Paeds

Question 1

Difference between familial short stature and constitutional delay

Answer 1

Familial - always small

Constitutional - reach normal height but slower, can induce puberty with androgens/ oestrogen

Question 2

Causes of failure to thrive

Answer 2

Inadequate Nutritional Intake

• Maternal malabsorption if breastfeeding
• Iron deficiency anaemia
• Family or parental problems, neglect

Difficulty Feeding

• Poor suck, for example due to cerebral palsy
• Cleft lip or palate (can be caused by maternal AED use)
• Genetic conditions with an abnormal facial structure
• Pyloric stenosis
• Vomiting/ GORD

Malabsorption

• Cystic fibrosis
• Coeliac disease
• rs milk intolerance
• Chronic diarrhoea
• Inflammatory bowel disease

Increased Energy Requirements

• Hyperthyroidism
• Chronic disease, for example congenital heart disease and cystic fibrosis
• Malignancy
• Chronic infections, for example HIV or immunodeficiency

Inability to Process Nutrients Properly

• Inborn errors of metabolism
• Type 1 diabetes

Question 3

What are the primitive reflexes

Answer 3

Moro - extension and abduction of arms when baby feels like they are falling

Palmar grasp - flexion of fingers when item placed in palm

Rooting - baby turns head towards stimulus near mouth

Asymmetric tonic neck reflex - when turn head to one side that arm extends, opposite side flexes

Top 4 should be present from birth, may not be present if premature <34w or asphyxia. If last longer than expected consider cerebral palsy

Placing feet reflex - stepping movements when held vertically

Startle reflex - loud noise causes baby to flex elbows and clench fist

Babinski reflex - Upward movement of toes

Question 4

What is given to babies immediately after birth and why

Answer 4

Vitamin K injection - to prevent haemorrhagic disease of the newborn. Also available in tablet form

Question 5

Foods to avoid in babies

Answer 5

Avoid honey, raw shellfish, raw eggs, salt, sugar for first 6m

Avoid whole nuts until 5yo

Avoid gluten and nut products before the age of 6m due to risk of allergy/ intolerance

Be careful introducing allergens if hx of atopy

Question 6

causes of obesity in young child + management

Answer 6

hypothyroid
Prader-willi
Cushings
Overfeeding
leptin deficiency

Manage with lifestyle changes to allow child to grow into their weight. 60 mins of exercise per day, cut down on snacking, reduce portion sizes and fizzy drinks

In severe obesity or complications of obesity consider orlistat or metformin

Question 7

Causes of abnormal motor development

• developmental red flags

Answer 7

Cerebral palsy
Primary myopathies e.g. muscular dystrophy
Neurological problems e.g. spina bifida

Environmental factors e.g. malnutrition, rickets, post-natal infection/trauma

present from 2m - 3yr as most rapid development of motor skills

Red flags
o Poor head control or floppiness at 6 months
o Unable to sit unsupported at 9 months
o Not weight bearing through legs at 12 months
o Not walking at 18 months
o Not running at 2 years, or persistent toe walking

Question 8

How to assess children with poor speech progression

Answer 8

symbolic toy test and Reynell test

Question 9

Autism spectrum disorder - diagnosis

Answer 9

For diagnosis requires elements of: abnormal social interaction, speech/language disorder, restrictive/repetitive behaviour/ interests and one of the following before the age of 3:

• lack of social attachments
• abnormal/ delayed speech development
• abnormal/ lack of symbolic play

Management:

• Behavioural management and educational measures
• Applied behavioural analysis
• Key worker
• Social funding/ benefits
• Primary/ secondary care reviews
• Management of comorbs e.g. ADHD

Question 10

Red risk foetal observations + what to do

Answer 10

Pale, mottled or blue

Non responsive, does not awake, weak cry

Grunting, RR >60, recession skin between ribs on inspiration

Reduced skin turgor

Aged <3m + temp >38, bulging fontanelle, neck stiffness, non-blanching rash, seizures/fits

If red signs present - call 999 and arrange ambulance transfer to A&E

Question 11

Amber risk foetal observations + what to do

Answer 11

pale

abnormal response, not smiling, decreased activity, only wakes with lots of stimulation

RR >40 (over 12m), >50 (6-12m), flaring of nostrils, sats <95%, crackles

Dry mucus membranes, poor feeding, reduced urine output, >160 bpm under 1 year, >150 bpm 1-2 years, >140bpm 2-5 years, CRT > or equal to 3s

Aged 3-6m + temp >39, fever for >4days, rigors, swelling of limb/joint, not weight bearing/ using a limb

Bring patient in for face to face appointment and consider referral to A&E or hospital

Question 12

If child has fever, not weight bearing - causes?

Answer 12

Septic arthritis, transient synovitis or osteomyelitis

Question 13

Emergency causes of fever in a child + what investigations to do

Answer 13

Septicaemia due to pyelonephritis, osteomyelitis, septic arthritis, Kawasaki

Meningitis - fever + neck stiffness, bulging fontanelle

Encephalitis - fever + neuro signs e.g. focal seizure

FBC, U&E, LFT, CRP, CXR, CSF, Urine MC&S, Blood culture, stool culture

Question 14

Child presents with headache, rhinitis, sore throat and fever. Symptoms free for 7-10 days then develop rash over cheeks, sparing nose, peri-orbital regions.

• cause, name of rash and treatment

Answer 14

Slapped cheek - caused by parvovirus-B19

manage with supportive care
Not infective when have rash so no need to keep home from school
Avoid pregnant women - can cause hydrops fetalis or miscarriage

Question 15

Child presents with hx of fever, cough, coryza, conjunctivitis, white spots in mouth and new onset rash over forehead and neck - cause, Ix, Mx

Answer 15

Red/brown rash, white spots = kolpiks spots in mouth

May be swelling around eyes and photophobia

Measles - inform public health

Ix - salivary swab or serum sample for measles specific IgM

Mx - supportive with fluids, rest, paracetamol + stay at home

Complications: panencephalitis, bronchopneumonia - safety net, come back if headache/ seizure or SOB

Question 16

Scarlet fever - presentation and management

Answer 16

= group A strep

Often progresses from tonsillitis/ pharyngitis -strep pyogenes

Prodrome of sore throat, fever, headache, vomiting, abdominal pain, and myalgia

Rash on neck, chest and scapula - sandpaper feel
Pin point dark red spots on pale red skin
Pale around mouth
White strawberry to red strawberry tongue
Red haemorrhagic spots on palate

Do throat swab, antibody/ antigen test

PenV or azithromycin 10d
Rest, fluids, ibuprofen/ paracetamol
return to school after 24 hrs of Abx

Question 17

Chicken pox

Answer 17

Presents initially as fever, headache, abdo pain

Develops vesicular rash starting over head and trunk - papule to vesicle to pustule to crust. Can be very itchy

Infective from 2-3 days before rash until crusts have fallen off.

Clinical diagnosis - CXR or LP if pneumonia/ neuro complications

Management is supportive:

Fluids, rest, avoid vulnerable
Antihistamines for itch + emolient
Paracetamol
Abx if secondary bacterial infection

In adults can give acyclovir if present within 24hrs, severe chicken pox or high risk of complications

Question 18

Fever >39, hypotension and diffuse erythematous macula rash - cause?

Answer 18

toxic shock syndrome

Question 19

Eczema herpeticum

Answer 19

Secondary infection with herpes virus in child with pre-existing atopic eczema

Presents with fever, shivering, painful vesicular blisters often over or around site of eczema

Do viral PCR and bacterial swabs

Treat with oral acyclovir

Question 20

Maculopapular rash that turns vesicular affecting mouth, soles of feet/ hands - cause + management?

Answer 20

Hand foot and mouth

• caused by cox sackie or enterovirus
• no need to notify
• supportive management of rest, fluids, ibuprofen/ paracetamol and soft diet

Question 21

Mumps - spread by resp droplets

Answer 21

Presents with parotitis +/- orchitis/ epididymitis
Redness over parotid - also earache and trismus
Clinical diagnosis confirmed with oral fluid sample
Doppler us to exclude torsion
Can cause pancreatitis
Can cause meningitis/ encephalitis
Can cause glomerulonephritis, arthritis, myocarditis, pancreatitis

Most have mumps vaccine

Ix
- antibody titres

tx

• notify public health
• keep isolated for 5 days - self limiting
• supportive care
• most recover in 1-2w

Question 22

Diptheria

Answer 22

Presents with onset of cold like symptoms, watery nasal discharge that turns purulent and bloody. Sore throat, difficulty swallowing due to paralysis of the palate, cervical lymphadenopathy, oedema of the neck (bull neck).

Confirm diagnosis with culture and positive toxin assay

Treat with abx - erythromycin or azithromycin
Complete course of immunisations
Treat all contacts prophylactically

Question 23

Pertussis

Answer 23

1st stage - URTI - cough, headache, fever, rhinorrhoea
2nd stage - Longstanding cough >14d, paroxysmal coughing fits followed by whooping inhale and vomiting. If <3mo more likely to have apnoea, gasping, cyanosis, apparent life threatening event
3rd stage - recovery

Increase production of mucus causes coughing
Airway inflammation causes whooping

Can cause seizures, encephalopathy, death

If sx onset <2w diagnose with nasal swab culture
If >2w and 5-16 do oral fluids
If >2w and <5 or >16 do serology
If hospitalised infant do PCR

Management is supportive with macrolide to reduce infectivity.

• <1mo - clarithro
• > 1m - azithro or clarithro
• pregnant - erythromycin

Notify public health, isolate and give prophylactic macrolide to close contacts

Pregnant women given vaccine in 3rd trimester

Question 24

Tetanus

Answer 24

Initially fever, malaise, headache. Can then progress truisms (lock jaw), neck stiffness, trouble swallowing, abdo regidity, spasms

Ix - clinical diagnosis, gag reflex causes bite

Mx

• immediate IV tetanus immunoglobulins
• delayed debridement
• Metronidazole can be given
• prophylactic sedation and intubation
• benzodiazepines to prevent seizures
• botulinum toxin for muscle spasms

Question 25

Rheumatic fever - how to diagnose and treat

Answer 25

Jones criteria for diagnosis

Evidence of strep infection (strep throat, rapid throat swab, scarlet fever, raised step antibody titre) +
2 of carditis, polyarthritis, chorea, erythema Marginatum, subcut nodules
or 1 of above plus 2 of polyarthralgia, prolonged PR, fever, inflam markers, hx of rheumatic fever

Ix:

• throat swab, Rapid streptococcal antigen test (RAST), Anti-streptococcal antibodies, bloods.
• ECG/ CXR/ Echo

Mx:

• IM benzylpenicillin
• strict bed rest until CRP normalises
• NSAID for arthritis
• treat HF - ace inhibitors
• corticosteroids may be needed for carditis
• Benzos for chorea

Prophylaxis with benzathine penicillin injections or oral penicillin should be carried out for 5 years if no carditis, 10 if carditis, life if carditis and valve issues.

