Paediatrics Flashcards
1
Q
Outline the neonatal life support process
A
- If pink, give back to mother
- If not, rub vigorously
- If unsuccessful, start bag and mask ventilation (e.g. Neopuff at 6mmHg)
- If not pinking up, add oxygen
- Give IV adrenaline 0.3ml 1:1000; followed by 1ml and then an infusion 20ml/kg 0.9% saline
- Check glucose
- If meconium, suction and wash out oropharynx
- Consider endotracheal intubation
2
Q
What is the scoring system used to assess the progress of life support in the neonate?
A
Apgar Score (monitors vital signs inc. pulse, respirations, tone and colour)
3
Q
Outline the ABCE approach of neonatal intensive care
A
Airway
Breathing
Circulation
Epithelium (lung/gas exchange, barrier functions of the gut and skin for digestion, keeping out bacteria, intact neuroepithelium lining ventricles and retina)
4
Q
What common vital signs are monitored in neonatology intensive care?
A
Temperature, BP, pulse, respiration, blood gases, pulse oximetry, U/Es, FBC, weight etc.
5
Q
List some common problems facing babies on the NICU?
A
Hypothermia Hypoxia Hypoglycaemia Respiratory Distress Syndrome Infection Intraventricular haemorrhage Apnoea Retinopathy of prematurity Necrotising enterocolitis
6
Q
What is the pathophysiology of intraventricular haemorrhage in preterms?
A
Preterms are at particular risk due to:
1 Unsupported blood vessels in the subependymal germinal matrix
2. Unsupported blood pressure
7
Q
What are the signs associated with intraventricular haemorrhage?
A
Seizures, bulging fontanelle, cerebral irritability, cerebral palsy.
Many are asymptomatic
8
Q
What is neonatal apnoea?
A
Neonatal apnoeas are episodes when an infant fails to make any respiratory effort.
They are defined as:
1 .No respiratory efforts for a period of more than 20 sec
- A break in respiration of less than 20 sec but associated with bradycardia
- Reduction in heart rate of more than 30%
9
Q
What are some common causes of neonatal apnoea?
A
Prematurity Infection Hypothermia Aspiration Congenital heart disease
10
Q
What is necrotising enterocolitis?
A
Medical condition where a portion of the bowel dies.
11
Q
What are the signs of necrotising enterocolitis?
A
Poor feeding, bloating, decreased activity, blood in the stool, or vomiting of bile
12
Q
What is the mortality rate associated with necrotising enterocolitis?
A
25%
13
Q
What is retinopathy of prematurity?
A
Fibrovascular proliferation of retinal vessels leading to retinal detachment/impaired vision
14
Q
What are the non-invasive techniques for neonatal ventilation?
(3)
A
CPAP
NIPPV (nasal intermittent positive pressure ventilation)
HFNC
15
Q
What are the invasive techniques for neonatal ventilation?
3
A
Timed-cycled pressure limited ventilation
Patient-triggered ventilation
High-frequency ventilation
16
Q
List some complications of long-term ventilation in neonates
A
Lung (pneumothorax, pulmonary haemorrhage, pneumonia)
Airways (upper airway obstruction)
Others (patent-ductus arteriosus, pneumomediastinum
17
Q
How does neonatal sepsis present?
A
Non-specific and subtle signs
Labile temperature, lethargy, poor feeding, respiratory distress, collapse, DIC
18
Q
How is neonatal sepsis managed?
A
ABC approach Supportive (ventilation, volume expansion, ionotropes) Bloods (FBC, CRP, glucose, cultures) CXR Lumbar puncture
Failure to respond within 24hrs - consider stool samples for virology, throat swab, urine CMV culture
19
Q
What empirical antibiotics are given in the case of early-onset neonatal sepsis?
What antibiotics would you consider if meningitis or listeria are suspected?
A
Benzylpenicillin and gentamicin
If meningitis is suspected - give ceftriaxone
If listeria suspected (purulent conjunctivitis, maternal infection) - give amoxicillin/ampicillin
20
Q
What empirical antibiotics are given in the case of late-onset neonatal sepsis?
A
Flucloxacillin and gentamicin
21
Q
What organism causing late-onset neonatal sepsis associated with central venous catheters in place? How would you treat it?
A
Coagulase-negative Staph.
Vancomycin and discuss removing the catheter
22
Q
What other type of organism may you consider if treatment with antibiotics fails in the case of late-onset neonatal sepsis?
A
Fungal sepsis
23
Q
What are the definition of early and late-onset neonatal sepsis?
A
Early ( <3 days)
Late ( >3 days?
24
Q
List some causes of neonatal seizure
A
Hypoxic-ischaemic encephalopathy (due to antenatal or intrapartum hypoxia)
Infection (meningitis/encephalitis)
Intracranial haemorrhage
Metabolic disorder/disturbance (e.g. hypoglycaemia, hypocalcaemia etc.)
Kernicterus
25
How are neonatal seizures medically aborted?
First line: Phenobarbital
Second line: Phenytoin
Third line: Midazolam et al.
26
How are neonatal seizures investigated and managed?
Rule out reversible causes
Start empirical antibiotics
IV access (FBC, U/Es, LFTs, calcium, glucose, magnesium, blood gases)
Commence cerebral function analysis monitoring
Radiological imaging (CT, MRI cranial US)
Treat prolonged seizures
27
What is hypoxic-ischaemic encephalopathy?
Clinical syndrome of brain injury secondary to hypoxic-ischaemic insult.
Causes could be antepartum (abruption), intrapartum (cord prolapse) or postpartum
28
What are the signs of hypoxic-ischaemic encephalopathy at birth?
Respiratory depression
pH <7 and base excess worse than -12
Encephalopathy develops within 24hrs
29
How is hypoxic-ischaemic encephalopathy treated?
Resuscitation, avoidance of hypothermia, treat seizures and therapeutic hypothermia to reduce death and disability
30
What is neonatal shock?
