WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:42.890 fast. Welcome to the emergency room. You know, 00:00:47.509 --> 00:00:50.750 usually when we talk about plumbing, it implies 00:00:50.750 --> 00:00:53.130 this sort of boring maintenance. Right. You fix 00:00:53.130 --> 00:00:55.890 a leak, you unclog a pipe, you move on. Exactly. 00:00:55.909 --> 00:00:58.759 You just move on. But looking at the research 00:00:58.759 --> 00:01:01.840 for today's deep dive into the pediatric genitourinary 00:01:01.840 --> 00:01:05.099 system, the GU track, I realize that metaphor 00:01:05.099 --> 00:01:07.280 is actually kind of dangerous. Oh, it really 00:01:07.280 --> 00:01:10.040 is. Because in pediatrics, the plumbing is where 00:01:10.040 --> 00:01:13.000 some of the most deceptive exam questions and 00:01:13.000 --> 00:01:15.260 honestly, the most deceptive clinical presentations 00:01:15.260 --> 00:01:19.400 hide. I mean, you miss one subtle symptom like 00:01:19.400 --> 00:01:22.120 the specific shade of a child's urine. Yeah. 00:01:22.260 --> 00:01:24.099 And you aren't just failing a test. You might 00:01:24.099 --> 00:01:26.760 be treating the completely wrong disease. Right. 00:01:26.780 --> 00:01:30.140 It's true. The GU system is just notorious for 00:01:30.140 --> 00:01:32.459 that. It feels straightforward until you realize 00:01:32.459 --> 00:01:35.099 that a child's kidney isn't just a miniature 00:01:35.099 --> 00:01:37.420 version of an adult's kidney. Not at all. Their 00:01:37.420 --> 00:01:39.680 filtration rate is slower. Their buffers are 00:01:39.680 --> 00:01:42.299 different. And the developmental stakes are just 00:01:42.299 --> 00:01:45.230 massive. We aren't just preserving an organ here. 00:01:45.290 --> 00:01:47.430 We are preserving their future fertility, their 00:01:47.430 --> 00:01:49.609 physical growth, and honestly, their psychological 00:01:49.609 --> 00:01:52.030 well -being. Yeah. Which is so crucial. And that 00:01:52.030 --> 00:01:55.129 is exactly our mission today. For those of you 00:01:55.129 --> 00:01:57.189 joining us, we are taking this massive stack 00:01:57.189 --> 00:02:00.310 of materials we have, Chapter 21, the medication 00:02:00.310 --> 00:02:02.629 protocols, the nursing care plans, and we're 00:02:02.629 --> 00:02:05.090 going to distill it all down to the Pareto 8020. 00:02:05.209 --> 00:02:08.050 The 20 % of the concepts that answer 80 % of 00:02:08.050 --> 00:02:10.030 the questions. Exactly. And more importantly, 00:02:10.129 --> 00:02:12.330 the concepts that keep these kids safe at the 00:02:12.330 --> 00:02:15.129 bedside. And the lens we're using for everything 00:02:15.129 --> 00:02:17.949 today is growth and development. Because, you 00:02:17.949 --> 00:02:20.530 know, a toddler needing dialysis is a completely 00:02:20.530 --> 00:02:22.509 different universe than a teenager needing it. 00:02:22.810 --> 00:02:24.870 Absolutely. You just can't treat the kidney without 00:02:24.870 --> 00:02:28.210 treating the child attached to it. So let's organize 00:02:28.210 --> 00:02:31.530 this chaos. Looking at the data we uploaded, 00:02:32.030 --> 00:02:34.729 the source material really falls into three distinct 00:02:34.729 --> 00:02:37.199 patterns. Right, the high yield patterns. Yeah, 00:02:37.580 --> 00:02:39.280 you have the filter failures, which are your 00:02:39.280 --> 00:02:42.259 glomerular disorders. You have the structural 00:02:42.259 --> 00:02:45.300 issues, which are surgical, and you have the 00:02:45.300 --> 00:02:47.620 acute emergencies. I'm going to start with the 00:02:47.620 --> 00:02:49.240 filter failures because this seems to be the 00:02:49.240 --> 00:02:52.020 biggest trap for everyone. The battle between 00:02:52.020 --> 00:02:55.639 nephrotic syndrome and acute post -striptococcal 00:02:55.639 --> 00:03:00.280 glomerulonephritis or APSGN. Yeah, these two 00:03:00.280 --> 00:03:02.340 are the heavy hitters and they are constantly 00:03:02.340 --> 00:03:05.439 confused because they both involve the kidneys 00:03:05.439 --> 00:03:07.819 filtration system going haywire, but they do 00:03:07.819 --> 00:03:10.060 it in completely opposite ways. Let's break down 00:03:10.060 --> 00:03:12.259 nephrotic syndrome first. Literature calls this 00:03:12.259 --> 00:03:14.740 a permeability problem. The way I visualized 00:03:14.740 --> 00:03:18.159 it while reading was like a colander or a strainer. 