DR HY PEDS REVIEW

• Any neonate < 28 days old with fever must be hospitalized for safety & complete sepsis workup
o CBC, UA, urine cx, LP
• neonate who is between 0 to 3 months old and they have signs of infection (suspect PNA or meningitis)
o what are the MC bugs
o BEL
▪ Group B Strep
▪ E coli
▪ Listeria
o treat with ampicillin or gentamicin
• once they're older than three months & have sx of infx (suspect PNA & meningitis)
o what are the MCC (of PNA) 1. Strep pneumo
▪ Strep pneumo 2. H flu
3. N. meningitidis
▪ H flu
▪ Moraxella
o Treat with empiric antibiotics = vancomycin and ceftriaxone
• MENINGITIS
o CSF findings

India ink

IC pts; MC = cryptococcus neoformans.

tx w/ amphotericin
• TB is weird → high lymphocytes, low glucose
o basilar enhancement on brain imaging

• HSV meningitis has involvement of the temporal lobe as well as seizures

• SINUSITIS
• MOST are viral → supportive tx
• bacterial sinusitis
o Signs that sinusitis is bacterial
▪ if it's been over a week and the “viral” sinusitis is worsening/not improving
▪ purulent nasal discharge
o treat with antibiotics = amoxicillin
▪ covering the MC bugs:
• strep pneumo, H flu & moraxella
o these are MC for sinusitis, PNA, acute otitis media (AOM)
o complications
▪ Cavernous sinus thrombosis

• Infections starts to invade your venous sinuses → irritation of cranial nerves

o III, IV, V1, V2, VI → blurry vision or double vision
o If it seems to be progressing beyond just the sinuses and it seems to be getting
worse → GET HEAD CT
•
 • Upper respiratory tract infection
o MOST are viral → supportive tx (adequate hydration is key)
▪ Rhinovirus
▪ Mostly diagnosis of exclusion
o Presentation:
▪ Cough, runny nose, sore throat, +/- fever
• Diphtheria
o pharyngitis with the gray leather plaque in the pharynx (grey pseudomembrane)
o kid has no history of DTaP vaccine
o treat with diphtheria antitoxin
• Ear infections of childhood (very common)
o Acute otitis media
▪ Diagnose with otoscopy
AOM = kid’s pain is • Bulging erythematous TM
relieved when you ▪ Pneumatic insufflation (blow air against the eardrum) → very stiff
pull ear (this is why ▪ Presentation:
ear pulling is a sx) • fever and ear pain that is relieved with ear pulling
▪ Risk factors
Otitis externa =
hurts when you • smoking, bottle feeding
pull kid’s ear ▪ Treat with amoxicillin < augmentin (amox + clav)
o Otitis externa
▪ The TM will be fine; it's the ear canal that is inflamed and infected
• MCC = Pseudomonas
• Treat w/ antibiotic (FQ) eardrops
o Otitis media with effusion
▪ Otoscopy shows serious fluid with little bubbles behind the TM in the middle ear
▪ don't treat bc it is not infected; you just let it drain & pass
• Cervical lymphadenitis
o lymph node that is erythema painful and swollen (infected)
▪ MCC = staph aureus
o treat with either a first-gen cephalosporin or penicillin
• Parotitis
o BL → MUMPS
▪ Viral infection
▪ Preventable by MMR vaccine
▪ Can also cause meningitis, orchitis, pancreatitis
o UL → staph aureus impetigo
▪ kid who has like a honey crusted lesion around his mouth (extremely contagious)
▪ first-line treatment = muprocin
• Erysipelis vs cellulitis
Erysipelis Cellulitis
BOTH MCC BY STREP PYOGENES – BOTH TREATED WITH CEPHALOSPORIN OR PCN
o Rapid onset (over the course of 1 day) o Indolent infection (over the course of a few days)
o Sharp, well demarcated borders o Indistinct borders
o Dermal lymphatic infection (superficial infx) o Dermis & subQ infection (deeper infx)

• Necrotizing fasciitis
o 2 MCC = strep pyogenes and Clostridium perfringens
o Symptoms: hx of skin wound that looks a little red but when you touch it there is severe pain out of
proportion. May see hemorrhagic bullae. +crepitus (gas bubbles) → C perfringens infection
• Scarlet fever
o strep throat plus a sandpaper rash
▪ rash usually starts on the trunk and spreads to the limbs
• PSGN vs IgA nephropathy → both are nephritic
o PSGN starts off with strep throat and then two weeks later the kid will complain of cola colored urine (hematuria
& RBC casts)
▪ Cannot be prevented by treating strep throat with abx (unlike rheumatic fever)
o IgA nephropathy starts off with upper respiratory tract infection and then three to five days (less than 1 week)
later, the kid has hematuria
• Toxic shock syndrome
o MCC = staph aureus
o Patient’s history will include either: a nosebleed with packing that was in there too long or female who has had a
tampon in for too long
▪ This leads to septic shock because the staph aureus exotoxin stimulates the T cells to release a lot of
cytokines. There will also be desquamation of the skin.
o treat with IVF, antibiotics, remove inciting factor (tampon or packing)
• Gastroenteritis
o MCC = rotavirus and Norwalk virus → present in daycares & schools
▪ Rotavirus is more in the winter months
• vomiting and diarrhea (non-bloody, no WBC in stool)
• self-limited – supportive tx
▪ Norwalk virus (norovirus) → CRUISE SHIPS
• Vomiting & diarrhea (non-bloody)
• Inflammatory (BLOODY) diarrhea → first step in management = stool analysis: will show WBC in stool (indicating
inflammatory diarrhea). These patients might have fever.
o Campylobacter: eating raw chicken, Guillain Barre
o Enterohemorrhagic ecoli (EHEC): undercooked hamburger, HUS (do not give abx → will make worse)
o Salmonella: reptiles, raw eggs, petting zoos
o Shigella: SEIZURES, HUS
o Yersinia: PSEUDOAPPENDICITIS (+periumbilical → RLQ pain)
• Clostridium difficile
o Associated with taking broad-spectrum antibiotics → leads to opportunistic infection of CDiff (colonizes your
intestine and colon and it can cause pseudomembranous colitis)
▪ Pseudomembranous colitis = raised lesions in the colon and then they can mimic ulcers
o Treatment
▪ Classically: metronidazole or PO vancomycin
▪ What we actually do now: straight PO vancomycin
• Pneumocystis jirovecci
o opportunistic infection (AIDs or pts on immunosupressants)
o sx: dry cough with fever
▪ CXR reveals diffuse interstitial pulmonary infiltrates
o treat with TMP SMX
• infectious mono “the kissing disease”
o caused by epstein-barr virus (EBV)
▪ atypical lymphocytes (downey cells) on peripheral blood smear
o transmitted by saliva
o can present very similarly to strep throat → pharyngitis w/ exudates, posterior cervical LAD, +/- splenomegaly
▪ BUT mono has severe malaise → these kids will be very exhausted and tired
o treat this supportively because it's a virus – also avoid contact sports!
▪ if dr. thinks it is strep pharyngitis initially and gives amoxicillin → can cause a rash
• measles
o paramyxovirus
o vaccine preventable (MMR)
o initially presents with the four C's: cough, coryza, conjunctivitis & Coplik (Koplik) spots
▪ coryza = runny nose
▪ koplik spots = bluish ulcers on buccal mucosa
o then causes a rash a maculopapular rash that starts at the head and descends
 ▪ vs rubella, which also starts at the head then goes down but it does not have the 4C’s and rubella has
+joint pain
o treat with vitamin A
o complications
▪ pneumonia
▪ sspe (subacute sclerosing panencephalitis): a severe brain infection that can happen 10 years later on that
will be fatal
• Rubella
o Vaccine preventable (MMR)
o Rash that starts at the head then goes down plus +joint pain
o Dangers of rubella → if a mom gets rubella when pregnant then her kid the fetus is at danger for being born with
some congenital defects: cardiac defects (PDA & pulm stenosis) & cataracts, deafness, blueberry muffin baby
o supportive tx
• Aspergillus
o lung infection with EOSINOPHILIA
o 3 subtypes
▪ allergic bronchopulmonary aspergillosis (ABPA)
• presents like asthma (+wheezing), +/- hemoptysis, +/- fever but the key thing
is eosinophilia
• treat with steroids
Loves upper lobe of lung = ▪ systemic Aspergillus
TB, silicosis & aspergillus • hemoptysis, fever, night sweats, weight loss (kinda looks like
TB) but add in EOSINOPHILIA
▪ aspergilloma (fungal ball in upper lobe found on CXR)
• MC in pts with PMx of TB or silicosis bc they have cavities in UL of lung
• Entamoeba histolytica
o RUQ pain with diarrhea after pt travelled to south america
▪ Can form liver abscesses
o treat w/ metronidazole
▪ “GET GAP on the metro” → Giardia, Entamoeba, Trich, Gardnerella, Anaerobes, Protozoa
• Giardia
o Sx: Greasy, fatty, bulky stools
o Transmission: people who go hiking and drink contaminated spring water
o treat with metronidazole
• malaria
o recent travel to Africa with recurrent fevers (different malarial strains cause different cycling fevers)

