Category: Pediatrics

Neonatal Conjunctivitis

The 3 Worst Causes of Neonatal Conjunctivitis

  • Gonorrhea
    • Causes corneal ulcers and sepsis
    • Red flags
      • 1st week of life
      • Copious purulent drainage
    • Diagnose with cultures
    • Treatment
      • Cefotaxime (3rd generation cephalosporin)
      • Admit
  • Chlamydia
    • Occurs in 1st month of life
    • Treat with PO erythromycin
  • HSV
    • Can disseminate to the brain
    • Red flags
      • Mother tested positive (or had active lesions)
      • Vesicles on baby
    • Treatment
      • IV acyclovir
      • Admit

Other Causes of Conjunctivitis

  • Viral/other bacterial
    • Treat with erythromycin ointment
  • Chemical conjunctivitis
    • Caused by eye drops given after birth
  • Dacryostenosis (closed eye ducts)
    • Watery eyes from tears not draining

Additional Reading

  • Neonatal Conjunctivitis (CDC)

Blood in the Diaper

The 4 Most Common Causes of Blood in Diaper

  • Urinary crystals
    • Will be guaiac negative
    • Common in first few weeks of life
  • Vaginal bleeding
    • Common in newborn females as they withdraw from maternal estrogen
  • Maternal blood
    • Swallowed during birthing process
    • Breastfeeding with cracked/bleeding nipples
  • Anal fissures
    • Common and will improve on its own

Basic Approach

  • Step 1: Check if guaiac positive
    • If negative, it’s not blood
    • Urinary crystals, food coloring, etc
  • Step 2: Consider vaginal bleeding
  • Step 3: Perform apt test
    • Diagnoses maternal blood
  • Step 4: Check for anal fissure
    • Self resolve
  • Step 5: Expand the differential diagnosis
    • Necrotizing enterocolitis
    • Intussusception
    • Cow’s milk allergy
    • Colitis
    • Red Food Dye

Additional Reading

Neonatal Jaundice

Physiology

  • RBC hemoglobin breakdown -> unconjugated (indirect) bilirubin
  • Unconjugated (indirect) bilirubin -> liver -> conjugated (direct) bilirubin
  • Conjugated (direct) bilirubin -> Eliminated in stool

Causes of Hyperbilirubinemia

  • Increased RBC turnover
    • Sepsis
    • Rh incompatibility
    • RBC disorders
    • Maternal diabetes
    • Scalp hematoma
  • Decreased/slow conjugation by the liver
    • Peaks around day 5 of life
    • Congenital liver disorders
      • Gilbert/Crigler Najjar Syndromes
    • Breast milk jaundice
      • Breast milk inhibits conjugation of bilirubin
  • Decreased excretion
    • Bowel obstruction
    • Breast feeding failure (dehydration)
      • Decreased stool output results in reabsorbed bilirubin

Kernicterus

  • Brain damage from severe hyperbilirubinemia (>25 mg/dL)
  • Compare measured bilirubin to established nomogram
  • Treatment is phototherapy
    • (Worst case scenarios require exchange transfusion)

Additional Reading

Peds T- Tummy and Non-Accidental Trauma

Non-Accidental Trauma

  • Estimated 10% of pediatric patients are victims of abuse
    • Sexual abuse
    • Physical abuse
    • Neglect
  • Common red flags
    • Changing story
    • Story that doesn’t make since
    • Delays in seeking care
    • Unusual bruising locations
      • Torso
      • Ears
      • Neck
  • Common tests if non-accidental trauma suspected
    • Skeletal survey x-rays
    • Head CT
      • Especially if altered mental status
    • Abdominal CT
      • Especially if abdominal trauma
  • Report to child protective services (CPS)

Tummy Ache

  • Necrotizing enterocolitis
    • Classic presentation
      • Premature baby
      • 1st month of life
      • Ill appearing
    • Classic finding on x-ray
      • “Pneumatosis intestinalis”
  • Volvulus
    • Classic presentation
      • 1st month of life but previously healthy
      • Distended abdomen
      • Bilious vomiting
    • Testing
      • Abdominal Xray
      • Upper GI Series (ideal test)
  • Toxic megacolon
    • Complication of Hirchsprung Disease
    • Seen on x-ray
  • Intussusception
    • Telescoping bowel resulting in ischemia
    • Classic presentation
      • 2 months – 2 years old
      • Intermittent abdominal pain followed by lethargy
    • Diagnose with abdominal ultrasound
  • Pyloric stenosis
    • Classic presentation
      • Projectile vomiting
      • Normal appetite/hungry
      • Palpable “olive” in epigastrium
    • Testing
      • Electrolyte panel
        • Hypokalemia
        • Hypochloremia
        • Alkalosis
      • Abdominal ultraound

Additional Reading

Peds I- Inborn Errors of Metabolism and Endocrinology

Don’t be overwhelmed knowing/memorizing each inborn error of metabolism. The basic approach is actually quite easy!!!