Mitral stenosis is a complication

Question 26

Resus requirements - WETFLAG

Answer 26

Weight (quick estimation method)
o <12 months: (age in months/2) + 4
o 1–5yrs—Weight (kg) = (2 x Age years) + 8
o 6–12yrs—Weight (kg) = (3 x Age years) + 7

Energy
o 4 joules x kg for defibrillation

Tube
o Diameter: (age/4) + 4
o Length: (age/2) + 12

Fluids
o Resuscitation: 10ml/kg
o Maintenance: As above

Lorazepam
o 0.1mg/kg

Adrenaline
o 0.1ml/kg of 1:10,000 (10mcg)

Glucose
o 2ml x kg of 10% dextrose

Question 27

Main causes of cardiac arrest in paeds

Answer 27

Hypoxia - due to obstruction or respiratory depression

• asthma, inhalation of foreign body
• raised ICP, opiate poisoning, convulsions

Fluid distribution

• hypovolaemia due to vomiting, dehydration, blood loss, burns
• maldistribution due to anaphylaxis or sepsis

Question 28

BLS steps for cardiac arrest

Answer 28

Assess for global and local danger

1. Assess responsiveness - clap, call, elicit pain
2. Call for help
3. Assess airway - look feel move for 10s - clear any visible obstruction from airway and secure with guedel
4. Rescue breath x5 - only suction if visible meconium
5. Assess for signs of life - brachial pulse if <1, carotid if >1. Start chest compressions if no signs of life, no pulse or pulse <60bpm
6. Start chest compressions at 15:2 rescue breaths at rate of 100bpm
7. Call resus team after 1 min if alone

Question 29

Differentials for murmur in child

Answer 29

Innocent childhood murmur - soft, systolic, changes with position

Ejection systolic - aortic or pulmonary stenosis, teratology of fallow, truncus arteriosus, ASD

Pan-systolic - VSD, mitral regurg

Diastolic - mitral stenosis/ aortic regurg, ASD/ VSD

Continuous - venous hum, patent ductus arteriosus (mechanical), co-arctation of aorta

Question 30

Kawasaki - medium vessel vasculitis

Answer 30

Diagnosed if fever >39 for > 5days + 4 or more of:
C - conjunctivitis - bilateral, dry
R - Rash, maculopapular
E - edema, erythema, desquamation
A - lymphadenopathy
M - mucosal inflammation - strawberry tongue

Ix:

• FBC - leukocytosis/neutrophilia/ platelets high then low
• LFT - raised transaminase/ bilirubin
• urinalysis shows sterile pyuria
• abdo US shows gallbladder enlargement
• ECG - abnormalities due to carditis
• Echo - look for coronary artery aneurysms

Management

• admit to hosp and bed rest
• Aspirin + PPI high dose until fever subsides then low dose until repeat Echo at 6-8w
• IVIg is mainstay of treatment - 2g/kg over 10-12 hrs
• If resistant (persistent fever) repeat IVIg, give steroids, anti-TNF, plasma exchange, ciclosporin etc

For aneurysm

• refer to Paeds cardiologist
• percutaneous coronary intervention e.g. Intracoronary thrombolysis, balloon angioplasty, stent, ablation

Question 31

Causes of cyanosis in new born - what is the cause if non-responsive to oxygen

Answer 31

Congenital heart defect - non responsive to O2
Resp failure - meconium aspiration, surfactant deficiency
Shock, metabolic acidosis
Persistent pulmonary hypertension
Infection

Question 32

Most common cause of cyanotic congenital heart disease: ix and mx

Answer 32

tetralogy of fallot

Ventricular septal defect (VSD)
Pulmonary stenosis (PS)
Right ventricular hypertrophy (RVH)
Overriding aorta

Presents in 3 severities

• mild - just pulm stenosis/ RVH - often asymptomatic and present with cyanosis aged 1-3
• moderate to severe - present if first few weeks of life with cardio/resp distress
• extreme - identified on antenatal scan

Present with cyanosis, clubbing, signs of HF (oedema, tachycardia, sweating, pallor, basal crackles). Also have ‘tet’ spells of deep rapid inspiration, hypoxia, cyanosis, collapse and irritability/crying.

On exam:

• single S2 due to only aortic valve closure
• long systolic murmur due to VSD
• ejection systolic murmur
• Aortic click due to dilatation of aorta
• heave if RVH, thrill

Investigations:

• Obs e.g. O2 sats, BP etc
• ECG - RVH, R axis deviation
• Microarray/ karyotyping
• CXR - boot shaped heart
• Echo - gold standard
• MRI pre and post surgery

Management

• Conservative - squating to imrove venous return
• medical - Prostaglandin infusion (keep PDA),
• morphine (reduce hyperpnoea), beta blocker and saline bolus for tet spells
• surgical - palliative procedures can stent RVOT, definitive surgery at 3m - 4yrs old
• lifelong cardiac follow up

Question 33

Transposition of the great arteries

Answer 33

Presents with early cyanosis often triggered by crying - typically within 24hrs to 1w if no VSD. If VSD present then baby has mild cyanosis, signs of congestive cardiac failure e.g. tachycardia, tachypnoea, diaphoresis

On exam RV heave, loud single second heart sound, systolic murmur if VSD

Ix:

• O2 sats performed as screening, will be low
• Capillary blood gas - low PaO2 and high metabolic acidosis
• egg-on-a-string appearance on CXR
• ECG
• Echo gold standard

Mx:

• start prostaglandin infusion asap
• correct metabolic acidosis
• if needed do balloon atrial septostomy
• Cure with arterial switch operation at 3d old

Question 34

Eisenmengers - what is it

Answer 34

When VSD/ASD/ Patent ductus arteriosum mean that LtoR shunt becomes RtoL as a result of a rise in pulmonary vascular resistance

Question 35

Tricuspid atresia

Answer 35

Presents with cyanosis in first few weeks to month and poor feeding

On exam have loud S2, pan-systolic murmur of VSD

Ix:

• ECG - superior axis
• Echo - LVH, tricuspid atresia, small RV
• CXR - LVH, increased or decreased pulm vascular markings

Mx:

• emergency give prostaglandin infusion and balloon septostomy
• Definitive surgery - multistage - relies on passive venous return to lungs

Question 36

Most common congenital heart defect - Presentation, Ix and Mx

Answer 36

VSD

Presentation depends on size

Small - often asymptomatic, discovered due to audible systolic murmur
Moderate - sweating, easily fatigued, tachypnoea
Severe - sx of heart failure - SOB, chest pain, cough, failure to thrive, freq chest infections

Ix:

• bloods to look for non cardiac causes e.g. infection
• Microarray if suspect genetic cause
• CXR - cardiomegaly, pulm oedema, pleural effusion
• ECG - LVH
• Echo gold standard

Mx:

• adequate calorie intake and furosemide to reduce pulm vascular resistance first line
• 2nd line is ACEi to reduce size of shunt or digoxin to improve contraction
• surgery done at 3-4m if signs of congestive cardiac failure or pulm hypertension - place patch over defect from left ventricle. Open or trans catheter.

Question 37

ASD

Answer 37

Majority asymptomatic, can present in young with tachypnoea, failure to gain weight or recurrent chest infections. Majority of cases presents after a stroke or with arrhythmia/ HF in older patients.

Associated with smoking, foetal alcohol syndrome, maternal diabetes, rubella, genetics, DS

On exam hear soft systolic murmur, wide fixed second heart sound, diastolic rumble of increased blood through tricuspid

ECG - Normal or R axis deviation, tall P waves, RBBB
CXR - Normal in kids, cardiomegaly in adults
Echo - gold standard
CT/MRI look for structural defects around heart

Mx:
Kids - do not exercise limit, if small <5mm will close on own, if symptomatic repair with open or transcatheter surgery

Adults - manager arrhythmia/ HF, perform surgery once stable

Question 38

PDA

Answer 38

Most asymptomatic. Large shunt can cause poor weight gain, feeding and recurrent LRTI

Continuous murmur beneath left clavicle/ upper left sternal boarder. Wide pulse pressure and bounding pulse

Echo gold standard, may also do CXR/ECG

If asymptomatic regular echo until 1yo to monitor, if still patent close via end-vascular occlusion

Indomethacin, ibuprofen can be given to close the PDA, more effective in premature neonates

If symptomatic - diuretics for HF sx, close earlier

If raised pulmonary resistance due to another CHD then keep open with prostaglandin E1 infusion

Question 39

Heart defect most commonly associated with downs syndrome

Answer 39

AVSD

Question 40

Coarctation of aorta

Answer 40

If severe can present with tachypnoea, shock, collapse, HF on 2nd day of life

If ductus arteriosus is patent - often less severe - can present later or in childhood with neuro or musculoskeletal signs e.g. headache, nosebleed, leg cramps, lower limb weakness, cold feet

On exam;
Distal pulses reduced and delayed - weak or absent femoral pulse
Upper limb BP higher than lower limb
Late systolic murmur over infraclavicular region, radiates to back over scapula

Ix:
Bloods if shock to rule out other causes e.g. sepsis
CXR may show notching of ribs (dilation of collateral vessels), indentation of aorta, HF
ECG
Echo - allows assessment of severity
MRI
CT angiogram

Mx:
Medical
- treat HF with diuretic, ACEi + BB, Digoxin as in VSD and AVSD
- prostaglandin E1 to maintain PDA

Surgical

• catheter balloon angioplasty or stenting
• more complex procedures if needed e.g. surgical resection

Question 41

Congenital diaphragmatic hernia

Answer 41

Usually diagnosed prenatally via US scan - if not is a paediatric emergency at birth

Causes cyanosis, tachypnoea, tachycardia, asymmetrical chest wall, absent breath sounds on one side and bowel sounds in the chest

Ix:

• do CXR/ US to confirm
• Do ABG to check pH and PaO2/CO2
• general bloods
• Screen cardiac, neuro, urinary systems for associated defects

Mx:

• intubation, avoid bag and mask as can inflate bowels
• blood pressure support with fluids/ ionotropes
• insert orogastric tube for decompression of stomach
• surfactant may be needed
• monitor blood glucose and calcium

Definitive treatment is surgery to replace bowel in abdomen and close defect in diaphragm

Question 42

Infantile colic

Answer 42

Presents with irritability, crying, fussing that begin/ end for no reason and last > or equal to 3 hours, on 3 or more days for greater or equal to a week

Baby has inconsolable crying, red face, clenched fists, brings knees to chest, flatus

Clinical diagnosis - do general exam and hx
Baby should be normal weight, if failure to thrive consider alternative diagnosis

Management:

• general advice on feeding regimes, temperature of house, babies clothing and course of condition (usually resolves by 4m)
• shared care for baby to prevent mental exhaustion
• hold upright after feeding, wind, rocking
• hypoallergenic diet beneficial in some
• simethicone can reduce flactulance but no proven efficacy

Question 43

Food allergy/ intolerance

Answer 43

Allergy can be IgE mediated causing urticaria, angioedema, anaphylaxis or non IgE mediated causing delayed diarrhoea, vomiting, abdominal pain

Investigate with skin prick test, ELISA allergen test, exclusion and re-introduction diet

Treat allergy with exclusion from diet, extensively hydrolysed/ amino-acid based milks, sodium cromogilcate/ antihistamines/ corticosteroids

if 1st degree relative has food allergy exclusively breastfeed for 1yr

Majority resolve by 2yrs old

Question 44

Most common cause of lactose intolerance in kids

Answer 44

Post viral gastroenteritis lactase deficiency - causes diarrhoea, vomiting, abdo pain after milk consumption. Lasts 4-6w after viral infection.

