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131 Cards in this Set

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constipation (rome criteria)
2 of the following, once per week for 2 mos:
-2 or less bm's per week
-1 episode of fecal incont. per week
-hx of excessive stool retention
-hx painful hard bm's
-hx large diameter stools that may plug toilet
-large fecal mass in rectum
encopresis
fecal incontinence after 4, occurs 1x per month for 2 months
tx of constipation
develop regular bowel routine
evacuation of bowel to start
bowel retraining
ongoing maintenance of diet, exercise and toilet hygiene to prevent recurrence
**diet change may be enough if there is no stool retention, pain or rectal bleeding
if has any of above tx with PEG or mineral oil
**infant juice, suppository or rectal stim
differentials for constipation
hypothyroid, lead, celiac, hirschsprungs, spina bifida, cf
times constipation is likely to occur
intro of solids or milk
toilet training
school entry
physiological complications of stool retention
distention of colon
stretching of rectum
ineffective peristalsis
decreased sensory threshold in rectum
weakened rectal and sphincter muscles
**may feel mass in left lower quadrant
Functional abdominal pain (Rome Criteria)
No organic etiology
following must occur 1/wk for 2 months
-abdominal pain
-no evidence of other disorder
-no criteria for other fxnl disorders
Red flags for functional abdominal pain
localizing pain away from umbilicus
pain assoc with change in bm's
night awakening
fever, loss of appetite or energy
child <4
blood in stool or emesis
wt loss
organomegaly
localized abdominal tenderness
perirectal abnormalities
joint swelling
testing for fxnl abd pain
initial approach:
cbc,esr,crp,amylase, lipase, CMP,ua and abdominal us, abd xray
3 day trial of lactose free diet
can also do stool studies
differentials for abd pain
uti, ibs, celiac, lactose intol, constipation, depression, IBD
managment of fxnl abd pain
establish therapeutic relationship (dont over test-it encourages)
explain brain-gut interaction (closely related-stress can cause abdominal pain etc)
meds sparingly (can use Levsin antispasmotic or periactin)
discuss the possibility of it being FAP (inorganic) early on
***encourage return to school and dont give excessive attention
CAM therapies-bland diet, etc
look at stressors, couseling
discuss alarm symptoms
GERD etiology
young infants have increase intra-abd pressure because do not sit upright
relaxation of LES
delayed gastic emptying
s/s gerd
regur
wt loss or no gain
rumination
heart burn
hematemesis
dysphagia
wheeze/cough
infants may have irritability, arching, gagging
older children-abd and chest pain
dx of gerd
tests not needed- hx and pe sufficient
prn can do:
cbc, ua, FOB, h.pylori
(esophageal ph is gold standard)
red flags with GER
bilious vomiting
gi bleed
forceful vomiting or starting after 6 mos
FTT
diarrhea/constipation
fever
lethargy
hsm
mgmnt GERD
h2 blocker or PPI (zantac 2-4mg/kg/dose)
nutrition (feeding techniques, volumes, frequency)
hydrolyzed formula
1tsp rice per ounce of formula
if not improving with meds may need referral
lactose intolerance s/s
abd pain
diarrhea
nausea
gas
boating
cause of lactose intol
deficiency of lactase (enzyme)
dx/tx of lactose intol
lactose hydrogen breath test
trial of lactose free for 2 week
tx: lactose free diet
lactase suppl
cow's milk allergy or Protein intol symptoms and tx
can have allergic rhinitis
asthma, congestion
eczema, rashes , irritability
gi symptoms (vomiting/diarrhea, blood in stool)

