Paediatrics Flashcards
1
Q
How many neonates died globally in 2020?
A
2.4 - 2.6 million cases
Highest incidence in areas which are experiencing significant conflict
2
Q
82% of neonatal deaths are attributable to three main causes. What are they?
A
Preterm birth (16%)
Infection (11%)
Complications during childbirth, including hypoxic ischaemic encephalopathy (birth asphyxia)
3
Q
When do most neonatal deaths occur?
A
First 24h (± 1 million deaths)
4
Q
What SDG is focused on addressing neonatal mortality?
A
SDG 3: ‘Good Health and wellbeing’
5
Q
What is the Every Newborn Action Plan (ENAP)?
A
A document which aims to galvanise the global community to improve neonatal outcomes
AIMS:
1. Prevent all avoidable neonatal deaths
2. End preventable stillbirths
6
Q
What is essential newborn care?
A
- The care that every newborn baby needs, regardless of where it is born or its size
Encompasses days 1-7 of life
Aim: prevent early deaths
7
Q
What are the key steps of Essential Newborn Care?
A
- Keep baby warm (skin to skin)
- breathing support
- Early initiation of breastfeeding
- Kangaroo care to support small babies (BW <2000g)
- Protect baby from HIV (PEP)
- Vit K and immunisations
- monitor baby for ‘danger’ signs
8
Q
What urgent vaccines do you give to the newborn/
A
- Hepatitis B
- BCG
- Vitamin K
9
Q
When should you advise chlorhexidine cleaning of the cut cord site?
A
4% chlorhexidine gel for home deliveries in settings with NMR >30 per 1000 live births)
10
Q
What are neonatal ‘danger signs’
A
- Cessation of feeding
- Hypothermia / pyrexia
- Grunting, fast or slow RR , cyanosis, chest in-drawing
- Eye and skin infection
- Jaundice in <24h
- Abdo distension –> omphalitis, ,blood oozing from umbilical stump, persistent vomiting
- CNS - floppy baby, convulsions
11
Q
What is ophthalmia neonatorium?
A
red, swollen discharging eyes
Caused by maternal chlamydia / gonorrhoea
12
Q
What antibiotics does the WHO recommend for neonatal sepsis?
A
Ampicillin + Gentamicin (7/7)
**There are differences in local guidelines
13
Q
What are the two types of neonatal sepsis?
A
- Early Onset
- Delayed (late) onset
14
Q
What is early onset neonatal sepsis?
A
infection within the first 72h of life
Represents vertical meternal - child transmission
Associated with pneumonia, meningitis
15
Q
What infection is implicated with early onset neonatal sepsis?
A
GBS
16
Q
When does late onset neonatal sepsis occur?
A
manifestations of sepsis 3-7 days after birth
17
Q
What maternal infections can be passed to the baby?
A
Rubella
toxoplasmosis
Syphilis
Cytomegalovirus
Zika
Chickenpox
HSV
HIV
Hep B
GBS
18
Q
What are risk factors in neonatal sepsis?BC
A
Pre-PROM/PROM
Chorioamnionitis
Maternal pyrexia / GBS carriage
Home delivery
Prematutiry
low BW
Congenital abnormalities
complicated delivery
Unclean birth conditions
19
Q
What are important organisms in neonatal sepsis?
A
Staph Aureus (25%
Listeria
E Coli
Strep spp.
GBS
Klebsiella
20
Q
Where are gram -ve infections most likely in the neonate?
A
South East Asia, Asia, Russia
21
Q
How do you diagnose neonatal sepsis?
A
- Blood Cultures (0.5 - 1ml of blood)
- Blood tests (CRP, white cells)
- ± LP (normal LP is likely to have WCC up to 10 in a newborn)
22
Q
What oragnism is implicated in tetanus?
A
Clostridium tetani
23
Q
What is the mortality rate of tetanus in neonates?
A
85%
24
Q
When do you suspect neonatal tetanus?
A
ability to suck at birth and for first few days followed by inability to suck starting between 3 and 10 days of age, spasms, stiffness, convulsions and death
25
How many tetanus injections does a mother require to prevent transmission to her baby?
3 tetanus toxoid boosters
26
How does CMV present in the neonate?
Hepatosplenomegaly
Jaundice
Microcephaly
Hydrocephalus
Petichial rash
IUGR
27
How does Toxoplasmosis present in the neonate?