00:03:18.300 --> 00:03:20.500 Okay, I like that. Normally the holes are small 00:03:20.500 --> 00:03:22.719 enough that the pasta or in this case the protein 00:03:22.719 --> 00:03:26.080 stays inside, but in nephrotic syndrome those 00:03:26.080 --> 00:03:28.569 holes get stretched out. That's a perfect visualization. 00:03:29.110 --> 00:03:31.610 The glomerular basement membrane becomes highly 00:03:31.610 --> 00:03:34.370 permeable to massive amounts of protein. So the 00:03:34.370 --> 00:03:37.030 child loses albumin, which is the main protein 00:03:37.030 --> 00:03:39.669 in our blood, right into the toilet. It dumps 00:03:39.669 --> 00:03:43.229 out. It dumps out. And this is where the physiology 00:03:43.229 --> 00:03:45.909 gets really interesting. Albumin acts like a 00:03:45.909 --> 00:03:48.860 sponge. It holds fluid inside our blood vessels. 00:03:49.319 --> 00:03:52.080 When you lose that sponge, the fluid has literally 00:03:52.080 --> 00:03:54.159 nothing to hold it in the vasculature. So it 00:03:54.159 --> 00:03:56.439 leaks out into the tissue. Exactly. It third 00:03:56.439 --> 00:04:00.099 spaces. So clinically, you see a child with massive 00:04:00.099 --> 00:04:03.539 generalized edema. I mean, they are puffy everywhere. 00:04:03.860 --> 00:04:06.159 And because that protein is churning out into 00:04:06.159 --> 00:04:08.379 the urine, if you looked at the toilet bowl, 00:04:08.379 --> 00:04:10.620 it would look frothy. Think of it like beating 00:04:10.620 --> 00:04:13.360 egg whites. Oh, that's a visceral image. It is. 00:04:13.639 --> 00:04:16.259 Frothy urine is the absolute hallmark of nerf. 00:04:16.040 --> 00:04:20.100 Okay, so nephrotic is the leaky filter, frothy 00:04:20.100 --> 00:04:23.160 urine, massive swelling. Now, contrast that with 00:04:23.160 --> 00:04:25.439 APSGN. This one seems to have a very specific 00:04:25.439 --> 00:04:28.740 timeline attached to it. It does. APSGN is an 00:04:28.740 --> 00:04:31.600 immune response. It happens typically 10 to 21 00:04:31.600 --> 00:04:34.920 days after a group A beta -hemolytic strip infection. 00:04:35.019 --> 00:04:37.100 Oh, so the kid had strep throat or maybe a skin 00:04:37.100 --> 00:04:39.160 infection two weeks ago. They got completely 00:04:39.160 --> 00:04:41.680 better and now they're suddenly sick again. Yes. 00:04:42.000 --> 00:04:44.300 And the mechanism here isn't a leaky filter. 00:04:44.439 --> 00:04:46.240 It sounded more like a clog in the readings. 00:04:46.740 --> 00:04:49.459 Think of it like a traffic jam. Your body created 00:04:49.459 --> 00:04:52.079 all these antibodies to fight the strep. The 00:04:52.079 --> 00:04:54.959 war is over, but the wreckage of that war, the 00:04:54.959 --> 00:04:57.579 immune complexes, are still circulating in the 00:04:57.579 --> 00:04:59.399 blood. And they end up in the kidney. Right. 00:04:59.420 --> 00:05:01.579 They get swept into the kidneys' filter, but 00:05:01.579 --> 00:05:03.300 they are just too big to pass through, so they 00:05:03.300 --> 00:05:06.600 get stuck in the mesh. This causes massive inflammation 00:05:06.600 --> 00:05:09.779 and essentially clogs the filter. So unlike nephrotic 00:05:09.779 --> 00:05:11.800 syndrome, where the fluid leaks out into the 00:05:11.800 --> 00:05:15.339 tissue, in APSGN, the fluid is trapped in the 00:05:15.339 --> 00:05:18.319 blood because the kidney can't pee it out. Precisely. 