Paediatrics Flashcards
(120 cards)
1
Q
Murmur from patent ductus arteriosus
A
Continous Decresendo “machinery” murmur
2
Q
Murmur in tetralogy of Fallot
A
Pulmonary stenosis
Ejection systolic murmur (loudest at pulmonary area)
3
Q
Types of right to left shunt heart defects in children
A
Ventricular septal defect (VSD) Atrial septal defect (ASD) Patent ductus arteriosis Transposition of the great arteries Tetralogy of Fallot (includes VSD, overriding aorta, pulmonary valve stenosis and right ventricular hypertrophy)
4
Q
Which of the childhood heart diseases, actually causes cyanosis in children and why?
A
Transposition of the great arteries - because the right side of the heart pumps blood directly into the aorta and systemic circulation
Tetralogy of Fallot - as has right to left shunt (so blood doesn’t get oxygenated
5
Q
Risk factors for patent ductus arteriosus (PDA)
A
Rubella infection
Prematurity
6
Q
Signs of patent ductus arteriosus
A
Shortness of breath
Difficulty feeding
Poor weight gain
Respiratory tract infections
7
Q
Why does the patent ductus usually close in the first few days of life
A
Increased pulmonary flow which enhances prostaglandin clearance
Lack of prostaglandin results in closure of duct
8
Q
Management of patent ductus arteriosus
A
Indomethacin / Ibuprofen
These inhibit prostaglandin synthesis and help to close the connection
9
Q
Which genetic conditions are ventricular septal defects associated with?
A
Down’s syndrome
Turners syndrome
10
Q
Murmur heard in ventricular septal defect
A
Pan systolic murmur - prominently heard at left lower Sternal border in 3rd/4th intercostal space
11
Q
What is Eisenmenger Syndrome
A
Where you get a right to left shunt - causing cyanosis
It occurs secondary to either arterial/ventricular septal defect or patent ductus arteriosus (note these are usually non cyanotic heart defects). After 1-2 years of life these left to right shunts become right to left shunts due to the increases pressure in the pulmonary vessels and pulmonary hypertension
12
Q
What is the only definitive management of Eisenmenger syndrome
A
Heart-lung transplant
13
Q
Which genetic condition is coarction of the aorta associated with?
A
Turner’s syndrome
14
Q
Presentation of coarction of the aorta in neonates
A
Weak femoral pulses Systolic murmur - heard below the left clavicle Tachypnoea Poor feeding Grey and floppy baby
15
Q
How is severe coarctation managed in neonates
A
Prostaglandin - to keep open ductus arteriosus (so blood can get to systemic system distal to coarctation)
Emergency surgery - to correct the coarctation
16
Q
What is ebstein’s anomaly
A
Congenital heart condition associated with lithium in pregnancy
Abnormally shaped tricuspid valve - leads to larger right atrium and smaller right ventricle
Causes right to left shunt between right and left atria (ASD) causing cyanosis
17
Q
Cause of bronchiolitis
A
Respiratory syncytial virus (RSV)
18
Q
Common age of presentation for bronchiolitis
A
Children <1 year
Usually occurs in winter
19
Q
Pathophysiology of bronchiolitis
A
Inflammation and infection in the bronchioles (the small airways of the lungs)
20
Q
Presentation of bronchiolitis
A
Coryzal symptoms (snotty nose, sneezing, mucus, watery eyes) Signs of respiratory distress Dyspnoea Tachypnoea Poor feeding Mild fever (under 39) Wheeze and crackles on auscultation
21
Q
What are the signs of respiratory distress in children
A
Raised RR Use of accessory muscles of breathing - e.g, sternocleidomastoid, abdominal, intercostal Intercostal and subcostal recessions Nasal flaring Head bobbing Tracheal tugging Cyanosis (due to low oxygen sats) Abnormal airway noises - e.g, wheezing, grunting, stridor
22
Q
Reasons for admission to hospital in infants with bronchiolitis
A
Under 3 months
Pre existing condition - prematurity, Down’s syndrome, cystic fibrosis
Clinical dehydration
RR >70
Sats <92%
Moderate to severe respiratory distress signs
Apnoeas
Parents struggling/not confident managing at home
23
Q
Management of bronchiolitis in hospital
A
Supportive management
Adequate fluids - orally, NG or IV depending on severity
Supplementary oxygen - if sats <92%
Ventilatory support if required
NOTE: little evidence for nebulised bronchodilators, steroids or abx
24
Q
What is the monoclonal antibody given for prophylaxis against bronchiolitis
Which babies are given it?
