Paediatrics Flashcards
(57 cards)
Fever in Under 5s
TRAFFIC LIGHT RISK ASSESSMENT Green (low risk: - Normal skin colour - Responsive/ smiling / not crying - No resp symptoms
Amber (intermediate risk)
- Pallor
- Activity= Abnormal response to cues/ not smiling/ wakes after increased stimulation
- Resp= Nasal flaring, mild tachypnoea, sats <95, crackles in chest
- Circulation=Tachycardia, CRT >3 seconds, cry, reduced UO, poor feeding
- Temper >39 in 3-6 months
- Rigors
- Fever >5 days
- Limb= Swelling or not weightbearing
Red (high risk)
- Mottled/blue colour
- Activity = Unresponsive, high pitched/weak/continuous cry, doesn’t wake
- Circulation= Reduced skin turgor
- Resp=Tachypnoea, recession, grunting
- <3 months with temp>38
- Non-blanching rash
- Neck stiffness
- Status epilepticus
- Focial neurological signs
- Focal seizures
- Bulging fontanelle
DIFFERENTIAL DIAGNOSIS
- Bacterial meningitis
- Herpes simplex encephalitis
- Kawasaki diease
- UTI
- Pneumonia
- Septic arthritis or osteomyelitis
MANAGEMENT IN PRIMARY CARE
S/S of child suggest risk to life–> 999 call
Red features but no immediate risk to life–> Referral urgent to paediatric specialist
Amber features but no diagnosis risk–> Sent home with safety net
Green features only–> Care at home with advice
Important points:
- S/S of pneumonia do not get a CXR if not admitted to hospital
- Test the urine
- Do not prescribe oral Abx if not apparent source
- Give parenteral Abx if suspected meningococcal disease (benzylpenicillin or 3G cephalosporin)
IN SECONDARY CARE PAEDIATRIC SPECIALIST
Immediate Tx:
Features of fever and shock –> IV fluid bolus 20mk/kg
Shocked /unarousal /meningococcal disease S/S–> Parenteral Abx (plus listeria Abx if child <3 monthse.g. ampicillin or amoxicillin)
S/S suggestive of herpes simplex encephalitis–> Give IV aciclovir
S/S shock or Sats <92%–> Oxygen
Investigations:
Child <3 months= Vitals, FBC, blood culture, CRP, urine, CXR (if resp signs), stool culture (if diarrhoea), LP (in all <1 month or 1-3 months who appear unwell or have low WBC). If given parenteral Abx: 3G cephalosporin (cefotaxime if <3months) + Ampicillin/ Amoxicillin (for listeria)
Child > 3months: 1 of more…
- Red feature = RBC, blood culture, CRP, urine. Consider LP, CXR, electrolytes, blood gas
-Amber feature–> Urine, CRP, blood culture, LP, CXR
-Green features–> Urine and assessment for pneumonia.
-If parenteral Abx indicated: Ceftriaxone
Cerebral palsy
What? Group of permanent, non-progressive movement and posture disorders that limit activity, primarily due to insult to the brain before the age of 2
Prevalence:
2/1000 children
M:F equal
Aetiology:
80% due to antenatal events: TORCH, chorioamnionitis, prematurity, multiple pregnancy
10% intrapartum: Asphyxiation, head trauma
10% postnatal: Meningitis, IVH, head trauma
Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes infections
Presentation:
- Weakness
- Paralysis: Hemiparesis, spastic diplegia (scissoring)
- Delayed milestones (Not sitting by 8 months, not walking by 18 months, hand dominance before 12 months)
- Abnormal motor development: Late head control, rolling and crawling, bum-shuffling
- Abnormalities in tone: Hypotonia, dystonia (BG lesion), spasticity (pyramidal lesion)
- Language and speech problems
Associations:
- Learning disability
- Epilepsy
- Hearing impairment
DDx for delayed walking:
- Chronic illness
- Global delay (ASD?)
