:neonatal jaundice

breast feeding jaundice vs breast milk jaundice: vvimp

 ‫المرض االوالنى سببه االساسى االم مش بترضع الولد كمية لبن‬
‫كفاية علشان كده عالجه االساسى هو نزود كمية اللبن فى‬
‫الرضاعة و الصفرة هتختفى بالكامل‬
‫المرض التانى سببه مش واضح اوى اللبن هو اللى بيعمل‬
‫و بعدين نرجع ترضع تانى‬..... ‫المشكلة الحل نوقف الرضاعة شوية‬
‫مهم جدا جدا جدا االم ترجع تانى طبيعى بعد فترة‬

:Physiological hyperbilirubinemia
Timing……3rd day

When it start to appear ?????

 appears in the sclera 35-40 micromol

 appears in the skin 70 - 100 micromol/L


Prevention of jaundice

 Early and frequent breastfeeding (8-12 times per day

for the first few days)

:Pathological jaundice
:Causes
:Hemolytic disease of the newly born -1
Cause…..Rh (-) mom and Rh(+) baby
Most common cause of sensitization of the mom…..hidden
feta-maternal hge bleeding
How to prevent…….anti-D after any maternal bleeding
:ABO incomptability-2
If mom is O and the baby is A, B or AB
Can occur if first baby born
Mild hemolysis
:Sepsis-3
Fever, bad general condition and jaundice

Choledecal cyst :-4

Cystic dilatation of extrahepatic biliary system
TTT…..surgery
Classification of hyperbilirubinemia according to
dates:vvvvvv imp
First day:VVVVVVVV IMP
TORCH infection-1
Rh and ABO incomptability-2
Hemolytic anemia……..hereditary spherocytosis-3
:2nd-3rd day
Physiological
Cephalohematoma
More than 7 days
Breast milk jaundice
Hypothyroidism
weeks…….biliray atresia 1-2

:Complications of pathological jaundice

:"Kernicterus
Organ affected…….basal ganglia
Cp….lethargy, seizures and hypotonia
TTT…..exchange transfusion
:Investigation
Bilirubin….direct and indirect….1st step .…vvvv imp


 When to do phototherapy????

 bilirubin >270micromol/L

When to do exchange transfusion????:

 bilirubin >340 micromol/L

Comb's test……for hemolysis

:Management
Phototherapy…..blue green light-1
Side effects……hyperthermia, dehydration, skin rash, bronze
baby syndrome corneal damage
::Precautions
Cover the eye and the genitalia
Frequent change of the position
Increase fluid intake
 :Exchange tansfusion-2
:Indications
Symptoms of kernicterus
Marked elevation of bilirubin
)-(Blood used……fresh, warm , irradiated, Group O Rh

Phenobarbital-3
:N:B
When to say direct hyperbilirubinemia……..when direct is
more than 20% of the total
Direct hyperbilirubinemia after 1st week………biliary atresia

:Congenital hypothyrodism
 Most common cause…….thyroid dysgenesis
Cp…..prolonged jaundice, constipation, hypotonia, enlarged
tongue, umbilical or inguinal hernia, mental retardation

:prevention
Screening……..2nd and 7th day of life
Technique………blood sample from the heel
TTT…..thyroxine

:Gilbert syndrome
Most common cause of hyperbilirubinemia
Genetics…..AD
Cause….low glucuronyl transferase
Cp…..jaundice
Type…..indirect hyperbilirubinemia
TTT…..none
:Crilger Najar
Same as Gilbert
But more severe ….needs ttt
:Dubin Johonson and Rotor syndrome
Conjugated hyperbilirubinemia
No ttt
With Dubin Johonson…..green colored liver biopsy
:Neonatal seizures

Most common cause….hypoxic ischemic encephalopathy

:TTT

First step….airway and o2……. Diazepam, Phenobarbital

:Neonatal hypoglycemia

Most common cause….DM

Cp:….tachycardia, pallor, sweating, lethargy, convulsions, coma

Inv….blood glucose level

:TTT
IV glucose….if hypoglycemia persist give IM Glucagon…vvv imp

:Neonatal hypothermia

Cp…low temperature, facial erythema, bradycardia,

hypotension, apnea
TTT….gradual warming

…choanal atresia:

:Cp

RDS

Cyanosis…improves with crying..key

word

Test…failure to pass a catheter

through the nose

Inv of choice….CT with contrast

:TTT

First step…..airway to keep the mouth open

Surgery

:Cytomegalovirus in neonate
Most common cause of congenital neonatal infection
Most common cause of birth defect
:Cp
 Hearing loss
 Vision loss…..pigmented
retina
 Mental disability
 Small head size………microcephaly
 Seizures
 Death
  Inv of choice……urine antigen
TTT…….ganicyclovir

