Paediatrics Pt. 5 Flashcards

Question

What is the management of Osgood-Schlatter syndrome?

Answer 1

- Rest: Avoidance of offending activity and other sports with strain on quadriceps. Aim is the achievement of pain-free state. - Medical: NSAIDs (pain relief/reduce inflammation). - Orthopaedic devices: Infrapatellar strap and in severe cases a knee immobiliser splint may be used. - Surgical: Excision of the mobile ossicle is rarely required (skeletally mature adults). - Rehabilitation: Quadriceps-stretching and hip extension exercises should be advised after the acute symptoms have resolved so as to reduce tension on the tibial tubercle.

Answer 2

- Non-union of the tibial tubercle - Patellar tendon avulsion - Continuing pain - Bony prominence.

Answer 3

- Benign self-limitng disease

Answer 4

- Avascular necrosis of the capital femoral epiphysis of the femoral head due to interruption of the blood supply - This is followed by revascularisation and reossification over 18-36 months

Answer 5

- Insidious onset - Limp or hip or knee pain - May initially be mistaken for transient synovitis

Answer 6

- If suspected, X-rays of both hips should be performed - Early signs include increased density in the femoral head, which subsequently becomes fragmented and irregular - Bone scan and MRI may be helpful

Answer 7

- Acute Pain - supporting care with simple analgesia - < 5 years - Mobilisation and monitoring (healing potential is good at this age) - Non-surgical containment using splints - 5-7 years - Mobilisation and monitoring - Surgical containment - 7-12 years - Surgical containment - Salvage procedure (remodel the acetabulum) - 12+ years - Salvage procedure - Replacement arthroplasty - Older children have a poorer prognosis

Answer 8

- Infection of the metaphysis of long bones - MOST COMMON sites: - Distal femur - Proximal tibia - However, any bone can be affected - Usually caused by haematogenous spread of a pathogen - It can arise from direct spread from an infected wound - Skin is swollen over the affected site - Sometimes osteomyelitis can spread to cause septic arthritis - Sickle cell disease is associated with an increased risk of staphylococcal and salmonella osteomyelitis - TB can cause osteomyelitis, especially in immunodeficient children

Answer 9

- Most infections are caused by Staphylococcus aureus - Other causes include: - Streptococcus - Haemophilus influenzae

Answer 10

- Markedly painful, immobile limb (pseudoparesis) - Acute febrile illness - Swelling and exquisite tenderness over the infected site - Movement of the limb causes severe pain - May be a sterile effusion of an adjacent joint - Back pain (vertebral infection) - Limp or groin pain (pelvis infection) - Occasionally there will be multiple foci - NOTE: osteomyelitis can also present insidiously or non-specifically in pre-verbal children

Answer 11

- Blood cultures (usually positive) - WCC and CRP are raised - X-rays are initially normal - After 7-10 days, subperiosteal new bone formation and localised bone rarefaction become visible - Ultrasound may show periosteal elevation at presentation - MRI allows identification of infection in the bone (subperiosteal pus and purulent debris in the bone) - Radionuclide bone scan may be helpful if the site of infection is unclear

Answer 12

- High-dose IV empirical antibiotics (usually for 2-4 weeks) - Once the patient has demonstrated clinical recovery and acute-phase reactants have returned to normal, patients can be switched to oral antibiotics - IMPORTANT: take blood cultures before starting antibiotics - The regimen should be altered once results of MC&S arrive - NOTE: in children who respond well, early transition to oral antibiotics (after 3 days to 1 week) may be considered - Affected limbs should be immobilised, analgesia should be given and associated comorbidities should be addressed - Surgical debridement may be necessary if there is dead bone or a biofilm

Answer 13

- Clinical assessment, disease staging (Cierny-Mader classification) and optimisation of comorbidities - Surgical debridement - IV antibiotics - Functional rehabilitation

Answer 14

- Unretractile foreskin secondary to either a physiological or pathological process.

Answer 15

- Physiological phimosis: The foreskin is not fully developed at birth. Unretractile foreskin may be normal until adolescence. Ballooning of the foreskin is a normal process that aids the breakdown of adhesions. Foreskin protects the glans whilst the neonate is incontinent of urine (ammoniacal). - Pathological phimosis: Most likely to be secondary to balanitis xerotica obliterans (BXO) which is a progressive fibrotic condition of unknown aetiology (may also affect the urethral meatus).

Answer 16

- Physiological: 50% of cases at 1 year of age, 90% by 3 years of age, and 99% by age 17. - Pathological: BXO = 0.6% (<15 years).

Answer 17

- General: Forceful retraction should not be attempted. Often the child will self-retract, allowing inspection. - Physiological: May have a history of ballooning and spraying of urine. Distal erythema (secondary to urine ammonia irritation). Should have a spout of mucosa as the foreskin is retracted. - Pathological: There is a white fibrotic ring at the distal foreskin. Absence of normal mucosal spout. Associated with pain +/- haemorrhage. - Balanitis: Often misdiagnosed. True balanitis involves oedema, erythema and generation of purulent material from the distal phimotic foreskin. - Investigations aren't normally required

Answer 18

- Conservative: Don't retract a foreskin. Variable results for the use of topical steroids for physiological phimosis. Gentle retraction with tissue drying in older boys may aid retraction and prevent ammonia irritation. - Preputial plasty: Small non-traumatic dorsal slit procedure to widen the meatus. - Circumcision: Only treatment for BXO. Usually performed under a GA with the sleeve dissection method. In neonatal ritual procedures, devices such as the PlastibellTM may be used.

Answer 19

- Pathological: Progressive phimosis and possible urinary retention. - Circumcision: Haemorrhage, infection, meatal stenosis, glans injury, urethrocutaneous fistula, anaesthetic risks.

Answer 20

- Physiological: Majority will retract with time. - Pathological: Advanced BXO may affect the urethral meatus and extend proximally which may require extensive reconstructive surgery

Answer 21

- Infection of the lung parenchyma.

Answer 22

- Neonates: Organisms from the female genital tract: group B haemolytic streptococcus, Escherichia coli and gram-negative bacilli, Chlamydia trachomatis - Infants–preschool children: - Viral (most common): parainfluenza, influenza, adenovirus and RSV. RSV can be particularly dangerous to ex-preterm infants and infants with underlying CLD of prematurity. - Bacterial: Streptococcus pneumoniae (90% of bacterial pneumonia). Staphylococcus aureus is uncommon but causes severe infection. - Older children–adolescents: As above, but also atypical organisms such as Mycoplasma pneumoniae and Chlamydia pneumoniae. TB should be considered at any age. - Aspiration pneumonia: Enteric gram-negative bacteria +/- Strep. pneumoniae, Staph. aureus - Non-immunised: Haemophilus influenzae, Bordetella pertussis, measles. - Immunocompromised (inherited or acquired): - Viral: CMV, VZV, HSV, measles and adenoviruses. - Bacterial: Pneumocystis carinii, TB.

Answer 23

- 29/10,000 children <5 years of age. 12/10,000 children <14 years of age. - Decreasing since the introduction of the conjugate pneumococcal vaccine in all children

Answer 24

- General: Fever, tachycardia, tachypnoea, cough, sputum (yellow, green or rusty in Strep. pneumoniae), vomiting particularly post-coughing, poor feeding, diarrhoea, preceding URTI (especially viral infections). - Signs of consolidation: decreased Breath sounds, dullness to percussion, increased tactile/vocal fremitus, bronchial breathing, coarse crepitations.

Answer 25

- CXR: Focal consolidation suggests a bacterial cause; diffuse consolidation bronchopneumonia suggests a viral cause. - Bloods: increased WCC, increased ESR/CRP, U&Es (SIADH), mycoplasma serology. - Urine: Pneumococcal antigen. - Microbiology: Blood and sputum MC&S. - Blood film: RBC agglutination by Mycoplasma (cold agglutinins; see Haemolytic anaemia). - Immunofluorescence/PCR: Can detect RSV on nasopharyngeal aspirate.

