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Paediatrics 2 Flashcards

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1
Q

What are the 4 most common paediatric malignancies?

A 
Leukaemia/lymphoma 
Brain tumours 
Neuroblastoma
Wilm's tumour 
Bone tumours
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2
Q

What is a Wilm’s tumour?

A

A rare kidney cancer that primarily affects children

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3
Q

How do brain tumours present?

A 
Raised ICP - early morning headache, vomiting, papilloedema
Focal seizures 
Neurological signs 
Endocrine disturbance 
Raised OFC
Developmental delay/regression
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4
Q

What investigations should be done if a brain tumour is suspected?

A 
CT or MRI 
Tumour biopsy 
Tumour markers 
Endocrine screen 
CSF cytology and tumour markers
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5
Q

What are the most common malignant bone tumours in children?

A

Osteosarcoma

Ewing’s sarcoma

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6
Q

How do bone tumours present?

A 
Often delayed 
Persistent nocturnal pain 
Swelling 
Deformity 
Pathological fractures 
Systemic symptoms - fever, weight loss
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7
Q

How is Ewing’s sarcoma treated?

A

Chemotherapy
Surgery
Autologous stem cell transplant
Radiotherapy

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8
Q

How is osteosarcoma treated?

A

Chemotherapy

Surgery

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9
Q

Why is long term follow up required for patients treated for bone tumours?

A

Significant toxicity associated with treatment

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10
Q

What are the common malignant causes of an abdominal mass?

A 
Neuroblastoma 
Wilm's tumour
Hepatoblastoma
Lymphoma
Germ cell tumour 
Soft tissue tumour
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11
Q

What are blueberry muffin skin nodules associated with?

A

Neuroblastoma

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12
Q

What investigation should be done if neuroblastoma is suspected?

A

Urinary catecholamines

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13
Q

What malignancy causes leucocoria?

A

Retinoblastoma

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14
Q

What malignancy causes a bitemporal hemianopia?

A

Craniopharyngioma

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15
Q

What are children receiving chemotherapy at increased risk of?

A

Neutropenic sepsis

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16
Q

What is tumour lysis syndrome?

A

Breakdown of malignant cells results in hyperuricaemia, hyperkalaemia, hypophosphataemia and hypocalcaemia, causing AKI, seizures, arrhythmia and death if left untreated

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17
Q

When is tumour lysis syndrome most likely to occur?

A

During induction chemotherapy

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18
Q

How is tumour lysis syndrome managed?

A 
Regular observation and monitoring
U&Es and bone profile
IV fluids 
Xanthine oxidase inhibitor (allopurinol)
Manage hyperkalaemia 
Renal dialysis
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19
Q

What are the early and late effects of chemotherapy?

A

Early - marrow suppression, temporary hair loss, nausea and vomiting, renal impairment
Late - cardiac toxicity, infertility, risk of secondary malignancy

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20
Q

Give an example of passive immunisation

A 
Normal immunoglobulin (IV/subcutaneous)
Specific antibodies (e.g. varicella zoster IgG)
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21
Q

Give an example of active immunisation

A

Foreign antigen stimulates a host immune response
Live attenuated vaccines
Inactivated vaccines

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22
Q

Give 2 examples of live attenuated vaccines

A 
BCG
MMR 
Rotavirus 
Influenza 
Oral polio
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23
Q

Give 2 examples of inactivated vaccines

A 
Polio 
Trivalent influenza 
Diphtheria and tetanus
Pertussis 
HPV
MenB
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24
Q

What is the major difference in immune response between children and adults in regards to vaccination?

A

Polysaccharide antigens do not stimulate an effective and lasting immune response in children < 2
Polysaccharide blocks opsonisation, preventing phagocytosis and subsequent antigen presentation to T-cells in association with MCH by APCs. The immune response is therefore largely T-cell independent and relies on the formation of antibody by B-cells.

Infants have low numbers of/immature B cells, and without T-cell activation may produce only small numbers of short-lived antibodies.

To induce T-cell responses the polysaccharide antigen of pathogenic microbes can be linked to a carrier protein (e.g. tetanus or diphtheria toxoid), to which the child reacts.