Routine screening……not done

How to asses acute infection…..IgM
Best way to asses fetal infection….amniotic
fluid sampling
:Neonatal sepsis

cp: fever, poor suckling, hypotension

Most common organism………Group B- steroptococcus

:Oral candidiasis

,Cp….difficult suckling
Exam….whitish lesion removed easily

TTT…..oral nystatin

:Innocent murmur

:Characteristics

Age……less than 12 months

Absence of any cardiac symptoms…..as cyanosis or dyspnea

NO other congenital abnormalities

Site…..best between left sternal edge and the apex

Changes with change in posture or respiration

Decreases by sitting up

Systolic never diastolic, Soft

MANAGEMENT…………reassure and refer to pediatrician…..imp

:Umbilical Granuloma

Cause…..remnants of the umbilical cord

TTT…… silver nitrate

Complication…….infection

: Omphalitis

Inflammation of umbilical cord stump

Organism……staph (most common)

Most common source of infection…umbilicus

Cp….pain, redness, swelling, pus

Fever
Omphalocele vs Gastroschisis

Both of them ……. Herniation of

abdominal viscera

Omphalocele……….there is a sac

Gastroschiasis……….nooooo sac

:TTT

Gastroschisis…….emergency surgery

:Omphalocele

First step….. cover contents with a gauze

Then……NG suction….Then surgery

:Tongue tie

Family history usually positive

Does it affect speech?....noooo

Does it affect suckling?...Yesss

:Timing of repair

months or 3-4

years 1-2

:Cleft lip and palate

Usually unilateral

Most common cause…genetic

?Complications of cleft palate

affect feeding -1

affect speech-2

repeated ear infection…..deafness -3

aspiration pneumonia-4

:Timing of surgery

Cleft lip……Less than 3 months

Cleft palate …..6- 12 months

:Fused labia in babies

Most common cause….adhesion secondary to inflammation

Timing……majority after 3 months

Do not try to pull them apart

:TTT

The most safe ttt……….leave it alone….vvvvvvvv imp

Medical treatment, massage or cream is not usually needed.
Labial fusion does not have any effect on future fertility

Key points to remember

 Labial fusion is common.

 It does not usually cause any other symptoms.
 It is not related to other problems.
 The fusion will normally separate naturally by the time your
daughter has her first period.
 The safest, most effective and least stressful thing to do is no
treatment.

:Metatarsus adductus

Cp…..adducted foot

Bean shaped sole of foot

On exam….. the heel can go flat on the surface

Resolution…..usually by 3 years

Referral……3 months after surgery

Main ttt…..serial cast

Surgery if no resolution after 3 years

:CLUB FOOT ( talipes equinovarus)

Common esp. in males

Majority of cases……just postural ( esp.

primigravida) or congenital

Heel cannot go flat on the surface

:TTT

Usually NO ttt

CORRECTIVE SHOES

SERIAL CASTING

IF NOT…..SURGERY

:INTERNAL TIBIAL TORSION

AGE…….toddler

Site of the lesion……tibia

:TTT

OBSERVE

Resolution by 3-4 years

Refer after 6 months of presentation

:Medial femoral torsion

Site …..femur

:TTT

Reassure and just observe

Resolution….by 8-9 ys

Refer after 8 ys of presentation

:Pediatrics infections

:Types of skin rashes

:maculopapular-1
Measles

Mumps

Roseola infantum

Scarlet fever

Infectious mononucleosis

SLE

Juvenile rheumatoid arthritis

Sweat rash

Vesicular rash………chicken pox, herpes zoster, herpes simplex

:Roseola infantum

Cause…..herpes simplex virus 6

Cp……3 day fever followed by maculopapular rash

Complications……febrile convulsions

TTT…….symptomatic

:Rubella

Cp….fever

Marked posterior lymphadenopathy….key word

:Measles

IT IS A NOTIFIABLE DISEASE

:Cp

Cough, conjunctivitis, coryza

Koplik's spots

Maculopapular rash after the Koplik's

Most common complication……otitis media

Most imp vitamin to give,,……vitamin A

Main TTT …….support

Erythema infectiousm: (fifth's disease)

