OME Notes

NEWBORN MANAGEMENT (incomplete)

● Newborn Care: first measure baby, (3)

○ Weight
○ Length
○ Head circumference
● Newborn Care: second, look at the cord (2)
○ 2 arteries + 1 vein
○ Clamp, remove excess
● Newborn Care: third, shots and drops (3)
○ Vitamin K
○ Hep B vaccine
○ Eye drops - conjunctivitis prophylaxis (erythromycin)
● Well Baby Exam
○ Scalp - cephalohematoma
○ Red reflex - retinoblastoma
○ Mouth - cleft lip/palate
○ Clavicle - feel for crepitus or dislocation
○ Heart - murmurs
○ Lungs - lung sounds
○ Cord - bowel problem/omphalocele/gastroschisis
○ Genitalia - cryptorchidism, hypospadias, etc
○ Anus - imperforate anus
○ Skin - jaundice
○ Ortolani/Barlow maneuvers

NEONATAL ICU
Bronchopulmonary Dysplasia
Caused by: decreased surfactant, collapse of alveoli
Diagnosis: XRay - ground glass opacities
Treatment: surfactant after birth (steroids before birth)
F/U: diffuse pulmonary lung disease

Retinopathy of Prematurity
Caused by: neoangiogenesis (worsened by increased FiO2 requirements)
Presentation: premature
Diagnosis: eye exam in a premature infant
Treatment: laser ablation of the vessels
F/U: glaucoma

Intraventricular Hemorrhage
Caused by: highly vascular lining of cerebral ventricles
Susceptible to rupture by changes in blood pressure
Presentation: Increased ICP, bulging fontanelles in a premature infant
Diagnosis: Cranial doppler
Treatment: VP shunts and drains to decreased ICP
FU: Mental Retardation & Seizures

Necrotizing Enterocolitis
Presentation: Premature infant with bloody stools
Diagnosis: XRay will show air in the wall of the bowel - pneumatosis intestinalis
Treatment: Stop oral feeding (NPO), total parenteral nutrition, antibiotics
F/U: Surgery, resection
 FAILURE TO PASS MECONIUM

● What is failure to pass meconium?

○ Have not passed meconium in 48 hours
○ Most kids pass in 24 hours

// Imperforate Anus
● Imperforate Anus, diagnosis?
○ XRay Cross table
● Imperforate Anus, treatment if mild?
○ Surgical repair at birth
● Imperforate Anus, treatment if severe?
○ Colostomy now
○ Surgical repair later
● Imperforate Anus, part of which syndrome?
○ VACTERL syndrome
● VACTERL,
○ V - Vertebral - US of sacrum
○ A - Anus - XRay
○ C - Cardiac - Echo
○ TEF - Cather + Xray, look for it to coil + XRay
○ E - Esophageal atresia - Catheter + Xray, look for it to coil + XRay
○ R - Renal - U/S
○ L - Limbs - XRay

// Meconium Ileus
● Meconium, typically seen in which pathology?
○ Cystic Fibrosis
● Meconium Ileus, diagnosis?
○ XRay - may show
● Meconium Ileus, treatment?
○ Water enema
● Meconium Ileus, follow up?
○ Sweat Chloride test
○ Supplementation
■ Pancreatic enzymes
■ Vitamin ADEK

//Hirschsprung
● No meconium, palpable colon, explosive diarrhea
○ Hirschsprung
○ -
○ 10% only present with chronic diarrhea + overflow incontinence
● Hirschsprung, dx
○ XRay
■ Good colon - dilated
■ Bad colon - normal
○ Contrast Enema
○ Anorectal Manometry
■ Will see increased tone
○ Best diagnostic - rectal suction biopsy
● Hirschsprung, treatment?
○ Surgical resection

// Voluntary Holding
● Child who recently started school + not passing a lot of stool + overflow incontinence
○ Voluntary holding
 ○ (may have transitioned to involuntary incontinence)
● Voluntary holding of stool, diagnosis?
○ Clinical picture
● Voluntary holding of stool, treatment?
○ Behavioural - Create bowel passing regimen
○ Disimpaction - under anesthesia

