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I N N O V A T I V E • C O M P R E H E N S I V E • H A N D S - O N

INTENSIVE UPDATE& BOARD REVIEW

AUGUST 24 - 26, 2018Loews Chicago O’Hare Hotel

Rosemont, IL

Bringing Up Baby - Key Concerns

Sarah Hall, DO

8/3/2018

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Sarah Hall, D.O.

August 24, 2018

ACOFP Intensive Board Review

You are seeing a newborn at 72 hours for an initial newborn visit in your office. The baby was born at 37 weeks after a prolonged spontaneous vaginal delivery and is exclusivelybreastfeeding. APGARS were 7/9. Discharge papers indicate that at 24 hours, the baby’s Total bilirubin level was 8 mg/dL and the direct bilirubin level was 0.2 mg/dL. The baby is urinating and sleeping well. Baby is nursing every 3-4 hours for 10 minutes but falls asleep at the breast. +3 stools in the last 24 hours. On exam, the infant is afebrile and has lost 13 percent of birth weight. The baby’s eyes, tongue, and skin appear yellow down to the umbilicus. Anterior fontanelle is open and flat. The infant is alert and has a 3 cm cephalhematoma located on the left parietal area. A STAT Total serum bilirubin level is 17 mg/dL at 72 hours.

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A. Reassure parents that this is normal. And follow up in 2 days.

B. Repeat total and direct bilirubin levels in 24 hours.

C. Admit the infant and initiate exchange transfusion.

D. Initiate home phototherapy and follow up in 24 hours.

E. Admit the infant and start IVIG and phenobarbital.

Unconjugated hyperbilirubinemia

Peak values occur at 48-96 hours

Resolves within 1-2 weeks after birth

Pathologic if noted in the first 24 hours of life

Different nomograms for determination of risk, phototherapy treatment and exchange transfusion

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Bryon J. Lauer, and Nancy D. Spector

Pediatrics in Review 2011;32:341-349

Phototherapy

24 hrs-bilirubin > 10 mg/dL

48 hrs-bilirubin>13 mg/dL

72 hrs-bilirubin>15 mg/dL

24 hrs-bilirubin >16.5 mg/dL

48 hrs-bilirubin > 19 mg/dL

72 hrs- bilirubin> 21 mg/ dL

Exchange transfusion

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Phototherapy

24 hrs-bilirubin > 12 mg/dL

48 hrs-bilirubin>15 mg/dL

72 hrs-bilirubin>18 mg/dL

24 hrs-bilirubin >19 mg/dL

48 hrs-bilirubin > 22 mg/dL

72 hrs- bilirubin>24 mg/ dL

Exchange transfusion

Amy, a 4 day old female comes to the clinic because “she is yellow”. She was born at term to a 25 year old woman. Maternal labs results are as follows: blood type A pos, syphilis negative, rubella immune, GBS negative. Amy has been breastfeeding every 3-5 hours. She has had one stool and three urine diapers a day. Her weight is 15 % less than her birth weight. On your exam, she is jaundiced from head to thighs. Her total bilirubin is 25.2 mg/ dL. The conjugated (direct) bilirubin is 0.4 mg/dL and the unconjugated (indirect) bilirubin is 21.2 mg/dL. Which of the following is correct?

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A. she has breastfeeding failure jaundice

B. she has physiologic jaundice

C. she has biliary atresia; you must consult pediatric gastroenterology

D. There is an ABO incompatibility between the mother and the child

E. she has pathologic jaundice

Develops within the first few days of life as opposed to breast milk jaundice which develops later

Due to inadequate breastmilk production

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Which of the following is NOT a risk factor for severe neonatal hyperbilirubinemia?

A. Exclusive breastfeeding

B. Gestational age over 41 weeks

C. Significant birth trauma

D. Visible jaundice in the first 24 hours of life

E. East Asian race

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Amy’s CBC is unremarkable and blood type is A pos.

Which of the following is the most appropriate initial therapy for this patient. Her total bilirubin is 25.2 mg/ dL. The conjugated (direct) bilirubin is 0.4 mg/dL and the unconjugated (indirect) bilirubin is 21.2 mg/dL.

