Miscellaneous Topics

Question 1

What are the causes of conjunctivitis ?

Answer 1

In adults
- Viral
- Allergic

In children
- Bacterial > staphylococcal or streptococcal
- Allergic

In neonates
>Be wary of sight-threatening conjunctivitis in neonates
- <48hrs = gonococcus
- 1-2wks = chlamydia trachomatis

Question 2

What are the S/S of conjunctivitis?

Answer 2

Bacterial
- Painful red eyes
- Purulent discharge
- Lacrimation
- ‘Gritty eyes” > may be “stuck together” in the morning
- NO visual change

Allergic
- Bilateral
- Pruritic
- Conjunctival swelling
- Hx of atopy
- May be seasonal (pollen) or perennial (dust mites, washing powder, other allergens)

Neonate gonococcus
- Discharge +/- conjunctivitis
- Swelling eyelids

Neonate chlamydia
- Discharge +/-conjunctivitis
- Swelling eyelids
+/- pneumonia

Question 3

What are the investigations for conjunctivitis?

Answer 3

· Bacterial > swab MC&S
· Viral > rapid adenovirus immunoassay
· Neonate gonococcal > gram stain, culture
· Neonate chlamydia > immunofluorescent staining

Question 4

What is the management for conjunctivitis?

Answer 4

Most viral/bacterial infections are self-limiting and resolve without tx in 1-2wks

Neonate
- Cleaning with water and saline is sufficient in most cases
- Discharge / redness suggestive of Staphy/Strep infection can be treated with topical ointment (e.g. neomycin)

Neonate gonococcal
- Immediate empirical tx > 3rd generation cephalosporin (i.e. ceftriaxone)

Neonate chlamydia
- Oral erythromycin 2wks

Allergic
1st line > topical or systemic antihistamines
2nd line > topical mast-cell stabilisers e.g. sodium cromoglicate and nedocromil

Bacterial
- Topical abx therapy e.g. chloramphenicol (drops are given 2-3 hourly initially whereas ointment given qds initially)
- Topical fusidic acid if pregnant

Advice
- Don’t share towels
- School exclusion not necessary

Question 5

What is hypermetropia?

Answer 5

Long sightedness
(see long distance not close distance, rays focus behind the retina)
· Mild hypermetropia common in early childhood
· Corrected by improvement of accommodation reflex
· Mx = glasses (convex lens)

Question 6

What is myopia?

Answer 6

Short sightedness
(see short distance not long distance, rays focus in front of retina)
· Uncommon in childhood, more common in teenagers
· Childhood conditions > pre-term refractive errors
· Mx = glasses (concave lens)

Question 7

What is retinopathy of prematurity (ROP)?

Answer 7

Affects developing blood vessels at the junction of the vascularised and non-vascularised retina

Question 8

What are the RFs for ROP?

Answer 8

Uncontrolled use of high concentrations of oxygen
(seen in 35% of LBW infants)

Question 9

What are the S/S of ROP?

Answer 9

Unusual eye movements
White pupils and vision loss

Question 10

What is the management of ROP?

Answer 10

Screening:

• LBW <1500g
• Prematurity <32wks gestation

1st line:

• Laser photocoagulation
• Or cryotherapy

Question 11

What is the prognosis of ROP?

Answer 11

Severe bilateral visual impairment in 1% LBW infants (mainly <28wks)

Question 12

What is strabismus?

Answer 12

Abnormal alignment of eyes
· Diagnosed 1-4yrs
· Normal in young infants before 6m

Question 13

What are the types of strabismus?

Answer 13

Non-paralytic = refractive error in one or both eyes

Paralytic = squinting eye could be caused by motor nerve paralysis or SOL, i.e. 3rd nerve palsy

Question 14

What are the S/S of strabismus?

Answer 14

· Eyes look in different directions
· Eyes don’t focus simultaneously on a single point

Question 15

What is the management of strabismus?

Answer 15

Before 8yrs, as this is when brain connections can be rewired until
· 1st line = eyeglasses
· 2nd line = eye patching
· 3rd line = eye drops
· 4th line = eye muscle surgery

Question 16

What are parental RFs for NAI?

Answer 16

· Poor socio-economic status
· Co-occurrence of domestic violence within family / abusive relationship between partners
· Psychological problems
· Substance abuse
· Lacking parental knowledge
· Parental / carer exposure to maltreatment as a child

Question 17

What are child RFs for NAI?

Answer 17

· Children with mental / physical health problems
· Children with disabilities
· LBW
· Excessive crying / frequent tantrums
· Twins / other multiples

Question 18

What are the most common fractures associated with NAI?

Answer 18

• Radial
• Humeral
• Femoral

Question 19

What are the S/S of NAI?

