Paeds

Question 1

Risk factors for DDH (developmental dysplasia hip)

Answer 1

Breech presentation in 3rd trimester
FHx DDH (parent or sibling)
Oligohydramnios
Twins
Congenital or position talipes
Congenital knee dislocation
Plagiocephaly or torticollis
Neuromuscular or syndromic condition
Birth weight>4.5 kg

Question 2

Examination features DDH

Answer 2

Age<3m, barlow and ortolani’s causing hip clunk when relaxed
Age>3m asymmetrical limited abduction, leg length discrepancy, asymmetrical hip skin creases
Limp/toe walking due to shorter leg
USS via hip screening or in 2ndary care
If older, urgent T+O appt

Question 3

What features show flat foot as being flexible?

Answer 3

Arch reconstitutes when on tiptoes
Arch reconstitutes when not weight-bearing
Heel swings into varus

Question 4

Obs meaning a child should be admitted

Answer 4

Sats<92%
Fever:
Age<3 months >=38°C
Aged 3 -6 months>=39°C
RR:
Aged 0- 5 months>60
Aged 6-12 months >50
Age>12 months>40
HR:
<1 year>160
Age 1-2 years >150
Age 3-4 years>140
CRT> 2 seconds

Question 5

Examination findings meaning a child should be admitted

Answer 5

Appears seriously unwell, does not wake or doesn’t stay awake
Nasal flaring, Tracheal tug
Cyanosis, Apnoea
Grunting
Intercostal/subcostal recessions
Marked abdominal breathing
Auscultation suggesting effusion, abscess, or empyema
Poor feeding < half of normal
Dehydration (no wet nappy 12 hrs)

Question 6

Management acute severe wheeze in children

Answer 6

Salbutamol neb:
Age<5 years – 2.5 mg
Age>5 years – 5 mg
Ipratropium neb – 250 micrograms
repeat every 20 minutes for the first hour.

Or salbutamol MDI 10 puffs via spacer, 5 tidal breaths each puff. Can be repeated every 10 to 20 minutes if needed. + ipratropium MDI via spacer 2 puffs every 20 minutes for 1 hour
PO prednisolone:
Age< 5 years – 20 mg
Age> 5 – 40 mg

Question 7

What age do you start giving pred for wheeze?

Answer 7

Don’t give under age 2
Do not routinely given under age 4 unless known asthma

Question 8

Features septic arthritis/osteomyelitis

Answer 8

a limp.
single, painful, or swollen limb.
refusal to weight-bear
unable to move a limb normally (in infants who are not yet mobile).
unwell with a fever, but no obvious cause.
skin infection that is slow to resolve especially if over a joint.

Question 9

Features bronchiolitis

Answer 9

Coryzal, then persistent cough, increased work of breathing, widespread wheeze or crackles, and a fever of less than 39°C
usually peaks day 3- 5 and resolves within 3 weeks.

Question 10

Features diabetes

Answer 10

Thirst (polydipsia)
Thinner (weight loss)
Toilet – passing urine frequently (polyuria)
Tired
Enuresis or nocturia in a previously toilet trained child
Recurrent thrush esp if prepubertal
Recurrent UTI

Question 11

When should you consider IBD in abdo pain in children?

Answer 11

perioral and/or perianal symptoms
blood in stool
poor growth
FHx
raised platelets + CRP

Question 12

When should you consider coeliac disease in abdo pain in children?

Answer 12

non-specific GI symptoms
lethargy
poor growth
refractory iron deficiency
FHx
Delayed puberty, short stature

Question 13

Features functional abdo pain

Answer 13

Recurrent central abdominal pain (context of anxiety)
Recurrent of nausea and upper GI pain (before school)
Strong colic reflex (cramps before soft bowel motions, usually soon after meals)
Abdominal migraines (periodicity of attacks, associated nausea +/- vomiting, FHx migraines)

Question 14

Ix for abdo pain in children

Answer 14

Diarrhoea – molecular enterics
upper GI – H. Pylori faecal antigen
sus IBD – faecal calprotectin if teen
Consider urinalysis.
FBC, ferritin, CRP, U+E, bone, LFT.
Coeliac screen (need 6 weeks of normal gluten intake) and total IgA.
Finger prick glucose if ?diabetes

Question 15

Where is gluten found?

