Paeds Mx Flashcards
1
Q
Signs, Ix and Management of ASDs?
A
Sx: Ejection systolic murmur (upper L sternal edge), fixed wide splitting of S2
Ix: (severe, long term cases)ECG: RAD, RBBB for secundum. partial AVSD - the AV node is displaced and therefore it conducts the ventricles superiorly giving a negative reflection of QRS in the AVF lead. Echo will show the abnormality.
Observation is main treatment, as it may close or shrink; measured by ratio of pulmonary to systemic blood flow, where <1.5 is of little prognostic importance. >1.5 = large enough to cause RV dilatation and will require surgical closure at 2-4 years of age.
Secundum ASDs - managed by cardiac catheterisation with the insertion of an occlusive device (percutaneous closure/endovascular closure) but may need
surgical closure under GA.
Partial AVSD - managed by surgical correction
Prophylactic amoxicillin for the first 6m after device insertion
2
Q
Sx and Mx of VSD?
A
Signs:
• Pansystolic murmur (lower L sternal edge) (loud murmur = smaller defect) (will be soft/absent in large VSD)
• Quiet P2
• Large VSD will have apical mid-diastolic murmur from increased flow over the mitral valve
• Signs of HF if large VSD (hepatomegaly, SOB, failure to thrive, recurrent chest infections) (From 1 week old)
Ix: ECG will show biventriuclar hypetrophy if LVSD. (Upright t wave in V1 indicates pul HTN).
Management Depends on size! If smaller than AV node diagemeter (~ 3mm), they will close spontaneously, ascertained by the disappearance of the murmur and normal ECG/Echo. While the VSD is present, prevention of bacterial endocarditis is by maintaining dental hygiene. Proph amoxicillin if high risk.
More than 3mm: Drug therapy for HF is with diuretics furosemide, often combined with captopril and digoxin. Additional calorie input is required.
Surgery 3-6months is required to manage HF and prevent lung damage from pul HTN. This procedure (pulmonary artery banding) narrows the pulmonary artery to reduce the blood flow to the lungs. When the child is older, an operation is done to remove the band and fix the VSD with open-heart surgery if the opening is large.
3
Q
Signs, IX and management of PDA?
A
Signs: Continuous murmur below L clavicle (cont. as Pa in pul artery always less than aorta)
ECG- Large L-R shunt will cause RVH (+ Pul HTN) and LVH and so indistinguishable from large VSD.
If a cyanotic disease is dependent on a PDAs (e.g. TGA), the patient should start a prostaglandin infusion to keep the PDA open until corrective surgery can be performed
• The duct can be closed using:
o IV Indomethacin – 1st line treatment
o Prostacyclin synthetase inhibitor
o Ibuprofen ( Usually done in premature/VLBW infants)
• If pharmacological methods are unsuccessful, surgical ligation or PCD closure may be used
• Term infants:
o Symptomatic >6mo, PCD closure ASAP
o Usually closed using a coil or occlusive device introduced through a cardiac catheter at ~1yo via femoral.
o Diuretics can be given if delay of closure, to manage symptoms
4
Q
Acute diagnosis and management of cyanotic heart disease in neonate
A
Ix: Nitrogen washout test ( The infant is placed in 100% oxygen (headbox or ventilator) for 10 min. If the right radial arterial PaO2 from a blood gas remains low (<15 kPa, 113 mmHg) after this time, a diagnosis of ‘cyanotic’ congenital heart disease can be made if lung disease and persistent pul HTN of newborn have been excluded)
Mx: ABC, artificially ventilate if necessary. Start prostaglandin infusion (PGE, 5 ng/kg per min). Most infants with cyanotic heart disease presenting in the first few days of life are duct dependent; i.e. there is reduced mixing between the pink oxygenated blood returning from the lungs and the blue deoxygenated blood from the body. Maintenance of ductal patency is the key to early survival of these children. Observe for potential side-effects – apnoea, jitteriness and seizures, flushing, vasodilatation and hypotension
5
Q
TOF Ix and Mx
A
Sx: loud systolic MURMUR FROM DAY1, murmur will shorten with time and cyanosis will increase. Clubbing in older children. Can present with severe cyanosis on d1 or much later with hypercyanotic spells (squatting on exs).
Ix: CXR: boot-shaped heart (RVH), pul artery ‘bay’ (concavity where the PulA should be). ECG normal at birth. RVH eventually.
Initial mx is medical, with definitive surgery at 6 months. It involves closing the VSD and relieving right ventricular outflow tract obstruction, sometimes with an artificial patch, which extends across the pulmonary valve.
• Infants who are very cyanosed in the neonatal period require a shunt to increase pulmonary blood flow. This is usually done by surgical placement of an artificial tube between the subclavian artery and the pulmonary artery (a modified Blalock–Taussig shunt), or sometimes by balloon dilatation of the RV outflow tract. ±ECMO.
• Hypercyanotic spells are usually self-limiting and followed by a period of sleep. If prolonged (beyond about 15 min), they require prompt treatment with:
– sedation and pain relief (morphine is excellent)
– IV propranolol (or an α adrenoceptor agonist), which probably works both as a peripheral vasoconstrictor and by relieving the subpulmonary muscular obstruction that is the cause of reduced pulmonary blood flow
- bicarb to correct acidosis
6
Q
Ix & TGA management
A
Signs: Cyanosis is the main sx and it is always present. Often presents on day 2 when the PDA closes with increased cyanosis. Presentation can be delayed if there are other SDs. Loud S2 that is single. Generally, NO MURMUR. (Can have systolic murmur from pul stenosis -> increased blood flow)
Ix: CXR can show ‘egg on the side’ on cardiac contour, ECG is normal, Echo shows the deformity.
Mx: In a cyanosed neonate, the key is to improve mixing.
• Maintain patency of DA with PG infusion is mandatory.
• A balloon atrial septostomy is a life-saving procedure which may need to be performed in 20% of those with TGA. A catheter, with an inflatable balloon at its tip, is passed through the umbilical or femoral vein and then on through the right atrium and foramen ovale. The balloon is inflated within the left atrium and then pulled back through the atrial septum. This tears the atrial septum, renders the flap valve of the foramen ovale incompetent, and so allows mixing of the systemic and pulmonary venous blood within the atrium.
• All pts need the arterial switch procedure in the neonatal period. In this operation, performed in the first few days of life, the pulmonary artery and aorta are transected above the arterial valves & switched over. coronary arteries have to be transferred across to the new aorta also.
7
Q
Signs and management of cardiac outflow obstructions in the well infant
A
Well children (if asymptomatic -> f/u, no intervention) Aortic Stenosis - murmur on UR sternal edge, carotid thrill; Mx is Trans-catheter balloon dilatation (balloon valvulotomy) If severe, transcatheter aortic valve replacement (TAVR) with proph abx and anticoag.
Pul stenosis - Murmur UL sternal edge, no carotid thrill; Transcatheter balloon dilatation 1st line, valvulostomy 2nd line.
Coarctation -Systemic HTN, Stent insertion or surgery
8
Q
Signs & Mx for outflow obstructions in the sick child
A
Sick infant (i.e. duct dependent) ALL PRESENT WITH COLLAPSE. ALL NEED ABC + PG.