00:05:18.639 --> 00:05:21.600 And that fluid overload in the vascular space 00:05:21.600 --> 00:05:24.620 drives the blood pressure through the roof. This 00:05:24.620 --> 00:05:26.699 is the critical safety distinction you have to 00:05:26.699 --> 00:05:30.040 make. OK, tell me. Kid is puffy, but usually 00:05:30.040 --> 00:05:33.620 has normal blood pressure. And APSGN Kid is hypertensive. 00:05:33.959 --> 00:05:35.959 And because the filter is actively damaged by 00:05:35.959 --> 00:05:38.920 inflammation, it leads. So you don't get frothy 00:05:38.920 --> 00:05:41.319 urine, you get hematuria. Which the textbooks 00:05:41.319 --> 00:05:44.019 describe as... Tea -colored or cola -colored 00:05:44.019 --> 00:05:46.920 urine. Because it's old, oxidized blood. I really 00:05:46.920 --> 00:05:49.079 want to nail this distinction because it dictates 00:05:49.079 --> 00:05:52.120 the entire treatment plan. If I have a nephrotic 00:05:52.120 --> 00:05:56.040 kid who is leaking protein, the treatment is 00:05:56.040 --> 00:05:59.180 steroids. to stop the inflammation and seal the 00:05:59.180 --> 00:06:01.939 leak, right? Yes. High dose steroids like prednisone. 00:06:02.199 --> 00:06:04.660 But that brings its own problems. If you put 00:06:04.660 --> 00:06:07.439 a child on massive doses of steroids, you are 00:06:07.439 --> 00:06:09.860 actively suppressing their immune system. So 00:06:09.860 --> 00:06:12.220 now, infection prevention becomes the number 00:06:12.220 --> 00:06:14.420 one priority. You have to keep them away from 00:06:14.420 --> 00:06:17.259 sick contacts. Whereas with the APSGN kid, the 00:06:17.259 --> 00:06:19.899 problem is they are basically a pressurized water 00:06:19.899 --> 00:06:22.519 balloon. They have too much fluid and extremely 00:06:22.519 --> 00:06:24.990 high blood pressure. So the intervention completely 00:06:24.990 --> 00:06:27.329 flips. We aren't pushing steroids as much as 00:06:27.329 --> 00:06:30.370 we are managing volume. We're talking fluid restrictions, 00:06:30.529 --> 00:06:33.009 sodium restriction, and aggressive antihypertensives. 00:06:33.310 --> 00:06:35.329 We have to bring that blood pressure down before 00:06:35.329 --> 00:06:38.490 they cease. Wait, before they cease? Yes. Hypertensive 00:06:38.490 --> 00:06:41.850 encephalopathy is the scary complication of APSGM. 00:06:41.970 --> 00:06:44.449 If that pressure gets too high, the brain swells. 00:06:44.610 --> 00:06:47.009 So if you are taking care of a kid with tea -colored 00:06:47.009 --> 00:06:49.170 urine who suddenly starts complaining of a headache 00:06:49.170 --> 00:06:51.870 or gets super irritable, you need to move fast. 00:06:52.069 --> 00:06:54.850 That is a cru - can't miss item. And let's look 00:06:54.850 --> 00:06:57.350 at the developmental impact here because we promised 00:06:57.350 --> 00:06:59.449 to view this through that lens. We're talking 00:06:59.449 --> 00:07:01.750 about school -age kids mostly for these filter 00:07:01.750 --> 00:07:04.209 issues. Right, usually early elementary age. 00:07:04.290 --> 00:07:07.490 So imagine being a seven -year -old. You're puffy, 00:07:08.029 --> 00:07:11.029 your face is swollen, period orbital edema is 00:07:11.029 --> 00:07:13.449 huge with nephrotic syndrome, and you have to 00:07:13.449 --> 00:07:15.589 go to school looking like that. It's devastating 00:07:15.589 --> 00:07:18.110 for their body image. Erickson's stage here is 00:07:18.110 --> 00:07:20.540 industry versus inferiority. They just want to 00:07:20.540 --> 00:07:22.740 be like their peers. If they look different or 00:07:22.740 --> 00:07:24.699 if the steroids make them gain weight and get 00:07:24.699 --> 00:07:27.560 that classic moon face, they might just refuse 00:07:27.560 --> 00:07:29.879 to go to school. They withdraw completely. They 00:07:29.879 --> 00:07:33.139 do. Plus, if they are immunocompromised from 00:07:33.139 --> 00:07:35.079 the steroids, they can't even have normal play 00:07:35.079 --> 00:07:38.620 dates. The isolation is very real. So as clinicians, 00:07:39.019 --> 00:07:40.560 we aren't just checking urine protein levels. 