Paediatrics Flashcards

Question

What are the key presentations of asthma?

Answer 1

- Episodic symptoms - Diurnal variability - Typical triggers - A history of other atopic conditions such as eczema, hay fever and food allergies - Family history of asthma or atopy - Bilateral widespread “polyphonic” wheeze heard by a healthcare professional - Symptoms improve with bronchodilators

Answer 2

- Wheeze only related to coughs or colds - Isolated or productive cough - Normal investigations - No response - Unilateral suggests a focal lesion or foreign body

Answer 3

Spirometry with reversibility testing (in children aged over 5 years) Direct bronchial challenge test with histamine or methacholine Fractional exhaled nitric oxide (FeNO) Peak flow variability measured by keeping a diary of peak flow measurements several times a day for 2 to 4 weeks

Answer 4

- SABA as required - Steroid or leukotriene antagonist

Answer 5

Start a short-acting beta-2 agonist inhaler (e.g. salbutamol) as required Add a regular low dose corticosteroid inhaler Add a long-acting beta-2 agonist inhaler (e.g. salmeterol). Continue salmeterol only if the patient has a good response. Titrate up the corticosteroid inhaler to a medium dose. Consider adding: Oral leukotriene receptor antagonist (e.g. montelukast) Oral theophylline Increase the dose of the inhaled corticosteroid to a high dose. Referral to a specialist. They may require daily oral steroids.

Answer 6

Start a short-acting beta 2 agonist inhaler (e.g. salbutamol) as required Add a regular low dose corticosteroid inhaler Add a long-acting beta-2 agonist inhaler (e.g. salmeterol). Continue salmeterol only if the patient has a good response. Titrate up the corticosteroid inhaler to a medium dose. Consider a trial of an oral leukotriene receptor antagonist (i.e. montelukast), oral theophylline or an inhaled LAMA (i.e. tiotropium). Titrate the inhaled corticosteroid up to a high dose. Combine additional treatments from step 4, including the option of an oral beta 2 agonist (i.e. oral salbutamol). Refer to specialist. Add oral steroids at the lowest dose possible to achieve good control under specialist guidance.

Answer 7

- Some parents are worried that they can slow growth of up to (1cm) when used long term - This effect is dose-dependant meaning it is less of a problem with smaller doses

Answer 8

Once a month and make sure they are air dried as static can prevent medication inhalation

Answer 9

Small children under the age of 3 have small airways. So when the encounter a virus they develop inflammation and oedema

Answer 10

Swelling and constriction of the airway caused by a virus has little noticeable effect on the larger airways of an older child or adult, however due to the small diameter of a child’s airway, the slight narrowing leads to a proportionally larger restriction in airflow. This is described by Poiseuille’s law, which states that flow rate is proportional to the radius of the tube to the power of four. Therefore, halving the diameter of the tube decreases flow rate by 16 fold.

Answer 11

Family history

Answer 12

Presenting before 3 years of age No atopic history Only occurs during viral infections

Answer 13

Evidence of a viral illness (fever, cough and coryzal symptoms) for 1-2 days preceding the onset of: Shortness of breath Signs of respiratory distress **Expiratory wheeze throughout the chest**

Answer 14

Not asthma or viral If you hear a focal wheeze be very cautious and investigate further for a focal airway obstruction such as an inhaled foreign body or tumour.

Answer 15

Describes inflammation and infection in the bronchioles.

Answer 16

- Most common in under a year- particularly in under 6 months - Can occur in older children particularly in premature babies with chronic lung disease

Answer 17

- Coryzal symptoms - Signs of resp distress - Dyspnoea - Tachypnoea - Poor feeding - Mild fever - Apnoea's are episodes where the child stops breathing - Wheeze and crackles on auscultation

Answer 18

- Raised Resp rate - Use of accessory muscles for breathing - Intercostal and subcostal recessions - Nasal flaring - Head bobbing - Tracheal tugging- downward displacement during inspiration - Cyanosis - Abnormal airway noises

Answer 19

Wheezing is a whistling sound caused by narrowed airways, typically heard during expiration Grunting is caused by exhaling with the glottis partially closed to increase positive end-expiratory pressure Stridor is a high pitched inspiratory noise caused by obstruction of the upper airway, for example in croup

Answer 20

- Aged under 3 months or any pre-existing condition - 50-75% reduction in milk intake - Clinical dehydration - Resp rate over 70 - Oxygen sats below 92% - Head bobbing - Apnoea's

Answer 21

Ensuring adequate intake. This could be orally, via NG tube or IV fluids depending on the severity. It is important to avoid overfeeding as a full stomach will restrict breathing. Start with small frequent feeds and gradually increase them as tolerated. Saline nasal drops and nasal suctioning can help clear nasal secretions, particularly prior to feeding Supplementary oxygen if the oxygen saturations remain below 92% Ventilatory support if required

Answer 22

Capillary blood gases Rising pCO2- Shows the airways have collapsed and can't clear CO2 Falling pH- shows the CO2 is building up and not able to buffer the acidosis

Answer 23

**Palivizumab** is given as monthly injection to prevent it

Answer 24

An inherited autosomal recessive multi-system disease affecting the mucus glands

Answer 25

cystic fibrosis transmembrane conductance regulatory gene on **chromosome 7**

Answer 26

- The CFTR protein gets misfolded and can't migrate from the RER to the cell membrane - The CFTR is a channel protein that pumps chloride ions into various secretions helping to thin them out meaning secretions are left overly thick

Answer 27

- Results in dry airways and impaired mucociliary clearance - The low volume thick airway secretions result in reduced airway clearance increasing chances of infection and this chronic inflammation can lead to bronchiectasis

Answer 28

- Thickened secretions within small and large bowel can make it difficult to pass stools resulting in bowel obstruction

Answer 29

Thick pancreatic and bile secretions can block the pancreatic ducts resulting in a lack of digestive enzymes this can also result in pancreatitis and diabetes

Answer 30

Thickened biliary secretions may block the bile ducts resulting in liver fibrosis and cirrhosis

Answer 31

- Can result in pulmonary hypertension leading to right sided heart failure - In males there is bilateral absence of vas deferens so it means there is male infertility

Answer 32

**meconium ileus**

Answer 33

- In babies the first stool passed is called the meconium and it is black and sticky and should be passed within 48 hours - In babies with CF the meconium does not pass as it is too sticky so it causes bowel obstruction occurs in 20% of babies with CF

Answer 34

- Low weight - Nasal polyps - Finger clubbing - Crackles and wheezes - Abdominal distension

