PEDIATRICS

UW EXPLANATIONS
Exudative Effusions
o Definition: movement of fluid into pleural space due to:
o Increased permeability of the pleural OR capillary membranes
o Disruption of thoracic lymphatic drainage
o Characterized by ↑ levels of pleural protein and LDH
o Classifications:
o Chylothorax: lympahtic flow through the thoracic duct is disrupted → direct leakage of chyle (lymphatic fluid) into pleural
cavity
o Clinical Symptoms: increased work of breathing, tachypnea, hypoxia, dullness to percussion
o Chyle composition: T-cell lymphocytes, immunoglobins, lipid transporting chylomicrons that contain TAGs
o Milky white fluid
o Lymphocyte predominant
o ↑ TAGs
o Treatment: drainage via thoracentesis OR chest tube placement; limitation of dietary fats; thoracic duct ligation
o Empyema: bacterial infection of the pleural space
o Pleural fluid composition: low glucose, low pH, neutrophil predominant w/ elevated cell count, + Gram stain, +bacterial culture
o Malignancy
o Tuberculosis
Transudative Effusions
o Defintion: movement of fluid into pleural space due to:
o Oncotic or hydrostatic pressure differentials
o Classifications:
o Protein loss: ↓ plasma oncotic pressures
o Nephrotic syndrome
o ↑ Pulmonary vascular pressures: ↑ hydrostatic forces
o Cardiac failure
o Pulmonary embolism
o Hepatic hydrothorax: ascitic fluid flows from below [high pressure] diaphragm into the pleural cavity [lower
pressure]
Brain Abscess
o Etiology: direct spread of otitis media or mastoiditis infection into brain tissue
o Clinical Symptoms:
o Headaches → in supine position ↑ICP due to gravity → exacerbations at nighttime or early morning
o Morning vomiting/Nausea → ↑ICP stimulates receptors in medullary vomiting center in Area Postrema
o Focal neurological deficits, seizures, fever
o ↑ICP → CN III and CN VI deficits; papilledema; cerebral edema
o Diagnosis: hypodense center and ring-enhancing lesion on imaging; surrounding edema
o CT with contrast = faster; better able to visualize bone [including damage to mastoid indicated route of infection
spread]
o MRI = no use of ionizing radiation; better able to visualize soft tissue
o Better able to distinguish edema vs necrosis
o Better delineates ring-enhancement
o Can be early indicator of cerebritis
o Treatment: broad spectrum antibiotics; needle aspiration or surgical drainage of abscess
o Lumbar puncture contraindicated due to ↑ICP; risk of cerebral herniation and death
o Corticosteroids may be used to alleviate edema; reduces risk of herniation, BUT reduce efficacy of ABx
Aplastic Crisis
o Definition: sudden halt in RBC production (erythropoiesis) → acute, SEVERE anemia
o Acute drop in Hgb
o Low reticulocyte count (<1%); WBCs and platelets are normal
o NO splenomegaly
o Clinical Symptoms: severe anemia (<6g/dL), pallor, weakness, fatigue; functional systolic murmur due
to hyperdynamic blood flow
o Risk Factors: sickle cell disease; hereditary spherocytosis
o Parvovirus B19 = infects erythrocyte precursors
o Treatment: blood transfusion
o Differentials
o Splenic sequestration crisis = Increased reticulocyte count, rapidly enlarging spleen
o Vasoocclusion and pooling of blood in spleen
o Myocardial infarction = chronic anemia → ↑ cardiac output + infarction of cardiac microvasculature; more likely in
adults
o Autoimmune Hemolytic Anemia = idiopathic or secondary (d/t SLE) → Increased reticulocyte count + jaundice
Aplastic Anemia
o Definition: Pancytopenia characterized by severe anemia, leukopenia, & thrombocytopenia
o Normal cell morphology BUT hypocellular BM with fatty infiltration = dry bone marrow tap
o Etiology: drugs (eg NSAIDs, sulfonamides); toxic chemicals (eg benzene, glue); idiopathic; viral infections
(eg HIV, EB, respiratory); immune disorders; thymoma; congenital; radiation; insecticides
o Treatment: hematopoietic stem cell transplant
o Presentations: pallor, fatigue, weakness, loss of appetite, easy bruising, petechiae, mucosal
hemorrhage, fever
o Fanconi Anemia [X-linked] = DNA repair defect causing BM failure; chromosomal breaks on genetic analysis
o Bone Marrow = aplastic anemia and progressive BM failure = PANcytopenia
o Appearance = short stature, microcephaly, abnormal thumbs, & hypogonadism
o Skin = hypo/hyperpigmented areas, café au lait spots, LARGE freckles
o Eyes/ears = strabismus, low set ears, & middle ear abnormalities (eg hemorrhage, incomplete development, chronic
infections)
Thalassemia Minor - ⍺/B
o Definition: Microcytic hypochromic anemia with target cells and teardrop cells on peripheral blood
smear
o Laboratory Investigations:
o Peripheral Blood Smear
o ↓MCV = abnormally small red blood cells
o NORMAL RcDW
o NORMAL RBC Count
o Hematocrit usually >30%
o Mentzer Index = MCV/RBC [count] < 13
o Greater than 14 = iron deficiency anemia
o Less than 12 = thalassemia trait
Anemia of Prematurity
o Definition: most common cause of anemia in PRE-term infants
o Caused by impaired erythropoietin production, short RBC lifespan, iatrogenic blood sampling while child is
hospitalized in NICU
o Although erythropoietin levels decrease in newborns after birth and ↓ reticulocyte count, due to ↑ oxygen levels, this is
exacerbated by short RBC lifespan in PREterm infants

