Paediatrics Flashcards
1
Q
What is Autism Spectrum Disorder and when does it present?
A
- Behaviour beyond cultural norms
- Affects communication, social relatedness, movement, and interpersonal relations.
- Presents 2-4y
2
Q
Diagnosis of Autism Spectrum Disorder
A
At least 6 of:
- Failure to use eye contact, facial expression and body language
- Lack of socio-emotional repicoty
- Language delay
- Lack of spontaneously seeking to share enjoyment
- Failure to initiate and sustain conversation
- Stereotyped repetitive words
- No make believe play
- Regimented routines
- Failure to develop peer relationships
3
Q
Complications/ co-morbidities of autism
A
- Mental retardation
- Language delay
- ADHD
- Epilepsy (1/4)
- Learning and attention difficulties
4
Q
Investigations and managment of autism spectrum disorder
A
- Ix: Educational psychologist, information from school, SALT assessment
- Tx: Psychoeducation. MDT- paeds, school, SALT, OT. ?Respiridone ?melatonin to improve sleep
5
Q
What are the features of ADHD?
A
- = Neurodevelopmental disorder with Sx <7y in 2 different environments (home and school)
- Inattention - poor attention to detail, fails to engage with tasks, poor organisation, loses things, distracted, forgetful
- Impulsivity - Blurts out answers, fails to wait in line
- Hyperactivity - Fidgets, leaves seat when expected to sit, runs inappropriately, noisy, persistent pattern excessive motor activity
6
Q
ADHD Ix and Tx
A
- Ix: Conner’s questionairre, home/ school assessment
- Tx:
- Conservative: psychoeducation, involvement of parents, routine
- Medical: Psychostimulatns (eg methylfenidate) to improve concentration, non-stimulants (eg atomoxetine)
7
Q
What are the 2 patterns of attachment disorder and their features?
A
- Disinhibited- Result of institutional care and no main care giver. ++ friendly with strangers, overreactive
- Reactive- Result of abuse/neglect. Fearfullness and hypervigilance
8
Q
What is attachment disorder?
A
Abnormal social functioning that is aparent during 1st 5y of life, causing significant emotional disturbance. Persists into later childhood.
9
Q
Treatment of attachment disorder
A
- Support care givers
- Nurturing care setting
- Family therapy, play therapy
- High risk of other mental health conditions –> screen
10
Q
What are the main pathogens of pneumonia in different age groups of children?
A
- Newborn- Bacteria from genital tract eg Group B Strep
- Infants- RSV, Strep. pneumoniae, HiB
- >5y- S. pneumoniae, chlamydia pneumoniae
- Newborn= broad spectrum IV ABx
- Older infants- ?PO ABx
11
Q
What might you suspect in a child diagnosed with pneumonia with persistent fever despite 48h ABx?
A
?Parapneumonic effusion –> drainage w/ USS
12
Q
Indications for admission of a child with pneumonia
A
- Sats <93%
- Tachypnoea
- Respiratory distress
- Poor feeding
- <6 months
- Apnoeas
13
Q
How might a child with croup present?
A
- 6m-6y
- Often in Autumn
- Stridor
- Barking cough
- Temp >38.5
- Hoarse voice
- Often preceded by fever and coryza
- Respiratory distress and cyanosis
- DON’T EXAMINE THROAT- ?epiglottitis
14
Q
Croup- investigations and management
A
- Ix: O2 sats, NPA (parainfluenza)
- Tx: Usually home.
- Humidified air
- Dexametasone/pred PO
- NEB budesonide
- Adrenaline + o2 in severe
15
Q
How might a child with Bronchiolits present? + RF + organisms
A
- <2y
- RF: Prematurity, CF, congenital heart disease
- Organisms: RSV, S. pneumoniae, H. Influenzae
- Sx:
- Coryza –> dry cough –> SOB
- Poor feeding
- Apnoeas
- Crackles
- Hyperinflation
- Tachypnoea/Tachycardia
- Signs of resp distress
16
Q
Investigations and management of bronchiolitis
A
- Ix: Obs, NPA, CXR, ?ABG
- Tx:
- Conservative- Humidifies o2, NG
- Medical- IVT, ?trial bronchodilator
- NIV in severe
17
Q
What are the key features of Epiglottitis?
A
- ++ Unwell. DO NOT EXAMINE THROAT
- Rapid onset, no prodrome
- No cough
- Unable to drink, drooling, mouth open
- Temp >38.5C
- Stridor (soft)
- Unable to speak/cry
- –> Intubation and IV ABx eg cefuroxime
18
Q
Signs of respiratory distress in a child
A
- Tachypnoea
- Tachycardia
- Low GCS
- Nose flaring
- Recessions
- Sweating
- Stridor
- Wheezing
- Accessory muscles
- Grunting
- Cyanosis
19
Q
Presentation of inhaled foreign body
A
- Hoarse
- Cough
- Dysphonia
- Haemoptysis
- Stridor
- Wheeze
- SOB
- Cyanosis
- Apnoea (complete obstruction)
20
Q
Congenital heart disease: Types of non-cyanotic (L –> R shunt)
A
- Atrial septal defect
- Ventricular septal defect
- Persistent ductus arteriosus
- Coarction of aorta
- Aortic stenosis
21
Q
Atrial septal defect: Presentation, Ix, Tx
A
- Murmur- Ejection systolic, ULSE
- Sx- ASx, recurrent chest inf
- Ix: ECG (RAD), CXR (cardiomegaly), ECHO
- Tx: Surgery 3-5y with occlusion device
22
Q
Ventricular septal defect: Presentation, Ix, Tx
A
- Small <3mm: ASx, loud pansystolic murmur LLSE
- Large >3mm: quieter murmur. Sx- HF + SOB, FTT, recurrent chest inf, raised RR/HR
- Ix: ECG, CXR, ECHO. Cardiomegaly
- Tx: Small= none. HF= diuretics, ++ calories. Surgery 3-6m.
23
Q
Persistent Ductus Arteriosis (>1m): Presentation, Ix, Tx
A
- Presentation: Continual machinery murmur under L clavicle. Collapsing pulse. Usually ASx.
