Pediatrics

Front 1

 There is a high prevalence of ADHD in school-age populations:
______% of school-aged children
9 % of males
3% of females
 Estimated 30 million children 6-12 years old in US
1,800,000 to 3,000,000 6-12 year olds with ADHD
 9.7 million physician office visits in 2001
 30- 50% of mental health referrals for children

Back 1

6 - 10%

Front 2

a behavioral syndrome of uncertain etiology consisting of a cluster of behaviors that are not abnormal in and of themselves, and occur on a continuum

Back 2

ADHD

Front 3

what are the two core symptoms of ADHD?

Back 3

inattention
hyperactivity/impulsivity

Front 4

Does Treatment of ADHD with Stimulant Medications Lead to Later Substance Abuse?
Meta-analysis examining impact of early medication treatment for ADHD in childhoods on subsequent substance abuse in teens and young adults showed that stimulant med therapy significantly __________ (increased or decreased?) risk for substance abuse

Back 4

decreased

Front 5

What are the only 2 EBM tx for ADHD?

Back 5

stimulant medication and/or behavior therapy to improve target outcomes

 FDA-approved
 Stimulants
• Methylphenidate (generic, Ritalin, Ritalin SR, Ritalin LA, Concerta, Metadate, Focalin)
• Dextroamphetamine (Dexedrine, Dexedrine spansules, Dextrostat)
• Dextroamphetamine/amphetamine salts (Adderall, Adderall XR)
 Nonstimulants
• Atomoxetine (Strattera)
 Off-label (Not FDA-approved but some research suggests possible benefit)
 Tricyclic antidepressants, bupropion (Wellbutrin), venlafaxine (Effexor), clonidine

 Stimulants 1st line drugs in most case
 Consider atomoxetine in teens w/drug abuse concerns
 Otherwise, atomoxetine considered 2nd line after unsuccessful stimulant trial
 Methylphenidate generally first choice over amphetamines- slightly favorable side effect profile

Front 6

This is the most common preventable cause of mental retardation:

Back 6

fetal alcohol syndrome

Front 7

These may be caused by metabolic, traumatic, anoxic, or infectious insult to the brain:

Back 7

seizures

Front 8

This term is used when seizures are reported and have no evident cause:

Back 8

epilepsy

Front 9

When is the incidence of seizures the highest?

Back 9

• The incidence of seizures is highest in the newborn period; It is higher in childhood than in later life

Front 10

• The chance for a child to have a second seizure after having an initial seizure is __%
• The chance of having a remission from epilepsy in childhood is ___%

Back 10

• The chance for a child to have a second seizure after having an initial seizure is 30%
• The chance of having a remission from epilepsy in childhood is 50%

Front 11

• __________ seizures most often appear between the ages of 4 and 16 and are only classified as ________ when all other causes are ruled out.

Back 11

• Idiopathic seizures most often appear between the ages of 4 and 16 and are only classified as idiopathic when all other causes are ruled out.

Front 12

• The younger a child is, the more likely we will find the cause of his or her seizures
o Key to diagnosis is the _________

Back 12

history

Front 13

a nonepileptic phenomenon that can mimic a seizure:

Back 13

pseudoseizure

Front 14

a warning that the seizure is coming; may or may not precede the seizure
o Feeling fearful, numbness, tingling in fingers, bright lights

Back 14

aura

Front 15

o Feeling of unwellness, or a premonition that something is going to happen
o Can also be a recurrent thought for minutes to hours before the aura and before the seizure

Back 15

prodrome

Front 16

A clinical or electrical seizure lasting AT LEAST 30 minutes OR a series of seizures without complete recovery for AT LEAST 30 minutes
oThis is a MEDICAL EMERGENCY
oFebrile seizures RARELY present as this.

Back 16

status epilepticus

Front 17

What do these have in common:
Hypoxia, Acidosis, Depletion of energy stores, Cerebral edema, Structural damage, Fever, Hypotension, Respiratory depression, Death.