Answer 15

Wheat, rye, and barley.
Oats are generally tolerated but normal oats can be heavily contaminated with wheat. 5% of coeliac patients will be intolerant to oats.

Question 16

Untreated coeliac disease risks

Answer 16

anaemia
nutritional deficiencies
osteopenia or osteoporosis
malignancy, particularly small bowel carcinoma or lymphoma

Question 17

If low total IgA, symptoms suggestive coeliac disease and negative IgA TTG, what is the next step?

Answer 17

IgG TTG
as could be false negative

Question 18

Red flags for constipation in children

Answer 18

Meconium passage>48 hours after birth
Symptoms within 1st week of life
Faecal incontinence or soiling in a school-aged child without known constipation
Ribbon stools from birth
Leg weakness
Unintentional weight loss

-> same day paeds

Question 19

Contributory factors for constipation in children

Answer 19

Medications or supplements (eg thickener)
Excessive cow’s milk intake
When solids are introduced, during toilet training, or when starting school.

Question 20

Features of faecal impaction

Answer 20

Failing to pass a stool for several days, followed by a large, often painful or distressing, bowel motion.
Soiling of underclothes between bowel motions
Vomiting.
Severe abdominal pain.
Palpable mass.
Loss of awareness.
Urinary retention or wetting.

Question 21

Management constipation

Answer 21

Adequate fluid (eg adding water inbetween feeds if bottle fed)
Regular toileting (5 mins BD after meals)
Fibre (6 fruit/veg daily with peel)
Cycling legs, massage

Question 22

When to do cxr in children with cough

Answer 22

Cough> 8 weeks.
features suggesting a chronic respiratory condition, e.g. poor growth, chest deformity, finger clubbing.

Question 23

Features IgE mediated cows mild protein allergy

Answer 23

Reactions <2 hours after ingestion, usually within 20mins
Urticaria, angio-oedema, itching, cough, hoarseness, wheeze, or breathlessness
Vomiting, diarrhoea, oral itching

Unlikely if no eczema

Question 24

Featured non IgE mediated CMPA

Answer 24

Delayed until 2-72hrs after ingestion.
GORD, abdominal discomfort, constipation, diarrhoea, or atopic eczema, particularly if symptoms are severe or resistant to treatment.
Unlikely if no eczema
Blood/mucus stool, perianal redness

Question 25

Management CMPA

Answer 25

trial elimination of all cows' milk. If non‑IgE‑mediated symptoms, planned early reintroduction of cows' milk after 4 weeks Prescribe an appropriate hydrolysed formula (nutramigen or aptamil pepti) If severe symptoms/no reponse to hydrolysed, trial amino acid based (alfamino/neocate) If symptoms resolve, and return on reintroduction- urgent dietician cows' milk-free diet until 9 -12 months old, for a duration of at least 6 months.

Question 26

Referral criteria CMPA

Answer 26

Admit if unwell +: rectal bleeding ?proctocolitis. profuse vomiting and/or diarrhoea 2 -4 hours after food (?enterocolitis) Routine paeds if CMPA suspected +: faltering growth, or significant IgE‑mediated CMPA symptoms or severe non‑IgE mediated symptoms.

Question 27

Features croup

Answer 27

Sudden‑onset, seal‑like barking cough, often accompanied by stridor, hoarseness, and increased work of breathing. Symptoms are typically worse at night and increase with agitation.

Question 28

Management croup

Answer 28

Reduce anxiety O2 non rebreathe 15 L Nebulised adrenaline (5 mL 1:1000) Dexamethasone 0.15 mg/kg as 2 mg/5 mL oral solution or prednisolone 1-2 mg/kg

Question 29

When to admit ?diabetes

Answer 29

Blood glucose >7 (>11 ?DKA) Features DKA (vomiting, abdo pain, ketotic breath, lethargy)

Question 30

What is a simple febrile seizure?

Answer 30

Generalised seizures lasting <5 mins, not occurring > once per febrile illness. No hx of afebrile seizures, neurological abnormality or evidence of CNS infection. Recurrence rate of febrile seizures is around 30%, with 10% of children having more than 3 febrile seizures.

Question 31

Define complex febrile seizure

Answer 31

Focal or prolonged>15 minutes, or recurring within a 24‑hour period. Increased risk of afebrile seizures. Lifetime risk of developing epilepsy increases from 1.5% to 4%.