Hepatosplenomegaly
Jaundice
Microcephaly
Hydrocephalus
Petichial rash
IUGR
Viral exanthem
Eye findings
Adenopathy
28
How does Rubella present in the neonate
Hepatosplenomegaly
Jaundice
petichial rash
Heart defects
Bony lesions
IUGR
Adenopathy
Eye findings
29
What is Hypoxic Ischaemic Encephalopathy? (HIE)
1. Significant event causing
hypoxia or ischaemia
2. Poor condition at birth – need
for resuscitation, Apgar <5 at 5
minutes
3. Multi-organ failure
30
What causes HIE?
placental insufficiency
uterine rupture
prolong/obstructed labour
inadequate resuscitation
31
What are the clinical consequences of HIE?
Seizures (biggest cause of seizures in term/preterm babies world wide
Poor tone
Death
Resp Apnoea/Failures
32
What are the APGARs?
Appearance (colour)
Pulse
Grimace (reflex)
Activity (tone)
Respiration
Hypotension
Metabolic Acidosis
Hypoglycaemia
Hyponatraemia
AKI
Poor UO
Feed intolerances
DIC
33
When should an APGAR score be calculated?
A minutes 1, 5 and 10 post delivery
34
What is the Helping Babies Breathe document?
A neonatal resus guideline (simple) which can be used globally
35
What is the 'Golden Minute' in neonatal birth?
the baby should be breathing within the first 60 seconds of life
36
What ventilation advice does the Helping Babies Breathe document suggest (different from UK guidelines)
If baby has required assistance w/ ventilation?
Ventilate for 1 minute --> reassess
If HR <60 continue ventilating
37
What is the definition of extremely low birth weight (eLBW)?
weight at birth <1000g
38
What is the definition of very low birth weight (vLBW)
1001-1500g
39
What is the defition of LBW?
<2500g
40
What are the definitions related to prematurity?
- moderate to late preterm
32-37 weeks
41
What are the definitions related to prematurity?
- Very preterm
28-32 weeks
42
What are the definitions related to prematurity?
- Extremely preterm
<28 weeks
43
What are the risk factors for pre-term birth?
* Not known!! (the most common situation!!)
* Multiple pregnancies
* Maternal infections (e.g. malaria, urinary tract infections/pyelonephritis, HIV)
* Inadequate birth spacing
* Maternal undernutrition (height <145 cm)
* Complications of pregnancy (pre-eclampsia, gestational diabetes)
* Maternal chronic disease (hypertension)
44
What strategies could be implemented to reduce the risk of pre-term birth?
* Optimising maternal nutrition.
* Addressing adolescent and unplanned pregnancies (contraceptives).
* Timely and appropriate management of infections in pregnancy.
* Preventing tobacco and substance abuse.
* Adequate antenatal care (8 contacts with health professionals).
* Social support
45
How many babies die each year when born pre-term?
1 million
46
What are the long-term outcomes of pre-term birth?
Visual and hearing impairment (retinopathy of prematurity)
Learning difficulties
Poor growth
Susceptibility to infections in infancy
Stigma
47
Who should receive antenatal steroids?
Babies who are at a risk of premature birth between 24-34 weeks if:
* gestational age assessment can be accurately undertaken;
* preterm birth is considered imminent (within 7 days);
* there is no clinical evidence of maternal infection;
* adequate childbirth care is available;
* the preterm newborn can receive adequate care if needed;
**must be used in a facility where women and baby can be assessed for infection, and have infection subsequently managed
** dexamethasone in the correct conditions reduces all cause mortality (apart from infection)
48
Continuous positive airway pressure therapy is recommended for the treatment of preterm newborns with respiratory distress syndrome.
Why does it work?
* Reduced need for mechanical ventilation (~50%)
* Less resource intensive
* Reduction in RDS mortality (~30%)
* Reduction in bronchopulmonary dysplasia
* Reduced time in establishing enteral feeds
49
How should LBW infants be fed?
breast feed ASAP from birth
50
How should vLBW infants be fed?
Enteral feeds from day 1 (breast milk) 10ml/kg increasing feeds by 30ml/kg/day
51
What are common causes of atrumatic coma in children?
Cerebral Malaria
Meningitis
Neuro abscess
Hypoglycaemia
Hepatic failure
ICH
SAH
ADEM
Dengue
Measles
52
What is the Balantyre Coma Scale?
