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TMDEJA REVIEW Pediatrics Brooke T. Davey, MD Resident in Pediatrics Morgan Stanley Children’s Hospital of New York-Presbyterian New York, New York Class of 2006 New York University School of Medicine New York, New YorkNew York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto
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This book is dedicated to my mother, Sharon, my father, Ken,my brother, James, and my grandparents, Marge and Mike. Thank you for your never-ending support and love.I would also like to especially thank my husband, Greg Milos, for being my biggest advocate and my best friend.
2 Deja Review: PediatricsHow are infants with excessive fetal Infants with excessive fetal growthgrowth defined and what are their are defined as large for gestationalneonatal complications? age (LGA) or macrosomic. Their weight is above the 90th percentile, which usually corresponds to a birth weight >4,000g. Neonatal complications include increased birth traumas, such as shoulder dystocia, brachial nerve palsy and perinatal asphyxia.A diabetic mother gives birth to her large Plasma glucose levels by means offor gestational age (LGA) daughter. What dextrose stick should be obtainedblood test is important in the management to check for hypoglycemia. This isof this newborn? because the baby may have been exposed to high glucose levels in utero, which results in increased insulin production by the pancreatic β-cells. At birth, after the cord clamping, glucose levels drop but the insulin levels remain high, causing hypoglycemia.A fetus with a neural tube defect has Impaired swallowing of a fetusimpaired swallowing function. What may lead to polyhydramnios,obstetric condition can lead to premature which is an excessive amount oflabor for this baby? amniotic fluid over 2 liters.A fetus has bilateral renal agenesis. What Bilateral renal agenesis causesadditional deformities would you expect to oligohydramnios resulting inappreciate in this patient? Potter’s syndrome. Decreased amniotic fluid causes compression of the fetus by the uterine wall resulting in features such as club feet, compressed facial features, and pulmonary hypoplasia.What are other common causes of Other causes include post-maturity,oligohydramnios? intrauterine growth retardation, amniotic fluid leak, twin-to-twin transfusion syndrome, utero- placental insufficiency, placental abruption, maternal preeclampsia, and idiopathic causes.What pathogens are the most common Toxoplasmosis, Treponemacauses of congenital infections? pallidum Others, including Hepatitis B, Epstein-Barr virus (EBV), and Parvovirus B19
Birth and Prematurity 3 Rubella CMV Herpes, HIVA baby is born with microcephaly and This baby likely has toxoplasmosis.chorioretinitis. Soon after birth she has Pregnant women should avoida seizure. CT scan shows intracranial changing kitty litter as cat fecescalcifications and hydrocephalus. What may be a source of exposure to theanticipatory guidance should have been toxoplasma oocysts of thisgiven to the mother during pregnancy to protozoal parasite. These mothersavoid this infection? are often asymptomatic during the initial infection.What is the recommended treatment for Treatment consists of a synergistica baby with stable or rising antibodies to combination of sulfadiazinetoxoplasmosis? and pyrimethamine. If a baby has falling levels of IgG antibodies to toxoplasmosis during the first year of life, this likely represents the mother’s transplacental antibodies rather than a congenital infection.A newborn whose mother did not undergo This patient has syphilis andprenatal testing develops a fever, should be treated with IV penicillinmaculopapular rash on the chest, palms G for 10 days. In addition, theand soles, rhinitis, and hepatosplenomegaly. mother should be treated as theThe nasal secretions are placed under infection was most likelydarkfield microscopy and T. pallidum is transmitted transplacentally.visualized. What is the next step intreatment?What is the adequate treatment of syphilis Pregnant women with earlyin pregnancy? acquired syphilis should receive 2 doses of Penicillin G benzathine given 1 week apart.In addition to an RPR or VDRL and Long bone radiographs should bea confirmatory fluorescent treponemal obtained to rule outantibody absorption test (FTA-ABS), what osteochondritis, in addition to aadditional tests are typically performed on complete blood cell and plateletbabies with suspected congenital syphilis? count, chest radiograph and liver function tests.A baby is born with cataracts, A first trimester infection of rubellasensorineural hearing loss, a PDA, often results in neurologicalmeningoencephalitis, microcephaly, and impairments as well as visual,mental retardation. The baby has a +IgM auditory, and cardiac defects.rubella antibody in his blood. At whatstage of pregnancy did this child acquirethis congenital infection?