Answer 26

- Determine severity - Measure temperature - Examine chest - Record BP, HR and RR - Note the degree of agitation and consciousness - Note signs of exhaustion, cyanosis and accessory muscle use - Assess hydration status (capillary refill, examining skin turgor, dry mucous membranes and urine output) - Immediately refer to hospital if: - Persistent SpO2 < 92% on air - Grunting, marked chest recession, RR > 60/min - Cyanosis - Child looks seriously unwell, does not wake, or does not stay awake if roused or does not respond to normal social cues - Temperature > 38 degrees in a child < 3 months - Consider admission if: dehydration, decreased activity, nasal flaring, predisposing diseases (e.g. chronic lung disease) - Whilst awaiting hospital admission - Give controlled supplemental oxygen if SpO2 < 92% - If hospital admission is not needed - Most children can be managed at home - Prescribe antibiotics - IMPORTANT: all children with a clinical diagnosis of pneumonia should receive antibiotics because bacterial and viral pneumonia cannot be reliably distinguished from each other - NOTE: children < 2 yrs presenting with mild respiratory tract symptoms do NOT usually have pneumonia and do not usually require antibiotics - AMOXICILLIN is first-line for 7-14 days - Alternatives: co-amoxiclav, cefaclor or macrolides (e.g. erythromycin) - Macrolides can be added at any stage if there is no response to first-line treatment - Advice - Paracetamol or ibuprofen if the child is distressed by the fever (should NOT be given simultaneously but may be interchanged) - Advise adequate fluid intake - Advise parents not to smoke at home - Check on the child regularly through day and night - Seek medical advice if they are unable to cope or the child's condition deteriorates (e.g. signs of increased respiratory effort/distress, reduced fluid intake, reduced responsiveness, worsening or unresolving fever)

Answer 27

- Pleural effusion, empyema, lung abscess, septic shock, ARDS, ARF.

Answer 28

- Most resolve within 1–3 weeks; however, children with an underlying respiratory, cardiac, immune or neurological abnormality may respond more slowly to treatment, and have a higher mortality.

Answer 29

- Characterised by hypoalbuminaemia, proteinuria and oedema.

Answer 30

- All causes of glomerulonephritis (GN) can cause nephrotic syndrome. - Primary: Minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS) and membranous nephropathy (MN). - Secondary: SLE, post-infectious (group A b-hemolytic streptococcus, syphilis, malaria, TB, varicella, hepatitis B, HIV, EBV), collagen vascular disease, HSP, hereditary nephritis (Alport syndrome), sickle cell disease.

Answer 31

- Developed countries: 2–7/100,000/year (UK). MCD is the cause of nephrotic syndrome in 90% of children; most common in boys <5 years. Peak age: 2–4 years. - Developing countries: Infectious causes of GN: malaria (40%), HBV infection (6%) and group A b-haemolytic streptococcal infection (rare).

Answer 32

- General: Anorexia, lethargy, oliguria, hypertension. - GI: Diarrhoea, poor feeding, abdominal pain. - Oedema: Swelling of face, ascites, oedema of legs/scrotum. - Symptoms of complications: Infections, renal vein thrombosis, loin pain, haematuria.

Answer 33

- Bloods: U&E, decreased albumin, "ESR/CRP, lipid profile (secondary hyperlipidaemia). - Post-infectious nephropathy: Plasmodium falciparum (thick and thin blood films), ASOT, HBV/EBV/HIV serology, HIV PCR. - Urine dipstick: 3/4 + protein, microscopic haematuria. - MSU: MC&S. - 24-h urine collection: Creatinine clearance and 24-h protein excretion - Renal USS: Other renal diseases may cause proteinuria, e.g. polycystic kidney disease. - Renal biopsy: Ror older children with haematuria, "BP, renal impairment, steroid-resistant patients. - Doppler USS, renal angiogram, CT, MRI: If renal thrombosis is suspected.

Answer 34

- Symptomatic treatment: Limit oedema with low-sodium diet and diuretics. - Monitor: BP, U&E, Ca2+, weight, fluid balance. - Treatment of initial presentation: Longer duration (6 months) of initial prednisolone treatment is associated with fewer relapses and lower total prednisolone dose over the first 2 years. - Treatment of relapse: Prednisolone daily until in remission, then a slow gradual reduction of dosage. - Treatment of steroid-resistant patients: Alternate-day prednisolone with long-term cyclosporin or cyclophosphamide. Steroid-sensitive patients (85–90% cases) respond after 4 weeks, steroid-resistant (10–15% cases) have no remission after 4 weeks. - Treatment of hypertension: ACE inhibitors are the drug of choice. - Prevention of complications: Penicillin prophylaxis to prevent pneumococcal peritonitis and septicaemia, mobilisation/TED stockings to prevent thrombosis.

Answer 35

- Renal failure: secondary to hypovolaemia, diuretics or renal vein thrombosis. - Increased Infection risk: Peritonitis, pneumococcal infections due to urinary loss of Ig - Hypercoagulability: Renal vein thrombosis and DVT secondary to hypovolaemia, urinary loss of antithrombin III, protein C and S, increased synthesis of fibrinogen in the liver, immobility secondary to leg oedema and steroid therapy. - Hyperlipidaemia: Increased Synthesis of triglycerides and cholesterol with albumin in the liver.

Answer 36

- Steroids have improved prognosis but still is affected by complications and S/E of treatment.

Answer 37

- A significant deterioration in renal function occurring over hours or days, resulting in increased plasma urea, creatinine and oliguria. Complete recovery of renal function usually occurs within days/weeks.

Answer 38

- Pre-renal 1. Hypovolaemia (haemorrhage, GI losses, DKA, burns, diarrhoea, septic shock) 2. Cardiac failure (severe coarctation, hypoplastic left heart, myocarditis) 3. Hypoxia (pneumonia, RDS). - Intrinsic renal 1. Acute tubular necrosis (ATN) (80% of instrinsic renal causes) due to circulatory compromise or nephrotoxic drugs (paracetamol, aminoglycosides) 2. Acute GN (see chapter) 3. Acute interstitial nephritis (infection, drugs: NSAIDs, frusemide, penicillin) 4. Small/large vessel obstruction (renal artery/vein thrombosis, vasculitis, HUS, TTP). - Post-renal (obstructive) 1. Neuropathic bladder: may be acute in transverse myelitis, spinal trauma 2. Stones (bilateral pelviureteric junction or ureteral) 3. Urethral prolapse of bladder ureterocoele 4. Iatrogenic: catheters, stents, nephrostomy or surgery.

Answer 39

- 0.8/100,000 children

Answer 40

- Vomiting, anorexia, oliguria, convulsions, previous sore throat and fever (post-streptococcal GN), bloody diarrhoea and progressive pallor (HUS), drug history.

Answer 41

- Assess intravascular volume status: volume depleted (cool peripheries, tachycardia, postural hypotension) or overloaded (oedema, weight gain, pulmonary oedema) ? Is patient septic? Is patient obstructed? Examine abdomen for palpable bladder.

Answer 42

- Bloods: decreased Hb (hypovolaemia/haemorrhage), increased WCC, increased CRP, blood cultures (sepsis), increased urea, increased creatinine, increased K+ , increased phosphate, increased Ca2+ , decreased Mg2+, LFTs, venous capillary blood gas, clotting (DIC), ASOT (post-streptococcal GN). - Blood film: HUS/TTP (RBC fragmentation). - Urine: Urinalysis for blood, protein (GN), glucose (interstitial nephritis), microscopy for casts (GN), urine Na + , urea, creatinine, osmolality to differentiate between pre-renal and intrinsic renal failure. - ECG: Signs of hyperkalaemia; tall tented T waves --> small or absent P waves --> increased P–R interval --> widened QRS complex --> sine wave pattern --> asystole. - CXR: Signs of pulmonary oedema. - Renal USS: In ARF, kidneys appear normal or increased in size and echogenicity, may detect stones or clot in renal vein thrombosis (RVT). - Renal biopsy: If diagnosis has not been determined. - Monitor: Daily U&E, temperature, PR, RR, BP, O2 saturation, strict input/output (need to catheterise), daily weights.