- Ix: CXR + ECG normal, seen on ECHO
24
Q
Coarction of the Aorta: Presentation, Ix, Tx
A
- Presentation: Systolic murmur. Day 1 normal. Day 2 neonatal circulatory failure. No femoral pulses
- Ix: Severe metabolic acidosis, CXR (cardiomegaly)
- Tx: Surgery/ stent. Prostaglandins
25
Aortic Stenosis in children: Presentation, Ix, Tx
* Presentation: Ejection systolic murmur in RSE --\> carotids. Most **ASx**. Exercise intolerance, chest pain, syncope.
* Ix: ECG (LV hypertrophy), CXR (cardiomegaly)
* Tx: Balloon valvotomy/ replacement valve
26
Congenital Heart Disease: Types of cyanotic (R --\> L shunt)
* Transposition of the great arteries
* Tetralogy of Fallot
* Hypoplastic L Heart syndrome
* Eisenmenger Syndrome
* Tricuspid atresia
27
Transposition of the Great Arteries: Presentation, Ix and Tx
* Cyanosis (++ Day 2) as DA closes
* Ix: ECG, CXR (narrow upper mediastinum), ECHO
* Tx: Prostaglandins, balloon septostomy
28
Tetralogy of Fallot: Presentation, Ix and Tx
* = Large VSD, overriding aorta, subpulmonary stenosis, RV hypertrophy
* Presentation: Harsh ejection systolic murmur LSE. Sx- cyanosis, irritable, SOB, pallor, cyanotic spells.
* Ix: CXR- boot shaped heart, ECG- RV hypertrophy, ECHO, catheterisation
* Tx: Surgery at 6m to close VSD and relieve RV obstruction.
29
Hypoplastic L heart syndrome: Presentation, Ix and Tx
* = Underdevelopment of L side --\> no flow through L side --\> no o2 to body. Rely on ductal circulation.
* Presentation: Profounf acidosis, rapid CVS collapse, weak/ absent peripheral pulses
* Tx- Surgery, prostaglandins
30
What is Eisenmenger Syndrome?
Large L-R shunt not treated early --\> pulmonary arteries thick and resistant. 10-15y shunt reverses --\> RHF, cyanosis
31
Causes of Heart failure in children
* Neonates- Obstructed systemic circulation, hypoplastic L heart syndrome, critical aorta stenosis, interruption of aortic arch
* Infants- Pulmonary hypertension, VSD, ASD, PDA
* Older children- R/L HF, Eisenmenger's, rheumatic heart disease, cardiomyopathy
32
Presentation of heart failure in children
* SOB - exertion/ feeding
* FTT
* Cyanosis
* Tachycardia/tachypnoea
* Murmur
* Enlarged heart
* Hepatomegaly
* Recurrent chest infections
* Poor feeding
* Sweating
33
BTS stepwise management for asthma in kids
* ALL THROUGH SPACER
* INH salbutamol PRN
* V. low ICS or montelukast in \<5y
* V. low ICS + LABA or montelukast \<5y
* Response to LABA - cont/stop/increase ICS. ?+montelukast
* Med dose ICS trial. Addition of theophylline. Refer.
* PO steroid, cont. med dose ICS. Refer.
* \*\* personalised asthma action plan \*\*
34
HR and RR parameters in severe asthma attack in kids
* RR:
* 2-5y: \>40
* 5-12y: \>30
* 12-18y: \>25
* HR:
* 2-5y: \>140
* 5-12y: \>125
* 12-18y: \>110
35
Key features of coeliac in children
* RF: T1DM, AI, Down's
* Presentation:
* 8-24m when weaning
* FTT
* Abnomal disstention
* Irritability
* Muscle wasting
* Abnormal stools
* Anaemia
* Ix: Anti-transglutaminase, biopsy
* Tx: GF diet. No wheat, barley or rye
36
What is CF and how does it present?
* = Autosomal recessive disease from Ch 7. Defective CFTR. Mutation= deltaF508
* Affects exocrine glands - resp tract, pancreas (lipase, amylase, protease), sweat glands.
* Presentation:
* Newborn - Dx on screening, meconium uleues
* Infant - prlonged neonatal jaundice, FTT, recurrent chest infections w/ HiB/Staph A (hyperinfaltion, creps, wheeze), malabsorption --\> steatorrhoea. Salty sweat --\> dehydration
* Young child - bronchiectasis, nasal polyps, sinusitis
* Adolescent - DM, cirrhosis, intestinal obstruction, finger clubbing, sterility in males
37
Ix and Tx of CF
* Ix:
* Bedside:
* Heelprick (high immunoreactive trypsinogen)
* Sputum sample
* Sweat test= Dx. ++Chloride
* Faecal elastase
* Bloods - LFTs
* Imaging - CXR
* Special - genetic testing, spirometry
* Tx: MDT!!!
* Cons- chest physio, psych, school support, exercise, vaccinations, high calorie diet, avoid other CF Pt
* Med- ABx, ?prophylactic ABx eg anti-pseudomonal INH, NEB hypertonic saline, creon, ursodeoxycholic acid, laxatives
* Surg- lung/ liver transplant
38
Childhood obesitity - definition, complications, Tx
* Overweight = BMI \>91st centile, obese = BMI \>98th centile
* Complications:
* SUFE
* Hypoventilation
* NAFLD
* PCOS
* T2DM
* HTN
* Higher risk obesity as adults
* Tx:
* Cons - healthy eating, physical activity, less TV etc
* Med/surg- ?orlistat in children \>12y with BMI\> 40 or \>35 w/ complications
39
Key features of allergic rhinitis in children
* Presentation:
* Seasonal
* Conjunctivitis
* Coryza/ discharge
* Cough/ sneezing
* Poor sleep and concentration
* Ix: IgE, skin testing
* Tx: Avoid allergens, antihistamines, topical steroids, immunotherapy, decongestants --\> montelukast?
