Child Health Flashcards
(336 cards)
1
Q
diagnostic criteria from bronchiolitis
A
coryzal prodrome lasting 1-3 days followed by;
persistant cough
tachypnoea and or chest recession
wheeze and or crackles on auscultation
REMEMBER <6 weeks may present with apnoea without other signs
2
Q
when should bronchiolitis be IMMEDIATELY referred to hospital
A
apnoea child looks seriously unwell severe resp distress (grunting, marked chest recession, resp rate >70) central cyanosis persistent sats <92% on air
3
Q
when should you consider referring a child with bronchiolitis
A
resp rate >60
difficulty breast feeding or inadequate oral fluid intake
clinical dehydration
4
Q
management of bronchiolitis
A
supplemental oxygen if persistently <92%
give fluids by naso- or oro-gastric tube if not feeding
5
Q
what information must be passed on to parents if child is not admitted
A
red flags: increased work of breathing (grunting, nasal flaring, marked chest recession), fluid intake is 50-75% normal or no wet nappy in 12 hours, apnoea or cyanosis, exhaustion
no smoking in the home
follow up if needed
6
Q
differentials for bronchiolitis
A
pneumonia - high fever (>39) - persistently focal crackles viral-induced wheeze or early-onset asthma - persistent wheeze without crackles - recurrent episodic wheeze - personal or family history of atopy
7
Q
risk factors for severe bronchiolitis
A
chronic lung disease haemodynamically significant congenital heart disease age <3 months premature birth, esp <32 weeks neuromuscular disorders immunodeficiency
8
Q
discharge a child with bronchiolitis when
A
clinically stable
taking adequate oral fluids
maintained sats >92% in air for 4 hours, including a period of sleep
9
Q
temperature measurement in <4 weeks
A
electronic thermometer in axilla
10
Q
temperature measurement in 4 weeks to 5 years
A
electronic thermometer in axilla
chemical dot thermometer in the axilla
infra-red tympanic thermometer
11
Q
high risk symptoms in feverish child
A
pale, mottled, ashen, blue skin lips or tongue
no response to social cues
appearing ill to health care professional
does not wake or if roused does not stay awake
weak, high-pitched or continuous cry
grunting
resp rate >60
moderate or severe chest indrawing
reduced skin turgor
bulging fontanelle
12
Q
intermediate-risk symptoms in feverish child
A
pallor of skin, lips or tongue reported by parent or carer not responding normally to social cues no smile wakes only with prolonged stimulations decreased activity nasal flaring dry mucous membranes poor feeding in infants reduced urine output rigors
13
Q
low-risk symptoms in feverish child (and no high or intermediate risk symptoms)
A
normal colour of skin, lips and tongue responds normally to social cues content/smiling stays awake or wakens quickly strong normal cry or not crying normal skin and eyes moist mucous membranes
14
Q
cap refill over ____ is a sign of intermediate-risk illness
A
cap refill over 3 secs is a signs of intermediate-risk illness
15
Q
temperature has different risk factors in different age groups
which temperatures are associated with which risk groups in <3 months and 3-6 months
A
<3 months: temp >38 = high risk group
3-6 months: temp 39 = at least intermediate risk group
16
Q
fever lasting >5 days should be assessed for…
A
Kawasaki disease
duration of fever should not be used to predict likelihood of serious illness otherwise
17
Q
definition of tachycardia in different age groups
A
<12 months = >160
12-24 months = >150
2-5 years = >140
18
Q
signs of dehydration in children with fever
A
prolonged cap refill abnormal skin turgor abnormal resp pattern weak pulse cool extremities
19
Q
when to consider meningococcal disease in a child with fever
A
non-blanching rash plus any of
- ill looking child
- lesions >2 mm (purpura)
- cap refill >3 secs
- neck stiffness
20
Q
when to consider bacterial meningitis in a child with fever
A
neck stiffness
bulging fontanelle
decreased LOC
convulsive status epilepticus
classic signs (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants
21
Q
when to consider herpes simplex encephalitis in feverish child
A
focal neurological signs
focal seizures
decreased LOC
22
Q
when to consider pneumonia in child with fever
A
tachypnoea crackles in chest nasal flaring chest undraping cyanosis sats <95% on air
23
Q
definition of tachypnoea in different age groups
A
0-5 months = >60
6-12 months = >50
>12 months = >40
24
Q
when to consider UTI in child with fever
A
in ALL children >3 months + fever
> 3 months
- vomiting
- poor feeding
- lethargy
- irritability
- abdominal pain or tenderness
- urinary frequency or dysuria
25
when to consider septic arthritis/osteomyelitis in a child with fever
swelling of a limb or joint
not using an extremity
non-weight bearing
26
when to consider Kawasaki disease in child with fever
```
fever >5 days
bilateral conjunctival injection without exudate
erythema and craving of lips
strawberry tongue
erythema of oral and pharyngeal mucosa
oedema and erythema in hands and feet
polymorphous rash
cervical lymphadenopathy
```
ask about presence of symptoms since onset of fever as they may have clears up by time of assessment
27
which investigations should be performed in infants younger than 3 months with fever
```
FBC
blood culture
CRP
urine testing
CXR if respiratory signs suggestive of pneumonia
stool culture if diarrhoea present
```
28
indications of LP in feverish children <3 months
>1 month
all infants 1-3 months who appear unwell
1-3 months with a WCC <5x10^9 or >15x10^9
29
which investigations should be performed in infants >3 months with fever
FBC
blood culture
CRP
urine testing
30
which investigations should be considered in children with red/high risk features with fever
LP
CXR
serum electrolytes and blood gas
31
how to investigate child with no apparent source of fever with 1 or more amber features
urine sample
bloods (FBC, CRP, cultures)
LP (if <1 year)
CXR (fever >39, WBC <20x10^9)
32
immediate management of children presenting with fever and shock
IV fluid boys of 20 ml/kg (normally 0.9% NaCl)
| actively monitored and given further fluid boluses if necessary
33
when to give immediate parenteral abx to a feverish child
shock
unrousable
sign of meningococcal disease
34
which empirical IV abx should be given to feverish children
>3 months: third generation cephalosporin (cefotaxime or ceftriaxone)
<3 months: add in listeria cover (ampicillin or amoxicillin)
35
what to give children with symptoms suggestive of herpes simplex encephalitis
IV aciclovir
36
which infections are covered by 3rd generation cephalosporin
```
Neisseria meningitidis
step pneumoniae
E coli
staph aureus
HiB
```
37
advice to parents caring of a feverish child at home
```
regular fluids
signs of dehydration
non-blanching rash
check during the night
no nursery or school while fever persists but notify them of illness
```
38
when parents should seek help if caring of a feverish child at home
fits
non-blanching rash
they feel they are less well than when they first sought advice
fever lasts >5 days
39
initial assessment of under 12's with suspected sepsis
```
temperature
heart rate
resp rate
O2 sats
cap refill
```
assess BP too if heart rate or cap refill are abnormal
40
why is measuring blood pressure less prioritised in children
hypotension occurs much later in children as they are much better at peripheral constriction
correctly sized cuffs may not be available in non-paediatric settings
41
what skin signs should be assessed for in suspected sepsis
```
mottled/ashen skin
cyanosis of skin, lip or tongue
non-blanching rash
