PNP Mangement 2 Final Exam

-Physical Neglect
-Physical Abuse
-Emotional Abuse
-Sexual Abuse

Neglect

-Unexplained burns, cuts, bruises or welts in the shape of an object:
belt buckles “C” or “U” shaped
loop
linear
-Bite marks:
any part of body
pattern doughnut shape or double-horseshoe
adult bite diagnostic with space between canine teeth >3cm

-Anti-social behavior
-Problems in school
-Fear of adults

-Bilateral black eyes
-Earlobe
-Cheeks
-Lip, frenulum
-Scalp
-Neck
-Genitals
-Buttocks
-Chest
-Back

-Rib fractures, especially posterior
-Classic Metaphyseal lesions
-Scapular fractures
-Spinous process fractures
-Sternal fractures

-Unsuitable clothing for weather
-Dirty or un-bathed
-Extreme hunger
-Apparent lack of supervision

-Malnutrition
-Non organic Failture to Thrive
-Intentional withholding:
food
clothing
shelter
medical care

-Failure to provide adequate:
food
clothing
shelter
medical care
supervision

-Malnourished
-Inadequately dressed
-Inadequate medical/dental care
-Chronic fatigue or hunger

-Apathy
-Depression
-Hostility or stress
-Lack of concentration
-Eating Disorders (Failure to Thrive)

The use, persuasion, or coercion of any child to engage in sexually explicit conduct, or any simulation of such conduct for producing any visual depiction of such conduct, or rape, molestation, prostitution, or incest with children

-Inappropriate interest or knowledge of sexual acts
-Nightmares and bedwetting
-Drastic changes in appetite
-Over-compliance or excessive aggression
-Fear of a particular person or family member
-Adolescents-self-injurious behavior (cutting)

-Incest
-Molestation
-Exhibitionism
-Child pornography
-Child Prostitution
-Pedophilia

-Pain on urination
-Discharge or bleeding
-Enuresis and encopresis
-Urethral or lymph inflammation
-Rashes
-Labial adhesions

-Injuries/Blunt force trauma
-Bruising
-Scratches
-Bites
-Grasp marks
-Swelling of genitalia

-Any child >3 years old that tests positive for gonorrhea, syphilis, HIV and chlamydia
-Adolescent that tests positive for trichomonas
-Underage chid that is pregnant

-Most victims have no significant physical findings
-Most abuse does not involve penetrating trauma

-Foreskin too tight to be retracted
-Physiologic phimosis in first 6 years

Occurs over the first 6 years of life when the glands has not completely separated from the epithelium

Tight, pinpoint opening of foreskin

Thickened, rolled foreskin

-Normal cleansing
-Gentle stretching
-Circumcision if urinary obstruction or infection
-Corticosteroid cream if persistent

-Retracted foreskin that cannot be reduced to normal position
-Can occur with masturbation, sex

Edema, bluish glans/foreskin

-Lubricate foreskin to reduce
-Surgical emergency if not successful

Urethral meatus located anywhere from proximal glans to perineum on ventral surface

-Family history
-Child sits to void or has difficulty with aim
-Dorsally hooded foreskin in newborn
-Visualization of meatus or urinary stream

-Surgical repair for functional, normal-appearing penis
-Do not do circumcision; refer to pediatric urologist

-Five or more RBCs per HPF (high power field) in three consecutive specimens obtained over several weeks

Glomerular origin

Lower tract

-Previous history of cystic kidney disease
-Preceding illness (strep)
-Onset, duration, frequency, enuresis
-Pain (back, abdomen or flank); straining with urination
-Trauma, sexual activity or abuse
-Current menstruation
-Edema, rash, pallor, arthralgia
-Medications and certain foods can discolor urine including food color, beets, blackberries, rhubarb, and paprika but will not result in RBCs in the urine

-Growth parameters:
FTT or falling off growth curves can indicate chronic renal insufficiency or long-standing acidosis
-Vital signs, especially BP
-Malformed ears can point to congenital renal disease
-Oliguria or anuria

-Edema, hypertension, and proteinuria suggests glomerular disease
-Flank pain is suggestive of an upper tract disorder such as pyelonephritis
-Abdominal or flank mass
-External genitalia:
excoriation or bleeding
foreign body
abuse

-Urine dipstick should be confirmed by urinalysis
-Urine dipstick for pyuria, proteinuria, hematuria
-Microscopic exam for RBCs: if more than 1+ hematuria
-Proteinuria requires rapid evaluation, and early referral to a nephrologist
-Microscopic examination of urine
-Distorted RBCs of different sizes indicates glomerular disease
-Crystalluria is most often caused by hypercalciuria

-Urine culture
-24-hour urine collection
-Renal ultrasound if Wilms’ tumor suspected
-Systemic symptoms (edema, hypertension, changes in urine output) require further evaluation
-Renal biopsy for recurrent gross hematuria and coexisting nephrotic syndrome, HTN, renal insufficiency, systemic illness, or parental anxiety

-Obtain urine culture if suspected UTI
-If >5 RBCs:
obtain a renal ultrasound
if that is abnormal, obtain a VCUG
-If >5 RBC's and elevated calcium/creatinine ratio:
obtain a 24 hour urine collection
refer to nephrology

-Monitor
-Consider repeating UA

-Positive urine culture:
refer to treatment for UTI
-Negative culture:
continue workup for microhematuria

Glomerular impairement

Renal involvement secondary to systemic disease

-Secondary to strep
-Classic form
-Occurs most commonly in ages 5 to 12 years and more in males

-Streptococcal skin (more likely) or pharyngeal infection in past 2-3 weeks
-Abrupt onset gross hematuria
-Decreased urine output
-Lethargy, anorexia, N/V, chills, fever, backache
-Medications taken in the past few weeks

