Paediatrics

Question 1

Grading the severity of croup

Answer 1

Question 2

When should you consider admission for a child with croup?

Answer 2

• < 6 months of age
• known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
• uncertainty about the diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)

Question 3

Investigations for Croup

Answer 3

• Clinical Diagnosis
• CXR:
  
  • PA view shows subglottic narrowing (steeple sign)
  • Lateral view shows swelling of the epiglottis - the ‘thumb sign’

Question 4

Management of Croup

Answer 4

• Single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity
• prednisolone is an alternative
• Emergency treatment
  
  • high-flow oxygen
  • nebulised adrenaline

Question 5

Medical asthma management (5-16)

Answer 5

1. Short-acting beta agonist (SABA)
2. SABA + paediatric low-dose inhaled corticosteroid (ICS)
3. SABA + paediatric low-dose ICS + leukotriene receptor antagonist (LTRA)
4. SABA + paediatric low-dose ICS + long-acting beta-agonist (LABA)
5. SABA + switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a paediatric low-dose ICS
6. SABA + paediatric moderate-dose ICS MART
7. SABA + one of the following options:

increase ICS to paediatric high-dose, either as part of a fixed-dose regime or as a MART

• Consider trial of theophylline
• Seek advice

Question 6

How do you diagnose asthma?

Answer 6

FeNO

• in adults level of >= 40 parts per billion (ppb) is considered positive
• in children a level of >= 35 parts per billion (ppb) is considered positive

Spirometry

• FEV1/FVC ratio less than 70% (or below the lower limit of normal if this value is available) is considered obstructive

Reversibility testing

• in adults, a positive test is indicated by an improvement in FEV1 of 12% or more and increase in volume of 200 ml or more
• in children, a positive test is indicated by an improvement in FEV1 of 12% or more

Question 7

Definition of asthma

Answer 7

Episodic, reversible airway obstruction due to bronchial hyper-reactivity to a variety of stimuli.

Question 8

Conservative management of asthma

Answer 8

M TAME

General

• MDT: GP, specialist nurses, respiratory physician
• Technique for inhaler use
• Avoidance: allergens, smoke (ing), dust
• Monitor: Peak flow diary (2-4x/d)
• Educate
  
  • Liaise with a specialist nurse
  • Need for Rx compliance
  • Emergency action plan

Question 9

Features of acute asthma exacerbations

Answer 9

Anormal pCO2 in an acute asthma attack indicates exhaustion and should, therefore, be classified as life-threatening.

Question 10

Features of bronchiolitis

Answer 10

• coryzal symptoms (including mild fever) precede:
• dry cough
• increasing breathlessness
• wheezing, fine inspiratory crackles (not always present)
• feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission

Question 11

When should you definitely admit a child with bronchiolitis?

Answer 11

• Apnoea (observed or reported)
• Child looks unwell
• Severe respiratory distress
  
  • grunting
  • marked chest recession,
  • RR > 70 breaths/minute
• Central cyanosis
• Oxygen saturation

Question 12

When should you consider admission to a hospital for a child with bronchiolitis?

Answer 12

• RR > 60
• Difficulty with breastfeeding/ oral intake (50-75%)
• Clinical dehydration

Question 13

Management of bronchiolitis

Answer 13

• Humidified oxygen via a head box (for persistently < 92%)
• NG if refusing feeds
• Suction for excess secretions
• Consider palivizumab

Question 14

How do you manage respiratory disease caused by CF?

Answer 14

1st Line: Physio to mobilise secretions. VEST therapy (a vest which vibrates at high frequencies)

• Plus: Inhaled bronchodilator
• Plus: Inhaled mucolytic (hypertonic saline)
• Adj: Inhaled tobramycin for chronic Pseudomonas
• Adj: Inhaled corticosteroid
• Adj: Ivaftor- CFTR potentiator (increases the number proteins carried to the cell surface

​2nd Line: Lung transplant

Question 15

General management for CF patients

Answer 15

• high calorie diet, including high fat intake*
• patients with CF should try to minimise contact with each other to prevent cross infection with Burkholderia cepacia complex and Pseudomonas aeruginosa
• vitamin supplementation
• pancreatic enzyme supplements taken with meals

Question 16

How do you diagnose CF?

Answer 16

Sweat test

• Normal value < 40 mEq/l
• CF indicated by > 60 mEq/l

Causes of a false-positive sweat test

• malnutrition
• adrenal insufficiency
• glycogen storage diseases

Question 17

Features of intussuception

Answer 17

• Paroxysmal abdominal colic pain
• During paroxysm, the infant will characteristically draw their knees up and turn pale
• Vomiting
• Bloodstained stool - ‘red-currant jelly’ - is a late sign
• Sausage-shaped mass in the right upper quadrant

Question 18

Management of intussuception

Answer 18

• Reduction by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema
• Signs of peritonitis, surgery is performed

Question 19

Management of Coeliac disease

Answer 19

• Avoid gluten
• Dietician
  
  • wheat: bread, pasta, pastry
  • barley: beer
  • Rye and oat
• Vitamin supplementation
• Pneumococcal vaccines due to functional hyposplenism

Question 20

Biopsy of a patient with coeliac

Answer 20

• Crypt hyperplasia
• Villous atrophy
• Infiltrative lymphocytes

Question 21

Investigations and management of pyloric stenosis

Answer 21

• Ix: US, test feed
• Correction of hypochloraemic, hypokalaemic alkalosis
• Ramstedt pylorectomy

Question 22

Counselling for febrile seizure

Answer 22

• Occur between the ages of 6 months and 5 years
• Seen in 3% of children
• Usually occur early in a viral infection as the temperature rises rapidly
• Lasting less than 5 minutes
• If recurrences, try teaching parents how to use rectal diazepam or buccal midazolam.
• Parents should be advised to phone for an ambulance if the seizure lasts > 5 minutes
• Regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring

Question 23

Management of UTI

Answer 23

• <3 months old should be referred immediately
• >3 months old with an upper UTI should be considered for admission to hospital.
  
  • If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
• > 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin.
  
  • Parents should be asked to bring the children back if they remain unwell after 24-48 hours
• Antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs

Question 24

Vaccination counselling

Answer 24

• vaccination programme is very safe (almost all children have it)
• Protects child and other children
  
  • stops spread
  • stops short and long term consequences
    *

Question 25

Management of Migraine

Answer 25

* ibuprofen * NICE CKS recommends that triptans may be used in children \>= 12 years but follow-up is required * Sumatriptan nasal spay (licensed) is the only triptan that has proven efficacy but it is poorly tolerated by young people who don't like the taste in the back of the throat * it should be noted that oral triptans are not currently licensed in people \< 18 years * the GOSH: pizotifen and propranolol

Question 26

Causes of constipation

Answer 26

* dehydration * low-fibre diet * medications: e.g. Opiates * anal fissure * over-enthusiastic potty training * hypothyroidism * Hirschsprung's disease * hypercalcaemia * learning disabilities

Question 27

Management of constipation

Answer 27

* polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment * add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks * substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated * inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain

Question 28

Management of CMPA

Answer 28

* Continue breastfeeding * Eliminate cow's milk protein from maternal diet. * Consider prescribing calcium supplements for breastfeeding mothers whose babies have, or are suspected to have, CMPI, to prevent deficiency whilst they exclude dairy from their diet * Use eHF milk when breastfeeding stops, until 12 months of age and at least for 6 months