PAEDIATRICS Flashcards
(137 cards)
1
Q
What are the red flag symptoms in a child presenting with failure to thrive?
A
- Red features on traffic light
- Chronic diarrhoea
- Developmental delay
- Regression i.e. weight loss
2
Q
What are some differentials for a child presenting with failure to thrive? List as many as possible
A
- PRE-NATAL
- prematurity, maternal malnutrition, congenital infections, IUGR, Toxin exposure in utero - INTAKE ISSUES
- cerebral palsy, chronic GORD, pyloric stenosis - MALABSORPTION
- Cystic fibrosis, coeliac disease, Cow’s milk protein allergy, Lactose intolerance - METABOLIC DISORDERS
- Hypothyroidism, Diabetes mellitus - CONSTITUTIONAL DELAY
- Short parents, genetic predisposition - INADEQUATE FEEDS
- NEGLECT!
3
Q
When does GORD tend to present in children? What symptoms shall they have?
A
Typically develops before 8 weeks
- vomiting/regurgitation following feeds
4
Q
How are children with GORD managed?
A
- Position during feeds - 30 degrees head up
- Sleep on backs still (decreases risk of cot death)
- Ensure not being overfed + consider smaller, frequent feeds
- Trial of thickened formula or alginate therapy - but never both!
- Only use PPI or H2 antagonist if at least one of:
- Unexplained feeding difficulties
- Distressed behaviour
- Faltering growth - If severe complications (e.g. FTT) + medical treatment is ineffective fundoplication may be considered
5
Q
What are the 3 main consequences of cystic fibrosis?
A
- Thick pancreatic + biliary secretions = causes blockage of ducts, resulting in a lack of digestive enzymes (e.g. pancreatic lipase in digestive tract)
- Low volume thick airway secretions that decrease airway clearance resulting in bacterial colonisation + susceptibility to airway infections
- Congenital bilateral absence of vas deferens in males. They have healthy sperm but no way of getting from testes to ejaculate => male infertility
6
Q
What are the signs + symptoms of CF?
A
SYMPTOMS:
- Chronic cough, thick sputum, recurrent RTIs, steatorrhoea, abdo pain + bloating, child has concentrated salt in sweat, poor weight + height (failure to thrive)
SIGNS:
- Low weight/height on growth charts, nasal polyps, finger clubbing, crackles + wheeze on auscultation, abdominal distension
7
Q
How is cystic fibrosis diagnosed?
A
- Newborn blood spot testing picks up most cases
2. Chloride sweat test is gold standard (over 60mmol/L)
8
Q
How is cystic fibrosis managed?
A
- Chest physio several times/day to clear mucus + decrease risk of infection
- Exercise
- High calorie diet
- Creon tablets - to digest fats in pts with pancreatic insufficiency
- Prophylactic flucloxacillin
- Treat chest infections when they occur
- Bronchodilators
- Nebulised DNAse can be secretions less viscous + easier to clear
- Nebulised hypertonic saline
- Vaccinations - pneumococcal, influenza + varicella
9
Q
What monitoring is required in patients with CF?
A
Followed up in specialist clinics every 6 months
Require regular monitoring of sputum for colonisation
- screening also needed for diabetes, osteoporosis, vit D deficiency and liver failure
10
Q
What is the prognosis for patients with CF?
A
Life expectancy is IMPROVING + is currently is 47 years
- 90% develop pancreatic insufficiency
- 50% of adults with CF develop CF related diabetes
- 30% adults with CF develop liver disease
11
Q
How is coeliacs disease diagnosed?
A
Jejunal biopsy showing subtotal villous atrophy
- anti-EMA and anti-gliadin antibodies are useful screening tests
12
Q
What are the extra-intestinal features of IBD?
A
- Clubbing
- Erythema nodosum
- Pyoderma gangrenosum
- Episcleritis + iritis
- Inflammatory arthritis
- PSC (only really in UC)
13
Q
What investigations would you perform in a child with suspected IBD?