Answer 35

- Chronic cough - Thick sputum production - Recurrent respiratory infections - Loose, greasy stools (steatorrhea) due to a lack of fat digesting lipase enzymes - Abdominal pain and bloating - Poor weight and height gain (failure to thrive) -Parents may report the child tastes particularly salty when they kiss them, due to the concentrated salt in the sweat

Answer 36

- It is found during the **heel-prick/Guthrie test** which screens for CF in babies by looking for serum immunoreactivity trypsinogen

Answer 37

The sweat test

Answer 38

test for CF - **Pilocarpine** is applied to the skin and electrodes are placed either side of the patch with small current to cause skin to sweat - The sweat is absorbed and sent to lab for testing a diagnostic test of chloride concentration above **60 mmol/l is diagnostic

Answer 39

- Staphylococcus aureus- patients take long term prophylactic flucloxacillin - Pseudomonas aeruginosa- can be harder to treat and worsen the prognosis

Answer 40

- Chest physiotherapy at least twice a day to remove mucus - Exercise - Salbutamol - Nebulised DNase (dornase alfa wolf) an enzyme that breaks down DNA material in respiratory secretions - Nebulised hypertonic saline

Answer 41

- CREON tablets helps to digest fats in patients with pancreatic insufficiency (missing lipase) - High calorie diet to make up for malabsorption and calories needed for respiratory effort

Answer 42

. Life expectancy is improving and currently the cystic fibrosis trust gives a median life expectancy of 47 years. - 90% of patients with CF develop pancreatic insufficiency - 50% of adults with CF develop cystic fibrosis-related diabetes and require treatment with insulin - 30% of adults with CF develop liver disease Most males are infertile due to absent vas deferens

Answer 43

Kaftrio, described by patient groups as a ‘revolutionary drug’, is a triple combination treatment combining three drugs which perform different functions – ivacaftor, tezacaftor and elexacaftor – and tackles the underlying causes of the disease, by helping the lungs work effectively.

Answer 44

Inflammation and swelling of the epiglottis caused by infection. The epiglottis can swell to the point of completely obscuring the airway within hours of symptoms developing

Answer 45

Haemophilus influenza B

Answer 46

- Sore throat and stridor - **Drooling** - **Tripod position** - High fever - Muffled voice - Septic and unwell appearance

Answer 47

- If patient is unwell and it is suspected then do not perform investigations - Lateral x-ray of the neck will show **thumb sign**

Answer 48

- Consult an anaesthetist and make sure that the airway is secure - Once airway is secure give IV ceftriaxone and dexamethasone

Answer 49

An epiglottic abscess

Answer 50

- Infection of the middle ear which is the space that sits between the tympanic membrane and the inner ear - This is where the nerves are found

Answer 51

- Bacteria enter from the back of the thorat through the eustachian tube - A Viral URTI often precedes otitis media

Answer 52

Strep pneumoniae

Answer 53

- **Ear pain** - Reduced hearing - Feeling unwell - Signs of URTI

Answer 54

- Otoscope tympanic membrane will look bulging red and perforation will show discharge and hole in tympanic membrane

Answer 55

Most otitis media cases will resolve without antibiotics within around three days, sometimes up to a week. Antibiotics make little difference to symptoms or complications. Amoxicillin for 5-7 days first-line Clarithromycin (in pencillin allergy) Erythromycin (in pregnant women allergic to penicillin)

Answer 56

- Symptoms lasting longer than 4 days - Systemically unwell - Immunocompromised - Younger than 2 years with bilateral - Perforation/discharge in canal

Answer 57

It is known as otitis media with effusion. The middle ear becomes full of fluid and causes ;loss of hearing in that ear

Answer 58

The Eustachian tube connects the middle ear to the back of the throat. It helps drain secretions from the middle ear. When it becomes blocked, this causes middle ear secretions (fluid) to build up in the middle ear space.

Answer 59

Reduction in hearing in that ear.

Answer 60

A dull tympanic membrane with air bubbles or a visible fluid level

Answer 61

Referral for audiometry to help establish the diagnosis and extent of hearing loss. Glue ear is usually treated conservatively, and resolves without treatment within 3 months. Children with co-morbidities affecting the structure of the ear, such as Down’s syndrome or cleft palate may require hearing aids or grommets.

Answer 62

Tiny tubes inserted into the tympanic membrane by an ENT surgeon. This allows fluid to drain from the middle ear Grommets usually fall out within a year and don't need to be reinserted

Answer 63

- Maternal rubella or CMV - Genetic deafness - Associated syndromes e.g. down's syndrome

Answer 64

- Prematurity - Hypoxia during or after birth

Answer 65

- Jaundice - Meningitis and encephalitis - Otitis media and glue ear - Chemotherapy

Answer 66

- Newborn hearing screening assessment tests hearing in all neonates

Answer 67

Ignoring calls or sounds Frustration or bad behaviour Poor speech and language development Poor school performance

Answer 68

- Charts that document the volume at which patients can hear different tones. The frequency in hertz is plotted on x-axis and decibels on Y axis - It is recorded as the minimum volume required to hear each frequency, the worse the hearing the lower down on the chart - Both air and bone conduction are tested separately

Answer 69

X – Left sided air conduction ] – Left sided bone conduction O – Right sided air conduction [ – Right sided bone conduction

Answer 70

**Both air and bone conduction** readings will be more than **20 dB, plotted below the 20 dB** line on the chart.

Answer 71

In patients with conductive hearing loss, bone conduction readings will be normal (between 0 and 20 dB), however air conduction readings will be greater than 20 dB, plotted below the 20 dB line on the chart. In conductive hearing loss, sound can travel through bones but is not conducted through air due to pathology along the route into the ear.

Answer 72

In patients with mixed hearing loss, both air and bone conduction readings will be more than 20 dB, however there will be a difference of more than 15 dB between the two (bone conduction > air conduction).

Answer 73

1. Glue ear. 2. Ear wax. 3. Otitis media. 4. Perforated ear drum.

Answer 74

ongenital infection, eg rubella, CMV Meningitis Genetics Consanguinity. Usher Syndrome hypoxic-ischemic injury to the brainstem, hemorrhage into the inner ear, toxic effects of bilirubin or aminoglycoside,

Answer 75

Sensori-neural hearing loss is often managed by a paediatrician. Treatments involve hearing aids or cochlea implants.

Answer 76

You would address the conductive problem first and then offer a hearing aid.