Question 32

Risk factors for febrile seizure

Answer 32

T> 39°C Aged 6 months-5yrs Viral infection- HHV‑6, influenza, adenovirus Recent vaccination – DTP, MMR

Question 33

Acute seizure management

Answer 33

Recovery position. Ensure adequate airway and ventilation. Administer oxygen by mask. Check finger‑prick glucose level. If blood sugar<3 mmol/L, treat hypoglycaemia with Glucogel If>5 mins 999 and buccal midazolam Younger than 1 year – 2.5 mg Aged 1 to 4 years – 5 mg Aged 5 to 9 years – 7.5 mg

Question 34

Referral criteria febrile seizure

Answer 34

Admit if: Hypoglycaemia after treatment. Persisting postictal paresis or other neurological abnormality. 1st presentation of febrile seizure If occurs after the 2nd day of febrile illness. Symptoms or signs of meningism. Prolonged seizure or postictal period. Recurrent complex febrile seizure. Focal neurological deficit. Decreased level of consciousness before the seizure. Recently antibiotics (may mask signs of CNS infection). Parent or carer anxiety and/or difficulty coping. Age< 1 year. Diagnostic uncertainty >1 seizure per febrile illness.

Question 35

Features kawasaki

Answer 35

High fever>5 days Widespread macular rash Swelling or peeling of hands and feet Conjunctival redness or injection Red, dry, or cracked lips Lymphadenopathy

Question 36

Concerning features for admission in D+V

Answer 36

Temperature more than: 38°C <3 months 39°C > 3-6 months Neck stiffness Bulging fontanelle Non-blanching rash Blood and/or mucous in stool Bilious vomit Severe or localised abdominal pain Abdominal distension or rebound tenderness

Question 37

When to do stool culture in D+V in children

Answer 37

blood/mucus in stool. immunocompromised recently been abroad. diarrhoea that has not settled by day 7. multiple attendances. an uncertain diagnosis.

Question 38

Symptoms of underlying cardiac abnormality in school age children

Answer 38

Reduced exercise tolerance Dyspnoea or cough on exertion – may be misdiagnosed as exercise‑induced asthma Angina Palpitations Syncope with exertion

Question 39

Symptoms of underlying cardiac abnormality in infants

Answer 39

Poor feeding Rapid breathing Failure to thrive Profuse sweating (when feeding) Cyanosis or dusky spells Frequent or recurrent respiratory infections

Question 40

Risk factors for congenital heart disease

Answer 40

Maternal diabetes, antenatal infection, maternal medications, alcohol in pregnancy FHx CHD, SIDS, sudden cardiac death, HOCM Trisomy 21, and 22q deletions Syndromic or dysmorphic features Marfan syndrome

Question 41

Features of innocent murmur

Answer 41

Systolic, Short Musical, high‑pitched, whistling Soft Left sternal edge Non‑radiating, no associated thrill, clicks, or extra heart sounds Varying with body position and breathing Intermittent with high heart rate Normal femoral pulses No syndromic features Thriving Sats> 95%

Question 42

Pathological murmur features

Answer 42

Pansystolic, diastolic, or continuous High‑grade, harsh sounding, loud Widespread or radiating Abnormal pulses (bounding or absent femorals) Associated click, abnormal S2, added heart sound, thrill Tachypnoea Poor perfusion, mottling, CRT>2 Central cyanosis – blue tongue, not just perioral duskiness Sats<95% Hepatomegaly Clubbing (rare, late sign)

Question 43

In a child with a head injury, when should you be concerned about NAI

Answer 43

injury details are absent, vague, or change over time or between caregivers. injury is inconsistent with the developmental stage of the child. unexplained delay in seeking help. history or findings of repeated injuries. unexplained loss of consciousness, persistent vomiting, or oro-nasal bleeding in a young infant

Question 44

Definition of prolonged jaundice

Answer 44

>14 days if term (37+/40) >21 days if preterm

Question 45

Meanings of split bilirubin results

Answer 45

Unconjugated hyperbilirubinaemia: Can be physiological Commonly breast milk jaundice can also be caused by UTI, sepsis, hypothyroidism, and liver disease. Conjugated hyperbilirubinaemia: when conjugated fraction>20 or >20% of the total serum bilirubin Congenital biliary atresia Always needs Ix

Question 46

Risk factors neonatal jaundice

Answer 46

Birth trauma (bruising), prematurity, maternal diabetes ABO and Rh incompatibility Sepsis or congenital infection FHx neonatal jaundice G6PD deficiency (African, Middle Eastern, Mediterranean ethnicity) Neonatal hypothyroidism

Question 47

Referral criteria neonatal jaundice

Answer 47

Admit it: jaundice within 24 hours of birth. unwell with jaundice. jaundice and pale stools. bilirubin level is above treatment line. conjugated hyperbilirubinaemia. weight gain or feeding is unsatisfactory.

