Paediatrics Flashcards
(435 cards)
1
Q
How is chronic lung disease of prematurity managed?
A
prophylaxis / preventions: give mum IM steroids if <34 weeks and consider between 34-36 weeks
Respiratory support: A-E approach - high flow oxygen via nasal cannula or incubator oxygen - if >2L of oxygen then humidify CPAP Invasive ventilation Give surfactant
medications:
- dexamethasone if >/= 8 days and on ventilator
- caffeine citrate if =/<30 weeks corrected gestational age
- nitric oxide: only if pulmonary hypoplasia or pulmonary HTN
2
Q
How are cleft lip and palate managed?
A
feeding: early assessment and intervention may be needed e.g. NG tube / specialised teat / dental palate
MDT team for CL / CP:
- early referra
potential airway problems (Pierre-Robin sequence) may occur and need management
pre-surgical: lip taping, oral appliances or pre surgical nasal alveolar moulding may be needed to narrow the cleft
surgery: at 3 months for CL, between 6-12 months for CP
seech and language therapy
may requires orthodontists
3
Q
How is CMV in the newborn treated?
A
Urine for CMV and viral PCR
- definitive test for congenital CMV id done in the first 2 weeks of life
Barrier nursing - as CMV is shed in the urine and body secretions
CMV usually has no long term implications
Life threatening infection: IV ganciclovir or Oral valganciclovir
CNS infection: IV ganciclovir or oral valganciclovir (have been shown to prevent long term hearing loss in the babies)
4
Q
How is a congenital diaphragmatic hernia in children managed?
A
In utero
o In utero surgical repair, and tracheal plugging or ligation have been attempted
- Outcomes have been variable
Resuscitation after birth o Intubate o Positive pressure ventilation o Wide-bore NG tube (8 Fr) - Aspirate and then leave on free drainage
o IV access
- Sedation and muscle relaxation
o HFOV and exogenous surfactant
- If respiratory failure severe
o Persistent pulmonary hypertension of the New-born
- Common and may require iNO
Surgery o Diaphragmatic defect is closed with primary repair or synthetic patch o Only done after baby is stabilised o Post-operative support may include: - HFOV - iNO - ECMO
5
Q
How is conjunctivitis in the newborn managed?
A
all acute cases of bacterial conjunctivitis require an urgent same day referral to an ophthalmologist
Mild bacterial conjunctivitis:
o Chloramphenicol eye drops
• Moderate-severe bacterial conjunctivitis:
o Systemic antibiotics
- Chlamydial: Oral erythromycin
Gonococcal: Single dose of parenteral cefotaxime/ ceftriaxone
- Pseudomonal: Gentamicin eye drops plus systemic antibiotics
• Viral: no specific antiviral, may use topical antihistamine and artificial tears to relieve itching
6
Q
How is Down syndrome managed?
A
Urgent PCR for trisomy 21
Full clinical exam especially of CVS
Echocariogram FBC and Blood film Hearing screening test SALT Opthalmologist MDT approach
Support: Down’s Syndrome Association
genetic counselling and early intervention therapies (physiotherapy and occupational therapy for fine motor skills)
individualised educational plan
monitor for associated problems
7
Q
Why is an echocardiogram done in a suspected down syndrome case?
A
if abnormal send to cardiologist,
congenital heart defects very common, 45% of Down Syndrome babies have it, mainly AVSD
8
Q
Why is a blood film and FBC done in a suspected case of Down Syndrome?
A
10% have transient abnormal myelopoiesis, so baby is at higher risk of leukaemia
polycythaemia also common and need to be excluded
refer to haematologist if suspicious
9
Q
Which early intervention therapies are suggested in down syndrome?
A
physiotherapy
occupational therapy
10
Q
What conditions needs to be monitored for in Down syndrome?
A
Duodenal atresia o Hirschsprung disease o Coeliac disease o Hypothyroidism o Epilepsy o Hearing and visual defects o Periodontal disease o Atlantoaxial instability
11
Q
How is GBS prevented?
A
intrapartum ABx (IV benzylpenicllin / clindamycin if allergy) in women who have:
- a previous baby with an invasive group B streptococcal infection
-group B streptococcal colonisation, bacteriuria or infection in the current
pregnancy
12
Q
Which medications are given if there are clinical signs of GBS?
A
Penicillin and gentamicin
13
Q
If CSF fluid is positive for GBS, how is this managed?
A
Benzylpenicillin 50mg/kg every 12h (at least 14 days)
and Gentamicin in starting dosage of 5mg/kg every 36h (for 5 days)
- dose adjustments made based on clinical judgement
14
Q
How is haemolytic disease of the new born prevented?
A
maternal Anti-D
- at 28 weeks, 34 weeks and birth
-rarely can be given as a single 1500iU between 28-30 weeks
15
Q
How is haemolytic disease of the newborn managed in newborns?
A
Resuscitation
- A to E approach particularly if preterm, anaemic or hydropic
o Exchange transfusion
- Indicated if:
• Bilirubin rapidly rising (>8-10 μmol/l/hr) despite adequate phototherapy
• Severe hyperbilirubinaemia insufficiently responsive to phototherapy
and supportive care
• Significant anaemia (Hb <100 g/l)
o Phototherapy
- Do not delay if baby thought to clinically have significant jaundice
• Transcutaneous bilirubin measurement can be taken to confirm/ if
unsure
o IVIG
- Only for immune haemolysis
16
Q
How is haemolytic disease of the newborn followed up?
A
check for late anaemia at 4-6 weeks
- consider folate supplementation to protect against this
hearing screen
counsel parents on recurrence in future pregnancies
17
Q
Which neonates require the Hepatitis B vaccine?
A
Acute: supportive care
HBsAg positive should receive:
- monovalent hepatitis B vaccine within 24h of birth (also at 4 weeks and 1 year)
- hexavalent (6in1) at normal times
18
Q
Which neonates require HBIG?
A
- If mum is HBsAg positive (even if HBeAg negative)
- if mum had acute hepatitis B during pregnancy
- mother had an HBV DNA level equal or above 1/10^6 in any antenatal sample during current pregnancy
HBIG should idealy be given simultaneously with Hep B vaccine but a different site
19
Q
How is HSV in the neonate managed?
A
if mum has primary disease 6 weeks before delivery then elective c-section is indicated
if primary infection earlier in pregnancy then offer prophylactic oral aciclovir from 36 weeks until delivery
aciclovir / valaciclovir can be given prophylactically to baby during the ‘at-risk’ period
20
Q
How is mild HIE managed?
A
Resucitate
Therapeutic hypothermia
ventilation - consider respiratory support early
Ensure PaCO2 4.5-6 kPa
Cardiovascular:
- consider invasive monitoring of BP and inotropic support early
- consider dobutamine to maintain BP ( > 40 MABP in term infants)
Fluids:
- 60-80% of maintenance
monitor urine output
21
Q
How is moderate HIE managed?
A
- Prompt treatment of seizures
• EEG to be considered - Maintain normoglycaemia (2.6-8.0 mmol/l)
- Treat hypocalcaemia if present
- Measure LFTs to assess liver injury
- Ensure IM phytomenadione (vitamin K) is given
- Monitor coagulation
- Withold feeding for at least 48 hours (due to increased risk of NEC)
22
Q
How is severe HIE managed?
A
Cranial ultrasound scan
• Important in excluding other causes of encephalopathy e.g.
haemorrhage
-MRI brain
-Consider switching to palliative care
• Continuing efforts with intensive care may be futile
• Requires MDT approach and discussion with family
23
Q
How is Listeria monocytogenes infection managed?
A
Amoxicillin and gentamicin (if blood cultures or CSF come back positive for Listeria)
24
Q
How is meconium aspiration treated?
A
Use BMJ best practice flow chart
If normal term infant with meconium-stained amniotic fluid but no history of GBS, observation is recommended
• If there are risk factors or laboratory findings that are suggestive of infection, consider antibiotics:
o IV ampicillin AND gentamicin
- Oxygen therapy and non-invasive ventilation (e.g. CPAP) may be used in more severe cases
- Boluses of surfactant and inotropes given in moderate cases
25
How is necrotising enteroclitis managed?
• Stop enteral feeding and medications
o TPN may be required if feeds stopped >24 hours
o For confirmed NEC cases feeds stopped for 7 days
• NG tube
o Leave on free drain
o Monitor hourly gastric aspirates
• Broad-spectrum antibiotics
o Must cover both aerobic and anaerobic organisms
o For example: cefotaxime and vancomycin
• Respiratory support
o May require high ventilation pressures due to abdominal distension
• Fluids
o For cardiovascular support, may require addition of inotropes
• Surgery
o Indicated if:
- Perforation
- Failure to respond to medical treatment
o Laparotomy with resection of necrosed bowel with either a primary anastomosis or a
defunctioning stoma
26
How is neonatal hypoglycaemia prevented?
feed baby within 30 minutes of birth
subsequent frequent milk feeding (every 2-3hours)
27
How is a neoante with a blood glucose of <1.5 managed?
o Admit to neonatal unit (NNU)
o Confirm hypoglycaemia with laboratory blood glucose assay
o IV 10% glucose 2ml/kg bolus
o Followed by an infusion of 3.6ml/kg/hr of 10% glucose
o Frequently recheck glucose until stable
- Aim for 3-4mmol/l
28
How are neonates with a blood glucose of 1.5-2.5 managed?
Feed immediately
o Recheck glucose after 30 mins
- If glucose still low, consider admitting and starting IV glucose
- If hypoglycaemia persistent refer to endocrinology team for further investigation
- If hypoglycaemia is secondary to hyperinsulinism give one of:
o Glucagon infusion
o Diazoxide + chlorthiazide
o Somatastatin analogue
29
How is pathological unconjugated jaundice managed?
Acute bilirubin encephalopathy:
1. Immediate exchange transfusion
2. Phototherapy
3. Hydration
4. IVIG
o Total bilirubin >95th centile for phototherapy
1. Phototherapy
2. Hydration
o Total bilirubin >95th centile for exchange transfusion
1. Exchange transfusion
2. Phototherapy
3. Hydration
4. IVIG if ABO
30
How is pathological conjugated jaundice treated?
Treat the underlying cause e.g. surgery for biliary atresia
31
How is breast milk jaundice treated?
Temporary cessation of BF and supplemental feeding
phototherapy and hydration
exchange transfusion
32
PACES: neonatal jaundice
common
Will Ix if < 1 day or > 14 days
Explain what happens if physiological
Tx: light therapy, not harmful but regular blood samples
breastfeeding can continue as per usual, every 3h and wake baby to feed if required
explain need to stay after phototherapy to check for rebound hyperbilirubinaemia
resources: NHS choices and breastfeeding network, Bliss for premature and sick babies
33
How is persistent pulmonary hytertension of the newborn managed?
* Oxygen
* Aim to maintain relatively high PO2 (10-13kPa in infants born >34 weeks gestation or 7-9kPa for those born <34 weeks)
• Ventilation
- Use appropriate pressures to achieve and maintain good lung inflation
- Consider sedation and paralysis to optimise efficiency of ventilation
• Minimise handling
• Surfactant
- Consider so as to optimise lung inflation
• Treat underlying cause
• Suction of secretions from ETT
• Fluids and inotropes
- To optimise cardiac output
• Inhaled nitric oxide
- Used if severe hypoxic respiratory failure despite maximal respiratory support
• High-frequency oscillatory ventilation
- If oxygenation is still problematic despite optimal conventional ventilation and surfactant
34
How is a pneumothorax in the neonate managed?
• Small pneumothorax
o Close observation (even if ventilated)
o 100% oxygen for 1-2 hrs to ‘wash out’ nitrogen
• Needle drainage
o If urgent decompression is required e.g. infant at immediate risk of respiratory failure
• Chest drain insertion
o For all tension pneumothoraces
o For all ventilated or preterm infants with non-tension pneumothoraces who deteriorate
35
How is respiratory distress syndrome managed?
ABC resus
Review Hx and cause
```
Respiratory support
o Ambient/headbox/ nasal cannula O2
- If baby:
• Looks comfortable
• FiO2 <0.3
• Blood gas normal
```
```
o Nasal continuous positive airway pressure (nCPAP)
- If baby:
• >30 wks and >1000g
• Baby looks well
• FiO2 <0.4
• pH <7.20, PCO2 <7.0-7.5
```
o Positive pressure ventilation
- If baby does not meet above parameters (e.g. <30 wks, looks unwell etc.)
• Fluids
o Usually 60ml/kg/day
o Initially dextrose
• IV antibiotics
o Broad spectrum combination
- Such as benzylpenicillin and gentamicin (unless listeria in which case start
amoxicillin and gentamicin)
• CXR
o Do ASAP unless mild respiratory distress where this can be delayed
36
How is SIDS prevented?
Infants should be put to sleep on their back
o Avoid overheating
o Place ‘feet to foot’ position i.e. feet at foot of cot
o No smoking exposure
o Baby at parents’ bedroom for the first 6 months
o Baby not in parents’ bed when they are tired, have taken alcohol, sedative medicines
or drugs
o Ideally infant should be breastfed
37
How is toxoplasmosis of the neonate managed?
Symptomatic babies
• Pyrimethamine + Sulfadiazine + Folinic acid
-Continue all 3 for 1 year
• Monitor LFTs and FBCs every 4-6 weeks
• Asymptomatic babies with positive serology
- No definitive guidelines present as treatment is controversial
- Discuss individual cases with infection and virology specialists
• Ophthalmology and audiology assessment recommended
38
How is TOF / Oesophageal atresia managed?
Primarily surgical correction
• Type A:
o Stabilisation and gastrostomy #1
o Oesophageal replacement
• Type B/D:
o Suction catheter and surgical correction
• Type C:
o Stabilisation and surgical correction
• Type E:
o NBM and surgical division of fistula
39
How is transient tachypnoea of the newborn managed?
Supportive therapy – O2 through hood/nasal cannula maintaining O2 sats >90%
* Maintain neutral thermal environment
* Provide nutrition – if respiratory rate 60-80 breaths per minute then use NGT or TPN
* If tachypnoea persists more than 4-6hrs begin antibiotics (ampicillin + gentamicin)
* Fluid restriction may be helpful in severe cases
40
How is aortic stenosis in the neonate managed?
Associated with Williams syndrome
Balloon valvulotomy:
- if high resting pressure gradient (>65mmHg)
- If symptomatic
- Sometimes used as a temporising measure surgery before or TAVR
Transcatheter aortic valve replacement (TAVR):
- most children with significant stenosis will require this
41
How is an atrial septal defect in the newborn managed?
(Ejection systolic murmur best heard at the upper left sternal edge and fixed wide-split second heart sound)
• Observation
o Main management strategy as the defect may close or shrink with time
• Measurement ratio of pulmonary to systemic blood flow (Qp:Qs)
o If <1.5 then does not require closure
o If >1.5 or ASD is large enough to cause right ventricular dilatation will require closure
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• Closure of ASD
o Usually undertaken pre-school age
o Approaches:
- Transcatheter closure
• Secundum ASD
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- Open heart surgery
• Primum ASD (and sometimes Secundum ASD)
42
How is coarcatation of the aorta managed in the newborn?
98% occur in the left subclavian artery
most common presentation is at 48 hours when the ductus arteriosus closes
prostaglandin E1 infusion: given to maintain duct patency
surgical repair:
End-to-end anastomosis or arch reconstruction with patch placement or bypass graft
o Older patients may require stent insertion or surgical resection
43
How is congenital cyanotic heart disease managed?
• Stabilise the airway, breathing and circulation (ABC), with artificial ventilation and
supplemental oxygen if necessary
o Place UVC/UAC
• Prostaglandin E1 infusion
o 0.05mcg/kg per minute
o Most infants with cyanotic heart disease presenting in the first week of life, are ductdependent
o Maintaining duct patency is key to early survival
o Prostaglandins help maintain duct patency
o Side-effects of prostaglandins: apnoea, jitteriness and seizures, flushing, vasodilation,
hypotension
• Start IV broad-spectrum antibiotics
44
What are the main aims of managing heart failure?
reduce preload (diuretics)
enhance contractility (IV dopamine, digoxin)
Reduce afterload (ACEi, IV hydralazine)
Improving oxygen delivery (beta blockers)
enhance nutirion (increase caloric diet)
Exercise and physical activity (depends on capacity)
45
How is infective endocarditis managed in the neonate?
Antibiotic prophylaxis
MDT
Surgery
46
When is ABx prophylaxis recommended for infective endocarditis?