o Clinical Symptoms: asymptomatic; tachypnea, apnea, poor weight gain

o Laboratory Findings:
o ↓ Hemoglobin ↓ Hematocrit
o ↓ reticulocyte count
o Normocytic, normochromic blood cells
o Treatment: minimize blood draws in NICU, iron supplements, transfusion
Transient Erythroblastopenia of Childhood [TEC]
o Definition: acquired red cell aplasia
o Occurs in healthy children between ages 6 months - 5 years old
o Clinical Symptoms: pallor, decreased activity
o Laboratory Findings:
o ↓ Hemoglobin ranging around 3 – 8 g/dL
o ↓ reticulocyte count
o Normocytic, normochromic blood cells
Hereditary Spherocytosis
o Definition: Extravascular hemolysis d/t defect in proteins that interact with RBC membrane skeleton and
plasma membrane (eg ankyrin, spectrin, band 3, protein 4.2)
o Autosomal dominant; common in Northern European descent
o Clinical Symptoms: hemolytic anemia, jaundice, splenomegaly
o Laboratory investigations: ↑ [mean corpuscular hemoglobin] ↑ osmotic fragility (on acidified glycerol
lysis test)
o Spherocytes, negative Coombs test, abnormal Eosin-5-maleimide binding test
o Fragile spherocytes less able to travel through microcirculation [eg spleen] = hemolytic anemia
o Severe anemia as infants are less able to generate erythropoiesis to compensate
o ↓ Hemoglobin, ↑ LDH
o Treatment: folic acid supplementation, blood transfusions, splenectomy
o Complications: pigment gallstones; aplastic crisis d/t parvovirus B19
Bilious Emesis
Biliary Atresia
o Definition: progressive obliteration of the extrahepatic biliary ducts connecting the liver to the small
intestine
o Most common indication for pediatric liver transplant
o Without treatment, liver will inflame (hepatomegaly, hepatitis) and eventually fibrose
o Clinical Symptoms:
o Initially well
o Within 2 months, develop conjugated hyperbilirubinemia → jaundice, pale stools, dark urine, hepatomegaly,
conjugated hyperbilirubinemia, mild ↑ in LFTs
o Conjugated hyperbilirubinemia = > 2mg/dL of direct bilirubin fraction that is >20% of total bilirubin level
o Diagnosis: US of gallbladder initial evaluation → Hepatobiliary Scintigraphy: looking for failure of liver
to excrete tracer into small intestine → Cholangiogram: obtained in OR
o Treatment: eventual liver transplant
o Kasai procedure: a hepatoportoenterostomy to improve morbidity/mortality
Biliary Cyst
o Definition: congenital dilation of the biliary tree
o May be singular or multiple; intra- or extra-hepatic
o Type I Cyst = extrahepatic, single cystic dilation of bile duct
o Clinical Symptoms: pain, jaundice, palpable mass; majority present at age < 10
o Infants = jaundice, acholic stools
o Older children = pancreatitis
o Adults = vague epigastric pain or RUQ pain; cholangitis
o Diagnosis: US
o If obstruction is suspected, perform endoscopic retrograde cholangiopancreatography
o Complications: biliary cyst → can become cholangiocarcinoma
o Treatment: surgical resection to relieve obstruction & prevent malignant transformation
Gastrointestinal Bleeding
o Definition: divided into upper & lower bleeding by ligament of Treitz
o Melena = stomach OR proximal small bowel → black tarry stools
o Hematochezia = distal small bowel OR colon → bright red stools
o Hematochezia: hemorrhoids, infectious colitis, intussusception, Inflammatory Bowel Disease, Meckel’s
diverticulum
o Meckel’s diverticulum = most common congenital anomaly that results from incomplete obliteration of the fetal
vitelline [omphalomesenteric] duct
o Contain gastric or pancreatic tissue
o Largely asymptomatic
o Ectopic gastric tissue secretes HCl → mucosal ulceration of surrounding small bowel → painless hematochezia most common
presentation → hemorrhagic shock + anemia
o Diagnosis = technetium-99 scan [scintigraphy]
o Treatment = surgical resection to prevent further bleeding + intussusception
Celiac Disease
o Definition: immune mediated hypersensitivity to gluten leading to impaired nutrient absorption in
proximal small intestine
o Clinical Symptoms:
o Gastrointestinal = abdominal pain, nausea & vomiting, diarrhea, flatulence, bloating
o Extraintestinal = weight loss; short stature; IDA; dermatitis herpetiformis
o Dermatitis Herpetiformis: pruritic, papular, OR vesicular rash associated with celiac; knees, elbows, forearms and buttocks