00:07:40.959 --> 00:07:42.939 We're checking their mental state. We need to 00:07:42.939 --> 00:07:44.879 help them maintain social connections safely. 00:07:45.439 --> 00:07:48.339 Exactly. We encourage FaceTime, writing letters, 00:07:48.620 --> 00:07:51.019 maybe safe outdoor activities, anything to keep 00:07:51.019 --> 00:07:53.480 them part of the group. Okay, let's shift gears 00:07:53.480 --> 00:07:56.019 a bit. Those were the slow burn filtration issues. 00:07:56.459 --> 00:07:58.180 Now I want to talk about the acute emergencies. 00:07:59.060 --> 00:08:00.899 The moments where the kidneys aren't just struggling, 00:08:01.339 --> 00:08:03.300 they're actively shutting down right in front 00:08:03.300 --> 00:08:05.920 of you. It's scary stuff. Yeah. The big one in 00:08:05.920 --> 00:08:09.980 the text is hemolytic uremic syndrome, HUS. HUS 00:08:09.980 --> 00:08:12.399 is the most common cause of acute renal failure 00:08:12.399 --> 00:08:14.740 in young children, usually under five years old. 00:08:15.319 --> 00:08:17.779 And it's terrifying because it starts out so 00:08:17.779 --> 00:08:20.699 innocently. It almost always follows a simple 00:08:20.699 --> 00:08:23.480 diarrheal illness. Usually E. coli. Right. Like 00:08:23.480 --> 00:08:25.980 from eating undercooked meat or visiting a petting 00:08:25.980 --> 00:08:28.639 zoo. Exactly. The child gets a stomach bug, maybe 00:08:28.639 --> 00:08:30.540 has some bloody diarrhea, and then they actually 00:08:30.540 --> 00:08:33.240 start to recover. But those bacterial toxins 00:08:33.240 --> 00:08:36.500 are still in their system. And those toxins attack 00:08:36.500 --> 00:08:38.580 the lining of the small blood vessels in the 00:08:38.580 --> 00:08:40.740 kidney. And the body tries to heal that. Right. 00:08:40.860 --> 00:08:43.759 The body reacts by sending platelets to fix the 00:08:43.759 --> 00:08:47.440 damage, which creates thousands of tiny microclots 00:08:47.440 --> 00:08:50.559 inside the kidneys vessels. And those microclots 00:08:50.559 --> 00:08:53.320 act like a shredder for red blood cells. That's 00:08:53.320 --> 00:08:55.539 the perfect image for it. The red blood cells 00:08:55.539 --> 00:08:58.200 try to squeeze past these microscopic clots and 00:08:58.200 --> 00:09:01.200 literally get sheared apart. That leads to the 00:09:01.200 --> 00:09:04.259 triad of HUS that you absolutely have to memorize 00:09:04.259 --> 00:09:08.409 for any exam. OK, wait up for us. One. Hemolytic 00:09:08.409 --> 00:09:10.529 anemia, because the cells are being actively 00:09:10.529 --> 00:09:14.389 destroyed. Two, thrombocytopenia, or low platelets, 00:09:14.490 --> 00:09:16.389 because they are all being used up to make those 00:09:16.389 --> 00:09:19.149 clots. And three, acute kidney injury, because 00:09:19.149 --> 00:09:21.110 the clots are blocking the blood flow to the 00:09:21.110 --> 00:09:23.889 kidneys. So clinically, this kid looks like a 00:09:23.889 --> 00:09:26.389 wreck. They're pale as a ghost from the anemia. 00:09:26.769 --> 00:09:29.269 They might have bruising or petechia all over 00:09:29.269 --> 00:09:32.149 from the low platelets. And the big tell, they 00:09:32.149 --> 00:09:34.850 just stop peeing. Alleguria, or total anuria. 00:09:35.029 --> 00:09:37.240 And they look toxic. This isn't a kid's - sitting 00:09:37.240 --> 00:09:39.480 up playing with an iPad. This is a lethargic, 00:09:39.740 --> 00:09:41.799 pale, really sick child. And what's the treatment? 00:09:42.220 --> 00:09:44.220 It's purely supportive. We can't just fix it 00:09:44.220 --> 00:09:46.299 with a pill. We have to manage their fluids and 00:09:46.299 --> 00:09:48.840 electrolytes meticulously. But often the kidneys 00:09:48.840 --> 00:09:51.240 shut down completely and these little toddlers 00:09:51.240 --> 00:09:54.500 end up needing dialysis. And that brings us to 00:09:54.500 --> 00:09:56.720 the developmental trauma of all this. Dialysis 00:09:56.720 --> 00:09:59.809 for a two -year -old. It's incredibly hard. Toddlers 00:09:59.809 --> 00:10:03.169 are all about autonomy versus shame and doubt. 