Pediatric Notes

. Nutritional requirements for adult depend on phys ical 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
gradua lly 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 wei ght 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 nu trition 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 requirement s 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 fe eding 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 الأم : لغويا

o تحويل الطفل من حليب الأم إلى الغذاء الصلب أو شبه الصلب : إصطلاحيا


 Important question : Breast milk contain all materials for baby except:
o Iron  add it to baby feedi ng at fourth month of life.
o Vit B  add it to baby feedi ng at first week of life.
o Fluoride  add it to baby feedi ng 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
trime ster  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 mi lk contain cholesterol m ore than formula milk b ut 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
 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 period s of
amenorrhea.
 Post -partum hemorrhage (PPH)  stop by oxytocin  breast feeding incr ease 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 jaun dice  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 الكلمة of 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
co untries .
 Breast feeding is not contraindicated in mastitis because the only way to reduce the
engorgement is increasing breast feeding.
 Unmodified cows milk:
o Contain p rotein 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 w ith vitamins and minerals .
 Whey is easily digested and casein is di fficult to diges t 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 indica te 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 t he 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 ve ntricles 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 ol d 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 m ost 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 m urmur 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  bo ot 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  becaus e there is no
blood in the lung.
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 TGA is less common than TOF, but TGA also is common.
 In TGA patient there i s 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 vent ricle 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  ca lled atri lization 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 oth er usual
signs of HF but baby will present by feeding dyspnea , hypertension, hyperpnoea ,
tende r hepatomegaly , pulmonary sounds.
 Older children with CHF present with fatigue and exercise intolera nce.
 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, o r 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.
 M anagement of H.F: admission + bed rest + elevate head + O2 + sodium, potassium ,
digoxin lev el + PO2 and PCO2 + g ive 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 vaso constriction 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 in fection but heart
diseases occu r 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 ty pe 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 للاطلاع

 Cardiomyopathy  H.F without murmur or recurrent ches t infection without
murmur  death or cardiac transplantation.