Paediatrics Flashcards
Theme: Developmental milestones - gross movement
A. 3 months B. 4-6 months C. 7-8 months D. 10-11 months E. 12 months F. 18 months G. 2 years H. 2 ½ years I. 3 years J. 4 years
For each of the following milestones select the average age at which a child attains the ability to perform the task
Sits without support
C. 7-8 months
Developmental milestones: gross motor
The table below summarises the major gross motor developmental milestones
Age Milestone
3 months - Little or no head lag on being pulled to sit. Lying on abdomen, good head control. Held sitting, lumbar curve
6 months - Lying on abdomen, arms extended, Lying on back, lifts and grasps feet. Pulls self to sitting. Held sitting, back straight, Rolls front to back
7-8 months - Sits without support (Refer at 12 months)
9 months - Pulls to standing, Crawls
12 months - Cruises, Walks with one hand held
13-15 months - Walks unsupported (Refer at 18 months)
18 months - Squats to pick up a toy
2 years - Runs, Walks upstairs and downstairs holding on to rail
3 years - Rides a tricycle using pedals. Walks up stairs without holding on to rail
4 years - Hops on one leg
Notes
the majority of children crawl on all fours before walking but some children ‘bottom-shuffle’. This is a normal variant and runs in families
Theme: Developmental milestones - gross movement
A. 3 months B. 4-6 months C. 7-8 months D. 10-11 months E. 12 months F. 18 months G. 2 years H. 2 ½ years I. 3 years J. 4 years
For each of the following milestones select the average age at which a child attains the ability to perform the task
Runs
G. 2 years
Developmental milestones: gross motor
The table below summarises the major gross motor developmental milestones
Age Milestone
3 months - Little or no head lag on being pulled to sit. Lying on abdomen, good head control. Held sitting, lumbar curve
6 months - Lying on abdomen, arms extended, Lying on back, lifts and grasps feet. Pulls self to sitting. Held sitting, back straight, Rolls front to back
7-8 months - Sits without support (Refer at 12 months)
9 months - Pulls to standing, Crawls
12 months - Cruises, Walks with one hand held
13-15 months - Walks unsupported (Refer at 18 months)
18 months - Squats to pick up a toy
2 years - Runs, Walks upstairs and downstairs holding on to rail
3 years - Rides a tricycle using pedals. Walks up stairs without holding on to rail
4 years - Hops on one leg
Notes
the majority of children crawl on all fours before walking but some children ‘bottom-shuffle’. This is a normal variant and runs in families
Theme: Developmental milestones - gross movement
A. 3 months B. 4-6 months C. 7-8 months D. 10-11 months E. 12 months F. 18 months G. 2 years H. 2 ½ years I. 3 years J. 4 years
For each of the following milestones select the average age at which a child attains the ability to perform the task
Rides a tricycle sing the pedals
I. 3 years
Developmental milestones: gross motor
The table below summarises the major gross motor developmental milestones
Age Milestone
3 months - Little or no head lag on being pulled to sit. Lying on abdomen, good head control. Held sitting, lumbar curve
6 months - Lying on abdomen, arms extended, Lying on back, lifts and grasps feet. Pulls self to sitting. Held sitting, back straight, Rolls front to back
7-8 months - Sits without support (Refer at 12 months)
9 months - Pulls to standing, Crawls
12 months - Cruises, Walks with one hand held
13-15 months - Walks unsupported (Refer at 18 months)
18 months - Squats to pick up a toy
2 years - Runs, Walks upstairs and downstairs holding on to rail
3 years - Rides a tricycle using pedals. Walks up stairs without holding on to rail
4 years - Hops on one leg
Notes
the majority of children crawl on all fours before walking but some children ‘bottom-shuffle’. This is a normal variant and runs in families
A 2-month old baby is admitted to the Paediatric Ward with persistent vomiting and failure to gain weight.
Bloods taken on admission show the following:
Na+ 136 mmol/l
K+ 3.1 mmol/l
Cl- 81 mmol/l
HCO3- 30 mmol/l
An ultrasound of the stomach and duodenum is performed:
What is the most likely diagnosis?
A. Duodenal atresia B. Pyloric stenosis C. Malrotation D. Gastro-oesophageal reflux disease E. Coeliac disease
B. Pyloric stenosis
The ultrasound demonstrates a thickened and elongated pylorus. The bloods also show a hypochloraemic, hypokalaemic alkalosis in keeping with the diagnosis.