A. admit for exchange transfusion

B. admit for fluids to improve hydration

C. admit for phototherapy

D. discharge home encourage formula feeding, light exposure, and follow up bilirubin tomorrow

Severe neonatal bilirubinemia TB> 25 mg/ dLBilirubin induced neurologic dysfunction (BIND) Acute bilirubin encephalopathy (ABE)

Chronic and permanent sequela of BIND=kernicterus

***Treated with exchange transfusion

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You admit Amy for further management. You confirm Amy’s current weight, which is down 15 % from birth weight. Beyond what point in time is it considered problematic if the patient has not returned to his or her birth weight?

A. 5 days

B. 7 days

C. 10 days

D. 14 days

E. None of the above

By 14 days-regain birth weight

By 6 months-double birth weight

By 12 months-triple birth weight

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The current recommendation for the treatment of breast milk jaundice is:

A. Continue to breastfeed

B. Stop breastfeeding and change to cow’s milk formula

C. Stop breastfeeding and change to soy milk formula

D. Stop breastfeeding and treat with rehydration solution

Continuation of breastfeeding, increase frequency, formula supplementation

Phototherapy

Exchange transfusion

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A 2 week old infant presents to the office with mom and complaint of poor feeding for the last 2 days. She has noted that the infant has been more fussy and has been sleeping more. The baby has been formula feeding 2 ounces/ 3-4 hours until 2 days ago at which time the infant would only take 1 ounce every 6-8 hours. Urine output has decreased from 8 wet diapers to 3 wet diapers/ day. Vitals-T101 ° F, HR-167, RR-60-fontanelle is sunken and MM dry. Heart is tachycardic without Murmurs. Lungs are clear without wheezes or rhonchi. Abdomen is soft, no masses or erythema noted at umbilicus. Decreased bowel sounds in all quadrants.

A. Administer acetaminophen and obtain labs.

B. Administer ceftriaxone and follow up in 24 hours.

C. Admit the infant for work up and empiric antibiotics.

D. Arrange for home health to assist with improved feeding.

E. Obtain prenatal history and birth history.

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History and Physical

CBC and CMP

Blood culture

Urine culture

CSF culture

Total and direct bilirubin if jaundiced

HSV culture of vesicles if present

Age Organism Empiric treatment

Neonate (<28 days) GBSE.ColiListeriaEnterococcusS. AureusHSV

Ampicillin + Cefotaxime OrAmpicillin + Aminoglycoside and Acyclovir

Infant (29-90 days) S. PneumoniaH. InfluenzaN. MeningiditisGBSE.ColiListeriaEnterococcusS. AureusPseudomona

Well appearing, no CSFpleocytosisCeftriaxone or cefotaxime

CSF pleocytosis or ill appearingVancomycin + Ampicillin and Ceftriaxone or cefotaxime

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A 7 month old fully immunized female presents to the office with fever. Mom reports she has not been herself and felt a bit warm. Vitals reveal a temperature of 39.2 ° C. Physical exam reveals a toxic appearing infant. You perform a complete history and physical but are unable to identify a source of her fever. What is the most likely etiology of her fever?

A. Bacteremia

B. Urinary tract infection

C. Pneumonia

D. Meningitis

Type of Infection Prevalence

Urinary tract infection 72

Bacteremia 20

Soft tissue infection/ cellulitis 13

Meningitis 6

Pneumonia 4

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Age younger than 28 days

Maternal infection in pregnancy or labor

Temperature over 40° C (104 F)

Unimmunized

Prematurity

Chronic illness

Antibiotic administration with in 7 days

Social barriers to follow up

An 18 month old male presents to your office for well child check. His weight has dropped from 30th

percentile to 5th percentile since his last well check 6 months ago. Father reports that he is a picky eater and mainly consumes apple juice and rice cereal. He has refused milk and his mother believes he is lactose intolerant and therefore has not been receiving any. He has 6 wet diapers/ day and 4-5 loose stools/ day. On physical exam you note symmetric bruising on the upper arms and healed circular burns on the buttocks and lower back.

