Paediatrics Flashcards
1
Q
What organism causes roseola infantum?
A
human herpesvirus 6 (HHV6)
2
Q
What is the typical presentation of roseola?
A
- high fever, mild pharyngitis, lymphadenopathy
- -> fever improves, develop rose-pink non-pruritic macular rash
- exanthem prominent over trunk, thighs + buttocks - macules may be surrounded by haloes
- Nagayama spots - papular enanthem on uvula/soft palate
- diarrhoea common
- febrile convusions (10-15%)
3
Q
What speech milestone do you typically expect babies to meet by each of hte following ages:
- 3 months
- 6 months
- 9 months
- 12 months
- 12-15 months
- 2 years
- 2.5 years
- 3 years
- 4 years
A
- 3 months: quietens to parents voice, turns to sound, squeals
- 6 months: double-syllable sounds ‘erleh’ ‘adah’
- 9 months: ‘mama’ ‘dada’, understands no
- 12 months: knows/responds to name
- 12-15 months: knows 2-6 words (refer at 18 months)
- 2 years: can string 2 words together, points to parts of the body
- 2.5 years: knows 200 words
- 3 years: talks in 3-5 word sentences, can say ‘who’ and ‘what’ sentences, colours, counts to 10
- 4 years: can ask ‘why’ ‘when’ and ‘how’ sentences
4
Q
At what ages is the meningococcal B vaccination given?
A
- 2 months
- 4 months
- 12-13 months
5
Q
What 9 conditions are screened for on the neonatal blood spot test?
A
- congenital hypothyroidism
- cystic fibrosis
- Sickle cell disease
- Phenylketonuria
- Medium chain acyl-coA dehydrogenase deficiency (MCADD)
- Maple syrup urine disease (MSUD)
- Isovaleric acidaemia (IVA)
- Glutamic aciduria type 1 (GA1)
- Homocystinuria (pyridoxine unresponsive) (HCU)
6
Q
What is the most important investigation for screening for complications of Kawasaki disease?
A
Echocardiogram - can cause coronary artery aneurysms - all patients should have ECHO at diagnosis, 1-2 weeks and 6-8 weeks after treatment
7
Q
What are 3 aspects of the management of Kawasaki disease?
A
- high dose aspirin
- IV immunoglobulin
- ECHO - look for coronary aneurysms
8
Q
In which age group should peak expiratory flow be attempted in children?
A
a children >5 years
9
Q
How should bronchodilator therapy be delivered in children with acute exacerbation of asthma?
A
spacer; if <3 years, close-fitting mask
give 1 puff every 30-60 seconds up to maximum of 10 puffs
10
Q
What steroid dose should be given to children with an acute exacerbation of asthma?
A
- age 2-5 years: prednisolone 20mg OD
- > 5 years: 30-40mg OD
- (1-2mg/kg OD max 40mg)
11
Q
What age group is affected by bronchiolitis?
A
aged <2 years - peak incidence 3 - 6 months
12
Q
What is the first sign of puberty in boys?
A
Testicular growth (>4mls)
13
Q
What is the first sign of puberty in boys?
A
Testicular growth (>4mls)
14
Q
What investigation should be organised and when for children presenting with UTI <6 months old?
A
Ultrasound - within 6 weeks (VUR)
15
Q
Should children >6 months have further investigation if they present with UTI?
A
Imaging not required unless recurrent or features of atypical infection:
- seriously ill
- poor urine flow
- abdominal or renal mass
- raised creatinine
- sepsis
- failure to respond to suitable abx within 48h
- non E. coli cause
16
Q
What is the investigation of choice to look for renal scarring after UTI and when is it done?
A
Static radioisotope scan - E.g DMSA. Should be done 4-6 months after initial infection
17
Q
What is the investigation of choice to look for vesicoureteric reflux in paediatric patients with UTI?
A
Nifty rating cystourethography
18
Q
What virus causes measles?
A
RNA paramyxovirus
19
Q
When is the a) infective period and b) incubation period of measles?
A
a) infective = from prodrome until 4 days after rash onset
b) incubation period = 10-14 days
20
Q
What is the prodromal phase of measles?
A
irritable, conjunctivitis, cough, coryza (3 Cs), fever; also develop Koplik’s spots before rash onset - white spots (grains of salt) on buccal mucosa
21
Q
Describe the rash seen in measles
A
- starts behind the ears, then to whole body
- discrete maculopapular rash becoming blotchy and confluent
- desquamation that typically spares the palms + soles may occur after a week
22
Q
What is the management of measles?
A
conservative; admit if immunosuppressed/ pregnant; notifiable disease -> PHE
23
Q
What is the most common complication of measles?
A
otitis media
24
Q
What are 9 complications of measles?
A
- otitis media
- pneumonia
- encephalitis - 1-2 weeks after onset
- subacute sclerosing panencephalitis - 5-10 years
- febrile convulsions
- keratoconjunctivitis / corneal ulceration
- diarrhoea (seen in 10%)
- increased incidence of appendicitis
- myocarditis
25
What is the management if a child not immunised against measles comes into contact with someone with measles?
offer MMR vaccination within 72h
26
What are 3 critical referral points for children not meeting milestones?
1. doesn't **smile** at 10 weeks
2. can't **sit** unsupported at 12 months
3. cannot **walk** at 18 months
27
At what point in child development is hand preference abnormal?