Recommended for patients at highest risk of IE:
- Patients with any prosthetic valve, including a transcatheter valve, or those in whom any prosthetic material was used for cardiac valve repair
- Patients with a previous episode of IE
- Patients with CHD:
• Any type of cyanotic CHD
• Any type of CHD repaired with a prosthetic material, whether placed surgically or by percutaneous techniques, up to 6 months after the procedure or lifelong if residual shunt or valvular regurgitation remains
47
Which antibiotics are used in infective endocarditis in native valves?
Penicillin-sensitive Streptococcus viridans
• Beta-lactam +/- gentamicin or vancomycin
Methicillin-sensitive Staphylococcus aureus
• Beta-lactam or vancomycin or daptomycin or co-trimoxazole and
clindamycin
48
Which antibiotics are used in prosthetic valve infective endocarditis?
Penicillin-sensitive Streptococcus viridans:
• Beta-lactam +/- gentamicin or vancomycin
Methicillin-sensitive Staphylococcus aureus
• Nafcillin or oxacillin or cefazolin or vancomycin and rifampicin and
gentamicin
49
When is surgery indicated in infective endocarditis?
for removal of infected prosthetic material
50
Why should a PDA be closed?
to abolish lifelong risk of bacterial endocarditis and pulmonary vascular disease
51
When should a prostaglandin infusion be given?
If cyanosis is dependent on the PDS
52
How can a PDA be closed?
1st - IV indomethacin
Prostacyclin synthetase inhibitor
Ibuprofen (in premature / VLBW infants)
53
If pharmacological methods of closing a PDA are unsuccessful what can be done?
surgical ligation or percutaneous catheter device closure
Term infants:
o Symptomatic >6mo, percutaneous catheter device closure ASAP
o Usually closed using a coil or occlusive device introduced through a cardiac catheter at about 1 year of age, or delayed until 1yo
o Diuretics can be given if delay of closure, to manage symptoms
54
How is pulmonary stenosis in the neonate treated?
mild - asymptomatic and rarely progressive so just follow up
Moderate and severe:
- Transcatheter balloon dilatation is the treatment of choice
o Surgical valvuloplasty is 2nd line
o Endocarditis prophylaxis given before high-risk procedures
55
How is acute rheumatic fever managed?
Bed rest nad anti-iniflammatory agents
(aspirin, high dose for 1-2 weeks or 6-8 weeks)
anti-streptococcal ABx if there is sign of infection e.g. penicillin V, benzathine benzypenicillin or amoxicillin)
56
How is symptomatic heart failure following rheumatic fever treated?
diuretics and ACEi
| -prednisolone may be required
57
How is rheumatic fever prevented from recurring?
prophylaxis
monthly injections of benzathine penicillin (or oral pencillin OD)
prophylaxis for 10 years after last episode of until age of 21
lifelong for those with severe valvular disease
surgical treatment and valve repair may be needed
58
How is supraventricular tachycardia managed?
• If haemodynamically stable:
o 1st line: vagal manoeuvres preferably in the supine position with legs raised
o 2nd line: adenosine
-50-100mcg/kg then 100-200mcg/kg then increase in increments up to a single
dose of 500mcg/kg)
o 3rd line is a choice of one of the following:
- DC cardioversion
- Amiodarone 5 mg/kg
- Procainamide 15mg/kg
- Fleicainide 2mg/kg
• If haemodynamically unstable:
o Attempt vagal manoeuvres and adenosine as above but do not delay DC
cardioversion
• Catheter ablation is recommended if recurrent/ accessory pathway
59
How are hypercyanotic spells in tetraology of fallot treated?
- Place the patient in the knee-to-chest position
- Administer oxygen
- Insert IV line and administer phenylpephrine, morphine sulphate and
propranolol
- Prolonged attacks require sodium bicarbonate
- Refer to cardiac centre
60
How is transposition of the great arteries managed?
maintain body temperature
correct acidosis / hypoglycaemia
prostaglanding E1 infusion
Balloon atrial septostomy
- give heparin bolus before
61
How is tricuspid atresia managed initially?
medical:
given prostaglandin E1 infusion to maintain adequate flow through PDA
cardiorespiratory support: O2 and mechanical ventilation, inotropes, IV fluid
62
How is tricuspid atresia managed surgically?
First stage in neonates:
§ Early palliation to maintain a secure supply of blood to the lungs at low pressure by:
• Blalock-Taussig shunt insertion (between subclavian and pulmonary
arteries)
• Pulmonary artery banding operation to reduce pulmonary blood flow if breathless
o Second stage at 3-6m old:
- Removal of shunt and direct anastomosis of SVC to Right pulmonary artery = Glenn
o Third stage at 2-5yo:
§ Direct venous pathway from IVC into pulmonary arteries = Fontan
o Needs antibiotic prophylaxis
63
How is vasovagal syncope managed?
Education: teach them to spot warning signs, avoid triggers and learn how to abort attacks
physical techniques e..g physical counter-pressure manoeuvres and tilt training stop the faint when warning signs appear
increase volume e.g. salt in diet and electrolyte rich sports drinks, may give fludrocortisone
64
What murmur is heard in a ventricular septal defect managed?
loud pansystolic murmur at the lower left sternal edge, quiet pulmonary second heart
sound
65
How are small VSDs managed?
observation as they usually disappear by themselves
66
What should be given while the VSD is present?
prophylactic ABx to prevent bacterial endocarditis (amoxicillin)
67
How is a large VSD managed?
Heart failure is treated with diuretics (furosemide), or may need furosemide + captopril + digoxin
o Additional calorie input
o Open surgery is usually performed to:
- Prevent permanent lung damage from pulmonary hypertension and high blood flow (i.e. prevent Eisenmenger syndrome)
- Manage heart failure and faltering growth
68
How is an AVSD managed?
Treat heart failure medically and surgical repair at 3-6 months
69
Which children with otitis media need to be admitted?
severe sytemic infection
complications (e.g. meningitis, mastoiditis and facila nerve palsy)
Children < 3 months with a temperature > 38 degrees
70
When should parents of a child seek help?
if symptoms show no improvement after 3 days
71
When should back up antibiotics be prescribed in acute otitis media?
advise that it is not needed immediately but should use if symptoms have no improvement after 3 days
72
When should antibiotics be prescribed immediately in acute otitis media?
children with otorrhoea or children < 2 with bilateral OM
and advise to seek seek if they worsen or become systemically unwell:
-amoxicillin 5-7 days is first-line
Penicllin allergy: clarithromycin / erythromycin
73
Which children with otitis media should be referred to ENT?
Structural defects e.g. cleft palate or Down syndrome
74
PACES: otitis media
infection of middle ear
common in young children, usually lasts up to a week with improvement after 3 days
urgent help if they become systemically unwell
ABx if no improvement after 3 days
symptomatic management with fluids, paracetamol
75
How is acute epiglottitis treated?
admit and ICU
intubate and give supplemental oxygen blood culture
IV 2nd / 3rd generation cephalosporins for 7-10 days e.g. ceftriaxone
steroids and adrenaline may be used to reduce inflammation in some cases
prolonged intubation may be needed
usually recover within 2-3 days
76
What medication is given to close contacts of patients with acute epiglottitis?
Rifampicin
77
How is intermittent mild allergic rhinitis managed?
allergen advice
oral / intranasal antihistamine
2nd: LTRA (leukotriene receptor antagonist)
78
How is persistent mild / intermittent moderate or severe allergic rhinitis treated?
allergen avoidance
oral =/- intranasal antihistamine OR LTRA
2nd: intranasal corticosteroid
3rd sublingual / SC immunotherapy
adjuncts: intranasal decongestant or nasal saline irrigation
79
How is persistent moderate to severe allergic rhinitis managed?
allergen avoidance
intranasal corticosteroid =/- anti-histamine
2nd: sublingual / SC immunotherapy
adjuncts:
- intranasal decongestant
- nasal saline irrigation
- intranasal ipratropium
- oral antihistamine
80
How is rapidly developing angio-oedema without anaphylaxis managed?
Chlorphenamine and hydrocortisone:
- given rapidly as IV or IM
- emergency admission
81
How is stable angioedema without anaphylaxis managed?
identify underlying causes
82
What treatment if given to people with angio-oedema that requires treatment?
Cetrizine (or other non-sedatine antihistamines such as fexofenadine or loratidine) for up to six weeks
oral corticosteroid (e.g. prednisolone 40mg for up to 7 days) if sever Sx, in addition to non-sedating oral antihistamine
safety net: call 999 if they are unable to breathe
resources: british association of dermatologists
83
How is asthma in children <5 managed?
1. SABA
2. moderate dose ICS (this is first step if child is waking at night from asthma or having Sx more than 3 times a week)
- if Sx resolve at 8 weeks but recur within 4, LOW DOSE ICS
- if Sx resolve and recur after 4 weeks repeat moderate dose 8 week trial
3. LTRA to LOW dose ICS
4. STOP LTRA and refer to specialist
84
How is asthma in children 5-16 managed?
1. SABA
2. LOW dose ICS (first step if waking at night from asthma or Sx 3 times a week)
3. LTRA
4. Stop LTRA and add LABA
5. Switch ICS and LABA to MART with LOW dose ICS
6. Increase this to moderate dose ICS
7. Seek advice from specialist, consider either high dose ICS or theophylline
85
What are the non pharmacological aspects of asthma management?
assess baseline status using asthma control questionnaire or spirometry
personalised action plan from asthma uk
ensure all vaccines are up to date
advise about trigger avoidance e..g NSAIDs
assess for depression / anxiety
ensure patient has peak flow meter and assess inhaler technique
resources: Asthma UK
86
What needs to be addressed at an asthma review?
Confirm medication adherence
review inhaler technique
consider medication change
ask about occupational asthma and triggers
87
PACES: asthma
explain it is a condition where the airways are sensitive and can tighten suddenly and make it hard to breathe
explain the steps of treatment
discuss action plan, (blue inhaler carried everywhere, 10 puffs every 30-60s if breathless and ambulance if no presonse)
explain how to use a peak flow meter
advise on identifying triggers
support: Asthma UK and itchywheezysneezy
88
How is bronchiectasis investigated in secondary care?
Bronchiectasis severity index: calculated to gauge severity of disease
sweat chloride test or genetic testing for CF: offered to all children
Screen for antibody deficiency: done for all patients with a confirmed diagnosis
test for primary ciliary dyskinesia ( if no other cause)
89
How is bronchiectasis managed?
treat underlying cause e.g. CF
Vaccination against streptococcus pneumoniae and seasonal influenza
90
Which antibiotics are given to children aged 1 month - 11 years for non CF bronchiectasis exacerbation?
1st line
• Amoxicillin
• Clarithromycin
- 2nd line
• Co-amoxiclav
91
Which antibiotics are given to children aged 12 - 17 years for non CF bronchiectasis exacerbation?
```
1st line:
• Doxycycline
• 2nd line:
• Co-amoxiclav
• Ciprofloxacin can be started following specialist advice if co-amoxiclav cannot
be used
```
92
Which antibiotics are given empirically if child is unwell / unable to take oral medication?
* 1 month to 17 yrs
* Co-amoxiclav
* Piperacillin and tazobactam
* 1yr to 17yrs
* Ciprofloxacin (following specialist advice)
93
When should children with bronchiectasis be referred to secondary care?
3 or more exacerbations in 1 year
they have had a severe infection
symptoms not responding to repeat courses of ABx
cardiorespiratory failure or sepsis should be referred
British Lung Foundation patient information leaflet
94
When should children with bronchiolitis be referred via 999?
- apnoea
- child looks unwel
- signs of respiratory distress
- central cyanosis
- persistent oxygen saturation < 92% on air
95
How is bronchiolitis managed?
Humidified oxygen is < 92%
CPAP if impending respiratory failure
upper airway suction (do not perform routinely)
Fluids (by NG tube if cannot take fluid by mouth, IV cannot tolerate oral)
96
How can bronchiolitis be prevented?
infection control measures are required in the ward the patient is placed as RSV is highly infectious,
pavlizumab reduces the number of hospital admission in high risk preterm infants
97
PACES: bronchiolitis
explain it is a common chest infection that affects about 1 in 3 children < 1 year, and usually resolves by itself over 2 weeks
advise on maintaining good hydration and using paracetamol if child over 3 months old and distressed
safety net about A&E if apnoea or respiratory distress
NHS page on bronchiolitis
98
How is mild-moderate IgE-mediate CMPA?
onset minutes - 2 hours of ingestion
- Allergy testing at specialist allergy clinic
- Paediatric dietician referral
- Exclusively breast feeding mother
• Exclusion of all cow’s milk protein from mother’s diet
• Mother to take calcium and vitamin D supplements
-Formula fed or mixed feeding
• Trial of extensively hydrolysed formula
99
How is severe IgE-mediate CMPA?
As mild and:
- Consider elemental (amino acid) formula if extensively hydrolysed formula not
effective
- Refer to A&E if severe respiratory or CVS signs present – risk of anaphylaxis
100
How is mild/moderate non IgE mediated CMPA managed?
Be wary of diagnosing infant with CMA as GI symptoms of vomiting and
diarrhoea are very common
- Exclusively breast feeding mother
• Exclusion of all cow’s milk protein from mother’s diet
• Mother to take calcium and vitamin D supplements
-Formula fed or mixed feeding
• Trial of extensively hydrolysed formula
101
How is severe non IgE mediated CMPA managed?
Classified as severe if above measures taken and symptoms persist and are severe – symptoms to look out for:
• Skin: prurits/ erythema/ atopic eczema
• GI: GORD/ vomiting/ loose stools/ blood or mucus in stools/ abdominal
pain or discomfort/ infantile colic/ food refusal or aversion/ constipation/
perianal redness/ pallor or tenderness/ faltering growth
• Resp: cough/ chest tightness/ wheezing/ shortness of breath
Continue management as per mild/moderate non-IgE mediated CMA plus:
• Urgent referral to local paediatric allergy service
• Urgent referral to dietician
102
How are infants / older children with a CMPA managed?
Exclude cows' milk protein from their diet
o Offer nutritional counselling with a paediatric dietician
o Regularly monitor growth
o Re-evaluate the child to assess for tolerance to cows' milk protein (every 6-12 months)
- this involves re-introducing cows' milk protein into the diet
§ If tolerance is established, greater exposure of less processed milk is advised
following a 'Milk Ladder' (available from Allergy UK)
103
PACES: CMPA
explain it is an allergic reaction to some of the proteins in milk
5-15% of infants have this
treatment is simply to avoid cow's milk in maternal diet / switch to formula and add vitamin D for mum (takes 2-3 weeks to fully eliminate cows milk from breastmilk)
many children grow out of it between 6 months - 12 months (reintroduce using milk ladder)
monitor growth regularly
resources: british dietetic association
104
How is croup managed?
Oral dexamethasone (0.15mg/kg)
if oral not possible:
- inhaled beclomethasone (2mg)
- IM dexamethasone (0.6mg/kg)
105
How is mild croup managed?
admission not required
safety net:
- take to hospital if stridor or pulling between ribs
-ambulance if pale, blue, grey for more than a few seconds, sleepy, breathing trouble, upset and cannot be calmed, unable to talk or drooling
106
How is moderate croup treated?
oxygen
107
How is severe croup treated?
oxygen and nebulised adrenaline (1 in 1000 (1mg/ml))
108
PACES: croup
common infection of airways
explains it improves over 48h and steroids have been given to help that
if it worsens, come back
if child becomes blue, pale for more than a few seconds, unusually sleepy or unresponsive or serious breathing difficulties call and ambulance
paracetamol or ibuprofen if feerish
fluid intake
regularly checking on child at night as it worsens
109
What is the common mutation identified in cystic fibrosis and how is this treated?
delta F508 (specific mutation can be treated with lumacaftor / ivacaftor which increase CFTR protein trafficking to cell membrane)
110
What are the common pulmonary complications of cystic fibrosis?
pneumonia
nasal polyps
sinusitis
111
What is the general prophylactic management of the pulmonary complications of CF?
airway clearance techniques
mucoactive agents:
- rhDNAase
- hypertonic sodium chloride +/- rhDNAse
- mannitol dry powder for inhalation
112
How is staphylococcus pneumonia in CF treated?
flucloxacillin (prophylaxis)
given between 3-6 years of age
113
How is acute pseudomonas aerguinosa pneumonia treated in CF?
local guidelines with oral / inhaled ABx (IV if unwell)
114
How is chronic pseudomonas aerguinosa pneumonia treated in CF?
1st line: nebulised/ inhaled Colistimethate sodium
• Plus oral antibiotic/ 2 IV antibiotics of different classes if clinically
unwell with a pulmonary disease exacerbation
2nd line: Tobramycin DPI
115
How are GI complications of CF managed?