tx: change to hypoallergenic formula
FTT criteria
BMI <5%
length for age and sex <5%
wt decel >2 percentile lines
wt <80% of median wt for ht
wt for length <10 % tile
causes of FTT:
inadequate calories
inadequate calorie absorption
excessive calorie expenditure
***>80% caused by nutritional deficiency
**2wks to 4 mos is more likely congenital
**btwn 4-8 mos consider feeding problems
high risk-poverty, hiv, developing countries
diagnostic studies for FTT
feeding hx
ability to suck, swallow, chew
type of food
24 diet recall
labs:cbc, CMP, tsh, t4, esr, crp, ua, sweat test-do at cf center
may to ugi or swallow study
normal wt gains throughout childhood
0-3 mos 25-30 gm per day
3-6 mos 15-20 gm per day
6-12 mos 10-15 gm per day
1-3 yrs 4-6 lbs per year
3-6 yrs 4.5 lbs per year
6-12 7 lbs per yr
normal ht gains childhood
0-3 mos 3.5 cm/mon
3-6 mos 2.0 cm/mon
6-12 mos 1.5 cm/mon
1-3 years 12 cm/yr
4-12 years 6 cm/yr
puberty 8-14 cm
hirschprungs symptom
absence of gangion cells in bowel wall
s/s
no meconium in first 48 hrs
FTT
poor feeding
chronic constipation
down syndrome
dx: xray shows dilated loops of bowel, barium enema
tx: surgical resection
intussusception
section of intestine pulled into adjacent intestine=bowel is trapped
most common in 5-10 mos of age
s/s colicky intermittent pain
vomiting
currant jelly stool
may palpate sausage like mass in abdomen RUQ
abd distended and tender to palpation
bloody stool
*u/s is test of choice
tx: surgical-air contrast enema
cryptosporidium
parasite
diarrhea, cramps
spread fecal-oral or undercooked food
tx: supportive
giardia
parasite
watery diarrhea, greasy foul smelling stools
fecal oral or contaminated food or water (from dogs, beavers etc)
tx: flagyl
dont swim for 2 weeks
IBS define and rome criteria
chronic or FAP with altered bowel habits and bloating not explained by structural or chemical abnormality
Must include **once per week for 2 months
1. abdominal discomfort with 2 or more-
improvement with defecation
onset with change in frequency of stool
onset with change in appearance of stool
2. no evidence of pathology
celiac disease path
autoimmune disease triggered by dietary exposure to wheat gluten
associated with HLA's-autoantibodies to enzyme TTG-activate t-cells and lead to mucosal damage and malabsorption
celiac s/s and dx test
diarrhea, n/v, wt loss, fatigue, abd distension, short stature
**white lines on teeth, delayed puberty, thyroiditisa and dermatitis herpetiformis
dx: celiac panel- ttg iga ema iga- if positive keep on gluten free diet so diagnosis can be confirmed
celiac tx
gluten free diet
monitor thyroid, viat d, screen family and sibs
untreated can lead to lymphoma
eosinophilic esophagitis
inflam condition of esophagus
s/s: dysphagia, choking, chest or abd pain, food avoidance, heart burn, emesis
dx: egd, trial of acid reducer
tx: pulmicort respules with splena swallowed, all kids sent to allergist
IBD s/s
crohn's (throughout)
UC (just colon)- can be cured by removing colon
av age of dx:12
presents with-wt loss, bloody diarrhea, abnormla labs-anemia, low protein and increased esr,crp
pale, fatigue, joint pain
IBD tx
assess growth
medication, correct deficiencies and increase calories
cystic fibrosis GI manifestations
infancy-meconium ileus from dessicated fecal material
pancreatic insuff, rectal prolapse
85% of children have FTT due to pancreatic insuff
thick fat laden stools
infants that are fed soy based formula do poorly due to
proteinemia
cyclic vomiting and abdominal migraines
CV-recurrent stereotypical attacks of intense nausea and vomiting with intervening periods of wellness
children 2-7
family hx migraines
tx:periactin or elavil
zantac dosing
4-6mg/kg/day divided 2-3 times per day
omeprazole dosing/ lansoprozole dosing