o Risk Factors:
o 1st degree relative with Celiac
o Autoimmune thyroiditis
o Type 1 Diabetes
o Down’s Syndrome
o Selective IgA Deficiency
Developmental Dysplasia
◦ Definition: dislocation of femoral head from acetabulum
◦ Early diagnosis critical before age of 6 months to portend a favorable prognosis
◦ Delayed diagnosis most common cause of limp, scoliosis, arthritis, & avascular necrosis
o Etiology: possibly breech presentation; idiopathic
o All infants should be examined until 1 year of age for hip examination
o Diagnosis: Barlow and Ortolani Maneuver: feeling for dislocation and reducibility of an unstable joint
o Palpable clunk is alarming = automatic referral to orthopedic surgeon
o Soft clicks, leg-length discrepancy, & asymmetric inguinal skin folds
o Imaging ONLY recommended after infant is > 2 weeks = US test of choice
o Infants over 6 months, hip has ossified = X-ray test of choice
o Treatment: prompt referral to orthopedic surgeon
o Under 6 months = Pavlik harness
o Over 6 months = surgery with anesthesia; CT and MRI can be used at this time for assessment
Juvenile Idiopathic Arthritis
o Definition: chronic autoimmune disorder of childhood marked by typically symmetric arthritis of > 1
joint within first 6 mo of symptom onset; at least 6 weeks of symptoms
o Polyarticular = >5 joints involved
o Oligoarticular = <5 joints involved
o Clinical Symptoms: symmetric arthritis of upper and lower extremities;: knees, wrists, ankles, cervical
spine, small joints of hands and feet
o Laboratory Findings: ↑ESR, ↑CRP
o Hyperferritinemia
o Hypergammaglobulinemia
o Thrombocytosis
o Anemia → chronic inflammation and iron deficiency → ↑ hepcidin → inhibits iron absorption across small
intestine and iron release from macrophages + RES of liver; improve with MTX
Precocious Puberty
o Definition: Development of secondary sexual characteristics for girls {<8 years} and boys {<9 years}
o Diagnostics:
I. Bone age = bone age must be performed to assess for advanced skeletal maturation
o If NORMAL
o Isolated breast development = Premature thelarche
o Isolated pubic hair development = Premature adrenarche: caused by adrenal androgen production
o RISK: PCOS, DM T2, Metabolic Syndrome
II. LH = must be performed before & after GnRH stimulation to determine peripheral or central source
o Central precocious puberty/Gonadotropin-dependent precocious puberty (GDPP) = ↑FSH & ↑LH. Early activation of
hypothalamic-pituitary-ovarian (HPO) axis.
o All patients w/ central precocious puberty should receive brain imaging w/ CT or MRI
o Treatment = GnRH analog/agonist therapy → prevention of premature epiphyseal plate fusion + maximization of adult
height potential
o Peripheral precocious puberty = ↓FSH & ↓LH. Gonadal or adrenal release of excess sex hormones.
o Late-onset (nonclassical) congenital adrenal hyperplasia secondary to 21-hydroxylase deficiency
o Presents in late childhood with signs of excess androgens → premature adrenarche/pubarche, severe treatment
resistant cystic acne, accelerated linear growth, advanced bone age
o Normal electrolytes
Abnormal Uterine Bleeding
o Definition: immature hypothalamic-pituitary-ovarian axis → anovulation → heavy, irregular menstrual
bleeding
o During anovulatory states → persistent endometrial proliferation → heavy menses when ovulation finally occurs
o Exaggerated necrosis of superficial layer of endometrium → continues to bleed due to lack of tissue stability

