When should the mother expect milk to come in abunduntly?
3-5 days post delivery
Describe physiologic jaundice:
- why it happens
- when it’s mostly seen
- bilirubin levels
Physiologic jaundice:
- newborn’s liver is unable to process the RBC load from the birth experience, as this was previously the job of the placenta.
- most notable at 2-4 days. Gone by 2 weeks.
- indirect bilirubin: 12 or less
Describe pathologic jaundice
- why it happens
- when it occurs
Pathologic jaundice: AKA direct hyperbilirubinemia
- caused by sepsis, ABO incompatibility, toxoplasmosis, or occult hemorrhage
- appears at 24 hours of life
When should a clinician worry about jaundice?
1 Major risk factor + High Bhutani score
Known FHx of inherited disorder
Presentation varies widely from typical
Infant is not responding to phototherapy
What are the major risk factors of jaundice? (6)
- High bilirubin levels
- Jaundice within first 24 hours
- Gestational age 35-36 weeks
- Previous sibling treated with phototherapy
- Bruising
- Exclusive breastfeeding
Describe breast milk jaundice:
- when it occurs
- bilirubin levels
- how long it lasts
Breast milk jaundice: AKA indirect hyperbilirubinemia
- occurs after 7 days of life and peaks between 2-3 weeks of life
- indirect bilirubin: 15-17 or less
- lasts 1+ months
What child characteristics puts a child at risk for abuse?
- Prematurity
- Physical / developmental disabilities
- < 4 years old
What is the single most common presentation of child physical abuse?
Bruising
Bruises are rare in children of what age?
Less than 6 months as they are not mobile at this time.
“No cruise, no bruise”
What patterns of bruising in childhood are suggestive of abuse?
- away from bony prominences
- MC: head, neck, face (excluding forehead)
- buttocks, trunk (excluding spinous processes), arms
- large, multiple, and clustered
- patterned
What is the MC cause of death from abuse?
Head trauma due to a direct blow and/or shaking
A toddler presents with posterior rib fractures and no altered mental status. Does this warrant a head CT?
Yes – neurologically asymptomatic kids with rib fractures, multiple fractures, facial injury, and anyone less than 6 months of age with suspicious injury require a head CT/MRI.
Additionally, all patients with neurological symptoms and with concerns of child physical abuse require a head CT/MRI.
An 18 month old comes in with bruising and abdominal trauma. What is your next best step in management?
Skeletal survey.
All children <2 years of age with concerns of physical abuse require a skeletal survey.
Skeletal surveys have little value in those >5 yo.
Who needs screening for occult abdominal injury and when would you consider an abdominal CT?
Children less than 5 years old and suspected victim of physical abuse.
Screening test – AST and ALT
- if AST or ALT >80, obtain abdominal CT.
Drowning is the process of experiencing respiratory impairment through submersion or immersion. Describe the difference between submersion and immersion.
Submersion: airway under water
Immersion: significant amount of water enters oropharynx through splashing
Drowning has a higher chance of having a fatal outcome before coming to the hospital under what conditions?
No supervision
Age <2
Under water for >5 minutes or unknown
What are the best preventative methods one should utilize to prevent drowning?
Pool fencing - BEST
Life jackets
Swim lessons (1+ yo)
Supervision
Lifeguards
What are the most common scenarios of drowning by age group - babies, toddlers, teens?
Babies - bathtubs and buckets
Toddlers - swimming pools
Teens - freshwater
What is first line treatment for drowning?
Initiate CPR (respiratory first, then cardiac) at the scene, call EMS
Prioritize respiratory support
No need to stabilize C-spine
Under which drowning conditions would you observe a patient for 4-8 hours? What are you looking for in those 4-8 hours?
Conscious with no respiratory distress
Looking for:
- Cough, tachypnea
- Vomiting
- Mental status changes
In order for a child to be defined as having a febrile seizure, they must have what?
Be 6 months to 60 months (5 yo)
Have a temperature of >38 C (100 F)
No known intracranial, metabolic cause or history of afebrile convulsions
For a seizure to be defined as a simple febrile seizure, what characteristics must it have?
Lasts less than 15 min
Generalized tonic-clonic activity
No recurrence within 24hrs
No underlying neurologic disease
For a seizure to be defined as a complex febrile seizure, what characteristics must it have?
Last more than 15 mins
Focal
Recur within 24hrs
Associated with postictal neurological abnormalities
Under what conditions is a lumbar puncture warranted in those who have a simple febrile seizure?
If less than 6 months of age
If 6-12 months of age and immunizations are incomplete or unknown due to Hib or Strep. pneumo meningitis
If persistent lethargy (beyond typical post-ictal length), meningeal signs, or clinical suspicion