<12 months
28
What early intervention services can all children with developmental delays benefit from?
* occupational therapy
* speech and language therapy
* physiotherapy
* educational support
29
What are 5 types of acyanotic congenital heart disease?
1. ventricular septal defects (VSD)
2. atrial septal defect (ASD)
3. patent ductus arteriosus (PDA)
4. coarctation of the aorta
5. aortic valve stenosis
30
What is more common of VSDs/ ASDs and which is more commonly prescribed in adult patients?
VSDs more common; ASDs are more common as a new diagnosis in adults as usually present later
31
What are 3 causes of cyanotic congenital heart disease?
1. tetralogy of Fallot
2. transposition of the great arteries (TGA)
3. tricuspid atresia
(all begin with T)
32
At what age do patient's with tetralogy of Fallot tend to present?
1-2 months of age
33
When does transposition of the great arteries tend to present?
at birth
34
What is more common, transposition of the great arteries or tetralogy of Fallot?
tetralogy of Fallot, although TGA more commonly diagnosed at birth
35
What are 3 key diagnostic features of clubfoot (talipes equinovarus)?
Foot is:
1. Inverted
2. Plantar flexed
3. Not passively correctable
36
Which gender does talipes equinovarus have a predilection for?
Clubfoot is twice as common in MALES
37
What proportion of talipes equinovarus are bilateral?
50%
38
What are 5 associations of clubfoot (talipes equinovarus)?
1. Spina bifida
2. Cerebral palsy
3. Edwards syndrome (trisomy 18)
4. Oligohydramnios
5. Arthrogryposis
39
How is a diagnosis of clubfoot made?
Clinical - not passively correctable
40
How is a diagnosis of bronchiolitis made?
* clinical diagnosis - no diagnostic studies usually necessary
* coryzal prodrome, tachypnoea, chest recession, wheeze / crackles, fever, poor feeding, apnoea
* immunofluorescence of nasopharyngeal secretions may show RSV
41
If CXR is performed in bronchiolitis, what may be seen?
hyperexpansion, peribronchial thickening, infiltrates (diffuse interstitial infiltrates to segmental or lobar consolidation)
42
When do bronchiolitis symptoms peak?
3-5 days after onset
43
What are 4 indications for hospital admission in bronchiolitis?
1. persistent hypoxaemia
2. tachypnoeia impeding oral feeding / hydration
3. apnoea
4. concern for impending respiratory failure
44
What are the indications for ribavirin in bronchiolitis?
severe RSV bronchiolitis
immunodeficiency
underlying chronic lung disease
(routine use not recommended)
45
What type of organism is most commonly associated with acute otitis media?
viral pathogens e.g. RSV + rhinovirus
46
What are 5 viral pathogens associated with AOM?
1. RSV
2. rhinovirus
3. adenovirus
4. influenza virus
5. parainfluenza virus
47
What are 3 most common bacterial organisms that cause AOM?
1. streptococcus pneumoniae
2. haemophilus influenzae
3. moraxella catarrhalis
48
What are 9 risk factors for AOM?
1. children - horizontal, short eustachian tubes
2. male
3. smoking
4. daycare / nursery attendance
5. formula feeding
6. craniofacial abnormalities
7. dummy use
8. GORD
9. prematurity
49
What is bullous myringitis?
blisters on the TM caused by Mycoplasma pneumoniae
50
What are the indications for admission for AOM?
* < 3 months with fever >38
* **complications** suspected: meningitis, mastoiditis, facial nerve paralysis
+ **consider**: children <3 months, 3-6 months >39, systemically very unwell
51
What are 5 serious complications of AOM?
1. mastoiditis
2. meningitis
3. intracranial abscess
4. sinus thrombosis
5. facial nerve paralysis
52
What is the usual prognosis for AOM?
without abx, symptoms usually improve within 24h in 60% of children + most recover within 3 days
53
What type of metabolic abnormality occurs in pyloric stenosis?
**hypochloraemic**, **hypokalaemic** metabolic **alkalosis**
54
What is the investigation of choice for pyloric stenosis?
ultrasound
55
What is pyloric stenosis?
hypertrophy of the smooth muscle of the antrum and pylorus of the stomach
56
When does pyloric stenosis typically present?
1st week of life - 3 months
57
What is the management of pyloric stenosis?
Ramstedt's or laparoscopic pyloromyotomy
58
What does the presence of lanugo in a newborn indicate?
sign of premature birth
59
What is the management of an acute asthma exacerbation which is mild-moderate in chidlren?
* beta-2-agonist via spacer for child (face mask if <3y) - 1 puff every 30-60s for up to 10 puffs
* steroid therapy for all children for 3-5 days
60
What are 4 causes of Kayser-Fleischer rings?
1. Wilson's disease
2. Cholestasis
3. Primary biliary cirrhosis
4. Cryptogenic cirrhosis
61
62
What are different terms for CMPI and CMPA?
Delayed/non-IgE mediated and immediate/IgE mediated
63
How is CMPI/CMPA diagnosed?
Of the clinical
- skin prick / patch testing
- total IgE and specific IgE (RAST) for CMP
64
What is the management of CMPA/CMPA?
* if mild-moderate - extensive hydrolysed formula
* second line or severe - amino acid-based formula
65
What is the management of CMPI/CMPA if breastfed?