Fever occurs when malaria

bursts out of RBC

▪ anopheles (female) mosquito

o attacks RBC → will see markers of hemolysis:
▪ anemia, elevated reticulocyte count and decrease haptoglobin
• Toxoplasma
o associated with cat feces and eating undercooked meat
o TORCH infection = dangerous to the unborn fetus in pregnant female
▪ although mom can have mild mono-like illness in fetus it is SEVERE and causes chorioretinitis,
hydrocephalus, intracranial (PARENCHYMAL) calcifications
• vs. CMV → microcephaly, periventricular calcifications, venticulomegaly, HSM, jaundice,
thrombocytopenia, sensorineural hearing loss
• enterobius vermicularis
o SEVERE ANAL ITCHING AT NIGHT
o dx: scotch tape test
o treatment: albendazole or pyrantel pamoate
• Strongyloides, ancylostoma and Makeda = hookworms
o Walking through the sand barefoot and then step on them → the worm will penetrate skin, goes into the lungs
and then you cough it up and then swallow it into GI system and it invades your GI lumen and this will cause iron
deficiency anemia dt chronic bleeding
o EOSINOPHILIA
o Treatment: - bendazoles (bc worms are bendy)
• Neurocystercercosis
o infestation of T solium eggs
o causes calcifications in the brain → seizures
• TICK BITES
o Rocky Mountain spotted fever
▪ Rickettsia Rickettsia
▪ attacks the vascular endothelium → rash that starts at extremities and moves inwards towards trunk
• Hemorrhagic rash dt attack on endothelium → inflammation and dilation of BV → anemia,
thrombocytopenia & sx of septic shock
▪ Treat with doxycycline no matter what age!
o ehrlichia
▪ attacks agranulocytes (monocytes & lymphocytes) → low WBC
o Anaplasma
▪ Attacks granulocytes (Basophils, neutrophils, eosinophils) → low WBC
o Lyme disease
▪ Erythema migrans (bullseye rash)
▪ Late manifestations include: Bells palsy, complete AV block, meningitis, arthralgias
▪ Treat with amoxicillin < 8 yo to avoid brown teeth, treat with doxycycline > 8 yo
o Babesia
▪ Attacks RBC (kinda like malaria)
• Evidence of hemolysis
• cat scratch disease
o bartonella henselae
▪ causes inflammation of a lymph node & its drainage proximal to the lesion
▪ treat with macrolides or doxycycline
• Tuberculosis
o latent TB
▪ presentation: when you do a PPD test → positive swelling. then you do CXR and it is negative.

▪ Treat with isoniazid 9 months

o active TB
▪ presentation: night sweats, fevers, weight loss, hemoptysis
▪ CXR: patchy reticulonodular opacities, parenchymal cavitary lesions that
prefers the upper lobes
▪ Treatment: RIPE = rifampin, isoniazid, pyrazinamide, ethambutol
• cardiology
o key to the clinical vignette: if the kid was given 100% O2 test and the PaO2 doesn't rise then that means it's a
congenital heart defect whereas if the PaO2 does rise up then that's a lung problem
o ASD = fixed, split S2
o Coarctation of aorta
▪ treat it initially with prostaglandin E until you can do surgery/balloon angioplasty to open up the
narrowed portion of the aorta → it has an excellent prognosis
• because distal to the coarctation there's not enough blood flow
o you want to keep PDA open to improve blood flow to the lower limbs (even though that
blood flow is hypoxemic it's better than having not enough blood)
o transposition of the great vessels
▪ aorta and pulmonary artery are switched
• aorta coming out of RV and pulm artery coming from LV
▪ treatment: only way to fix this is to do an arterial switch operation → need to give PGE to keep the PDA
open until surgery
 • allows the oxygenated blood from the L heart (pulm a) to go to the R heart (via the PDA) where it
can be pumped out to the rest of the heart via the aorta
▪ HY association = pregestational diabetes
o tricuspid atresia
▪ tricuspid valve doesn't open and doesn't work → so to survive the baby relies on
an ASD to go from R → L and then when it goes down to the LV → there are 2
different variants, in one there is VSD and in the other there is no VSD
▪ *Unique* bc it's the only cyanotic heart condition that has left ventricular
hypertrophy
o Cyanotic Right Now (cyanotic at birth, R → L shunts & they all have a single S)
▪ 4 T’s
• Transposition of the great vessels
o single s comes because the aorta is anterior and it drowns out the pulmonic valve so you
hear the aorta more (it's very loud)
• Tricuspid atresia
o single s because usually the pulmonic valve is atretic (too weak and doesn’t really make
noise)
• Truncus arteriosus
o single s because there is no separation between the aorta and pulmonary artery it's just
one giant pipe
o also, since there's excess flow to the pulmonary artery and all of its branches, these
patients develop PHTN easily
• Tetralogy of Fallot
o PROVe
▪ Pulm stenosis ****this is the main murmur****
▪ RVH
▪ Overriding aorta
▪ VSD
o TET spells: when these pts are crying or exercising they have decreased SVR → and since
there is such low pressure in the aorta, this can favor flow through the path of least
resistance across the VSD then up the aorta (R → L shunt) instead of going towards the
pulmonary artery.
▪ Child will turn blue.
▪ To counteract the Tet spell, they squat. This increases total peripheral
resistance (SVR) → increases the pressure over the aorta → favoring right-
sided blood from the right ventricle to travel through the pulmonary artery
instead of through VSD.
o Treatment: surgery
o any holosystolic murmur or any diastolic murmur is considered pathological
▪ NBSIM = echo
▪ Only three types of holosystolic murmurs
• MR
• TR
• VSD = MC congenital heart defect
o Remember: large VSD = quiet murmur but small VSD = loud murmur
• Random HY cardio
o only give prophylactic antibiotics for dental surgery if they've had some sort of congenital heart disease, if they've
have prosthetic heart valves or if they've had previous infective endocarditis
o fetus born with complete heart block → what is most likely wrong with the mother? the mother most likely has
lupus. And now the baby has neonatal lupus bc it passively acquired the autoimmune Ab from mom