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25
Give 2 examples of conjugates vaccines
Hib Group C meningococcus Pneumococcal Group ACWY meningococcal
26
What immune protection is offered by the placenta, covering babies up to 2 months?
IgG
27
Why are booster vaccinations needed?
Live vaccine produce long lasting immunity after 1 or 2 doses but inactivated vaccines need several doses
28
What is the main contraindication to vaccination?
Confirmed anaphylaxis to previous vaccine with same antigens or other vaccine components (e.g. neomycin/streptomycin)
29
In what population is the yellow fever vaccine contraindicated?
Those with a confirmed anaphylaxic reaction to egg
30
In whom are live vaccines contraindicated?
Immunosuppressed Primary immunodeficiency, chemo/radio therapy in last 6 months, bone marrow transplant treatment in last 12 months, high dose steroids until 3 months without, immunosuppressant medication in last 6 months HIV (no BCG but may have MMR)
31
How long should there be between live vaccine administration?
3 weeks
32
How long should vaccination be postponed for if a patient has received immunoglobulin?
3 months
33
What is subacute sclerosing panencephalitis?
Very rare, but fatal disease of the central nervous system that results from a measles virus infection acquired earlier in life SSPE generally develops 7 to 10 years after a person has measles, even though the person seems to have fully recovered from the illness
34
What is the incubation and infectivity period for measles?
7-14 days | 1-2 days before symptoms to 4 days after rash
35
What are the clinical features of measles?
3-5 days prodrome of fever, coryza, cough, conjunctivitis and Koplik's spots Maculopapular rash starts behind ears and migrates to face/trunk/limbs Associated cervical lymphadenopathy and fever
36
What are the complications of measles?
``` Otitis media Lymphadenitis Interstitial pneumonitis Secondary bacterial bronchopneumonia Myocarditis Post-infectious demyelinating encephalomyelitis SSPE ```
37
What is the incubation and infectivity period for chicken pox?
14-21 days | 2 days before and 5 days after rash
38
What are the clinical features of chicken pox?
48 hours of fever, malaise, headache and abdominal pain | Itchy crops of erythematous macules -> papules -> vesicles of serous fluid
39
What are the complications of chicken pox?
``` Secondary bacterial infection (Group A strep, S.aureus) Pneumonia Encephalitis Progressive disseminated varicella Cerebellar ataxia Thrombocytopenia Purpura fulminans Post-infectious encephalitis ```
40
How is zaricella zoster prevented?
Vaccination for high-risk patients | Post-exposure prophylaxis with varicella zoster immunoglobulin (IVIG) if immunocompromised
41
What is the incubation and infectivity period for mumps?
14-21 days | 1-2 days prior to 9 days after parotid swelling
42
What are the clinical features of mumps?
Prodrome - fever, anorexia, headache | Painful uni/bilateral salivary +/- submandibular gland swelling
43
What are the complications of mumps?
``` Meningoencephalitis Deafness Orchitis Epididymitis Pancreatitis Nephritis Myocarditis Arthritis Thyroiditis ```
44
What is the incubation and infectivity period for parvovirus B19?
4-14 days | Not infectious once rash appears
45
What is parvovirus B19 also known as?
Erythema infectiosum Slapped cheek Fifth's disease
46
What are the clinical features of parvovirus B19?
Prodrome - low grade fever, malaise Maculopapular spots on cheeks which coalesce to give slapped cheek appearance Fine lacy rash extends to trunk and limbs Associated arthralgia and arthritis Lasts 2-30 days
47
What are the complications of parvovirus B19?
Aplastic crisis in sickle cell/thalassaemia/immunocompromised
48
What is the incubation and infectivity period for rubella?
14-21 days | 1-2 days before to 7 days after rash appears
49
What are the clinical features of rubella?
Prodrome - coryza, tender cervical lymphadenopathy Fine maculopapular rash on face and spreads to trunk Arthralgia and palatal petechiae
50
What are the complications of rubella?
Encephalitis Thrombocytopaenia Congenital rubella syndrome
51
What is the incubation and infectivity period for HHV6?
7-14 days | Until fever subsides
52
What is HHV6 also known as?
Human herpes virus 6 Roseola infantum Sixth disease
53
What are the clinical features of HHV6?
Sudden onset high fever with mild coryza which resolves on day 3-4 and maculopapular rash appears on trunk and limbs for 1-2 days
54
What are the complications of HHV6?
Febrile convulsions in 6-18 month olds | Encephalitis
55
What is the incubation and infectivity period for pertussis?
7-14 days | Whilst coughing during catarrhal phase
56
What are the clinical features of pertussis?
Catarrhal phase - low grade fever, coryza, conjunctivitis for 1-2 weeks Paroxysmal phase - severe cough +/- whoop, vomiting, cyanosis, apnoea for 2-8 weeks Convalescent phase - cough subsides over weeks/months
57
What are the complications of pertussis?
``` Apnoea Secondary bacterial pneumonia Weight loss Bronchiectasis Otitis media Seizures Encephalopathy Subconjunctival/subarachnoid/intraventricular haemorrhage Umbilical/inguinal hernia Ruptured diaphragm ```
58
How is pertussis diagnosed?
Nasal swab for PCR testing and culture | Associated lymphocytosis
59
How is pertussis treated?
Supportive | Macrolides
60
Give 4 causes of meningitis
``` Bacterial Viral Fungal Parasitic Malignancy Immune-mediated Drugs ```
61
What are the 2 most common causative bacterial organisms in meningitis in children?
Neisseria meningitidis Streptococcus pneumoniae Haemophilus influenzae TB Group B strep
62
What is the most common cause of viral meningitis in children?
Enterovirus
63
What is the most common cause of bacterial meningitis in neonates?
Group B streptococcus Listeria monocytogenes E.coli
64
How does bacterial meningitis present?
``` Fever Headache Nausea and vomiting Neck stiffness Photophobia Lethargy Decreased level of consciousness Seizures Positive Kernig's sign and Brudzinski sign ```
65
What is Kernig's sign?
Positive when flexing the thigh at the hip and knee to 90 degree angles, and subsequently extending the knee is painful (leading to resistance) This may indicate subarachnoid haemorrhage or meningitis
66
What is Brudzinski's sign?
Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed
67
Give 4 ways in which an infant may present with bacterial meningitis
``` Unexplained fever Lethargy High pitched/irritable cry Cannot be soothed by parents Poor feeding Apnoeic/cyanotic attacks Posturing Seizures Bulging fontanelle ```
68
How is bacterial meningitis diagnosed?
LP
69
What are the contraindications to LP?
Cardiovascular compromise Signs of increased ICP (herniation risk) Abnormal clotting/low platelets (subdural/epidural haematoma) Skin infection at site
70
Give 4 signs of increased ICP
``` GCS <9/drop of 3 or more Bradycardia and HTN Focal neurological signs Abnormal posturing Unequal/dilated/poorly responsive pupils Papilloedema Abnormal doll's eye movements ```
71
What will CSF analysis reveal in suspected meningitis?
WCC >5 (>20 neonates) - polymorphs = bacterial, lymphocytes = viral Elevated protein and decreased glucose = bacterial or TB Organisms may be seen on staining PCR for pneumococcus/meningococcus/Hib/HSV/ZVZ/enterovirus
72
What is the empirical treatment for suspected bacterial meningitis?
IV cefotaxime (+ amoxicillin and gentamicin if <6 weeks) (+ dexamethasone if >3 months and no purpura)
73
What is the definitive treatment for Neisseria meningitidis meningitis?
7 days IV cefotaxime/ceftriaxone
74
What is the definitive treatment for Streptococcus pneumoniae meningitis?
14 days IV cefotaxime/ceftriaxone
75
What are the complications of meningitis?
``` Hydrocephalus Deafness (Hib) Neuromotor disorders Seizures Visual disorders Speech and language disorders Learning difficulties Behavioural problems ```
76
What is the difference between septicaemia and sepsis?
Septicaemia - infection of the blood stream | Sepis - systemic inflammatory response to infection
77
What is sepsis syndrome/severe sepsis?
When sepsis is associated with hypoperfusion resulting in organ dysfunction which can lead to septic shock and multiple organ failure
78
What is the pathophysiology of meningococcal sepsis?
Capillary leak Coagulopathy Myocardial depression Metabolic derangement
79
How does meningococcal bacteraemia present?
Fever Petechial/purpuric rash Relatively well child who rapidly deteriorates
