22. Pediatrics



“The child is the father of a man.”



22.1 Few Important Points in Pediatrics




  • Parents bring in a child with concern for increased crying/irritability, decreased feeding, and playing:




  • If persistent-something is wrong (pathologic).



  • If transient (e.g., child gets fussy and irritable for 1 hour and later plays well), it is most likely physiologic. Reassure the parent.




  • Examination of fontanels:

















Full


Normal


Bulging


Increased intracranial pressure (ICP). NSIM is cranial imaging.


Sunken


Dehydration. NSIM is intravenous (IV) fluids.




  • Pay attention to child’s age in the exam question (very important clue).



  • Sepsis in neonates can present with hypothermia (≤ 36 °C) and/or jaundice. In adults, jaundice as a presentation of sepsis is uncommon.



  • Heart rate (HR) and respiratory rate (RR): Resting HR and RR of newborns can be as high as 190 and 60, respectively.



    1 Just for your reference (no need to memorize)

    Resting HR and RR decrease as children get older. Be careful in interpreting tachycardia or tachypnea as a sign of sepsis, dehydration, or respiratory distress in newborns and children. Look for other danger signs.



22.2 Newborn Assessment


Immediately after delivery, the first step is to calculate the APGAR score. Calculate it again 5 minutes after delivery.









































APGAR Score

2


(Healthy baby score)

1

0

Appearance


All pink

Trunk is pink, but hands and feet are blue or pale

No part of body is pink (baby is blue and pale)


Pulse (beats per minute)


≥ 100

< 100

0


Grimace


Grimaces, coughs, and cries

Only grimaces, or weak grimace

0


Activity


Active

Some activity

Limp (zero movement)


Respiration


Regular

Irregular

0





















APGAR score

Management

8-10

No resuscitation required


4-7

May require additional resuscitative measures


0-3

Immediate resuscitation


Fontanels are space between the bones of the skull in an infant or fetus , where ossification is not complete and the sutures are not fully formed.





MRS

Note: Normal newborns typically get the score of 8-9. Nobody is a perfect 10.



22.3 Neonatal Resuscitation







aRemember the exact sequence of initial steps of neonatal resuscitation.


bHR < 100/min is an indicator of decreased cardiac output in neonates.


cIt is a great IV access in neonates.


dSee next page for differential Diagnosis of Respiratory Distress in a Newborn (nasal flaring, grunting, tachypnea, and hypoxemia).



22.3.1 Routine Care in All Newborns (Within the First Few Hours of Birth)




  • Topical antibiotic to the eyes (e.g., erythromycin or silver nitrate solution) to prevent gonococcal or chlamydial conjunctivitis.



  • IM vitamin K—to prevent bleeding.



  • Screening for hypothyroidism and other congenital conditions.



  • Consider Hep B vaccination. Infant of mother with positive HBsAg (Hep B virus surface antigen) should also receive Hep B immunoglobulin.



MRS

MRS-1Newborn with HR of <60/min is treated in the same manner as asystole in adults.


Note: Normal respiratory rate is 30-60/min in neonates.



Clinical Case Scenarios

A newborn baby is being assessed after a complicated delivery. She has a heart rate of 90 and her trunk is pink. The baby is coughing and has some activity. Her respirations are irregular and labored.




  1. What is her APGAR score?



  2. What is the immediate NSIM?




  1. Airway (position the baby and clear secretions)



  2. Stimulate the baby



  3. Dry and warm the baby (put infant under a radiant warmer)



22.3.2 Differential Diagnosis of Respiratory Distress in a Newborn (Nasal Flaring, Grunting, Tachypnea, and Hypoxemia)













Abbreviation: CXR, chest X-ray.



22.4 Birth-Related Injuries















22.5 Pathologic Conditions More Commonly Seen in Preterm (Born before 37 Weeks of Gestation) and Low-Birth-Weight Infants (< 3.3 lbs or < 1,500 g)










































Condition

Additional information

Intraventricular hemorrhage




  • Occurs due to immature autoregulation and increased capillary fragility.



  • Presentation: Signs of increased intracranial pressure (bulging fontanels, seizures, bradycardia, etc.).