Shock is an acute state in which circulatory function is inadequate to supply sufficient amounts of O2 and other nutrients to tissues to meet metabolic demands
31
What are the common causes of neonatal shock?
Blood loss (placental haemorrhage, TTTS, lung haemorrhage)
Capillary plasma leaks (sepsis, hypoxia, acidosis)
Fluid loss (diuresis)
32
What are the signs of neonatal shock?
High HR
Low BP
Decreased urine output
Coma
33
How is neonatal shock managed?
ABC
Give colloid 10-20ml/kg IV as needed
Ionotropes e.g. dopamine +/- dobutamine
34
How common is neonatal jaundice?
Very common
| 60%
35
Hyperbilirubinaemia (<200micromol/L) after 24hrs is usually described as _________. Meaning benign.
Physiological
36
What are the causes of physiological jaundice in the neonate?
1. Increased bilirubin production
2. Decreased bilirubin conjugation
3. Absence of gut flora impedes bilirubin elimination
4. Breastfeeding
37
List some causes of visible jaundice within 24hrs of birth
Sepsis
Rhesus haemolytic disease
ABO incompatibility
Red cell anomalies (e.g. congenital spherocytosis or G6PD deficiency)
38
List some causes of common causes of prolonged jaundice?
```
Breastfeeding
Sepsis
Hypothyroidism
Cystic fibrosis
Biliary atresia
```
39
How is prolonged bilirubin treated?
Phototherapy
40
What is kernicterus?
Clinical features of acute bilirubin encephalopathy
Symptoms; lethargy, poor feeding, hypertonicity
41
What are some long term sequelae of kernicterus?
Athetoid movements, deafness and decreased IQ
42
What is Rhesus Haemolytic Disease?
When a Rh- mother delvers a Rh+ baby. Leaking of foetal blood into maternal circulation leading to isoimmunisation.
There is a wide clinical spectrum.
43
Sensitising events in pregnancy include what?
| 6
```
Threatened miscarriage
APH
Mild trauma
Amniocentesis
Chorionic villous sampling
External cephalic version
```
44
What is hydrops fetalis?
A severely effected foetus from Rhesus haemolytic disease causing oedema (wit stiff, oedematous lungs.
45
How is hydrops fetalis managed?
| 7
```
Get specialist involved
Correct glucose
Drain ascites
Correct anaemia
VIt K correction
Treat heart failure
Limit IV fluids
```
46
What is biliary atresia?
Biliary tree occlusion due to congenital angiopathy leading to destruction of extra-hepatic bile ducts
47
How does biliary atresia present?
Jaundiced
Yellow urine
Pale stools
Hepatosplenomegaly
48
How is biliary atresia treated?
Kasai procedure (hepatoportoenterostomy)
49
What is respiratory distress syndrome?
Condition caused by surfactant deficiency leading to atelectasis and respiratory failure
50
What are the risk factors for developing RDS?
Commoner in maternal diabetes, males, 2nd twins and Caesarian sections
51
What are the signs of RDS?
```
Increased work of breathing shortly after brith
Tachypnoea
Grunting
Nasal flaring
Intercostal recession
Cyanosis
```
52
How does RDS appear on a Chest X-Ray?
Diffuse granular patterns
53
Give three differentials of RDS
Transient tachypnoea of the newborn (resolves pithing 24hrs)
Meconium aspirate
Congenital pneumonia
54
How is RDS prevented in the antepartum period?
Steroid injections given to all women at risk of preterm labour
55
How is RDS treated?
Delay of cord clamping (to promote placenta-foetal transfusion
Give an oxygen/air blend (21%)
Prophylactic surfactant
56
What is bronchopulmonary dysplasia?
A complication of ventilation in RDS causing persistent hypoxia and difficulty weaning off.
Due to barotrauma and oxygen toxicity
Prevented by both antenatal and post-natal steroids, surfactant and high-calorie feeding
57
What is pulmonary hypoplasia?
Suspect in all infants with persisting neonatal tachypnoea, difficulties feeding (particularly if a history of prenatal oligohydramnios)
58
Describe the appearance of bronchopulmonary dysplasia on a Chest X-Ray.
Hyperinflation, rounded radiolucent areas, alternating with thin denser lines
59
What is meconium aspiration syndrome?
Foetal distress in the infant born through meconium-stained amniotic fluid leading to airway obstruction, surfactant dysfunction and pulmonary vasoconstriction.
Treated with surfactant, ventilation, inhaled nitric oxide and antibiotics
60
What is haemorrhagic disease of the newborn?
Occurs 2-7 days postpartum due to a lack of enteric bacteria used to make vitamin K.
Characterised by widespread bleeding and bruising with increased PT and APTT.
Prevention with postpartum 1mg Fit K injection IM
61
What is DIC? How is it characterised, diagnosed and treated?
Disseminated intravascular coagulation (due to NEC or sepsis etc.)
Characterised by petechiae, venipuncture oozing, GI bleeding
Diagnosed by decreased platelets and the presence of schistocytes (fragmented red cells)
Treat the underlying cause, platelet transfusion, cryoprecipitate
62
What is autoimmune thrombocytopenia?
Congenital autoimmune destruction of platelets.
Treated with compatible platelets or irradiated maternal platelets
63
What are strawberry naevi?
Benign vascular malformations develop over few months and then regress. Treat with propranolol if in sensitive area or large
64
What are milia?
1-2mm pearly white/cream papules caused by retention of keratin in the dermis found on forehead, nose, cheeks
Resolve spontaneously
65
What is erythema toxicum (neonatal urticaria)?
Harmless red blotches with central white pustules which come and go in crops. They last approx. 24hrs
66
What is miliaria crystallina?
Prickly heat-like rash develops due to transient sweat-pore disruption
Called milia rubra is there is surrounding flush
67
What is a stork mark?