80
What are the features of septic shock?
``` Difficulty breathing Tachycardia Hypotension Cool extremities Leg pain CRT >2 secs Decreased conscious level Moribund ```
81
How is septic shock managed?
High flow oxygen 15L via facemask with reservoir bag IV fluid bolus of 20ml/kg of 0.9% saline; repeat once if needed, then consult PICU IV cefotaxime 50mg/kg Correct any metabolic derangements and coagulopathy
82
What are the 5 F's of abdominal distension?
``` Fat Fluid Faeces Flatus Foetus ```
83
Give 2 scars that might be present on abdominal examination of a nephrology patient
Nephrectomy - hockeystick at flank | Renal transplant - LIF
84
Give 3 renal causes of a unilateral mass on abdominal examination
``` Multicystic kidney Compensatory hypertrophy Obstructed hydronephrosis Wilms tumour Renal vein thrombosis Neuroblastoma ```
85
Give 3 renal causes of a bilateral mass on abdominal examination
AR/AD polycystic kidney disease Tuberous sclerosis Renal vein thrombosis
86
Give 3 urinary tract abnormalities
``` Absent kidney/s Multicystic dysplastic kidney Duplex Horseshoe/pelvic kidney Obstruction ```
87
What is Potter's syndrome?
Describes the typical physical appearance caused by pressure in utero due to oligohydramnios, classically due to bilateral renal agenesis
88
What is a duplex kidney and what are its complications?
2 ureters Upper - obstructs, associated with ureterocele Lower - reflux (VUR)
89
Give 2 points of the urinary system which commonly obstruct
Posterior urethral valves - bladder hypertrophy, hydronephrosis, renal failure VUJ PUJ
90
Give 2 causes of oedema in children
HF Nephrotic syndrome Liver failure Malnutrition
91
Give 3 pathological causes of proteinuria
Glomerular - sclerosis, nephritis, nephrotic syndrome, familial haematuria Tubular Physiological stress - exercise, cold, febrile, HF
92
Define nephrotic syndrome
Proteinuria (>1g/m2/day), Hypoalbuminaemia (<25 g/l) Oedema
93
What test can be used to diagnose nephrotic syndrome?
Protein to creatinine ratio from one early morning urine sample Normal <20 mg/mmol Nephrotic >150 mg/mmol
94
What type of patient is at higher risk of nephrotic syndrome?
Asian (x6) boys (2:1)
95
How is nephrotic syndrome classified?
Idiopathic - minimal change disease, focal segmental glomerulosclerosis Secondary - HSP, SLE Congenital
96
Give 3 investigations for nephrotic syndrome
Bloods - FBC, U&Es, LFT’s, C3/C4, Varicella status and ASOT Urine - protein creatinine ratio, culture BP
97
Give 2 complications of nephrotic syndrome
Hypovolaemia Thrombosis Infection Hypertension
98
How is nephrotic syndrome treated?
Prednisolone - high dose and then reduce 20% albumin and furosemide - hypovolaemia/oedema Pneumococcal vaccination Penicillin prophylaxis Salt/fluid restriction
99
What percentage of patients with nephrotic syndrome will have a relapse?
60-70%
100
Give 5 non-glomerular causes of haematuria
``` Infection Trauma Stones Sickle cell Coagulopathy/bleeding disorder Renal vein thrombosis Tumour Structural abnormality Munchausen by proxy ```
101
Give 2 glomerular causes of haematuria
Acute/chronic glomerulonephritis IgA nephropathy Familial nephritis
102
Give 3 things to find out about while taking a history for haematuria
``` Pain Timing Trauma Recent URTI Rash Medications FH renal disease or deafness ```
103
Give 4 investigations for haematuria
Bloods - FBC, coagulation, U&Es, ASOT, ANF, complement Urine - MC&S, oxalate, calcium, phosphate and urate levels, calcium creatine ratio AXR, renal USS, +/- renal biopsy
104
How is hypertension defined in children?
BP persistently >95th% for age and gender/height
105
Give 5 causes of hypertension
``` Renal parenchymal disease Renovascular Renal tumours Coarctation of the aorta Phaeochromocytoma Neuroblastoma Congenital adrenal hyperplasia Cushing's Hyperthyroidism Essential HTN Obesity Drugs - steroids, stimulants, recreational, liquorice ```
106
Give 5 first line investigations for hypertension
Bloods - FBC, U&Es, creatinine, albumin, bicarbonate, calcium, phosphate, LFTs, plasma renin activity, aldosterone, plasma catecholamines Urine - urinalysis, urine microscopy and culture, urinary protein to creatinine ratio, urinary catecholamines Imaging - renal USS with Doppler flow of the renal vessels, echo, ECG, CXR, DMSA
107
What is a DMSA scan?
Radionuclide scan that uses di mercapto succinic acid (DMSA) in assessing renal morphology, structure and function
108
How can end organ damage be assessed in hypertension?
Echo Fundoscopy Urinalysis for proteinuria
109
How is hypertensive crisis treated?
Labetalol/sodium nitroprusside infusion
110
What can be caused by UTI in presence of VUR?
Scarring of the kidneys
111
Give 3 causes of UTI
``` Infrequent voiding Vulvitis Hurried micturition Constipation VUR Neuropathic bladder ```
112
What is the most causative organism in UTI?
E.coli (85%) ``` Proteus (boys) Staphylococcus Klebsiella Enterococcus Pseudomonas (structural) ```
113
What are the symptoms of a UTI in an infant and older child?
Infant - fever, vomiting, lethargy, irritability, poor feeding, failure to thrive, sepsis, shock Older - frequency, dysuria, changes in continence, abdominal pain, loin tenderness, fever, malaise, vomiting, haematuria
114
What investigations should be done in suspected UTI?
Urinalysis Urgent urine culture and microscopy if <3 months MSSU Imaging
115
How does the imaging required for UTI differ depending on age?
<6 months - USS in 6 weeks (acute if recurrent/atypical); DMSA and MCUG 4-6 months after infection if recurrent/atypical >6 months - atypical need acute USS and DMSA at 4-6m; recurrent need USS at 6w and DMSA at 4-6m
116
What are most UTIs resistant to?
Amoxicillin
117
How can recurrence of UTI be prevented?
Fluids Prevention/treatment of constipation Complete bladder emptying Good perineal hygiene (girls)
118
Give 3 methods of urine collection in babies/children
Clean catch - unable to do MSSU (too young) MSSU - mid-stream, gold standard CSU - catheter SPA - suprapubic aspiration Urine bags - not sterile, can be used to measure volume
119
Define acute renal failure
Sudden reduction in renal function | Oliguria <0.5ml/kg/hr
120
Give a pre-renal, renal and post-renal cause of acute renal failure
Pre - hypovolaemia, HF Renal - HUS, ATN, GN, NSAIDs Post - urinary obstruction
121
What are the 5 indications for dialysis?
``` Severe volume overload Severe hyperkalaemia Symptomatic uraemia Severe metabolic acidosis Removal of toxins ``` AEIOU - acidosis, electrolyte imbalances, ingestion, overload (volume), and uraemia
122
What is a renal USS good for?
General idea of renal anatomy (size, shape, symmetry and position of kidneys and tracts) Vascular perfusion by Doppler Screening tool
123
What is a DMSA scan good for?
Static scan to delineate divided function of kidneys Identifies scars Needs to be done at least 3 months after UTI
124
What is a DTPA scan good for?
``` Dynamic scan allows assessment of drainage and obstruction Micturating cystourethrogram (MCUG) - looking for vesicoureteric reflux, bladder outline, and the presence of posterior urethral valves ```
125
What is an AXR good for (renal)?
Stones
126
Define diabetes mellitus
Metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both.
127
What is the pathophysiology of type 1 diabetes?
Autoimmune beta cell destruction, leading to absolute insulin deficiency
128
What is the pathophysiology of type 2 diabetes?
Non-autoimmune, multifactorial condition with insulin resistance and/or relative deficiency
129
What does 'walking wounded' mean?
Presentation of 70% Glasgow paediatric new-diagnoses - patient walks into hospital with absent/minimal dehydration and acidosis
130
Give 5 signs/symptoms of diabetes
``` Thirst Weight loss Polydipsia Dehydration Polyuria Nocturia Nocturnal enuresis Lethargy Behavioural change Infection (balanitis, candidiasis) ```
131
Give 5 signs/symptoms of ketoacidosis
``` Ketotic breath Dehydration Laboured breathing - Kussmaul's Nausea/vomiting Abdominal pain Headache Irritability Confusion Unrousable Features of cerebral oedema - sunken eyes, reduced skin turgor, CRT >2 secs, cool peripheries, tachycardia, hypotension Raised ICP/altered consciousness ```
132
Name 4 types of diabetes
``` Type 1 Type 2 MODY Disease related - CF, haemochromatosis, acromegaly, Cushing's Steroid induced Syndromal - Trisomy 21, Prader-Willi ```
133
Name 2 types of insulin regimen
Twice daily - rarely used, inflexible, simple Split evening - young children Basal bolus - flexible, correction doses
