W: Primary And Acute Care Pediatrics

Front 1

Primary vs. Secondary vs. Tertiary Prevention

Back 1

Primary: actions to reduce adverse outcomes by reducing risk exposure

Secondary: prevention of adverse outcomes in asymptomatic patients who already have a disease (ie: screening growth, development, vitals, hearing, vision, etc.

Tertiary: actions to maintain function, limit disability or progression of disease in symptomatic patients with specific disorders

Front 2

Folic Acid in Pregnancy

Back 2

0.4mg (400mcg) or 4mg in women with other children with NTD

Front 3

Fetal Alcohol Syndrome: char by

Back 3

1. prenatal and post natal growth deficiency
2. mild to moderate MR
3. Microcephaly
4. Infantile irritability
5. Characteristic facial features

Front 4

Fetal Alcohol Effects: char by

Back 4

1. ADHD
2. Fine Motor Impairment
3. Clumsiness
4. subtle delays in motor performance
5. speech disorders

Front 5

HIV ppx in pregnancy: Mothers and Infants

Back 5

Mothers: PO Zidovudine 300mg BID or 200mg TID at 14-34wks), then IV Zidovudine (1mg/kg/hr) throughout L&D.

Infants: PO Zidovudine 2mg/kg q6H for the first 6weeks of life

Front 6

Postpartem Infectious ppx in the Newborn
1. Hemorrhagic Disease of the Newborn
2. Funiculitis or Omphalitis
3. Opthalmia Neonatorum
4. NSVD untreated gonorrhea
5. HBsAg+ Moms

Back 6

1. HDN: 0.5-1.0mg vitamin K (phylloquinone) IM
2. Omphalitis: triple dye (=broad spec abx effective ag. MRSA)
3. ON: erythromycin or tetracycline ointment
4. Gonorrhea NSVD: Single IM injection CTX
5. HBsAg+: HBIG + Vaccine

Front 7

IPV Vaccine

Back 7

IPV promotes some mucosal immunity, not as much as OPV.

IPV is safe in immunocompromised pts or household contacts and when there's an adult household contact who is known to be inadequately vaccinated against polio

Front 8

OPV Vaccine

Back 8

OPV off US market dt vaccine-associated poliomyelitis

Vaccine of choice for global eradication, esp. where wild-type poliovirus still exists, and when inadequate sanitation makes mucosal immunity paramount

May be administered to immunocompetent individuals at 3rd and 4th dose before visiting a polio-endemic country, or to control a polio outbreak

Front 9

IPV dosing schedule

Back 9

D1, 2 @ 2mo, 4mo
B1, 2 @ 6-18mo, 4-6yo

Front 10

Hib Vaccine

Back 10

all Hib vaccines are conjugates of Hib capsular polysaccharide and a carrier protein

Front 11

Hib dosing schedule

Back 11

D1, 2, 3 @ 2mo, 4mo, 6mo
B1 @ 12-15mo

Front 12

MMR, VZV dosing schedule

Back 12

D1, 2 @ 12mo, 4-6yo (min 4 wks between doses)
can give on same day, but if not, must wait 4wks between MMR and VZV

Front 13

VZV vaccine in cases of non-immunized person exposure to chickenpox

Back 13

Recommended for:
non-immunized and susceptible patients within 3 days of exposure to an index case of chicken pox.

Front 14

Hep B vaccine in cases of HBsAg(+) pregnancy

Back 14

give initial dose + HBIG within 12 hours of birth

Front 15

Hep B in previously non-immunized teens

Back 15

11-15yo: 2 dose series, 4-6 months apart

Front 16

IVIG and measles vaccine

Back 16

IVIG interferes with immunogeniticty of measles vaccine

Front 17

Measles Vaccine and PPD

Back 17

MMR interferes with tuberculin reactivity. If not performed before or at the time of vaccine, defer PPD for 4-6 weeks.

Front 18

Vaccines in congenital immunodeficiency?

Back 18

live-bacteria and live-virus vaccines are contraindicated

Front 19

Corticosteroids and Vaccine

Back 19

If received high doses of CS (2mg/kg/D or >20mg/day for weight >10kg) for 14 days or more should not receive live-virus vaccines until steroid Rx dc'd for at least 1 month

When a lower dose or shorter duration of therapy is used, there is no contraindication

Front 20

the following are NOT contraindications to vaccines

Back 20

1. Mild acute illness with LG fever or mild diarrheal illness
2. current abx or convalescent phase of illness
3. reaction to previous DTaP dose involving soreness, redness, swelling, temp <105 (40.5)
4. Pregnancy of mother or household contact
5. Breast-feeding
6. Allergies to PCN or any other abx (except anaphylactic to neomycin or streptomycin
7. FHx of adverse event after vaccination

Front 21

Body Composition in Utero and Term, Puberty

Back 21

In Utero - H2O is 96% embryonic weight

Term - H20 is 70% body weight, fat is 25%

At Puberty - Skeletal Muscle is 45% of body weight

Front 22

Caloric Requirement (based on body weight)

Back 22

Neonatal Period - 120kcal/kg to support metabolic needs and growth

Thereafter:
100kcal/kg for initial 10kg, 50kcal/kg for next 10kg, 20kcal/kg for the next 50kg.