• pulmonology
▪ Laryngomalacia
• caused by collapsed larynx cartilage – “omega shaped larynx”
o inspiratory stridor that is worse when supine bc the
cartilage collapses even more

upper airway obstruction → Stridor

lower airway obstruction → wheezing
▪ Vascular ring
• Dt anomaly of the aortic arch where it makes a ring around the trachea → chokes it off
o inspiratory and expiratory Stridor
o IMPROVES WITH EXTENSION OF NECK!
▪ croup
• MCC = viral (parainfluenza)
• Steeple sign on lateral cervical xray
• Clinical sx: seal bark cough with inspiratory stridor
• three tiers of treatment
1. cool mist if there is no stridor at rest & no respiratory distress
2. systemic steroids if there is + stridor at rest but no respiratory distress
3. racemic epinephrine if there is + stridor at rest and pt is in respiratory distress
• sometimes viral croup can progress to a bacterial tracheitis
o MCC = staph aureus
o Sx: fever, lots of mucus and pus in the trachea
▪ Atelectasis
• collapse of the lung
• CXR: can show up like opacities → can look like PNA
▪ Bronchiolitis
• MCC = RSV (respiratory syncytial virus)
• usually the kid (< 2 yo) starts w/ an upper respiratory tract infection
o runny nose, cough
• then progresses to a PNA/asthma-like presentation w/ wheezing, tachypnea and +/- crackles
• CXR: hyperinflation w/ atelectasis
• Supportive tx
▪ Pneumonia
• MCC = viral
o CXR: interstitial infiltrates
o Lymphocytosis & fever
• If bacterial → typical PNA → lobar consolidation on CXR
o Neutrophilia & worse sx than viral PNA
o strep pneumo, H flu or Moraxella
• if bacterial → atypical PNA → BL interstitial infiltrates on CXR
o mycoplasma, chlamydia or Legionella
▪ ** chlamydia pneumonia = staccato cough & eosinophilia **
o Treat with macrolide
▪ Pertussis (aka whooping cough = hundred-day cough)
• Prodrome for about 2 weeks; nonspecific sx = runny nose
• Whooping cough stage that lasts for about 4 months
o Post-tussive emesis or bloodshot eyes dt such extreme coughing fits
o Whoop = inspiratory gasp for air after coughing so much
• Treat with macrolides
▪ asthma
• most common pediatric disease
• can be exercise-induced or just occur randomly throughout the day
o episodes of coughing, wheezing and difficulty breathing w/o signs of infection
• CXR: hyperinflation
o Obstructive lung disease
▪ bronchoconstriction of the smooth muscles of the bronchioles
• treat this depending on certain stages
 ▪ cystic fibrosis
• kids < 20 years = staph aureus
• kids > 20 years = Pseudomonas
• CFTR mutation → causes problems with chloride transport → less water in secretions → thick secretions
o Super salty sweat
o Thick sticky mucus in lungs (increased risk of infection, like repeated PNA)
▪ Can also lead to bronchiectasis → permanently destroyed blown up bronchi and there are no
cilia → so they can continue to get repeated infections

o Decreased ability to secrete enzymes from pancreas

▪ Decreased ability to absorb fats & fat soluble vitamins (ADEK) bc pancreatic lipase not secreted
• Restrictive lung disease
• Treatment: supplement with pancreatic enzymes and good pulmonary hygiene
o GI
▪ GERD
• kids can present w/ sx of asthma
• stomach acid refluxes up to the LES → triggering CN X causing reflux bronchoconstriction → wheezing
▪ Ladd's bands
• Little peritoneal adhesion bands that can squeeze off the duodenum
o seen in a midgut volvulus → acute small bowel obstruction
▪ Midgut volvulus
• small intestine doesn't twist 270’ CCW and it doesn't come back into the abdomen
properly → malpositioned intestines (cecum in RUQ)
• symptoms: abdominal pain, nausea, bilious vomiting (bc obstruction is usually distal to
the sphincter of Oddi which secretes bile acids), no flatus, no BM
• NBSIM: upper GI series (swallow contrast fluids & take Xray to show where blockage is)
o If there is blockage → this is surgical emergency
▪ First NG decompression to avoid aspiration from vomiting
▪ jejunal atresia
• triple bubble sign
• usually dt vascular accidents in utero
o HY association w/ maternal cocaine use
▪ duodenal atresia
• double bubble sign
• HY association w/ down syndrome Jujenal atresia = Duodenal atresia =

▪ Intussusception triple bubble sign double bubble sign

• telescoping of the ileum into the cecum → inflammation and ischemia of the part that has telescoped (ileum)
• symptoms: RLQ colicky pain w/ currant jelly stools (dt mucosal sloughing off of the ischemic telescoped part)
o child will try to relieve the colicky pain by bending their knees up to their chest
• diagnose and treat with air enema or a contrast soluble dye (gastrografin)
o don't use barium enema!
▪ Because if barium leaks out into the peritoneum there will be issues
▪ meckel's diverticulum
• true diverticulum (contains all 3 layers); is the remnant of the omphalomesenteric duct
• rule of 2’s
o 2 feet proximal from ileocecal valve, 2% of population, 2x more likely in boys, present by 2 yo, 2 inches
long & 2 types of ectopic tissue: ectopic gastric and pancreatic tissue → can cause painless bleeding
▪ difference between intussusception (PAINFUL) and meckel's (PAINLESS)
 ▪ inflammatory bowel diseases
• usually seen in teenagers (older kids)
o ulcerative colitis
▪ always involves rectum, continuous, severe inflammation that involves mucosal layer only,
associated with toxic megacolon, PSC and pyoderma gangrenosum (sterile white ulcers on skin
that you tx with steroids)
o Crohn's disease
▪ Skip lesions from mouth to anus, transmural (full thickness inflammation), caseating granulomas