Answer 43

- Ultrasound may be useful to identify obstruction, small kidneys in CKD or large, bright kidneys with loss of cortical medullary differentiation (typical of an acute process) - Use diuretics when necessary (i.e. to treat fluid overload or oedema whilst the patient is awaiting renal - Fluid restriction will also be helpful - Pre-renal failure: Hypovolaemia should be urgently addressed with fluid replacement and circulatory support - Renal failure: A high-calorie, normal protein feed will decrease catabolism, uraemia and hyperkalaemia - Manage metabolic abnormalities - Refer immediately to urology if any of the following are present: - Pyelonephrosis - Obstructed solitary kidney - Bilateral upper urinary tract obstruction - Complications of AKI caused by urological obstruction - Relief can be achieved by nephrostomy or bladder catheterisation (Post-renal failure) - Dialysis

Answer 44

- Failure of conservative management - Hyperkalaemia - Severe hyponatraemia or hypernatraemia - Pulmonary oedema or severe hypertension due to volume overload - Severe metabolic acidosis - Multisystem failure

Answer 45

- Heart failure and pulmonary oedema (volume overload) - GI bleeding (gastric ulceration and platelet dysfunction) - Muscle wasting due to hypercatabolic state - Uraemic encephalopathy.

Answer 46

- Depends on the causative factor. - Recovery of renal function following ARF is most likely following pre-renal causes, HUS, ATN, acute interstitial nephritis or uric acid nephropathy

Answer 47

- Characterised by decreased GFR, persistently increased urea and decreased creatinine concentration.

Answer 48

- Age <5 years: Congenital abnormalities: hypoplasia, dysplasia, obstruction (posterior urethral valve), malformations. - Age >5 years: 1. Hereditary disorders: Alport syndrome (thickened glomerular basement membrane), autosomal recessive polycystic disease 2. All causes of GN and tubulointerstitial nephritis may lead to CRF (see GN chapter) 3. VUR 4. Systemic disease (HSP, SLE).

Answer 49

- CRF prevalence not known but prevalence of end-stage renal failure (ESRF) 15–40/million (UK) - More common in Asian children.

Answer 50

- Antenatal diagnosis - Failure to thrive - Delayed puberty, - Malaise, anorexia, anaemia, incidental (blood test/urinalysis).

Answer 51

- Palpable kidneys (polycystic disease) | - Pallor, oedema, pigmentation, scratch marks, hypertension, growth retardation and rickets.

Answer 52

- Bloods: decreased Hb, MCV (usually normocytic) decreased Na+ , increased K+ , increased urea, increased creatinine, decreased Ca2+, increased phosphate, increased ALP, increased PTH (secondary hyperparathyroidism). - Urine: 24-h collection for protein and creatinine clearance. - X-rays: For signs of osteomalacia and hyperparathyroidism. - Renal USS: For anatomical/hereditary abnormalities, measure size (small shrunken kidneys consistent with CRF), exclude obstruction/stones. - Renal biopsy: For changes specific to the underlying disease, contraindicated in shrunken kidneys.

Answer 53

- Aim to prevent symptoms and metabolic abnormalities, allow normal growth and development and preserve residual renal function - Diet - Anorexia and vomiting are common - Calorie supplements or NG/gastrostomy feeding is often necessary to optimise growth - Protein intake should be sufficient to maintain growth and normal albumin (but preventing the accumulation of toxic metabolic by-products) - Prevention of renal osteodystrophy - Decreased activation of vitamin D leads to phosphate retention and hypocalcaemia, which, in turn, leads to secondary hyperparathyroidism and eventually osteitis fibrosa cystica and osteomalacia - Phosphate restriction (by reducing milk), using calcium carbonate as a phosphate binder and activated vitamin D supplements can help - Control of salt and water balance and acidosis - Many children will also have obligatory loss of salt and water - They need salt supplements and a lot of water - Treatment with bicarbonate supplements is needed to prevent acidosis - Acidosis - Reduced EPO production and circulation of marrow-toxic metabolites leads to anaemia - Responds well to the administration of SC recombinant human erythropoietin - Hormonal abnormalities - Growth hormone resistance, characterised by a high GH level but poor growth, is a feature of CKD - Recombinant human GH is effective in improving growth for up to 5 years of us - Many children with stage 4/5 CKD will have delayed puberty or subnormal pubertal growth spurt

Answer 54

- Haematological: Anaemia, abnormal platelet activity (bruising, epistaxis). - Cardiovascular: Accelerated atherosclerosis, increased BP and pericarditis. - Neurological: Peripheral and autonomic neuropathy, proximal myopathy. - Renal osteodystrophy: Osteoporosis, osteomalacia, secondary/tertiary hyperparathyroidism. - Endocrine: Amenorrhoea. - Peritoneal dialysis: Peritonitis (e.g. Staphylococcus epidermidis). - Haemodialysis: 1. Acute: hypotension due to excessive removal of extracellular fluid 2. Long-term: atherosclerosis, sepsis (2 peritonitis with Staph. aureus infection) 3. Amyloidosis: leads to periarticular deposition, arthralgia (e.g. shoulder) and carpal tunnel syndrome - Transplantation/immunosuppression: Opportunistic infections (e.g. Pneumocystis carinii), malignancies (lymphomas and skin), and side effects of immunosuppressant drugs.

Answer 55

- Depends on complications | - Timely dialysis/transplantation improves survival.

Answer 56

- Bilateral inflammation of the renal glomeruli with proliferation of cellular elements secondary to an immunological mechanism.

Answer 57

- Post-infectious: secondary to group A b-haemolytic streptococcus; Other causative organisms: diplococcal, staphylococcal, mycobacterial, CMV, coxsackie virus, EBV. - Haemolytic uraemic syndrome: Haemolytic anaemia, thrombocytopenia and endothelial damage to glomerular capillaries due to E.coli 0157, Shigella or Salmonella. - Henoch–Schonlein purpura (HSP): Hypersensitivity vasculitis and inflammatory response within the glomerular capillaries - Berger disease: Diffuse mesangial deposition of IgA and IgG. - Systemic lupus erythematosus (SLE) nephritis: The immune system produces antinuclear antibodies. Antibodies and complement complexes accumulate in the kidneys resulting in an inflammatory response.

Answer 58

- Typically 2–12 years old, although may be any age - M : F = 2 : 1. - Incidence depends on underlying cause but generally rare. SLE is uncommon in children.

Answer 59

- General: Characterised by the sudden onset of haematuria, proteinuria and red cell casts. Often associated with hypertension, oedema (face, ankles and ascites) and impaired renal function. Flank pain may be present secondary to renal capsule swelling. - HSP: Characteristic petechial/purpuric rash on buttock and extensor surfaces, arthralgia commonly at the ankles, symptoms of nephritis, abdominal pain

Answer 60

- Urine: Microscopy; RBC +/- casts and culture, 24-hour collection; protein and creatinine clearance. - Bloods: decreased Hb, increased WCC, decreased Plt (HUS), increased urea, increased ESR/CRP, metabolic acidosis, GFR - Specific: increased Antistreptolysin titre, (increasedd in 1–3/52 and peaks at 3–5/52), RBC fragmentation, stool culture (HUS), IgA antibodies, antinuclear antibodies (SLE). - Imaging: Renal USS - Surgical: Renal biopsy may be necessary.

Answer 61

- General: Correct electrolyte abnormalities/acid–base imbalances. Fluid restriction if severe oedema present. - Medical: PO antibiotics for post-infective causes (penicillin for streptococcus), antihypertensive therapy, treatment of pulmonary oedema, possible use of steroids +/- cytotoxic/immunosuppressive agents (HSP, vasculitis).