Inborn Errors of Metabolism (IEM)

  • Almost always result in one of the following three clinical abnormalities
    • Buildup of toxins
      • Ammonia
        • To test for this, obtain an ammonia level
    • Buildup of acids
      • Methylmalonic acidemia
        • To test for this, obtain electrolyte panel and look for decrease CO2
    • Shortage of glucose
      • Glycogen storage disorders
        • To test for this, obtain a blood glucose level

Congenital Adrenal Hyperplasia (CAH)

  • Decreased 21-hydroxylase enzyme
  • Physiologic abnormalities
    • Decreased aldosterone
      • Low sodium (hyponatremia)
      • High potassium (hyperkalemia)
    • Decreased cortisol
      • Low glucose level
      • Hyperpigmentation
    • INCREASED sex hormone (androgens)
      • Fused labia
      • Partial male genitalia

Additional Reading

Peds H- Heart Failure and Congenital Heart Disorders

Common Chief Complaints

  • Cyanosis
  • Difficulty feeding
  • Failure to thrive

Cyanotic Heart Lesions

  1. Truncus arteriosus
    • Aorta and pulmonary artery are fused
    • Single vessel comes from both ventricles
  2. Transposition of great vessels
    • Aorta comes off RIGHT ventricle
    • Pulmonary artery comes off LEFT ventricle
  3. Tricuspid atresia
    • Blood unable to get from right atrium to right ventricle
  4. Tetrology of fallot
    • Overriding aorta
    • Ventricular septal defect
    • Right ventricular outflow tract obstruction
    • Hypertrophy of right ventricle
  5. Total anomalous pulmonary venous return
    • Pulmonary vein empties into the right ventricle

Ductal Dependent Lesions

  • Classically presents in first 30 days of life
  • Treatment = Prostaglandins
  • Common lesions
    • Hypoplastic left heart
    • Aortic stenosis
    • Coarctation of the aorta

Congestive Heart Failure

  • Common Presentation
    • Difficulty feeding
    • Organomegaly
    • Cardiomegaly on CXR
  • Treatment
    • Furosemide
    • Vasopressors
  • Admit

Additional Reading

Peds S- Sepsis and Serious Bacterial Infections

Pediatric “Sepsis”

  • Consider in any toxic appearing child/neonate
    • Especially with fever (or hypothermia)
  • Treatment
    • Early antibiotics
    • Fluid bolus

“Serious Bacterial Infections” (SBI)

  • Consider in any baby with fever
  • Three classic categories
    • Age <30 days
      • Introduction
        • Weak immune system
        • No immunizations
        • Very high risk for serious bacterial infections
      • Require a significant amount of testing
        • Urinalysis with Urine Culture
        • Blood Cultures
        • Lumbar Puncture with CSF Cultures
        • Chest X-Ray
      • Require admission and antibiotics
    • Age 30-60 days
      • ILL appearing
        • Treat same as fever in <30 day patient
      • WELL appearing
        • Testing and treatment differ by institution
        • Multiple criteria established to help in this age range
          • Rochester criteria
          • Philadelphia criteria
          • PECARN criteria
        • Choose one and use consistently
    • Age >60 days
      • (Assumes immunizations are up to date)
      • Workup is more targeted
        • Blood cultures, Urine cultures, Chest X-Rays still common

Additional Reading

  • Rochester Criteria Febrile Infants (MDCalc)
  • PECARN Rule for Low Risk Febrile Infants (MDCalc)

Peds H- Hyperglycemia and Hypoglycemia

Introduction

  • In pediatric patients, have a low threshold to check blood sugar
  • Undiagnosed diabetics commonly identified in ED during first episode of DKA
  • HYPOglycemia is very common in multiple conditions, especially in ill children

Hyperglycemia

  • DKA is different in kids
    • They get cerebral edema
      • Increased intracranial pressure with rapid fluid administration
    • Common symptoms
      • Headache
      • Altered mental status
      • Neurologic deficits
      • Cushings triad
        • Hypertension
        • Bradycardia
        • Irregular breathing
    • Treatment = mannitol

Hypoglycemia

  • Multiple causes
    • Sepsis
    • Inborn errors of metabolism
    • Endocrine disorders
  • Replace glucose using “Rule of 50s”
    • Dextrose % x Volume = 50
      • Neonates: 5ml/kg of D10
      • Pediatrics: 2ml/kg of D25
      • Teens/Adults: 1ml/kg of D50
    • 1 “amp” of D50 = 25g of sugar = 50ml

Additional Reading

Peds O- Oxygen, Airway, and Respiratory Disorders

Applying oxygen is one of the first steps in treating any crashing child!!!