  • It is the MC complication in very low birth-weight infants.



  • Rx: Mostly supportive. Infants with rapidly progressive hydrocephalus or signs of increased ICP will require neurosurgical intervention.


ARDS—aka hyaline membrane disease of newborn




  • Occurs in premature infants due to decreased lung-surfactant production.



  • Presentation: Acute onset of respiratory distress within minutes to hours of birth.



  • Rx: Mostly supportive. In severe cases, give surfactant therapy.


Bronchopulmonary dysplasia




  • Late sequelae of using supplemental oxygen for > 1 month (oxygen toxicity), lung infection, and/or mechanical ventilation in neonates.



  • Pathophysiology: Disruption of lung development with abnormal pulmonary vasculature and large alveoli (uniformly dilated acini with thin septa are seen). Severe disease may lead to necrotizing bronchiolitis and scarring.



  • Presentation: Persistent requirement of supplemental oxygen for > 28 days after birth.



  • Rx: Mostly supportive.


Retinopathy of prematurity




  • Another late sequela of using supplemental oxygen.



  • Pathophysiology: Occurs due to disorganized retinal vascularization, which may lead to scarring, retinal detachment, and blindness, if not treated.



  • Rx: Treat significant disease with laser photocoagulation and intravitreal injection of anti-VEGF (anti-vascular endothelial growth factor) agents (e.g., ranibizumab).


Patent ductus arteriosus


• Normally, rise in blood oxygen levels after birth signals ductus closure. In preterm or low-birth-weight infants, there is an increased risk of hypoxia, resulting in increased risk of this condition.


Necrotizing enterocolitis




  • Risk factor: Prematurity and formula feeding.



  • Pathophysiology: Preterm babies do not have fully developed digestive system, resulting in increased bacterial fermentation and risk of bowel-wall injury.



  • Discussed further in pediatric Gastroenterology section.


Apnea of prematurity




  • Due to immature neurorespiratory system.



  • Presentation: Apneic episodes (baby stops breathing for > 20 seconds and is associated with hypoxemia).



  • Rx: Supportive care, CPAP and methylxanthine (e.g., caffeine or theophylline).


Bile-acid deficiency diarrhea




  • Preterm or low-birth-weight infants have a low pool of bile acids.



  • Presentation: Malabsorption syndrome (poor weight gain and diarrhea).



  • Rx: Dietary modification with a change to medium-chain-triglyceride feeds can improve this, as these do not require bile acid for absorption.


Anemia of prematurity




  • Pathophysiology: Due to shortened RBC life span and decreased RBC production.



  • Lab values: Normocytic anemia with low reticulocyte count and low erythropoietin level.



  • Rx: Supportive.


Anemia of iron deficiency


Prevention: All preterm infants who are exclusively breastfed should be on iron supplementation till 1 year of age.


Preterm and small for gestational age infants also have increased risk of the following conditions:




  • Perinatal asphyxia Meconium aspiration



  • Hypothermia



  • Hypoglycemia



  • Hypocalcemia



  • Polycythemia Jaundice.


In preterm infants (<34 weeks gestation age), antenatal corticosteroid therapy has been shown to reduce the incidence of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, and neonatal mortality by approximately 50 percent.



22.6 Infant Feeding

























Human milk vs. formula feeds




  • Human milk has more whey protein than formula feeds. Whey improves gastric emptying and is absorbed better.



  • Human milk has significant immunoglobulin A (IgA) content which improves gut immunity of the baby.



  • Human milk has less vitamin D. Consider vitamin D supplementation, beginning the first few weeks of life, in infants who are exclusively breastfed.a


Formula feeds




  • A common cause of failure to thrive in infants is improper mixing of formula (e.g., mixing with too much water).



  • Usually contains supplemental vitamin D.


Cow milk




  • It is usually fortified with vitamin D.



  • Exclusive cow milk feeding is associated with iron deficiency.


Goat milk


• It is low in vitamin D and folic acid.

aRecent studies show that maternal supplementation of vitamin D in recommended dosages will obviate the need for infant supplementation.



22.7 Normal Variants in Newborns and Children (!)





Caution

(!) These are commonly used as red herrings in board questions.