Answer 62

- Hypertension: Encephalopathy, convulsions, end-organ damage, cerebral haemorrhage. - Renal failure: Uraemia, metabolic acidosis, electrolyte abnormalities, fluid overload.

Answer 63

- General: 10% may develop chronic glomerulonephritis. Mortality depends on cause. - Post-infection: Good for >95%; acute phase lasts 1–2/52, hypertension for 3–4/52 and microscopic haematuria for <12/12 but rapidly progressive to CRF in 1%. - HUS: Life-threatening condition: mortality 5–30%; some may relapse. - IgA nephropathy: 10–30% progress to CRF. - HSP: Usually resolves spontaneously without treatment. 1–2% develop CRF.

Answer 64

- Originates from embryonal renal tissue - MOST COMMON renal tumour of childhood - Over 80% of patients present < 5 years of age

Answer 65

- Large abdominal mass - Usually found incidentally in an otherwise well child - Haematuria - Rare symptoms: abdominal pain, anorexia, anaemia, hypertension

Answer 66

- Ultrasound - CT/MRI - Shows an intrinsic renal mass

Answer 67

- Surgery and chemotherapy (may be post-operative or pre-operative) - Subsequent management is dependent on histological findings - 5% have bilateral disease - More than 80% of patients are cured

Answer 68

- Oxygen requirement at corrected age of term with characteristic radiological changes (also known as bronchopulmonary dysplasia).

Answer 69

1. Volutrauma and barotraumas 2 to positive pressure ventilation (PPV) 2. High inspired oxygen concentration (>40%); toxic to the immature lung 3. Activation of inflammatory mediators (2 to free radicals, barotraumas and infection) 4. Inadequate nutritional supplementation.

Answer 70

- Inversely related to gestation and birthweight. | - Increased incidence secondary to increased survival of very low-birthweight infants.

Answer 71

- Most properly managed neonates are asymptomatic as they are given ventilatory support, but some CLD babies may have some chronic recession. - Poor weight gain with increased energy intake.

Answer 72

- ABG: Compensated respiratory acidosis reflecting chronic high pCO2. - CXR: Characteristic hyperinflation and cystic changes. Used to determine severity, and distinguishes CLD from atelectasis, pneumonia and air-leak syndrome.

Answer 73

- General: PPV and oxygen therapy are still necessary for preterm survival; therefore must reduce tisk - Ventilation: Oxygen toxicity, barotraumas and volutrauma can be minimised by strict monitoring and maintenance of pH, pCO2 and pO2 within small ranges dependent on age of preterm infant. There is no evidence that high-frequency ventilation is superior to conventional in prevention (Cochrane database). - Nutritional support: Early parenteral nutrition. Prevents further lung injury and aids tissue repair. - Prevention: 1. Surfactant within 2 hours with early extubation to nasal CPAP for the treatment of RDS decreases incidence of CLD. 2. Use of steroids to prevent CLD is highly controversial as it has been shown to have an adverse affect on neurodevelopmental outcome. Steroids are generally only used in ventilator-dependent neonates who are ‘stuck’ on the ventilator. - Long-term: Home O2 supported by community children’s nurses; ‘hospital at home’ team.

Answer 74

- Pulmonary hypertension ---> cor pulmonale, increased risk of respiratory infections especially RSV pneumonia (paliviazumab, monoclonal antibody prophylaxis for RSV, is currently being considered by NICE).

Answer 75

- Severely affected may need long-term home O2 therapy

Answer 76

- Pain, swelling, heat, redness and restricted movement in a joint - In acute monoarthritis, the child may be systemically unwell with a fever - If septic arthritis or osteoarthritis is suspected, urgent diagnosis and treatment is required

Answer 77

- MOST COMMON form of arthritis in childhood - Characterised by transient joint swelling (< 6 weeks) - Often affects the ankles and knees - Usually follows evidence of extra-articular infection - Possible low grade fever

Answer 78

- Enteric bacteria (Salmonella, Shigella, Campylobacter and Yersinia) are often the cause in children - Sexually transmitted infections (Chlamydia, Gonococcus) is more likely in adolescents - More rare causes include Mycoplasma and Borrelia burgdorferi (Lyme disease) - Rheumatic fever and post-streptococcal reactive arthritis are more common in low-income countries

Answer 79

- NO treatment required - it is self-resolving - NSAIDs for pain-relief - Others: steroids, DMARDs

Answer 80

- Serious infection because it can lead to bone destruction - Most common in children < 2 yrs - Usually results from haematogenous spread - However, it can occur following a puncture wound or an infected skin lesion (e.g. chickenpox) - Can occur from the spread of adjacent osteomyelitis to the joint capsule - Usually only ONE joint is affected - The hip is of particular concern in infants and young children - After the neonatal period, the most common organism is Staphylococcus aureus - Consider predisposing illnesses such as immunodeficiency and sickle cell disease

Answer 81

- Erythematous, warm, acutely tender joint - Reduced range of movement - Acutely unwell, febrile child - Infants may hold the limb still (pseudoparesis, pseudoparalysis) - Infants will cry when the affected limb is moved - Joint effusion - Co-existent osteomyelitis (15%) - Pain may be referred to the knee

Answer 82

- High WCC - Raised acute-phase proteins - Ultrasound of deep joints (reveal an effusion) - X-rays to exclude trauma (X-rays are likely to be normal in septic arthritis) - Aspiration under ultrasound guidance is the definitive investigation - This should be performed IMMEDIATELY

Answer 83

- Prolonged course of antibiotics (initially IV for 2 weeks, followed by 4 weeks of oral antibiotics) - Suspected Gram-positive - Vancomycin + joint aspiration - 2nd line = clindamycin or cephalosporin + joint aspiration - Suspected Gram-negative - 3rd generation cephalosporin (e.g. ceftriaxone) + joint aspiration - 2nd line = IV ciprofloxacin + joint aspiration - Affected joints should be aspirated to dryness as often as required (through closed needle aspiration or arthroscopically) - Washing out of the joint or surgical drainage may be required

Answer 84

- MOST COMMON chronic inflammatory joint disease in children - Defined as persistent joint swelling (> 6 weeks duration) presenting before 16 years of age in the absence of infection or any other defined cause - There at least 7 subtypes of JIA

Answer 85

- Oligoarthritis (persistent) - Oligoarthritis (extended) - Polyarthritis (RF negative) - Polyarthritis (RF positive) - Systemic arthritis - Psoriatic arthritis - Enthesitis-related arthritis - Undifferentiated arthritis

Answer 86

- Polyarthritis = > 4 joints - Oligoarthritis = < 4 joints - Systemic = with fever and rash - Other subtypes: psoriatic arthritis, enthesitis - Subtyping can be further classified by the presence of rheumatoid factor and HLA-B27 tissue type

Answer 87

- Gelling (stiffness after rest) - Morning stiffness - Joint pain - Young children: may present with intermittent limp or deterioration in behaviour or mood or avoidance of previously enjoyed activities - Joint swelling (may be minimal)

Answer 88

- Baseline investigations may be normal at first - ANA may be present - IMPORTANT: in any child with widespread joint pain, fatigue or multisystem involvement, possibly consider connective tissue disorder - If there are systemic features, consider sepsis or malignancy

Answer 89

- Bone expansion (leading to leg lengthening or valgus deformity, or discrepancy in digit length) - Chronic anterior uveitis - If not detected and treated, it could lead to severe visual impairment - Flexion contractures of the joints - Occurs when the joint is held in the most comfortable position for a long time - Can lead to joint destruction - Growth failure - May be generalised from anorexia, chronic disease and systemic corticosteroid therapy - Localised overgrowth can occur due to prolonged active knee synovitis - Constitutional problems - Osteoporosis - Amyloidosis

Answer 90

- Managed by a specialist paediatric rheumatology MDT - Physical and occupational therapy - Inactivity leads to deconditioning, disability and decreased bone mass - NSAIDs for pain and stiffness - Corticosteroids are useful adjunctive agents - DMARDs (oral or SC methotrexate is the first-line DMARD) - used when the disease fails to respond to conventional treatments - 2nd line: sulfasalazine - Other treatments: TNF-alpha inhibitors, interleukin receptor antagonists, anti-emetics

Answer 91

- Most children can expect good disease control and quality of life - With poor disease control, patients can experience significant morbidity from joint damage and visual impairment leading to uveitis and fractures from osteoporosis

Answer 92

- Bacteraemia: Proliferation of bacteria in the circulation. - Septicaemia: Systemic response to infection; tachypnoea, tachycardia and fever or hypothermia. - Sepsis syndrome/systemic inflammatory response syndrome (SIRS): Evidence of reduced end-organ perfusion (oliguria/altered GCS) with elevated lactate levels. - Septic shock: Sepsis syndrome plus hypotension that does not respond to fluid therapy.

