Pediatric Potpourri

Barb Bancroft RN, MSN, PNP

BBancr9271@aol.com

The approach—newborn-- first 28-30 days of life

• Newborn vision is the only special sense that is not mature at birth—visual acuity for a newborn is 20/100 to 20/200

• Bladder capacity is only 15 ml (1-2 ml per hour per kg of body weight)—lots of diaper changes –6 to 8 wet diapers per day (weigh their diapers for I & O)

The approach—infant-- 30 days to first birthday

• Infant—consistency of care is essential for an infant to develop trust; attend to expressed needs immediately and consistently; observing your facial expressions and moods at one month

• Causes of depression

Mirror neurons

• Monkey see, monkey do

Learning, learning, learning…from their environment

• Synapses are forming in the newborn and infant brain at the incredible rate of 3 billion/second

• 28 week old fetus—124 million connections• Newborn—253 million• 8 months—572 million

The approach—toddler– One to 3 years old

• Toddler—autonomy; 300 words; begin to tolerate some separation from primary caregiver; temper tantrums are normal; negativism is common; enjoy rituals, consistency, learning toileting skills and locomotion; egocentricity—don’t ever ASK if you can do something…can I look in your ears? NOOOOOOO

Which ear would you like me to look in first?

• How do you look at the back of a toddler’s throat?

• Open your mouth and pant like a doggie…

• Turn them upside down if they won’t open their mouth…

Life revolves around their “head”… DON’T go to the head first

The approach—the preschooler– Three-years old to fifth birthday

• Preschooler—may talk incessantly (900 words); evolving from “me, me, me” to seeing other’s viewpoints; use magical thinking to solve problems and make sense of their environment; may deny pain or other problems through magical thinking (KENDRA)

May be dependent on security objects and items…HANDLE WITH CARE AND DO NOT LOSE!! “ my bankie, my teddie”

• Preschoolers are also very aware of surroundings; always include the child in conversations

• Don’t forget that hearing is the LAST special sense to go in patients in a coma (STACY)

• CONCRETE thinking

The approach—school-age—Early: 6 to 10Late: 10 to 12 years

• Acquisition of skills achieves a sense on competency; failure to do this may lead to a sense of inferiority

• Conscience is forming and peer group interactions are highly influential

• Concrete thinking (early)• Early—engage about schoolwork/sports/art

projects; encourage, praise efforts• Late—computer games, sports

The approach—adolescence—13 to 18 years

• Think beyond the present, are logical and use reasoning (HAHAHA…)

• Abstract thinking• Group identity is paramount and risk-taking is

common secondary to peer pressures

• The teen-age brain

The prime real estate of the brain—the frontal lobe

• The prefrontal cortex• The motor association area• The motor cortex• Broca’s area—voluntary speech and

communication• (the last 2 areas are well-developed in early

adolescence, however the prefrontal cortex and the association areas are immature in teenagers and continue to develop into the early 20s)

So, what is the prefrontal cortex?

• It’s the center for judgment, insight, reasoning, organization, future planning and problem solving, and it has extensive connections with the emotional and instinctual centers in the limbic system, especially the amygdala.

• These levels are critical for emotional learning and high-level self regulation.

• This is the pathway that is immature in the adolescent brain

An easier way to put it—the prefrontal cortex is your MOTHER

• And MOM is inhibitory---what’s the only word a MOM needs to know? NO.NO.NO.NO.NO.

• Judgment and insight• Socialization• She puts the checks and balances on behavior—

especially on the amygdala—the wild beast within (the instinctual nucleus of the brain)

• Parents, who act like parents, do this for teenagers; parents who act like teenagers, do not

The anterior cingulate gyrus of the prefrontal cortex

• Weighs options, makes decisions• Girls brains mature faster; pruning starts

earlier than boys; girls move more quickly toward maturation of all brain circuits and mature 2-3 years earlier than boys

Neuronal dropout over the first 21 years—inverse relationship to brain development

• PRUNING• # of neurons at birth ~ 4000 per mm³• # at age 21 ~ 2100 per mm³• #at age 75 ~ 1050 per mm³

While they’re pruning neurons, the pathways are continuing to mature

• In addition, the pathways continue to develop, gradually improving the precision and efficiency of normal communication—completed in the early 20s

• Especially the large bundle connecting the two hemispheres with the limbic system—the corpus callosum

• And the pathways connecting the prefrontal cortex with the limbic system

The teenage limbic system

• The limbic areas mature earlier than those involved in judgment, organization, and reasoning

• DISCONNECT BETWEEN THE TWO• This discrepancy between expressing feeling

vs. thoughtful evaluation accounts for many of the teen behaviors that dismay parents and teachers…

• “but he was such a sweet little boy…”

The Teenage Brain

• “I just don’t understand what happened…”

The biggest MISCONCEPTION: Looking like an adult means they act like an adult…

• Even though they may “look like adults” adolescents find it more difficult to:

Think before acting…

• Difficult to interrupt an action under way—ramming the back of the car in front of you…for example

• The teenager freezes and screams (the limbic system--emotions)

• The adult brakes hard and steers out of the way (the prefrontal cortex)

• Back to the prefontal lobe that underlies planning and voluntary behavior

Adolescents find it more difficult to:

• Choose between safer and riskier alternatives• Difficulty resisting peer pressure• It’s that prefrontal cortex again—they’re using

it somewhat, but it’s overtaxed…throw in peer pressure…”Aw c’mon, just once…” the stressful situation on an already taxed prefrontal lobe may give in to better judgment--

General Assessment--observation

• The most useful information is often acquired by watching the child move and play.