breaches of skin integrity (cuts, burns, skin infections)
other rashes
```
42
features in history that are high risk for sepsis >12 yo
objective evidence of new altered mental state
43
features in history that are moderate-high risk for sepsis >12 yo
reports of new onset altered behaviour or mental state
history of acute deterioration of functional ability
impaired immune system (illness or drugs)
trauma, surgery or invasive procedure in the last 6 weeks
44
resp signs that are high risk for sepsis >12 yo
resp rate >25
| new need for oxygen (40% FiOs or more) to maintain sats to 92%
45
resp signs that are mod/high risk for sepsis >12 yo
resp rate 21-24
46
circulatory signs that are high risk for sepsis >12 yo
HR >130
| not passed urine in previous 18 hours
47
circulatory signs that are mod/high risk for sepsis >12 yo
HR 91-130
| not passed urine for 12-18 hours
48
blood pressure that is high risk for sepsis >12yo
systolic >90 mmHg
| or systolic >40 mmHg less than normal
49
blood pressure tat is mod/high risk for sepsis >12 yo
91-100 mmHg
50
behaviour signs that are high risk for sepsis 5-11 yo
objective evidence of altered behaviour or mental state
appears ill to a healthcare professional
does not wake or does not stay awake
51
behaviour signs that are mod-high risk for sepsis 5-11 yo
not behaving normally
decreased activity
parent or carer concern that child is behaving differently than normal
52
resp signs that are high risk of sepsis 5-11 yo
All ages: sats <90% on air
5 yo: resp rate >29
6-7 yo: RR >27
8-11 yo: RR >25
53
resp signs that are mod-high risk of sepsis 5-11 yo
all ages: sats <92% on air
5 yo: RR 24-28
6-7 yo: RR 24-26
8-11 yo: RR 22-24
54
circulatory signs that are high risk of sepsis 5-11 yo
all ages: HR <60
5 yo: HR >130
6-7: HR >120
8-11: HR >115
55
circulatory signs that are mod-high risk for sepsis 5-11 yo
all ages: cap refill >3 secs, reduced urine output
5 yo: HR 120-129
6-7 yo: HR 110-119
8-11 yo: HR 105-114
56
temperature that is mod-high risk for sepsis 5-11 yo
all ages: temp <36
57
other signs that are mod-high risk for sepsis 5-11 yo
leg pain
| cold hands or feet
58
management of patients with 1+ high risk sepsis factor
arrange for immediate senior review
venous blood test for: blood gas (glucose and lactose), culture, FBC, CRP, U&E, creatinine, clotting screen
broad spectrum abx
fluid bolus if lactate >2 mmol/L or systolic BP <90 mmHg
59
when managing a patient >12 yo with sepsis a consultant should be alerted if the patient fails to respond to initial abx/fluid resuscitations in 1 hour
failure to respond includes:
systolic BP persistently <90 mmHg
reduced LOC despite resuscitation
resp rate >25 or new need for mechanical ventilation
lactate not reduced by >20% of initial value
60
when to consider inotropes or vasopressors in children 5-11 with suspected sepsis
any high risk criteria
lactate >4 mmol/L
ALSO give IV fluid bolus
61
when managing a patient <12 yo with sepsis a consultant should be alerted if the patient fails to respond to initial abx/fluid resuscitations in 1 hour
failure to respond includes:
reduced LOC despite resuscitation
HR or RR fulfil high risk criteria
lactate remains >2 mmol/L
62
fluid resus guidelines in patients <16 with suspected sepsis
glucose-free crystalloids containing sodium in range of 130-154 mmol/l
bolus of 20 ml/kg over less than 10 mins
63
fluid resus guidelines in neonates with suspected sepsis
glucose-free crystalloids containing sodium in range of 130-154 mmol/l
bolus of 10-20 ml/kg over less than 10 mins
64
what are contraindication for LP
```
suggested raised ICP
reduced or fluctuating LOC
relative bradycardia and hypertension
focal neuro sings
abnormal posture or posturing
unequal, dilated or poorly responsive pupils
abnormal 'doll's eye' movements
shock
extensive or spreading purpura
after convulsion until stabilised
coagulation abnormalities
local superficial infection at LP site
resp insufficency
```
65
define sepsis
life-threatening organ dysfunction due to a dysregulated host response to infection
66
define early onset neonatal bacterial infection
infection with onset within 72 hours of birth
67
signs that are suggestive of early onset neonatal infection
```
abnormal behaviour
unusually floppy
difficulty feeding or tolerating feeds
abnormal temperature (<36 or >38)
rapid breathing
change in skin colour
```
68
when to offer intrapartum antibiotics and which abx should be used
previous baby with invasive group B strep infection
group B strep colonisation, bacteriuria or infection in the current pregnancy
IV benzpen
69
what is first line empirical treatment of early onset neonatal infection
IV benpen with gentamicin
70
investigations in suspected neonatal infection
CRP before starting abx
| CRP after 18-24 hours
71
consider stopping abx after 36 hours if
blood culture is negative
initial clinical suspicion of infection was not strong
clinical condition is reassuring with no clinical indicators of possible infection
levels and trends of CRP are reassuring
72
risk factors for early onset neonatal infection
invasive group B strep in previous baby
maternal group B strep colonisation, bacteriuria or infection in current pregnancy
PROM
preterm birth following spontaneous labour (<37 weeks)
suspected or confirmed ROM for more than 18 hours in a preterm birth
intrapartum fever >38
parenteral abx given to woman during labour or in 24 hours before or after
infection in another baby if multiple pregnancy
73
clinical indications of early onset neonatal infection
```
altered behaviour or responsiveness
altered muscle tone eg floppy
feeding difficulties
feed intolerance (vomiting, excessive gastric aspirates, abdominal distension)
abnormal HR
signs of resp distress
resp distress starting more than 4 hours after birth
hypoxia
jaundice within 24 hours of birth
apnoea
neonatal encephalopathy
seizures
need for CPR
need for mechanical ventilation
temp
shock
bleeding
oliguria >24 hr after birth
altered glucose homeostasis
Metabolic Acidosis
local signs of infection
```
74
investigations before starting antibiotics in neonatal infection
CRP
| LP (strong clinical suspicion or signs of meningitis)
75
when should skin swabs be taken in neonatal infection and which empirical abx should be started in each instance
purulent eye discharge (chlamydia and gonococcus)
abx: cover gonococcus
purulent discharge or signs of periumbilical cellulitis
abx: IV fluclox and gentamicin
76
what is first line empirical abx for neonatal infection
IV benpen with gent
benpen: 25 mg/kg every 12 hours
gent: 5 mg/kg starting dose (every 36 hours)
77
consider stopping abx for neonatal infection after 36 hours if
blood culture is negative
initial clinical suspicion of infection was not strong
baby's clinical condition is reassuring with no clinical indicators of possible infection
levels and trends of CRP concentration are reassuring
78
how long should standard abx treatment be in babies with positive blood culture or with negative culture and strong clinical suspicion
7 days
| longer if not yet recovered or advisable based on the pathogen
79
what is the trough concentration
gentamicin concentration just before giving another dose
80
what are the recommended thought concentrations for gentamicin
<2 mg/litre
| if lasts more than 3 doses aim for <1 mg/litre
81
what features would cause you to withhold a gentamicin dose
evidence of renal dysfunction eg elevated serum urea or creatine concentration, or anuria
82
when would you measure peak gentamicin concentrations
1 hour after starting infusion
83
when would you measure peak blood gentamicin