High calorie diet
o Pancreatic enzyme replacement therapy (e.g Creon)
- Insufficiency of pancreatic enzymes can be tested with faecal elastase
o H2 receptor antagonist or PPI
- If malabsorption persistent despite optimal pancreatic enzyme replacement therapy
116
PACES: CF
lifelong genetic condition characterised by recurrent respiratory infections and malabsorption
management requires MDT approach
will be referred to a specialist CF centre to discuss the ongoing management
aspects:
- pulmonary: physio and mucolytics
- infection: prophylactic ABx and monitoring
- Nutrition: enzyme tablets, high calorie diet and monitor growth
- psychosocial: support for child and carers
genetic counselling if considering more children / other siblings
117
What are the 3 aspects of managing a food allergy?
Dietary treatment:
- excluding offending foods
- paediatric dietician referral
- exclusion in mum if breastfeeding
drug treatment:
- mild - non-sedating antihistamines (diphenhydramine)
- severe (CVS, airways involvement): IM adrenaline and salbutamol if bronchospasm
education child and parent with allergy action plan:
- epi-pens for home use, 2 doses with them and one for school
food challenge may be considered after 6-12 months of being symptom free
118
PACES: food allergy
explain immune system reacts to parts of the food that other people do not
mainstay is to avoid
allergy action plan needed
some grow out of it
using of non sedating antihistamines and adrenaline
CMPA / egg often resolves in early childhood so gradual reintroduction may be possible
nuts and seafood usually persist to adulthood
119
How is hereditary lactose intolerance managed?
Dietary modification by avoidance and trialling different foods to discover their lactose
threshold
- Should be done with a dietician
o Can use lactase-treated dairy products or oral lactase supplementation
o Supplementation of calcium and vitamin D is required
120
How is acquired lactose intolerance managed?
Treat the underlying cause
o Consult a dietician to do dietary modification
o Can use lactase-treated dairy products or oral lactase supplementation
o Supplementation of calcium and vitamin D is required
121
How is laryngitis with airway compromised managed?
If patient doesn’t have diptheria then can give:
- Dexamethasone sodium phosphate: to reduce oedema
- Cefalozin and cefalexin: administered IV to start and then changed to oral antibiotics
o If patient has diptheria:
- Patient needs to be isolated
- Benzylpenicillin sodium IV/IM for 14d
- Diptheria antitoxin
122
How is laryngitis without airway compromised managed?
Viral:
- Analgesia as required: paracetamol
- Vocal hygiene: voice rest for 3-7d, increase hydration, humidification,
decreased caffeine intake
- Mucolytic can be given to help lubricate the vocal folds
o Bacterial:
-Phenoxymethylpenicillin for 14d
- Analgesia as required: paracetamol
-Vocal hygiene: voice rest for 3-7d, increase hydration, humidification,
decreased caffeine intake
- Mucolytic can be given to help lubricate the vocal folds
123
how is bacterial otitis externa treated?
Initial treatment:
- Antibacterial ear drops: ciprofloxacin and dexamethasone otic (0.3%/0.1%) 2x day for 7-10 days
• Ear needs to be cleaned of wax first and may need a wick to deliver the drops if the ear is too swollen
- Ibuprofen/paracetamol can be used for pain management. If severe pain and
>12yo, then can use codeine with the paracetamol
o If infection hasn’t responded to treatment, then can give oral ciprofloxacin
124
How is fungal otitis externa managed?
Non-perforated tympanic membrane:
-Topical acetic acid/hydrocortisone otic (2%/1%) 3x day for 7-10d
§ Ibuprofen/paracetamol can be used for pain management. If severe pain and >12yo, then can use codeine with the paracetamol
o Perforated tympanic membrane:
- Tolnaftate topical (1%) 3-4x day for 7d, with frequent ear cleaning
- Ibuprofen/paracetamol can be used for pain management. If severe pain and >12yo, then can use codeine with the paracetamol
125
How is pneumonia (not requiring admission) treated?
Most children can be managed at home
o Prescribe Amoxicillin is first-line for 7-14 days
- Alternatives: co-amoxiclav, cefaclor or macrolides (e.g. erythromycin)
- Macrolides can be added at any stage if there is no response to first-line treatment
- Bacterial and viral pneumonia are difficult to differentiate so all children should be given antibiotics.
o Paracetamol or ibuprofen can be used as antipyretics
o Keep adequate hydration
o Seek medical advise if RR increases, dehydration occurs or worsening of fever
126
When should children with pneumonia be referred for hospital admission?
Persistent SpO2 < 92% on air
o Grunting, marked chest recession, RR > 60/min
o Cyanosis
o Child looks seriously unwell, does not wake, or does not stay awake if roused or does
not respond to normal social cues
o Temperature > 38 degrees in a child < 3 months
o Consider admission if: dehydration, decreased activity, nasal flaring, predisposing
diseases (e.g. chronic lung disease)
o Whilst awaiting hospital admission
§ Give controlled supplemental oxygen if SpO2 < 92%
127
PACES: pneumonia
explain it is a chest infection
explain whether admission is needed
explain treatment (ABx) - amoxicillin for non-severe 5 days
advise to use paracetamol and maintain fluid intake
advise against smoking
check on child regularly during day and night
medical advice if child deteriorates
128
How is scarlett fever managed?
Notify the Health Protection Unit (HPU)
• Antibiotics
o Phenoxymethylpenicillin (penicillin V) - 4/day for 10 days
o Azithromycin (if penicillin allergy)
o Stay away from nursery/school for 24 hours after starting antibiotics
* Paracetamol or ibuprofen can be given for symptomatic relief
* Symptoms should settle down after around 1 week
* Treatment for 10 days is needed to prevent complications such as acute glomerulonephritis and rheumatic fever
129
How is sinusitis (<10 days) managed?
Do NOT offer an antibiotic
o Advice
-Acute sinusitis is usually caused by a virus and takes 2-3 weeks to resolve
- Symptoms, such as fever, can be managed using paracetamol or ibuprofen
-Some people may find some relief using nasal saline or nasal decongestants
• Can be given intranasal corticosteroid for congestion
-Medical advice should be sought if symptoms worsen rapidly, if they do not improve in 3 weeks or become systemically unwell
130
How is sinusitis >10 days but < 4 weeks managed?
Commonly bacterial infection
o Consider high-dose nasal corticosteroid for 14 days for adults and children > 12
years old (e.g. mometasone)
- May improve symptoms but unlikely to affect duration of illness
- Could cause systemic side-effects
o Consider NO antibiotic prescription or back-up prescription
-Watchful waiting for up to 10d and then give amoxicillin
- Antibiotics are unlikely to change the course of the illness
- The back-up prescription should be used if symptoms get considerably worse
of it is still has not improved by 7 days
-1st line: phenoxymethylpenicillin
• NOTE: clarithromycin if penicillin allergy
2nd line: co-amoxiclav
o Advise patients to seek medical advice if they develop complications or their symptoms
don't improve/worsen
131
How is sleep disordered breathing managed?
Children with adenotonsillar hypertrophy may need adenotonsillectomy which usually
causes a dramatic improvement in symptoms
* Other children may benefit from CPAP or BiPAP to maintain their upper airway at night
* Can use montelukast +/- intranasal budesonide if surgery didn’t improve the obstruction
132
When are children with pharyngitis / sore throat admitted?
Difficulty breathing
o Clinical dehydration
o Peri-tonsillar abscess or cellulitis
o Signs of marked systemic illness or sepsis
o A suspected rare cause (e.g. Kawasaki disease, diphtheria)
133
When are antibiotics given in pharyngitis?
Given if either
Group A Streptococcus has been confirmed:
• FeverPAIN score (4 or 5) or Centor scor (3 or 4)
• Throat cultures
• Rapid antigen testing
OR Person is experiencing severe symptoms
o Phenoxymethylpenicillin
- Given for 10 days
o Clarithromycin - If penicillin allergy
o Avoid amoxicillin because it may cause a widespread maculopapular rash if the tonsillitis is due to infectious mononucleosis
134
PACES: pharyngitis and tonsillitis
explain that it is tonsillitis
explain the ABx need to be taken correctly for ten days even if symptoms improve
avoid school for 24h until
ABx have been taken
advise to use paracetamol, lozenges, salt water gargling and difflam for symptomatic treatment
135
How is urticaria managed?
avoid triggers: identify triggers and if possible avoid
symptom diaries: determine frequency, duration and severity of urticarial episodes
UAS7 score (<7 in 1 week indicates control of disease, whereas more than 28 in a week is severe disease)
136
How is urticaria in people with symptoms requiring treatment managed?
Cetirizine (or other non-sedating antihistamine e.g. fexofenadine or loratadine)
- Usually given for up to 6 weeks
• Can be given for up to 3-6 months if it is likely that symptoms will recur
```
o Prednisolone (or other oral corticosteroid)
-If symptoms severe
```
137
When are children with urticaria referred to the dermatologist or immunologist?
Painful and persistent
o Symptoms not well controlled with antihistamines
o Acute severe urticaria due to food or latex allergy
138
How is viral episodic wheeze treated?
DO NO DIAGNOSE AS ASTHMA AS MANY PRESCHOOL CHILDREN WILL GROW OUT OF THEIR ILLNESS BY AGE 6 AND CAN AFFECT THEIR LIFE E.G. PILOTS
139
how is viral episodic wheeze managed?
1st line: salbutamol
-Inhaler used with a spacer
- Burst Therapy is often used for viral-induced wheeze
• The child is given 10 puffs of salbutamol using a spacer
• They are then assessed for a response to treatment
• If they can last 4 hours without the symptoms reappearing, they can be discharged
• They will be given a weaning regime for the salbutamol inhaler with a
spacer
o 2nd line: leukotriene antagonist and/or intermittent inhaled glucocorticoids
- Can be used at the start of an URTI and continued up to 10d
- This can also be used as continuous prevention
• Encourage parents who are smokers to stop
140
PACES: viral episodic wheeze
Explain the diagnosis (narrowing of the airways due to a viral chest infection causes
difficulty breathing)
* Inhaled medication helps to open up the airways and make you breathe easier
* Explain that the child will be monitored for 4 hours to see whether they can be symptomfree for 4 hours after the episode
• Discharge with salbutamol and spacer
o 10 puffs through spacer maximum of every 4 hours
o If no response after 10 puffs, seek help
o If symptomatic 48 hours after discharge, seek help
141
How is whooping cough managed?
Admit in isolation if:
o < 6 months old or acutely unwell
o Significant breathing difficulties (e.g. apnoea, severe paroxysms, cyanosis)
o Significant complications (e.g. seizures, pneumonia)
• Pharmacological Treatment - if admission is not needed, prescribe an antibiotic if the onset
of the cough is within 21 days.
o < 1 month old = clarithromycin
o >1 months old and not pregnant = azithromycin
o If pregnant = erythromycin
- Recommended >32 weeks gestation without vaccination to reduce the risk of
transmission to the newborn
• Advice
o Rest, adequate fluid intake and the use of paracetamol or ibuprofen for symptomatic relief
o Inform the parents that, despite antibiotic treatment, the disease is likely to cause a protracted non-infectious cough that may take weeks to resolve
o Advise that children should avoid nursery until 48 hours of appropriate antibiotic treatment has been completed or until 21 days after the onset of the cough if it was not treated
o Once the acute illness has been dealt with, advice parents to complete any outstanding immunisations
142
PACES: whooping cough
Explain the diagnosis (cough that lasts for a reasonably long time)
• Explain that it isn’t seen very often because of the immunisation programme (and discuss concerns about immunisation with the parent)
• Explain that having it once does not mean you can’t have it again
• Explain that antibiotics can help treat the condition, but the cough often persists for a long time
• Exclude from school until 48 hours after starting antibiotics
143
How are anal fissures managed?
```
Ensure stools are soft and easy to pass
o Increase dietary fibre (include foods containing whole grains, fruits and vegetables)
o Increase fluid intake
o Consider constipation treatment
o Stool softeners
```
• Manage pain
o Glyceryl trinitrate intra-anally
o Offer simple analgesia (paracetamol or ibuprofen)
o Sitting in a shallow, warm bath can help relieve the pain
* Advise on the importance of anal hygiene
* Advise against stool withholding
• Advise the parents that if it has NOT healed after 2 weeks or the child remains in a great deal
of pain, they should seek help
144
How is acute appendicitis managed?
Surgical emergency
• The patient should be nil-by-mouth from the time of diagnosis
* IV fluids should be started
* Requires immediate hospital admission
• Appendectomy performed without delay - open/laparoscopic
o Consider IV antibiotics (cefoxitin)
145
How is coeliac disease managed?
All products containing gluten (wheat, rye and barley) are removed from the diet
* Consider referral to dietician if there are problems with adhering to the diet
* Calcium and Vit D supplements +/- Iron should be given
• Arrange annual review
o Check height, weight and BMI
o Review symptoms
o Review adherence to diet - IgA-tTG titre every 3m until normalised and then yearly
o Consider blood tests (coeliac serology, FBC, TFT, LFT, vitamin D, B12, folate, calcium, U&E)
o Bone mineral density evaluated after 1yr
146
PACES: coeliac disease
Explain the diagnosis (caused by an inability to digest gluten (present in barley, rye and
wheat)
• Reassure that it is a common condition (1 in 100) and the treatment is fairly straight forward
(gluten-free diet)
• Explain that they will be put in touch with a dietician
• Explain the importance of keeping to a strict gluten-free diet (complications include
malnutrition and cancer)
• Explain that follow-up is usually necessary every 6-12 months
• Advise regular measurements of height and weight on centile charts
• Support: Coeliac UK
147
How is constipation managed?
Exclude red flag symptoms
• Reassure that underlying causes of constipation have been excluded
• Laxatives - may have to be taken for several months
• Check for faecal impaction - if present, recommend disimpaction regimen
o Osmotic laxative + dietary/lifestyle modification
o May need other laxatives too (stimulant, faecal softener)
• Start maintenance laxative treatment if impaction is not present/has been treated
o Dietary modification + osmotic laxative
* Advise behavioural interventions (scheduled toileting, bowel habit diary, reward system)
* Follow up to assess adherence and response to treatment
* Secondary behavioural problems are common
148
What are the different types of laxative?
Bulk-forming: fybogel, methylcellulose
o Osmotic: lactulose, Movicol
o Stimulant: Bisacodyl, senna, sodium picosulphate
o Stool-softener: arachis oil, docusate sodium
149
PACES: constipation
Explain that this is simple constipation and that it is very common
• Explain treatment (want to break the cycle of a hard stool being difficult to pass)
• Explain that Movicol takes time to work
o Disimpaction: escalating dose for 2 weeks
o Maintenance: can be used for a long time until bowel habits are re-established (no dangers)
• Advise encouraging the child to sit on the toilet after mealtimes (reflex)
• Advise behavioural intervention (star chart) to aid motivation
150
What is the medical management of Crohn's disease?
Steroids (prednisolone) may be used to induce and maintain remission
o Immunosuppressive drugs (azathioprine, methotrexate)
o Biologic therapies (e.g. infliximab)
o Aminosalicylates (e.g. mesalazine)
151
PACES: crohn's
Explain the diagnosis (a disease with an unknown cause that causes inflammation of the
digestive system leading to malabsorption and bloody diarrhoea)
• Explain that it is a life-long condition and there is always a risk of relapse
• Reassure that there are many medications that can be used to settle down the inflammation
any time it flares up (and explain that they will be seen by a gastroenterologist)
• Explain complications (malabsorption and bowel cancer)
• There is no special diet but you may find that certain foods will make it worse
• Support: Crohn’s and Colitis UK
152
How is GOR managed in breastfed infants?
-Carry out a breastfeeding assessment
-positional!
- If issue persists despite advice, consider trial of alginate therapy for 1-2 weeks
(stop at intervals to check whether the infant has recovered)
153
How is GOR managed in formula fed infants?
Review feeding history
- positional!
- Reduce feed volumes if excessive for infant’s weight (aim for 150-180mL/kg/day)
- Offer a trial of smaller, more frequent feeds
- Offer a trial of thickened formula or anti-regurgitant formula
- Offer alginate therapy without feed thickeners (stop at intervals to see if the infant has recovered)
154
What pharmacological options are available for the management of GOR?