▪ necrotizing enterocolitis
• preemie that feeds to early gets rectal bleeding
• abdominal Xray shows pneumocystis intestinalis (air in the intestinal walls)
• treatment: stop feeding baby
▪ liver crap
• Crigler-Najjar syndrome
o absent or defective uridine diphosphate glucuronosyltransferase-1A1 (UGT1A1)
▪ → cannot conjugate bilirubin → unconjugated hyperbilirubinemia
o how to diagnose?
▪ Hyperbilirubinemia = bilirubin > 1
• direct bilirubin > 20 % → direct hyperbilirubinemia
o Direct = conjugated = water soluble → cannot cross BBB
• direct bilirubin is < 20 % → indirect hyperbilirubinemia
o indirect = unconjugated = water insoluble → YES CAN PASS THROUGH BBB →
CAN CAUSE KERNICTERUS by damaging basal ggl
• Gilbert syndrome
o “Crigler-Najjar light”
o Mild deficiency in UGT → only get the unconjugated hyperbilirubinemia/jaundice when sick or stressed
and then that is when they start to show sx. But normally they don’t show s/s
• Dubin Johnson
o BLACK LIVER
▪ able to conjugate the bilirubin but they're not able to let it
escape out of the hepatocytes dt ABCC2 gene defect
• direct hyperbilirubinemia
• Rotor syndrome
o Impaired hepatocellular storage of conjugated bilirubin so it leaks into the plasma
o Kinda similar to Dubin Johnson, in that there is also direct hyperbilirubinemia, but there is NO black liver
o nephrology
▪ minimal change disease (MCD)
• MCC of nephrotic syndrome in kids
o Light microscopy looks normal
o Electron microscopy shows effaced podocytes → this causes the
proteinuria
▪ Effaced podocytes lose their negative charge so now negatively
charged albumin (& other proteins will be able to pass thru the
GBM podocyte barrier and into the urine)
• treat with steroids
 NEPHROTIC SYNDROME:
• proteinuria > 3.5g/day or protein:creatinine > 3.5
o excrete albumin → decreased intravascular oncotic pressure → increased swelling of face & body = EDEMA
▪ body tries to compensate by making more coagulation factors and more lipids
o excrete Ab → more prone to infections
▪ specifically encapsulated bugs
• Please SHiNE My SKiS
o Pseudomonas
o Strep pneumo
o H influenzae
o Neisseria meningitidis
o E coli
o Mycoplasma
o Salmonella
o Klebsiella
o group B Strep
o excrete anticoagulation factors (protein C&S, AT-III) → prothrombotic state → increased risk for renal v thrombosis
▪ renal v thrombosis → sudden o/s flank pain
• hyperlipidemia