Coarctations -> Collapse, absent FEMORAL pulses. Abc + PG infusion + Surgery.
Interruption of Aortic Arch - distal aortic arch is attached (via a duct) to pulmonary artery instead of aorta. VSD usually present. Syndromic associations e.g. DiGeorge. Present with collapse, absent LEFT BRACHIAL pulse. Surgical repair and closure of VSD in first few days of life.
Hypoplastic LH syndrome: (MV and AV is small/absent, coarctation, LV is v small -> no flow on left hand side of heart.) Present antenatally or post natally with collapse and severe acidosis. Absence of all peripheral pulses. Surgical management: Norwood procedure (neonatally) and then Glenn/hemi-Fontan (6 months) and Fontan (at 3 yo)
9
Q
Cardiac arrhythmia management
A
It is important to differentiate normal and pathological arrhythmias:
Normal sinus arrhythmia are cyclical changes in HR with respiration. Acceleration in inspiration and slowing on expiration (HR can change by 30 beats/min)
SVT - most common arrhythmia (250-350 b/min) due to premature activation of atrium via accesspory pathway (rarely a structural issue), echo needed. Mx depends on severity and whether there are signs of HF on investigation e.g. T wave inversion on lateral precordial leads.
1) Circulatory and resp support, correct acidosis
2) Vagal stimulating maneouvers e.g. carotid sinus massage or cold ice pack to face (v successful)
3) IV adenosine is treatment of choice (safe, effective, induces AV block and terminates tachycardia by breaking re-entry circuit that is set up between AV node and accessory pathway) Given in incrementally in increasing doses
4) If adenosil fails, Electircal cardioversion with synchronised DC shock
Once sinus rhythm is restored -> Maintenance therapy using flecainide (na channel blocker) or sotalol (beta blocker). 90% of children have no further attacks. The eons that do can be treated with cryoablation of accessory pathway.
10
Q
Rheumatic fever Mx
A
QUICK RECAP: Rare in developed countries, rare Cx of strep throat infection where pt develops fever, painful joints etc. After several attacks, in 50% of cases there is an autoimmune reaction towards GBS bacteria causing scarring and fibrosis of valve leaflets.
Acute - anti-inflam and bed rest, aspirin in high dosage with monitoring. If inflammation doesn’t resolve-> corticosteroids.
Chronic -ACE inhibitors and diuretics if severe HF.
Anti-strep abx if any evidence of persisting infection
Maintenance: monthly injections of benzathine penicillin is is most effective prophylaxis. Most recommend to treat until 18-21.
11
Q
Rheumatic fever diagnosis
A
JONES CRITERIA (2 major or 1 major and 2 minor) Major criteria Polyarthritis: large joints, usually starting in the legs and migrating upwards. Subcutaneous nodules: Painless, firm collections of collagen fibers over bones or tendons. Erythema marginatum: reddish rash that begins on the trunk/arms as macules -> spread outward and clear in the middle to form rings, which continue to spread and coalesce with other rings, ultimately taking on a snake-like appearance. This rash typically spares the face and is made worse with heat. (RARE) Sydenham's chorea: series of involuntary rapid movements of the face and arms. This can occur very late in the disease for at least three months from onset of infection. Pancarditis: Myocarditis (Inflammation of the heart muscle- can leads to HF & death), Endocarditis (murmur + valve dysfunction), Pericarditis (pericardial friction rub + pericardial effusion) Minor criteria: Fever, polyarthralgia, hx rheumtaic fever, PR interval prolonged, raised acute phase reactant on FBC
12
Q
Infective endocarditis management
A
Most common causative organism is alpha haemolytic strep (strep viridans). It is usually treated with a beta-lactam (e.g. high dose penicillin) and aminoglycoside e.g. genta (broad spec abx for g-ve) IV therapy for 6 weeks.
If the causative organism is Staph Aureus, treat as above + clindamycin.
If there is a prosthetic valves/VSD patches shunts etc. This might have been the cause and there is less chance of eradication- surgical removal might be required.
PROPHYLAXIS - good dental hygiene! strongly encouraged in all children with congenital heart disease. Proph abx no longer recommended. Avoid piercings.
13
Q
Myocarditis /cardiomyopathy management
A
RECAP: Can be caused by either direct viral infection, secondary to metabolic disease or inherited - any child with enlarged heart and HF should be suspeted to have cardiomyopathy.
Mx: symptomtic with ACE inhibitors and carvedilol (a Beta-adrenoceptor blocking qagent)
14
Q
Pul HTN Management
A
Key is to reduce pressure to prevent irreversible damage to the pulmonary vascular bed (which is not correctable other than herat-lung transplant)
Medications that target GMP pathway (inhaled NO) or cAMP pathway (IV prostacyclin) can cause vasodilation and allow transplant to be delayed for many years. Or endothelin antagonists (e.g. oral bosentan).
15
Q
Causes of pul HTN
A
1) Arterial HTN (persisnt pul htn of newborn; post tricuspid shunts e.g. VSD, PDA, AVSD; HIV; idiopathic)
2) Venous HTN (L sided heart disease, pul vein stenosis)
3) Systemic HTN + resp diseae
4) Pulmonary thromboembolic disease
5) Pul. inflammatory or capillary disease
16
Q
Presentations of congenital heat diseae
A
- BREATHLESS (or asymptomatic) - ASD, VSD, PDA
- BLUE (R-L shunts) TOF, TGA
- BREATHLESS AND BLUE (Common mixing, AVSD, complex congenital heart disease e.g. tricuspid atresia)
- ASYMPTOMATIC (AS, adult type coarc, PS)
- COLLAPSED WITH SHOCK (Coarcation, HLHS)
17
Q
What is AVSD?
A
Complete AVSD:
1) Defect in atrial septum
2) Defect in ventricular septum
These in turn then result in the mitral/tricuspid valve being deformed, and is regarded as having one single five leaflet common valve which stretches across tha triovetircular junction that tends to leak. This results in pul HTN.
18
Q
upper UTI/pyelonephritis management
A
NICE GUIDELINES:
<3 mnths - refer to hospital asap, IV abx therapy (eg cef)
> 3 mnths
1. Cefalexin (o) 12.5 mg/kg or 125 mg twice a day for 7 to 10 days (If older than a year its 3x a day)
- If can’t tolerate (o) or severely unwell:
IV Co-amoxiclav (only in combo or if culture results available and susceptible) 30 mg/kg three times a day (max 1.2 g 3 times a day)
IV Cefuroxime 20 mg/kg three times a day (max 750 mg/ dose), increased to 50 to 60 mg/kg three or four times a day (maximum 1.5 g per dose) for severe infections
19
Q
lower UTI management
A
NICE GUIDELINES:
If under 3 months -> IV abx therapy (3rd gen ceph e.g. cefotaxime or ceftriaxone) and refer to paed specialist
> 3 mnths - oral abx:
Trimethoprim if low risk of resistance, (25 mg twice a day for 3 days)
Nitrofurantoin if eGFR>45ml/min (750 mcg/kg four times a day for 3 days
If no improvement after 48 hrs ->
Nitrofurantoin if not used as first choice
Amoxicillin (only if culture results available and susceptible, 125 mg three times a day for 3 days)
Cefalexin (125 mg twice a day for 3 days, if over 1yo dose is three times a day)
20
Q
UTI preventative care & follow up
A
Good perineal hygiene
High fluid intake
Ensuring complete bladder emptying by encouraging children to try a second time
Regular voiding
Lactobacilllus acidophilus - probiotic that reduces pathogen organism
Abx prophylaxis if under 2 and has congenital abnormality of kidneys (trimethoprim 2mg/kg at night)
Followup for children with reflux, recurrent UTIs or scarring:
Urine culture for every non-specific illness
Circumcision in boys can be considered
Annual BP checks if defects are present
Regular assessment of renal growth and function if bilateral defects.
