Paeds Flashcards
(87 cards)
1
Q
APGAR SCORE
* carried out at 1, 5 and 10 mins post birth
* includes 5 aspects each with score 0-32
* what does a score of less than 3, 4-6, >7 indicate?
A
- Appearance: pink, blue peripherally, blue centrally
- Pulse: >100, <100, absent
- Grimmace (response to stimulation): good, little, none
- Activity (muscle tone): active, flexed limbs, floppy
- Resps: strong, slow, absent
Scoring
* <3: immediate resus
* 4-6: repeat every 5 mins
* 7: good
2
Q
Signs of respiratory distress (facial, chest, sounds, obs)
Mx (maternal prevention & foetal mx)
Maintain prem neonates sats to …
A
-
Facial
1. nasal flaring
2. head bobbing
3. Cyanosis -
ChestRecessions
1. intercostal
2. supraclavicular
3. tracheal tug
Using accessory muscles of aspiration
Sounds: Abnormal airway noises
1. wheeze
2. stridor
3. grunting -
OBS x 3
1. Increased RR >60
2. Hypotension, systolic <70
3. Increased PR >160
Management
- Neonate: intubate or ventilate (endotracheal, biPAP, NIV) surfactant (LASA via tube) O2 (high-flow nasal cannula) +/- abx.
sats
91-95%
3
Q
Necrotising enterocolitis
prem baby 1-2wks old; can progress to peritonitis –> sepsis, shock
* key features (4)
* Abdo XR findings (3) - related to gas - hallmark finding
* Mx (3)
A
- poor feeding, abdominal distension, bloody stools, vomiting
- gas in bowel wall; intramural (pneumostosis intestinalis); gas in peritoneum (pneumoperitoneum); gas in portal veins
- Sepsis 6; NBM; surgery (drainage/laparotomy)
4
Q
Key features of retinopathy of prematurity
* Monitoring for babies <32wk
* treatment
A
- retinal vacularisation is stimulated by hypoxia and can take place up to 40 weeks.
- RoP - overoxygenation –> during further hypoxic event –> overcompensation and neovascularisation.
- Can lead to retinal detachment
- <32 week –> opthal review biweekly
- photocoagulation
5
Q
Chronic lung disease of prematurity (aka bronchopulmonary dysplasia) presents with poor feeding &weight gain, IWOB, low O2 sats
- O/E
- seen most commonly in (2)
- Diagnosis can be made by ….
- prevention (maternal)
- req monthly injections with *Palivizumab *against which virus?
A
- crackles and wheeze on lung auscultation
- CXR or a baby requiring o2 past 36 weeks
- prem babies who require I&V
- Betamethasone if PTB lkely <36 weeks
- RSV
6
Q
Neonatal abstinence syndrome
Treatment (weaned down) for
- opiate withdrawal
- non-opiate withdrawal
Which substance is most likely to present with symptoms weeks later (rather than within few days)?
A
- morphine
- phenobarbitone
- e.g. 21 days - Methadone
7
Q
GBS sepsis
* 85% of cases present with (1)
* What is the preventative treatment and when is it administered?
* Which conditions require mother to take preventative treatment?
* Treatment to baby with confirmed GBS?
A
- Respiratory distress
- IV Benzylpenicillin to mother during labour
- mothers who contract GBS during current pregnancy or who previously had a baby infected with GBS
- Benzylpenicillin or Gentamicin
8
Q
Distinguish early onset from late onset neonatal sepsis
A
Early - within 72 hrs
Late - after 72 hrs
9
Q
Define transient hypoglycaemia of the newborn
Other causes for reduced glucose in newborns?
- maternal factors
- fetal factors
Management for prolonged/severe hypoglycaemia of the newborn
: if symptomatic, or glucose <1mmol (jittery, poor feeding, seizures, drowsiness..)
- if asymptomatic, low glucose but >1mmol
A
Blood glucose <2.6mmol without symptoms. Common and normal within first 24hrs of life.
Blood sugars drop due to the stress of birth; and after transition from maternal blood to their own blood.
Lowered glucose causes -
* maternal diabetes, beta blocker use
* fetal - large birth weight, BW syndrome
* increased demand - sepsis, HIE, hypothermia, prem.
Mx-
* 10% dextrose IV, NICU.
* Or encourage normal feeding (breast/bottle) and monitor blood glucose frequently (e.g every 2hours)
10
Q
Neonatal jaundice
* Timings: normal vs abnormal
* Treatment (UCB vs CB)
* Prevents risk of ?
A
- Normal between 24 hrs and 2 weeks. Pathological <24s and prolonged >2 weeks.
- UCB -** photoisomerisation** - blue light therapy to convert UCB to isomers –> excretion via urine & bile.
- CB - surgery to rule out bilary atresia
- Kernicterus (high bilirubin levels in brain)
11
Q
Neonatal jaundice treatment graphs
* If >50 below treatment line, no sx, no risk factors
* If <50: rules for at 18 hrs and 24 hrs
* If above first treatment line
* If above second treatment line, showing signs of acute toxicity or marked rise in bilirubin –>
A
- No need to repeat
- Repeat at 18 hrs (if RFs) or 24 hrs (if none)
- Phototherapy
- Consider exchange transfusion. NICU admission.