40
Key features of mesenteric adenitis
* = Inflammation and swelling of LNs in abdo.Mimics acute appendicitis
* Presentation:
* Usually + viral infection
* Fever
* Malaise
* Central abdo pain
* N+V
* Diarrhoea
* Ix: Period of observation - will stay same/ get better
* Tx: Conservative - HWB, para, IVT
41
Paeds Development milestones
* Birth - 8w: Primitive reflexes, pull to sit, fix + follow, startles to noise, social smile
* 6m: sit without support, roll, palmar grasp, transfer hand-hand, babbles
* 9m: cruising, pincer grip, responds to name, stranger fear
* 12m: walks unaided, bricks x2, 3 words, waves "bye bye"
* 18m: runs + jumps, drawing, bricks x4, 1-6 words
* 2y: Throws ball, stairs 2 feet, bricks x8, 2 words together, eats with spoon
* 2.5y: kicks ball, draws horizontal line
* 3y: stairs 1 foot, draw circle, fork and spoon, shares toys
* 4y: draws shapes, complex instructions, bladder contol, dressing, eats skillfully
42
Paeds development limit ages
* Motor
* Head control- 4m
* Walking - 18m
* Fine motor + vision:
* Fix + follow- 3m
* Transfers- 9m
* Pincer grip - 12m
* Speech and language:
* Babble - 7m
* 6 words + meaning - 2y
* Social and emotional:
* Smile- 8w
* Feeds self - 18m
* Symbolic play- 2-2.5y
43
What is cerebral palsy and what causes it?
* = Chronic disorder of **movement** and/ or **posture**
* Cause= static injury of developing brain
* **80% antenatal**. **Vascular** occlusion, cortical migration, **structural** maldevelopment
* Genetic
* Congenital **infection**
* 10% **hypoxic ischaemic injury**
* Post-natal - meningitis, encephalitis, head **trauma**
44
Presentation of cerebral palsy
* Presentation:
* ?Hx prematurity/ hypoxic-ischeamic injury
* Presentation **\<2y** --\> persists
* Delayed **milestones**
* Abnormal limb/ trunk **posture**
* Feeding difficulties - incoordination, gagging, vomiting
* **Asymmetrical** hand function \<12m
* Primitive reflexes persist
* Abnormal gait
45
Clinical forms of cerebral palsy
* **Spastic** (90%): UMN. **Increased tone + brisk** reflexes. **Spasticity**. Paralysis. **Dysphagia**/ dribbling. Tip toe walking
* **Choreoathetosis**/ dyskinetic- invol, uncontrolled, stereotyped movements. Chorea (sudden)/ dystonia (twisting)/ athetosis (writhing). ++ tone awake, not asleep.
* **Ataxic**: **Genetic**. Reduced tone, poor balance. Dealyed motor development.
46
Ix and Tx of cerebral palsy
* Ix: MRI scan - pyramidal tracks
* Tx: MDT. Cons- physio. Movement and posture exercises, wheelchair, OT + aids, education
47
What is Down's syndrome and how does it present?
* **Trisomy 21**
* RF: FHx, maternal age
* Presentation:
* **Facial appearance** - round face, flat nasal bridge, epicanthic folds, brushfield spots on iris, small mouth, protruding tongue, small ears + low folded, flat occiput
* **Small** stature, short neck
* Single **palmar crease**
* Delayed **motor milestones**
* Learning difficulties
* **Hearing** impairment
* **Visual** impairment - cataract, swuint, myopia
* Reduced **tone**
* Hyperflexibility
* At higher risk of: leukaemia, solid tumour, hypothyroid, coeliac, **congenital heart defects (40%)**, epilepsy, dementia, duodenal atresia/hirschprung's,
48
Ix and Tx of Down's
* Ix:
* Antenatal - **beta-hCG, PAPA + nuchal translucency** --\> amniocentesis \>15w
* Suspect at birth - bloods + FISH
* Newborn screening in Down's - **cardiac**, feeding, vision, hearing, thyroid, haematological abnormalities
* Tx: MDT. Aim to reduce complications
* Cons- parental support
* Annual r/v - feeding, bowel, bladder, behavioural disturbance, vision, hearing, resp, cardio
49
Presentation of adenoidal enlargement in kids
* Adenoids enlarge until **8y**. Airway narrowing 2-8y
* Presentation:
* Difficulty **breathing**/ noisy
* Nasal voice
* Snoring
* Apnoeas
* Inc. otitis media
50
Intestinal obstruction in kids - presentation, causes, Ix and Tx
* Causes:
* Small bowel - duodenal **atresia**/ stenosis, volvulus, **meconium** plug, **Meckel's** diverticulum
* Large bowel - ileal atresia, **intussesception**, **Hirschsprung's**, meconium ileus, rectal atresia
* Presentation:
* Colicky abdo pain
* Bilious vomit
* Abdominal distention
* Absence of meconium
* Resonant bowel sounds
* Ix: USS, AXR
* Tx:
* Cons - NG tube, IVT , air enema
* Med - analgesia
* Surg
* Complications - dehydration, perforation, peritonitis
51
Constipation in children - causes, presentation, Ix and Tx
* Normal fequency:
* 1st week: 4/d
* 1st year: 2/d
* \>4y = Normal
* Causes:
* Babies - Hirschprung's, anorectal deformity, hypothyroid, hypercalcaemia
* Dehydration
* Immobility
* Toilet training/ stress
* Sx- abdo pain, infants sit in way to hold poo
* Ix- detailed dietary Hx, bloods
* Tx:
* Diet - increased fluid + fibre
* Behaviour training
* Warm water/ vaseline
* Abdo massage
* Med - laxatives
52
Key features of non-organic abdo pain in children
* Chemicals from brain/ gut --\> hypersensitivity
* Presentation:
* Older children
* Umbilical pain
* Acute/ insidious, constant/ fluctuating
* +/- dyspepsia, N+V, early satiety
* Psychogenic Sx es anxiety + depression
* Dx of exclusion
* Tx: reassurance, lifestyle, antispasmodics, TCAs
53
Common organisms of gastroenteritis in children
* **Rotavirus** - most common. Immunization.
* Bacterial more common \<2y. Include: Salmonella, campylobacter, shigella, E. coli, C. diff, cholera
* Transmission: faecal-oral. Water, meat, eggs, prev. cooked rice etc.
* Bacterial - ++ unwell, blood,
* Ix- stool sample, bloods, culture
* Tx- Usually supportive- IVT. ABx if ?sepsis
54
How does IBD present in children?