prilosec and prevacid
1-3 mg/kg/day
***start 1mg/kg/day
for >2 yo
eradication of h.pylori
amox, clarith and prilosec
or
clarith, flagy, prilosec
work up for constipation
barium enema- if suspect hirschprungs
sweat test- CF
rectal exam
tsh, t4
celiac panel
stool for occult blood
vit d recc for breast fed infants
400 iu until 12 mos old
What are macronutrients
carbs, fat and protein
fat intake for children
1-3 30-40%
>3 25-30%
what are the fat soluble vitamins
a,d,e,k,
stored for long periods in body
vit d
essential for bone growth and development, regulated absorption of calcium
defeciency-ricketts, skeletal malformation, delayed teeth
source: sunlight, fortified food
need to supplement bf babies unless formula intake is up to 1 liter per day
vit e
antioxidant, traps free radicals
deficit-anemia and dermatitis, neuro defects
source-veg oils, margarine, nuts, green leafy
vit a
for vision, cell growth and immune system
source-liver, fish oil, eggs, carrots, drk greens

def-anorexia, dry skin, eye probs
vit c
tissue repair, wound healing, iron absorption
def-scurcy, cracked lips
thiamin b1
riboflavin b2
niacin b3
b12
thi-carb metabolism, in whole grains, nuts, seeds
def-beriberi-weakness, confusion
ribo-oxidation, intergrity of skin, lips- in diary poultry fish, def-oral lesions, dermatitis
niacin-energy metabolism-nervous system and skin, source meats, milk, eggs def-pellegra-dermatitis, diarrhea, indigestion
b12- metabolism and rbc's, in animal products, eggs, meat, shell fish. def-megaloblastic anemia, neuro symptoms
folate
essential for RBc formation, found in liver, drk greens, legumes, fruit, def-poor growth, anemia
calcium
bones, nerve conduction, muscle contraction
sources- milk, green leafy, broccoli
def-risk for fractures, dec bone strength
phosphorus
bone integrity and metabolism
sources- almost all food, meat, poultry, fish
def-bone loss, weakness, malaise
magnesium
transmission of nerve impulses, cell metabolism
source-nuts, green veg, bananas
def-muscle weakness, nausea
iron
formation of heme molecule, oxygen transport
source-meat, eggs, cereal, spinach

def-anemia
iron rich foods
almonds, cashews, cereals, pumpkin seeds, apricots, kidney beans, spinach, tofu, ground beef, potatoes, peas
define overweight, obese, and underweight
overwt->85%-<95% BMI