Question 48

Phases of measles

Answer 48

Incubation period – 10 days Prodromal period – 2- 4 days with malaise, fever, cough, conjunctivitis, then the rash develops, behind ears then spreads. Infectious period – from the day symptoms first appear (about 4 days before the rash) to 4 days after the onset of rash.

Question 49

Features measles

Answer 49

Prodrome lasting 2 to 4 days with: Fever, typically over 39°C, persists until the eruption of the rash and spikes when the rash erupts Cough Coryza Conjunctivitis Malaise Koplik spots- blue-white spots on the inside of the mouth opposite the molars, occur 24–48 hours before the rash Rash- flat, red macules non-itchy rash begins on the face and behind the ears. Within 24–36 hours it spreads over the entire trunk and extremities (palms and soles rarely involved), becomes confluent

Question 50

Name 6 complications of measles

Answer 50

Pneumonitis Otitis media Diarrhoea, stomatitis, dehydration Encephalitis Keratoconjunctivitis Myocarditis

Question 51

Features rubella

Answer 51

typically mild illness, rash not confluent. If fever is present, it rarely starts on the day of the rash. Post-auricular or suboccipital lymphadenopathy may occur. Koplik spots absent.

Question 52

Features HSV6

Answer 52

Roseola infantum mild illness, may be asymptomatic. Typically fever for 3 to 5 days followed by maculopapular rash as clinical improvement occurs

Question 53

Features parvovirus B19

Answer 53

Slapped cheek disease bright red rash on cheeks, lacy rash on trunk, Koplik spots absent. Arthralgia or arthritis may occur in adults.

Question 54

Management measles

Answer 54

Admit if complications or very unwell Public Health Paeds advice if age<2 or immunocompromised Pt will be sent 2 swabs in post Self isolate min 4 days after the onset of rash, ideally until they are fully recovered Avoid contact with susceptible individuals – those not immunised or partially immunised, pregnant, or immunocompromised.

Question 55

Features + risk factors for craniosyntosis

Answer 55

Palpable raised sutures Slowing of head growth Syndromic appearance Family history Maternal sodium valproate use in pregnancy

Question 56

Features + risk factors for hydrocephalus

Answer 56

Excessive head growth Tense bulging fontanelle Sunsetting eyes

Question 57

Features raised ICP

Answer 57

Unwell, vomiting, often irritable with altered or fluctuating consciousness level Abnormal posturing Abnormal pupils(sunset eyes) Classic triad of low heart rate, high blood pressure, and abnormal breathing (late sign)

Question 58

Features congenital torticollis

Answer 58

Breech position or difficult delivery. Few weeks -few months after birth. Resting position of head is rotated to opposite side and tilted to same side as the tight muscle. Tight and a painless swelling Plagiocephaly

Question 59

Referral criteria for plagiocephaly

Answer 59

Urgent paeds: ?hydrocephalus or craniosynostosis Community paeds: Plagiocephaly with dysmorphic features Paediatric physiotherapy if: neck movements are restricted and suspected congenital muscular torticollis plagiocephaly with developmental delay.

Question 60

Features pyloric stenosis

Answer 60

Progressive thickening of the circular muscle of the pylorus. This leads to gastric outlet narrowing. Age 2- 6 weeks. Vomiting is: Progressively more forceful and may be projectile Non-bilious Blood-stained in up to 10% of cases. Predominantly in male patients The infant is often hungry after vomiting. There may be weight loss or inadequate weight gain.

Question 61

Risk factors for GORD in children

Answer 61

patients with neurological impairment, e.g. cerebral palsy. premature infants. cystic fibrosis. oesophageal abnormalities.