Front 23

Breastmilk decreases incidence of what diseases?

Back 23

1. NEC
2. diarrhea
3. LRTI
4. AOM
5. bacteremia +/- meningitis
6. UTI.
7. ? IDDM
8. ? IBD
9. Atopic disease (eczema, asthma)

Front 24

Nutritional Composition of Breastmilk

Back 24

6% protein
54% fat
40% carbs

Protein:
80% Whey / 20% Casein

Fat: Polyunsaturated fat, cholesterol

Carb: lactose

Front 25

Iron in breastmilk

Back 25

Iron content is lower than cowsmilk, but high bioavailability due to lactoferrin. No supplementation necessary unless iron stores are low

Front 26

Vitamin D in breastmilk

Back 26

lower than cowsmilk. supplement all exclusively breastfed babies

Front 27

Strict Vegans and breastmilk - what are the deficiencies

Back 27

vitamins B6 and B12 (found only in animal protein sources). Also at risk for riboflavin, vitamin D, and mineral deficiency states.

Front 28

Absolute Contraindications to Breastfeeding

Back 28

1. HIV or HTLV
2. Active TB
3. HSV localized to the breast
4. galactosemia
5. maternal use of recreational drugs (amphetamines, marijuana, phencyclidine, opiates other than methadone, chemotherapy, radioactive drugs, ergot alkaloids, iodides, lithium, atropine, cyclosporine, Abx: chloramphenicol and metronidazole?)
6. environmental toxins: DDt, methyl mercury, polychlorinted biphenyls (PCBs)

Front 29

Relative Contraindications to Breastfeeding

Back 29

Hep B is no post-exposure ppx given; Hep C if bleeding or cracked nipples

Front 30

Infants who feed sufficiently should..

Back 30

1) not lose >10% BW
2) urinate at lease 6x/day
3) pass 3-4 stools within 24hrs
4) regain BW by 10-14 days life

Front 31

Weaning from the breast at or after 6 mo and before 12mo should not include cows milk because...

Back 31

increased risk iron-deficiency anemia (poor absorption of iron from cow's milk)

Front 32

Fluoride Supplementation - When is supplementation required?

Back 32

B/W ages of 6mo-3yo: only if water supply is severely deficient (contains <0.3ppm) or a ready-to-feed formula without fluoride is used exclusively.

Supp Fluoride is also recc for older children beginning at age 3 if fluoride concentration in drinking water is B/W 0.3-0.6ppm.

Front 33

What is the amount of fluoride supplementation recommended if fluoride concentration in community drinking water is >0.6ppm?

Back 33

>0.6ppm (1ppm = 1mg/L)
0mo - 6mo: none
6mo - 3yo: none
3yo - 6yo: none
6yo - 16yo: none

Front 34

What is the amount of fluoride supplementation recommended if fluoride concentration in community drinking water is <0.3ppm?

Back 34

<0.3ppm
0mo - 6mo: none
6mo - 3yo: 0.25mg/day
3yo - 6yo: 0.5mg/day
6yo - 16yo: 1.0mg/day

Front 35

What is the amount of fluoride supplementation recommended if fluoride concentration in community drinking water is 0.3 - 0.6ppm?

Back 35

0.3 - 0.6ppm
0mo - 6mo: none
6mo - 3yo: none
3yo - 6yo: 0.25 mg/day
6yo - 16yo: 0.5 mg/day

Front 36

Recommended Amount of fluoride intake at different ages

Back 36

0mo - 6mo: none
6mo - 3yo: none
3yo - 6yo: 0.25 mg/day
6yo - 16yo: 0.5 mg/day

(so if water contains <0.6ppm, then need to supplement)

Front 37

Volume - breastmilk or formula intake in the first 3 months of life

Back 37

20kcal/oz or 67kcal/100mL

150-200ml/kg per day providing 100-135kcal/kg per day

Front 38

Protein Requirements in Infancy

Back 38

FT infants require 2-2.5g/kg/d duirng first few months of life
Decreasing to 1.5g/kg/d by age 6 months.

90% of protein ingested by infants is incorporated into tissues, the end products of protein metabolism do contribute to the renal solute load.

Front 39

Protein content of Modified Cow's Milk Formulas vs. Breastmilk

Back 39

50% higher in formula than in human milk.

Front 40

Two classes of protein in human milk/formulas...

Back 40

Whey = acid soluble, produces small curds.
Casein = acid insoluble and produces large curds

Front 41

Whey: Casein Ratio in Formula vs human milk...

Back 41

Formula --> 20:80
Human Milk --> 70:30

Front 42

Characteristics of Whey-predominant formula-fed infants

Back 42

Whey - have higher blood levels of threonine, valine, methionine, phenylalanine, leucine, and isoleucine compared with infants fed human milk.