-Transient hypertension (resolves in 1-2 weeks)
-Periorbital edema
-Circulatory congestion (dyspnea, cough and pallor)
-Ear malformations
-Flank pain/abdominal pain (Wilm's tumor)
-Costovertebral angle tenderness (pylonephritis)
-Rashes/arthralgias or evidence of trauma or abuse

-UA with microscopic (tea-colored with elevated specific gravity)
-Serum C3 or C4 (low)
-Total protein, albumin (elevated)
-CBC
-ESR
-ASO (elevated): recent strep infection
-Streptozyme test (+)
-DNA antibody titer
-Electrolytes, BUN, creatinine, cholesterol

-Consultation with nephrology recommended in all cases of GN
-Supportive with spontaneous resolution
-Hospitalization if severe oliguria, hypertension
-Antibiotics for positive cultures
-Resolution begins with diuresis
-Gross hematuria persists for 1-2 weeks
-Urine can remain abnormal for up to 6-12 weeks
-Microscopic hematuria for up to 2 years

-Twisting of spermatic cord
-Compromised blood supply
-Six hours between twisting and significant ischemic damage

-Sudden onset of unilateral scrotal unrelenting pain often with N/V
-History of bouts intermittent testicular pain
-Minor trauma, physical exertion
-Fever minimal or absent

-Ill-appearing, anxious
-Gradual, progressive swelling; redness, warmth
-Ipsilateral scrotum may be edematous, erythematous, warm
-Thickened, twisted, tender spermatic cord
-Testis exquisitely painful
-Transillumination reveals solid mass
-Absent cremasteric reflex on the side with the torsion

-Doppler ultrasound
-UA (usually normal)

Surgical emergency

-Scrotal/inguinal swelling including abdominal contents
-Can cause labial swelling in females
-Incomplete closure of processus vaginalis
-Obese males/weight lifters with history of undescended testicles have increased risk

-Family/personal history of undescended testicles
-Swelling in inguinal area, scrotum (comes & goes with crying or straining)
-Prematurity
-Weight lifting
-Obesity

-Swelling in inguinal, scrotal, labial area
-Reducible hernia
-Transillumination does not occur
-Direct:
push outward at weakest point in the abdominal wall
-Indirect:
push downward into inguinal canal
-Incarcerated: child fussy; abdomen distended

-While you palpate the spermatic cord, you can feel two surfaces rubbing against each other
-Used to check for indirect inguinal hernias

-Ultrasound
-Want to differentiate between hernia and hydrocele

-Reducable:
see urology in 1 to 2 weeks
-Non-reducable:
hospitalized
surgical repair within 24 to 48 hours
-Painful, hard, tender, red mass:
urgent referral

Undescended testicle

3 to 6 months old

Surgery if not descended by 6 months

-Cancer
-Inguinal hernia
-Testicular torsion

-Regurgitation of urine from the bladder into the ureters and potentially the kidneys
-Major concern is the exposure of the kidney to infected urine and the potential for pyelonephritis
-Classified as primary or secondary

-The most common form
-It is caused by an abnormally short ureter and ineffective valve

Caused by a bladder outlet obstruction

Does not reach the renal pelvis

Up to renal pelvis without dilation

Up to renal pelvis with mild to moderate dilation

-Distension of ureters and renal pelvis
-Hydronephrosis or reflux into the intrarenal collecting system

-Positive history for previous UTI
-Abnormal voiding pattern or dysfunciton
-Unexplained febrile illness
-Chronic constipation
-UTI symptoms

-Ultrasonography:
may be normal even when reflux is present
-VCUG:
establishes the presence of reflux and determines the grade
-DMSA:
to look for renal scarring if renal ultrasound is abnormal
-BP and serum creatinine:
if bilateral renal abnormalities are found
-If urinalysis suggests UTI, then a subsequent urine culture is needed

-Goal of treatment is the prevention of infection and subsequent scarring, so early detection is critical
-Grades I and II resolve spontaneously in 85% of cases
-Grade III resolves spontaneously in 50% of cases
-Factors associated with a decreased chance for resolution:
grades IV and V reflux
bilateral reflux
older children who present with reflux

-Grade V is unlikely to resolve on its own
-Most children outgrow their reflux, due to an increased length in the urethra as they grow
-Very few children require surgery

-Monitor Clinically: Yes
-Treat Bowel Bladder Dysfunction: Yes
-Continuous Antibiotic Phrophylaxis: Avoid
-Yearly Renal Ultrasound and VCUG: Avoid
-Surgical Correction: Avoid

-Monitor Clinically: Yes
-Treat Bowel Bladder Dysfunction: Yes
-Continuous Antibiotic Phrophylaxis: Consider
-Yearly Renal Ultrasound and VCUG: Consider
-Surgical Correction: Consider

-Monitor Clinically: Not alone
-Treat Bowel Bladder Dysfunction: Yes
-Continuous Antibiotic Phrophylaxis: Yes
-Yearly Renal Ultrasound and VCUG: Yes
-Surgical Correction: Consider

-Monitor Clinically: Not alone
-Treat Bowel Bladder Dysfunction: Yes
-Continuous Antibiotic Phrophylaxis: Yes
-Yearly Renal Ultrasound and VCUG: Yes
-Surgical Correction: Consider

-VUR does not cause scarring; infection does
-VUR is a risk factor for pyelonephritis resulting in scarring
-Promptly treat UTIs
-Emphasize the need for urine culture with any suspicious symptoms
-The potential for untreated, chronic UTI leading to chronic renal disease must be explained to parents and caregivers
-Monitor blood pressure and growth
-Siblings no longer routinely screened for VUR
-Give prophylactic medications at night because of urinary stasis while sleeping