• Mood and behavior• Level of activity• Toddlers usually lie down when sick

School bullying

• Schoolyard bullies are at increased risk to grow up as abusive adults

• 4 x greater risk of striking or threatening an intimate partner

• (Falb K, et al. Arch Pediatr Adoles 2011)

The order of the exam is not carved in stone…

• Try to do everything you can with infants and toddlers sitting on their parent’s ankles or on their lap

• Lying the child on the examination table increases vulnerability

The order of the exam is NOT carved in stone…

• Take advantage of all opportunities• If the diaper needs changing, check the

external genitalia

• If they offer…GO for it…

If they are relaxed, check their belly…

• “Ms. Bancroft, can I ask you a question?• Have you ever….?”

Facial expressions and the cranial nerve exam…

• Frown, smile• Facial nerve (VII)

• Cross your eyes… Make a face• Raspberry• CN III (oculomotor) – eyes• Facial expression (VII)

• Stick your tongue out (XII)

Don’t go to the painful area first..

• Compare the good side with the bad side—looking at the good side first

• Good ear, bad ear• Good ankle, bad ankle

State of hydration..

• Does this infant continue to feed?• Quality of cry—tears (+ or -) grunting• Drooling in kids can lead to dehydration

quickly

DIGRESSION ON HYDRATION I KIDS:What 3 individual clinical features are the most

accurate for predicting 5% dehydration? • Abnormal capillary refill• Abnormal skin turgor• Abnormal respiratory pattern

• What conditions can lead to dehydration? Vomiting, diarrhea, diabetic ketoacidosis (DKA)

Clinical findings to estimate the degree of dehydration—mild dehydration

• Body fluid lost (mL/kg) -- < 50• Weight loss -- < 5%• State of shock--impending• General appearance—thirsty, alert, restless• Systolic blood pressure -- normal• HR -- normal• Respiration -- normal• Radial pulse – normal rate and strength

Clinical findings to estimate the degree of dehydration—mild dehydration

• Capillary refill -- < 2 seconds• Skin elasticity – retracts immediately• Anterior fontanel -- flat• Mucous membranes – normal to dry• Tears – present• Skin color -- pale

Clinical findings —moderate dehydration

• Body fluid lost (mL/kg) – 50-100 • Weight loss – 5-10%• State of shock -- compensated• General appearance – thirsty, restless or

lethargic; irritable to touch• SBP – normal (orthostatic)• HR – slight elevation (orthostatic)• Respiration – deep, may be rapid• Radial pulse – rapid and weak

Clinical findings —moderate dehydration

• Capillary refill –2-3 seconds• Skin elasticity – retracts slowly (> 3 seconds)• Anterior fontanel -- depressed• Mucous membranes – very dry• Tears – absent• Skin color -- gray

Clinical findings to estimate the degree of dehydration—severe dehydration

• Body fluid lost (mL/kg) -- >100• Weight loss -- >10%• State of shock -- uncompensated• General appearance –drowsy, limp, cold, sweaty,

older may appear apprehensive, younger may be comatose

• SBP – very low or absent• HR – very elevated• Respiration – deep and rapid (hyperpnea)• Radial pulse – feeble, rapid, may be impalpable

Clinical findings to estimate the degree of dehydration—severe dehydration

• Capillary refill -- > 3 seconds• Skin elasticity – retracts very slowly• Anterior fontanel -- sunken• Mucous membranes—very dry to cracked• Tears -- absent• Skin color -- mottled

Dehydration and urine volume/osmolarity/specific gravity

• Mild less than 2-3 mL/kg/h; 600 mOsm/L; 1.010

• Moderate (oliguric) less than 1 mL/kg/h; 800 mOsm/L; 1.25

• Severe=anuric; maximal osmolarity; maximal

Assessment of pain

Vital signs in kids• Weight (always!!! Basis for fluid replacement,

doses of medication, fluid and electrolyte balance)

• Temperature—rectal, oral, axillary, tympanic membrane

• Pulse (apical heart rate is best for young kids)• Respirations—place your hand on the infant

chest to determine RR• Blood Pressure—proper cuff size!!• Pulse oximetry

Weight …

• Best index for a healthy child is appropriate weight gain

• ALARM SIGN: Failure to gain weight is the first indication of a serious problem

• Weights are essential for determining fluid requirements and medication dosages

• Breast-fed babies gain weight more slowly• Benefits of breast feeding?• Teeth alignment• Immune system• Response to vaccines• IQ• Reduction in IgE-mediated allergies

Obesity in kids…33%

• Complications of obesity—the first generation to NOT outlive their parents at the rate we’re going

• Type 2 diabetes—50% of all kids with newly diagnosed diabetes have type 2 diabetes

Is it any wonder?

• French fries are addicting (as are illicit drugs and nicotine)

• The earlier you start…• Areas of the brain that have to do with

addiction—the nucleus accumbens and the ventral tegmentum

• Why isn’t anyone addicted to??

ALARM…rapid weight gain in girls

• RAPID weight gain in young girls or teenage girls

• Sexual abuse ?• PCOS (polycystic ovary syndrome)

Height/length

• Growth occurs in a step-wise pattern• Spurts and lulls• Vertical growth occurs during sleep when GH

is released during the late stages of SWS• Do kids have growing pains at night?• Adenoiditis, sleep apnea, and growth• How about tonsillectomies for hyperactive

kids? ADHD?

Vertical growth and Iron

• Iron is essential for growth• Iron deficiency anemia in kids usually due to dietary

deficiency OR• Consider celiac disease• (may also have a bleed somewhere, but most iron deficiency

in kids is due to a lack of adequate iron in their diet)• Ulcerative colitis causes bleeding in GI tract• Teenage girls? Menstrual blood loss…

Temperatures• Temperature-regulating mechanisms are not well

developed in infants and young children, so temperature may fluctuate as much as 3° F in one day

• Young infants do not shiver and lack adequate adipose tissue to insulate against heat loss

• Exercise, stress, crying, ambient temperature, and diurnal variations all influence body temperature

• Always document route (po, axilla, rectal, tympanic)

Temperature

• The diagnosis of fever is a rectal temperature of at least 38.0º C (100.4º F).