Question 45

Cows milk protein allergy

Answer 45

Often presents in first 3 months of life, more common in formula fed babies

Either IgE or non-IgE mediated

IgE presents with urticaria, angioedema, pruritus, erythema, N+V, diarrhoea, colicky abdo pain and upper/lower resp tract symptoms

Non- IgE does not present with urticaria/ angioedema or upper resp tract sx of allergy e.g. itching/ sneezing/ congestion. Does present with more abdominal sx including GORD, infantile colic, blood/ mucus in stool, food aversion, faltering growth etc.

Clinical diagnosis - may do RAST if diagnosis unclear or associated asthma/ atopic disease

Management

• Exclusion diet until 9-12mo then try reintroducing every 6-12m
• If breast fed mum has to become dairy free
• If bottle fed - hydrolysed 1st line, amino acid 2nd line

Question 46

anaphylaxis

Answer 46

a- look and relieve obstruction/ allergen
b- treat bronchospasm/ resp distress
c- pulse, colour, bp
d- consciousness, blood glucose 
e - expose but avoid heat loss

If mild give oral antihistamines and observe for 2hrs

if severe:

• high flow o2 via reservoir, intubate as needed
• lie flat, raise legs
• IM adrenaline, dose adjusted to age. repeat after 5 mins as needed. >12 0.5mg, 6-12 0.3mg, <6 0.15mg, up to 6m 0.1-0.15mg 1in1000
• Try IV if 2x doses, no improvement
• Nebulised adrenaline if stridor/ laryngeal oedema
• iv fluid challenge 20ml/kg warmed colloid
• after acute management give chlorphenamine/ hydrocortisone

admit for 6-12 hours, measure tryptase after emergency treatment to confirm then 1-2 hours later

Question 47

GORD

Answer 47

Presents commonly in babies/ young children with regurgitation following feeding, irritability, distressed behaviour, hoarse/ chronic cough, faltering growth, pneumonia, feeding difficulties (gagging, choking).

Key features - occurs after feeds, no bile/ blood in vomit, no projectile vomiting

Generally is a clinical diagnosis - may use endoscopy, 24hr pH probe, radioisotope milk scan, oesophageal manometry, CXR if needed

Mx:

• hold baby upright after feeds, do not feed just before bed
• formula fed: 1st ensure baby not fed too much (no greater than 150ml/kg/day), 2nd reduce quantity and increase frequency of meals, 3rd add thickener, 4th remove thickener and add alginate
• breast fed: give alginate mixed with water after feed

If no improvement with alginate after 2w of use then consider ranitidine or omeprazole

Consider pads referral/ further investigations/ surgery if still no improvement

Question 48

Vomiting differentials

Answer 48

Differentials

• Pyloric stenosis - young child in first few weeks of life
• GI obstruction
• Appendicitis
• Gastroenteritis
• GORD
• Raised ICP, head trauma
• Urinary tract issues: UTI, stones
• Hirschprungs
• DKA
• Testicular torsion
• ptussis

Question 49

Pyloric stenosis

Answer 49

Presents with vomiting in 2-8w old.

• non bilious
• 30-60 mins post meal
• increases in severity over time as stomach contracts to try and empty - becomes projectile
• may be some haematemesis
• baby still hungry - is thin, failure to thrive

Also have reduced bowel movements, dehydration/ weight loss, abdominal ‘olive sized’ pyloric mass in epigastrium

Ix:

• US gold standard - hypertrophy of pylorus muscles
• U&E/ Blood gas may show low K+/Cl- and metabolic alkalosis
• Test feed to feel pyloric mass/ observe peristalsis is sometimes performed

Mx:

• correct electrolyte and fluid imbalances
• NG tube used to aspirate stomach
• regular blood gas/U&E
• surgery - Ramstedt pyloromyotomy (open or laparoscopic)

Question 50

Acute diarrhoea causes and management

Answer 50

Most commonly cause is viral gastroenteritis

Other causes

• bloody diarrhoea think bacterial infection
• systemic infections e.g. pneumonia, UTI
• NEC
• Intussusception/ appendicitis
• Abx associated colitis, lactase deficiency
• hirschsprungs, meckels, volvulus, short bowel syndrome
• haemolytic uraemic syndrome
• acute presentation of crohns, UC, coeliac, CF

Ix:

• stool sample - culture and sensitivity, calprotectin if suspect IBD
• Bloods - signs of infection, U&E for electrolytes and dehydration, IgA/ tTg, inflam markers
• Abdo xray - NEC, volvulus, intussusception, short bowel, hirschsprungs
• Breath test for h pylori, biopsy, endoscopy, sweat test

Management:

• Treat cause
• If viral - supportive care, bed rest, oral rehydration
• If bacterial/ protozoal - Abx based on stool culture
• If supportive not sufficient consider racecadotril for symptomatic relief and rehydration
• cont breast feeding

Admit to hospital if

• Diagnosis unclear, not just viral
• systemically unwell
• signs of dehydration esp if <6m old
• cant orally rehydrate
• pre-existing medical condition e.g. diabetes

Question 51

Toddlers diarrhoea

Answer 51

Present with multiple wet loose stools per day. Often more pale and smelly than normal, is presence of undigested food and rarely abdo pain

Examination commonly normal, child 1-5yo, no problems with growth, happy and otherwise well

Clinical diagnosis - most grow out of it by 5

Management

• monitor fluid intake, make sure not too much
• limit fruit juices and squash
• increase fat in diet
• change fibre in diet (too high or too low is bad)

Question 52

Gastroenteritis

Answer 52

Usually viral (rotavirus or Norovirus), can be bacterial (campylobacter or Ecoli) or protozoal

Presents with:

• acute onset watery diarrhoea w/without vomiting
• generalised abdominal pain
• fever
• dehydration
• hx of recent contact/ recent travel
• bacterial may have bloody diarrhoea

Clinical diagnosis, do stool sample if:

• suspect septicaemia
• blood/ mucus
• last >7 days
• immunocompromised
• recently been abroad
• diagnostic uncertainty

Assess hydration status - if clinically dehydrated or in shock refer to hospital

Mx:

• continue with normal feeds
• encourage fluids, add ORS
• stop fruit juices and carbonated drinks

If dehydrated
- Give ORS 50ml/kg over 4hrs alongside normal fluid intake

If in shock, red flags or cont dehydration start IV fluids

Racecadotril can be used to reduce sx and improve rehydration if >3mo
Abx if bacterial and suspect septicaemia

After rehydration

• start full fat milk immediately
• slowly reintroduce solid food
• no carbonated or fruit juice until diarrhoea stops
• no school until 48hrs after last episode
• no swimming until 2w after last episode

Question 53

NEC

Answer 53

Characteristically low birth weight preterm babies in first few weeks of life - presents with not tolerating feed, N+V, change in bowel habit (bloody stools), abdo distention and abdo wall erythema.

May also see fever, signs of shock (bradycardia, tachypnoea), on exam

On exam see visible intestinal loops, erythema of abdomen, reduced bowel sounds, ascites/ abdo mass

Ix:

• AXR - pneumatosis intestinalis (gas cysts), dilated bowel loops, perforation, thickened bowel wall
• bloods - FBC (low platelets/neutrophils), raised CRP, U&E as baseline, blood gas (lactic acidosis)
• US may be helpful
• new biomarkers can help with early diagnosis
• blood cultures

Mx: stop feed, decompress, correct electrolytes, abx

• Admit to hosp, NBM
• nasogastric tube for intermitted bowel decompression
• IV fluids, TPN and IV abx for 10-14 days
• amoxicillin/cefotaxime/gent + metro/clindamycin
• ventilatory support/ circulatory support (dopamine/naloxone) if shock
• consider antifungals if not improving with abx or recent course of abx
• paracentesis for ascites

Surgery may be indicated if perforation or section of necrotic bowel

complications: DIC, sepsis, acquired short bowel (malabsorption), perforation, strictures/ abscess

Question 54

Straining and crying for 10 mins before passing stool, cause in <6 month old

Answer 54

Dyschezia

Question 55

Constipation

Answer 55

2 or more of following in last 8w

• <3 stools per week
• pain on passing stool
• > 1 incontinence per week
• palpable stool in abdomen
• passing stools that block toilet
• withholding behaviours

Red flags:

• sx commence from birth
• delayed passage of meconium >48hrs
• Ribbon stools
• leg weakness
• abdo distension w. vomiting
• abnormal exam findings

Treatment of idiopathic constipation:

Conservative

• diet - increase fluids and fibre
• address anxiety
• encourage using toilet with regular toilet breaks, stars/ rewards,

Medical - disimpaction

• 1st line - movicol
• 2nd line if not effective in 2w - Senna

Treat anal fissure with lignocaine ointment

Maintenance = long term movicol

Question 56

Hirschprungs

Answer 56

Failure to pass meconium within 48 hrs, abdo distension/ vomiting in neonates

Treatment resistant constipation, abdo distension/pain and poor weight gain in older kids

Can present as enterocolitis
- fever, abdo pain, foul smelling and bloody diarrhoea, vomiting

Ix:

• gold standard is rectal biopsy
• also consider AXR (see fluid levels), anal manometry, barium enema
• Bloods (FBC for raised WCC in enterocolitis)

Mx:

• manage obstruction with nasal or rectal decompression/ washout and fluids and NBM
• manage enterocolitis with NBM, IV fluids, IV Abx

Long term treatment for hirschprungs is surgery

Question 57

Abdominal migraine

Ask about

• SOCRATES
• Triggers
• Headaches, N+V, photophobia, better when lie down, headache?
• Blood in stool
• Change in bowel habit
• Relieved by sleep?
• How long last
• Growth
• Fever
• wake up at night?
• Family hx of migraines

Answer 57

Bouts of abdominal pain (poorly localised around umbilicus), N+V, but no headache, followed by sleep and recovery, well between bouts - last 2-72 hours
- may have associated features of migraine e.g. light sensitivity, nausea, sensitivity to movement

At least twice in the preceding 12 months, all of the following:

• Paroxysmal episodes of intense, acute periumbilical pain lasting at least an hour.
• Intervening periods of normal health, lasting weeks to months.
• Pain interferes with normal activities.
• Pain associated with two or more: anorexia, nausea, vomiting, headache, photophobia, pallor.
• Symptoms cannot be attributed to another medical condition.

Important to exclude other causes e.g.

• Intususseption - US
• Volvulus - AXR
• Pyloric stenosis - olive sized mass, repeated projectile
• apendicitis - fever, raised CRP/ WCC
• mesenteric adenitis - fever
• constipation - abnormally hard stools

Conservative - lie down in a dark room, rest, regular sleeping and eating routine

Acute attack - paracetamol, sumitriptan, antiemetics
Preventative - pizotifen
Antiemetic - domperidone

Question 58

Mesenteric adenitis

Answer 58

Inflammed abdo LN due to viral illness

hx of cold/ sore throat, pain in umbilicus/RIF, high fever, nausea/ diarrhoea

differentiating from appendicitis:

• rosvings sign negative
• upon observation pain stays steady or improves, not get worse
• higher fever than to be expected from appendicitis
• appetite retained unlike appendicitis
• WCC, CRP often normal

Ix:

• often clinical diagnosis
• if unsure have period of observation, do US
• blood tests

Tx:

• rest, painkillers
• safety net
• Abx if suspected bacterial cause

Question 59

Intussusception

Answer 59

Often 5m - 3yo

Present with acute onset colicky abdominal pain every 10-20 mins associated with crying, irritability, pallor, raising knees up to chest. Child feels better or tired between episodes. As symptoms progress develop bilious vomiting and red current jelly stool.