21
Q
Nephrotic syndrome mx
A
Steroid sensitive:
60mg/m2 /day of prednisolone (o). After 4 weeks, reduce to 40mg/m2 on alternate days for 4 weeks and then top. Urine should be protein free by ~11 days.
If steroid resistant, refer to paediatric nephrologist and manage oedema with diuretic therpay, salt restriction, ACE inhibitors.
22
Q
AKI Ix and Mx
A
Overall, care is symptomatic and dependent on the cause
- USS to identify obstructive cause, see if it is chronic (small kidneys) or acute (large, bright kidneys with loss of corticomedullary differentiation).
- Use fluid balance charts to monitor intake
- If there is circulatory overload, restrict fluids and challenge with diuretic.
- Metabolic abnormality management:
1. HyperK-> SABA, Ca gluconate if ECG changes, Glucose
and insulin, dietry restriction
2. HyperP -> Calcium carbonate, dietary restriction
3. Met acidosis -> Sodium bicarbonate
4. HUS -> Anti-hypertensives, 50% of kids will need
dialysis
- Dialysis criteria: FISH. Failure (of conservative mx or multisystem failure); Increased bp or pul oedema; Severe (acidosis, hypo/hypernatraemia), Hyperkalaemia
- Post renal failure -> obstruction relief by nephrostomy or bladder catheterisation, surgery can be performed once stable
- If cause not known -> renal biopsy to rule out rapidly proressive glomerulonephritis (if +ve treat immediately with immunosuppressants)
23
Q
Bacterial meningitis Mx
A
NICE:
<3 months with ?bacterial meningitis using IV cefotaxime plus amoxicillin or ampicillin
>3 mnths ^^^^ IV ceftriaxone
Treat ?meningococcal disease using IV ceftriaxone.
If has travel hx or prolonged/ multiple exposure to abx (within 3 mnth) with additional VANCOMYCIN.
Give DEXAMETHOSONE (0.15 mg/kg to a max dose of 10 mg, four times daily for 4 days) if LP reveals: purulent CSF, WCC > 1000/microlitre, raised WCC with protein concentration greater than 1 g/litre or bacteria on Gram stain. To prevent long term Cx such as deafness
24
Q
meningitis & encephalitis causative organisms
A
BACTERIAL
< 3 months - GBS, Ecoli (and other coliforms), Listeria monocytogens
1 month - 6 years - Haemoph & Neisseria & Strep pneumoniae
> 6 years - Neisseria & Strep pneumoniae
VIRAL:
Enteroviruses, EBV, adenovirus and mumps
ENCEPHALITIS:
Enteroviruses, respiratory viruses and herpes viruses in UK, (worldwide mycoplasma, lyme disease).
25
Bacterial meningitis, confirmed organism mx
< 3 months:
GBS IV cefotaxime for at least 14 days. If the clinical course is complicated consider extending
L monocytogenes - IV amoxicillin or ampicillin for 21 d in, plus gentamicin for at least the first 7 days.
Gram-ve (Ecoli) bacilli with IV cefotaxime for at least 21 d
> 3 months, unless directed otherwise by abx sensitivities:
H influenzae type b - IV ceftriaxone for 10 days
S pneumoniae - IV ceftriaxone for 14 days
26
Contraindications to LP
```
Increased ICP (bradycardia, papilloedema, coma, high BP)
Thrombocytopenia
Coagulopathy
Cardioresp instability
Focal neuro signs
Local infection at LP site
```
27
What can strep pneumoniae cause?
Asymptomatic in majority of children. Pharyngitis, conjunctivitis, sinusitis, otitis media, invasive infection (pneumonia , sepsis and meningitis).
28
CMV disease
CMV disease may be treated with ganciclovir or
| foscarnet, but both have serious side-effects.
29
Kawasaki causes
Unknown but likely as a result of hyperactivity to variety of riggers in a genetically suscpetible host e.g. a polymorphism in the ITPKC gene- a negative regulatory of T cell-activation on chromosome 19 is strongly associated with susceptibility to the disease.
30
Kawasaki management
IVIG within first 10 days reduces coronary artery aneurysms, aspirin reduces the risk of thrombosis, given at high anti-inflammatory dose until fever subsides and inflammatory markers return to normal. Then it is continued at allow anti-platelet dose until echo at 6 weeks reveals absence of aneurysms. If there is persistent inflammation ans fever, may require second IVIG or treatment with infliximab (anti-TNF alpha antibody), steroids or ciclosporin.
31
Down's
Trisomy 21
- 95% meiotic-nondisjunction, 5% transloc, 1% mosacism
- most common inherited cause of LD
- 1.5 per 1,000 births
- Symptoms: Hypotonia, single palmar crease, low set ears, flat nasal bridge, sandal gap, incurved 5th finger
- 50% live over 50 yo
- Cx: Congenital Heart disease (atrioventricular canal defect)
Ix: Picked up on antenatal scanning. Biochemical markers can indicate higher risk. USS increased nuchal thickness is a risk factor. If positive, amniocentesis for karyotyping can be carried out. Rapid FISH can also be done 24-48hr (can be done on amniotic fluid if urgent)
32
Edward's
Trisomy 18
- can be diagnosed by USS in 2nd trimester
- Sx: cardiac and renal malformations, small chin/mouth, LBW, short sternum
- 1 in 8,000
- most die in infancy
33
Patau's
Trisomy 13
- can be diagnosed by USS in 2nd trimester
- Sx: C+ R malformations, scalp defect, small eyes, structural brain defect
- 1 in 14,000
- most die in infancy
34
Turner's
!! 45 X !!
