⚕️ Pediatric Medicine Topics: Clinical Review

Disclaimer: Content is for educational exam preparation only and does not constitute medical advice. Medicine changes quickly; always verify with current, local guidelines before applying to patient care.

I. Pediatric Diarrhea and Dehydration

A. Etiologies of Bloody Diarrhea (Pneumonic: SYSCO + Ciff)

• C - Clostridium difficile (C Diff)

• S - Salmonella

• Y - Yersinia

• S - Shigella

• C - Campylobacter

• O - O157:H7 E. coli

B. Reasons Diarrhea is Worse in Pediatrics

• Larger extracellular fluid compartment (more fluid to lose rapidly).

• Higher metabolism (turn over fluid more quickly).

• Lower glycogen, oxygen, and fat stores (less stores of fluid).

• Kidneys have a decreased ability to conserve water.

• Higher total body water content and surface area (to lose fluid through other means).

C. Treatment Specifics

• Antibiotics and antimotility agents should not be used if there is bloody diarrhea (due to concern for O157:H7).

• Antibiotics for Invasive Pathogens (Non-bloody): Cipro (once species is confirmed to not be Shiga toxin producing).

• C. diff: PO Vancomycin.

• Cryptosporidium: Nitazoxanide.

• Giardia and Entamoeba: Flagyl (Metronidazole).

D. Indications for Evaluation, Culture, and Hospitalization with diarrhea (Pneumonic: DAMSON)

• D - Dysentery (bloody diarrhea).

• A - Age:

  • Less than 6 months old (should be investigated).

  • Less than 3 months old (should be admitted).

  • Duration more than 2 weeks (culture should be obtained).

• M - Medical problems.

• S - Systemic illness or complications.

• O - Output decreased or significant dehydration.

• N - Not improving despite treatment.

E. Dehydration Assessment and Treatment Specifics

💡 Clinical Dehydration Scale (TEAM)

• T - Tears (0 to 2 points).

• E - Eyes (whether they are sunken, 0 to 2 points).

• A - Appearance (e.g., interactive, lethargic, 0 to 2 points).

• M - Mucous membranes (0 to 2 points).

• Scoring: 1 to 4 points total is considered mild.

Dehydration Severity Guide

• Mild

  • Total Body Water Deficit: 3 to 5%

  • Fluid Deficit (mls/kg): 30 to 50 mls/kg

  • Fluid Repletion Plan: Replete total fluid over 4 hours (ideally orally).

• Moderate

  • Total Body Water Deficit: 6 to 10%

  • Fluid Deficit (mls/kg): 60 to 100 mls/kg

  • Fluid Repletion Plan: Replete total fluid over 4 hours (ideally orally).

• Severe

  • Total Body Water Deficit: 10% plus

  • Fluid Deficit (mls/kg): Greater than 100 mls/kg

  • Fluid Repletion Plan: 1. Give 20 cc/kg fluid bolus. 2. Give remaining 10% deficit over 24 hours (first half in 8 hours, second half in 16 hours). 3. Add maintenance fluids on top.

II. Pediatric Nephrology and Urology

A. Priapism Etiologies (Pneumonic: THANKS TF)

• These are low-flow causes (ischemia, acidosis, pain):

  • T - Toxin (spider/scorpion bites/stings).

  • H - Hematology (Sickle cell disease, leukemia, thalassemia, TTP, HUS, polycythemia).

  • A - Anti-drugs (Anti-hypertensives, anti-depressants, antipsychotics, anticoagulants, anti-PDE5).

  • N - Neurogenic.

  • K - Krebs (Metabolic: Gout, hyperlipidemia, diabetes).

  • S - Street drugs (Meth, cocaine, alcohol, marijuana).

• These are high-flow causes (less pain, no acidosis/ischemia):

  • T - Trauma or lacerations.

  • F - Fistula (AV).

B. Priapism Management Specifics

• Analgesia: Dorsal nerve or ring block.

• Medication Trial: Terbutaline 10 mg PO every 15 minutes.

• Ambulation: Try getting them to walk around.

• Aspiration/Instillation:

  • Insert 18 gauge needle into corpus cavernosum.