CONGENITAL DEFECTS

Congenital Diaphragmatic Hernia

Presentation: scaphoid abdomen + bowel sounds in the lungs + hypoplastic lungs
Diagnosis: XRay - babygram
Treatment: surgical correction of hernia + corticosteroids for lung

Gastroschisis + Omphalocele
Gastroschisis
Presentation: Right of midline + not covered by membrane
Diagnosis: Clinical
Treatment: Silo

Omphalocele:
Presentation: Midline + covered by membrane
Diagnosis: Clinical
Treatment: Silo

Exstrophy of the Bladder

Presentation: Midline + wet with urine + shiny and red + no bowel
Diagnosis: clinical
Treatment: surgery

Biliary Atresia
Presentation: worsening jaundice at 2 weeks + direct hyperbilirubinemia
Diagnosis: Ultrasound - will see no ducts
HIDA scan after 5-7 days of phenobarbital (which stimulates release of bile, which will never make it there)
Treatment: surgical resection

Cleft lip/Cleft Palate

Cause: varied
Presentation: Cosmetic defect
Diagnosis: Clinical diagnosis
Treatment: Surgical (lip at 7-12 weeks ; palate at 7-12 months)
Complications: Recurrent infections + failure to thrive

Spina Bifida
Caused by: folate deficiency or genetics
Diagnosis: Prenatal US/IncreasedAFP or Antenatal defect/clinical
Treatment: surgical repair
F/U: associated with Arnold Chiari 2; Hydrocephalus; neurologic effects below the level of the lesion

BABY EMESIS

Baby Emesis
Non-projectile, Formula colored = normal

Bilious vs Non-Bilious
Bilious - green - abnormal
Means obstruction its distal to biliary tree
Diagnosis: XRay - double bubble

Malrotation - Bilious
Failure of rotation of the gut, bowel strangulate itself
Diagnosis: XRay - double bubble - normal gas pattern beyond
Confirm: upper GI series, looking for obstruction
Treatment: NGTube to decompress, surgery
Complication: Volvulus

Duodenal Atresia - Bilious

Pathogenesis: Failure to recanalize the duodenum
Associated with: Polyhydramnios, Down syndrome
Diagnosis: XRay - double bubble - no gas beyond
Treatment: Surgery

Annular Pancreas - Non-bilious

Pathogenesis: Failure of apoptosis
Associated with: Polyhydramnios, Down syndrome
Diagnosis: XRay - double bubble - no gas beyond
Treatment: Surgery

Intestinal Atresia - Non-bilious

Pathogenesis: vascular accidents in utero (loss of blood flow to intestine)
Presentation: infant to mom who uses a vasoconstrictor (ie cocaine)
Associated with: polyhydramnios
Diagnosis: XRay - double bubble - multiple air fluid levels
Treatment: Surgery to remove + confront mom about the cause (ie cocaine use)
F/U: Short Gut Syndrome

TE Fistula - Non-bilious
Presentation: emesis + bubbling and gurgling
Diagnosis: NG tube coils
Treatment: Parenteral nutrition, Surgery

Pyloric Stenosis - Non-bilious

Presentation: Weeks 2-8, male, projectile vomiting, non-bilious
Olive shaped mass, visible peristalsis
Diagnosis: Ultrasound, CMP (look for hypochloremic, hypokalemic, metabolic acidosis)
Treatment: Fluids (to correct electrolytes) then Pyloromyotomy

WELL CHILD VISIT

Talk about Vaccinations (covered later)

Growth Chart (in order of importance)

Head circumference
Height
Weight

Failure to Thrive
Kids fall off the growth chart
Only concerning if they persistently stay off the chart
They fall off in the reverse order (weight, then height, then head circumference)
Must separate organic vs non-organic causes
Organic - Genetic, Heart disease, Pyloric stenosis/GERD
Non-organic - Formula, Feeds, Frequency