o Evaluation: CBC, pregnancy test, coagulation studies

o Treatment Approach:
o Hemodynamically stable → intravenous estrogen (conjugated equine estrogen) OR high-dose estrogen/progestin
oral contraceptive pills OR high-dose progestins for patients with contraindications (eg thromboembolism)
o Estrogen serves to stabilize denuded endometrium + stop menstrual bleeding
o Progestin only pills less effective than estrogen
o Hemodynamically unstable → dilation and curettage
Neonatal Respiratory Distress Syndrome
o Definition: pulmonary condition caused by immature lungs and surfactant deficiency
o Severity is inversely proportional to gestational age
o Risk Factors:
o Prematurity
o Maternal diabetes → ↑ fetal insulin → insulin antagonizes cortisol → block maturation of sphingomyelin
o C-section → ↓ released of fetal glucocorticoids
o Clinical Symptoms: tachypnea, retractions, grunting, nasal flaring, cyanosis at birth
o Subcostal and intercostal retractions
o Coarse breath sounds on auscultation
o Investigations:
o Diffuse reticulogranular pattern = “ground glass opacities”
o Air bronchograms = tubular outline of an airway made visible by filling of surrounding alveoli by fluid or inflammatory
exudates
o Treatment: early continuous positive air pressure ventilation (CPAP)
o Intubation, mechanical ventilation, EXOgenous surfactant therapy
o Complications: bronchopulmonary dysplasia
Bronchiolitis
o Definition: common winter respiratory tract infection caused by respiratory syncytial virus (RSV)
o Clinical Symptoms:
o Older children = self-limited, mild, URT infection
o Younger children (< age 2) =
o Antecedent: nasal congestion + discharge, cough
o Lower respiratory tract involvement → wheezing, crackles with a waxing + waning course; peaks at 5-7 days of illness

o Diagnosis: Clinical diagnosis

o Treatment: supportive (hydration, saline nasal drops, nasal bulb suction)
o IF High risk: Preterm birth (<29 weeks of gestation), Chronic lung disease of prematurity, Hemodynamically
unstable congenital heart disease, then give:
o Prophylaxis = Palivizumab (used in children <2 years of age who are at high risk of complications)

o Complications: occur in neonates <2 months old

o Develop wheezing throughout out childhood
o Apnea and respiratory failure
Neonatal Infectious Workup
o Neonates with suspected infection require FULL infectious workup
o CBC, blood cultures, lumbar puncture, UA, urine cultures
o Neonates have open fontanelles → relief of ICP → do not experience herniation after lumbar puncture
o Head CT not required before lumbar puncture in neonate cases