• For every one degree F increase in temp above normal, the basal metabolic rate increases by 10%

• Increased BMR = increased insensible water loss• SKIN: proportionally larger body surface area in kids

leads to greater amounts of body fluid loss and less temperature regulation

• Dehydration occurs much sooner in kids with fever• Drooling kids

Temperatures

• Rectal temps for mouth breathers, infants and toddlers (0.9º F or 0.5º C higher than p.o.)

• Not a core temp• Axillary temps most difficult to interpret but if

necessary add 1º C or 1.8º F• Tympanic membrane temps are highly

variable and therefore can be inaccurate (otitis, screaming kids, ear variation)

“I have a sore throat and I can’t swallow…”

• Group A Beta Hemolytic Strep (peritonsilar abscesses)

• 60% of 5-15 year olds with exudative pharyngitis and fever above 101.8º, anterior cervical nodes, NO cough, coryza, hoarseness

• PCN x 10 days• Prednisone to reduce the inflammation

More strep notes• 40% of kids with sore throats have GABHS• 10% of adults and teenagers• Rapid Ag test 80% accurate• 10% of EBV will be + on rapid Ag test• #1 cause of recurrent strep is non-compliance; #2

cause is starting Rx too early—wait 48-72 hours unless really sick or M13 or M18 strains; #3 cause is retreating with same AB after failure of 1st Tx; #4 tooth brushes and dental devices re-infecting

Guidelines for Pre- and Peritonsillectomy decisions

• Recurrent pharyngitis—some benefits for children with > 7 in past year; 5 per year in past 2 years; 3 infections per year for past 3 years (documented w/ fever, cervical adenopathy, tonsillar exudate, positive ASO titers

• Tonsillectomy for sleep-disordered breathing—might benefit from tonsillectomy, particularly children with growth retardation, enuresis, poor school performance or behavioral problems, or tonsillar hypertrophy on physical exam

• Baugh RF et al. Clinical practice guideline: tonsillectomy in childrenn. Otolaryngol Head Neck Surg 2010 Dec 31;144:S1.

Fever

• Children with temps over 40º C or 104º F• Only 1 in 4 have a bacterial infection• Moral of the story—all high fevers are NOT associated with

bacterial infections• Acute pyelonephritis (could follow an untreated strep throat

—APSGN0• Fever, nausea, vomiting, back pain (CVA tenderness)--girls

The treatment of fever

• 50% of Primary Care Practitioner’s alternate acetaminophen with Ibuprofen to reduce fever

• This is NOT condoned by the American Academy of Pediatrics; the most common cause of overdose deaths in the US is acetaminophen, owing to its widespread availability and frequency of use in accidental and suicidal intoxications.

• Use one or the other• Acetaminophen is preferable for any viral illness

Fever

• Aspirin can be used with Kawasaki’s disease and Juvenile Rheumatoid Arthritis

• Aspirin should NOT be given to a child with a viral syndrome

• Reye’s syndrome (rare today) due to parents using acetaminophen or ibuprofen for fever in kids with infections

• If it looks like Reye’s syndrome (liver dysfunction and brain dysfunction) and there is NO history of aspirin ingestion—consider another diagnosis

Fever

• Factitious fever—uncommon in kids unless the caretaker is causing the fever (Munchausen’s by proxy)—single spikes of temperature cannot be documented by the HCW and only occur when the caretaker is present (distant spouse, M.D. shopping, knowledge of health care, history of sibling death such as SIDS)

How many infections are too many infections in kids?

• Consider age: in an infant, 3-4 infections in 6 months is too many

• During the second year of life, toddlers experience an average of 8 respiratory infections

• Double that number if they are in day care• After age 2, 3-4 infections per year; should

gradually decrease until they enter school

Hypothermia and infections

• Is a fever good for you?• Immune system mounts an response to boost the

WBC function• Also fever inhibits the ability of bacteria to use

iron (no iron? No growth)• But…hypothermia is an ALARM sign in a child

with an infection (sepsis)• Salmonella sepsis• NO REPTILES FOR KIDS UNDER 6

Simple febrile seizures• Common—observed in 2-5% of children • DEFINITION: a seizure accompanied by fever, but not central

nervous system infection or electrolyte imbalance; simple febrile seizures are primary generalized seizures that last for less than 15 minutes and do not recur within 24 hours

• Usually observed with viral infections of the upper respiratory or GI tract (usually occurs within the first 24 hours of the illness); after a vaccination (6x greater on the day of DPT up to 72 h after (6-9 per 100,000); 8-14 days after MMR vaccine 25-34/100,000)

Simple febrile seizures• Most common between the ages of 18 months to 3 years range is 6 months to 60 months)• Family history is common; M > F (pathway maturity)• Treatment? Rectal diazepam if needed…most of the kids have

finished seizing by the time they arrive at the ER• ALARM: COMPLEX febrile seizures: focal, lasting longer than

15 minutes or recurrence within 24 hours; potential long-term complications with complex although the risk is low; developing subsequent seizures WITHOUT FEVER may cause impaired cognition long-term

Inquiring minds want to know…what is the risk of developing a seizure disorder after a simple febrile

seizure?• In otherwise normal children, the risk of developing a

seizure disorder is 2% after a simple febrile seizure• HOWEVER: if any of the following is present… 1) close family history of nonfebrile seizures 2) prior neurologic or developmental abnormalities 3) atypical or complex seizures occurred1 risk factor? 3% All three? 5 to 10%

(Waruiru C, Appleton R: Febrile seizures: an update. Arch Dis Child 2004; 89:751-756.

