Pediatrics

Key Pediatric Insights:

  • Normal fetal heart rate: 120-160 bpm.
  • Aspirin is contraindicated in children due to the risk of Reye’s syndrome.
  • Button batteries can cause severe esophageal burns—urgent removal is required.
  • Unvaccinated febrile children need a more extensive evaluation (e.g., lumbar puncture to rule out meningitis) compared to vaccinated children.

APGAR Scoring System

A – Appearance (Skin color)
P – Pulse (Heart rate)
G – Grimace (Reflex irritability)
A – Activity (Muscle tone)
R – Respiratory effort

Assessment Criteria0 points1 point2 points
Skin ColorPale or bluishBluish extremities (acrocyanosis)Fully pink
Heart RateNot detectableBelow 100 BOMAbove 100 BPM
Reflex ResponseNo reactionGrimaceStrong cry or active movement
Muscle ToneFlaccidSome bending of limbsVigorous movement
Breathing effortNo breathingWeak cry, slow breathingStrong cry, regular breathing

APGAR Scoring Interpretation

7-10: Normal—reassuring signs

0-3: Critically low—requires immediate resuscitation

4-6: Moderately low—may need intervention

Newborn Oxygen Saturation

  • At birth, oxygen saturation should be 60-65%.
  • It takes about 10 minutes to reach >90%, as the ductus arteriosus closes and lungs clear fluid.

Intussusception

  • Classic sign: “Red currant jelly” stool
  • Typically affects children 16 months to 5-6 years
  • Occurs when one section of the bowel telescopes into the adjacent segment
  • Can lead to bowel wall necrosis → peritonitis → sepsis → death
  • Associated with recent gastroenteritis, celiac disease, IBS (but can occur without these)
  • Most common site: Ileocecal region

Early Symptoms:

  • Episodic, crampy abdominal pain
  • Intermittent fussiness or irritability
  • Vomiting
  • Periods of sleepiness post-episodes

Late Symptoms:

  • Pale, ill-appearing (signs of sepsis)
  • Severe abdominal pain
  • Persistent vomiting
  • “Sausage-shaped” abdominal mass
  • Possible bloody, mucus-like stool (“currant jelly”)
  • Possible fever

Diagnosis: Ultrasound (confirms but does not treat)

Treatment: Hydrostatic, barium, or pneumatic enema (both diagnostic & therapeutic)

Meningitis

  • Symptoms range from lethargy to irritability.
  • Any infant under 2 months with fever should be evaluated for meningitis.
  • Bacterial meningitis: Common signs include headache, fever, and possibly a stiff neck.

Infectious Symptoms:

  • Vomiting
  • Headache
  • Neck stiffness
  • Altered mental status

Vital Signs:

  • Fever
  • Possible tachycardia
  • Bradycardia (late finding)
  • Cushing’s Triad (indicative of increased ICP):
  • Widened pulse pressure
  • Irregular, slow breathing (Bradypnea)
  • Bradycardia

Intracranial Hemorrhage

Subarachnoid Hemorrhage (SAH)

  • Caused by blunt trauma or shearing injury
  • Symptoms:
    ✔ Severe headache
    ✔ Photophobia
    ✔ Nausea/vomiting
    ✔ Neck stiffness (nuchal rigidity)

Subdural Hemorrhage (SDH)

  • Common in infants and young children (e.g., shaken baby syndrome)
  • Caused by shearing forces
  • May have lucid intervals followed by deterioration

Symptoms:

  • Headache, nausea
  • Lethargy, irritability
  • Bulging fontanel (in infants)

Epidural Hemorrhage (EDH)

Intracranial Hemorrhage

Subarachnoid Hemorrhage (SAH)

  • Caused by blunt trauma or shearing injury

Symptoms

  • Severe headache
  • Photophobia
  • Nausea/vomiting
  • Neck stiffness (nuchal rigidity)

Subdural Hemorrhage (SDH)

  • Common in infants and young children (e.g., shaken baby syndrome)
  • Caused by shearing forces
  • May have lucid intervals followed by deterioration

Symptoms:

  • Headache, nausea
  • Lethargy, irritability
  • Bulging fontanel (in infants)

Epidural Hemorrhage (EDH)

  • Blunt head trauma (e.g., falls, sports injuries)
  • Middle meningeal artery rupture

Symptoms:

  • Headache, vomiting
  • Lucid period followed by rapid deterioration
  • Lethargy, altered consciousness

Seizures in Infants

  • Regardless of the cause, management begins with ABCs, glucose monitoring, and temperature regulation.

Infectious Causes

Bacterial Infections

  • Group B Streptococcus
  • Escherichia coli
  • Listeria monocytogenes
  • Streptococcus pneumoniae

Viral Infections

  • Cytomegalovirus (CMV)
  • Influenza virus
  • Herpes simplex virus (HSV)
  • Rubella virus
  • Enteroviruses

Metabolic Causes

Hypoglycemia

  • When glucose is depleted, the body shifts to fat and protein metabolism, producing keto acids and increased urea, leading to acidosis.

Neonatal hypoglycemia risk factors:

  • Maternal diabetes
  • Perinatal asphyxia
  • Neonatal infection
  • Hypothermia
  • Poor feeding

Hypoglycemia in infants:

  • Inborn errors of metabolism (IEM) → Genetic mutations affecting biochemical pathways
  • Infections
  • Toxin ingestion
  • Type 1 diabetes (IDDM)
  • Hypothermia

Signs: Poor feeding, vomiting, seizures, encephalopathy

Hypoxia (Can Lead to Cerebral Palsy)

  • Fetal Hypoxia: Due to inadequate maternal oxygenation
  • Postnatal Hypoxia: Can result from anemia, respiratory failure, or congenital heart disease

Trauma-Related Seizures

  • Occurs in 5–33% of children after significant head injury
    • Higher risk in:
      Younger children
      Glasgow Coma Scale (GCS) < 8
      Severe head trauma, especially with intracranial hemorrhage (ICH)

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