MRS

< 7% weight loss within the first 7 days of life is normal.



22.8 Sudden Infant Death Syndrome (SIDS)

2SIDS is the MCC of death in infants.


Background: Unexplained sudden death of an infant (i.e., < 1-year-old). Postmortem exam may reveal unexplained intrathoracic petechiae or mild pulmonary edema.


Risk factors: The most important risk factor is prone sleeping (sleeping on stomach). Other risk factors include siblings of infants who died from SIDS, prematurity, low birth weight, and exposure to cigarette smoke.


Best method for prevention: Sleeping in supine position (placing the infant on the back).



22.9 Primitive Reflexes in Infants







MRS

SMRPA: She Makes Robots Play Arrows for 6 months. The last of these reflexes generally disappear by 6 months.



22.10 Developmental Milestones


The MRS in this table might sound a little too stretched out, but give it a try and see if it helps remembering this high-yield topic. If not create your own.
























































































Skills

Age

Motor

Language

Social

MRS ☺

2 months




  • When in prone position can lift head to 45 degrees



  • Tracks to midline

• Coos


  • Looks for familiar objects and people



  • Social smile

4 months (3-5 months)




  • Can lift head to 90 degrees



  • Can roll from front to back and back to front



  • Can sit when trunk is supported



  • Tracks past midline


  • Turns to sound of voice



  • Laughs

• Can mimic some facial expressions


  • You must put your hand for support to help the baby sit. For = four = “4 months”



  • Front rolls = front = four = rolls at 4 months of age



  • Comedy is “FOR” laughs. FOR = four


6-8 months




  • Can sit momentarily without support



  • Can transfer objects from one hand to other


  • Responds to name



  • Babbles

• Can become anxious when strangers are present


  • “6” looks like a picture of a baby sitting with its back arched.



  • “666”—baby recognizes the number of the beast = stranger anxiety in 6 months. Also recognizes its own name.


10 months




  • Can pull to stand and walk by holding/ supporting



  • Can crawl (the mobile stage where babyproofing the house is needed)



  • Uses three fingers for pincer grasp

• Can say mama and dada

• Can wave goodbye

• “A decade of supporting walkathon.” Decade = 10: support walks.


12 months (1 year)




  • Can walk first few steps alone



  • Can throw ball



  • Can do two-finger pincer grasp

• Responds to simple spoken requests, makes sounds with changes in tone (sounds more like speech), says “mama” and “dada” and tries to say words.


  • Imitates



  • Separation anxiety



  • Can come to you when called


  • 1 year:



  • One can walk alone for more than one steps for the first time



  • One can do proper finger grasp



  • One can throw



  • One can speak more than one word besides dada and mama



  • One becomes anxious of leaving one’s parent



  • One can imitate


14-15 months




  • Can walk backwards



  • Can build two-block towers

• Can understand simple commands without gesture

• Tries to get attention from adults

18 months




  • Can run and kick ball



  • Can feed themselves



  • Can build 2-4-block towers


  • Points to body parts



  • Can speak 10-25 words

• Can play alone


(pretend play)


  • 18 is the age of emancipation of minors. Now think of it like this— they can run away from home, eat by themselves, and play by themselves. 18-month-old baby does the same.



  • 18 months can speak ≈ 18 words.


24 months


= 2 years


  • Can walk up and down the stairs



  • Can jump and climb



  • Can build six-block towers


  • Can form two-word combinations



  • Can speak approximately 200 words



  • Half of speech is understandable by strangers

• Engages in parallel play


  • Can walk two directions in stairs



  • Can speak two-word combinations



  • Can verbalize 200 words



  • Every second sentence is understandable—half of speech is understandable



  • 2 = 1 +1 = parallel play


3 years




  • Can ride a tricycle



  • Can draw or copy a circle


  • Three-word sentence



  • More than half of speech is understandable by strangers

• Knows age and gender


  • 3 years = 3-word sentence



  • 3 years = TRIcycle; cycle can be associated with circle = can draw a circle



  • (This is the MRS method of associating one fact with another)


4 years




  • Can hop on one foot



  • Can draw/copy a square



  • Can draw a man’s picture with 4 parts


  • Four-word sentence



  • Can identify colors

• Co-operative play (can play team sports like soccer)


  • Square has 4 equal sides



  • 4 years old = 4-word sentences



  • Can play in a team of 4


5 years




  • Can draw a triangle



  • Can walk backwards



  • Can skip


  • Five-word sentences



  • Counts till 10

• Starts having friends


  • Drawing a triangle is more complex than drawing a circle or a square.



