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Pediatrics Review

Pediatrics Review . Gina Neto, MD FRCPC Pediatric Emergency Medicine. Objectives. To review Pediatric Emergency in 45 min! Review significant pediatric presentations from newborn to older children Present evidence based management of key pediatric conditions. Neonatal Jaundice.

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Pediatrics Review

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  1. Pediatrics Review Gina Neto, MD FRCPC Pediatric Emergency Medicine

  2. Objectives To review Pediatric Emergency in 45 min! Review significant pediatric presentations from newborn to older children Present evidence based management of key pediatric conditions

  3. Neonatal Jaundice • Most common medical presentation in 1st week of life • Unconjugated vs Conjugated • Physiologic jaundice • 3rd day of life •  RBC mass, Immature liver conjugation, Increased enterohepatic circulation • Poor feeding and dehydration • “Not Enough Breastfeeding Jaundice” • Increased enterohepatic circulation, Decreased bilirubin clearance

  4. Neonatal Jaundice • Breast milk jaundice • Starts Day 5-7, Well baby • May last for several weeks • ? Component in milk that inhibits conjugation • Blood destruction • Immune (Hemolysis) • ABO incompatibility, Rh Disease • Non-Immune • Blood Disorders (G6PD, Spherocytosis) • Hematoma, Polycythemia • Sepsis • Other (Gilbert, Crigler-Najjar, Hypothyroidism)

  5. Neonatal Jaundice • Conjugated hyperbilirubinemia is always pathologic • Liver Disease • Biliary obstruction (atresia, choledochal cyst) • Hepatitis • Sepsis • STORCH infection • Syphilis, Toxoplasmosis, Rubella, CMV, HSV, Hep B • Metabolic disorders • Galactosemia, Tyrosinemia

  6. Neonatal Jaundice Bilirubin Induced Encephalopathy • Basal ganglia involvement • Early • High-pitched cry, lethargy, hypotonia • Late • Hypertonia, extensor rigidity, seizures, coma, death • Long term • Athetoid cerebral palsy, deafness

  7. Neonatal Jaundice • Labs • Bilirubin – total and conjugated  STAT ! • CBC, Blood group, Direct antibody test (Coombs)     • Consider Septic Workup, Lytes, BUN, Cr, Glu, VBG • Start phototherapy immediately • Converts unconjugated bilirubin into water soluble isomers • If treatment needed: • Consider IV hydration, Keep baby warm • Catheter Urine • ~8% will have a UTI

  8. Neonatal Jaundice Remember to also plot on Exchange Transfusion Graph if in treatment range

  9. Septic Appearing Newborn Signs and symptoms Fever, hypothermia Lethargy, irritability Seizures Tachypnea, grunting Apnea Poor feeding Vomiting, diarrhea Gastric distension

  10. Septic Appearing Newborn “THE MISFITS” (Causes of Shock in the Newborn) • Trauma • Non-accidental • Heart • Duct dependent lesions • Coarctation of aorta, Hypoplastic left heart, Aortic stenosis • Arrythmias – SVT • Endocrine • Congenital Adrenal Hyperplasia • Thyrotoxicosis

  11. Septic Appearing Newborn “THE MISFITS” (Causes of Shock in the Newborn) • Metabolic - Hypoglycemia, Hyponatremia • Inborn errors of metabolism • Sepsis • Formulaerrors • Intestinal catastrophes - Volvulus, Necrotizing Enterocolitis • Toxins • Seizures

  12. Sepsis • Risk factors • Prematurity • PROM >18 hrs • fever in mother or infant at delivery • multiple births • previous sibling with GBS infection • Pathogens • Group B Strep 30% • E. coli 30-40%, Other Gram neg 15-20% • Gram pos (including Listeria monocytogenes) 10% • Viral (HSV, HZV, RSV, Coxsackie), Chlamydia