134
What are correction and ketone doses?
Correction - rapid acting insulin to lower high BG if > 8mmol/l and ketosis minimal; dependent on blood glucose Ketone - rapid acting insulin to clear moderate/large ketosis if BG > 14 mmol/l; independent of blood glucose
135
Give 3 methods of insulin administration
Subcutaneous fat injection (pen & needle device or (rarely) syringe) Subcutaneous fat infusion (via “insulin pump”) Intravenous infusion (ketoacidosis or while fasting (+ IV dextrose)) Other - islet cell transplant, implanted pump
136
Give 3 causes of ketosis/ketoacidosis
``` Lack of awareness Delay of diagnosis Infection Trauma Insulin pen/pump failure Insulin omission (accidental/deliberate) ```
137
How is ketoacidosis investigated?
Glucose, U&E, Blood Gas ([H+], [HCO3-], UA (ketosis) | Other - Osmolality; consider Septic screen (blood, urine, etc.)
138
How is ketoacidosis managed?
``` Managed in HDU/ITU A-E assessment IV fluids - rehydrate slowly IV insulin - syringe driver IV K+ - once shock is corrected Monitoring - BP, ECG, neuro ```
139
What are the complications of ketoacidosis?
Cerebral oedema Arrhythmia Renal failure
140
How is cerebral oedema secondary to ketoacidosis managed?
``` Exclude hypoglycaemia Restrict fluid Mannitol Ventilate CT ```
141
What are the signs/symptoms of hypoglycaemia?
Mild neuroglycopenia - feeling faint, hunger, headache, confusion Autonomic symptoms - pallor, sweating, nausea, tachycardia Severe neuroglycopenia - slurred speech, seizure, coma, death
142
How is hypoglycaemia treated in the outpatient setting?
Rapid-acting oral glucose, followed by slower-acting carbohydrate “GlucaGel” oral glucose gel (if can tolerate oral intake) IM Glucagon injection, anterior thigh (if unconscious, fitting)
143
How is hypoglycaemia treated in the inpatient setting?
Oral glucose if conscious and able to take orally | IV dextrose bolus +/- infusion (if unconscious, persistent low BG)
144
Why do diabetics need additional management when ill?
Immune response impaired in those with T1DM Metabolic stress causes catabolism and hormone release May cause relative insulin deficiency and increased insulin requirement Causes hyperglycaemia with ketosis/ketoacidosis
145
How does acute epiglottitis present?
3-7 year old Drooling and stridor Toxic within a few hours
146
What should be avoided in a child presenting with epiglottitis and why?
Visualisation of epiglottis or distressing the child (e.g. cannulation) May precipitate respiratory arrest
147
How should epiglottitis be managed?
ITU Intubation Humidified air/oxygen IV chloramphenicol/ampicillin
148
What is the differential diagnosis for epiglottitis?
Foreign body Retropharyngeal abscess Diphtheria Croup
149
How does croup present?
``` Age 6 months - 3 years May have preceding coryzal symptoms Inspiratory stridor Wheeze Mild fever and fatigue Barking cough ```
150
How is croup managed?
Humidified air/oxygen | No antibiotics
151
Give 5 causes of acute respiratory failure
Central - head injury, drugs, convulsion, infection Airway - acute epiglottitis, foreign body Parenchymal - pneumonia, bronchiolitis, asthma Chest wall - polio, trauma
152
How does acute respiratory failure present?
Restless, agitated from hypoxia, cyanosis, silent chest not moving sufficient air Blood gases - low PaO2 and/or rising CO2 on oxygen
153
How is acute respiratory failure managed?
Secure airway - bag valve mask, intubation, assisted ventilation Deal with primary cause
154
How does acute bronchiolitis present?
``` 6 weeks - 6 months old Preceding coryzal symptoms 3-5 days prior Progressive cough Wheeze Difficulty feeding Similar signs to asthma Fine inspiratory crepitations ```
155
What causes bronchiolitis?
Respiratory syncytial virus
156
How is bronchiolitis managed?
Oxygen Suction of secretions Tube feeding/IV fluids if unable to tolerate oral Antibiotics if bacterial infection suspected
157
What is the prognosis of bronchiolitis?
May recur | Third develop asthma in later life
158
How does acute asthma present?
``` >1 year old Expiratory wheeze Difficulty speaking Extended head Flared nostrils Increased AP chest diameter Accessory muscle use Tachycardia Cyanosis ```
159
How is acute asthma managed?
``` Oxygen Nebulised salbutamol and ipratropium bromide Oral prednisolone IV theophylline Monitor ```
160
What type of pneumonia is more common in pre-school children?
Bronchopneumonia (as opposed to lobar pneumonia)
161
How does pneumonia present?
Babies - ill, grey, cyanosed, increased WOB and RR, febrile convulsion Children - can mimic acute appendicitis, upper respiratory rattle
162
What investigations should be done for pneumonia?
``` CXR Bloods - Hb, FBC Throat swab Blood culture Mantoux (if severe) Sweat test (if recurrent or staph) ```
163
How is pneumonia managed?
``` Suction of secretions PT Oxygen NG/IV feeds Antibiotics - ampicillin/penicillin and gentamicin (sick) +/- flucloxacillin (staph) ```
164
Give 3 symptoms which may indicate cardiac failure
``` Lethargy Feeding problems/breathless on feeding Sweating Failure to thrive Recent excessive weight gain/oedema Blue attacks Precipitated or exacerbated by illness ```
165
Give 2 signs which may indicate cardiac failure
Tachycardia Tachypnoea Hepatomegaly Femoral pulse changes
166
How is cardiac failure managed?
``` Position - sitting/incline, head up Diuretic (e.g. furosemide) Digoxin Oxygen Morphine Treat cause ```
167
In what condition is digoxin contraindicated?
Tetralogy of Fallot
168
How should burns and scalds be managed immediately at home?
Strip off soaked clothing Immerse in cold running water Cover area in clean dry sheet/towel/dressing
169
How should burns and scalds be managed in hospital?
``` Airway - soot in nostrils, wheeze IV access Analgesia - IV morphine Plasma expanders if >10% surface affected to prevent shock/renal failure Blood transfusion for full thickness Weight Check Hb for anaemia Monitor closely for renal failure ```
170
How is % burn calculated in children?
Head 18%, legs 13%, arms 8%, trunk 18% | Child's palm = 1%
171
What is the difference between superficial and superficial dermal burns?
Superficial - sunburn, no blisters | Superficial dermal - good blood supply, blistered
172
How do deep dermal and full thickness burns differ?
Deep dermal - altered sensation but not painless, may have blisters, well demarcated, speckled appearance Full thickness - painless, white/brown, dry
173
What % cut offs are important clinically in regards to burns?
>3% need referral Full thickness >1% need to be seen >10% needs IV fluids >30% needs ICU
174
How is isotonic dehydration quantified in children?
As percentage loss of body weight 5% = mild = 50ml/kg 10% = moderate = 100ml/kg 15% = severe = 150ml/kg
175
Give 2 symptoms/signs of mild dehydration
Lethargic Loss of skin turgor Dry mouth Slack fontanelle
176
Give 2 symptoms/signs of moderate dehydration
``` Tachycardia Tachypnoea Sunken fontanelle Sunken eyes Mottled skin Oliguria ```
177
Give 2 symptoms/signs of severe hydration
Shock Coma Hypotension
178
How are fluid boluses calculated in children?
20ml/kg
179
How should oral rehydration solution be administered?
5-10ml every 1-5 minutes (to replace deficit in 6 hours)
180
How might meningitis present?
``` Gastroenteritis Irritable cry Coma Convulsion Apnoea Bulging fontanelle Head retraction and resistance to flexion Otitis media Purpura ```
181
What investigations should be done for meningitis?
LP for CSF cells, Gram stain and glucose Bacteriology Hb, WBC, U&Es, blood glucose Chest x-ray
182
How is meningitis treated?
Neonate - probably e.coli/GBS = benzylpenicillin and chloramphenicol >3 months - probably H.influenzae/meningococcus/pneumococcus = ampicillin and chloramphenicol
183
Give 4 important complications of meningitis
``` Convulsions Cerebral oedema Subdural effusion Hydrocephalus Hyponatraemia (inappropriate ADH) Deafness Fever (rises after initial fall) Mental handicap Cerebral palsy Epilepsy ```
184
What early symptoms may indicate osteomyelitis/septic arthritis?
Reluctance to use a limb Local swelling Local tenderness
185
How are osteomyelitis/septic arthritis treated?
IV antibiotics - flucloxacillin and ampicillin Immobilise the limb Monitor
186
When is surgery indicated for osteomyelitis/septic arthritis?
Infants - immediately for septic hip | Older children - poor response to treatment after 24 hours
187
Give 4 symptoms of UTI