- >95% early miscarriage and picked up by fetal neck oedema, hands, feet or cystic hygroma
- Symptoms really vary, can have short stature only or also webbed fingers, lymphoedema in hands/feet of neonate, spoon-shaped nails, widely spaced nipples
- GH therapy or oestrogen therapy for secondary sexual characteristics
35
Kleinfelter's
XXY
- Infertility
- Hypogonadism
- Pubertal development may appear normal
- Tall stature
- Gynaecomastia in adolescence
- Although they can face problems during adolescence, often emotional and behavioral, and difficulties at school, most of them can achieve full independence from their families in adulthood & lead a normal, healthy life
36
AR diseases
Thalassemia Tay-Sachs disease, Ocultunaeous albinism, Phenylketonuria, Friedrich Ataxia, CF, CAH, SCD, SMA-11 (Werdnig-Hoffman), Hurler Syndrome, Poly, Galactosaemia, Glycogen disorder,
37
AD diseases
Polyposis Choli, Achondroplasia, Tuberous Sclerosis, Ehlers Danlos, Hypercholesterolaemia (familial) Huntington, NeurofibromaTOSIS, Noonan Syndrome, marfan's, Myotonic dystrophy, Osteogenic Imperfecta, Osteosclerosis
38
DKA mx acute
To restore circulating volume if systolic blood pressure is below 90 mmHg (adjusted for age, sex, and medication as appropriate), give 500 mL sodium chloride 0.9% by intravenous infusion over 10–15 minutes; repeat if blood pressure remains below 90 mmHg and seek senior medical advice.
When blood pressure is over 90 mmHg, sodium chloride 0.9% should be given by intravenous infusion at a rate that replaces deficit and provides maintenance; see guideline or suggested regimen.
Include potassium chloride in the fluids unless anuria is suspected; adjust according to plasma-potassium concentration (measure at 60 minutes, 2 hours, and 2 hourly thereafter; measure hourly if outside the normal range).
Start an intravenous insulin infusion: soluble insulin should be diluted (and mixed thoroughly) with sodium chloride 0.9% intravenous infusion to a concentration of 1 unit/mL; infuse at a fixed rate of 0.1 units/kg/hour.
Established subcutaneous therapy with long-acting insulin analogues (insulin detemir or insulin glargine) should be continued during treatment of diabetic ketoacidosis.
Monitor blood-ketone and blood-glucose concentrations hourly and adjust the insulin infusion rate accordingly. Blood-ketone concentration should fall by at least 0.5 mmol/litre/hour and blood-glucose concentration should fall by at least 3 mmol/litre/hour.
Once blood-glucose concentration falls below 14 mmol/litre, glucose 10% should be given by intravenous infusion (into a large vein through a large-gauge needle) at a rate of 125 mL/hour, in addition to the sodium chloride 0.9% infusion.
Continue insulin infusion until blood-ketone concentration is below 0.3 mmol/litre, blood pH is above 7.3 and the patient is able to eat and drink; ideally give subcutaneous fast-acting insulin and a meal, and stop the insulin infusion 1 hour later.
39
Microcephalic, small eyes
Cleft lip/palate
Polydactyly
Scalp lesions
Patau syndrome (trisomy 13)
40
```
Learning difficulties
Macrocephaly
Long face
Large ears
Macro-orchidism
```
Fragile X
41
Micrognathia
Low-set ears
Rocker bottom feet
Overlapping of fingers
Edwards (trisomy 18)
42
Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis
Noonan
43
Micrognathia
Posterior displacement of the tongue (may result in upper airway obstruction)
Cleft palate
Pierre -Robin Syndrom
44
Hypotonia
Hypogonadism
Obesity
PW syndrome
45
```
larynx and neurological problems
Feeding difficulties and poor weight gain
Learning difficulties
Microcephaly and micrognathism
Hypertelorism
```
Cri du chat
| Characteristic cry (hence the name) due to the larynx/neuro issues
46
```
Short stature
Learning difficulties
Friendly, extrovert personality
Transient neonatal hypercalcaemia
Supravalvular aortic stenosis
```
William's Syndrome
47
When do we give kids PPI for gord?
NICE do not recommend a proton pump inhibitor (PPI) or H2 receptor antagonists (H2RA), to treat overt regurgitation in infants and children occurring as an isolated symptom. A trial of one of these agents should be considered if 1 or more of the following apply:
unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
distressed behaviour
faltering growth
48
False positives for the sweat test for CF test?
```
malnutrition
adrenal insufficiency
glycogen storage diseases
nephrogenic diabetes insipidus
hypothyroidism, hypoparathyroidism
G6PD
ectodermal dysplasia
```
49
Differential for stridor in an infant
* Laryngomalacia
* Laryngeal cyst, haemangioma or web
* Laryngeal stenosis
* Vocal cord paralysis
* Vascular ring
* Gastro-oesophageal reflux
* Hypocalcaemia (laryngeal tetany)
* Respiratory papillomatosis
* Subglottic stenosis
50
Impetigo Mx NICE
Localised:
Hydrogen peroxide 1% cream (2-3x times daily for 5 days) for people who are not systemically unwell or at a high risk of complications.
If not 3x a day for 5d of a topical abx fusidic acid 2% (if resistance suspected use mupirocin 2%)
Widespread:
Offer cream as above. If not offer oral flucloxacillin for 5 days (62.5–125 mg 4x daily for children aged 1 month to 1 year; 125–250 for aged 2–9 years; 250–500 mg for children aged 10-17 years) (double after 1 year and 10y)
51
Status Epilepticus Mx
ABC and DEFG (if glucose under <3mmo/L give glucose IV and recheck blood glucose).
If we don’t vascular access, give a diazepam (PR) or midazolam (buccal) 0.5mg/kg as a trial and aim to get IV access and follow below protoco (only give lorazepam once)l. If you can’t obtain IV access, skip to the PR step.
If you have vascular access, you give lorazepam 0.1mg/kg IV. Repeat in 10 min if no reponse. If there is still no response in 10 in we give Paraldehyde 0.4ml/kg PR. If there is still no response in 10 min you call for senior help and give phenytoin 18mg/kg IV/IO over 20 min (unless the pt is on oral phenytoin in which case we give phenobarbital 15mg/kg).Call anaesthetist if there is no response in 20min and transfer to PICU for rapid sequence induction with thipoental.
52
Anaphylaxis Mx
Call for help + put pt in supine position with legs raised
Adrenaline 1:1000 dose IM.
<6 years - 150micrograms (0.15ml)
6-12 years 300 micrograms (0.3ml)
>12 years 500mcg (0.5ml)
Establish airway and give high flow oxygen
IV Fluids (20ml/kg crystalloids)
Chlorpheniramine (IM or slow IV0
Hydrocortisone (IM or slow IV)
Monitor: pulse ox, ecg and BP
CHOAF - chlorpheniramine, hydrocortisin, o2, adrenaline and fluids
53
Headache Mx
Rescue Treatments
Analgesia, NSAIDs
Anti emetics -> Metoclopromide and Procholperazine
5-HT1 agonists e.g. Sumatriptan (a nasal prep is licenced for use in children 12+)
Conservative
Therapy, CBT, headache diaries
Prophylaxis (only if v. severe)
Pizotifen (5-HT antagonist) can cause weight gain and sleepiness
Beta blockers - propanolol, contraindicated in asthma
Na channel blockers (valproate)
For cluster: verapamil if >12, subcut sumatriptan if <12
54
Acute Liver failure Ix and Mx
Ix: Transaminases are greatly elevated (10-100x n), ALP raised, coagulation abnormal, ammonia is elevated. ABG and blood glucose monitoring is crucial. EEG will show the encephalopathy. CT might show cerebral oedema.