Answer 77

- In periorbital cellulitis there is fever with erythema, tenderness and oedema of the eyelid or other skin adjacent to the eye

Answer 78

- It should be treated quickly with intravenous antibiotics such as **high-dose ceftriaxone** to prevent posterior spread which can cause orbital cellulitis

Answer 79

- It refers to the misalignment of the eyes **strabismus** - In childhood the brain will cope with this misalignment by reducing the signal from the less dominant eye hence a squint - If this is not treated the lazy eye becomes disconnected from the brain and the problem becomes worse this is called **amblyopia**

Answer 80

Concomitant (non paralytic) squints are due to differences in the control of the extra ocular muscles. The severity of the squint can vary. Paralytic squints are rare. They are due to paralysis in one or more of the extra ocular muscles.

Answer 81

orneal light reflex test A Light in shone from a distance at both corneas simultaneously. If the light reflection does not appear in the same position in the two pupils, a squint is present Cover test The child is encouraged to look at a toy/light. If the fixing **(dominant)** eye is covered, the *squinting eye will move to take up fixation.** Cover test should be performed at different distances

Answer 82

Infections: Infections like meningitis or encephalitis can damage the nerves or areas of the brain responsible for controlling eye movement. Birth Trauma: During delivery, if there's trauma or injury to the baby's head or the nerves controlling eye movement, it can lead to a squint. Neurological Disorders: Cerebal Palsy and other conidtiosn that hinder muscle control and coordination can also result in paralytic squints. Tumors or Growth: Any abnormal growths or tumors in or around the eye, brain, or nerves controlling eye movement can put pressure on these structures, causing paralysis or weakness. Accidents or Injuries:

Answer 83

- A congenital hole in the septum between the ventricles - They can occur in isolation but are often due to underlying genetic condition such as Down's or Turner's syndrome

Answer 84

- Due to increased pressure in the left compared to the right the blood will flow from right to left through the hole - As blood will still flow around the body they will remain acyanotic - However this will cause a right side overload and lead to heart failure and increased low into the pulmonary vessels leading to **pulmonary hypertension**

Answer 85

- Poor feeding - Dyspnoea - Tachypnoea - Failure to thrive

Answer 86

- Pan systolic murmur

Answer 87

- Surgery if big hole - Increased risk of IE so give antibiotic prophylaxis if surgery is required

Answer 88

During the development of the fetus the left and right atria are connected. Two walls grow downwards from the top of the heart, then fuse together with the endocardial cushion in the middle of the heart to separate the atria. **These two walls are called the septum primum and septum secondum** Defects in these two walls lead to atrial septal defects, a hole connecting the left and right atria. There is a small hole in the septum secondum called the foramen ovale. The foramen ovale normally closes at birth.

Answer 89

Ostium secondum, where the septum secondum fails to fully close, leaving a hole in the wall. Patent foramen ovale, where the foramen ovale fails to close (although this not strictly classified as an ASD). Ostium primum, where the septum primum fails to fully close, leaving a hole in the wall. This tends to lead to atrioventricular valve defects making it an atrioventricular septal defect.

Answer 90

- Stroke instead of PE - AF - Pulmonary hypertension and HF - Eisenmenger syndrome - Can cause arrhythmias in early childhood

Answer 91

- Mid systolic cresendo-descendo murmur - Also a link to migraine with aura and patent foramen ovale

Answer 92

Eisenmenger syndrome occurs when blood flows from the right side of the heart to the left across a structural heart lesion, bypassing the lungs. There are three underlying lesions that can result in Eisenmenger syndrome: Atrial septal defect Ventricular septal defect Patent ductus arteriosus

Answer 93

- When pulmonary pressure is greater than the systemic pressure blood begins to flow from the right side of the heart to the left - This causes deoxygenated blood to bypass the lungs and enter the body. This causes **cyanosis**

Answer 94

- More RBCs produced leading to polycythaemia which causes plethoric appearance and increases chances of blood clots

Answer 95

Cyanosis Clubbing Dyspnoea Plethoric complexion (a red complexion related to polycythaemia)

Answer 96

Pregnancy can make the problem worse

Answer 97

Once the syndrome has occurred it is irreversible so should be treated before it occurs

Answer 98

The ductus arteriosus normally stops functioning within 1-3 days of birth, and closes completely within the first 2-3 weeks of life. When it fails to close, this is called a “patent ductus arteriosus” (PDA). The reasons why it fails to close are unclear, but it may be genetic or related to maternal infections such as rubella. Prematurity is a key risk factor.

Answer 99

a continuous crescendo-decrescendo “machinery” murmur Have a bounding pulse

Answer 100

Hypoplastic left heart syndrome -*left side of the heart severely underdeveloped* * Critical aortic valve stenosis * Severe coarctation of the aorta * Interruption of the aortic arch - transposition of the great arteries - **Think - all lead to obstructed systemic circulation, so causes heart failure straight away**

Answer 101

- Large PDA, VSD or ASD - Anything that causes mixes of circulation

Answer 102

More due to acquired conditions: Rheumatic fever, cardiomyopathies, Eisenmenger syndrome

Answer 103

Shortness of breath – Inability to gain weight/poor growth – Predisposition to recurrent chest infections – Hepatomegaly – Signs of specific cause –> e.g., murmur, cardiomegaly, cyanosis

Answer 104

* Bed rest and nurse in semi-upright position: infants in chair/seat. * Supplemental oxygen **(not in left to right shunt).** * Diet: sufficient calorie intake. * Diuretics. * Angiotensin converting enzyme inhibitors

Answer 105

Tetralogy of Fallot Transposition of the great arteries Eisenmenger

Answer 106

- VSD - Overriding aorta - Pulmonary valve stenosis - Right ventricular hypertrophy

Answer 107

- Rubella - Increased age of mother - Alcohol consumption in pregnancy - Diabetic mother

Answer 108

Most cases are picked up before the child is born during the antenatal scans. Additionally, an ejection systolic murmur caused by the pulmonary stenosis may be heard on the newborn baby check. Severe cases will present with heart failure before one year of age. In milder cases, they can present as older children once they start to develop signs and symptoms of heart failure.

Answer 109

- Cyanosis - Clubbing - Poor feeding - Poor weight gain - Ejection systolic murmur - Tet spells

Answer 110

- When right to left shunt is increased due to an decrease in the systemic resistance or increase in pulmonary vascular resistance - Lots of exercise produces Co2 which reduces vascular résistance - These episodes may be precipitated by waking, physical exertion or crying. The child will become irritable, cyanotic and short of breath. Severe spells can lead to reduced consciousness, seizures and potentially death.

