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131 Cards in this Set
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constipation (rome criteria)
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2 of the following, once per week for 2 mos:
-2 or less bm's per week -1 episode of fecal incont. per week -hx of excessive stool retention -hx painful hard bm's -hx large diameter stools that may plug toilet -large fecal mass in rectum |
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encopresis
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fecal incontinence after 4, occurs 1x per month for 2 months
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tx of constipation
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develop regular bowel routine
evacuation of bowel to start bowel retraining ongoing maintenance of diet, exercise and toilet hygiene to prevent recurrence **diet change may be enough if there is no stool retention, pain or rectal bleeding if has any of above tx with PEG or mineral oil **infant juice, suppository or rectal stim |
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differentials for constipation
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hypothyroid, lead, celiac, hirschsprungs, spina bifida, cf
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times constipation is likely to occur
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intro of solids or milk
toilet training school entry |
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physiological complications of stool retention
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distention of colon
stretching of rectum ineffective peristalsis decreased sensory threshold in rectum weakened rectal and sphincter muscles **may feel mass in left lower quadrant |
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Functional abdominal pain (Rome Criteria)
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No organic etiology
following must occur 1/wk for 2 months -abdominal pain -no evidence of other disorder -no criteria for other fxnl disorders |
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Red flags for functional abdominal pain
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localizing pain away from umbilicus
pain assoc with change in bm's night awakening fever, loss of appetite or energy child <4 blood in stool or emesis wt loss organomegaly localized abdominal tenderness perirectal abnormalities joint swelling |
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testing for fxnl abd pain
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initial approach:
cbc,esr,crp,amylase, lipase, CMP,ua and abdominal us, abd xray 3 day trial of lactose free diet can also do stool studies |
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differentials for abd pain
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uti, ibs, celiac, lactose intol, constipation, depression, IBD
|
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managment of fxnl abd pain
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establish therapeutic relationship (dont over test-it encourages)
explain brain-gut interaction (closely related-stress can cause abdominal pain etc) meds sparingly (can use Levsin antispasmotic or periactin) discuss the possibility of it being FAP (inorganic) early on ***encourage return to school and dont give excessive attention CAM therapies-bland diet, etc look at stressors, couseling discuss alarm symptoms |
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GERD etiology
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young infants have increase intra-abd pressure because do not sit upright
relaxation of LES delayed gastic emptying |
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s/s gerd
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regur
wt loss or no gain rumination heart burn hematemesis dysphagia wheeze/cough infants may have irritability, arching, gagging older children-abd and chest pain |
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dx of gerd
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tests not needed- hx and pe sufficient
prn can do: cbc, ua, FOB, h.pylori (esophageal ph is gold standard) |
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red flags with GER
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bilious vomiting
gi bleed forceful vomiting or starting after 6 mos FTT diarrhea/constipation fever lethargy hsm |
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mgmnt GERD
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h2 blocker or PPI (zantac 2-4mg/kg/dose)
nutrition (feeding techniques, volumes, frequency) hydrolyzed formula 1tsp rice per ounce of formula if not improving with meds may need referral |
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lactose intolerance s/s
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abd pain
diarrhea nausea gas boating |
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cause of lactose intol
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deficiency of lactase (enzyme)
|
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dx/tx of lactose intol
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lactose hydrogen breath test
trial of lactose free for 2 week tx: lactose free diet lactase suppl |
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cow's milk allergy or Protein intol symptoms and tx
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can have allergic rhinitis