53
How do you approach the child with coma?
Airway
- Recovery position, clear airway, Intubate, NG Tube
Breathing
- O2 and Ventilation
Circulation
- IV Access, Fluids
Disability
- IV Abx
- IV Artesunate
- Glucose
54
What are common causes of convulsions in children?
Febrile seizures
CNS infection
Cerebral malaria
Cerebral abscess
Hypoglycaemia
Hypoxia
Trauma
Vascular accidents (would be pretty uncommon unless SCD)
55
How do you manage convulsions?
1. O2
2. check BM
3. Antibiotics: Ceftriaxone 100mg/kg
4. Artesunate <20kg = 3mg/kg, >20kg 2.4mg/kg
±Diazepam (or midazolam/lorazepam if avilable!) IV/PR
± phenobarbitol IM/IV (or phenytoin)
56
What is the dose of diazepam to terminate status in paeds?
Diazepam IV: 0.25mg/kg
57
What is the loading dose of phenobarbital in seizure cessation?
LOADING: 15mg/kg IV over 15 min
MAINTENANCE: 5mg/kg OD for 2/7
58
Which neonatal infected site is most associated with tetanus infection?
Omphalitis
59
How many children under 5 died in 2019?
5.2 million
60
When is a child lethargic?
A. The child will not wake, even after shaking
B. The child is sleeping more often than usual, but will wake up if you set them down to walk
C. The child is drowsy and will not follow movement or noise in the room
C
61
The IMCI (Integrated Management of Childhood illness) gives generic guidelines for management of common childhood illness.
What ages do they aim their guidance at?
2m - 5years
62
How do you manage a child <12m with severe dehydration and shock?
1. 30ml/kg over one hour --> 70ml/kg over 5h
±2. 70ml/kg of Hartmanns over 5 hours
3. Reassess - switch to ORS as soon as patient able to drink (5ml/kg/hour)
63
How do you manage a child >12m with severe dehydration and shock?
1. 30ml/kg over 30 min --> 70ml/kg over 2.5h
±2. 70ml/kg of Hartmanns over 2.5h
3. Reassess and switch to ORS as soon as patient able to drink (5ml/kg/hour)
64
Which neonates should be given prophylatic antibiotics?
What is the antibiotic of choice?
Give prophylactic antibiotics only to neonates with documented risk factors for infection:
* Membranes ruptured > 18 h before delivery
* Mother had fever > 38 °C before delivery or during labour.
* Amniotic fluid was foul-smelling or purulent
Give IM or IV ampicillin and gentamicin for at least 2 days
65
How much fluid per day should the neonate gat over the first 3 days of life?
Day 1 60 ml/kg per day
Day 2 90 ml/kg per day
Day 3 120 ml/kg per day
Then increase to 150 ml/kg per day
66
What is Opthalmia Neonatorium?
Neonatal conjunctivitis, usually secondary to gonorrhoea. Can lead to blindness so prompt rx. necessary
Ceftriaxone stat + eye ointment (cholamphenical/tetracycline)
67
Give 3 symptoms/examination findings of severe diarrhoea in the child?
68
How do you manage Cholera in a child?
1. Manage dehydration
2. Antibiotics: Erythromycin/ciprofloxacin/co-trimoxazole
3. Zinc until Diarrhoea stops
** All children with diarrhoeal illness should get Zinc supplements
69
What are the features of Severe Acute Malnutrition?
■ weight-for-length/height < -3SD
(wasted)
or
■ mid-upper arm circumference
< 115 mm
or
■ oedema of both feet (kwashiorkor
with or without severe wasting).
70
How do you manage, in hospital, a child with Complication SAM?
1. Antibiotics --> Broad spectrum, IV Benpen and IV Gent
2. Hypoglycaemia control: 50ml of 10% glucose if will tolerate PO, otherwise IV
3. Hydration (slow - do not treat the same as shock): ReSoMal 5ml/kg every 30 min for the first 2h then reassess
4. Measles Vax (unless in shock)
5. Eye disease: Chloramphenical drops and Vitamin A supplements
6. Kwashiorkor skin: Zinc
71
What is EPI?
