Febrile Child

Question 1

What are the infections that predispose a child to congenital abnormalities?

Answer 1

TORCH

T - toxoplasmosis

O - other .e.g HIV

R - Rubella

C - CMV

H - Herpes

Question 2

What question can we ask if we want to QUICKLY screen for a child development (in history taking)

Answer 2

‘Compared to his/her peers/siblings, how do you think is he/she doing?’

Question 3

What is the recommended feeding amount for a baby?

Answer 3

Aiming for 150-200 mls/kg per 24 hours

Question 4

How much ml is 1 ounce (1 oz)?

Answer 4

1 oz = 30 ml

*as parents in the UK will usually give that amount when asked how much they baby feeds/ is there in the bottle

Question 5

When is the appropriate time for weaning?

Answer 5

Weaning is roughly 6 - 9 months

*in practice it may be even at 4 months - if a child clearly want to try solids etc, no reason to stop them

Question 6

Mesenteric Adenitis

• characteristics of infection
• type of pathogen likely to cause it
• other symptoms
• management

Answer 6

• enlarged lymph nodes (mostly abdominal ones)
• viral pathogen (possibly same viruses causing cold or flu)
• other possible symptoms: fever, pain, feeling unwell, nausea and vomiting, cold-like symptoms, sore throat
• Management: analgesia (paracetamol, ibuprofen), antibiotics (if other bacterial condition develops), surgical review (to role out appendicitis)

Question 7

What is a paediatric equivalent to an adult neck stiffness (in meningitis)?

Answer 7

Bulging fontanelle

Question 8

what is a possible diagnosis for these ‘red flag’ symptoms?

• easy bruising
• weight loss/ night sweats
• rapid presentation
• lymph nodes enlarged

Answer 8

Lymphoma/ Leukaemia

Question 9

What are possible late complications of undetected UTI in children?

Answer 9

• renal scarring
• early onset hypertension *it is also a possible sign of a structural abnormality in renal system

If a febrile child and unsure diagnosis = always check for UTI (urinalysis)

Question 10

What’s the typical age at which febrile seizures commonly occur?

What stage of the fever do they usually happen?

Answer 10

• 6 months - 6 years
• happen usually at the beginning of the fever

Question 11

What meds can you give a child in order to relieve their fever?

Answer 11

• Ibuprofen
• Paracetamol
• Calpol

Question 12

Measles symptoms

Answer 12

• fever
• macular rash
• conjunctivitis
• coryza
• Koplik spots (mouth)

Question 13

Possible complication of Measles

Answer 13

encephalitis (during the onset of acute illness) -> death

• blindness, deafness
• bacterial pneumonia

Question 14

Presentation of Scarlet fever

What pathogen is responsible for it?

Answer 14

Scarlet fever (due to group A Streptococcus)

• rash
• strawberry tongue
• bacterial tonsillitis (exudate)

Question 15

Possible complications of Scarlet fever

Answer 15

• Rheumatic Fever
• Glomerular Nephritis

Question 16

Treatment of Scarlet Fever

Answer 16

Antibiotic: Penicillin V (oral) for 10 days

Question 17

Slapped Cheek

• pathogen causing it
• symptoms
• complications

Answer 17

• Parvovirus B19
• symptoms: fever, red cheeks/rash
• complications: usually not dangerous, but dangerous in pregnancy (Hydrops Foetalis - foetal heart failure due to severe anaemia caused by destruction of RBCs)

Question 18

• What are the characteristics of a common rash in infants with viral illness?
• Do we need to worry about that?

Answer 18

• Characteristics: blanching and macular
• If it’s blanching and a child is otherwise well, no need to worry

Question 19

What are possible causes of non-blanching rash?

Answer 19

• meningitis
• vasculitis

Question 20

Characteristics of a chickenpox rash

Answer 20

• vesicular
• different stages
• fever and then rash

Question 21

Treatment for impetigo

Answer 21

Topical: FuciBET

oral: Flucloxacillin

Question 22

What’s a possible complication of pre-orbital cellulitis?

What is the best IV treatment option?

Answer 22

Pre-orbital cellulitis -> it can progress to orbital cellulitis (affect vision)

*hospital admission is required

Treatment option: IV cephalosporins

*possible treatment with Vancomycin, Clindamycin, or Doxycycline due to resistance

Question 23

‘hand, foot and mouth disease’

• • what type of pathogen causes it
• • does the child need to be isolated?
• what’s treatment?