Capillary dilation of the eyelid, forehead and back of neck.
Blanching and fade over time
68
What are the signs of suffusion of the face following delivery?
Petechial haemorrhage
Facial cyanosis
Subconjunctival haemorrhage
69
Outline the cause of swollen breasts in the neonate
Due to exposure to maternal hormones in utero
May become infected and treated with antibiotics
70
Outline the process of separation of the umbilicus
Dries and separates through a moist base around day seven after delivery.
Can become infected (signs of odour, pus, malaise, erythema)
Rule out patent urachus if failure to close
71
Outline the causes of a sticky eye in the neonate?
Commonly due to blocked tear duct
Swab for ophthalmia neonatourm/chlamydia/gonorrhoea
72
Outline the causes of a red-stained nappy
Usually due to urinary urates but may also be due to blood from the cord or vagina
73
What is harlequin colour change?
Transient and episodic erythema left or right of the midline and contralateral blanching. Self-limiting condition.
74
List endogenous causes of eczema
```
Atopic
Seborrhoeic
Discoid
Pomphylx
Varicose
```
75
What is atopic dermatitis?
Genetic barrier dysfunction linked to other atopic conditions (asthma, hayfever etc.)
76
Outline the presentation of atopic eczema in both infants and older children
Infants - starts on face/neck and spreads more generally
Older children - flexural pattern predomiantes
77
What is seborrhoeic eczema?
Scaling irritation of the skin. Associated with proliferation of commensal malassezia (yeast)
Often occurring in babies under 3 months and resolving within a year
78
What is discoid eczema?
Scattered annular patchy of itchy eczema
79
What is pomphylx eczema?
Vasicles affecting palms and soles. Intensely itchy
80
What is varicose eczema?
Irritation of the skin associated with oedema and venous insufficiency.
May be complicated by ulceration
81
List exogenous causes of eczema
Allergic contact dermatitis
Irritant contact dermatitis
Photosensitive/photoaggressive dermatitis
82
Outline the presentation of allergic dermatitis
Immediate reaction with severe itching and unresponsive to treatment.
83
How is allergic dermatitis diagnosed?
Blood test - IgE specific to certain common allergens and skin prick testing
84
Flares of all types of eczema can be associated with what occurances?
```
Infections
Environment (hot or cold air)
Pets: if sensitised/allergic
Teething
Stress
Sometimes no cause found
```
85
How is eczema managed?
```
Emollients (lotions, creams or ointments)
Topical steroids
Calcinurin inhibitors
UVB therapy
Immunosuppressive medication
```
86
Outline the varying strengths of topical steroid creams
Mild - hydrocortisone
Moderate - eumovate (25x)
Potent - betnovate (100x)
Very potent (derogate (600x)
87
What is impetigo?
Common acute bacterial skin infection caused by Staph aureus.
Characterised by gold-crusted pustules
88
How is impetigo managed?
Topical antibacterial -fucidin
| Oral antibiotic - flucloxacillin
89
What is molluscum contagiosum?
Common benign and self-limiting viral infection fo the molluscipox variety
90
How is molluscum contagiosum transmitted?
Close direct contacts
91
What si the incubation time of molluscum contagiosum?
2 weeks to 6 months
92
How long can it take for a bout of molluscum contagiosum to clear?
Up to 2 years
93
Describe the molluscum contagiosum lesions
Pearly papule with an umbilicated centre
94
How is molluscum contagiosum treated?
Topical 5% potassium hydroxide
95
What are viral warts?
Common, non-cancerous growths of the skin caused by infection with HPV (transmitted by direct contact)
Treated: cryotherapy, topical paint (salicylic acid)
96
What are viral exanthems?
Skin manifestations of viral illnesses(either a reaction to a toxin, damage to the skin or an immune response)
97
Give some examples of viral exanthems
```
Chickenpox (varicella-zoster virus)
Measles (Rubeola virus)
Rubella
Roseola (HSV6)
Erythema infectiosum (provirus B19)
```
98
What is the colloquial name of erythema infectiosum?
Slapped cheek
99
What are the features of erythema infectiosum?
Erythematous rash on face and lace network rash on trunk/limbs
100
What rare complications are associated with erythema infectiosum?
Aplastic crisis
| Risk in pregnancy (spontaneous miscarriage, IUD, hydros fetalis)
101
Describe the presentation of primary VZV infection?
Red papules progressing to vesicles often on the trunk which is intensely itchy and can be accompanied by viral symptoms
102
What causes hand, foot and mouth disease?
Enterovirus (often Coxackie A16)
103
Outline the presentation of Coxsackie A16 infection?
BListers on hand, feet and in the mouth (epidemics in the autumn and summer months)
Self-limiting
104
What is orofacial granulomatosis?
Lip swelling and fissuring with oral mucosal ulcers and tags (cobblestone appearance) often seen in Crohn's disease
105
What is erythema nodosum?
Skin inflammation that is located in a part of the fatty layer of skin
Resulting in reddish, painful, tender lumps most commonly on the legs below the knees
106
List some causes of erythema nodosum?
```
Infections strep. URTI
IBD
Sarcoidosis
Drugs (OCP, penicillin)
Idiopathic
```
107
What is dermatitis herpetiformis?
Rare but persistent immunobullous disease that has been linked to coeliac disease causing itchy blisters in clusters (often symmetrical) on the scalp, shoulders, buttocks, elbows and knees
108
What is urticaria?
Also called hives/wheels
Associated with angioedema with rash lasting from a few minutes up to 24hrs
109
What are the two types of urticaria?
Acute (<6wks)and Chronic (>6wks)
110
List some causes of urticaria
Viral infection
Bacterial infection
Fod/drug allergy
NSAIDs, opiates
111
How is urticaria treated?
Consider triggers and avoid
| Antihistamines (desloratadine 1tds)
112
What common lesions comprise congenital heart disease?