12
Q
Distinguish the two antiglobulin tests (Coombs)
A
Direct (DAT) - haemolytic anaemia
Indirect (IAT) - prenatal testing & prior to blood transfusion
13
Q
DDH
- Risk factor mnemonic
- Routine screening with Otolani & Barlow’s for all babies at newborn and 6-8 week check. Which babies require additional screening with ultrasounds (3)?
- Investigation options (2)
- Generally it stabilises within 6 weeks. What is the management for babies younger than 4-5mo, and if older?
A
Fing bollocks: First born, breech presentation, oligohydramnios, large birth weight, left hip, congenital calcaneovalgus foot deformity, >2.5kg, FHx, sex - male
* Breech >36 weeks
* FHx of DDH
* Multiple pregnancy
* Ultrasound or XR (>4.5m)
* Pavlik harness, or surgery (>4-5mo)
14
Q
Congenital diaphragmatic hernia
* Abnormal sign O/E
* Most likely causes a Bochdalek hernia - what is this?
* Complications (3)
* Mortality rate
A
- tinking - bowel sounds auscultated within chest
- left sided hernia (posterolateral)
- pulmonary hypoplasia, HTN, RDS
- 50%
15
Q
Distinguish oomphalocele from gastroschisis.
How does the mx differ?
Which is associated with Beckwith-Wiedemann syndrome and Down’s?
A
Oomphalocele is a defect of the umbilical cord whereby the gut contents herniate out of the body, into the peritoneal sac. Associated with BWS and Down’s. (or umbilical hernia).
- staged surgical repair over 6-12mo (reduce risk of resp compromise)
Gastroschisis is a defect of the abdominal wall where the contents herniate out without being covered by sac; exposed.
- cover with cling film (silo), return to theatre asap and surgically correct within 5 days
16
Q
Pyloric stenosis
projectile vomiting 30 mins post feeding, visible persistalsis, results in
- which electrolyte abnormality?
- and post abo US what is surgical management?
- typical patient profile
A
- Metabolic alkalosis
- Ramstedt pyloromyotomy (good prog)
- White, caucasian males 2-4 weeks
17
Q
CMPA/CMPI occur typically within first 3 months in formula-fed infants (or rarely breast fed infants later in life).
Distinguish cow’s milk protein allergy and cows milk protein intolerance.
Mx - maternal avoidance of dairy products. Breast feeding is encouraged; once breast-feeding stops what formula options are there (2), until 1yr, for at least 6 mo?
A
- Allergy - IgE mediated; normally resolves by 2-3
- Intolerance - non-IgE; 55% resolve by 5yrs.
- Both have symptoms of bloating, vomiting, diarrhoea
- but allergy also has symptoms like urticaria, wheeze and angio-edema.
- Options -** extensive hydrolysed formula (EHF - cow’s milk with porteins broken down; or AAF - amino acid formula)**
18
Q
Meckel’s diverticulits
* rule of 2s
* gold standard imaging (if stable)
* presentation (2)
* treatment
A
- Meckel’s diverticulum is found in 2% of population, is found 2 feet from ileocecal valve, affects males:females 2;1, and is 2 inches long.
- rectal bleeding, abdominal pain similar to appendicitis
- Technetium-99-pertechnetate- a type of scintigraphy
- surgery if symptomatic
19
Q
Meconium ileus
Presentation
Association
Abdo XRAY findings
Management (3 options)
Comparison to Hirschprung’s
Other differential
A
Delayed meconium >24hrs, abdominal distension and bilious vomiting
Cystic fibrosis
Dilated bowel loops, lack of fluid level, “soap bubble” or ground glass sign due to presence of air in the meconium
1. PR contrast study
2. NG NAC
3. Surgery
**Hirschprung;s **also presents with delayed meconium and abdominal distension and xray shows dilated bowel loops WITH FLUID LEVELS. Biopsy “gold standard” - aganglionic section of large bowel. Management is by rectal washouts or with anorectal pullthrough procedure.
Differential - meconium plug syndrome: preterm birth, use enema; diagnosis of exclusion
20
Q
Breast-feeding
* encouraged by NICE until how many months - weaning?
* What is normal for the first 5 days but abnormal if carries on for 2 weeks?
* By what age should a child have doubled and then tripled in weight?
* Reduces risk of (2 examples for fetus, 3 for mother)
A
- 6
- to lose 10% of body weight. Still losing weight at 2 weeks ?FTT
- doubled by 5 months, tripled by 1 year
- Cardiovascular disease, diabetes
- Maternal - ovarian cancer, breast cancer, osteoporosis (reduced oestrogen plasma levels during breast-feed)
21
Q
Assessing growth
* MPH & MPH target height (girls, boys).
* Method to record weight over time
* How to assess bone age?
A
- BOys = (maternal height + paternal height +14 / 2) Girls = maternal height + paternal height -14/2)
- <Target is MPH +/- 10cm
- Growth charts: age in mo, weight (x, y) -* if 25% centile, 75% of babies same age are heavier*
- Xray left wrist; assess bone age against chronological age - maturity obvious from epiphyseal centres
22
Q
Short stature - genetic, acquired, FHX, constiutional delay.
Think pie chart for causes.
Genetic causes of short stature (4)
A
- Noonan’s
- Down’s
- Turner’s
- Prader-Willi
23
Q
Developmental disorders
* HPG Axis
* Types of delayed puberty (2)
* and precocious (2)
*
A
- Hypo (GnRH;pulsatile) –> anterior pituitary (gonadotrophins - LH&FSH; pulsatile) –> gonads - testes and ovaries (sex hormones: testosterone, estradiol & progersterone).