  • Five guys are friends who started a hamburger business.



  • Five = 5-word sentences



Clinical Case Scenarios

3. A mother brings in her 13-month child for a routine check-up. The baby can say simple words like “mama” and “ta-ta.” She can walk alone a few steps and is able to throw a ball. What is the likely developmental assessment in this child?




  1. Language delay, gross normal



  2. Language normal, gross delay



  3. Language delay, gross delay



  4. Normal development


4. Delia can draw a circle, Maya can draw a square, and Akbar can draw a triangle. How old are they?



22.11 Pediatric Vaccination





























































































































Vaccine

Birth

2 months

4 months

6 months

12 months

15 months

18 months

—

4-6 years

Hep B


First dosea


Second dose (1-2 months)

Third dose

DTaPb


First dose

Second dose

Third dose

Booster dose

Booster dose


RV (rotavirus)


First dose

Second dose

Third dosec


HiB (Haemophilus influenzae B)


First dose

Second dose

Third dosed


Booster dose

IPV (inactivated polio vaccine)


First dose

Second dose

Third dose

Booster dose


PCV-13


First dose

Second dose

Third dose

Booster dose

Chicken pox (varicella zoster)


First dose

Booster dose


Hep A virus


First dose (given between 1 and 2 years of age) e


MMR


First dose

Booster dose

aIn preterm babies, age count starts from the day of birth. Give vaccination as above, starting from birth. The only exception is to hold Hep B vaccine if baby’s weight is < 2 kg or <4.4 lbs.


bDTaP is stronger than TDaP. DTaP is used for primary vaccination in children < 10 years of age, whereas TDaP is given as booster dose in adolescents and adults.


cThere are two types of vaccines available for rotavirus. One type needs only two doses; the other one, three doses.


dThere are two types of commercial vaccines available for Haemophilus. The second type does not need re-dosing at 6 months.


eTwo doses are needed for lasting protection. The second dose can be given 6 to 18 months after the first dose.


Additional vaccination: Influenza is given yearly after 6 months of age. Children 6 months to 8 years of age who are receiving flu vaccination for the first time in their life, require 2 doses of vaccine in that single season to optimize response.



MRS

☺ Hep B = B at birth.


☺ DR HIP is given at 2, 4, and 6 months-DTaP, RV, HiB, IPV, PCV.


☺ At 12-15 months: ☺ 1-year old CHAMP: Chicken pox, HiB, A = Hep A virus, MMR, PCV-13.


☺ Whichever alphabets of DR HIP are included in CHAMP are booster doses. That means HP are the booster doses given at 12-15 months.


☺ 4-6 years (5 ± 1): ☺ MeDIC is given at 5 years = MEasles-mumps-rubella, DTaP, IPV, Chicken pox. MeDIC has 5 letters.


☺ Live vaccines are LIVE CRIME = CRIME = Chicken pox, Rotavirus, Influenza-live-attenuated type, MMR, and lastly for E (just a random fact that you might not need) Epidemic typhus.



MRS



  • vs. TDaP.



  • D is given to Diapers.



  • T is for Ten years and older



  • D is given Double boosters : i.e., 2 booster doses are given after 1st round of vaccination.



22.11.1 Contraindications to Vaccines




















Pertussis-containing vaccines


Encephalopathy (e.g., coma, decreased level of consciousness, prolonged seizures) within days of vaccine administration not attributable to another identifiable cause


Any live vaccine


Severe immunodeficiency (e.g., HIV with low CD4 count < 200/ mm



3Presence of right-to-left shunt may lead to paradoxical emboli, i.e., DVT leading to arterial emboli (e.g., CCS: symptoms of DVT with a new stroke or acute claudication).

