Fifth stage
Pediatric
Notes
د.ربيع
7/10/2015
Notes of lec1-2-3-4-5
Nutritional requirements for adult depend on physical activity and it is 30 Kcal/kg/day
for adult weight 70 kg.
Nutritional requirements for infancy in the first few months of age = 120 Kcal/kg/day
that is means 4 times more than adult, then the nutritional requirements decrease
gradually and at first year of life it is 100-120 Kcal/kg/day.
Normal term baby weight is 3-3.5 Kg at birth and it become 10 kg at first year of life
that is mean the child weight is triple in one year only, and this thing will not happen
again through his entire life.
In your entire life you will need nutrition mainly for survival and health but in your
first year of life you need nutrition mainly for growth.
Average nutritional requirements of pediatric is much more higher than nutritional
requirements of adult in relation to age. ((iron requirement x3 // Calcium
requirements x3 // Vit B and phosphorus and Mg requirements are more))
Premature baby rapid rate of growth so need more nutrition.
WHO and American academy of pediatric suggest that exclusive breast feeding is
recommended in the first 6 months of life.
Exclusive breast feeding means that baby not drink water, not eat food, and depend
only on the breast milk but also can take some Vitamins and minerals (iron, zinc) that
are deficit in the breast milk.
Weaning:
o
إعطاء الطفل أي شيء عدا حليب األم:ايوغل
o
تحويل الطفل من حليب األم إلى الغذاء الصلب أو شبه الصلب:ايحلاصا
Important question: Breast milk contain all materials for baby except:
o Iron add it to baby feeding at fourth month of life.
o Vit B add it to baby feeding at first week of life.
o Fluoride add it to baby feeding after several weeks of life.
Premature baby start iron at second month of life.
Baby how had blood transfusion in the first week start iron at second month
because Hb of transfused blood contain 13-14 Hb level and baby Hb level is 18 and
above.
Iron + calcium + IgG (immunity) transfer from mother to fetus in the third
trimester so premature baby deficit from these materials.
Diarrhea is leading cause of pediatric death worldwide.
Ph of stool normally is alkaline.
Important question: bottle feeding baby has alkaline Ph stool, breast feeding baby
has acidic Ph stool because there is lactoferin in breast milk so lactose intolerance
cannot be diagnosed from acidic Ph of stool only but need further investigations.
Breast milk contain cholesterol more than formula milk but it reduce the incidence of
atherogenic vascular diseases and coronary artery diseases and CVA.
Premature baby has asphyxia, respiratory distress syndrome and apnea of maturity
(
(
غير متأكد من الكلمة lead to cerebral anoxia lead to developmental defects
breast milk protect against this thing.
Breast feeding has benefits on social development of baby.
Breast feeding is natural contraceptive because it increase the periods of
amenorrhea.
Post-partum hemorrhage (PPH) stop by oxytocin breast feeding increase the
oxytocin level so it decrease PPH.
In the first week of breast feeding there is painful uterine contractions due to
oxytocin.
Baby take breast feeding only 6 diaper that are full by urine means good hydration
and it means good breast feeding.
Let-down reflex baby feed from one breast and the other one eject milk in
response to oxytocin.
Prolactin is responsible for milk formation, and oxytocin is responsible for secretion
and ejection of milk.
Breast engorgement is culture for streptococcus.
Breast engorgement is treated by teach mother the proper way of breast feeding and
mother can use analgesics or emollient.
Breast engorgement not empty the breast lead to breast abscess.
Hemorrhagic diseases of newborn is due to Vit K deficiency because Vit K produced
from normal flora in the intestine and the intestine of baby is sterile also breast milk
is sterile so you should give vit K supplements.
Breastfeeding jaundice occur in the first week of life due to inadequate breast
feeding.
Breast milk jaundice occur after 10 days and it is due to presence of some
substances in breast milk that lead to prologation (
(
غير متأكد من الكلمةof jaundice in the
baby.
In Africa and some countries baby take breast milk from mother with HIV is much
more better from dyeing due to diarrhea if take formula milk so HIV is
contraindicated in developed countries and not contraindicated in developing
countries.
Breast feeding is not contraindicated in mastitis because the only way to reduce the
engorgement is increasing breast feeding.
Unmodified cows milk:
o Contain protein 4% (human milk 1%) so it lead to exhaustion of liver and kidney.
o Much higher sodium than breast milk hypernatremic dehydration.
o Higher phosphorus chelate calcium lead to convulsion.
Unmodified cows milk not give to baby less than one year age but modified cow milk
suitable from birth.
Water, solids, calories, fat same level in human and cow milk.
Modified cows milk is cow milk with less protein and sodium and phosphorus and
contain oils to prevent calories deficiency.
Modified and fortified milk is modified milk with vitamins and minerals.
Whey is easily digested and casein is difficult to digest but make baby less hungry.