Delayed
Hypergonadotrophic hypogonadism = excess FSH, LH due to impaired gonad function (inability to recognise gonatropins; no negative feedback to AP,)
Hypogonadotrophic hypogonadim = reduced FSH, LH due to impaired function of hypothal or AP.
Precocious - Central/true - HPG axis dependent - impaired HPG axis.
- Peripheral/pseudo - “ independent; excess sex hormones: e.g. congenital adrenal hyperplasia, gonadal hyperplasia, gonadotrophin release from intracranial lesion
24
Q
Puberty
- Normal age range (boys, girls)
- First sign (boys, girls)
- Time to completed puberty (“)
- Delayed puberty
- Precocious puberty
A
Boys
* 10.5-13.
* Testicular enlargement.
* Delayed if >16.
* Precocious if <9
Girls
* 8.5-12.5.
* Thelarche.
* 2.5 yrs –> menarche –> ovulation (same time or mo later).
* Delayed if >13..
* Precocious if <8.
monitored TE with orchidometer.
25
DELAYED PUBERTY
Condition and levels of LH/FSH
* hypo
* hyper
gonadotropic hypogonadism
- CDGP
**Hypo**
- Low gonadotrophs = Low LH/low FSH
- Impairment in H or P of HPG axis.
- Congenital cause: **Kallmann syndrome: **
1. hypogonadotrophi
2. anosmia
3. X-linked
**Hyper**
* Klinefelters (XXY) and Turner's (XO)
* Excess gonadotrophs = High LH/high FSH
* impairment in gonads to respond to gonadotrophs
* other causes = congenital adrenal hyperplasia (excess sex hormones produced from adrenals), gonadal tumour, gonadotrophin ectopic release
26
**Turner's syndrome** (45XO) -
* Associations (cardiac, ENT, endocrine, intellectual)
* Typical appearance (5)
* Features
* Treatment (daily; and additional at 12-14 yrs)
* Coartation of the aorta, recurrent otitis media, hyperthyroid, obesity, intellectual disability
* Short stature, wide spaced nipples, webbed neck, cubitus valgus
* Delayed puberty; infertility in most (underdeveloped ovaries)
* GH daily + oestrogen/progesterone at puberty. Fertility treatment.
27
Examples of X-linked recessive conditions (A-W)
- remember no male to male transmission
- affected males - can have carrier daughters and unaffected males only
Examples of X-linked dominant conditions (3)
Androgen insensitivity syndrome (CAIS)
Becker's and Duchenne's muscular dystrophy
Colour blindness
G6PD deficiency
Haemophilia A and B
Nephrogenic Diabetes Inspidius
Retinitis pigmentosa
X linked dominant:
- Alport's
- Rett
- VD resistant rickets
28
**Growth hormone deficiency = pituitary dwarfism**
* most frequent cause
* non-physical cause
* sign at infancy and in childhood
* daily SC treatment of:
* cranial radio therapy
* psychosocial deprivation - reversible after removal from adverse environment
* infancy - **hypoglycaemia**
* childhood - **short stature** & slow growth rate & delayed closure of anterior fontanelle
* rhGH = recombinant human growth hormone
29
**Complete androgen insensitivity syndrome**
* chromosomal makeup
* phenotype
* what surgery may be required due to increased risk of cancer?
* what is different about partial and mild types (PAIS and MAIS)
* 46 XY; X-linked condition
* male genotype but female phenotype; aka female genitalia but with testes rather than ovaries
* bilateral orchidectomy - testicular ca risk
* partial = ambigiuous genitalia
* mild = male genitalia but with female puberty traits e.g. breast development
30
Causes of tall stature
4 ps, 2ks, 2 ms
* pituitary adenoma
* parents
* puberty
* proteus syndromes
* Marfans
* MEN2
* Klinefleter
* Kallman
31
Opthalmia neonatorum - infection of newborn's eye
* organisms
* mx
- chlaymidia/ neisseria gonorrhoea
- same day opthalmology/paeds assessment
32
**Bronchiolitis**
RFs: prem, immunosuppression, maternal DM, CHD.
* Presents with respiratory distress & signs of dehydration.
* Clinical course ?
* Criteria for considering admission (mainly supportive mx + high flow O2 if sats <92) (4)
* Criteria for **immediate admission**
* Common causative organism and preventative measure
* Monitoring required (2)
* Differential
1. <3 mo
2. Comorbidity
3. Clinically dehydrated
4. Feeding less than 50-75% normal intake.
**Immediate**
- severe respiratory distress (grunting, marked chest recession, RR >70)
- apnoea, central cyanosis, looks seriously unwell
- sats <20% persistently
**Clinical course**
* Coryza (1-2days) --> chest infection (3-7days) ---> full resolution by 3 weeks.
* RSV
* *Pavalizumab* mAB.- monthly injection to high risk babies - not a true vaccine.
* Capillary blood gas (VBG) - monitoring Co2 and pH (respiratory failure).
* Viral induced wheeze - similar to Asthma but in children under 3 - episodic bronchoconstriction reversed by salbutamol.
33
**Paediatric acute resp: condition and mx**
* 1 yr old with barking cough, stridor, fever; caused by RSV/parainfluenza/adenovirus.