Answer 23

• viral illness
• it is common in the nurseries - child does not need to be isolated although disease is contagious
• child is usually well

No need for treatment, possible use anaelgesia if painful; should resolve on its own in a week time

Question 24

Do we give Ibuprofen in chickenpox?

Answer 24

NO - no NSAIDs as that will increase the risk of Necrotising Fascitis

Question 25

What do we need o to remember about the vaccination schedule (roughly)

Answer 25

- lots of vaccines in 2, 3, 4th months of life - then when 1 year old - then yearly vaccine (flu) - 12-13 girls HPV vaccine - 14 years ACWY

Question 26

What are signs of dehydration?

Answer 26

* sunken eyes * sunken fontanelle (in infants) * dry mucous membranes (look at the tongue) * mottled skin/cold extremities * skin turgor * prolonged cap refill * increased HR, poor pulse volume

Question 27

Where would you manage the child based on 'Traffic light' system? - green - amber - red

Answer 27

* green - manage at home * amber - safety netting (careful planning); possible paeds admission unit * red - admission to hospital

Question 28

Why do we worry about a baby that is \<3 months old and have a fever of 38C or above?

Answer 28

This age group is likely to show no focal/ localised signs, therefore even a serious illness may not manifest itself clearly

Question 29

Investigations used in **An Infection Screen**

Answer 29

* FBC * blood cultures * urine culture * CXR * stool MC&S if diarrhoea * LP (especially if unwell and \<3 months old with raised WCC * U&E * ABG * glucose

Question 30

Spot diagnosis: what is this?

Answer 30

***Measles*** _Notes:_ Measles -\> viral infection _Symptoms:_ * Fever, rash (starts head- body), red maculo-papular (red-brown) * 3C’s (cough, coryza and conjunctivitis) * Non purulent conjunctivitis * Pathognomonic sign: Koplik spots (prodromic viral enanthem of measles manifesting two to three days before the measles rash itself. * Incubation 10 days prior to rash * MMR live vaccine 13m and prior to school _Complications:_ encephalitis, pneumonia, hepatitis- disability deafness, blindness

Question 31

Spot diagnosis: what is this?

Answer 31

***Scarlet fever*** _Notes:_ * Children (\<10) * *Streptococcal* infection (most *strep A*) _Symptoms:_ * fever, sore throat, rash (toxins) * Strawberry tongue (or white strawberry tongue is coated usually earlier in illness) * Rash- like **sandpaper** to touch _Management:_ Penicillin V 10 days \* Notifiable _Complications:_ OM, pneumonia, meningitis Later (immune complexes)- RF, GN

Question 32

Spot diagnosis: what is this?

Answer 32

***Parvovirus B19 / Slapped cheek*** _Notes:_ - Usually mild illness - Age 3-15 _Symptoms:_ * Rash: bright red to cheeks and can spread to body * May have non-specific illness _NB - caution if:_ * harm to pregnant women (if not had previously- check serum if exposure esp \<20 weeks) Lifelong immunity if infected before * immunocompromised (possible serious illness) and flare-ups in Sickle-Cell

Question 33

Spot diagnosis: what is this?

Answer 33

***Eczema Herpeticum*** _Notes:_ * HSV1 (cold sores) * affect pts with underlying inflammatory skin conditions- atopic eczema (when eczema comes to contact with HSV) * Commonly face and neck (but can be widespread and potentially serious) _Symptoms_: rash (sore and itchy), fever, systemic upset and Lymph nodes \*Rash: vesicular/blistering- on normal or inflamed skin) _Treatment_: antivirals ASAP - may need admission for IVs Advice to avoid immunosupressed: very young/old etc (not contagious to those with normal immunity)

Question 34

What is this?

Answer 34

***Roseola***

Question 35

What is this? Treatment

Answer 35

***Kawasaki Disease*** (may lead to coronary arteries aneurysm) Investigation to do: ECHO _Treatment:_ Aspirin (in that case we do not bother about Reye) an immunoglobulin

Question 36

Criteria for diagnosis of ***Kawasaki disease***

Answer 36

Question 37

What's that?