Bergsten called hypoallergen formula milk contain polypeptide and amino
acids not lead to allergy.
Important question: preparation of milk (in the lecture page 6)
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In heart failure there is dyspnea on excretion baby with HF feed (excretion) then
go to sleep and after sleeping he is hungry so he should feed (excretion) then sleep
and so on.
Important question: Cardinal signs of H.F in pediatric Rapid pulse – rapid
reparation – tender enlarged live – pulmonary sounds (crepitation, ronchi)
Important question: How to differentiate between small and large VSD?? Presence
of growth failure and heart failure indicate large VSD.
Important question: In pediatric you should measure BP in upper and lower limbs
because baby could be presented with coarctation of aorta.
In pediatric pulse rate above 160 mmHg is tachycardia and below 100 or 80 is
bradycardia.
Important question: What are the DDx of cyanosis in newborn (few hours age)?
o Cardiac cause (right to lest shunt)
o Respiratory (respiratory distress syndrome, elevated diaphragmatic hernia)
o CNS
o Hematological (not hemoglobinemia)
And how to different between them?
o CNS: cyanosis associated with apnea, loss of conscious, coma, drowsiness,
irregular respiration, and other CNS problems.
o Reparatory: cyanosis with dyspnea.
o Cardiac: cyanosis with murmur.
o Hyperoxia test (100% O2 in mask) if PO2 above 100 (respiratory), if PO2 below
100 (cardiac)
Congenital heart diseases (CHD) are multifactorial diseases: the causes could be
genetic, teratogens, drugs, radiation, maternal metabolic diseases, alcohol, and other
causes.
Incidence of CHD is 8 in 1000 (1 in 100) in normal mother and father without family
history of CHD, But if this family has one child with CHD the incidence in the second
baby will become 2-4 in 100, and third baby 8 in 100, and fourth baby 25 in 100.
If first baby has TOF the next baby could become with TOF or one of its component.
Important question: AV canal is the most common abnormality in baby with down
syndrome (40%)
AV canal = endocardial cushion defect = ostium primum ASD + High VSD + mitral
and/or tricuspid regurgitation.
Q: what is the case?
A: it is down syndrome.
Q: what do you want to examine?
A: cardiovascular system.
Q: what is the most common problem?
A: AV canal.
Eisenmenger syndrome L to R shunt become R to L shunt and the baby die, it is
not seen in baby less than 8 years of age.
Wide fixed S2 sound not seen in disease other than ostium secondium ASD.
Tricuspid valve diastolic murmur (flow murmur) indicate large valve defect.
Dominant ventricle in fetus is right ventricle physiological dominance of right
ventricle because aorta is connected to the placenta so the function of lest ventricle
is less and there is ductus arteriosus so right ventricle take 50% of function of left
ventricle and lung not function when baby is born the connection with placenta is
lost, and the lung is functioning, and the ductus arteriosus closed after few days
the physiological dominance of right ventricles become less and less.
RAD (right axis deviation) in newborn is normal but in adult is abnormal.
In newborn there is physiological dominance of right ventricle but in adult there is
right ventricular hyperplasia both have the same ECG changes.
In normal adult V1 lead (QRS complex directed downward) V6 lead (QRS complex
directed upward)
V1 with QRS complex directed upward in baby few months age is normal.
V1 with QRS complex directed upward in baby 5 years or 10 years or adult 50
years old is abnormal:
o Right ventricular hypertrophy.
o Pulmonary hypertension (cor pulmonale).
o RBBB.
o Pulmonary embolism.
o Reciprocal changes of posterior MI.
LAD (left axis deviation) in baby is pathological with central cyanosis (tricuspid
atresia) without cyanosis (ostium premium ASD)
Ostium Secondum ASD narrow M shaped QRS in lead V1 (incomplete RBBB).
Most of ASD need surgical repair to close.
Most of VSD close by itself.
If systemic blood flow double the pulmonary blood flow indicator of closure of
defect.
If pulmonary blood flow double the systemic blood flow need surgery.
Infective endocarditis is very rare in ASD.
VSD is the most common CHD, it is 1/4 of all CHD.
Cheyne Stokes respiration normal in neonate especially in premature especially in
sleeping.
Peripheral cyanosis is normal in few days in neonate but central cyanosis is abnormal.
Hb level in neonate is 18-20 and in adult is 13-14 the baby become cyanosed in
cold weather or blood exchange.
Primum ASD lead to runs of arrhythmia, one component of AV canal, can lead to
LAD in children.
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Pathological Q wave occur in MI and hypertrophic obstructive cardiomyopathy.
Cardiothoracic ratio (CT ratio) normally in adult is 50% and in infant is 60% because
adult can hold his breath during measuring the CT ration but infant cannot.
Don't diagnose baby as heart failure if there is no cardiomegaly in CXR.
