Paediatrics

Question 1

What you need to know

Answer 1

• When did it start?
• Where did it start?
• Where did it spread?
• Any other symptoms?
• Contact with children with rash?
• Past history of rash?

Question 2

Chickenpox (also known as varicella)

Answer 2

• Incubation time (time between contact & development of rash) is ≈10-20 days. Rash can be preceded by up to 3 days of feeling unwell with fever, sore throat & headache
• The rash typically begins on the face, stomach and back before spreading to other parts of body. Initially, they appear as small red lumps that rapidly develop into vesicles, which crust over after 3-5 days. New lesions tend to occur in crops of 3-5 for the first 4 days. The rash is usually itchy and irritating.
• Once the spots have all formed crusts, the individual is no longer contagious.
• CKS advise exclusion from school/work is not necessary after 6 days from onset. The whole infection is usually over within 1 week but can be longer and severe in adults.

Question 3

Measles

Answer 3

• Caused by an RNA virus & spread by droplet inhalation. Incubation period ≈7-14 days
• Rash is preceded by 3–4 days of illness with symptoms of cold, cough, fever & conjunctivitis. Small white spots (Koplik spots - like grains of salt) surrounded by inner red ring on the inner cheek & gums can be seen.
• 2-4 days after initial symptoms a rash starts behind ears, spreading to face & trunk. The spots are small, red patches (macular) that blanch if pressed.
• Infectious for ≈5 days after rash onset (stay off from school). Immediately refer to GP

Question 4

Mumps (Epidemic parotitis)

Answer 4

• Caused by a paramyxovirus & transmitted by airborne droplets from nose/throat.
• Incubation period is ≈ 16-21 days. Symptoms: Fever, headache, malaise, pain when opening mouth due to inflammation of one or both parotid glands (sides of face)
• Treatment: Paracetamol or ibuprofen for symptomatic relief. Keep hydrated
• Stay away from school for ≈5 days after swelling appears.

Question 5

Roseola infantum (sixth disease)

Answer 5

• A common, mild viral infection mostly in children <2 (seen in 3 months-4y).
• It can be confused with a mild attack of measles.
• Prodromal period of 3–4 days of sudden high fever followed by a rash similar to measles but is mainly confined to the chest and abdomen. Once the rash appears, there is usually an improvement in symptoms, in contrast to measles, and it lasts only about 24 h.

Question 6

Fifth disease (erythema infectiosum)

Answer 6

• A mild, self-limiting viral infection (parvovirus B19) usually affects children. It doesn’t often cause systemic upset but may cause fever, headache & rarely, painful joints.
• The rash characteristically starts on the face & often called ‘slapped cheek’ disease due to appearance of reddened cheeks. The rash can then appear on limbs & trunk as small red spots that blanch with pressure.
• It is usually short lived but can have adverse effects in immunocompromised or pregnant. If the infection occurs in the first 20 weeks of gestation, there is an increased chance of miscarriage and a small chance of the baby becoming anaemic.

Question 7

Rubella (German measles)

Answer 7

• Caused by an RNA virus & spread by close personal contact or airborne droplets
• A generally mild viral infection; its main significance being the problems caused to the foetus if the mother develops the infection in early pregnancy.
• Incubation time is ≈14-21 days. The rash usually appears first & starts on the face spreading to trunk/limbs. The spots are very fine & red & blanch with pressure. The appearance of the rash is followed by a mild cough & runny nose. There is often enlargement of glands around the neck and head.
• In women, rubella may be associated with painful joints (this is rare in children/men)
• The rubella rash lasts for 3–5 days (stay off from school for ≈6 days once rash starts)

Question 8

Meningitis

Answer 8

• A very serious infection caused by bacterial (meningococcal, pneumococcal), viral (herpes simplex virus) or fungal infections. Bacterial meningitis is life-threatening.
• Meningococcal septicaemia usually presents with flu-like symptoms that may rapidly worsen. There may be an associated rash that appears as tiny purplish red blotches or bruises caused by blood leaking out of capillaries. Doesn’t blanch with pressure.
• The spots will start as a few tiny pinpricks and progress to widespread larger ones that coalesce together. Any suspicion of this condition requires emergency help.
• Meningitis can have other symptoms: Fever >37.5o, Feeling/being sick, Irritability, Lack of energy, Headache, Aching muscles/joints, Breathing quickly, Cold hands/feet, Pale-mottled skin, Stiff neck, Confusion, Dislike of bright lights, Drowsiness, Seizures.
• Babies may also: Refuse feeds, Agitated, Not want to be picked up, Bulging soft spot on head (fontanelle), Be floppy or unresponsive, Unusual high-pitched cry, Stiff body.
• These symptoms can develop in any order & some may not even appear.