Answer 37

***Henoch Schonlein Purpura (HSP)*** - an IgA mediated small vessel vasculitis - usually seen in children following infection _Features_ * palpable purpuric rash (with localized oedema) over buttocks and extensor surfaces of arms and legs * abdominal pain * polyarthritis * features of IgA nephropathy may occur e.g. haematuria, renal failure **Tetrad:** Rash, abdominal pain, arthralgia, nephritis (+/- diarrhoea, rectal bleeding, haematuria) _Treatment_ * analgesia for arthralgia * treatment of nephropathy is generally supportive. There is inconsistent evidence for the use of steroids and immunosuppressants _Prognosis_ * usually excellent, HSP is a self-limiting condition, especially in children without renal involvement * around 1/3rd of patients have a relapse

Question 38

What's that?

Answer 38

Hand Mouth and Foot disease _Notes:_ * Viral (enterovirus:- coxsackievirus, enterovirus 71- rare complication is encephalitis) _Symptoms:_ Non-specific symptoms- coryzal, cough, anorexia, fever Mouth ulcers Rash- papules and vesicles * Contagious while unwell _Management:_ Conservative management ​

Question 39

What's that?

Answer 39

Chicken Pox/ Varicella-Zoster virus

Question 40

What's that?

Answer 40

***Mumps*** _Pathogen_: RNA paramyxovirus _Clinical features_ - fever - malaise, muscular pain - parotitis ('earache', 'pain on eating'): unilateral initially then becomes bilateral in 70% _Management_ * rest * paracetamol for high fever/discomfort * notifiable disease _Complications_ * orchitis - uncommon in pre-pubertal males but occurs in around 25-35% of post-pubertal males. Typically occurs four or five days after the start of parotitis * hearing loss - usually unilateral and transient * meningoencephalitis * pancreatitis

Question 41

What's that?

Answer 41

***Impetigo*** and ***bullous impetigo***

Question 42

What is that?

Answer 42

***Pre-orbital cellulitis*** _Notes_ * usually children \<5 (5-10) (but can affect any age) \*in young children the orbital septum not fully developed) * Infection/inflammation of soft tissues superficial to orbital septum * orbital function remains in tact _Cause__:_ Can come from superficial site- insect bite, folliculitis, trauma, can spread from any URTI infection **!** in children can be caused by sinusitis _IMPORTANT_ can rapidly progress to orbital cellulitis involves deeper tissues within orbit- fat and muscles and thus orbital dysfunction= requires urgent admission/imaging/surgical assessment _Complications_: abscess, Cavernous Sinus Thrombosis, Intracranial abscess, loss of vision, death _Symptoms:_ redness and swelling around eye, warmth and tenderness +/- malaise, irritability and fever (caution with fever- think orbital as differential) (less common: pain or visual disturbance).

Question 43

What's that?

Answer 43

Meningococcal disease

Question 44

What's that?

Answer 44

***Meningococcal septicaemia*** - a very late sign of a disease \*child is very sick

Question 46

**ABCDE** in a sick child What to look for in **A**?

Answer 46

***Airway*** – Is it obstructed?eg secretions, foreign body, stridor

Question 47

**ABCDE** in a sick child What to look for in **B**?

Answer 47

**B – *Breathing*** – Is the child struggling to breathe? Assess respiratory rate, look for recession/accessory muscle use, check oxygen saturation, auscultate the chest

Question 48

**ABCDE** in a sick child What to look for in **C**?

Answer 48

**C –** ***Circulation*** – Is there evidence of poor circulation? Assess colour skin, heart rate, capillary refill time (on sternum and fingers/toes), blood pressure, warm or cold hands/feet?

Question 49

**ABCDE i**n a sick child What does **D** mean? What do we assess?

Answer 49

**D –** ***Disability*** – What is the child’s neurological state? Assess pupil response to light, limb tone and movement, AVPU score/GCS, temperature, glucose, urinalysis

Question 50

**ABCDE** in a sick child What does **E** mean? What do we assess?

Answer 50

**E – Exposure** – Have you exposed the child and examined top-to-toe? Rashes – viral rash, infectious disease rash, non-blanching rash (septicaemia?) Any evidence of injury/trauma

Question 51

What signs to look for in an abdominal examination of an unwell child?