1. Asymptomatic Bacteriuria
2. Cystitis
3. Pyelonephritis

-Presence of bacteria in the urine without other symptoms
-It is benign and does not cause renal injury

-Infection of the bladder that causes lower renal tract symptoms
-Fever and renal injury are not seen

-Classified as one with:
fever
toxicity
dehydration
any UTI in children under three to six months of age

-Most common cause of serious bacterial infection in infants younger than 24 months old with fever without a focus
-Identified as either:
a first occurrence
recurrent (reinfection within two weeks with the same organism or any reinfection with a different organism)
chronic (ongoing, unresolved, often caused by a structural abnormality or resistant organism)

E. coli

-Family history of VUR, recurrent UTI
-Prenatally diagnosed renal abnormality
-Previous infection
-Circumcised or uncircumcised
-Hygiene, constipation, perianal itching, or irritants
-Sexual activity, masturbation, or abuse
-Other infections such as pinworms or diaper rash

-For girls, are they wiping front to back?
-A full bowel with constipation sits on the renal system and doesn’t allow the bladder to fully empty, developing a medium for bacterial growth and risk for UTI
-Perianal itching may be caused by pinworms
-Irritants include nylon underwear or clothing (spandex, tight pants, or shorts that rub), bubble baths, or sitting in soapy water

-Appearance: do they look toxic?
-Vital signs: temperature, BP
-Growth parameters: may be decreased with chronic UTI or renal insufficiency, especially in infants
-Flank pain or costovertebral angle tenderness
-Suprapubic tenderness, bladder distension, fecal impaction
-Genitalia: erythema, edema, irritation, discharge, labial adhesions, uncircumcised male
-Neurological examination for dysfunctional voiding: lower extremity reflexes, sacral dimpling

-Jaundice
-Hypothermia
-Failure to thrive
-Sepsis
-Vomiting or diarrhea
-Cyanosis
-Abdominal distention
-Lethargy

-Malaise
-Irritability
-Diffculty feeding
-Poor weight gain
-Fever (pyelonephritis sign)
-Vomiting
-Malodor
-Dribbling
-Abdominal pain/colic

-Altered voiding pattern
-Malodor
-Abdominal/flank pain (pyelonephritis sign)
-Enuresis
-Vomiting or diarrhea (pyelonephritis sign)
-Malaise
-Fever (pyelonephritis sign)
-Diaper rash

-Classic dysuria with frequency, urgency and discomfort
-Malordor
-Enuresis
-Abdominal and flank pain (pyelonephritis sign)
-Fever/chills (pyelonephritis sign)
-Vomiting or diarrhea (pyelonephritis sign)
-Malaise

-Used only to raise or lower UTI suspicion.
-Suspicious findings include: foul odor, cloudiness, nitrites, leukocytes, alkaline pH, proteinuria, hematuria, pyuria, and bacteriuria.
-Bagged urine specimens, even after cleaning the external genitalia prior to placement, produce a high incidence of false-positive UA results due to contamination; therefore, they must not be used to determine or treat a UTI
-If a child is unable to void on their own and is symptomatic, a catheterized specimen needs to be obtained.

-Older children who can void on their own should be able to obtain a clean-catch void
-Having a female sit with their knees apart and feet supported on the toilet separates the labia and decreases the risk for specimen contamination.
-Another trick is to have them sit backward on the toilet, causing them to instinctively separate their legs and knees

-Urine culture confirms the diagnosis and is considered positive if there are more than 100,000 of a single pathogen in a clean-catch sample, more than 50,000 in a catheterized/suprapubic sample, or more than 10,000 in a symptomatic child
-CBC, ESR, CRP, BUN, and creatinine in children younger than one year with pyelonephritis or those who appear toxic
-A blood culture should be obtained if sepsis is suspected

-To diagnose a UTI in a child 2 to 24 months of age, both a UA suggesting infection and a positive urine culture from a sterile catheterized urine specimen with at least 50,000 CFU/ml is needed
-If there are no leukocytes in the UA, no treatment is indicated

-White race
-Age younger than 12 months
-Temperature of at least 102.2 °F (39 °C)
-Fever lasting at least two days
-Absence of another source of infection

-Non-Black race
-Temperature of at least 102.2 °F (39 °C)
-Fever lasting more than 24 hours
-Absence of another source of infection

-Suspect UTI?
obtain UA/culture

-<50,000 WBC's
assess for symptoms
->50,000 WBC's
assess for symptoms

-Upper urinary tract symptoms
treat with antibiotics
assess for bowel bladder dysfunction
-Lower urinary tract symptoms
assess for bowel bladder dysfunction

-Upper urinary tract symptoms
consider clinical status
-Lower urinary tract symptoms
treat with antibiotics
assess for bowel bladder dysfunction

-Treat with antibiotics
-Assess for bowel bladder dysfunction
-Obtain renal ultrasound
-VCUG following treatment is US is abnormal

-Assess for bowel bladder dysfunction
-Clinically monitor

-Treat with antibiotics
-Assess for bowel bladder dysfunction
-Obtain renal ultrasound
-VCUG following treatment is ultrasound is abnormal or if not first UTI

-Consider clinical status
non-toxic
toxic and/or dehydrated

-Treat with antibiotics
-Assess for bowel bladder dysfunction
-Obtain renal ultrasound
-VCUG following treatment if ultrasound is abnormal or not first UTI

-IV/IM antibiotic
-Consider need for inpatient
-Obtain renal ultrasound
-Asses for bowel bladder dysfunction
-VCUG following treatment if ultrasound is abnormal or not first UTI

