Breath Holding attacks, GBS, Head lice, MMR and Otitis Media

Question 1

What are breath holding attacks?

Answer 1

A devleopmental condition in which the child experiences a biref episode of apneoa.

Question 2

What is the background of breath holding attacks?

Answer 2

2% children 6m-5y. 75% between 5-18m.

Pallid attack: abnormal sensitivity to carotid sinus or ocular compression – causing temporary asystole or marked bradycardia

Cyanotic attack: Unclear – centrally mediated reduced respiratory effort, altered lung mechanics that timulate pulmonary reflexes, resulting in aopnea.

Question 3

What do you want from history and exam for breath holding attacks?

Answer 3

History
Pallid: Fear/Pain > Stop breathing > LOC . Pale and hypotonic > ?seizure

Cyanotic: Anger/frustration > cries and holds breath > Cyanosis LOC > Tonic clonic jerks and arching of back à Bradycardia

Attacks last less than one minute.

Examination
Neuro exam to exclude underlying disease.

Question 4

What investigations do you do for breath holding attacks?

Answer 4

Not usually required. EEG if worried about siezures, if during attack shows generalised flattening (=cerebral hypoxia). Interictal EEG normal.

ECG: if arrhythmia is suspected.

Question 5

What is the management of breath holding attacks?

Answer 5

Parental education – no reinforcement of behavior pattern. Lie child flat during attack to increase cerebral eprfusion. Atropine sulphate can be considered if refractory pallid attack.

Question 6

What is the complications and prognosis of breath holding attacks?

Answer 6

Danger of injury if falling over.

Usually stops at 5-6y.

Question 7

What is a GBS infection?

Answer 7

Bacterial infecton caused by strep agalactiae causing neonatal sepsis.

Question 8

What is the background of a GBS infection?

Answer 8

3/1k live births. Maternal colonisation 30%.

Common infection in adults. Colonises GI, GU, throat. Most common cause of NN sepsis, vertical (in utero) or intrapartum transmission. Early>late infection.

· Early: first day-week. Vertical transmission. Sepsis, pneumonia, meningitis.

· Late: between 1-3months. Vertical transmission with delayed infection or horixonta in hospital or community. Meningitis 85%.

Related to prematurity, prolonged rupture of membranes, maternal GBS +, chorio-amnionitis, previous GBS in sibling.

Question 9

What do you want from history and exam for a GBS infection?

Answer 9

Sepsis:

· Pyrexia, temperature instability, hypothermia

· Shock, irritability, seizures, drowsy, neutrophilia, inflammatory markers.

· Vomiting, abdo distension, jaundice, poor feeding.

· Aopnea, bradycardia.

Meningitis: As for sepsis with tense fontanelle and head retraction ophistotonos.

Pneumonia: Respiratory distress: recession, tracheal tub, grunting, flaring etc.

Question 10

What investigations do you do for a GBS infection?

Answer 10

Radiology: CXR

Bloods: FBC and WCC, Glucose, inflammatory markers, CULTURES.

Urine and CSF culture, blood too.

Question 11

What is the management of a GBS infection?

Answer 11

Preventive: Identify at risk, colonised mothers, and intrapartum IV penicillin G.

Treatment: admit to NNU with IV access, IVI fluid, blood and cultures. BSAbx started before culture available – IV penicillin and gentamicin.

Future: vaccination?

Question 12

What is the complications and prognosis of a GBS infection?

Answer 12

Hearing and vision loss, neurodevelopment impairment

Morbidity 5% and mortality with meningitis 50%.

Question 13

What are head lice?

Answer 13

Infestation of the head with lice.

Question 14

What is the background of head lice?

Answer 14

Peak age 3-11 y, high lifetime incidence, underreported due to stigma
Padinculosis humanis capitis: six legged flat body no wings.

Spread by head to head contact or with sheets. Eggs can live up to 1m.

Question 15

What do you want from history and exam for head lice?

Answer 15

History
Pruritus and hx of contact

Examination
Urticarial macules and excoriations, can see live lice and eggs o/e scalp.

Question 16

What investigations do you do for head lice?

Answer 16

Wood’s light exam reveals fluorescent lice in head.

Question 17

What is the management of head lice?