In late cases get signs of dehydration and shock

On exam may feel sausage shaped mass in RUQ or R flank

Ix:

• gold standard is US - see target sign
• Bloods for signs of infection/ dehydration/ DIC/ shock
• AXR - may show gas filed proximal bowel, no gas in distal bowel, may show perforation
• Barium enema shows proximal contrast, closure of bowel and minimal distal contrast

Mx:

• hospital admission
• IV fluids and NG tube drainage
• pain killers

1st line = enema to reverse invagination - air or barium

• try 3x for 3 mins
• not do if perforated or peritonitis

2nd line = surgery

• do if peritonitis/ perforation
• pathological lead point
• enema not effective
• symptoms>24hrs

Question 60

Volvulus

Answer 60

Can occur in adults or children, sigmoid most common across all ages, midgut specifically in babies and children

Presents with sudden onset bilious vomiting, abdominal discomfort, constipation, bloating. if develop ischaemia get intense abdominal pain, bloody stool and signs of septic shock/ peritonitis

Ix

• first line is emergency contrast imaging using barium via milk or NG tube. See bird beak sign and corkskrew duodenum.
• AXR shows double bubble sign
• US can exclude intussusception
• do bloods (FBC, U&E, CRP) and screen for sepsis

Mx

• admit to hospital
• drip and suck - IV fluids and NG tube aspiration
• emergency Ladd’s procedure to rotate obstructed bowel
• do secondary procedure 36 hours later if suspect bowel ischaemia and remove as needed

Question 61

Most common cause of painless GI bleed in children

Answer 61

Meckels diverticulum

commonly also presents with obstruction, may be pathological lead point for intussusception

Ix:
Scintigraphy for bleed
AXR or US for obstruction

Mx
Manage shock/ obstruction
surgical resection

Question 62

Biliary atresia - how present, what ix, management - here

Answer 62

Cause of prolonged jaundice in newborn

• have associated light stool and dark urine
• failure to thrive due to malabsorption

Hepato/ splenomegaly on exam

Ix:

• raised bilirubin levels (serum or transcutaneous)
• conjugated hyperbilirubinaemia
• hepatic biopsy confirmative
• scintigraphy, US also useful
• abnormal LFTs - raised GGT
• exclude alpha-1 antitrypsin deficiency and cystic fibrosis (sweat chloride test)

Mx:
Medical - give Abx to avoid cholangitis, UDCA to improve bile flow, fat soluble vitamin supplements

Surgery - portoenterostomy - attach small bowel to portal triad of liver. Liver transplant as last resort

Question 63

Cause of low platelets with normal clotting vs abnormal clotting

Answer 63

Normal = haemolytic uraemic syndrome

Abnormal clotting = DIC

Question 64

how does alpha 1 anti-trypsin present

Answer 64

Can present in neonates with cholestasis, jaundice and hepatitis

Typically presents in 30-40s with early onset emphysema/ COPD

Can also present in adulthood with hepatitis, liver failure, cirrhosis

Question 65

Asthma diagnosis and management

Answer 65

In kids <5 not able to diagnose as they cannot before objective tests - treat based on clinical sx and needs

step 1 - SABA
step 2 - 8w trial of moderate dose paeds ICS and reviews. Continue on low dose paeds ICS if sx return in <4w
step 3 - add in LTRA
step 4 - stop LTRA and refer to secondary care

In kids >5 can do objective tests:

1st line investigation is spirometry. If FEV1/FVC <0.7 suggests obstruction and consider confirming with bronchodilator reversibility test. If >12% + 200ml is positive for diagnosis of asthma

If ambiguity 2nd line test is FENO - >35ppb is +ve for asthma

If diagnosis still uncertain consider 2-4w peak flow diary to look for variability >20%

step 1 - Saba
step 2 - low dose ICS
Step 3 - add LTRA
Step 4 - swap LTRA for LABA
Step 5 - Mart
Step 6 - moderate dose ICS + LABA (mart or not)
Step 7 - refer

Question 66

low, moderate, high ICS doses in 5-16yo

Answer 66

For children and young people aged 16 and under:

Low = 200 mpg or less budesonide 
Moderate = 200-400
High = >400

Question 67

What to ask in paeds asthma history

Answer 67

• Age at onset of symptoms
• Frequency of symptoms
• Severity of symptoms (how many days of school missed? Can the child do PE at school? Can they play with their friends without getting symptoms? Night time symptoms?)
• Previous treatments tried
• Any hospital attendances (A+E or admissions – including HDU/ITU admission – ventilated?)
• Presence of food allergies
• Triggers for symptoms: Exercise, cold air, smoke, allergens, pets, damp housing
• Disease history: Viral infections, eczema, hay fever
• Family history of atopy

Question 68

Management of acute asthma - moderate, severe and life threatening

Answer 68

Moderate - sats >92

• 4 puffs of salbutamol followed by 2 puffs every 2 mins up to max of 10
• oral prednisolone
• review, if worsening admit, if better discharge with 3d oral steroids and tapering SABA, review in 48hrs

Severe - sats <92, peak flow 33-50% predicted

• consider admission
• nebulised salbutamol +/- ipratropium
• oral prednisolone
• oxygen - aim sats 94-98%

Life threatening - sats <92, cyanosed, silent chest, unconscious, peak flow <33%

• oxygen
• nebulised salbutamol + ipratropium
• IV hydrocortisone
• aminophylline
• magnesium sulphate
• escalate

When discharge put on wheeze discharge plan - look at

Question 69

Bronchiolitis

Answer 69

Occurs in infants up to 2 years of age, caused by RSV

Presents with coryza for 1-3 days followed by all of

• persistent cough (often wet sounding)
• tachypnoea/ chest recession
• fine crackles/ end expiratory wheeze

can also have fever, tachycardia, poor feeding, rhinorrhoea

ix

• pulse oximetry
• consider throat swab for RSV in secondary care
• CBG
• CXR if temp>39 or focal resp signs indicative of pneumonia
• cultures/ urine dip if pyrexic

mx

• primary care = supportive. encourage fluids, feeding, give antipyretics only if child distressed
• immediately refer if sats <92, apnoea, signs of resp distress, cyanosis, RR >70, consider referral if dehydrated, less than 50% normal feeding, Comorbs, RR>60, <3mo or premature

in secondary care = supportive

• fluids if needed
• high flow nasal oxygen if sats <92%, CPAP if resp failure
• NG tube for feeding
• Upper airway suction if issues feeding or apnoea

Discharge once

• clinically stable
• taking oral fluids
• O2 sats > 92 for 4hrs

Palivizumab can be used for prophylaxis treatment in vulnerable

Question 70

Pneumonia

Answer 70

Presents with SOB, productive cough, fever, raised RR, cyanosis, focal coarse crackles, absent breath sounds/dull percussion if effusion

May do CXR if diagnosis uncertain
nasopharyngeal aspirate/ sputum culture can help identify cause
blood cultures necessary if suspected sepsis

Treatment is supportive
if critically unwell with signs of resp distress, low O2 sats, cyanosis, dehydration admit to hospital

Give antipyretics, IV fluids, first line abx is amoxicillin for 7-14 days, second line is co-amoxiclav

Question 71

Cause of focal wheeze in kids

Answer 71

Obstruction due to inhaled foreign body or tumour

Question 72

Viral induced wheeze

Answer 72

Occurs in children aged 6m to 5yr

Involves onset of SOB, resp distress, cough and generalised expiratory wheeze after symptoms of viral infection (sore throat, coryza etc)

Due to inflammation, oedema and swelling of airway. No other triggers other than viral infection. Often no hx of atopy.

No crackles differentiates from bronchiolitis

Management:

• identify life threatening attack - cyanosis, sats <92, unresponsive etc and admit to hosp
• treat as acute asthma with oxygen, salbutamol puffs/ nebs, steroids, ipratropium
• discharge with discharge wheeze plan

Question 73

CF

Answer 73

Presents differently at different ages

• in neonate presents with meconium ileus
• in infant presents with failure to thrive, recurrent chest infections and steatorrhoea
• in childhood presents with rectal prolapse, nasal polyp and sinusitis
• in adolescence presents with DM, chronic lung disease, gallstones, liver cirrhosis

Ix: Most detected via screening in neonates

• raised immunoreactive trypsinogen on heel prick
• confirm with sweat test - Cl >60 with Na lower on 2 occasions
• CXR - hyperinflation, inflam, infiltrates, bronchial dilation
• Spirometry
• Sputum culture
• LFT, FBC, U&E, fasting glucose, vitamin lvls
• Faecal elastase for pancreatic issues

Management

• for resp do chest physio, give oral abx for prophylaxis (fluclox from diagnosis to age 3 or azithromycin), IV abx in exacerbation, give dornase alfa + hypertonic saline to help reduce and clear secretions. May need transplant
• start on high calorie diet, supplementary fat soluble vitamins
• monitor growth
• CREON may be needed if pancreatic insufficiency - take immediately before or just after each meal
• Insulin for diabetes
• nasal polyp - nasal steroids or polypectomy
• fertility treatment with IVF for azoospermia
• liver transplant for liver failure, UDCA can improve bile flow but not alter disease
• protect against osteoporosis with vit D, ca, bisphosphonate

Question 74

Types of JIA + management

Answer 74

oligoarthritis - <4 joint involvement in first 6m

Polyarthritis: >4 joints in first 6m, can be RF +ve or -ve

Systemic arthritis: peaking temperature >39, lymphadenopathy, salmon pink rash, serositis, hepatic/splenomegaly

psoriatic: 2 of: dactylitis, nail pitting/ onycholysis, 1st degree relative with psoriasis

All present with morning stiffness, joint swelling, pain

Mx
Involve MDT - physio, OT, social care, child psychologist etc

Nsaids for pain relief
Steroid joint injections
If steroid injections not effective, same joint needs >3 then start on methotrexate. Alternatives to methotrexate include Etanercept or tocilizumab

joint replacement, synovectomy may be needed

Question 75

Causes of toe walking

Answer 75

Distinguish from mild cerebral palsy or tightness of the Achilles tendons or inflammatory arthritis in the foot/ankle

In boys exclude DMD

If unilateral consider DDH

Question 76

Transient tenosynovitis

Answer 76

Most common cause of hip pain in children aged 2-12

Presentation

• Hip pain
• Difficulty weight bearing
• fever
• irritability

Acute onset followed by spont recovery with no systemic upset. May be preceded by a viral illness

Important to differentiate from septic arthritis 
Use kosher criteria:
- Pain causing inability to weight bear
- ESR >40
- WCC >12 
- Temperature >38.5 degrees 

+ve leg roll, no pain at rest and pain only at extremes of ROM is indicative

USS and US guided joint aspiration can give definitive differentiation

Management

• rest, analgesics e.g. NSAIDS/ paracetamol
• Mobilise once pain improved
• Safety net to go to A&E if pain gets worse or develop a fever
• Review in a week to check for resolution

Question 77

Most common cause of septic arthritis and its treatment

Answer 77

Most common cause is staph A

Do US, bloods, joint aspiration

Question 78

DDH

Answer 78

subluxation/ dislocation of hip due to poor growth/form of the acetabulum/femur

Commonly presents in 0-5yo
More common in females

RF are family hx, breech birth, multiple pregnancy, first born, swaddling, large size, prematurity, oligohydramnios

Screen all babies for DDH with Barlow and Ortolani
If first relative hx, breech at birth before 36w or breech presentation after 36w then screen with US instead

Commonly presents on exam with asymmetrical skin folds, leg length (Galeazzi sign) and limitation/asymmetry of the hip on abduction when flexed to 90 degrees.