* 1.5yr old with 4Ds; in tripod positon; missed the 2 in 1 vaccine amongst others
* Few week old baby with noisy breathing and "ohm" sign on view through scope
* Child with paroxysmal coughing fits, inspiratory whoop, fainting, vomiting. Investigation options - early and late (2). Admit if 2 considerations. Abx for patient and for vuln contacts.
* **Croup.** Westley Croup Score for severity. Supportive (fluids+rest) or *Dexamethasone/inh Budesonide*
* **Epiglottitis** - HiB/diptheria. Drooling, dysphagia, dysphoria, distress. **EMERGENCY** - X examine/distress.* I+V; Cef & Dex.*
* **Laryngomalacia** - "floppy voice box". Self resolves by 2.
* **Pertussis** - bordella pertussis. Nasal PCR or anti-pertussis toxin IgG test (if >2 weeks). ADmit if <6 mo, presence of severe sx (apnoea, cyanosis etc). Azithromycin.
34
Chronic paeds resp:
**Cystic fibrosis**: chronic autosomal recessive multi-organ condition due to mutation of CTFR gene; causing thickened secretions
* Investigations (3)
* First sign
* How does CF affect **lungs**, **GI tract**, **endocrine**, *male reproductive organs*
* MDT mx
* Differential - autosomal recessive condition associated with consanguinity.
* Newborn blood spot test, CTFR gene testing, sweat test (Cl>60)
* Meconium ileus (delayed meconium > 24hrs)
* Chronic cough; recurr. inf. Pancreatitis. Diabetes. steatorrheoa. Absence of vas deferens.
* SABAs and chest physio; CREON - enzyme replacment. Insulin therapy. Fertility treatment.
* General - high calorie diet, vaccinations (pneumococcal, influenza and varicella).
* **Primary cilary dyskinesia** - sinusitis, bronchiolectasias, reduced fertility. Kartagener's syndrome is PCD with situs inversus.
## Footnote
more energy needed to breathe properly and fight off infections (immuno-compromised - require more calories)
35
**Congenital heart disease**
* Acyanotic vs cyanotic causes
* Which is L->R shunt and which R->L?
* Most common cause of CHD overall; Most common cause of acyanotic
* Associated with Down's?
* Turner's?
* WPW?
* Acyanotic - VSD, ASD, PDA (+aortic/pulmonary stenosis), L--> R shunt.
* Cyanotic - Tetralogy of Fallot, Transposition of the Great Arteries, Tricuspid valve anomaly (Ebstein's), Total anomaous pulmonary drainage, R--> L shunt.
* Tetralogy of Fallot, VSD.
* VSD (& ASD).
* Co-arctation of the aorta (& ASD).
* Ebstein's anomaly.
36
**Acyanotic CHD**
* types of murmurs (ASD, VSD, PDA).
* Mx - ASD, VSD
Mx - PDA
* **Septal defects**= Both left sternal edge. ASD = mid-diastolic murmur. VSD = pan-systolic mumur.
* **PDA** = machinery like murmur.
*Mx*
* **Septal defects** = watch&wait - may require surgery; leads to HF in later life.
* **PDA**- Indomethacin/Ibuprofen to close duct. Prostaglandin E1 to keep duct open in presence of other defects --> open until surgical repair.
37
What is Eisenmenger's syndrome?
Emergency condition where VSD/ASD (L--R shunt) becomes a R--L left shunt due to remodelling of the pulmonary vasculature, resulting in **pulmonary artery hypertension**. Reqs heart-lung transplantation.
38
**Cyanotic CHD**: Tetralogy of Fallot
* 4 features (PROV)
* presents with ...
* finding on CXR and O/E
* When is surgical repair carried out?
* Severity depends on severity of...
* Overriding aorta, RVH, Pulmonary stenosis (Right ventricle outflow obstruction) VSD
* "tet spells" - cyanosis worse when crying/feeding
* Boot shaped heart. O/E - ejection systolic murmur from pulmonary stenosis. Heart failure in older children.
* OPen heart surgery at **4 months.**
* Severity of RVOT.
## Footnote
4 features, 4 months til surgery.
39
**Cyanotic**
transposition of the great arteries.
* What is it?
* What does immediate survival depend on?
* Presents with?
* When is definitive surgery carried out?
* aorta and pulmonary arteries are attached in wrong places
* presence of other defects to compensate for first few weeks
* **immediate cyanosis** followed by respiratory distress, tachycardia etc as it starts decompensating
*** open heart surgery 2-3 weeks** with prostaglandin infusion in meantime to maintain DA
40
**Cyanotic** - Ebstein's anomaly
* What is it?
* Sign O/E
* Associated with?
* lower set tricuspid valve (atrialisation of the ventricle; smaller v and bigger a)
* Gallop: S1 + S2 + S3 + S4 (trusty Eb-steed)
* Associated with WPW syndrome
41
Features of innocent murmurs
types in kids (2)
soft, symptomless, heard at sternal edge, positonal (sitting/standing), systolic
venous hums (subclavicular) or still's (left lower sternal edge)
42
**Antenatal screening for trisomy 21, 18 and 13.** (Down's, Edward's, Patau's.)
* 1st line, 11-14 weeks = Combined test (21, 18, 13).
* 14-20, e.g. if women have missed original combined test: Quadruple test (21) & 20-week scan (18, 13).
What do these tests include?
After initial screening from the combined or quadruple test, 1>150 (5% of women) are offered which further tests - which are these?
What would the bloods from a neural tube defect show?