Answer 93

- Early-onset neonatal sepsis: due to GBS or E. coli. - Late-onset neonatal sepsis: Usually due to Neisseria meningitidis, Streptococcus pneumoniae, Hib, HSV, CMV or enterovirus. - Hospital acquired: Due to S. aureus, S. epidermidis or gram-negative organisms. - Immunocompromised septicaemia: Infected by broader spectrum of pathogens including fungi. - Older children: Usually caused by Neisseria meningitides or Strep. pneumoniae.

Answer 94

Presentation depends on the system affected: - CNS: infant: bulging fontanelle (neonates), lethargy, irritability, poor feeding. Child: headache, photophobia, neck stiffness, seizures, decreased GCS. - Respiratory: tachypneoa, apnoea, grunting, cyanosis. - Cardiovascular: tachycardia, hypotension. - GI: poor feeding, abdominal pain, vomiting, diarrhoea. - General: lethargy, fever, hypothermia, purpuric rash.

Answer 95

- Bloods: increased/decreased WCC (neutropenia/neutrophilia), increased CRP, U&E, blood glucose, clotting, ABG (hypoxia, metabolic acidosis). - Radiology: CXR, USS abdomen if intra-abdominal sepsis is suspected. - MC&S: MSU, blood culture CSF (LP if vital signs are stable enough to tolerate procedure). LP is contraindicated if there are signs of raised ICP, purpura or deranged clotting (DIC).

Answer 96

- Assess HIGH RISK of severe illness or death from sepsis: - Behaviour: - No response to social cues - Appears ill - Does not wake, or if roused does not stay awake - Weak, high-pitched and continuous cry - Heart Rate: - Tachycardia (different at different ages) - < 60 bpm at any age - Respiratory Rate - Tachypnoea (different at different ages) - Grunting - Apnoea - SpO2 < 90% on air - Mottled or ashen appearance - Cyanosis of the skin, lips or tongue - Non-blanching rash - Aged < 3 months with temperature > 38 degrees - Temperature < 36 degrees - Transfer IMMEDIATELY to an acute hospital setting if there are signs of severe illness or if immunity is impaired - If in the community and meningococcal disease is suspected, give IM benzylpenicillin - Identify the source of infection - Investigations include: FBC, blood culture, CRP, urinalysis, LP, CXR - Contraindications for LP: signs of raised ICP, focal neurological signs, shock, purpura - Perform LP in the following children with suspected sepsis: - < 1 month - 1-3 months who appear unwell - 1-3 months with WCC < 5 or > 15 x 109/L

Answer 97

- Carry out VBG for - Blood gas (including glucose and lactate) - Blood culture - FBC - CRP - Urea and electrolytes - Creatinine - Review venous lactate within 1 hour - Lactate > 2 mmol/L or evidence of AKI - Treat as HIGH RISK - Lactate < 2 mmol/L - Repeat structured assessment at least hourly - Ensure review by senior clinician within 3 hours of meeting 2 or more of the moderate to high risk criteria - Once the cause is identified, manage it

Answer 98

- Arrange immediate review by senior clinician - Carry out VBG for: - Blood gas (including glucose and lactate) - Blood culture - FBC - CRP - Urea and electrolytes - Creatinine - Clotting screen - Give broad spectrum antibiotics at the MAXIMUM dose without delay - Monitor children continuously - Monitor mental state of the child using GCS or AVPU - Lactate > 4 mmol/L - Give IV fluid bolus without delay - Refer to critical care for review of central access and initiation of inotropes or vasopressors - Lactate 2-4 mmol/L - Give IV fluid bolus without delay - Lactate < 2 mmol/L - Consider IV fluids - Antibiotics - If meningococcal sepsis - IM benzylpenicillin (in the community) - IV ceftriaxone (in hospital) - Follow local guidelines for other infections - Neonates presenting within the first 72 hours of life should receive IV benzylpenicillin + gentamicin - IV fluid

Answer 99

- Give high flow oxygen - Obtain IV/IO access and take bloods - Blood gas and lactate (FBC, U&E, CRP) - Blood glucose (treat hypoglycaemia) - Blood cultures - Give IV/IO antibiotics - Consider fluid resuscitation - Aim to restore normal physiological parameters (urine output > 0.5 ml/kg/hr) - Give 10-20 ml/kg isotonic fluid over 5-10 mins - Repeat as necessary, monitor urine output - Involve senior clinicians early - Consider inotropic support early - If normal physiological parameters are not restored after > 40 ml/kg fluids, consider ICU admission

Answer 100

- Common - Irritant (contact) dermatitis - Infantile seborrhoeic dermatitis - Candida infection - Atopic eczema - Rare - Acrodermatitis enteropathica - Langerhans cell histiocytosis - Wiskott-Aldrich syndrome

Answer 101

- Irritant dermatitis is the MOST COMMON type of nappy rash - This can occur if the nappy is not changed frequently but it can also happen even with regular cleaning of the nappy area - It tends to be due to the irritant effects of urine on the skin of susceptible infants - The flexures tend to be spared in irritant dermatitis causing nappy rash (this distinguishes it from other causes of nappy rash) - The rash is erythematous and may have a scalded appearance - MANAGEMENT: mild cases respond to the use of protective emollient - More severe cases may require topical corticosteroids

Answer 102

- Advise the parents/carers about self-management strategies - Consider using a nappy with high absorbency and ensure that it fits properly - Leave nappy off as much as possible to help skin drying of the nappy area - Clean the skin and change the nappy every 3-4 hours or as soon as possible after wetting/soiling, to reduce skin exposure to urine and faeces - Use water, or fragrance-free or alcohol-free baby wipes - Dry gently after cleaning - Bath the child daily - Do NOT use soap, bubble bath, lotions or talcum powder - ADVICE: NHS choices leaflet on nappy rash - If mild erythema and child is asymptomatic - Advise on the use of barrier preparation to protect the skin (available OTC) - Apply thinly at each nappy change - Options: Zinc and Castor oil ointment BP, Metanium ointment, white soft paraffin BP ointment - If the rash appears inflamed and is causing discomfort - If > 1 month = hydrocortisone 1% cream OD (max 7 days) - If the rash persists and CANDIDAL INFECTION is suspected or confirmed on swab - Advise against the use of barrier protection - Prescribe topical imidazole cream (e.g. clotrimazole, econazole, miconazole) - Frequency depends on preparation used - If the rash persists or BACTERIAL INFECTION is suspected or confirmed on swab - Prescribe oral flucloxacillin for 7 days - If penicillin allergy: clarithromycin (7 days) - Arrange to review the child

Answer 103

- Tends to present in the first 3 months of life - It tends to start on the scalp as an erythematous scaly eruption - The scales form a thick yellow adherent layer, commonly called cradle cap - The rash may spread to the face and then extend to the flexures and napkin area - Unlike atopic eczema, this rash is NOT itchy and the child does not seem to be bothered by it - It is associated with a subsequent risk of developing atopic eczema