In older children presents with delayed walking, painless limp, toe walking on affected side, sensation of instability, increased ROM, trendelenburg gait or waddling gait if bilateral.

Diagnose with dynamic US, in older kids xray can be used

Treatment

• if <6mo first line is bracing using a pavlik harness
• if >6mo consider surgery with closed or open reduction and casting, osteotomy may be needed in older kids

Question 79

Perthes

Answer 79

Avascular necrosis of the femoral epiphysis leading to subchondral collapse and fracture.

Most common in boys age 3-10, predisposes to developing OA

Presents with several week onset of hip pain, limp and poor hip rotation

On exam see stiffness of all movements in particular of internal rotation and abduction, +ve leg roll, antalgic gait if early, Trendelenburg if late

Ix:

• xray in early disease may show increased joint space, later shows compressed, patchy femoral head, then shows collapse, deformity and new bone formation
• MRI/ technetium bone scan can show avascular pathology
• FBC/ ESR to exclude inflam causes

Mx:
If <6yo - conservative mx - rest, not weight bear, painkillers , casting/ traction and physiotherapy until ossification complete
If >6yo - consider surgery with pelvic/femoral osteotomy

Regular X-rays to monitor healing

Often need early hip replacement later in life due to OA

Question 80

SCFE

Answer 80

Occurs in obese adolescents aged 10-15

Can be acute or chronic, stable (can weight bear) or unstable (cant weight bear, high risk of osteonecrosis)

Acute presents within 3w of sx onset with sudden onset severe hip pain so cant walk or stand, external rotation of the hip, limp, reduce internal rotation

Chronic presents after 3w of onset, sx milder, able to walk but antalgic gait, external rotation of leg while walking, shortening of leg, atrophy of thigh may be noted

Both present with Drehmann’s sign - on flexion of hip, get passive external rotation

Ix:

• xray - shows slipped capital femoral epiphysis, line of Klein fails intersect the epiphysis during acute phase (Trethowen sign)
• US, CT, MRI may be used
• Bloods to rule out inflam cause
• Technetium bone scan

Mx:

• stop weight bearing immediately, prevent movement, rest and admit to hospital
• give analgesia for pain
• insertion of hip screw is first line surgical treatment
• open reduction +/- osteotomy is alternative

Question 81

Testicular torsion

Answer 81

Most common in adolescents - intravaginal - just testes rotates. Can also occur in neonates - extravaginal - testes and tunica vaginalis rotates

Presents with acute onset severe testicular and lower abdominal pain associated with nausea and vomiting often after a period of exercise. Often had a brief episode of previous pain with spont resolution

On examination the scrotum on the affected side is red, swollen and the testicle is sitting higher than normal. Lifting the testicle does not ease pain and the cremasteric reflex is absent

Doppler US can be performed to confirm diagnosis but should not delay treatment

Treatment involves NBM, analgesics and immediate referral to surgery for de-torsion and bilateral orchidopexy

Question 82

Cryptorchidism

Answer 82

Undescended testes

Differentials are retractile testes that elevate out of scrotum when triggered by cremasteric reflex (can become ascending testes), or ectopic testis

Identified on routine neonatal examination

Not uncommon at birth

• if one, review at 6-8w
• if bilateral do abdo US to locate testes and perform tests to identify congenital adrenal hyperplasia
• β-hCG, α-FP, and LDH to check for embryonal cell carcinoma

If needed diagnostic US, MRI can be used

Management:

Observe until 6m - most resolve on own
If still undescended at 4-5m refer to paeds surgery
hormone treatment can be used: beta hCG or GnRH
First line treatment is orchidopexy

Increased risk of testicular cancer in later years so educate need for self examination. Also risk of infertility if not corrected timely. Increased risk of torsion

Question 83

Ballooning of foreskin on micturition, dysuria, haematuria and white, scarred foreskin on exam - cause?

Answer 83

BXO - balanitis xerotica obliterans

Treat with circumcision

Question 84

Bilateral hydronephrosis in male neonate - suspected cause, what to do to identify/ treat

Answer 84

Suspect posterior urethral valves, do US within 48hrs, emergency surgery

Question 85

Nocturnal enuresis management

Primary - child never achieved continence
Secondary - Child previously had at least 6m of continence

Look for causes if new onset e.g. constipation, UTI, diabetes

Ask about

• when start
• always happened or been dry before
• how often
• multiple during night or just once
• daytime symptoms
• constipation
• any behavioural problems or developmental delay
• difficulty at home
• can they access a toilet easily at night, any fear around using toilet

Answer 85

Reassure parents mostly resolves on own 
Punishment does not help 
Reduce drinking/ caffeine before bed
Manage constipation 
Use toilet before bed
Wake up in night to go to toilet 

If consistent enuresis over age of 6 consider:

• enuresis alarm
• desmopressin for short term relief

If daytime symptoms need to do urinalysis to exclude infection, DM + do US/ MRI to look for neuropathic bladder, ectopic ureter etc

Question 86

child presents with hx of URTI or gastroenteritis, fever, joint pain, abdo pain/ GI bleeding, protein/heamaturia and new onset purpuric non blanching rash over lower limbs - cause?

Answer 86

Henoch-Schonlein purpura
- IgA mediated vasculitis

If abdo pain - do US as associated with intussusception

Rest, rehydration, analgesia
Monitor urinalysis and bp for signs of renal involvement
Steroids/ plasma exchange may be considered in severe renal failure

Usually self resolves after 4-6w

Question 87

2 main causes of tonsillitis and their mx

Answer 87

strep pyogenes and EBV

Feverpain

• absence of cough
• onset in last 3d
• fever in last 24hrs
• purulent tonsils
• sever inflammation

2or3 - delayed abx
4or5 - 5-10d phenoxymethylpenicillin

Do not give amoxicillin to glandular fever - risk of rash

tonsillectomy if >7 in one year, 5 per year for 2 year, 3 per year over 3yr

Question 88

Croup - subglottic inflammation and oedema

Vs epiglottitis

• hoarse voice
• prodromal coryza
• onset over days
• barking cough

Ask about voice, cough, worse at night? Ask if painful swallow to differentiate from epiglottitis

Answer 88

Presents with signs of URTI e.g. coryza, cough, fever, sore throat that then develops into characteristic barking cough, hoarse voice/cry (both worse at night), inspiratory stridor, increased work of breathing.

Affects children 6m-12yr

Most often parainfluenza (viral)

Assess severity - westly clinical scoring system

• mild - just barking cough
• moderate - barking cough, stridor, sternal recession
• severe/ resp failure - above + agitation/ lethargy, cyanosis

If mild can treat at home

If moderate to resp failure refer to hospital

Often clinical diagnosis - not want to do ix if not needed as will distress child and worsen breathing

• sats
• CXR see steeple sign
• laryngoscopy if suspect obstruction

Mx:

• supportive care with rest, antipyretics if fever causing distress and fluids
• one off oral dexamethasone 0.15mg/kg (alternative is nebulised dobutamine or IM dex)

If severe:

• nebulised adrenaline to dilate airways
• O2 therapy if sats low

Question 89

Peritonsillar abscess

Answer 89

Presents with severe one sided thoat pain, difficulty swallowing, drooling, trismus, hot potato voice

On exam see swelling superior to tonsil on one side with shift of uvula away from the midline

Can do US to differentiate from peritonsillitis and locate optimal location for drainage

Treatment is a combination of rest, fluids, analgesia, IV or oral Abx (amoxicillin with clindamycin or metro), IV steroids, and surgical treatment with aspiration, incision and drainage or therapeutic tonsillectomy

Question 90

Epiglottitis

Vs croup

• silent/ weak voice
• no prodromal coryza
• acute onset over hours

Answer 90

Caused by strep e.g. pyogenes or HIB

Presents with dysphagia, odynophagia, drooling, hot potato voice, fever, sore throat, tenderness over anterior neck, inspiratory stridor, dyspnoea

Often have tripod sign - sit forward with hands on knees

Do not use tongue depressor - refer for laryngoscopy (gold standard, perform in theatre incase intubation/ tracheostomy needed). Alternative is neck xray. Once stabilised do throat swabs.

• blood cultures if systemically unwell
• CT/MRI if suspect abscess

Mx:

• conservative with fluids, IV/ oral Abx
• O2 therapy
• nebulised adrenaline can act as bridging therapy until airway control
• If acute resp failure may need to intubate or perform tracheostomy
• drain abscess if present

Question 91

DKA

Answer 91

Present with feeling generally unwell and lethargic, nausea and vomiting and abdominal pain.

On exam see deep sighing (kussmauls breathing), tachypnoea and intercostal recession. Also see shock - tachycardia, low BP and increased CRT, May be change in consciousness

pH <7.3 or bicarb <15
Glucose >11
Ketones >3

AtoE

Airway - intubate if reduced consciousness
Breathing - high flow O2 via face mask
Circulation
- If in shock give 20ml/kg fluid over 15mins
- If not in shock give 10ml/kg fluid over 1 hour
- ECG for potassium, take bloods, blood gas
Disability
- if reduced consciousness or vomiting insert NG tube
Exposure
- examine for signs of sepsis - fever

Start on IV insulin infusion 1-2hrs after fluids - 0.05 – 0.1 units/kg/hour of a soluble insulin e.g. actrapid
Retest blood glucose levels, if drop below 11 give 10% dextrose
Treat high/low K+

DKA is considered to be resolved once the child is clinically well, drinking and tolerating food and the blood ketones are less than 1mmol/litre or pH is normal. Subcutaneous insulin can then be started and IV insulin stopped one hour later.

Question 92

Differentials for eyelid swelling in young baby

Answer 92

cavernous haemangioma, pre/orbital cellulitis

Question 93

Differential for bruising/ non accidental injury in newborn

Answer 93

Mongolian blue spots

Question 94

Pink birthmark on face - 2 causes

Answer 94

Small, round macule = capillary haemangioma, often self resolve
Large patch/ discolouration = port wine stain, remain present throughout life, improve appearance with laser therapy

Question 95

Management of headlice

Answer 95

First line is wet combing or use of dimeticone 4% lotion. Alternative is malathion 0.5%

Repeat treatment after 7 days to treat any lice hatching from eggs.

Question 96

ALL - here

Answer 96

Lymphoblasts take over bone marrow, reduce:
Hb (anaemia): lethargy, fatigue and pallor
neutropaenia: frequent or severe infections
Platelets (thrombocytopenia): easy bruising, petechiae

Also get organomegaly (splenic), testicular enlargement, lymphadenopathy, gum hypertrophy, headaches, bone pain, pain over sternum

Ix:

• Tdt, PAS +ve
• common in trisomy 21
• do karyotyping
• do FBC - altered WCC, neutropenia, LFT/U&E prior to tx
• Blood film - identifies blast cells
• CXR to identify mediastinal mass
• bone marrow biopsy and aspirate to confirm diagnosis
• LP for CNS involvement

Mx:

• supportive measures including abx/ anti fungal for infection, G-CSF for myelosuppression, transfusion, allopurinol/rasburicase for tumour lysis syndrome
• induce remission with vincristine, steroid, anthracycline
• CNS protection
• Maintenance with methotrexate and 6-mercaptopurine for 2.5-3 years
• stem cell transplant

Question 97

High urinary catecholamine breakdown products in child under the age of 5 presenting with sweating, agitation, vomiting, abdo mass, weight loss, fatigue and possible racoon eyes, blueberry muffin appearance, horners syndrome, bone pain - cause?