A
- Blood test for anaemia, infection, thyroid, kidney + liver function
- Faecal calprotectin
- Endoscopy (OGD + colonoscopy) with biopsy is gold standard
- Imaging - US, CT + MRI to look for complications
14
Q
How is UC managed in kids?
A
Inducing remission:
1st = aminosalicylates (mesalazine oral or rectal)
2nd = corticosteroids
If severe use IV corticosteroids (hydrocortisone)
Maintaining:
- aminosalicylates (mesalazine)
- azathioprine
- mercaptopurine
15
Q
How is Crohns managed in kids?
A
Inducing remission:
1st = steroids
2nd = add immunosupressant meds (azathioprine, methotrexate)
Maintaining:
1st = azathioprine/mercaptopurine
Alternatives = methotrexate, infliximab, adalimumab
16
Q
What investigations should be performed in children with suspected diabetes?
A
- Routine bloods
- Blood cultures
- Hb1Ac
- TFTs + TPO for thyroid condition
- tTG antibodies for coeliacs
- Insulin antibody, anti-GAD + islet cell antibody
17
Q
What are the red flag symptoms in a child presenting with a rash?
A
- Non-blanching rash
- Headache
- Neck stiffness
- Photophobia
- Generally unwell
18
Q
Give an example of a steroid for each level of the ladder (from mild to very potent)
A
Mild = Hydrocortisone 0.5%, 1% and 2.5%
Moderate = eumovate (clobetasone butyrate) 0.05%
Potent = Betnovate (betametasone 0.1%)
Very potent = Dermovate (clobetasol propionate 0.05%)
19
Q
What is guttate psoriasis?
A
Transient psoriatic rash frequently triggered by strep infection
- multiple red, teardrop lesions appear on body
20
Q
What are the 2 main types of contact dermatitis?
A
- Irritant contact dermatitis = common
- non-allergic reaction due to weak acids/alkalis
- often on hands
- erythema, crusting, (vesicles are rare) - Allergic Contact Dermatitis = type IV hypersensitivity
- uncommon, often seen on head following hair dyes
- acute weeping eczema
- treatment = topical potent steroid
21
Q
How do you manage seborrhoeic dermatitis on (i) scalp (ii) Face + body?
A
(i) OTC meds containing zinc pyrithione (head + shoulders) + tar (T gel Neutrogena)
(ii) Topical antifungals = ketoconazole
- topical steroids, best for short periods
- more tricky to treat, recurrence is common
22
Q
What is the infectivity period of VZV (chickenpox)?
A
Infectivity = 4 days before rash until 5 days after rash appeared
23
Q
How long should children remain off school if they have chickenpox?
A
Until all the lesions are dry + have crusted over
- usually about 5 days after onset of rash
24
Q
What are the clinical features of cellulitis?
A
Commonly on shins
- erythema, pain, swelling
- may be some associated systemic upset e.g. fever
25
How is cellulitis managed?
Diagnosis is CLINICAL
Mild/moderate = Flucloxacillin. If allergic to penicillin use clarithromycin, erythromycin (use in pregnancy) or doxycycline
Severe = co-amoxiclav, cefuroxime, clindamycin or ceftriaxone
26
What are the clinical features of CROUP?
Seal-like barky cough, stridor, respiratory distress
- symptoms worsen with agitation
- typically kids 6months to 3 years in late Autumn
27
How is croup diagnosed?
CLINICALLY
| - do NOT perform ENT exam as can precipitate worsening obstruction
28
How do you manage croup? (i) MILD (ii) MODERATE (iii) SEVERE?
(i) MILD (no stridor at rest)
1. Dexamethasone 0.15mg/kg
- review after 2-hours
- can repeat dose every 12 hours
(ii) MODERATE (stridor + sternal recession at rest)
1. Nebulised adrenaline 5ml 1:1000
2. Dexamethasone or Budesonide if severe hypoxia/vomiting/respiratory distress
(iii) SEVERE (agitation/lethargy)
1. Nebulised adrenaline 5ml 1:1000
2. Corticosteroids
3. Intubation if impending respiratory failure
29
What organism most commonly causes bronchiolitis?