Answer 104

- Reassure the parents (it is NOT a serious condition) - Resolves over a few weeks/months - If scalp is affected, advise: - Wash scalp with baby shampoo, followed by gentle brushing with a soft brush to loosen scales and improve the condition of the skin - Softening the scales with baby oil first, followed by gentle brushing, then washing off with baby shampoo - Soaking the crusts overnight with white petroleum jelly or slightly warmed vegetable/olive oil, and shampooing in the morning - Emulsifying ointment can be used if these measures don’t work - If conservative measures are ineffective, prescribe topical imidazole cream (e.g. clotrimazol, econazole, meconazole) - Use 2-3 times per day (depending on preparation) until symptoms disappear - Consider specialist advice if it lasts > 4 weeks - If other areas of skin are affected, advise bathing the infant at least once per day using an emollient as a soap substitute

Answer 105

- 20% prevalence amongst children in the UK - Onset is usually within the first year of life - Most cases will resolve in adolescence

Answer 106

- Clinical - NOTE: if the disease is unusually severe, atypical or associated with unusual infections or faltering growth, an immune deficiency should be excluded

Answer 107

- Itching (pruritus) - This leads to scratching and exacerbation of the rash - Excoriated areas become erythematous, weeping and crusted - Distribution of the eruption changes with age - Atopic skin is usually dry - Prolonged scratching and rubbing can lead to lichenification (accentuation of normal skin markings)

Answer 108

- Causes of exacerbation of eczema: - Bacterial infection - Viral infection (e.g. HSV) - Ingestion of an allergen (e.g. egg) - Contact with an irritant or allergen - Environment (heat, humidity) - Change or reduction in medication - Psychological stress - Unexplained - Skin infection is usually caused by Staphylococcus or Streptococcus - Staphylococcus aureus, in particular, thrives on atopic skin and releases superantigens, which seem to worsen eczema - Herpes simplex virus infection, although rare, is potentially very serious because it can spread rapidly on atopic skin causing an extensive vesicular reaction called eczema herpeticum - Regional lymphadenopathy is common in active eczema and resolves when the skin improves

Answer 109

- Assessment of Eczema (Severity) - CLEAR - normal skin with no evidence of active eczema - MILD - areas of dry skin and infrequent itching - MODERATE - areas of dry skin, frequent itching and redness (with/without excoriation and localised skin thickening) - SEVERE - widespread areas of dry skin, incessant itching and redness (with/without excoriation and localised skin thickening) - INFECTED - eczema is weeping, crusting or there are pustules with fever and malaise - IMPORTANT: remember to assess the psychological impact of eczema on the child - Consider using questionnaires such as the Children's Dermatology Life Quality Index (CDLQI) - Separate management depending on severity - Emollients used in all eczema - Eczema herpeticum treated with systemic aciclovir - Dietary elimination - Food allergy should be suspected in young children with moderate/severe, particularly if associated with gut dysmotility (colic, vomiting, altered bowel habit) or faltering growth - MOST COMMON allergens resulting in eczema: - Egg - Cow's milk - Allergen specific IgE antibodies in the blood and skin-prick testing may be helpful - Dietary elimination for 4-6 weeks may be necessary to detect a response

Answer 110

- Emollient - Consider prescribing a mild corticosteroid (e.g. hydrocortisone 1%) for areas of red skin - This should be continued for 48 hours after the flare has been controlled - Routine follow-up is not normally necessary - Refer for a routine dermatology appointment if the diagnosis is uncertain, current management has failed to control eczema, there is facial eczema or there is a recurrent secondary infection

Answer 111

- Emollients used - Prescribe a moderately potent topical steroid: betamethasone valerate 0.025% or clobetasone butyrate 0.05% - Treatment should be continued for 48 hours after the flare has been controlled - If there is severe itching or urticaria, consider prescribing a 1-month trial of a non-sedating antihistamine (e.g. cetirizine, loratidine, fexofenadine) - Consider prescribing a maintenance regimen of topical corticosteroids to control areas of skin prone to frequent flares (not face, genitals or axillae) - 2nd line: topical calcineurin inhibitors (e.g. tacrolimus) - only prescribed by a specialist - Review regularly if the child is young and using a large amount of topical corticosteroids

Answer 112

- Prescribe a potent corticosteroid: betamethasone valerate 0.1% to be used on inflamed areas - For delicate areas of inflamed skin (e.g. face and flexures) use a moderate potency steroid - Occlusive dressings or dry bandages may be useful - Consider non-sedating antihistamine if there is severe itching - If the itching is affecting sleep, consider using a sedating antihistamine (e.g. chlorphenamine) - If there is SEVERE, extensive eczema causing psychological distress, consider a course of oral corticosteroids - Prescribe a maintenance regimen of topical corticosteroids

Answer 113

- Swab the infected skin - 1st line: flucloxacillin - If penicillin allergy: erythromycin (or clarithromycin) - If the area of infection is localised, topical antibiotics should be effective - NOTE: these should NOT be used for longer than 2 weeks

Answer 114

- The sudden death of an infant <1 year that remains unexplained after a thorough case investigation, including performance of a complete postmortem, examination of the death scene and a review of the clinical history (National Institute of Child Health and Development).

Answer 115

- Many factors have been implicated but none has been proven. - Prolonged QT interval: Is a marker of reduced cardiac electrical stability and is strongly associated with SIDS. " Sympathetic activity in these infants may be sufficient to cause fatal arrhythmias such as torsades de pointes. - Upper Airway Obstruction 1. Infants have sites of anatomical and physiological vulnerability such as a shallow hypopharynx and position of the tongue and epiglottis 2. Infants are obligate nasal breathers for the first few months of life and so prone positioning may compress their only airway. - Central apnoea: Infants can have reflex-like apnoeic responses to a number of conditions such as hypoxia, hypoglycaemia, infection and stimulation of the upper larynx (e.g. GOR). Such apnoeic responses are probably due to incomplete development of the CNS, increased vagal tone and decreased respiratory muscle reserve. - Thermoregulatory dysfunction: Minor changes in temperature (hot or cold) can induce autonomic dysfunction in infants. - Brainstem dysfunction: Cardiorespiratory function, autonomic mechanisms, chemoreceptor sensitivity and thermoregulation are all controlled by the medullary and related structures of the brain. Autopsy examinations of the brainstems of infants with a diagnosis of SIDS have demonstrated hypoplasia or decreased neurotransmitter binding of the arcuate nucleus (medulla).

Answer 116

- SIDS is the most common cause of death in infants aged 1 month to 1 year. - Peak incidence: 1–4 months. - UK incidence: 300 cases/year. M > F. - Prevalence: 1.7 cases/1000 live births. - Seasonal variation: More common during winter.

Answer 117

- Diagnosis of exclusion - Classic presentation: 1. Usually occurs during hours of extended sleep (10pm–10am) 2. Child is found dead usually in the position the child was put to bed 3. Checks whilst the child was asleep usually revealed no problems 4. Parent may report that the child was not himself or herself before going to sleep 5. May report GI or respiratory infection in the weeks preceding death. - Alerts for child abuse: Unclear, inconsistent history, unwanted child, poor antenatal/postnatal care, age >6 months.

Answer 118

- Fully undress the child and note: 1. General condition of child (hygiene, nutrition, growth parameters) 2. Signs of illness (vomit, hydration, nasal discharge, rash) 3. Signs of trauma, abuse (see Safeguarding Children chapter) or evidence of bleeding 4. Clothing (do not discard – should stay with the child).

Answer 119

- Blood culture should be obtained in all cases. - Depending on history and examination, further microbiological samples may be taken (swabs, SPA, LP) or metabolic samples (blood, urine, CSF) may be required. - Postmortem examination.