To LP or not to LP?• LP should be performed only in a child with a seizure, fever and signs of

meningitis• LP is an option in any child aged 6 to 12 months with a simple febrile

seizure if immunization status is unknown or insufficient for H. flu type b or strep pneumoniae

• LP is an option for a child with a simple febrile seizure who has received antibiotics

• An EEG should not be performed in an otherwise neurologically healthy child with a simple febrile seizure

• Serum electrolytes, calcium, phosphorus, magnesium, blood glucose, and a CBC should not be performed routinely to identify the cause of a simple febrile seizure

• Subcommittee on Febrile Seizures. Clinical Practice Guideline—Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics 2011 Feb;127:389)

Febrile seizures and meningitis• Seizures occur in 30% of patients with meningitis; kids who

have seizures within the first 48-72 hours of illness generally have a better prognosis are and less likely to require long-term anticonvulsant therapy than those that occur later in the course of the disease

• Focal seizures are more likely to occur in this group with localized infection or with subdural effusions

• Generalized seizures are due to diffuse irritation of cerebral tissue, diffuse ischemia, and hyponatremia

Status epilepticus in kids• 0-5 minutes: Airway, O2, suction as needed• Vital signs, pulse oximetry, ECG• IV, draw blood for glucose, electrolytes, CBC, toxicology,

blood culture, anticonvulsant levels• Antipyretics as needed• 5 to 10 minutes: if hypoglycemic, administer 2 mL/kg of D25W

or 5mL/kg of D10W; monitor O2 with pulse oximetry• IV lorazepam 0.1 mg/kg (up to 4 mg) OR rectal diazepam, 0.5

mg/kg rectally• 10 to 20 minutes—re-administer lorazepam if seizures persist• If seizures persist, fosphenytoin is the anti-convulsant of

choice for kids• (see BIB: Abend, Goldstein, and Yoong)

Heart rate

• Very labile in kids; more sensitive to the effects of illness, exercise, medication, pain and emotions

• Check for a full minute; use apical rate• Check radial with femoral for coarctation of

the aorta (more valuable in older infants and toddlers; in infants a PDA may shunt blood to the lower extremities, bypassing a severe coarctation (M>F)

Heart rate

• Newborn (100-180)• Infant (80-120)• Toddler (80-110)• School age (70-110)• Adolescent (55-90)

Heart rate

• Beta-2 agonists for bronchodilation in asthmatics may cause tachycardia even tho’ they are beta-2 specific

• Tremor and saturation of B-2 receptor sites• An extremely rapid heart rate occurs before

notable alterations in blood pressure in infants and young children

Respirations• Newborn (35+) (obligate nose breathers for

the first 8 to 12 weeks)• Infant (30+)Place your hand on the chest of a

neonate/infant to assess respirations; count for a full minute, especially with a resp. illness

• Toddler (23-25)• School-age (17-21)• Adolescent (17-18)

Respirations

• The respiratory tract of a young child has a narrow lumen until age 5—makes the child more prone to airway obstruction and respiratory distress from inflammation

• Aspiration and obstruction of airway by a foreign object is the number 1 cause of death children less than a year old

• Sudden onset of acute respiratory distress in an infant crawling on floor—consider foreign object!

• ALARM SIGN: tripod breathing position (jaw thrusted out, leaning forward, drooling)

• Acute epiglottitis (rare today except in kids who have NOT been vaccinated, kids coming from foreign countries without vaccinations

• Hemophilus influenzae B • Peritonsillar abscess

Respirations• ALARM: Respiratory rates greater than 70 in

infants—consider lower respiratory tract infection; under one year consider Respiratory Syncytial Virus (RSV), bronchiolitis*

*underdeveloped intercostal muscles—severe retractions

• HEAD INJURY: Hyperventilating a child with increased ICP reduces the PaCO2 from 40 mmHg to 25-30 mmHg and decreases the cerebral blood volume by 50% and increases CPP (cerebral perfusion pressure)—and that’s GOOD…decreases cerebral edema

Acidosis

• Kussmaul respirations (deep, regular, rapid) and acidosis—the physical findings of acidosis are primarily respiratory—tachypnea, hyperpnea, hyperventilation

• Mnemonic K U S M A L• Ketones, Uremia, Salicylates, Metabolic,

Alcohol, Lactic

Digression—Type 1A diabetes

• 25% of all kids with type 1 diabetes present with diabetic ketoacidosis

• Autoimmune disease—inability to recognize self vs. non-self

• Antibodies formed against pancreatic beta cells or components of pancreatic beta cells

• Genetic susceptibility with an exogenous trigger--Type 1 diabetes—HLA-DR3, HLA-DR4

Type 1 diabetes—how many triggers?

• genes that have been found mediate the immune response to viruses (explains the viral hypothesis as a possible trigger)

Too little dirt

• The hygiene hypothesis—back to the GUT bacteria and priming the immune system

• Germphobic (mysophobic) *moms• Triclosan/antibiotic soap maniac moms• LET THEM EAT DIRT!• (*irrational fear of DIRT)

Too little sun

• Sunphobia• Sunscreen maniac moms• Kids playing inside (the “thumb tribe”)• Pushes the immune system in the wrong direction—• 2 pathways—TH1 and TH2 • Taking the TH2 pathway increases the risk of

allergies and autoimmune disease

Too much cow’s milk…

• Decreased risk in babies who are breast fed• Increased risk in drinking cow’s milk—is there

a protein that aggravates the immune system and triggers diabetes in genetically susceptible individuals?

