A 5-year-old girl is a well known patient to you who suffers from congestive heart failure. Today she comes in with leg edema. Your goal is to induce rapid therapeutic diuresis.
Which one of the following would be most effective medication?
Correct Answer B:
There are several types of medications used to treat congestive heart failure in children. Improvement in symptoms can be achieved by diuretics, digoxin, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs). Diuretics decrease preload by promoting natriuresis, and provide relief of volume overload symptoms such as pulmonary and peripheral edema. Loop diuretics inhibit sodium and chloride reabsorption in the thick ascending limb of the loop of Henle. Furosemide (choice B) is the most commonly used loop diuretic.
→ Thiazide diuretics inhibit reabsorption of sodium and chloride ions from the distal convoluted tubules of kidneys. They generally are used as second-line agents and often in combination with a loop diuretic. Commonly used thiazide diuretics are chlorothiazide (choice A), hydrochlorothiazide, and metolazone.
→ Although digoxin (choice C) is no longer used in children with asymptomatic ventricular dysfunction, it continues to be used in the treatment of infants and children with stage C heart failure because of its physiologic benefit and symptom relief. However, for this patient, a loop diuretic would be the first choice in treatment.
→ Aldosterone antagonists (choice D) decrease sodium reabsorption and potassium excretion in the collecting ducts of kidneys. Their potassium-sparing diuretic effect makes them particularly suitable for use in conjunction with loop diuretics and thiazides. Both spironolactone and eplerenone have been shown to reduce mortality in adults with heart failure when added to standard therapy.
→ Based on the current evidence in adult and pediatric patients, most pediatric heart failure experts use carvedilol (choice E) in children with a systemic LV and systolic dysfunction in stage C heart failure who are stable on other heart failure medications. Beta-blockers are usually added to an established regimen of diuretics, digoxin, and an ACE inhibitor.
Which one of the following historical features is most suggestive of congestive heart failure in a 6-month-old white male presenting with tachypnea?
Correct Answer A:
Symptoms of congestive heart failure in infants are often related to feedings. Only small feedings may be tolerated, and dyspnea may develop with feedings. Profuse perspiration with feedings is characteristic, and is related to adrenergic drive. Older children may have symptoms more similar to adults, but the infant’s greatest exertion is related to feeding.
Fever and nasal congestion are more suggestive of infectious problems. Noisy respiration or wheezing does not distinguish between congestive heart failure, asthma, and infectious processes. A staccato cough is more suggestive of an infectious process, including pertussis.
Which one of the following is the most common etiology of recurrent epistaxis in children?
Correct Answer E:
Childhood epistaxis is common and rarely severe enough to require hospitalization. Epistaxis that occurs in children younger than 10 years usually is mild and originates in the anterior nose, whereas epistaxis that occurs in individuals older than 50 years is more likely to be severe and to originate posteriorly. Nosebleeds in children have a variety of etiologies, ranging from self-limited mucosal irritation to life-threatening neoplasms.
Local causes:
Systemic causes:
Recurrent epistaxis is usually related to the recurrent/chronic nasal trauma (choice E) or irritation, but may be the presenting symptom of bleeding disorder, hereditary hemorrhagic telangiectasia, nasopharyngeal carcinoma, posttraumatic pseudoaneurysm of internal carotid artery.
A 4-year-old girl presents with a 2-day-history of low-grade fever and headaches, followed by an onset of erythematous facial flushing, most prominent on her cheeks. Examination reveals a macular rash on her face (particularly cheeks), trunk and extremities and arthritis of wrist joints.
Which of the following is the most likely cause of the infection?
Correct Answer C:
Erythema infectiosum (fifth disease, parvovirus B19 infection) is a contagious viral infection that causes a blotchy or raised red rash with mild illness. Erythema infectiosum is caused by human parvovirus B19 and occurs most often during the spring months, often in geographically limited outbreaks among children and adolescents. Infection is spread mainly by breathing in small droplets that have been breathed out by an infected person. The infection can also be transmitted from mother to fetus during pregnancy, rarely resulting in stillbirth or severe anemia and excess fluid and swelling (edema) in the fetus (hydrops fetalis).
Symptoms begin about 4 to 14 days after infection but many children have none. However, some have a low fever and feel mildly ill for a few days. Seven to 10 days later, children develop red cheeks that often look like they have been slapped as well as a rash, especially on the arms, legs, and trunk but not usually on the palms or soles. The rash can be itchy and consists of raised, blotchy red areas and lacy patterns, particularly on areas of the arms not covered by clothing, because the rash may be worsened by exposure to sunlight.
Which one of the following is the most likely cause of hearing loss in newborns?
Correct Answer D:
Genetic disorders (e.g., Waardenburg syndrome, Usher’s syndrome, Alport syndrome, and Turner’s syndrome) are responsible for more than 50% of hearing impairments in children.
→ Intraventricular hemorrhage is a central cause of hearing loss, and is rare.
→ Conductive abnormalities such as external canal anomalies and congenital cholesteatoma, and sensorineural causes other than genetic disorders (e.g., infectious diseases) are important but less frequent.
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