o Neonates should receive empiric antibiotics AFTER cultures are obtained

o Ampicillin and gentamicin
o Lethargy, irritability, hypotonia, and hypothermia are suspect for Neonatal meningitis
o Poor feeding and decreased activity are earliest signs of infection
Intraventricular Hemorrhage
o Definition: common complication in neonates born at <30 weeks gestation or <1500g
o Due to capillary fragility of the subependymal germinal matrix & immature autoregulation of cerebral blood flow
o MUST screen for with serial head US as many cases are asymptomatic
o Will observe bilateral IVH and dilated ventricles
o Clinical Symptoms: lethargy, hypotonia, high-pitched cry
o Rapidly increasing head circumference
o Bulging fontanelles
o Complications:
o Communicating hydrocephalus [non-obstructive] → accumulating blood irritates arachnoid villi → impairing
ability to absorb CSF
o Increased risk of death
o Cerebral palsy
o Prophylaxis: antenatal administration of corticosteroids
o Diagnosis: cranial doppler
o Treatment: ↓ICP via VP shunts and drains
Viral Myocarditis
o Definition: potentially lethal inflammatory disease of myocardium
o Newborns at greatest risk for death as immature myocardium is less adaptable to acute insult
o Pathogenesis → direct viral injury → autoimmune inflammation → myocyte necrosis → impairment of systolic and
diastolic function
o Etiology: toxins, autoimmune diseases, infections (eg. Cocksackie B virus, adenovirus)
o Clinical Symptoms:
o Viral prodrome (eg. Upper respiratory infection) → acute left heart failure → pulmonary edema →worsening respiratory
distress (eg. Tachypnea, dyspnea, wheezing, crackles)
o Hepatomegaly
o Dilated cardiomyopathy → holosystolic murmur
o Diagnostic Investigations:
o CXR: Cardiomegaly
o Echocardiography: Global Hypokinesis
o Viral studies
o GOLD STANDARD: myocardial biopsy → inflammatory infiltrate of myocardium w/ myocyte necrosis
o Treatment: diuretics, inotropes
Child Renal Workup
o First UTI in a child between 2- 24 months → renal and bladder US
o Evaluation for any anatomic abnormalities that might predispose to VUR/UTI

o Recurrent UTIs → voiding cystourethrogram

o Evaluation for VUR
Beckwith-Wiedemann Syndrome
o Definition: overgrowth disorder characterized by a predisposition to neoplasms
o Results from sporadic or inherited mutation of CH 11p15 → encodes insulin-like growth factor 2 → similar effects
to insulin
o Dysregulation of imprinted gene expression