Continue breastfeeding, exclude cows milk from maternal diet (consider calcium supplements); EH milk until 12 months and for at least 6 months
66
What organism causes croup?
Parainfluenza virus
67
Which age group is affected by croup?
6 months to 3 years
68
Which season is croup more common?
Autumn
69
What key features differentiate mild, moderate and severe stridor?
- mild: no stridor, no intercostal recession, child E+D and playing
- moderate: easily audible stridor at rest, suprasternal and eternal wall retraction, no or little distress to child
- severe: distress, agitation, lethargy, restless, tachycardia
70
What are 4 situations when children with croup should be admitted?
- all cases moderate or severe
- < 6 months old
- upper airway abnormalities - down’s, laryngomalacia
- uncertainty about diagnosis
71
What are 4 situations when children with croup should be admitted?
- all cases moderate or severe
- < 6 months old
- upper airway abnormalities - down’s, laryngomalacia
- uncertainty about diagnosis
72
How is a diagnosis of croup made?
Clinical diagnosis
73
What will CXR show in croup if performed?
PA film will show subglottic narrowing (steeple sign)
[vs acute epiglottis - lateral view shows swelling of epiglottis - thumb sign]
74
What’s the management of croup?
Single dose dexamethasone 0.15mg/kg
High flow O2 and nebuliser adrenaline if needed
75
What are 6 steps if a child is found unresponsive?
1. Shout for help
2. Open airway
3. Look, listen feel for breathing
4. **5 rescue breaths** - BEFORE compressions
5. Check for brachial (infants) or femoral pulse
6. Chest compressions 15:2
76
What is the rate of chest compressions for infants and children?
100-120 per minute for infants and children
77
What is the site and depth of chest compressions for infants and children?
Lower sternum; 1/3 depth of chest - 4cm for infants, 5cm for children
78
What is the management of all children with purpura/ petechiae?
Admit immediately under paediatrics - exclude meningococcal sepsis and acute lymphoblastic leukaemia (ALL)
79
What is the commonest intra-abdominal tumour of childhood?
Wilm's nephroblastoma
80
What is Wilms' nephroblastoma?
abnormal proliferation of metanephric blasema cells (believed primitive embryologic cells of the kidney)
81
What are 2 syndromes that Wilms' nephroblastoma is associated with?
1. Beckwith-Wiedemann syndrome
2. WAGR syndrome (Wilms, Aniridia, GU malformations, Retardation)
82
What is the mean age of diagnosis of Wilms' tumour?
3.5 years
83
What is the typical presentation of Wilms' tumour?
* abdominal mass - commonest
* abdominal pain
* hypertension
* fever caused by tumour necrosis
* haematuria
* anaemia
84
What is the treatment for Wilms' tumour?
highly treatble involving multimodal therapy (surgery, radiation, chemotherapy)
85
What is facioscapulohumeral muscular dystrophy?
muscle involvement in face, progresses to shoulder girdle, humeral muscles + abdominal muscles, then anterolateral compartment of leg. very slow progression of weakness.
86
When does facioscapulohumeral muscular dystrophy usually present?
first and second decades of life, but may be any age
87
What is the genetic inheritance pattern of facioscapulohumeral muscular dystrophy?
dominant
88
What is the classical presentation of facioscapulohumeral muscular dystrophy?
* initial weakness in orbicularis oculi, mouth and cheek - difficulties whistling, drinking through a straw, blowing balloons
* eyes may remain open when asleep / can't screw eyelids to bury lashes
* winging of scapula (more lateral than normal) - characteristic, due to weakness of thoracoscapular muscles
89
What are Forchheimer spots and when are they seen?
* small red spots or petechiae
* on soft palate
* seen in patients with rubella, measles and scarlet fever
90
What are Koplik's spots?
white spots on buccal mucosa opposite lower first and second molars - pathognomonic for measles
91
When do Koplik spots occur in relation to the measles rash?
seen prior to eruption of rash
92
What is the presentation of pinworm infection?
pruritus ani + pruritus vulvae, restlessness during sleep, excoriation or erythema of perineum, vulvae, or both
93
How does pinworm infection occur?
faecal-oral contamination via fomites (toys, clothes); worms live in intestinal lumen, female worm migrtes to rectum after copulation and then migrates to perineum (often at night) to release eggs
94
Which age group is typically affected by pinworm?
5-9 years (but can be all ages)
95
What pathogen causes pinworm?
nematode - Enterobius vermicularis
96
How is a diagnosis of pinworm infection made?
visual sighting of worms or using selotape against perineum at night or morning before bathing to capture eggs + examined under microscope
97
What is the treatment of pinworm infection?
mebendazole >2 years (single oral dose, repeated after 2-3 weeks) - treat all family together if possible
98
What is the commonest cause of jaundice in the first day of life?
Haemolysis - Rhesus or ABO incompatability
99
What proportion of babies born at term develop jaundice in the first week of life?
60%
100
How is neonatal jaundice broken down into 3 groups based on timing?
1. first 24h
2. 2-14 days
3. jaundice after 14 days (prolonged)
101
What are 7 causes of jaundice int he first 24 hours?