Mx: Maintain blood glucose >4mmol/L using IV dextrose, IV Vit K/FFP to prevent haemorrhage, fluid restrict if cerebral oedema. Without transplantation, 70% of children who progress to coma will die.
Cx: Cerebral oedema, haemorrhage from gastritis or coagulopathy, sepsis and pancreatitis
55
Autoimmune hepatitis Mx
check for other autoimmune signs e.g. rash, AIHA, arthritis.
Presents 7-10 years, girls > boys.
Requires close monitoring.
Ix: Diagnosis is based on hypergammaglobulinaemia (IgG>20g/L), positive antibodies and low C4 serum.
Mx: Prednisolone and azathioprine
56
Idiopathic intracranial HTN management
Medical Management: acetazolamide
- 2nd line: furosemide, topiramate
Analgesia (e.g. amitriptyline or naproxen) can be offered for persistent headaches
CSF shunting (ventriculoperitoneal shunt) may be used for intractable headache
57
Paeds Resus
SAFE approach (Shout for help, Approach with care, Free from danger, Evaluate ABC)
Airway & B - Assess (look for obstruction and chest movement, listen for breaths, feel for air movement)
Open airway (head tilt, chin lift gently)
Reassess airway for max 10 seconds
BREATH- 5 x RESCUE BREATHS: pinch nose, mouth to mouse (unless infant in which case mouth over infant’s mouth and nose). Chest should rise.
Reassess - for max 10 seconds, check breathing or pulses (if less than 1 year old check femoral/brachial) if more than 1 year carotid, femoral. Pulse more than 60/min? -> STOP
COMPRESS CHEST - 15 chest compressions + 2 breaths. Infant - two thumbs, Small child - one hand. Large child - two hands.
58
Tricuspid Atresia Mx
Only the left ventricle is effective, the right being small and non-functional. Presentation depends on whether cyanosis or HF i s more predominant.
Initial medical: Maintain adequate flow through PDA = prostaglandin E1 IV
Cardiorespiratory support = O2 and mechanical ventilation, inotropes, IV fluid
Surgical:
o First stage in neonates:
Early palliation to maintain a secure supply of blood to the lungs at low pressure by Blalock-Taussig shunt insertion (allows mixing) & Pulmonary artery banding operation (reduces pulmonary blood flow + keeps at low pressure).
o Second stage at 3-6m old:
Removal of shunt and direct anastomosis of SVC to Right pulmonary artery = Glenn
o Third stage at 2-5yo:
Direct venous pathway from IVC into pulmonary arteries = Fontan. Needs antibiotic prophylaxis
• Important: complete corrective surgery is not possible in most cases because there is only one functioning ventricle
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PPHTN of the newborn
Due to a failure of the pulmonary vascular resistance to fall
PC: Cyanosis soon after birth (grunting etc)
Ix: Urgent echo to establish no CHD
Mx: Mechanical ventilation and circulatory support. Sildenafil (Viagra) is a vasodilator which can be used. ECMO is indicated for severe, reversible cases.
Aetiology: anything that causes respiratory distress e.g. RDS, MAS, pneumonia, also congenital diaphragmatic hernia.
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RDS
Surfactant deficiency causes low surface tension, alveolar collapse and inadequate gaseous exchange
PC: develops at birth either immediately or over a few hours while the neonate absorbs the lung fluids with increased resp work, grunting etc
Ix: CXR Ground glass, indistinct heart borders
Mx: CPAP & Pulmonary surfactant (CPAP- give positive pressure to airways continuously as opposed to pushing air in and out). If severe, intubate and give surfactant through endo-trach tube
Cx: Pneumothorax (unequal chest inflation, dip o2 sats, cold light exam -will see a red bit around touch due to space not lung; baby might become bradycardic
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NEC
! Pneumostasis Intestinalis - gas cysts in bowel !
Most common life threatening emergency experienced by premature babies
Epi: Occurs in ~15% of LBW prem infants
Path: Essentially, the neonatal gut overreacts to insult and this causes inflammation. In turn, the premature gut reacts unfavourably to the inflammatory mediators and this results in the symptoms. Examples of ‘insult’ are hypoxia and hypoperfusion, enteral feeding with infant formula, and eventually, aberrant colonization of the premature gut, result in injury to the epithelial cells and subsequent intestinal inflammation. (Leaky gut -> slippery slope)
PC: Bell staging criteria can be used to grade severity. Distension, PR bleeding/fresh blood in stool. More severe: R. LQ mass, ascites, absent bs, peritonitis. (Plus all ‘ill’ signs: temperature, lethargy, apnea)
Ix: XR for bowel dilation, ileus, pneumatosis intestinalis (gas cysts in bowel wall). Sometimes air in portal tract / under diaphragm if perforation.
Mx: Stop oral feeding, broad-spec Abx, parentral nutrition, artificial ventilation. S if bowel perforation/necrosis- exploratory laparotomy, bowel resection and osteomy has a fatality of 50%.
Cx: Those who survive are at risk of SHORT BOWEL syndrome (malabsorption due to lack of SI presenting with diarrhoea), parenteral nutrition-associated cholestasis, prolonged neonatal hospitalization, significantly impaired growth, and poor long-term neurodevelopment. As well as failure to thrive
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Soft Tissue birth injuries
Caput succedaneum - fluid accumulates subcut, resolves in a few days, due to ‘tourniquet’ effect of cervix and occurs around the presenting part of the scalp, poorly defined margins
Cephalhaematoma - haematoma under the periosteum and so bulge is confined to suture lines. Centre of haematoma feels soft. Resolves over weeks.
Chignon - occurs with ventouse delivery (vacuum device used to deliver baby in second stage of labour if prolonged)
63
Nerve palsies due to birth injury
Usually ones involving the brachial plexus or facial nerve. May occur at breech deliveries or shoulder dystocia (look for ‘turtle sign’ as an indicator of shoulder dys).
Brachial Plexus - Erb’s palsy, ‘waitiers tip’ C5 and C6 injury, can be accompanied by phrenic nerve palsy resulting in elevated diaphragm
Facial nerve palsy - due to facial nerve compressing again mother’s ischial spine. Unilateral facial weakness e.g. eye remaining open whilst crying
Most palsies resolve completely but should be referred to orthopod or plastic surgeon if not resolved in 2-3months. Most recover by 2 years.
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How to manage suspected hypoxia ischaemic encephalopathy
Respiratory support
EEG to detect abnormal background activity (seizures, encephalopathy)
Anticonvulsant therapy for seizures
Monitoring! Hypoglycemia,electrolyte imbalance, hypocalcaemia
Treat hypotension with ionotropes
Fluid restriction due to transient renal impairment
RCT have shown that hypothermia within 6 hours of birth can reduce brain damage from HIE
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TTN
TTN- accounts for 60% of respiratory distress
Aetiology:due to incomplete clearance of fluid in lungs.
Rf: <39 weeks, born via c section without labour (fluid isn’t ‘squeezed out of the lungs’), maternal gestational diabetes*, male
Ix: OE lungs can be clear or crepitations, XR - shows fluid in interlobar fissure (looks like a slug), hyperinflation/hyperexpanded lungs, prominent vasculator. But no major changes.