* **Combined -**Ultrasound (nuchal translucency; thickness >6mm) & maternal bloods (beta hCG, PAPPA). High risk for Down's = high beta-HCG, low PAPP-A. For Trisomy 13 and 18 = similar results to Down's but hCG tends to be lower.
* **Quadruple** - bloods - BAOI (beta-HCG, AFP, Oestradiol, Inhibin A). HIgh risk = high beta HCG, low AFP, low oestradiol, raised inhibin A.
**Further Antenatal testing:** - options
1. Amniocentesis (U/S guided aspiration once enough Amniotic fluid)
2. Chorionic villous sampling (U/S guided biopsy of placental tissue before 15 weeks)
3. NIPT (maternal blood tests for fragments of baby;s DNA) - least invasive
NTD - isolated rise in AFP
43
Edward's syndrome
* Trisomy 18
* Small head
* Clubbed/rocker bottom feet
* Low set ears, micrognathia
* Heart/lung abnormality
44
Prader-Wili
* Absence of PW gene (chr 15)
* Hypogonadism, excessive eating
* Obesity
* **Neonatal hypotonia**
* imprinting inheritance- deletion must occur on gene from mother or father
45
Infant < 8 weeks, presents with milky vomits after feeds, often after being laid flat, excessive crying.
Likely diagnosis?
Risk factor?
GORD
Prem.
most common cause of vomiting in infancy.
conservative management, advice or thickening agent (X PPI)
46
**Viral induced wheeze**
1st and 2nd line treatment
1. SABA nebs - salbutamol
2. LTRA (montelukast) or inhaled corticosteroids
47
Mesenteric adenitis and intussusception are both associated with concurrent/preceding viral illness.
**Intussusception**
condition affecting infants causing telescoping of the bowel
* Which other conditions is it associated with?
* Presentation (3) and examination finding (1)
* Dx by U/S scan & contrast enema. Mx options (2)
* Meckel's diverticulum (in 2%), HSP, CF, polyps.
* Paroxysmal severe colicky abdominal pain, red currrent jelly stool (late)
* therapeutic enemas (contrast/water/air) or surgical reduction.
48
**Recurrent abdominal pain** - *1/10 kids*
Types = functional abdominal pain, functional dyspepsia, IBS, functional abdominal pain syndrome & abdominal migraine.
- Describe typical sx of **abdo migraine**
- What other non-gastro sx are common with **RAP**?
- What ix are important (to rule out conditions)?
- Psychosocial factors?
- General mx and specific for abdo migraine
* Severe umbilical pain >1hr
* Headache and limb pain
* Faecal calprotectin (IBD), TTG serology (coeliac), FBC U&E CRP (inf?), specific IgE to food allergenes; stool test for helicobacter
* Stress, conflict, previous hospitalisation etc - reassurance reqd as 7/10 resolve
* General - conserv; CBT/family therapy.
* Pizotifen (5HT agonist) - for abdominal migraine
49
Fatigue
Anaemia
Weight loss
Impaired growth
Pubertal arrest; secondary amenn.
Vitamin deficiency
Reduced bone development
These symptoms may all be a sign of...
IBD - much more subtle in paeds
50
**Ricket's **- Vitamin D deficiency:
**Define the following features:**
- craniotabes
- delayed closure of fontanelle
- skull frontal bossing
- dental hhypoplasia
- rachitic rosary
- pectus carinatum
- Harrison's sulcus
- widened wrists
- genu varum or genu varus
- kyphoscoliosis
* Craniotabes: sotening of skull bones
* rachitic rosary: swelling at CC junction
* Pectus excavatum: pigeon chest
* Harrison's sulcus: indentation at level of 6th rib - *associated with rickets and severe asthma*
* Swollen wrists (end of long bones widening)
* Dental hypoplasia: Delayed teeth growth
* kyphosis (hunched back) + scoliosis (S-shaped spine) - *causes lung restiction
*
51
**Paeds MSK**
* <6 mo, detected by Otolani and Barlow's
* <4 yrs with red, hot swolllen joint, fever and unable to weight bear.
* <4 yrs with swollen joint, limp, no fever and a recent hx or viral URTI. Most common cause of hip pain.
* 4-10 yrs with progressive hip pain, IWB due to avascular necorosis of the femoral head.
* 4-10yrs with 5 day hx of fever, salmon-pink rash and arthralgia. Bloods are sero-negative.
* 4-10yrs with pain at tendon insertions, e.g. wrist and IP joints.. HLA-B27 associated. Paediatric version of sero-negative spondyloparthropathy.
* Type of JIA that can be either sero-ve or +ve, affecting >=5 joints.
* Type of JIA affecting <=4 joints, associated with anterior uveitis.
* Type of JIA with skin involvement.
* DDH
* Septic arthritis
* Transient synovitis
* Perthes' disease.
* Juvenile idiopathic arthritis - Still's disease (systemic type).
* Juvenile enthesitis.
* Polyarticular JIA
* Oligoarticular JIA
* Psoriatic JIA
52
**Problems during growth spurt - boys 10-14**
* Obese child with difficulty in internal rotation of hip
* Caused by repeated traction of the patellar tendon (e.g. during sport) before growth plate ossifies.
* Child presenting with knee pain & swelling, leg locking. Typically in lateral aspect of medial epicondyle. May have loose body (on CXR).