**ALWAYS PATHOLOGICAL**
1. rhesus haemolytic disease (**commonest**)
2. ABO haemolytic disease
3. hereditary spherocytosis
4. glucose-6-phosphodehydrogenase
5. TORCH infections
6. increased haemolysis e.g. due to haematoma following ventouse delivery
7. enzyme deficiencies: Crigler-Najjar syndrome, Dubin Johnson, Gilbert's
102
What is the commonest cause of jaundice in the newborn age 2-14 days?
mostly phsyiological / breastmilk jaundice
| will be unconjugated
103
What causes physiological neonatal jaundice age 2-14 days?
* fetal Hb has shorter lifespan
* broken down at higher rate
* newborn liver can't keep up
| peaks on day 3-5 then decreases
104
What is breastmilk jaundice of the neonate?
* prolongation of physiological jaundice in breastfed babies
* mechanism unknown - possible reasons include inhibition of hepatic bilirubin excretion
| peaks day 7-15
105
What are 9 causes of pathological jaundice >14 days?
1. sepsis
2. bruising
3. galactosemia
4. hereditary fructose intolerance
5. A1AT deficiency
6. hypothyroidism
7. Gilbert's syndrome
8. Crigler-Najjar syndrome
9. Congenital obstruction / malformation of biliary system e.g. biliary atresia
10. congenital infections - TORCH
106
What are 10 risk factors for neonatal jaundice?
1. gestational age <38 weeks
2. sibling with neonatal jaundice requiring phototherapy
3. exclusively breastfed babies
4. bruising
5. cephalhaematoma
6. male
7. maternal age >25y
8. maternal DM
9. Asian, European or native American
10. dehydration
107
What are signs of bilirubin encephalopathy in a jaundiced neonate?
atypical sleepiness, poor feeding, irritability
108
What is the primary care management of a jaundice neonate at <24h of age?
urgent admission within 2 hours
109
When should urgent admission be arranged within 6 hours for neonatal jaundice? 6 situations
1. jaundice first appears at >7d of age
2. neonate is unwell (lethargy, fever, vomiting, irrability)
3. gestational age <35w
4. prolonged jaundice - >14 days of jaundice
5. poor feeding
6. pale stools / dark urine
110
What are 3 options for neonatal jaundice management in primary care?
1. **no treatment** - if well with phsyiological or breastmilk jaundice, bilirubin level < treatment threshold on Bhutani normograms
2. **phototherapy**
3. **exchange transfusion** - if bilirubin encephalopathy, high risk of kernicterus, not responding to phototherapy
111
What helps decide whether bilirubin levels are at the threshold for treatment in neonatal jaundice?
Bhutani nomograms
112
What is the nitrogen washout test?
used in cyanosis in neonatal period - differentiates cardiac from non-cardiac causes. infant given **100% O2 for 10 min**, then ABG done; pO2 <**15** kPa indicates **cyanotic** congenital heart disease
| aka hyperoxia test
113
What is the management of suspected cyanotic congenital heart disease?
* supportive care
* **prostaglandin E1** e.g. **alprostadil** - maintains **PDA** in ductal-dependent congenital heart defect as holding measure til surgery
114
What is acrocyanosis?
seen in **healthy** newborns - peripheral c**yanosis around mouth + extremities** - caused by **benign** vasomotor changes resulting in peripheral vasoconstriction + increased tissue oxygen extraction
115
How is acrocyanosis differentiated from other causes of peripheral cyanosis in newborns with pathology?
occurs immediately after birth in healthy infants
116
How long may acrocyanosis persist for?
24-48h
117
What is meconium aspiration syndrome?
respiratory distress in the newborn due to meconium in the trachea
118
What are 5 risk factors for meconium aspiration syndrome?
1. post-term delivery
2. maternal hypertension
3. pre-eclampsia
4. chorioamnionitis
5. maternal smoking
6. maternal substance abuse
119
What is the management of mucous white discharge in a female baby at birth?
Most have some mucous white discharge - reassure, usually disappears by 3 months
120
What is the commonest gynaecological problem in paediatrics?
Vulvovaginitis
121
Which organisms may cause vulvovaginitis in the paediatric population?
Bacterial e.g. Gardnerella and Bacteroides, fungal
122
What are 5 aspects of the management of paediatric vulvovaginitis?
- advice about hygiene
- soothing creams
- topical antibiotic/antifungals
- oestrogen cream if resistant
- shouldn’t perform VE or swabs - refer to paediatric gynae
123
What is a risk factor for necrotising enterocolitis?
Premature birth
124
What are the early features of necrotising enterocolitis?
Refusing feed, abdominal distension, bloody diarrhoea
125
What 7 things may be seen on abdo XR in necrotising enterocolitis?
1. Dilated bowel loops
2. Bowel wall oedema
3. Pneumatosis intestinalis (intramural gas)
4. Portal venous gas
5. Pneumoperitoneum- perforation
6. Rigler sign - air inside and outside bowel
7. Football sign - air outlining falciform ligament
126
When should suction be performed for neonates who aren't breathing?
only if there is obviously thick meconium - because can cause reflex bradycardia
127
What should be done in a neonate who is not breathing with HR>100?
5 breaths of air via face mask
128
What are the 5 components of the APGAR score?
1. Colour
2. Pulse
3. Muscle tone
4. Reflex irritability
5. Respiratory effort
129
How is colour scored for the APGAR score?