- Benign immaturity
- Duchenne muscle dystrophy in boys
- Congenital hip dysplasia if limping
- Generalised joint hypermobility
Referral:
If child at increased risk of CP—>Follow-up my MDT until 2 years (CGA)
If child suspected CP –> Referral for MDT assessment
Management:
1st line hollistic MDT (Physio, OT, orthopaedic surgeon)
Considerations: Epilepsy Tx, Spasticity Tx, Hungarian Peto approach.
Co-morbidities
- Nutritional problems
- Pain
- Mental health problems
- GORD
- Constipation
- Respiratory problems
Prognosis
By 6yrs old, half with quadriplegia gain urinary continence spontaneously. Less if low IQ.
Life expectancy: The greater the severity the lower the life expectancy
Child maltreatment
Be alert to possibility of maltreatment if the following are present in absence of suitable explanation:
- Frequent attendance or unusual injury pattern
- Unusual or marked change in child’s behaviour/emotional state, different from what is expected for their age and development
- Evidence of sexual abuse or neglect
- Any evidence of sexual activity, esp when underage
- Harmful interaction between child and care giver
- Appears neglected
Failure to access or attend hospital, give prescriptions
Consent:
Should be obtained before sharing confidential information UNLESS there will be risk of harm to the child/young person
Referral:
If there is suspicious that maltreatment is occurring, contact child’s social care to discuss need for referral.
If child in immediate danger, contact police
Declaration of FGM, report to police.
Trafficking suspicion, refer to social care and contact police
Sexual abuse suspicion, do not perform intimate exam and refer urgently for forensic evidence collection.
Referral not justified:
Child reviewed regularly
Confirmation of referral:
Confirm in writing, within 48 hours, any telephone referral to children’s social care;they will formally acknowledge your written referral within 48 hours after receipt. Contact local social care again if your referral has not been acknowledged within 3 working days.
Notification procedures: Child protection referral --> IRD (Interagency referral discussion) consisting off: - Healthcare team - Social work - Police (Education)
GORD in children
Define RF's Px Ddx Assessment Referral
Definition: Symptomatic or complicated reflux of abdominal contents into oesophagus
Aetiology: Child at risk due to shorted oesophagus Risk factors: - Overfeeding - Premature - FH of GORD - Previous surgeries to correct diaphragmatic hernias - Obesity -Hiatus hernia - Neurodisability
Presentation Onset: Before 8 weeks and usually resolves by 1 year <1 year old, presents with regurgitation +: - Irritability /discomfort - Faltering growth - Feeding difficulties - Single pneumonia ep - Hoarse voice / chronic cough >1 year: - Epigastric pain -Retrosternal pain - Heartburn
DDx:
- Benign GOR
- Pyloric stenosis
- Cow’s milk protein intolerance
- Sepsis
- Intussusception
Assessment:
Clinical diagnosis.
O/E = Check chest for aspiration pneumonia. Temperature for sepsis.
OFC for intracranial causes.
Abdomen palpation for obstructive causes.
Check growth chart.
Check for rash.
Management:
Regurgitation only: Reassure, resolves typically by 12 months
F-F infant with GORD: 1-2week trial of Gaviscon Infant
F-F and B-F infant with GORD: 1st line Continue gaviscon infant if successful. Withhold and reassess every 2 weeks. 2nd line 4 week trial of Omeprazole or Ranitidine 3rd line Specialist referral
1-2 yrs old with GORD: 1st line 4 week trial of omeprazole or ranitidine. 2nd line Specialist referral
Referral: Same-day if: - Haematemesis -Malaena -Dysphagia
T2DM
MANAGEMENT:
Education:
To child and carers covering:
- HbA1c monitoring and targets
- Influence of diet, exercise, body weight and incurrent illness of BM
- Aims of metformin and possible adverse effects
- Complications of T2DM and how to prevent
Monitoring:
As other children, advised to have:
- Regular dental examination
- Eye examination every 2 years
Substance Abuse:
Advise against smoking due to risk of vascular complications
Advice against substance misuse due to unpredictable effect on blood glucose control
Immunisation:
Annual influenza
Pneumococcal (for those taking insulin or oral hypoglycaemics)
Dietary management:
Encourage healthy eating and regular physical activity
Measure weight, heighter –> Calculate BMI. Plot on growth chart
Benefits: Reduced hyperglycaemia, CV risk
Metformin:
Offer standard release
HbA1c
Targets: 48mmol/mol (6.5%) or lower
HbA1c monitoring: Offer to T2DM 4 times a year
MONITORING Annual: - From diagnosis: ○ Hypertension ○ Dyslipidaemia ○ Diabetic kidney disease (as moderate increase ACR 3-30mg/mmol) - From 12 years ○ Diabetic retinopathy
Hypertension:
Annual monitoring.