-Consider 2-4-week trial of PPI or histamine antagonist in children who have 1 or more of the following:
• Unexplained feeding difficulties (refusing feeds, choking)
• Distressed behaviour
• Faltering growth
- Consider specialist referral if still no resolution
155
PACES: GORD
Explain the diagnosis (due to immaturity of the gullet leading to food coming back the wrong
way)
• Reassure that this is common and usually gets better with time
• Breastfeeding: offer assessment -> alginate therapy
• Formula: review feeding history -> smaller, more frequent feeds -> thickeners -> alginate
therapy
• Safety net: keep an eye on the vomitus (if it’s blood-stained or green seek medical attention)
156
How are hernias managed?
* #1: surgical repair for inguinal hernia. Timing is based on whether hernia is reducible
* If it is reducible, then manual reduction is preferred, with elective surgery being scheduled for repair
* If it is incarcerated, manual reduction is attempted if no signs of peritonitis, intestinal obstruction or toxicity and then surgery is scheduled to repair it
157
How is Hirschsprung disease managed?
Initial management involves bowel irrigation
• Surgical - usually involves an initial colostomy followed by anastomosing normally innervated
bowel to the anus (anorectal pull-through)
• Total colonic agangliosis would require initial ileostomy with later corrective surgery
158
How is infant colic in a breast fed infant managed?
continue and mother may benefit from following a hypoallergenic diet
159
How is infant colic in a formula fed infant managed?
Check bottle teat size is correct for infant
o Hypo-allergenic formula may be beneficial but should have food challenges periodically
to check if it has resolved naturally
o Avoid Soy formula
support: NHS Choices leaflet, health visitor (help with feeding
techniques etc.)
• Strategies to sooth a crying infant: holding the baby, gentle motion, white noise
• Encourage parents to look after themselves: get support from family and friends, meet
other parents at a similar state (NCT), resting, putting the baby in a safe place to give yourself
a time out
• Do not recommend things like Infacol and Colief because there is an insufficient evidence base
160
How is intussussception managed?
ABCDE approach
• IV fluids and NG tube aspiration may be needed
• Unless there are signs of peritonitis, reduction of the intussusception by rectal air insufflation (with fluoroscopy guidance) is usually attempted by a radiologist
• Clinically stable with no contraindications to contrast enema reduction
o Fluid resuscitation
o Contrast enema (air or contrast liquid)
o Contraindications
- Peritonitis
- Perforation
- Hypovolaemic shock
o Broad-spectrum antibiotics
- Clindamycin + gentamicin OR tazocin OR cefoxitin + vancomycin
o 2nd line: surgical reduction with broad-spectrum antibiotics
• If recurrent intussusception - consider investigating for a pathological lead point (e.g. Meckel's diverticulum)
161
PACES: intussussception
Explain that it is caused by telescoping of the bowel and typically occurs in young children
• If needing reduction, explain the procedure
• Explain that NG tube aspiration may be required
• Explain the supportive treatment (fluids and antibiotics)
• Explain about the possibility of needing an operation if rectal air insufflation is unsuccessful (75% success rate)
• 5% risk of recurrence (usually within a couple of days of treatment)
162
How is Meckel's diverticulum managed?
Asymptomatic
o Incidental imaging finding - no treatment required
o Detected during surgery for other reasons - prophylactic excision
• Symptomatic
o Bleeding - excision of diverticulum with blood transfusion (if hemodynamically unstable)
o Obstruction - excision of diverticulum and lysis of adhesions
o Perforation/peritonitis - excision of diverticulum or small bowel segmental resection with perioperative antibiotics
163
How is malrotation managed?
If there are signs of vascular compromise, an Emergency laparotomy is needed
• Ladd procedure - detorting the bowel and surgically dividing the Ladd bands
o This is either done laparoscopically (if elective or non-urgent) or during open laparotomy (emergency or urgent)
o The bowel is placed in the non-rotated position with the duodenojejunal flexure on the right and the caecum and appendix on the left
o Note: the appendix is usually removed to avoid diagnostic confusion in case the child presents again with an acute abdomen
• Antibiotics (cefazolin)
164
How is Mesenteric Adenitis managed?
Self-limiting condition, so supportive care:
| o Pain management and adequate hydration
165
How is acute bleeding peptic ulcer managed?
Endoscopy +/- blood transfusion
• And PPI
Surgery or embolization
166
How is a non-bleeding h pylori negative peptic ulcer disease managed?
Treat underlying cause + PPI
2nd line: H2 antagonist
167
How is a non bleeding, pylori positive peptic ulcer disease managed?
H. pylori eradication triple therapy for 7d:
| • PPI BD + clarithromycin 500mg BD + amoxicillin 1g BD
168
How should children with a suspected peptic ulceration be treated?
treated with proton-pump inhibitors
(e.g. lansoprazole 30 mg)
• If they fail to respond to treatment, an upper GI endoscopy should be performed
o If this is normal, functional dyspepsia is diagnosed
o Note: functional dyspepsia is probably a variant of IBS
169
How is pyloric stenosis mamanged?
IV fluid resuscitation
o This is essential to correct the fluid and electrolyte disturbance before surgery
o This should be provided at 1.5 x maintenance rate with 5% dextrose + 0.45% saline
o Add potassium once urine output is adequate
• Definitive treatment is by performing a Ramstedt pyloromyotomy
o This involves dividing the hypetrophied muscle down to but not including the mucosa
o Can be open or laparoscopic
170
How is recurrent abdominal pain managed?
Important to say that pain is real, not faked.
• Reassurance and continuation with physical activities
• Psych interventions may be helpful – CBT, family therapy
171
How is small bowel atresia managed?
Initially: nil by mouth, NGT placed for suction, IV hydration, broad spectrum antibiotics given.
• Surgical approach depends on the atresia site, mainly end-to-end attachment to form an anastomosis.
172
How is mild UC managed?
Oral 5-ASA
o Continue as maintenance if no relapse
o Relapse = use oral prednisolone and taper
- If they relapse with steroids, then it is called steroid dependent disease
173
How is moderate UC managed?
Oral prednisolone for 2-4wks and taper
o If good response = treat with oral 5-ASA and continue for maintenance
o If relapse frequent, then steroid dependent disease
o If bad response to oral prednisolone, then IV can be given. Should be tapered off to oral and maintain remission.
174
How is steroid dependent UC managed?
#1: Thiopurine or infliximab
o If successful continue with medication as maintenance
o If inadequate:
- Colectomy, adalimumab or vedolizmab
- Colectomy is the final treatment option
175
How is severe UC managed?
Medical emergency
o High dose IV Methylprednisolone
o Oral 5-ASA should be stopped
o Antibiotics can be used with bacteraemia
o Parenteral nutrition needed until improvement or surgery
176
How is the severity of UC calculated?
```
Paediatric Ulcerative Colitis Activity Index (PUCAI)
o Severe > 65 points
o Moderate - 35-64 points
o Mild – 10-34 points
o Remission – 0-9 points
```
177
PACES: UC
Explain the diagnosis (condition with unknown cause that leads to inflammation of the
bowel, which leads to symptoms)
• Explain that it isn’t common but is a well-known disease (1 in 420
• Explain that there is no cure and it is a condition that tends to come and go in flareups every so often
• Reassure that there are medications that can be used to reduce the likelihood of
flare-ups and to treat flare-ups when they happen
• Explain the complications (growth issues, bowel cancer)
• Explain that they will be seen by a gastroenterologist
• Support: Crohn’s and Colitis UK
178
How is acute liver failure managed?
Early referral to a national paediatric liver centre
• Steps to stabilise the child:
o Maintaining blood glucose (> 4 mmol/L) with IV dextrose
o Preventing sepsis with broad-spectrum antibiotics and antifungals
o Preventing haemorrhage with IV vitamin K and H2 antagonists/PPIs
o Prevent cerebral oedema by fluid restriction and mannitol diuresis
• Management is dependent on the suspected cause of acute liver failure
179
What are the features of a poor prognosis in acute liver failure?
```
Shrinking liver
o Rising bilirubin
o Falling transaminases
o Worsening coagulopathy
o Coma
```
assess for liver transplantation (PT is the best marker)
180
How is autoimmune hepatitis managed?
Most children with autoimmune hepatitis will respond to prednisolone and azathioprine
• Sclerosing cholangitis is treated with ursodeoxycholic acid
• Liver transplants may be considered in severe cases
181
How is biliary atresia managed?
Surgical intervention is recommended immediately (ideally within the first 60 days of life)
• Kasai hepatoportoenterostomy -
• Liver transplantation is considered if the Kasai procedure is unsuccessful
182
How are the complications of biliary atresia managed?
Complications: growth failure, portal hypertension, cholangitis, ascites
o Choleretics: Ursodeoxycolic acid promotes bile flow
o Nutritional supplementation:
o Fat-soluble vitamins
o Prevent cholangitis: During the first year of life, prescribe prophylactic antibiotics (usually co-trimoxazole)
183
How is cirrhosis and portal hypertension managed?
Sodium and fluid restriction
• Diuretics
• Refractory ascites: albumin infusion, paracentesis
184
How is hepatic encephalopathy managed?
Supportive (frequent monitoring of neurological and mental status)
• Identify and correct precipitating factors (e.g. GI bleeding, infections, electrolyte disturbances, drugs)
• Reducing nitrogenous load
o Dietary protein restriction
o Nitrogenous load from the gut can be reduced using non-absorbable disaccharides (e.g.lactulose) or antibiotics (e.g. rifaximin)
185
How is hepatitis A managed?
Supportive for pain, nausea, or itch as required
• Close contacts should be vaccinated within 2 weeks of the onset of illness
• Unvaccinated patients with recent exposure to hepatitis A should have human normal
intramuscular immunoglobulin or the hepatitis A vaccine
• Notify the Health Protection Unit (HPU)
186
How is acute hepatitis b managed?
Supportive for pain, nausea, or itch as required
o Anti-viral therapy (lamivudine, entecavir, tenofovir disoproxil)
o with/without liver transplant
• Notify the Health Protection Unit (HPU)
187
How is chronic hepatitis B managed?
Supportive (usually asymptomatic)
o Interferon or antiviral monotherapy (e.g. entecavir, tenofovir disoproxil, interferon alfa,
peginterferon alfa, lamivudine) is recommended in some patients
188
How is hepatitis B prevented?
ALL pregnant women should have antenatal screening for HBsAg
o Babies of all HBsAg-positive mothers should receive hepatitis B vaccination
o Hepatitis B immunoglobulin is also given if the mother was HBeAg-positive
o Other members of the family should also be vaccinated
189
How is hepatitis C managed?
Treatment decisions are based on genotype of the HCV
• Subcutaneous injections of Pegylated interferon alpha AND daily oral dose of Ribavirin
• New drugs are particularly effective (e.g. sofosbuvir)
* NOTE: treatment is NOT undertaken until > 3 years of age because vertically acquired infections may resolve spontaneously
* Notify the Health Protection Unit (HPU)
190
How is wilson's disease managed?
Zinc - blocks intestinal copper resorption
• Trientine - increases urinary copper excretion
• Pyridoxine (vitamin B6) - given to prevent peripheral neuropathy
• Dietary restrictions (reduce liver and shellfish intake)
• NOTE: neurological improvement may take up to 12 months
• Liver transplantation - considered in children with end-stage liver disease
191
How is non-alcoholic fatty liver disease managed?
Weight loss through diet and exercise (and bariatric surgery)
• Treatment for insulin resistance and diabetes
• Statins
• Vitamin E
• Liver transplantation - considered in children with end-stage liver disease
192
How is bacterial meningitis in < 3 months old managed?
Antibiotics: IV ampicillin/amoxicillin + cefotaxime
o Supportive therapy:
-Oxygen
-Anticonvulsant therapy
- IV fluids: saline and dextrose
- Vasopressors if hypotensive without fluid resuscitation response
193
How is bacterial meningitis managed in > 3 months old?
IV ceftriaxone
o Supportive therapy:
- Oxygen: reservoir rebreathing mask, unless intubation required
- Anticonvulsant therapy
- IV fluids: sodium chloride 0.9% and dextrose 5%
• If shocked: fluid bolus of 20 ml/kg sodium chloride 0.9% over 5–10
minutes
- Vasopressors if hypotensive without fluid resuscitation response
194
When might dexamethasone be given in bacterial meningitis?
if >3 months old and presents with these in CSF analysis:
o Frankly purulent CSF
o CSF WBC > 1000/µL
o Raised CSF WBC + protein concentration > 1 g/L
o Bacteria on Gram stain
o Note: steroids should not be used in meningococcal septicaemia
195
How should children with bacterial meningitis be followed up?
Discharge and Follow-Up
o All children should be reviewed by a paediatrician 4-6 weeks after discharge
o Offer formal audiological assessment
o Treating Contacts: ciprofloxacin is preferred over rifampicin
- This includes anyone who has had close contact with the patients in the 7 days before onset
196
PACES: meningitis
Explain the diagnosis (infection of the tissues surrounding the brain)
• Explain that it is a serious condition, but we have effective antibiotics that can treat the
infection
• It will require hospital admission to administer the antibiotics and monitoring
• There can sometimes be long-term complications, the most common is hearing loss, and
offer formal audiological assessment as follow up
• Follow-up with paediatricians in 4-6 weeks
• Offer ciprofloxacin prophylaxis for contacts
• Support: Meningitis Now
197
How is moderate chickenpox managed?
Oral aciclovir for 5d
| o Oral paracetamol and topical emollient (e.g. calamine lotion) to reduce itching
198
Whens should children with chickenpox be admitted?
Admit to hospital if there are serious complications (e.g. pneumonia, encephalitis, dehydration, bacterial superinfection)
• Inform the person to seek urgent medical advice if their condition deteriorates or they develop complications
199
How should severe chickenpox be managed?
Treated with IV aciclovir for 7-10d
| o Oral paracetamol and topical emollient to reduce itching
200
How should neonatal chickenpox be managed?
immediate specialist advice
201
How could chickenpox be prevented in immunocompromised patients?
Human varicella zoster immunoglobulin should be used in high-risk immunocompromised individuals with deficient T cell function following contact with chickenpox
202
How is WHO group A Dengue managed?
Tolerating adequate fluid volume, passing urine every 6hrs
o Sent home
o Rest and take oral fluids (rehydration products)
o Monitor for warning signs
o Paracetamol and tepid sponging can be used to reduce fever
203
How is WHO group B managed?
Hospital admission
o IV/oral fluids
o Monitor for progression of warning signs
o Discharge once patient is afebrile for >48hrs
204
How is WHO group C managed?
```
Hospital admission to ICU
o Consider blood transfusion
o IV 0.9% NaCl: maintenance + 5% fluid deficit
- 100ml/kg for first 10kg
- 50ml/kg for second 10kg
- 20ml/kg for >20kg
o Monitoring for worsening signs
o Investigation for other causes
o Discharge once patient is afebrile for >48hrs
```
205
How is EBV managed?
Supportive care:
o Paracetamol (10-15mg/kg every 4-6hrs) or ibuprofen (5-10mg/kg every 4-6hrs)
o Good hydration
o Rest, without physical activity and contact sports up to 8wks after
• Explain the expected course of the illness
o Symptoms usually last for 2–4 weeks.
o Tiredness is common
o exclusion from work or school is not necessary
o avoid heavy lifting and contact or collision sports for the first month of the illness
• Oral prednisolone may be given if upper airway obstruction is present
o Patient should be admitted to hospital
• IVIG may be given in patients with active bleeding
206
Which children with EBV should be admitted to hospital?
Stridor
o Dehydration or difficulty swallowing fluids
o A suspected potentially serious complication, such as splenic rupture.
207
How should encephalitis be managed?
• All suspected cases of encephalitis should be admitted and treated as an emergency (A to E approach)
• Suspected viral encephalitis treated with IV aciclovir until cause is determined.
• Supportive care should be done in ICU:
o Endotracheal intubation and mechanical ventilation
o IV fluids
o Decrease intracranial pressure if elevated - with corticosteroids and mannitol
o Deep venous thrombosis prophylaxis
• After acute, life-threatening phase, rehabilitation for both cognition/behaviour and motor/ambulatory
208
What antibiotic prophylaxis is offered to children with t cell and neutrophil defects?
co-trimoxazole to prevent PCP
itraconazole or fluconazole to prevent other fungal infections
209
What antibiotic prophylaxis is offered to children with B cell defects?
azithromycin to prevent recurrent bacterial infections
210
How are children with immunodeficiencies treated when they have an infection?
antibiotic treatment:
- prompt treatment of infections
- longer courses
- lower threshold for IV therapy
211
What are the aspects of management for children with hereditary immunodeficiency?
Antimicrobial prophylaxis
Antibiotic treatment
Screening for end organ disease
Immunoglobulin replacement therapy
bone marrow transplantation (e.g. SCID chronic granulomatous disease)
gene therapy
specialist referral
212
How is HHV-6 / HHV-7 treated?