obese- >95%bmi

underweight- <5% bmi
electrolytes
Electrolytes are important because they are what your cells (especially nerve, heart, muscle) use to maintain voltages across their cell membranes and to carry electrical impulses (nerve impulses, muscle contractions) across themselves and to other cells.
Na+ extracellular fluid volume (lost with vomiting, diarrhea, sweat)
K+ intracellular-transmission of nerve impulses
Cl- fxn with Na for fluid balance, (loss with vom, diarr, sweat)
nutritional assessment
food intake
eating patterns
reactions and attitudes about food
mngmt of food in family
health status affected by nutrition ie. elim, dental family hx
nutritional assessment dx tests
hgb
iron and or ferritin
various elements-albumin, minerals, lipids
bone radiographs
reasons to start solids 6 mos
avoids food allergies
sucking patterns have changed to allow chewing
sit with support
head control
iron stores depleting
grasp and rake objects
growth demands require other nutrients
cog, sensory and motor stimulation from new foods, textures, smells etc
rice most non-allergenic
risk factors for obesity
prenatal- maternal wt gain, smoking
post natal- decrease sleep
rapid wt gain in first months of life
bottle after 12 mos
intro of solids <4 mos
lifestyle- low income
non-nutritional foods
not eating as a family
excessive screen time, decreased physical activity
sugary drinks
vegan diets need what supplement
b12
differential for FTT
clinical findings are
poor wt gain associated with-
poor intake
vomiting
diarrhea
food refusal
anticipatory gagging
dd: CHD, GI, renal, pulmonary, endocrine, error of metabolism/genetic, autoimmune**wt loss think diabetes
disorders requiring increased calorie intake
premie and LBW
chf
malabsorption
renal disease
meds
increased activity_CP
hiv, cancer, fever etc
nutritional mgmt of late preterm
prefer breast feeding
may add fortifiers
nutritional mngmt premie
fortify breast milk
screen for anemia at 6-9 mos
vitamin supp- iron 2-4mg/kg/day (taken from 2 weeks to 1 yr)
formula fed-enfacare or neosure
transition to regular formula at EDC-consider
sick infants with catch-up growth kept on formula until size is WNL for gest age
*transition to whole milk 12 mos after EDC
child vegetarian mngmt
lab assessment of b12, zinc, iron. Vit d may be necessary
variety of configurations of protein
b12-cereal, soy milk and nutritional yeast
ZINC-cheese, legumes and grains
obesity workup
bp
bmi
skin for acanthosis
lipids
glucose tol test
tsh, t4
metabolic panel
mngmt of obesity
goal- to normalize not reduce (prevent gain)
educate parents-healthy habits, increase physical activity, decrease high fat, sugary foods, portion sizes
increase fruit and veg, decrease juice and pop
tv <2 hrs per day
eat breakfast
exercise 1 hr per day
testing for food allergies
skin test
serum ige
patch test
rast
**food elim challenge -done under supervision of allergiest (stop for 2 weeks then reintroduce)
frontal lobe
parietal
temporal
occipital
parts of cerebrum (cortex-gray matter)
frontal-emotion, memory, judgement
parietal-language, reading, writing
temporal-memory, auditory, olfaction
occipital-visual
thalamus
hypothalmus
part of the diencephalon of cerebrum
thalamus-recieves and sorts sensory input
hypothal-integrates autonomic fxn
pons
medulla
cerebellum
hindbrain of cerebrum
pons-bridge
medulla-arousal
cerebellum-coordination, balance
parasympathetic vs. sympathetic
para-enervation results in slowed activity, active when a person is relaxed (acetylcholine-inhibits)

symp-fight or flight, when person is stressed (epi and norepi-excites)
degenerative vs. non degenerative neuro disorders
degenerative-affect the white or gray matter, lead to insults to major portions of brain, -loss of structure or fxn of neurons in brain or spinal cord

non- ie. CP, bells palsy, epilepsy
patho of seizures
misfiring of cortical neurons of brain
**called epilepsy when sx are recurrent and not r/t fever
differentiate btwn partial and generalized seizures
partial (focal)- originates in 1 part of brain, unilateral

generalized- involves entire brain, deep, LOC
types of partial seizures
simple-no LOC, no confusion, last 5-10 seconds, may have aura, shaking in localized area, numbness

complex- LOC, automatisms (lip smacking, chewing), lasts **1-2 minutes (can be several minutes), staring spell, aura, followed by confusion
types of complex partial sz
temp lobe-70% aura, oral or motor automatisms,contra-lateral twitching, 60-90 sec and post-ictal fatigue

frontal lobe- 20%, abrupts onset, vocalizations, humming, occurs surrounding sleep, complex mvmtns
Absence sz
generalized
no aura
LOC
onset and recovery brief
duration is <10 seconds
brief unresponsiveness and discontinuation of activity
may be triggered by hypoventilation
myoclonic sz
generalized
Brief <5 sec shock-like muscle contraction
clonic
generalized
rhythmic, repetitive muscle contractions
most often arms
impaired consciousness
tonic
generalized
sustained muscle contraction
several seconds
abrupt onset and return to baseline
atonic
generalized
abrupt loss of tone
1-2 seconds
loc but quickly recovered
tonic clonic
can include a long prodrome (irritable, HA)
muscle contractions lead to fall
LOC
tonic phase last 10-30 sec apnea, cyanosis
clonic 30-60 sec, jerking then becomes limp
may have agitation and confusion
symptomatic sz
provoked
occurs with CNS insult
infection, brain injury, stroke, med withdrawal, drugs
first unprovoked sz eval and mngmt
eval-EEG
labs based on individual circumstances
toxicology considered if questionable exposure
LP little value
MRI if cognitive or motor impairment, focal sz, under 1 yr of age or abnormality on exam
Emergent MRI if post ictal deficits