2 = pink
1= body pink, extremities blue
0 = blue all over
130
How is pulse scored for APGAR score?
2 = >100
1 = <100
0 = absent
131
How is muscle tone scored for APGAR score?
2 = active movement
1 = limb flexion
0 = flaccid
132
How is reflex irritability scored for APGAR score?
2 = cries on stimulation/sneezes, coughs
1 = grimace
0 = nil
133
How is respiratory effort scored for APGAR score?
2 = strong, crying
1 = weak, irregular
0 = nil
134
How is APGAR scored?
score 0-1 is very low (bad), 4-6 is moderate low, 7-10 = baby in a good state
135
What are 8 features suggestive of constipation in a child < 1 year?
1. <3 complete stools / week (type 3 or 4 on Bristol Stool form scale)
2. Hard large stool
3. Rabbit droppings (type 1)
4. Distress on passing stool
5. bleeding associated with hard stool
6. straining
7. previous episode(s) of constipation
8. previous or current anal fissure
136
What is retentive posturing suggestive of constipation in children?
typical straight-legged, tiptoed, back-arching posture
137
What are 8 red/amber flags for underlying disorder in constipation in children?
1. reported from birth or first few weeks of life
2. meconium passage >48h of life
3. 'ribbon' stools
4. faltering growth (amber)
5. previously unknown / undiagnosed weakness in legs
6. locomotor delay
7. distended abdomen
8. disclosure or evidence that riases concerns of child maltreatment (amber)
138
What are 3 features suggestive of faecal impaction in children with constipation?
1. symptoms of severe constipation
2. overflow soiling
3. faecal mass palpable in abdomen (note DRE should only be carried out by specialist)
139
What is the management of paediatric faecal impaction?
* polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) - escalating dose regimen
* add stimulant laxative if no disimpaction after 2w (e.g. senna)
* substitute macrogol stimulant laxative and/or osmotic laxative (e.g. lactulose) if not tolerated
140
What is the maintenance treatment for paediatric constipation?
* Movicol Paediatric Plain first line
* add stimulant laxative if no response
* substitute stimulant if Movicol not tolerated
* add lactulose or docusate if stools hard
* continue at maintenance dose for several weeks after regular bowel habit established, then gradually reduce
141
What is the management of constipation in infants not yet weaned + bottle fed?
extra water in between feeds, gentle abdo massage + bicycling legs
142
What is the management of constipation in infants not yet weaned + breast fed?
constipation is unusual, organic causes should be considered
143
What is the management of constipation in infants who are being weaned?
offer extra water, diluted fruit juice + fruits; consider adding lactulose if not effective
144
What is the pathophysiology of Henoch-Schonlein purpura (HSP)?
IgA mediated small vessel vasculitis - aka IgA vasculitis
(degree of overlap with IgA nephropathy (Berger's disease)
145
What is the classic patient which Henoch-Schonlein purpura is seen in?
in children following an infection
146
What are 4 key features of Henoch-Schonlein purpura?
1. palpable purpuric rash (+ localised oedema) over buttocks + extensor surfaces of arms + legs
2. abdominal pain
3. polyarthritis
4. features of IgA nephropathy (haematuria, renal failure)
147
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What is the treatment of Henoch-Schonlein purpura?
* analgesia for arthralgia
* treatment of nephropathy - supportive (inconsistent evidence for use of steroids + immunosuppressants)
148
What is the prognosis for HSP?
usually excellent - self-limiting, especially without renal involvement
149
What proportion of children with Henoch-Schonlein purpura have a relapse?
1/3rd
150
What should be monitored to detect renal involvement in Henoch-Schonlein purpura?
blood pressure + urinalysis
151
What are 4 examples of duct-dependent (patent ductus arteriosus dependent) congenital cardiac lesions?
1. Tetralogy of Fallot
2. Ebstein's anomaly
3. pulmonary atresia
4. pulmonary stenosis
152
What is the treatment of duct-dependent congenital heart disease?
prostaglandin E1 to keep the duct (ductus arteriosus) open until after surgical repair
153
What is a patent ductus arteriosus?
form of congenital heart defect where there is a connection between the pulmonary trunk and descending aorta; normally closes with first few breaths due to increased pulmonary flow which enhances prostaglandin clearance
154
What are 3 causes of patent ductus arteriosus?
1. premature babies
2. babies born at high altitude
3. maternal rubella infection in first trimester
155
What are 5 clinical features of a patent ductus arteriosus?
1. left subclavicular thrill
2. continuous **machinery** murmur
3. large volume, **bounding, collapsing pulse**
4. **wide pulse pressure**
5. heaving apex beat
156
What are the treatment options for patent ductus arteriosus?
* **indomethacin** or **ibuprofen** - to **CLOSE** connection
* **prostaglanin E1** - keeps duct **OPEN** until after surgical repair if associated with another congenital heart defect
| P = keep it patent
157
What is the management approach to umbilical hernias in children?
common - usually no treatment required, typically resolve by 3 years of age (routine referral to surgeons at 2-3 years if not resolved)
158
What are 3 associations of umbilical hernia in children?
1. Afro-Caribbean infants
2. Down's syndrome
3. mucopolysaccharide storage diseases
159
What provides protection to newborns against RSV (and therefore bronchiolitis)?
maternal IgG
160
In which season is there a higher incidence of bronchiolitis?