* As per adults. 1/4 present children/ adolescents.
* Faltering growth, pubertal delay
* UC- 90% pancolitis in children
* Systemic features - eyes, skin, arthritis, weight loss
55
GORD in children - presentation, Ix, Tx
* Common in infancy. Usually resolves by **12m**.
* Cause- inappropriate relaxation of **LOS** as a result of functional immaturity.
* Contributing factors - overfeeding, mainly fluid diet, horizontal posture
* Presentation:
* **Frequent, non-forceful regurg of milk**/ gastric contents
* Put on **weight**. Otherwise well.
* Ix:
* Usually clinical
* 24h oesophageal **pH** monitoring
* Endoscopy + oesophageal biopsy
* Tx:
* Parental reassurance. Feed at 30 degrees
* ?**Thickening** agents
* Serious --\> **ranitadine** (surg)
56
Pyloric stenosis - presentation, Ix, Tx
* = Hypertrophy of **pyloric muscle** --\> gastric outlet obstruction. M:F 4:1
* Presentation:
* **Projective vomiting**
* **Visible peristalsis**
* **Olive** shaped mass RUQ
* **Hunger** after feeding
* **Weight loss**
* **Dehydration**
* Hypokalaemia, hyponatraemia, alkalosis, low chloride
* Ix: Test feed +/- USS
* Tx:
* IVT - fluid + electrolyte correction
* Surg - pyelomyotomy. Post-op feed 6h --\> discharge 2h later.
57
Key features of overfeeding in infants
* Reccommended feding vol = **150mL/kg/24h**
* Presentation:
* **Weight gain**
* \>8 **heavily wet nappies**/ d
* Frequent **sloppy**, foul smelling bowel motions
* Extreme flatulance and belching
* Milk regurg
* Irritability + sleep disturbance
* Tx: education
58
Key features of food intolerance/ allergy in children
* Intolerance= hypersensitivity, allergy= IgE mediated
* Infants - milk/ egg (often resolve by 2y), peanut
* Children- peanut, tree nut, fish, shellfish. Persist.
* Presentation:
* IgE mediated- FTT, urticaria, swelling, anaphylaxis
* Non-IgE mediated - few hours later. D+V, FTT, abdo pain, eczema, colic
* Ix:
* Skin prick test - RAST for IgE
* 6-12m Sx free --\> controlled food challenge
* Tx:
* Cons- avoid food, educate on acute Tx
* Med- antihistamines, anaphylaxis Tx
59
Key features of lactose intolerance
* Commonly post-viral gastroenteritis eg **rotavirus**
* Rarely primary congenital lactase deficiency. Severe.
* Usually transient - 4-6w
* Older children - lactase levels decline --\> intolerance of varying severity
* Presentation:
* **Diarrhoea**
* **Flatus**
* Colic
* Peri-anal excoriation
* Stool pH \<5
* Tx: lactose-free formula milk. X soya milk \<6m
60
Key features of abdominal migraine
* Presentation: **4% paeds migraines!**
* **Nausea +/- vomiting**
* **Abdo pain**
* Pallor
* **Headaches**
* Anorexia
* Strong **FHx** of migraines
* Tx:
* **Dietary** - avoid citrus, choco, caffeine, solid cheese
* Drugs - **pizotifen, sumitriptan**, gabapentin, amitriptylline
61
Key features of cow's milk protein allergy
* = commonest allergy in infancy. Usually present **3m**
* Presentation: (depends where inflamm)
* Upper GI - **Vomiting**, **feeding** aversion, pain, regurg
* Small intestine - Diarrhoea, **abdo pain**, **FTT**
* Large intestine- acute **colitis** w/ blood + mucus
* Other - **wheeze**, chronic cough, urticaria, atopic eczema
* May occur in breast-fed infant when **mum** drinking milk
* Ix: Skin prick, IgE
* Tx:
* Limit cow's milk (+goats, soy) intake. Mum- no cow's milk
* ?Elemental formula
* After weaning, intro cow's milk protein free diet. ?Challenge after **6-12m**
* Majority resolve by **5y**.
62
Intussusception- definition, presentation
* = **Telescoping** of proximal bowel into distal segment. Esp **ileocaecal valve**.
* Presentation:
* **\<2y**. Peak 6-18m
* Pallor
* Draw knees up
* Palpable **sausage** shaped mass
* **Red current jelly stools**
* Vomit
* Intermittent colicky pain- 2-3mins --\> pale and floppy between.
63
Ix and Tx of intussusception + complications
* Ix: USS - **target** sign
* Tx:
* ABCDE + Resus - IVT
* Cons - **NG**, air enema
* Med - **ABx, analgesia**
* **Surg** - reduction
* Complications:
* Dehydration
* Venous obstruction
* **Small bowel obstrution** --\> perforation
* **Peritonitis** + gut perforation
* **Shock**
64
Hepatitis in children - causes, presentation, Ix, Tx
* Presentation:
* N+V
* Jaundice
* Malaise, anorexia
* RUQ pain
* Ascites
* Varices
* Hepatosplenomegaly
* Fulminant - Jaundice,
* Causes:
* Viral - hep A/B/C/D/E, EBV, HIV, CMV
* Poisons - paracetamol
* Wilson's
* AI hepatitis
* Reye's syndrome - **aspirin**
* Neonatal liver disease
* CF
* Ix: **LFTs**, glucose, viral serolosy, paracetmol level, Ix for AI/ hereditary liver disease
* Tx: supportive, IVT, manage sugar, haemorrhage, cerebral oedema
65
Febrile convulsions - Presentation, Ix, Tx
* Presentation:
* **6m-6y**, ?FHx
* Temp **\>39** eg viral illness
* Generalised **tonic-clonic** seizures
* **No focal signs**
* Brief **\<15m**. Quick recovery - should no longer be drowsy by 1h.