• Large scale clinical trial called TRIGR, testing this hypothesis and is scheduled for completion in 2017

Ketoacidosis (DKA) in Type 1 diabetes

• Type 1 ketoacidosis is a prolonged fasting state with an absolute deficiency of insulin;

• Accounts for 8-29% of all hospital admissions in kids with T1DM; usually precipitated by an infection

• Glucagon is working overtime—glycogenolysis; lipolysis; and gluconeogenesis

• Weight loss; hyperglycemia; osmotic diuresis; fatty acid release (ketones)—DKA

• A young girl presenting with alternating hypoglycemia and DKA – consider an eating disorder

Diabetic Ketoacidosis (DKA)

• Dehydration (assess based on clinical signs mentioned earlier)

• Abdominal pain (may mimic acute appendicitis)• Anorexia, weight loss• Kussmaul’s respirations (acidosis) • Tachycardia• Weakness, fatigue• Fruity breath odor• hypotension• N or V• Confusion, decreased reflexes, coma

Lab tests• Severe hyperglycemia (greater than 250 mg/dl) and

glycosuria• Acidosis less than 7.30 with PCO2 less than 40 mm Hg• Ketonuria (ketonemia) and glycosuria• Serum bicarb (HCO- 3) is usually less than 15 mEq/L• Serum potassium may be low, nl, high (remember there is

always significant K+ depletion regardless of initial level)• Serum sodium is usually decreased as a result of

hyperglycemia; if elevated initially it may be due to dehydration

• AG = Na+ - (Cl- + HCO- 3) (usually greater than 10)

Lab tests

• CBC, UA, cultures to R/O infection• Ca+, Mg+, Ph+• BUN, Creatinine• Amylase and liver enzymes for patients with

abdominal pain• CXR to R/O pneumonia (may initially be

negative due to dehydration)

Diabetic Ketoacidosis (DKA)

• Dehydration is your biggest concern initially (usually 6-8 L fluid deficit – 100 ml/kg)

• GIVE FLUIDS…what kind? NS or RL • Not too fast—should not exceed

4L/m2/24 hours to avoid cerebral edema

Then what?

• Then what? Regular insulin IV (0.15 to 0.3 U/kg as an initial bolus (controversial about the bolus) and then 0.1 U/kg / hour (make sure the serum K+ is greater than 3.3 mEq/L to prevent life-threatening hypokalemia

Then what?• Potassium replacement: average total potassium loss in

DKA is 300 to 500 mEq• Amount varies with the patient’s serum K+ level, degree of

acidosis, and renal function• As a ROT (rule of thumb) potassium replacement may be

started when there is no ECG evidence of hyperkalemia (tall, narrow T waves; decreased or absent P waves; short QT intervals; widening of the QRS complex)

• Monitor serum K+ every hour for first 2 hours and then every 2-4 hours

• Should bicarb be given? Routine use is contraindicated; only consider if pH is less than 6.9 and HCO-3 is less than 5

DKA

• Average mortality rate is 5-10%• In kids less than 10, DKA causes 70% of

diabetes-related deaths• Cerebral edema occurs in 1% of episodes of

DKA I children and is associated with a mortality rate of 40-90%

• (Ferri’s Clinical Advisor 2011)

Blood pressure

• Recommend at age 3;• Ages 1 to 5 90 + age in years/56 4 yr- old? 94/56• Ages 6 to 18 83 + 2 x age in years/52 + age in years 8-yr old? 83 + 16/52+8 = 99/60• Proper cuff size (no less than ½ to no more than

2/3 of the length of the upper arm or upper leg)

Hypertension in kids• Consider family history and the size of the child• Most hypertension in kids is due to primary kidney disease

(80%); renal artery stenosis (12%); coarctation of the aorta (2%)

• APSGN (1-2 weeks after strep throat; 2-4 weeks after strep pyoderma)

• Cola-colored urine, BP 150/100; pulse 100• 1-2+ protein• Nephritis vs nephrotic syndrome (3+-4+)

Acute renal failure in kids

• #1 cause• E. Coli O157:H7

Common Skin Conditions

• Is it a macule, papule, vesicle, bullae?• Skin color—gray or mottled, jaundice (best

observed in natural light)

Common skin conditions…

• Petechiae—what are the causes in kids?• Platelet type bleeding? Mucous membrane

bleeding, oozing around IV sites, hematuria, purpura, petechiae due to low platelets

• Causes of thrombocytopenia?

Infectious diseases associated with low platelets…

• N. meningitidis• H. influenzae B• N. gonorrhea• S. pneumoniae• S. pyogenes• Y. pestis• Enteroviruses• Rubella• Rickettsiae• EBV, CMV• Kawasaki’s• HIV

Child abuse and bruises

• “The skin and the bones tell a story that the child is either too young or too frightened to tell.”

• Normal bruises are facial scratches, one bruise on forehead (toddler), knee and chins

Age of bruise• Is it red, purple, blue?• Green, yellow, brown?• Reddish/blue less than 1 day, immediate• Blue/purple 1-5 days• Green 5-7 days• Yellow 7-10 days• Brown 10-14 days • Resolution 2-4 weeks

Bite marks

• From another child? Adult? Animal? A diameter of greater than 3 cm between cuspids is human

• Human bites—crescent• Dogs—tear and triangular• Cats--puncture

French proverb: The mother of a child who elects to re-wed, has taken the enemy into her bed.

• “A child living with a stepparent is 100 times as likely to suffer fatal abuse.”

• (Daly M, Wilson M. The Truth About Cinderella: A Darwinian View of Parental Love, Yale University Press, 1999)

• A stepparent can also be an opposite –sex partner who lives with the parent, like a boyfriend.

• Eating disorders• Pet abuse/spousal abuse/child abuse

•Report child abuse!! •It’s the LAW!!

Head and neck—facial features

• Head circumference—measure as a vital sign in infants; measure heads daily (paper tape measure) in infants with meningitis

• Rapid head growth in first year, suspect autism• Head size—small head circumference at birth

followed by a sudden excessive increase in head size the first year

• The most severely autistic children were those whose heads grew the fastest--especially the frontal lobe

• (Courchesne E. JAMA July 16, 2004)

Autism--what do we know?

• Exposure to toxins during pregnancy?• Gene(s) malfunction?• Older parents?• The “GEEK” theory• Broken Mirror Neurons?

Clues to early diagnosis of autism?