If resting measurement above 95th percentile, repeat. If persistent, confirm with 24-hour ambulatory blood pressure monitoring. Start anti-hypertensives if confirmed.
Dyslipidaemia:
Annual monitoring.
What for: LDL, HDL, total cholesterol, non-HDL cholesterol and triglycerides.
If raised level, repeat sample (fasting or non-fasting).
Diabetic kidney disease:
Annually
○ Looking for mod raised albuminuria ACR in early morning urine
○ Result between ACR 3-30mg/mmol –> Repeat test on 2 occasions
○ Result ACR >30mg/mmol –> Investigate
Diabetic retinopathy:
Annual screening from age 12.
Referred to eye screening clinic on diagnosis by GP. Consider early referral if suboptimal control.
Aim: Early detection of background retinopathy.
T1DM
Average onset at 5-7 years
Presentation Tired Thin Toilet (polyuria) Thirst
DDx:
T2DM
Monogenic or mitochondrial diabetes (<1 yrs, no ketonuria, optic atrophy)
Diagnosis:
-Symptoms of hyperglycaemia
- Non-fasted Bm of >11 (fasted >7)
Screening at diagnosis = Coeliac and TFTs
Referral:
All suspected T1DM for same-day to MDT
Management:
Insulin therapy from diagnosis= 1st line: Multiple daily injection of basal bolus regime. 2nd line: CSII (i.e. insulin pump)
Advice = Honeymoon period for first 6 months, rotate sights of injecting, provide rapid acting insulin for during illness and hyper’s.
Immunisations:
Annual influenza
Offer pneumococcal vaccine if taking oral hypoglycaemia or insulin
Monitoring:
BM= Should be going >5/day. Should be 4-7 fasted or on waking. Should be 5-9 after eating. CGM indicated by hypo risk history. CGM consider for younger patients , those with high levels of physical activity or co-morbidities.
HbA1c= Target <48mmol/mol (6.5%). Offer to measure 4 times a year
Emergencies:
Hyperglycaemia = Rapid acting insulin available during “sick day rules” and hypo episodes. Advised about monitoring of BM and ketones, and adjustments of insulins. Give blood ketones testing strips and meter.
Mild-moderate hypo= First give oral fast acting glucose 10-20g. Recheck BM in 15 mins. Repeat if not corrected. Once normoglycaemia or symptoms resolved, give complex long-acting oral carbohydrate
Severe hypoglycaemia= If IV access give 10% dextrose (max 500mg/kg). If no IV access give IM glucagon (>8 yrs 100ug glucagon, <8 get 50ug of glucagon) or concentrated glucose solution oral. If no improvement after 10 minutes, seek medical advice. Once Sx improved or normoglycaemic, give oral complex long acting carbohydrate
Alcohol: Risk of hypo, esp when sleeping. Eat carbohydrate before and after drinking. Regular BM monitoring. IM glucagon may be ineffective
Screening:
At diagnosis: TFTs and coeliac
Annual: TFTs
Annual after 12yrs: TFTs, diabetic retinopathy and diabetic kidney disease
DKA
Px Ix Diagnosis Mx Complications
Presentation:
- N/V
- Abdominal pain
- Dehydration
- Altered conscious level
- Hyperventilation
Investigation:
1st line in primary care: BM. If known diabetic, check ketones.