  • Aspirate 20 to 30 cc's of blood.

  • Instill 100 micrograms of phenylephrine every 5 minutes as needed.

• Consult: Call urology if all fails.

C. Paraphimosis Management

• Analgesia (dorsal or ring block).

• Compression or moist gauze with sugar on the foreskin.

• Manual reduction (thumbs and forefingers).

• Add Addison forceps for traction if manual reduction fails.

• Micro puncture the foreskin to reduce swelling.

• Consult urology or perform a dorsal slit (in the community setting).

D. Pediatric Hematuria Causes

• Systemic (Bleeding/Clots): HUS, TTP, HSP, Sickle cell disease, leukemia, lupus, bleeding disorders, anti-coagulant medications.

• Extra Renal (within the urinary tract): Trauma, stones, tumor, infections (cystitis), menstruation, foreign bodies.

• Renal: Pyelonephritis, stone, tumor, nephritis, AIN (Acute Interstitial Nephritis), or ATN (Acute Tubular Necrosis).

E. Pediatric UTI Workup and Treatment Specifics

• Age Group:

  • Workup/Imaging: Full septic workup (as you'd only recognize this if there's a fever), catheterization, admission.

  • Treatment: Amp, Gent.

  • Duration: Admitted.

• Age Group: 2 months - 2 years

  • Workup/Imaging: Screen with bag urine (if positive, confirm with cath urine). Renal ultrasound (after first UTI). VCUG (after second UTI, or if significant hydronephrosis on ultrasound).

  • Treatment: Amoxiclav, 3rd gen cephalosporin, or Septra.

  • Duration: 7 to 10 days.

• Age Group: > 2 years (Cystitis)

  • Workup/Imaging: Based on symptoms.

  • Treatment: Keflex (simple) or upper tract agents.

  • Duration: 3 days.

• Age Group: > 2 years (Pyelonephritis i.e. upper tract)

  • Workup/Imaging: Based on symptoms.

  • Treatment: Amoxiclav, 3rd gen cephalosporin, or Septra.

  • Duration: 7 to 10 days.

Note: UTI Risk Factors: Females 39°C; History of UTI.

F. Pediatric Hypertension Differential (Pneumonic: VECTOR)

• V - Vascular (HSP, Kawasaki, renal artery stenosis or clot).

• E - Endocrine (Thyroid, pheochromocytoma, or Cushing's).

• C - Cardiac (Coarctation or CHF).

• T - Toxin (Cocaine or Meth).

• O - Oncology (Wilms tumor, neuroblastoma, pheochromocytoma).

• R - Renal (HSP, HUS, polycystic kidney disease, or nephritis).

G. Hemolytic Uremic Syndrome (HUS) (Pneumonic: FAT RN)

• F - Fever.

• A - Anemia (microangiopathic).

• T - Thrombocytopenia.

• R - Renal involvement.

• N - Neuro involvement.

• Specific Triad: Anemia, thrombocytopenia, and renal involvement.

• Management: Supportive, transfuse as needed, plasma pheresis. If complement mediated, Eculizumab can be given.

H. Henoch-Schönlein Purpura (HSP) Symptoms (Pneumonic: ARENA)

• A - Abdo pain.

• R - Rash (palpable purpura in dependent areas).

• E - ESR.

• N - Nephritis.

• A - Arthralgias.

• Common Causes: Post-viral, Mycoplasma, Campylobacter, drugs, horse serum, cold, insect bites.

I. Nephrotic vs. Nephritic Syndrome

• Nephrotic Syndrome

  • Pathophysiology & Specific Values: Loss of protein through kidneys. Diagnostic Values: Protein on dip (3+ or more) or 24-hour loss (3.5 grams or more). Low albumin (less than 25). High lipids (liver compensation).

  • Key Features: Edema (due to low protein). High VTE risk (clots).

• Nephritic Syndrome

  • Pathophysiology & Specific Values: Inflammation leading to hypertension, hematuria, and renal failure.

  • Key Features: Hypertension. Hematuria. Renal failure.

Note: Workup for Nephrotic and Nephritic Syndromes: SPEP, UPEP, ACR, IgA levels, ANCA, ANA, C3C4, ASOT, and anti-GBM.