Front 43

Characteristics of Casein-predominant formula-fed infants

Back 43

Casein - have higher blood levels of tyrosine, phenylalanine, valine, and methionine compared with infants fed human milk

Front 44

Taurine

Back 44

the largest source of nonprotein nitrogen in human milk and important in retinal development is added to all formulas

Front 45

The higher proportion of whey in human milk is beneficial for infants because...

Back 45

1 - compared to casein, whey is more easily digested and is associated with more rapid gastric emptying
2 - the whey protein fraction provides lower concentrations of potentially deleterious amino acids that may interfere with brain development

Front 46

Other benefits of human milk over formula:

Back 46

human milk has higher levels of CYSTINE (needed to synthesize the antioxidant glutathione) and TAURINE (needed for bile conjugation and brain development) than bovine milk

Front 47

Benefits of the major human whey protein vs. bovine

Back 47

Human whey composed of lactoferrin, secretory IgA, and lysozyme (improves host defenses) + alpha-LACTALBUMIN

the predominant whey protein in cow's milk is beta-LACTOGLOBULIN (which may contribute to milk protein allergy and colic)

Front 48

Nitrogen content of human milk vs. bovine milk

Back 48

human: ~20% of total nitrogen is in the form of nonprotein nitrogen-containing compounds such as nucleotides, free AA, and urea.

Nucleotides represent 2-5% of the nonprotein nitrogen in human milk and are lacking in bovine milk. (nucleotides are important for GI, immune, and metabolic fxns (enhance development of intestinal villi and immune development by promoting T-lymphocyte maturation)

Formula has <5% non protein nitrogen.

Front 49

Lipid (fat) in human milk

Back 49

Lipids represent ~50% of the calories in human milk

Front 50

Cow's Milk Fomula Lipid Content

Back 50

contains lipids in the form of vegetable oils (soy, corn, coconut, safflower, and palm) or a mixture of vegetable oil and animal fate, which account for 40-50% of the total energy content. Balance of saturated and polyunsaturated fatty acids of variable chain lengths.

Human milk - enhanced lipid absorption

Front 51

Cholesterol in formula vs. human milk

Back 51

formulas prepared with vegetable oils have littelt o no cholesterol compared with breastmilk with have 10-15mg cholesterol per 100mL

Front 52

How does formula compensate for better lipid absorption of human milk?

Back 52

To match the overall lipid absorption from human milk, formula has a greater quantity of passively absorbed MCFA than human milk. (so MCFA decreases the content of LCFA in formula compared to human milk.)

Front 53

What important Fatty Acids are lacking in cow's milk formulas but present in breastmilk?

Back 53

cow's milk formulas lack omega-3 and omega-6 fatty acids along with their long-chain polyunsaturated derivatives, including arachadonicand (AA) and docosahexanoic acids (DHA), which are present in human milk and may be important for optimal cognitive and visual development, esepcially in preterm infants. (cow's milk formulas are now supplemented)

Front 54

Consequences of lactose in human milk for the infant...

Back 54

softer stools, nonpathogenic bacterial fecal flora, improved mineral absorption.

Front 55

Benefits of lactose...

Back 55

helps promote calcium absorption from the GIT.

Front 56

Lactose Content in Breastmilk

Back 56

40% total calories

Front 57

Mineral concentrations in formula vs. human milk

Back 57

mineral content in formula usually exceed human milk with the exception of sodium. Mineral content of formula also contribute to renal solute load. Formula is also supplemented with water and fat-soluble vitamins, as well as iron.

Front 58

Soy Formulas - benefits

Back 58

the equivalent to lactose-based formula in supporting linear growth, bone mineralization, and weight gain in TERM infants.

Front 59

Who should NOT receive soy formulas

Back 59

not recommended in premies and infants <1800g; (+) association with osteopenia

Should NOT be used to prevent colic or atopic disease or as an alternative formula for infants with documented cow's milk protein-induced enterocolitis

Front 60

Soy milk vs. cows milk based formula

Back 60

Soy requires added methionine (bc it is lacking). Carbohydrate source = sucrose or constarch hydrolysates or a combo.

Front 61

When should iron supplementation begin in exclusively breastfed infants?

Back 61

by 6mo

Front 62

Extensively-Hydrolyzed Protein Hydrolysate Formulas - Benefits

Back 62

- carbohydrate source is not lactose (lactase not required to absorb carb)
- contain varying amts of MCTG (bile salts not needed for absorption)
- contains free AA and peptides of varying lengths
allows for absorption from GIT following degredation by BB enzymes w/o need for pancreatic proteolytic enzymes

Front 63

Extensively-Hydrolyzed Protein Hydrolysate Formulas - Cons

Back 63

- may have poor tolerance bc osmolality is high
- result may be net water flux interfering with nutrient and/or water absorption, or diarrhea