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A. Contact a pediatric dietician for outpatient consultation

B. Inpatient admission for work up and initiation of nutritional support

C. Notify local authorities to escort the father out of the clinic

D. Perform labs to screen for underlying medical disorder

E. Perform skeletal survey for inherited bone disease

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Nutritional

Medical

Developmental/behavioral

Psychosocial factors

Interdisciplinary approach is critical to success

Indication for Hospitalization Severe malnutrition

Dehydration

Serious illness

Child at risk for harm

Failed OP management

Severe parental mental health disorders

Loss of follow up due to location or transportation

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A family has moved into the area and brings their 12 month old girl in for a well child check. They bring her medical records with them. Her parents have no concerns, and she has been healthy. Her growth chart reveals her length tracks along at 25 th % and her weight has decreased from 50th % at 6 months to 10th% at 9 months and now is at the 5th %. Which of the following most likely explains her pattern of growth?

A. Normal

B. Familial short stature

C. Prenatal insult such as exposure to drugs or infection

D. Hypothyroidism

E. Inadequate nutrition

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FTT is a sign not a diagnosis

Occurs in 5-10 % of children in primary care

Also called weight faltering, failure to gain weight appropriately, or undernutrition

Weight loss across two standard deviations on the growth chart

Weight less than 80 percent ideal weight for age

Weight below the 2nd percentile

Rate of daily weight gain less than expected

Taking more history you discover that she eats mostly rice and fruit. She does not like meat. Her parents endorse that she is very picky. She drinks about 12 oz or whole milk and 12 oz apple juice each day. She is active and developmentally appropriate. Her ROS is negative as is her past medical history. What is the least appropriate way to proceed with evaluation and management of this patient?

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A. Allow the child to feed herself whenever she is hungry or thirsty.

B. Obtain cbc, iron studies and urinalysis

C. Limit juice

D. Consult a nutritionist

E. Prescribe a multivitamin

A 14 month old female presents to the ED with mom and chief complaint of emesis and diarrhea for the last 48 hours. She cannot tell if the child has had urine output because of the watery diarrhea. On examination, her temperature is 102.5 ° F, heart rate is 180 bpm, blood pressure is 80/50 mm HG. Her weight is 8 kg. She is lying very still in her mother’s lap. She has dry, cracked lips and dry skin. Her capillary refill is about 4 seconds and you note mottling of the extremities. What is the most appropriate next step in the management of this patients condition?

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A. Evaluate for underlying bacterial infection with blood, urine and stool cultures.

B. Admit to an inpatient pediatric until and begin maintenance IV fluids

C. Infuse 20 mL/kg normal saline over 20 minutes

D. begin oral rehydration with Pedialyte

E. Infuse 10mL/kg D5 ½ NS over 2 hours

Finding Mild Moderate Severe

Pulse Normal Rapid Rapid, weak, orabsent

Systolic pressure Normal Normal to low Low

Respirations Normal Deep, may be ↑ Deep, ↑ or ↓

Buccal mucosa Normal Sunken Markedly sunken

Anterior fontanelle

Normal Sunken Markedly sunken

Eyes Normal Sunken Markedly sunken

Skin turgor Normal Reduced Tenting

Skin Normal Cool Cool, mottled, acrocyanosis

Urine output Normal Markedly reduced

Anuria

Systemic signs Increased thirst Listlessness, irritability

Grunting, lethargy, coma

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A 3 year old female presents with her mother with a complaint of productive cough over the last 3 days. The sputum is described as copious and is yellowish white in color. She does go to day care and there have been several kids out due to some respiratory illness. Vitals T 102°F, HR 150, RR 65. She is ill appearing and clinging to her mother. Heart is tachycardic without murmur. Lungs reveal rhonchi in the right lower lung field. Retractions are noted.