This is roseala infantum
will resolve over a few days / week
Paracetamol (10-15mg/kg every 4-6hrs) or ibuprofen (5-10mg/kg every 4-6hrs) for
symptomatic relief
• Advise to maintain adequate hydration
213
How is vertical transmission of HIV prevented?
C section
washing and drying infant
avoidance of breastfeeding
ART by week 24 and zidovudine for 6 weeks for the neonata
214
How should children who have been diagnosed with HIV be managed?
1st: 2 NRTI with an INSTI or NNRTI or PI
```
counselling to commit to ART
prophylaxis for infections
micronutrient supplementation
MDT
vaccinations but not live vaccines
```
215
What PEP therapy is given to children within 72h of exposure and lasts up to 28 days?
Tenofovir disoproxil + emtricitabine + raltegravir as 1st line (2NRTI and HIV integrase
inhibitor)
216
How is Parvovirus B19 managed?
Erythema Infectiosum
Paracetamol (10-15mg/kg every 4-6hrs) or ibuprofen (5-10mg/kg every 4-6hrs) for
symptomatic relief
• Encourage adequate fluid intake and rest
• Secondary arthritis may be treated with ibuprofen (4-10mg/kg every 6-8hrs)
• If infection persists >3wks:
o Give IVIG for 5d
o May need a RBC transfusion for anaemia
217
Outline the management of MRSA confirmed impetigo in superficial / limited infections in infants / children
```
Topical fusidic acid (2%) for 5-7d
Hygiene: 2x/d washing with soap
and water
Intranasal mupirocin topical 2%
given as prevention for recurrences
```
218
Outline the management of MRSA confirmed impetigo in infants or children with a widespread / cutaneous lesions
```
Oral clindamycin for 7d
Hygiene: 2x/d washing with soap
and water
Intranasal mupirocin topical 2%
for 7d given as prevention for
recurrences
```
219
Outline the management of MRSA excluded impetigo in infants or children with a widespread / cutaneous lesions
```
Oral flucloxacillin for 7d
Hygiene: 2x/d washing with soap
and water
Intranasal mupirocin topical 2%
for 7d given as prevention for
recurrences
```
220
Outline the management of MRSA excluded impetigo in superficial / limited infections in infants / children
```
Topical fusidic acid (2%) for 5-7d
Hygiene: 2x/d washing with soap
and water
Intranasal mupirocin topical 2%
given as prevention for
recurrences
```
221
How is Kawasaki disease managed?
IVIG
• High-dose aspirin (reduce thrombosis risk) for 24-72hrs after the fever and then low-dose is given for 8 weeks
* 2nd line treatment options include corticosteroids and infliximab if resistant to IVIG
* 3rd line treatment options includes clospirin or anakinra or plasma exchange
222
How is low risk for myocardial ischaemia following kawasaki disease treated?
no further medications after 8wks of aspirin
223
How is moderate risk for myocardial ischaemia following kawasaki disease treated?
Moderate risk: low dose aspirin until aneurysm regression is demonstrated, with ECG and echo follow up annually
224
How is high risk for myocardial ischaemia following kawasaki disease treated?
High risk: low dose aspirin long term, with ECG and echo follow up twice a year
- Need long term warfarin (INR target: 2-3)
- May need clopidogrel
225
How is plasmodium falciparum / ovale / vivax / malariae / knowlesi infection managed?
chloroquine phosphate, or
| if resistant then quinine sulfate and doxycyline
226
How is severe plasmodium falciparum managed?
Parenteral artesunate then switch to oral artesunate, with primaquine
o Supportive care +/- intensive care
227
How is Measles managed?
Immediately notify the local Health Protection Team (HPT)
• Rest and drink plenty
• Paracetamol or ibuprofen for
symptomatic relief
• Respiratory support can be given if pneumonia or neurological support in case of encephalitis
• Vitamin A is given orally for 2d, especially in those hospitalised or <2 years old
228
How is mumps managed?
Notify the local Health Protection Unit (HPU)
• Advise patient to rest and take in adequate fluids
• Paracetamol or ibuprofen for symptomatic relief
• Stay away from school for 5 days after the development of parotitis
229
How is rubella managed?
Notify the local Health Protection Unit (HPU)
| • Rest and take in adequate fluids
230
How is staphylococcal scalded skin syndrome managed?
Hospital admission
• IV antibiotics (flucloxacillin)
• Analgesia - especially when changing dressings
• Emollient to alleviate pruritus and tenderness
• Monitoring hydration and fluid balance, give IV fluid
231
How is toxic shock syndrome managed?
Intensive care support is required to manage patients in shock
o IV Fluid
o Antibiotic therapy
o Vasopressor support
• Areas of infection should be surgically debrided
o Removal of infected tissue to prevent progression of disease, may need amputation also
• Start clindamycin and either meropenem or co-amoxiclav before culture reports return
• Antibiotics used often include:
o Clindamycin and
o Vancomycin or meropenem
o IVIG (for streptococcal TSS)
232
How is tuberculosis managed?
Notify the Health Protection Unit (HPU)
• Arrange hospital admission if the patient has suspected active TB and is unwell
• If hospital admission is not needed, arrange urgent referral to specialist TB service for
confirmation of diagnosis and ongoing management
233
What medication is used for tuberculosis?
Rifampicin + Isoniazid - 6 months
o Pyrazinamide + Ethambutol - first 2 months
o Pyridoxine hydrochloride (vitamin B6) is given weekly to prevent peripheral
neuropathy due to isoniazid
o In tuberculous meningitis, dexamethasone is given initially to reduce the risk of longterm sequelae, rifampicin and isoniazid should be continued for 10 months after initial 2m
o Latent TB Treatment
• Isoniazid – 6 months OR
• Rifampicin + Isoniazid – 3 months
234
What else needs to be done to manage a child with TB?
Risk assessment for drug-resistant TB
• A multidisciplinary approach should be taken including a key worker who should monitor the patient's adherence to treatment (directly observed therapy), clinical response and any adverse effects
• Do contact tracing
235
How is suspected typhoid managed?
Suspected:
o Ceftriaxone +/- azithromycin
o Supportive care: antipyretics, IV fluids
236
How is confirmed typhoid managed?
Ciprofloxacin 7d treatment
o Supportive care: antipyretics, IV fluids
o If no response after 4/5d of treatment add azithromycin
o If encephalopathic, add high-dose dexamethasone
237
What advice is given to children with acne?
Avoid over-cleaning the skin (may cause dryness and irritation - twice daily
washing with gentle soap is adequate)
• If make-up, emollients and cleansers are used, non-comedogenic
preparations are recommended with a pH close to the skin
• Avoid picking and squeezing scars due to the risk of scarring
• Treatments are effective but may take a while to work (up to 8 weeks) and
may initially irritate the skin
• Maintain a healthy diet
238
How is mild to moderate acne treated?
Single topical treatment:
o Retinoid = adapalene +/- benzoyl peroxide
o Antibiotic = clindamycin (1%) + benzoyl peroxide
o Azelaic acid 20%
• Creams and lotions are preferable in patients with dry skin
• Frequency of application can be increased gradually from 1/week if tolerated
• Apply a thin layer to clean skn at nighttime
• Washing affected areas with salicylic acid preparations
239
How is moderate acne not responding to topical treatments treated?
Consider oral antibiotics for a maximum of 3 months
o Lymecycline or Doxycycline
• Topical retinoid or benzoyl peroxide co-prescribed with antibiotic
• Change to an alternative antibiotic after 3 months if no improvement
• Oral antiandrogens e.g. cyproterone +/- spironolactone if signs of
hyperandrogenism
• If not responding after 2 courses of antibiotics or if they are scarring, refer to
dermatology for consideration of treatment with isotretinoin (Roaccutane)
• COCP in combination with topical agents can be used as an alternative to
systemic antibiotics in girls
o Note: progesterone only contraceptives or progestin implants with
androgenic activity may worsen acne
240
How is severe acne treated?
Refer to dermatologist
• Oral isotretinoin
• High-dose oral antibitoics for 6 months or longer
• Systemic corticosteroids
241
When are children with acne referred to a specialist?
Severe variant (e.g. acne conglobata or acne fulminans)
• Severe acne with scarring or risk of scarring
• Multiple treatments have failed
• Significant psychological distress
• Diagnostic uncertainty
242
When should children with acne be followed up?
8-12 weeks
243
How is mild eczema treated?
```
Emollient with frequent and liberal use
+
Mild topical corticosteroid with continued
treatment until >48hrs after flare has
been controlled
```
244
How is moderate eczema managed?
Admit if eczema herpeticum.
Emollient with frequent and liberal use + Moderate topical corticosteroid with continued treatment until >48hrs after flare has been controlled
Consider maintenance regimen if prone to frequent flares
2nd line: topical calcineurin inhibitors Bandages
245
How is severe eczema treated?
```
Emollient with frequent and liberal use
+
Potent topical corticosteroid with
continued treatment until >48hrs after
flare has been controlled
Consider maintenance regimen if prone
to frequent flares
```
2nd line: topical calcineurin inhibitor Bandages
246
Which emollients can be used in eczema?
E45, diprobase and cetraben and aveeno
247
Which steroids are moderate and which are potent?
betamethasone valerate 0.025% or
clobetasone butyrate 0.05%
potent: : betamethasone valerate 0.1%, mometasone
248
When are bandages used in children with eczema?
areas of chronic lichenified skin
249
How are antihistamines given in eczema?
Offer a 1-month trial of a non-sedating antihistamine (e.g. fexofenadine, cetirizine)
if there is severe itching or urticaria (review every 3 months)
o Consider a 7-14 day trial of a sedating antihistamine (e.g. promethazine,
chlorphenamine) if an acute flare is causing sleep disturbance
250
How is infected eczema managed?
Swab the affected area
1st line: Flucloxacillin (oral if extensive, topical if local)
- Penicillin allergy: erythromycin (alternative: clarithromycin)
- Use antibiotics for no longer than 2 weeks
251
How is eczema herpeticum treated?
Oral aciclovir
- If widespread, start aciclovir immediately and refer for same-day dermatological advice
- If around the eyes, refer for same-day ophthalmological and dermatological specialist review
- Provide parents and children advice on how to identify eczema herpeticum (rapidly worsening painful eczema, clustered blisters, punched-out erosions)
252
When are children with eczema referred?
Eczema herpeticum (immediate referral)
o Urgent referral (2 weeks) if severe atopic eczema has not responded to optimum therapy within 1 week or treatment to bacterially infected eczema has failed
o Refer if diagnosis is uncertain, atopic eczema on the face is not responding, contact allergic dermatitis is suspected, causing significant social and psychological problems or severe recurrent infections
253
PACES: eczema
Explain the diagnosis (characterised by dry, itchy skin)
• Explain that it is very common, and many children grow out of it
• Explain the management (and use of steroids if necessary)
o Patients often worry about use of steroids
o Explain that these are topical not systemic
o Only a short course required – it is better to use 1-2 weeks short course to clear up
eczema than to let child suffer for months.
• Encourage frequent, liberal use of emollients (and as a soap substitute)
• Explain the association with other atopic conditions
• Advise avoidance of triggers (e.g. types of clothes, detergents, soaps, animals)
• Avoid scratching if possible (keep nails short, use anti-scratch mittens in infants)
• Safety net about signs of infection (oozing, red, fever)
• Information and Support
o Itchywheezysneezy.co.uk - excellent website demonstrating how to apply emollients
254
How is cellulitis treated?
Uncomplicated cellulitis can be managed at home with oral antibiotics
```
Complicated cellulitis (e.g. cellulitis with systemic illness) may require admitting, resuscitation with oxygen and fluids and IV antibiotics.
o Switch to oral when fever settles, cellulitis has regressed and CRP is reducing
```
High-dose flucloxacillin for 7 days
o Penicillin allergy: clarithromycin
• Arrange a review in 48 hours by phone or in person
• If cellulitis occurring on top of VZV, prescribe flucloxacillin + amoxicillin
o Penicillin allergy: ciprofloxacin + metronidazole/clarithromycin
255
How is erysipelas treated?
similar to cellulitis but demarcated rash
penicillin V
256
How is guttate psoriasis treated?
1st: Phototherapy: narrow band UVB 2-3 times/week
• Topical preparation offered:
o Emollient to reduce scales and relieve itch (E45, Oilatum, Emulsiderm)
o Potent topical corticosteroid with vitamin D preparation +/- salicylic acid if scales are problematic
• Refer if lesions are extensive, severe or not responding to treatment
257
How are haemangiomas treated?
Usually are asymptomatic and undergo involution
• If there is functional impairment or cosmetic disfigurement:
o Beta-blocker +/- corticosteroid continued until theoretical involution or 12m
o May need surgery
- Cryotherapy
- Electrotherapy
- Vascular laser surgery
• If it is ulcerated:
o Barrier protection and Burow’s solution for gentle debridement
o May need topical antibiotics (metronidazole)
o Beta blocker may be used if haven’t previously been treated with it
258
How is hand, foot and mouth disease treated?
Symptomatic treatment only (hydration and analgesia)
• Keep blisters clean and apply non-adherent dressings to erosions
• No link to disease in cattle
• Do not need exclusion from school
259
How is lyme disease managed?
doxycycline, amoxicillin and cefuroxime
260
How are animala nd human bites managed?
Check for risk of tetanus
§ If unknown: tetanus/diptheria/pertussis vaccine, tetanus immunoglobulin and another tetanus/diptheria vaccine >4wks after and 6-12m later
o Check for rabies risk:
§ Non-immunised: Rabies vaccine + rabies immunoglobulin
§ Immunised: rabies vaccine
o Co-amoxiclav for 7 days
§ Penicillin allergy: metronidazole + doxycycline (7 days)
o Safety net about signs of infection
261
How is milia treated?
```
May be removed if not cosmetically pleasing
o Can do it using a fine needle
o Cryotherapy can be used
o Laser treatment
o Dermabrasion
o Chemical peeling
```
262
How is molluscum contagiosum treated?
Does not require treatment if immunocompetent (it is self-limiting), with spontaneous resolution usually occurs within 18 months
• Advise against squeezing mollusca to avoid the spread of infectious material and reducing risk of super-infections
• Avoid sharing towels, clothing and baths with uninfected people (e.g. siblings)
• If eczema or infection develops around the lesions, treat appropriately (e.g. emollients and steroids or antibiotics)
• Chemical or physical destruction may be done by a specialist and only if lesion has become symptomatic
263
How is mild erythema in an asymptomatic child with nappy rash treated?
Advise on the use of barrier preparation to protect the skin (available OTC) and apply
thinly at each nappy change
o Options: Zinc and Castor oil ointment BP, Metanium ointment, white soft paraffin BP
ointment
264
How is an inflamed rash causing discomfort in a nappy rash treated?
If > 1 month = hydrocortisone 1% cream OD (max 7 days)
265
How is a nappy rash suspected of candidal infection treated?
Advise against the use of barrier protection
| o Prescribe topical imidazole cream (e.g. clotrimazole, econazole, miconazole)
266
How is a persistent nappy rash with a suspected bacterial infection treated?
Prescribe oral flucloxacillin for 7 days
o If penicillin allergy: clarithromycin (7 days
F/U and review
267
How can nappy rash be prevented?
Consider using a nappy with high absorbency and ensure that it fits properly
o Leave nappy off as much as possible to help skin drying of the nappy area
o Clean the skin and change the nappy every 3-4 hours or as soon as possible after wetting/soiling, to reduce skin exposure to urine and faeces
- Use water, or fragrance-free or alcohol-free baby wipes
- Dry gently after cleaning
- Bath the child daily
- Do not use soap, bubble bath, lotions or talcum powder
268
How is necrotising fascitis treated?
Surgical emergency
• Surgical debridement of all infected and devitalised tissues, should go beyond visible areas of necrosis
• IV fluids
• Empirical IV antibiotics (vancomycin, linezolid, daptomycin, tedizolid phosphate, tazocin, meropenem, imipenem/cilastatin, ertapenem = 2 or 3 at the same time)
• +/- intravenous immunoglobulin (IVIG)
269
How is infantil sebhorreic dermatitis treated?
'cradle cap'
emollients, sulphur and salicylic acid
ointment, topical corticosteroid, psychosocial
270
How is scabies managed?
treat child and whole family, 5% permethrin cream or 0.5% malathion lotion to whole
body below neck, washed off after 12 hours
271
How is head lice treated?