``` Dysuria Frequency Haematuria Foul smelling urine Bedwetting Abdominal pain Pyrexia of unknown origin Malaise Not feeding ```
188
What investigations should be done for UTI?
BP Hb, WBC, U&Es, serum creatinine, urine and blood culture Ultrasound Radio isotope studies for scarring, pelvi-ureteric obstruction and ureteral reflux, duplex collecting systems, bladder diverticuli/obstruction
189
What bacteria are most commonly implicated in UTI?
<1 year = E.coli | > 1 year = E.coli, proteus
190
Give 4 symptoms/signs of DKA
``` Polydipsia/polyuria for days or weeks Weight loss Dehydration Vomiting Abdominal pain, Infection associated Coma ```
191
How is severe DKA managed?
0.9% saline K+ supplementation Insulin bolus and then IV infusion until glucose falls to 15mmol/L Then give dextrose instead of saline and insulin every 4-6 hours
192
How is poisoning managed immediately at home?
Induce vomiting with fingers (unless volatile hydrocarbons, caustics or the child is unconscious)
193
How is poisoning managed in hospital?
Establish what has been taken, in what volume, when and how Induce vomiting with 15ml syrup of ipecac and water, repeat if no result after 20 mins/gastric lavage if unconscious Give specific antidotes
194
What is the antidote for paracetamol poisoning?
Acetyl cysteine/methionine
195
What is the antidote for TCA or theophylline poisoning?
Activated charcoal
196
What is the antidote for opiate poisoning?
Naloxone
197
What is the antidote for alcohol poisoning?
Glucose (hypoglycaemia can be severe)
198
How should pyrexia be investigated?
Infection screen - blood culture, urine culture +/- lumbar puncture, Hb, WBC, ESR, chest x-ray
199
How are seizures managed?
Keep child safe | Give diazepam IV or rectal -> paraldehyde if no response after 10 minutes
200
How are infantile spasms treated?
ACTH/corticosteroids | Benzodiazepines
201
How is a petit mal seizure treated?
Ethosuximide | Sodium valproate
202
How is temporal lobe/focal epilepsy treated?
Carbamazepine | Phenytoin
203
What is sudden infant death syndrome?
Sudden and unexpected death of an apparently normal 1 month-1 year old after which a properly performed autopsy fails to reveal a major cause of death
204
What are the risk factors for SIDS?
Male Low birth weight Winter Adverse social/domestic conditions
205
How should SIDS be managed?
Attempt resuscitation if appropriate Inform parents cot death is likely Offer holding the baby Inform GP, health visitor and social services Procurator Fiscal and police will investigate Emphasise routine nature of inquiries and remove blame from parents/carers Suppress lactation if breastfeeding
206
What is non-accidental injury?
Where abuse is inflicted or knowingly not prevented by person(s) caring for a child and signs are present of physical injury and/or neglect, drug administration, failure to thrive, emotional or sexual abuse
207
What factors may make you consider NAI?
Injuries inconsistent with explanation Delay in seeking help Medical advice sought for many minor injuries Young, single parent Known to social services Handicapped child Physical signs of neglect/abuse - bruising of different ages, black eyes, torn frenulum, retinal detachment/bleeds, genital bruising, withdrawn, drugged, burns/scalds, fractures
208
What gene mutation is associated with eczema?
Filaggrin
209
How can the skin barrier be improved in eczema?
Bathing without soap | Liberal and frequent emollients
210
What are the main areas of management for eczema?
Improve skin barrier Avoid irritants Reduce itching Topical steroids
211
How can itching be improved in eczema?
Sedative anti-histamines Cotton clothing Scratch mitts Keep nails short
212
What steroids regimen is suitable for eczema of the body?
Medium potency for 7 days for flares and 2-3 times weekly for chronic patches Increase to potent steroid if suboptimal response
213
What steroids regimen is suitable for eczema of the face?
1% hydrocortisone safe for daily use (eyelids 3 times weekly only) Short 3 day course of moderate steroids for flares
214
How does irritant contact napkin dermatitis occur?
Moisture and friction disrupt skin barrier and allow irritants from urine/faeces to penetrate
215
Give 3 features of irritant contact napkin dermatitis
Can be associated with candida and bacterial overgrowth Glazed erythema Sparing of skin folds Can ulcerate if left untreated/diarrhoea occurs Wrinkled scaly appearance during resolution
216
How is irritant contact napkin dermatitis treated?
``` Frequent nappy changes Avoid soap/wipes Greasy zinc-based emollient Topical steroid/antifungal cream if very inflamed Anti-yeast if candida infection ```
217
How does candida associated with irritant contact napkin dermatitis present?
Satellite papules and pustules which spread to flexures
218
Give 3 features of vulvitis
Pre-pubertal girls Localised eczema Atopic children Itch, erythema, discharge, stinging passing urine
219
Why is candidiasis not a probable differential in young girls?
pH of vulval skin before puberty does not support candidal overgrowth
220
How is vulvitis managed?
Cotton underwear Avoid tights and soap/wipes Greasy zinc-based emollient Topical steroid cream if very inflamed
221
How is lick lip dermatitis managed?
Greasy emollient | Topical steroid with anti-yeast when red
222
How does pityriasis alba present?
``` Hypopigmentation Dry rough skin on cheeks of atopic children 4-12 year olds Coloured skin Patchy and poorly demarcated ```
223
How is pityriasis alba managed?
Emollients | Sunscreen (prevent surrounding skin tanning which makes it more obvious)
224
Give 3 features of juvenile plantar dermatosis
``` Affects anterior plantar surface Predominantly boys Onset 4-7 years, resolves with puberty Main trigger is sweating Worse in winter Erythema, hyperkeratosis and fissuring ```
225
How is juvenile plantar dermatosis treated?
Avoid occlusive footwear/synthetic socks Aluminium hydrochloride powder can reduce sweating Emollients and topical steroids
226
What area should be carefully managed if affected by HSV skin infection and why?
Periorbital | Check eyes for corneal involvement as it can cause scarring
227
What organism commonly causes impetigo?
Staphylococcus aureus
228
How does impetigo present?
Annular erythematous lesions with honey coloured crust | May become bullous if epidermis is exfoliated by staph
229
How is impetigo managed?
Reduce spread Topical antiseptic Topical/oral antibiotics (flucloxacillin)
230
How does molluscum contagiosum present?
Small pearly umbilicated papules
231
What causes molluscum contagiosum?
DNA pox virus
232
How is molluscum contagiosum treated?
Usually resolve spontaneously Topical antiseptics to avoid infection Can be physically/chemically irritated to clear
233
How does scabies present in children?
Extremely itchy rash Burrows may be seen on the soles of the feet Nodules may be seen in warm/moist areas (e.g. axilla, groin)
234
What organisms cause tinea capitis?
Trichophyton tonsurans | Microsporum canis
235
How does tinea capitis present?
Diffuse scale/patchy alopecia with black dots (broken hairs) or widespread pustules with associated lymphadenopathy
236
How is tinea capitis managed?
Terbinafine (unlicensed) | Ketoconazole shampoo prevents spread to other children
237
Give 4 common dermatological conditions seen in newborns
``` Sebaceous hyperplasia Milia Miliaria Naevus flammeus Mongolion/blue spot Congenital melanocytic naevi Haemangiomas Capillary malformations/port wine stain Urticaria ```
238
What causes sebaceous hyperplasia, what does it look like and how is it managed?
Hypertrophy of sebaceous glands due to maternal androgens Yellow/white pinpoint lesions clustered around the nose Resolves spontaneously in 4-6 weeks
239
What is milia, what does it look like and how is it managed?
Epidermal inclusion cysts Discrete white/yellow papules on chin/cheeks/forehead/mouth/genitalia Spontaneously resolve in few weeks
240
What are the 2 types of miliaria, what do they look like and what is their cause?
Crystalina - clear vesicles which may wipe away; superficial duct obstruction and trapping of sweat Rubra - erythematous papules/pustules over head/neck/trunk; deep obstruction of sweat ducts
241
What is a naevus flammeus and where does it most commonly occur?
Capillary vascular malformation | Nape of neck (persist)/face (fade)
242
What causes the blue colour of Mongolion spots and when do they resolve?
Deep dermal melanocytes | Resolve within 4 years
243
Give 3 features of congenital melanocytic naevi