At hospital: Blood glucose, blood ketones and capillary/venous pH and HCO3
Diagnosis:
Mild-moderate DKA = pH<7.3 (or HCO3 <18) + BM >11 + ketonaemia/ketonuria
Severe = pH <7.1
Management:
- Initial assessment
- VIP Check notes
- Close monitoring
Complications:
- Cerebral oedema
- VTE
- Hypokalaemia
Coeliac Disease
Definition: Autoimmune enteropathy induced by gluten leading to villous atrophy to the small bowel lining
Prevalence: 1%
Risk factors:
FH
Associated conditions = T1DM, Hypothyroidism
Presentation:
- Distension
- Diarrhoea
- Steatorrhoea?
- Failure to thrive
- Anaemia
- Decreased growth upon weaning
Investigation:
1st line blood serology for total IgA and tTGA (whilst eating a gluten containing diet)
2nd line blood serology for EMA
Indications? Typical coeliac presentation, T1DM, hypothyroid, Down’s syndrome, FH in first degree relative
Referral indications to paediatric gastroenterologist:
Positive result in primary care
Child younger than 18months
Follow-up:
Annual review (disease management, assess need for bloods and serology)
Assess need for referral back to paediatric gastroenterologist (e.g. faltering growth, S/S persistent, suspicion of GI cancer)
Complications:
- Anaemia
- malabsorption
- Faltered growth
- Splen dysfunction
- Bacterial overgrowth
- Cancer e.g. hodgkin’s and non-hodgkin’s lymphoma
Constipation
Constipation is a decrease in the frequency of bowel movements characterized by the passing of hardened stools which may be large and associated with straining and pain.
Normal stool frequency in children ranges from an average of 4 per day in the first week of life to 2 per day at 1 year of age. Passing between 3 stools per day and 3 per week is usually attained by 4 years of age
.
Constipation is termed idiopathic (functional) if it cannot be explained by any anatomical or physiological abnormality.
Contributing factors for constipation include pain, fever, inadequate fluid intake, reduced dietary fibre intake, toilet training issues, the effects of drugs, psychosocial issues, and a family history of constipation
.
Two or more of the following clinical features indicate that a child is constipated:
-Fewer than three complete stools per week (unless exclusively breastfed, when stools may be infrequent).
-Hard, large stool.
-‘Rabbit droppings’ stool.
-Overflow soiling in children older than 1 year of age (commonly very loose, smelly stools, which are passed without sensation or awareness).
Faecal impaction should be suspected if there is:
- A history of severe symptoms of constipation.
- Overflow soiling.
- A faecal mass palpable on abdominal examination.
No specific investigations are required in primary care to diagnose idiopathic constipation.
If constipation is diagnosed, red or amber flags suggesting an underlying cause or condition should be excluded.
- If red flags are present, urgent referral to an appropriate specialist should be arranged, and treatment for constipation should not be initiated in primary care.
- If amber flags are present, referral should be arranged (the urgency depending on clinical judgement), and treatment for constipation can be initiated in primary care.
Management of a child with idiopathic constipation in primary care includes:
- Offering reassurance that underlying causes of constipation have been excluded.
- Advising that idiopathic constipation is treatable with laxatives, although they may need to be taken for several months.
- Offering sources of information and support.
- Treating faecal impaction with a recommended disimpaction regimen.
- Starting maintenance laxative drug treatment if impaction is not present or has been successfully treated.
- Advising on behavioural interventions such as scheduled toileting, use of a bowel habit diary, and reward systems.
- Arranging regular follow-up to assess adherence and response to treatment.
- Considering the need for specialist referral if symptoms do not respond to optimal treatment in primary care, or if there is faecal impaction and the child is very distressed.