Answer 97

Neuroblastoma

Diagnose by combination of bone marrow biopsy and urinary catecholamines

Do US, MRI and MIBG scan (metastasic disease)

Treat with monitoring if low risk or combination of surgery/radiotherapy/ chemotherapy if higher risk

Question 98

Nephroblastoma

Answer 98

Presents with asymptomatic abdominal mass
- may be UTI, haematuria, anorexia, abdo pain

Ix:

• FBC, U&E
• US or IV pyelogram can be used to visualise malformation of renal pelvis and hydronephrosis
• Renal angiogram
• CT can be used to define tumour, look for metastasis
• Do not take a biopsy

Managment

• most treated with nephrectomy and chemo
• If stage 3 might need postop radiotherapy
• neoadjuvant chemo if unrescectable, bilateral or causing vena cava thrombus

Question 99

Retinoblastoma

Answer 99

Can be hereditary or sporadic

Presents with leukocoria (white pupil reflex), new onset squint or in later presentations visual disturbance/ red irritated eye/ enlargement of eye

Refer immediately to ophthalmology if suspected

• Exploration under anaesthesia with dilated pupil
• US
• MRI
• Genetic counselling

Refer to bham children’s or royal London

• cryotherapy, phototherapy, chemo
• enucleation as last resort

Question 100

Cause of childhood hypothyroidism (not congenital hypothyroidism)

Answer 100

Hashimotos - presents initially with slowing of growth, sleepiness, weight gain, skin changes, cold intolerance

Can also cause delayed puberty

Question 101

Congenital adrenal hyperplasia

Answer 101

Commonly caused by 21-hydroxylase deficiency

Can present as salt wasting or non salt wasting

Boys - might be hyperpigmentation/ slight enlargement of genitals otherwise normally present at 7-14 days with a salt wasting crisis: lethargy, vomiting, weight loss, dehydration, shock, low Na, high K+

Females - typically present with ambiguous genitalia, enlarged clitoris and common urogenital sinus. Precedes salt wasting crisis

Can also present later in milder forms with irregular or absent periods, severe acne, rapid growth during childhood, early appearance of pubic hair

Ix:

• raised 17-hydroxyprogesterone is diagnostic of 21- OHD
• check U&E for low sodium, high K+
• do blood glucose
• corticotrophin stimulation test - see if rise in cortisol
• pelvic US for ambiguous genitalia
• Genetics/ karyotyping

Mx

• Hydrocortisone to replace glucocorticoids
• Fludrocortisone to replace mineralocorticoids
• 2-3x dose if unwell, may also need fluids, NaCl supplementation
• medical alert card/ bracelet
• surgery for ambiguous genitalia

Question 102

Cerebral palsy

Answer 102

Occurs due to immature brain injury - many causes including hypoxia, intracranial bleed, foetal alcohol syndrome, cocaine, congenital torch infections, asphyxia, birth trauma

4 main types

• Spastic - increased tone and pathological hyper-reflexia (cortex issue)
• Athetoid - Hyperkinesia (chorea, dyskinesia, athetosis), normal reflexes (basal ganglia issue)
• Ataxic (loss of muscular co-ordination)
• Mixed

As well as above sx typically presents with:

• delayed milestones e.g. not sitting by 8m, not walking by 18m
• learning difficulties, epilepsy, feeding problems, failure to thrive, sensory impairment, toe walking

Ix:

• Brain US can identify major intracranial lesions, if not MRI can be used to investigate cause of known or suspected CP
• TFTs, CSF, pyruvate, lactate and protein, chromosomal
• EEG can help detect damage from hypoxia and vascular insult
• evoked potentials can identify sensory issues e.g. hearing

Mx:
Involves MDT for physio stretching, Orthotics splints, SALT for feeding, speech and language, OT for wheelchair, hoists, social care for schools etc

Medication

• Baclofen for long term spasticity
• Diazepam for short term spasticity relief in pain crisis
• Botulinum A for focal spasticity
• Levodopa or baclofen for dystonia
• treat pneumonia/ epilepsy

Surgery

• Tendon releases
• Bone osteotomy and realignment
• correction of scoliosis
• Dorsal rhizotomy

Question 103

ADHD

In counselling discuss
- Stressing the positive aspects of the diagnosis (accessing help, understanding the issues and symptoms) as well as acknowledging the negative aspects such as stigma.
- Discussing potential effects of ADHD.
- Some day-to-day activities might be more difficult for you and your child, including:
getting your child to sleep at night
getting ready for school on time
listening to and carrying out instructions
being organised
social occasions
shopping

Although it can be difficult at times, it’s important to remember that a child with ADHD cannot help their behaviour. People with ADHD can find it difficult to suppress impulses, which means they may not stop to consider a situation, or the consequences, before they act.

Things that can help

• Plan the day, set routines, use clear steps
• Set clear boundaries - know what behaviour is expected, reinforce positive behaviour with rewards and praise, negative with consequences such as taking away privilege
• Be positive
• Give specific praise - Instead of saying a general: “Thanks for doing that,” you could say: “You washed the dishes really well. Thank you.”
• Give brief clear instructions - tell them to put toys in box rather than just tidy room
• incentive schemes - good behaviour can earn a privilege
• Intervene early - If your child looks like they’re becoming frustrated, overstimulated and about to lose self-control, intervene. Distract them, take them out of situation.
• Social situations - short and sweet
• Exercise - Make sure your child gets lots of physical activity during the day.
• Eating - Keep an eye on what your child eats. If your child is hyperactive after eating certain foods, which may contain additives or caffeine, keep a diary of these and discuss them with a GP.
• Bedtime - Stick to a routine - Avoid overstimulating activities in the hours before bedtime, such as computer games or watching TV.
• Night time - often will get up at night, making symptoms worse - follow a routine that works
• Help at school - speak to teachers and educational co-ordinators
• Discussing effects on relationships.
• Explaining the potential effect on driving.
• Offering advice on appropriate sources of information.
• Offering advice about consistent behaviour management and parenting skills and explaining that any recommendation of parent-training/education does not imply bad parenting, but that extra parenting skills are needed for children and young people with ADHD.
• Asking about goals, preferences for treatment, concerns and worries.
• Forming an individualised shared treatment plan.

Answer 103

Defined as >6 symptoms of inattention or hyperactivity lasting >6m with significant impairment on functional well being, affecting >2 settings e.g. home/work and present before the age of 12

If suspected in primary care do a 10w watch and wait, if sx still present then refer to secondary care specialist for full psychosocial assessment
- can use strengths and difficulties questionnaire or conners rating scale

Exclude differentials e.g. caffeine, hyperthyroid, steroids, beta agonists, bipolar, personality disorder

Mx:

• education, school involvement, environment modification, diet (no sweetners) and exercise
• can do a food diary and refer to dietician
• Psychosocial support: group parent training programme for preschool age, group parent and child programme for school age. CBT can also be helpful
• Medication - first line methylphenidate (only if above not worked, >5yrs old), monitor weight, height, pulse and BP 6monthly.

Do weight, height, BP, pulse, CV exam and ECG before starting meds

SE include stunted growth, hypertension, palpitations, disturbed sleep, appetite suppression

Question 104

DMD

Answer 104

Presents with proximal muscle weakness/wasting and loss of function. Commonly children have delayed walking (later than 18m), waddling gait on running, gowers manoeuvre when standing from sitting, enlarged calf muscles

Also commonly have speech and language delay, failure to thrive

Due to absence of dystrophin

Diagnosis

• Raised CK may be first indication
• Diagnosis based on combination of genetic testing, muscle biopsy and clinical exam

Management
- important to do early genetic testing and counselling before have another baby

in early years:

• physio for contracture
• orthoses to prolong walking
• may need serial leg casting
• wheel chair, adaptations
• prednisolone can help improve muscle strength and function
• Vit D/ Ca supplements
• Bisphosphonate if vertebral fractures

In older years:

• management of respiratory complications such as hypoventilation (NIV, oxygen), absent cough (cough assist, physio) and recurrent infections (prompt treatment)
• management of cardio complications such as dilated cardiomyopathy (regular monitoring with ECG/ Echo and treatment with ACEi, beta blockers, diuretics, anticoag)

Question 105

Migraine

Answer 105

Present at any age, more commonly bilateral and may be associated with auras including hemiparesis, ophthalmoplegia and dizziness/syncope

Criteria for diagnosis

• with aura: 2 or more attacks with 3 of: aura present that comes on gradually, is fully reversible, lasts <60mins or is followed by headache within 60mins
• without aura: 5 or more attacks lasting 2-72hrs with 2 of: uni/bilateral, throbbing, moderate-severe, aggravated by physical activity + 1 of N/V or photo/phonophobia

RF - family hx, past hx of abdo migraine,

Management

• reassurance, headache diary to detect triggers, sleep/diet
• acute attacks - paracetamol/ibuprofen first line, triptans second line. Domperidone/ prochlorperazine (>12yo) if nauseous
• prophylactic - if significant affect on life - topiramate, propanalol, pizotifen first line

Question 106

Hydrocephalus - 2 types and management

Answer 106

Can be communicating or noncommunicating/ obstructive

Obstructive = aqueduct stenosis, mass, malformation, haematoma

communicating = infection, SAH, intraventricular haemorrhage

Presents with irritability, vomiting, headache (in older kids), large head size, tense fontanelles, impaired consciousness, papilloedema, 6th nerve palsy.

Sunsetting sign of eyes, cracked pot sound on head percussion may be present

Investigate with CT/US/MRI

Managment

• often just monitor
• If needed acetazolamide and furosemide can help inhibit CSF secretion
• Isosorbide can increase reasorbtion
• Serial LP can precent need for neurosurgery in communicating
• Mannitol can be used in an emergency
• May need insertion of drain/shunt

Question 107

definition of macro and microcephaly

Answer 107

macro = head circumference >98th centile
Micro = <2nd centile

Question 108

Reflex anoxic seizures
- differential is breath holding attacks in infants

If occur when startled = reflex anoxic seizure

If occur after prolonged crying = cyanotic breath holding spell - occur when the child is really upset, worked up and crying. After letting out a long cry they stop breathing, become cyanotic and lose consciousness. Within a minute they regain consciousness and start breathing. They can be a bit tired and lethargic after an episode.

Answer 108

Differential for epilepsy

Triggered by fear/anxiety/ pain

Increased vagal responsiveness leads to asystole

Child goes pale, looses consciousness, then limbs go stiff and exhibit clonic jerking
Lasts 30-60s with quick recovery (shorter than epilepsy)
Some fatigue after
No tongue biting

Ix:
No EEG changes
Do ECG to look for cardiac differentials
May consider vagal stress test

Mx:
Treat with reassurance and education on seizure management e.g. recovery position
If severe, frequent attacks consider pacemaker insertion

Question 109

Movement of eyelid with jaw movements when feeding - cause?