  13. Sepsis • ABC’s, Fluid Resuscitation, Glucose • “Septic work up” • CBC, Blood C&S • Cath urine R&M, C&S • LP - if stable • CXR - if resp sx's • Viral serology • Treatment • Ampicillin & • Gentamycin or Cefotaxime • If suspect herpes – Add Acyclovir

  14. Congenital Adrenal Hyperplasia • Most common is 21 hydroxylase deficiency (95%) • Aldosterone and cortisol deficiency • Excess production of testosterone • girls - ambiguous genitalia • boys - adrenal crisis/shock at ~1 week • Management: • Correct fluid and electrolyte imbalances • Low Glu, Low Na, High K • Hydrocortisone • Fludrocortisone

  15. Cardiogenic Shock • Acyanotic duct dependent lesions • Critical left heart obstruction • Poor systemic blood flow • Acidosis and shock • Hypoplastic left heart syndrome • Coarctation of the aorta • Aortic stenosis • Total anomalous pulmonary venous return

  16. PDA Closure • Increased O2 sat with first breath  contraction of ductus arteriosus • physiologic closure at ~12 hrs • anatomic closure at 2-3 wks • Duct dependent lesions • No pulmonary blood flow  cyanosis • No systemic blood flow  shock

  17. Cardiogenic Shock Acyanotic duct dependent lesions • ABC’s • Fluid resuscitation • Consider Intubation • Maintain relative hypoxia and hypercarbia • Start Prostaglandin E1 • Infusion at 0.05-0.1 g/kg/min • Complications: • Apnea in ~15%, Hypotension, Fever, Seizures • Improvement within 15-30 min

  18. Cyanotic Newborn Cyanotic heart lesions • Decreased pulmonary blood flow • Tetralogy of Fallot (TOF) • Pulmonary atresia or stenosis • Desaturated blood shunted to systemic circulation • Transposition of great vessels (TGA) • Truncus arteriosus • Tricuspid atresia • Total anomalous pulmonary venous return (TAPVR)

  19. Cyanotic Newborn • Upper airway obstruction • Choanal atresia, laryngeal web, vascular ring • Pulmonary disease • Pneumonia, pneumothorax • Diaphragmatic hernia • Persistent pulmonary hypertension • Neurologic • hemorrhage, hydrocephalus, infection, seizures • neuromuscular disorders • Polycythemia • Methemoglobinemia

  20. Cyanotic Newborn Management • ABC’s, Glucose • 100% oxygen test • Poor response to oxygen suggests cyanotic cardiac lesion • Use only diagnostically  O2 promotes closure of PDA • Maintain relative hypercarbia and hypoxia • pCO2 45-50, O2 sat <90% • Start Prostaglandin E1 • Infusion at 0.05-0.1 g/kg/min

  21. Congestive Heart Failure • Left to Right shunts • Presentation at 1 month • Decreasing pulmonary vascular resistance 1st month of life • Symptoms • Irritability, Diaphoresis • Poor feeding (early fatigue), Failure to thrive • Signs • Tachypnea, Tachycardia • Respiratory distress, Poor perfusion • Enlarged liver

  22. Congestive Heart Failure • VSD most common 25% • Other: ASD 5-10%, PDA 10% • Diagnosis • Pansystolic Murmur, Hyperactive precordium • ECG – LVH • CXR – cardiomegaly, vascular redistribution • Management • ABC’s, Glucose • Furosemide • CPAP

  23. Congenital Heart Disease - Age of presentation

  24. Volvulus • 40% present in first week, 80% present by 1 month • Malrotation • Short small bowel mesentery, ligament of Treitz poorly fixed • Twisting of the bowel around the superior mesenteric artery • Sudden onset of bilious vomiting • Acute abdomen with shock • Bowel ischemia and necrosis, GI bleeding • ABC’s, Fluid resuscitation, Glucose • Upper GI series • Emergent surgery