Referral guidelines:
RED FLAGS (urgent referral needed, don’t initiate treatment)
-Symptoms during first weeks of life
- Delayed passage of muconium >48hrs
-Abdo distension with vomiting
-FH hirschsprung’s
-Ribbon stool pattern
-Leg weakness or motor delay
- Abnormal appearance of the anal, lumbosacral or gluteal region
-LL deformity or abnormal neuromuscular signs
AMBER FLAGS (specialist referral, okay to initiate treatment)
- Faltering growth, developmental delay or wellbeing concerns
-Triggered by Cow’s milk
-Child maltreatment concern
Obesity
Prevalence:
20% of children are obese by the age of 11
1/3 of 2-15yr olds are obese
Risk factors:
- Poor diet
- Sleep deprivation
- Low exercise
- Female
- Asian (4x risk of Caucasian children)
- Tall (above 50th cc)
- FH obesity
- Drugs (NaVal, carbamezapine, mirtazepine, steroids)
- SE background (parental low education, low SES)
Medical causes (rare)
- Hypothyroid
- Cushings
- GH deficiency
- Prader-Willi
Diagnosis: 2-20yrs 1990 BMI chart >91st cc = overweight >98th cc = obese (screen for co-morbidities) >99.6th cc = Severely obese
Co-morbidities screening
- HTN
- T2DM
- Lipids
Referral for:
- > 98th cc
- Suspect organic cause
- Weight related morbidities
Management:
- Diet and exercise modification
- Referral to dietician considered
- MEND programme (Mind, exercise, nutrition, DO IT!)
Complications:
- Ortho e.g. SUFE
- Cardio e.g. IHD, CVD, atherosclerosis, HTN
- Resp e.g. OSA
- Endo e.g. T2DM, PCOS, Vit D Def, infertility
- Neuro e.g. poor self esteem, depression
- GI e.g. NAFLD
- Breast + bowel cancer
Meningitis
Causative agents:
Neonates: Streptococcus agalactiae, streptococcus pneumoniae, GBS, E.coli, listeria monocytogenes
Children >3 months: Neisseria meningitidis, streptococcus pneumoniae, Hib
Who, risk factors:
- Younger children
- Winter season
- Immunocompromised
- Chronic illness
- Passive smoking
Presentation:
Non-specific signs of infection
Specific: Neck stiffness, photophobia, altered consciousness, Rash (non-blanching), seizures
DDx
- Viral meningitis
- Fungal meningitis
- TB meningitis
- Viral encephalitis
- Malignancy
- SLE erythomatous
Ix:
Full septic screen
Note: LP contraindicated if signs if increase ICP (bulging fontanelle, papilloedema, cerebral herniation), Meningococcal septicaemia, DIC, focal neurology
Manangement
Bacterial meningitis: Urgent hospital admission (without parenteral Abx). GivenIV ceftriaxone + dexamethasone (with Amoxicillin if immunocompromised)
Non-blanching rash or meningococcal septicaemia: Urgent parenteral Abx (IM or IV benzlypenicillin) then transfer to hospital
Complication 30-50% will develop PERMANENT NEUROLOGICAL SEQUELAE. Common outcomes are: - *hearing loss* -Cognitive impairment -Seizures -Motor deficit - Visual disturbance -Hydrocephalus
Prognosis:
Worse for pnuemococcal
Faltering growth
Diagnosis: Using height-weight charts
If in the first days of life: Weight loss >10% or birthweight not returned by 3 weeks
If after the first few days of life:
- Weight <2nd centile
- Drop in 1+ centiles if birthweight at <9th cc
-Drop in 2+ centiles if birthweight 9th-91st cc
-Drop in 3+ centiles if birthweight was >91st centile
-Length/height more than 2 centiles below mid-parental height
DDx: Problem with intake, absorption, excessive expenditure
Management: If in the first few days of life, refer to paediatrician if weight loss >10% or birthweight hasn't returned in 3 weeks. If referral not indicated, reassure patient and advise on feeding. Follow-up review of weight. If older than 1 month, refer to paediatrics if... - Safeguarding issue -S/S of chronic illness -Slow linear growth -Short stature -Rapid weight loss