asthma, congestion eczema, rashes , irritability gi symptoms (vomiting/diarrhea, blood in stool) tx: change to hypoallergenic formula |
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FTT criteria
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BMI <5%
length for age and sex <5% wt decel >2 percentile lines wt <80% of median wt for ht wt for length <10 % tile |
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causes of FTT:
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inadequate calories
inadequate calorie absorption excessive calorie expenditure ***>80% caused by nutritional deficiency **2wks to 4 mos is more likely congenital **btwn 4-8 mos consider feeding problems high risk-poverty, hiv, developing countries |
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diagnostic studies for FTT
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feeding hx
ability to suck, swallow, chew type of food 24 diet recall labs:cbc, CMP, tsh, t4, esr, crp, ua, sweat test-do at cf center may to ugi or swallow study |
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normal wt gains throughout childhood
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0-3 mos 25-30 gm per day
3-6 mos 15-20 gm per day 6-12 mos 10-15 gm per day 1-3 yrs 4-6 lbs per year 3-6 yrs 4.5 lbs per year 6-12 7 lbs per yr |
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normal ht gains childhood
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0-3 mos 3.5 cm/mon
3-6 mos 2.0 cm/mon 6-12 mos 1.5 cm/mon 1-3 years 12 cm/yr 4-12 years 6 cm/yr puberty 8-14 cm |
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hirschprungs symptom
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absence of gangion cells in bowel wall
s/s no meconium in first 48 hrs FTT poor feeding chronic constipation down syndrome dx: xray shows dilated loops of bowel, barium enema tx: surgical resection |
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intussusception
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section of intestine pulled into adjacent intestine=bowel is trapped
most common in 5-10 mos of age s/s colicky intermittent pain vomiting currant jelly stool may palpate sausage like mass in abdomen RUQ abd distended and tender to palpation bloody stool *u/s is test of choice tx: surgical-air contrast enema |
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cryptosporidium
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parasite
diarrhea, cramps spread fecal-oral or undercooked food tx: supportive |
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giardia
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parasite
watery diarrhea, greasy foul smelling stools fecal oral or contaminated food or water (from dogs, beavers etc) tx: flagyl dont swim for 2 weeks |
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IBS define and rome criteria
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chronic or FAP with altered bowel habits and bloating not explained by structural or chemical abnormality
Must include **once per week for 2 months 1. abdominal discomfort with 2 or more- improvement with defecation onset with change in frequency of stool onset with change in appearance of stool 2. no evidence of pathology |
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celiac disease path
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autoimmune disease triggered by dietary exposure to wheat gluten
associated with HLA's-autoantibodies to enzyme TTG-activate t-cells and lead to mucosal damage and malabsorption |
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celiac s/s and dx test
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diarrhea, n/v, wt loss, fatigue, abd distension, short stature
**white lines on teeth, delayed puberty, thyroiditisa and dermatitis herpetiformis dx: celiac panel- ttg iga ema iga- if positive keep on gluten free diet so diagnosis can be confirmed |
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celiac tx
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gluten free diet
monitor thyroid, viat d, screen family and sibs untreated can lead to lymphoma |
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eosinophilic esophagitis
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inflam condition of esophagus
s/s: dysphagia, choking, chest or abd pain, food avoidance, heart burn, emesis dx: egd, trial of acid reducer tx: pulmicort respules with splena swallowed, all kids sent to allergist |
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IBD s/s
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crohn's (throughout)
UC (just colon)- can be cured by removing colon av age of dx:12 presents with-wt loss, bloody diarrhea, abnormla labs-anemia, low protein and increased esr,crp pale, fatigue, joint pain |
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IBD tx
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assess growth
medication, correct deficiencies and increase calories |
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cystic fibrosis GI manifestations
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infancy-meconium ileus from dessicated fecal material
pancreatic insuff, rectal prolapse 85% of children have FTT due to pancreatic insuff thick fat laden stools infants that are fed soy based formula do poorly due to proteinemia |
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cyclic vomiting and abdominal migraines