III. Pediatric Neurology

A. Altered Mental Status (Pneumonic: AEIOU TIPS or DIMS)

• A - Ammonia or Alcohol.

• E - Electrolytes.

• I - Insulin, Inborn errors, or Insomnia.

• O - Oxygen (Hypoxia) or Overdose.

• U - Uremia.

• T - Trauma or Tumors.

• I - Infection.

• P - Psych.

• S - Seizures or Subarachnoid hemorrhage.

B. Meningitis

• Causes (

• Causes (General): Strep pneumo, N. meningitidis, H. flu (less common due to vaccination).

Treatment by Age Group:

• 0 to 28 days old: Ampicillin + Cefotaxime + maybe Acyclovir.

• Over 1 month old: Ceftriaxone + Vancomycin + maybe Acyclovir.

Additional Notes:

• Risk Factors for HSV encephalitis: Maternal herpes, newborn vesicles, seizures, or focal neuro deficits.

• Indications for CT before LP (Increased ICP): Focal deficits, seizures, significantly altered mental status, signs of elevated ICP (Cushing Triad or Papilledema), trauma, immunocompromised status, or history of CNS disease.

• Indications for Steroids: Give before or with antibiotics in infants over 6 weeks old if H. flu (benefit for hearing loss) or Strep pneumo (mortality benefit) is suspected.

C. Seizures Management and Specifics

• Causes (Pneumonic: DIMS):

  • D - Drugs/Toxins (mushrooms, jet fuel, withdrawal, TCAs overdose).

  • I - Infection (meningitis, encephalitis).

  • M - Metabolic (electrolytes, glucose, oxygen/hypoxia).

  • S - Structural (masses, bleeds, TBI, strokes).

• Indications for CT after Seizure: Continuing reduced level of consciousness, focal deficit, trauma, partial/focal onset seizure, or continued bad headache. (Generally required unless generalized seizure with return to baseline and no status, or known history matching previous seizures).

Initial Management (Dosing) by Age Group:

• Neonates: Phenobarb 20 mg/kg. Then anti-epileptic drug or Midazolam.

• Infants (Status): Benzodiazepines x 2 (Ativan or Midazolam) then AED.

Anti-Epileptic Drug Dosing (Infants/Status):

• Keppra at 60 mg/kg.

• Valproic acid at 40 mg/kg.

• Fosphenytoin at 20 mg/kg.

• Note: Repeat the anti-epileptic drug with a different agent before moving on.

Simple Febrile Seizure Criteria

• Age: 6 months to 6 years old.

• Duration: Lasting less than 15 minutes.

• Type: Must be generalized.

• Frequency: Must be a single episode in 24 hours.

• Baseline: Must be neurodevelopmentally normal and return to baseline.

• Workup: If all criteria are met, the only necessary workup is for the fever.

D. Pediatric Ataxia

• Most Common: Acute cerebellar ataxia post-Varicella or Coxsackievirus.

• Other Post-Infectious: Demyelinating encephalopathy (ADEM, Listeria, Enterovirus); Brainstem encephalitis (EBV, Listeria, Enterovirus).

• Miller Fisher GBS Triad: Ataxia and areflexia (Weakness is descending, unlike classic GBS).

• CSF findings: High protein and normal white blood cells.

E. Pediatric Stroke Risk Factors (mnemonic: BET)

• B - Bleed (Trauma, Moyamoya, sympathomimetic use).

• E - Embolic (Congenital heart disease, endocarditis, pre- or post-op).

• T - Thrombotic (Sickle cell disease, vasculitis, pregnancy, OCP, migraine, lupus, HUS).

F. Vertigo Categories

• Acute Vestibular Syndrome (Constant Vertigo):

  • Posterior stroke, posterior bleed, abscess, or mass.

  • Vestibular neuritis (no hearing loss).

  • Labyrinthitis (recent URI, with hearing loss; requires steroids and acute otitis media treatment if present).

• Spontaneous Episodic Vestibular Syndrome:

  • TIAs, vestibular migraines, cardiac dysrhythmias.

  • Meniere's disease (episodic, spontaneous, caused by fluid in the ear, has hearing loss).