Short stature
What? Height <3rd cc
Cause:
Any chronic disease
Hypopituitarism
GH deficiency
Assessment: Weight + height Calculate mid-parental height Bloods (Coeliac screen, IGF-1, TFTs, LFTs, FBC, U+Es, Ca, K) Karyotype Bone age scan
Bronchiolitis
What? Viral LRTI of children under 2 years
Causative agent: RSV Can be adenovirus, parainflueza or mycoplasmai
Risk factors:
- Prematurity
- Passive smoking
- Chronic lung or heart condition
- Down’s
- neuromuscular disorder
- Immunocompromise
Diagnosis: 1-3 days of coryzal prodrome then - Wheeze +/- crackles - Tachypnoea +/- chest recession - Persistent dry cough Definitive: NPA
Warning signs of severe disease:
- Dry nappies for 12 + hours
- Febrile
- Altered consciousness
- Unable to feed
DDx: Pneumonia, VIW/early onset asthma
Signs of impending respiratory failure
- Exhaustion
- O2 <92% despite O2 therapy
- Recurrent apnoeas
Symptoms that indicate hospital admission
- Persistent severe respiratory distress (Resp recession, grunting, RR>70)
- Unable to feed
- Sats <92%
- Apnoea
If admitted, 1st line treatment is SUPPORTIVE - O2 (low-flow NC --> NFNC --> CPAP) -Suction -Feeding support (NG/OG --> IV isotonic fluids)
Treatments not advised
- Abx
- Corticosteroids
- LTRA
- LABAs
- Hypertonic saline
Prognosis:
Self-limited (Resp sx resolve in 5 days. Cough resolves in 3 weeks.
Can return to nursery with cough, if aprexia and no feeding/ respiratory problems
Enuresis
Defintions:
- Primary enuresis = Child never achieved more than 6 months of urinary continence
- Secondary enuresis = child has achieved 6 months dry before
Prevalence:
Males>
Tends to resolve completely by 9 years
(Most children continent by 3-4 years.)
Complication: Psychological impact on parents and child
Assessment History: - Family situation - Sleep habit - Bowel habit - Voiding pattern - Daytime symptoms - Fluid intake - FH Examination: - Height and weight - Abdominal examination - Perineal examination - Spine - LL neuro - BP - BM - Urine dipstick /culture
Management: 1st line conservative advice: - Regular voiding (double micturition, before before) - Treat constipation - Restrict pre-bed fluids - Trial of waking overnight - Remove nappies or pull ups - Avoid bladder stimulants - ERIC website Reward charts (for fluids and voiding, not dry nights) 2nd line interventions - Bladder retraining exercises: Regular / double micturition - Desmopressin (for child >7 yrs) - Anti-cholinergics • Oxybutinin • Tolterodine - Alarms (For child <7yrs) Antibiotic prophylaxis
Laryngomalacia
What?
Congenital abnormality of the larynx.
Presentation:
Infants typical present at 4 weeks of age with:
• Stridor
Management:
Intervention rarely required
Hydrocoele
What?
A hydrocele describes the accumulation of fluid within the tunica vaginalis.
Classification
They can be divided into communicating and non-communicating:
• Communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life
• Non-communicating: caused by excessive fluid production within the tunica vaginalis
Aetiology Hydroceles may develop secondary to: • epididymo-orchitis • testicular torsion • testicular tumours
Presentation
O/E
• soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
• the swelling is confined to the scrotum, you can get ‘above’ the mass on examination
• transilluminates with a pen torch
• the testis may be difficult to palpate if the hydrocele is large
Investigations + Diagnosis
Diagnosis may be clinical but ultrasound is required if there is any doubt about the diagnosis or if the underlying testis cannot be palpated.
Management:
Infant = 1st line Watch and wait for spontaneous resolution. 2nd line repair
Juvenile Idiopathic arthritis
What?