Answer 111

- Position child with knees to their chest which will increase systemic vascular resistance - Beta blockers can relax the right ventricle and improve flow to the pulmonary vessels. IV fluids can increase pre-load, increasing the volume of blood flowing to the pulmonary vessels. Morphine can decrease respiratory drive, resulting in more effective breathing. Sodium bicarbonate can buffer any metabolic acidosis that occurs. Phenylephrine infusion can increase systemic vascular resistance.

Answer 112

Coarctation of the aorta is a congenital condition where there is narrowing of the aortic arch, usually around the ductus arteriosus. The severity of the coarctation (or narrowing) can vary from mild to severe. It is often associated with an underlying genetic condition, particularly Turners syndrome. Narrowing of the aorta reduces the pressure of blood flowing to the arteries that are distal to the narrowing. It increases the pressure in areas proximal to the narrowing, such as the heart and the first three branches of the aorta.

Answer 113

*Weak femoral pulses is often the sign** - Poor feeding - Grey and floppy baby - Tachypnoea Signs over time: - Left ventricular heave - Underdevelopment of left arm - Underdevelopment of legs

Answer 114

- Give **prostaglandin E** to keep DA open otherwise this worsens symptoms - Fix with surgery when ready

Answer 115

- When the attachments of the aorta and pulmonary trunk are swapped

Answer 116

- Will often be picked up on scan - will develop respiratory distress, tachycardia, poor feeding, poor weight gain and sweating.

Answer 117

Where there is a ventricular septal defect, this will allow some mixing of blood between the two systems and provide some time for definitive treatment. A prostaglandin infusion can be used to maintain the ductus arteriosus. This allow blood from the aorta to flow to the pulmonary arteries for oxygenation. Balloon septostomy involves inserting a catheter into the foramen ovale via the umbilicus, and inflating a balloon to create a large atrial septal defect. This allows blood returning from the lungs (on the left side) to flow to the right side of the heart and out through the aorta to the body. Open heart surgery is the definitive management. A cardiopulmonary bypass machine is used to perform an “arterial switch” procedure within a few days of birth. If present, a VSD or ASD can be corrected at the same time.

Answer 118

- An autoimmune condition triggered by streptococcus bacteria causes antibodies to target areas of the boddy

Answer 119

group A beta-haemolytic streptococcal, typically streptococcus pyogenes causing tonsillitis

Answer 120

Symptoms 2-4 weeks after sore throat such as: - Fever - Joint pain - Rash - SOB - Chorea - Nodules

Answer 121

- Joint involvement: migratory arthritis affecting the large joints, with hot, swollen, painful joints. -Inflammation throughout the heart, with pericarditis, myocarditis and endocarditis, leads to: Tachycardia or bradycardia Murmurs from valvular heart disease, typically mitral valve disease Pericardial rub on auscultation Heart failure - Subcutaneous nodules and Erythema marginatum rash - Chorea if the nervous system

Answer 122

The jones criteria

Answer 123

Major J- Joint arthritis O- organ inflammation N- Nodules E – Erythema marginatum rash S – Sydenham chorea Minor F- Fever E- ECG Changes (prolonged PR interval) without carditis A- Arthralgia without arthritis R- Raised inflammatory markers (CRP and ESR) Two major criteria OR One major criteria plus two minor criteria

Answer 124

Pen V for 10 days

Answer 125

Recurrence of rheumatic fever Valvular heart disease, most notably mitral stenosis Chronic heart failure

Answer 126

There is immaturity of the lower oesophageal sphincter. It is normal to have reflux and fine if baby keeps gaining weight 90% resolves within a year of birth

Answer 127

Chronic cough Hoarse cry Distress, crying or unsettled after feeding Reluctance to feed Pneumonia Poor weight gain

Answer 128

- Not keeping down any feed - Projectile or forceful vomiting - Bile stained - Haematemesis - Abdominal distension - Reduced consciousness, bulging fontanelle or neurological signs (meningitis or raised intracranial pressure) - Respiratory symptoms (aspiration and infection) - Blood in the stools (gastroenteritis or cows milk protein allergy) - Signs of infection (pneumonia, UTI, tonsillitis, otitis or meningitis) - Rash, angioedema and other signs of allergy (cows milk protein allergy) - Apnoeas are a concerning feature and may indicate serious underlying pathology and need urgent assessment

Answer 129

- Abnormal movements associated with GORD Torticollis: forceful contraction of the neck muscles causing twisting of the neck Dystonia: abnormal muscle contractions causing twisting movements, arching of the back or unusual postures

Answer 130

In simple cases some explanation, reassurance and practical advice is all that is needed. Advise: Small, frequent meals Burping regularly to help milk settle Not over-feeding Keep the baby upright after feeding (i.e. not lying flat) More problematic cases can justify treatment with Gaviscon mixed with feeds Thickened milk or formula (specific anti-reflux formulas are available) Proton pump inhibitors (e.g., omeprazole) where other methods are inadequate

Answer 131

- the pyloric sphincter is a ring of smooth muscle that forms between the stomach and duodenum. - Hypertrophy and therefore narrowing of this canal prevents the passage of food - Eventually due to increased peristalsis of stomach it will cause projectile vomiting from oesophagus as food can't reach duodenum

Answer 132

- Projectile vomiting (failure to thrive in early weeks of life) - Firm round mass like a large olive in upper abdomen - Hypochloric on blood gas (metabolic alkalosis) due to vomiting of HCL

Answer 133

- Abdominal ultrasound for diagnosis - a laparoscopic pyloromyotomy (known as “Ramstedt’s operation“).

Answer 134

- Gastritis is inflammation of the stomach and presents with nausea and vomiting - Enteritis is inflammation of the intestines and presents with diarrhoea Gastroenteritis is inflammation all the way from the stomach to the intestines and presents with nausea, vomiting and diarrhoea.