Pyloric stenosis
Pyloric stenosis typically presents in the second to fourth weeks of life with vomiting, although rarely may present later at up to four months. It is caused by hypertrophy of the circular muscles of the pylorus
Epidemiology incidence of 4 per 1,000 live births 4 times more common in males 10-15% of infants have a positive family history first-borns are more commonly affected
Features
‘projectile’ vomiting, typically 30 minutes after a feed
constipation and dehydration may also be present
a palpable mass may be present in the upper abdomen
hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
Diagnosis is most commonly made by ultrasound
Management is with Ramstedt pyloromyotomy
A mother brings her 14-month-old son into surgery. Since yesterday he seems to be straining whilst passing stools. She describes him screaming, appearing to be in pain and pulling his knees up towards his chest. These episodes are now occurring every 15-20 minutes. This morning she noted a small amount of blood in his nappy. He is taking around 50% of his normal feeds and vomited once this morning. On examination he appears irritable and lethargic but is well hydrated and apyrexial. Abdominal examination is unremarkable. What is the most likely diagnosis?
A. Constipation B. Intussusception C. Gastroenteritis D. Meckel's diverticulum E. Volvulus
B. Intussusception
Intussusception describes the invagination of one portion of bowel into the lumen of the adjacent bowel, most commonly around the ileo-caecal region.
Intussusception is usually affects infants between 6-18 months old. Boys are affected twice as often as girls
Features
paroxysmal abdominal colic pain
during paroxysm the infant will characteristically draw their knees up and turn pale
vomiting
blood stained stool - ‘red-currant jelly’
sausage-shaped mass in the abdomen
Investigation
ultrasound is now the investigation of choice and may show a target-like mass
Management
the majority of children can be treated with reduction by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema. If this fails, or the child has signs of peritonitis, surgery is performed
A 2-month-old boy is brought to the afternoon surgery by his mother. Since the morning he has been taking reduced feeds and has been ‘not his usual self’. On examination the baby appears well but has a temperature of 38.7ºC. What is the most appropriate management?
A. Advise regarding antipyretics, to see if not settling
B. IM benzylpenicillin
C. Advise regarding antipyretics, booked appointment for next day
D. Admit to hospital
E. Empirical amoxicillin for 7 days
D. Admit to hospital
Any child less than 3 months old with a temperature > 38ºC is regarded as a ‘red’ feature in the new NICE guidelines, warranting urgent referral to a paediatrician. Although many experienced GPs may choose not to strictly follow such advice it is important to be aware of recent guidelines for the exam
Feverish illness in children
The 2007 NICE Feverish illness in children guidelines introduced a ‘traffic light’ system for risk stratification of children under the age of 5 years presenting with a fever. These guidelines were later modified in a 2013 update.
It should be noted that these guidelines only apply ‘until a clinical diagnosis of the underlying condition has been made’. A link to the guidelines is provided but some key points are listed below.
Assessment
The following should be recorded in all febrile children: temperature heart rate respiratory rate capillary refill time
Signs of dehydration (reduced skin turgor, cool extremities etc) should also be looked for
Measuring temperature should be done with an electronic thermometer in the axilla if the child is 50 breaths/minute, age 6-12 months; >40 breaths/minute, age >12 months • Oxygen saturation 160 beats/minute, age 150 beats/minute, age 12-24 months >140 beats/minute, age 2-5 years • Capillary refill time >=3 seconds • Dry mucous membranes • Poor feeding in infants • Reduced urine output
- Age 3-6 months, temperature >=39ºC
- Fever for >=5 days
- Rigors
- Swelling of a limb or joint
- Non-weight bearing limb/not using an extremity
Red - High risk
• Pale/mottled/ashen/blue
- No response to social cues
- Appears ill to a healthcare professional
- Does not wake or if roused does not stay awake
- Weak, high-pitched or continuous cry
- Grunting
- Tachypnoea: respiratory rate >60 breaths/minute
- Moderate or severe chest indrawing
• Reduced skin turgor
- Age =38°C
- Non-blanching rash
- Bulging fontanelle
- Neck stiffness
- Status epilepticus
- Focal neurological signs
- Focal seizures
Management
If green:
Child can be managed at home with appropriate care advice, including when to seek further help
If amber:
provide parents with a safety net or refer to a paediatric specialist for further assessment
a safety net includes verbal or written information on warning symptoms and how further healthcare can be accessed, a follow-up appointment, liaison with other healthcare professionals, e.g. out-of-hours providers, for further follow-up
If red:
refer child urgently to a paediatric specialist
Other key points include
oral antibiotics should not be prescribed to children with fever without apparent source
if a pneumonia is suspected but the child is not going to be referred to hospital then a chest x-ray does not need to be routinely performed
A 3-year-old girl is brought in by her mother. Her mother reports that she has been eating less and refusing food for the past few weeks. Despite this her mother has noticed that her abdomen is distended and she has developed a ‘beer belly’. For the past year she has opened her bowels around once every other day, passing a stool of ‘normal’ consistency. There are no urinary symptoms. On examination she is on the 50th centile for height and weight. Her abdomen is soft but slightly distended and a non-tender ballotable mass can be felt on the left side. Her mother has tried lactulose but there has no significant improvement. What is the most appropriate next step in management?