, severe combined immunodeficiency)


Rotavirus


Hx of intussusception


Any vaccine


Severe allergic reaction (e.g., anaphylaxis)




  • Vaccinations are life-saving. Outside of the information mentioned above, it might be safe to say that there are NO other contraindications.



  • Per CDC, even development of Guillain-Barre syndrome after vaccination is not a contraindication but requires caution in the future.



Clinical Case Scenarios

5. Parents refusing vaccination for their child. What is the NSIM?


6. A pediatric patient is here for vaccination. His mother reports ongoing mild illness (e.g., mild cold). What is the NSIM?



22.12 Pediatric Cardiology















Physiologic Murmur

The only murmur that might be physiologic is the grade I or II ejection mid- systolic murmur that decreases with preload reduction (e.g., standing, Valsalva). – NSIM in a well-looking child is reassurance, after ruling out anemia.

Pathologic murmur


Ejection systolic murmur more than grade II, and all holosystolic or diastolic murmurs are likely pathologic.


– NSIM is echocardiography.



22.12.1 Congenital Heart Disease



MRS

ASD in ADults




















Acyanotic heart defects

Cyanotic heart defects



  • VSD (ventricular septal defect)—MC heart defect seen in children



  • ASD (atrial septal defect)—MC congenital heart defect encountered in adults



  • PDA (patent ductus arteriosus)


  • Tetralogy of Fallot (MC cyanotic congenital heart defect)



  • Transposition of great vessels (most common cyanotic congenital heart disease that presents in a neonate)



  • Tricuspid valve atresia



  • Truncus arteriosus



  • Tiny left ventricle (hypoplastic left ventricle)



  • Total anomalous pulmonary vein return, with obstruction


(6 T of cyanotic heart disease)


As left-sided heart pressures are higher than the right-sided ones, there is only left-to-right shunt; hence, no mixing of oxygenated and deoxygenated blood in the left side of heart.

In these conditions, right-to-left shunt leads to mixing of deoxygenated and oxygenated blood in the “left side of heart” leading to cyanosis.




  • NSIDx is echocardiography.



  • Most accurate test is cardiac catheterization.



22.12.2 Acyanotic Congenital Heart Defects (VSD, ASD, PDA)


These conditions can have the following common features:




  • Small defects can be asymptomatic and sometimes are detected incidentally in adults.



  • Larger defects can present with heart failure (increased RR, dyspnea, and feeding difficulty), which may manifest at birth (very large defects) or few months later (moderate-sized defects).



  • Development of right-to-left shunt can occur later in life, due to development of the following pathology: increased pulmonary artery blood flow pulmonary hypertension (loud pulmonic S2) increased right heart pressure RV (right ventricle) hypertrophy. Pressure generated by hypertrophied right heart + increased pulmonary pressure leads to right-sided pressure becoming greater than on the left side, resulting in right-to-left shunt and development of cyanosis. This is called Eisenmenger syndrome and it usually develops later.3


Specific features:


























Type of acyanotic heart disease

Exam finding


(all may have loud pulmonic S2)

Treatment

VSD


• Harsh holosystolic murmur over left lower sternal border


  • For small and asymptomatic defect, do expectant management (may spontaneously close by 1-2 years of age).



  • For symptomatic or large defects, recommend surgical repair.


ASD


• Fixed wide splitting of S2


  • Most close spontaneously



  • For symptomatic patients or who have significant left-to-right shunt, do surgical repair.


PDA




  • Loud, machinery-like continuous murmur (the ductus never closes as it is not a valve, hence continuous murmur is heard throughout systole and diastole)



  • Wide pulse pressure and bounding pulse


  • In premature infants, first try COX-2 inhibition with ibuprofen or indomethacin.



  • In preterm infants who fail COX-2 inhibition and term infants, who have audible murmurs, percutaneous PDA closure or surgery is recommended.


Few points on PDA




  • Present at birth in all neonates. After birth, rise in neonatal blood oxygen levels signals ductus closure.



  • Neonatal hypoxemia increases risk of PDA. Premature babies have increased risk of hypoxemia, hence premature infants have increased risk of PDA.