Answer 135

Stools from normal babies can vary from loose stools several times a day to one stool per week. Steatorrhoea means greasy stools with excessive fat content. This suggests a problem with digesting fats, such as pancreatic insufficiency (think about cystic fibrosis). Other conditions are: - Infection - IBD - Lactose - Coeliac - CF - Toddler's diarrhoea - IBS - Medications

Answer 136

- Rotavirus - Norovirus - Adenovirus

Answer 137

gns of dehydration: – Reduced urine output, lethargic, sunken eyes – However, they are haemodynamically stable (normal BP, normal capillary refill time, warm extremities) Signs of shock: – Reduced consciousness, pale skin, appears unwell – They will start to get haemodynamically compromised –> low BP, high HR, long CRT, cold extremities

Answer 138

- Children need to stay off school for 48 hours after symptoms have resolved - Main thing is keeping the child hydrated if they can tolerate fluid then they are okay to carry on and can be discharged

Answer 139

- Loperamide but **don't give antiemetic metoclopramide or others** - Also don't give medication in E.coli or shigella infections where there is bloody diarrhoea or high fever

Answer 140

Lactose intolerance Irritable bowel syndrome Reactive arthritis Guillain–Barré syndrome

Answer 141

- Less than 3 stools per weeks - Hard stools (rabbit dropping stools) - Abdo pain - Abnormal posture (retentive posture) - Overflow soiling - Loss of sensation of the need to open bowels

Answer 142

- Only considered pathological after age of 4, it is where the rectum becomes stretched and losses sensation - Large stools remain and only loose stools can bypass and this causes soiling

Answer 143

Often patients develop a habit of not opening their bowels when they need to and ignoring the sensation of a full rectum. Over time they loose the sensation of needing to open their bowels, and they open their bowels even less frequently.

Answer 144

Not passing meconium within 48 hours of birth (cystic fibrosis or Hirschsprung’s disease) Neurological signs or symptoms, particularly in the lower limbs (cerebral palsy or spinal cord lesion) Vomiting (intestinal obstruction or Hirschsprung’s disease) Ribbon stool (anal stenosis) Abnormal anus (anal stenosis, inflammatory bowel disease or sexual abuse) Abnormal lower back or buttocks (spina bifida, spinal cord lesion or sacral agenesis) Failure to thrive (coeliac disease, hypothyroidism or safeguarding) Acute severe abdominal pain and bloating (obstruction or intussusception)

Answer 145

- High fibre diet and good hydration - Start laxatives (movicol is first-line) - Faecal impaction may require a **impaction regimen** - Encourage and praise visiting the toilet. This could involve scheduling visits, a bowel diary and star charts. Laxatives should be continued long term and slowly weaned off as the child develops a normal, regular bowel habit.

Answer 146

- Ectopic pregnancy - Ovarian cysts - Meckel's diverticulum - Mesenteric adenitis - Appendix mass

Answer 147

The herniation of the bowel content through the umbilicus. It is a common finding in neonates and usually asymptomatic

Answer 148

**Direct**: the hernia protrudes through the posterior wall of the inguinal canal (20%) **Indirect**: hernia protrudes through the deep inguinal ring and into the inguinal canal

Answer 149

- Groin swelling - Nausea, vomiting, constipation, abdominal pain/discomfort - A scrotal mass you can't get above - Is reducible when lying flat - Does not trans illuminate - Has a positive cough reflex

Answer 150

- Most hernias can be successfully reduced by taxis (gentle compression in the line of the inguinal canal) - If reduction is impossible then emergency surgery is required to reduce the risk of compromise to bowel, testes or ovaries

Answer 151

An umbrella term for the two main diseases causing inflammation of the GI tract.

Answer 152

Ulcerative colitis and Crohn's disease

Answer 153

Transmural inflammation of the GI tract (anywhere from mouth to anus).

Answer 154

Terminal ileum and Colon

Answer 155

- Has a peak onset in early life (20-40 years). - More common in female than male

Answer 156

CARD15 and NOD2 mutation

Answer 157

Cobblestone appearance

Answer 158

- Abdominal tenderness - Fever - Mouth ulcers - Rectal examination will show blood, skin tags, fissures and fistulas

Answer 159

- Weight loss - Diarrhoea - Abdominal pain (most common in RLQ where the ileum is) - Lethargy and malaise also symptom

Answer 160

- Faecal calprotectin (released by intestines when inflamed) - C- reactive protein is a good indication of current inflammation

Answer 161

Colonoscopy- will show mucosal inflammation (deep ulcers, skip lesions and cobblestone appearance) Histology will show transmural inflammation with granulomas and goblet cells

Answer 162

- Azathioprine - Methotrexate - Mercaptopurine Levels of **Thiopurine methyltransferase** should be measured before using

Answer 163

Infliximab and Adalimumab

Answer 164

- First line= Azathioprine or mercaptopurine - Second line- Methotrexate with Infliximab

Answer 165

- When distal ileum is inflamed can surgically resect the area to prevent flare ups - Also used to treat strictures and fistulas

Answer 166

A type of IBD that typically involves the rectum and variable lengths of the colon. Will never spread beyond the ileocecal valve

Answer 167

- Bimodal peak at 15-25 and 55-70 - More common in non-smokers

Answer 168

- Non smoker - NSAIDs - Chronic stress/depression

Answer 169

- Ulcers tend to form along the inner surface or lumen of the large intestine and rectum - Thought to be autoimmune in nature cytotoxic T cells attack the lining of the colon - Also thought that patients have higher proportion of gut bacteria that release sulphides

Answer 170

p-ANCAs -perinuclear antineutrophilic cytoplasmic antibodies) in their blood - antibodies that target antigens in the body’s own neutrophil

Answer 171

- Abdominal tenderness - Fever - in acute UC - Tachycardia - in acute severe UC - Fresh blood on rectal examination

Answer 172

- Erythema nodosum - inflammatory disorder affecting subcutaneous fat. - Pyoderma gangrenosum - rapidly enlarging, very painful ulcer.

Answer 173

- Diarrhoea - Blood and mucus in stool - LLQ pain - Weight loss - Cramping rectal pain

Answer 174

- Faecal calprotectin - LFT to screen for PSC - Raised C-reactive protein

Answer 175

Colonoscopy and biopsy Would show: -**shallow ulceration** - No inflammation beyond submucosa - Crypt abscesses - Goblet cell depletion

Answer 176

Truelove and Witts' severity index

Answer 177

- First line: Aminosalicylate (mesalazine) - Second line corticosteroid (prednisolone)

Answer 178

- First line: IV corticosteroid hydrocortisone - Second line IV ciclosporin

Answer 179

- Aminosalicylate, azathioprine, mercaptopurine -May use biological therapy e.g., Infliximab if nothing else is working

Answer 180

- Removal of the colon and rectum (panproctocolectomy) - Left with ileostomy or or **J-pouch** this is where small intestine is used to make rectum Surgery will be curative

Answer 181

A PIE SAC - Ankylosing spondylitis (HLA B27!) - Pyoderma gangrenosum - Iritis (aka anterior uveitis) - Erythema nodosum - Sclerosing cholangitis - Aphthous ulcers / amyloidosis - Clubbing

