Child Health

Question 1

What is meningitis?

Answer 1

the inflammation of the meninges covering the brain

Question 2

What is the most common type of meningitis in infants?

Answer 2

viral meningitis

Question 3

What is the most common mechanism by which bacterial meningitis occurs?

Answer 3

inflammation of the meninges following bacteraemia.

Question 4

What is the pathophysiology of bacterial meningitis, secondary to bacteraemia?

Answer 4

inflammatory mediators and activated leukocytes

endothelial damage → cerebral oedema → raised ICP

decreased cerebral oedema

Question 5

What organisms most commonly cause bacterial meningitis in a child less than 3 months old?

Answer 5

Group B Streptococcus, Listeria monocytogenes, E. coli and other coliforms

Question 6

What organisms most commonly cause bacterial meningitis in a child older than 3 months of age?

Answer 6

Neiserria meningitides, Streptococcus pneumoniae

Question 7

What viruses can cause meningitis in children?

Answer 7

enteroviruses, parechovirus, Epstein–Barr virus (EBV), adenoviruses, and mumps.

Question 8

Children of what age group are mainly affected by tuberculous meningitis?

Answer 8

children under the age of 5 years

Question 9

How common is meningitis caused by mumps in the UK?

Answer 9

rare

this is because of the measles, mumps, and rubella (MMR) vaccine

Question 10

What are the features of meningitis to ask for in a history?

Answer 10

fever, headache, photophobia, lethargy, poor feeding/vomiting, irritability, hypotonia, drowsiness, loss of consciousness, seizure

Question 11

What are signs of meningitis on examination?

Answer 11

fever, purpuric rash, neck stiffness, bulging fontanelle in infants, opisthotonus (arching of the back), positive Brudzinski/Kernig sign, shock, focal neurological signs, altered consciousness level, papilloedema (rare)

Question 12

What is a purpuric rash in a child with meningitis indicative of?

Answer 12

meningococcal disease

Question 13

What are the late signs of meningitis?

Answer 13

bulging fontanelle, neck stiffness, arched back (opisthotonos)

Question 14

How does meningitis caused by parechovirus typically present?

Answer 14

with a ‘sepsis’-like syndrome — very unwell and with a high temperature

Question 15

What investigations should be considered in a child with suspected meningitis?

Answer 15

full blood count, blood glucose and blood gas, coagulation screen, C-reactive protein, Ureas and electrolytes, LFTs, culture of blood; throat swab, urine and stool culture for bacteria, viral PCR on collected samples, lumbar puncture unless contraindicated

Question 16

What are the contraindications for lumbar puncture in a child?

Answer 16

cardiorespiratory instability, focal neurology signs, signs of raised intracranial pressure, coagulopathy, thrombocytopenia, local infection at site of lumbar puncture, if doing so would cause a delay

Question 17

What are the changes that occur in CSF in bacterial meningitis?

Answer 17

Appearance: turbid

White blood cells: very increased polymorphs

Protein: very increased

Glucose: very decreased

Question 18

What are the changes that occur in CSF in viral meningitis?

Answer 18

Appearance: clear

White blood cells: increase in lymphocytes (initially it may be polymorphs)

Protein: normal or increased

Glucose: normal or decreased

Question 19

What are the changes that occur in CSF in tuberculous meningitis?

Answer 19

Appearance: turbid or clear or viscous

White blood cells: increased lymphocytes

Protein: extremely increased

Glucose: extremely decreased

Question 20

What investigation is used to diagnose suspected viral meningitis?

Answer 20

a PCR of cerebrospinal fluid (CSF)

Question 21

What is the aim of management for meningitis?

Answer 21

to treat the source of infection

Question 22

What is the preferred antibiotic to cover common causes of meningitis in a child over 3 months?

Answer 22

ceftriaxone

Question 23

What investigation should be performed in a child with suspected meningitis who has already been given antibiotics?

Answer 23

PCR

Question 24

What are the complications of meningitis that can occur in a child?

Answer 24

hearing impairment, local vasculitis, local cerebral infarction, subdural effusion, hydrocephalus, cerebral abscess

Question 25

What causative organism is most associated with subdural effusion as a complication of meningitis?