4 Deja Review: PediatricsWhat are the clinical manifestations in an A baby with congenital rubella caninfant with a congenital rubella infection? present with classic “blueberry muffin spots,” liver dysfunction, bone disease, and growth retardation. Congenital rubella has decreased dramatically in incidence due to widespread use of the vaccine.How does the syndrome of CMV infection Both congenital infections causecompare to that of toxoplasmosis? similar lesions, including chorioretinitis, intrauterine growth retardation, liver dysfunction, microcephaly, and intracerebral calcifications. On CT scans, the intracranial calcifications of CMV are located periventricularly, while in toxoplasmosis, they are found in the basal ganglia or in other locations in the brain.A neonate with suspected CMV is placed Babies with congenital CMVin isolation. If protective gowns and gloves continue to shed the virus afterare worn, is it acceptable for a pregnant birth, so despite the protectiveresident to care for the baby? measures, pregnant nurses, doctors, and other health care workers should not be exposed to this patient.Is HSV typically transmitted congenitally HSV is usually transmitted as theor perinatally? baby is exposed to active lesions during vaginal delivery. Therefore, perinatal transmission is most common.A 2-week-old baby develops chorioretinitis, No. This baby should be treatedconjunctivitis, and vesicular lesions on the empirically with acyclovir as he ormouth and skin. The mother had some she likely has skin, eye, and mouthnew vaginal lesions prior to delivery. (SEM) disease of HSV. TreatmentShould treatment be delayed until the should start immediately as thisresults of the laboratory tests come back? baby is at risk for HSV meningitis or disseminated HSV.How do patients with HSV meningitis These patients often present withtypically present? classic symptoms of meningitis including fever, irritability, lethargy, and poor feeding. Additional symptoms seen in HSV meningitis include focal or generalized seizures; subsequent disseminated disease causes liver dysfunction and DIC.
Birth and Prematurity 5A mother develops chicken pox 3 days This baby should receive varicellaprior to the birth of her baby. What is the zoster immune globulin (VZIG) atappropriate treatment for a baby that does birth. Any infant whose mothernot show signs of infection? develops varicella 5 days prior to birth to 2 days after birth should receive VZIG within 4 days of life.A baby is born with many cutaneous scars No. This congenital infection likelyand CNS abnormalities as well as limb occurred in the first trimester ofhypoplasia and growth retardation. pregnancy, so the baby is no longerCongenital varicella is the suspected actively shedding varicella-zosterculprit. Should this baby be placed in virus.isolation after birth?A 6-month-old girl born to a known drug Vertical transmission of HIV fromuser presents to clinic with persistent mother to child is decreased bythrush. She has frequent diarrhea, multiple treating the mother withinfections, failure to thrive, and has not hit antiretroviral medications in theher developmental milestones. She third trimester, performing asubsequently tests positive for HIV. How C-section, avoiding breastfeeding,could this illness have been prevented? and treating the baby with antiretroviral medications.What treatment regimen is appropriate for These patients should receivea patient with congenital HIV? multidrug antiretroviral therapy, trimethoprim-sulfamethoxazole for pneumocystic carinii pneumonia (PCP) prophylaxis, as well as nutritional supplementation and treatment for frequent bacterial and viral infections.Why is erythromycin ophthalmic ointment This ointment is used to preventplaced in the eyes of neonates after birth? chlamydial conjunctivitis and gonococcal ophthalmia. The ointment is used on all infants prophylactically.A newborn was delivered using a vacuum The patient has a cephalohematomaand now has a soft collection of blood caused by a bleed that occurs underunder the scalp that does not cross suture the periosteum.lines and does not discolor the overlyingskin. What birth trauma did it undergo?How does a cephalohematoma differ from Unlike a cephalohematoma, a caputa caput succedaneum? succedaneum causes discoloration of the overlying skin and crosses suture lines. Molding of the skull during vaginal delivery is associated with caput succedaneum. No treatment is necessary for either of these conditions.
6 Deja Review: PediatricsA mother calls the office because she This patient likely has a clavicularnoted that her 2-week-old daughter, who fracture. No further diagnosticwas LGA and delivered vaginally, has studies or treatment are necessary.a bump on her clavicle. What is the nextstep in treatment?A baby is born with a “waiter’s tip.” What This baby has Erb’s palsy andcranial nerves were damaged during the cranial nerves 5 and 6 were likelybirth? stretched and damaged from traction of the neck during delivery. This results in an extended, internally rotated arm with flexion of the wrist.An infant is born at 28-weeks GA and is Intubation and mechanicalfound to be grunting and retracting. ventilation exposes a baby to highRespiratory distress syndrome is pressures, with subsequent lungsuspected. If continuous positive airways barotraumas that can lead topressure (CPAP) is able to provide chronic conditions such asadequate respiratory support, why is it bronchopulmonary dysplasia.a better option than intubation and CPAP allows for more gentle O2mechanical ventilation? and pressure administration.A 3-month-old premature infant who was Retinopathy of prematurity isborn at 24-weeks GA and required caused by abnormal growth andmechanical ventilation for a month after excessive proliferation of thebirth is found to have retinal detachment immature vessels of the retina afterand blindness. What is the exposure to high oxygen tensions.pathophysiology of this disorder?As a woman is giving birth to a full term The baby is likely hypoxic and is atbaby boy, the monitor detects decelerations risk for meconium aspiration.of the baby’s heart rate and meconium is Suction of the oropharynx shouldnoted. What step should be taken as the begin once the head is delivered.baby is delivered? After delivery is completed, the baby should be intubated with suction of the trachea if the infant has poor respiratory effort, decreased tone and a heart rate less than 100 beats per minute.A fetus with meconium aspiration at birth The chronic and/or acute hypoxiais born with a persistent PDA and PFO and experienced by this patient canappears mildly cyanotic. How does oxygen cause persistent fetal circulationadministration help resolve cyanosis in and pulmonary hypertension.this patient? Cyanosis results as right to left shunting is promoted through the PDA and PFO. Oxygen promotes dilation of the pulmonary vasculature and closure of the PDA.