00:10:03.669 --> 00:10:06.129 They want control over their bodies. Dialysis 00:10:06.129 --> 00:10:08.750 takes away all control. It involves needles, 00:10:09.230 --> 00:10:11.669 physical restraint, being tethered to a loud 00:10:11.669 --> 00:10:14.090 machine. You see a lot of regression here. Like 00:10:14.090 --> 00:10:16.450 what kind of regression? Well, a kid who is fully 00:10:16.450 --> 00:10:18.970 potty trained will suddenly start wetting themselves 00:10:18.970 --> 00:10:21.309 again. They lose their words. And that regression 00:10:21.309 --> 00:10:23.450 is totally normal. Right. We shouldn't punish 00:10:23.450 --> 00:10:25.549 it. Oh, completely normal. It's a basic coping 00:10:25.549 --> 00:10:27.870 mechanism. As nurses, we have to reassure the 00:10:27.870 --> 00:10:29.909 parents. We tell them, look, this is temporary. 00:10:30.009 --> 00:10:32.750 Don't punish them. Focus on survival and comfort 00:10:32.750 --> 00:10:34.769 right now. Speaking of survival and comfort, 00:10:34.850 --> 00:10:36.929 let's talk about the everyday plumbing maintenance. 00:10:37.970 --> 00:10:40.909 Urinary tract infections and VUR viscicritoral 00:10:40.909 --> 00:10:43.649 reflux. This seems super common, but the presentation 00:10:43.649 --> 00:10:46.549 varies wildly by age. It really does. If an adult 00:10:46.549 --> 00:10:48.649 has a UTI, they just tell you it burns when they 00:10:48.649 --> 00:10:50.840 pee. But a six -month -old can't tell you that. 00:10:51.220 --> 00:10:53.720 Right. In infants, the signs are incredibly vague. 00:10:54.080 --> 00:10:57.179 Unexplained fever, vomiting, poor feeding, or 00:10:57.179 --> 00:11:00.460 just acting off. Any infant with a fever of unknown 00:11:00.460 --> 00:11:03.639 origin gets a urine culture. Period. But in the 00:11:03.639 --> 00:11:06.039 older kid, like the preschooler, we start to 00:11:06.039 --> 00:11:08.980 see the classic signs. And there's one symptom 00:11:08.980 --> 00:11:11.659 here, that the source material flagged as a major 00:11:11.659 --> 00:11:16.450 red flag. Enuresis. Yes. Bedwetting. If a child 00:11:16.450 --> 00:11:18.970 has been reliably potty trained for six months 00:11:18.970 --> 00:11:21.669 or a year and suddenly starts wetting the bed, 00:11:22.190 --> 00:11:24.769 do not assume it's behavioral. That is the body 00:11:24.769 --> 00:11:26.830 screaming that something is irritating the bladder. 00:11:27.029 --> 00:11:29.789 And often that irritation is caused by VUR, right, 00:11:29.809 --> 00:11:33.090 the backflow. Exactly. VUR is a structural issue 00:11:33.090 --> 00:11:35.529 where the valve between the ureter and the bladder 00:11:35.529 --> 00:11:38.250 doesn't close right. So when the bladder squeezes 00:11:38.250 --> 00:11:40.629 to pee, some urine shoots backward up towards 00:11:40.629 --> 00:11:43.240 the kidney. It's like a plumbing backup. Which 00:11:43.240 --> 00:11:45.700 carries bacteria right up into the kidney. Yes, 00:11:45.840 --> 00:11:48.399 causing pilonephritis and eventually kidney scarring. 00:11:48.720 --> 00:11:50.659 And that kidney scarring is permanent. That's 00:11:50.659 --> 00:11:53.179 the real why we care here. Exactly. Scarring 00:11:53.179 --> 00:11:55.519 leads to hypertension and major renal issues 00:11:55.519 --> 00:11:58.460 later in life. So we use prophylactic antibiotics 00:11:58.460 --> 00:12:01.039 to keep the urine sterile while we wait for the 00:12:01.039 --> 00:12:04.500 child to hopefully just outgrow the reflex. Now, 00:12:04.679 --> 00:12:07.440 regarding prevention, we always hear wipe front 00:12:07.440 --> 00:12:10.460 to back. But the source material mentioned constipation 00:12:10.460 --> 00:12:14.029 as a major culprit for UTIs. I feel like parents, 00:12:14.230 --> 00:12:16.870 and even some clinicians, completely miss this 00:12:16.870 --> 00:12:19.330 connection. They do, all the time. Think about 00:12:19.330 --> 00:12:21.850 the anatomy for a second. The rectum is right 00:12:21.850 --> 00:12:24.409 behind the bladder. If the rectum is full of 00:12:24.409 --> 00:12:27.049 hard stool, it pushes forward and physically 00:12:27.049 --> 00:12:29.289 squishes the bladder. So the bladder just can't 00:12:29.289 --> 00:12:31.590 empty completely. Right. It prevents emptying. 