oedema
macrosomia (BW >4.5 kg)
unsatisfactory response to treatment
proven gram-negative infection
84
most common cause of meningitis in children
Neisseria meningitidis
strep pneumo
HiB
85
most common cause of meningitis in <3 months
group B strep
E coli
strep pneumo
listeria monocytogenes
86
describe IV fluid resus in children with suspected/confirmed meningococcal sepsis
immediate fluid bolus 20 ml/kg NaCl 0.9% over 5-10 mins
give second bolus 20 ml/kg NaCl or albumin 4.5% over 5-10 mins
if still shocked after 40 ml/kg:
- give third bolus
call anaesthetics for urgent tracheal intubation and mechanical ventilation
start vasoactive drugs
87
investigations in a child/young person with unexplained petechial rash and fever
```
FBC
CRP
coagulation screen
blood culture
PCR for N meningitidis
blood glucose
blood gas
```
88
abx in child/young person with suspected meningitis
IV ceftriaxone
89
abx in infant <3 months with suspected meningitis
IV cefotaxime plus amoxicillin
90
when should vancomycin be added in meningitis
recent travel outside the UK or have had prolonged exposure to antibiotics within the past 3 months
91
in which patient group should ceftriaxone not be used and why
premature babies or babies with jaundice, hypoalbuminaemia or acidosis
may exacerbate hyperbilirubinaemia
92
which metabolic disturbances should be monitored for in children with bacterial meningitis
```
hypoglycaemia
acidosis
hypokalaemia
hypocalcaemia
hypomagnesaemia
anaemia
coagulopathy
```
93
in a child/young person with meningitis what are the indications fo intubation
threatened or actual loss of airway patency
need for assisted ventilation
clinical observation of increasing work of breathing
hypoventilation or apnoea
features of resp failure
94
along with abx, which drug should be given in meningitis
dexamethasone before or with first dose of abx
do not start more than 12 hours after abx started
95
possible long term complications of meningitis
```
hearing loss
orthopaedic complications
skin complications (scarring from necrosis)
psychosocial problems
neurological and developmental problems
renal failure
```
96
sings of UTI in infants <3 months
most common:
fever, vomiting, lethargy, irritability
less common:
poor feeding, failure to thrive
least common:
abdominal pain, jaundice, haematuria, offensive urine
97
signs of UTI in preverbal children
most common:
fever
less common:
abdominal pain, loin tenderness, vomiting, poor feeding
least common:
lethargy, irritability, haematuria, offensive urine, failure thrive
98
signs of UTI in verbal children
most common:
frequency, dysuria
less common: dysfunctional voiding, changes to continence, abdominal pain, loin tenderness
least common:
fever, malaise, vomiting, haematuria, offensive urine, cloudy urine
99
what is the recommended way to collect a urine sample from children?
if this is not possible which other methods are available?
clean catch urine sample
urine collection pads
catheter samples
suprapubic aspiration
100
which tests should be performed on urine samples in children:
<3 months
3 months - 3 years
over 3 years
<3 months:
send sample for urgent microscopy and culture
3 months - 3 years:
dipstick testing
>3 years:
dipstick testing
101
indications for antibiotic treatment in suspected UTI age <3 months
start empirical abx if clinical suspicion
IV amoxicillin and gent
send urine for culture but do not delay abx
102
indications for abx in suspected UTI age 3 months - 3 years
leukocyte esterase, nitrite or both are positive on dipstick start abx and send urine for culture
trimethoprim PO or nitrofurantoin PO
103
indications for abx in suspected UTI age >3 years
leukocytes + nitrite positive:
abx
leukocyte negative + nitrite positive:
abx
leukocyte postive + nitrite negative:
abx started only if there are clinical signs of UTI (may be indicative of infection elsewhere)
both negative:
no abx, no UTI
104
when should urine sample be sent for culture
suspicion of acute pyelonephritis or upper UTI
high-intermediate risk of serious illness
<3 months
positive result for leukocyte or nitrite
recurrent UTI
doesn't respond to treatment in 24-48 hours
clinical symptoms and negative dipstick
105
what are risk factors for UTI and may indicate serious underlying pathology
```
poor urine flow
previous UTI
recurrent fever of uncertain origin
antenatally diagnosed renal abnormality
Fix of vesicoureteric reflux or renal disease
constipation
dysfunctional voiding
enlarged bladder
abdominal mass
evidence of spinal lesion
poor growth
high BP
```
106
how to differentiate between acute pyelonephritis/upper UTI and cystitis/lower UTI
bacteriuria and fever >38 = pyelonephritis/upper UTI
fever <38,loin pain/tenderness and bacteriuria = pyelonephritis/upper UTI
bacteriuria - systemic signs or symptoms = cystitis/lower UTI
DO NOT USE CRP ALONE
107
investigation of UTI in children <6/12
US in all to detect structural abnormality
VCUG and venogram (after 4/12) if US abnormal
atypical UTI (non E Coli, no response to abx)
recurrent UTI
108
investigation of UTI in children 6 months to 3 years
no imaging if uncomplicated UTI
US and venogram if atypical or recurrent
no VCUG
109
investigation of UTI in children >3 years
US and renogram only if recurrent UTI
110
features of atypical UTI
```
seriously ill
poor urine flow
abdominal or bladder mass
raised creatinine
sepsis
failure to respond to abx in 48 hours
infection with E coli
```
111
define recurrent UTI
2 or more episodes of UTI with acute pyelonephritis/upper UTI
1 episode of UTI with acute pyelonephritis/upper UTI PLUS one or more episode of lower UTI
3 or more episodes of lower UTI
112
when is referral to a paediatric nephrologist necessary in children with UTI
bilateral renal abnormalities
impaired kidney function
raised blood pressure
proteinuria
113
when should stool samples be performed on children with diarrhoea
suspicion of sepsis
blood/mucous in stool
immunocompromised
consider them if;
recent travel abroad
diarrhoea not improved in 7 days
uncertainty about diagnosis
114
fluid management in children with gastroenteritis but no clinical dehydration
continue breast feeding/other milk feeds
encourage fluid intake
discourage drinking fruit juices and carbonated drinks
oral rehydration solutions if increased risk of dehydration
115
fluid management in children with gastroenteritis and clinical dehydration
low osmolarity oral rehydration solution
(50 ml/kg over 4 hours as well as maintenance fluid)
consider using NG tube if unable to drink/persistent vomiting
116
when to use IV fluid in fluid management in gastroenteritis
shock is suspected/confirmed
evidence of deterioration despite oral rehydration therapy
persistent vomiting of ORS (orally or NG)
117
questions to ask in suspected gastroenteritis
recent contact with someone with acute diarrhoea and/or vomiting
exposure to known source of enteric infection (contaminated water or food)
recent travel abroad
118
signs that suggest diagnosis other that simple gastroenteritis
```
fever
SOB/tachyp
altered conscious state
meningism
bulging fontanelle
blood/mucous in stool
bilious green vomit
severe or localised abdominal pain
abdominal distension or rebound tenderness
```
119
which children are at greater risk of dehydration due to diarrhoea/gastroenteritis
<1 year, particularly <6 months
low birth weight
>5 diarrhoeal stools in previous 24 hours
>2 vomits in previous 24 hours
not been offered/tolerate supplementary fluids
stopped breastfeeding
malnutrition
120
red flags for dehydration
```
appears unwell/deteriorating
altered responsiveness
sunken eyes