Answer 182

- The small bowel in particular the jejunum - There will be **crypt hyperplasia and atrophy of intestinal villi**

Answer 183

- Failure to thrive - Diarrhoea - Weight loss - Mouth ulcers - Anaemia - Dermatitis herpetiformis Can also present with neurological symptoms

Answer 184

HLA-DQ2 gene (90%) HLA-DQ8 gene

Answer 185

Tissue transglutaminase antibodies (anti-TTG) Endomysial antibodies (EMAs) Remember to calculate total IgA as it can be low which will give negative test

Answer 186

Crypt hypertrophy Villous atrophy

Answer 187

When a child in deficient in all macronutrients and in it the child has a wasted, wizened appearance. Oedema is not present Affected children are often withdrawn and apathetic

Answer 188

kwashiorkor is a type of malnutrition caused by protein deficiency. It mainly occurs in children who are weaning off breast milk, while marasmus can develop in infants.] If your diet has a lot of carbohydrates and very little proteins, you may develop kwashiorkor Will cause swelling in the stomach often seen when children are breastfed for too long

Answer 189

Is a congenital condition where nerve cells of the **myenteric plexus** are absent in the distal bowel and rectum

Answer 190

- The absence of the parasympathetic ganglion cells. In development these nerves start higher in the GI tract and migrate down - The area of the colon that is affected will vary from patient to patient. If the entire colon is affected this is called total **colonic aganglionosis**

Answer 191

- Family history - Down syndrome - Neurofibromatosis - Waardenburg syndrome - Multiple endocrine neoplasia type II

Answer 192

- Acute intestinal obstruction shortly after birth - Delay in passing meconium - Chronic constipation - Abdominal pain and distension - Vomiting - Poor weight gain and failure to thrive

Answer 193

- Is inflammation and obstruction of the intestine occurring in 20% of neonates with the condition - It presents with fever, abdominal distention and diarrhoea 2-4 weeks after birth - It can lead to **toxic megacolon** and bowel perforation.

Answer 194

Rectal biopsy which will show the **absence of ganglionic cells**

Answer 195

Surgical resection of the aganglionic section of the bowel

Answer 196

Where the bowel "invaginates" on itself and telescopes into itself This thickens the overall size of the bowel and narrows the lumen. This leads to a palpable mass and obstruction to faeces **typically between 6 months to 2 years and more common in boys**

Answer 197

- Concurrent viral illness - Henoch-schonlein purpura - CF - Intestinal polyps - Meckel diverticulum

Answer 198

- Redcurrant jelly stool - Right upper quadrant mass on palpation, this is described as sausage shaped

Answer 199

- Severe colicky abdominal pain - Pale lethargic and unwell child - Vomiting - Intestinal obstruction

Answer 200

- Ultrasound - Contrast enema

Answer 201

- Enemas can be used to reduce the Intussusception - Surgical resection

Answer 202

- It is an outpouching or bulge in the lower part of the small intestine which contains ectopic gastric mucosa or pancreatic tissue

Answer 203

The pouch releases acid like the stomach which over time can cause ulcers to develop in the small intestine These can worsen and bleed which shows as blood in the poo, it can also leak the liquid inside the small intestine into the abdomen

Answer 204

Generally asymptomatic, but may present with bleeding or intussusception or volvulus: 1. Severe rectal bleeding 2. Intussusception 3. Volvulus

Answer 205

undiagnosed coeliac disease or excessive ingestion of fruit juice, especially apple juice. temporary cow’s milk allergy following gastroenteritis, when a trial of a cow’s milk protein free diet may be helpful. dysmotility of the gut (a form of irritable bowel syndrome) So rule out Coealiac and Cows milk allergy first

Answer 206

The term ‘colic’ is used to describe a common symptom complex that occurs during the first few months of life. Paroxysmal, inconsolable crying or screaming often accompanied by drawing up of the knees and passage of excessive flatus takes place several times a day.

Answer 207

- A condition affecting infants and young children under 3 years - It involves hypersensitivity to the protein in cow's milk.

Answer 208

- IgE mediated that involves a rapid response within 2 hours of digestion - Non IgE mediated where a reaction occurs more slowly over several days

Answer 209

- Usually presents before one year of age, it may be apparent when weaned from breast milk to formula milk or food containing milk - Can present in breast fed babies and mother is consuming dairy products

Answer 210

- Bloating and wind - Abdo pain - Diarrhoea - Vomiting - Urticarial rash - Facial swelling - Cough - Sneezing - Watery eyes - Eczema

Answer 211

Skin prick testing

Answer 212

- Breast feeding mothers to avoid dairy products - Replace formula with special hydrolysed formula - Children will outgrow it so progress up milk ladder

Answer 213

No allergic symptoms but GI symptoms present

Answer 214

A congenital condition where a section of the bile duct is either narrowed or absent resulting in **Cholestasis**

Answer 215

**Conjugated bilirubin** is excreted in bile therefore biliary atresia prevents the excretion of it resulting in: - Significant jaundice lasting more than 14 days in term babies and 21 days in preterm babies

Answer 216

A high proportion of conjugated to unconjugated bilirubin

Answer 217

“Kasai portoenterostomy” involves attaching a section of the small intestine to the opening of the liver, where the bile duct normally attaches

Answer 218

- Babies have lots of RBCs and they are more fragile, also break down more easily - This will cause mild yellowing of skin and sclera 2-7 days of age and resolved by 10

Answer 219

Kernicterus: Now rare due to good treatment of jaundice Bilirubin crosses the blood brain barrier Excessive bilirubin causes direct damage to the central nervous system Presents with less responsive, floppy, drowsy baby with poor feeding Leads to permanent damage (cerebral palsy, learning difficulties, deafness

Answer 220

Phototherapy

Answer 221

Baby has intrauterine growth restriction, Jaundice, failure to thrive, itchy rash, dark urine and hepatomegaly.