Birth and Prematurity 7A premature, low birth weight infant is not This baby has necrotizingtolerating feeds and her abdomen becomes enterocolitis (NEC) and should bedistended. Her stool is bloody and an made NPO and supported with IVabdominal x-ray shows gas within the fluids. An NG tube should be placedbowel wall known as pneumatosis for decompression and antibioticsintestinalis. What is the next step in should be started. Serial abdominaltreatment? x-rays are needed to evaluate for perforation.What are the signs of perforation in an Air in the peritoneal cavity indicatesinfant with NEC? perforation and surgical manage- ment is warranted.Why is NEC more likely to be seen in Premature infants are at increasedpremature infants? risk for hypoxia, hypoperfusion of the intestine and sepsis, all of which can lead to necrosis of the bowel.A premature female infant has no She likely has central apnea as thererespiratory effort or chest wall movement is no effort to make respirations. Infor 25 seconds. Does she have central or obstructive apnea there is chest riseobstructive apnea? and efforts to breath but no air exchange.The premature infant who has been apneic Bag mask ventilation is a fast andfor 25 seconds turns pale and limp and is easily accessible way to provide airunresponsive to your touch. What is the exchange at this time.next step in treatment?In addition to assisted ventilation, what Additional treatment includesadditional treatment methods may benefit supplementary oxygen to maintaina premature infant with an apneic episode? appropriate oxygenation, positioning and tactile stimulation, chest PT and suctioning of secretions, and a proper incubator environment to maintain a stable body temperature. Treatment with respiratory stimulants may also benefit infants with frequent, severe apneic episodes.A premature, low birth weight infant This patient has a grade II IVH.develops a high-pitched cry and has a poor Grade I is a bleed confined to thesuck reflex. A head ultrasound of the germinal matrix, where thefontanelle shows an intraventricular vasculature is immature, grade IIhemorrhage (IVH) in the germinal matrix involves blood within the ventricle,and blood in the ventricles, but no dilation grade III consists of a largeof the ventricles or parenchymal damage. intraventricular bleed that leads toWhat grade is the IVH? dilation of the ventricle, and grade IV is an intraventricular bleed complicated with parenchymal bleeding.
8 Deja Review: PediatricsA patient with a grade IV IVH develops One of the complications of ana bulging fontanelle and a down-looking intraventricular bleed isgaze several days after the insult. What hydrocephalus, which this infantwill a CT scan likely show? likely has. A ventriculoperitoneal shunt may be placed if the hydrocephalus does not stabilize, but worsens.What infants should be screened for IVH? Premature babies that are >1500 g should be screened for IVH with a head ultrasound within the first week of birth, because about 15–20% of them are found to have an IVH. Among all premature infants found with IVH, only 5% of them develop bleeding after the fifth day of life.On a 30-week prenatal ultrasound, a fetus This patient has an omphalocele.is observed to have a herniation of the Ten percent of children withabdominal viscera through the abdominal Beckwith-Wiedemann syndromewall that is covered by peritoneal and are born with this defect.amniotic membranes. What syndrome hasbeen associated with this defect?This patient with the omphalocele is born Staged surgical compression of thevia C-section and an NG tube is placed to bowel and eventual closure ofdecompress the abdomen. The membranes the abdominal wall is the definitiveand viscera are wrapped in gauze and treatment. The surgery must besterile bandages to protect the gut and staged to prevent compartmentprevent temperature instability. What is the syndrome that could occur if thedefinitive treatment? entire bowel is compressed too quickly within the abdomen.How do infants with gastroschisis differ The infants with gastroschisis havefrom those with omphalocele? no sac covering the herniated gut. While infants with omphalocele have herniated viscera through the umbilicus and within the umbilical cord, in gastroschisis the herniation happens through a wall defect typically lateral to the umbilicus. These infants are more prone to infection and dehydration due to the lack of membrane covering the viscera.An SGA fetus is delivered and becomes Cocaine has vasoconstrictive effectsirritable, tremulous and is not feeding on the placenta that decrease bloodwell. The mother tested positive for flow to the fetus, causing IUGR andcocaine on a prenatal urine toxicology. sometimes birth defects or cerebralWhat types of short- and long-term effects infarcts. After birth, 10–30% of themay be seen in this baby? infants exhibit signs of cocaine
Birth and Prematurity 9 intoxication. Long term consequences are increased incidence of learning disabilities and Attention-Deficit/ Hyperactivity Disorder (ADHD).A newborn of a mother in a Methadone No. Although this infant is affectedprogram develops irritability, poor feeding by narcotic abstinence syndrome,and sleeping, sweating, and a high-pitched which occurs in 70–90% of thecry. Should this infant have received infant born to mothers treated withNaloxone at birth? Methadone, Naloxone is contraindicated because it may precipitate an acute abstinence syndrome with seizures. Severe abstinence syndrome may be treated with Phenobarbital, Paregoric, Diazepam or Methadone.A mother drank six or more servings of This amount of alcohol exposurealcoholic beverages per day during her can lead to fetal alcohol syndrome.pregnancy. What are the teratogenic effects The baby may experience IUGRthat the fetus may experience? as well as mental retardation, microcephaly, characteristic facial anomalies such as a flat philtrum, a depressed nasal bridge, and micrognathia, as well as kidney and heart defects.What antibiotics must be avoided during Tetracyclines should be avoided aspregnancy due to its effects on teeth and they produce a permanentbone of the fetus? discoloration of tooth enamel and a transient delay of bone growth.