  • It is also more common in females than males.



  • PDA is associated with maternal rubella infection.



  • When Eisenmenger syndrome develops in PDA, postductal circulation starts receiving mixed blood, which results in differential cyanosis (lower body is cyanotic, toes develop clubbing, whereas upper body remains unaffected).



    4 Diff erential cyanosis with Eisenmenger syndrome due to PDA



Reminder: Heart sounds














S1


Closure of mitral and tricuspid valve causes blood flow disruption leading to vibration or sound heard as S1.


S2


Due to closure of aortic and pulmonic valves


• Physiologic splitting of S2 occurs during respiration.



MRS

SAD to see it split in two. Split in two = S2 is split. SAD = ASD.



MRS

Ruby wears PADS = congenital Rubella infection is associated with PDA.


Ruby is a female, so PDA is more common in females.


• Prostaglandins keep the PDA Patent. Ibuprofen, by decreasing prostaglandin production, promotes closure of PDA.




Differential cyanosis can also occur with preductal coarctation and coexistent PDA. In this case the differential cyanosis is early-onset as it does not require development of Eisenmenger syndrome (area distal to coarctation may have lower pressures than pulmonary circulation leading to right-to-left shunt).



22.12.3 Cyanotic Congenital Heart Defects





MRS

Fallot has the right point of view.



MRS

Fallot has the right boots.






































Condition

Presentation/exam

Cardiomegaly and mediastinal findings in X-ray

Pulmonary vascular markingsa


Tiny left ventricle (hypoplastic left ventricle)




  • Severe cyanosis in the first week of birth



  • Single S2 (as there is no aortic component)


  • Right-sided heart enlargement



  • As opposed to TAPV, there is no large shadow above the heart.

May show increased pulmonary venous congestion


Transposition of great vessels Aorta originates from the right ventricle and pulmonary artery from the left ventricle.


Blood mixing occurs with VSD, ASD, and/or PDA




  • It is the most common cyanotic heart disease that presents in a neonate.



  • Common in diabetic mothers


  • Big aorta is abnormally located anteriorly to pulmonary artery, hence the aortic component easily dwarfs the pulmonic component of S2, resulting in single S2 sound.



  • Presence of VSD/ PDA or ASD murmur

“Egg-on-a-string” sign: egg = heart and string = narrow mediastinum

Increased pulmonary vascular markings


Truncus arteriosus


• Pulmonary artery and aorta are abnormally merged to form a big outflow tract that gets blood from both the ventricles.

Single S2—with ejection systolic murmur due to increased flow

Increased pulmonary vascular markings.


Reason: In the normal state, RV (right ventricle) has much lower pressure than LV (left ventricle). In this case both RV and LV have equal pressure, with more than usual blood flowing through RV.

aNote the conditions that have increased pulmonary vascular markings versus the ones that do not.


bTOF and TVA may have some common features. To differentiate TOF from TVA, look at the axis on EKG: there is right-axis deviation in TOF and left-axis deviation in TVA ( see next page discussion on how to determine axis in EKG).


cTo be compatible with life, most neonatal cyanotic heart diseases (e.g., transposition of great vessels, TAPV, TVA, hypoplastic left heart) require PDA or ASD (in some cases VSD) to supply systemic circulation. These conditions may become acutely symptomatic after 2-3 days, when ductus arteriosus normally closes.



5Exceptions are:


• TOF (already has a VSD), and


• Truncus arteriosus (mixing occurs in the trunk itself).

Prostaglandin infusion (PGE1) can be used to keep the PDA patent until definitive surgical correction.



MRS

I misplaced my egg today. Misplaced = transposed.



In a nutshell


Cyanosis presentation time

















Severe defect

Cyanosis at birth, e.g., TOF with pulmonary atresia (severe pulmonary valve stenosis)


Less severe defect (ductal-dependent)

2-3 days after birth, when ductus closes


Mild to moderate defects

Late-onset cyanosis


For example, cyanosis during feeding or crying


How to determine the axis?