tachycardia/tachyp
reduced skin turgor
```
121
which features suggest Hypernatraemia dehydration
```
jittery movements
increased muscle tone
hyperreflexia
convulsions
drowsiness or coma
```
122
when to give abx in gastroenteritis
suspected/confirmed sepsis
extra-intestinal spread of bacterial infection
<6 months, malnourished or immunocompromised with salmonella
C diff, giardiasis, shigella
123
abx in C diff in children
1st line PO met
| 2nd line PO vanc
124
when to suspect croup
```
sudden onset, seal-like barking cough
stridor
chest wall or sternal undraping
worse at night
increase with agitation
```
125
differentials for croup
```
bacterial tracheitis
epiglottitis
foreign body
quinsy
allergic reaction
```
126
features of epiglottitis
```
sudden onset fever
dysphagia
drooling
anxiety
non-barking cough
preferred posture if upright with head extended
```
127
features of foreign body in upper airway
sudden onset dyspnoea and stridor
usually history of inhalation of object
no prodrome or viral symptoms
128
features of quinsy
```
dysphagia
drooling
stridor (occasionally)
dyspnoea
tachyp
neck stiffness
unilateral cervical adenopathy
more gradual onset
```
129
what is croup
laryngotracheobronchitis
symptoms caused by upper airway obstruction due to generalised inflammation of the airways
typically parainfluenza virus types 1 or 3
130
risk factors for croup
6 months - 6 years
male sex
previous intubation
131
how to categorise severity of croup symptoms
mild: seal-like barking cough, no stridor or recession at rest
moderate: seal-like barking cough with stridor/recession at rest; no agitation/lethargy
severe: like moderate but with agitation/lethargy
132
signs of impending resp failure in croup
```
increasing upper airway obstruction
sternal/intercostal recession
asychronus chest wall and abdominal movement
fatigue
pallor/cyanosis
decreased level of consciousness
tachycardia
resp rate >70
```
133
when to consider hospital admission for children with croup
```
moderate or severe illness
resp rate >60
<3 months
inadequate fluid intake
immunodeficiency
```
134
pre-hospital management of moderate/severe croup
supplementary O2 if severe
| oral dexamethasone or inhaled budesonide
135
management of mild croup (at home)
single dose of oral dexamethasone
advise symptoms should resolve in 48 hours
take to hospital if continuous stridor, undraping, restless or agitated
ambulance if very pale/blue/grey, unusually sleepu or unresponsive, struggling to breath, want to sit instead of lie down etc
136
children and young people presenting with suspected seizure should be seen by a specialist in the diagnosis and management of epilepsy within _______ of presentation
2 weeks
137
define suspected epileptic seizure
acute episode of altered functioning, presumed to be the direct result of a change in electrical activity in the brain
138
what is SUDEP
sudden unexpected death in epilepsy
139
how is the risk of SUDEP reduced
optimising seizure control
| being beware of the potential consequences of nocturnal seizures
140
investigations in suspected epilepsy
EEG
MRI
CT if not MRI
141
MRI is particularly important in the diagnosis of epilepsy in which population
<2 years
focal onset on history, examination or EEG
continued seizures in spite of first-line medication
142
treatment of generalised seizures
first line: sodium valproate, lamotrigine, levetiracetam or topiramate
143
treatment of focal seizures with or without secondary generalisation
first line: lamotrigine, carbamazepine or levetiracetam
second line: sodium valproate or topiramate
144
which epileptic drugs are hepatic enzyme inducers and therefore reduce the effectiveness of hormonal contraceptives
carbamazepine
topiramate >200 mg/day
sodium valproate is teratogenic
145
define focal seizure
originate in networks limited to one hemisphere, and may be localised or more widely distribution
divided into retained awareness or impaired awareness
146
define generalised seizures
originate in bilaterally distributed networks and can include cortical and subcortical structures
divided into motor and non-motor (absence) seizures
147
risk factors for epilepsy
```
premature birth
complicated febrile seziures
brain development malformations
family history
head trauma, infections or tumours
CVD or stroke (older people)
dementia and neurodegenerative disorders
```
148
what should history include when assessing possible seizure
subjective symptoms at the start of the seizure (aura)
potential triggers (sleep deprivation, stress, light sensitivity, alcohol use)
specific features of the seizure
residual symptoms after the attack (post-ictal)
149
describe a tonic seizure
short lived (<1 min)
abrupt, generalised muscle stiffening (may cause a fall)
rapid recovery
150
describe a generalised tonic-clonic seizure
generalised stiffening and subsequent rhythmic jerking of the limbs
urinary incontinence
tongue biting
151
describe an absence seizure
behavioural arrest
152
describe atonic seizure
sudden onset of loss of muscle tone
153
describe myoclonic seizure
brief, 'shock-like' involuntary single or multiple jerks
154
what is the differential for epileptic seizure in children
febrile convulsions
breath-holding attacks
night terrors
stereotyped/ritualistic behaviour (LD)
155
what long term monitoring is needed for people taking anti-epileptic drugs
adverse effects and compliance
osteoporosis risk
- long term carbamazepine, phenytoin, primidone, phenobarbital, sodium valproate
- calcium and vit D supplements if appropriate
women of child-bearing age
- contraception, AEDs during pregnancy etc
156
define simple febrile seizure
isolated, generalised, tonic-clonic seizures
lasts less than 15 mins
do not recur within 24 hours or within same febrile illness
complete recovery within 1 hour
157
define complex febrile seizure
one or more of;
partial (focal) seizure (movement limited to one side of the body or one limb)
duration >15 mins
recurrent within 24 hours or within same febrile illness
incomplete recovery within 1 hr
158
define febrile status epilepticus
>30 mins
| series of seizures without full recovery in between lasting 30 mins or more
159
typical features of simple febrile seizure
6 months - 6 years
2-3 minutes, rarely >10 mins
generalised tonic-clonic
may be foaming at the mouth, difficulty breathing, pallor, cyanosis
brief post-ictal drowsiness, irritability, confusion
complete recovery within 1 hour
160
typical features of complex febrile seizure
partial onset or focal features
>15 mins
recurrent within 24 hours or same febrile illness
incomplete recovery within 1 hour
prolonged post-ictal drowsiness or transient hemiparesis (Todd's palsy)
161
differential diagnosis of febrile convulsion
with fever
- CNS infection eg meningitis/encephalitis
- rigors/delirium
- shivering
- febrile myoclonus
```
without fever
- syncope
- breath-holding attacks or reflex anoxic seizure
- head injury
- hypoglycaemia/metabolic
drug use/withdrawal
epilepsy
```
162
what is the most common cause of bacterial pneumonia in children
```
strep pneumoniae
also;
group A strep
staph aureus
haem influenzae
```
163
when to consider pneumonia in a child
```
high fever
cyanosis
raised resp rate
signs of increased work of breathing
persistently focal crackles
sats <95%
```
164
features of pneumonia in children
age, resp rate, hyperflation, wheeze, crackles
age: any age
resp rate: usually increased
hyperinflation: not present
wheeze: not usually present
crackles: course crackles, usually focal
165
features of bronchiolitis in infants
age, resp rate, hyperflation, wheeze, crackles