Macular area of pigmentation Colour varies from light brown to near black Scalp lesions may disappear with time and overlying hair may be hyperpigemented/thicker
244
What are the complications of congenital melanocytic naevi?
Risk of melanoma in very large naevi >25cm is 5-14% | Naevi overlying spine or skull may be associated with neurological pathology
245
How are congenital melanocytic naevi managed?
Cover and sunscreen Monitoring advice Can excise if monitoring difficult or cosmetically visible
246
Why might dermabrasion/cutterage in first few weeks of life be counterintuitive?
Theoretically by reducing the melanocytic load it could reduce the risk of malignant transformation but by leaving only the deeper melanocytes it may mask the appearance of melanoma
247
Give 2 features of epidermal naevi
Linear plaques of warty pigmented skin along Blaschko's lines Become darker and more verrucous with age May be uni/bilateral
248
What are Blaschko's lines?
Lines of normal cell development in the skin
249
Give 3 features of sebaceous naevi
Predominantly on scalp and face Usually flat and pale at birth with waxy smooth surface Can darken and become verrucous over time, especially behind ears May develop into secondary tumours after puberty Most are benign
250
How are sebaceous naevi managed?
Excise for cosmesis | CO2 resurfacing laser and dermabrasion can be used to flatten but scarring and recurrence common
251
How are vascular anomalies classified?
Vasclar tumours - infantile haemangioma | Vascular malformation - fast flow, slow flow, combined
252
Name 2 infantile haemangiomas
Kaposiform haemangioendothelioma (HE) Tufted angioma (TA) Rapidly involuting congenital haemangioma (RICH ) Non-involuting congenital haemangioma (NICH)
253
Name a fast flow, slow flow and combined vascular malformation
Fast - arterial, arteriovenous fistula, arterial venous malformation Slow - venous, lymphatic, capillary Combined - CLM, CVM, CLVM, LVM, CAVM,
254
What are the risk factors for infantile haemangiomas?
Female Preterm Low birth weight Twin pregnancies
255
How do infantile haemangiomas present?
Within first 6 weeks Preceded by bruising/telangiectasia/pallor Superficial, deep or mixed Grow rapidly for 6 week to 6 months and then very slowly involute
256
How do infantile haemangiomas involute?
Darkening of superficial redness Slow breaking up of colour starting from the centre Softening and flattening of deep component Deep component need fibrofatty tissue/lax skin surgically removed
257
Give 2 features of segmental haemangiomas
Large Plaques Associated with underlying visceral lesions/abnormalities related to their location
258
What are the complications of segmental haemangiomas and how are they treated?
Ulceration - beta-blocker (3 months) Infection - antibiotics Bleeding - pressure for 10-15 minutes Obstruction of visual axis or airway - beta-blocker (12-18 months)
259
Give 2 features of capillary malformations/port wine stain
Present at birth Size remains constant Occur anywhere on the body Bright red initially, violaceous with time
260
What should be considered if a port wine stain overlies the V1 distribution of the facial nerve?
Sturge Weber syndrome - neurological and ocular complications
261
What is Klippel-Trenaunay syndrome?
Capillary malformation associated with lymphatic and venous malformation Limb overgrowth may occur
262
Give 4 triggers for urticaria
``` Infection Infestation - worms Injection - drugs, blood, vaccination Ingestion - drugs, food Inhalation - pollen, mould ```
263
Over what duration is urticaria classed as being acute?
<6-8 weeks
264
How is urticaria managed?
Chlorpheniramine (and antihistamine if >6 months)
265
How much fluid/milk do neonates need per day?
150 ml/kg/day
266
How are fluids prescribed in children?
421 rule First 10kg = 4ml/kg/hr Next 10kg = 2ml/kg/hr Rest = 1ml/kg/hr
267
What are the daily requirements for Na, Cl and K?
Na 2-4 mmol/kg/day Cl 2-4 mmol/kg/day K 1-2 mmol/kg/day
268
Give 3 important features to ask about when a baby presents with vomiting
``` Bilious Projectile Feeding Weight gain Fever Rash ```
269
How do oz of milk equate with mls?
1 oz = 30mls
270
Give 4 causes of a vomiting baby
``` Overfeeding Posseting GORD Pyloric stenosis Obstruction ```
271
At what age does pyloric stenosis present and what factors make it more likely?
2-6 weeks | Male, FH
272
How does pyloric stenosis present?
``` Rapidly progressive projectile vomiting Soon after feeds No bile Hungry baby Acute weight loss Dehydration Hypochloraemic hypokalaemic metabolic alkalosis ```
273
How is pyloric stenosis diagnosed and managed?
Diagnosis - test feed (visible peristalsis and palpable olive in RUQ), USS Management - correct electrolyte imbalance, pyloromyotomy
274
Give 3 causes of bilious vomiting in a baby
``` Malrotation +/- volvulus Necrotising enterocolitis Atresia Hirschsprungs Meconium ileus/plug ```
275
What causes malrotation?
Failure of intestinal rotation (270 degrees) and fixation which should occur at week 4-12 of gestation
276
What is the most common abnormality with malrotation?
Caecum lies close to DJ flexure resulting in abnormally narrow midgut mesentery which is liable to twist (volvulus)
277
How does malrotation present?
Early - collapse and acidosis due to intestinal infarction | Late - bile stained vomit and distension
278
How is malrotation diagnosed and managed?
Barium contrast studies | Resuscitation and laparotomy
279
What is necrotising enterocolitis?
Acute inflammatory disease occurring in the intestines of premature infants which can lead to necrosis of the bowel
280
How does necrotising enterocolitis present?
``` Abdominal distension Blood in stool Feeding intolerance Vomiting (bilious) Pyrexia ```
281
How is necrotising enterocolitis managed?
Conservative - stop feeds, give IV fluids and antibiotics | Needs surgery if severe - bowel resection and stoma formation
282
What is intestinal atresia?
Congenital malformation resulting in narrowing/absence of a segment of intestine
283
What is the most common site for intestinal atresia?
Ileum and jejunum
284
What condition is associated with duodenal atresia?
Down's syndrome
285
Give 3 features of Hirschsprungs
Aganglionic section of bowel Starts at anus and progresses upwards Causes bowel obstruction Often presents with delayed passage of meconium Can present late with distension, constipation, failure to thrive and obstruction
286
Give 3 things to ask about in acute abdomen
``` SOCRATES pain Urinary/bowel symptoms LMP in girls Last meal DH and allergies ```
287
Give 3 differentials for acute abdomen in children
``` Acute appendicitis Mesenteric adenitis Constipation Gastroenteritis UTI ```
288
Give 3 features of acute appendicitis on abdominal x-ray
Scoliosis due to pain Faecolith Absent right psoas shadow Intraperitoneal gas indicating perforation Abnormal caecal gas or small bowel dilatation
289
What is intussusception?
Full thickness invagination of proximal into distal bowl | Telescoping
290
Where does intussusception most commonly occur and why?
Ileo-colic | Enlarged Peyer's patches due to viral illness/Meckel's diverticulum
291
Give 2 conditions associated with intussusception in older children
HSP Lymphoma CF
292
What is the classic triad of intussusception symptoms?
Severe intermittent abdominal pain Redcurrant jelly stools Vomiting
293
What imaging modalities are available for intussusception, what do they show and which is better?
Abdominal x-ray - absence of air and soft tissue density in ascending colon Abdominal USS* - target lesion/doughnut sign
294
How is intussusception diagnosed and managed?
Contrast enema can do both | May need surgery
295
What is a hernia?
Protrusion of a viscus/part of a viscus into a cavity where it should not lie
296
How are incarcerated hernias managed?
Resuscitate Reduce Repair
297
What are the risk factors of hernias in neonates?
Male Premature LBW
298
What is a hydrocele?
Fluid in the scrotum due to a patent processus vaginalis
299
Give 2 features of a hydrocele
``` Noticed with systemic illness Can have a blue hue Can get above it on examination Transilluminates Most resolve spontaneously in first year of life ```
300
What is the management pathway for undescended testes?
Detected at baby check/8 week check --> referred as outpatient to surgeon --> surgical correction before first birthday
301
Give 3 causes of an acute scrotum
Testicular torsion Torsion of the appendage (hydatid of Morgagni) Epididymo-orchitis Hydrocele (rarely painful) Idopathic scrotal oedema (rarely painful)