* Slipped upper femoral epiphysis
* Osgood-Schlatter's
* Osteochondritis dessicans
53
Monitoring of growth
infants aged 0-1 years should have at least 5 recordings of weight
children aged 1-2 years should have at least 3 recordings of weight
children older than 2 years should have annual recording of weight
children below 2nd centile for height should be reviewed by their GP
children below 0.4th centile for height should be reviewed by a paediatrician
54
Constipation guideline
* If faecal impaction present
* Maintenance theapy (first & second line)
* Infants <6 months (not yet weaned)
* Movicol (polyethylene glycol + electrolytes)
* Movicol, or if no response add stimulant laxative (senna)
* Bottle-fed: Extra water in between feeds, bicycling legs + abdo massage. Breast-fed - consider other causes.
55
* Indicators of **sepsis** in kids: ILLNESS
* Sepsis guidelines for <3 month old
* Septic screen includes:
* Irritability, Lethargy, Low CRT, Neutropenia or Neutrophilia. Elevated or Low temperature. = Serious Sepsis. Vague signs - poor feeding, insolable crying, high pitched/weak cry, floppy, skin colour changes.
* **Assume sepsis for febrile baby (>38) less than3 months until proved otherwise**
* Blood culture, Bloods (FBC, CRP), LP, Urine sample.
* Imaging (e.g. CXR or abdo/pelvic US).
* LP (if meningitis suspected)
56
Lumbar puncture - contraindications are signs of raised ICP
* Focal neurological signs
* Papilloedema
* Bulging of fontanelle (neonates)
* DIC
* Cerebral herniation (bradycardia, increased PR)
57
**FEVER in UNDER 5s - NICE **
1. A-E; ?sepsis
2. Detect fever
3. Consider antipyretics
4. Assess risk of **serious illness** with **traffic light system** (obs)
5. Triage
What is the triage system (4); and which examination findings is it based off (5)?
1. Life-threatening: emergency care
2. Red: urgent referral to paeds
3. Amber: refer to paeds OR safetynet
4. Green: @ home and safetynet
Includes colour, activity, respiratory, circulation, other concerning signs.
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**PAEDS RASH**
= maculopapular, vesicular, haemorrhagic, urticarial, erytheme multiforme, erythema nodosum.
**Causes of maculopapular rash**
and which are notifiable diseases to Public Health?
* Measles
* Rubella - lymphadenopathy & facial rash
* Roseola infantum
* Enteroviral
* Glandular fever (infectious mononucleosis)
* Kawasaki disease
* Erythema infectiosum
* Cellulitis
Notifiable: Measles, Rubella, Scarlet Fever.
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**Measles**
* clinical features
* Complications (2)
* mx
* Coryza/conjunctivitis --> Koplik spots (white spots on buccal mucosa) --> rash.
* Otitis media, encephalitis, febrile convulsions
* Supportive unless I/S
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**Roseola infantum**
* Cause
* clinical features
* Complications (2)
* mx
* Herpes (6/7)
* Fever --> uvula/soft palate spots
* Meningitis and febrile convulsions
* supportive; recover in 1 week
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**Scarlet fever**
* Cause
* clinical features
* Complications (2)
* mx
* Strep A
* Strawbery tongue, sore throat, lymphadenopathy, rash on trunk outwards, sandpaper skin, fever, flushed face
* Penicillin V (phenoxymethylpenicillin)
* Post-strep glomerularnephritis & acute rheumatic fever
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**Acute rheumatic fever**
* what is it?
* criteria: major JONES minor FEAR - 2 x Major or 1Major, 2 Minor
* type of rash
* mx
* An infection few weeks after strep A tonsillitis/pharyngitis (e.g. scarlet fever) - causing arthritis, myo/endo/pericarditis, chorea and rash
* Erythema marginatum = annular (rash) of toso & limbs
* Major JONES = joint involvement, organ invovlement, nodules, erythema marginatum, sydenham chorea
* Minor FEAR = fever, ECG changes (prolonged PR), arthralgia, raised inflamm markers
* Pen V
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**Parvovirus b19; erythema infectiosum**
* clinical course
* mx?
* at risk patient groups (3)
* complications (3)
* complications in pregnancy (3)
* fever coryza --> slapped cheek rash --> reticular prurituc rash on trunk and limbs
* self-limiting
* pregnant, immuno-compromised, haematological (Sickel cell anaemia e.g.)
* **aplastic anaemia**, meningitis, pregnancy complications
* fetal hydrops, miscarriage, anaemia
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Causes of vesicular rash
chicken pox, eczema herpeticum, hand foot and mouth disease, impetigo, nappy rash, scabies, staph scalded skin syndrome
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Causes of meningococcal rash (non-blanching)
* Meningococcal septicaemia
* Acute leukaemia
* Rhesus haemolysis disease
* Idiopathic thrombocytopenic purpura
* Henloch-Shonlein purpura
* Bleeding disorders - haemophilia, VW, Ehlos Danlos
Treat **non-blanching** or **rapidly spreading** rash as meningoccal sepsis until proven otherwise.