Airway Emergencies

  • Foreign body (FB)
    • Patient presentation
      • Stridor
      • Choking episode
    • Testing
      • CXR
        • May directly show foreign body
        • May show secondary effects of a foreign body
          • Hyperinflated/collapsed lobes of the lung
    • Patient needs bronchoscopy if suspicion is high
  • Peritonsillar abscess
    • Visible in the pharynx
  • Bacterial tracheitis
    • HIDDEN IN the airway
  • Epiglottitis
    • HIDDEN ABOVE the airway
  • Retropharyngeal abscess
    • HIDDEN BEHIND behind the airway
  • Common presentations of airway emergencies
    • Voice changes
    • Drooling
    • Stiff neck
  • Testing
    • Most are seen on neck X-Ray
    • Peritonsillar abscess is clinical diagnosis
  • Treatment
    • Manage the airway
    • IV Antibiotics
    • Peritonsillar abscess needs drainage

Breathing Emergencies

  • Bronchiolitis = Badly breathing booger babies
    • Upper respiratory infection caused by virus
    • Signs of severe illness requiring admission
      • Grunting
      • Nasal flaring
      • Retractions
      • Hypoxemia
      • Unable to tolerate PO
    • Treatment
      • Deep suctioning
      • Can consider albuterol trial
      • Oxygen supplementation as needed
    • Generally avoid
      • Chest X-rays
      • Steroids
      • Antibiotics
  • Asthma
    • Treatment
      • First line
        • Albuterol/ipratropium
        • Steroids
      • Additional options as needed
        • Magnesium
        • Ketamine
        • IV epinepherine
  • Croup
    • Presentation
      • Barky cough
      • Stridor
    • Treatment
      • Steroids
      • Consider racemic epinephrine
  • Pneumonia
    • Diagnosed by x-ray
    • Treat with antibiotics
  • Cystic fibrosis
    • Albuterol/ipratropium
    • Nebulized saline
    • Antibiotics

Additional Reading

How to Save a Dying Baby

When you have a critically ill child in front of you, always remember, OH SHIT, Grab the Broslow!!!

Oxygen- Apply Oxygen and Consider Airway/Respiratory Emergencies

  • Foreign body
  • Peritonsillar abscess
  • Bacterial tracheitis
  • Epiglottitis
  • Retropharyngeal Abscess
  • Bronchiolitis
  • Asthma
  • Croup
  • Pneumonia
  • Cystic Fibrosis

Hyper/Hypoglycemia- Check Blood Glucose

  • Hypoglycemia
  • DKA

Sepsis- Consider Sepsis and Serious Bacterial Infections

  • Pediatric sepsis
  • Fever <30 days of age
  • Fever 30-60 days of age
  • Fever >60 days of age

Heart- Consider Congenital Heart Abnormalities

  • Truncus arteriosis
  • Transposition of great vessels
  • Tricuspid atresia
  • Tetrology of fallot
  • Total anomalous pulmonary venous return
  • Ductal dependent lesions
  • Congestive heart failure

Inborn Errors of Metabolism/Endocrinology

  • Congenital adrenal hyperplasia

Tummy/Trauma- Consider Abdominal Processes and Non Accidental Trauma

  • Non-accidental trauma
  • Necrotizing enterocolitis
  • Volvulus
  • Toxic megacolon
  • Intussusception
  • Pyloric stenosis

And never forget… If you feel flustered… GRAB THE BROSLOW!!!