Answer 51

***Tummy*** – Is this soft? Distended? Tender? What are the bowel sounds like? Any masses?Any hernias?(In boys, never forget to examine the testis - testicular torsion = surgical emergency)

Question 53

What antipyretics would you use in a child ?

Answer 53

Antipyretics if a child is distressed: o ***Paracetamol*** ***o Ibuprofen*** \*Do not use both antipyretics together routinely (change agents if one isn’t working)

Question 54

Should you use Ice or cold bath in a child with a fever?

Answer 54

Do not use cold water baths or ice (shivering can increase basal body temperature)

Question 55

Safety netting advice for a child with a fever

Answer 55

Safety Netting: When to seek further advice * Seizure * Non-blanching rash * Parents/carer feel child is worsening * Fever \>5 days

Question 56

What medications and when give to a child with a seizure?

Answer 56

* rectal ***diazepam*** repeated once after 5 minutes if the seizure has not stopped * or one dose of buccal ***midazolam***

Question 57

When to do 'infection screen' on a child with a fever?

Answer 57

The following children will require an infection screen in hospital: * All children \< 3 months old with fever * Fever without apparent source and red or amber criteria on NICE Traffic Light System * Any child with red criteria on NICE Traffic Light System

Question 58

What investigations does 'Infection Screen' consist of?

Answer 58

* FBC * Blood Cultures * CRP * Urine Culture * CXR * Stool MC&S if diarrhoea * Lumbar puncture (especially in unwell \<3month old who are unwell with raised WCC) * U&E * ABG

Question 60

***Orbital Cellulitis*** - symptoms

Answer 60

_Symptoms:_ Ptosis, orbital pain (can be severe-compartment syndrome), visual disturbance/loss, proptosis, chemosis, fever, headache, systemic symptoms, ( uncommon: vomiting, altered consciousness consider meningeal involvement)

Question 61

***Orbital Cellulitis*** - investigations - management

Answer 61

_Investigations:_ FBC, swab, Ct sinus/orbits or MRI, LP _Management:_ Po ***co-amoxiclav***, IV ***cephalosporin*** (plus ***flucloxacillin*** and or ***metronidzole*** – covering for staph and anaerobes). Alternatives (if Penicillin allergy): include ***clinadmycin*** and ***quinolone***

Question 62

When is LP contraindicated in a picture of meningitis?

Answer 62

**LP** contraindicated in the face of widespread purpura, severe coagulopathy and cardiovascular shock

Question 63

What are contraindications to giving a vaccine?

Answer 63

Confirmed **anaphylaxis** to a previous dose (or a vaccine with the same antigen) or to a component of the vaccine (eg *neomycin, streptomycin, polymyxin B* in some vaccines) **Influenza** and **yellow feve**r: confirmed anaphylaxis to ***egg***

Question 64

Who should not receive a live vaccine?

Answer 64

- pregnant women - immunocompromised - timing frame with receiving another life vaccine

Question 65

***Croup*** - pathogen - symptoms - management

Answer 65

_Pathogen:_ Para-influenza virus (RSV next common) _Symptoms:_ **barking cough, stridor,** hoarse voice _Management:_ A. Symptomatic: Paracetamol, Ibuprofen, fluids B. Steroids (single, oral dose) e.g. Dexamethasone

Question 66

Viral URTI - pathogen (common) - symptoms - management

Answer 66

_Pathogen_: ***Rhinovirus*** _Symptoms:_ cough (green sputum), sneezing, sore throat, hoarse voice _Management:_ Symptomatic - *Ibuprofen, Paracetamol* ,fluids \* use CENTOR criteria to assess for the need of antibiotic treatment

Question 67

**UTI** - pathogen - symptoms/investigation finding - management

Answer 67

Pathogen: E.Coli _Investigations:_ Nitrites + Leucocyte on urinalysis Symptoms: abdominal pain, hematuria, burning pain on passing urine _Management:_ A. Send the sample - Clean catch urine sample or MSU B. Antibiotics

Question 68

***Tonsillitis*** - pathogen - presentaiton - management

Answer 68

_Pathogen:_ *Group A beta-haemolytic streptococcus* \* often viral _Presentation_: Exudates (bacterial), tender cervical lymphadenopathy, sore throat, absence of a cough \*use CENTOR criteria to assess if bacterial and if Abx needed Management: symptoms relief by Ibuprofen or Paracetamol; Abx depends on if bacterial or not