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School exclusion guideliens from Health Protection Agency
* 24 hrs after abx
* 2 days after abx
* 4-5 days from onset of rash
* Until lesions crusted over
* 5 days after onset of swollen glands
* Until sx settled
* Until treated
* Untl recovered
* Scarlet fever
* Pertussis
* Measles, Rubella
* Chicken pox
* Mumps
* Impetigo
* Scabies
* Influenza
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Rash**: erythema multiforme** = target lesions + others (macules, papules, bullae)
* Most common causative organism(3)
* Rare, potentially fatal rash caused by adverse drug reaction in adults and infections in children
EM can also be autoimmune, or drug related, but most commonly is **idiopathic**
* Herpes simplex (90%)
* Stevens-Johnson syndrome (toxic epidermal necrolysis)
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Rash**: erythema nodosum **- red, tender nodular lesions usually on shins
Associated with (3)
1. IBD
2. Sarcoidosis
3. Strep infections
4. TB
Other (drugs/idio).
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**Meningitis**
* Bacterial causes - most common in children/adults (2) and neonates
* Viral causes - this is milder & normally only requires supportive treatment/Aciclovir.
* Lumbar puncture guidelines (<1mo, <3mo, <1 yr)
* What are Kernig's & Brudzinski's?
* A/C - Neisseria meningococcus (causes non-blanching rash) and streptococcus pneumonia. Neonates - group b strep.
* Viral - HSV, enterovirus, VZV.
* LP for all with fever <1mo, fever + unwell <3mo, unexplained fever + other features of serious illness for <1yr - basically very **low threshold for neonates.** to have LP.
* Special tests for meningeal irriation
Kerning's - knee straightening test with hip flexion --> pain
Bruzkinski's - head flexion --> involuntary hip/knee flexion
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**Bacterial meningitis- mngmnt** Community / Hospital
* ix (3)
* Specific abx for: <3 mo and >3mo
* Dexamethasone can be added to reduce incidence of..
* What can be given to people within 7 days of contact?
* Ben-Pen urgent IM/IV
* Ideally Culture & LP & bloods for meningococcal PCR
* <3mo - Cefotaxine + Amoxicillin (to cover Listeria from preg)
* >3mo = Ceftriaxone
* Hearing loss
* PEP: Abx single dose - e.g. Ciprofloxacin.
## Footnote
note that for pyelonephritis the managment is Ceftriaxone for <3mo and abx as per guideliens ofr >3mo.. the most important one to remember though is for menigitis
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What distinguishes between viral and bacterial meningitis?
LP - CSF analysis & culture.
Viral - clear, normal protein & glucose, raised WCC - **lymphocyte** negative culture.
bacterial - cloudy, raised protein, low glucose, raised WCC - **neutrophil**, bacterial culture.
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**Renal/Urological anomalies detected on antenatal scan**
Oligohydramnios = VUR, PUV, ARPK.
Both vesicoureteric reflux and posterior urethral valves can present with **recurrent UTIs**.
* Ix for both.
* Distinguishing features (e.g. unilateral/bilateral)
* How does the management differ?
ARPK disease is a congenital condition caused by mutation on chromosome 6. This affects epithelial tissue production of which organs?
Ix: Abdo U/S, MCUG (micturating cysto-urethrogram), cystoscopy
**PUV**
* can be detected antenatally as bilateral hydronephrosis / olighydramnios
* palpable bladder O/E
* monitor +/- removal of excess tissue during cystoscopy
**VUR**
* can be unilateral or bilateral
* normally resolves as valve matures
* req abx prophylaxis (surg if severe)
**ARPK**
- much less common than autosomal dominant form, can be detected antenatally with abdominal mass
- affects kidneys, pancreas & liver
- can cause **Potter syndrome** (oligohydramnios; rarely survives - the boy who lived) and congenital lliver fibrosis. Renal failure and oligohydramnios - key features
73
**Inguinal hernias**
* direct/indirect and why
* red flag signs
* requires urgent refferal to urology for what age group?
* mx (6 and 2 rule)
* indirect hernia (through deep and superficial rings) due to patency of tunica vaginalis
* irreducible, strangulated, obstructed.
* * <1 yr - urgent referral
* <6 weeks - req surgery in 2 days
* <6 mo; 2 weeks
* <6 yr: 2 months
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**Hydrocele** - *collection of fluid within tunica vaginalis*
* Distinguish communicating from non-communicating (simple)
* Examination findings
* Which type normally resolves and which reqs surgery?
*
* **Communicating:** fluid from peritoneal cavity enters tunica vaginalis; causing a swelling fluctuating in size depending on contents of peritoneal cavity. Reqs surgery.
* **Non-communicating:** fixed within tunica vaginalis; resolves normally by resorption.
* **Examination**: soft, mobile, transilluminates, fixed in size or fluctuating, non tender.
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**Cryptorchidism** - undescended testes; 5%.
* Should descend by how many months?
* Referral age for orchidoplexy
* Major complications if untreated (3)
* 3 mo
* 3 mon. surgery between 6-12mo.
* testicular torsion, ca or infertility if left for >4yrs
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**Hypospadias** - *opening of the urethral meatus is abnormally placed*
- most common place
- finding if severe
- if surgery required (post 3.mo) what is contra-indicated?
* glans (90%)
* chordee (bending of penis)
* circumcision
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**UTI/pyelopnephritis**
Assessment depends on age of child.
If <3 treat as **fever in under 3mo** -
If <3mo
If <5
* <3mo - septic screen. IV broadspec Abx (Ceftriaxone) +/- LP.
* >3mo- oral/IV abx as per guidelines depending on severity.
* <5yr - triage as per fever in under 5s guidelines.
