aspirin- high followed by low dose

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


    Oncology

    ONCOLOGY situation?


    Acute lymphocytic leukemia
    Acute Lymphocytic Leukemia situation?

    • 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 situation?

    • Bone marrow failure: anemia, low plts, neutropenia

    • Lymphadenopathy

    • Hepatosplenomegaly

    • Bone pain


    Acute lymphocytic leukemia1
    Acute Lymphocytic Leukemia situation?

    • Relapse 30 - 40%

      • bone marrow

      • CNS

      • testes

    • Long term problems

      • secondary tumours

      • infertility

      • learning disability


    Neuroblastoma
    Neuroblastoma situation?

    • 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 situation?

    • 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%


    Retinoblastoma
    Retinoblastoma situation?

    • Bilateral (40%)

      • hereditary - AD

      • osteogeneic carcinoma

    • Unilateral (60%)

      • sporadic


    Slide 3 situation?


    Brain tumors
    Brain Tumors situation?

    • 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


    Hematology

    HEMATOLOGY situation?


    This child is at risk for
    This child is at risk for: situation?

    • 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: situation?

    • 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 situation?

    • 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


    Anemia
    Anemia situation?

    • 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 situation?

    • 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


    Slide 1 situation?

    .


    Spherocytosis
    Spherocytosis situation?

    • 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



    G6PD situation?

    • 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 situation?

    • Newborn asymptomatic

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

    • Crises

      • sequestration

      • vaso-occlusive

      • aplastic(Parvovirus)

      • hyperhemolytic

      • infections

    • Prevent infections (considered asplenic)



    Slide 2 situation?


    Classic hemophilia
    Classic Hemophilia situation?

    • 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 situation?

    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 situation?

    • Treatment:

      - prevention of trauma

      - FVIII concentrates

      - strict avoidance of drugs that affect platelet function


    Immune thrombocytopenic purpura itp
    Immune Thrombocytopenic Purpura (ITP) situation?

    • 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


    Slide 5 situation?


    Child abuse

    CHILD ABUSE situation?


    Child abuse1
    Child Abuse situation?

    • 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 situation?

    • 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


    Slide 4 situation?


    Slide 1 situation?


    Slide 2 situation?


    Slide 6 situation?


    Slide 7 situation?


    Slide 3 situation?


    Adolescence

    ADOLESCENCE situation?


    Adolescence heeadss
    Adolescence- HEEADSS situation?

    • Home

    • Education

    • Eating

    • Activities

    • Drugs

    • Sexuality

    • Suicide


    Adolescent suicide warning signs
    Adolescent Suicide situation?Warning Signs

    • Depression

    • Psychosomatic complaints

    • Acting out

    • Previous attempt

    • Family history


    Orthopedics

    ORTHOPEDICS situation?


    Growing pains
    Growing Pains situation?

    • 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 situation?(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 situation?

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

    Treatment:

    • 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


    Slide 2 situation?


    Metatarsus adductus
    Metatarsus Adductus situation?

    • 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


    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 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 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


    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 Femoral 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 beEpiphysis

    • 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 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

    • 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


    Dermatology

    DERMATOLOGY 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


    Slide 3 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


    Pityriasis rosea
    Pityriasis rosea 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

    • 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 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

    • 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


    Impetigo
    Impetigo 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

    • + 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


    Impetigo1
    Impetigo 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

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

    • Spread by contact to other parts of body

      Treatment:

      • local measures...personal hygiene

      • compresses to remove crusts

      • systemic antibiotic


    Atopic dermatitis
    Atopic Dermatitis 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

    • Inflammatory skin disorder

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

      exudation, crusting & scaling

    • > risk to develop allergies & asthma


    Atopic dermatitis1

    Infancy 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:

    1st 2 to 3 months

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

    Childhood:

    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 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

    Other signs:

    “Mask of atopic dermatitis”

    • Hyperpigmentation of skin

    • Lichenification


    Atopic dermatitis3
    Atopic Dermatitis 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

    • Itch - scratch - itch cycle Rx:

      • antihistamines

      • topical corticosteroids

      • topical immune modulators (Protopic)

      • hydrating lotions


    Slide 2 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


    Slide 1 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


    Seborrheic dermatitis
    Seborrheic Dermatitis 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

    • 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


    Treatment 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: 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






    Erythema multiforme
    Erythema Multiforme 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 (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 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.

    • 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.)


    Milia
    Milia 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.

    • 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) 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.

    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

    BENIGN & SELF-LIMITING

    Erythema Toxicum Neonatorum


    Class of 2011 faculty of medicine university of ottawa

    CLASS OF 2011 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. FACULTY OF MEDICINE UNIVERSITY OF OTTAWA

    GOOD LUCK!


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