12 Deja Review: PediatricsTable 2-1 Primitive ReflexesReflex Timing Elicit ResponseMoro Birth to 3–6 months Allow head to fall back Symmetric extension suddenly about 3 cm and adduction, then while supine flexion, of limbsStartle When Moro Startle Limbs flex disappears to 1 yearGalant Birth to 2–6 months Stroke paravertebral Pelvis moves in region of back while direction of prone stimulated sideSucking Birth to 3 months Stimulate lips Sucks (then becomes voluntary)Babinski Birth to 4 months Stroke outer sole of Fanning of toes and foot dorsiflexion of great toeTonic Birth to 4–6 months Rotate head laterally Extension of limbs on neck while supine chin side and flexion of limbs on opposite side (fencing posture)Rooting Birth to 4–6 months Stroke finger from Head turns toward mouth to earlobe stimulus and mouth opensPalmar/ Birth to 4–9 months Stimulation of palm or Palmar grasp/plantar plantar plantar surface of foot flexion graspParachute Appears at Horizontal suspension Extension of 9 months and quick thrusting extremities movement toward surface grow along genetically determined percentiles, and this child is not deviating from his growth curve. Lastly, the standard growth curves used in practice were determined using mostly white, middle class children, so children of different races or ethnicities may not have the same standard parameters for growth.A 1-year-old boy is failing to meet This child is presenting with failureexpected norms for weight and height and to thrive (FTT), defined as a weight,is noted to have subcutaneous fat loss, height, or head circumference belowloss of muscle mass, edema, distended the third to fifth percentile, falling off
Growth, Development, and Nutrition 13abdomen, and hair loss. These symptoms the growth curve by crossing twoare a sign of which condition? major percentiles on a growth chart, or weight <80% of ideal body weight for age. It is not a diagnosis; it is a sign of an underlying organic or nonorganic disorder.What is the first growth parameter to be Weight is generally the firstaffected in FTT? parameter to be affected, but with prolonged duration of malnourish- ment, length and head circumference may also adversely be affected.What is the most common cause of FTT Nonorganic or psychosocial causesin the United States? including abuse, neglect, and improper feeding are the most common causes of FTT; however, gastrointestinal, pulmonary, renal, endocrine, central nervous system, and other organic causes must be considered as well.How is organic FTT distinguished from A thorough history and physicalnonorganic FTT? exam, including observation of the parent-child feeding interaction, and screening tests such as a complete blood count (CBC), electrolytes, blood urea nitrogen (BUN), creatinine, albumin, and total protein should be done to differentiate organic from nonorganic causes of FTT. Organic causes of FTT generally have other manifestations in addition to FTT.When should you hospitalize a patient Patients are hospitalized for FTTfor FTT? when there is suspicion or evidence of abuse or neglect, severe malnutri- tion or medical complications, or if outpatient treatment is unsuccessful.A newborn presents with weight, length, An intrauterine insult or geneticand head circumference significantly abnormality is most likely responsiblebelow age-matched norms. What is the when multiple growth parametersmost likely cause? are below average at birth.A newborn presents with weight and Likely causes include constitutionallength below average and head growth delay, genetic short stature,circumference within normal limits. or endocrine causes of growthWhat are some possible causes? failure.A newborn presents with weight Likely causes include insufficientsignificantly below average with sparing caloric intake or a hypermetabolicof the height and head circumference. state.What are some possible causes?