302
What is the difference in pain of testicular torsion, appendage torsion and epididymo-orchitis?
TT - sudden, severe AT - gradual over 2-3 days EO - gradual, less severe
303
What is the difference in examination of testicular torsion, appendage torsion and epididymo-orchitis?
TT - high riding, swollen, hard, red, tender AT - localised to upper scrotum, blue spot, hydrocele EO - swelling, red, oedema
304
What are the 2 peaks of age for testicular torsion?
0-2 and 10-15 years
305
At what fluid resuscitation requirement following trauma should a surgeon be called?
>40ml/kg
306
Give 3 anatomical features of children which need to be considered in trauma situations
``` Small body size Large surface area Relatively large head Compliant elastic skeleton Airway differences (small cavity, large tongue, short trachea, <6m are nose breathers) ```
307
What are the 5 principles of a primary survey?
Airway and C-spine Breathing – look listen feel; administer O2 Circulation; HR BP CRT; IV access, bloods Disability – GCS (modified) /AVPU Exposure - remember hypothermia and glucose
308
How can a child's weight be estimated for calculation of fluid/drug doses?
Weight = (age + 4) x 2 | Weight at birth average 3.5kg, 6 months 7.5kg and 1 year 10kg, gain 2kg a year after that
309
Give 3 features to ask about when a child presents with head injury
``` Mechanism Vomiting LOC Amnesia Other injuries NAI ```
310
Give 3 things to check on examination when a child presents with head injury
``` GCS/AVPU HR and BP Head examination - boggy haematoma Signs of skull fracture Neurological examination ```
311
Give 6 indications for head CT on head injury in children
Witnessed loss of consciousness >5 minutes Amnesia (antegrade or retrograde) >5 minutes Abnormal drowsiness ≥3 Discrete episodes of vomiting Clinical suspicion of non-accidental injury Post-traumatic seizure (no PMH of epilepsy) GCS <14 in emergency room (Paediatric GCS <15 if aged <1) Suspected open or depressed skull fracture or tense fontanelle Signs of base of skull fracture Focal neurological deficit Aged <1 - bruise, swelling or laceration on head >5 cm Dangerous mechanism of injury (high-speed RTA, fall from >3 m, high-speed projectile)
312
Define amblyopia
Poor vision in a structurally normal eye | E.g. if image from one eye is clearer, the brain will switch off the other blurrier eye and cause visual loss
313
By what age is most visual development complete?
7 years
314
Give 2 causes of amblyopia
Reduced view through eye - ptosis, cataract Unequal focus - one eye more long/short sighted (anisometropia) Misalignment of eyes - squint
315
How is amblyopia treated?
Occluding patch over stronger eye | Atropine eye drops
316
What are the 2 types of squint?
Inwards/esotropia/convergent | Outwards/exotropia/divergent
317
What is an important differentials to consider for squint?
Eye movement syndromes | Cranial nerve palsies
318
How is a squint managed?
Glasses (correct long-sightedness)
319
How do you know if a squint is fully or partially accommodative?
Fully - will correct fully with glasses | Partially - only partially corrected with glasses
320
Give 2 causes of leukocoria
``` Cataract Retinoblastoma Retinal detachment Toxoplasmosis Uveitis ```
321
What may be seen on examination of the eye in NF1?
Lisch nodules
322
What may be seen on examination of the eye in albinism?
Iris transillumination
323
What may be seen on examination of the eye in Marfan's syndrome?
Dislocated lens
324
What may be seen on examination of the eye in JIA?
Anterior uveitis
325
What is nasolacrimal duct obstruction?
Incomplete canalisation of the duct causing a sticky watery eye in the absence of conjunctivitis; resolves by 1 year
326
What is the most common type of permanent deafness?
Sensorineural
327
How are neonates screened for deafness?
Auditory brainstem response (ABR) screening
328
Give 3 acquired causes of deafness
Prenatal - toxoplasma, rubella, CMV Perinatal - hypoxia, kernicterus, aminoglycoside antibiotics Postnatal - meningitis, head injury, ototoxic drugs (e.g. cisplatin, antibiotics)
329
Give 2 congenital causes of deafness
Syndromic - Usher's, Pendred's, branchio-oto-renal, Jervell and Lange-Nielsen, Stickler's Non-syndromic - AR mutation in connexin 26 gap junction protein gene
330
How is deafness managed?
Cochlear implantation
331
What condition can cause a transient conductive deafness?
Otitis media with effusion (glue ear)
332
When is glue ear considered pathological?
Mucus fluid present for >3 months
333
How does the tympanic membrane look on examination in otitis media with effusion?
Dull Retracted Yellow/grey colour
334
How does conductive hearing impairment due to OME present?
Speech delay
335
How is hearing investigated in OME?
Audiometry - excludes sensorineural | Tympanometry - fluid pressure
336
How is OME managed?
Watch and wait Grommet insertion Removal of adenoids
337
What are the signs/symptoms of tonsillitis?
``` Prolonged sore throat Tonsillar exudate Fever Cervical lymphadenopathy Malaise ```
338
When is tonsillectomy advised for tonsillitis?
5 episodes per year over 2 years or 7 episodes in 1 year
339
What is the most common cause of nasal obstruction in pre-school children and what are its associations?
Physiological hypertrophy of adenoids | Snoring and green rhinorrhoea
340
When do adenoids spontaneously shrink?
6 years old
341
How is nasal obstruction due to adenoids managed?
Saline nasal douches | Adenoidectomy (severe)
342
What is the most common cause of nasal obstruction in school children and what are its associations?
Allergic rhinitis | Sneezing and clear rhinorrhoea
343
How is allergic rhinitis managed?
Topical nasal steroid spray | Oral non-sedating antihistamine
344
What is the most important thing to ask in the history of nasal obstruction?
Sleep quality
345
What can cause obstructive sleep apnoea in children aged 2-7?
Physiological hypertrophy of tonsils and adenoids
346
How can OSA be diagnosed?
Sleep studies - overnight pulse oximetry/12 channel polysomnography
347
Give 3 points to ask about in a sleep history when OSA is suspected
``` Sleep quality Snoring Breath holding during sleep Waking during the night Restless/sweaty at night ```
348
Give 3 causes of chronic stridor
Laryngomalacia (benign, self-limiting) Subglottic stenosis Airway haemangioma Tracheal stenosis
349
How is the cause of chronic stridor established?
Airway endoscopy
350
Give 2 causes of lumps/bumps in the head and neck area
Branchial lesions Thyroglossal cysts Dermoids
351
What is the most common cause of cervical lymphadenopathy?
Reactive lymphoid hyperplasia (infection)
352
What 2 types of cancer are common in the head and neck of children?
Lymphoma | Rhabdomyosarcoma
353
From what sources can information be gathered when carrying out a psychiatric assessment?
``` Interview parents/carers FH, PMH, PH Interview and observe child Other assessments - community paediatrics, psychologist, SLT, OT Educational attainment ```
354
What contextual factors should be taken into account for psychiatric assessment?
``` Ability of parent to meet child's needs Parental mental health Child's relationships with other family members Child's home environment Major life events ```
355
What are the 2 main groups of mental disorder a child may present with? Give examples
Internalising/emotional behaviour disorder (e.g. phobias, OCD, depression, psychosomatic complaints) Externalising/disruptive behaviour disorder (e.g. ADHD, conduct disorder, oppositional defiant disorder)
356
What are the biopsychosocial features of ADHD?
Restlessness, overactivity, inattentiveness, impulsivity Poor self-esteem, low mood, learning difficulties Poor peer and family relationships
357
How can ADHD be managed?
Stimulant (methylphenidate) or non-stimulant medication Therapy - individual, family Clubs/activities
358
How is ADHD diagnosed?
Careful evaluation of full history and observation | Features must occur in >1 setting
359
What is conduct disorder?
Group of behavioural problems where a child is aggressive (verbal or physical), antisocial and defiant to a much greater degree than expected for their age
360
What are the features of conduct disorder?
Violation of rights of others and social norms Fighting and physical cruelty (people and animals) Destructiveness (usually of property) Lying and stealing Violation of rules (e.g. truancy, running away from home)
361
