Paediatric core conditions 5 Flashcards
Testicular torsion- basics
- twist of the spermatic cord resulting in testicular ischaemia and necrosis.
- most common in males aged between 10 and 30 (peak incidence 13-15 years)
Testicular torsion- features
- pain is usually severe and of sudden onset
- the pain may be referred to the lower abdomen
- nausea and vomiting may be present
- on examination, there is usually a swollen, tender testis retracted upwards. The skin may be reddened
- cremasteric reflex is lost
- elevation of the testis does not ease the pain (Prehn’s sign)
- Lie of the testis may be horizontal (bell-clapper position)
- In neonatal torsion the patient may be asymptomatic and present as a firm, hard and enlarged testis in a blue scrotum
Testicular torsion: mangement
- treatment is with urgent surgical exploration with fixation of the testicles with bilateral orchidoplexy
- if a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.
- Manual detorsion can be performed if the patient presents early
- Post operatively the patient is provided with scrotal support and advised bed rest for 24 hours and refrain from heavy lifting or exercise for the first few weeks
Testicular torsion: investigations and complications
Investigations
* Doppler ultrasound scan: shows lack of blood flow to the testis
* Surgical exploration confirms the diagnosis
Complications: atrophy or necrosis of the testis, infection, subfertility
Neonatal hypoglycaemia
Normal term babies often have hypoglycaemia especially in the first 24hrs of life but without any sequelae as they can utilise alternate fuels like ketones and lactate. Normally <2.6 mmol/L. Transient hypoglycaemia in the first few hours after birth is common.
Persistent/severe hypoglycaemia may be caused by: Preterm birth (<37 weeks), maternal diabetes mellitus, IUGR, Hypothermia, Neonatal sepsis, Inborn errors of metabolism.
Neonatal hypoglycaemia: features
- May be asymptomatic
- Autonomic (hypoglycaemia -> changes in neural sympathetic discharge)= jitteriness, irritable, tachypnoea, pallor
- Neuroglycopenic= poor feeding/sucking, weak cry, drowsy, hypotonia, seizures
- Other features: apnoea, hypothermia
Neonatal hypoglycaemia: management
- Asymptomatic: encourage normal feeding (breast or bottle), monitor blood glucose
- Symptomatic or very low blood gas: admit to the neonatal unit, intravenous infusion of 10% dextrose.
Transient tachypnoea of the newborn: pathophysiology
- It is a parenchymal lung disorder characterised by pulmonary oedema resulting from delayed resorption and clearance of foetal alveolar fluid.
- It is the commonest cause of respiratory distress in the term baby.
- Commonly occurs after a C-section as passage through the birth canal applies external pressure on the thorax to help expel the fluid
- Some babies have delayed resorption of the fluid due to suboptimal epithelial clearance
Transient tachypnoea of the neonate: presentation, diagnosis, management
Presentation= respiratory distress (tachypnoea, increased work of breathing and potentially desaturated/cyanotic)
Diagnosis= TTN is diagnosed both clinically an by hyperinflated lungs and fluid level on the chest x-ray
Management= oxygen support. Should resolve in a couple of days with resorption of lung fluid within the first 3 days of life
Respiratory distress syndrome: surfactant
- Neonatal respiratory distress syndrome (NRDS) is caused by a lack of surfactant.
- Surfactant is a phospholipid-containing fluid produced by type 2 pneumocytes.
- It acts to lower the surface tension in the alveoli helping to keep them open. A lack of surfactant increases surface tension and causes alveoli to collapse, triggering respiratory distress.
- Surfactant is made from around 26 weeks gestation, although adequate levels are not achieved until about 35 weeks. This means premature babies are at increased risk of NRDS.
RDS: diagnosis
- Diagnosis of neonatal respiratory distress syndrome is principally through clinical evaluation.
- A ‘ground glass’ appearance may be seen on chest x-ray.
RDS: management and complications
Management
* Treatment of neonatal respiratory distress syndrome is with intratracheal instillation of artificial surfactant.
* Additionally, if preterm delivery is suspected, giving the mother glucocorticoids before delivery can increase surfactant production in the baby.
Complications= NRDS is a major cause of pre-term infant mortality and so prompt recognition and treatment is essential.
Overfeeding
Really common, uses feeding to settle babies. No sense of ‘fullness’
Signs:
* More than average weight gain
* 8 or more wet nappies per day
* Loose stool
* Milk regurgitation
* Irritability
* Sleep disturbances
What are the appropriate feeding volumes in babies
- 60 ml/kg day 1
- 90 ml/kg day 2
- 120 ml/kg day 3
- 150 ml/kg day 4 and onwards
Preemies and underweight babies may require more. Every 2-3h for 1st few weeks (up to 4h) then longer. Eventually they transition to feeding on demand (when hungry)
Self harm
Very common. 32% of 15 year old females, and 11% of 15yo males
Investigations= usually opportunistic. Full physical exam, opportunities to look for signs
PATHOS instrument to assess suicide risk after adolescent OD
- Have you had Problems for over a month?
- Were you Alone in the house at the time?
- Did you plan the overdose for longer than Three hours?
- Are you feeling HOpeless about the future?
- Were you feeling Sad for most of the time before the overdose?
High risk >2 but use clinical judgment.
Suicide risk- management per BMJ best practise
- ensure safety
- treat any self-harm or underlying physical illness
- determine treatment setting (opt for least restrictive that is also safe and effective)
- safety plan - collaborative, will belong to the patient
- psychotherapy (e.g. CBT, counseling, …)
- treat any underlying psychiatric illness (e.g. depression, anxiety)
How is weight faltering defined
- falling across 2 major weight centile lines
- or being at a weight centile 2+ centiles below length/height
- or head circumference or weight centile below 2nd centile for age
When is it normal for babies to loose weight
-Babies often lose up to 10% of birthweight in the first few days from fluid shifts but should have regained birthweight by 2 weeks.
-This is why the UK-WHO growth charts centile lines start at 2 weeks of age, rather than birth.
-Infants who become acutely ill often lose weight but usually regain their centile within 2-3w
-Some infants with severe IUGR remain small, though most exhibit catch-up growth