tx: no meds needed unless EEG abnormal
no activity restrictions (same safety precautions)
diastat not needed
only 50% chance of recurrance
febrile sz (simple vs complex)
simple
generalized tonic-clonic
resolve 10 min
return to normal alert status- immed followed by sleepiness and confusion
doesn't recur
fever over 38
complex- doesn't meet above (longer than 15 min, focal)
assessment of febrile sz
hx: recent illness, abx, duration, fam hx, imms

test: LP for meningeal signs, consider if imms not UTD, option for child with pretreatment of abx
labs not necessarily needed
MRI- no
EEG-no unless complex febrile sz
diastat-not needed
evaluation of epilepsy
EEG
MRI-indicated for focal epilepsy, optional for generalized forms
treatment of epilepsy
50% need 1 med
30% poly meds

Partial- trileptal (may use tegretol, phenobarb, dilantin)
Generalized-
tonic/clonic (depakote, topamax, phenobarb and dilantin)
absence-zarontin, lamictal, depakote
atonic-topamax
myoclonic- depakote, lamictal, keppra **do not give dilantin
surgery-used for intractable partial epilepsy
ketogenic diet-increase fat, lower protein and carbs
VNS-pacemake device attached to vagal nerve
how to proceed through a neuro exam
cerebral fxn first: behavior and mental status, language, speech, memory
cranial nerves
motor fxn- gait, balance, strength, symmetry, tone
sensory-pinprick
reflexes-dtr, primitive, superficial
cranial exam-HC
meningeal signs- kernig and brudzinski
When to do imaging with HA
abnormal neuro exam
finding indicating IICP-papilledema, nystagmus, motor or gait dysfunction, sz, loc change
consider with-recent onset severe HA, change in type of HA or neuro dysfxn
patho of migraine
excitability of cerebral cortex
waves of depolarization
inflamm of meningeal vessels
migraine with aura (general description)
most common
prodrome-mood change, irritable, lethargy
begins gradually with local mod to severe pounding pain
assoc with photophobia, phono, nausea, vomiting, abd pain
lasts hrs to day 6-8x/mon
migraine w/o aura (general description)
child-has after school
tween-lunchtime
teen-morning HA
dx criteria migraine with aura
ha lasts 1-72 hrs
at least 2:
unilateral (may be bilat)
pulsing
mod to severe
aggrevated by activity
with:
n/v
photo or phonophobia
no other disorder contributing
at least 5 attacks
*may have visual disturbances before HA
red flags for migraine auras
sudden images
complex visual perceptions *not just shapes
transient visual obscurations
bizzarre visual illusions (can be sz)
presenting symptoms of secondary headaches
worse in am on awakening then fades
increase in frequency and severity over a few weeks
wakens from sleep
vomiting s nausea/relieves ha
visual distrubances-diplopia
increase with straining
occipital pain
personality/behavior changes
sz
unsteady
fever
persistent unilateral HA
abnormal dtr's
basilar migraine
attacks of dizziness, vertigo and visual distubances followed by HA
childhood periodic syndromes
cyclic vomiting-sterotypical onset, duration 24-48 every 2-4 weeks- outgrow by 10

abdominal migraine- epigastric pain for 1-72 hrs, moderate to severe, well btwn

benign vertigo- abrupt episode of unsteadiness, resolves with sleep
tx of migraine
rescue-NSAIDS
abortive- triptans
antiemetics