age: <2 yo, peak at 3-6 months
resp rate: usually increased
hyperinflation: often present (difficult to detect in infants <6 months)
wheeze: may be present
crackles: fine crackles present throughout lung fields
166
features of viral-induced wheeze
age, resp rate, hyperflation, wheeze, crackles
age: under 5 yo
resp rate: may be normal of increased
hyperinflation: may be present
wheeze: present
crackles: not usually present
167
features of infective exacerbation of asthma
age, resp rate, hyperflation, wheeze, crackles
age: any age
resp rate: may be normal or increased
hyperinflation: may be present
wheeze: present
crackles: not usually present
168
abx for non-severe CAP in children
amoxicillin PO (7 days)
clarithromycin if penicillin allergic
<1 year use co-amoxiclav PO
169
abx for severe CAP in children
co-amoxiclav IV then PO (10 days)
add clarithromycin if features of atypical pneumonia or pertussis
170
risk factors for asthma
personal or family history of aortic disease
respiratory infections in infancy
exposure (including prenatally) to tobacco smoke
premature birth and low birth weight
obesity
171
features of ciliary dyskinesia
persistent moist cough present from birth
172
features of cystic fibrosis
persistent moist cough and GI symptoms that are often present from birth
finger clubbing
failure to thrive
173
first line management of asthma in children
SABA reliever inhaler
174
second line management of asthma in children
why would it be indicated
inhaled corticosteroids
SABA use 3+ times a week
asthma symptoms 3+ times a week
woken at night by asthma symptoms 1+ times a week
175
third line management of asthma in children
leukotriene receptor antagonist (montelukast)
then LABA
176
features of a moderate asthma exacerbation in children
PEFR at least 50% best or predicted
normal speech
no features of severe/life-threatening asthma
177
features of acute severe asthma exacerbation in children
```
PEFR <50% best or predicted
resp rate >25/30/40
heart rate >110/125/140
inability to complete full sentences in one breath
accessory muscle use
inability to feed (infants)
sats <92%
```
178
features of life-threatening asthma exacerbation in children
```
PEFR <33% best or predicted
sats <92%
altered consciousness
exhaustion
cardiac arrhythmia
hypotension
cyanosis
poor respiratory effort
silent chest
confusion
```
179
management of acute asthma attack while awaiting admission to hospital
O2: aim for sats 94-98
nebuliser salbutamol
can add in nebuliser ipratropium bromide
PO prednisolone, IM methylprednisolone, IV hydrocortisone
180
what would be defined as a dangerous mechanism or high-energy head injury
fall from >1 m or 5 stairs
| car crash
181
important symptoms to ask about after a head injury
```
loss of consciousness
amnesia
vomiting
headache
neck pain
```
182
what signs are suggestive of basal skull fracture
clear fluid (possible CSF) leaking from the ear/nose
periorbital haematomas with no associated damage around the eyes
bleeding from one of both ears, blood behind ear drum, new deafness
battle's sign: bruising behind one or both ears over the mastoid process
183
suspect NAI as cause of head injury if
child is not yet independently mobile
injury/brusie over non-bony part of face or on both sides
bruises that are disproportionate, present in multiple sites/clusters, similar size/shape
retinal haemorrhages
explanation is implausible, inadequate or inconsistent
delay in presentation
184
typical symptoms of appendicitis
abdo pain:
periumbilical or epigastric pain that worsens, migrates to right lower quadrant
fever (low grade), general malaise, anorexia
nausea and vomiting
constipation
185
examination signs of appendicitis
tenderness in LQ
| abdo dissension, guarding, rebound tenderness
186
which investigations may be performed to rule out alternative cause of appendicitis
FBC
CRP
urine dipstick
pregnancy test (ectopic pregnancy)
187
GI differentials for appendicitis
```
gastroenteritis
intestinal obstruction
incarcerated inguinal hernia
intussusception
malrotation of gut
meckel diverticulum
biliary colic
perforated ulcer
IBD
constipation
```
188
features of intussusception
right lower quadrant tenderness
sausage shaped mass in abdo
redcurrant jelly stool
189
urological differentials for appendicitis
```
ureteric colic
pyelonephritis
UTI
retention
testicular torsion
```
190
what is mesenteric adenitis
enlarged mesenteric lymph nodes caused by viral infection
191
signs of testicular torsion
acute onset unilateral scrotal pain (may be abdominal)
nausea and vomiting
high-riding or transverse testis
blue dot sign
192
signs of epididymo-orchitis
pain/swelling
symptoms of lower UTI/urethral discharge
tender on palpation
193
which virus causes slapped cheek
human parvovirus B19
194
symptoms of slapped cheek
```
fever
headache, runny nose
rash on arms, legs, trunk
red rash on cheeks
rash fades from centre outwards - lacy appearance
```
195
risks of parvovirus in pregnancy
anaemia
hydrops fetalis
miscarriage
196
fluid management in paediatrics: maintenance volume (volume/kg)
1st 10 kg = 100 ml/kg
2nd 10 kg = 50 ml/kg
further kg = 20 ml/kg
197
fluid management in paediatrics: bolus
20 ml/kg
198
what is tested for on the new born bloodspot screening programme
```
cystic fibrosis
congenital hypothyroidism
phenylketonuria
MCADD
sickle cell disease
maple syrup urine disease
homocystinuria
clutaric acuduria type 1
isovaleric aciduria
```
199
in which patients might faecal elastase be measured and why
infants with CF
marker of exocrine pancreatic function
pancreatic duct becomes obstructed with thick secretions leading to malabsorption or fats (failure to thrive)
can be given pancreatic enzyme replacement to maintain growth
200
which vitamins need to be supplemented in children with cystic fibrosis
fat soluble vitamins
| A, D, E, K
201
common presentations of cystic fibrosis in infants/children
recurrent resp infections:
sticky secretions are difficult to clear, allowing bacteria to colonise them
can lead to bronchiectasis
meconium ileus:
intestinal obstruction due to excessively sticky stool in neonatal period
failure to thrive:
pancreatic insufficiency leads to malabsorption with pale, offensive stools that float and poor growth
202
why is cystic fibrosis associated with diabetes
causes endocrine pancreatic dysfunction as well as exocrine
relative insufficiency of insulin results in high fasting blood glucose levels
203
who would be part of an MDT for a child with cystic fibrosis
physio
dietitian
GP
as they get older will also transition with adult CF services
204
what are the main organs affected by cystic fibrosis
lungs
GI tract
pancreas
205
what are common late complications of cystic fibrosis
```
bronchiectasis (due to recurrent RTI)
diabetes
distal intestinal obstruction syndrome
cirrhotic liver disease (blockage of ducts in liver)
infertility
```
206
what is the cause of respiratory distress syndrome in neonates
lack of surfactant
| underdeveloped alveoli
207
risk factors for respiratory distress syndrome in neonates
```
male gender
maternal diabetes and HTN
IGUR <29 weeks
sepsis
hypothermia
delivery be c-section
second twin
```
208
pathology of RDS
surfactant deficiency leads to
alveolar collapse
low lung volumes
low lung compliance
stiffer lungs = poorer gas exchange
209
how is surfactant given
via catheter down an ET tube
210
which drugs may be given in the neonatal period and why
vitamin K: prevent haemorrhage disease of the newborn (IM injection)
caffeine: early Peter babies to prevent apneoic episodes and also neuroprotection
ABIDEC: multivitamin
sytron: iron