A. Switch to polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) and review in two weeks
B. Speak to a local paediatrician
C. Reassure normal findings and advise Health Visitor review to improve oral intake
D. Prescribe a Microlax enema
E. Continue lactulose and add ispaghula husk sachets
B. Speak to local paediatrician
The history of constipation is not particularly convincing. A child passing a stool of normal consistency every other day is within the boundaries of normal. The key point to this question is recognising the abnormal examination finding - a ballotable mass associated with abdominal distension. Whilst an adult with such a ‘red flag’ symptom/sign would be fast-tracked it is more appropriate to speak to a paediatrician to determine the best referral pathway, which would probably be clinic review the same week.
Wilms’ tumour
Wilms’ nephroblastoma is one of the most common childhood malignancies. It typically presents in children under 5 years of age, with a median age of 3 years old.
Features
abdominal mass (most common presenting feature)
painless haematuria
flank pain
other features: anorexia, fever
unilateral in 95% of cases
metastases are found in 20% of patients (most commonly lung)
Associations
Beckwith-Wiedemann syndrome
as part of WAGR syndrome with Aniridia, Genitourinary malformations, mental Retardation
hemihypertrophy
around one-third of cases are associated with a mutation in the WT1 gene on chromosome 11
Management nephrectomy chemotherapy radiotherapy if advanced disease prognosis: good, 80% cure rate
Histology
Histological features include epithelial tubules, areas of necrosis, immature glomerular structures, stroma with spindle cells and small cell blastomatous tissues resembling the metanephric blastema
A 6-month-old baby who was born in Bangladesh is brought to surgery. Around one week ago he started with coryzal symptoms. His mother reports he has not been feeding well for the past two days and has started to vomit today. Her main concern is a cough which occurs in bouts and is so severe he often turns red. No inspiratory or expiratory noises are noted. Clinical examination reveals an apyrexial child with a clear chest. What is the most likely diagnosis?
A. Bronchiolitis B. Mycoplasma pneumonia C. Pertussis D. Afebrile pneumonia syndrome E. Tuberculosis
C. Pertussis
The inspiratory ‘whoop’ is uncommon in patients this young.
Whooping cough (pertussis)
Overview
caused by the Gram negative bacterium Bordetella pertussis
incubation period = 10-14 days
infants are routinely immunised at 2, 3, 4 months and 3-5 years. Newborn infants are particularly vulnerable, which is why the vaccincation campaign for pregnant women was introduced
neither infection nor immunisation results in lifelong protection - hence adolescents and adults may develop whooping cough despite having had their routine immunisations
around 1,000 cases are reported each year in the UK
Features, 2-3 days of coryza precede onset of:
coughing bouts: usually worse at night and after feeding, may be ended by vomiting & associated central cyanosis
inspiratory whoop: not always present (caused by forced inspiration against a closed glottis)
persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope & seizures
symptoms may last 10-14 weeks* and tend to be more severe in infants
marked lymphocytosis
Diagnosis
per nasal swab culture for Bordetella pertussis - may take several days or weeks to come back
PCR and serology are now increasingly used as their availability becomes more widespread
Management
oral erythromycin to eradicate the organism and reduce spread
has not been shown to alter the course of the illness
Complications subconjunctival haemorrhage pneumonia bronchiectasis seizures
Vaccination of pregnant women
In 2012 there was an outbreak of whooping cough (pertussis) which resulted in the death of 14 newborn children. As a temporary measure a vaccination programme was introduced in 2012 for pregnant women. This has successfully reduced the number of cases of whooping cough (the vaccine is thought to be more than 90% effective in preventing newborns developing whooping cough). It was however decided in 2014 to extend the whooping cough vaccination programme for pregnant women. This decision was taken as there was a ‘great deal of uncertainty’ about the timing of future outbreaks.