```
Septal defects (ventricular and atrial)
Patent ductus ateriosus
Stenosis (pulmonary and aortic)
Coarctation of the aorta
Transposition of the Great Arteries
Tetralogy of Fallot
```
113
Congenital heart disease accounts for what percentage congenital conditions?
30%
114
What environmental hazards are associated with congenital heart disease?
Drugs (alcohol, amphetamines, cocaine, ecstasy, phenytoin, lithium)
Infections (TORCH and others)
Maternal (DM, SLE)
115
What chromosomal abnormalities are associated with congenital heart disease?
Downs Syndrome (Trisomy 21) 40% AVSD
Edwards Syndrome (Trisomy 18) 80% VSD and PDA
Patau Syndrome (Trisomy 13) 90% VSD and ASD
116
What congenital heart conditions are associated with the following genetic conditions:
1. Turner syndrome
2. Noonan syndrome
3. Williams syndrome
4. DiGeorge (22q11 deletion) syndrome
1. Coarctation of the aorta
2. Pulmonary stenosis
3. Supravalvular AS
4. Interrupted aortic arch, truncus arteriosus and tetralogy of Fallot
117
How is congenital heart disease treated?
Surgical correction (fix it)
Medication to improve situation
Palliative procedures e.g. BT shunt, balloon valvo-plasty, prostaglandin infusion, pulmonary banding
Transplantation surgery
118
How are murmurs characterised?
Timing (systolic/diastolic/continuous)
Duration (early/mid/late or ejection/pan-systolic)
Pitch/quality (harsh/soft/vibrstory/pure frequency)
119
List the four types of innocent murmurs?
Stills Murmur (LV outflow murmur)
Pulmonary Outflow Murmur
Venous Hum
Carotid/Brachiocephalic Arterial Bruit
120
What age does Still's murmur commonly present?
Aged 2-7
121
Describe the character of Still's murmur?
Soft, systolic; vibratory musical and twangy
122
Where is Still's murmur most clearly heard?
Apex, left sternal border.
Increases in the supine position and with exercise
123
What age does a pulmonary outflow murmur commonly present?
Age 8-10
124
Describe the character of a pulmonary outflow murmur
Soft systolic; vibratory
125
Where is pulmonary outflow murmur most clearly heard?
Upper left sternal border, well localised and not radiating to the back
Increases in the supine position and with exercise
126
At what age is a venous hum most likely to develop?
Age 3-8
127
Describe the character of a venous hum
Soft and indistinct continuous murmur with diastolic accentuation
128
Where is a venous hum most clearly heard?
Supraclavicular and only in the upright position
129
Describe the character and age of onset of a carotid/brachiocephalic arterial bruit
Systolic murmur heard in the supraclavicular regions with neck radiation
Decreases on turning the head or extending the neck
Most likely to arise between ages 2-10yrs
130
What are the three main types of ventricular septal defects?
Subaortic, perimembranous and muscular
131
How do ventricular septal defects present?
Pansystolic murmurs at the lower left sternal edge (sometimes with a thrill)
132
What is Eisenmenger Syndrome?
Eisenmenger syndrome refers to any untreated congenital cardiac defect with intracardiac communication that leads to pulmonary hypertension, reversal of flow, and cyanosis
133
How is VSD treated?
VSD closure surgery with either:
Amplatzer device or a patch closure
134
How do atrial septal defects present in childhood and in adulthood?
Childhood (early on, often incidental finding)
Adulthood (AF, HF, pulmonary hypertension)
135
What does an atrial septal defect sound like on auscultation?
Wide fixed splitting of 2nd heart sound with pulmonary outflow murmur.
136
How does pulmonary stenosis present?
Asymptomatic in mild stenosis
Moderate/severe - exertion dyspnoea and fatigue
137
What does pulmonary stenosis sound like?
Ejection systolic murmur in the upper left sternal border with radiation to the back
138
How is pulmonary stenosis treated?
Balloon valvoplasty
139
How does aortic stenosis present?
Ejection systolic murmur on the upper right border of the sternum with neck radiation
Often asymptomatic. If severe, reduced exercise tolerance, exertion chest pain and syncope
140
What changes occur to foetal blood circulation at birth?
| 5
```
Pulmonary vascular resistance decreases
Systemic vascular resistance increases
Ductus arteriosus closes
Foramen vale closes
Ductus venosus closes
```
141
What type of infants has a higher likelihood of patent ductus arteriosus?
Preterm infants
142
How is patent ductus arteriosus treated?
```
Fluid-restriction / diuretics
Prostaglandin inhibitors (indomethacin)
Surgical ligation
```
143
What is transposition of the great arteries/
Congenital condition where the aorta arises from the right ventricle and and the pulmonary artery arises from the left.
144
How is transposition of the great arteries treated?
Switch procedure
145
What is the tetralogy of Fallot?
*Remember PROV*
A congenital defect characterised by:
Patent ductus arterosus
Right ventricular hypertrophy
Overriding aorta
Ventricular septal defect
146
What are the two indications for enteral feeding/
Poor oral intake (e.g. disorder of swallow/suck, prematurity, neurological impairment etc.)
Disorder of digestion and absorption (e.g. cystic fibrosis, short bowel syndrome etc.)
147
What factors need to be considered before initiating enteral feeding?
```
Quality of life
Psychological factors
Ethics and prognosis
Information and consent
Clinical status
```
148
List some methods of enteral feeding?
PEG tubes (with or without jejunum extension)
NG tube
NJ tube
149
Outline some complications of enteral tubes
Infection of stoma site
Over-granulation of stoma site
Buried bumper (he internal bumper of the PEG tube erodes into the gastric wall and lodges itself between the gastric wall and skin)
Tube dislodgement
150
Outline the components of LFTs
```
Bilirubin
ALT/AST
Alkaline phosphatase
GGT
Functional tests (coagulation, albumin, blood glucose, ammonia)
```
151
Outline the types of bilirubin tested in LFTs
Total (both conjugated and unconjugated)
Split - direct (conjugated) and indirect (unconjugated)
152
Raised AST/ALT indicates what?