Winter
161
In addition to RSV what are 2 other organisms that can cause bronchiolitis?
1. mycoplasma
2. adenoviruses
162
What are 3 conditions that can make bronchiolitis more serious?
1. bronchopulmonary dysplasia (e.g. premature)
2. congenital heart disease
3. cystic fibrosis
163
What are 7 criteria when NICE recommend immediate referral (via 999 ambulance) to hospital in bronchiolitis?
1. apnoea (observed or reported)
2. child looks seriously unwell to HCP
3. grunting
4. marked chest recession
5. respiratory rate >70
6. central cyanosis
7. persistent sats <92%
164
When does NICE suggest that a diagnosis of pneumonia is more likelly than bronchiolitis?
* high fever (over 39) and/or
* persistently focal crackles
165
What are the clinical features of broncioliitis?
* coryzal symptoms precede
* mild fever
* increasing breathlessness
* dry cough
* wheezing
* fine inspiratory crackles
* feeding difficulties associated with increasing dyspnoea (often reason for hospital admission)
166
What is caput succedaneum?
oedema of scalp at presenting part of the head (typically vertex) - soft, puffy swelling due to localised oedema, **crosses suture lines**
167
How long does it take caput succedaneum to resolve?
resolves spontaneously within a few days
168
What can cause caput succedaneum?
mechanical trauma of initial portion of scalp pushing through the cervix in a prolonged delivery, or due to use of ventouse (vacuum) delivery
169
What are 3 key differences between caput succedaneum and cephalohaematoma?
1. Caput succedaneum is **present at birth** whereas cephalohaematoma typically **develops several hours after birth**
2. capus succedanem typically forms over the **vertex** and **crosses the suture lines,** cephalohaematoma is most common in the **parietal** regino and **doesn't cross the suture lines**
3. caput succedaneum resolves within **days**, cephalohaematoma may take **months** to resolve
170
What are 3 similarities between caput succedaneum and cephalohaematoma?
1. swelling of head of a newborn
2. more common following prolonged, difficult deliveries
3. managed conservatively
171
What is the presentation of congenital diaphragmatic hernia?
presents immediately after birth
* respiratory distress
* reduced air entry b/l - pulmonary hypoplasia
* medially displaced heart sounds
* concave (scaphoid) abdomen - presents of abdo contents in thoracic cavity
* hypertension
172
What causes congenital diaphragmatic hernia?
failure of pleurperitoneal canal to close completely - herniation of abdominal viscera into chest cavity due to incomplete formation of the diaphragm
173
What is the commonest type of congenital diaphragmatic hernia?
L sided posterolateral Bochdalek hernia (85%)
174
What is the survival rate of congenital diaphragmatic hernias?
only around 50% survive
175
Which 3 risk factors for DDH warrant ultrasound screening?
1. 1st degree FH of hip problems in early life
2. Breech presentation at or after 36w (irrespective of delivery presentation)
3. Breech presentation at delivery if earlier than 36w
176
At what age are babies with specific risk factors for DDH sent for ultrasound?
6 weeks
177
What are 8 overral risk factors for developmental dysplasia of the hip?
1. Female (6x)
2. breech presentation
3. positive family history
4. firstborn chlid
5. oligohydramnios
6. birth weight >5kg
7. congenital calcaneovalgus foot deformity
178
Which hip is DDH more common in?
Left
179
In what proportion of cases is DDG congenital?
20%
180
When are the Barlow and Ortolani tests performed?
newborn check and 6 week check
181
What is done if Barlow or Ortolani tests are abnormal?
refer for hip ultrasound
182
How are Barlow and Ortolani tests assessed?
* Barlow: attempts to dislocate articulated femoral head
* Ortolani: attempts to relocate dislocated femoral head
183
In addition to abnormal Barlow and Ortolani, what are 3 other examination findings suggestive of DDH?
1. asymmetry of leg length
2. level of knes when hips and knees bilaterally flexed
3. restricted abduction of hip in flexion
184
At what age is US no longer first line investigation for DDH?
if infant >4.5 months - xray first line
185
What is the management of DDH?
* most spontaneously resolve by 3-6 weeks
* Pavlik harness (dynamic flexion-abduction orthosis) in children < 4-5 months
* older children may require surgery
186
What is cephalohaematoma?
ruptured blood vessels causing subperiosteal swelling **limited by suture lines**, develops hours after delivery, takes months to resolve
187
What are 4 ways that congenital heart disease may present in the neonate?
1. antenatal period: imaging of heart at 18-20 week fetal anomaly scan
2. murmur (routine newborn exam)
3. cyanosis
4. heart failure - poor feeding, SOB, sweating, wheeze, **hepatomegaly**
188
What is the commonset cause of death from measles?
pneumonia
189
What can cause a raised INR in newborn babies?
relative vitamin K deficiency - can lead to haemorrhagic disease of the newborn (HDN)
190
Which 2 factors put newborn babies at increased risk of vitamin K deficiency & HDN?
1. breast feeding (breast milk poor source of vit K)
2. maternal antiepileptics
191
Waht is done due to the relative deficiency of vitamin K in all newborns?
all newborns offered vitamin K
192
At what age and temperature should all paediatric patients be referred for urgent paediatric assessment?