A
Palivizumab
Ex-Premature babies and those with congenital heart defects
Given once monthly - as levels of circulating antibodies decrease over time
25
Differentiating between viral induced wheeze and asthma in children?
Viral induced wheeze:
- Presents before 3 years of age
- no atopic Hx
- only occurs during viral infections
26
Age of presentation of Croup
6 months - 2 years
27
Causes of croup
Parainfluenza virus (most common)
Influenza
RSV
28
Presentation of Croup
```
Increased work of breathing
“Barking” cough
Hoarse voice
Stridor
Low grade fever
```
29
Management of croup
Mild - managed at home
| Moderate-severe - oral Dexamethasone (prednisolone if dex is not available)
30
When to admit to hospital with Croup
Moderate/severe e.g, easily audible stridor at rest
Children <6 months
Patients with underlying conditions e.g, Down’s syndrome
31
Cause of epiglottitis
Why is epiglottitis not seen regularly anymore
Haemophilus influenza type B
Due to HiB vaccine given to children
32
Presentation of epiglottitis
```
Sore throat
Stridor
Drooling
High fever
Septic and unwell child
Scared and quiet child
```
33
X-ray of neck finding in epiglottitis
Thumb sign - looks like thumb pressed into the trachea (causes by oedematous and swelled epiglottitis)
34
Management of epiglottitis
Senior paediatrician and anaesthetics
| Secure the airway
35
What is laryngomalacia?
Where the supraglottic larynx is structured in a way that allows it to cause partial airway obstruction
36
Common age of presentation of laryngomalacia
6 months
37
Management of laryngomalacia
The problem usually resolves as the larynx matures and grows and is better able to support itself from flopping over the airway
Rarely tracheostomy or surgery may be needed
38
Cause of whooping cough
Bordetella pertussis
39
Presentation of whooping cough
Sudden and recurring attacks of coughing with free periods in between (paroxysmal coughing)
Loud inspiratory whoop when coughing ends
Apnoeas
Patients may cough so much they faint or vomit
40
Management of whooping cough
Notify public health
Supportive care
Macrolide abx e.g, erythromycin can be beneficial in early stages
Symptoms typically resolve within 8 weeks
41
What is chronic lung disease of prematurity (CLDP)?
Respiratory distress syndrome occurring in premature babies (those born before 28 weeks gestation)
42
What measure is taken to prevent chronic lung disease of prematurity (CLDP)
Giving corticosteroids (betamethasone) to mothers that show signs of premature labour (<36 weeks)
This can help speed up the development of the fetal lungs before birth and reduce the risk of CLDP
43
What is the number of people that are carriers of the cystic fibrosis gene in the UK
1 in 25
44
What is an early sign of cystic fibrosis in newborns
Meconium ileus - where meconium is not passed within the first 24 hours
This can present with abdominal distension and vomiting
45
How is cystic fibrosis usually diagnosed at birth?
What are the other ways of diagnosing it?