• Triggered Episodic Vestibular Syndrome:

  • BPPV and CPPV (uncommon in pediatrics).

  • Orthostatic hypotension.

IV. Pediatric Musculoskeletal (MSK)

A. Salter Harris Classification (Pneumonic: SALTER)

• S - Straight through the physis.

• A - Above and through the physis (Metaphyseal into the physis and out).

• L - Lower (Through the physis and down through the joint of the epiphysis).

• T - Through the physis (Above and below).

• ER - Erasing of the physis.

B. Gartland Classification (Supracondylar Fractures)

1. Non-displaced.

2. Displaced with the posterior cortex intact (like a hinge).

3. Displaced with no cortex intact. Even the periosteum is disrupted.

   1. Diagnostic Value: Bowman's angle (normally 75 to 80°) can help find subtle supracondylar fractures.

   2. Complications: Volkmann's contracture/ischemia, gunstock deformity (varus deformity), brachial artery injury, nerve injuries (predominantly median, also radial).

C. Elbow Ossification Centers (nmemonic: CRITOE)

• C - Capitellum (1 year).

• R - Radial head (3 years).

• I - Internal epicondyle (5 years).

• T - Trochlea (7 years).

• O - Olecranon (9 years).

• E - External epicondyle (11 years).

D. Forearm Fractures (Mnemonic: MUGR)

• MU - Monteggia: Ulnar fractured with a dislocation of the radial head.

• GR - Galeazzi: Radius fractured and the ulna is dislocated through a DRUJ injury.

• Essex-Lopresti: Radial head is fractured with a DRUJ injury (similar to Galeazzi but different fracture location).

E. Developmental Dysplasia of the Hip (DDH)

• Risk Factors: Female, family history, breech presentation, oligohydramnios, big baby, post-dates, swaddling (especially through the bottom part).

• Diagnostic Values (Shenton Line):

  • Abnormal: More than 30°.

  • Dislocation: More than 40°.

• Physical Exam (

• Physical Exam (> 6 weeks): Increased abduction and a leg length discrepancy.

• Treatment:

  • Less than 6 weeks: Pavlik harness.

  • Greater than 6 weeks: Hip spica.

F. Pediatric Limp Differential (Mnemonic LIMPSS)

• L - Legg-Calvé-Perthes.

• I - Infection (septic joint, osteomyelitis, Lyme disease, transient synovitis).

• M - Malignancy (Ewing's, osteosarcoma, leukemia, or mets).

• P - Pain from trauma (fractures or non-accidental injuries).

• S - SCFE (Slipped Capital Femoral Epiphysis).

• S - Something in the abdomen (torsion, ectopics, etc.).

G. Septic Hip Screen (Kocher Criteria - Mnemonic: FEW WALK)

• F - Fever over 38.5°C.

• E - ESR over 40.

• W - WBC over 12.

• WALK - Unable to ambulate on the affected side in the emergency department.

• Note: Meeting any of these criteria suggests a non-zero chance of septic hip, requiring an ultrasound.

H. Septic Arthritis Organisms (Bugs)

• Less than 2 years old: GBS, Gram negative bacteria, Gonorrhea, Staph aureus.

• Otherwise: Staph aureus or GAS (most likely).

• Sexually Active: Gonorrhea.

• Sickle Cell Disease: Salmonella.

• IV Drug User/Immunocompromised: Gram negative (Pseudomonas).

• Specific: Kingella kingae (can present with normal labs).

Synovial Fluid Analysis Values (from Rosen's)

• Negative Fluid Analysis (Normal):

  • WBCs: Less than 5,000.

  • PMNs: Less than 25%.

• Positive Fluid Analysis (Bacterial):

  • WBCs: Greater than 50,000.

  • PMNs: Greater than 90%.

• Inflammatory/Equivocal Region:

  • WBCs: Between 8,000 and 20,000.

  • PMNs: Over 70%.

• Practical Rule: If WBCs are over 5,000 AND there are more than 25% PMNs, bacterial septic joint cannot be ruled out.

I. Slipped Capital Femoral Epiphysis (SCFE)

• Common Age: 12 to 16 year olds.