▪ hemolytic uremic syndrome

• Microangiopathic hemolytic anemia caused by either EHEC (eating undercooked beef) >> shigella
o Inflammatory bloody diarrhea that can progress to HUS
▪ If given abx (FQ) there is increased risk of progressing to HUS bc the bacteria will be lysed and the
shiga toxins that cause HUS will be released and go start attacking the endothelial cells in the
kidney
o Has a very similar mechanism to TTP (thrombotic thrombocytopenic purpura)
▪ FAT RN = fever, anemia, thrombocytopenia, renal & neuro issues
▪ Caused by autoAb against ADAMST13 → cannot break down VWF → increased plt adhesion
(consumption of plts into these clumps → thrombocytopenia) form little platelet clumps in the
BV that cannot be broken down → cause the RBC that are trying to pass to be destroyed/sheared
(→ anemia)
o HUS is basically TTP without FN… so just RAT
▪ Renal (UREMIA), anemia & thrombocytopenia
• Sx of uremia: pericarditis, platelet dysfunction
o Treatment of uremia = DIALYSIS
• Tx of HUS – supportive care
▪ Alport syndrome
• Type IV collagen (BM) defect
• hematuria and deafness
▪ RTA’s
• Type 1: cannot excrete hydrogen → hydrogen builds up → acidosis Recall major effects of aldosterone on principal cells:
o KIDNEY STONES!!! + Enac to reabsorb Na
+ ROMK channels to secrete K
o Type ONE has kidney stONEs
• Type 2: cannot absorb bicarb → acidosis
o Type 2 = Bi = Bicarb
• Type 4: hypoaldosteronism
o Hyperkalemia & hyponatremia → possibly low blood pressure
▪ **only one with hyperkalemia**
o Type 4 = ALDO (has 4 letters)
▪ posterior urethral valve
• suspect in any boy who was born and still hasn't urinated. If it was present in utero,
there would have been evidence of oligohydraminos.
• diagnose w/ VCUG
• treat with surgery
▪ UTI
• Increased risk = females, uncircumscised males, any GU anomaly
• The only bug that has a high urinary pH (>8) is Proteus
o neurology
▪ spinal muscular atrophy (Wernig Hoffman Dz)
• destruction LMN in the anterior horn of the spinal cord grey matter → hyporeflexia, fasciculations, flaccid paralysis
o MANIFESTED SINCE BIRTH FLOPPY BABY
Wernig Hoffman disease (SMA) – floppy from birth
Botulism – floppy after inciting event aka eating honey
cretenism
 ▪ Vs botulism that can present similarly with a floppy baby but the child was doing fine before
▪ botulism
• affects GI tract (CONSTIPATION = 1st sign), pupils (MYDRIASIS), HR (TACHYCARDIA), breathing, sweating
o Botulism toxin prevents the release of Ach → flaccid paralysis (top down)
• Dx with stool toxin
• Treat with botulism immunoglobulins
▪ dandy Walker
• congenital absence of cerebellum
o → compensation of the enlarged fourth ventricle → blocks flow of CSF →
hydrocephalus & increased ICP
• Sx of increased ICP: headache, nausea and projectile vomiting
• If pt has sx of increased ICP & you suspect meningitis → NBSIM: head CT BEFORE LP
to prevent herniation
o the only exception is in infants whose fontanelles still haven’t fused yet (space to relieve pressure)
▪ Tuberous Sclerosis
• ASHLEAF
o Ash leaf spots
o Shagreen patches
o Heart tumor = rhabdomyosarcoma
o Lung hamartoma
o Epilepsy
o Angiomyolipoma
o Facial angiofibroma
• Treat with ACTH
▪ Migraine headaches
• POUND criteria
o Pulsatile
o One day duration
o UL
o Nausea/Vomiting
o Debilitating – worse with noise
▪ Better with quiet & darkness
• Treatment: start with tylenol. If that doesn’t work → sumatriptan (serotonin agonist)
o Prophylaxis = beta blocker or TCA
▪ Guillain Barre syndrome
• symmetrical ascending paralysis
o worry about respiratory paralysis
▪ NBSIM: check pt’s vital capacity (to see how much they can breath)
• If it is concerning → intubate
• CSF findings: cytoalbuminologic dissociations
o No WBC but a lot of albumin
• Treat with IVIG & plasmapheresis (takes out the Ab that are attacking your peripheral NS)
▪ muscular dystrophy
• Duchennes muscular dystrophy
o Complete l/o dystrophin gene
o Early o/s
o Muscle gets completed replaced by fibroblasts & lipids
▪ Pseudohypertrophy of calves
▪ Gower sign (use hands to push up on legs to stand up)
• Becker's muscular dystrophy
o Partial l/o dystrophin gene
o Later o/s → can survive into 20 yo
o hematology/oncology
▪ cow milk is low in iron → iron def anemia
• when supplementing iron, give with vitamin C bc it helps to increase Fe absorption
• spoon shaped nails (koilonychia)
▪ goat milk is low in folate → macrocytic/megaloblastic anemia
 ▪ von Willebrand's disease
• deficiency or defective von willebrand factor → increased bleeding time bc vWF is needed for plt adhesion to
endothelium
o additionally, vWF stabilizes factor VIII (part of intrinsic pathway) so there can also be an increase in PTT
▪ wiskott-aldrich syndrome
• WATER
o Wiskott
o Aldrich
o Thrombocytopenia
o Eczema
o Recurrent infections
• Cytoskeleton abnormality
▪ WWAGR
• Wilms tumor
• Weidman-beckwith
• Aniridia
• GU anomalies
• Retardation
▪ Abdominal masses
• Wilms vs Neuroblastoma
o WILms tumor
▪ WILL NOT cross midline
o Neuroblastoma
▪ Can cross midline
▪ High levels of catecholamines → HTN & flushing
▪ Opsoclonus *dancing eyes* & myoclonus *dancing feet*
▪ VACTERL
• Vertebral anomalies
• Anal atresia
• Cardiovascular anomalies
• TEF
• Esophageal atresia
• Renal anomalies
• Limb defects
▪ CHARGE
• Coloboma
• Heart defect (congenital)
• Atretic Choana
• Retardation
• Genital anomalies
• Ear anomalies
▪ Hodgkin vs Non-Hodgkin Lymphoma
• B symptoms = fever, night sweats, weight loss
▪ Bone Tumors
• Ewing Sarcoma
o Onion skinning
o Small round blue cells
• Osteosarcoma
o Codman’s triangle & sunburst pattern
• Osteoid Osteoma
o Small, benign LYTIC bone lesion on cortex that gets better with NSAID’s
o Allergy & immunology
▪ treatment of rhinitis (runny nose) → intranasal steroids
▪ CVID (combined variable immunodeficiency)
• low antibodies only
▪ SCID (severe combined immunodeficiency)
• Low T cells & low B-cells → low Ab
 • present similarly with kids who have AIDS
o they'll have thrush, diarrhea & Pneumocystis jirovecci
• treatment: monthly IVIG and PCP prophylaxis. possibly BMT
▪ ataxia telangiectasia
• the A should remind you of low IgA
▪ Bruton hypogammaglobulinemia
• the B should remind you of low B cells → low Ab & Boys (XLR)
• treat with IVIG monthly
▪ CGD (chronic granulomatous disease)
• dt NADPH oxidase deficiency → have trouble killing bacteria bc they don't have their oxidative burst anymore.
Now they have to hydrogen peroxide to kill bacteria → but bc of this they are now susceptible to infections by
catalase + bacteria (can easily break down H2O2)
o cat+ bacteria = BASS = Burkholderia, Aspergillus, Serratia, Staph aureus
• treatment: BMT
▪ Chediak-Higashi
• Albinism & huge granules in PMN
▪ LAD (leukocyte adhesion deficiency)
• Defective CD18
• Delayed umbilical stump detachment
• Leukocytosis, no pus in skin wounds, poor wound healing bc WBC cannot get into tissues
o RHEUM & RASHES
▪ henoch-schonlein purpura
• lower extremity purpura (butt & posterior thighs) + arthralgias + hematuria
▪ kawasaki disease
• CRASH & burn Rashes that occur on palms & soles:
o Conjunctivitis Kawasaki CARS:
o Rash Kawasaki disease
o Adenopathy (cervical) Coxsackie A
RMSF (Rickettsia rickettsia)
o Strawberry tongue
Syphillis (2’)
o Hands & feet → rash & swollen
o Burn → fever
• Big worry = coronary artery aneurysm or MI
• Treatment = aspirin & IVIG
▪ Lupus
• SOAP BRAIN MD → if you have 4/11 there is 99% chance you have lupus
o Serositis
o Oral ulcers
o Arthritis
o Photosensitivity
o Blood (pancytopenia)
o Renal → diffuse GN (hematuria)
o ANA (one of the most sensitive markers)
o Ig → anti-dsDNA, anti-Smith
o Neuro → psychiatric (psychosis)
o Malar rash
o Discoid lupus
• Acute treatment = NSAID
• Remission treatment = hydroxychloroquine
• Future flares (e.g. lupus nephritis or end organ damage) = steroids
▪ dermatomyositis
• weakness, grotton’s papules (erythema over the knuckles), heliotrope rash around the eyes
• associated with underlying malignancy
• can have elevated CPK indicating muscle inflammation & breakdown
• treat with steroids
o orthopedics
▪ torticollis
• contraction of the sternocleidomastoid
 • treat with stretching exercises
▪ Down syndrome
• strong association with Atlantoaxial instability, duodenal atresia and hirschsprung disease
▪ scoliosis
• to check: have child bend over and you'll see that one hump is higher than the other
• treatment:
o 20-40’ → bracing
o >40’ → surgery
▪ spondylolysis versus spondylolisthesis
• spondylolysis = fracture of the pars interarticularis
• spondylolisthesis = anterior slippage of the lumbar vertebral body
▪ developmental dysplasia of the hip vs SCFE vs Legg-Calve-Perthes disease
• developmental dysplasia of the hip
o dt malformed acetabulum (hip socket)
▪ +clunking felt
▪ +asymmetric thigh/butt fold
o Dx with U/S → will show malformed acetabulum
o Tx: Pavlik harness
o Complications = avascular necrosis which can lead to permanent limb length discrepancies
• SCFE (slipped cap femoral epiphysis)
o MC in 12 yo fat kid
o Pelvis Xray shows slippage of femoral epiphysis
o Treatment: surgical pinning
• Legg-Calve-Perthes disease
o idiopathic avascular necrosis of the hip
o treatment: physiotherapy (good prognosis)
▪ septic arthritis vs transient synovitis of the hip
• septic arthritis
o hip/knee will be really red and inflamed → cannot bear weight
o systemic symptoms (+fever and leukocytosis)
o NBSIM? Arthrocentesis (stick needle in joint & drain/aspirate joint space)
▪ If WBC count > 50,000 → septic arthritis
o Treatment: abx
• Transient synovitis
o Afebrile, WBC < 20,000 in aspirate
o **kid usually has recent hx of URT infection or diarrhea** (within the past week) and now they have hip
pain → but they can still bear weight on it
▪ Kid steps on a nail → associated bacterial infection = PSEUDOMONAS!
▪ genu varum vs genu valgum
• genu varum = bow-legged
o reassure parents, normal up to 3 yo
• genu valgum = knock-knees
o reassure parents, should resolve by 8 yo
▪ knee problems
• osgood-schlatters disease
o inflammation / little micro fractures of the tibial tuberosity
▪ a lot of pain over tibial tuberosity
o worsened on knee extension
▪ bc quadricep pulling on tibial tuberosity
o treat this supportively with rest and stretching
• patellofemoral pain syndrome
o pain paused between friction between the underside of the patella and the femur
▪ when patella rubs on femur (extension + compression) → crepitus & pain
o treatment: supportive care, rest & physiotherapy
• patellar tendonitis
o pain over the patellar tendon (btw patella & tibial tuberosity)
o treatment = supportive
 • pre patellar bursitis
o pain over the patella
o repetitive actions on the knees (carpenters)
• anserine bursitis
o pain over the medial aspect of the knee below the joint line
• stress fracture
o low BMI
▪ supracondylar fracture
• EMERGENCY!
• Occurs at the distal humerus
o Must fix right away bc it's at high risk for compartment syndrome
▪ increased edema and swelling within the compartment surrounded by
fascia (limited ability to stretch) → increased pressure will cut off blood
supply & compress nerves → permanent ischemia & necrosis of distal
muscles as well as permanent nerve damage
• treat compartment syndrome with fasciotomy
▪ two fractures of the forearm the mnemonic is MUGR