Expanded Programme on Immunisation:
Goal: to make immunization against diphtheria, pertussis, tetanus,
poliomyelitis, measles and tuberculosis available to every child in the world by 1990
Help by GAVI, the vaccine alliance, which aims to vaccinate all children, especially focusing on the countries with most missed childhood vaccinations
72
What are the main 7 EPI vaccines?
bacillus Calmette-Guérin vaccine (BCG)
Oral polio vaccine (OPV)
Diphteria-pertussis-tetanus (DPT)
Hepatitis B
Measles
Yellow fever vaccine
Tetanus toxoid
±Haemophilus influenzae type b (Hib)
Rotavirus
Neisseria meningitidis Group A
Human papillomavirus (HPV)
Pneumococcal conjugate vaccine (PCV)
Typhoid
Varicella, Malaria, Dengue, Ebola
73
What is the basic EPI vaccination schedule for the first year of life?
Birth: OPV0 + BCG
6 weeks: OPV1 + DPT1
10 weeks: OPV2 + DPT2
14 weeks: OPV3 + DPT3
9-12 months: Measles, Yellow Fever
74
Pedro is 9 months old. His sister has brought him to the clinic for the measles vaccine.
It is 15 minutes before closing time. You would have to open a new 10-dose bottle. If you opened the bottle the rest of the bottle (9 doses) would be wasted.
What would you do?
A. Open the bottle and give the vaccine
B. Ask his sister to come back tomorrow
A. Open the bottle and give the vaccine
75
Name 3 vaccines which cannot be frozen
76
If you are concerned that an unfreezable vaccine has been frozen, what can you do to check?
The Shake Test
To check whether freeze-sensitive
vaccines have been damaged by exposure to temperatures below
0 °C
* Needed if a freeze indicator has been activated, or temp recordings show negative temps
77
What is Noma?
Necrotising Gingivitis
Infection affect children <7 years old
OI, mostly occurring in areas of severe poverty
Often occurs in the context of malnutrition, measles, HIV
78
How do you manage Noma?
Penicillin + Metronidazole
Refeeding
Assess for parasitic infection, malaria, anaemia, HIV
Offer surgical follow up in a year
Case fatality 70-90% if untreated
79
In which two countries is Polio still endemic?
Afghanistan
Pakistan
80
What Form of meningitis classically occurs within the meningitis belt?
Meningitis A
- Caused an epidemic which killed 25000 people in the 90s
MenAfriVac exists to reduce
81
The proportion of vaccines for children typically wasted is
A. 5%
B. 10%
C. 20%
D. >30%
E. 50%
D. >30%
82
What temperature does a measles vaccine need to be kept at?
A. -8 to -2 °C
B. -8 to -4 °C
C. -2 to 2 °C
D. 2 to 8 °C
E. 4 to 8 °C
E
83
Which of the following vaccines can be frozen at HQ?
A. Measles
B. Diphtheria
C. Pertussis
D. Oral polio
E. Conjugate polysaccharide vaccines
A
84
IMCI recommends asking about 4 specific symptoms. What are they?
Cough
Diarrhoea
Fever
Ear symptoms
85
SDG 3 has a specific goal about mortality in U5s - what is it?
Sustainable Developmental Goal (SDG) 3 aims to reduce under-5 mortality in all countries to at least as low as 25/1000 live births by 2030.
86
Give 5 differentials of Fever and a rash in a child
Bacterial: Meningococcal meningitis, pnuemococcus, scarlet fever (strep pyogenes), Leptospirosis, Typhoid
Viral: Parvovirus, Measles, Rubella, Adenovirus, HHV6 (roseola infantum), Dengue, Chikungunya, Yellow Fever
Rickettsial infections: Spotted fevers, Scrub typhus, typhus group
87
Name 4 bacteria which cause meningitis in children
Meningococcal
Pneumococcal
HiB
Group B Strep
88
Give a differential (5) of causes of myocarditis in a child
Viral
* Adenovirus
* Parvovirus B19
* Coxsackie virus
* Enteroviruses
Bacterial
* Brucella
* Mycoplasma
* Mycobacteria
* Typhoid fever
Fungal
* Aspergillus
Parasites
* Visceral larva migrans,
schistosomiasis
Non-infective
* Heavy metal, chemotherapy,
hyperpyrexia
89
Give 5 management steps for convulsions in a child
90
How long should you wait before attempting to terminate an absence seziure in a child
15 minutes
91
Name 3 ETAT emergency signs (red flags) in a child
* obstructed or absent breathing
* severe respiratory distress
* central cyanosis
* signs of shock, defined as cold extremities with capillary refill time >3s and a weak, fast pulse
* coma (or seriously reduced level of consciousness)
* seizures
* signs of severe dehydration in a child with diarrhoea with any two of these signs: lethargy or unconscious,
sunken eyes, very slow
* return after pinching the skin
92
Name 3 main organisms in Bacterial Meningitis in the neonate
Group B Strep
Strep Pneumoniae
Listeria
E Coli
93
Name 3 main organisms in Bacterial Meningitis in children
Group B Strep
Strep Pneumonia
Niseria Meningitis
Haemophilus Influenzae
Mycobacterium Tuberculosis
94
What is ETAT?