Respiratory syncytial virus (RSV)
30
What are the symptoms of bronchiolitis?
At worst between days 3 and 5
- early symptoms = blocked/runny nose, cough + slightly high temp
- Signs of respiratory distress
- Dyspnoea, tachypnoea
- Poor feeding, fever less than 39 degrees
- Apnoeas = episodes where child stops breathing
- Wheeze + crackles on auscultation
31
How is bronchiolitis diagnosed?
Made clinically
| - if uncertain, immunofluorescence of nasopharyngeal secretions may show RSV
32
How is bronchiolitis treated?
SUPPORTIVE management. Should clear within 2-3 weeks
- ensure adequate intake of food + fluids
- saline nasal drops + nasal suctioning can help clear secretions
- oxygen if sats remain below 92%
- ventilatory support if required
33
What is the difference between viral induced wheeze + asthma?
VIW will:
- present before 3yrs age
- No atopic hx
- only occurs during viral infections
Note: asthma can be triggered by bacterial/viral infections but also has other triggers e.g. exercise, cold weather, dust + strong emotions
34
How is viral induced wheeze treated?
Managed the same as that for ACUTE ASTHMA
1. Salbutamol via spacer
2. Intermittent Montelukast and/or intermittent corticosteroids
35
What investigations are required to diagnose asthma in children?
1. Spirometry with reversibility testing in children over 5y
2. Direct bronchial challenge test with histamine or metacholine
3. Fractional exhaled nitric oxide
4. Peak flow variability - measured by keeping diary of measurements taken severe times a day for 2-4 weeks
36
How is asthma managed in under 5s?
1. SABA
2. SABA + 8-week trial of moderate dose ICS
- if symptoms did not resolve consider alterative ddx
- if symptoms stopped then returned within 4wks of stopping ICS, restart at low-dose ICS
- if symptoms resolved but return after more than 4wks, repeat 8-week trial again
3. SABA + low dose ICS + LTRA (Montelukast)
4. Stop LTRA + refer to paediatric asthma specialist
37
How is asthma managed in children aged 5-16 yrs?
1. SABA
2. SABA + low dose ICS
- if not controlled on previous step OR newly diagnosed asthma with symptoms for 3 or more times/week or night time waking
3. SABA + low dose ICS + LTRA (Montelukast)
- stop LTRA if it doesn't help
4. SABA + low-dose ICS + LABA
5. SABA + switch LABA/ICS to MART using low dose ICS
6. SABA + moderate dose ICS in MART
7. SABA + one of following options:
- increase ICS to high-dose
- trial additional drug (theophylline)
- advice from paeds asthma specialist
38
What are the most common causes of pneumonia in children?
Streptococcus pneumoniae
and
RSV
39
How is pneumonia managed in children?
7-day course of amoxicillin
- add macrolide (erythromycin/clarithromycin) if no response or chlamydia/mycoplasma
- if penicillin allergic give erythromycin or clarithromycin
Oxygen to maintain sats above 92%
40
What is bronchiectasis?
Permanent dilatation of bronchi due to destruction of muscular components of bronchial wall
- recurrent pulmonary infection leads to progressive bronchial damage
41
What are some risk factors for developing bronchiectasis in children?
1. CF
2. Immunodeficiency
3. Previous infections
4. Congenital disorders of bronchii
5. Alpha-1 antitrypsin deficiency
42
What is the gold standard investigation to diagnose bronchiectasis?
High-resolution CT
- dilatation of bronchi
- thickened airways
- cysts
43
How do you manage children with bronchiectasis?
1. Exercise + improved nutrition
2. Airway clearance therapy
3. Inhaled bronchodilator e.g. salbutamol
4. Inhaled hyperosmolar agent e.g. hypertonic saline (inh)
44
What can pseudomonas colonisation be treated with long term?