Abuse/Neglect
Any injury in an infant
Suspicious injuries (ie shape and location)
Big injuries (ie fractures, subdurals)

Safety (Parental Education)

Smoking cessation
Seatbelts
Car Seats
Gun safety
Drowning/Pool
Trampolines

Developmental Milestones
Months
2 - lift their head (+ smile)
4 - roll over
6 - sit up (+ stranger anxiety)
Years
1 - cruise/walk (+ separation anxiety)
2 - stairs/step
3 - Tricycle
4 - Hop
5 - Skipping

VACCINATIONS

Active Vaccine
Body’s APCs detect and present antigen
Body makes antibodies against antigen
Ready to fight infection in the future
Body can recognize toxins/toxoids, antigens of an organism, or the organism itself

Passive Vaccine
Mom’s antibodies, protect the baby for about 6 months
IVIg - we can give them antibodies instead

Herd Immunity
Enough get vaccinated

Reactions

Egg Allergy
Do not give: Yellow Fever
Can give: MMRV, Flu (used to be made of egg, but changed, so now its safe)

Immunocompromised
Do not give: Live attenuated vaccines
Do not give: MMRV
Can give: Intranasal Flu

Normal Reaction to Vaccine

Fever of less than 104
Erythema at the sight
Baby will be consolable
Abnormal Reaction to Vaccine
Fever of over 104
Anaphylaxis
Inconsolable child

Notes:
Acute illness - is not a contraindication
Family history - is not a contraindication (on personal history)

Pediatric Vaccinations (know who gets what)

Diseases You Should NOT SEE

DTap - kids 5 doses

Tdap - adults 1 dose (at least once)
Td - booster - every 10 years
TIg - IVIg

Tetanus
Lock Jaw, Spastic paralysis
Diagnosis: clinical
Treatment: intubate, protect airway, muscle relaxers, IV antibiotics

Tetanus - Wound Management

Do not give TIG (IVIg) if they have received more than 3 lifetime doses

Clean wound
Less than 3 doses - Tdap
More than 3 + last dose over 10 years ago - Tdap
More than 3 + last dose under 10 years ago - send home (nothing)

Dirty wound
Less than 3 doses - Tdap + TIG (IVIg)
More than 3 + last dose over 5 years ago - Tdap
More than 3 + last dose less than 5 years ago - send home (nothing)

Diphtheria
Presentation: Fever + dysphagia + dyspnea + psudomebranes
Diagnosis: clinical
Treatment: intubate, antitoxin, IV antibiotics

Pertussis
Catarrhal phase: infectious + non-specific symptoms (like a cold)
Phase 2: Paroxysmal cough + large inspiratory efforts that sound like wheezing
Phase 3: Resolution
Diagnosis: clinical
Treatment: Erythromycin + supportive treatment

HPV
Both boys and girls
9 - 26 years old
Prevents cancer

Varicella
No chicken pox
Watchout for shingles later in life if no vaccine
Rotavirus
Oral vaccine
Contraindicated in intussusception

Vaccinations

Hep B - What to give Baby

Mom is Hep B positive → Hep B Ig + Hep B vaccine - NOW
Mom is Hep B negative → Hep B vaccine within 2 months
Mom Hep B unknown → Hep B vaccine now + check Mom for HBsAg

DTap
Kids - 5 total doses
Year 1 → 3 doses
Years 1 to 4 → 2 doses
Boosters every 10 years
Td or Tdap
At least once in teenage years
Lifetime
Need at least 3 doses in life

Hib (H. Influenza type B)

Under 2 years old
Helps protect from epiglottitis and meningitis

MMRV
Vaccine and booster before school

Pneumococcal
Immunocompromised
Asplenic patients (ie sickle cell pts)
13 for infants, add 23 if risk factors present

Meningococcal
Everyone
Especially college or military

HPV
Everyone
Helps prevent cancer

Hep A/B
All boys and girls 9-26
2 for A, 3 for B
Pick up where you left off **

Flu shot
Everyone
 ALTE BRUE and SIDS

ALTE - Apparent Life Threatening Events (old name)