* Complex - Focal, \>15mins, \>1 ep in a day
* Ix: **Infection screen** - cultures, urine dip, LP. EXCLUDE MENINGITIS
* Tx: Self limiting
* Cons - **educate**: strip off, safe area
* Med- **antipyretics**
* **\>5 mins** --\> 999
* \>10mins= status epilepticus
* Risk of recurrence= 1/3. 2% --\> epilepsy
66
Presentation of brain tumours in children
* **Headache** - worse **lying** down/ in morning
* Confusion
* Morning **N+V**
* Fits/ **seizures**
* Recent change in **personality**/behaviour/ performance
* Weight loss/ **FTT**
* CN abnormality
* **Torticolis**
* **Incoordination**, loss of balance
* Gait change
* Eye changes
* Back pain
67
Ix and Tx of brain tumours in children
* Ix:
* Bedside - Obs, **fundoscopy** (?papilloedema), BMI, full **neuro** exam, head circumference, pubertal status
* Bloods - ?infection
* Imaging - **MRI**
* Special - LP, biopsy
* Tx: **Refer**! Same day if high risk
* Support of carers + of education
* Palliation
* Chemo/ radio/ surgery
68
Key features of neonatal epilepsy
* Presentation - lip smacking may be sign of seizure
* Ix-
* Bloods - FBC, CRP, glucose, electrolytes
* LP
* Tx:
* Phenobarbital
* Pyridoaxal phosphate
* Clonazepam
69
Key features of West Syndrome
* Triad of:
* Infantile **spasms** - short tonic contractions of trunk with upward elevation of arms
* **Developmental** delay/ regression
* **EEG** - hypsarrhythmia
70
Head injury in children - presentation, causes, Tx
* Haemorrhage in kids:
* Epidural - direct trauma
* Subdural - direct trauma/ **shaking**
* Presentation:
* ++ **Vomiting**
* ++ **Crying**
* ++ **Headache**
* Bulging **fontanalles**
* Seizures
* Reduced **GCS**
* ?Basal skull #
* Neck stiffness
* Neuro eg gait change
* Red flags for **NAI**: \<1y, skull haemorrhage, injury around eye
71
Ix and Tx of head injury in children
* Ix- bloods, CT head
* Tx:
* ABCDE
* Mild - home, written advice
* Severe - Resus, CT scan, neuro referral
* Med- analgesia, steroids, diuretics, anticonvulsants
* ?Surg
72
Treatment of migraines in children
* Dx after at least **5** attacks lasting 1-48h
* Features:
* Unilat or **bilat** in children, pulsatile, mod-severe, aggravated by routine activity.
* During attack - N+V, photo/phonophobia
* Cons - avoid **triggers**, hydration, reg meals/sleep
* 1st line - **Paracetamol**, **domperidone** (tx headache and nausea)
* Prophylaxis - if frequent enough to affect school. 1st line = **pizotofen** --\> propranalol --\> amitryptilline. Sumatriptan if \>12y
73
Meningitis organisms in children
* Organisms:
* Neonates - **GBS**, E. Coli, listeria monocytogenes
* Infants - **Hib**
* Older children - **N. Meningitidis**, S. Pneumoniae, Hib
* Ix- CT head, LP
* Tx- IM dexamethasone --\> IV cefotaxime + Ben Pen
74
Idiopathic Thrombocytopoenia- what is it? Presentation, Ix, Tx
* ITP = AI - type 2 hypersensitivity. Ab to surface **platelet** antigens secondary to viral infection --\> ++ bleeding
* Presentation:
* **Petechiae**/purpura
* Bruising
* Non-blanching rash
* **Bleeding** - nose, gums, haematuria, rectum
* Rare - intracranial bleed
* Ix:
* FBC (**isolated thrombocytopoenia** - platelets \<150)
* Blood film to exclude DDx
* DDx- leukaemia, sepsis, haemophila, NAI, aplastic anaemia
* Tx: Based on Sx
* No bleeding - **supportive**. Education on red flags
* Mild bleeding - **tranexamic acid**
* Specialist - steroids, IV immunoglobulins, splenectomy last resort
75
Henoch Schonlein Purpura - what is it? presentation, Ix, Tx
* = **Vasculitis**. **IgA** deposited in BVs. Triggers- **URTI** (90%)
* Classically in pre-pubertal boys
* Presentation: (Triad= Arthralgia, palpable purpura, abdo pain)
* **Abdo pain** - diffuse, colicky
* **Joint** pain/ swelling - esp lower limbs
* Palpable painless **purpura** on buttocks/ backs of legs. Gravity driven.
* Bloody diarrhoea
* **Renal** - microscopic haematuria +/- proteinuria
* Ix:
* Bedside- **urine** dip
* Bloods- FBC, U+Es
* Biopsy - crescentic IgA GN
* Tx:
* Cons- supportive, self-resolving
* Med- **NSAIDs** for joint pain
* Monitor protein + BP
76
NAI red flags
* Trigger usually inconsolable crying baby :(
* **Bruising** - immobile babies, buttocks, cheeks, upper arms, ears, abdo, feet, hands, neck, forearm
* **Scalding/ burns** - Post. location, well demarcated lines, sparing of creases, absence of splash marks, glove and stocking appearance
* **Bites**
* **Fractures** - metaphyseal fracture, rib, femoral
* **Shaken baby** - apnoea, retinal haemorrhage, seizure, irritability, lethargy, poor feeding, vomiting, subdural haematoma
* **Oral** injuries
* **DON'T ALLOW TO GO HOME**
77
Key features of measles
* = RNA Paramyxovirus
* Presentation:
* Rash- **macularpapular**, **palmar** sparing. Starts behind ears --\> spreads
* Prodrome- **4-5d cold** like Sx, cough, fever, conjunctivitis
* **Koplik** spots
* Ix: IgM, IgG
* Tx:
* **Notifiable** disease
* Supportive, isolation, prevent secondary infection
* Prevention - **MMR**
* Complications - otitis media, deafness, pneumonia, encephalitis
78
Key features of mumps
* = **Paramyxovirus**. Infective 7d before and 9d after parotid swelling
* Presentation:
* **Parotid** swelling
* Fever, headache, malaise, myalgia, anorexia
* +/- Erythematous rash on extensor surfaces
* Tx: Supportive. MMR vaccine = prevention
* Complications - liver involvement, encephalopathy, **infertility**
79
Key features of Rubella (German Measles)
= German measles. Incubation 2-3w
* Presentation:
* **Arthralgia**
* **Maculopapular rash** - pink macules
* Swollen tender **LNs**
* Fever
* Tx: Supportive. Prevention with MMR. Notifiable.
