Questions 9 - 16

9.  EVALUATION OF AN ADOLESCENT WITH GYNECOMASTIA

 

• Once the diagnosis of gynecomastia is established, review all medications, including OTC and herbal products that may be associated with gynecomastia.  (antiandrogens, spironolactone, cimetidine, environmental estrogens or antiadrogens, one or more components of highly active antiviral therapy used for HIV especially protease inhibitors, some chemotherapeutic drugs such as alkylating agents, phenytoin, metoclopramide)  Drug abuse, especially with anabolic steroids, alcohol, marijuana or opioids should also be considered. 

• Consider other conditions that may cause gynecomastia:  Klinefelter´s syndrome, familial or sporadic excessive aromatase activity, incomplete androgen insensitivity, feminizing testicular or adrenal tumors, hyperthyroidism. 
  
  
• Patients with physiologic gynecomastia do not require further evaluation.
• Further evaluation is necessary in patients with the following:
  -  Breast size greater than 5 cm (macromastia)
  -  A lump that is tender, of recent onset, progressive, or of unknown duration
  -  Signs of malignancy (eg, hard or fixed lymph nodes or positive lymph node findings)
• If the adolescent presents with unilateral or bilateral gynecomastia that is painful or tender, and patient´s hx and PE don´t reveal the cause, order hCG, LH, test, estradiol.

·        A serum chemistry panel may be helpful in evaluating for renal or liver disease.

·        A free or total testosterone, LH, estradiol, and dehydroepiandrosterone sulfate levels to evaluate a patient with possible feminization syndrome.  Measurement of these levels is recommended in the morning since testosterone and LH have a circadian rhythm (highest levels in the morning). 

·        Obtain thyroid-stimulating hormone (TSH) and free thyroxine levels if hyperthyroidism is suspected.

·        Order a mammogram if one or more features of breast cancer are apparent upon clinical examination. This can be followed by fine-needle aspiration or breast biopsy, as the case merits.

·        Obtain a testicular ultrasound if the serum estradiol level is elevated and the clinical examination findings suggest the possibility of a testicular neoplasm.

·        Asymptomatic and pubertal gynecomastia do not require further tests and should be reevaluated in 6 months.

Gynecomastia. www.emedicine.com Nov. 15, 2006

 

 

10.  ASSESSMENT OF INFECTION RISK IN CHILDREN WITH HIV INFECTION

 

• Watch for any changes in health or the way the child acts. Watch for breathing problems, fever, unusual sleepiness, diarrhea, or changes in how much they eat.
• Evaluate child before administering any immunizations (especially live vaccines) or booster shots.
• Stuffed and furry toys can hold dirt and might hide germs that can make the child sick. Plastic and washable toys are better. If the child has any stuffed toys, recommend washing them in a washing machine often and keeping them as clean as possible.
• Keep the child away from litter boxes and sandboxes that a pet or other animal might have been in.
• Counsel family on avoiding being around other children with infectious diseases such as chickenpox. 
• Bandage any cuts or scrapes quickly and completely after washing with soap and warm water. Use gloves if the child is bleeding.

cdc.gov

 

 

11.  MANAGEMENT OF TRICUSPID ATRESIA

-  The following 3 considerations guide the treatment of infants with tricuspid atresia:

1.      The amount of pulmonary blood flow must be regulated in order to decrease hypoxemia or symptoms of congestive heart failure.

2.      Myocardial function, the integrity of the pulmonary vascular bed, and pulmonary vascular integrity must be preserved in order to optimize conditions for a later Fontan operation.

3.      The risk of bacterial endocarditis and thromboembolism must be minimized.

-         Initiate prophylaxis against bacterial endocarditis when any invasive or dental procedure is contemplated. 

-         Severely cyanotic neonates should be maintained on an infusion of prostaglandin E1 in order to maintain patency of the ductus arteriosus and improve pulmonary blood flow until a surgical aortopulmonary shunt procedure can be performed to increase pulmonary blood flow.

-         Infants with increased pulmonary blood flow because of an unobstructed pulmonary outflow tract require pulmonary arterial banding to decrease the sx of heart failure and protect the pulmonary bed from the development of pulmonary vascular disease. 

 

 

 

12.  RECOGNITION OF SYMPTOMS OF POSTERIOR FOSSA TUMOR

 

• Posterior fossa tumors include: 

            Brainstem gliomas (15%)

Medulloblastomas  (15%)

Ependymomas  (4%) – Most common occurring mainly in childhood with mean age of 6 yrs.  70% of ependymomas in childhood occur in the posterior fossa.

Cerebellar astrocytomas  (15%)

• Most patients with posterior fossa lesions have evidence of increased intracranial pressure. As a result, headache, nausea and vomiting, ataxia, vertigo, and papilledema are common at presentation. Cranial nerve palsies are very common, especially involving cranial nerves VI to X. Brain stem invasion may occur.

 

Nelson Textbook of Pediatrics, 17^th Edition.  Ependymoma, UpToDate.com

 

 

13.  RENAL PHYSIOLOGY IN THE PREMATURE INFANT

 

At birth, renal function is generally reduced, particularly in premature infants. GFR increases progressively during gestation, particularly during the 3rd trimester. By age 3 yr, GFR, urea clearance, and maximum tubular clearances have reached adult levels.  GFR is modulated by the renin-angiotensin system and prostaglandins; because of this, the fetus and neonate are particularly susceptible to renal injury following the administration of ACEI or NSAIDS. There is reduced renal concentration and acidification ability, which can be further compromised by obstructive uropathy. Urine calcium excretion is high in the neonate, which can be aggravated by calciuric drugs, such as furosemide and glucocorticoids.   J Urol. 1996 Aug ;156 (2 Pt 2):714-9 8683767

 

 

14.  EPIDEMIOLOGY OF BURN INJURIES IN YOUNG CHILDREN

 

• Burns occur in 6-20% of physically abused children.
• Factors associated with inflicted or concerning burns include: single parent families, burns to both hands or both legs, increased frequency of necessity for skin grafting, increased need for intensive care, and prior notification for abuse or neglect
• The pattern of injury suggests the mechanism or object used to inflict it. Burns indicative of abuse include the following:

Brands/contact burns

Cigarette burns

Immersion burns

Microwave oven burns

Stun gun burns

 

Physical abuse in children: Epidemiology and clinical manifestations, UpToDate.com

 

 

15.  MANAGEMENT OF AN INFANT EXPOSED TO MECONIUM AT DELIVERY

 

• Meconium stained AF can result in acute upper airway obstruction. 
• The AAP and AHA recommend endotracheal suctioning when meconium is present in the AF and the infant is not vigorous (strong resp. efforts, good muscle tone, HR>100)
• If the AF is clear, or if the meconium-stained baby is vigorous, it is not necessary to suction the trachea. 
• If meconium has been suctioned below the cords, suctioning should be repeated after reintubation. 
• These steps can be continued for up to 2 min after delivery, but then other resuscitative measures, especially ventilation and oxygenation must be started. 

2006 AHA Textbook of Neonatal Resuscitation, 5^th Edition

 

 

16.  EFFECTS OF STRICTLY VEGAN MATERNAL DIET ON A BREAST-FED INFANT

 

• Vegan diet in lactating women can induce vitamin B12 deficiency for their children with risk of an impaired neurological development, such as impaired growth, hypotonia, and cerebral atrophy on MRI.
• Vegan diet is a totally inadequate regimen for pregnant and lactating women, especially for their children. Prevention is based on screening, information and vitamin supplementation.

J Gynecol Obstet Biol Reprod (Paris). 2005 Oct;34(6):610-2.