multivitamins added once fully enterally fed
211
fluid management/feeding in preterm babies
75 ml/kg/day 10% dextrose initially
introduce trophic feeds of EMB
gradually work up on enteral feeds to 120-150 ml/kg/day
around 34 weeks introduce suck feeds (breast feeding/bottles)
212
```
which type of IBD:
affects whole GI tract
skip lesions
transmural involvement
granulomas
cobble stone appearance
```
Crohn's
213
```
which type of IBD:
affects colon only
diffuse progression from rectum upwards
mucosal involvement
crypt abscesses
pseudopolyps
```
ulcerative colitis
214
gold standard investigation for IBD
upper and lower GI endoscopy preferably including terminal ileum and multiple biopsies
215
as well as endoscopy, which other investigations should be considered in diagnosis of IBD
barium meal and follow through
| MRI abdo
216
which autoantibody is associated with UC
pANCA
217
```
the following complications are more likely in UC or Crohn's:
risk of bowel cancer
fistulae
toxic megacolon
abscesses
primary sclerosis cholangitis
strictures infective colitis
perforation
```
Crohn's:
fistulae
abscesses
UC:
risk of bowel cancer
toxic megacolon
primary scelrosing cholangitis (HLA-B27)
both:
strictures
infective colitis
perforation
218
extra-intestinal manifestations of IBD
```
growth failure
delayed puberty
erythema nodosum/pyoderma gangrenous
arthritis
ank spon/sacroiliitis
osteoporosis
iritis/uveitis
psychological impact
```
219
management of crohn's
induce remission:
exclusive enteral nutrition (EEN) for 6 weeks
steroids
```
maintenance:
aminosalicylates (sulfasalazine/mesalazine)
thiopurines (azathioprine)
anti-TNF (infliximab/adalimumab)
methotrexate
surgery if needed
```
220
management of UC
mild:
mesalazine
steroids
mod/severe:
corticosteroids
cyclosporin
anti-TNF (infliximab)
221
what is a toxic megacolon
acute life threatening toxic colitis with colonic distension
222
management of toxic megacolon
```
IV fluids and NBM
IV antibiotics
IV steroids
blood transfusion if necessary
urgent surgical review
```
223
common causes of limp in children
trauma
transient synovitis/irritable hip
septic arthritis or osteomyelitis
developmental dysplasia of the hip
224
less common causes of limp in children
```
leg length discrepancy
neuromuscular disorders (cerebral palsy, Spina Bifida, muscular dystrophy)
cellulitis
slipped upper femoral epiphysis
perthes disease
cancer
```
225
what is SUFE
slipped upper femoral epiphysis
top portion of femur moves
most commonly in overweight, adolescent boys
226
what is perthes' disease
idiopathic avascular necrosis of the femoral head
227
why do children with leukaemia complain of bone pain
bone marrow is working harder because of uncontrolled proliferation of leukaemia clone of WBCs
228
why is there recurrent infection in leukaemia
despite increased WBCs they do not function normally as they are the mutated clone
229
which type of cells are indicative of leukaemia on blood film
blast cells
230
which investigations should be done in the investigation of suspected leukaemia
bone marrow aspiration
renal function (chemo can damage kidneys so baseline function is important)
chicken pox serology (may be given chicken pox immunoglobulin)
LP (look for leukaemia cells in CSF)
CXR (look for mediastinal masses)
231
common chemo side effects
mucositis: can affect all mucous membranes, makes eating painful, can require NG or TPN
N+V: give anti-emetics with chemo
abscess/neutropenic sepsis: chemo causes chronic neutropenia, any fever needs blood, throat and urine cultures and IV abx
bruising/bleeding: may need PLT transfusions
232
what is the most common type of leukaemia in children
acute lymphoblastic leukaemia (ALL)
acute myeloid is 2nd common
233
management of cardiac failure in congenital cardiac defect
reduce pulmonary blood flow: lower volume, high calorie formulas, may need NG tube
diuretics: furosemide/spironolactone
ACEI: captorpil
pulmonary artery band
234
why is a combination of furosemide and spironolactone commonly used in heart failure in congenital heart defects
furosemide used to inhibit water reabsorption and treat pulmonary oedema
spironolactone is weak diuretic but prevents hypokalaemia
235
how is captopril (ACEI) useful in heart failure in congenital cardiac defects
peripheral vasodilation
| reduces vascular resistance and reduces the left to right shunt
236
what are indications for surgical management of congestive heart failure
medical management is not enough to control symptoms or allow adequate weight gain
237
what is Eisenmenger syndrome
chronic pulmonary over circulation causes irreversible hypertrophy of the pulmonary arterioles increasing pulmonary vascular resistance
causes increase in pressure in right ventricle above the pressure in the left ventricle
reverses the shunt to right-to-left, causes cyanosis
238
differentials for "fits, faints, funny turns"
neuro, cardiac, metabolic, ENT, general, infection, behavioural/psych
neuro: seizures, febrile convulsions, migraine
cardiac: vaso-vagal syncope, cardiac arrhythmias
metabolic: hypoglycaemia, electrolyte imbalances
ENT: vertigo
general: rigor, NAI, reflex anoxic seizures
infection: meningitis, encephalitis
behavioural/psych: pseudo-seizures, anxiety, self gratification, breath holding, benign myoclonus, daydreaming, night terrors
239
when is an EEG indicated after a first seizure
a focal seizure
not after a generalised seizure
240
which investigations may be useful after a first afebrile generalised seizure
ECG
| blood sugar/blood gas: metabolic cause
241
how would you describe an EEG to a parent
involves attaching small sensors to the scalp that pick up electrical signals that brain cells send to each other
these are recorded and analysed
child doesn't need to do anything special beforehand
the electrodes are stuck on with a special glue
takes about 30 minutes
242
will an EEG give a guaranteed diagnosis about epilepsy in a child
some types of epilepsy have a characteristic EEG pattern
but children without may have abnormal EEG and children with can have normal EEG
EEG will give more information but diagnosis will be made on clinical info
EEG should not be used to exclude epilepsy or used in isolation to diagnose epilepsy
243
clinical features of non-QT syndromes
pallor, LOC, stiffness, anoxic seizures
associated with exercise, fright, emotional or auditory stimuli
can occur in sleep
244
how is long QT syndrome diagnosed
family history
12 lead ECG
ion channel mutational analysis
245
what can cause jitteriness in a young infant
hypoglycaemia
hypocalcaemia
hypomagnesaemia
drug withdrawal
246
what is measured in the Apgar score
```
appearance (colour)
pulse (heart rate)
grimace (reflex)
activity (muscle tone)
respiratory effort
```
247
how is the APGAR score calculated
appearance:
0 = white
1 = blue peripheries, pink central
2 = pink all over
pulse:
0 = absent
1 = <100
2 = >100
grimace:
0 = no response
1 = grimace, feeble cry
2 = active, spontaneous movements
activity:
0 = floppy
1 = flexion
2 = strong
respiration:
0 = none
1 = irregular respirations
2 = lusty cry
248
briefly describe the changes in cardiorespiratory system after birth
in utero oxygenated blood travels via the umbilical vein to the heart (via the portal circulation), bypassing the lungs to reach the systemic circulation
lungs are filled with fluid, pulmonary vessels constricted
during birth liquid is pushed out of the lungs and after first breath the rest is absorbed
breathing causes dilatation of pulmonary circulation and decreased PVR
clamping the cord caused a rise in systemic pressures causing closure of ductus arterioles and foramen ovale