<3 months with fever <38 C
193
What should be done in children with a fever without apparent source with regards to antibiotics?
oral antibiotics should not be prescribed
194
What is the commonest cause of hypothyroidism in children?
autoimmune thyroiditis
| other causes: post total-body irradiation, iodine deficiency
195
What are 7 clinical features of hand, foot and mouth disease?
1. sore throat
2. fever
3. oral ulcers
4. followed by vesicles on palms and soles of feet
5. cough
6. abdominal pain
7. anorexia
196
What organism causes hand, foot and mouth disease?
picornaviridae family - coxsackie A16 and enterovirus 71
197
What is the management of hand, foot and mouth disease?
* symptomatic - hydration, analgesia
* no need for school exclusion unless unwell
* contact HPA if LARGE outbreak
198
What are 5 causes of snoring in children?
1. obesity
2. nasal problems - polyps, deviated septum, hypertrophic nasal turbinates
3. recurrent tonsillitis
4. Down's syndrome
5. hypothyroidism
199
What are 5 factors putting neonates at increased risk of meningitis?
1. low birth weight
2. prematurity
3. traumatic delivery
4. fetal hypoxia
5. maternal peripartum infection
200
What are 3 organisms most likely to cause meningitis in infants from the neonatal period to 3 months?
1. Group B streptococcus
2. E coli
3. Listeria monocytogenes
201
What are 3 organisms most likely to cause meningitis age 1 month to 6 years?
1. Neisseria meningitidis
2. Streptococcus pneumoniae
3. Haemophilus influenzae
202
What are 2 organisms most likely to cause meningitis in children age >6 years?
1. Neisseria meningitidis (meningococcus)
2. Strepcococcus pneumoniae (pneumococcus)
203
What are labial adhesions?
fusion of labia minora in midline - seen in girls 3 months - 3 years, tends to spontaneously resolve around puberty
204
What are 2 features of labial adhesions?
1. micturition problems including pooling in vagina
2. O/E - thin semitranslucent adhesions covering vaginal opening between labia minora
205
What are the management options for labial adhesions?
1. conservative in majority
2. if recurrent UTIs - try oestrogen cream
3. surgical intervention if this fails
206
When do strawberry naevi (capillary haemangioma) usually develop?
rapidly during first month of life (not present at birth) - increase until 6-9 months then regress over next few years
207
What are 4 risk factors for strawberry naevus (capillary haemangioma)?
1. white infants
2. female infants
3. premature infants
4. mother undergone CVS
208
What are 4 potential complications of strawberry naevi?
1. mechanical e.g. obstructive visual fields or airway
2. bleeding
3. ulceration
4. thrombocytopenia
209
What treatment can be given if required for strawberry naevi?
propranolol, or topical beta blockers e.g. timolol
210
What are 3 associations of aortic stenosis in children?
1. William's syndrome
2. coarctation of the aorta
3. Turner's syndrome
211
What causes tetralogy of Fallot?
result of anterior malalignment of aorticopulmonary septum
212
What are 4 characteristic features of tetralogy of Fallot?
1. ventricular septal defect (VSD)
2. right ventricular hypertrophy
3. right ventricular outflow tract obstruction, pulmonary stenosis
4. overriding aorta
213
What are 4 key features in the presentation of tetralogy of Fallot?
1. cyanosis - episodic hypercyanotic 'tet' spells due to near occlusion of R ventricular outflow tract (tachypnoea, cyanosis)
2. ejection systolic murmur (pulmonary stenosis)
3. CXR - boot shaped heart
4. right sided aortic arch in 25%
214
What type of shunt is caused by tetralogy of fallot?
right to left
215
What is the management of tetralogy of fallot?
surgical repair - 2 parts
beta blockers to reduce infundibular spasm + help cyanotic episodes
216
At what age is considered precocious puberty?
<8y in girls, <9y in boys
217
What 2 groups can precocious puberty be classified into?
1. **Gonadotrophin dependent** ('central', 'true')
due to premature activation of the hypothalamic-pituitary-gonadal axis
FSH & LH raised
2. **Gonadotrophin independent** ('pseudo', 'false')
due to excess sex hormones
FSH & LH low
218
What suggests the cause of precocious puberty in males with bilateral testicular enlargement?
gonadotrophin release from intracranial lesion
219
What suggests the cause of precocious puberty in males with unilateral testicular enlargement?
gonadal tumour
220
What suggests the cause of precocious puberty in males with small testes?
adrenal cause (tumour or adrenal hyperplasia)
221
What is 1 example of an organic cause of precocious puberty in females?
McCune Albright syndrome
222
What is the commonest cause of respiratory distress in the newborn period?
transient tachypnoea of the newborn
223
What can cause transient tachypnoea of the newborn?
delayed resorption of fluid in the lungs - more common after C section (fluid not squeezed out during passage through birth canal)
224
What may be seen on CXR in transient tachypnoea of the newborn?
hyperinflation of the lungs and fluid in the horizontal fissure
225
What are 3 aspects of transient tacphypnoea of the newborn?
1. observation
2. supportive care
3. supplementary O2 if required
226
What is the prognosis for transient tachypnoea of the newborn?
usually settles within 1-2 days
227
What age do children normally achieve urinary continence?
3-4 years
228
What are 3 organic causes / triggers for nocturnal enuresis?