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CV-recurrent stereotypical attacks of intense nausea and vomiting with intervening periods of wellness
children 2-7 family hx migraines tx:periactin or elavil |
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zantac dosing
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4-6mg/kg/day divided 2-3 times per day
|
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omeprazole dosing/ lansoprozole dosing
prilosec and prevacid |
1-3 mg/kg/day
***start 1mg/kg/day for >2 yo |
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eradication of h.pylori
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amox, clarith and prilosec
or clarith, flagy, prilosec |
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work up for constipation
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barium enema- if suspect hirschprungs
sweat test- CF rectal exam tsh, t4 celiac panel stool for occult blood |
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vit d recc for breast fed infants
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400 iu until 12 mos old
|
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What are macronutrients
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carbs, fat and protein
|
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fat intake for children
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1-3 30-40%
>3 25-30% |
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what are the fat soluble vitamins
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a,d,e,k,
stored for long periods in body |
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vit d
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essential for bone growth and development, regulated absorption of calcium
defeciency-ricketts, skeletal malformation, delayed teeth source: sunlight, fortified food need to supplement bf babies unless formula intake is up to 1 liter per day |
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vit e
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antioxidant, traps free radicals
deficit-anemia and dermatitis, neuro defects source-veg oils, margarine, nuts, green leafy |
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vit a
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for vision, cell growth and immune system
source-liver, fish oil, eggs, carrots, drk greens def-anorexia, dry skin, eye probs |
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vit c
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tissue repair, wound healing, iron absorption
def-scurcy, cracked lips |
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thiamin b1
riboflavin b2 niacin b3 b12 |
thi-carb metabolism, in whole grains, nuts, seeds
def-beriberi-weakness, confusion ribo-oxidation, intergrity of skin, lips- in diary poultry fish, def-oral lesions, dermatitis niacin-energy metabolism-nervous system and skin, source meats, milk, eggs def-pellegra-dermatitis, diarrhea, indigestion b12- metabolism and rbc's, in animal products, eggs, meat, shell fish. def-megaloblastic anemia, neuro symptoms |
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folate
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essential for RBc formation, found in liver, drk greens, legumes, fruit, def-poor growth, anemia
|
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calcium
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bones, nerve conduction, muscle contraction
sources- milk, green leafy, broccoli def-risk for fractures, dec bone strength |
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phosphorus
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bone integrity and metabolism
sources- almost all food, meat, poultry, fish def-bone loss, weakness, malaise |
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magnesium
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transmission of nerve impulses, cell metabolism
source-nuts, green veg, bananas def-muscle weakness, nausea |
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iron
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formation of heme molecule, oxygen transport
source-meat, eggs, cereal, spinach def-anemia |
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iron rich foods
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almonds, cashews, cereals, pumpkin seeds, apricots, kidney beans, spinach, tofu, ground beef, potatoes, peas
|
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define overweight, obese, and underweight
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overwt->85%-<95% BMI
obese- >95%bmi underweight- <5% bmi |
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electrolytes
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Electrolytes are important because they are what your cells (especially nerve, heart, muscle) use to maintain voltages across their cell membranes and to carry electrical impulses (nerve impulses, muscle contractions) across themselves and to other cells.
Na+ extracellular fluid volume (lost with vomiting, diarrhea, sweat) K+ intracellular-transmission of nerve impulses Cl- fxn with Na for fluid balance, (loss with vom, diarr, sweat) |
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nutritional assessment
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food intake
eating patterns reactions and attitudes about food mngmt of food in family health status affected by nutrition ie. elim, dental family hx |
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nutritional assessment dx tests