Answer 25

*Pneumococcal meningitis*

Question 26

What investigations can be used to diagnose cerebral abscess as a complication of meningitis?

Answer 26

CT or MRI scan

Question 27

What intervention can be used as prophylactic treatment to eradicate nasopharyngeal carriage of meningococcal meningitis in the household of a child with meningitis?

Answer 27

ciprofloxacin

Question 28

What vaccine should contacts of a patient with A, C, W and Y infection be offered?

Answer 28

MenACWY

Question 29

What is squint?

Answer 29

The visual axis is not properly aligned, such that the eyes cannot focus on one object at the same time.

Question 30

What is the most common cause of squint in the UK?

Answer 30

Idiopathic.

Question 31

What are non-idiopathic causes of squint to consider?

Answer 31

Reduced vision in one eye: refractive errors, retinoblastoma, cataracts, ocular malformations; Neurodevelopmental disorders (i.e. cerebral palsy and Down syndrome); Abnormalities of extra-ocular muscles and their control: congenital abnormalities, acquired abnormalities (i.e. myasthenia gravis, head injury, hydrocephalus).

Question 32

What risk factors for squint?

Answer 32

Low birth weight and premature infants; maternal smoking during pregnancy; hypermetropia; family history; pseudo squint: the child appears to have a squint, but the eyes are correctly aligned.

Question 33

How can you classify squint?

Answer 33

Esotropia: where the other eye turns inwards; exotropia: where the other eye turns outwards; hypertropia: where the other eye turns upwards; hypotropia: where the other eye turns downwards.

Question 34

What percentage of children are affected by squint or strabismus?

Answer 34

About 2.1% of UK children.

Question 35

In which ethnicities are higher rates of squint reported?

Answer 35

Higher rates globally are reported in white and Asian children.

Question 36

What are clinical features of squint?

Answer 36

A turning eye, poor motor coordination, reduced vision in a child → squint.

Question 37

What tests can be done in general practice for squint?

Answer 37

Corneal light reflex test; cover test.

Question 38

How do you perform the corneal light reflex test?

Answer 38

A light is shone onto the eyes. If eyes are normally aligned, the reflection will be symmetrical in both eyes. In squint, the reflection will be asymmetrical.

Question 39

How do you perform the cover test?

Answer 39

Have the child fix their vision on an object. Cover one eye and watch the uncovered eye for movement. Repeat this with the alternate eye. In the case of squint, the eye will move to uptake fixation on the object whilst the other is covered.

Question 40

How should a child with squint identified in general practice be managed?

Answer 40

Refer to ophthalmology.

Question 41

How do you distinguish between Kawasaki disease and Scarlet fever?

Answer 41

Scarlet fever spares the peri-oral area

Question 42

Pansystolic murmur in infant with cardiomegaly → ?

Answer 42

Ventricular septal defect

Question 43

What is the genetic defect in fragile X syndrome?

Answer 43

trinucleotide repeat in FMR1 gene

Question 45

What medication is used to treat patent ductus arteriosus if the baby is well?

Answer 45

Ibuprofen, indomethacin, paracetamol ## Footnote Ibuprofen = I don’t want you open, indomethacin = I don’t want the cold air in, paracetamol = Uhh, I don’t want to see blood at all.

Question 46

What is the management for patent ductus arteriosis if the baby is unwell?

Answer 46

Surgical procedure ## Footnote Transcatheter PDA closure.

Question 47

What are the indications for transcatheter PDA closure to treat patent ductus arteriosus?

Answer 47

if it is moderate or large, the baby had endocarditis, or the patent duct is audible,

Question 48

What are the features of an innocent murmur?

Answer 48

short, systolic, single, sensitive, soft, small

Question 49

What follow-up should be performed for a neonate treated for a urinary tract infection?

Answer 49

ultrasound in 6 weeks!

Question 50

What is the summary of pathophysiology of pyloric stenosis?

Answer 50

Thickening of the pylorus leading to gastric outflow obstruction.

Question 51

What is the age range of onset in pyloric stenosis?