Women who are between 28-38 weeks pregnant will be offered the vaccine.
*weeks, not days
At what age would the average child acquire the ability to walk unsupported?
A. 6-7 months B. 8-9 months C. 10-11 months D. 13-15 months E. 2 years
D. 13-15 months
Developmental milestones: gross motor
The table below summarises the major gross motor developmental milestones
Age Milestone
3 months - Little or no head lag on being pulled to sit. Lying on abdomen, good head control. Held sitting, lumbar curve
6 months - Lying on abdomen, arms extended, Lying on back, lifts and grasps feet. Pulls self to sitting. Held sitting, back straight, Rolls front to back
7-8 months - Sits without support (Refer at 12 months)
9 months - Pulls to standing, Crawls
12 months - Cruises, Walks with one hand held
13-15 months - Walks unsupported (Refer at 18 months)
18 months - Squats to pick up a toy
2 years - Runs, Walks upstairs and downstairs holding on to rail
3 years - Rides a tricycle using pedals. Walks up stairs without holding on to rail
4 years - Hops on one leg
Notes
the majority of children crawl on all fours before walking but some children ‘bottom-shuffle’. This is a normal variant and runs in families
A male child from a travelling community is diagnosed with measles. Which one of the following complications is he at risk from in the immediate aftermath of the initial infection?
A. Arthritis B. Pancreatitis C. Infertility D. Subacute sclerosing panencephalitis E. Pneumonia
E. Pneumonia
Subacute sclerosing panencephalitis is seen but develops 5-10 years following the illness. Pancreatitis and infertility may follow mumps infection
Measles
Overview RNA paramyxovirus spread by droplets infective from prodrome until 4 days after rash starts incubation period = 10-14 days
Features
prodrome: irritable, conjunctivitis, fever
Koplik spots (before rash): white spots (‘grain of salt’) on buccal mucosa
rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent
Complications encephalitis: typically occurs 1-2 weeks following the onset of the illness) subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness febrile convulsions giant cell pneumonia keratoconjunctivitis, corneal ulceration diarrhoea increased incidence of appendicitis myocarditis
Management of contacts
if a child not immunized against measles comes into contact with measles then MMR should be offered (vaccine-induced measles antibody develops more rapidly than that following natural infection)
this should be given within 72 hours
Which one of the following is the most common cause of nephrotic syndrome in children?
A. Minimal change disease B. IgA nephropathy C. Focal segmental glomerulosclerosis D. Chronic pyelonephritis E. Infantile microcystic disease
A. Minimal change disease
Minimal change glomerulonephritis nearly always presents as nephrotic syndrome, accounting for 80% of cases in children and 25% in adults. The majority of cases are idiopathic and respond well to steroids
Nephrotic syndrome in children
Nephrotic syndrome is classically defined as a triad of
proteinuria (> 1 g/m^2 per 24 hours)
hypoalbuminaemia (
A 5-year-old boy from a travelling community presents to the Emergency Department with breathing difficulties. On examination he has a temperature of 38.2ºC, stridor and a toxic looking appearance. A diagnosis of acute epiglottitis is suspected. Which one of the following organisms is most likely to be responsible?
A. Epstein Barr Virus B. Streptococcus pneumoniae C. Neisseria meningitidis D. Haemophilus influenzae E. Staphylococcus aureus
D. Haemophilus influenzae
Patients from travelling communities may not always receive a full course of immunisation
Acute epiglottitis
Acute epiglottitis is rare but serious infection caused by Haemophilus influenzae type B. Prompt recognition and treatment is essential as airway obstruction may develop. Epiglottitis was generally considered a disease of childhood but in the UK it is now more common in adults due to the immunisation programme. The incidence of epiglottitis has decreased since the introduction of the Hib vaccine
Features rapid onset high temperature, generally unwell stridor drooling of saliva
At what age would the average child start to smile?