BRUE - Brief Resolved Unexplained Event
SIDS - Sudden Infant Death Syndrome

ALTE - Change in Color, Tone, Breathing

50% of time - nothing found

The key is HISTORY

GERD
Lower Airway Infection
Seizure
Abnormal eye movements
Limb jerking

Things you need to keep an eye on

Sepsis
Look for: Fever (or change in Temp)

Heart Disease
Look for: Failure to thrive + Murmur

Abuse
Look for: Multiple injuries

BRUE Criteria
Under 1 year old
Less than 1 minute in duration
Change in color, tone, breathing or responsiveness

Low Risk
No history to support
No physical findings
No CPR was required
First time event happened
Age - preterm higher risk
Next step: do nothing

High Risk
Anything not low risk
Next step: Monitor + Investigate

SIDS
Child who dies for no reason
Diagnosed after death
Prevention
Sleep on their back
Don't share a bed with an adult
Smoking cessation

PREVENTABLE TRAUMA

Head Trauma - Bleed

Epidural - Lens shaped
Ball sports
Skiing
Walk, Talk and Die
Lens shaped

Subdural - Crescent shaped

Pedestrian struck by car
Motor Vehicle accident
Abuse**

Contusion - Punctate hemorrhages

Deceleration injury
Usually a Sports injury

Prevention
Car safety
Booster seat - rear facing
Booster seat - restrained by seat belt
Helmet
Trampolines

Head Trauma - No bleed

Concussion
Head trauma, no intracranial bleed
Sports injury

Mild Concussion
Loss of conciousness less than 60s
No amnesia
No focal deficits
No headache
Next Step: nothing, home

Severe Concussion
Loss of consciousness more than 60s
Worsening headache (+/- nausea, vomiting)
Retrograde amnesia
Next step: CT scan, admit

Return to Sports: Stepwise play

Drowning
Who: Young kids or Babies (poor swimmers)
Where: tubs, pools, buckets
Prevention: Limit access (ie gate) or Supervision (always!)
Flotation: not good (they don't keep the head up) … use life jackets instead

Burns

Parkland formula
50% first 8 hours
50% next 16 hours

% body surface areas burnt (1st degree) x body weight (kg)

Rule of 9s (each of these is 9)
Front of Head
Back of Head
Chest (front)
Abdomen (front)
Upper back
Lower back
Each Arm (front and back)
Each Leg (front and back - 3 9s)

Guns /Chemical
Out of reach - Keep them up high
Locked away (ie cabinet)
Weapon separate from ammo (for guns specifically)

CHILD ABUSE

Abuse
Positive symptoms
Intentional
Parent is doing something they should not be doing
Active event (doing something bad)

Neglect
Negative symptoms
Intentional or Unintentional
Parent is not doing something they should be doing
Passive event (not doing something good)

Risk factors - Children more likely to be abused

Mental retardation
Premature infants
Have disabilities (physical or cognitive)

Risk factors - Parent more likely to be abusive

Those who have been abused themselves (most predictive risk factor)
Single parent
Young parent
Low Socioeconomic Status
Non-biological parents

Presentation - Injuries

Fractures
Skull or Femur

Bruises
Bruises in different stages of healing
Especially in unusual locations of the body
Subdural Hematoma - Shaken Baby Syndrome **

Burns
Dunk Wonder - buttock or foot burns
Punctate circular burns - cigarettes

Sexual
Any STD
Anal or Vaginal trauma

Presentation - Child
Absence of crying (in the presence of severe injury) - learned behaviour
Runs from caretaker
Finds comfort with healthcare provider

Responitibied - Healthcare Provider

Report to CPS - Child Protective Services
Report to Abuser
Tell them why you're doing what you're doing - try to maintain family cohesion, and let them know it's for pt safety
Hospitalization - last resort - no other alternative - separate child from abuser
Help family cope - abuse is not always bc of malicious intent, ie you may be able to help parent cope with a stressor better

PEDS INFECTIOUS RASHES

ALLERGIES

EAR, NOSE AND THROAT