Answer 51

2-8 weeks of age.

Question 52

What is the gender predominance of pyloric stenosis?

Answer 52

More common in boys (2:1).

Question 53

What is the sibling order predominance in pyloric stenosis?

Answer 53

Particularly on the first-born.

Question 54

What side of the family is likely to have a history of pyloric stenosis?

Answer 54

Maternal history.

Question 55

What are the features of vomiting in pyloric stenosis?

Answer 55

Non-bilious; increases in frequency and force (→projectile).

Question 56

What biochemical disturbance is associated with pyloric stenosis?

Answer 56

Hypochloraemic hypokalaemic hypernatraemia. ## Footnote Low chloride, low potassium, high sodium.

Question 57

What signs are associated with pyloric stenosis?

Answer 57

Gastric peristalsis.

Question 58

purpura on the lower limbs + abdominal pain + arthritis → ?

Answer 58

Henoch-Schonlein purpura

Question 59

purpura on the lower limbs + abdominal pain + arthritis → essential initial investigation to perform?

Answer 59

urine dipstick (Henoch-Schonlein purpura)

Question 60

A halo sign on X-ray in the oesophagus suggests → ?

Answer 60

the patient has swallowed a battery button.

Question 61

Investigation to evaluate the presence and severity of developmental dysplasia of the hip?

Answer 61

ultrasound (hip)

Question 63

When should admission for otitis media be considered?

Answer 63

Children under 3 months with a temperature of 38 or more. Children with suspected acute complications of otitis media such as meningitis, mastoiditis, or facial nerve palsy. Children who are severely systemically unwell.

Question 64

When may antibiotics be considered to treat acute otitis media?

Answer 64

It may be considered if the child has otorrhoea or is aged < 2 years and has bilateral AOM.

Question 65

What is the first-line treatment for acute otitis media?

Answer 65

amoxicillin for 5-7 days

Question 66

What is the most reliable diagnostic test for whooping cough?

Answer 66

PCR

Question 67

What is the Galeazzi test used to do?

Answer 67

to determine if leg length discrepancy in developmental dysplasia of the hip is tibial or femoral

Question 68

What criteria can be used to diagnose a septic arthritis?

Answer 68

Kocher Criteria

Question 69

What are the parts of the Kocher criteria for septic arthritis?

Answer 69

* Are they weight bearing? * Is their temperature above 38.5C? * Is their ESR avove 40mm/hr? * Is their WBC above 12 000 cells/mm3?

Question 70

What is the inheritance pattern for Duchenne’s muscular dystrophy?

Answer 70

X-linked recessive pattern

Question 71

swelling on baby’s head + crosses suture lines → ?

Answer 71

caput succedaneum

Question 72

What is the most common cause of obstructive sleep apnoea in children aged 2-6 years?

Answer 72

adenotonsilar hypertrophy

Question 73

How long is the incubation period of chickenpox?

Answer 73

3 weeks

Question 74

What is diabetic ketoacidosis?

Answer 74

D - diabetes = >11.0mmol/L K - ketones = urinary ketones 2+ OR blood ketone conc. >3.0 Acidosis = low blood pH or blood bicarbonate concentration of <15.0mmol/L

Question 75

What is the initial immediate management of diabetic ketoacidosis in a child?

Answer 75

initial bolus of 10ml/kg 0.9% NaCl over 15 minutes

Question 76

How many times should you repeat a fluid bolus to restore a child with diabetic ketoacidosis before seeking senior assistance to consider commencing inotropes?

Answer 76

4 times (at 40ml/kg)

Question 77

What fluid should be started after resuscitation in a child with diabetic ketoacidosis? And, when should you stop?

Answer 77

0.9% sodium chloride with 20 mmol potassium chloride in 500 ml (40 mmol per litre) when blood glucose levels fall below 14.0mmol/L

Question 78

When should insulin therapy be started in a child with diabetic ketoacidosis?

Answer 78

1-2 hours after beginning intravenous fluid therapy

Question 81

At what rate should insulin be administered in a child with diabetic ketoacidosis?

Answer 81

0.1units/kg/hour