1. constipation
2. diabetes mellitus
3. UTI
229
What are 4 options for treating nocturnal enuresis?
1. advice: fluid intake/toileting patterns/ lifting and waking
2. Star charts for using toilet before sleep
3. enuresis alarm - sensor pad for wetness
4. desmopressin - if short control needed e.g. sleepover
230
What age is typically affected by roseola infantum?
6 months - 2 years
231
What is the school exclusion advice for roseola infantum?
school exclusion not needed
232
How common are febrile convulsions in roseola infantum?
10-15%
233
What are Nagayama spots and when are they seen?
* papular enanthem on uvula and soft palate
* roseola infantum
234
What are 2 possible complications of roseola infantum?
1. aseptic meningitis
2. hepatitis
235
What are the steps of chronic asthma management in children 5 - 16 years?
* SABA
* SABA + paeds low dose ICS
* SABA + low dose ICS + LTRA
* SABA + low dose ICS + LABA (stop LTRA if hasn't helped)
* SABA + MART (LABA+ low dose ICS)
* SABA + MART (moderate dose ICS) or back to separate LABA + mod ICS
* SABA and: high dose ICS + LABA, or theophylline, or expert advice
236
What are the steps of chronic asthma management in children < 5 years?
* SABA
* SABA + 8 week trial **moderate dose ICS**
* after 8 weeks - if resolved low dose ICS, if recurred repeat 8 week trial of moderate ICS
* SABA + low dose + LTRA
* stop LTRA and refer to specialist
237
What investigations should be performed in a neonate with jaundice <24h?
measure and record serum bilirubin urgently (within 2 hours) with suspected / obvious jaundice in first 24h of life
238
What are 2 alternative names for surfactant deficient lung disease?
1. respiratory distress syndrome
2. hyaline membrane disease
239
What are 5 risk factors for surfactant-deficient lung disease (SDLD)?
1. prematurity
2. male sex
3. diabetic mother
4. C-section
5. second born of premature twins
240
What is seen on CXR in surfactant-deficient lung disease?
ground-glass appearance with indistinct heart border
241
What are 4 aspects of management of sufactant-deficient lung disease?
1. maternal steroids to induce fetal lung maturation - prevention
2. oxygen
3. assisted ventilation
4. exogenous surftant via ET tube
242
When do children with coeliac disease typically present?
before age of 3 years - with introduction of cereals to diet
243
What are the genetic associations of coeliac disease in children?
strongly associated with **HLA-DQ2** (95% of patients) and **HLA-DQ8** (80%)
244
How is a diagnosis of coeliac disease made in children?
endoscopy with jejunal **biopsy** showing **subtotal villous atrophy**
245
What is intussusception?
invagination of one portion of bowel into lumen of adjacent bowel, most commonly around ileo-caecal region
246
Which age group is commonly affected by intussusception?
infants 6 - 18 months old
247
What are the key features of intussusception?
* intermittent, severe, crampy, progressive abdominal pain
* inconsolable crying
* during paroxysm the infant will characteristically **draw their knees up** and turn **pale**
* vomiting
* bloodstained stool - '**red-currant jelly**' - is a late sign
* **sausage-shaped mass** in the right upper quadrant
248
What is the investigation of choice for suspected intussusception? What does it show?
ultrasound - target-like mass
249
What is the management of intussusception?
* majority can be treated with reduction by **air insufflation** under radiological control
* (^now widely used first-line rather than traditional barium enema)
* if this fails, or the child has signs of peritonitis, **surgery**
250
What is the school exclusion advice for measles?
4 days from onset of rash
251
What is the school exclusion advice for rubella?
5 days from onset of rash
252
What is the school exclusion advice for mumps?
5 days from onset of swollen glands
253
What are 7 childhood diseases that do not require school exclsuion?
1. Conjunctivitis
2. Fifth disease (slapped cheek)
3. Roseola
4. Infectious mononucleosis
5. Head lice
6. Threadworms
7. Hand, foot and mouth
254
What is the school exclusion advice for scarlet fever?
24h after antibiotics commenced
255
What is the school exclusion advice on impetigo?
until all lesions crusted and healed or 48h after commencing abx
256
What is the school exclusion advice for scabies?
until treated
257
What is the school exclusion advice for influenza?
until recovered
258
What is cradle cap
seborrhoeic dermatitis in children <8 months - affects scalp, nappy area, face and limb flexures
259
What is the treatment of cradle cap?
* massage topical emollient onto scalp to loosen scales, brush gently with soft brush and wash off with shampoo
* if severe/persistent - topical imidazole
260
What is the indication for caffeine in newborns?
aid weaning off a ventilator
261
What is the age at which xrays are first line for evaluation of DDH over US?
> 6 months
262
Which type of neonatal jaundice, conjugated or unconjugated, is more likely to be pathological?
conjugated - ALWAYS pathological
263
What is the commonest cause of failure to thrive in the UK?
non-organic causes e.g. social problems
(parental poor feeding skills, dysfunctional family interactions, lack of social support etc.)
264
What are 4 key aspects of the management of bronchiolitis?
1. **oxygenation** via headbox / NIV / invasive
2. **hydration** - IVF / NG
3. **ribavirin** - in severe cases, immunodeficiency, chronic lung disease
4. **suction** - sometimes used for excessive upper airway secretions