Answer 109

Marcus gunn

Question 110

Infantile spasm

Answer 110

Associated with brain damage e.g. hydrocephalus, hypoxia, Down syndrome or can be idiopathic

Presents with contractile spasms (sudden contractions followed by gradual relaxation) on waking or falling asleep. Tend to last several seconds and repeat over a period

To investigate

• do EEG - shows characteristic sign of hypsarrhythmia
• MRI to look for structural cause
• blood/ urine cultures if suspect infection
• blood tests

Management

• first line is vabigatran, prednisolone or ACTH
• second line is benzodiazepines, lamotrigine, valproate
• pyridoxine and ketogenic diet can also help

Question 111

Febrile convulsions

Answer 111

Seizure in presence of temperature >38 without CNS infection from age of 6m to 6yrs

Simple - generalised tonic clonic, last <15mins, not recur within 24hrs or illness, complete recovery within 1 hour

Complex - focal partial seizure often affecting one side of body/ limb or not matching above

Cause can be bacterial or viral

Assess for signs of infection to decide cause, as well as signs of meningitis/ septicaemia (pale, mottled, non blanching rash, abnormal behaviour, stiff/floppy, tense fontanelles, meningism)

Do traffic light signals

Ix:

• FBC, u&e, coag, glucose, CRP/ESR
• Blood cultures
• Urine mc&s
• LP

Mx:

• reassure parents and teach first aid
• recommend to call ambulance or try benzodiazepine if not resolve within 5mins
• admit to hosp if systemically unwell, unsure of diagnosis, neuro deficit, recurrent, first presentation
• Treat infection according to locus
• antipyretics, fluids, remove excessive clothing
• treat status as per normal

Most stop by 6 years, prognosis good, some risk of epilepsy development

Question 112

Epilepsy - types of seizures

Answer 112

Can be generalised or focal

Generalised =

• absence seizures - vacant and unresponsive with small motor movements, occur regularly and last several seconds
• tonic - stiff contraction
• clonic - rhythmic jerking
• myoclonic - quick shock like movements - juvenile myoclonic epilepsy - adolescents, seizure in morning, jerks of shoulders and arms, triggered by light or sleep deprivation (genetic)
• generalised tonic clonic
• spasm

Focal =

• simple - consciousness maintained or complex - lost
• frontal - motor sx, sound production
• parietal - sensory sx (numbness)
• ophthalmic - visual disturbance
• temporal - fear, auditory/ visual hallucinations

Question 113

Ix + Management of epilepsy - long term

Answer 113

Commonly do EEG after 2nd seizure (photic stimulation and hyperventilation). Do sleep or long term EEG if no findings.

Also consider MRI if present <2yo, focal onset, resistant to first line meds

Education - first aid, safety including not having baths, avoid cooking near flames, heights etc

Regular 3-12monthly reviews

Drug treatment - dependant on type

• tonic clonic - valproate or lamotrigine
• absence - ethosuximide or valproate
• tonic/atonic - valproate or levetiracetam
• myoclonic - valproate or levetiracetam
• infantile spasm - prednisolone or vigabatrin

Stick to mono therapy, same formula and brand, stress adherence. Consider slow withdrawal after 2yrs seizure free

Ketogenic diet can help as can vagal nerve stimulation in those resistant to first line AEDs

Consider surgery if drug resistant - involves resection

Question 114

Meningitis - what to give for shock/ raised ICP - here

Answer 114

Commonest causes are s pneumonia, Hib and Neisseria meningitides

In neonates most common causes are group b strep, listeria and e.coli

Present with general signs in neonates e.g. fever, irritability, change in colour, refusing food, N+V, joint pain, bulging fontanelle, non blanching rash

In older children present with neck stiffness, photophobia, headache, N+V, joint pain, cold extremities, shock, altered mental status, seizure

Ix:

• Immediate LP unless suspect raised ICP or severe sepsis/shock. Send for WCC, glucose, lactate, culture, PCR, protein
• Bloods including FBC, coag
• Blood culture
• Blood gas

Management

• immediate referral to secondary care
• if meningococcal septicaemia, non blanching rash give immediate IM/IV benzylpenicillin
• Supportive measures e.g. antipyretic, analgesic, nutritional, fluids
• if >3mo start dexamethasone asap 0.15mg/kg 4x daily for 4d
• Start on IV ceftriaxone if >3m or IV cefuroxime + amoxicillin or ampicillin if <3mo
• give O2 as needed

If raised ICP treat with fluid restriction, acetazolamide, mannitol

If shock give 20ml/kg 0.9% saline fluid boluses

Family prophylaxis with rifampicin or ciprofloxacin

Question 115

Child abuse investigations

Do MASH referral, contact lead consultant and set in place assessment within 48 hours

Answer 115

Blood tests: FBC, clotting screen
o Alternative cause for bruising

Skeletal survey or bone scan
o If physical abuse suspected, <2 years

Brain imaging:
o Needed if suspected head injury
o If physical abuse suspected, <1 year
o Looking for signs of skull fractures or bleed

Retinal examination
o If head injury
o Retinal haemorrhages are a sign of intracranial injury
o Also check for rib fractures

Spinal imaging:
o A full skeletal survey as part of bone scan - X-rays of the spine, including lateral views.
o If any fracture is seen or spinal cord injury is suspected, do an MRI scan of the spine.

Sexual health tests:
o If suspected sexual abuse

Forensic dentistry:
o Interpret bite marks, differentiating animal from human ones, and sometimes identifying the abuser.

Question 116

FGM definition + presentation

Answer 116

partial or total removal of the external genitalia or other injury to the genital organs for non-medical reasons

Abdominal pain, new onset urinary sx or bleeding from genitalia, signs of infection, trauma or change in behaviour

Question 117

Precocious puberty - 2 main types, management, definition

Answer 117

Onset of secondary sexual characteristics in girls before age of 8 and boys before age of 9

Can be central or precocious pseudopuberty (peripheral)

Central is due to raised GnRH and LH/FSH e.g. in intracranial tumours, intracranial infection, injury, hydrocephalus, can also be idiopathic

Peripheral is due to raised sex steroid hormones, LH/FSH low. Causes include: CAH, mccune Albright, adrenal tumours, ovarian/testicular tumours, testotoxicosis

Testes size helps with cause:
bilateral enlargement = gonadotrophin release from intracranial lesion
unilateral enlargement = gonadal tumour
small testes = adrenal cause (tumour or adrenal hyperplasia)

Ix:

• assess sex hormone levels
• Random LH - if high indicates central
• GnRH stimulation test - if LH/FSH rise indicates central
• TFT
• 17-hydroxylase for CAH
• US / MRI for adrenal/ ovarian tumours
• Brain MRI for intracranial masses
• Xray of wrist to assess bone age - bone age typically ahead of actual

Mx:

• may allow to continue as normal if idiopathic, not likely to affect height
• treat cause, remove tumour via surgery
• if early puberty likely to limit final height give GnRH analogues and delay puberty until appropriate age. Can give GH if needed
• Aromatase inhibit e.g. testolactone used in mccune Albright and testotoxicosis

Question 118

Delayed puberty

Answer 118

Absent testicular growth <4ml at age 14
Absent breast development by 13, primary amenorrhea by 15

Can be due to:

• normal HPG axis: constitutional delay, chronic illness, malnutrition, excessive exercise, steroid therapy
• abnormal HPG axis: tumour, irradiation, congenital, surgery

-peripheral: primary gonadal failure, syndromes e.g. kleinfelters, turners, cyclophosphamide, CAH, PCOS, testicular torsion, undescended testes

Ix:

• Investigate for chronic disease
• Karyotyping, genetic screen
• FSH/LH and sex hormone levels (low in constitutional delay, high in gonadal failure)
• Pelvic US
• Brain MRI
• bone age scan

Mx
- can reassure if constitutional delay
- induce puberty with
• Low dose testosterone therapy for 3-6m – Boys
• Gradually increasing oestrogen with eventual cyclical progesterone – Girls

If other cause - treat, induce puberty with testosterone injections, oestrogen/ progesterone as above

Question 119

Adolescent HEADS

Answer 119

Home life: relationships, support
Education: school, exams, future career/ further education
Activities: exercise, leisure, social relationships
Affect: body image, self-harm, depression
Drugs: cigarettes, alcohol, illicit substances. How much and how often is key
Diet: weight, caffeine, eating disorder
Sex: concerns, periods, contraception. Use gender neutral terms
Sleep

Question 120

Down syndrome causes, features, investigations

Answer 120

Can be caused by error in meiotic division leading to an extra chromosome, can be caused by mosaicism or can be caused by robertsonian translocation with chromosome 14 or 22

Features: hypotonia, epicanthic folds, Brushfield spots in iris, low set ears, high arched palate, loose skin on neck, single palmar crease, short little finger, wide gap between big and 2nd toe, heart defect (AVSD), duodenal atresia (double bubble sign)

Ix:

• Karyotyping to confirm diagnosis
• Bloods to identify myeloproliferative disorder, polycythaemia
• echo to look for structural heart defects
• Assess hearing using brainstem audiometry provoked response
• Do TFTs
• Assess tone, do swallowing assessment if issues feeding
• Assess red reflex for congenital cataract

Question 121

Short stature, webbed neck, wide spaced nipples, lymphedema, ovarian dysgenesis, coarctation of aorta, hypothyroidism - cause?

Answer 121

Turners - one X chromosome

Growth hormone and oestrogen replacement therapy

Ejection systolic murmur due to bicuspid aortic valve

Question 122

Tall, slim, gynaecomastia, wide hips, lack of facial or pubic hair, small hard testes, learning disabilities - cause

Answer 122

Klinefelters XXY

Give testosterone injections on start of puberty
Plastic surgery for gynaecomastia
ICSI if trying to have child

Question 123

Marfan features

Answer 123

Skin - striae, especially thoracolumbar and sacral.

Cardiovascular - thoracic aortic dilatation/rupture/dissection (usually asymptomatic), aortic regurgitation, mitral valve prolapse, mitral regurgitation, abdominal aortic aneurysm, cardiac dysrhythmia.

Lungs - bullae, pleural rupture causing pneumothorax

Eyes - lens dislocation, closed-angle glaucoma, high myopia.

Skeleton - arachnodactyly, hypermobility, arthralgia, joint instability, finger contractures, pectus excavatum or carinatum deformities, misshapen chest, kyphoscoliosis, protrusio acetabuli and hindfoot deformity.

Nervous system - dural ectasia hernias presenting with low back pain and symptoms akin to cauda equina syndrome or chronic postural headache due to CSF leakage

Facial characteristics - maxillary/mandibular retrognathia, long face (dolichocephaly) and high, arched palate, enophthalmos, downslanting palpebral fissures and malar hypoplasia

Question 124

Ash leaf macules (patches of depigmentation), adenoma sebaceum (red macules in butterfly pattern over nose), shagreen patches (irregular thicken skin on back with orange peel texture) and epilepsy (infantile spasm, focal seizure of generalised tonic clonic) - cause?

Answer 124

Tuberous sclerosis

Autosomal dominant due to TSC1 or TSC2 - hamartin or tuberin deficiency

Question 125

Developmental delay, very pale, blonde hair, blue eyes, musty odor, eczema, vomiting, seizure - cause and tx

Answer 125

Phenylketonuria

• Autosomal recessive
• Tested for in newborn heel prick
• treat with diet low in phenylalanine, some medication available to decrease phenylalanine levels

Question 126

Features of x linked inheritance on pedigree

• what condition we need to know is x linked?