Cause……….parvovirus B19

:Cp

Slapped cheek

Maculopapular rash
School exclusion…….none

TTT……symptomatic

Parvovirus in normal kids………..slapped cheek

Parvovirus in sickle cell patients…….aplastic anemia

Parvovirus in pregnancy………hydrops fetalis

:Scarlet fever

Cause…..group A streptococcus

:Cp

Strawberry tongue

Circumoral pallor

Sand paper rash

Complication…….glomerulonephritis

TTT……penicillin

:Hand, foot, mouth disease

Cause……. coxsackie virus

:Cp

Mouth………ulcer
Hands and foot …..maculopapular rash then vesicles

School exclusion…… Exclude until all blisters have dried

:herpangina

Organism…… coxsackie

Cp…..vesicles and ulcers in the mouth,

palate and uvula

:Herpangia vs herpes gingivostamatitis

Both of them………vesicles

Herpangia………….affecting mainly posteroir part of the mouth

Herpes…………….affecting mainly lips and anteroir part of the

mouth

:Bronchiolitis

Cause……RSV

Age…….2 weeks up to 2 years

Cp……wheezes and respiratory distress……..key word

Risk……asthma in the future higher risk

X-ray……hyperinflation

TTT,……supportive only (O2 and fluid)……via nasal prong

Hospitalization only if complicated

No antibiotics

Croup:( acute laryngotracheo bronchitis)

Cause…….parainfluenza virus

:Cp

fever

Inspiratory stridor worse in night

Harsh voice

Barking cough

Symptoms increase by lying on the back

……TTT

Mild to Moderate Croup…………… Prednisolone

Severe croup………nebulized adrenaline

Epiglottitis

Cause…….hemophilus influenza

:Cp

Very high fever

Toxic look

DROLLLLLLLLING of saliva

Expiratory stridor with soft voice

Donot examine the throat

X-ray……thumb print sign

:/Management

First step……admission
Intubation

If cannot intubate…….cricothyrodectomy

Antibiotics

:KAWAZAKI disease
Inv…..ECHO….VVVVVVVIMP

First line of ttt………..IVIG

2nd line of ttt………….Aspirin

:ACUTE OTITIS MEDIA

::CAUSE……..step. pneumonia…….most commo

Fever, Crying and Pull their ears

Vomiting and feeding troubles

:Signs

Loss mobility OF EAR DRUM ……..vvvvvvvvvvvvv imp

:TTT

Drug of choice………paracetamol only

If no response……….amox

If still no response,………amox-clav
Most imp test to be done to the baby after recovery……hearing
assessment vvvvvvvvvvvvvvvv imp

:Complications of otitis media

Effusion……….usually resolve spontansouly -1

Mastoiditis :2

Cp…..swelling behind the ear

Inv……CT

:MENINGITIS-3

Organism……strep.pneumoniae

Cp……stiffness of the neck and

rash
Inv……..CT

Cholesteatoma…..whitish mass…..bone erosion-4

:Chronic otitis media

Persistent drainage from the middle ear lasting >6-12 wk
Inv……..CT
TTT……aural toilet ….main management
antibiotics

:Worm infections
:Ascaris lumbricoides
Most common worm …..very long worm
Complications….intestinal obstruction, lung affection
TTT….albendazole
Hook worm( ankylostoma)
Abdominal pain and diarrhea
Most common worm causing iron deficiency anemia in
kids
Hypoalbuminemia
Inv….stool analysis
TTT…..albendazole and iron
Enterobius vermicularis…vvvvv imp
Most common cp…….itchy anus
Inv of choice…….adhesive tape at night
TTT….single dose albendazole and repeat after 2 wks
:Trichinella spiralis
Undercooked meat
Most common cp…….muscle pain
Inv of choice……larva in muscle biopsy
TTT….mebendazole

:Trichuris trichura
Most common complication….rectal prolapsed
Cp….periumbilical pain
TTT….albendazole

Chicken pox ( varicella)

:Cp

Fever

Vesicular rash….different morphology( crops)

:Post exposure prophylaxis

Vaccine….live attenuated-1

only 1st 72 hours..…

IVIG…if pregnant or immunocompromised -2

Exclusion from school…vvvvvvvvvv imp

Exclude until all blisters have dried
At least 5 days after the rash
TTT….acyclovir, analgesics