Mx: resolves up to 2-3d after birth (self limiiting)
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Early onset neonatal pneumonia
Can occur due to chorioamniocentesis or via umbilical cord. Rf: premature, PROM.
Common organisms: GBS, Ecoli, Klebsiella, herpes simplex
Might require oxygen hood to keep oxygen sats above 90%.
Mx: Abx: IV Benzylpenicillin (25mg/kg 12 hourly) with gentamicin (5mg/kg, give second dose after 36 hours if still ill)
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Late onset sepsis management
Late-Onset Sepsis (> 72 hours)
The most common pathogen is coagulase negative staphylococcus (Staph epidermidis), kleb, pseudo
Other:
G-positive (e.g. S. aureus and E. faecalis)
G-negative (e.g. Klebsiella, Pseudomonas and Serratia)
oAmpicillin + gentamicin/cefotaxime
If resistant, specific antibiotics (e.g. vancomycin for coagulase-negative staphylococci or enterococci) or broad-spectrum antibiotics (e.g. meropenem) may be needed
•IMPORTANT: the use of prolonged or broad-spectrum antibiotics predisposes to invasive fungal infections (e.g. candidiasis)
• Serial measurements of CRP are useful to monitor response to therapy
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General neonatal sepsis mangement
NICE:IV benzylpenicillin + gentamicin as a first-line regimen for suspected or confirmed neonatal sepsis.
The exception to this is if microbiological surveillance data reveal local bacterial resistance patterns, in which case an alternative antibiotic should be considered
- CRP should be re-measured 18–24 hours after presentation in babies given antibiotics to monitor ongoing progress and guide duration of therapy
- Stop abx at 48 hours in neonates who have CRP of <10 mg/L and a negative blood culture at presentation and at 48 hours
- Normally, in neonates with culture-proven sepsis, duration will be approximately 10 days
Other important management factors to consider include:
Maintaining adequate oxygenation status
Maintaining normal fluid and electrolyte status: severely ill neonates may require volume and/or vasopressor support. Body weight needs to be measured daily for accurate assessment of fluid status
Prevention and/or management of hypoglycaemia
Prevention and/or management of metabolic acidosis
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Threadworm
Infestation with threadworms (Enterobius vermicularis, sometimes called pinworms) is extremely common amongst children in the UK. Infestation occurs after swallowing eggs that are present in the environment.
Threadworm infestation is asymptomatic in around 90% of cases, possible features include:
perianal itching, particularly at night
girls may have vulval symptoms
Diagnosis may be made by the applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs. However, most patients are treated empirically and this approach is supported in the CKS guidelines.
Management
CKS recommend a combination of anthelmintic with hygiene measures for all members of the household
mebendazole is used first-line for children > 6 months old. A single dose is given unless infestation persists
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The child appears alert with a temperature of 38.4C, something which the parents believe she has had for four days. Previously, calpol has helped bring this down from a high of 40.7ºC. You also note a pink, maculopapular rash on the chest with minimal spread to the limbs, something which mum says she noticed this morning. The child has been feeding but has had some diarrhoea and you feel some enlarged glands on the back of her head. There is no rash in the mouth. Given your findings, what do you feel is the most likely underlying cause of the child's symptoms?
Roseola infantum (also known as exanthem subitum, occasionally sixth disease) is a common disease of infancy caused by the human herpes virus 6 (HHV6). It has an incubation period of 5-15 days and typically affects children aged 6 months to 2 years.
Features
high fever: lasting a few days, followed later by a
maculopapular rash
Nagayama spots: papular enanthem on the uvula and soft palate
febrile convulsions occur in around 10-15%
diarrhoea and cough are also commonly seen
Other possible consequences of HHV6 infection
aseptic meningitis
hepatitis
School exclusion is not needed.
It is characterised by a 3-5 day high fever followed by a 2 day maculopapular rash which starts on the chest and spreads to the limbs. This generally occurs as the fever is disappearing.
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West Syndrome
Features
characteristic 'salaam' attacks: flexion of the head, trunk and arms followed by extension of the arms
this lasts only 1-2 seconds but may be repeated up to 50 times (unlike infantile colic)
progressive mental handicap (i.e. REGRESSES milestones)
Investigation
the EEG shows HYPSARRTHYMIA in two-thirds of infants
CT demonstrates diffuse or localised brain disease in 70% (e.g. tuberous sclerosis)
Management
poor prognosis
vigabatrin is now considered first-line therapy
ACTH is also used
Ddx infantile colic also draws up legs but not repeated like this; tonic clinic seizure has contraction but then shaking of the muscles; febrile seizures have a fever
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Reflex Anoxic Seizure vs Breath holding spells
Breath holding Seizures
Breath holding episodes - toddler precipitated by anger (crying) holds breath -> blue and then limp. Rapid recovery
Mx: Self limiting, behaviour therapy by districton
Reflex Anoxic Seizure
Response to pain, cold food.
Toddler stops breathing goes pale, brief seizure sometimes/ fall to floor.
Due to Cardiac asystole from vagal inhbition
Rapid recovery.
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Autism features / risk factors
Epidemiology
75% of children are male
usually develops before 3 years of age
All 3 of the following features must be present for a diagnosis to be made
global impairment of language and communication
impairment of social relationships
ritualistic and compulsive phenomena
```
Associated conditions/risk factors
Fragile X (tri nucleotide disorder)
Rett's syndrome
LBW
M:F 4:F
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Measles complication
otitis media: the most common complication
pneumonia: the most common cause of death
encephalitis: typically occurs 1-2 weeks following the onset of the illness)
subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness
febrile convulsions
keratoconjunctivitis, corneal ulceration
diarrhoea
increased incidence of appendicitis
myocarditis
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ADHD Mx
Ten-week 'watch and wait' period should follow to observe whether symptoms change or resolve. If they persist then referral to secondary care is required.
Drug therapy should be seen as a last resort and is only available to those aged 5 years or more.
Methylphenidate is first line in children and should initially be given on a six-week trial basis. It is a CNS stimulant which primarily acts as a dopamine/norepinephrine reuptake inhibitor. Side-effects include abdominal pain, nausea and dyspepsia. In children, weight and height should be monitored every 6 months
If there is inadequate response, switch to lisdexamfetamine;
Dexamfetamine should be started in those who have benefited from lisdexamfetamine, but who can't tolerate its side effects.
All of these drugs are potentially cardiotoxic. Perform a baseline ECG before starting treatment, and refer to a cardiologist if there is any significant past medical history or family history, or any doubt or ambiguity.
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Cystic Fibrosis Features
Presenting:
neonatal period (around 20%): meconium ileus, less commonly prolonged jaundice
recurrent chest infections (40%)
malabsorption (30%): steatorrhoea, failure to thrive
other features (10%): liver disease
```
Other:
short stature
diabetes mellitus
delayed puberty
rectal prolapse (due to bulky stools)
nasal polyps
male infertility, female subfertility
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Rocker bottom feet
Edward's
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Brushfield's spots
Spots, Brushfield's: Speckled iris. Little white spots that(are)slightly elevated on the surface of the iris and are arranged in a ring concentric
Feature of Down's
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Hypospadia
Hypospadias is characterised by
a VENTRAL urethral meatus
a hooded prepuce
chordee (ventral curvature of the penis) if severe
the urethral meatus may open more proximally in the more severe variants. However, 75% of the openings are distally located.