Answer 120

- Infants should sleep on their back - Overheating by heavy wrapping and high room temperature should be avoided (head should be uncovered and the blanked tucked in no higher than the shoulders) - Infants should be placed in the feet to foot position (feet a the foot of the cot) - No one should smoke near the infant - Parents should seek medical advice promptly if their infant becomes unwell - Parents should have the baby in their bedroom for the first 6 months of life - Parents should avoid bringing the baby into their bed when they are tired or have had alcohol or drugs - Parents should avoid sleeping with their infant on the sofa, settee or armchair - If possible, the infant should be breastfed

Answer 121

- Maldescent of the thyroid and athyrosis - MOST COMMON cause of sporadic congenital hypothyroidism - In early foetal life, the thyroid migrates from the base of the tongue to its normal site - In maldescent, the thyroid will halt at a point along this migration - Dyshormonogenesis - Inborn error of thyroid hormone synthesis - Iodine deficiency - MOST COMMON cause worldwide - TSH deficiency - Usually associated with pituitary dysfunction - Manifest with GH, gonadotrophin and ACTH deficiency

Answer 122

- Faltering growth - Feeding problems - Prolonged jaundice - Constipation - Pale, cold, mottled dry skin - Coarse facies - Hoarse cry - Goitre - Umbilical hernia - Delayed development

Answer 123

- Females > males - Short stature/poor growth - Cold intolerance - Dry skin - Cold peripheries - Bradycardia - Thin, dry hair - Pale, puffy eyes with loss of eyebrows - Goitre - Slow-relaxing reflexes - Constipation - Delayed puberty/amenorrhoea - Obesity - Slipped upper femoral epiphysis - Poor concentration - Deterioration in school work - Learning difficulties

Answer 124

- Thyroxine treatment should be started within 2-3 weeks of age to reduce the risk of impaired neurodevelopment - Treatment is life-long with oral replacement of thyroxine - With adequate and early intervention, intelligence and development should be normal

Answer 125

- Usually results from autoimmune thyroiditis - Increased risk in children with: - Down syndrome - Turner syndrome

Answer 126

- Usually results from autoimmune thyroiditis (Graves disease) secondary to the production of thyroid-stimulating antibodies

Answer 127

- Anxiety, restlessness - Increased appetite - Sweating - Diarrhoea - Weight loss

Answer 128

- Carbimazole or propylthiouracil - IMPORTANT: carbimazole is associated with a risk of neutropaenia - Families should be seek urgent medical attention and a blood count if a sore throat or fever occur whilst on treatment - Beta-blockers for symptomatic relief - Treatment is usually given for around 2 years - Other options: radioiodine treatment, surgery - NOTE: neonatal hyperthyroidism may occur due to the transplacental transfer of TSIs

Answer 129

- MOST COMMON infection of childhood - Features include clear or mucopurulent nasal discharge and nasal blockage - Educate the parents that colds are self-limiting and have no specific curative treatment - Pain may be treated with paracetamol or ibuprofen - Cough may persist for up to 4 weeks after a common cold

Answer 130

- Rhinoviruses - Coronaviruses - Respiratory syncytial virus (RSV)

Answer 131

- Reassure that the common cold is self-limiting - Symptoms may peak after 2-3 days and they will typically resolve within 2 weeks - Encourage rest, adequate fluid intake and a healthy diet - Encourage the use of paracetamol or ibuprofen for symptomatic relief

Answer 132

- In pharyngitis, the pharynx and the soft palate become inflamed and local lymph nodes are enlarged and tender - Usually due to viral infection (mainly adenoviruses, enteroviruses and rhinoviruses) - In older children, group A b-haemolytic streptococcus is common

Answer 133

- Tonsillitis is a form of pharyngitis characterised by intense inflammation of the tonsils, often with a purulent exudate - Common causes of tonsillitis: - Group A b-haemolytic streptococci - EBV

Answer 134

- Headache, apathy, abdominal pain, white tonsillar exudate and cervical lymphadenopathy are more common with bacterial infection

Answer 135

- Arrange hospital admission if: - Difficulty breathing - Clinical dehydration - Peri-tonsillar abscess or cellulitis - Signs of marked systemic illness or sepsis - A suspected rare cause (e.g. Kawasaki disease, diphtheria) - Specific cases to watch out for: - DMARDs - could cause immunodeficiency - Carbimazole - can cause idiosynchratic neuropaenia - NOTE: take urgent FBC in both cases - Medical Management (if bacterial tonsillitis is confirmed using rapid antigen testing) - Phenoxymethylpenicillin - If penicillin allergy: clarithromycin - To eradicate the organism completely, 10 days of antibiotic treatment is required for pharyngitis and tonsillitis - RARELY, children may be admitted to hospital for IV fluids and analgesia if they are unable to swallow solids or liquids - WARNING: amoxicillin should be avoided because it may cause a widespread maculopapular rash if the tonsillitis is due to infectious mononucleosis

Answer 136

- Adequate fluid intake - Paracetamol or ibuprofen when necessary - Salt water gargling, lozenges or anaesthetic sprays (e.g. Difflam) may provide temporary relief of throat pain - Children can return to school after fever has resolved and they are no longer feeling unwell and/or after taking antibiotics for 24 hours - Patients with recurrent tonsillitis may require referral to ENT

Answer 137

- Group A streptococcal infection can result in Scarlet Fever - Fever usually precedes the presence of headache and tonsillitis by 2-3 days - Appearance of the rash is variable - The typical rash will be a 'sandpaper-like' maculopapular rash with flushed cheeks and perioral sparing - The tongue is often white and coated and may be sore or swollen

Answer 138

- Antibiotics - Phenoxymethylpenicillin (penicillin V) - 4/day for 10 days - Azithromycin (if penicillin allergy) - Paracetamol or ibuprofen can be given for symptomatic relief - NOTIFIABLE disease so inform local PHE centre) - Symptoms should resolve after 1 week - Stay away from nursery/school for 24 hours after starting antibiotics - This is needed to prevent complications such as acute glomerulonephritis and rheumatic fever

Answer 139

- Suppurative: otitis media, throat infection/abscess, acute sinusitis/mastoiditis, streptococcal pneumonia, meningitis, endocarditis, osteomyelitis, necrotising fasciitis, toxic shock syndrome - Non-suppurative (autoimmune): rheumatic fever (arthritis, carditis, erythema marginatum), streptococcal glomerulonephritis

Answer 140

- Most children have at least one episode of acute otitis media - Most common: 6-12 months - Infants and young children are susceptible to otitis media because their Eustachian tubes are short, horizontal and function poorly

Answer 141

- Ear pain and fever - IMPORTANT: every child with a fever MUST have their tympanic membrane examined - In acute otitis media, the tympanic membrane is bright red and bulging with loss of the normal light reflection - Occasionally ,the tympanic membrane can perforate and pus can become visible in the external canal

Answer 142

- RSV - Rhinovirus - Pneumococcus - Haemophilus influenzae - Moraxella catarrhalis

Answer 143

- Mastoiditis | - Meningitis

Answer 144

- Admit if: - Severe systemic infection - Complications (e.g. meningitis, mastoiditis, facial nerve palsy) - Children < 3 months with a temperature > 38 degrees - ADVICE - Advise that the usual course of acute otitis media is about 3 days but can last up to 1 week - Advise regular doses of paracetamol or ibuprofen for pain - There is no evidence to support the use of decongestants or antihistamines - Medical Management - No antibiotic prescription - most cases will resolve spontaneously. Advise to seek help if the symptoms haven't improved after 3 days or if the child deteriorates clinically - Back-up antibiotic prescription - advise that the antibiotic is NOT needed immediately but should be used if the symptoms have not improved after 3 days or if they have worsened significantly at any time - Immediate antibiotic prescription - seek medical help if the symptoms worsen rapidly or the patient becomes systemically unwell - Amoxicillin - 5-7 days is first-line - Clarithromycin or erythromycin can be used if penicillin allergic - NOTE: antibiotics marginally reduce the duration of the pain but have no effect on risk of hearing loss