Hepatocellular damage (hepatitis)
153
What variables indicated biliary status?
Alkaline phosphatase and GGT
154
What are the coagulation tests?
Prothrombin time
| Activated thromboplastin time
155
What is jaundice?
Yellow discolouration of the skin and tissues due to accumulation of bilirubin (visible when total bilirubin is >40-50umol/L)
156
What enzyme is responsible for conjugation of bilirubin?
Glucuronic acid glucuronyl transferase
157
What are the three types of jaundice?
Pre-hepatic (mostly unconjugated)
Intrahepatic (mixed)
Post-hepatic (mostly conjugated)
158
Jaundice in infants is diagnosed based on the age of the infant. Outline different causes of early, intermediate and prolonged jaundice.
Early (<24hrs) - always pathological. Causes include haemolysis and sepsis
Intermediate (24hrs-2wks) - physiological, breast milk, sepsis, haemolysis
Prolonged (>2weks) - extra-hepatic obstruction, neonatal hepatitis, hypothyroidism
159
List two disorders of abnormal conjugation
Gilbert's disease - mild and common
| Crigler-Najjar syndrome - rare and severe
160
Why is unconjugated bilirubin potentially dangerous?
Unconjugated bilirubin is fat-soluble therefore crosses the blood-brain barrier and deposits in the brain causing kernicterus
161
What are the most common causes of biliary obstruction in infancy?
Biliary atresia
Choledochal cyst
Alagille syndrome
162
What is Alagille syndrome?
Congenital disorder characterised by intrahepatic cholestasis, dysmorphism and congenital heart disease.
163
List some causes of neonatal hepatitis
| 7
```
Alpha-1-antitrypsin disease
Galactosaemia
Tyrosinaemia
Urea cycle defects
Hypothyroidism
Viral hepatitis
Parenteral nutrition
```
164
List some features of chronic liver disease
| 8
```
Jaundice
Epistaxis
Bruising and petechiae
Ascites
Hypotonia
Hepatorenal failure
Peripheral neuropathy
Failure to thrive (malnutrition)
```
165
# Define:
Neonate
Infant
Toddler
Pre-school
Neonate <4wks
Infant <1yr
Toddler 1-2yr
Pre-school 2-5yrs
166
Why is breast milk better than formula?
```
Well tolerated
Less allergenic
Low renal solute load
Improves cognitive development
Reduces infection (macrophages, lymphocytes, lysozymes etc.)
```
167
What are the different types of specialised formula?
For Cows Milk Protein Allergy (either extensively hydrolysed or amino acid-based)
Nutrition dense
Disease-specific (lactose-free, soya milk, calories and calcium)
168
What areas of the brain are associated with wiht nausea and vomiting?
(5)
Cerebellum, vomiting centre, tractus solitarius, area postrema and CTZ
169
Outline the four types of vomiting
Vomiting with retching
Projectile vomiting
Bilious vomiting
Effortless vomiting
170
Bilius vomiting should always ring alarm bells. What assumption is made about the cause of bilious vomiting until proven otherwise?
Due to intestinal obstruction until proven otherwise
171
List some causes of bilious vomiting
```
Intestinal atresia (newborns)
Malrotation +/- volvulus
Intersussception
Ileus
Crohn's disease with strictures
```
172
What is volvulus? How does it present?
When a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool.
173
What is intussusception? How does it present?
A condition in which one segment of intestine "telescopes" inside of another, causing an intestinal obstruction (blockage).
Usually occuring at the junction of the small and large intestines
Stool mixed with blood and mucus stool
Vomiting, abdominal lump, lethargy, diarrhoea, fever
174
What investigations may help diagnose the cause of bilious vomiting?
Abdominal X-Ray (Consider contrast meal)
Surgical laparotomy
Abdominal US
175
What is pyloric stenosis? How does it present?
Narrowing of the opening from the stomach to the small intestine (the pylorus).
Symptoms include projectile vomiting without the presence of bile. This most often occurs after the baby is fed.
176
What ultrasound finding can diagnose intussusception?
Target sign
177
What characteristic electrolyte imbalance is associated with pyloric stenosis?
Metabolic alkalosis
Hypochloriaemia
Hypokalaemia
178
At what age does pyloric stenosis generally become symptomatic?
Babies aged 4-12 weeks
179
How does pyloric stenosis typically present?
Weight loss
Projectile, non-bilious vomitus
Dehydration and shock
180
How is pyloric stenosis treated?
Fluid resuscitation and Ramstedts pyloromyotomy
181
What is gastro-oesophageal reflux disorder?
Movement of gastric contents into the oesophagus
182
How can GORD present?
GI (vomiting, haematemesis)
Nutritional (feeding problems/failure to thrive)
Respiratory (apnoea, cough, wheeze, chest infections)
Neurological (Sandifer's syndrome)
183
What is Sandifer's syndrome?
Paroxysmal dystonic movement disorder occurring in association with gastro-oesophageal reflux, and, in some cases, hiatal hernia.
184
How is GORD investigated?
pH manography
Upper GI endoscopy
Barium swallow
185
How is GORD treated?
```
Feed thickeners
Adjust feeding position
Exclusion diet (milk free)
Nutritional support
Prokinetic drugs
Acid suppression drugs
```
186
In severe and refractory GORD, what management option is available?
Nissen fundoplication
187
What is the definition of chronic diarrhoea?
Four or more stools per day for more than four weeks
188
What is the definition of acute diarrhoea?
More than four stools per day for less than one week
189
What are some potential causes of chronic diarrhoea?
Motility disturbance (toddler diarrhoea, IBS)
Active secretion (acute infective, IBD)
Malabsorption (food allergy, coeliac disease, cystic fibrosis)
190
What are the four types of diarrhoea?