Hypospadias most commonly occurs as an isolated disorder. Associated urological abnormalities may be seen in up to 40% of infants, of these cryptorchidism is the most frequent (10%).
Corrective surgery is performed before 2 years of age. It is essential that the child is not circumcised prior to the surgery as the foreskin may be used in the corrective procedure. In boys with very distal disease no treatment may be needed.
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A 4-year-old girl presents to her GP following a productive cough and wheeze. On examination a systolic murmur is heard in the second intercostal space lateral to the left sternal edge. It has an intensity of 1/6 and is not audible when she lies flat. Which of the following is the most likely diagnosis?
Innocent, Coarctation of Aorta, VSD, ASD, Pul Stenosis
Innocent murmur.
They are Soft, Systolic, Short, Symptomless, Standing/Sitting (vary with position). Coarctation of the aorta is heard as an ejection systolic murmur which can be heard through to the back. Additionally, the murmur does not change on position. On examination hypertension of the upper extremities is present and a difference between blood pressure in the arms and legs is detected.
Ventricular septal defect present as a pansystolic murmur.
Atrial septal defect is an ejection systolic murmur but is often associated with fixed splitting of the 2nd heart sound.
Pulmonary stenosis is an ejection systolic murmur heard at the left upper parasternal edge
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Innocent Murmurs
Venous hums Due to the turbulent blood flow in the great veins returning to the heart. Heard as a continuous blowing noise heard just below the clavicles
Still's murmur Low-pitched sound heard at the lower left sternal edge
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Types of haemorrhage at birth
Caput succedaneum is caused by pressure on the fetal scalp during the birthing process. It results in a large oedematous swelling and bruising over the scalp. Treatment is not required as the swelling reduces over a few days.
A cephalohaematoma may occur after a spontaneous vaginal delivery or following a trauma from the obstetric forceps or the ventouse. A haemorrhage results after the presidium is sheared from the parietal bone. The tense swelling is limited to the outline of the bone. It reduces over a few weeks - months.
A Subaponeurotic haemorrhage, also known as a subgaleal haemorrhage is rare and is due to a traumatic birth. It may result in the infant losing large amounts of blood.
An intracranial haemorrhage refers to subarachnoid, subdural or intraventricular haemorrhages. Subarachnoid haemorrhages are common and may cause irritability and even convulsions over the first 2 days of life. Subdural can following the use of forceps. Intraventricular haemorrhage mostly affects pre-term infants and can be diagnosed by ultrasound examinations. Management is largely supportive
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SCFE
Basics
typically age group is 10-15 years
More common in obese children and boys
Displacement of the femoral head epiphysis postero-inferiorly
May present acutely following trauma or more commonly with chronic, persistent symptoms
Features
hip, groin, medial thigh or knee pain
loss of internal rotation of the leg in flexion
bilateral slip in 20% of cases
Investigation
AP and lateral (typically frog-leg) views are diagnostic
Management
internal fixation: typically a single cannulated screw placed in the center of the epiphysis
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PUD Mx
Suspected peptic ulceration, it should be treated with proton-pump inhibitors (e.g. lansoprazole 30 mg)
o If investigations suggest the presence of an H. pylori infection, eradication therapy should be given (amoxicillin AND metronidazole OR clarithromycin)
- 7-day triple therapy regimen of:
o PPI BD + amoxicillin 1 g BD + clarithromycin 500 mg BD OR metronidazole 400 mg BD
If penicillin allergic, omit amoxicillin and give the other three in combination
If they fail to respond to treatment, an upper GI endoscopy should be performed
If this is NORMAL, functional dyspepsia is diagnosed
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FD vs IBS vs RAP vs Abdomigraine
FD- non-ulcer dyspepsia, issues with functioning of GI tract, belching, cramping etc. Normal GI tract refractory to PPI treatment.
IBS
Idiopathic, diagnosis of exclusion (IBD, coeliac. Bloating, tenesmus constipation)
RAP
Definition: Pain sufficient to interrupt normal activities lasting for >3 months
Idiopathic - only <10% have an identifiable cause
Site: Classically periumbilical
Abdo migraine
Abdominal pain in addition to headaches
Midline abdominal ‘attacks’ associated with facial pallor and vomiting
FHx/ PMHx of migraine
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Gastroenteritis management
Abx not routinely required to treat gastroenteritis (even if the cause is bacterial)
Only indicated for:
- Suspected or confirmed SEPSIS
- Extra-intestinal spread of bacterial infection
- Salmonella gastroenteritis if < 6 months
- Malnourished or immunocompromised children
- Specific bacterial or protozoal infections (e.g. C. difficile associated with pseudomembranous colitis, cholera, shigellosis, giardiasis)
IF NOT SHOCKED ->
Use low-osmolarity ORS solution for oral rehydration therapy (50 ml/kg for fluid deficit replacement over 4 hours as well as maintenance fluid)
IF SHOCKED -> IV BOLUS
Rapid infusion: 20ml/kg of 0.9% NaCl Solution. Repeat again if still showing signs of shock.
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Post-gastroenteritis syndrome
rarely, you get Post-gastroenteritis syndrome. Following normal diet, watery diarrhea returns due to temporary lactose intolerance. Identified via positive ‘clinitest’ of the stools. Mx: ORS for 24 hours then reintroduce the diet again.
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Meckel's Diverticulum
Meckel's diverticulum is an outpouching or bulge in the lower part of the small intestine. The bulge is congenital (present at birth) and is a leftover of the umbilical cord. Most common congenital defect of the gastrointestinal tract
Ix: Technetium-99m pertechnetate
IF A/S - NO treatment required
IF S ->
Bleeding - excision of diverticulum with blood transfusion (if haemodynamically unstable)
Obstruction - excision of diverticulum and lysis of adhesions
Perforation/peritonitis - excision of diverticulum or small bowel segmental resection with perioperative antibiotics
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Coeliac Ix and Mx
1. FBC and blood smear (macrocytic anaemia)
2. Coeliac serology (anti-tTG and anti-EMA)
- If IgA deficient: IgG DGP (deimidated gliadin peptide)
3. OGD and duodenal biopsy - gold standard
(Very young children: may have a confirmatory EMA and HLA DQ2/DQ8 testing instead of a biopsy)
Mx: All products containing wheat, rye and barley are removed from the diet
referral to dietician if there are problems with adhering to the diet
- Arrange annual review & Check height, weight and BMI
- Autoimmune screen
Consider blood tests (coeliac serology, FBC, TFT, LFT, vitamin D, B12, folate, calcium, U&E)
o Non-adherence to the gluten-free diet results in:
• Micronutrient deficiency (especially osteopaenia)
• Small increased risk of bowel cancer (especially small bowel lymphoma)
• Hyposplenism
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Important thing to tell parents of crohn's disease?
patients on immunosuppressive therapies should NOT have live vaccines. They are at increased risk of influenza and pneumococcal infection so should receive vaccines.