Nebulised tobramycin
45
What are the 3 shunts in a foetus which allow blood to bypass the lungs?
1. Ductus venosus = connects umbilical vein to IVC + allows blood to bypass liver
2. Foramen ovale = connects RA with LA + allows blood to bypass RV + pulmonary circulation
3. Ductus arteriosus = connects pulmonary artery with aorta + allows blood to bypass pulmonary circulation
46
What keeps the ductus arteriosus open?
Prostaglandins
47
What closes the ductus arteriosus?
Increase in blood oxygenation causes a DROP in prostaglandins
48
What are the characteristics of an innocent murmur? (HINT: the 5 S's)
1. Soft
2. Short
3. Systolic
4. Symptomless
5. Situation dependent - particularly if it gets quieter with standing or only appears when child is unwell/feverish
49
What are features of a murmur which would prompt further investigations + referral to paediatric cardiologist?
1. Murmur louder than 2/6
2. Diastolic murmurs
3. Louder on standing
4. Other symptoms e.g. failure to thrive, feeding difficulty, cyanosis or SOB
50
What are the differentials for a pan-systolic murmur in children?
1. Mitral regurgitation heard loudest at mitral area
2. Tricuspid regurgitation heard loudest at tricuspid area
3. VSD loudest at lower left sternal border
51
What are the differentials for an ejection systolic murmur in children?
1. Aortic stenosis - aortic area
2. Pulmonary stenosis - pulmonary area
3. HOCM - heard at 4th ICS on left sternal border
52
What murmur is it in an ASD?
Mid-systolic, crescendo-decrescendo murmur
| - with a fixed split second heart sound
53
What murmur is heard in PDA?
If small, heart sounds may be normal
- if significant, they cause a normal first heart sound with continuous crescendo-decrescendo 'machinery' murmur which may continue to second heart sound
54
What murmur is heard in tetralogy of fallot?
Murmur arises from pulmonary stenosis => ejection systolic murmur
55
What is Eisenmenger syndrome?
When the pulmonary pressure is greater than the systemic pressure, this reverses the shunt from a L to R to a right to left shunt across
- this causes blood to bypass the lungs, causing cyanotic heart disease
- can occur in ASD, VSD or PDA
56
What is the difference in shunts of blood flow in cyanotic and acyanotic heart disease? Give examples of conditions for each.
CYANOTIC = Right to left shunt
e.g. Tetralogy of Fallot, Ebstein's anomaly, transposition of great arteries, tricuspid atresia
ACYANOTIC = left to right shunt
e.g. PDA, ASD, VSD, Coarctation of aorta, aortic valve stenosis
57
What heart defect is Downs syndrome commonly associated with?
Ventricular septal defects
58
What heart abnormalities is Turner's syndrome associated with?
VSD + Coarctation of aorta
59
What are the 4 features which make up Tetralogy of Fallot?
1. VSD
2. Overriding aorta (= aortic valve placed further right than normal)
3. Pulmonary valve stenosis
4. RV hypertrophy
60
What are some differentials for paediatric convulsions?
1. Febrile convulsions
2. Reflex anoxic seizures
3. breath holding attacks
4. Epilepsy
5. Meningitis
6. Tuberous sclerosis
7. Hypoglycaemia
8. Vasovagal syncope
9. BPPV
61
In what conditions is there an increased risk of developing epilepsy?
1. Tuberous sclerosis
2. Cerebral palsy
3. Mitochondrial diseases
62
What are the symptoms of a focal seizure?
Start in a specific area on one side of the brain
- can affect hearing, speech, memory + emotions
- hallucinations
- memory flashbacks
- deja vu
- lasts a few mins
63
What medication is used for focal seizures?
1st = carbamazepine or lamotrigine
64
What medication is used to treat generalised seizures?
Sodium valproate 1st
| 2nd line = lamotrigine
65
When is a seizure classed as status epilepticus?