Wet combing with a fine-tooth comb to remove live lice every 3-4 days for 2 weeks is useful
and safe
• Dimeticone 4% lotion or aqueous solution of malathion 0.5% is rubbed into the hair and scalp
and left on overnight and the hair is shampooed the following morning
• Treatment should be repeated a week later
DO NOT NEED TO STAY OFF SCHOOL
272
How is periorbital cellulitis treated?
```
IV antibiotics (e.g. high-dose ceftriaxone)
o MRSA will require vancomycin
```
need to prevent orbital cellulitis
273
How is mild ringworm treated?
topical antifungals
| o E.g. terbinafine cream, clotrimazole
274
How is severe ringworm treated?
systemic antifungals
o 1st line: oral terbinafine
o 2nd line: oral itraconazole
275
How is tinea capitis treated?
Systemic antifungal therapy (e.g. griseofulvin or terbinafine)
o 2nd line: itraconazole or fluconazole
125
o Topical antifungal shampoo is recommended in some patients (e.g. selenium sulfide
or ketoconazole topical)
276
How is scabies managed?
permethrin 5% cream applied to the whole body from the chin and ears downwards
o Particular attention should be payed to areas in between the fingers and under the
nails
o It should be applied to cool, dry skin and allowed to dry before the patient dresses
o Permethrin should be washed off after 8-12 hours
o A second application is required, 10-14d after the first application
o 2nd line: ivermectin 0.5% 200 mcg/kg (if permethrin is contraindicated/not tolerated)
277
How are viral warts treated in children?
Watchful waiting is most common in children
• Daily administration of proprietary salicylic acid or lactic acid paint or glutaraldehyde lotion
can be useful
• Cryotherapy with liquid nitrogen is effective but can be painful (should only be used in older
children)
278
How is sebhorreic dermatitis treated in children?
Massaging olive/vegetable oil onto scalp to loosen scales and then brush gently with soft brush and wash off with shampoo
o Thicker scales can be soaked overnight with olive/vegetable oil or petroleum jelly and then shampooed in the morning
topical imidazole cream (Use 2-3 times per day (depending on preparation) until symptoms disappear
Consider specialist advice if it lasts > 4 weeks
If severe: mild topical steroids (e.g. 0.25% hydrocortisone)
279
How is mild acute glomerulonephritis treated?
Treat the underlying cause
o Supportive treatment with close monitoring
o May need antibiotics, if post-strep GN
- Phenoxymethylpenicillin
280
How is moderate acute glomerulonephritis treated?
ACE inhibitor or ARB
o May need antibiotics, if post-strep GN
- Phenoxymethylpenicillin
o Furosemide
281
How is severe acute glomerulonephritis treated?
Corticosteroids and immunosupressants ( e.g. Rituximab)
282
How is acute glomerulonephritis with nephrotic syndrome treated?
Prednisolone +/- immunosuppressant
o Prophylactic trimethoprim – for early phases of treatment due to
immunosuppression
283
How is acute glomerulonephritis due to anti-GBM disease treated?
§ Plasmapheresis + prednisolone + cyclophosphamide
- Prophylactic trimethoprim – for early phases of treatment due to
immunosuppression
284
how is acute glomerulonephritis with immune complex (non-SLE) treated?
Prednisolone
| Phenoxymethylpenicillin
285
How is acute glomeruonephritis with immune complexes due to SLE treated?
Cyclophosphamide +/- prednisolone
Prophylactic trimethoprim – for early phases of treatment due to
immunosuppression
286
How is Pauci immune acute glomerulonephritis treated?
Methylprednisolone + cyclophosphamide
- Prophylactic trimethoprim – for early phases of treatment due to
immunosuppression
287
How is AKI treated?
'STOP'
septic screen
toxin identification
optimise hydration and fluid volume
prevent harm
288
Which complications of AKI would prompt referral for replacement renal therapy?
hyperkalaemia
acidosis
pulmonary oedema and overload
end organ complications uraemia
289
how is pre renal failure treated?
Hypovolaemia should be urgently addressed with fluid replacement and circulatory
support
o Dopamine/adrenaline in severe hypotension
o Furosemide if volume overloaded
290
How is renal failure treated?
Monitoring water and electrolyte balance
o A high-calorie, normal protein feed will decrease catabolism, uraemia and
hyperkalaemia
o Furosemide if volume overloaded
o IV fluid replacement if prerenal failure co-existing
o Consider renal replacement therapy
291
How is post renal failure treated?
Refer immediately to urology if any of the following are present:
- Pyelonephritis
- Obstructed solitary kidney
- Bilateral upper urinary tract obstruction
- Complications of AKI caused by urological obstruction
o Requires assessment of the site of obstruction
o Relief can be achieved by nephrostomy or bladder catheterisation
o Furosemide if volume overloaded
o Consider renal replacement therapy
292
When is dialysis indicated in AKI?
```
Failure of conservative management
§ Hyperkalaemia
§ Severe hyponatraemia or hypernatraemia
§ Pulmonary oedema or severe hypertension due to volume overload
§ Severe metabolic acidosis
§ Multisystem failure
```
293
how is primary bedwetting without daytime symptoms in a child < 5 managed?
Reassure the parents that many children aged < 5 yrs wet the bed and this
usually resolves without intervention
§ Ensure easy access to the toilet at night (e.g. potty near the bed)
§ Encourage bladder emptying before bed
§ Consider a positive reward system
294
how is primary bedwetting without daytime symptoms in a child > 5 managed?
If bedwetting is infrequent (< 2 per week) reassure the parents and offer watchand-see approach
• Can use a star or reward chart
• Don’t punish or make the child feel embarrassed
§ If long-term treatment is required, offer:
• 1st line: enuresis alarm with positive reward system
• 2nd line: desmopressin
o Note: fluid should be restricted 1 hour before desmopressin until
8 hours after
o May need to use detrusor-relaxing drugs if have nocturnally
overactive bladder
295
What may be given for short term control of enuresis?
desmopressin
296
When should children be referred for enuresis?
If bedwetting has NOT responded to two courses of treatment, refer to
secondary care, enuresis clinic or community paediatrician
297
Which children should be referred immediately to secondary care with enuresis?
primary bedwetting WITH daytime symptoms
298
Which three questions are vital to ask in enuresis?
Were they previously dry?
daytime symptoms?
how many times per week?
299
Which cases of secondary enuresis can be managed in primary care?
UTI and constipation
300
When cases of secondary enuresis need to referred for secondary care?
Diabetes
Recurrent UTI
§ Psychological problems
§ Family problems
§ Developmental, attention or learning difficulties
§ Known or suspected physical or neurological problems
301
How is HUS managed?
Monitor urine output and fluid balance
o In diarrhoea HUS (D+ HUS) use of antibiotics can worsen disease
o Maintain adequate hydration status (avoid cardiopulmonary overload) – IV isotonic
crystalloids
o Monitor blood pressure (treat if elevated)
§ Treatment should be with CCBs (ACE inhibitors can reduce renal perfusion)
o If anaemic, red cell transfusion is needed
o Avoid antibiotics, anti-diarrhoeals, narcotic opioids and NSAIDs
o 50% of patients will require dialysis in the acute phase
302
Why is long term follow up needed in HUS?
there may be persistent proteinuria and the
| development of hypertension and progressive CKD
303
How is TTP treated?
plasmapheresis
304
How is HSP managed?
Most cases will resolve spontaneously within 4 weeks
• Joint pain can be managed using paracetamol or ibuprofen
• If there is scrotal involvement or severe oedema or severe abdominal pain, oral prednisolone
may be given
o Rest, hydration and elevation of the affected area needed
• IV corticosteroids are recommended in patients with nephrotic-range proteinuria and those
with declining renal function
F?U to check BP and renal function
305
How is HSP with rapidly progressive nephritis treated?
IV corticosteroids + oral prednisolone + cyclophosphamine
| o Renal transplant or dialysis may be considered
306
How is nephrotic syndrome treated?
Initially give oral steroids (60 mg/m2 per day of prednisolone)
o After 4 weeks, the dose should be reduced or alternate days for 4 weeks
o Then it should be weaned or stopped
• Patients should be placed on a fluid restricted and low-salt diet
• May need albumin and furosemide if very advanced MCD
• Children who don’t respond after 4-6 weeks of corticosteroid therapy or have atypical features
may have a more complex diagnosis and need a renal biopsy
o Given ciclosporin or tacrolimus and methylprednisolone
307
What is the most common cause of nephrotic syndrome in children?
minimal change disease
308
How are urinary tract calculi managed?
Conservative management with IV fluids, analgesia (morphine) and anti-emetics
(ondansetron)
• Bacterial Infection - antibiotic treatment with co-trimoxazole or nitrofurantoin, or surgical
decompression
• Small stones - medical expulsive therapy
o May pass naturally
o Tamsulosin OR alfuzosin OR silodosin
• Larger stones and those that do not pass spontaneously - surgical removal
o 1st line: ESWL or ureteroscopy
• High fluid intake is recommended in all affected children
309
If urine dip is esterease negative and nitirite positive, what is the treatment?
start ABx if clinical evidence of UTI
310
How is esterase positive and nitrite negative urine dip treated?
only start ABx treatment if clinical evidence of UTI, Dx depend on urine culture
311
How are systemically stable with a UTI treated?
neonates + < 6 weeks
All to receive IV ampicillin and gentamicin or cefotaxime
All to be admitted to hospital after full sepsis screen
Oral therapy after clinical response + blood/CSF culture being
negative
312
How are systemically stable with a UTI treated?
6wks - 2 yrs
Oral cefixime for 7-10d
(Co-amoxiclav as an
alternate)
313
How are systemically stable with a UTI treated?
2-13yrs
Oral cefixime for 7-10d
(Co-amoxiclav as an
alternate)
314
How are systemically stable with a UTI treated?
> 13yrs
Oral cefixime for 3d
315
How are recurrent UTIS investigated?
USS, MCUG and DMSA for scarring and reflux
316
How are systemically unstable with a UTI treated?
<6wks
All to receive IV ampicillin and gentamicin or cefotaxime
All to be admitted to hospital after full sepsis screen
Oral therapy after clinical response + blood/CSF culture being
negative
317
How are systemically unstable with a UTI treated?
6wks - 2 years
IV ceftriaxone for 7-10d
If symptoms don’t resolve then
IV ampicillin and gentamicin
can be used
318
How are systemically unstable with a UTI treated?
2-13yrs
IV ampicillin and gentamicin for7-10d
If symptoms don’t resolve then
IV cefepime can be used
319
How are systemically unstable with a UTI treated?
>13
IV ampicillin and gentamicin for3d
If symptoms don’t resolve then
IV cefepime can be used
320
How is epididymo-orchitis treated?
-STI (Gonorrhoea or Chlamydia) – without waiting for results:
• ceftriaxone 1g IM single dose PLUS
• doxycycline 100mg PO TDS for 14 days
- Non STI-chlamydia or non gonococcal organism - doxycycline 100mg PO TDS for 14 days
- Enteric organisms – quinolone (e.g. ofloxacin, levofloxacin)
mumps - supportive
321
How is a hydrocele treated?
< 2 years (congential hydrocoele) = most resolve spontaneously before the age of 2 so
observation is appropriate unless there is bowel palpable in the groin and provided there is no
evidence of underlying pathology
• 2-11 years - hydrocele persists beyond 2 years
o Open repair
o Laparoscopic exploration
o Bilateral repair
o Abdominoscrotal hydrocoeles - require surgery through an abdominal incision
• 11-18 years - commonly non-communicating hydrocoele
o Idiopathic hydrocoele - observation is appropriate, however, surgery may be
considered if it is large or uncomfortable
o Hydrocoele after varicocelectomy - conservative management is the initial
approach, surgery is considered in cases that do not resolve
o Filarial-related hydrocoele (parasitic infection) - complete excision of the tunica vaginalis
322
How is hypospadias treated?
Surgery is NOT mandatory
• May be performed on functional or cosmetic grounds (after 3 months)
• Ultimate functional aim of surgery is to allow boys to pass urine in a straight line whilst standing and to have a straight erection
• Prepuce may be preserved and reconstructed, although for more proximal hypospadias, it is
sometimes required for the repair itself
• IMPORTANT: boys with hypospadias should NOT be circumcised before repair, because the
skin is important for the repair
323
How is paraphimosis treated?
Manipulation with topical analgesia (with ice packs, compression, osmotic agents)
• Puncture technique - perforating the foreskin at multiple locations to allow exudation of
oedematous fluid (if manipulation was unsuccessful)
• Surgical reduction followed by circumcision
324
How is testicular torsion managed?
Presenting within 4-6 hours of symptom-onset has a greater likelihood of testicular viability
• If suspected admit immediately to urology or paediatric surgery
o IV fluids, NMB, antiemetics, analgesia
• Non-Neonates
o Immediate urological consultation for operative repair
o Decision about orchidectomy vs orchidopexy is based on the extent of damage to testicular tissue
o During surgery, the contralateral testicle is fixed to the posterior wall
• Neonates
o Born with torsion - debate about whether surgical intervention is necessary (risk of anaesthesia)
o Born with normal testes but develop torsion - urgent surgical exploration is necessary
• Manual de-torsion may be attempted if surgery is not available within 6 hours
• Supportive Care
o Pain relief and sedation
o Anti-emetics
o If there no current scotal swelling but there are histories of pain and swelling – refer to
outpatient with urologist, urgency depends on frequency and duration of episodes
325
How is an undescended testicle in an infant < 3 months managed?
If possibility of disorder of sexual development (e.g. ambiguous genitalia or
hypospadias)
§ Urgently refer to a senior paediatrician within 24 hours as genetic or endocrine
testing may be necessary
o If undescended testes are bilateral at birth
§ Urgently refer to a senior paediatrician within 24 hours as genetic or endocrine
testing may be necessary
o If unilateral undescended testis
§ At birth - arrange review at 6-8 weeks
§ At 6-8 weeks
• If both testes are descended, no further action is necessary
• If unilateral undescended testis, re-examine at 3 months
§ At 3 months
• If both testes are descended, no further action is needed
• If both testes are in the scrotum, but one or both are retractile, advise
the parents that annual follow up is needed throughout childhood as
there is a risk of ascending testes
• If the testis is still undescended, refer the child to a paediatric surgeon
before 6 months of age
326
What surgery is done for an undescended testicle?
Undescended palpable testis -> Orchidopexy (placement of testis in the scrotum) is
performed for the following reasons:
§ Cosmetic
§ Reduced risk of trauma and torsion
§ Fertility (particularly important if bilateral)
§ Malignancy (increased risk in an undescended testis)
§ (Ideally, surgery should be performed <1 year of age)
327
What are some high risk prognostic factors for ALL?
age <1 or >10
tumour load
cytogenetics and molecular genetics
speed of response to initial therapy
minimal residual disease assessment
328
What supportive therapy is given in ALL?
Allopurinol / rasburicase to prevent tumour lysis syndrome
sufficient fluid intake to guarantee urine output of 100mL / hour
329
How is ALL without CNS involvement treated?
Induction chemotherapy
- Standard induction includes prednisolone, vincristine, anthracyclines (e.g.
doxorubicin, daunorubicin) and/or L-asparaginase)
- Dexrazone (prevent cardiotoxicity from doxorubicin)
- Rituximab (if CD20+ ALL)
- Tyrosine kinase inhibitors (e.g. imatinib) - for Philadelphia chromosome-positive patients
330
What other supportive therapies can be offered to children with ALL?
Bleeding patients or low platelet count may require tranfusions
o Prophylactic antibiotics, antifungals, and antivirals
o Prophylactic use of haematopoietic growth factors e.g. CSF (filgrastim) in those at risk
of febrile neutropenia
o Norethisterone can be given to female patients to suppress periods during therapy and
periods of thrombocytopenia
331
How is ALL with CNS involvement managed?
Standard induction therapy with intensified intrathecal chemotherapy
o intrathecal methotrexate alone
or with cytarabine and hydrocortisone ('triple'), and consolidation therapy containing
systemic treatment with high-dose cytarabine (HDAC) or high-dose methotrexate
(HDM) to ensure good blood-brain penetration
332
What is the second phase of treatment after induction of remission?
consolidation and maintenace
333
What combination therapy is used for hodgkin lymphoma?
ABVD: Adriamycin (Doxorubicin), bleomycin, vinblastine and
| dacarbazine) with/without radiotherapy
334
How is favorable hodgkin lymphoma treated?
two cycles of ABVD followed by low dose radiation
335
How is unfavourable hodgkin lymphoma treated?
four cycles of ABVD followed by medium radiation OR
• BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisolone), followed by two cycles of ABVD and radiotherapy
336
How is refractory / relapse hodgkin lymphoma treated?