Answer 222

Liver biopsy will show: Multinucleated giant cells & Rosette formation. This will both ↑unconjugated + ↑ conjugated bilrubin. With associated deranged LFT’s

Answer 223

They are cystic dilatations of the extrahepatic biliary system They present with neonatal jaundice or, in older children, presentation is with abdominal pain, a palpable mass, jaundice, or cholangitis

Answer 224

ultrasound or magnetic resonance cholangiopancreatography. Treatment is by surgical excision of the cyst

Answer 225

Infection (most common is herpes simplex) Metabolic disease Seronegative hepatitis Drug induced Neonatal haemochromatosis

Answer 226

Gastro-oesophageal reflux Feeding problems Infection: * Gastroenteritis * Whooping cough (pertussis) * Meningitis Infection – including pyelonephritis, septicaemia, meningitis Appendicitis

Answer 227

Intussusception * Malrotation * Volvulus * Adhesions * Foreign body – bezoar Plyoric stenosis * Atresia – duodenal, other sites Hirschprungs disease

Answer 228

**Fever** may be only symptom, always exclude a UTI in a child with a fever Baby symptoms: - Lethargy - Irritability - Vomiting - Poor feeding Infant/children symptoms: - Abdo pain- suprapubic - Vomiting - Dysuria - Frequency - Incontinence

Answer 229

- Temp greater than 38 - Loin pain or tenderness

Answer 230

- Nitrites- E.coli and other gram neg break down nitrates into nitrites - Leukocytes- they are white blood cells normally found in small quantities in the urine an increase can suggest a UTI Nitrites are a better indication of a UTI

Answer 231

- They should start immediate IV antibiotics (ceftriaxone) - Have a full septic screen Consider a lumbar puncture

Answer 232

IF symptoms of pyelonephritis or sepsis admit for IV antibiotics if not use oral such as: - Trimethoprim - Nitrofurantoin - Cefalexin - Amoxicillin

Answer 233

Can lead to scarring in the tissue and reduction of kidney function

Answer 234

- Children under 6 months with **first UTI** should have an ultrasound within **6 weeks** or during if there are **recurrent or atypical** - Children with recurrent UTIs should have an abdominal ultrasound within 6 weeks - Children with atypical UTIs should have an abdominal ultrasound during the illness

Answer 235

DMSA scan will be performed **4-6 months** after the illness. It tells you how well the material is taken up by the kidneys and if there is any damage

Answer 236

- When urine flows back into the bladder from the ureters It is diagnosed using MCUG and managed: - Avoid constipation - Avoid full bladder - Prophylactic antibiotics - Surgical input

Answer 237

Cystitis - oral antibiotic treatment should be started with trimethoprim (if there is low risk of resistance), or nitrofurantoin Acute Pyelonephritis - oral antibiotic treatment should be started, with either cefalexin, or co-amoxiclav.

Answer 238

Infants younger tahn 3 months - 2-4 IV cefuroxime (1st gen Ceph, cant get through BBB so need to rule out meningitis). followed by oral - full septic screen, bloods, cultures, lactate Systemically well children - Treat with 3 days oral antibiotics. Advised to return if no better at 24-48hrs for reassessment - **Trimethoprim** Systemically unwell - (Fever > 38 +/- loin pain / tenderness) Treat with 7-10 days oral antibiotics (Consider IV antibiotics according to clinical judgement. Use lower threshold for IV antibiotics in younger children, those with significant risk factors and severely ill.)

Answer 239

Micturating cystourethrogram (MCUG) should be used to investigate atypical or recurrent UTIs in children under 6 months. It is also used where there is a family history of vesico-ureteric reflux, dilatation of the ureter on ultrasound or poor urinary flow. A MCUG is used to diagnose VUR. It involves catheterising the child, injecting contrast into the bladder and taking a series of xray films to determine whether the contrast is refluxing into the ureters. Children are usually given prophylactic antibiotics for 3 days around the time of the investigation.

Answer 240

Failure to control urination normally controlled in the day by 2 years and at night by 3-4 years

Answer 241

- When a child has never been consistently dry at night often a normal variation in children aged 5 and above

Answer 242

Overactive bladder. Frequent small volume urination prevents the development of bladder capacity. Fluid intake prior to bedtime, particularly fizzy drinks, juice and caffeine, which can have a diuretic effect Failure to wake due to particularly deep sleep and underdeveloped bladder signals Psychological distress, for example low self esteem, too much pressure or stress at home or school Secondary causes such as chronic constipation, urinary tract infection, learning disability or cerebral palsy

Answer 243

When a child starts wetting the bed when previously being dry for at least 6 months

Answer 244

- UTI - Constipation - T1DM - New psychosocial problems - Maltreatment Always think about abuse and safeguarding, particularly with deliberate bedwetting, punishment for bedwetting (despite parental education) or unexplained secondary nocturnal enuresis.

Answer 245

Desmopressin is an analogue of vasopressin (also known as anti-diuretic hormone). It reduces the volume of urine produced by the kidneys. It is taken at bedtime with the intention of reducing nocturnal enuresis. Oxybutinin is an anticholinergic medication that reduces the contractility of the bladder. It can be helpful where there is an overactive bladder causing urge incontinence. Imipramine is a tricyclic antidepressant. It is not clear how it works, but it may relax the bladder and lighten sleep.

Answer 246

IF symptoms of pyelonephritis or sepsis admit for IV antibiotics if not use oral such as: - Trimethoprim - Nitrofurantoin - Cefalexin - Amoxicillin

Answer 247

Shock- due to fluid or blood loss or sepsis Decompensated liver disease- Hepatorenal syndrome GI loses

Answer 248

Vascular: **– haemolytic uraemic syndrome** - most common type of renal – vasculitis – embolus * Tubular: – acute tubular necrosis – ischaemic – toxic - drugs * Glomerular: – glomerulonephritis * Interstitial: – pyelonephritis

Answer 249

Obstruction - Congenital e.g. posterior urethral valves - Acquired e.g. blocked urinary catheter

Answer 250

- Liver cirrhosis leads to portal hypertension, in response to this **portal blood vessels dilate** causing blood to pool there - This causes a lack of blood volume elsewhere including the kidneys Leads to **hypotension in the kidney and activation of the RAAS.** This causes renal vasoconstriction, which combined with low circulation volume leads to starvation of blood to the kidney *Hepatorenal syndrome is fatal within a week or so unless liver transplant is performed*

Answer 251

circulation and fluid balance meticulously monitored urgently corrected with fluid replacement and circulatory support

Answer 252

1. **IV stat of Calcium Gluconate** - Stabilisation of the myocardium 2. **Variable rate insulin with dextrose infusion - to increase cellular uptake of potassium** = Reduction of serum potassium 3. **oral calcium resonium** - Reduction of total body potassium - treat underlying cause

Answer 253

1 >90 Normal or increased GFR with other evidence of renal damage* 2 60–89 Slight decrease GFR with other evidence of renal damage* 3 A - 45–59, 3 B - 30–44 = Moderate decreased GFR with or without evidence of other renal damage 4 15–29 Severe decreased GFR with or without evidence of renal damage 5 <15 Established renal failure