14 Deja Review: PediatricsA child sits well unsupported, transfers 6 months. See Table 2-2.objects between hands, rolls over, andbabbles. What is the child’s approximateage?A child crawls, says “mama,” and can 10 months, as this child haspick up his food with his fingers. What developed the pincer grasp.is this child’s approximate age? See Table 2-2.A child walks up and down stairs, runs, 2 years. See Table 2-2.says two-word phrases, and half of hisspeech is understood by strangers. Whatis his approximate age?A parent of a 7-month-old (ex-28 week GA) An age correction for prematuritypreterm boy is concerned that her should be used when evaluating forson is not yet sitting by himself, when all developmental milestones during theher other children had achieved this first 18–24 months of life. When themilestone by 6 months of age. How would age correction is applied to thisyou counsel her? patient, he should be evaluated in terms of milestones for a 4-month- old, and therefore he is not delayed. In addition, milestones are acquired in an age range, and it is the overall pattern of development that is important as an indicator of neurologic function.A 2-year-old child presents for a well- The Denver Developmentalchild check. What screening test is Assessment Test (Denver II) isused in the office to assess development administered to screen forand what skills does it evaluate? developmental milestones. The basis of the test is that development occurs in a predictable pattern, with new skills built on previously acquired skills. Any abnormal findings must be followed up with further diagnostic evaluation.What skills does the Denver II assess? It evaluates gross motor, fine motor, language, and social skills by both directly observing the child and obtaining information from caregivers about specific milestones.A Denver II screening test is performed Isolated language delays may beat a well-child visit of a 2-year-old girl. suggestive of a hearing problem,She has adequate fine and gross motor inadequate environmental stimula-and social development but is not tion, mental retardation, or autismmeeting expected language milestones. spectrum disorder. The first stepWhat is your next step? should be to evaluate this child for
Growth, Development, and Nutrition 15Table 2-2 Developmental Milestones Age Gross motor Fine motor Language Social/Cognitive2–3 Head up Tracks past Coos Social smile months prone midline Alerts to sound Recognizes parent4–5 Rolls front to Grasps object Orients to voice Laughs months back6–7 Rolls back to Transfers Babbles Stranger anxiety months front objects Sleeps all night Sits un- between supported hands Raking grasp9–12 Pulls to Pincer grasp Mama-dada Waves bye-bye months stand (nonspecific) Responds to name Finger feeds Understands12–14 Walks Mature pincer “no” Imitates actions months Throws Mama-dada Comes when object (specific) called15–17 Walks Uses cup 4–6 words Temper tantrums months backwards18–23 Runs Uses spoon Names Copies parent in months Kicks a ball Builds tower common tasks2 years Walks up of 2–4 cubes objects and down Builds tower 2-word phrases Follows 2-step 1 stairs of 6 cubes /2 of speech commands Jumps Copies understood by Parallel play a line strangers Removes 3-word phrases Knows first and 3 clothes /4 of speech last name, age,3 years Rides tricycle Copies a understood by gender Helps dress circle strangers and undress Uses utensils Recognize Group play self 3 colors Brushes teeth and4 years Alternates Copies a cross Counts to 10 washes hands feet going Catches ball Speech with help down stairs Dresses alone completely Cooperative play Hops on one understood by Imaginative play foot strangers Throws Tells a story overhand
16 Deja Review: Pediatrics hearing loss using behavioral testing, otoacoustic emissions testing, or brainstem-evoked response audiometry.A mother notices that her 4-month-old Motor development progresses inson has good truncal control but poor both a cephalocaudal and a central-finger dexterity. What is the normal to-peripheral manner, and thereforesequence for development of motor truncal and extremity controlcontrol? precede finger dexterity. Motor development parallels central nervous system development, with myelination beginning prenatally and continuing up to 2 years of age in a cephalocaudal direction.A child identified with developmental Mental retardation is defined asdelay is evaluated and found to have an intellectual functioning, measured byintelligence quotient (IQ) of 55. What is an IQ, more than two standardthe definition of mental retardation? deviations below the population mean on standardized intelligence tests (such as the Stanford-Binet or Wechsler intelligence tests). Mental retardation is usually associated with functional deficits in areas such as self-care, communication, or social interactions. Mild retardation is defined as an IQ of 50–70, and moderate-severe retardation is defined as an IQ less than 50.What is the best predictor of a child’s Language and speech developmentsubsequent cognitive performance? are the best indicators of future intelligence.A 7-year-old boy is referred to you by his Learning disabilities occur in 5–10%teacher for poor spelling, slow learning, of children, with dyslexia being theand poor overall school performance. most common. This child may haveHe has no known medical problems. dyslexia, which is the failure toWhat are you concerned about? acquire reading skills in the usual time course due to inability to properly interpret written language.How is dyslexia diagnosed? Dyslexia is not related to intelligence and may be diagnosed based on a discrepancy between reading ability estimated on the basis of IQ and actual reading ability. The patient should have a complete psychoe- ducational assessment.
Growth, Development, and Nutrition 17A 3-year-old girl throws a temper tantrum Breath holding spells involve suddenin a store when her parents tell her that cessation of breathing in response toshe can not have a toy. Suddenly, the a strong emotional stimulus and maychild turns blue and syncopizes. What is lead to unconsciousness if prolonged.the most likely cause of her syncope? Cyanotic breath holding spells occur predictably upon upsetting or scolding the child and resolve spontaneously. They are rare at <6 months of age, peak at 2 years of age, and resolve by 5 years of age. Pallid breath holding spells tend to occur with painful or frightening experiences, and they also resolve spontaneously. Both types of spells will resolve without intervention and have no sequelae.A first-time mother asks about the normal Infants sleep 18 hours per day,sleeping pattern for a newborn. How evenly distributed over day andwould you counsel her? night for short intervals of 2–3 hours. Fifty percent of this sleep is rapid eye movement sleep (REM). By 4–6 months of age, nighttime sleep becomes consolidated.A mother of a 2-month-old boy states that Colic is excessive, unexplainedher son has colic. What is colic? paroxysms of crying lasting >3 hours a day for >3 days per week in an otherwise healthy infant, and it occurs in 10–30% of infants.What treatment strategies are used for Colic usually begins in the first weekcolic? of life and self-resolves by 3–4 months, regardless of treatment strategies used. Suggested interventions include decreased stimulation (swaddling, dark quiet room), gentle rhythmic stimulation (rocking, walking), pacifier, swing, car or stroller ride, rubbing or patting infant, and singing or music.A mother brings in her 7-day-old, Term infants can lose up to 10% offull-term infant with concerns that the their birth weight soon after birth,infant’s current weight is 10% less than which is due to loss of extracellularbirth weight. What is the next step? water and calorie requirements that are initially higher than the infant can meet. The infant should stop losing weight by 5–7 days and regain birth weight by 10–14 days. Reassurance for the parent and monitoring of the infant’s weight are important.