249
what is transient tachypnoea of the newborn
self-limiting period of respiratory distress most often seen in babies following C-section
due to delayed absorption of lung fluid
may require oxygen therapy
250
what is meconium aspiration syndrome
hypoxic infant begins to gasp in utero and aspirate meconium stained liquor
pulmonary vasodilation is delayed and results in persistent pulmonary hypertension
251
what is haemorrhage disease of the newborn caused by
relative deficiency of factors II, VII, IX, X
vitamin K deficiency
252
why are babies given a vitamin K injection after birth
to prevent haemorrhagic disease of the newborn
253
how does haemorrahgic disease of the newborn present
early (24 hours):
mucosal bleeding, GI bleeding, cephalohaematoma, shock, intracranial bleeding
classic (1-7 days)
mucosal bleeding, circumcision bleeding
late (7+ days)
intracranial bleeding
254
what is a cephalohaematoma
what cause them (in birth)
what are they like
cephalohaematoma = subperiosteal haematoma
prolonged labour, instrumental delivery
usually over parietal bone, cannot cross a suture line
255
if you notice a cephalohaematoma during a baby check what should you tell the parent
```
like a bruise around the bone
not harmful
should resolve in a few days-weeks
calcification can lead to a prominent ring of bone around a central defect after resolution
may cause/exacerbate jaundice
```
256
what is caput
what type of delivery is most likely to cause it
what are its features on examination
oedema and bruising over the scalp
commonly caused by ventouse deliveries
can cross suture lines, pitting oedema
257
```
what are (Mongolian) blue spots
where/in who are they most common
why are they important to document
```
dark blue/grey lesions
over the sacrum
in afro-caribbean and asian parents
tend to fade but should be carefully documented as they can be confused with bruising in later life, and can cause concerns re NAI
258
describe the course of erythema toxicum
lesions generally appear on day 1/2 and increase in number over the next several days
spontaneous resolution in about a week
259
describe the lesions in erythema toxicum
central yellow plaque with a halo of erythema
not itchy
260
what causes neonatal gynaecomastia
when should you consider another cause of breast enlargement
due to falling levels of maternal oestrogen, baby's release prolactin causing enlargement of breast tissue
unilateral enlargement consider breast abscess or mastitis (esp if unwell, heat/erythema at site)
261
apart from neonatal gynaecomastia, what other effects can maternal oestrogen have on newborns
withdrawal bleeding/discharge in females
swelling of labia/clitoris
262
what are the feeding recommendations for newborns
exclusive breast feeding for 6 months
no solids before 4 months
263
why do babies get jaundiced
breakdown of fatal Hb and immature liver can handle it
UNconjugated bilirubin
264
what is a possible complication of hyperbilirubinaemia in babies
kernicterus
265
what is the definition of prolonged jaundice in term and preterm infants
>14 days in term
>21 days in preterm
266
what is a benign and a pathologic cause of prolonged jaundice in babies
breast milk jaundice (reabsorption of unconjugated bilirubin from the gut)
```
biliary atresia (absence of biliary tree)
- elevated conjugated bilirubin
```
267
which babies are more prone to severe jaundice
preterm
sepsis
severe haemolysis (Rh-incompatibility, AO incompatibility, G6PD deficiency, spherocytosis)
bruising (cephalohaematoma)
268
which infants are most at risk of group B strep infection
```
premature
mother is colonised by GBS
previous child with GBS infection
evidence of maternal infection (pyrexia or elevated CRP)
prolonged rupture of membranes
evidence of fatal distress
```
269
when is the best time to screen Down's syndrome antenatally
11+0 - 14+1 weeks
combined test
US nuchal transparency measurement plus serum biochemistry to measure beta hCG and PAPP-A
270
how is definitive antenatal diagnosis of Down's syndrome carried ut
chorionic villous sampling or amniocentesis
271
when does the fatal anomaly scan take place
18-21 weeks
272
which blood infections are routinely screened for in pregnant women
hep B
HIV
syphilis
rubella susceptibility
273
when does hearing screening take place in newborns
within first 2 weeks of life
274
what is PKU?
inability to metabolise phenylalanine
untreated leads to LD, behavioural problems
dietary management
275
what is MCADD and why is it screened for in the bloodspot test
medium chain acyl-coA dehydrogenase deficiency
autosomal recessive condition
inability to metabolise a type of fat
can become acutely unwell when starved or stressed
diagnosis allows education and planning
276
what is the marker for CF on the bloodspot test
immunoreactive trypsin (IRT)
277
what is a risk factor for retinopathy of prematurity
excessive oxygen therapy in infants borns before 32 weeks
causes neovascularisation of the retina which then is at risk of bleeding
278
infants born before ______ are likely to have problems feeding as they have not yet developed suck, swallow and breathing coordination
32-34 weeks
279
what are prem babies at increased risk of infection
immunodeficiency
readily broken down skin
increased medical input with indwelling devices
280
describe the action of fast acting insulin and give some examples
start acting in 15 minutes, last 2-3 hours
novorapid, Humalog, actrapid
281
describe the action of long acting insulin and give some examples
slower onset, last 20-24 hours
| glargine, levemir, insulatard
282
which types of insulin are used in mixtures and give some examples
fast and medium acting insulins
mixtard30, Humalog mix 25, novomix 30
283
what are the main differences between a basal bolus and mixed insulin regime
basal bolus
long acting insulin given at night, with a bolus of fast acting insulin given before each meal time
mixed
2 injections of mixture of fast and slower acting insulin given at about 10 hours apart
284
which type of insulin is used in insulin pumps
fast acting
285
what is the definition of DKA
blood glucose >11 mmol/L
ketones and glucose on urine dipstick
metabolic acidosis (pH <7.3 or bicarb <14 mmol/L)
286
how does DKA cause dehydration (2 ways)
increased stress hormones leading to increased glucose mobilisation from body stores and gluconeogenesis in the liver as well as absorption from the gut --> high blood glucose causes osmotic diuresis with increased urine production
low intracellular glucose leads to ketosis, which act on emesis centres causing N+V
287
what are the common presenting features of DKA in children
breathlessness
N+V
abdo pain
constipation
288
complications of DKA
cerebral oedema:
can be exacerbated by rapid fluid resuscitation or beginning insulin therapy too early
hypoglycaemia:
giving too much insulin without monitoring blood sugar (switch to insulin/dextrose infusions)
hypokalaemia:
insulin drives K+ into cells leading to reduced blood levels
289
what is the difference between primary and secondary nocturnal enuresis
primary: child has never been dry at night
secondary: child has been dry for at least 6 months
290
what are differentials for primary nocturnal enuresis
delayed development: mature CNS so not aware when they need to go
small bladder capacity
too little ADH: normally there is increased ADH over night to reduce urine production
sound sleeping: may not be woken by urge to pee
psychosocial
FHx
291
what are differentials for secondary nocturnal enuresis
```
UTI
constipation
DM
seizure disorder
medication side effect
