Pediatrics
Board Review Online

Diuretics, such as triamterene, spironolactone, and amiloride, require routine monitoring of electrolytes to ensure the child does not develop hyperkalemia. Angiotensin-converting enzyme inhibitors (e.g., captopril, lisinopril) and angiotensin-receptor blockers (e.g., losartan) require routine serum studies to monitor for hyperkalemia and azotemia.

Reference:

National Heart, Lung, and Blood Institute, National Institutes of Health. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents. Accessed September 20, 2012.

Educational Objective:

Discuss signs and symptoms that suggest the need for neonatal resuscitation.

Key Point:

Indicators for further resuscitation immediately after birth are only based on 2 vital signs: heart rate < 100 beats/minute and/or abnormal respirations (gasping, apnea, or increased respiratory effort).

Explanation

The historical practice of evaluating “color” during the “golden minute” is no longer recommended. Studies have shown that neither presence nor absence of cyanosis distinguishes stable from unstable babies immediately following birth. Skin color correlates very poorly with oxyhemoglobin saturation during the immediate neonatal period, including LACK of cyanosis being a very poor indicator of adequate oxygenation. 

The Apgar score (a method for evaluating the health of a neonate by assigning points for heart rate, respirations, muscle tone, reflex irritability) is also no longer used to dictate resuscitative requirements. 

EARLY MONITORING IS IMPORTANT: If a need for resuscitation is discovered, a 3-lead ECG should be placed on the newly born during the first resuscitation interventions in order to immediately obtain heart rate monitoring (counting is too inaccurate). A pulse oximeter to assess oxygen saturation may also be placed while (not prior to) ventilatory interventions are taking place. The pulse oximeter is sufficiently reliable to assess oxygenation, but NOT heart rate. Attaching a monitoring device should NOT delay but occur in parallel to first interventions.

References:

American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (This site blends the 2019 Focused Updates with the 2015 AHA Guidelines for CPR and emergency cardiovascular care) – Part 13: Neonatal Resuscitation. https://eccguidelines.heart.org/circulation/cpr-ecc-guidelines/part-13-neonatal-resuscitation/  (Accessed on April 20, 2020)

Newborn screens in over 70% of U.S. states now screen for congenital adrenal hyperplasia. Once called with an abnormal value, it is not acceptable to await the family’s call or to postpone evaluation and diagnosis. The child should be seen promptly and electrolytes and repeat hormone levels checked. Newborn screens have been instituted to allow physicians to prevent patients from presenting with life-threatening adrenal crisis. Failure to acknowledge these results may be deleterious for the infant.

Reference:
Levine. Congenital Adrenal Hyperplasia. Pediatr. Rev. 2000; 21; 159.

Educational Objective:

Recognize medications that may cause thrombocytopenia.

Key Point:

Drug-induced thrombocytopenia is an immune-mediated disease resulting from production of antiplatelet antibodies. Several medications, including trimethoprim/sulfamethoxazole, may cause thrombocytopenia.

Explanation:

Medications may induce thrombocytopenia by causing the production of antiplatelet antibodies that mediate platelet destruction in the circulation. Numerous drugs can cause these reactions. The medications most likely to cause these reactions include:

• Abciximab
• Carbamazepine
• Ceftriaxone
• Eptifibatide
• Ibuprofen
• Penicillin
• Quinidine
• Quinine
• Mirtazapine
• Oxaliplatin
• Rifampin
• Suramin
• Tirofiban
• Trimethoprim/sulfamethoxazole
• Vancomycin

Other drugs, such as ciprofloxacin and naproxen, may cause thrombocytopenia, but they do not cause thrombocytopenia as commonly as the other listed medications. Patients typically present with thrombocytopenia that cannot be explained by other causes. In such cases, thrombocytopenia may be severe.

References:

Arnold D, Kukaswadia S, Nazi I, et al. A systematic evaluation of laboratory testing for drug-induced thrombocytopenia. J Thromb Haemost. 2013;11(1):169-176.

George JN, Arnold DM. Drug-induced immune thrombocytopenia. Updated April 26, 2017. Accessed July 5, 2017.

In shock states peripheral hypoperfusion results in anaerobic glycolysis with increased lactate production, while hepatorenal hypoperfusion results in impaired lactate clearance. Both these mechanisms contribute to the development of lactic acidosis. Administration of IV fluids and oxygen are the two most crucial steps to correcting his acidosis and respiratory compensation. It will be necessary to diagnose the etiology of shock, but the first step, pursuant with the ABCs of resuscitation, is to correct his acidosis.

Additional Reading:
Nelson Textbook of Pediatrics. 18th ed. Elsevier.

Yudkoff. Lactic Acidosis in Children – Pathophysiology, Diagnosis and Treatment: A Workbook Exercise. Pediatr. Rev. 1983; 4; 225-230.