:MUMPS

Cp….fever, fatigue

Enlarged parotid, tender, bilateral in 25%

Commonest complication in kids……encephalitis

Commonest complication in adult…..orchitis…testicular

atrophy….infertility

Pancreatitis, deafness, myocarditis, arthritis

TTT….supportive

School exclusion….. Exclude for 9 days or until swelling goes

down

Pertussis (whooping cough)….vvvvvvvvvvvv imp

Organism….bortedella pertussis

:Infectivity period

During catarrhal and paroxysmal stages

Up to 5 days after starting antibiotics

:Stages

Catarrhal stage(1-2 weeks)

Fever, mild cough, sneezing

Paroxysmal stage (2-4 weeks)

Severe paroxysmal spasmodic cough

The cough ends by characteristic whoop (sudden inspiratory crow)

Convalescent stage(2 weeks)

Decrease frequency and severity

:Complications

Subconjuctival hge….very common due to severe cough

CNS…..convulsions

Otitis media, pneumonia, pneumothorax

Inv of choice …. PCR of nasopharyngeal swap (-) after 3 wks

Serology…..low value

Prevention….DTP vaccine

:TTT

Erythromycin or azithromycin ….drug of choice

School exclusion:…vvvvvvv imp

Exclude the child for 3 weeks after the onset of cough

.or until they have completed 5 days of antibiotic
Protection of the contacts:……VVVVVV IMP
:antibiotics prophylaxis-1

 Most school-aged children who are fully vaccinated and

do not have symptoms do not require prophylaxis.

All the family members should receive erythromycin

regardless of their age or immunization status
2- Vaccination prophylaxis:

 Close contacts that are not up to date with their pertussis

immunisation should be given DTPa or dTpa as soon
after exposure as possible.
 dTpa for adults who have not had pertussis-containing
vaccine in the last 10 years.

:IMPORTANT PEDIATRICS SYNDROMES

:Down syndrome
Cause…..Triosomy 21
:CP
upward slanting palbebral fissure
inner epicanthal fold
open mouth with tongue protrusion
hypotonia
Hearing loss
Simian crease
Gonadal deficiency
Hypothyroidism
Antanto-axial instability
:Very important tips for down
Most common genetic disorder…..non-dysjunction
Most common risk factor……maternal age
Most common cause of death…..leukemia (acute
lymphoblastic)
Mentally…..early onset alzeheimer
Most common CVS abnormality….endocardial cushion
defect followed by VSD
Most common GIT abnormality……duodenal atresia
Most common endocrine abnormality…..hypothyrosim
Most common spine abnormality….. Antanto-axial
instability
Recurrence rate with Down…..1%
risk of down syndrome by age chart Australia: vvvimp
1/870……20
1/500.……30
1/200.……35
1/100.……40
1/25……45
1/10……49

:Klienfelter syndrome
Genetics…..47XXY
:Cp
Tall man
Long limbs
Slim
Hypogonadism….small testis
Decreased testosterone hormone
gynecomastia
Low IQ
Behavioural problems

Turner syndrome: ( 45X0)

Most imp inv……FSH….increased
TTT…..hormonal replacement after puberty

:FETAL ALCOHOL SYNDROME

:Most imp cp
Thin upper lip
Absent or short philthrum
Mental retardation
???When grow up
Irritability and hyperactivity
Safe amount of alcohol during
pregnancy….not known
Most common cause of MR in
Australia….FAS
How do u screen during
pregnancy?....US
Most common CVS
anomaly…..VSD

:Marfan syndrome
Genetics….AD
Mutation in fibrillin gene
Tall stature
Long slim limbs
Decreased U:L limb ratio
Arachnodactyly
Joint laxity and subluxation
Eye…..upward subluxation of the lens
Heart….AR
Aortic dissection
Spine…..scoliosis
Pectus excavatum
 E
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:ndrome
Genetics….AD
Hyperextensible skin
Easily fragile
Joint laxity
MVP
AR
Aortic dissection
Blue sclera

:Osteogenesis imperfecta
Genetics….AD
Blue conjunctiva
Scoliosis
Recurrent multiple fracture
DD….child abuse

:
: .…Peutz-jeghers syndrome
VVVVVVVV IMP
Genetics……AD
Lips……pigmentation
Colon…..polyps
:Risk
intussception-1
colon cancer….SCREEN-2

..…:Fetal hydantoin syndromes

:Causes
Drugs….valproic acid, phynetoin, carbamazepine
 :Fragile x-syndrome
Genetics:…x-linked
‫كل حاجة كبيرة اال عقلة صغير‬
Large ears
Large skull
Large testis
Mental retardation