Arthritis in an under 16 years old for more than 6 weeks
Systemic onset JIA: Aka Still's disease. What? Autoinflammatory disease Features - Pyrexia * - Salmon-pink rash * - Lymphadenopathy - Arthritis - Uveitis - Anorexia - Weight loss
Investigations:
- ANA positive (esp in oligoarticular JIA)
Rheumatic factor negative
Childhood cancers
Overview: Rare and good prognosis (70%)
“Late effects”:
- Despite cure, still residual impact on…
- Growth
- Hearing
- Endocrine
- Vision
- Cardiac
- Immunity
- Renal
- Lung
- Thyroid
- Neuropsych
- Fertility
- Family
Indications for early referral:
- Lumps
- Bone pain
- Bruising or pallor
- Morning headaches
- Vomiting
Main types:
- Sarcomas (osteosarcoma’s* and Ewing’s sarcoma)
- Brain tumours (mainly medulloblastoma)
- Lymphomas (Hodgkin’s and non-hodgkin’s)
- Wilm’s tumour
- Neuroblastoma (at Adrenal*, or paraspinal sympathetic tissue)
- ALL
SARCOMA (O: 5%. E:2.5%)
- Where? Osteosarcoma at metaphysis long bones mainly LL. Ewing’s sarcoma at be diaphysis of long bone and flat bones, mainly pelvis and LL.
- Mets to the lungs and bone marrow
- Progression. Initially asymptomatic painless mass. Slow growly. Presents with pain, swelling and nocturnal pain. If pelvic Ewing’s can lead to cord compresion
- Who? Males in adolescent years.
- Tx: Chemo for 9-12 months. Ewing’s can get radiation. Consider surgery for limbs (salvage or amputation)
- Prognosis 30-60%
NEUROBLASTOMA (6%)
- Presentation? Adrenal has abdominal mass that crosses midline and calcified on imaging. Paraspinal sympathetic tumours if pelvic lead to cord compression, if cervical/high thoracic leads to horner’s.
- Mets? To bone often at diagnosis. If skull mets, “racoon” eyes
- When? In <6s
- Tx and Prognosis varied
WILM’S TUMOUR (5%)
- Presentation? Unilateral painless mass in flank. 1/3 have autonomic arousal. 1/4 have hypertension
- Who? In <3s
- Tx: Chemo 3-9month, nephrectomy +/- radiation
BRAIN TUMOURS
- Presentation dependent on location. Main type is medulloblastoma
- Age? Generally consistent
- Tx: Surgery/ chem/ radiation /rehab/ long term effects
- Prognosis varies (Craniopharyngioma»_space;» high grade glioma)
LYMPHOMA (Hodgkin’s lymphoma)
- Presentation? Painless adenopathy (Cervical or supraclavicular). Can be firm and rubbery. Mediastinal involvement common. Systemic features present (weight loss, night sweats, fever)
- Who? 20-24yrs, 75-79ys
- Tx 4-6 months chem+/- radiation
- Prognosis 90% 5 year survival if Dx before 15
ALL - Acute Lymphoblastic Leukaemia (33%)
Presentation? Bone marrow infiltration Sx (anaemia, low platelets, neutropaenia, pain).
Who? Age 2-5
Treatment? Immediate IV fluids, sample of bonemarrow, LP and initiate chemo. Bone marrow result is “packed”. Chemo duration for 2.5-3.5 years
Prognosis:91.5% survival
Developmental delay
Important developmental milestones:
- Sitting by 12 months
- Walking by 18 months
- No hand dominance before 12 months
- 2 word phrases by 2 years
Assessment tools
- Griffith’s scale
- Denver charts
- “Schedule of growing skills”
Presentation: Delayed talking
DDx: Isolated speech delay, language problem, communication problems
Ix: Hearing tests, comprehension delay test, assess for autistic behaviour
Presentation: Delayed walking
DDx: Global delay, isolated late walking, neuromuscular problems
Ix: CK in boys 18months not walking
Assessment of severity: Uses scores of <70 DQ (developmental quotient)
Patterns:
Down’s –> Global delay
Autistic –> Social and language skills delay
LD –> Decline in Cognitive skills
Intussusception
What?