-Short-term (three- to five-day) antibiotic can be prescribed
-Children aged 2 to 24 months and those who are febrile should have a seven- to 14-day course of antibiotics
-Ciprofloxacin may only be used in those 18 years of age or older
-Recurrent UTIs require further evaluation and the use of prophylactic antibiotics is controversial

-Antibiotics used in the treatment of UTIs are:
TMP–SMX
amoxicillin
amoxicillin–clavulanate
cephalexin
cefixime
cefpodoxime
nitrofurantoin

Follow-up cultures are not routinely needed
-Follow-up urine culture should be done 48 to 72 hours after initiating treatment if symptoms persist or organism resistance is found in the community
-If the culture is not sterile or if no clinical improvement is seen, an antibiotic change should be based on a sensitivity report
Urine should be sent for bacterial identification and sensitivity studies if not performed initially, and an alternative broad-spectrum antibiotic should be used pending those results

->2 months old: 8 to 12 mg/kg in 2 doses
-Adolescents: 160 mg Q12 hours

-<3 months: 20 to 30 mg/kg/day in 2 divided doses Q12 hours
->3 months: 25 to 50 mg/kg/day in 2 divided doses
-Adolescents: 250 to 500 mg Q8 hours or 875 mg Q12 hours

-<3 months: 30 mg/kg/day in 2 divided doses
->3 months: 20 to 45 mg/kg/day in 2 to 3 divided doses
-Adolescents: 250 to 500 mg Q8 hours or 875 mg Q12 hours

-50 to 100 mg/kg/day divided in 4 doses Q6 hours
-Max of 4 grams per day

->6 months: 16 mg/kg/day divided every 12 hours for first day, then 8 mg/kg/day divided every 12 hours to complete the 13-day treatment
-Adolescents: 400 mg every 12 to 24 hours

->1 month: 5 to 7 mg/kg/day divided every 6 hours (max of 400 mg/24 hours)
-Adolescents: 50 to 100 mg/dose every 6 hours (macrocrystals) or 100 mg BID (dual release)

-Phenazopyridine
-6 month to 12 years: 12 mg/kg/day TID
->12 years: 200 mg TID
-DMSA scan may be obtained when renal scarring is suspected or when a diagnosis of pyelonephritis is uncertain

There is controversy about if and when prophylaxis should be used
-If a decision to use prophylaxis is made, and depending on the source, between one quarter to one half of the treatment dose may be given at bedtime

-Nitrofurantoin: Older than 2 months old; 1 to 2 mg/kg as a single daily dose; expensive; liquid form poorly tolerated; consider sprinkling capsules over applesauce, yogurt, or pudding
-Trimethoprim–sulfamethoxazole (TMP–SMX): 2 mg/kg as a single daily dose or 5 mg/kg twice per week (based on TMP component) if older than 1 month
-Cephalexin: 10 mg/kg as a single daily dose
-Amoxicillin: 10 mg/kg as a single daily dose; can be used for a newborn or premature infant; not used past the first two postnatal months; shelf life for liquid is 14 days

-Order a renal and bladder ultrasound on children with the first positive urine culture and with fever and systemic illness
-In children with one or more infections of the lower urinary tract (dysuria, urgency, frequency, suprapubic pain), renal and bladder ultrasound may be considered; however, assessment and treatment of bladder and bowel dysfunction are most important.
-If the renal ultrasound is abnormal, a voiding cystourethrogram is indicated.

-Cost:
least expensive
-Advantages:
shows structure, shape, and growth
detects structural abnormality, obstruction, pyelonephritis, large scars
painless, low risk, no radiation, noninvasive, available
-Disadvantages:
does not detect small scars of VUR
poor visualization of ureters
does not measure renal function or transient injury to kidney
-Use:
initial evaluation with first UTI and follow-up

-Cost:
least expensive
-Advantages:
detects and grades VUR if high or low pressure, high or low bladder volumes, during voiding, during early or later bladder filling
visualizes bladders and urethra (especially in males) and diverticula
-Disadvantages:
does not detect obstruction, pyelonephritis, scars
greater radiation than with scan
requires intravesical administration of contrast
-Use:
indicated in infants and children with abnormal ultrasound

-Cost:
most expensive
-Advantages:
detects acute inflammation, scars, and obstruction
earlier detection of parenchymal damage—large or small scars, permanent or focal—than with intravenous pyelogram (IVP)
-Disadvantages:
does not detect VUR or measure renal function
does not evaluate calyces, ureters, bladder, or urethra
-Use:
follow-up for fever of unknown origin and negative ultrasound in neonates
to diagnose acute pyelonephritis
to detect renal scars

-Cost:
expensive
-Advantages:
detects obstruction, pyelonephritis, large scars
-Disadvantages:
does not detect small scars or VUR
risk of an allergic reaction, acute renal failure
-Use:
trauma

-Cause, complications, treatment plan
-Frequent and complete voiding, increase fluids: scheduled voiding times, voiding with knees spread apart, or double voiding (voiding and then immediately attempting to void again)
-Proper hygiene and avoidance of irritants
-Treatment of constipation, pinworms
-Sexually active females: void after intercourse
-Decrease intake of bladder irritants: four Cs (caffeine, carbonated beverages, chocolate, citrus), aspartame (NutraSweet), alcohol, and spicy foods
-Prompt medical attention with recurrence of fever and/or duration of fever for more than 48 hours, especially if younger than 24 months old.

-Most severe pediatric UTI
-It involves the kidneys and can cause irreversible renal damage
In infants, symptoms consistent with pyelonephritis are fever, irritability, and vomiting
-In older children, fever, bacteriuria, vomiting, and flank pain can be seen
-These children are typically very ill and hospital admission with IV antibiotics might be necessary.