18 Deja Review: PediatricsA first-time mother has just delivered Newborns generally start feedinga healthy, full-term infant, and she asks within the first 6 hours of life. Theywhen she can start feeding and how often should be fed with breast milk orshe should feed her baby. How should formula on demand everyyou counsel her? 11/2–3 hours in the first few weeks and should not go longer than 4–5 hours without feeding. Caregivers should be counseled to feed at signs of hunger and to stop at signs of satietyWhat is the breast milk expressed The milk expressed for 2–4 days afterimmediately after delivery? delivery is called colostrum, and it is high in protein, minerals, and immunologic factors (especially IgA) but low in carbohydrates.A new mother is also concerned about Mom will supply enough milk forproducing enough milk for her child. her child because the more the babyHow would you address her concerns? breastfeeds, the more milk will be produced. It is normal to feed every 1–2 hours, 8–12 times per day. If mom starts supplementing with formula milk, the infant will breastfeed less, and less breast milk will be produced. The child’s weight should be monitored to ensure adequate growth.How many calories per day are required Newborns require 110–115 kcal/by newborns? (kg · day) and should grow about 30 g/day.What are the benefits of breastfeeding? For the infant, there is decreased incidence of infection (otitis media, pneumonia, bacteremia, meningitis) due to immunologic factors such as antibodies and macrophages present in breast milk and decreased exposure to enteropathogens. For the mother, there is decreased postpartum bleed- ing, more rapid involution of uterus, decreased menstrual blood loss, delayed ovulation, and decreased risk of ovarian and breast cancer. Other benefits include maternal- child bonding, convenience, and low cost.What are the absolute contraindications Contraindications to breastfeedingto breastfeeding? include some medications (lithium, cyclosporine, ergotamines, and bromocriptine, which suppresses
Growth, Development, and Nutrition 19 lactation), cancer chemotherapy, exposure to radioactive isotopes, illicit drugs (cocaine, heroin), herpes simplex breast lesions, untreated active tuberculosis, human immuno- deficiency virus infection (in developed countries), and infant galactosemia.An exclusively breastfeeding mother asks Breast milk may be deficient inif she needs to give her newborn any vitamins A, D, K, B12, thiamine, andsupplements. How do you counsel her? riboflavin; infants exclusively breastfed should be given vitamin supplements starting at 4 months of age. Commercial formulas are often fortified with vitamins and minerals so that no additional supplements are required.Is iron supplementation required for In a full-term infant, iron storesnewborns? are sufficient for 6 months, and iron supplementation is started at 4–6 months. In preterm infants, iron supplementation is started at 2 months. The iron content of breast milk is less than that of formula but has greater bioavailability due to the presence of lactoferrin in breast milk.A breastfeeding mother presents with This mother has mastitis, mostthe periareolar area of a tender, warm, commonly caused by Staphylococcuserythematous lesion of her right breast aureus from the oropharynx of herand a low-grade fever. What is the most infant transferred duringcommon source of this infection? breastfeeding.What is the treatment of mastitis, and The mother should be treated withshould a mother with mastitis discontinue compresses, analgesics, and possiblybreastfeeding until the infection resolves? antibiotics, and the infant should continue breastfeeding on the affected breast.What is the difference between Breastfeeding jaundice is due tobreastfeeding jaundice and breast milk insufficient milk intake, which leadsjaundice? to infrequent bowel movements and increased enterohepatic circulation of bilirubin. It occurs during the first week of life. Breast milk jaundice is unconjugated hyperbilirubinemia due to a bilirubin conjugation
20 Deja Review: Pediatrics inhibitor in the breast milk. It occurs after the first week of life, is usually transient, and no treatment is required.A first-time mother of a healthy, full-term Most formulas for healthy, full-termboy decides that she wants to use infants are cow’s milk protein-basedformula feeds for her newborn son. with lactose as the carbohydrateWhat type of formula would you source. Soy protein formulas are alsorecommend? available and use sucrose or corn syrup solids as the source of carbo- hydrates; they may be used for transient lactase deficiency following significant diarrheal illness. Formulas come in powders, concentrate, or ready-to-eat forms, which are all equivalent and are fortified with vitamins and minerals. They do not require supplements. Standard formulas contain 20 kcal/oz.A mother of a 7-month-old baby boy who Whole cow’s milk is not recom-has started solids asks if she can give her mended until 1 year of age becauseson the same whole cow’s milk that she an infant’s gastrointestinal tract isgives to her 2-year-old daughter. What is not mature enough, and it canyour response? predispose the infant to allergy, gastrointestinal blood loss, and iron deficiency anemia (due to both the low iron content of whole cow’s milk and occult gastrointestinal blood loss).A 5-month-old child taking cow’s Consider cow’s milk protein allergymilk-based formula presents with in this child, which occurs in 1–7% offrequent diarrhea, poor weight gain, and infants, and switch to soy protein-irritability. What is your next step in based formula. However, theremanagement? is significant cross-reactivity of 30–40% to soy protein, and a casein hydrolysate formula may be required.A mother of a 4-month-old child asks Solid foods should be startedabout starting solid foods. When and between 4 and 6 months of age, andhow should solids be introduced? new foods should be introduced individually about a week apart to identify any allergies the child may have. In order to start solids, a child should be able to sit with support, have hand-to-mouth coordination, and open mouth to the spoon. Avoid foods that can be choking hazards, such as peanuts, hard candy, or popcorn.