Back 17

these can occur after 30 minutes of seizure activity

Front 18

What is this?
 Criteria:
 Patient is age 3 months to 5 years old
 Patient has a fever of GREATER than 38.8 degrees Celsius or 101.8 degrees Fahrenheit
 Patient DOES NOT have a CNS infection. Big rule out is meningitis.
 Most occur between ages 6 months and 18 months of age

Back 18

febrile seizure

Front 19

More than 90% of febrile seizures are: generalized or partial?

And most last less than _____ minutes?

Back 19

generalized

five

Front 20

 Usually occur during the early phase of the illness that is causing the fever
 Occur in 2-3% of children
 Family history of febrile seizures is common
 Causes of febrile seizures:
 Acute respiratory illness
 Gastroenteritis, especially caused by Shigella or Campylobacter
 Urinary tract infections
 Immunizations
 Roseola infantum:

Which of these is by far the most common and which of these is rare, but classic cause of febrile seizures?

Back 20

acute resp illness is the most common cause

roseola infantum is rare for a classic cause

Front 21

 A cause of gastroenteritis in children
 Shigellae are nonmotile gram-negative rods
 Closely related to E coli
 Characterized by cramps, bloody diarrhea, high fever, malaise, seizures
 Pus and blood in stools on microscopic exam
 Diagnosis is made by stool culture

Back 21

Shigella

can cause febrile seizures

Front 22

 Small gram-negative bacilli that causes enteritis
 Colonizes in domestic and wild animals, especially poultry
 Common routes of transmission: contaminated food and water, improperly cooked poultry, fecal-oral transmission human to human
 Characterized by fever, vomiting, abdominal pain, diarrhea
 Associated with febrile seizures
 Definitive diagnosis is by stool culture

Back 22

Campylobacter

Front 23

 Rare but classic cause of febrile seizure
 Also called Exanthema Subitum
 Benign illness caused by herpes virus
 Fever to 105 degrees F in a mildly ill child
 When fever abruptly ceases, a characteristic rash appears
 Occurs in children aged 6 months to 3 years
 Causes febrile seizures in ___% of children

Back 23

Roseola infantrum

10%

Front 24

simple or complex febrile seizure?

lasts less than 15 minutes and shows no lateralizing (or localized) signs;
if more than one seizure occurs in a brief period,
the total episode lasts no more than 30 minutes

Back 24

simple

Front 25

simple or complex febrile seizure?

lasts more than 15 minutes and MAY have lateralizing signs;
if several seizures occur,
the whole episode may last longer than 30 minutes

Back 25

complex

Front 26

 There is a higher chance that febrile seizures will lead to epilepsy later in life IF:
 The febrile seizures have complex features
 Last longer than ____ minutes
 More than one seizure in the same day
 Seizure has focal features
 There is a history of abnormal neurological status before the febrile seizures (ex: mental retardation or cerebral palsy)
 Onset of febrile seizures was before what age?
 There is a family history of epilepsy

Back 26

 There is a higher chance that febrile seizures will lead to epilepsy later in life IF:
 The febrile seizures have complex features
 Last longer than 15 minutes
 More than one seizure in the same day
 Seizure has focal features
 There is a history of abnormal neurological status before the febrile seizures (ex: mental retardation or cerebral palsy)
 Onset of febrile seizures was before 1 year of age
 There is a family history of epilepsy

Front 27

• How often do febrile seizures lead to epilepsy in later childhood or adult life when…
o There are no associated adverse factors?
o There are adverse associated factors?

Back 27

• How often do febrile seizures lead to epilepsy in later childhood or adult life when…
o There are no associated adverse factors? 1-2%
o There are adverse associated factors? 15-20%

Front 28

Are these helpful in the work up of febrile seizures?
• Serum electrolytes, serum glucose, serum calcium, skull radiographs, and brain imaging studies

Back 28

NO!

Front 29

• MUST do thorough physical examination for febrile seizures
o MUST RULE OUT __________!!!!!!!!!!!!!!!!!!!!!!

Back 29

MENINGITIS

Front 30

o Children with _______ can present with fever and seizure
o Typical signs of _______ in a child (bulging fontanelle, stiff neck, stupor, irritability) MAY ALL BE ABSENT, especially if child is < 18 months old
o A white count of > 20,000 MAY correlate with bacteremia
o CBC
o Blood cultures
o Serum sodium: often slightly low but NOT enough to need treatment or to have caused the seizure

Back 30

meningitis

Front 31

true or false?
• The younger the child, the more important the spinal tap because symptoms aren’t as obvious in younger infants.