Question 9

Rashes that do not blanch (Glass tumbler test)

Answer 9

• Should be referred to a doctor. These rashes occur when blood leaks out of capillaries, which may be caused by an infection or blood disorder. It could be the first sign of leukaemia but can arise from less serious conditions.

Question 10

Molluscum contagiosum

Answer 10

• Is a species of virus in the poxvirus family. Lesions are usually spread over the body involving face, trunk, arms & legs & can range in numbers from a few to over a 100.
• Small, raised, smooth, pink pearl like spots, usually in clusters. All lesions have a central punctum that is a diagnostic feature
• It should spontaneously resolve (usually within 12 months) but if parent/child is anxious, then refer to GP as liquid nitrogen can be used to remove the lesions.

Question 11

Impetigo

Answer 11

• Caused by a bacterial infection (Staphylococcus aureus or Streptococcus pyogenes)
• It presents mainly on the face, around the nose and mouth. It usually starts as a small red itchy patch of inflamed skin that quickly develops into vesicles that rupture & weep. The exudate dries to a brown, yellow sticky crust
• It is contagious and children should be kept off school until the rash clears.
• Do not share towels, keep nails short to prevent scratching of the lesions.
• Treatment involves topical or systemic antibiotics (e.g., fusidic acid or flucloxacillin)

Question 12

Glandular fever (infectious mononucleosis)

Answer 12

• Caused by Epstein–Barr virus & most commonly seen in 15-24 year olds. It is transmitted from close salivary contact (also known as kissing disease)
• Incubation period of 4-7 weeks. Vague symptoms characterised by fatigue, sore throat, headache & swollen/tender lymph glands. A macular rash can also occur.
• The symptoms are mild but can stay for many months.

Question 13

Infantile colic

Answer 13

• Crying for >3 hours a day for >3 days a week for > 3 weeks. The cause is unknown. It generally begins when baby is a few weeks old & usually resolves by 3–4 months old.
• Usually crying occurs in late afternoon/evening, baby has red/flushed face by crying & may draw the knees up. Clenching of the fists and arching of the back is common. Passing wind & difficulty in passing stools may occur.
• If a baby becomes inconsolable/cannot be comforted, refer to GP or OOH.
• Reassure parents that colic is a natural occurrence and babies should grow out of it.
• For breastfed infants the mother can try excluding cow’s milk & other dairy products
• Massaging babies has had reported benefit.
• Simeticone (Infacol & Dentinox): 2.5 mL (21 mg) after each feed.
• Lactase enzyme (Colief): If breastfed, add 4 drops to small amount of expressed milk & breastfeed as normal. If using formula, make up as usual & add 4 drops to warm formula. If making formula in advance, add 2 drops of Colief & store in fridge for 4h

Question 14

Nappy rash

Answer 14

• When to refer: Broken skin/severe rash, Unwell baby, Signs of infection, Other body areas affected, Persistent rash (>2 weeks)
• Treatment: Satellite papules (small, red lesions) can indicate a fungal infection & be treated with clotrimazole. Dimeticone is a water repellent. Zinc is a soothing agent. Lanolin is an effective emollient to hydrate skin. Castor oil provides a water-resistant barrier. Routine use of a barrier creams is widely recommended by experts.
• Nappies should be changed frequently & be left off wherever possible for as long as possible. At each nappy change, cleanse skin thoroughly by washing with warm water or using lotion or fragrance/alcohol free wipes. Dry the skin thoroughly.