Answer 19

· Bruising (on non-contact areas)
· Broken bones (spiral fractures of long bones, non-ambulant)
· Drowsiness (subdural)
· Failure to thrive
· Neglect (unkempt)
· STIs, recurrent UTIs
· History non consistent
· Torn frenulum labii superioris (tongue)
· Glove and stocking burn
· Anal fissures, encopresis

Question 20

What is shaken baby syndrome?

Answer 20

Classical triad of features:
· Retinal haemorrhages
· Brain swelling / encephalopathy (CT)
· Subdural haematoma (CT)

Question 21

What are the investigations for NAI?

Answer 21

· Full body +/- skeletal survey (note all blemishes on body on body map)
· Check child protection register
· CT head
· Bloods and bone profile (rule out leukaemia, ITP, haemophilia)
· Fundoscopy

Question 22

What is the management of NAI?

Answer 22

If suspecting NAI > always safe to admit child

Child in need plan
- Plan made to give children extra support for health, safety +/-developmental issues

Child protection plan
- Plan made to protect children thought to be at risk of significant harm

Communication
- “This is a routine requirement for all children in these situations, and our aim is to keep your child safe”
- “Sometimes when children have similar injuries, they don’t happen by accident and are caused others”

Question 23

Who do you get involved for NAI?

Answer 23

Senior colleagues, named doctor for child protection, social services (make formal referral)

Consider contacting police (Child Abuse Investigation Team / CAIT)
- Convene a case conference
- Support to parents
- Childs name on child protection register
- Ask for regular follow-up by paediatricians

Consider contacting Multi-Agency Safeguarding Hub (MASH)
- Includes variety of people that help mx different aspects of a child’s life

Question 24

What is SIDS?

Answer 24

Sudden death of an infant <1yr that remains unexplained after a thorough case investigation, including performance of a complete post-mortem, examination of the death scene and review of clinical hx

Question 25

What are the RFs for SIDS?

Answer 25

· Putting the baby to sleep prone
· Parental smoking
· Prematurity
· Bed sharing
· Hyperthermia / head covering
· Prolonged QT interval
· Multiple births
· Social classes IV and V
· Maternal drug use
· Incidence increases in winter
· Male

Question 26

What are protective factors for SIDS?

Answer 26

· Breastfeeding
· Room sharing
· Dummies

Question 27

What are the S/S of SIDS?

Answer 27

Diagnosis of exclusion
· Usually occurs during hours of extended sleep (10pm-10am)
· Child is found dead usually in position they were put to bed
· Checks whilst child was asleep usually revealed no problems
· Parent may report child was not themselves before going to sleep
· Parent may report GI or resp infection in the weeks preceding death

Question 28

What is the management of SIDS?

Answer 28

> Following cot death, siblings should be screened for potential sepsis and inborn errors of metabolism

Avoid by:
- Sleep positioning/wrapping
- Supine sleep position (back for first 6m)
- Avoid overheating baby (no heavy wrapping or high room temp)
- Feet to foot position in cot

General advice
- Share room with baby for first 6m
- Never sleep on sofa or armchair with baby
- Do not co-sleep
- Breastfeed if possible
- Keep baby smoke free

Support
- Lullaby Trust > info, leaflets, bereavement support, helpline, support groups

Question 29

Exclusion for Scarlet Fever?

Answer 29

Yes - 24hrs after starting abx

Question 30

Exclusion for Whooping cough?

Answer 30

Yes - 48hrs after starting abx (if no abx are given, exclude for 21d from sx onset)

Question 31

Exclusion for Measles or Rubella?

Answer 31

Yes - 4d from onset of rash

Question 32

Exclusion for Chickenpox?

Answer 32

Yes - until all lesions crusted over

Question 33

Exclusion for Impetigo?

Answer 33

Yes - until all lesions crusted over

Question 34

Exclusion for Mumps?

Answer 34

Yes - 5d from onset of swollen glands

Question 35

Exclusion for D&V?

Answer 35

Yes - until sx have settled for 48hrs

Question 36

Exclusion for scabies?

Answer 36

Yes - until treated

Question 37

Exclusion for influenza?

Answer 37

Yes - until recovered

Question 38

What is foetal alcohol syndrome?

Answer 38

Maternal alcohol abuse during pregnancy

Question 39

What are the S/S of foetal alcohol syndrome?

Answer 39

Baby may show symptoms of alcohol withdrawal at birth e.g. irritable, hypotonic, tremors

• IUGR
• Microcephaly
• Midfacial hypoplasia
• Micrognathia
• Smooth philtrum
• Microphthalmia
• Short palpebral fissures
• Thin upper lip
• Irritability
• ADHD