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hgb
iron and or ferritin various elements-albumin, minerals, lipids bone radiographs |
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reasons to start solids 6 mos
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avoids food allergies
sucking patterns have changed to allow chewing sit with support head control iron stores depleting grasp and rake objects growth demands require other nutrients cog, sensory and motor stimulation from new foods, textures, smells etc rice most non-allergenic |
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risk factors for obesity
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prenatal- maternal wt gain, smoking
post natal- decrease sleep rapid wt gain in first months of life bottle after 12 mos intro of solids <4 mos lifestyle- low income non-nutritional foods not eating as a family excessive screen time, decreased physical activity sugary drinks |
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vegan diets need what supplement
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b12
|
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differential for FTT
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clinical findings are
poor wt gain associated with- poor intake vomiting diarrhea food refusal anticipatory gagging dd: CHD, GI, renal, pulmonary, endocrine, error of metabolism/genetic, autoimmune**wt loss think diabetes |
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disorders requiring increased calorie intake
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premie and LBW
chf malabsorption renal disease meds increased activity_CP hiv, cancer, fever etc |
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nutritional mgmt of late preterm
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prefer breast feeding
may add fortifiers |
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nutritional mngmt premie
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fortify breast milk
screen for anemia at 6-9 mos vitamin supp- iron 2-4mg/kg/day (taken from 2 weeks to 1 yr) formula fed-enfacare or neosure transition to regular formula at EDC-consider sick infants with catch-up growth kept on formula until size is WNL for gest age *transition to whole milk 12 mos after EDC |
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child vegetarian mngmt
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lab assessment of b12, zinc, iron. Vit d may be necessary
variety of configurations of protein b12-cereal, soy milk and nutritional yeast ZINC-cheese, legumes and grains |
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obesity workup
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bp
bmi skin for acanthosis lipids glucose tol test tsh, t4 metabolic panel |
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mngmt of obesity
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goal- to normalize not reduce (prevent gain)
educate parents-healthy habits, increase physical activity, decrease high fat, sugary foods, portion sizes increase fruit and veg, decrease juice and pop tv <2 hrs per day eat breakfast exercise 1 hr per day |
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testing for food allergies
|
skin test
serum ige patch test rast **food elim challenge -done under supervision of allergiest (stop for 2 weeks then reintroduce) |
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frontal lobe
parietal temporal occipital |
parts of cerebrum (cortex-gray matter)
frontal-emotion, memory, judgement parietal-language, reading, writing temporal-memory, auditory, olfaction occipital-visual |
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thalamus
hypothalmus |
part of the diencephalon of cerebrum
thalamus-recieves and sorts sensory input hypothal-integrates autonomic fxn |
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pons
medulla cerebellum |
hindbrain of cerebrum
pons-bridge medulla-arousal cerebellum-coordination, balance |
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parasympathetic vs. sympathetic
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para-enervation results in slowed activity, active when a person is relaxed (acetylcholine-inhibits)
symp-fight or flight, when person is stressed (epi and norepi-excites) |
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degenerative vs. non degenerative neuro disorders
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degenerative-affect the white or gray matter, lead to insults to major portions of brain, -loss of structure or fxn of neurons in brain or spinal cord
non- ie. CP, bells palsy, epilepsy |
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patho of seizures
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misfiring of cortical neurons of brain
**called epilepsy when sx are recurrent and not r/t fever |
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differentiate btwn partial and generalized seizures
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partial (focal)- originates in 1 part of brain, unilateral
generalized- involves entire brain, deep, LOC |
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types of partial seizures
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simple-no LOC, no confusion, last 5-10 seconds, may have aura, shaking in localized area, numbness
complex- LOC, automatisms (lip smacking, chewing), lasts **1-2 minutes (can be several minutes), staring spell, aura, followed by confusion |