What is the relevance of age in conduct disorder?
<10 years old = early onset conduct disorder | >10 years old = adolescent onset conduct disorder
362
What are the risk factors for conduct disorder?
Genetic - parent with antisocial personality disorder/who had CD Individual - difficult temperament Physical - problems processing social information/cues (e.g. disability, brain injury) Environmental - family/parenting problems, deprived area Emotional - depression, isolation
363
How are conduct disorders managed?
Group based parent training/education programmes | CBT
364
What is reactive attachment disorder (RAD)?
Hypersensitive to changes in their environmental circumstances due to their adverse early life experiences
365
What are the features of RAD?
Lack of emotional responsiveness Fearfulness and hypervigilance Aggressive or defiant behaviour Inhibition or hesitancy in social interactions Disinhibition or inappropriate familiarity or closeness with strangers RAD may be accompanying disorder of a child who shows a failure to thrive
366
What is the most common type of mental health disorder in children?
Anxiety disorders
367
What is PANDAS?
Paediatric autoimmune neuropsychiatric disorders associated with strep (A infection) - can cause OCD which presents suddenly
368
Give 7 signs/symptoms of depression in children
Appearing unhappy much of the time Outbursts of shouting, crying or unexplained irritability Having poor self-esteem, guilt or recurrent feelings of worthlessness Loss of interest/lack of pleasure in enjoyable activities Suicidal thoughts Spending a lot of time in bed but sleeping badly and experiencing early morning awakening Major changes in weight and appetite Headaches, stomach aches, tiredness and other vague physical complaints that appear to have no obvious cause.
369
When is medication used to treat depression in children?
Severe cases
370
Give 3 conditions associated with autism spectrum disorder
``` Depression Anxiety disorders (social, OCD) ADHD Learning disability Epilepsy GI (IBS) Tourette’s Genetic disorders ```
371
What is the ASD triad of impairment?
Social interaction Social communication Stereotyped behaviour/sensory sensitivites/restricted interests
372
What is the difference between autism and Asperger's syndrome?
Asperger’s syndrome - IQ is at least average and there was no language delay in early childhood Autism - IQ can be anywhere on the scale and there is a history of language delay
373
How is ASD managed?
``` Behavioural interventions SLT Appropriate schooling OT Medication for anxiety/aggression Education ```
374
What are tics?
Tics are sudden, involuntary, non-rhythmic motor movements or vocal productions which are purposeless, happen rapidly and are often repetitive in nature
375
What types of tics exist?
Simple motor - blinking, twitching Complex motor - facial grimace and head twist Simple vocal - grunt, cough Complex vocal - full words/sentences
376
What is Tourette's?
Combined vocal and motor tic disorder that can often persist into adult life
377
Give 2 behaviours occurring in anorexia nervosa
``` Intense fear of weight gain Obsession with eating Weighs self repeatedly State they are overweight and exercise excessively Counts or portions food carefully and may only eat certain foods Increased consumption of liquids Rigid meal or eating rituals May refuse to eat in front of others ```
378
What are the physical signs/symptoms of anorexia?
Weight loss Cessation of growth/arrested pubertal development Osteopenia Lanugo body hair, brittle nails and hair, dry skin Constipation/abdominal discomfort
379
What biopsychosocial developmental changes occur in early adolescence?
Bio - males (testicular enlargement), females (breast buds, pubic hair development) Psych - concrete thinking, moral concepts, awareness of sexual identity Soc - emotional separation from parents, peer identification, exploratory behaviours
380
What biopsychosocial developmental changes occur in mid adolescence?
Bio - males (sperm production, voice breaks, growth spurt), girls (menarche, change in body shape) Psych - abstract thinking, believe they are immortal, increasing verbal dexterity, fervent ideology Soc - continuing parental separation, heterosexual peer interest, early vocational plans
381
What biopsychosocial developmental changes occur in late adolescence?
Bio - males (continued growth in height) Psych - complex abstract thinking, increased impulse control, development of personal identity Soc - social autonomy, develop intimate relationships, develop financial independence
382
What tool should be used to take a history from an adolescent?
``` HEADS H - home life E - education A - activities D - drinking, driving, drugs S - sex, smoking, suicide ```
383
What is the sequence of puberty in females?
Breast development (8-12 years) -> pubic hair growth -> rapid growth spurt -> menarche (2.5 years after puberty starts)
384
What is the sequence of puberty in males?
Testicular enlargement -> pubic hair growth (10-14 years) -> height spurt (1.5 years after puberty starts)
385
Define delayed puberty
Absence of pubertal development by age 14 in girls and 15 in boys More common and benign in boys
386
Give 2 causes of delayed puberty
``` Constitutional delay Hypogonadotrophic hypogonadism (Crohn's, CF, anorexia, intracranial tumour, panhypopituitarism) Hypergonadotrophic hypogonadism (Turner/Klinefelter syndrome, trauma, chemotherapy, torsion) ```
387
How is delayed puberty assessed?
Male - pubertal staging, growth parameters, exclude chronic systemic disease Female - pubertal staging, growth parameters, karyotype, thyroid hormone, sex hormones
388
How is delayed puberty managed?
Reassurance Male - oxandrolone/low dose testosterone Female - oestradiol
389
Give 2 concerning features when considering sexual health of adolescents
``` Age <13 years Power imbalance Coercion Substance misuse Risk ```
390
Give 2 risk factors for STIs in adolescents
Avoidance of barrier contraception Multiple partners Mental illness Substance misuse
391
Give 2 risk factors for substance misuse in adolescents
``` Conduct disorder Poor parenting Early experience of substance misuse Peer group pressure Poor social environment ```
392
Give 2 negative effects of chronic illness in adolescents
``` Constitutional delay in growth/puberty Negative self-image Low mood Poor school attainment Poor peer development ```
393
How can transition from paediatric to adolescent services be optimised?
``` Inform adolescent and parents early Run specific teenage clinic Involve GP to maintain continuity Encourage adolescent to take charge Support and educate parents to allow adolescent to take over ```
394
In what situation would it be necessary to administer a drug by IM injection (which is usually avoided where possible due to pain)?
Benzylpenicillin should be given IM by GP in suspected meningococcal sepsis
395
Other than according to age and weight, how else can medications doses be prescribed?
Body surface area (e.g. aciclovir) using Boyd equation (back of BNF)
396
How does drug absorption differ in babies?
Gastric and bile acid secretion and intestinal motility are reduced in babies which affects bioavailability especially of acidic drugs
397
How does drug distribution differ in young children?
Higher percentage body weight is water and there is reduced plasma protein binding due to low albumin so higher doses of water soluble drugs are needed
398
How does drug metabolism differ in babies?
``` Immature liver enzymes Conjugation reactions (e.g. oxidation) are not developed until 1 year (limits drugs which can be used before 1 year) ```
399
How does drug metabolism differ in children 1-12 years old?
Faster than adults until 2 years and then slowly declines | May need to increase dose or frequency for drugs which undergo hepatic metabolism
400
How does drug excretion differ in babies and children?
Increased half-lives of renally excreted drugs; renal function complete at 6-8 months
401
Under what circumstances does a man have parental rights?
If they are listed on the birth certificate | If they are married to the child's mother
402
Who has parental rights in a same sex partnership?
Both if they were civil partners at time of conception | If not, they can apply for parental responsibility
403
At what age would a young person be considered unable to consent to sex and therefore it be considered statutory rape?
13 years of age

Year 5 (10 decks)

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