Intussusception is a condition where the bowel ‘telescopes’ in on itself. This causes the bowel walls to press on one another, blocking the bowel. This can lead to reduced blood flow to that part of the bowel.
Epidemiology
Age? 3-18months
2M:1F
Presentation:
- Severe abdo pain* (initially lasting 2-3 minutes, after 12hrs constant)
- Pallor, floppy, tired
- -> If obstruction –> Vomitting and constipation
- -> Eventually “red current jam” stools, high temperature and swollen stomach
Investigations
Initial: Abdo palpation of sausage at RUQ
Diagnosis: US shows target-like mass
Risk:
- Dehydration
- Bowel ischaemia
Management
(Pre-treatment: IV fluids, Abx, NG tube)
1st line = Air enema
2nd ine= reduction by laparoscopy or laparotomy
Prognosis:
10-15% recurrence
HSP
Henoch-Schoenlein Purpura
What? IgA mediated vasculitis that manifests in skin, joint, bowels and kidneys
Who?
50% in under 5s
Risk factors: Can present after bout of UTRI or gastroenteritis
Diagnosis:
Clinically (Triad of purpura, abdo pain and arthritis/arthralgia)
Later kidney involvement: Haematuria either microscopic or macroscopic (“Cocacola urine”). Proteinuria can develop, risk of oedema at legs/feet.
Treatment:
1st line: s Conservative and reassurance of resolution in a few weeks. If no kidney involvement consider Ibuprofen for pain. If kidney involvement, hospital admission.
Prognosis:
Self-limiting, resolves in a few weeks.
6-12 monthly kidney function checks
Common to relapse, but self-limiting and mild
Headache red flags
• acute and severe
• Progressive, chronic headaches
• focal neurological symptoms
• age under 6yrs
• headache/vomiting that wakes child or present on waking (symptoms of raised intracranial pressure (ICP))
• consistent location of recurrent headaches
• presence of ventriculoperitoneal (VP) shunt
known systemic disorder (hypercoagulable state, genetic disorder, cancer, rheumatological disorder, immunosuppression, hypertension)
Febrile convulsion
Definition:
Seizure that occurs with fever without CNS infection, which occurs in infants and children
Classification:
- Simple febrile seizures: Isolated, generalised tonic-clonic seizures lasting <15 mins that do not recur within 24 hours or within the same febrile illness, with complete recovery within 1hr
- Complex febrile seizures: Have one or more of the following:
- A partial (focal) seizure
- Duration >15 mins
- Recurrence within 24 hours or within same febrile illness
- Incomplete resolution within 1 hour
Who:
Aged between 6 months and 6 years.
3% of children will have at least 1 febrile seizure
Diagnosis:
If the following occur together:
1. A tonic/clonic, symmetrical generalised seizure with no focal features
2. Occurring as the temperature rises rapidly in febrile illness (temperature can be record either before or after seizure)
3. If normally developing child between 6 months and 6 years
4. No signs of CNS infection or previous epilepsy
DDx:
- Meningoencephalitis
- Trauma
- Hypoglycaemia
- Low Ca, Mg
- CNS lesions
Ix
1st line: FBC, MSU, CSR, ENT swabs, ?LP
Management;
1st for acute febrile seizure= First aid cushioning of the head. If seizure not resolve in 5 mins give PR diazepam or buccal midazolam. Wait 10 minutes. If not resolved then repeat and Call 999.
Hospital admission indications:
To A+E: Suspected CNS infections or sepsis or pneumonia
Immediate paediatric assessment: <18 months, first febrile seizures, recurrent complex seizures, recent Abx use, parental anxiety, decreased consciousness pre-seizure.
Parental education{:
- Allay fear
- Teach how to use rectal diazepam
- Reassure about low risk of epilepsy
- Oral antipyretics used to avoid fever
- Vaccines up to date
Prognosis:
1% will develop epilepsy if no focal signs, single occurrence and <30 mins
30% will have a recurrence