22.12.4 Coarctation of the Aorta


Pathophysiology: Narrowing of the aorta, due to thickening of tunica media near the ductus arteriosus. It is often associated with other heart defects such as ASD, VSD, PDA, and/or bicuspid aortic valve.






To know the axis, look at the first and third lead




  • When both are up, then thumbs up for both, meaning axis is normal.



  • When only lead I is up, your left hand is up, and axis is tilted to left side = left-axis deviation. Note: when you write 1, 2, 3, 4, …, 1 is always written in the left side, and 3 is always written in the right.



  • When lead III is up, your right hand will be up = right-axis deviation.


6Preductal coarctation means location of coarctation is proximal to ductus arteriosus.


Common features:




  • Increased perfusion in the head, upper torso, and upper extremities




  • HTN in upper extremity.



  • Increased pressure in intercostal arteries, leads to pressure atrophy of posterior ribs and rib notching (it takes time to develop this, hence not seen in infants).



  • Increase risk of intracranial aneurysm and rupture.




  • Decreased perfusion below the aortic arch.



  • Low BP and decreased pulses in lower extremities.



  • Decreased renal perfusion.



  • Decreased leg perfusion (presents as claudication).


NSIDx: Transthoracic echocardiogram


Management: For significant stenosis, do surgical repair or percutaneous angioplasty.



Clinical Case Scenarios

7. A 6-month-old male baby is brought in for a routine check-up. As soon as you put the stethoscope on the baby’s chest he starts crying, breathes rapidly, and begins to turn a dusky blue color. In addition to oxygen, which of the following will rapidly alleviate these symptoms?




  1. Keep in upright position



  2. Give intramuscular epinephrine



  3. Place in lateral knee-chest position



  4. Give an infusion of PGE1 (prostaglandin)


8. You are examining a newborn male baby just after delivery. His entire trunk is blue. He has a pulse rate of 90, grimaces with some activity. His respirations are irregular with an oxygen saturation of 80%. He ends up requiring intubation. On auscultation you hear a single loud S2 and a harsh murmur in the left lower sternal border. What is the baby’s APGAR score and the likely diagnosis?




  1. APGAR 6; transposition of the great vessels



  2. APGAR 4; tetralogy of Fallot



  3. APGAR 5; tetralogy of Fallot



  4. APGAR 4; transposition of the great vessels



22.13 Differential Dx of Chronic Stridor

































Condition

Laryngomalacia

Vascular anomaly (ring or slings)

Choanal atresia

Diagnosis


Laryngoscopy


  • CT or MRI angiography and echocardiogram



  • Bronchoscopy can be done, if concerns for airway obstruction.


  • Best initial step: try to pass a catheter through the nose to posterior pharynx.



  • NSIDx—CT imaging (test of choice). Caution: do not choose rhinoscopy.


Management




  • For mild symptoms, reassurance, as it mostly resolves on its own.



  • For severe symptoms (e.g., poor weight gain, rapidly worsening symptoms), laryngoplasty can be done.

For symptomatic lesions, recommend surgical correction.

Endoscopic or surgical repair

aCaution: may get confused with Tet spells.



22.14 Pediatric Gastroenterology



22.14.1 Congenital Abdominal Wall Defects Due to Errors in Fetal Development







a Silo bag is commonly made up of silicone







a Silo bag is commonly made up of silicone







a Silo bag is commonly made up of silicone





22.14.2 Causes of Gastrointestinal Obstruction in Pediatrics













aGI obstruction before ampulla of Vater (point of entry for bile duct) does not present with bilious vomiting (e.g., congenital or acquired pyloric stenosis).


bWith increased loss of gastric acid (H+Cl–), there is metabolic alkalosis (high serum bicarbonate) with compensatory respiratory acidosis. Also look for low serum chloride.


cAll other conditions listed in the table can be differentiated from Hirschsprung disease by looking at colonic air. Hirschsprung has increased colonic air. If colonic air is absent, it is not Hirschsprung.


dUS of abdomen can be used to differentiate in between them. Images of dilated bowel loops in meconium ileus are filled with echogenic material, while the loops in atresia are fluid-filled.

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Dec 11, 2021 | Posted by in PEDIATRICS | Comments Off on 22. Pediatrics

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