High-dose chemotherapy and autologous stem cell transplantation (ASCT)
• Brentuximab vedotin (anti CD30) can be prescribe if ASCT fails or is ASCT is
unsuitable
• Nivolumab and Pembrolizumab (both block PD-1) are last line
337
What is the cure rate of hodgkin lymphoma?
80%
338
retinblastoma / neuroblastoma - check guide
check guide
339
How is nephroblastoma treated?
Surgery (nephrectomy) and chemotherapy (may be post-operative or pre-operative)
* Radiotherapy in more advanced disease
* More than 80% of patients are cured
340
How is beta thalassaemia major treated?
The transfusions aim to maintain the Hb concentration > 100 g/L to reduce growth failure and
prevent bone deformation
• Repeated blood transfusion can cause iron overload
341
What drugs can be used to chelate iron?
Chelators include SC desferrioxamine or oral deferasirox
342
What is the only cure for beta thalassaemia major?
Bone marrow transplantation is the only cure for beta-thalassemia major
o However, this is reserved for children with an HLA-identical sibling
• Splenectomy may be required
343
How is beta thalassaemia trait managed?
Genetic counselling and iron advice
| • Prenatal diagnosis via chorionic villus sampling
344
How is DIC treated?
Treat underlying cause (usually sepsis)
• Supportive care
• Replacement therapy - replacement of platelets (platelet transfusion), coagulation factors
(FFP) and cryoprecipitate transfusions
• Restoration of physiological coagulation pathways (e.g. heparin – however use is
controversial)
• Antithrombin – minimal data on effectiveness and safety – should not be used
• Protein C concentrates may be used, particularly in purpura fulminans due to meningococcal
septicaemia or congenital protein deficiency (in neonates)
• Chronic DIC may required herparin and tranexamic acid
345
How is G^PD deficiency managed in an acute haemolysis?
Supportive care + folic acid
o Blood transfusion and renal support may be given in cases of severe anaemia with
renal impairment
346
How is G6PD deficiency with prolonged hyperbilirubinaemia treated?
1st line: Phototherapy
2nd line: Exchange therapy
347
Why is desmopressin given to children with mild haemophilia a?
stimulates the endogenous
| release of factor 8 and vWF
348
How is hereditary spherocytosis treated in neonates?
Supportive +/- red blood cell transfusion
o Folic acid supplementation
o Consider phototherapy or exchange transfusion if the baby also has jaundice
349
How is hereditary spherocytosis treated in infants, children and adults?
Supportive care +/- red blood cell transfusion
o Folic acid supplementation (2-5 mg oral OD)
o Splenectomy may be considered with a pre-operative vaccination regimen for
encapsulated bacteria (H. influenzae, meningitis C and S. pneumoniae)
o Cholecystectomy may be performed because gallstones are common in HS
o Pneumococcal prophylaxis (oral penicillin)
• Aplastic crisis is caused by parvovirus B19 and requires blood transfusions
350
How is ITP treated?
In 80% of children, the disease is acute, benign and self-limiting
• It will resolve spontaneously within 6-8 weeks
• Most children can be managed at home
• Treatment is indicated if there is evidence of major bleeding (e.g. intracranial or
gastrointestinal) or persistent minor bleeding that affects daily life (e.g. excessive epistaxis)
351
How is life / organ threatening bleeding treated in ITP?
```
IVIG + corticosteroid + platelet transfusion
o Antifibrinolytics (Aminocaproic and tranexamic acid) may be used
```
352
How is ITP in a child with chronic disease treated?
Mycophenolate mofetil
o Rituximab
o Eltrombopag (thrombopoietin receptor agonist)
o 2nd line: splenectomy (if persistent)
353
How is iron deficiency anaemia treated?
Oral ferrous sulphate 200 mg tablets (2/3 per day)
§ Should be continued for 3 months after iron deficiency is corrected to allow
stores to be replenished
§ If not tolerated, consider oral ferrous fumarate or ferrous gluconate
advise re side effects on stool and nausea and to take with food
354
How should iron deficiency anaemia be monitored?
Recheck haemoglobin levels (FBC) after 2-4 weeks of iron supplement treatment
- Hb should rise by 2 g/100 mL over 3-4 weeks
o If the level has risen sufficiently, check again at 2-4 months to ensure that Hb level
has normalised
o If it has NOT risen sufficiently, address compliance issues
o Once haemoglobin and red cell indices are normal:
- Continue iron treatment for 3 months to replenish iron stores
- Monitor FBC every 3 months for 1 year
- Recheck after another year
355
What prophylaxis is given to prevent sickling?
Immunisation against encapsulated organisms (e.g. S. pneumoniae and H. influenzae type B)
o Daily oral penicillin
o Daily oral folic acid
o Vaso-occlusive crises should be minimised by avoiding exposure to cold, dehydration, excessive exercise, undue stress or hypoxia
356
How is an acute sickling crisis managed?
Oral and IV analgesia (avoid morphine < 12 years)
o Good hydration (oral or IV)
o Infection should be treated with antibiotics
o Oxygen (if reduced saturation)
o Exchange transfusion is indicated for acute chest syndrome, priapism and stroke
357
What medication may prevent sickling in sickle cell children?
hydroxycarbimide but monitor for white cell supression
358
What can be given to treat type 1 von willebrand disease?
desmopressin
caution in children < 1 as it can cause hyponatraemia
359
How is DDH managed?
First line (<6 months old): Observation - Progress is monitored by repeat ultrasound or X-ray
* Second line: The infant may be placed in a splint or Pavlik harness to keep the hip flexed and abducted - follow-up with x-ray at 6 months of age.
* Third line: Surgery if conservative measures fail (reduction with spica casting)
• Indications for ultrasound scan at 6 weeks to check for DDH:
o Breech presentation at 36/40 (regardless of presentation at delivery)
o Breech delivery (including <36/40)
o Family history of DDH
360
How is JIA managed?
specialist paediatric rheumatology multidisciplinary
team
Pharmacological management:
o Simple analgesia e.g. Paracetamol
o NSAIDs are useful for controlling pain and stiffness
o Consider weak opioids e.g. codeine
Intra-articular, oral or IV corticosteroids are useful adjunctive agents (whilst waiting for
second-line agents to have an effect) – avoided if possible due to risk of growth suppression
and osteoporosis
• DMARDs - used when the disease fails to respond to conventional treatments
o 1st line: oral or SC methotrexate
o 2nd line: sulfasalazine
• Other treatments: Inflammatory cytokine blockade e.g. TNF-alpha inhibitors, interleukin
receptor antagonists, anti-emetics
361
What are some complications of JIA?
Joint damage
Anterior uveitis
Osteoporosis
Growth failure
362
How is Osgood-schlatter disease managed?
Advise about pain relief
o Analgesia - paracetamol or NSAIDs
o Intermittent application of ice packs over the tibial tuberosity (10-15 mins up to 3 times
per day, including after exercise)
o Protective knee pads (may relieve pain when kneeling)
Reassure the patient and parents that this will resolve over time but may persist until the end
of a growth spurt
• Reassure that usually stopping all sporting activity is not necessary
o Reduce sporting activity (intensity, frequency or duration)
o Change the type of exercise to limit the amount of running and jumping requiring
powerful quadriceps contraction if they cannot tolerate normal activity
o As symptoms decrease, they can gradually increase their exercise levels
o Introduce low-impact quadriceps exercises (e.g. isometric quadriceps contractions,
straight leg raises, cycling or swimming)
Victorian Paediatric Orthopaedic Network fact sheet on Osgood-Schlatter
disease
363
How is Osteochondritis Dissecan managed?
```
Pain relief (paracetamol or ibuprofen)
• Rest and quadriceps exercises
• Sometimes surgical intervention is needed (to remove intra-articular loose bodies)
```
364
How is osteomyelitis managed?
High-dose IV empirical antibiotics (usually for 2-4 weeks)
o Once the patient has demonstrated clinical recovery and acute-phase reactants have
returned to normal, patients can be switched to oral antibiotics
o IMPORTANT: take blood cultures before starting antibiotics
o The regimen should be altered once results of MC&S arrive
o NOTE: in children who respond well, early transition to oral antibiotics (after 3 days to
1 week) may be considered
§ 6-week course of oral antibiotics
o Affected limbs should be immobilised, analgesia should be given, and associated
comorbidities should be addressed
o Surgical debridement may be necessary if there is dead bone or a biofilm
365
How is Chronic Osteomyelitis managed?
Clinical assessment, disease staging (Cierny-Mader classification) and optimisation of comorbidities
o Surgical debridement
o IV antibiotics
o Functional rehabilitation
366
How is Perthes Disease managed?
Non-surgical treatment – benign self-limiting condition
• Supportive care for acute pain: simple analgesia, ice packs, protective pad over the tibial tubercle
• Activity continuation
• Physical therapy: stretching of the quadriceps and hamstring muscles, strengthening of the
quadriceps, encourage hip abduction
• Education about exacerbations and management
• Surgical treatment is reserved for patients who fail to respond to conservative measures (only
if >6yrs)
367
How is reactive arthritis managed?
```
No treatment is required as it is self-resolving
• Symptomatic relief:
o NSAIDs for pain-relief
o Steroids (severe)
o DMARDs (on-going)
```
368
How is rickets managed?
```
If calcium deficient rickets with vitamin D deficiency
o Daily calcium +
o Ergocalciferol (vit D2) / colecalciferol (vit D3)
```
• If pseudo-vitamin D deficiency (defect in 1-alpha hydroxylase)
o Calcitriol / alfacalcidol
* Phosphate salts are used in hypophosphataemic rickets
* Dietary: oily fish, egg yolk
369
What are the x-ray findings of rickets?
widened epiphysis, bowed diaphysis and cupped metaphysis
370
How is septic arthritis of a suspected gram positive bacteria treated?
Vancomycin
| § 2nd line = clindamycin or cephalosporin
371
How is septic arthritis in a suspected gram negative treated?
3rd generation cephalosporin (e.g. ceftriaxone)
| § 2nd line = IV ciprofloxacin
372
How is SUFE managed?
Don’t let the patient walk, analgesia, immediate orthopaedic referral
• Surgical repair
• In situ screw fixation across the growth plate
373
What are the x-ray findings of SUFE?
reduced external rotation
Trethowan’s sign: line of Klein does not intersect superior femoral
epiphyses/asymmetry between line of Klein’s on either side
374
How is ADHD < 5 managed?
1st line: Offer an ADHD-focused group parent-training programme to parents and
carers
§ 10-16 meetings in a group of 10-12 participants
o If this fails, seek advice from a specialist ADHD service
o Do NOT offer medication unless under the instruction of a specialist ADHD service
375
How is ADHD > 5 managed?
Recommend ADHD-focused group parent-training programme:
Offer individualised parent-training programmes if there are difficulties attending group
sessions or the needs are too complex
o Offer medication if ADHD symptoms persist and cause significant impairment despite
environmental modification
376
How is medication givne in children >5 for ADHD?
Offer methylphenidate
§ If 6-week trial of methylphenidate is deemed unsuccessful, consider switching
to lisdexamphetamine
§ If responding to lisdexamphetamine but not tolerating side-effects, consider
switching to dexamphetamine
§ Offer atomoxetine or guanfacine if methylphenidate or lisdexamphetamine
cannot be tolerated or symptoms have not responded to 6-week trials of both
§ Establish baseline physical state (height and weight) and do baseline ECG
before starting medication
§ Yearly off-medication trials are recommended
377
When is CBT indicated in ADHD?
significant impairment in:
§ Social skills, problem solving, self-control, active listening and dealing with
expressing feelings
378
What should be measured when on methylphenidate / ADHD medication?
Consider using symptom rating scales (e.g. Conner’s)
o Measure height every 6 months
o Measure weight every 3 months
o NOTE: if height/weight is significantly affected by the treatment, consider a planned break (treatment holiday) over school holidays
o Monitor HR and BP every 6 months
o Monitor for development of tics after taking stimulant medication
o Monitor for sexual dysfunction, seizures, sleep disturbance and worsening behaviour
379
PACES: ADHD
Explain the diagnosis
• Explain that the manifestation will change as the child gets older (e.g. hyperactivity tends to
become less of a problem, and inattention becomes more pronounced as the tasks they face
become more complex)
• Some may grow out of it
• Explain the management
• Watch and wait for 10 weeks
• Group parent training programme - will teach various parenting techniques to deal with
ADHD and meet other parents in similar situations
• If medication needed:
• Explain that it is a 6-week trial
• Side-effects: loss of appetite, mood changes, palpitations, tics
• If medication is continued, requires 6 monthly height and 3 monthly weight monitoring
380
PACES: Autism
Explain that autism is a spectrum, so it is difficult to predict the extent of the impact on the child’s life
• Explain that it is characterised by difficulties in social interaction, language impairment and ritualistic behavioural tendencies
• Explain that management involves:
o Psychological interventions to reduce ritualistic behaviours
o Speech and language therapy (with a focus on social skills)
o Educational assessment and plan
• Explain that the carer’s needs will also be attended to and link them to support websites:
o National Autistic Society
381
How is Becker muscular dystrophy managed?
Loss of independent ambulation in late 20s
| o Life expectancy middle to old age
382
What are the risk factors for cerebral palsy?
Antenatal: Chorioamnionitis, maternal respiratory or GU infection
o Perinatal: Preterm birth, LBW, neonatal encephalopathy, neonatal sepsis
o Postnatal: Meningitis, head trauma prior to 3 years
383
What are some early features of Cerebral Palsy?
Unusual fidgety movements or abnormality of movement (including asymmetry or paucity of movement)
- Abnormalities of tone (includes hypotonia, spasticity or dystonia (fluctuating tone))
- Abnormal motor developing (including late head control, rolling and crawling)
- Feeding difficulties
384
Which MDT members are involved in the management of cerebral palsy?
paediatrician, nurse, physiotherapist, occupational therapist, speech
and language therapist (safe swallow), dietetics, psychology
385
What other measures neede to managed in cerebral palsy?
Optimise nutritional status
o Managing saliva control
• Consider anticholinergics (e.g. glycopyrronium bromide, transdermal
hyoscine hydrobromide)
• Specialists may consider botulinum toxin A injection into salivary glands
o Low bone mineral density
• Non-ambulant children with CP are at risk of low-impact fractures
• Assess dietary intake of calcium and vitamin D
• Consider an active movement/weight bearing programme or dietetic
interventions
o Pain, discomfort and distress
• Consider reducing regime of paracetamol if no identifiable cause
o Sleep disturbance
• Optimise sleep hygiene
• Consider a trial of melatonin
§ Mental health problems
• Refer for specialist psychological assessment
o Visual impairment
• Refer all children with a hearing impairment for an initial baseline
ophthalmological and orthoptic assessment
• 1 in 2 children will have a visual impairment (e.g. issue controlling eye
movement, squint, refractive errors)
o Gastro-oesophageal reflux – refer to specialist
o Chronic constipation (3 in 5) - laxatives
o Epilepsy (1 in 3) – anticonvulsants
386
PACES: cerebral palsy
Explain the diagnosis (damage to the brain that would have occurred early in development)
• The damage to the brain doesn’t get worse, but the way it manifests will change as the child
gets older
• Refer to paediatrician specialising in developmental disorders
• Long-term management will include physiotherapy, speech and language therapy and
special educational needs
• Medications can also be given to help with symptoms
387
How is Duchenne's managed?
Physiotherapy helps prevent contractures
• Exercise and psychological support are necessary
• Tendoachilles lengthening and scoliosis surgery may be required
• Weakness of intercostal muscles may lead to nocturnal hypoxia
o This presents with daytime headache, irritability and loss of appetite
• Overnight CPAP may help
• Glucocorticoids (e.g. prednisolone) may help delay wheelchair dependence
• If the left ventricular ejection fraction drops, cardioprotective drugs (e.g. carvedilol) and left
ventricular assist devices may be considered
388
What advice is given to parents of children with epilepsy?
Advise parents and carers how to recognise a seizure
o Advise parents to record any future episode of possible seizures (e.g. by video)
o Advise that the patient avoid dangerous activities until the diagnosis is confirmed (e.g.
swimming, bathing)
o Advise the parent to seek help if another seizure occurs before the referral
389
What is the first choice of AED for:
Tonic clonic
1st line: Sodium valproate
o Alternatives: lamotrigine, carbamazepine, oxcarbazepine
o NOTE: these can exacerbate myoclonic (lamotrigine) and
absence (carbamazepine and oxcabazepine) seizures
• Adjunctive treatment: clobazam, lamotrigine, levetiracetam, valproate,
topiramate
390
What is the first choice of AED for:
absence?