Using the newborn blood spot test
```
Sweat test (gold standard) - pilocarpine is applied to patch of skin and electrodes are passed through causing skin to sweat, this is then tested in the lab for chloride concentration
Genetic testing - can be performed in pregnancy by amniocentesis or chorionic villous sampling, or as a blood test after birth
```
46
Symptoms of cystic fibrosis
```
Chronic cough
Thick sputum production
Recurrent respiratory tract infections
Loose, greasy stools
Abdominal pain and bloating
Salty skin
Failure to thrive
```
47
Management of cystic fibrosis
Chest Physiotherapy
High calorie diet
CREON tablets - to help with pancreatic insufficiency
Prophylaxtic abx - flucloxacillin to prevent staph aureus
Bronchodilators
Nebulised DNase (dornase Alfa) - can help with secretions
Vaccinations - including pneumococcal, influenza and varicella
48
What are the two most common infections in cystic fibrosis to remember?
Staph aureus - patients take prophylactic flucloxacillin for this
Pseudomonas - once this is colonised it is particularly hard to treat
49
Life expectancy of a patient with cystic fibrosis
47 years
50
Differentials for vomiting in children
```
Gastro-oesophageal reflux
Pyloric stenosis
Gastroenteritis
Appendicitis
Intussusception
Meningitis
```
51
Management of gastro oesophgeal reflux in infants
Encourage small meals, avoid over feeding
Burning regularly to help milk settle
Keep baby upright after feeds
Can use gaviscon rich feeds or ranitidine liquid formula
52
Common causes of gastroenteritis in children
Rotavirus
Norovirus
E.coli (consider e.coli 0157 in bloody diarrhoea and HUS)
Campylobacter (travellers diarrhoea)
53
School isolation in gastroenteritis
Children need to stay off school until 48 hours after symptoms have completely resolved
54
Pathophysiology of coeliac disease
Autoantibodies produced in response to exposure to gluten
Autoantibodies then attack the epithelial cells of intestine and lead to inflammation in small bowel
Causes atrophy of the intestinal villi
Leads to problems with absorption
55
Symptoms of coeliac disease in children
```
Failure to thrive
Diarrhoea
Fatigue
Weight loss
Mouth ulcers
```
56
What is the rash associated with coeliac disease called?
Dermatitis herpetiformis - blistering skin rash typically occurring on abdomen
57
Which endocrine condition is closely linked with coeliac disease
Type 1 diabetes
58
What are the auto antibodies produced in coeliac disease
```
Tissue trans glutaminase (anti-TTG)
Endomysial antibodies (EMAs)
```
These are both types of IgA antibodies and so you must test levels of IgA antibodies first - as if these are low you may get a false negative
59
What is biliary atresia?
Congenital condition
Where section of bile duct is either narrowed or absent resulting in cholestatis
This results in accumulation of conjugated bilirubin
60
What is Hirschsprung disease?
Congenital condition
| Results in absence of nerve cells in the myenteric plexus in the distal bowel and rectum
61
How does Hirschsprung disease present?
```
Delayed passage of meconium after birth (>48 hours)
Abdominal distention
Vomiting
Chronic constipation
Failure to thrive/poor weight gain
```
62
How is Hirschsprung disease diagnosed?
Rectal biopsy - will show absence of ganglion cells
63
Management of Hirschsprung disease
Surgical removed of a ganglionic section of bowel
64
What is intussusception?
Where there is telescoping of the bowel - the bowel folds in on itself
65
What age does intussusception usually present?
Age 6 months - 2 years
66
Presentation of intussusception
```
Severe colicky pain
Pale, lethargic and unwell child
Red currant jelly stool
Sausage shaped mass in RUQ
Vomiting
Intestinal obstruction
```
67
Diagnosis of intussusception
USS - will show target sign
68
Management of intussusception
Theraputic enemas - can be used to try to reduce the intussusception
Surgical reduction may be necessary
69
Pathophysiology of pyloric stenosis
Hypertrophy (thickening) of the pylorus in the stomach
Prevents food from traveling into the duodenum
Infants usually present with projectile vomiting
70
Blood gas seen in pyloric stenosis
Hypochlorite metabolic alkalosis - as the baby is vomiting up HCL from the stomach
71
Management of pyloric stenosis
Laparoscopic pyloromyotomy (Ramstedt’s operation)
72
When would you investigate further in UTIs in children?