More than 5 mins duration of seizure or 3 or more seizures in an hour
- if febrile seizure, it lasts more than 30 mins to be status epilepticus
66
How do you manage status epilepticus?
```
In community:
- buccal midazolam or rectal diazepam
In Hospital:
- secure airway
- high flow O2
- assess CVS + RS
- check BMs
1st line = IV lorazepam
If seizures persist give IV phenytoin or phenobarbital
```
67
What is the antibiotic management for bacterial meningitis in patients under 3 months?
Cefotaxime plus amoxicillin
| - steroids may be given to reduce hearing loss + neuro damage
68
What is the antibiotic management for bacterial meningitis in patients over 3 months?
Cefotaxime or Ceftriaxone
69
What are contraindications to performing a LP?
- focal neuro signs
- papilloedema
- significant bulging of fontanelle
- DIC
- signs of cerebral herniation
70
What are the red flag features for a child presenting with developmental delay?
1. Red light features on traffic light
2. Loss of skill at any age
3. Not fixing/following objects
4. Cannot sit unsupported by 12 months
5. No speech by 18 months
6. Not standing by 18 months
7. Persistent toe walking
8. Loss of hearing
71
What are some differentials for causes of a delay in motor development?
- Normal variation e.g. children who are bottom shufflers or commando crawlers are more likely to develop walking skills later
- Cerebral palsy
- Duchenne's muscular dystrophy
- Down's syndrome, tuberous sclerosis
- Ricket's, hypoglycaemia
- Environmental = child always kept in cot or bedbound through illness
72
What is gowers sign?
Child uses hands to 'climb up' legs in order to stand up
| - sign of Duchenne's
73
What are some differentials for causes of a delay in speech + language development?
- Normal variation e.g. FHx of delayed language development
- Hearing troubles e.g. glue ear
- autism spectrum disorder = deficit in social interaction, communication + flexible behaviour
- Cleft palate
- Learning difficulties
- environmental deprivation + neglect
74
What are the red flags for paediatric vomiting?
1. Projectile vomiting
2. Less than 50% feeds taken
3. Absence of wet nappies
4. Red features on traffic light
5. Non-blanching rash
6. Symptoms of UTI
75
What are some differentials for paediatric vomiting?
- GORD
- Pyloric stenosis
- Intussusception
- Coeliacs
- meningitis
- gastroenteritis
76
What is the management plan for children with GORD?
1. Feed with 30 degree head tilt
2. Do not overfeed + try small more frequent feeds
3. Can try thickened formula OR alginate therapy (Gaviscon)
- cannot use both together!
4. PPI/H2RA
77
When would you use a PPI in a child with GORD?
- unexplained feeding difficulties e.g. refusing feeds, gagging, choking
- distressed behaviour
- faltering growth
78
What common biochemical abnormality is seen in pyloric stenosis?
Hypochloraemic, hypokalaemic metabolic alkalosis
| - due to persist vomiting
79
How is pyloric stenosis diagnosed?
Abdominal USS to visualise thickened pylorus
80
How is pyloric stenosis treated?
Laparoscopic pyloromyotomy
| - known as Ramstedt's operation
81
How does intussusception present?
Infants 6-18 months
- severe, colicky abdominal pain (every 10-20 mins)
- pale, lethargic + unwell child
- redcurrant jelly stool
- RUQ mass on palpation (sausage shaped)
- vomiting (rapidly becomes bile stained)
- intestinal obstruction
82
How is intussusception diagnosed?
USS (shows characteristic target sign) or contrast enema
83
How is intussusception managed?
Therapeutic enema, if this does not work then surgical reduction is required (or if bowel becomes gangrenous or perforated)
- Abx and analgesia
84
What age does coeliac disease tend to present in children?
peak at 9 months to 3 years (typically after weaning)
85
How does coeliac disease present?