* Complications- artheritis, in utero malformations
80
Key features of Erythema Infectiosum (Fifth Disease)
* = **Parvovirus B19**
* Presentation:
* Usually quite well
* **Slapped** cheeks - firm, red, hot
* **Lace** pattern rash on limbs + trunk
* Slight fever
* Ix- IgM +ve
* Tx- supportive
* Complications with **pregnant** contacts - hydrops foetalis, death
81
Key features of chicken pox
* = **VZV**. Highly contagious between school children. Spreads through air/ skin.
* Presentation:
* **Vesicular** rash. Chest --\> spreads
* Fever
* Malaise
* Headache
* Tx: Usually supportive. **Aciclovir** in severe. Prevention= vaccine.
* **Shingles** = reactivation of VZV --\> dermatomal distribution.
82
Key features of Roseola
* = **HHV-6/7**
* Presentation:
* High **fevers**
* **Coryza**
* Irritability
* Rash - appears as recovery. Papular, red/pink, blanching. Starts trunk. Surrounding halo.
* Tx- supportive
* Complications - liver, encephalopathy
83
Key features of scarlet fever
* = **Strep pyogenes**. 2-4d incubation
* Presentation:
* Fever
* Rash - **Perioral** sparing. Palpable (**sandpaper**) on trunk and limbs
* Sore throat, irritability
* **Strawberry** tongue
* Tx: 10d **penicillin** V PO (alt azithromycin)
84
Key features of hand, foot and mouth disease
= Viral - **coxsackie**, enterovirus 71
* Presentation:
* **Ulcers** - mouth and tongue
* Sore throat
* Anorexia
* Temp \>**38**
* Red spots - **blisters on hands and feet**. **Vesicular** rash
* Tx: **self resolving** - 7-10d. Fluids, paracetamol.
85
Key features of transient synovitis
* 'Irritable hip'
* **2-12y**. Offen + viral infection
* Presentation:
* **Sudden** onset pain in **hip** w/ limp. Non-weight bearing.
* **No rest pain**
* Reduced **ROM**
* Pain may be referred to knee
* **Afebrile**, doesn't appear ill
* Ix: NEWS, bloods, joint **aspiration** if ?septic arthritis. Normal WCC, ESR, X-ray. USS - ?fluid in joint
* Tx: bed **rest** - improves in a few days
86
Key features of Perthes Disease
* 'Painless limp'
* = Transient **avascular necrosis** of femoral head due to interruption of blood supply --\> revascularisation + reosification over 18-36m.
* **Male** \> Female. 5-10y.
* Presentation:
* Insidious
* Limp
* Hip/ knee pain
* Bilateral 10-20%
* Antalgic **gait**
* Proximal thigh atropy
* Effusion
* Groing/ thigh **tenderness**
* Reduced **ROM**
* **Trendelenburg**
* Ix:
* **X-ray** both hips + frog views. Increased density in femoral head, fragmented and irregular
* **Bone scan**
* **MRI**
* Tx:
* NSAIDs, walking aids, physio
* Early + \<1/2 femoral head affected - bed rest and **traction**
* Late/ severe - maintain in **abduction** with **cast** - acetabulum acts as mould for re-ossification
* Higher risk of arthritis later in life.
87
Key features of SUFE
* = Slipped upper femoral epiphysis. Displacement of epiphysis of femoral head **postero-inferiorly**.
* **10-15y**. Esp **obese** adolescent boys. Associated with hypothyroidism/ hypogonadism.
* Presentation:
* **Limp**
* Hip/ knee **pain**
* Acute or insidious
* O/E reduction in **adduction + internal rotation**.
* Ix: X-ray inc frog and lat views
* Tx: ASAP to prevent avascular necrosis. **Surgical** fixation.
88
What is Juvenile Idiopathic Arthritis? + Types and presenatation
* = Persistent **joint swelling** **\>6w** presenting **\<16y** in absence of infection or other cause.
* Types:
* Polyarthritis - \>4 joints
* Oligoarthritis - upto 4 joints
* Systemic - + fever/ rash
* Presentation:
* Gelling - stiffness after long periods of rest
* Morning stiffness and pain
* Joint swelling
* Inflammation
* Long erm --\> bone expansion and valgus deformity
89
Management and complications of JIA
* Management: **Specialist** paeds rheum team
* Cons - continue sport at school unless flare
* Med -
* **NSAIDs**
* Joint **injections**
* **Methotrexate** - minimise joint damage. Weekly dose.
* Avoid systemic corticosteroids
* Biologics and immunotherapies
* 1/3 ongoing active disease into adult years.
90
Key features of UTI in children
* Presentation \<3m:
* Fever
* Vomiting
* Lethargy, **irritable**
* Poor feeding, **FTT**
* **Abdo pain**
* Offensive urine/ haematuria
* \>3m:
* Fever
* Frequency, dysuria, incontinence
* Abdo pain, loin tenderness
* Vomiting, diarrhoea
* **Poor feeding**, lethargy, irritable
* Recurrent --\> underlying cause eg **VUR**?
* Ix:
* Bedside- **urine** dip + culture
* Imaging
* Abdo **USS** if \<6m or atypical UTI
* **DMSA** isotope scan - renal morphology, structure and function. ?scarring
* **MCUG** - ?reflux
* **USS and DMSA on any child with proven UTI \<8y!!!**
* Tx: (NB to avoid long term damage).
* Mild - **nitrofuranroin**
* Severe - **IV cefuroxime/ gentamicin**
* VUR - prophylactic ABx
91
Key features of daytime enuresis in kids
* Lack of bladder control \>3y. Should be dry by day at **2y**.
* Causes: **neuropathic** bladder, **detrusor** muscle instability, bladder neck weakness, **UTI**, **constipation**, ectopic ureter
* Ix:
* Bedside - **Urine** dip + culture
* Imaging - **USS** - incomplete emptying, X-ray spine, ?MRI
* Special - ?urodynamics
* Tx:
* Cons - star charts, **bladder training, pelvic** **floor** exercises, portable alarm activated by urine
* Med- **oxybutinin**
92
Key features of nocturnal enuresis
* Should be dry by night at **3y**
* M:F 2:1
* Cause= **genetically** determined delay in sphincter competence. Most pyschologically and physiologically normal.