prophy-depokote, topamax, neurontin, elavil
beta blockers, cyproheptatidine
cam-botox, herbs, magnesium and riboflavin
behavior-avoid caffeine, regular meals, exercise, fluids. cheese and citrus, chocolate
tension headache criteria
30min to 7 days
at least 2:
bilateral
pressing/tightening
mild to mod
no n/v
not both photo and phono
no other cause
10 episodes for 3 mos 1-15d/month
cluster
uncommon in kids
unilateral
pain in bursts 30-90 min several times per day
hurts to lie down
stabbing
occurs after falling asleep
pseudotumor cerebri
mostly femle
global daily pounding ha
papilledema
patho-impaired csf reabsorption
causes-prg, meds, vita A intox, SLE, obesity, endocrine diseases
macrocephaly
2sd above mean
may be genetic
can be from hydrocephaly, subdural hematoma, tumor
microcephaly
hc 2 sd below mean
normal shape
may have delayed development and neuro probs
cause-disease process that interferes with brain growth or brain never formed correctly
craniosynostosis vs. plagiocephaly
plagio-paralellogram
cranio-may be present at birth, less frontal asym,* ear displaced posteriorly (instead of anteriorly) sagital syno- presents as long narrow head and *palpable bony ridge
mngmt of plagiocephaly
tummy time
reposition on mattress
toys on side of limitation
neck exercises with diaper change
helmet-after 6 weeks of repositioning
refer if: unclear dx, severe asym, refractory with position change after age 4-6 mos
strongest identifiable predisposing factor for asthma
atopic diseases:
allergy
eczema
factors associated with development of asthma
allergy
fam hx
tobacco
male gender
low birth wt
patho asthma
immune response that results in edema and inflam or airway
leads to brochoconstriction
mucous plugs
bronchospasm
asthma triggers
smoke
viral infxn
exercise
dust
animals
cockroaches
molds
cold air
stress
diagnosing asthma
*show episodic hyper-responsiveness
*airway obstruction partially reversible

spirometry gold standard- fvc deep breath, fev1 force for 1 sec
*therapeutic trial with meds can help diagnosis in younger (along with PE and hx)
conditions that complicate asthma
GERD
sinusitis
sleep apnea
additional studies for asthma
o2 sat
allergy testing
sweat test
exercise challenge
asthma management goals
regular monitoring
control triggers
meds
education
(prevent exacerbations, normal activity levels, prevent troublesome symptoms)
SABA'S
Relaxes bronchial smooth muscle-dilates
relief for acute symptoms
atrovent
anticholinergic
bronchodilator
not as effective as saba
slower onset
peak 30-90 min
signs of poor asthma control or need for step up
using rescue>2x/week
oral steroids >2x/yr
oral steroid for asthma
anti-inflam
tapering not necessary unless >10 d
speed resolution of mod to severe exacerbations
prednisolone 1-2mg/kg/day
inhaled steroids for asthma
most effective for long term control
qvarr
pulmicort
flovent
asmanex

monitor ht, rinse mouth after, reduce need for quick relief meds
leukotriene antagonist (ltra)
singulair
alone or in combo with ics, or ics/laba
alternative for step 2,3,4
Long acting b agonist
must combine with ICS or LTRA
relax bronchials for 12 hrs
advair approved down to 4
classify asthma severity for 0-4 year old
inter- no night wake, saba<2/wk, no prob with act

mil-1-2/mon night symp, saba>2/week, minor lim, steroids >2x in 6 mon

mod- 3-4 night wake, daily use of saba, mult steriods, limits on fxn

severe-1/wk night wake, saba several x per day
classify asthma severity for 5-12 and up
inter- <2 night wake, <2d/wk saba use, fev >80
mild- 3-4mon wake, saba >2x/wk, minor limits adl's
mod- 1/wk night wake, daily symptoms and saba, FEV 60-80
severe- nightly awake, saba several times/day, limited adl's, <60% predicted
mild acute exacerbation of asthma
wheeze
increased rr
no resp distress or cyanosis
normal sentences
mod acute asthma exacerbation
aud wheeze
accessory muscles
3-5 words
severe acute asthma episode
cyanosis
nasal flare
supra sternal retractions
agitation
1 word
loud wheeze on inhale and exhale