• Risk Factors: Obesity, male, CKD, radiation, hypothyroidism, growth hormone deficiencies, hypopituitary, renal osteodystrophy.

• X-ray Findings: Slippage of the epiphysis, positive Klein's line (line down femoral neck should transect physis), Steel sign (crescent-shaped, hyperdense overlap area), widened physis.

• Classification by Shaft Angle (Southwick):

  • Mild: Less than 30°.

  • Moderate: 30 to 50°.

  • Severe: Greater than 50°.

• Management:

  • Unstable SCFE: Non-weightbearing and emergent orthopedics consult.

  • Stable SCFE: Non-weightbearing and outpatient orthopedic follow-up (though discussion with ortho is recommended).

J. Legg-Calvé-Perthes Disease (LCPD)

• Common Age: 3 to 12 year olds.

• Pathophysiology: Avascular necrosis of the femoral head.

• Management: Technically follow up with ortho as an outpatient for bracing or surgical management; may be weightbearing as tolerated (though discussion with ortho is recommended).

K. Tibial Fractures

• Tillaux Fracture: Salter Harris III fracture of the anterolateral tibial epiphysis.

  • Management: Non-weightbearing, immobilized, consult ortho.

• Triplane Fracture: Salter Harris IV (fractures through the epiphysis, physis, and up through the metaphysis of tibia).

  • Management: Non-weightbearing, immobilized, consult ortho.

V. Pediatric Drugs and Infectious Disease

A. Drugs to Avoid in Pediatrics

• Ceftriaxone (less than 1 month): Can displace bilirubin.

• Septra (less than 1 month): Can displace bilirubin.

• NSAIDs (less than 6 months): Can harm kidneys.

• Over-the-counter cold medications (less than 5 years old).

• Aspirin (less than 15 years old): Risk of Reye's disease.

• Codeine (irregular metabolism).

• Pheninomes.

B. Lyme Disease (Specifics)

• Cause: Spirochete Borrelia burgdorferi.

• Vector: Deer tick (Ixodes scapularis).

• Stages: Early localized (flu-like illness, erythema migrans); Disseminated (arthritis, carditis, Bell's palsy, encephalitis); Late stage (arthritis, encephalitis).

• Diagnosis: Clinically, then Enzyme Immunoassay (EIA) followed by Western blot.

• Treatment: Amoxicillin or Doxycycline (varying durations). If Meningitis or Encephalitis is present, use Ceftriaxone instead.

VI. Non-Accidental Trauma (NAT)

A. Highly Specific Injuries/Locations

• TEN 4 FACES:

  • T - Torso.

  • E - Ears.

  • N - Neck.

  • 4 - Bruises in children less than 4 months old.

  • F - Frenulum.

  • A - Angle of the jaw.

  • C - Cheeks.

  • E - Eyelids.

  • S - Subconjunctival.

  • P - Patterned bruises or patterned burns.

B. Concerning Fracture Patterns

• Classic metaphysical injury (corner fracture).

• Long bone fractures if the child is not walking.

• Complex skull fractures.

• Fractures at different stages of healing.

• Posterior rib fractures (from shaking).

• Scapula fractures (from shaking).

• Femur fractures.

C. Mimics of NAT (Conditions Causing Brittle Bones)

• Osteogenesis Imperfecta.

• Rickets, Vitamin C deficiency, High Vitamin A.

• Syphilis, Osteomyelitis.

• Bone tumors or mets, Leukemia.

• Congenital insensitivity to pain.

D. NAT Workup and Admission Protocol (Mnemonic: A CRASH)

• Call CAS (Child Protective Services) and admit the patient.

• Perform the following tests:

  • A - AST or ALT (if less than 5 years old). (Abdo CT required if AST or ALT are over 80).

  • C - All Contacts (siblings less than 2 years old should get a skeletal survey).

  • R - Retinal exam (if TBI is present).

  • A - Abdo CT (if AST or ALT are over 80 or if history/physical suggests abdominal trauma).

  • S - Skeletal Survey (all 21 pictures) (required if less than 2 years old; maybe if less than 5 years old).

  • H - Head CT (required if less than 6 months old due to difficult neuro exam, or if any history/features of head trauma or signs of shaking).