Answer 145

- Can lead to otitis media with effusion (aka glue ear) - Children are usually asymptomatic except for possible reduced hearing - The eardrum is dull and retracted, often with a fluid level visible - This is common in 2-7 year olds - Usually resolves spontaneously - It may cause conductive hearing loss (most common cause in children) - This can interfere with normal speech development and result in learning difficulties - In these children, ventilation tubes (grommets) are often inserted - The benefits do NOT last longer than 12 months - If problems recur after the extrusion of the grommet, reinsertion of grommets with adjuvant adenoidectomy is often advocated

Answer 146

- Infection of the paranasal sinuses may occur with viral URTIs - Occasionally, you might get a secondary bacterial infection - The frontal sinuses are rarely affected because the frontal sinuses do not develop until late childhood - Antibiotics and analgesia may be used for acute sinusitis

Answer 147

- Refer to hospital if there are symptoms and signs of: - Severe systemic infection - Intraorbital or periorbital problems (e.g. periorbital cellulitis, displaced eyeball, double vision) - Intracranial complications (e.g. features of meningitis) - Symptoms lasting < 10 days - Do NOT offer an antibiotic - ADVICE - Acute sinusitis is usually caused by a virus and takes 2-3 weeks to resolve - It can be complicated by bacterial infection (2% risk) - Symptoms, such as fever, can be managed using paracetamol or ibuprofen - Some people may find some relief using nasal saline or nasal decongestants - Medical advise should be sought if symptoms worsen rapidly, if they do not improve in 3 weeks or become systemically unwell

Answer 148

- Refer to hospital if there are symptoms and signs of: - Severe systemic infection - Intraorbital or periorbital problems (e.g. periorbital cellulitis, displaced eyeball, double vision) - Intracranial complications (e.g. features of meningitis) - Symptoms lasting > 10 days - Consider high-dose nasal corticosteroid for 14 days for adults and children > 12 years old (e.g. mometasone) - May improve symptoms but unlikely to affect duration of illness - Could cause systemic side-effects - Consider NO antibiotic prescription or back-up prescription - Antibiotics are unlikely to change the course of the illness - The back-up prescription should be used if symptoms get considerably worse of it is still has not improved by 7 days - 1st line: phenoxymethylpenicillin - NOTE: clarithromycin if penicillin allergy - 2nd line: co-amoxiclav - Advise patients to seek medical advice if they develop complications or their symptoms don't improve/worsen - Consider alternative diagnoses such as dental infection - ADVICE: NHS Choices information on Sinusitis

Answer 149

- Symptomatic bacteriuria: Presence of urine bacteria which is not a contaminant of urethral flora with concomitant pyuria. Broad clinical categories: upper UTI (acute pyelonephritis) and lower UTI (cystitis, urethritis). - Asymptomatic bacteriuria: Detection of incidental bacteriuria in an asymptomatic child.

Answer 150

- General: Proliferation of bacteria in the urinary tract, ascending infections secondary to bacteria in the periurethral flora and distal urethra. F > M as short urethra and closer proximity of perianal colonic organisms - Neonates: 70% ascending infection, 30% are of haematogenous origin. - Infants, children, adolescents: Majority are ascending infections.

Answer 151

- Gram-negative bacteria: Escherichia coli (90%), Streptococcus faecalis and Klebsiella species from the child’s faecal flora - Proteus (males; present under the prepuce) - Staphylococcus saprophyticus (common in adolescent girls) - Pseudomonas (usually in children with congenital urinary tract anomalies (see chapter) or acquired renal problems, e.g. stones) - Adenovirus 11 and 12 in haemorrhagic cystitis.

Answer 152

- Seriously ill child, poor urine flow, abdominal/bladder mass, increased creatinine, septicaemia, failure to respond to treatment <48, non-E. coli infections.

Answer 153

- 2 + acute pyelonephritis/upper UTIs, 1 upper with 1 + lower UTI episodes, 3 + lower UTI episodes

Answer 154

- Fever - Vomiting - Lethargy or irritability - Poor feeding/faltering growth - Jaundice - Septicaemia - Offensive urine - Febrile seizure (> 6 months)

Answer 155

- Dysuria, frequency and urgency - Abdominal pain or loin tenderness - Fever with or without rigors - Lethargy and anorexia - Vomiting, diarrhoea - Haematuria - Offensive/cloudy urine - Febrile seizure - Recurrence of enuresis (bed wetting)

Answer 156

- Urine collection: All infants and children presenting with an unexplained pyrexia >38 should have a urine sample tested <24 hours. ‘Clean-catch’ sample/urine collection pads/suprapubic aspiration/mid-stream urine sample (MSU) dependent on age. Adhesive plastic bags/cotton wool balls may be contaminated with faecal +/- genital flora and are therefore not used. - Urine dipstick: May be diagnostic; Leucocyte esterase + ve/nitrite + ve (UTI). Leucocyte esterase - ve/nitrite + ve (suspected – treat as UTI). Leucocyte esterase + ve/nitrite -ve (suspected – await MC&S unless clinically apparent). Leucocyte esterase - ve/nitrite + ve (no UTI). - Urine MC&S: Pyuria + ve/bacteriuria - ve (UTI). Pyuria + ve/bacteriuria - ve and pyuria - ve/ bacteriuria + ve (suspected – treat as UTI). Pyuria -ve/bacteriuria - ve (no UTI). - Bloods: Possible increased WCC, increased CRP, U&Es. - Radiological investigation

Answer 157

- ALL infants < 3 months of age with suspicion or a UTI or if seriously ill should be referred IMMEDIATELY to hospital - IV antibiotics (e.g. co-amoxiclav) for at least 5-7 days - This should be followed by oral prophylaxis - Infants aged > 3 months and children with acute pyelonephritis/upper UTI - If urine dipstick is positive for either leucocyte esterase OR nitrites, send a urine sample for culture and start antibiotic therapy - Features of pyelonephritis: - Bacteriuria + fever > 38 degrees - Bacteriuria + loin pain/tenderness - Oral antibiotics (e.g. trimethoprim for 7 days) - NOTE: choice of antibiotic should be based on resistance patterns - If oral cannot be used, give IV antibiotics (e.g. co-amoxiclav for 2-4 days, followed by oral antibiotics for 7-10 days) - NOTE: the choice of antibiotic will vary depending on sensitivities - Children with cystitis/lower UTI - Features of cystitis/lower UTI: - Dysuria but NO systemic symptoms - Oral antibiotics (e.g. trimethoprim or nitrofurantoin) for 3 days - ADVISE - Seek medical attention if the child is still unwell after 24-48 hours of antibiotic treatment - Encourage adequate fluid intake - Infants and children with atypical UTI should have an ultrasound of the urinary tract to identify structural abnormalities - DMSA and MCUG may also be performed in children < 6 months presenting with atypical or recurrent UTI

Answer 158

- AIM: ensure washout of organisms that ascend into the bladder from the perineum and reduce the presence of aggressive organisms in the stool, perineum and under the foreskin - High fluid intake to produce high urine output - Regular voiding - Ensure complete bladder emptying - Treatment and/or prevention of constipation - Good perineal hygiene - Lactobacillus acidophilus - probiotic to encourage colonisation of the gut by this organism and reduce the number of pathogenic organisms - Antibiotic prophylaxis (controversial)

Answer 159

- Urine should be dipsticked with any non-specific illness in case it is caused by a UTI and urine should be sent for MC&S - Long-term low-dose antibiotic prophylaxis can be used - Circumcision in boys may be considered - Anti-VUR surgery may be considered if there is progression of scarring - Regular blood pressure checks if renal defects are present - Urinalysis to check for proteinuria (suggestive of progressive CKD) - Regular assessment of renal growth and function

Answer 160

- Chronic pyelonephritis, chronic renal failure (CRF) and hypertension (3%). - VUR accounts for CRF in 20% of children and 5–10% in adults.

Answer 161

- Infants who present with first symptomatic UTI aged <1 year are significantly more at risk of having recurrence (30% risk). Preschool presentation of a UTI has a recurrence of 12%