-Oral therapy has been found to be as effective as parenteral therapy
-Hospitalization will depend on symptom severity, as well as dehydration, vomiting, whether the child is drinking, and if the child is one month of age or younger
-Infants older than one month of age and children with uncomplicated pyelonephritis (well hydrated, no vomiting, no abdominal pain) can be effectively treated with cefixime, cephalexin, or amoxicillin–clavulanate
-Adolescents with uncomplicated pyelonephritis can be treated with either amoxicillin–clavulanate or ciprofloxacin.

-Incontinence during sleep
-Monosymptomatic nocturnal enuresis: when a child has normal daytime elimination then nighttime enuresis

-Cannot be diagnosed until a child is over 5 years old
-One episode a month for a duration of 3 months
-Considered frequent if it occurs 4 or more times a week
-Considered infrequent if it occurs 4 or less times a month

-Constipation
-Familial disposition
-Neurologic development delay
-Behavioral comorbidities (ADHD or OCD)
-Functional small bladder capacity
-Sleep distubances (OSA)
-Stress and family disruptions
-Polyuria
-Inappropriate toilet training

1. Determine if there are comorbid or underlying conditions that require pediatric urology referral
2. Establish the best approach to treating this particular child's condition

-Essential to gather the most honest nighttime and daytime history of bowel and bladder elimination habits
-Voiding characteristics:
urgency, dysuria, or dribbling
are there voiding or stooling postponement behaviors
number of voids per day
frequency of wetting
type of urination stream

-Fluid intake, including timing, type and volume
-UTI
-Family history
-Toilet training history
-Effect of enuresis on family and child
-Manner in which family deals with enuresis (punishments)
-Bowel patterns
-Sleep patterns (OSA)
-Changes in home environment

No

-Combined daytime incontinence and nocturnal enuresis
-Weak or interrupted urinary stream
-Need to use abdominal pressure to urinate

-Assess the external genitalia for signs of irritation, infection, labial fusion or meatal stenosis
-Examine abdomen for masses, especially at the suprapubic midline and in the left lower quadrant
-Examine the lower back for dimples and hair tufts
-Assess for neuological function and deep tendon reflexed

-UA is recommended
-Culture if there are clinical symptoms to warrant it

-Intervention is based on the underlying cause and involves behavioral modification, medication, treatment of comorbid or organic conditions or a combination of these modalities
-Treatment of daytime urinary dyfunction and constipation should be done before treating noctunal enuresis
-Delay aggressive treatment until child is 6 to 8 years old

-Non-pharmacological, nonsurgical intervention that is basic to enuresis treatment
-Increases daytime urination by establishing a regular voiding schedule
-Goal is for the bladder to hold urine production obernight
-Child should void before going to bed and immediately upon waking up
-Involves aggressive treatment of constipation

-Drug therapy can be combined with other therapies
-High initial response rates
-Expensive
-High rate of relapse once the drug is discontinued
-Very useful for overnight stays when staying dry is important to the child

-Tablet: 0.2 mg once daily at bedtime, but can be adjusted and go up to 0.6 mg/day
-Melt: 120 mcg once daily at bedtime, but can go up to 240 mcg/day

-Most effective in children with large nocturnal urine production and normal nocturnal bladder capacity
-Immediate effects and can only be taken on nights that the child wants to stay dry
-Short term treatment only (4 to 8 weeks)
-Take on empty stomach
-Not recommended for children <6 years
-Wake child to urinate 10 hours after taking the medication
-Black Box Warning: nasal spray can lead to hyponatremia

-Detected by dipstick
-Qualititative: positive if dipstick registers 1+ (30 mg/dL) or more in urine with a specific gravity of less than 1.015
-Quantitative:
measures the volume of urine over a set period
normal: <4
abnormal: 4 to 40
nephritic disease: >40

1. Isolated
2. Transient or functional
3. Glomerular
4. Tubulointerstitial

-Orthostatic proteinuria
-Persistent asymptomatic

-Accounts for 60% of cases of proteinuria
-Condition where child excretes abnormal amounts of protein when upright but normal amounts while laying down

-Transient
-In an otherwise healthy child, with normal clinical and laboratory workup with abnormally high level of protein in the urine

Caused by some type of stress
-Types:
excercised-induced
fever-induced

-Documented by collecting a urine sample, having the patient exercise viorously for several minutes and then collecting another sample
-Post exercise sample is usually strongly positive

-Can accompany any febrile state and usually subsides with resolution of the fever
-Resolves within 1 to 2 weeks

-Least common
-High proteinuria levels
-High suspicion for an underlying progressive renal disorder

-Most of the time a child is asymptomatic
-If it is significant enough then it can cuase hypoproteinemia or edema
-Growth and development parameters
poor weight gain or FTT with chronic disease
weight gain with nephrotic syndrome
-Edema, especially periorbital
-Abdominal examination for a mass, enlarged kidney, fluid, tenderness

-UA (repeated 3x over 1 to 2 weeks), perferably done on a first voided specimen
-A first void specimen is the first urine produced in the morning
-1+ protein is significant if the specific gravity is <1.015
-2+ protein is significant if the specific gravity is >1.015
-False-positive results occur in highly concentrated or alkaline urine (pH >5.5)
-False-negative results occur in dilute or acidic urine

-Rule out orthostatic proteinuria by comparing a first void specimen with a specimen collected a few hours later

-If protein by distick is trace or 1+ and specific gravity is >1.015:
reassurance
do monthly recheck of urine for 4 to 6 months
-If protein is persistent:
refer the patient to a nephrologist
-If protein by dipstick is >1+:
evaluate the child for orthostatic proteinuria
-If first morning urine protrein is 1+ or 2+:
perform either a quantitiative 12 to 24 hour urine protein excretion test or a
random urine total protein-creatinine ratio and UA with microscope