• The failure to mimic a mother sticking out her tongue

• Failure to respond to name being called• Quieter, more passive• Lag behind in motor skills like sitting up/reaching for

objects• Show extreme reactivity—either getting upset with a

new toy or activity or barely noticing it at all• May exhibit repetitive behaviors—rocking, fixation,

less responsive to playful interactions with others

Speech development and autism

• In speech development, the best results are achieved when deliberate exercises are instituted prior to the age of two. By the time the child is 3 or 4, deficits can be reduced but fundamental changes are no longer possible, because the critical period for speech development has passed.

Microcephaly

• Slowed brain growth• Hair patterns• Neurologic “soft-signs”

Microcephaly and fetal alcohol syndrome

• Alcohol is the most prevalent teratogen in Western society

• Microcephaly; short palpebral fissures, hypoplastic maxilla and midface with a short upturned nose, thin upper lip, hypoplastic philtrum

• Average IQ of 68? Where will that get you?

Down syndrome

• Flat facies• Frontal upsweep• Low-set ears• Cerebellar immaturity• Small oral cavity giving the appearance of a

large tongue

FLK and COUP syndrome

• Hmmm…

Lymph nodes

• Note local drainage patterns• Local lymphadenopathy?• Generalized lymphadenopathy?—2 or more

contiguous node groups• Check liver, spleen, joints, thyroid• Consider hematologic malignancies• Connective tissue disorders

Neck mobility

• Nuchal rigidity and meningitis• The sucker sign• Brudzinski’s sign—flexion of the thighs results when the

patients neck is passively stretched (meningeal irritation)

• Kernig’s sign—flex the hip to 90 degrees and attempt to extend the knee. The limitation of the knee extension results from painful resistance (meningeal irritation)

• The extraordinary success of the H. flu and pneumococcal vaccines

Cranial nerves

• CN II and III (Optic and Oculomotor)(congenital ptosis)

• Head injury and pupil size (hippus)• Anisocoria and pupil size• EOMs• Fundoscopic exam

Shaken impact or shaken baby syndrome

• Shaken impact or shaken baby syndrome—injury more likely to occur from severe shaking and/or impact

• Retinal hemorrhages may be the only sign in an infant of a nonaccidental shaking injury

• Almost never caused by seizures alone

ALARM:

• The prevalence of retinal hemorrhages with a seizure of only about 3 per 10,000 – an extremely small likelihood

• If retinal hemorrhages are found in a child with seizures, the possibility of nonaccidental injury must be explored

• Curcoy AL, Trencha V, Morales M, et al: Do retinal hemorrhages occur in infants with convulsions? Arch Dis Child 94:873-875, 2009.

Shaken impact or shaken baby syndrome—retinal hemorrhages

• Should always be assessed in an infant whose presenting symptoms include excessive irritability, lethargy, apnea, respiratory stress, sepsis-like appearance, seizures, or coma

• The symptoms may be mild and nonspecific and may mimic symptoms of viral illness, feeding disorder or dysfunction or even colic; may have a history of poor feeding, vomiting, lethargy, and/or irritability that may have gone on for days or months

• If suspicious, should be followed by a skeletal series and cranial neuroimaging (CT or MRI)

Skeletal survey up to 2 years of age

• Yield diminishes after age 2 and is of little value after age 5

• About 30% of child abuse cases involve bone fractures

• Anterior and posterior rib fractures from squeezing; humerus, femur are most common broken bones

• Total skeletal x-ray(AAP, Radiology: Diagnostic imaging of child abuse.

Pediatrics 123:1432, 2009

Corneal reflex (CN V and CN VII)

• Extensive area of brainstem• Absence of corneal reflex in a comatose child

is indicative of a brainstem injury• Bell’s palsy—Herpes simplex; Borrelia

burgdorferi• Racoon eyes—basilar skull fracture

Raccoon eyes

• Kids with disabilities have a higher risk of child abuse

Ear exam

• Favorite hiding place for foreign objects• Kids vs. adults hiding places• Don’t ask if you can do something—if an ear

hurts, ask “which ear can I look in first”?• Clean ‘em out. 1 mL of Colace liquid (not

Colace syrup); wait 10-15 minutes and irrigate with saline or H2O

Another sign of child abuse— “boxing ears”

• By virtue of their location, kids ears don’t get bruised with the normal rough and tumble play

• If they fall on their side, either their shoulder protects them or their head hits first

Some notes on acute otitis media…• To treat or not to treat?• Children who are treated with

amoxicillin fare significantly better and achieve symptom resolution much quicker

• However, some pediatricians still advocate watchful waiting in kids over 2 who look well, are old enough to easily evaluate, and can be comforted with supportive care

• UNDER 2? Always treat with AB• 2/3 Strep. pneumonia, moraxella,

H. flu• (Tahtinen PA, Hoberman, Klein)

• Bilateral otitis = bacterial infection (H. flu)

Embryologic development

• Ears and kidneys

Nose and Throat

• One airway theory—sinuses, nose, throat, airway

• Sinusitis, allergic rhinitis and asthma• Kiesselbach’s triangle and nose bleeds

The belly

• Ticklish? How to relax the abdomen…• Inspection…scars, bruises, distention• The 6 F’s (fat, flatus, feces, fibroid [tumor],

fluid, fetus)• Auscultation—are the bowel sounds present

or absent; does it matter where you place the stethoscope?