Answer 126

> Two males are affected, either siblings or in successive generations

No affected females

Affected males are linked through unaffected females

DMD is x linked

Question 127

Sepsis

Answer 127

Suspect in child presenting with hx of infection/ fever and signs of shock e.g. tachycardia, hypotension, prolonged CRT or altered consciousness

Ix

• As part of sepsis 6 do Blood cultures and blood gas for lactate (also may see metabolic acidosis)
• Also want to locate infection site: Urine culture, CXR, LP, Stool culture, PCR for Neisseria meningitides
• FBC, CRP and baseline bloods
• Blood glucose (often low in children with infection)

Treatment

• measure urine output
• give high flow O2
• Give fluids 10ml/kg if CRT >3s
• IV broad spectrum e.g. ceftriaxone or cefuroxime
• If blood sugar <3 give 2ml/kg 10% dextrose

Treat cause

• meningitis - IV ceftriaxone
• neonatal sepsis - IV benpen and gent
• Abdo sepsis - metro + gent
• Cellulitis - IV fluclox

Question 128

most common cause of recurrent UTI

Answer 128

Vesicoureteric reflux

• can be primary or secondary due to obstruction in the urethral tract

diagnose with US or voiding cystourethrogram

• Often improves on own
• Treat UTI with abx, if recurrent consider low dose prophylactic abx
• surgery may be indicated if no improvement or secondary cause

Question 129

Short stature causes and ix

Answer 129

• Familial short stature
• Achondroplasia
• Turners syndrome
• Downs
• Prader- willi
• Failure to thrive - malnutrition, anorexia, crohns, UC, coeliac

Question 130

How to calculate Childs growth potential

Answer 130

In a boy: Mid-parental height (cm) = (Father’s height + (Mother’s height + 13)) divided by 2.
In a girl: Mid-parental height (cm) = ((Father’s height - 13) + Mother’s height) divided by 2.

Question 131

How to assess volume status

Answer 131

o	Skin turgor
o	Moist membrane
o	Fontanelle 
o	Sunken eyes 
o	Capillary refil time

Question 132

Impetigo

Answer 132

Staph aureus or strep pyogenes

Risk factors include poor hygiene and skin conditions that lead to a break in the protective layers. Atopic eczema is a common risk factor; others include bites, trauma to the skin, scabies, chickenpox, burns and contact dermatitis.

Non-bullous lesions usually start as tiny pustules or vesicles that evolve rapidly into honey-coloured crusted plaques that tend to be under 2 cm in diameter.

Diagnosis is clinical, skin swab if unsure

Mx:
Keep the affected area(s) clean.
Wash hands after touching affected area(s).
Avoid sharing of towels and bathwater.
Avoid scratching the affected area. Keep fingernails short and clean.

Localised:

• 1st line - Hydrogen peroxide 1% cream
• If unsuitable - offer: fusidic acid 2%, alternative = mupirocin 2%.

If widespread, bullous or resistant to above try oral fluclox

Question 133

Developmental assessment

Answer 133

4 things to assess

• gross motor
• fine motor
• speech
• social

Gross motor
Newborn - Limbs flexed, symmetrical pattern, head lag on pulling up
6-8 weeks - Raise head when prone (tummy-time)
6-8 months - Sits without support (limit 9m)
8-9 months - crawl
10 months - stand independently, cruises around furniture
12 months - walks unsteadily with a broad gait, hands apart (limit 18m)
15 months - walks steadily
2.5 years - runs and jumps

Fine motor
6w - Follows moving object or face by turning the head (limit 3m)
4m - Reaches out for toys (limit 6m)
4-6m - Palmar grasp
7m - Transfers toys from one hand to another (limit 9m)
10m - Mature pincer grip (limit 12m)
16-18m - Makes marks with crayons
14m-4y - Brick building	
- Tower of three – 18 months 
- Tower of six – 2 years
- Tower of eight or a train with four bricks – 2.5 years
- Bridge (from a model) – 3 years
2-5ys - pencil skills 
- Line - 2yrs
- Circle - 3 years
- Cross - 3.5 years
- Square - 4 years
- Triangle - 5 years

Speech, hearing and language
Newborn - Startles to loud noises
3-4m - Vocalises alone or when spoken to, coos and laughs “aa, aa”
7m - Turns to soft sounds out of sight, polysyllabic babble (“babababa, lalalalala”)
7-10m - Sounds used indiscriminately then discriminately to parents at 10 months e.g. “Dada, Mama”
12m - Two to three words other than ‘Dada’ or ‘Mama’, understands name
18m - 6-10 words, Is able to show two parts of the body “Where is your nose?” – Baby will point
20-24m - Joins two or more words to make simple phrases “Give me teddy”
2.5-3 yrs - Talks constantly in 3 – 4-word sentences, understands 2 joined commands “Push me fast Daddy”

Social environmental and developmental
6w - Smiles (limit 8w)
6-8m - Puts food in their mouth
10-12m - Waves bye-bye, plays peek-a-boo
12m - Drinks from a cup with two hands
18m - Holds spoon and gets food safely to mouth
18-24m - Symbolic play (limit age 2-2.5yrs)
2yrs - toilet trained, pulls off some clothing
2.5-3yrs - Parallel play, interactive play evolving, takes turns

Question 134

Measurements/ growth charts

Answer 134

Height

• Measure supine using board if <2yo
• Measure standing up against backboard if >2yo
• Ensure corner of eyes in line with middle of ear
• measure to last complete mm

Weight

• Measure naked until 2 years old, then light clothing
• record to last gram for neonates, <4kg
• Record to last 100g if older or >4kg

Head circumference

• over ears
• midway between hairline and eyebrows to occipital protuberance
• measure to nearest mm

99% of children between the 0.4th – 99.6th centiles

A sustained drop of 2 or more centiles for height or weight < 0.4th centile should be investigated

Calculate mid parental centile - plot both heights, join with a line and that gives centile - >3 centiles below - investigate (9/10 within +/- 2)

Gestational correction - do for babies <36+6
If 37 or greater treat as term and dont use premature section of growth chart

At 42w switch to main section of growth chart - plot age in weeks with a dot and then do arrow back the number of weeks before 40 (term)

• Continue with this for one year 32-36+6
• Continue for 2 years once <32w

Question 135

Herald patch followed by widespread macule/ patchy rash often in Christmas tree pattern

Answer 135

Pityriasis Rosea

Question 136

Child daily fluid maintenance requirement

Answer 136

up to 10kg = 100ml/kg/day
next 10kg = 50ml/kg/day
per Kg after this = 20ml/kg/day

Question 137

drugs used to treat hf in babies/ kids

Answer 137

o Diuretics (furosemide) – reduce pulm congestion
o ACE inhib (captopril) – reduce afterload
o Digoxin – increases systolic contraction
• Added later If needed
o Adequate calorie intake

Question 138

When to treat hypoglycaemia in child

Answer 138

4 or below - oral glucose

2.5 or below - IV dextrose

Question 139

ITP

Answer 139

Otherwise normal platelets are destroyed by antibodies
Can be associated with viral infection
Low platelets lead to bleeding and bruising

Ix

• FBC
• Platelet count
• Blood film

Mx

• In majority of cases it improves on its own - most have complete recovery within 3-6m
• Avoid contact sports
• Avoid aspirin or ibuprofen
• Avoid IM injections
• Look out for spread of rash, large bruising or bleeding that won’t stop

In severe cases may need

• Prednisolone
• IV immunoglobulins
• Blood transfusions if required
• Platelet transfusions only work temporarily

Question 140

Non blanching rash

Answer 140

Meningitis, HSP, ITP, non accidental injury, viral infection, leukaemia, von-Willebrands

Question 141

Haemolytic uraemic syndrome

Answer 141

Reduced urine output, blood in urine, Abdo pain, bruising

Urgent referral to the paediatric renal unit for renal dialysis if required
Antihypertensives if required
Careful maintenance of fluid balance
Blood transfusions if required

Question 142

Hypoxic ischaemic encephalopathy

Answer 142

Therapeutic hypothermia

Question 143

Vasovagal

Answer 143

Consider bloods, ECG, echo, EEG

Avoid dehydration
Avoid missing meals
Avoid standing up for long periods
If feel hot/dizzy/clammy - sit or lie down and have some water

Question 144

Haemolytic disease of newborn

Answer 144

Is caused by rhesus incompatibility

Occurs in second pregnancy where rhesus negative mother has previously been exposed to rhesus positive baby

Autoantibodies attack the foetus’ red blood cells leading to a haemolytic anaemia

Use direct Coombs test to diagnose

Tests for differentials:
Full blood count for haemoglobin and MCV
Blood film
Reticulocyte count
Ferritin (low iron deficiency)
B12 and folate
Bilirubin (raised in haemolysis)
Direct Coombs test (autoimmune haemolytic anaemia)
Haemoglobin electrophoresis (haemoglobinopathies)

Question 145

Gallstones, jaundice in kids

Answer 145

Think hereditary spherocytosis, beta or alpha thalassaemia,

Question 146

How many infections normal for a child a year?

Answer 146

4-8

Question 147

Tongue tie

Answer 147

Due to a short lingual frenulum - prevents extension of tongue and latching onto breast

May not need treatment - monitor feeding

In some need to do frenotomy

Question 148

Glue ear

Answer 148

Occurs commonly after an episode of otitis media

Present with reduced hearing, inattention, developmental delay
Fullness and popping
Hx of ear infections
Loss of balance, clumsiness

Due to Eustachian tube dysfunction

Ix:
Otoscopy - effusion of glue-like fluid behind an intact tympanic membrane in the absence of signs and symptoms of acute inflammation. Opacity of drum, loss of light reflex, retracted drum, fluid level
Audiometry - hearing test - mild conductive hearing loss
Assess development

Mx

Often resolves on own within several months - year

Facing their child when speaking to them.
Slowing their speech.
Keeping speech clear.
Increasing speech volume slightly.
Turning off competing stimuli such as radio or TV.
Encouraging daily reading, which helps language development.

Autoinflation kits can be bought online to help open the eustachian tube

Gromits if

• persistent bilateral OME lasting three or more months.
• hearing loss in the best ear of 25-30 dB or worse, averaged at 0.5, 1, 2 and 4 kHz.
• social, educational or developmental difficulties

Question 149

Hip pain history

Answer 149

Hx of viral infection?
Growth spurt?
Fever
Waking at night with pain
Weight loss
Anorexia
Night sweats
Fatigue
Persistent pain
Stiffness in the morning
Swollen or red joint
Recent trauma?
Any rashes 

Any other illness
Any growth concerns

Question 150

Rickets

Answer 150

Caused by vitamin D or calcium deficiency

Can be caused by reduced vit D intake, reduced sun exposure, IBD, liver disease and CKD

Vitamin D is present in leafy green veg and meat

Bone pain, proximal muscle wasting, increased risk of fragility fractures

Thin soft skull bones, delayed closure of fontanelles, prominent frontal bone, protruding abdomen

Bloods: low vit d, low ca, high ALP

Treat with vitamin D supplements

Question 151

Osgood schlatters disease

Answer 151

Anterior knee pain worse on exercise

Treat with rest, NSAID, ICE