▪ radial head subluxation

• nursemaids elbow
• parent pulls kid up in arm by hand/wrist → subluxation of radial head
• treatment: hyperpronation of forearm then flexion
▪ when to suspect abuse
• FIRST THING YOU WANT TO DO IF YOU SUSPECT ABUSE (AKA on a question, what is the NBSIM?) IS ADMIT THE
CHILD TO THE HOSPITAL SO YOU CAN SEPARATE THEM FROM THE PARENTS TO EXAMINE/INTERVIEW THEM. ALSO
WANT TO CALL CPS
• fractures
o spiral fractures
o metaphysis fractures
o posterior rib fractures
o first rib fractures
• helps to know the pediatric milestones
o 8 month old cannot climb couch yet and fall off
• If you suspect that a head injury is dt abuse NBSIM:
o Fundoscopy exam (BL retinal hemorrhages = shaken baby syndrome ☹)
o bone x-ray to check for suspicious fractures
• bruises that are at different stages of healing
• unnatural burnmarks:
o hot water splashing → irregular marks
o dunking → straight line & sparing of the creases of skin
• Sudden changes in attitude: they used to be happy and now all of a sudden they are depressed or failing school
o EYE STUFF
▪ amblyopia
• important bc can cause permanent blindness
• etiologies = early cross eyed, strabismus, cataracts
o when kids are fairly young they really need a lot of light stimulation to their retina to activate that part of
their brain for vision → if it doesn't happen then this can cause blindness
▪ neonatal conjunctivitis
• you should know the timeline there's four types
 o Chemical
▪ Occurs during first 24 hrs
o gonorrhea
▪ occurs during first 3-5 days of life
▪ PURULENT
▪ Treat with topical erythromycin
• But now they just do erythromycin eye ointment PPx as soon as baby is delivered
vaginally
o chlamydia
▪ occurs during first 7-14 days of life
▪ treat with oral erythromycin
o herpes
▪ occurs after the first 14 days of life
▪ UL conjunctivitis and possible vesicles on the scalp
▪ Blepharitis
• inflammation of the eyelid that can cause crusting of the eyelashes in the morning
• MCC = staph aureus
• Treat with eyelid shampoo
▪ bacterial conjunctivitis
• BL (>> UL) purulent discharge
• MCC = strep pneumo, h flu and moraxella MCC of Sinusitis, AOM & PNA too!
• Treat with erythromycin
▪ viral conjunctivitis
• “pinkeye”; kid usually also has mild fever w/ runny nose
• Highly contagious
o Kid can go back to school once eye discharge stops
• MCC = adenovirus
▪ Hyphema
• Blood in anterior chamber of eye
▪ retinoblastoma
• tumor of retina
o increased risk of developing osteosarcoma later on in life
• sx: loss of red reflex in like a photo or on pupillary (fundoscopic) exam
Retinoblastoma (l/o red reflex) Normal (red reflex intact)
▪ Pre-orbital vs orbital cellulitis
• bug bites on the cheek can extend to the orbit and cause orbital cellulitis
o posterior to septum (fascia dividing eyelids) = orbital cellulitis → more dangerous → diplopia or difficulty
seeing and moving their eyes, blurry vision → treated in patient with IV abx
o anterior to septum (fascia dividing eyelids) = pre-orbital cellulitis → more benign → treat with PO abx
o DERM
▪ what's the difference between lotion cream and ointment?
• lotion is used for minimally dry skin
• cream is for moderately dry skin
• ointment is for maximally dry skin
▪ diaper rashes
• irritation dermatitis (actual diaper rash)
o caused by irritation (not infection) from feces and urine
o rash is more confined, does NOT involve the inguinal creases
o treatment: zinc paste
• Candida
o involves the inguinal creases
o satellite lesions (little papules that are not connected to the actual main rash)
o treatment: -conazoles
▪ pityriasis rosea
• Christmas tree pattern that starts with the Herald's patch
• treat with antihistamines
 ▪ tinea capitis
• patchy hair loss, broken hairs and little scales on the head. +/- occipital LAD
• caused by trichophyton (fungus)
• treat with oral griseofulvin
▪ tinea pedis
• athlete's foot
• it can also affect the nails (onychomycosis) making them look thick & yellow
• treated with oral terbinafine if nails involved
▪ tinea versicolor
• hypo pigmented areas over the back and shoulders
• caused by malassezia furfur
• treat this with selenium sulfide (selsun blue)
▪ molluscum contagiosum
• very contagious via direct contact
• associated with HIV
• treat it by observation
▪ hair lice
• treated with permethrin shampoo and fine tooth comb
▪ pubic lice
• black papules or blue macules
• treat with benzene lotion
▪ scabies
• lesions usually in btw finger webs that are extremely itchy, especially at night
• must treat entire house (very contagious) → all the people and bedding, etc
• treat with permethrin lotion
▪ vitiligo versus albinism
• vitiligo
o autoimmune l/o melanocytes
o treated with psoralen
• albinism
o melanocytes are present, but cannot synthesize melanin (what gives you pigmentation)
o not treated
▪ alopecia areata, totalis and universalis
• alopecia areata → patchy hair loss
o treated with intralesional steroids
• alopecia totalis → whole entire scalp is bald
• alopecia universalis → whole entire body is bald including the eyebrows
▪ acne
• can be caused by skin shedding, plugging of the ducts by sebum or by P. acnes bacteria
• treat in tiers:
o topical retinoids or benzoyl peroxide
o topical abx
o oral abx
o oral retinol aka isotretinoin aka accutane
▪ very teratogenic → women of child-bearing age must have negative pregnancy test before
starting this medication and needs to be on 2 forms of birth control
o emergency medicine
▪ MCC of cardiac arrest in a kid is lack of oxygen to the heart due to a lung problem such as choking or drowning
▪ anaphylactic shock is a extreme allergic reaction usually to foods
• MCC: peanuts or bee stings
• Pathophys = histamine mediated vasodilation which causes shock
• Treatment: IM epinephrine (1:1000) & IVF
▪ septic shock
• LPS from gram negative bacteria (usually) causes inflammation & NO release → leaky vessels
• Treat with fluids and antibiotics
▪ at what Glasgow Coma Scale do you intubate?
• < 8 → intubate
 ▪ how do you treat increased intracranial pressure?
• three things: hyperventilation, elevate the head of the bed and mannitol
▪ burns
• know the difference between a first degree vs second degree vs third degree