  25. Pyloric Stenosis • 4-6 weeks of age • Male to female 4:1, first born males • 5% of siblings and 25% if mother was affected • Symptoms of gastric outlet obstruction • Non-bilious vomiting • Emesis increases in frequency and eventually becomes projectile • Peristaltic wave, palpable mass in epigastrium “olive” • Labs – low K, low Cl, metabolic alkalosis • Ultrasound

  26. Intussusception • Usually invagination of ileum into cecum (75%) • 6 months to 3 yrs • 75% less than 2 years old • 40% present between 3-9 months old • Males to female 3:2 • 90% are idiopathic • Post viral illness – hypertrophy of Peyer patches • Pathologic causes • Meckel diverticulum, polyps, hematoma (Henoch-Schonlein Purpura), lymphoma/leukemia, cystic fibrosis

  27. Intussusception • Classic triad present in 10-30% • Intermittent, crampy abdominalpain • Vomiting • “Currant jelly" stools • Late sign, Intestinal edema and mucosal bleeding • Lethargy in 25% • Ultrasound (Sens 97-100%, Spec 88-100%) • AXR (Sens 45%, Spec 21%) • Lack of air in RLQ, obstruction • Target sign, Crescent sign

  28. Intussusception • Target sign

  29. Intussusception • Crescent Sign

  30. Intussusception • Air Contrast Enema • Success rate 95% • Bowel perforation in 1-3% • Recurrence rate 10-15% • 50% within first 24 hrs • Other 50% within 10 mos

  31. Henoch-Schonlein Purpura • IGA mediated vasculitis • 2-11 yrs • Rash 100% • Palpable petechiae/purpura, can be urticarial • Arthritis 70% • Ankles > knees >wrists > elbows • Abdominal pain 50% • Intussusception 2% • Nephritis 40% (ESRD in ~1%)

  32. Henoch-Schonlein Purpura • Investigations • CBC, PT PTT, Lytes, BUN, CR; Urinalysis • Prot, Alb, Immunoglobulins • Strep testing – Throat swab, ASOT • Weekly U/A and BP checks until symptoms resolved then monthly for 6 months • Treatment • NSAID’s for pain relief • Consider steroids for abdominal, testicular, CNS involvement • Not effective for renal complications • Nephrology consult if hypertension, nephrotic sx’s

  33. Kawasaki Disease • Usually < 4 yrs old • peak 1-2 yrs • Fever for > 5 days and 4 of: • Bilateral non-purulent conjunctivitis • Rash • Changes of peripheral extremities • Initial stage: reddened palms and soles • Convalescent stage: desquamation of fingertips and toes • Changes of lips and oral cavity • Cervical lymphadenopathy ( >1.5 cm)

  34. Kawasaki Disease • Subacute phase - Days 11-21 • Desquamation of extremities • Arthritis • Convalescent phase - > Day 21 • If untreated ~ 25% coronary artery aneurysms • Other manifestations: • Uveitis, Pericarditis, Myocarditis • Hepatitis, Gallbladder hydrops • Aseptic meningitis

  35. Kawasaki Disease Incomplete (Atypical) • Fever >5 d with 2-3 criteria AAP Kawasaki statement Newburger et al. Pediatrics, 2004

  36. Kawasaki Disease Supplemental Lab Criteria ESR >40 CRP >3 WBC > 15 000/mm Anemia Platelets after 7 days > 450 Elevation of ALT Albumin < 3 Urine >10 WBC/hpf

  37. Kawasaki Disease Treatment • IV Immunoglobulin (2 g/kg) • Reduces coronary aneurysms to 3% if given within 10 days of onset of illness • Defervescence with 48 hrs • ASA • During acute phase high dose (80-100 mg/kg/day) then low dose (3-5 mg/kg/day) for 6-8 weeks • Stop if normal ECHO

  38. Fever • Fever in most children is from self-limited viral illness • ~1% have serious illness • < 1 month have highest rate of SBI (serious bacterial illness) • SBI in ~ 12% • Bacteremia - 2%, Meningitis - 1%, UTI - 10% • < 2 weeks - SBI in ~30%