-Protein >2+:
evaluate for nephrotic syndrome
-If hematuria is present:
evaluate for nephritis
-Follow-up is important to monitor for any change in status

-If persistent unexplained nonorthostatic proteinuria
-Any hematuria or RBC or WBC casts
-Polyuria or oliguria
-Nephrotic levels of protein
-Elevated BUN or creatinine
-Elevated BP
-Systemic complaints (joint pain, rashes, oe athralgias)
-Child with a family history of renal failure, GN, sensorinueral hearing loss or kidney transplantation

-Significant differences in breasts can cause distress
-A breast exam should be done to confirm normal findings not due to a cyst or mass in the larger breast
-For younger adolescents, asymmetry improves over time

-Mild breast pain is common among young women
-Causes:
fibrocystic changes
mastitis
cysts
chest wall pain
pregnancy
-Breast cancer is extremely uncommon in adolescents so reassure patients and their parents

-Breast cancer is extremely rare in the adolescent population but requires appropriate clinical follow-up
-Breast ultrasound

-Normal adolescents can express a small amount of clear discharge from their nipples
-Spontaneous nipple discharge should be evaluated
-Causes:
mechanical stimulation
irritation from clothing
-Galactorrhea, milky white discharge from both nipples, can be caused by medications
-If persistent, refer to an adolescent gynecologist or pediatric endocrinologist

Absence of a menstrual cycle and may be temporary or permanent

-External genital exam to confirm that vagina is present, and that hymen is patent.
-Sexual maturity rating (SMR) of breasts given that menstrual periods usually occur when the breast is at SMR IV and, rarely, before SMR III.
-Physical signs of an eating disorder:
anorexia
dehydration
low pulse, blood pressure, and temperature
dry skin
lanugo
bulimia-swollen cheeks (parotid glands)
calluses on hands/fingers
enamel erosion and/or stains on teeth

-Signs of androgen excess:
cystic or severe acne
excess hair on face or body
male pattern (temporal) baldnesa
-Body changes suggestive of hyperinsulinemia:
central adiposity
acanthosis nigricans
striae

-Ceftriaxone 250mg IM in a single dose
PLUS
-Doxycycline 100mg PO BID for 14 days
WITH OR WITHOUT
-Metronidazole 500mg BID for 14 days

Recurrent, menstrual-related pain in the absence of pelvic pathology and is though to be due to the release of prostaglandins from endometrium

-Onset of severe cramps usually 1 to 2 years after the onset of menses, but can be anytime, especially if bleeding is heavy
-Pain is in the lower or midabdomen (may radiate to back or thighs)
-Character is crampy and stabbing at times (may be severe)
-NSAIDs and heat usually helpful but may not alleviate pain
-Missing school and activities not uncommon if pain is severe
-Absence of pain outside of menstruation
-Physical exam is normal

-Painful menstruation in the presence of pelvic pathology such as:
endometriosis
ovarian cysts
infection

-Education about the condition, tracking menstrual cycle and basic self-care before and during mentrual periods
-OTC medications:
take as soon as she knows menses is coming to block prostaglandin production
ibuprofen 400 to 800 mg Q8 hours
naprocen 550 mg Q12 hours
-Hormonal therapy:
oral contraceptive pills
skin ptch
vaginal ring

-Progesterone-only treatments:
levonorgestrel IUD
etongestrel subdermal implant
dept medroxyprogesterone acetate
norethindrone
-Patients who still have pain after several months of treatment should be referred to a gynecologist

-Common finding occurs primarily in girls from three months to six years of age
-Even with treatment, recurrence is common until puberty

Careful attention to vulvar hygiene and reassurance

Topical estrogen and/or steroid cream applied to the adhesion with gentle pressure

Azithromycin 1g PO

-<150kg:
ceftriaxone 500mg IM
->150kg:
ceftriaxone 1g IM

Metronidazole 2g

Penicillin G

Menstrual flow that occurs outside of normal volume, duration, regularity, or frequency parameters

-Heavy or prolonged menstrual bleeding that causes anemia or is ongoing since menarche
-History of surgical-related bleeding or bleeding associated with dental work
-Two or more of the following: bruising one to two times per month, epistaxis one to two times per month, frequent gum bleeding, and family history of excessive bleeding
-Family history of known bleeding disorder

-Pregnancy test
-Complete blood count (CBC) with platelets
-Ferritin to test for iron deficiency

-Patients who are actively bleeding and have significant anemia or who exhibit symptoms of hemodynamic instability (e.g., hypotension and tachycardia):
should be sent to an emergency department
assessed for a bleeding disorder
-A blood type screen and crossmatch should also be performed, along with consideration of blood administration and estrogen therapy
-Those with significant anemia, those who require hospitalization, and those who have a compelling history of a bleeding disorder should be screened for coagulopathy

-Pregnancy:
test all patients with abnormal uterine bleeding (AUB) even when sexual contact has not been reported
-Bleeding disorders (von Willebrand disease, platelet function disorders, acquired disorders):
screen if there is anemia or other concerning symptoms or signs
-Anovulation:
allows for a disordered endometrium, which can result in chaotic and heavy bleeding
consider lab testing for TSH, FSH, and androgens when indicated

-Medications:
hormonal therapy
contraception
anticoagulation therapy
-Cervicitis due to sexually transmitted infections (STIs):
test for chlamydia and gonorrhea
-Benign structural causes (fibroids or polyps):
uncommon in adolescents
-Rare tumors (estrogen- and/or androgen-secreting tumors, rhabdomyosarcoma):
uncommon, rare cause

