1. In a kid with tears/clear mucus coming out of one eye, think obstructed nasolacrimal duct (aka dacryostenosis). Presents in 6% of neonates, usually clears up on its own by 9-12 months. Parents can help by massaging the medial eye: pressure on lacrimal sac (proximal to duct) can push fluid distal, using hydrostatic pressure to open blockage. If it doesn't clear on its own, optho can put in a thin cathether or probe and open it up.
2. Night terrors are parasomnias, like sleepwalking. The pathophysiology is unclear, but some believe that it's a product of incomplete arousal from deep/NREM sleep. Corroborative with this, parasomnias are often triggered by things that cause nighttime waking, like OSA, GERD, restless legs. Kids are difficult to arouse during night terrors, and they should not be woken up. Night terrors are common after anaesthesia. Kids usually grow out of them by adolescence.
3. In a kid with progressive macrocephaly, think bleeding, tumors, hydrocephalus. In a kid with progressive microcephaly, think premature suture closure, TORCH infections (CMV).
4. Daily weight gain by age: From 0-4 months, expect on average a 30g/day, 4-6 months 15-20g/day, 6-12 mos 10-15 g/day. Before you diagnose failure to thrive, look at the kid. Infants store their fat in their abdomen, butt, thighs so if he looks big and healthy, and he appears active and alert, he is probably not failing to thrive.
5. Incomplete/inevitable/missed abortions can be managed expectantly, medically (miso) or surgically (d&c). Surgical procedures are most likely to have led to complete evacuation by 48 hours, and expectant least likely. Rates of infection (2-3%) are the same in all 3.
-Medical management: 800mcg miso vaginally: vaginal has better success rates than PO miso. Misoprostol (E1) is cheaper than E2s. In one large trial (n=652), 71% had complete explusion by day 3, 84% by day 8. Overall expulsion rate for missed ab (81%) vs inevitable/incomplete (93%). RCT data has shown no difference in miso alone vs miso+mifepristone, as there is already a low-progesterone state.
-Surgical management: indicated for women who don't want to wait and who are experiencing heavy bleeding or signs of infection. Give 100 mg doxycycline PO 12 hours apart on the day of the procedure.
6. Pregnancy termination:
0-9 weeks: medical
0-13 weeks: D&C
13+: D&E
Ectopic:
-Methotrexate: 35% of all patients are eligible for MTX therapy: subject must be unruptured, hemodynamically stable, mass <4 cm, can follow up, and b-hcg<5000. A systematic review (n=1300) found 4 dose MTX was slightly more effective than one dose (93 vs 88%) but carried significantly more side effects.
-Otherwise, either salpingostomy (don't suture, leave it open to heal) or salpingectomy. The data (cohort studies, with many confounders including tube status influencing choice of surgery) doesn't seem to show a major difference in fertility post-op, but a higher risk of repeat ectopic in salpingostomy.
7. Eye inflammation!
-Blepharitis: inflammation of whole eyelid. Treat with warm compress.
-Hordeolum/stye: infection of sebaceous or apocrine glands, often inside the eye. Can affect upper or lower lid, painful, acute onset. Treat with warm compress, wash with baby shampoo. Check visual acuity, ROM. If suspicion for/progression to cellulitis, then antibiotics.
-Chalazion: meboian gland cyst, only upper lid.
8. Eye cellulitis:
-Orbital/septal: inside eye cavity, can lead to proptosis (eval from above), changes in vision, loss of ROM, abscess formation. Usually from sinuses. Usually s.pneumo and staph. Treat: IV antibiotics: ceftriaxone to cover s.pneumo, clinda for staph. Can sub amp or unasyn (amp/sulbactam) if you feel like ceftriaxone is overkill for s.pneumo. Clinda has great tissue penetration, is a good drug for cellulitis.
-Preseptal/periorbital cellulitis: outside of the eye cavity, on the lids, less worrisome. Usually just staph. Treat with PO clinda. Differentitate from blepharitis: blepharitis is along the rim of the eye, usually just the upper lid, a little swelling; pre-septal cellulitis is the whole eyelid, upper and lower, often swelling the whole eye shut.
-DDx of swollen eye: insect bites, trauma. If its B/L think nephrotic syndrome, neuroblastoma, CHF.
9. Conjunctivitis:
-Within 24-48 hrs of birth: think chemical
-2-4 days: gonorrhea
-5-12 days: chlamydia
In older kids:
-Bacterial: mucopurulent discharge. Tx with erythromycin eye drops. If its otitis-conjuctivitis, think non-typeable H flu. This will not respond to amox alone, you need augmentin (amox+clavaluate).
-Viral: adenovirus. Clearer mucus discharge.
-Allergic: itchy, minimal drainage. Eye drop/systemic antihistamines.
10. Abdominal pain tips:
-colicky/crampy: suggests obstruction of peristaltic organ (ureter, bowel)
-insidious onset: suggests visceral peritoneum inflamm, or well-contained (abscess)
-in the absence of diarrhea, think outside of GI tract