Additional Reading

Pediatrics Exam

Mnemonic: ABCDEF

Appearance

  • The ‘A’ in the pediatric assessment triangle
    • Interactive vs distant
    • Good tone vs floppy
    • Calm and happy vs inconsolable

Breathing

  • The ‘B’ in the pediatric assessment triangle
    • Signs of respiratory distress
      • Nasal flaring
      • Retractions
      • Abnormal respiratory sounds

Color/Circulation

  • The ‘C’ in the pediatric assessment triangle
  • Pink = good
  • Abnormalities
    • Pallor
    • Cyanosis
    • Mottling

Distraction

  • Almost impossible to do a good peds exam in a crying kid
    • Easiest ways to keep kids distracted
      • Let parents hold/play with them
      • Toys
      • Stethoscope
      • Funny sounds/noises

ENT

  • Many times the kids don’t localize the symptoms
  • May present with vomiting, fever, irritability, etc
  • If difficulty examining pharynx, consider triggering a gag reflex

Fully Undress

  • Look for bruising, rash, blisters
  • Signs of non-accidental trauma
  • GU exam (especially in boys, check the testes!)

Additional Reading

Pediatrics History

Always ask about pediatric patient’s ‘P-I-S-S’ status!!!

Core Function Questions (P-I-S-S Status)

  • Peeing
    • Evaluates for dehydration
      • Number of wet diapers per day?
      • Same number as usual?
  • Intake
    • Rule of 3s
      • Estimates how much milk/formula an average infant should be taking
      • 3oz of milk or formula every 3 hours
  • Sleeping
    • Is the patient sleeping MORE than usual?
    • LESS than usual?
  • Stooling
    • Normal stool
      • Changes from dark meconium to tans/yellows

Pediatric Medical History

  • Prebirth
    • Did the patient have prenatal care?
    • Any issues with the pregnancy?
    • Was mom GBS positive?
  • Peribirth
    • What gestational age was patient born at?
    • Vaginal delivery or c-section?
    • How long did baby have to stay in hospital after delivery?
  • Postbirth
    • Diagnosed medical/surgical problems
    • Immunization status

Additional Reading

Brief Resolved Unexplained Events (BRUE)

3 Categories: High Risk BRUE. Low Risk BRUE. Not a BRUE.

Step 1: Is This a BRUE?

  • Brief
    • <60 seconds
  • Resolved
    • Exam and vitals back to baseline in the ED
  • Unexplained
    • No symptoms other than event itself
  • Event
    • Concerning change in any of the following…
      • Tone
      • Color
      • Breathing
      • Mental status

Step 2: Is This Low Risk BRUE?

  • Five low risk criteria
    • Age >2 months
    • Born at >32 weeks gestational age
    • First and only episode
    • No CPR by medical providers
    • No “Red Flags”

Step 3: Do They Have Red Flags?

  • For abuse
    • History of SIDS/BRUE in sibling
    • Mental illness at home
    • Drug use at home
  • For dysrhythmia
    • Family history of sudden unexplained death
  • For infection
    • Fevers
    • Unimmunized
    • Sick contacts
    • Rash

Step 4: Examine for Non-Accidental Trauma

  • Bulging fontanelle
  • Petechia
  • Torn frenulum
  • Blood

Step 5: Place Patient Into One of Three Categories

  • NOT a BRUE
    • Treat as you normally would
  • HIGH risk BRUE
    • Admit
  • LOW risk BRUE
    • Discharge without testing
    • May consider EKG and pertussis

Additional Reading

  • Brief Resolved Unexplained Events (AAP)

Pediatric GI Complaints

Don’t forget to do a thorough GU exam!

Step 1: Write Out Your Differential Diagnosis

  • Remember 2-4-2-4
  • (2) In the upper abdomen
    • Pyloric stenosis
    • Pneumonia
  • (4) In the lower abdomen
    • Hirschsprung’s disease
    • Intussusception
    • Appendicitis
    • Hernia
  • (2) Genitourinary
    • UTI
    • Testicular/Ovarian torsion
  • (4) Generalized
    • Volvulus
    • Necrotizing enterocolitis
    • Henoch Schonlein Purpura
    • Diabetic ketoacidosis

Step 2: Do Pediatric History and Exam

  • Pediatric assessment triangle
    • Appearance
    • Breathing
    • Color
  • Birth history
    • Gestational age
    • Complications
  • Eating/drinking/peeing/pooping
  • Immunizations
  • Physical exam
    • Don’t forget GU exam!

Step 3: Five Important Tests

  • Finger stick blood glucose
  • Urinalysis
  • Chest x-ray
  • Abdominal x-ray
  • Abdominal ultrasound

Step 4: Common Treatments

  • Fever/Pain
    • Acetaminophen
  • Vomiting
    • Zofran
  • Diarrhea
    • NOTHING
  • Dehydration
    • Pedialyte

Additional Reading

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