VSA and PDA need prophylaxis of infective endocarditis.
In ASD there is murmur in pulmonary area because of overflow through the
pulmonary valve and it is flow murmur.
Premature baby has PO2 96% then sudden drop in PO2 and sweating during feed
it is heart failure due to PDA.
No machinery murmur in neonate:
o Machinery murmur is systolic murmur that extend to diastole.
o Pressure in aorta is higher than in pulmonary artery in systole and diastole so
there is machinery murmur in PDA.
o No pressure gradient in neonate during diastole so there is only systolic murmur
(and no machinery murmur)
Indomethacin + O2 close ductus arteriosus.
Prostaglandin E1 + Not give O2 open ductus arteriosus.
Obstructive lesions in the right side (pulmonary atresia) in the left side (aortic
stenosis and coarctation of aorta)
Webbing of neck in female turner syndrome (come with coarctation of aorta and
aortic stenosis)
Coarctation of aorta is juxta ductal lesion, lead to radio-femoral delay, and the
femoral pulse is difficult to be felt.
TOF is the most common cyanotic CHD.
Important question: What are difference between cyanosis in TGA and TOF?
In TGA cyanosis at instant of birth.
In TOF cyanosis after few weeks.
The cyanosis increase when the stenosis of the infundibulum of aorta is increased.
In TOF the murmur is due to pulmonary stenosis and not due to VSD (rarely due to
VSD)
Most common complication of TOF is hypercyanotic spells.
Most serious complication of TOF is brain abscess and embolism.
TOF boot shaped heart.
Treatment of hypercyanotic spells Knee chest position + O2 + morphine (SC not
IV) + propranolol + sodium bicarbonate + phenylephrine.
Surgery of TOF palliative (bad prognosis) or corrective (good prognosis)
In TOF no HF, no orthopnea, no PND, no pulmonary edema because there is no
blood in the lung.
=======================================================================
TGA is less common than TOF, but TGA also is common.
In TGA patient there is a defect like VSD, ASD, or PDA to survive.
Balloon septectomy used to destroy the atrial septum and mix blood between
right and left side of the heart in TGA patient.
In TGA there is cyanosis without dyspnea.
Tricuspid atresia small right ventricle with large left ventricle / single S2 (only
aortic) / need VSA or PDA / O2 will close the defect of VSD or PDA so not give to this
patient.
Blalock taussig shunt it is artificial ductus arteriosus, it is connection between
subclavian and pulmonary artery.
Ebstein anomaly called atrilization of right ventricle (lead to prominent P wave in
the ECG) the function and size of right ventricle will be less than normal.
Congestive heart failure baby will not present with leg edema and other usual
signs of HF but baby will present by feeding dyspnea, hypertension, hyperpnoea,
tender hepatomegaly, pulmonary sounds.
Older children with CHF present with fatigue and exercise intolerance.
Causes of CHF:
o Endocardium valvular diseases.
o Myocardium cardiomyopathy and CHD.
o Pericardium pericardial effusion and tamponade.
o Hypertension 95% are secondary and 95% of them are due to renal problems.
o Tachy or brady cardia.
o Thyrotoxicosis, anemia.
Blood pressure not measured routinely in pediatric but it must be measured in any
child with heart diseases, renal diseases, convulsion, or take corticosteroids for long
duration.
Tachycardia + tachypnea + tender hepatomegaly + pulmonary rales seen in heart
failure and bronchiolitis so not diagnose H.F in pediatric without cardiomegaly in
CXR.
Management of H.F: admission + bed rest + elevate head + O2 + sodium, potassium,
digoxin level + PO2 and PCO2 + give furosemide (lasix) 1-2 mg/Kg I.V + give or not
give digoxin + other therapy like vasodilators (captopril).
HF + hypertension occur in cardiomyopathy give dopamine or doputamine
instead of lasix
Dopamine in increased dose cause vasoconstriction in renal artery but doputamine
does not lead to vasoconstriction so it is better.
2 months – 2 years age children myocardium can tolerate high doses of digoxin.
Any child take digoxin and lasix for 3 days you should give potassium.
Group B strepto renal diseases can occur by skin or throat infection but heart
diseases occur due to throat infection only.
Group B strepto infection in pediatric cannot be prevented by penicillin even if start
early.
All glomerulonephritis are type 3 hypersensitivity except goodpasture which is type 2
hypersensitivity (cause hematuria, hemoptysis)
For rheumatic fever if there is only criteria without evidence of strepto infection it
is not rheumatic fever except for choria (because it occur 6 months after infection)
Evidence of strepto infection ASO titer, culture, scarlet fever.
Clinical presentation of infective endocarditis Anemia + glomerulonephritis
(hematuria) + other presentations in the lecture.
Duke criteria ( )لإلطالع
Cardiomyopathy H.F without murmur or recurrent chest infection without
murmur death or cardiac transplantation.