o Clinical Symptoms: fetal macrosomia, rapid growth until late childhood, omphalocele or umbilical
hernia, macroglossia, hemihyperplasia
o Management:
o Hypoglycemia: monitor newborns closely
o Wilms Tumor + Hepatoblastoma: screen via abdominal US and/or ⍺-fetoprotein then renal US
I. Birth to 4 years → every 3 months → abdominal US + ⍺-fetoprotein
II. Age 4 to 8 years → every 3 months → abdominal US
III. Age 8 to adolescence → renal US
Wilms Tumor [Nephroblastoma]
o Definition: most common primary renal neoplasm of childhood; most commonly sporadic
o Usually diagnosed at age 2-5 years and affects single kidney
o Less than 5% of patients have bilateral presentation (Stage V disease)
o Clinical Symptoms: asymptomatic , firm, smooth abdominal mass incidentally found; does not cross midline
o Abdominal pain, HTN, hematuria, fever
o Diagnosis: Abdominal US → contrast enhanced CT of abdomen & chest (rule out metastasis)
o Treatment: surgery; chemotherapy +/- radiation
o Associated Syndromes
o WAGR [Wilms Tumor, Aniridia, Genitourinary Anomalies, intellectual disability (mental Retardation)] – WT1 del
o Beckwith-Wiedemann – WT, macroglossia, organomegaly, hemihypertrophy – WT2 mutation
o Denys-Drash – WT, early onset nephrOtic syndrome, male pseudohermaphroditism – WT1 mutation
o Differentials:
o Neuroblastoma: third most common pediatric cancer after leukemia & brain tumors; most common in 1st year of life
o Can arise anywhere in sympathetic nervous chain; most commonly arises on adrenal glands
o Abdominal mass, which crosses midlines + systemic symptoms
o Jerking movements of eyes and legs; bluish skin nodules; TENDER abdominal mass
o ↑urine HVA or VMA
Necrotizing Enterocolitis
o Definition: necrosis of intestinal mucosa with possible perforation via inflammation and damage to bowel wall
o Most common GI emergency in NICU
o Etiology: prematurity [<32 weeks] & very low birth weight
o Clinical Symptoms: ↑ gastric residual volume, vomiting, abdominal distension in preterm neonate
o Pathogenesis: Gut immaturity + exposure to bacteria via enteral feeds → premature intestinal mucosa → increased
permeability + bacterial penetration + immature local host defenses + decreased mobility → bacterial overgrowth → cascade
of inflammation + damage to bowel wall
o Prophylaxis: breastfeeding → may counteract issues associated with gut immaturity
o Diagnostics: Abdominal XR
o Air visible in bowel wall → “double-line” or “train-track” appearance → pneumatosis intestinalis
o Gas produced by bacteria IN portal veins OR via transmigration of gas from bowel wall to mesenteric veins + portal vein → linear,
branching areas over of lucency over liver → portal venous air
o Free air in under diaphragm → pneumoperitoneum
o Laboratory Investigations:
o Inflammation → leukocytosis
o Intestinal ischemia → metabolic acidosis
o Treatment: supportive care → stopping enteral feeds → gastric decompression w/ intermittent suction→ fluid repletion to
correct electrolyte abnormalities → BP support → parenteral nutrition → antibiotics → surgical resection of necrotic bowel
Meconium Aspiration
o Definition: meconium obstruction of airways in infants born through meconium-stained amniotic fluid
o May occur in term OR post-term infants
o Clinical Symptoms: respiratory distress
o Diagnostics: Chest XR
o Patchy infiltrates
o Coarse streaking of BOTH lung fields
o Flattening of diaphragm
o Treatment:
o Intrapartum → saline dilution of meconium
o Partum → suctioning of oropharynx before delivery of shoulder
o Post-partum → intubation + oxygen
o Complications: pulmonary artery HTN, pneumonitis
Jejunal Atresia
o Definition: atresia of the jejunum
o Clinical Symptoms: bilious emesis, abdominal distension
o Pathophysiology: vascular accident in utero → necrosis → resorption of fetal intestine → sealing off +
blind proximal and distal ends of intestine
o Etiology: poor fetal gut perfusion from maternal use of vasoconstrictive medications OR
cocaine/tobacco use
o Some cases associated with meconium ileus/CF → localized volvulus → ischemic necrosis
o Not associated with chromosomal abnormalities
o Diagnostics: Abdominal XR
o ”Triple-bubble” sign
o Gasless colon
o Treatment: initial focus on resuscitation and patient stabilization; then surgical correction
Choanal Atresia
o Definition: congenital nasal malformation caused by failure of posterior nasal passages to canalize
completely, leaving either bony OR membranous obstruction
o Condition may be isolated or part of a syndrome [eg. CHARGE = Colomba, Heart defects, Atresia choanae,
Retardation of Growth/Development, Genitourinary anomalies, Ear abnormalities/deafness]
o Clinical Symptoms: dependent on depth of obstruction and infant’s ability to breath through mouth
o Bilateral obstruction = cyclic cyanosis
o Worsens with feeding
o Improves with crying
o Unilateral obstruction = largely asymptomatic until 1st URT
o Diagnostics: Inability to pass a catheter from nares into oropharynx; confirmed via head CT
o Narrowing at level of pterygoid plate in posterior nasal cavity
o Obstructed air + fluid can be detected in front of obstruction
o Treatment: initial management with oropharyngeal airway + orogastric tube feeding; then surgical
correction
Laryngomalacia
o Definition: chronic stridor in children caused by increased laxity of the supraglottic structures that collapse
during inspiration
o Clinical Symptoms: stridor which begins in neonatal period; loudest at ages 4-8 months
o Inspiratory stridor worse in supine position
o Worsens by feeding or URIs
o Improved by prone position
o Diagnosis:
o Clinical diagnosis; may be confirmed via visualization with direct or flexible fiber-optic laryngoscopy for
moderate/severe cases
o Ω shaped epiglottis
o Treatment: spontaneous resolution of stridor by 18 months
o May be necessary to treat patients with symptomatic GERD
o Supraglottoplasty reserved for severe cases
o Differentials:
o Vascular rings = anomalous branch of aortic arch encircles trachea & esophagus
o Biphasic stridor due to dual compression
o Identified via barium swallow; confirmed by MRI with angiography
Asthma Exacerbation
Asthma Severity Symptom Nighttime Awakenings Indicated Therapy
Frequency/SABA Usage
Intermittent <2 days a week <2 times a month Short acting B-agonist
Mild Persistent >2 days a week 3-4 times a month Low dose inhaled CS
Moderate Persistent Daily >1 time a week Low dose inhaled CS +
Long acting B-agonist