00:12:32.009 --> 00:12:35.210 And stagnant urine grows bacteria. So treating 00:12:35.210 --> 00:12:37.629 a UTI often means you have to treat the constipation 00:12:37.629 --> 00:12:40.929 first. That's a huge clinical pearl. To fix the 00:12:40.929 --> 00:12:43.409 pee, check the poop. Exactly. Okay, let's move 00:12:43.409 --> 00:12:45.610 over to the structural and surgical bucket. We 00:12:45.610 --> 00:12:48.470 have kids born with plumbing defects, specifically 00:12:48.470 --> 00:12:51.450 hypospadias and bladder atrophy. Let's start 00:12:51.450 --> 00:12:53.789 with hypospadias. This is where the urethral 00:12:53.789 --> 00:12:56.370 opening is on the underside of the penis. What 00:12:56.370 --> 00:12:58.750 is the absolute can't miss rule here? The number 00:12:58.750 --> 00:13:02.070 one rule is no circumcision. Not initially, no. 00:13:02.470 --> 00:13:04.909 If a baby is born with hypospadias, you must 00:13:04.909 --> 00:13:07.190 stop the circumcision. The surgeon needs that 00:13:07.190 --> 00:13:10.299 foreskin. It's literally the skin graft material 00:13:10.299 --> 00:13:13.039 they use to rebuild the urethra later. If you 00:13:13.039 --> 00:13:15.379 cut it off, you've complicated the repair significantly. 00:13:15.679 --> 00:13:17.340 That makes perfect sense. Don't throw away the 00:13:17.340 --> 00:13:19.620 spare parts. Exactly. Now, bladder extrophy. 00:13:20.240 --> 00:13:23.000 This one is visually shocking. The bladder is 00:13:23.000 --> 00:13:25.440 literally outside the abdomen. It's a severe 00:13:25.440 --> 00:13:27.899 midline defect. The bladder is exposed, it's 00:13:27.899 --> 00:13:31.840 red, and it's constantly weeping urine. The immediate 00:13:31.840 --> 00:13:34.639 nursing priority at birth is covering it with 00:13:34.639 --> 00:13:37.580 a sterile non -adherent dressing to keep it moist 00:13:37.580 --> 00:13:40.159 and prevent infection. But looking long term, 00:13:40.480 --> 00:13:42.580 there is a fascinating and critical safety link 00:13:42.580 --> 00:13:45.379 here regarding allergies. Latex, right? Yes. 00:13:45.629 --> 00:13:48.230 the latex allergy risk. It's huge. These children 00:13:48.230 --> 00:13:50.929 require multiple surgeries and frequent catheterizations 00:13:50.929 --> 00:13:53.570 starting from day one of life. Because of that 00:13:53.570 --> 00:13:56.190 massive repeated exposure to latex products early 00:13:56.190 --> 00:13:59.070 on, they develop a latex allergy at a staggering 00:13:59.070 --> 00:14:01.509 rate. It's very similar to what we see in spina 00:14:01.509 --> 00:14:04.929 bifida patients. So for these kids, we are instituting 00:14:04.929 --> 00:14:08.409 latex precautions for life. No rubber gloves 00:14:08.409 --> 00:14:11.009 in the hospital, no latex balloons at birthday 00:14:11.009 --> 00:14:13.899 parties, checking their pacifiers. Everything. 00:14:14.120 --> 00:14:16.220 A balloon popping in their face at a party could 00:14:16.220 --> 00:14:20.139 trigger full anaphylaxis. It's a serious safety 00:14:20.139 --> 00:14:22.059 education point we have to drill into the parents. 00:14:22.259 --> 00:14:24.100 Okay, now let's talk about the reproductive system. 00:14:24.700 --> 00:14:26.899 We have to touch on the emergencies where time 00:14:26.899 --> 00:14:30.200 is tissue, specifically, testicular torsion. 