All children under 6 months with first UTI - USS within 6 weeks
Children with recurrent UTIs - USS within 6 weeks
Children with atypical UTI - USS during illness
DMSA scans should be used 4-6 months after the illness to assess for damage from recurrent or atypical UTIs
73
What is a DMSA Scan
Dimercaptocuccinic acid scan - involves injecting radioactive material (DMSA) and using a gamma camera to assess how well the material is taken up by the kidneys
Where there are patches of the kidney that have not taken up the material - this indicates scarring that may be as a result of a previous UTI
74
What is vesico-ureteric reflux (VUR)?
Where there is a backflow or urine from the bladder into the ureters
This predisposes children to developing UTIs and subsequent renal scarring
75
How is vesico-ureteric reflux diagnosed?
Using a micturating cystourethrogram (MCUG)
- contrast injected into bladder and taking a series of X-ray films to determine whether the contrast is refluxing back into the ureters
76
How is vesico-ureteric reflux managed?
Avoiding constipation
Avoiding excessively full bladder
Prophylactic abx
Surgical input from paediatric urology
77
Difference between primary and secondary nocturnal enuresis
Primary - where the child has never managed to be consistently dry at night
Secondary - where the child has previously been dry for at least 6 months
78
Causes of nocturnal enuresis
```
Overactive bladder
Psychological distress
Constipation
UTIs
Type 1 diabetes
```
79
Management of nocturnal enuresis
Lifestyle changes - reduced fluid in evenings, encouragement and positive reinforcement
Treat underlying factors - e.g, constipation
Enuresis alarms
Pharmacological treatment - e.g Desmopression
80
What are the different causes of neonatal jaundice?
```
Physiological Jaundice - e.g, in prematurity
Breast milk jaundice
Biliary atresia
Haemolytic disease of the newborn
Sepsis
G6PD deficiency
```
81
When would you be worried in neonatal jaundice?
If jaundice presents in first 24 hours following birth
| If jaundice persists >2 weeks following birth (>3 weeks for premature babies)
82
What is the pathophysiology of breast mild jaundice?
Components of breast milk inhibit the ability of liver to process bilirubin
Breast milk may lead to slowing of peristalsis in bowels - increasing reabsorption of bilirubin
83
Why is jaundice in newborns usually a normal physiological process ?
When would this be expected to end
Because fetus and neonate have less developed lever function
So there is a normal rise in bilirubin shortly after birth
Usually resolves by 10 days
84
Management of jaundice in newborns
Monitor unconjugated bilirubin levels
May require phototherapy
Extremely high levels may require exchange transfusion - removing the blood from the neonate and replacing it with donor blood
85
How does phototherapy work
Converts unconjugated bilirubin into isomers that can be excreted in bile and urine without requiring conjugation in the liver
86
What is the risk of excessive bilirubin levels in neonates
Kernicterus - type of brain damage caused by excessive bilirubin levels
87
Red flags in development milestones
Not able to hold object at 5 months
Not sitting unsupported at 12 months (should be 6 months)
Not standing independently at 18 months
Not walking independently at 2 years (should be walking by 15 months)
No words at 18 months (should be saying words by 1 year)
88
What is the age in which febrile convulsions present?
6 months - 5 years
89
What is the difference between cyanotic breath holding spells and reflex anoxic seizures
Cyanotic breath holding spell - LOC and seizure after child is really upset and crying so forget to breath
Reflex anoxic seizures - LOC and seizure after the child is startled
90
What is cerebral palsy?
Permanent neurological problems resulting from damage to the brain at around the time of birth
91
Causes of cerebral palsy
```
Maternal infections
Trauma during pregnancy
Birth asphyxia
Pre term birth
Meningitis in neonate
Severe neonatal jaundice
```
92
What are the different types of cerebral palsy?
Spastic - hypertonia due to damage to upper motor neurons
Dyskinetic - damage to basal ganglia
Ataxic - damage to cerebellum
93
Signs and symptoms of cerebral palsy in children?