OR

Med dose inhaled CS

Severe Persistent Throughout each day 4-7 times a week High dose inhaled CS
Long acting B-agonist

Omalizumab (for pts

with allergies)
GI Workup
o Necrotizing Enterocolitis → abdominal XR = air in bowel wall and portal veins
o Hirschsprung Disease → abdominal XR = healthy colon is dilated & pathologic colon is normal
o Contrast enema = narrow sigmoid + dilated remaining colon
o Intussusception → abdominal US = detect the telescoping bowel
o Administer air enema to alleviate obstruction
o Meconium Ileus → abdominal XR = detect air in bowel wall
o After exclusion of pneumoperitoneum → water-soluble contrast enema = microcolon appearance due to
underused contracted colon full of viscous meconium + obstruction in terminal ileum
o Administer hyperosmolar enema to break up meconium [Gastrografin]
o Surgery if enema is unsuccessful
o Pyloric Stenosis → abdominal US = thickened pylorus muscle
o Duodenal Atresia → abdominal XR = air in stomach + duodenum, NO distal air
o ”Double-bubble” sign
Foreign Body Workup
o FB trapped in GI tracts → flexible endoscopy
o FB trapped in airway → rigid bronchoscopy
Subcutaneous Emphysema
o Definition: wherein air leaks from the chest wall into the subcutaneous tissues due to the ↑
intraalveolar pressure [eg. provoked by a cough]
o May be also be a consequence of Boerhaave Syndrome
o Clinical Presentation: paroxysms of coughing
o Complications:
o Pneumothorax
o Perform CXR to rule out
Pediatric Stroke
o Definition: pediatric patient presenting with focal neurologic deficits
o Clinical Symptoms: focal weakness, hemiparesis, aphasia, seizures, or altered mental status
o Risk Factors:
o Sickle Cell Disease
o Chronic vasoocclusion → endothelial damage + intimal proliferation → vascular stenosis → cerebral ischemia → stroke
o Perform MRI to confirm vasooclusion
o Prethrombotic disorders
o Congenital cardiac disease
o Bacterial meningitis
o Vasculitis
o Focal cerebral arteriopathy
o Head/neck trauma
o Differentials:
o MELAS [mitochondrial encephalopathy w/ lactic acidosis & stroke-like episodes]
o Neurological changes; hemiparesis
o Investigate with serum lactate/pyruvate, CK levels
o Confirm via muscle biopsy
Neurofibromatosis
Gene Mutation
Location
Clinical Presentation
NF 1 von Recklinghausen NF 2
Disease Central
Neurofibromatosis
NF1 tumor suppressor NF2 tumor suppressor
gene → codes the protein gene → codes the protein
neurofibromin merlin
Ch 17 Ch 22
o Café-au-lait spots o Bilateral acoustic
o Neurofibromas neuromas
o Lisch nodules

o Prognosis: 15% of NF1 pts will develop optic pathway gliomas

o Manifests with unilateral vision loss, proptosis, esotropia, optic disc pallor
Pharyngitis
Flowchart
Primary
Amenorrhea