NSAIDs

-Iron supplementation
-Hormonal therapy

-Treat bleeding immediately
-Iron supplementation
-Hormonal therapy
-Prevent further bleeding

-Combined hormonal contraception (OCPs, skin patch, vaginal ring)
-Oral progesterone (e.g., norethindrone acetate)
-Depot medroxyprogesterone acetate
-Levonorgestrel IUD
-Subdermal implant
-If there are any concerns about safety given an adolescent’s medical conditions, providers may refer to the United States Medical Eligibility Criteria (USMEC) for evidence-based guidance

-Salter-Harris type 1 fracture in procimal femoral physis
-Shear force at the growth plate causes eiphsis to diplace posteriorly and inferiorly
-At risk for avascular necrosis
-Categorized as stable or unstable based on ability to bear weight
-Typically happens at the onset of puberty in overweight skeletally immature boys with delayed puberty
-Slippage is generally gradual, so it’s going to slip and be displaced posteriorly and inferiorly because of that Type 1 fracture through the femoral growth plate, and it’s going to be gradual

-Vague history of antecedent trauma
-Pain in hip, growin, thigh and knee
-Limping, gait abnormalities

-Obesity
-Delayed puberty
-Pain in groin, thigh
-Decreased internal rotation of hip
-Antalgic limp with short leg component
-External rotation of thigh when hip flexed
-Mild atrophy of thigh or gluteal muscles
-Limited abduction/extension

-AP pelvis, frog-leg lateral, true lateral views of the pelvis
-Flattening of epiphyseal prominence
-Slippage noted

-Refer immediately to orthopedic surgeon
-Place on crutches or wheelchair
-High incidence of contralateral SCFE in 6 to 12 months
-Support/monitor through treatment

-Avascular necrosis
-Chondrolysis (breakdown of cartilage)

-Not preventable
-Early identification/treatment to prevent complications

Occurs congenitally, or it develops in infancy, or childhood, and may actually be diagnosed many years after the newborn period
-Diagnosis doesn’t always occur early
-Majority resolve spontaneously by 6 to 8 weeks

-Newborns:
barlow/orolani
-Older infants:
limited abduction of the hip
shortening of thigh
asymmetry of inguinal and gluteal folds

-Children:
klisic and galeazzi test
-Older children:
short leg
trendelenburg sign (drop in pelvis when lifting opposite leg)
lordosis
toe walking
waddling gait/limp

-Ultrasound superior to radiograph
-After 4 weeks old

-Refer to ortho
-Restore articulation of femur acetabulum
-Majority of neonatal instability resolves in 6 to 8 weeks
-Pavlik harness 24 hours/day is the first step for 3 to 6 weeks
-Spica cast
-Skin care, cast care, car safety
-Annual and biannual follow up

-Child doesnt respond to the Pavlik harness
-6–18 months of age with a dislocated hip

-Skin irritation from cast/harness
-Delay in walking
-Permanent discolation if untreated

-Three-dimensional deformity
-Lateral curvature of spine in frontal plane
-Nonstructural vs. structural

-Curve in the spine without rotation of the vertebrae
-Reversible if it’s caused by:
poor posture
muscle spasms
pain
leg length discrepancy

-Actual rotational element of the spine
-Radiologist is going to use the Cobb’s method to measure the degree of curvature

-Idiopathic
-Congenital
-Neuromuscular

-Most common type
-See it mostly in preadolescent and adolescence (right thoracic curve)
-3 types based on age at onset
infantile: 0 to 3 years of age
juvenile: 3 to 10 years of age
adolescent: 11 years and older

Structural abnomality at birth

-Nonambulatory patients
-Due to weakness, or imbalance, or spasticity of the muscles of the trunk, and so they eventually just pull the patient in one direction or another, causing the scoliosis

-Hormonal changes play a role, and a rapid growth period is believed to be a significant growth factor
-Want to see when they started menarche
-Most vulnerable: a young female who has not gone through puberty yet, or has not started her menstrual cycle yet, and they have a large curvature

-Evaluate in standing position from front/side to look for asymmetry:
-Shoulder height
-Scapula prominences/height
-Waist angles
-Rib prominences/chest
-Elbow to flank distance
-Rib heights in forward bending position
-Leg lenghs
-Look for hairy patches, nevi, cafe au lait or dimples

-Cobb Method: use for curvature >10 degrees
-10 to 30% curve: small to moderate
-AP and lateral of spine

-Stop curvature progression/improve pulmonary function
-Observation, bracing, surgery
-Referral is essential

-<20 degrees:
monitor
->20 degrees:
possibly bracing
possibly surgery
-20 to 25 degrees:
bracing for:
skeletally immature, and who have had more than five degrees of progression since the last X-ray
->30 degrees:
definite bracing
-45 to 50 degrees:
surgery

-23 hours
-Can lead to decreaed compliance

-Newborns: from birth trauma
-Children: accidental/nonaccidental trauma

-Difficult delivery
-High birth weight
-Irritability when moved/lifted

-Pain with shoulder movement
-Decreased arm movement
-Asymmetric spontaneous arm movements
-Swelling
-Bony abnormality
-Crepitus
-Spasm of sternocleiodmastoid mucle on affected side
-Associated Erb's palsy

Radiologic imaging

-Neonates:
no treatment or immobilization depending on pain
can pin infant's sleeve to shirt for 1 to 2 weeks
-Child:
sling immobilization for comfort for 3 to 4 weeks
figure 8 brace
analgesics
surgery is uncommon

-Bowing of the legs
-Normal until the age of 3
-Pathologic: if bowing continues after 3
-Could be from blount disease, tumors, rickets, or neurologic problems