Question 62

Management GORD if formula fed

Answer 62

Each 1-2 weeks 1) Reduce volume of feeds if >150 mL/kg. 2) smaller, more frequent feeds 3) Thickener Carobel, SMA Staydown (if doesn't work, stop) 4) Alginates: gaviscon infant 5) PPI: 4‑week trial lansoprazole

Question 63

Management GORD if breastfed

Answer 63

1) Gaviscon infant, review at 2 weeks and stop if no improvement. 2) 4‑week trial of PPI lansoprazole

Question 64

Referral criteria GORD

Answer 64

Admit if: ?pyloric stenosis. bile-stained vomiting. poor weight gain. haematemesis. altered responsiveness. aspiration. malaena. dysphagia. Routine paeds if: symptoms do not resolve or recur after treatment. possetting ongoing aged 18 months.

Question 65

Features of childhood OSA

Answer 65

habitual noisy breathing or snoring >3 nights a week without URTI parent observes snorting, gasping, coughing, choking during sleep witnessed apnoea events nasal obstruction and daytime mouth breathing. a parent reports being afraid for their child's health because of breathing difficulties at night. the child needs to be woken in the morning. daytime hyperactivity or sleepiness.

Question 66

What would you examine in bedwetting/incontinence?

Answer 66

Abdomen – look for distension, feel for faecal loading, masses Spina bifida. Lower limb power, tone, reflexes, sensation. Perineum and genitalia – assess morphology and perineal sensation, look for inflammation. BP Urine dip Blood glucose

Question 67

Management night time wetting

Answer 67

Drinking earlier in the day. Bedtime routine Child has their own bed and access to a toilet Avoid lifting or waking the child If using continence products, the child should have time off pull‑up nappies, but try pants or underwear under the pull‑ups Makw the bed in layers so top layers can be taken off in the night. Consider mattress protectors, duvet protectors, pillow protectors, and waterproof sleeping bag liners for sleep‑overs and camping trips. Refer continence service re enuresis alarm and desmopressin Can consider short term desmopressin for school trip via GP

Question 68

Referral criteria urinary incontinence in children

Answer 68

Routine paeds: Recurrent UTIs always wet during the day (constant dribble). straining to void or weak stream. Paediatric continence: Support for child age>5years No improvement in daytime wetting after treatment. for alarm programmes or desmopressin.

Question 69

Features UTI in children

Answer 69

Unexplained fever, lethargy, irritability Poor feeding, vomiting Dysuria, frequency, urgency, poor flow, or new incontinence Abdominal, suprapubic, or loin pain Haematuria or offensive urine Unexplained poor growth High BP

Question 70

Indications for USS KUB in children with UTI

Answer 70

Infection with non-E coli organisms Seriously ill Poor urine flow Abdominal or bladder mass Raised creatinine Septicaemia Failure to respond to treatment within 48hrs OR recurrent UTI: 2+ upper UTI 1+ upper UTI and 1+ lower UTI 3+ lower UTI Or age<6 months – USS within 6 weeks of infection if responds well to abx treatment within 48hrs and not atypical or recurrent infection.

Question 71

Referral criteria UTI

Answer 71

Admit: Age<3 months Acutely unwell/suspected sepsis Poor urinary flow Enlarged bladder or any other abdominal mass Unable to tolerate oral medications. Fever>39 age 3-6 months No improvement 24-48hrs Recurrent UTI age<6 months. Routine if recovered from UTI and: age<6 months. atypical UTI or recurrent UTI.

Question 72

When to Ix childhood obesity

Answer 72

If >98th centile: Fasting glucose and HbA1c (if CBG normal) Fasting lipid profile if age>10 LFT Full blood count and ferritin Vitamin D levels and bone profile TFTs If short stature or high blood pressure, arrange 24‑hour urinary cortisol.

Question 73

When to suspect 2ndary causes obesity

Answer 73

Pregnancy – exclude in sexually active young people. Endocrine causes- hypothyroidism, Cushing's syndrome, growth hormone deficiency – usually also cause short stature. Single gene mutations – suspect if severe, early onset obesity in patients younger than 5 years. Genetic disorders- Prader‑Willi, Down, Turner, Noonan – suspect if dysmorphism or intellectual impairment.

Question 74

Red flag in ingestion of objects

Answer 74

Disc battery ingestion- hearing aid or camera Objects > 5 cm long, sharp objects Multiple magnets