Osmotic
Secretory
Motility
Inflammatory
191
What is the mechanism of motility diarrhoea?
Movement of water into the bowel to equilibrate osmotic gradient
192
What is the mechanism of secretory diarrhoea?
Intestinal fluid secretion driven by chloride secretion via CFTR transporter
193
What is the mechanism of inflammatory diarrhoea?
Malabsorption due to intestinal damage and protein exudate across epithelium
194
What is coeliac disease?
Intolerance to gliadin (component of gluten)
195
How does coeliac disease present?
Abdominal belatedness, diarrhoea, failure to thrive, constipation, dermatitis herpetiformis
196
What groups of people are more susceptible to coeliac disease?
T1DM
Autoimmune thyroid disease
Down's Syndrome
Family history of coeliac
197
How is coeliac disease tested for?
Serological (anti-tissue transglutaminase, anti-endomysial, IgA deficiency)
Duodenal biopsy (villous atrophy)
Genetic testing (HLA, DQ2, DQ8)
198
How is coeliac disease treated?
Strict control of diet to avoid gluten
199
What causes constipation?
```
Poor diet (insufficient fluids or fibre, excessive milk)
Intercurrent illness
Medication (opiates, ondansetron)
FHx
Psychological
Organic
```
200
How is constipation treated?
Social (explain to parents, improve diet)
Psychological (reduce adverse factors, avoid punitive behaviour, reward good behaviour)
Soften stool
201
Outline the different types of laxatives and their action
Osmotic laxatives - lactulose
Stimulant laxatives - senna and pico lax
Isotonic laxatives - movicol
202
What are some telltale signs of constipation in the history?
```
Poor appetite
irritable
Lack of energy
Abdominal pain or distention
Withholding or straining
```
203
What are the classical symptoms of IBD?
```
Diarrhoea
Rectal bleeding
Abdominal pain
Fever
Weight loss
Growth failure
Arthritis
```
204
What features are predominantly seen in Crohn's disease?
Weight loss
| Growth failure
205
What features are predominantly seen in ulcerative colitis?
Diarrhoea
| Rectal bleeding
206
What aspects of the history are important in the case of IBD?
```
Intestinal symptoms
Extra-intestinal manifestations
Exclude infection
Family history
Growth and sexual development
Nutritional status
```
207
What laboratory investigations are important in the diagnosis of IBD?
FBC (anaemia, thrombocytosis, raised ESR)
Biochemistry (stool calprotectin, raised CRP, low albumin)
Microbiology (no pathogens)
208
What are the definitive investigations for the diagnosis of IBD?
Radiology (MRI, barium meal and follow-through)
Endoscopy (colonoscopy, upper GI endoscopy, mucosal biopsy, capsule endoscopy, enteroscopy)
209
How is IBD treated?
```
Anti-inflammatories
Immune-suppressive
Biologics
Immunomodulation
Supplementation
Surgical intervention
```
210
What features of a history might ring alarm bells with regards to child protection?
Late presentation
History changes on repeating
History inconsistent with findings
211
What is the commonest cause of death due to physical abuse?
Abrasive head trauma
212
What is the mortality and morbidity associated with abrasive head trauma due to abuse?
30%
Half have a residual disability, retinal haemorrhages, neck and cervical spine injury
213
Outline the categories of neglect
```
Emotional
Abandonment
Medical
Nutritional
Educational
Physical
Failure to provide supervision
```
214
What is a paediatric fabricated illness?
Rare form of child abuse where the guardian/parent induces illness in their child
215
What are the measurements of normal growth/pubertal development?
Length (infants)
Height (standing/sitting)
Head circumference (routine in children <2yrs)
Target height and mid-parental height
Bone age (high-quality radiograph)
Growth velocity
Weight
216
How is pubertal stage measured?
Tanner statins (breast, genital, pubic/axillary hair and testicular volume)
217
How is testicular volume measured?
Prader orchidometer
218
Outline indications for referral to do with growth and development
```
Extremes of height
Abnormal high velocity
History of chronic disease
Obvious dysmorphic syndrome
Early/late puberty
```
219
At what ages is puberty considered to be early and late in the different sexes respectively?
Boys: Early <9 (rare) and late >14 (common)
Girls: Early <8 and late >13 (rare)
220
What is the most common cause of delayed puberty in boys?
Constitutional Delay of Growth and Puberty (CDGP)
221
List causes of delayed puberty
Gonadal dysgenesis (Turner 45X, Kleinfelter 47XXY)
Chronic disease (Crohn's, asthma)
Impaired HPG axis (sept-optic, dysplasia, craniophyringioma, Kallman's syndrome)
Peripheral (cryptorchidism, testicular irradiation)
222
List two causes of early sexual development
Central precious puberty
| Precocious pseudopuberty
223
What is central precocious puberty?
Early pubertal development (breast/testicular growth) and advanced bone age often due to pituitary lesion
224
What is precocious pseudopuberty?
Abnormal sex steroid secretion with low/prepubertal levels of LH/FSH
Clinical picture of secondary sexual characteristics
Need to exclude congenital adrenal hyperplasia
225
What pathology must be excluded in the case of ambiguous genitalia?
Congenital adrenal hyperplasia
226
Outline the causes of congenital hypothyroidism
Athryeosis (agenesis of the thyroid)
Hypoplastic (dysgenesis of the thyroid)
Ectopic (outside its usual anatomical bounds)
227
What is the most common cause of acquired hypothyroidism?
Hashimoto's thyroiditis
228
What childhood issues can be caused by hypothyroidism?
Lack of height gain
Pubertal delay (or precocity)
Poor school performance
229
Outline the presentation of diabetic ketoacidosis?