Family history is important

-Tibial–femoral angle greater than 15 degrees
-Associate internal tibial torsion
-Lower extremity length discrepancy
-Intercondylar distance with ankles together is more than 4 to 5 inches

-Physiologic:
no treatment
-Pathologic:
refer to ortho for perisistent or increaseing deformity
bracing

-Microtrauma in patellar tendon at insertion on tibial tuberosity
-Seen in adolescents or teenagers after going through a rapid growth spurt in the previous year
-Mostly in males

-Recent physical activity:
track
soccer
football
surfboarding
-Increased pain with activity
-Exacerbated with running, jumping, squatting, stairs

-May reproduce pain by:
extending knee against resistance
stressing quadriceps
squatting
-Focal swelling, heat, point tenderness

Diagnosis is based on history/physical exam

-Self-limiting; symptom management
-Education that disease can last up to 2 years
-Avoid activities that cause pain until inflammation subsides
-Ice or cold therapy for inflammation
-Quadriceps-stretching exercises when acute symptoms subside
-NSAIDs have questionable benefit and do not wanting them using it long term
-Neoprene sleeve to stabilize patella/patella tendon strap

-Adduction of forefoot in relation to hindfoot
-Caused by intrauterine molding in most cases

-Family history
-Intrauterine history

-Forefoot adducted; midfoot/hindfoot normal
-Lateral border has convex shape
-Grasp heel and abduct forefoot to see if flexible (differentiates from club foot)

None

-Flexible foot:
teach parents to stretch foot with each diaper change
-Non-flexible foot:
refer to ortho
may need serial casting

Fracture is in the physis but does not extend to the surrounding bone

-Like type I but has a metaphyseal fragment on the compression side
-Type II is the most common growth plate fracture

-Involves physeal separation with a fracture through the epiphysis into the joint
-Requires reduction and is usually an open approach

-Fracture involves:
metaphysis
physis
epiphysis

Involves a compression or crushing injury to the physis

-S:
separation or slippage (type I)
-A:
above (type II)
-L:
lower (type III)
-T:
through (type IV)
-R:
rammed, ruined, crushing (type V)

-Complete:
fracture fragments are separated
-Incomplete:
fragments remain attached

-Simple Fracture:
do not cause a break in the skin
-Compund Fracture:
open wounds through which bone protrudes
-Complicate Fracture:
when bone fragments have damaged other organs or tissues

-Headache:
upon awakening from sleep that then fades
increases in frequency and severity over a period of only a few weeks
is persistent and unilateral
-First or worst headache
-Pain that awakens the child from sleep
-Vomiting, but not nauseated, may relieve the headache or intractable vomiting
-Visual disturbances, diplopia, edema of the optic disc (papilledema)
-Increased pain with straining, sneezing, coughing, defecation, or changes in position

-Occipital region and neck pain
-Educational, mental, personality, or behavioral alterations; irritability
-New-onset seizures or facial or extremity numbness
-Unsteadiness or dramatic changes in balance, gait abnormalities
-Fever with or without nuchal rigidity
-Family history of neurologic disorders (e.g., brain tumors, neurofibromatosis, vascular malformations)
-The child has a history of:
ventriculoperitoneal shunt
meningitis
hydrocephalus
tumor
prior history of malignancy

-Most common type of seizure in the pediatric population
-Occur in conjunction with a fever
-Can be brief, generalized, clonic or tonic–clonic
-Classified as either simple or complex

-Generalized
-Last less than 15 minutes

-Generalized of focal seizures
-Last more than 15 minutes

-Etiology is unknown
-Children with:
a family history of febrile seizures
NICU for >30 days
developmental delay
attend daycare
-Age range: 6 to 60 months
-Boys have a higher prevalence

Risk factors for recurrence include:
first febrile seizure prior to 18 months of age
low degree of temperature at time of the seizure
fever not present until after the seizure
family history of febrile seizure

-Description of seizure duration, type (generalized or focal), frequency in 24 hours
-Relationship of the seizure to a febrile episode and level of temperature
-Any abnormal neurologic findings noted before the seizure (is not consistent with a febrile seizure)
-Family history of afebrile or febrile seizures
-Maternal smoking in the perinatal period
-Prematurity or neonatal hospitalizations for more than 28 days
-Parents’ perception of the development of the child

-Weakness or focal abnormalities on the neurologic exam
-Presence of seizure activity during the examination
-Hypertension (for renal disease)
-Signs of systemic disease or cardiovascular disorder
-Skin findings suggestive of neurocutaneous syndromes (i.e., café au lait spots, ash leaf spots, hypopigmented macules, or facial hemangiomas)
-Signs of head trauma
-Transillumination of the skull in infants

-Routine seizure first aid should be initiated:
protect the airway, breathing, and circulation if the seizure is still occurring
place the child in a side-lying position to prevent aspiration or airway obstruction
do not put anything into the child’s mouth during the seizure
for seizures lasting longer than five minutes, call 911
-Reduce fever with acetaminophen or ibuprofen after seizure stops
-Prophylactic management with antipyretics to prevent future febrile seizures is not recommended

-Rescue medications:
rectal diazepam
intranasal midazolam
buccal clonazepam
can be prescribed for prolonged febrile seizures or clusters of febrile seizures in the prehospital setting
-Antipyretics can reduce the discomfort associated with a fever but do not alter the risk of having another febrile seizure

-Risks, first aid, and management
-Risk factors for recurrence
-Assurance that nothing can be done to prevent the febrile seizures
-No long-term complications are associated with simple febrile seizures
-Simple febrile seizures can be managed in the outpatient setting
-Complex febrile seizures will need further evaluation and/or referral