Answer 254

- Anorexia - Polydipsia and polyuria - Failure to grow - Bone deformities - Hypertension - Proteinuria - Normocytic anaemia

Answer 255

When the basement membrane in the glomerulus becomes highly permeable to **protein**. This allows them to leak from the blood into the urine

Answer 256

- Low serum albumin - High urine protein content (frothy urine) - Oedema

Answer 257

- Deranged lipid profile: high cholesterol and triglycerides - High BP - Hyper-coagulability

Answer 258

Most common cause is **minimal change disease** which causes over 90% of cases in children under

Answer 259

**Intrinsic kidney disease**; - Focal segmental glomerulosclerosis - Membranoproliferative glomerulonephritis **Systemic illness** - HSP - Diabetes - Infection

Answer 260

High dose steroids (i.e. prednisolone) Low salt diet Diuretics may be used to treat oedema Albumin infusions may be required in severe hypoalbuminaemia Antibiotic prophylaxis may be given in severe cases

Answer 261

High dose steroids are given for 4 weeks and then gradually weaned over the next 8 weeks: 80% of children will respond to steroids, and are referred to as steroid sensitive 80% of steroid sensitive patients will relapse at some point and need further steroids Patients that struggle to wean steroids due to relapses are referred to as steroid dependant Patients that do not respond to steroids are referred to as steroid resistant In steroid resistant children, ACE inhibitors and immunosuppressants such as cyclosporine, tacrolimus or rituximab may be used.

Answer 262

- Hypovolaemia - Thrombosis - Infection - Acute or chronic renal failure - Relapse

Answer 263

Refers to inflammation within the nephrons of the kidneys causing: - Reduction in kidney function - Haematuria - Proteinuria

Answer 264

Post-streptococcal glomerulonephritis and IgA nephropathy (Berger’s disease).

Answer 265

Symptoms 1-3 weeks after a beta haemolytic streptococcus infection such as tonsillitis Management is supportive but may need treatment for hypertension

Answer 266

IgA nephropathy is also known as Berger’s disease. This condition is related to Henoch-Schonlein Purpura, which is an IgA vasculitis. IgA deposits in the nephrons of the kidney causes inflammation (nephritis). When a renal biopsy is taken the histology will show “IgA deposits and glomerular mesangial proliferation”. It usually presents in teenagers or young adults. Management involves supportive treatment of the renal failure and immunosuppressant medications such as steroids and cyclophosphamide to slow the progression of the disease.

Answer 267

It is a IgA vasculitis that presents with a purpuric rash affecting the lower limbs and buttocks in children. It occurs due to IgA deposits in blood vessels

Answer 268

Upper airway or GI infection and is most common in children under 10

Answer 269

Purpura (100%), Joint pain (75%), Abdominal pain (50%) Renal involvement (50%)

Answer 270

Legs and buttocks

Answer 271

Knees and ankles

Answer 272

Abdominal pain is indicative of gastrointestinal involvement. In severe cases, it can lead to gastrointestinal haemorrhage, intussusception and bowel infarction.

Answer 273

Rule out meningococcal septicaemia leukaemia, Idiopathic thrombocytopenic purpura and haemolytic uraemic syndrome - There are many different sets of criteria for diagnosing HSP, the most recent being the EULAR/PRINTO/PRES criteria from 2010. This requires the patient to have palpable purpura (not petichiae) + at least one of: Diffuse abdominal pain Arthritis or arthralgia IgA deposits on histology (biopsy) Proteinuria or haematuria

Answer 274

A condition affecting males where the opening of the urethra is abnormally displaced towards the underside of the penis. Can also be displaced down the shaft of the penis There can also be an associated condition called chordee, where the head of the penis bends downwards.

Answer 275

Difficulty urinating Cosmetic and psychological concerns Sexual dysfunction

Answer 276

It involves thrombosis in small blood vessels throughout the body triggered by shiga toxins from **E.coli or shigella**

Answer 277

Antibiotics and anti-motility medication (e.g., loperamide)

Answer 278

Microangiopathic haemolytic anaemia Acute kidney injury Thrombocytopenia

Answer 279

The formation of blood clots consumes platelets, leading to thrombocytopenia. The blood flow through the kidney is affected by thrombi and damaged red blood cells, leading to acute kidney injury. Microangiopathic haemolytic anaemia (MAHA) involves the destruction of red blood cells (haemolysis) due to pathology in the small vessels (microangiopathy). Tiny blood clots (thrombi) partially obstruct the small blood vessels and churn the red blood cells as they pass through, causing them to rupture

Answer 280

Diarrhoea which turns bloody within 3 days. Around a week after the onset of diarrhoea features of HUS will occur

Answer 281

- Fever - Abdo pain - Lethargy - Pallor - Reduced urine output - Haematuria - hypertension - Bruising - Jaundice (due to haemolysis) - Confusion

Answer 282

Stool culture is used to establish the causative organism. HUS is a medical emergency and requires hospital admission and supportive management with treatment of: Hypovolaemia (e.g., IV fluids) Hypertension Severe anaemia (e.g., blood transfusions) Severe renal failure (e.g., haemodialysis)

Answer 283

Polio Flu vaccine Hepatitis A Rabies

Answer 284

Pneumococcus Meningococcus Hepatitis B Pertussis (whooping cough) Haemophilus influenza type B Human papillomavirus (HPV) Shingles (herpes-zoster virus)

Answer 285

Measles, mumps and rubella vaccine: contains all three weakened viruses BCG: contains a weakened version of tuberculosis Chickenpox: contains a weakened varicella-zoster virus Nasal influenza vaccine (not the injection) Rotavirus vaccine

Answer 286

6 in 1 vaccine (diphtheria, tetanus, pertussis, polio, haemophilus influenzae type B (Hib) and hepatitis B) Meningococcal type B Rotavirus (oral vaccine)

Answer 287

6 in 1 vaccine (again) Pneumococcal (13 different serotypes) Rotavirus (again)

Answer 288

6 in 1 vaccine (again) Meningococcal type B (again)

Answer 289

2 in 1 (haemophilus influenza type B and meningococcal type C) Pneumococcal MMR Meningococcal type B

Answer 290

Influenza virus (nasal vaccine)

Answer 291

4 in 1 (diphtheria, tetanus, pertussis and polio) MMR vaccine (again)

Answer 292

Human papillomavirus (HPV) vaccine (2 doses given 6 to 24 months apart)

Answer 293

3 in 1 (tetanus, diphtheria and polio) Meningococcal groups A, C, W and Y