emotional, sexual or physical abuse
```
292
what is the single most useful investigation in a child presenting with secondary enuresis
urine dipstick
assessment of glycosuria and ketonuria (DM)
assessment of leucocytes and nitrites (UTI)
293
after diagnosis of DM is confirmed which other investigations should be carried out
HbA1c
thyroid function and thyroid peroxidase antibodies: autoimmune
coeliac screen: autoimmune
C-peptide: also made in beta-cells in pancreas so can distinguish between T1DM and T2DM
294
what are the general sick day rules of diabetics
never stop insulin completely: may need to be increased or decreased
check (blood) ketones is blood glucose is >14 mmol/L: if raised ketones and glucose give fast insulin, if raised ketones but low/normal glucose give sugar then insulin
if not eating give sugary drinks
295
when should a diabetic child who is unwell (generally not DKA-y) be admitted
does not have a blood glucose testing kit at home
high blood glucose and is vomiting or does not have ketone testing kit at home
vomiting and unable to keep fluids down
parents are worried
296
which fluids should be given in DKA
NaCl with KCl
when glucose lowers, give dextrose too to prevent hypokalaemia
297
what are the three main phases of growth
infant stage (0-2)
rapid linear growth
nutrition dependent
childhood stage
steady growth
hormone dependent
pubertal stage
rapid linear growth
depends on pubertal hormones and growth hormone
start of puberty in girls and end of puberty in boys
298
when should a child be referred for poor growth
when a child is short for parent's height
height velocity is below expected for age
height has crossed >2 centile lines (up or down)
height >3 SDs below mean (<0.4th centile)
child is at risk of poor growth
known to have a condition associated with poor growth
known to have treatment likely to affect growth
299
what is precocious puberty
onset before 8 in girls and 9 in boys
300
features of turners
```
short
ovarian dysgensis
congenital lymphedema
low posterior hair line
neck webbing
ear abnormalities
deafness
broad chest with widely space nipples
cubitus valgus hypoplastic nails
renal abnormalities
cardiac abnormalities
```
301
definition of chronic lung disease in the neonatal period
oxygen requirement beyond 36 weeks corrected gestation PLUS pulmonary parenchymal disease on CXR
302
causes of bilious vomiting
```
malrotation/volvulus
intussusception
ileus (post-op, sepsis)
duodenal/intestinal atresia
Hirschsprungs disease
meconium ileus
adhesions/obstructions
```
303
causes of non-bilious vomiting
```
pyloric stenosis
gastroenteritis
GORD
intolerance
intoxication
UTI
meningitis
```
304
what is pyloric stenosis
thickening of the pyloric muscle
305
features of pyloric stenosis
projectile non-bilious vomiting
dehydration
tired/sleeping more
not passing stool
306
how to diagnose pyloric stenosis
test feed
| abdominal USS
307
how to manage pyloric stenosis
stop oral feeds and site NG tube
fluids and electrolyte replacement/monitoring
surgery
308
what is intussusception
proximal part of bowel slips inside a more distal part
| commonly at ileocaecal valve
309
diagnosis of intussusception
abdominal US: target sign
310
management of intussusception
fluid resus
IV antibiotics
surgery = rectal insufflation
311
what are malrotation and volvulus
```
malrotation = failure of gut to complete normal rotation during gestation
volvulus = mesentery twists around itself
```
312
presentation of malrotation/volvulus
previously well develops bilious vomiting
distended tender abdomen
peritonitis
313
why is identification of malrotation or volvulus time critical
time = gut
| delayed diagnosis leads to ischaemia and possible necrosis of gut
314
diagnosis and management of malrotation/volvulus
urgent upper GI contrast study
agressive fluid resus
IV abx
emergency laparotomy
315
projectile vomiting, olive-shaped mass
pyloric stenosis
316
child born with Down syndrome, AXR shows double bubble
duodenal atresia
317
intermittent crying, drawing legs up to chest, red-currant stool
intussusception
318
failure to pass meconium in 48 hours
- with cystic fibrosis
- PR causes explosive air and faeces
CF = meconium ileus
explosive air/faeces = hirschprungs
319
common and uncommon causes of neonatal respiratory distress
```
common
transient tachypnoea of the newborn
surfactant deficiency
pneumonia
meconium aspiration
```
uncommon
pulmonary aplasia
congenital cystic adenoid malformation
congenital diaphragmatic hernia
320
radiological finding of surfactant deficiency
small volume lungs (bell shaped thorax)
diffuse granular opacification, progressing to opaque lungs, with bronchograms
no effusion unless complications arise
321
CXR findings of TTN
normal or overinflated lungs
interstitial lines and effusions
fluid in fissures
air space opacification
322
CXR findings of meconium aspiration
patchy opacities
overinflated lungs due to air trapping
air leaks
atelectasis
323
what is the cause of resp distress
31 weeks, premature rupture of membranes, vaginal delivery, no meconium, resp distress, ventilated
surfactant deficiency
324
what is the cause of resp distress
37 weeks, elective C-section for pre-eclampsia, no meconium, mild resp distress as 12 hours
TTN
325
what is the cause of resp distress?
37 weeks, premature rupture of membranes at 35 weeks, spontaneous labour at 37 weeks, normal vaginal delivery, increasing respiratory distress on day 3
neonatal pneumonia
326
what is the correct tip position for an endotracheal tube in a neonate
at or just below the carina
in the left main bronchus
2 cm above the carina at about T2/3
at the cricoid cartilage
327
what is the correct tip position for a nasogastric tube
stomach, should travel in midline until reaches the stomach
328
how many umbilical veins and arteries should a baby have
1 vein
| 2 arteries
329
where is the normal endpoint of an umbilical vein catheter
though which vessels does it pass
at or just above the right hemidiaphragm
from umbilicus --> umbilical vein --> left portal vein --> ductus venosus --> middle/left hepatic veins --> into IVC and right atrium
330
where is the normal endpoint of an umbilical artery catheter
through which vessels does it pass
low tip: L3/4, below renal arteries
high tip: T6-10
from umbilicus --> right or left internal iliac artery --> common iliac artery --> aorta
331
CXR signs of bronchiolitis
overinflated lungs
perihilar haze
scattered atelectasis
rarely more diffuse opacification
332
CXR signs of bacterial pneumonia
fluffy consolidation with air bronchograms
rounded, lobar or multifocal patterns
effusion
pneumothorax
333
CXR signs of inhaled foreign body
Lucent lung due to air trapping is common due to ball valve effect
mediastinum displaces away from he affected side
pattern exaggerated in expiration
334
which fracture patterns are suspicious of NAI
metaphysical corner fractures
posterior or lateral rib fractures
multiple fractures in different healing stages
sternal, scapular and spinous process fractures
spinal injuries with no clear history of major trauma
335
which fracture patterns are specific to children and adolescents
buckle fracture
green stick fracture
plastic bowing
growth plate injury
336
what is the grading system for growth plate injuries
salter Harris
I: along the growth plate
II: along the growth plate, with a small part of the proximal bone
III: fracture vertically through the distal end, then along the growth plate (proximal bone not fractured)
IV: vertical fracture through the distal end, growth plate and proximal bone
V: compression of growth plate