```
Failure to meet milestones
Increased or decreased tone in limbs
Hand preference before 18 months old
Problems with feeding/swallowing
Problems with coordination, speech or walking
```
94
Management of cerebral palsy
Multidisciplinary:
Physiotherapy
Occupational therapy - adaptions to everyday living
Speech and language therapy
Medications - e.g, baclofen for spastic muscles
95
What is the most common type of muscular dystrophy?
Duchennes muscular dystrophy
96
What is the common sign seen in children which indicates muscular dystrophy?
Gower’s sign
Children using hands and knees to get from sitting to standing - this is because the muscles around pelvis are not strong enough to get their body up without help of arms
97
Genetic pattern of inheritance in duchennes muscular dystrophy
X-linked recessive
Defective gene for dystrophin - a protein which helps hold muscles together at the cellular level
98
Usual age of presentation of duchennes muscular dystrophy
Age 3-5 years
99
Life expectancy of patients with duchennes muscular dystrophy
25-35 years
100
Pathophysiology of cow’s milk protein allergy
IgE mediated
Hypersensitivity to protein in cows milk
More common in formula fed babies
Non allergic
101
Presentation of cows milk protein allergy
Presents before age of 1 - when switching from breast to formula milk (or through breastfed milk when mother is consuming dairy products)
GI symptoms - bloating, coming, diarrhoea
Allergic symptoms - hives, angioedema, cough, wheeze, sneezing, watery eyes, eczema
102
Diagnosis of cows milk protein intolerance
Skin prick testing
103
Management of cows milk protein intolerance
Breast feeding milk - avoid dairy
Replace formula with hydrolysed formulas - where proteins are already broken down so they don’t trigger immune response
Most children will outgrow cows milk protein intolerance by age 3 (often earlier) - so every 6 months infants can be trial on milk ladder e.g, malt milk biscuits and slowly build up towards diet containing milk
104
Features of kawasakis disease
```
Fever for more than 5 days
Strawberry tongue
Cracked lips
Cervical lymphadenopathy
Bilateral conjunctivitis
```
105
Management of kawasakis disease
High dose aspirin - due to risk of thrombus
| IV immunoglobulins - to reduce risk of coronary artery aneurysms
106
Infectivity of chicken pox
4 days before rash
| 5 days after rash first appeared
107
Presentation of chicken pox
Fever initially
Itchy rash starting on head/trunk and spreading
Systemic upset usually mild
108
Management of chicken pox
Keep child cool
Calamine lotion
School exclusion - until lesions are dry and have crusted over (usually around 5 days after onset of rash)
109
Why should you avoid taking NSAIDs in chicken pox
These can increase the risk of bacterial infection of the lesions
110
Clinical features of measles
Conjunctivitis
Fever
Koplik spots - white spots on buccal mucosa
Rash - starts behind ears then spreads to whole body (maculopapular rash)
111
Most common complication of measles
Otitis media
112
Features of scarlet fever
```
Fever - lasting 24/48 hours
Headache
Nausea/vomiting
Sore throat
Strawberry tongue
Rash - fine punctuate erythema (pinhead) generally on torso (described as having a sandpaper texture)
```
113
Management of scarlet fever
Abx - oral penicillin V for 10 days
114
Complications of scarlet fever
Otitis media
Rheumatic fever - 20 days post infection
Acute glomerulonephritis - 10 days post infection
115
How does threadworms usually present
Perinatal itching (particularly at night)
116
Management of threadworms
Hygiene measures for household
| Mebendazole (medication to treat worms) - single dose given to all household members
117
Virus causing roseola infantum
Human herpes virus 6 (HHV6)
118
Typical age of presentation in roseola infantum
6 months - 2 years
119
Presentation of roseola infuntum
High fever of rapid onset
Maculopapular rash starting on trunk and limbs
Febrile convulsions occur in 10-15%
120
Virus causing hand foot and mouth disease
Coxsackie A16