:Not important syndromes

Edward syndrome : triosomy 18…. Not imp

patau syndrome….not imp

Waldenburg syndrome….not imp

Albinism
Blue eyes
Premature graying

Prader-willi syndrome … not imp

Marked obesity
Marked hypotonia
 Angelman syndrome….not imp
Marked laughter
MR

:Pediatric oncology

:SPINA BIFIDA vs MENINGOCELE vs MENINGOMYELOCELE

% Recurrence rate……2-5

How to diagnose?.....amniocentesis at 15 weeks

How to prevent?.......Folic acid supplementation

:Spina bifida occulta

No herniation covered by tuft of hair

Asymptomatic……..no ttt

:Meningocele
Herniation…..meninges but not the spinal cord

Covered by skin

Do ct ……exclude hydrocephalus

TTT……surgery

:Meningomyelocele

Herniation….meninges and spinal cord

No skin covering (thin membrane)

Cp……paraplegia and spincteric disturbances

Inv….CT….exclude hydrocephalus

T
T
T
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…
s
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e
ry

:Wilms tumour

Age……2-5 ys
Usually unilateral

:Association

Hemi hypertrophy

Aniridia

Urinary tract abnormalities

Cp…….asymptomatic abdominal pain does not cross midline

Hypertension and hematuria

Inv……CT is the best

:TTT

Nephrectomy IS THE MAIN TTT

Then chemotherapy

If both kidneys affected…….unilateral nephrectomy and partial

contralateral nephractomy

Prognosis…..excellent

:Neuroblastoma

Origin……neural cells

Cp:…..age usually less than 2 ys

Painful abdominal mass crosses the midline

Nausea, vomiting and fever

Periorbital ecchymosis

:Inv

Vanillymanillic acid……increased
The best inv…………..CT

TTT…..SURGERY and radio

:N:B

Wilms tumour is much more common than neuroblastoma….in

.the exam if you are confused go to wilm's

:Craniopharyngioma

Suprecellar calcification…….vvvvv imp

:Cp

Increased ICP

Growth failure and loss vision

Panhypopituitarism

The best…..MRI

x-ray……calcification

TTT…..surgery

:Infratentorial tumours

Astrocyroma:…….most common

Medulloblastoma……second most common

Both of the arise from cerebellum

Medulloblastoma…….midline infratentorial
 :Pediatrics toxicology

:Lead poisoning

key word………….Old housing...

Low socioeconomic status

:Cp

Behavioral….hyperactivity, aggression, irritability

GIT….abd. pain , vomiting and constipation

CNS…..affect memory, seizures and lethargy

Confirmatory test…..venous sampling…..ivn of choice

Confirmed with an elevated BLL (>0.48 µmol/L or 10 µg/dL).
Un Safe amount of lead in if more than 5 µg/dL.
Overt clinical toxicity from lead may not become apparent until BLL
exceed 40 µg/dL.
X-ray of long bone…..dense lead line

CBC….microcytic hypochromic anemia with basophilic stippling

TTT……chelation

:Acetaminophen

Nausea and vomiting

RUQ pain

:Labs

Acetaminophen level after 4 hs……..vvvvvvvv imp

Check Liver functions test and renal fuctions

TTT:……. N- acetylcystine

How is it given……..iv

Duration …..for 21 hours

Side effect of NAC infusion?

Anaphylactoid reactions
Management of this reaction????
Cease the infusion for 30 minutes, give promethazine then
recommence the infusion at half the previous rate
:Aspirin

First symptom……hyperventilation

:Cp

Vomiting

Lethargy, seizures and dehydration

TINNITUS
:ABG

First stage……respiratory alkalosis

Then…..metabolic acidosis

TTT…….alkalinization of urine

:Carbon monoxide

Cause…..fire, sleeping in the garage

Cp……cherry red color

Headache, irritability and

lethargy

Complications…..rhabdomyelosis……renal failure

TTT……..high flow O2

Organophosphorus:……….PESTICIDES

:Increased all body secretions

Diarrhea

Urination

Lacrimation and salivation

Bradycardia

Miosis

Twitching and fasciculation

Exposure………..insecticide and fertilizers

FIRST STEP……..REMOVAL OF ALL CLOTHES

imp
Atropine…….ttt the symptoms

Pralidoxime……the definitive ttt

:Iron

Main source……multivitamins pills

:Cp

Abd. Pain, nausea and vomiting

Liver dysfunction

:Inv

X-ray……radioopaque tablets in the staomach….imp

TTT……deferoxamine

:TCA

WHITE TABLETS

CP……SEIZURES WITH ARRYTHMIA

First step…….ECG…….wide QRS

TTT…….sodium bicarbonate