o first degree burn is usually looks like a sunburn
o second degree burn starts to have blisters
o third degree burn has the white leathery look to it and at that point there is no pain anymore
▪ key smell associations
• smells like almonds think of cyanide poisoning
• smells like garlic think of arsenic poisoning
▪ cherry color skin Association think of carbon monoxide or cyanide poisoning
▪ gray cyanosis think of methemoglobinemia
▪ if a kid had some sort of caustic ingestion (they drank toilet bowl cleaner or a drain cleaner)
• NBSIM → remove all the clothes and then immediately do an endoscopy to assess for damage.
• Toilet bowl cleaner is acidic → coagulative necrosis on histology
• Drain cleaner, bleach & laundry detergent is basic (alkali) → liqufactive necrosis on histology
o THESE ALKALI SOLUTIONS CAUSE MUCH DEEPER DAMAGE THAN THE ACIDIC SOLUTIONS!!!!
▪ overdose antidotes
• beta-blocker overdose
o treat with glucagon
• aspirin overdose
o treat with sodium bicarb, charcoal and gastric lavage
▪ BITES (cat, dog & human bites)
• All are treated with augmentin (amoxicillin clavulanic acid)
• dog and cat bites → Pasteurella
• human bites have multiple different bugs. Usually from being in a fight
o glycogen storage disorders
▪ VonGierkes disease
• Glucose 6 phosphatase deficiency
o Hypoglycemia, high ketones, lactic acidosis, doll face (round face dt lipid accumulation)
▪ Gaucher disease
• glucocerebrosidase deficiency
o bone pain, hepatomegaly, crumpled tissue paper macrophages
o syncope versus seizure
▪ syncope
• no post-ictal state
• MCC = orthostatic HoTN, vasovagal & arrythmogenic
▪ seizure
• yes post-ictal state = after they wake up they're confused syncope
o febrile UTI
▪ First step → bladder & renal U/S
• VCUG (voiding cystourethrogram) is performed for hydronephrosis, recurrent UTI, UTI due to some abnormal bug
(anything other than ecoli) or Posterior urethral valve
o epiglottitis
▪ tripod position (dt difficulty breathing), drooling, cherry red epiglottis
▪ caused by H flu (vaccine preventable)
▪ NBSIM: intubate
o microcytic anemias
▪ MCV < 90
▪ 4 types → FAST
• Fe deficiency anemia
• ACD
• Sideroblastic anemia
• Thalassemia
▪ Look at red cell distribution width
• If increased → Iron def
• If normal → thalassemia
 ▪ ACD will have hints of chronic disease or inflammation
• Will also have increased ferritin & decreased serum iron & TIBC
▪ Sideroblastic anemia
• Increased ferritin, increased serum iron → bc iron is spilling out of the cells & decreased TIBC
o Friedreich's ataxia
▪ Trinucleotide repeat GAA (anticipation)
▪ Ataxia, scoliosis, HOCM
• MCC death is HOCM
o Neonatal erythema toxicum
▪ rash that shows up in the first two weeks of life & goes away it's on its own
▪ biopsy will have EOSINOPHILS
o celiac disease
▪ gluten intolerance → villous atrophy of duodenum → patient cannot absorb iron or fat soluble vitamins (ADEK)
▪ Ab → anti-tTG or anti-gliadin
▪ treatment: avoid gluten & supplement vitamins ADEK
o DeGeorge
▪ CATCH-22
• Cleft lip
• Abnormal facies
• Thymic aplasia
o No T cells → lots of opportunistic infections
• Cardiac defects
o Truncus arteriosus or ToF
• Hypocalcemia (hypoparathyroidism)
o Trousseau (BP cuff causing carpopedal spasm) & Chvostek signs (cheek tapping)
• 22 → defect on CH22q11
o primary amenorrhea
▪ FIRST: do pelvic exam or ultrasound to see if there's a uterus
• if uterus is present → measure FSH level
o Turner syndrome = 45, XO > 46, XY (streak ovary in XY is malignant) → high FSH & low E
▪ webbed neck, low hairline, shield chest, horseshoe kidney, bicuspid aortic valve, coarctation of
the aorta, streak ovary
▪ Will have trouble growing to full height and developing 2’ sexual characteristics w/ low GH & E
▪ Treat: supplement with GH & E
o Hypogonadotropic hypogonadism → low FSH
▪ MC than Turners
▪ Issue with the pituitary → dt excess stress, low BMI, malnutrition, excess exercise
• if uterus is absent → need to do karyotype
o Mullerian agenesis = 46, XX
▪ genetically female that is missing the mullerian system → no uterus → cannot have period
o Androgen insensitivity syndrome = 46, XY
▪ genetically male with a defective testosterone receptor → during normal development of the
embryo, testosterone helps convert the vagina into the external penis and scrotum but since the
testosterone receptors are defective, externally these pts have a vagina internally there will be
testicles and no uterus
• the testicles can become malignant → need to remove them
• these pts DO develop breasts bc the excess testosterone floating around gets aromatized
to estrogen → and estrogen will cause breasts to grow
o drawing milestones 4th → 5 yo
▪ PlayStation controller
• Clockwise
• Starting with O 3rd → 4 yo 1st → 3 yo

2nd → 3 yo
o a parent is not allowed to refuse life-saving treatment for a child and if they do get a court-order
▪ classic example is the Jehovah Witness father who refuses for their kid to have red blood cell transfusion during some sort
of emergency
• correct answer is transfuse anyway
o it's normal for a newborn to have bloody discharge and have breast hypertrophy or galactorrhea
▪ caused by retained maternal estrogen that is withdrawing
▪ reassure parents!
o if a kid has recurrent unilateral pneumonia → think of some sort of blockage in the airway (like a foreign body)
▪ treat with bronchoscopy
▪ similar in adults… but the blockage is usually cancer
▪ or if a kid has unilateral discharge like pus (from nose, ear or vagina) → think foreign body
that they stuck up there
▪ of if it is difficult to auscultate one lung after you r/o other possible illnesses and there are
no associated sx → think possible foreign body
o cephalohematoma vs caput seccundum vs subgaleal hemorrhage
▪ most superficial (bleeding within the scalp) = caput seccundum
• caput does not stay put → it can cross over it and move over suture lines
▪ cephalohematoma is subperiosteal
• does not cross suture lines
▪ subgaleal hemorrhage is underneath the aponeurosis of the muscle
• dangerous bc they can bleed out (emergency)
o 2 instances where you need to remember a kid with a large tongue and protuberant abdomen with a umbilical hernia
▪ Cretinism