Emergency Triage, Assessment and Treatment
A triage system used to determine which children in LMICs are the most unwell on admission
Found that ETAT can help reduce child mortality in the first 24-48h of hospital admission
95
What is Diptheria?
Bacterial infection causing acute membranous pharyngitis with fever
96
What is the epidemiology of Diptheria?
Children > Adults
Unvaccinated populations
97
How does Diptheria present?
Fever
Pharyngitis
Gray fibrous adherent membrane on throat
Stridor
Bull neck from lymphadenopathy
98
What is the differential of Diptheria?
Quinsy
EBV
Bacterial Tonsillitis
Melioidosis (Parotitis)
Lymphangitis
Cutaenous Vesicles with Eschars
99
How is Diptheria Diagnosed?
Nasopharyngeal swab:
- Culture
- PCR
ELEK test (rarely done as quite technical)
100
What toxin is assocaited with Diptheria?
AB Toxin (same as in Cholera)
101
How is Diptheria spread?
Droplets
102
How is Diptheria managed?
Diptheria Equine Antitoxin + BenPen for 14/7
+
Immunisation / booster
+
F/U in 3-6 months to check for complications
103
What are the complications of Diptheria infection?
Mortality 5-10% (although some cases say up to 40%)
Airway Obstruction
Myocarditis
Polyneuropathy
Renal Failure
Local tissue necrosis
NOTE: Diptheria bacteria does not spread throughout the body; complications occur as a result of the AB toxin in diptheria, which is why you should give Anti-toxin as soon as possible
104
What organism causes Diptheria?
Corynebacterium diphtheriae
105
From a PH point of view, how do you prevent outbreaks of diptheria?
1. Contact tracing
-- throat swab and PCR
2. Erythromycin to contacts for 7/7
3. Vaccine coverage assessment --> administer as required
4. Follow up
106
How many doses of Diptheria Vaccines does a child need to get?
4 doses
107
What are risk factors for a Diptheria outbreak?
Poor vaccine coverage
Overcrowding
Refugee/Emergency settings
108
In which countries is Diphtheria still a significant problem?
India
Nigeria
Ethiopia
Pakistan
Indonesia
109
What is the most likley diagnosis in a 7 day old child?
Tetanus
110
What organism causes Tetanus
Clostridium Tetani
111
What is the differential diagnosis of spasm (incl. lock jaw and opisthotonus). Give 5 causes (child or adult)
Neonates
tetanus
hypocalcaemia
hypoglycaemia
meningitis
meningoencephalitis
seizures
Adults
Tetanus
Dental abscess
Orofacial infections
Meningitis
Tetany (hypocalcaemia)
Strychnine poisoning
Drug induced dystonic reactions
Neuroleptic malignant syndrome
Oculogyric crisis (metoclopramide)
Rabies
112
How do you manage tetanus?
Treat with wound debridement, tetanus antitoxin, penicillin or metronidazole and intensive
supportive treatment (tracheostomy, ventilation, benzodiazepines, morphine, muscle
relaxants, magnesium)
Adequate wound management important to prevent development of tetanus
113
What are the main causes of penumonia in children <5
Strep Penumonia
H. Influenzae
RSV
Adenovirus
Influenze
114
How can we prevent Strep Pneumoniae?
Pneumococcal Conjugate Vaccine
PCV13
** all children should receive at least 3 doses
115
What is the commonest cause of bacterial meningitis in children <5
H. Influenza
116
Give a differential for causes of emyema in children (name 3)
* S pneumoniae
* S aureus
* Group A streptococci.
* H influenzae rarely
* Anaerobic infections secondary to aspiration.
* Fungal or mycobacterial infections in immunosuppressed patients.
* Mycoplasma pneumoniae and viruses can rarely result in exudative pleural effusions.