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types of complex partial sz
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temp lobe-70% aura, oral or motor automatisms,contra-lateral twitching, 60-90 sec and post-ictal fatigue
frontal lobe- 20%, abrupts onset, vocalizations, humming, occurs surrounding sleep, complex mvmtns |
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Absence sz
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generalized
no aura LOC onset and recovery brief duration is <10 seconds brief unresponsiveness and discontinuation of activity may be triggered by hypoventilation |
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myoclonic sz
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generalized
Brief <5 sec shock-like muscle contraction |
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clonic
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generalized
rhythmic, repetitive muscle contractions most often arms impaired consciousness |
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tonic
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generalized
sustained muscle contraction several seconds abrupt onset and return to baseline |
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atonic
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generalized
abrupt loss of tone 1-2 seconds loc but quickly recovered |
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tonic clonic
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can include a long prodrome (irritable, HA)
muscle contractions lead to fall LOC tonic phase last 10-30 sec apnea, cyanosis clonic 30-60 sec, jerking then becomes limp may have agitation and confusion |
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symptomatic sz
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provoked
occurs with CNS insult infection, brain injury, stroke, med withdrawal, drugs |
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first unprovoked sz eval and mngmt
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eval-EEG
labs based on individual circumstances toxicology considered if questionable exposure LP little value MRI if cognitive or motor impairment, focal sz, under 1 yr of age or abnormality on exam Emergent MRI if post ictal deficits tx: no meds needed unless EEG abnormal no activity restrictions (same safety precautions) diastat not needed only 50% chance of recurrance |
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febrile sz (simple vs complex)
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simple
generalized tonic-clonic resolve 10 min return to normal alert status- immed followed by sleepiness and confusion doesn't recur fever over 38 complex- doesn't meet above (longer than 15 min, focal) |
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assessment of febrile sz
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hx: recent illness, abx, duration, fam hx, imms
test: LP for meningeal signs, consider if imms not UTD, option for child with pretreatment of abx labs not necessarily needed MRI- no EEG-no unless complex febrile sz diastat-not needed |
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evaluation of epilepsy
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EEG
MRI-indicated for focal epilepsy, optional for generalized forms |
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treatment of epilepsy
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50% need 1 med
30% poly meds Partial- trileptal (may use tegretol, phenobarb, dilantin) Generalized- tonic/clonic (depakote, topamax, phenobarb and dilantin) absence-zarontin, lamictal, depakote atonic-topamax myoclonic- depakote, lamictal, keppra **do not give dilantin surgery-used for intractable partial epilepsy ketogenic diet-increase fat, lower protein and carbs VNS-pacemake device attached to vagal nerve |
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how to proceed through a neuro exam
|
cerebral fxn first: behavior and mental status, language, speech, memory
cranial nerves motor fxn- gait, balance, strength, symmetry, tone sensory-pinprick reflexes-dtr, primitive, superficial cranial exam-HC meningeal signs- kernig and brudzinski |
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When to do imaging with HA
|
abnormal neuro exam
finding indicating IICP-papilledema, nystagmus, motor or gait dysfunction, sz, loc change consider with-recent onset severe HA, change in type of HA or neuro dysfxn |
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patho of migraine
|
excitability of cerebral cortex
waves of depolarization inflamm of meningeal vessels |
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migraine with aura (general description)
|
most common
prodrome-mood change, irritable, lethargy begins gradually with local mod to severe pounding pain assoc with photophobia, phono, nausea, vomiting, abd pain lasts hrs to day 6-8x/mon |
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migraine w/o aura (general description)
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child-has after school
tween-lunchtime teen-morning HA |
|
dx criteria migraine with aura
|
ha lasts 1-72 hrs
at least 2: unilateral (may be bilat) pulsing mod to severe aggrevated by activity with: n/v photo or phonophobia no other disorder contributing at least 5 attacks *may have visual disturbances before HA |
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red flags for migraine auras
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sudden images