- failure to thrive
- diarrhoea (steatorrhoea)
- fatigue
- weight loss
- mouth ulcers
- anaemia 2ndary to iron, B12 or folate deficiency
- dermatitis herpetiformis (= itchy blistering skin rash which you can get on the abdomen)
86
How is coeliac disease diagnosed?
1. Raised anti-TTG (1st choice)
2. Raised anti-EMA
3. Endoscopy with intestinal biopsy is gold standard
- crypt hypertrophy + villous atrophy
87
What antibiotics are used to treat bacterial meningitis in children under 3 months?
Cefotaxime plus amoxicillin
88
What antibiotics are used to treat bacterial meningitis in children over 3 months?
Cefotaxime OR ceftriaxone
89
What are some complications which can occur in children post-gastroenteritis?
- lactose intolerance
- IBS
- Reactive arthritis
- Guillain-Barre syndrome
90
What is the typical presentation of lactose intolerance in children?
Commonly post-viral infection + is short lasting (4-6wks)
- diarrhoea, excessive flatus, colic, peri-anal excoriation
- stool pH less than 5
91
What are the typical features of cows milk protein allergy/intolerance?
- vomiting + diarrhoea
- urticaria, atopic eczema
- colic = irritability, crying
- wheeze, chronic cough
rarely, angioedema + anaphylaxis may occur
92
How do you diagnose CMPA?
Diagnosis is often clinical (e.g. improvement with cow's milk protein elimination).
Investigations include:
- skin prick/patch testing
- total IgE and specific IgE (RAST) for cow's milk protein
93
How do you manage cows milk protein allergy/intolerance?
FORMULA FED:
- use hydrolysed formula milk
BREAST-FED:
- maternal exclusion required
94
What is the outlook/prognosis for children with cows milk protein intolerance/allergy?
- in children with IgE mediated intolerance around 55% will be milk tolerant by the age of 5 years
- in children with non-IgE mediated intolerance most children will be milk tolerant by the age of 3 years
A test of reintroduction can be done in hospital if high risk of anaphylaxis
95
How do you manage necrotising enterocolitis?
STOP milk feeds for 10-14 days
- insert NG tube on free draining
IV Abx for 10-14 days e.g. benzylpenicillin
- may need surgery
96
What are the clinical features of Henoch-Schonlein Purpura ?
- palpable purpuric rash (with localised oedema) over buttocks and extensor surfaces of arms and legs
- abdominal pain, typically colicky
- polyarthritis: short lived affecting large joints (knees, ankles, elbows)
- features of IgA nephropathy may occur e.g. haematuria, renal failure, proteinuria
- may also have malaena, haematemesis, intussusception, perforation, appendicitis
97
How do you manage HSP?
Condition is self-limiting - should resolve within 6 weeks
1. Analgesia for arthralgia e.g. NSAIDs
2. Steroids can help with abdominal pain + joints
3. Monitor for any renal failure if suspected
- around 1/3rd will relapse
98
What is the typical triad of features in haemolytic uraemic syndrome?
- acute kidney injury
- microangiopathic haemolytic anaemia
- thrombocytopenia
99
What investigations should be performed in suspected HUS?
1. FBC: anaemia, thrombocytopaenia, fragmented blood film
2. U+E - AKI
3. Stool culture
4. Looking for evidence of STEC infection (E.Coli 0157)
5. PCR for Shiga toxins
100
How do you manage HUS?
1. Treatment is SUPPORTIVE = Fluids, blood transfusion and dialysis if required
- NO role for antibiotics
101
What is the most common cause of diarrhoea in children aged 6 months to 5 years?
Toddlers diarrhoea
- reassure, dietary advice = increase fat intake, decrease milk + fruit juice consumption
- loperamide occasionally needed if severe
102
What is Hirschsprung's disease? Who does it tend to affect?
Aganglionic segment of bowel causing absence of co-ordinated peristalsis + functional intestinal obstruction at junction (transition zone)
- common in children with downs syndrome + in males
103
How does Hirschsprung's disease tend to present?