```
Nausea and vomiting
Abdominal pain
Sweet-smelling breath
Drowsiness
Rapid, deep, sighing respiration
Coma
```
230
List the THINK Symptoms of diabetes
```
Thirsty
Thinner
Tired
Toilet
Other (blurred vision, candidiasis, constipation, recurring skin infections etc.)
```
231
List the domains of child development
```
Gross motor skills
Fine motor skills
Speech and language
Social/personal activities of daily living
Performance and cognition
```
232
What is global delay?
Delay in two or more of the following domains (motor, language, cognitive, social and emotional)
233
List four assessment tools for development?
ASQ (ages and stages questionnaire)
PEDS (parents evaluation of developmental status)
M-CHAT (Autism in toddlers checklist)
SOGS-2 (Schedule of growing skills )
234
What are the red flags for childhood development?
```
Loss of developmental skills
Concerns about revision/hearing
Floppiness
No speech by 18-24 months
Asymmetry of movement
Persistent toe walking
```
235
List developmental milestones
Sit unsupported at 12 months
Walk by 18 months (boys) or 2yrs (girls)
Run by 2.5 years
Hold objects at 5 months
Reach for objects by 6 months
Points to objects to share interest by 2 yrs
236
List some common developmental issues in the motor domain
Delayed maturation
Cerebral palsy
Developmental coordination disorder
237
List some common developmental issues in the sensory domain
Deafness
Visual impairment
Multi-sensory impairment
238
List some common developmental issues in the language/cognition domain
Specific learning impairment
| Learning disability
239
List some common developmental issues in the social/communication domain
Autism
Asperger syndrome
Elective mutism
240
What formula is used to estimate weight in children?
Weight (kg) = 2*(age+4)
241
What is the estimated blood volume of a child?
Blood volume (mls) = 80mls/kg
242
What is the average urine output of a child?
0.5-1ml/kg/hr
243
What is the volume of insensible loss in children?
20mls/kg/L
244
What is the estimated systolic blood plessure for children?
Systolic BP (mmHg) = 80 + (2 x age)
245
Outline the change in respiratory rate from the ages of <1 to >10
<1yo - 30-40
2-5yo - 25-30
5-10yo - 20-25
>10yo - 15-20
246
Outline the change in heart rate from the ages of <1 to >10
<1yo - 110-160
2-5yo - 95-140
5-10yo - 80-120
>10yo - 60-100
247
Outline the change in blood pressure from the ages of <1 to >10
<1yo - 70-90
2-5yo - 80-100
5-10yo - 90-110
>10yo - 100-120
248
Under what age is codeine not recommended?
<12 years old
249
Outline fluid resuscitation requirements in children
20ml/kg bolus 0.9% NaCl
250
Outline fluid maintenance requirements in children
4ml/kg for the first 10kg (40ml)
2ml/kg for the next 10kg (20ml)
1ml/kg for every kg thereafter
251
How does appendicitis present?
Murphys triad (pain in McBurney's point, vomiting, fever)
252
What complications can occur in appendicitis?
Abscess
Mass
Peritonitis
253
What is non-specific abdominal pain (NSAP?
Acute abdominal pain less than one week in duration, for which there is no diagnosis despite investigations and comprises a spectrum of undiagnosed conditions, both somatic and functional, and remains a “diagnosis of exclusion.”
254
What pathologies usually underlie NSAP?
Mesenteric adenitis (high temp, URTI, not well)
Pneumonia (sicker than abdominal signs, usually right lower lobe)
255
How is intussusception treated?
Penumostatic reduction (try to avoid laparotomy)
256
What is gastroscisis?
Type of congenital abdominal wall defect.
Gut eviscerated and exposed
Treated with TPN and primary/delayed closure
257
What is exomphalos?
Umbilical defect covered in viscera
Managed with primary/delayed closure
25% post-natal mortality
258
A defect in what structure results in an epigastric hernia?
Defect in linea alba above the umbilicus leading to protrusion of preperitoneal fat
259
Outline the common organisms responsible for gastroenteritis in children
(9)
Rotavirus, adeno, entero, noro
E.coli, Shigella, Salmonella, Campylobacter
Giardiasis, Amoebiasis
260
Outline the potential presentation of urological conditions in paediatrics
Systemic (fever, vomiting, failure to thrive, anaemia, hypertension, renal failure)
Local (pain, changes in urine, abnormal voiding, mass)
Antenatal (asymptomatic, permits immediate postnatal assessment)
261
How are inguinal hernia managed?
<1 years old - urgent referral
>1 years old - elective referral and repair
Incarcerated - reduced and repair on the same admission
262
What is a hydrocele?
Painless cystic scrotal swelling - increases in size with crying, straining etc.
Managed conservatively until the age of five
263
What is cryptorchidism?
Any testis that cannot be manipulated into the bottom half of the scrotum
264
What are the different types of cryptorchidism?
True
Retractile
Ectopic
Ascending testis
265
What is the main risk factor for the development of cryptorchidism?
Preterm labour
266
What are the indications for orchidopexy?
```
Fertility - 1% loss germ cells per month of undescent
Malignancy
Trauma
Torsion
Cosmetic
```
267
What is circumcision?
Removal of foreskin
268
What are the absolute and relative indications for circumcision?
Absolute - balanitis xerotica obliterates (BXO)
| Relative (balanoposthitis, religious, UTI)
269
What complications can occur after a circumcision?
Bleeding
Meatal stenosis
Fistula
Cosmetic
270
What is acute scrotum?
Sudden onset scrotal pain
271
Outline three differential diagnoses for the acute scrotum
Torsion
Torsion appendix testis
Epididymitis
272
What can cause epididymitis?
Trauma, haematocele, incarcerated, inguinal hernia
273
After 6-8hours of an undiagnosed acute scrotum, what is the best course of action?
Explore surgically to recover testis
274
Why do we investigate UTIs in children?
Prevent renal scarring and hypertension
275
How does UTI cause renal scarring?
Reflux nephropathy and chronic renal failure
276
How is reflux nephropathy managed?