Answer 17

Non medical management: wet combing and dimeticone 4% (Covers lice and disrupts their water balance).

Medical: peniculicides such as mathation and phenotinon, kill lice. OTC. Apply and remove lice with comb.

Environmental eradication, wash sheets, hairbands etc. Treat contacts if chance of infection.

Question 18

What is the complications and prognosis of head lice?

Answer 18

Infection of bites and excoriations. Good prognosis.

Question 19

What is an MMR infection?

Answer 19

Infection with MM or R RNA viruses

Question 20

What is the background of an MMR infection?

Answer 20

Each has a 4/100k incidence.

Measles: Contact, droplet, 7-14d incubation, 4d infection

Mumps: Contact, droplet, 14-21d incubation, 7d infection

Rubella: Contact, placental, 14-21d incubation, 14d infection

Association w/ malnutrition, immuncompromise, lack of immunisations,

Question 21

What do you want from history and exam for a measles (Morbilivirus) infection?

Answer 21

Prodrome: 4d: Fever, conjunctivitis, koplik spots, coryza
Symptoms: Rash behind ear
Examination: Maculopapular and then blotchy, spreads to whole body

Question 22

What investigations do you do for an MMR infection?

Answer 22

Clinical dx with serology.

Question 23

What is the management of an MMR infection?

Answer 23

Antipyretic, encourage oral intake, notify CDC. Prevent with immunisation.

Question 24

What is the complications and prognosis of an MMR infection?

Answer 24

Measles: otitis media, encephalitis. Moderate high mortality rate.

Mumps: Viral meningitis, encephalitis, orchitis. Self resolving usually.

Rubella: arthropathy, encephalopathy, thrombocytopenia, cardiomyopathy, congenital Rubella stnydome. Self limiting in adults but worse in infants.

Question 25

What is otitis media?

Answer 25

AOM: inflammation of the middle ear chamber

CSOM: glue ear, middle ear effusion without perforation for >3m.

Question 26

What is the background of otitis media?

Answer 26

AOM: viral mostly (rhinovirus and RSV) bacteria in 35%, Strep pneumonia and Hib. Parental smoking, contacts, nursery increase risk.

CSOM: Obstruction of eustachian tube due to adneoidal hypertrophy, allergic rhinitis or craniofacial abnoramlities. Most likely in children <2yo with recurrent AOM.

Epidemiology

80% have had AOM by 3y. CSOM in 70% of 3yos.

Question 27

What do you want from history and exam for otitis media?

Answer 27

AOM: ear pain and pulling after URTI symtpoms. May have hearing loss and vomiting/diahrrea/poor feeding.

AOM: red eardrum, inflamed, narrowed tube. May have effusion. Loss or normal light reflex and may have perforation.

CSOM: reduced hearing, inattention.

CSOM: tympanic membrane retraced and large effusion in front. May have speech and hearing issues. CHECK FOR MASTOIDITIS mastoid tenderness.

Question 28

What investigations do you do for otitis media?

Answer 28

Simple AOM: fever and obs, swabs may be taken from ear for MCS.

Recurrent AOM/CSOM: may warrant screening for immune deficiency

CSOM: audiology tests

Question 29

What is the management of otitis media?

Answer 29

AOM acute: analgesia, antibiotics if suspect bacterial cause. No aminoglycosides (ototoxic).

AOM prophylaxis: pneumococcal vaccinaton in children with recurrences.

CSOM: no benefit for antihistamines, little benefit with steroids. If severe and persisting consider adenoidectomy or gromlets

Question 30

What is the complications of otitis media?

Answer 30

AOM: perforation of middle ear and ifnection. Avoid swimming.

CSOM: hearing loss and therefore delay in speech and language. Choleastoma exclude. Mastoiditis rare but serious complication. (à meningitis/brain abscess).

Question 31

What do you want from history and exam for a mumps (paramyxo) infection?

Answer 31

Prodrome: Fever, muscle pain, headache, malaise
Symptoms: Swelling of parotids
Examination: Parotid swelling

Question 32

What do you want from history and exam for a Rubella (rubivirus) infection?

Answer 32

Prodrome: Fever, malaise lymphadenopathy
Symptoms: Rash
Examination: Small, pink maculopapular, face initially then down to thights.