Back 31

true

Front 32

What are these recommendations for?
o If child is younger than 18 months old
o If the child is slow to recover from the seizure
o If no other cause of the fever can be found
o If close follow-up is not possible
o A negative ______ DOES NOT rule out the possibility of meningitis occurring during this febrile illness
o Sometimes a second _________ must be done

Back 32

spinal tap

Front 33

 Prophylactic _________ are NOT required after an uncomplicated febrile seizure
 They can be used if the seizure is complicated or prolonged
 May reduce incidence of febrile and nonfebrile seizures
 One therapy: Diazepam at first onset of fever, and throughout the febrile incidence
 Can also use phenobarbital
 Phenytoin and carbamazepine have NOT shown effectiveness in preventing febrile seizures

Back 33

anticonvulsants

Front 34

what do these have in common?
 Sponging or tepid baths
 Antipyretics (Tylenol, Motrin)
 Antibiotics for proven bacterial infection
 All of the above are reasonable and useful, but have NOT been shown to prevent recurrent _______

Back 34

non-medical tx for febrile seizures

Front 35

 Simple febrile seizures have NO long term adverse consequences
 ____ is usually normal in an uncomplicated febrile seizure
 If the febrile seizure is complicated or unusual, perform an ____
 Abnormalities will be found in 22%
 The older the child, the more helpful the ____
 The ___ should be properly timed

Back 35

EEG

Front 36

The most appropriate time to perform an EEG on a pediatric patient who had a complicated febrile seizure is:

Back 36

At least a week after the illness has resolved
(You want to avoid picking up any transient changes due to the fever or due to the seizure itself)

Front 37

What do these have in common?
 Breath-holding attacks
 Tourette syndrome/tics
 Night terrors/nightmares
 Migraines (confusional state)
 Shuddering/shivering (may be forerunner of essential tremor later in life)
 Temper tantrums
 Staring spells
 GERD

Back 37

non-epileptic events that can mimic seizures

Front 38

Seizure Treatment
 Ideal treatment is to correct the specific cause

True or false:Even when a biochemical disorder, tumor, meningitis, or other cause is treated, anticonvulsant drugs are still required

Back 38

True

Front 39

 Summary: an otherwise normal 2-year-old boy with a family history of seizure in his father, has a brief, generalized, self-limited seizure associated with an elevated temperature. His examination is normal. He has completely recovered within 2 hours of the seizure.
 What is the most likely diagnosis? Simple febrile seizure
 Best management is to Educate parents about seizures, Controlling a fever in a child, injury prevention during a seizure
 Expected course:
 Child is likely to “grow out” of this condition by age ___
 Child may have more seizures with fevers
 He is not likely to have any sequelae from seizure
 Expect him to have normal development

Back 39

age 5

Front 40

nightmare or night terror?

Having recurring extremely frightening dreams
Feeling threatened by the content of the dreams
Detailed memories of the dream that are hard to erase from the mind
Usually occur in the latter half of the sleep period

Back 40

nightmare

Front 41

nightmare or night terror?

Recurring abrupt arousals from sleep
Usually occur earlier in sleep , often in the first third of the sleep period
Screaming
Intense fear
Rapid breathing and heartbeat
Sweating
No response to efforts to comfort the dreamer
No recall of the episode in the morning
No medical or mental cause for these episodes

Back 41

night terror

Front 42

What % of preschool children have developmental or behavioral problems?

Back 42

16%

mental retardation 25/1000
learning disability 75/1000
ADHD 90/1000
autism 3/1000

Front 43

what are the ages for early diagnosis of visual and hearing impairment?

What are the ages of early diagnosis for autism

What are the ages of early diagnosis for learning disabilities?

Back 43

visual and hearing 0-12 months

autism: 1 - 3 years

learning disabilities: 2 - 4 years

Front 44

any boy not walking by 15 months should get a CPK to rule out?