Conservative - voiding advice, constipation, fluids
ABx prophylaxis until aged 4 (trimethoprim)
277
What is the definition of a UTI?
Pure growth of bacteria >10^5
Pyuria/Dysuria etc.
Systemic upset (fever, vomiting)
278
How is UTI investigated?
History and examination (FH, bowels habit, voiding)
USS (hydronephrosis)
Renography (MAG3 for drainage function and reflex, DSMA for function and scarring)
Micturating cystourethrogram (MCUG)
279
What is hypospadias?
Urethral meatus on the mental aspect of the penis
280
How is hypospadias managed?
Investigated associated anomalies e.g. ambiguous genitalia
US scan
Surgery correction
281
Outline the common features of a history detailing childhood migraine
```
Associated nausea and vomiting
Pallor
Photo/phonophobia
Relation to stress/fatigue
Often positive family history
```
282
What types of headache history might a child give?
Isolated/recurrent acute
| Chronic progressive/non-progressive
283
What examinations may be indicated with a child presenting with a headache?
```
Sinuses, teeth, visual acuity
Fundoscopy
Visual fields
Cranial bruit
Focal neurological signs
Cognitive/emotional status
```
284
What indications are there for neuroimaging?
```
Features of cerebellar dysfunction
Features of raised ICP
New focal deficit e.g. new squint
Seizures
Personality change
Unexplained deterioration of school work
```
285
What presentation would make you consider a neuromuscular junction disorder?
```
Floppy baby
Slipping from hands
Paucity of movement
Alert but less motor activity
Delayed motor milestones
Able to walk to frequent falls
```
286
What mutation is associated with Duchenne's muscular dystrophy?
Xp21 dystrophin gene
287
How does Duchenne's muscular dystrophy?
Symmetrical proximal weakness(waddling gait, calf hypertrophy, Gower's sign positive)
Elevated creatine kinase (>1000U)
Cardiomyopathy and respiratory involvement
288
What is the definition of a seizure/fit?
Any sudden attack from whatever cause
289
What is a febrile convulsion?
An event occurring in infancy (usually between 3m-5yrs) associated with fever but without evidence of intracranial infection or organic cause
290
What is adolescence?
Specific, unique developmental stage occurring between the ages of 11-25
291
What social, emotional and physical changes occur?
Social (independence, self-identity, sexual identity)
Emotional (regulation)
Physical (planning, organising, reasoning, abstract thinking)
292
What is the most common childhood malignancy?
Leukaemias
293
List some acute complications of chemotherapy
```
Hair loss
Neausea and vomiting
Mucositis
Diarrhoea/constipation
Bone marrow suppression (anaemia, bleeding, infection)
```
294
List some chronic complications of chemotherapy
Organ impairment
Reduced fertility
Second cancer
295
List some acute complications of radiotherapy
Lethargy
Skin irritation
Swelling
Organ inflammation - bowel, lung
296
List some chronic complications of radiotherapy
Fibrosis/scarring
Second cancer
Reduced fertility
297
List some oncological emergencies
```
Sepsis/febrile neutropenia
Raised ICP
Spinal cord compression
Mediastinal mass
Tumour lysis syndrome
```
298
What are some risk factors for developing febrile neutropenia?
ANC <0.5x10^9
Indwelling catheter
Mucosal inflammation
High dose chemotherapy
299
What are the most common organisms associated with febrile neutropenia
```
Pseudomonas aerignenosa
E. coli
Enterococci
Staph
Fungi (aspergillus, candida)
```
300
How does febrile neutropenia present?
Fever (or low temp)
Rigors
Drowsiness
Shock
301
OUtline the management of febrile neutropenia
```
IV access
Bloods
CXR
Other investigations (urine microscopy, throat swab, LP, viral PCR, CT/USS)
Broad spec. ABx
Oxygen, fluids, inotropes
```
302
Describe the presentation of early raised ICP
Early morning headache
Tense fontanelle
Nausea/vomiting
303
Describe the presentation of late raised ICP
```
Constant headache
Papilloedema
Diplopia
Loss of upgaze
Reduced GCS
Cushing's triad (Chenyes-Stokes, bradycardia, hypertension)
```
304
How is raised ICP managed?
Dexamethasome if due to tumour
Neurosurgery (ventriculostomy, extra ventricular drain, ventricle-peritoneal shunt) )
305
Outline the pathophysiology of spinal cord compression in paediatric malignancy
Invasion from paravertebral disease via intervertebral foramina (CSF seeding or direct invasion)
306
How may spinal cord compression present?
Weakness, pain, sensory disturbance, sphincter disturbance
307
How is suspected spinal cord compression investigated?
Urgent MRI of spine
308
How is spinal cord compression managed?
Dexamethasome to reduce per-tumour oedema
Chemotherapy/spinal decompression surgery
309
How may a mediastinal mass present in the emergency setting?
Superior Vena Cava Syndrome
310
List some common causes of superior vena cava syndrome?
Lymphoma
Neuroblastoma
Germ cell tumour
Thrombosis
311
How does superior vena cava syndrome present?
Facial, neck and upper thoracic plethora (redness)
Oedema, cyanosis, distended veins and reduced GCS
312
How is superior vena cava syndrome investigated?
CXR/CT chest
| Echocardiogram
313
How is superior vena cava syndrome managed?
Keep the patient upright and calm
Urgent biopsy
Definitive treatment is required urgently (chemotherapy and radiotherapy)
314
What is tumour lysis syndrome?
Rapid death of tumour cells and release of intracellular contents secondary to treatment
315
What are the biochemical markers of tumour lysis syndrome?
Hyperkalaemia
Hyperuraemia
Hyperphosphataemia
Hypocalcaemia
Acute renal failure
316
How is tumour lysis syndrome treated?
ECG monitoring
Hyperhydration
Diuretics
Renal replacement therapy (dialysis etc.)