complex visual perceptions *not just shapes transient visual obscurations bizzarre visual illusions (can be sz) |
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presenting symptoms of secondary headaches
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worse in am on awakening then fades
increase in frequency and severity over a few weeks wakens from sleep vomiting s nausea/relieves ha visual distrubances-diplopia increase with straining occipital pain personality/behavior changes sz unsteady fever persistent unilateral HA abnormal dtr's |
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basilar migraine
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attacks of dizziness, vertigo and visual distubances followed by HA
|
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childhood periodic syndromes
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cyclic vomiting-sterotypical onset, duration 24-48 every 2-4 weeks- outgrow by 10
abdominal migraine- epigastric pain for 1-72 hrs, moderate to severe, well btwn benign vertigo- abrupt episode of unsteadiness, resolves with sleep |
|
tx of migraine
|
rescue-NSAIDS
abortive- triptans antiemetics prophy-depokote, topamax, neurontin, elavil beta blockers, cyproheptatidine cam-botox, herbs, magnesium and riboflavin behavior-avoid caffeine, regular meals, exercise, fluids. cheese and citrus, chocolate |
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tension headache criteria
|
30min to 7 days
at least 2: bilateral pressing/tightening mild to mod no n/v not both photo and phono no other cause 10 episodes for 3 mos 1-15d/month |
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cluster
|
uncommon in kids
unilateral pain in bursts 30-90 min several times per day hurts to lie down stabbing occurs after falling asleep |
|
pseudotumor cerebri
|
mostly femle
global daily pounding ha papilledema patho-impaired csf reabsorption causes-prg, meds, vita A intox, SLE, obesity, endocrine diseases |
|
macrocephaly
|
2sd above mean
may be genetic can be from hydrocephaly, subdural hematoma, tumor |
|
microcephaly
|
hc 2 sd below mean
normal shape may have delayed development and neuro probs cause-disease process that interferes with brain growth or brain never formed correctly |
|
craniosynostosis vs. plagiocephaly
|
plagio-paralellogram
cranio-may be present at birth, less frontal asym,* ear displaced posteriorly (instead of anteriorly) sagital syno- presents as long narrow head and *palpable bony ridge |
|
mngmt of plagiocephaly
|
tummy time
reposition on mattress toys on side of limitation neck exercises with diaper change helmet-after 6 weeks of repositioning refer if: unclear dx, severe asym, refractory with position change after age 4-6 mos |
|
strongest identifiable predisposing factor for asthma
|
atopic diseases:
allergy eczema |
|
factors associated with development of asthma
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allergy
fam hx tobacco male gender low birth wt |
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patho asthma
|
immune response that results in edema and inflam or airway
leads to brochoconstriction mucous plugs bronchospasm |
|
asthma triggers
|
smoke
viral infxn exercise dust animals cockroaches molds cold air stress |
|
diagnosing asthma
|
*show episodic hyper-responsiveness
*airway obstruction partially reversible spirometry gold standard- fvc deep breath, fev1 force for 1 sec *therapeutic trial with meds can help diagnosis in younger (along with PE and hx) |
|
conditions that complicate asthma
|
GERD
sinusitis sleep apnea |
|
additional studies for asthma
|
o2 sat
allergy testing sweat test exercise challenge |
|
asthma management goals
|
regular monitoring
control triggers meds education (prevent exacerbations, normal activity levels, prevent troublesome symptoms) |
|
SABA'S
|
Relaxes bronchial smooth muscle-dilates
relief for acute symptoms |
|
atrovent
|
anticholinergic
bronchodilator not as effective as saba slower onset peak 30-90 min |
|
signs of poor asthma control or need for step up
|
using rescue>2x/week
oral steroids >2x/yr |
|
oral steroid for asthma
|
anti-inflam
tapering not necessary unless >10 d speed resolution of mod to severe exacerbations prednisolone 1-2mg/kg/day |
|
inhaled steroids for asthma
|
most effective for long term control
qvarr pulmicort flovent asmanex monitor ht, rinse mouth after, reduce need for quick relief meds |
|
leukotriene antagonist (ltra)
|
singulair
alone or in combo with ics, or ics/laba alternative for step 2,3,4 |
|
Long acting b agonist
|
must combine with ICS or LTRA
relax bronchials for 12 hrs advair approved down to 4 |
|
classify asthma severity for 0-4 year old
|
inter- no night wake, saba<2/wk, no prob with act
mil-1-2/mon night symp, saba>2/week, minor lim, steroids >2x in 6 mon mod- 3-4 night wake, daily use of saba, mult steriods, limits on fxn severe-1/wk night wake, saba several x per day |
|
classify asthma severity for 5-12 and up
|
inter- <2 night wake, <2d/wk saba use, fev >80
mild- 3-4mon wake, saba >2x/wk, minor limits adl's mod- 1/wk night wake, daily symptoms and saba, FEV 60-80 severe- nightly awake, saba several times/day, limited adl's, <60% predicted |
|
mild acute exacerbation of asthma
|
wheeze
increased rr no resp distress or cyanosis normal sentences |
|
mod acute asthma exacerbation
|
aud wheeze
accessory muscles 3-5 words |
|
severe acute asthma episode
|
cyanosis
nasal flare supra sternal retractions agitation 1 word loud wheeze on inhale and exhale |