• Palpation for lumps, bumps, growths, tumors, pain

Selected conditions

• Gastroenteritis—peri-umbilical pain• Acute diarrhea—watery—think viral? Bloody—think

more invasive, bacterial?• Acute appendicitis—no more than a 5-day disease;

periumbilical pain followed by pain in the RLQ; increased WBC with left shift; fever; psoas sign; “the walk”

• ULTRASOUND• Other causes of abdominal pain in kids

Selected conditions

• Child abuse injuries• The second most common cause of death from child

abuse is injury to abdominal organs• Small intestine, especially the duodenum, followed

by mesenteric hemorrhage and liver lacerations• Accidental abdominal injury—spleen, kidney• Liver damage and coagulopathies

The lungs…

• Pearls for listening• Warm the stethoscope• Bell for low pitched sounds; diaphragm for high-pitched

sounds; Use a pediatric stethoscope for young kids and infants

• Right mainstem bronchus is more vertical than left; foreign objects down the right

• Sudden onset of acute respiratory distress especially if they are crawling

The lungs• Rule of finger—the trachea of the child is approximately the

diameter of the child’s little finger• Drinking straw 4mm—adult trachea is 20 mm• Obligate nose breathers up to 6 months of age; listen over the

nose with stethoscope• 6 months to 6 years—abdominal breathers—feel abdomen• After 6 they use the intercostals; (intercostal retractions are

prominent as the flexible rib cage is pulled inward)

The lungs

• Inspection—shape of thorax, AP/lateral diameter; deformities? Retraction of interspaces?; tracheal tug; Rate and rhythm?

• Respiratory excursion• Auscultation—where should you place your

stethoscope? Remember that the base of the lungs is POSTERIOR; mainstem bronchii are in the 2nd intercostal spaces; trachea over the suprasternal notch

The lungs…

• Crackles—popping, crackling sounds produced by fluid in the alveolar spaces or small airways; re-opening of closed alveoli on inspiration

• Early inspiratory crackles? Late?• Rhonchi—coarse, rumbling, low-pitched produced by airflow

over secretions in the larger airways• Wheezes—mostly high-pitched sounds heard during

expiration or inspiration

The lung…

• Vagal input to the bronchii—increased input during sleep causing bronchoconstriction; 8% bronchoconstriction in the healthy lung vs. 56% in the asthmatic lung

• Peak bronchoconstriction between 4-6 a.m.• Compare PEFRs at 3 p.m. and 3 a.m. to assess nocturnal

respiratory function• The ONE AIRWAY hypothesis—allergic rhinitis and asthma

Asthma…IgE mediated disease

• Mast cell release of primary and secondary granules

• Histamine causes the first wave of symptoms• Triggers—dust mites; cat, dog, cockroach

dander; ragweed, pollen

Criteria for assessing the severity of an acute asthma attack--mild

• PEFR –70-90% of predicted personal best• RR, resting or sleeping – nl to 30% above mean• Alertness--normal• Dyspnea—absent or mild; speaks in complete

sentences• Pulsus paradoxus--< 10 mm Hg• Accessory muscle use—none to mild• Color--good• Auscultation—end-expiratory wheeze only• O2 saturation 95%• PCO2--< 35

Criteria for assessing the severity of an acute asthma attack--moderate

• PEFR – 50-70% of predicted personal best• RR, resting or sleeping – 30-50% increase above mean• Alertness--normal• Dyspnea—moderate; speaks in partial phrases• Pulsus paradoxus—10-20 mm Hg• Accessory muscle use—moderate intercostal retraction s;

use of SCM; chest hyperinflation• Color--pale• Auscultation—wheeze during entire inspiration and

expiration• O2 saturation—90-95%• PCO2--< 40

Criteria for assessing the severity of an acute asthma attack--severe

• PEFR –< 50% predicted of personal best• RR, resting or sleeping – increase > 50% above the mean• Alertness—may be decreased• Dyspnea—severe; speaks only in single words or short phrases• Pulsus paradoxus—20-40 mm Hg• Accessory muscle use—severe intercostal retractions,

tracheosternal retractions with nasal flaring during inspiration• Color—possibly cyanotic• Auscultation—breath sounds becoming inaudible• O2 saturation--< 90%• PCO2 40

Treatment of an acute asthmatic episode

• Coffee is a potent bronchodilator if in a pinch• Beta-2 agonists• Corticosteroids• Epinephrine if severe• May see magnesium sulfate added for smooth

muscle relaxation and additional bronchodilation

RSV…respiratory syncytial virus

• Fusion protein protein that results in cells forming a syncytium; Jan/Feb/March; RR=70; rhonchi, crackles, wheezes; rhinorrhea; pharyngitis

• Monoclonal antibody—palivizumab (Synergis) targets the fusion protein

• Pneumonia—place child on the good side; gravity increases perfusion to the good lung facilitating optimal CO2 and O2 exchange

CV exam• Auscultation—4th L ICS medial to MCL in kids under 7• Lub dub Lub dub systole diastole sys diastoleRemember: Significant heart disease is infrequent in the absence

of a murmurRemember: Almost all (99.9%) of diastolic murmurs are

pathologic; Functional murmurs—systolic; grade 1 or 2; low-pitch; 3rd to 4th

ICS @ L parasternal border; no thrills, clicks; increases with fever and increased with sitting up

Non-innocent or organic murmurs before the age of 3, consider a congenital heart defect; after age 3, consider rheumatic valvulitis

Pathologic systolic murmurs

• Harsh with thrill• Pansystolic or late systole• Murmur at upper L sternal border• Grade 3 or greater• Early or mid-systolic click • Abnormal second heart sound

Non-cardiac factors that indicate a murmur is pathologic

• Growth retardation • Dysmorphic features• Exertional blueness, pallor, dyspnea with minor exertion• Short feeding times and volumes in infants• Syncopal or presyncopal episodes• IV drug use• Maternal history of DM (VSD, transposition, septal

hypertrophy)• FH• Fetal alcohol syndrome—pulmonic stenosis, VSD

Neuro exam

• Age related for mental status exam• Observation• Developmental tests• Major components—mental status, Cranial

nerves (see head and neck exam), motor exam, cerebellar function, sensory exam

Motor exam

• Gait• Deep tendon reflexes• Babinski sign (always positive prior to walking)• Cerebellum—muscle tone, synergy, wide-

based gait• Abnormal (involuntary) movements—

kernicterus

Sensory testing

• Dermatomes• Touch • Pain• Temperature• Proprioception• Symmetry is the RULE!!