00:14:30.279 --> 00:14:32.960 This is the heart attack of the groin. The spermatic 00:14:32.960 --> 00:14:36.120 cord twists, completely cutting off blood supply 00:14:36.120 --> 00:14:39.340 to the testicle. The pain is sudden, it's severe, 00:14:39.620 --> 00:14:42.090 and it's often accompanied by vomiting. And the 00:14:42.090 --> 00:14:44.450 need to know here is the clock. You have about 00:14:44.450 --> 00:14:46.990 four to six hours to untwist that cord surgically 00:14:46.990 --> 00:14:49.129 before the testicle dies. So if a teenage boy 00:14:49.129 --> 00:14:51.549 comes into the ER hunching over, walking funny, 00:14:52.009 --> 00:14:54.350 or complaining of severe lower abdominal pain, 00:14:54.929 --> 00:14:57.179 you need to check the scrotum. You absolutely 00:14:57.179 --> 00:15:00.519 have to. Adolescents are modest. They might lie 00:15:00.519 --> 00:15:02.240 and say their stomach hurts because they're just 00:15:02.240 --> 00:15:04.019 too embarrassed to say their testicle hurts. 00:15:04.399 --> 00:15:06.460 You have to physically check. If it's swollen, 00:15:06.740 --> 00:15:08.740 high -riding, and painful, they go to the operating 00:15:08.740 --> 00:15:11.799 room immediately. You do not wait for labs. Contrasting 00:15:11.799 --> 00:15:14.450 that with cructorchidism. which is undescended 00:15:14.450 --> 00:15:17.950 testes. This isn't an emergency today, but it's 00:15:17.950 --> 00:15:20.750 a massive risk for tomorrow. Right. If the testes 00:15:20.750 --> 00:15:23.230 don't descend, the sperm producing cells get 00:15:23.230 --> 00:15:25.509 damaged by the core body heat. This leads to 00:15:25.509 --> 00:15:28.559 infertility. But the much bigger risk is testicular 00:15:28.559 --> 00:15:31.759 cancer. Even after surgery? Yes. Even after we 00:15:31.759 --> 00:15:33.860 surgically bring them down, a procedure called 00:15:33.860 --> 00:15:37.019 an orchiopexy, the risk of cancer remains significantly 00:15:37.019 --> 00:15:39.899 higher. So these boys need to be taught how to 00:15:39.899 --> 00:15:42.539 do testicular self -exams early on. Let's weave 00:15:42.539 --> 00:15:44.539 in the pharmacology now. The source material 00:15:44.539 --> 00:15:46.940 highlighted a few specific meds, and I really 00:15:46.940 --> 00:15:50.629 want to focus on oxybotin. Dytropam, I usually 00:15:50.629 --> 00:15:52.570 think of this for overactive bladder in adults, 00:15:52.649 --> 00:15:54.629 but why are we giving it to kids post -op? It's 00:15:54.629 --> 00:15:57.149 a powerful antispasmodic. After we do surgery 00:15:57.149 --> 00:15:59.429 on the bladder -like for the hypospadias repair 00:15:59.429 --> 00:16:01.769 or the extra fee we talked about, the bladder 00:16:01.769 --> 00:16:05.669 gets angry. It spasms. And bladder spasms are 00:16:05.669 --> 00:16:09.590 excruciating. Like cramping. Yes. Sharp, severe 00:16:09.590 --> 00:16:12.210 cramping pain that regular opioids often don't 00:16:12.210 --> 00:16:16.309 even touch. Oxybutynin relaxes that smooth muscle. 00:16:16.590 --> 00:16:18.990 But. It's an anticholinergic. And we all know 00:16:18.990 --> 00:16:21.850 the rhyme. Can't see, can't pee, can't spit. 00:16:22.009 --> 00:16:24.750 Can't poop. That's the danger. Severe constipation. 00:16:25.070 --> 00:16:27.289 So wait, we've given this to stop the spasm, 00:16:27.330 --> 00:16:29.289 but then they get constipated. Right, and think 00:16:29.289 --> 00:16:31.490 about the physics of that. If you have a child 00:16:31.490 --> 00:16:34.049 who just had major bladder reconstruction and 00:16:34.049 --> 00:16:36.350 they get constipated from the oxybutynin, they're 00:16:36.350 --> 00:16:39.250 going to strain on the toilet. That Valsalva 00:16:39.250 --> 00:16:41.789 maneuver increases intra -abdominal pressure. 00:16:41.830 --> 00:16:44.690 Oh no. Yes, that pressure pushes right against 00:16:44.690 --> 00:16:47.110 the fresh sutures in the bladder. You could literally 00:16:47.110 --> 00:16:50.250 blow the repair wide open. Wow. So managing the 00:16:50.250 --> 00:16:52.049 side effect isn't just about the kid's comfort, 00:16:52.110 --> 00:16:54.429 it's about physically protecting the surgery. 