Question 15

Headlice

Answer 15

• Live lice should have been seen to warrant treatment
• Wet combing of the hair is a reliable detection method. Comb the child’s hair over a piece of white cloth, using a fine-toothed comb.
• After treatment, check it has been successful by doing detection combing on day 2 or 3 after completing treatment course and again after a further interval of 7 days.
• Physical products kill the lice by a variety of means, such as physically coating their surfaces and suffocating them (dimeticone) or dissolving the wax coating of the louse and causing death by dehydration. Dimeticone products are usually applied to dry hair and are left on for 8h (or overnight) and washed out with shampoo. This is usually repeated after 7 days. They can be used in people with eczema or asthma.
• Isopropyl myristate/cyclomethicone solution, is applied to dry hair and washed out after 10 min. May need further application in 7 days if detection combing is positive.
• The recommended regimen for wet combing treatment is four sessions spaced over 2 weeks (on days 1, 5, 9 & 13), continued if necessary, until no full-grown lice are seen for three consecutive sessions. Do 2 combing procedures at each session.
• Chemical insecticides (malathion, permethrin) are reserved for 2nd line use as physical insecticides are more effective & do not cause resistance to develop. Malathion is applied to dry hair & left on for 12h (or overnight). A repeat application after 7 days is recommended to kill any lice that have emerged from eggs since. Eggs take around 7 days to hatch. A detection comb should be used at day 4 and day 8–10
• Malathion is available as alcoholic & aqueous lotions (not suitable in eczema or asthma). When an alcoholic lotion is used, keep hair away from naked flames.
• Pay attention to the nape of the neck and behind ears, where lice are often found.
• Malathion (Derbac- M liquid)
  Derbac-M should be applied to dry hair and left for 12h before washing off.
• Dimeticone 4% Lotion & Spray (Hedrin)
  Lotion is applied to dry hair ensuring it is spread evenly from roots to ends. The spray should be applied approx. 10cm from the hair making sure it is evenly distributed over dry hair. Both need to be left on for 8h (or overnight) before washing.
• Dimeticone 4% Gel (Hedrin Once Liquid gel)
  Applied in the same way as the lotion but only needs to be left on for 15 mins.
• Dimeticone 92% Spray (NYDA)
  Comb hair with fine-tooth comb & apply the spray over the entire head. Once applied, re-comb the hair after 30mins. The dimeticone should be left on the hair and scalp for 8h or overnight, and then washed out using shampoo.
• Isopropyl myristate in cyclomethicone (Full Marks Solution and Spray)
  This is applied in the same manner as dimeticone, but the contact time is 10 mins. It is only recommended for adults and children > 2 years.

Question 16

Threadworms

Answer 16

• Very common in schoolchildren.
• Perianal itching is a classic symptom and is caused by an allergic reaction to the substances in and surrounding the worms’ eggs that are laid around the anus.
• Sensitisation takes a while to develop. 1st time infection may not experience itching.
• Itching is worse at night (at that time female worms emerge from anus to lay eggs on surrounding skin). The eggs are secreted with a sticky irritant fluid onto the perianal skin. Persistent scratching may lead to secondary bacterial infection (rare). If the perianal skin is broken & there are signs of weeping, refer to doctor for antibiotics.
• In some patients, scabies or fungal infection may produce perianal itching.
• The worms can be seen in the faeces as white/cream coloured thread-like objects, up to 13mm L & < 0.5mm W. Males are smaller. The worms survive outside the body for a short time and may be seen moving. The eggs are too small to be seen & can survive for up to 3 weeks outside the body.
• In severe cases of infection, diarrhoea may be present and, in girls, vaginal itch.
• Refer: Different infection suspected  Recent travel abroad, Medication failure, Children <2 years, Pregnant or breastfeeding
• Mebendazole acts by inhibiting uptake of glucose by the worms, causing death within a few days. It is largely unabsorbed from the gut and systemic adverse effects are minimal. It is the preferred treatment and should be given to the whole family at the same time. It is also active against whipworm, roundworm and hookworm.
• Available as liquid or tablet OTC for >2y (can be prescribed for >6 months to 2y). Reinfection is common hence 2nd dose should be given to entire family after 2 weeks
• Mebendazole is not recommended for pregnant or breastfeeding women. Advise them to practise hygiene measures for 6 weeks to break the cycle of infection.
• Side effects: abdominal pain/discomfort (most common), diarrhoea and rash.
• It interacts with cimetidine, increasing mebendazole plasma levels. Phenytoin & carbamazepine decreasing mebendazole plasma levels, hence mebendazole dose may need to be increased
• Non-drug treatment: Adult threadworms don’t live >6 weeks. Wash perianal area, immediately after rising to remove eggs laid at night. Wash hands & scrub nails on waking, before eating & after each toilet visit. Children <6 months are best managed without medication - clean bottom gently & thoroughly at each nappy change
• On 1st day of treatment  Wash sleepwear, bed linen, towels at normal temp. Thoroughly vacuum daily (also vacuum mattresses) & damp dust.
• Wear close-fitting underpants or knickers at night. Change them every morning.
• Cotton gloves may help prevent night-time scratching. Wash them daily.
• Discourage nail biting and finger sucking. Avoid the use of shared towels or flannels.