Usually within first few days of life with low intestinal obstruction i.e. failure to pass meconium, abdominal distension + billous vomiting
104
What investigations should be performed in Hirschsprung's?
1. AXR = distal intestinal obstruction
2. Rectal biopsy = GOLD STANDARD
- no ganglion cells in submucosa
105
How is Hirschsprung's disease managed?
1. Initially: rectal washouts/bowel irrigation
| 2. Definitive management: surgery to affected segment of the colon (single-stage pull through)
106
What are some GI + non-GI causes of constipation in children?
GI:
- Hirschsprung's disease
- Anal disease = infection, stenosis, ectopic, fissure
- Partial intestinal obstruction
- Food hypersensitivity
- Coeliac's
Non-GI:
- Hypothyroidism
- Hypercalcaemia
- Neuro diseases e.g. spinal disease
- Chronic dehydration (diabetes insipidus)
- Drugs (opiates, anticholinergics)
- Sexual abuse
107
How do you manage constipation in kids?
Increase oral fluid + fibre intake
- natural laxatives e.g. fruit juice + dried fruits
Regular 5 min toilet time after meals
- encourage + praise visiting toilet, could have scheduling visits, bowel diary or star chart
Medication can be used for disimpaction + maintenance
- treat for at least 3 months
- faecal softeners = movicol or lactulose
108
What is normal physiological jaundice?
Appears after 24hrs
- peaks around days 3-4 + usually resolves by 14 days
- due to immaturity of hepatic bilirubin conjugation but poor feeding can contribute
- foetal Hb breakdown high as has shorter lifespan, liver cannot cope with all bilirubin
109
What are some causes of jaundice which presents within the first 24h of birth?
- haemolysis from ABO incompatibility
- Rhesus disease of newborn
- Hereditary spherocytosis
- infection of mothers genital tract/amniotic fluid
- sepsis from TORCH infections
- severe bruising
110
How many days does jaundice have to be present to be prolonged? (HINT: different in term + pre-terms)
more than 14 days in term babies
| - more than 21 days in pre-term babies
111
What are some causes of prolonged jaundice?
- breastfeeding (benign, self-limiting, usually resolves by 12 wks)
- enclosed bleeding (cephalhaematoma)
- prematurity
- haemolysis
- sepsis (CMV, toxoplasmosis)
- hypothyroidism
- biliary atresia
- conjugated jaundice
- hepatic enzyme disorders (Crigler-najjar syndrome, lucy-driscoll disease)
112
What is kernicterus?
When bilirubin is greater than 360micromol/L + crosses blood brain barrier
- lethargy
- coma
- poor feeding
- fits
113
What investigations should you perform in a jaundices neonate?
1. Thorough hx + exam
2. Bloods: bilirubin, FBC, blood film, blood group, LFT, TFT
3. Blood culture
4. Coombs test
5. Urine dipstick - r/o sepsis
6. USS - r/o biliary atresia
114
In what condition do you see a double-bubble sign on abdominal x-ray? Who does this condition tend to affect?
Duodenal atresia
| - children with Down's syndrome, presents in first few hours after birth
115
How do you treat duodenal atresia?
Early = remove fluid from stomach via NG tube + give fluids IV
Definitive treatment is surgery (Duodenoduodenostomy)
116
How do you diagnose ITP?
FBC - low platelet count in isolation with otherwise normal results
Should exclude secondary causes:
- leukaemia, heparin induced thrombocytopenia
117
What information do you need to give to parents whose children have ITP?
Usually no treatment required + should return to normal within 3 months
- most severe bleeds tend to happen in first week + platelets under 20
- those with platelet count over 20 can return to school immediately. If below 20, can return in 1 week
- avoid contact sports whilst platelets below 50
- avoid holidays abroad for 3 months
118
What are the clinical features of Kawasaki disease?
1. High grade fever which lasts for more than 5 days + resistant to antipyretics
2. Conjunctival injection (red eyes)
3. Bright red, cracked lips
4. Strawberry tongue
5. Cervical lymphadenopathy
6. Red palms + soles, which later peel
119
How is Kawasaki disease diagnosed + managed?