*** Recurrent/atypical**
* Urinalysis & urine sample for MC&S
* Abdo U/S if <6 mo or recurrent/atypical UTIs
* DMSA - radioactive DMSA localises in scarring
* MCUG - if recurrent UTI and ?VUR/PUV
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**Haemolytic uraemic syndrome (HUS)** - widespread thrombosis throughout the body
* clinical triad
* precending infection and causative agent
* mx (3 options)
* morality rate
* why are abx not routinely used for gastroenteritis?
* haemolytic anaemia, AKI and thrombocytopenia
* sx of haematuria, reduced urine output, abdo pain, bruising
* preceded by gastroenteritis (E-Coli producing Shiga toxin or Shigella producing); 5 days of **blood diarrhoea**
* antihypertensives (renal protective) +/- transfusion or haemodialysis
* because abx/antimotility (Loperamide) can increase the risk of Shiga toxin and thus increase risk of HUS
79
What is
**persistent urachus** and
**persistence of vitello-intestinal duct**
* urinary discharge from umbilicus.
* rare to have completete persistence. but partial remnant of the duct is the same as Meckel's.
80
**Causes of Neck Lump**
*Cysts*
* Hygroma
* Branchial
* Thyroglossal
* Desmoid
*Infective/reactive*
* Lymphadenopathy - e.g. mumps
* *Malignancy*
* Lymphoma - Non-Hodgkin's (Burkitt's)
* *Derm*
* infantile hemangioma
* atypical mycobacterium
* congenital defect
* **anterior triangle**; "gill" area - arising from 3/4th branchial clefts. Presents in teens. Can have pouch sinus, cleft sinus or fistulae. Excision if causing infections.
* common congenital **midline** cyst; thyroglossal duct normally regresses once thyroid fully formed, cyst can form if remnant. Moves with tongue movement.
* midline/ear folds (in areas of embryonic fusion); arising from ectoderm; may contain hair follicles
* most common childhood cancer worldwide
* strawberry naevus - blood vessel malformation. presents in first few weeks.
* lymphadenitis secondary to infection with mycobacterium; immunoc
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Steroid use for bacterial meningitis
- rules for under 3 months
do not use!!!!
*insufficient evidence that it helps reduce hearing loss in this age group*
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What is hydrocephalus?
Main causes (3)
Presents with signs of raised ICP.
Increased CSF in brain or spinal cord. Caused by increased production or decreased drainage of CSF.
**AAA** emergency!!!
1. Aqueductal stenosis (congenital narrowing between 3rd and 4th ventricles)
2. (Arnold)Chairi II malformation (cerebellum herniates through foramen magnum) or other congenital cause/chromosomal abnormality
3. Arachnoid cyst - reduced drainage
Can be treated with **vento-peritoneal shunt**
83
**Newborn head shapes**
* Closing of anterior fontanelle before 1yr of age is a sign of...
* Plagiocephaly and brachycephaly are both..
* craniosynostosis
* caused by positioning of baby; tendency for baby to rest head on particular area
84
**Cerebral palsy** - permanent neurological motor condition resulting from damage to the brain perinatally (antenatal or at birth). Not progressive condition but symptoms may vary. Can cause mono/hemi/di/quadraplegia.
* Most common subtype
* Signs (4)
* Management
* Spastic (UMN/pyramidal)
* hand preference before 18 months, failing to meet milestones (e.g. speech and gross motor), increased or reduced tone.
* MDT - neurologist, OT, SALT, feeding (NG/PEG tube) symptomatic relief - muscle relaxant and glycopyronium bromide for secretions
85
**Febrile convulsions**
* Describe features of seizure
* Age of onset
* Types: simple vs complex
* Risk of developing epilepsy
* How long would you expect a febrile convulsion to terminate?
* What is the risk of having another febrile seizure after having the first?
* What other conditions need to be ruled out in the history? (Differentials - with fever (3) /without (3) )
* generalised with motor onset (tonic clonic) - can have short post ictal period (recovery within 1 hr) + face twitching/eye-rolling/LoC
* simple - less than 15mins, tonic-clonic, once during febrile illness
* complex - features such as - focal, prolonged, **over 15 mins**, recurrent - multiple times during illness
* 6mo --> 6 yr
* 2.5% (simple); if complex - up to 20%
* 1/3 have another
* Differentials -
* With fever - meningitis (non-blanching rash, neck stiffness; febrile myoclonus (benign, affects one limb), Dravet syndrome (epileptic prolonged seizure triggered by fever - ND delay)
* Without fever - hypoglycaemia, trauma, epilepsy (suspect if complex/ND delay),
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Precocious puberty
- Central
- Peripheral (pseudo)
Central: early activation of HPG axis
Peripheral: independent of HPG axis
* Mc-Cune Albright syndrome (PP, cafe-au lait; bone disorder -.e.g skull)
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**WARFARIN REVERSAL GUIDELINES**
Major bleeding (x3)
Minor bleeding:
INR >8
INR 5-8
No bleeding:
INR >8
INR 5-8
For minor and no bleeding when should the warfarin be restarted?
**Major bleeding**
1. Stop warfarin
2. IV Phytomenadione (Vit K)
3. PCC (factor 10,9,7,2)
**Minor bleeding**
INR >8 or 5-8: Stop warfarin, IV Vit K 1-3mg
**No bleeding**
INR >8: Stop warfarin, Oral Vit K 1-5mg
INR 5-8: Omit 1-2 doses of warfarin, give lower maintenance dose
Restart when INR less than 5. And for no bleeding butbinr 5-8 restart on a lower maintenance dose.