Question 17

Oral thrush

Answer 17

• White plaques are formed which cannot be removed.
• Broad-spectrum antibiotics, cytotoxics and corticosteroids may predispose to thrush.
• When to refer: Babies <4 months, No obvious cause, Recurrent/persistent thrush, Failed medication (no improvement in symptoms after a week of treatment)
• Miconazole oral gel is available OTC & should be applied to the plaques using a clean finger QDS after eating in adults & children >6y and BD in children 4 months to 5y.
• Continue treatment for 2 days after symptoms have gone, to eradicate all infection.
• Miconazole oral gel is not licensed for OTC use in children <4 months. Also, not suitable for patients on warfarin as it can increase their INR.

Question 18

Whooping Cough (Pertussis)

Answer 18

• Incubation period ≈7 days (range: 5-21 days)
• Catarrhal phase: ≈1-2 week. Starts with dry cough. May show signs similar to URTI such as catarrh.
• Paroxysmal phase: ≈1 month. Paroxysms (rapid/intense bouts) of coughs to expel mucus from chest, with whooping heard when breathing in after coughing. Post-tussive vomiting and generalised symptoms.
• Convalescent phase: Can last >2 months. Gradual improvement in symptoms.
• Treatment: Paracetamol or ibuprofen for symptomatic relief. Keep hydrated
• If suspected/confirmed, stay away from school for ≈5 days after starting antibiotics, or 21 days after the start of cough (whichever sooner).

Question 19

Cradle Cap (Infantile seborrhoeic dermatitis)

Answer 19

• Seen on scalp (but can appear on other areas e.g. face/napkin area). Scales are yellow/brown, large & greasy. Other areas may appear red. Rash is confluent, and itching is relatively mild if at all. Usually starts <6 months old & is self-limiting.
• Treatment: Regularly wash scalp with baby shampoo and brush with soft brush to loosen scales. Can also oil scalp then gently brush to soften scales then shampoo.
• Could suggest ketoconazole 2% shampoo twice weekly or Dentinox Cradle Cap

Question 20

Atopic dermatitis

Answer 20

• A chronic non-infective inflammatory skin condition characterised by itchy red rash. Usually starts within first 6 months of life & predominantly affects young children.
• Refer: Moderate/severe atopic dermatitis, Medication failure - 2 or more flare-ups per month, Presence of secondary infection (weeping & crusting lesions).
• Avoid irritants, use emollients frequently, keep nails short, rub with fingers for itch
• Use antihistamine for itching e.g. Chlorphenamine:
  o Children 1-2 years: 2.5mL (1 mg) BD.
  o Children 2-5 years: 2.5 mL (1 mg) TDS-QDS.
  o Children >6 years: 5 mL (2 mg) TDS-QDS

Question 21

Ibuprofen doses

Answer 21

• 3 months & > for fever caused by immunisation - ONE 2.5ml dose up to twice a day (6h apart)
• 3 - 6 months (>5kg): 2.5ml TDS.
• 6 months - 1 year: 2.5ml TDS-QDS.
• 1 - 3 years: 5ml TDS.
• 4 - 6 years: 7.5ml TDS.
• 7 - 9 years: 10ml TDS.
• 10 - 12 years: 15ml TDS.

Question 22

Paracetamol: 120mg/ml

Answer 22

up to QDS
• 3 - 6 months	2.5 ml
• 6 months - 2 years	5 ml
• 2 - 4 years	7.5 ml
• 4 - 6 years	10 ml

Question 23

Paracetamol: 250mg/ml

Answer 23

• 6 - 8 years 5 ml
• 8 - 10 years 7.5 ml
• 10 - 12 years 10 ml
• 12 – 16 years 10-15ml
• Over 16 years 10-20ml