Diagnosed clinically
- high dose aspirin
- IVIG
- Echo - used to screen for coronary artery aneurysm
120
What is still's disease? What are the clinical features?
Systemic onset JIA
- pyrexia
- salmon-pink rash
- lymphadenopathy
- arthritis
- uveitis
- anorexia/weight loss
121
What is enthesitis? What group of conditions is it associated with?
Inflammation of the point at which tendon of muscle inserts into bone
HLA-B27 conditions = psoriatic arthritis, reactive arthritis, IBD-related arthritis
122
What are the red flags in a paediatric limp presentation?
1. Nocturnal pain, night sweats, weight loss = ALL
2. High fever, holding leg abducted, not allowing internal rotation due to pain = Septic arthritis
3. High fever, non-weight bearing = osteomyelitis of femur/pelvis
4. Changing hx/unusual mechanism of injury = NAI
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Who does transient synovitis of hip tend to affect? When does it tend to occur?
2-12 yrs age.
2x as common in BOYS
- temporary inflammation secondary to viral URTI
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How is transient synovitis managed?
SELF-LIMITING
- Rest
- analgesia (ibuprofen)
F/U recommended at 7-10 days
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Who does Perthe's disease tend to affect? What is the underlying mechanism behind it?
4-8 yrs old
5x more common in BOYS
- caused by avascular necrosis of femoral head
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What are the clinical features of Perthe's?
1. Hip pain:
- onset over weeks
2. Limp
3. Stiffness and reduced range of hip movement
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What are the features on x-ray to indicate Perthe's disease?
Early changes = widening of joint space
| Later changes = decreased femoral head size/flattening
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How is Perthe's disease managed?
1) Treat Acute Pain + rest during acute exacerbation
2) Abduction plasters to keep femoral head in acetabulum if symptoms severe
3) UNDER 6 YRS = observation, non-surgical methods above
4) OLDER: surgical (containment/salvage) management with moderate results
- in children over 12 there is poor prognosis as limited remodelling potential
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Who does SUFE tend to affect? What is SUFE?
10-15 YRS
- obese + males
= Displacement of the femoral head epiphysis postero-inferiorly
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What clinical features are seen in SUFE?
1. Pain
2. Leg held in external rotation
3. Abnormal gait/limp- Trendelenburg gait
4. Decreased ROM
5. Weakness + muscle atrophy
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What is the diagnostic investigation for SUFE?
AP + lateral (typically frog leg) x-rays
| - Klein lines drawn along femoral neck do not intersect epiphysis
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How do you manage SUFE's?
INTERNAL FIXATION: typically a single cannulated screw placed in the center of the epiphysis
- done BILATERAL even if symptomatic on only one side
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What are risk factors for developmental dysplasia of the hip?
1. FHx of DDH
2. Breech baby
3. Female sex
- more sensitive to mothers hormones = ligaments lax
4. Fixed foot deformity
5. Torticollis
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What screening is performed for DDH?
Screening at newborn + 6-week check:
- Ortolani + Barlow tests
Positive if able to dislocate + relocate hip
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What are clinical features you will see on examination in DDH?
- leg length discrepancy
- limitations in hip abduction due to contractures
- Trendelenburg gait + toe walking
- Asymmetrical buttock creases
- hip locking/clicking
- pain
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What investigation(s) should be performed in DDH?
USS in infants under 4.5 months
| Older = AP pelvic x-ray
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How is DDH managed?
Most unstable hips will spontaneously stabilise by 3-6 weeks of age.
1. LESS THAN 6 MONTHS = Pavlik harness (dynamic flexion-abduction orthosis)
2. 6-18 MONTHS/FAILURE OF HARNESS
- closed reduction + spica casting
3. OVER 18 MONTHS/FAILURE OF ABOVE
- Surgery = open reduction + hip reconstruction