00:16:54.590 --> 00:16:58.129 Precisely. Stool softeners. Aggressive hydration 00:16:58.129 --> 00:17:01.350 and monitoring bowel movements are absolutely 00:17:01.350 --> 00:17:03.970 non -negotiable when you are using oxybutynin 00:17:03.970 --> 00:17:06.589 in these post -op kids. That is such a great 00:17:06.589 --> 00:17:08.769 connection. The other meds mentioned in the module 00:17:08.769 --> 00:17:11.150 were topical steroids and antibiotics. Quick 00:17:11.150 --> 00:17:13.369 hits on those. Topical steroids are used for 00:17:13.369 --> 00:17:16.329 thimosis, which is a tight foreskin. It thins 00:17:16.329 --> 00:17:18.390 the skin over time to help it stretch so you 00:17:18.390 --> 00:17:20.910 hopefully don't have to do surgery. And antibiotics, 00:17:20.950 --> 00:17:23.609 as we mentioned earlier, are crucial for VUR 00:17:23.609 --> 00:17:26.430 prophylaxis to prevent that permanent renal scarring. 00:17:26.779 --> 00:17:29.359 Man, we have covered a ton of ground today. We've 00:17:29.359 --> 00:17:32.640 gone from the traffic jam of APSGN to the shredder 00:17:32.640 --> 00:17:36.460 of HUS to the plumbing backups of VUR. But before 00:17:36.460 --> 00:17:37.900 we close, I want to circle back to something 00:17:37.900 --> 00:17:40.700 you touched on earlier, the bedwetting in Euresis. 00:17:40.720 --> 00:17:42.740 Yeah. You called it a provocative thought in 00:17:42.740 --> 00:17:45.400 our pre -show notes. Why? Because it's the perfect 00:17:45.400 --> 00:17:48.220 example of why pediatrics requires a detective's 00:17:48.220 --> 00:17:50.220 mind. Think about it. If a seven -year -old comes 00:17:50.220 --> 00:17:52.779 into the clinic with enuresis, it is so easy 00:17:52.779 --> 00:17:55.240 to dismiss it. Parents are annoyed. They just 00:17:55.240 --> 00:17:56.980 want it fixed. Maybe they think the kid is being 00:17:56.980 --> 00:17:58.640 lazy. Right. They just want a quick solution. 00:17:59.099 --> 00:18:01.480 Exactly. But as a clinician, you have to pause. 00:18:01.579 --> 00:18:04.059 You have to ask yourself, what is the body really 00:18:04.059 --> 00:18:07.480 saying? Is it a structural issue, like VUR? Is 00:18:07.480 --> 00:18:10.519 it a hidden UTI from constipation? Yes. Or is 00:18:10.519 --> 00:18:13.599 it the polyuria of new onset type 1 diabetes? 00:18:13.839 --> 00:18:16.339 That's a very classic presentation. A kid who 00:18:16.339 --> 00:18:18.440 is suddenly drinking a lot of water and wetting 00:18:18.440 --> 00:18:20.700 the bed at night. Oh, wow. I wouldn't have instantly 00:18:20.700 --> 00:18:23.220 jumped to diabetes. You have to. Or, and this 00:18:23.220 --> 00:18:25.460 is the really uncomfortable one, is it sexual 00:18:25.460 --> 00:18:28.380 abuse? Regression and sudden bedwetting can be 00:18:28.380 --> 00:18:30.619 a major sign of trauma. It's just a symptom, 00:18:30.740 --> 00:18:33.660 not a diagnosis. Exactly. Never take wetting 00:18:33.660 --> 00:18:35.420 the bed at face value. You have to peel back 00:18:35.420 --> 00:18:37.579 the onion. You might find a simple infection, 00:18:37.680 --> 00:18:40.519 or you might save a child from DKA, or you might 00:18:40.519 --> 00:18:42.980 pull them out of an unsafe home situation. You 00:18:42.980 --> 00:18:45.960 always have to stay curious. That is an incredibly 00:18:45.960 --> 00:18:48.079 powerful reminder. It's not just about the plumbing. 00:18:48.240 --> 00:18:50.400 It's about the whole child. Well, expert, thank 00:18:50.400 --> 00:18:52.940 you so much for breaking this all down. To our 00:18:52.940 --> 00:18:55.900 listeners, take these 80 -20 patterns, the filter 00:18:55.900 --> 00:18:58.000 failures, the emergencies, the structural fixes, 00:18:58.240 --> 00:19:00.740 and use them to organize your studying and your 00:19:00.740 --> 00:19:03.940 bedside care. And remember, protect the kidneys, 00:19:04.420 --> 00:19:07.220 protect their growth, and always listen to the 00:19:07.220 --> 00:19:09.000 parents. We'll see you in the next Deep Dive.