A. Birth B. 2 weeks C. 6 weeks D. 3 months E. 4 months
Developmental milestones: social behaviour and play
The table below summarises the major social behaviour and play milestones
Age Milestone
6 weeks Smiles (Refer at 10 weeks)
3 months Laughs
Enjoys friendly handling
6 months Not shy
9 months Shy
Takes everything to mouth
Feeding
Milestone Age
May put hand on bottle when being fed 6 months
Drinks from cup + uses spoon, develops
over 3 month period 12 -15 months
Competent with spoon, doesn’t spill
with cup 2 years
Uses spoon and fork 3 years
Uses knife and fork 5 years
Dressing
Milestone Age
Helps getting dressed/undressed 12-15 months
Takes off shoes, hat but unable to replace 18 months
Puts on hat and shoes 2 years
Can dress and undress independently
except for laces and buttons 4 years
Play
Milestone Age
Plays ‘peek-a-boo’ 9 months
Waves ‘bye-bye’
Plays ‘pat-a-cake’ 12 months
Plays contentedly alone 18 months
Plays near others, not with them 2 years
Plays with other children 4 years
A 7-year-old boy is brought in to the GP surgery with an exacerbation of asthma. On examination he has a bilateral expiratory wheeze but there are no signs of respiratory distress. His respiratory rate is 36 / min and PEF around 60% of normal. What is the most appropriate action with regards to steroid therapy?
A. Oral prednisolone for 3 days B. Admit for intravenous steroids C. Give a stat dose of oral dexamethasone D. Double his usual beclometasone dose E. Do not give steroids
A. Oral Prednisolone for 3 days
Asthma in children: management of acute attacks
Children with severe or life threatening asthma should be transferred immediately to hospital.
Children between 2 and 5 years of age
Moderate attack
SpO2 > 92%
No clinical features of severe asthma
Severe attack
SpO2 140/min
Respiratory rate > 40/min
Use of accessory neck muscles
Life-threatening attack
SpO2 5 years.
Moderate attack SpO2 > 92% PEF > 50% best or predicted No clinical features of severe asthma
Severe attack
SpO2 125/min
Respiratory rate > 30/min
Use of accessory neck muscles
Life-threatening attack
SpO2 5 years 30 - 40 mg od 1-2 mg/kg od (max 40mg)
A 9-year-old boy is brought to surgery with recurrent headaches. What is the most common cause of headaches in children?
A. Migraine B. Depression C. Refractive errors D. Tension-type headache E. Cluster headache
A. Migrane
Migraine is the most common cause of headache in children
Headache in children
Some of the following is based on an excellent review article on the Great Ormond Street Hospital website.
Epidemiology
up to 50 per cent of 7-year-olds and up to 80 per cent of 15-year-old have experienced at least one headache
equally as common in boys/girls until puberty then strong (3:1) female preponderance
Migraine
Migraine without aura is the most common cause of primary headache in children. The International Headache Society (IHS) have produced criteria for paediatric migraine without aura:
A >= 5 attacks fulfilling features B to D
B Headache attack lasting 4-72 hours
C Headache has at least two of the following four features:
bilateral or unilateral (frontal/temporal) location
pulsating quality
moderate to severe intensity
aggravated by routine physical activity
D At least one of the following accompanies headache:
nausea and/or vomiting
photophobia and phonophobia (may be inferred from behaviour)
Acute management
ibuprofen is thought to be more effective than paracetamol for paediatric migraine
the use of triptans in children should only be initiated by a specialist
sumatriptan nasal spay (licensed) is the only triptan that has proven efficacy but it is poorly tolerated by young people who don’t like the taste in the back of the throat
orodispersible zolmitriptan (unlicensed) is widely used in children aged 8-years and older
side-effects of triptans include tingling, heat and heaviness/pressure sensations
Prophylaxis
the evidence base is limited and no clear consensus guidelines exist
the GOSH website states: ‘in practice, pizotifen and propranolol should be used as first line preventatives in children. Second line preventatives are valproate, topiramate and amitryptiline’
Tension-type headache (TTH)
Tension-type headache is the second most common cause of headache in children. The IHS diagnostic criteria for TTH in children is reproduced below:
A At least 10 previous headache episodes fulfilling features B to D
B Headache lasting from 30 minutes to 7 days
C At least two of the following pain characteristics:
pressing/tightening (non/pulsating) quality
mild or moderate intensity (may inhibit but does not prohibit activity)
bilateral location
no aggravation by routine physical activity
D Both of the following:
no nausea or vomiting
photophobia and phonophobia, or one, but not the other is present