A. Group B streptococcus

B. Klebsiella pneumonia

C. Listeria monocytogenes

D. Pseudomonas aeruginosa

E. Streptococcus pneumonia

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Age Organism Treatment

<1mo Group B strep, E. Coli, Klebsiella, Pseudomonas, Listeria

Amp + Aminoglycoside OR Amp + Cefotaxime

1-3 moH. influ, S. pneumonia, Grp A or B strep, pertussis

Amp + Cefotax

3mo- 5 yrS. pneumonia, H. influ, Staph aureus, Grp A Strep, pertussis

Cephalosporin + anti-staph or pertussis if indicated

>5yo S. pneumonia, H. influ, Grp A Strep

PCN OR Amp OR Cephalosporin + anti-staph or pertussis if indicated

The parents of a 2 month old present with concerns that their daughter vomits at least 2 ounces of formula with every feed. There is no blood in the vomit and the baby appears to be hungry after she vomits. She has no respiratory symptoms. They burp her for 5-10 minutes after each feeding. She is at the 70th percentile for height, 50th percentile for weight, and 60th percentile for head circumference which is consistent with her growth measurements since birth. Physical exam reveals a cheerful infant otherwise unremarkable.

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A. Order lab tests to rule out underlying medical condition

B. Counsel the parents regarding lifestyle modifications.

C. Refer the baby to a gastroenterologist

D. Prescribe ranitidine

E. Prescribe omeprazole

Conservative therapy Lifestyle changes

Upright position after feedings

Small frequent feedings

Thickening formula or breastmilk

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Proton pump inhibitors Omeprazole (Prilosec)

Lansoprazole (Prevacid)

Rabeprazole (Aciphex)

Esomeprazole (Nexium)

Hydrogen 2 blockers

Ranitidine (Zantac)

Nizatidine (Axid)

A two year old male presents to your office with his father complaining that the patient has had intermittent crying followed by episodes of profound lethargy during which he is difficult to arouse. The father further describes the episodes explaining the patient will sometimes clutch his abdomen and roll into the fetal position. This started about 4 hours prior to presenting to your office. He denies any fever, vomiting, or diarrhea. He denies any sick contacts. He is developmentally normal and has a negative past medical history. His examination reveals an afebrile non toxic appearing male. His abdominal exam is unremarkable.

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A. Meningitis

B. Renal Colic

C. Intussusception

D. Gastric outlet obstruction

E. Appendicitis

Section of intestine telescopes into the adjoining bowel leading to bowel obstruction

Often presents with non bilious vomiting, colicky abdominal pain, passage of blood and mucus “currant jelly” stools, lethargy and a palpable abdominal mass in the right

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A. CBC

B. UA

C. Glucose

D. Serum lactate

E. None of the above

Lab analysis in intussusception is generally not helpful in aiding the diagnosis

Later in the disease course may see leukocytosis, evidence of dehydration, and electrolyte imbalance

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A. Upper GI with barium

B. A plain film of the abdomen

C. An air enema

D. An abdominal ultrasound

E. CT scan of the abdomen with oral contrast

“Bull’s eye” appearance on ultrasound confirms the diagnosis of intussusception

Air enema is the preferred non surgical treatment

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A 7 year old male presents to your clinic with his mother with the complaint of enuresis. The child has never been continent at night, wetting his bed several times per night. This is becoming a problem for him and the family. He denies any urge or overflow problems. UA was unremarkable. Physical exam reveals a well developed, well nourished child. Abdominal exam is unremarkable.

Which of the following recommendations would be the initial treatment for primary enuresis?

A. Patient education and motivational training

B. Over-learning

C. Enuresis alarm

D. Nasal desmopressin (DDAVP)

E. Oral desipramine

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Initial treatment

Behavioral modification

Education

Patient and caring paternal attitude

Normal daytime voiding and stooling pattern

After 3 months: may consider alarm therapy or pharmacologic therapy

Oral DDAVP – 6 years or older, 0.2-0.6 mg q hs, restrict fluid intake for 1 hour or more before administration

If initial treatment fails

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Questions:

Sarah Hall, D.O.

OSU Center for Health Sciences

Associate Professor of Family Medicine

Sarah.e.martin@okstate.edu

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14. Immunization Action Coalition. http://www.immunize.org/catg.d/p4211.pdf.

15.e http://phil.cdc.gov/phil/details.asp?pid=3168. L accessed July 9, 2015.ters for Disease

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28. Kliegman S. Nelson Textbook of Pediatrics 20th ed. Ch 102 Digestive System Disorders. 2016.

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29. Kliegman S. Nelson Textbook of Pediatrics 20th ed. Ch 109 Infections of the Neonatal Infant. 2016.

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