Growth, Development, and Nutrition 21The mother of a 5-year-old boy with body Emphasize an overall healthymass index (BMI) in the 99th percentile lifestyle for the patient and theasks for information about how to family, including a balanced diet,improve the health and weight of her son. regular exercise, and less sedentaryHow would you counsel her? activity including television. The goal is not to lose weight but to meet all nutritional needs and slow the rate of fat deposition.A 3-year-old child presents with This child has marasmus due toprogressive weight loss, constipation, caloric deficiency. This can be causedmuscular atrophy, and edema. His mother by inadequate calorie consumption,states that they are going through poor feeding, metabolic disease, ora difficult time and food is short. What is congenital abnormalities.the diagnosis?A newborn is given an injection of Vitamin K is given to preventvitamin K in the delivery room. Why is hemorrhagic disease of the newborn.vitamin K given? Newborns have transient vitamin K deficiency and resulting deficiency of vitamin K-dependent clotting factors (II, VII, IX, X) due to lack of free vitamin K in the mother and lack of bacterial intestinal flora that synthesize vitamin K. See Table 2-3.An 18-year-old boy was recently found to Pyridoxine (vitamin B6) should bebe PPD positive and was started on given as well because isoniazidisoniazid. What supplement should he competitively inhibits pyridoxinetake with the isoniazid? metabolism and can cause peripheral neuropathy. Pyridoxine supplements are given to adolescents but generally not to children, as peripheral neu- ropathy is rarely seen in children. See Table 2-3.A 5-year-old boy presents with diarrhea, Niacin (vitamin B3) deficiency causesrash and altered mental status. What pellagra, which is manifested by thedeficiency in his diet may cause these three Ds, which are diarrhea,symptoms? dermatitis, and dementia. Niacin is derived from tryptophan and is a constituent of nicotinamide adenine dinucleotide (NAD) and nicotinamide adenine nucleotide phosphate (NADP), which are important for electron transfer and glycolysis. See Table 2-3.A 4-year-old child with gastroenteritis This child is moderately to severelypresents to the emergency room with dehydrated and requires fluidsevere vomiting and diarrhea. He is therapy to rapidly expand histachycardic, hypotensive, and irritable, vascular space, correct his fluidhe has not urinated all day, and his deficit, and restore tissue perfusion.
Table 2-3 Vitamins Vitamin Function Source Deficiency Excess Vitamin A Constituent of visual Carrots, milk, eggs, liver, Night blindness, dry skin, Arthralgias, headaches, (retinol) pigments, immune system green leafy vegetables infections skin changes, alopecia. Vitamin B1 Carbohydrate Fortified breads, cereals, Beriberi: congestive heart — (thiamine) metabolism pasta, meat, fish, soy, failure, peripheral neuritis, whole grains confusion Vitamin B2 Carbohydrate, fat, and Meat, eggs, legumes, Angular stomatitis, cheilosis, — (riboflavin) protein metabolism nuts, dairy, leafy green corneal vascularization, (constituent of FAD), vegetables dermatitis vision Vitamin B3 Carbohydrate, fat, and Red meat, poultry, fish, Pellagra: dermatitis, diarrhea, Vascular dilation causes (niacin, protein metabolism fortified cereals, dementia “niacin flush”: flushing, nicotinic (constituent of NAD/ peanuts burning, itching22 acid) NADP), nerve function Vitamin B5 Carbohydrate, fat, and Meat, eggs, vegetables, Dermatitis, enteritis, — (pantothenate) protein metabolism legumes, whole wheat alopecia, adrenal (constituent of CoA), insufficiency neurotransmitters Vitamin B6 Important for brain and Leafy green vegetables, Peripheral neuropathy, Sensory neuropathy, (pyridoxine) nerve function, potatoes, bananas, convulsions, pain, fever erythropoiesis seeds, nuts hyperirritability Vitamin B9 Important for DNA and Dried beans, legumes, Macrocytic, megaloblastic — (folic acid, RNA synthesis, citrus fruits, poultry, anemia folate) erythropoiesis leafy green vegetables