SVT: narrow QRS (< 0.12)

▪ Beckwith Weidman syndrome Vtach: wide QRS (> 0.12)

o ACLS PROTOCOLS
▪ Stable supraventricular tachycardia → adenosine
▪ Unstable supraventricular tachycardia → cardiovert
▪ stable ventricular tachycardia → amiodarone
▪ unstable (pulseless) ventricular tachycardia → cardiovert
o jaundice on the first day of life
▪ NBSIM = Coombs test
o Immunosuppressive disease hints
▪ T cell = thymus
▪ B cell = tonsil
o Short kids
▪ Late bloomer = constitutional growth delay (parents were also late bloomers)
• Bone age < real age
▪ Familial short stature (parents are also short)
• Bone age = real age
o Definition of infant = 1 mon – 1 yo
o If mom has hepatitis B → give baby hep B vaccine and hep B Ig at birth
o Vaccines
▪ 2, 4, 6 mon → H flu, DTaP, rota, hep B, IPV, Pneumovax if there's a healthy person who has been exposed
▪ Starting at 6 mon then annually give influenza vaccine to chicken pox who has never had it before and
aren't immune you give them vaccine.
▪ 12 mon → give live attenuated vaccines (MMR & VZV) if they're immunosuppressed and they've been
▪ 4 yo → VZV exposed you give the antibody → you can't give
o Lysosomal storage diseases them the vaccine because it's a live vaccine
▪ Neimann Pick
• Cherry red spot on macula
• Hepatomegaly
 ▪ Tay-Sachs
• Cherry red spot on macula
o Thymus on CXR in infant = SAIL SIGN on right side of chest near heart (right atrium)
o Intubate if APGAR < 7 & irregular breathing
o Chest compressions if HR < 60
▪ Want HR > 100

o Choanal atresia
▪ obstructed nasal septum
▪ Cyanosis that's aggravated by feeding (breathing thru nose) and relieved when crying (breathing thru mouth)
▪ Dx: try to place NGT. Either 1) you can’t pass it or 2) take Xray and realize it doesn’t go all the way down and it curls up
▪ CHARGE
o failure to pass meconium
▪ no stool passed in the first 48 hours of life
▪ 3 reasons
• Imperforate anus
o VACTERL
o Dx: visual inspection or note on xray
o Tx: surgery
• Hirschsprung’s disease (congenital megacolon)
o associated with downs syndrome
o failure of NCC to migrate to distal colon → failure of meissner & aurbach plexus to form → no peristalsis
▪ on inspection there will be very tight anal sphincter & +squirt sign
o abd xray shows enlarged distal colon, proximal to the region of colon lacking NCC
o dx used to be → bx to show that there is no meissners or auerbach plexus
o tx: resect bad part of colon
• Meconium ileus
o cystic fibrosis pts have meconium plug from very dry stool. This ends up obstructing the terminal ileum →
cannot pass stool (-squirt sign)
o abd xray = air dilatation proximal to the ileum
o tx: water enema
▪ also CF pts need get pancreatic enzyme supplements as well as fat soluble vitamin (ADEK)
replacements
▪ dx CF with sweat chloride testing if > 60
o treatment of hyperbilirubinemia
▪ total bilirubin >15 → UV light therapy
• note: phototherapy only helps with unconjugated (indirect) hyperbilirubinemia
▪ total bilirubin >20 → this is severe. Do blood exchange transfusion.
o breastfeeding jaundice (< 2 wks old)
▪ failure to feed (baby’s fault) → baby is dehydrated → intestine will absorb excess bilirubin → hyperbilirubinemia
o breast milk jaundice (> 2 wks old)
▪ baby is feeding excessively but there is a problem with the milk (mom’s fault). it has an enzyme that deconjugates bilirubin
→ unconjugated bilirubin stays in baby’s system longer → hyperbilirubinemia
▪ treatment: reassure the mom to keep feeding and eventually it'll pass
o intussusception
▪ rotavirus vaccine is contraindicated
▪ associated with henoch-schonlein purpura or URT infx
o pyloric stenosis
▪ projectile, nonbilious vomiting in a baby that is 3-6 wks old
▪ first born male, associated with maternal macrolide use
▪ abdominal U/S shows target (or doughnut) sign
o cataracts in a newborn/infant → congenital rubella or galactosemia
o ureteropelvic Junction obstruction
▪ teenager who drinks EtOH → pain urinating that goes away after a few hours
• they have a narrow renal pelvis at the ureteropelvic junction and since EtOH is like a diuretic and makes you pee a
lot there will be backup into the kidney since there is that narrowing → pain for a few hours while drinking
o C1 esterase deficiency is associated with angioedema
o C5-C9 mac attack complex deficiency is associated with neisseria infections
o first tooth that should erupt is the lower central incisor and tooth eruptions happen normally between 3 and 16 months old
o pediatric milestones
▪ two months old you can lift your head
▪ four months old you can roll over
▪ six months old you can sit up straight
• separation anxiety at 6-18 mon
▪ nine months old you can crawl and start cruising. Also object permanence
▪ twelve months you should start being able to walk & should be able to say one two three words
▪ two years old you can say two word sentences with 100’s of words (two zeros)
▪ three years old you can say three word sentences with 1000’s of words (three zeros)
▪ WORRISOME:
• Hand dominance → red flag for motor development delay (weakness)
• Language delay → first thing to r/o is hearing problem
o cerebral palsy
▪ scissoring when standing (when they stand up their legs cross)
▪ associated with hypoxia, vascular insults or premature baby
o vernix caseosa = thick white creamy material found out around the newborn it's completely normal
o Nevis simplex vs Nevis flamus
▪ Nevis simplex goes away
▪ Nevis flamus does not
• AKA port wine stain simplex
o strawberry hemangioma flamus

▪ tumor like vascular formations on the skin

▪ they go away with time → reassure parents
o DKA
▪ complication of undiagnosed/poorly managed T1DM
▪ anion gap metabolic acidosis (Na – Cl – HCO3 > 12 or 16… the cut offs are controversial)
▪ high blood glucose levels ~ 300’s
▪ +ketones on UA, metabolic acidosis
▪ Kussmaul breathing (respiratory compensation for metabolic compensation)
▪ N/V & abd pain
▪ Treat: potassium, insulin & IVF (& dextrose as MBG corrects but waiting for AG to close and still giving insulin)
o Severe hypocalcemia
▪ Can be caused by RBC transfusions (substance in bag of blood will bind up Ca2+)
▪ Treat with IV calcium gluconate
o Hypercalcemia
▪ Treat with IVF