  39. Fever 1-3 months • Overall Rate of Infection is ~8% • Bacteremia 2% • Meningitis 0.8% • UTI 5% • Low Risk Infant Rate of Infection is 1% • Bacteremia 0.5% • Meningitis <0.1%

  40. Fever Low Risk Criteria for Febrile Infants 1-3 mos • Previously healthy • Born at term (> 37 weeks) • No hyperbilirubinemia, No hospitalizations • No chronic or underlying diseases • No focal bacterial infection (except otitis media) • Laboratory parameters: • WBC count 5-15/mm3 • Urinalysis WBC count < 5/hpf • Stool WBC count < 5/hpf (if infant has diarrhea)

  41. 3-36 months • UTI in 5% • Highest risk in girls, uncircumcised boys • Bacteremia < 0.5% • S.pneumoniae, N.meningitidis, Gram negatives • Before HIB and Pneumococcal vaccine bacteremia rate 5% • S.pneumoniae 75%, H.flu 20%, N.meningitidis 1% • Pneumonia • Occult pneumonia can occur with no resp sxs • CXR if persistent fever

  42. Periorbital Cellulitis • Focus of infection is the skin • Conjunctivitis • Dacrocystitis • Skin lesion – Bite, Laceration, Chicken Pox • Treat as any skin infection – IV or PO depending on severity • Does not become an orbital cellulitis • Insect bites can be very swollen • Itchy, doughy, non-tender

  43. Orbital Cellulitis • Sinus infection – usually ethmoid • Through thin ethmoid bone (lamina papyracea) into orbit • Inside orbital septum (limited by periosteum of frontal bone) • Unwell, fever, eye pain • Limitation of ocular movements, proptosis late • Admit • IV antibiotics (Ceftriaxone and Clinda) • Monitor vision, EOM regularly

  44. Diabetic Ketoacidosis • pH<7.30 and/or HCO3<15 mmol/L • Ketonuria • Symptoms • Polyuria/Polydipsia, Wt loss • Abdominal pain, Fatigue • Signs • Kussmaul respirations • Ketotic breath • “Look dry”; usually mild-mod dehydration • CNS changes – headache, confusion, irritability, lethargy

  45. Diabetic Ketoacidosis • Cerebral edema in 0.7-3.0% • Patient risk factors • Age < 5 years • New onset DM, Longer duration of Sx • High initial urea, Low initial pC02, pH < 7.1 • Treatment risk factors • Rapid administration of hypotonic fluids • IV bolus of insulin • Early insulin infusion • Failure of serum Na to rise during treatment • Use of NaHCO3

  46. Diabetic Ketoacidosis • Diabetic ketoacidosis in children and adolescents with diabetes. Wolfsdorf J et al. Pediatric Diabetes 2009

  47. Diabetic Ketoacidosis • Fluid bolus only if hypotensive • 10 ml/kg over 30-60 min • Calculate fluids based on 10% dehydration replaced over 48 hrs • NS + 40 meq KCl/L (if voiding and K<5)

  48. Diabetic Ketoacidosis • Start Insulin infusion 1-2 hrs after IV fluids • Insulin 0.1 units/kg/hr • No Insulin bolus • No Bicarbonate • Monitor hourly VS, neurovitals, glucose • Gas, lytes, osm, urine ketones q2-4h

  49. Diabetic Ketoacidosis Cerebral Edema • For headache alone • Raise head of the bed to 30o • Decrease fluids to maintenance • Consider treatment of sxs don’t improve • If GCS < 10 • 3% Saline 5 cc/kg over 20 min OR • Mannitol 0.5 gm/kg iv over 20 min • Prepare for intubation • STAT CT scan

  50. Asthma Decide treatment based on severity Pediatric Respiratory Assessment Measure (PRAM)

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