Vitamin B12 Important for DNA and Animal products- fish, Macrocytic, megaloblastic — (cobalamin) RNA synthesis, red meat, poultry anemia with neurologic erythropoiesis, nerve symptoms, glossitis function Biotin Carbohydrate and fat Fruits, nuts, rice, egg Dry skin, fatigue, depression, — metabolism yolk, milk muscular pain Vitamin C Collagen synthesis, Citrus fruits, red berries, Scurvy: swollen gums, Kidney stones, cramps, (ascorbic facilitate iron and calcium broccoli, spinach, bruising, anemia, poor diarrhea, nausea acid) absorption, immune peppers wound healing system Vitamin D Facilitate intestinal Fortified milk, egg yolks, Rickets: defective Hypercalcemia, nausea, (ergosterol) absorption of calcium and fish oils mineralization of bone diarrhea, soft-tissue phosphate matrix, rachitic rosary, calcification craniotabes Vitamin E Antioxidant Leafy green vegetables, Increased fragility of —23 (tocopherol) nuts, whole grains erythrocytes Vitamin K Carboxylation of clotting Leafy green vegetables Hemorrhage — (menadione) proteins
24 Deja Review: Pediatricsmucous membranes appear dry. What is Lactated Ringer’s or normal saline isthe next step in his management? the fluid of choice, with 20 cc/kg given over 1–2 hours.The child above weighs 23 kg. How much The Holliday-Segar method can befluid would you administer? used to determine intravenous fluid requirements: give 100 mL/kg of water for the first 10 kg, 50 mL/kg of water from 10 to 20 kg, and 20 mL/kg of water for every kg over 20 kg. When divided by 24 hours, the 4-2-1 rule approximation can be used: give 4 mL/(kg ¥ h) for the first 10 kg, give 2 mL/(kg ¥ h) from 10 to 20 kg, and give 1 mL/(kg ¥ h) for every kg over 20 kg. In this example of a child weighing 23 kg:Using the Holliday-Segar method:(100 mL/kg × 10 kg) + (50 mL/kg × 10 kg) + (20 mL/kg × 3 kg) = 1560 mL over 24 hoursUsing the 4-2-1 rule:(4 mL/(kg ⋅ h) × 10 kg) + (2 mL/(kg ⋅ h) × 10 kg) + (1 mL/(kg ⋅ h) × 3 kg) = 63 mL/hA child with nephrotic syndrome is found This child has hypervolemic hypona-to have a serum sodium of 115 mEq/L. He tremia due to fluid retention fromhas a headache and his mother notices nephrotic syndrome. His headachesome mental status changes. How would and mental status changes areyou correct his serum sodium? due to cerebral edema as the water flows from the hyponatremic serum into the hypertonic intracellular fluid, and the serum sodium must be corrected in order to prevent brain herniation. The sodium deficit is calculated: Na+ deficit = (Na+ desired − Na+ observed) × body weight in kg × 0.6. Half of the deficit is given in the first 8 hours, and the rest is given over the next 16 hours. Hyponatremia should not be corrected >2 mEq/(L ¥ h) in order to prevent cerebral pontine myelinolysis.A 3-month-old child presents to the You would ask about formulaemergency room with a generalized tonic preparation. If the formula is dilutedclonic seizure and is found to be to make it last longer, the child is
Growth, Development, and Nutrition 25hyponatremic. The child is formula fed. taking in too much water. This canWhat would you ask the caregiver? cause hyponatremia and water intoxication, which then can cause seizures.A child presents with mental status This child most likely has diabeteschanges, irritability, and muscle insipidus (DI), causing a low urinetwitching. His urine specific gravity is specific gravity and hypernatremic1.003 and his serum sodium is 160 mEq/L. dehydration. The serum sodium isWhat is your next step in management? lowered gradually at a rate of 10–15 mEq/(L ¥ day) in order to prevent cerebral edema due to fluid shifts into the central nervous system.A diabetic child presents to the Intravenous potassium is given ifemergency room in diabetic ketoacidosis. patient is symptomatic, but the rateShe has tachycardia and hyporeflexia on should not exceed 0.5 mEq/(kg ¥ h).physical exam, U waves on ECG, and If potassium is not dangerously low,a serum potassium of 2.5 mEq/L. How oral potassium may be given. Placewould you treat the hypokalemia? the patient with hypokalemia on a cardiac monitor, as arrhythmias may occur.A patient with hypoaldosteronism Calcium chloride or gluconate can bepresents with arrhythmias, muscle given to stabilize cardiac cellularweakness, and the serum potassium is membranes, sodium bicarbonate,7.3 mEq/L. She has peaked T waves and albuterol, or glucose with insulin canwidened QRS complexes on ECG. How be given to shift potassium into thewould you treat the hyperkalemia? cells. Kayexelate can be given to bind potassium in the gastrointestinal tract though it works more slowly, furosemide can be given to enhance urinary excretion of potassium, and hemo- or peritoneal dialysis can be used in extreme cases. Patients with hyperkalemia should also be placed on cardiac monitors, as arrhythmias may occur.