* Organic causes: **UTI**, **constipation**, **DM**
* Ix: **Urine** sample
* Management:
* **Cons** - explanation, star chart, supportive parents, no punishment
* --\> enuresis **alarm**
* Med - **desmopressin**
93
Key features of HUS
* = Haemolytic Uraemic Syndrome. 2 Types:
* Atypical - no diarrhoea
* Epidemic - **E. coli 0157** --\> toxins cause gastroenteritis and bloody diarrhoea
* Presentation:
* Prodrome - gastroenteritis w/ **bloody diarrhoea**
* Triad:
* **Thrombocytopoenia**
* **Microangiopathic haemolytic anae**mia
* **Acute renal failure**
* Pancreas - glucose intolerance, pancreatitis, jaundice
* Ix:
* Bedside - stool + urine C+S
* Bloods - culture, FBC, film, U+Es, LFTs, E. Coli PCR
* Tx: Early liason with paeds renal team
* Mainly **supportive**. Monitor and Tx electrolytes, fluid balance, nutrition, HTN
* **No ABx**
* ?Transfusion ?dialysis
94
Key features of neonatal 'small for dates' + risk after birth
* = Birthweight **\<10th centile** for gestational age. Usually small but normal. +/- Preterm +/- IUGR
* Low birthweight = **\<2.5kg**
* At birth liable to:
* Hypothermia
* Hypoglycaemia - poor fat/ glycogen stores
* Hypocalcaemia
* Polycythaemia
95
Neonatal intestinal obstruction - main causes
* Proximal - **duodenal atresia**, duodenal web, **annular pancreas**
* Distal - **Ileal atresia**, **intussusception**, **Hirschsprung's**, **meonium ileus** (CF), **meconium** plug syndrome, **anorectal** malformation
* Both - **volvulus**, pseudoobstruction, SOL (hernia, cyst, tumours)
96
Neonatal intestinal obstruction- presentation, Ix, Tx, complications
* Presentation:
* Vomiting - green
* Constipation
* Abdo pain/ tenderness
* Reduced appetite
* No wind/ stool
* Lethargy
* Distention
* Jaundice
* Dehydration/ sunken fontanalles
* Ix:
* NEWS
* Bloods
* USS, AXR/ CT
* Tx:
* Cons - NG tube, air enema
* Med - Analgesia
* Surg
* Complications:
* Dehydration and electrolyte imbalance
* Infection/ peritonitis --\> necrotising enterocolitis
97
Key features of Hirschsprung's Disease
* = Failure of ganglion cells to migrate to hindgut --\> lack of peristalsis. Congenital.
* Sx- no meconium passage, resistant constipation, green bile vomit/ obstruction
* Ix- AXR, rectal biopsy (no ganglion cells)
* Tx- Bowel washout, pull through operation.
98
Key features of Meckel's diverticulum
* = Persistence of embyronic **vitelline duct** --\> GI **bleeding**, **obstruction**, imflammation, umbilical discharge
* Tx: laparotomy, resection
99
Key features of intestinal atresia
* = Complete blockage of bowel. Rare in colon.
* Presentation:
* Well at birth
* --\> no passage of **meconium**
* --\> Intestinal **obstruction**
* Ix:
* Antenatal **USS**
* **AXR**
* Laparoscopy
* Tx:
* **NG** tube
* **Surgical**
100
Key features of neonatal hypoglycaemia
* Esp in 1st hour of life!
* RF: **IUGR/ macrosomia, DM** in mum, hypothermia, polycythaemia, ill
* Presentation:
* Jittery/ **irritable**
* **Apnoea**
* **Lethargy**/ drowsy
* Seizures
* Neonates tolerate well - utilise lactate and ketones
* Tx:
* Reg **BMs**
* IV **dextrose**
* Prevention= early feed.
101
Neonatal respiratory distress syndrome - RF, presentation, DDx
* Affects 1/2 babies **28-32w**
* Pneumocytes usually produce surfactant form 30w --\> more compliancy and don't collapse. Premature babies have insufficient **surfactant**.
* RF:
* **Premature**
* **DM** in mum
* **C-section**
* FHx
* Lack of antenatal steroids
* Peri-partum hypoxia
* Presentation: 4-6h
* **Apnoeas** + **hypoxia**
* Fatigue
* Signs of **respiratory distress**
* DDx: Transient tachypnoea of newborn (c-section, usually term), infection, MAS, pneumothorax, congenital heart disease.
102
Ix and Tx + prevention of neonatal respiratory distress syndrome
* Ix:
* Bedside - **O2** + obs
* Bloods - **ABG**, U+Es, glucose, LFTs, culture
* Imaging - **CXR**= ground **glass** appearance, **bell** shaped thorax, reduced lung vol, air **bronchograms**. RDS ruled out if normal CXR at 6 hours
* ECHO if ?heart disease
* Tx:
* Resus and stabilise + o2 (91-95%)
* **Surfactant replacement**
* **Supportive** - monitor bloods, obs, min handling, temps regulation, NG feed
* **NIV**
* Prevention - Mums given steroids if delivering \<34w gestation. ABx if PPROM or GBS
103
Complications of neonatal respiratory distress syndrome
* Acute:
* **Alveolar** rupture
* Pulm **haemorrhage**
* Procedure associated
* Patent ductus arteriosis
* Persistent pulm. **HTN**
* Chronic:
* **Bronchopulmonary dysplasia** = chronic lung disease. \>**28d**.
* **Retinopathy** of prematurity (sats too high)
* **Neurological** sequelae
* **Developmental** delay
* More prone to bronchiolitis
104
Key features of transient tachypnoea of the newborn
* = Lung fluid fails to resorb.
* **Term** babies, esp after **c-section**
* Presentation:
* **Tachypnoea**
* **Recessions**
* Nasal **flaring**
* **Grunting**
* +/- **cyanosis**
* Ix:
* CXR - **fluid** on horizontal fissure
* Tx: **Supportive**. Resolves 24h.