Back 44

muscular dystrophy

Gauer's sign
CPK >20 normal

Front 45

What is the best predictor of later cognitive function?

Back 45

language

early intervention yields best outcomes

Front 46

understands "no"

Back 46

9 - 11 months

Front 47

all children with a language delay should be referred for:

Back 47

a hearing assessment

Front 48

what does this indicate?

 A TRIAD of behaviors
Delayed and deviant social relatedness
Delayed and deviant communication
Restricted and repetitive stereotypic interests and activities

Back 48

autism

Front 49

 Calling another person’s attention to an object or event.
 Gaze monitoring
 Bringing to show
 Proto declarative pointing
If absent, most robust clue of autism!

Back 49

joint attention

Front 50

 A significant delay in 2 or more streams
 NOT a diagnosis
 NOT regression or loss of skills

Back 50

global developmental delay

Front 51

 2-3% of population
 Male 1.6 : Female 1
Most common genetic cause: Down Syndrome
Most common inherited cause: Fragile X
Most common preventable cause: Fetal alcohol

Back 51

mental retardation

Front 52

what level of mental retardation makes up the vast majority and is more common in boys

Back 52

mild: 85%

severe: is rare but the ratio between boys and girls is the same

Front 53

true or false?

the more severe the mental retardation, the more likely to find the etiology

Back 53

true

chromosome account for 40% of severe mental retardation

Front 54

what is the rule of 3's and 9's?

Back 54

head circumference

 Birth: 35 cm
 3 mo: 40 cm
 9 mo: 45 cm
 3 yrs: 50 cm
 9 yrs: 55 cm

Front 55

a common cause of both early and late sepsis:

Back 55

Group B streptococcus

early GBS sepsis: <5-7 days

late onset GBS sepsis: >5-7 days

Front 56

how is CMV diagnosed?

Back 56

urine culture

Front 57

 If you have _______, you typically don’t have pus on tonsils. You’ll have redness and palatal petechiae. If you have _____, you will have pus on tonsils.

Back 57

 If you have group A strep, you typically don’t have pus on tonsils. You’ll have redness and palatal petechiae. If you have mono, you will have pus on tonsils.

Front 58

these are caused by:
 Respiratory Infections
 Impetigo
 Cellulitis
 Necrotizing Fasciitis
 Streptococcal Toxic Shock Syndrome

Back 58

group A strep

Front 59

#1 cause of impetigo (honey colored crust)

Back 59

group A strep

Front 60

 Fever, butt hurts, and red ring around anus

Back 60

Streptococcal perianal cellulitis unique to children

Front 61

 A 3 year old child presents with pruritic, erythematous, well circumscribed perianal erythema for 3 weeks. He was treated 4 weeks ago with Septra for a sinusitis. Mom has observed blood in his stools. Which of the following would be appropriate management?

Back 61

 Obtain a surface culture and prescribe penicillin

Front 62

 Called to delivery of 32 weeker to a G1 who entered labor while ill with an influenza like illness. Infant rapidly develops shock and on the second day of life develops a papulopustular lesion on eryth base. Gram stain reveals G+ rods. Most LIKELY pathogen is:

Back 62

 Listeria Monocytogenes

Front 63

The presence of _____ or more minor anomalies is highly predictive of a major malformation (19.6%)
 Examples: bossing, absent hair whorl, anteverted nostrils, epicanthal folds, preauricular tags, pits, abnormal pinna of ears, bifid uvula, extra nipples, single umbilical artery, umbilical hernia, dimple over sacrum, single palmar creases, syndactyly, overlapping toes, recessed toes…..

Back 63

three

Front 64

Pits and tags
 1/100 –common!
 ALL need _____
 Renal US if:
– Other malformation
– FHx of deafness, ear or kidney issue
– Gestational DM

Back 64

hearing exam

Front 65

what test is required:

Sacral lesions
 Dimple – need if sacral is:
> 5 mm in size
> 2 cm away from anus
Associated with any other back lesion
-Hemangioma, hairy patch, tail, masses
 All hemangiomas, hairy patches, masses, tails (36% +)

Back 65

sacral neuro-imaging (US)