Get this for your practice/ER/Pediatricians in your

community!• Centers for Disease Control and Prevention.

Heads Up: Brain Injury in Your Practice: A Tool Kit for Physicians. (http://www.cdc.gov/ncipc/tbi/Physicians_Tool_Kit

The end.

• Barb Bancroft, RN, MSN, PNP• BBancr9271@aol.com• www.barbbancroft.com

Bibliography

• Abend NS, et al. Anticonvulsant medications in the pediatric emergency room and ICU. Pediatr Emerg Care 24:705-718, 2008

• Bailey BN et al. Prenatal exposure to binge drinking and cognitive and behavioral outcomes at age 7 years. Am J Obstet Gynecol 2004 Sep;191:1037-43.

• Briggs GG, Carson DS, Rayburn WF. Which medications are safe in pregnancy? Patient Care 2000 (December 30): 19-44.

• Christensen D. Sobering work: unraveling alcohol’s effects on the developing brain. Science News 2000 (158): 28-29.

• Fackelmann K. The birth of breast cancer: do adult diseases start in the womb? Science News 1997 (151):108-109.

• Falb K, el al. School bullying perpetration and other childhood risk factors as predictors of adult intimate partner violence perpetration.” Arch Pediatr Adoles 2011; DOI: 10.1001/archpediatrics.2011.91

• .

Bibliography• Goldstein J. Status epilepticus in the pediatric emergency

department. Clin Ed Emerg Med 9:96-100, 2008• Hoberman A et al. Treatment of acute otitis media in children under

2 years of age. N Engl J Med 2011 Jan 13;364:105. • Klein JO. Is acute otitis media a treatable disease? N Engl J Med

2011 Jan 13; 364:168.• McCormick DP et al. Laterality of otitis media: Different clinical and

micorbiologic features. Pediatr Infect Dis J 2007 Jul;26:583-8.• Nathanielsz, P. The Prenatal Prescription. HarperCollinsPublishers,

2001.• Rodier PM. The early origins of autism. Scientific American:

February 2000; 56-63.• Rosenberg, A. Brain damage caused by prenatal alcohol exposure.

SCIENCE & MEDICINE 1996 (July/August):42-52.

Bibliography• Tahtinen PA et al. A placebo-controlled trial of antimicrobial

treatment for acute otitis media. N Engl J Med 2011 Jan 13;364:116.

• U.S. Food and Drug Administration. Antidepressant Use in Children, Adolescents, and Adults. October 15, 2004. http://www.fda.gov/cder/drug/antidepressants/default.htm

• Verstraeten T et al. Safety of thimerosal-containing vaccines: A two-phased study of computerized health maintenance organization databases. Pediatrics 2003 Nov; 112-1039-48.

• Advice on SSRIs in Children from the Committee on Safety in Medicine. February 12, 2004. http://medicines.mhra.gov.uk/aboutagency/regframework/csm/csmhome.htm

• Yoong M, Chin RFM. Management of convulsive status epilepticus in children. Arch Dis Child Educ Pract 94:1-9; 2009.

When should the diagnosis of a seizure disorder be considered rather than a breath-holding spell?

• When the precipitating event is minor or non-existent• History of no or minimal crying or breath holding• Episode lasts longer than one minute• Period of post episode sleepiness is longer than 10 minutes• Convulsive component of episode is prominent and occurs

before cyanosis• Occurs in a child less than 6 months or greater than four years

Maternal infections and schizophrenia

• (References for those interested in this hypothesis: Brown AS, Biol Psychiatry, 49; 473-86, 2001. L. Shi et al., “Maternal influenza infection causes marked behavioral and pharmacological changes in the offspring.” J Neurosci, 23:297-302. Gilmore JH, et al., “Maternal infection regulates BDNF and NGF expression in fetal and neonatal brain and maternal fetal unit of the rat,” J Neuroimmunol, 138; 49-55, May 2003 Karlson H et al, “Retroviral RNA identified in the cerebrospinal fluids and brains of individuals with schizophrenia,” Proc Natl Acad Sci, 98:4634-9, 2001. Baker HF, et al.Psychol Med, 19:325-9, 1989)

• Clinical Quips (Barb’s newsletter), January 2004.

Weights in critically ill infants…

• Factor in diaper weight, arm board weights, bandages

• Daily weights and volume determinations• Mild dehydration with less than 5% weight

loss; moderate dehydration with 5-10%; severe dehydration greater than 15%

A brief digression on the WBC and differential

• Segs-- 57-63% of total (bacteria, acute necrosis) Bands (precursor to the segs) – 0-4%• Lymphs– 30% (viral infections; immune cells)(Young

kids with greater # of lymphs—immune system is “learning”)—(acute lymphoblastic leukemia most common in this age group)

• Monocytes– 4% (chronic inflammation; APC)• Eosinophils– 3% (allergies, parasites, drug fever)• Basophils– 1% or less (mast cells in tissues)

FINALLY! The teleologic explanation for nose-picking…

• Nose-picking and the immune system. Dr. Friedrich Bischinger, a leading Austrian pediatrician, extols the virtues of nose-picking. He states: “With the finger you can get to places you just can’t reach with a handkerchief, keeping your nose far cleaner.” He goes on to say, “And eating the dry remains of what you pull out is a great way of strengthening the body’s immune system.” Ingesting the bacteria from your nose helps inoculate the body against illness, which may be why this instinctual behavior evolved. Dr. Bischinger also recommends that parents encourage children to pick their nose; somewhat of a new approach to the habit wouldn’t you agree? (The Week, April 9, 2004)

www.Mdcalc.com

• Answers on Pediatric ET cuff size• Fluid calculations• Absolute neutrophil counts• Pulmonary Expiratory Flow estimates per age • GREAT WEBSITE…