105
Key features of meconium aspiration syndrome
* 5% term babies with meconium stained liquor --\> MAS
* Hypoxia --\> peristalsis --\> reflex gasping --\> meconium aspiration --\> inhibits surfactant + pneumonitis
* RF: Foetal distress, post-term, maternal drug abuse
* Presentation:
* Meconium stained liquor
* Low Apgar score
* Resp distress- tachypnoea, cyanosis
* Ix:
* ECG - ?pulm hypertension
* Bloods - ABG (resp acidosis), U+Es, FBC, CRP, culture
* Imaging - CXR (patchy infiltrate, hyperinflation), lung USS
* Tx:
* Supportive - o2, airway suction, ventillatory support
* Med- surfactant replacement, broad spec ABx, +/- steroids and antisurfactants
* Usually subsides 2-4d. Increased risk of asthma.
106
Key features of hypoxic ischeamic encephalopathy
* = Brain injury due to perinatal **asphyxia**
* Causes:
* Maternal **HTN**
* Foetal compromise - **IUGR**, **anaemia**
* Placental failure - **abruption**
* **Umbilical** failure - cord prolapse, cord compression
* Failure to **breath** at birth
* Presentation:
* Mild - **irritability**, **hypoventilation**, hypertonia, poor feeding
* Mod - abnormal **movement**, hypotonia, **seizures**
* Severe - no spontaneous movements/ pain response, fluctuating **tone**, prolonged seizures, **multiorgan failure**
* Tx:
* **Resus** + stabilise
* Mild **hypothermia** - cooling therapy to reverse hypoxia
* Prog - mild recover completely, mod recovery by **2w** or long term issues, severe- mortality 30-40%, 80% **neurodevelopmental disability**
107
Key features of neonatal sepsis
_Early onset infection (\<48h)_
* Bacteria from birth canal - **GBS**, **listeria** monocytogenes
* RF: **PPROM**, chorioamnionitis
* Presentation- resp **distress**, apnoea, **temp instability**
* Ix - CXR, **septic screen**
* Tx- IV ABx: **BenPen, amox + gent**. At least 48h.
_Late Onset (\>48h)_
* Esp in **NICU** - catheters, tracheal tube, invasive procedures. Most common organism = **staphylococcus epidermidies**
* Presentation- Fever, resp distress, jaundice, seizures, neutropoenia, irritability, high or low glucose, shock, abdo distention, **temp instability**, vomiting, **bulging fonanalles**
* Tx: **Fluclox + gent** --\> vancomycin?
108
Newborn jaundice - why and what causes it?
* Haemolysis of FBC in first few days of life + hepatic bilirubin metabolism less efficient
* \<24h causes:
* **Haemolysis**= unconjugated
* **Rh/ ABO incompatibility** --\> haemolytic disease of the newborn
* **G6PD deficiency** - Esp Mediterranean, Middle East, Far East, S American
* Congenital **infection**
* 24h-2w causes:
* **Physiological**
* **Breast-milk** jaundice - more prolonged. Enterohepatic bilirubin
* **Infection** - less fluids, haemolysis
* **Dehydration**
* **Haemolysis**
* **Bruising** eg ventouse
* Polycythaemia - more RBCs being broken down
* Crigler-Najjar syndrome - inborn error of metabolism
* \>2 weeks causes (prolonged):
* **Physiological/ breast milk**
* **Infection**
* **Hypothryoid** - heel prick test
* Haemolytic anaemia
* High GI obstruction
* Bile duct obstruction
* Neonatal hepatitis
109
Causes of congenital infection = TORCH
* Toxoplasmosis
* Other - HIV, syphilis, measles
* Rubella
* CMV
* HSV
110
Ix and Tx of neonatal jaundice
* Ix:
* Bilirubin - heel prick
* Bilirubinometer - check severity
* Coomb's test - RBC clump?
* TORCH screening
* FBC - infection, RBCs
* Tx:
* Hydration
* 1st line - phototherapy. Break down bili.
* Exchange transfusion
* Tx underlying cause
111
What is Kernicterus?
* = Complication of neonatal jaundice. Bilirubin **neuro toxicity**. Unconjugated bilirubin \> albumin binding capacity --\> crosses **BBB**
* Presentation:
* Early - **Lethargy**, poor feeding
* Late - **Irritability, increased muscle tone**
112
Key features of haemorrhagic disease of the newborn
* AKA **Vit K deficient bleeding**. Vit K doesn't pass freely from Mum to baby and less Vit K in mum's milk after colostrum.
* Babies at risk: **\<37w**, **forceps**/ventouse/c-section, **hypoxia** at birth, maternal co-morbidity + **meds** in pregnancy (lower Vit K)
* Presentation:
* **Bleeding** eg heel prick test, umbilical cord
* **Bruising**
* Haematuria
* Bleeding after procedures
* Ix: Exam, obs, **coags**, **clotting** factors, **PIVKA** (non-carboxylated clotting factors)
* Tx:
* IVT
* **Vit K 1-2mg parenteral**
* **FFP** (10-20ml/kg) in life threatening
* Bloods **transfusion** - ifi shock
* Prevention - **single dose IM vit K at birth** (1mg IV Vit K for those at risk). PO version - birth, 2, 4 weeks.
113
What's involved in Heel Prick / Blood Spot test at 5d?
* Sickle Cell
* CF
* Congenital hypothyroidism
* Inherited metabolic diseases:
* Phenyketonuria
* Maple syrup urine disease
* Isovaleric acidaemia
* Gluteric aciduria type 1
* MCADD
* HCU
114
Key features of developmental dysplasia of hip
* 'Clicky hip' on newborn exam
* RF: F\>M, breech, FHx, 1st child, oligohydramnios, birth weight \>5kg
* O/E - Barlow and ortaloni test
* Ix- USS
* Tx- Most spont 3-6w, harness, surgery
115
Key features of laryngomalacia
* = Floppy epiglottis
* Noisy breathing --\> worse on **eating**. **Stridor**
* Tx- usually **self limiting**. Surgery if signs of resp distress/ FTT