1st line: ethosuximide or valproate
o Alternative: lamotrigine
• Adjunctive treatment: consider a combination of 2 of these 3 -
ethosuximide, lamotrigine, valproate
391
What is the first choice of AED for:
myoclonic
1st line: valproate
o Alternatives: levetiracetam, topiramate
• Adjunctive treatment: levetiracetam, valproate, topiramate
392
What is the first choice of AED for:
focal
1st line: carbamazepine, lamotrigine
• Alternatives: levetiracetam, oxcarbazepine, valproate
§ Adjunctive therapy: carbamazepine, clobazam, gabapentin, lamotrigine,
oxcarbazine, valproate, topiramate
393
What non pharm treatements are there for epilepsy?
```
Ketogenic diets (low carb, fat based)
o Vagal nerve stimulation
o Surgery (only in children with epilepsy that has a well localised structural cause)
```
394
PACES: epilepsy
It is a tendency to have unprovoked seizures
• Aim to promote independence and confidence
• The school should be made aware of the condition
• Situations where having a seizure could lead to injury or death should be avoided (e.g. deep
baths, swimming unsupervised)
• Driving is only allowed after 1 year free of seizures
395
How is a febrile seizure managed during the seizure?
protect head and do not restrain
If the seizure lasts > 5 mins: (call ambulance)
§ Buccal midazolam or Rectal diazepam
§ Can be repeated once after 10 mins if the seizure hasn't stopped
Call an ambulance, if 10 mins after the first dose:
§ Seizure has NOT stopped
§ Child has ongoing twitching
§ Another seizure has started before the child has regained consciousness
o Measure blood glucose if the child cannot be roused or is convulsing
396
Which children with febrile seizures should be admitted?
First febrile seizure or if second seizure in a child who has not been assessed
before
§ < 18 months old
§ Diagnostic uncertainty about the cause of the seizure
§ Seizure lasted > 15 mins
§ Focal features during the seizure
§ Seizure recurred in the same febrile illness (or within 24 hours)
§ Incomplete recovery after 1 hour
§ No serious clinical findings but is currently taking antibiotics
§ Parents are anxious and feel that they cannot cope
§ Suspected cause of the fever (e.g. pneumonia)
397
What are some rescue treatments for headaches?
Analgesia (paracetamol and NSAIDs)
o Antiemetics (prochlorperazine)
o Triptans: ONLY NASAL preparations are licensed in <18yrs
o Physical treatments (e.g. cold compress, warm pads, topical forehead balms)
398
What prophylactic treatments are offered for headaches or migraines?
```
Sodium channel blockers (topiramate, valproate)
o Beta-blockers (propranolol)
- CONTRAINDICATED in asthma
o Tricyclics (pizotifen)
o Acupuncture
```
399
How is hydrocephalus treated?
Treatment is needed for symptomatic relief of raised ICP and to minimise the risk of neurological damage
• Insertion of a ventriculoperitoneal shunt (VP shunt)
o Shunts can malfunction due to blockage or infection -> often require replacement
• Sometimes, endoscopic treatment to create a ventriculostomy is performed
• Over-drainage can cause low pressure headache
400
How are migraines managed acutely (12-17)
Step 1: Simple analgesia (paracetamol or ibuprofen)
§ Only consider aspirin if > 16 (risk of Reye’s syndrome)
o Step 2: Nasal sumatriptan
§ NOTE: oral triptans are NOT licensed in people < 18 years
o Step 3: Combination therapy with nasal triptan and NSAID/paracetamol
§ Consider adding anti-emetic e.g. metoclopramide or prochlorperazine
o Arrange follow-up within 1 month, but ask them to return sooner if symptoms get worse
401
What prophylactic treatment is given for migraines?
Offer topiramate or propranolol – expert referral is advised
| - NOTE: topiramate has a risk of foetal malformations
402
How is muscular dystrophy managed?
Muscle involvement:
§ Physiotherapy (Strength and flexibility training),
§ Occupational therapy (Specially designed utensils for hand weakness, wrist
braces),
§ Orthopaedic (Ankle–foot arthroses for foot-drop)
§ Monitor for deformities.
o Muscle pain: NSAIDs, Gabapentin etc
o Myotonia: Mexiletine with careful supervision (used be treated with quinine or
procainamide in the past)
o Difficulties swallowing and dysarthria due to muscle weakness: SALT
o Cardiac disturbances: Refer to cardiologists
o Respiratory function and sleep:
§ Noninvasive positive airway pressure ventilation (NIPPV) may be useful in
correcting apnoea
§ Infants with congenital muscular dystrophy require continuous venilatory
support
o Cataracts: Surgery
o Genetic counselling: For antenatal diagnosis.
o Psychological support: For parent and child
403
How is neurofibromatosis managed?
Medical: Regular follow-up for monitoring BP, ophthalmology assessment, testing of
8th nerve and skeletal complications.
o Surgical: Laser removal of nodules, orthopaedic or neurosurgical intervention.
404
How is Tuberous Sclerosis managed?
Skin lesions – laser therapy
o Cardiovascular – anti-arrhythmics
o Epilepsy – anti-epileptics
o Renal - antihypertensives
405
How is status epilepticus managed?
Step 1: (0 min)
o Secure airway
o Check ABC, high flow Oxygen if available
o Check blood glucose
o Confirm clinically that it is an epileptic seizure
```
• Step 2: (5 min)
o If IV access, IV lorazepam
o If NO immediate IV access:
§ Buccal midazolam
§ Rectal diazepam
```
```
• Step 3: (15 min)
o if no response, give a second dose of IV lorazepam
o Call for senior help
o Start to prepare phenytoin for step 4
o Re-confirm it is an epileptic seizure
```
• Step 4: (25 min)
o Seek senior anaesthetist / inform ICU
o Phenytoin 20 mg/kg by intravenous infusion over 20 mins
§ or (if on regular phenytoin): Phenobarbital 20 mg/kg intravenously over 5 mins
o Consider rectal paraldehyde 0.8 ml/kg
• Step 5: (45 min)
o Rapid sequence induction of anaesthesia using thiopental sodium
• Consider dexamethasone if vasculitis/cerebral oedema is possible
• NOTE: treat reversible causes if identified (e.g. thiamine if malnourished or glucose if
hypoglycaemic)
406
How is tic disorders managed?
1st line: CBT with habit reversal technique
| • 2nd line: (more severe cases) alpha-2 adrenergic agonists e.g. clonidine, risperidone
407
How is West Syndrome managed?
Treatment is mainly with corticosteroids e.g. prednisolone or vigabatrin
• Infantile spasms have a POOR prognosis with loss of skills, learning disabilities and continuing
epilepsy
408
How is an acute crisis in CAH managed?
IV saline (0.9% sodium chloride), IV hydrocortisone 200mg, IV dextrose
409
How is CAH managed in the long term?
Life-long glucocorticoids (hydrocortisone) to suppress ACTH levels (and hence testosterone)
o Mineralocorticoids (fludrocortisone) if there is salt loss
o Monitoring growth, skeletal maturity, plasma androgens and 17α-hydroxyprogesterone
levels
o Additional hormone replacement at times of illness or surgery
410
When should corrective surgery in CAH be delayed until?
puberty
411
How is congenital hypothyroidism managed?
Thyroxine treatment should be started within 2-3 weeks of age to reduce the risk of impaired
neurodevelopment
• Treatment is life-long with oral replacement of thyroxine titrating dose to maintain normal
growth, TSH and T4 levels.
• With adequate and early intervention, intelligence and development should be normal
412
How is delayed puberty managed in boys?
1st line: observation - most do NOT need treatment
o 2nd line: short course of oxandrolone or testosterone (3-6 months)
- This can help increase growth velocity
413
How can delayed puberty be managed in girls?
1st line: observation - most do NOT need treatment
| o 2nd line: short course of oestrogen (3-6 months)
414
What IV fluid bolus shouldbe given in DKA if the child is shocked and is not shocked?
If shocked: 20ml/kg 0.9% saline
| • If not shocked: 10ml/kg 0.9% saline
415
Which fluids should be givne in DKA?
0.9% saline without added glucose should be used for rehydration and
maintenance until plasma glucose is < 14 mmol/L
• Change to 0.9% saline + 5% glucose after plasma glucose drops below 14
mmol/L
• IMPORTANT: Ensure all fluids administered to children with DKA contain 40
mmol/L potassium chloride (unless they have renal failure)
416
What counts as a mild and severe fluid deficit?
5% fluid deficit in mild to moderate DKA (pH > 7.1)
• 10% fluid deficit in severe DKA (pH < 7.1)
417
What dose should be given of insulin in DKA?
Use a soluble insulin infusion at a dose 0.05-0.1 units/kg/hour
• Do NOT give bolus doses of insulin
• If the child is using an insulin pump, disconnect it before starting IV insulin
418
Paces: DKA
Explain DKA (complication of diabetes where the blood sugars get very high)
• Explain the features of DKA (drowsiness, abdominal pain, nausea)
• Explain that DKA is important because it can lead to severe dehydration
• Explain the steps in the acute management of DKA (giving fluids and insulin to get the blood
glucose back to a healthy range)
• Discuss factors that led to this episode
• Advice on how to manage intercurrent illness (e.g. viral infections leading to increased
insulin demand)
• Arrange to see diabetes specialist to discuss treatment
• Support: Diabetes UK
419
What are the 3 types of insulin offered to children with T1DM?
Multiple Daily Injection Basal-Bolus: injections of short-acting insulin or
rapid-acting insulin analogue before meals, with 1 or more separate daily
injections of intermediate acting insulin or long-acting insulin analogue
- Continuous Subcutaneous Insulin Infusion (insulin pump therapy):
programmable pump and insulin storage device that gives regular or
continuous amounts of insulin (usually rapid-acting insulin or short-acting
insulin) by a subcutaneous cannula
- One, Two or Three Insulin Injections Per Day: injections of short-acting
insulin or rapid-acting insulin analogue mixed with intermediate-acting insulin
420
PACES: Type 1 DM
Explain diagnosis (a condition where the body is unable to control the sugar levels in the
blood)
• Explain that it is reasonably common, and it is well understood
• Explain that the management is quite intensive and involves regular self-monitoring of
glucose levels (using skin prick) and taking insulin injections
• Stress the importance of good blood glucose control
• Explain how to identify DKA
o Damage to kidneys and blood vessels
o Explain that they will be seen in a diabetes clinic to discuss ongoing management
• Encourage healthy, balanced diet and regular exercise
421
How is hyperthyroidism managed?
yperthyroidism
• 1st line: Medical - Carbimazole or propylthiouracil
• Important: both thionamides are associated with a risk of neutropaenia
o Families should be safe-netted about seeking urgent medical attention and a blood
count if a sore throat or fever occur whilst on treatment
• Adjunct: Beta-blockers may be considered for symptomatic relief of anxiety, tremor and
tachycardia
• Medical treatment is usually given for around 2 years
• 2nd line: Radioiodine treatment, Surgery (partial thyroidectomy)
• NOTE: neonatal hyperthyroidism may occur due to the transplacental transfer of TSIs
422
How is hypocalcaemia managed?
Management of Acute Symptomatic Hypocalcaemia
o IV calcium gluconate
• Management of Chronic Hypocalcaemia
o Oral calcium
o High dose vitamin D analogues
o Important: avoid hypercalciuria because it can lead to nephrocalcinosis so urinary
excretion should be monitored
423
How is mild / moderate hypoglycaemia managed?
Give fast-acting glucose by mouth (usually liquid carbohydrate (e.g. Lucozade))
o May need to be given in small amounts if vomiting
o Recheck blood glucose within 15 mins and repeat fast-acting glucose if hypoglycaemia persists
o As symptoms improve, give oral complex long-acting carbohydrate to maintain blood glucose levels
424
How is severe hypoglycaemia managed?
Treat in hospital
- Give IV 10% glucose (maximum dose of 500 mg/kg of bodyweight (5 ml/kg))
o If NOT in hospital
- IM glucagon or concentrated oral glucose solution (e.g. glucogel)
• IM glucagon: 500 µg for < 8 years; 1 mg for > 8 years
- Seek medical help if blood glucose remains low after 10 mins
- Once symptoms improve, give oral complex long-acting carbohydrate
• NOTE: alcohol is a risk factor for hypoglycaemia (they should eat carbohydrates before and
after drinking)
425
What medication might be offered to obese children over the age of 12?
orlistat which is a lipase inhibitor
426
How is gonadotrophin dependent precocious puberty managed?
90% in females has NO identifiable cause
o Manage associated brain neoplasms (e.g. optic nerve gliomas)
o GnRH agonist (e.g. leuprolide) can suppress puberty via negative feedback
o GH therapy (as GnRH agonists can stunt growth)
o Cryproterone (anti-androgen) is used by specialists
427
How is gonadotrophin independent precocious puberty managed?
McCune Albright or Testotoxicosis: ketoconazole or cyproterone, GnRH agonist, aromatase inhibitors
o Congenital Adrenal Hyperplasia: adjustment of hydrocortisone therapy, GnRH agonist
o Tumours: specialist referral
428
How is anaphylaxis managed?
ABC
Airway - look for and relieve obstruction, intubate if necessary
o Breathing - check whether it is normal
o If unresponsive and not breathing normally:
§ Start CPR immediately
§ Ensure help is on the way because advanced life support is essential
o If CPR is NOT required:
§ Examine chest for signs of airway obstruction
§ Check pulse and blood pressure for circulatory collapse
§ Check skin and inside the mouth for urticaria and angio-oedema
• Place in a comfortable position
o Sitting up if airway and breathing difficulty
o Lying flat with/without leg elevation if low blood pressure/feeling faint
o Recovery position if breathing but unconscious
• Give IM adrenaline 1: 1000 (as per age-related guidelines)
o Given in the anteriolateral aspect of thigh
o Assess response after 5 mins
o Repeat IM injection at 5 min intervals until there has been an adequate response
o Do NOT give IV adrenaline in primary care (however it may be given in cases of
cardiopulmonary arrest)
• Remove trigger if possible e.g. stinger after a bee sting
• Give high flow oxygen
• Give IV fluids
• Give IV chlorphenamine 10 mg + IV hydrocortisone 200 mg
429
PACES: anaphylaxis
Explain that this is a severe allergic reaction
• Explain that the priority right now is to treat this reaction and make sure the child is stable
• Explain that they will be referred to an allergy clinic where further tests may be required to
establish the exact allergens
• Explain that future management of allergy will be discussed (e.g. carrying an EpiPen)
o Check the airway
o Lie patient flat
o Raise legs
o Administer adrenaline into the thigh or arm (repeat after 5 mins if no response)
o Call an ambulance
430
How is a blue baby managed?
ABCDE approach
§ Oxygen
§ Oxygen saturation should be maintained >90%
§ Ventilation e.g. nasal CPAP should be considered
§ Fluids if hypotensive and shock
§ Antibiotics if evidence of sepsis or pneumonia
o Start prostaglandin infusion (5 ng/kg per min) to maintain ductus arteriosus patent.
o If suspected CHD, refer to tertiary care centre immediately
§ Treatment balloon atrial septostomy
431
What is the compression:breath for neonates?
3:1
432
What is the compression:breath for paediatric bls?
15:2
433
How is strbismus managed?
Correction of refractive error – corrective glasses
• Occlusion or penalisation therapy to treat amblyopia
o Occlusion of normal eye with a patch for a number of hours per day depending on age and severity
o Penalization – vision in the normal eye is deliberately blurred by using atropine drops and is used when problematic compliance to occlusion
• Eye exercises
• Extraocular muscle surgery
• Botulinum toxin – injection into an extraocular muscle causes paralysis for up to 3 months
and corrects squints
434
What are some contraindications for MMR?
Contraindications
o Severe immunosuppression
o Allergy to neomycin
o Children who have received another live vaccine by injection within 4 weeks
o Pregnancy should be avoided for at least 1 month following vaccination
o Immunoglobulin therapy within the past 3 months (there may be no immune response
if these antibodies are present)
• Adverse Effects
o Malaise, fever and rash may occur after the first dose of MMR. This typically occurs
after 5-10 days and lasts around 2-3 days.
o Anaphylaxis is very rare
435
PACES: NAI
We have to talk about what to do next from a medical and non-medical standpoint
• Whenever we have a case where we don’t know why an injury has occurred, we have to involve some other people
• This includes social services and the child safeguarding team (and maybe the police)
• 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 do not happen by accident and they are caused by someone else