91
What increases the likelihood of GI surgery for UC?
Increased likelihood of needing surgery if:
• Stool frequency > 8 per day
• Pyrexia
• Tachycardia
• AXR showing colonic dilatation
• Low albumin, low haemoglobin, high platelets or CRP
Offer IV corticosteroids to induce remission
Surgical - Colectomy with an ileostomy or ileojejunal pouch
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Constipation Management
CHECK FOR DISIMPACTION, IF NOT MAINTENANCE THERAPY!
(palpating feacal mass on abdomen, overfilling soiling)
Disimpaction
Step 1: Movicol Paediatric Plain (polyethylene glycol + electrolyte) escalating dose for 2 weeks
Step 2: Add a stimulant laxative (e.g. senna or sodium picosulphate)
If Movicol is not tolerated: a stimulant laxative (e.g. senna) can be used with lactulose or docusate (stool softeners)
Maintenance Therapy
Movicol with/without a stimulant laxative is the treatment of choice
Dose should be reduced over a period of months in response to an improvement in stool consistency and frequency
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Types of laxative
• Types of Laxative
o Bulk-forming: fybogel, methylcellulose
o Osmotic: lactulose, Movicol
o Stimulant: Bisacodyl, senna, sodium picosulphate
o Stool-softener: arachis oil, docusate sodium
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Noninfective causes of a prolonged fever
```
SJIA
Vasculitis (Kawasaki)
Macrophage activation syndromes e.g. HLH
Sarcoidosis
SLE
IBD
Malignancy leukaemia, lymphoma
Drug fever
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Periorbital cellulitis
Erythematous, tender swelling around eye, unilateral
In young un-immunised children can be due to Hib
Ix: CT scan to assess posterior spread. LP to exclude meningitis.
Mx: IV abx
96
TB Ix
Sputum samples are generally unobtainable from children under 8 yo as they usually swallow sputum so gastric washings on 3 consecutive mornings (before food) are required to visualise / culture acid-fast bacilli from lung via NG tube.
- Microscopy and histology
- Culture due to multi-drug resistant strains.
- Mantoux test (but this might be +ve from vaccination anyway)
- NAAT (for every specimen type)
Additional test:
IGRA - IFN gamma release assays can assess T cell response to in vitro stimulation with antigens found in TB (not in BCG).
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HIV ix in baby
Serology only confirms exposure
HIV DNA PCR is required. 2 negative tests within the first 3 months of life, at least 2 weeks after postnatal antiretroviral therapy prove infant is not infected. Needs to be confirmed after 18 months.
98
HIV Mx in babies
Infants - start ART shortly after diagnosis, due to having the highest risk of progression
Children - Combination of clinical status, HIV viral load and CD4 count
Prophylaxis - against PCP with co-trimoxazole in infants, or older children low CD4
Supportive therapy:
Immunisation - normal vaccination schedule without BCG (can cause disseminated infection) additional hep A, B and VZV should be considered
Regular follow up to monitor neurodevelopment and disease symptoms
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Measles Mx
Pt mx is mostly supportive as there is no cure (RIBVARIN in i/c pts)
Rest, drink plenty of water and nsaids if needed
Stay away from school for at least 4 days after rash onset
Return to hospital if SOB, uncontrolled fever, convulsions etc.
100
Lyme disease
DOXYCYCLINE* - uncomplicated over 12+
Amoxicillin if younger
IV Ceftriaxone if carditis/neuro
101
Eczema escalation management
1st line: emollients + education. Educate the patient/family about the amount and frequency of emollient usage i.e. one heaped finger of cream to cover a palm’s worth of surface area.
Add on topical corticosteroids after emollient usage if evidence of colonisation or infection
Oral Abx if persistent pruritus and causing sleep distubance.
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6 yo pt presents very unwell with fever 39.2, BP 70/40, widespread erythematous macular rash. She presented last week with chicken pox. O/E there is soft tissue swelling on the lower leg and bullae formation.
What is the initial and definitive management?
Initial: Fluid resus
Early and immediate treatment should include aggressive fluid resuscitation, empirical abx therapy, vasopressor support for refractory hypotension, haemodynamics optimisation, source control, and surgical debridement.
Ceftriaxone + clindamycin (switches of toxin production at ribosome)
IVIg can neutralise circulating toxin
1-2wks post infection -> desquamting palms
TOXIC SHOCK SYNDROME - staph A and gp A strep
Massive fluid resus is often needed because of the diffuse capillary leak phenomenon and the refractory hypotension.
Although varicella infection is often a self-limited infection in children, it can be associated with serious life-threatening infections in both immunocompetent and immunocompromised patients.
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A 35-year-old woman is admitted to hospital because of pain and swelling of the right thigh. The patient has been in excellent health until the morning before admission, when she observed a pimple on her right thigh. During the course of the day, the lesion enlarged, with increasing pain, swelling, and erythema, and was accompanied by nausea, vomiting, and delirium. Her temperature is 37.5°C (99.5°F), pulse is 128 bpm, and respirations are 20 breaths/minute. BP is 85/60 mmHg. On physical examination, the patient appears ill and in pain. A small, indurated area of skin breakdown with surrounding erythema and warmth is present on the right thigh; no fluctuance is detected. She is unable to flex or extend the right hip because of pain and reports pain on passive extension of the right ankle. The temperature soon rises to 38.4°C (101°F), and the BP drops to 70/40 mmHg.
Severe subcut infection often involving skin to muscle/fascia caused by staph a or group A strep ± anaerobic organism Surgical emergency.
PC: Severe pain, lots of oedema, necrotic tissue,
Mx Surgical debridement and intervention, IV abx , IVIg may be given.
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Describe features of febrile convulsions
- Occur typically 6months-5years
- Seen in 3%
- Happen early on in the viral infection when the fever rises rapidly
- most commonly tonic clonic
- Put children i recovery position and call 999 after 5 min
- complex febrile seizures slightly increase the risk of epilepsy
- 1 in 3 risk of happening again
- Admit after 1st seizure to do a work up or admit if its a complex seizure (15+, focal, etc)
105
When is intussception most likely to present?
More common 3-12 months
| XR is unlikely to show gas cysts and more likely to show obstruction.
106
DDH screening programme? (and inlcude Mx while you're here)
ALL: infants checked at newborn check and at the 6 week baby check using Barlow and Ortolani
Routine USS at 6 weeks if
1) BREECH at or after 36 wks (regardless of birth),
2) 1st degree FHx of hip problems in early life,
3) multiple pregnancy
Mx: Most will resolve by 3-6wks. Pavlik in children younger than 405 months, older requires surgery
For risk factors - remember the girl in clinic (female sex, oldest child in family etc.)
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Jennifer, an 11-year-old girl, is brought to the Emergency Department after collapsing at school. Her teacher described her standing in assembly, becoming pale and collapsing to the floor. She had a couple of jerking movements of her limbs lasting a few seconds. She returned to normal promptly. Jennifer says that she had not eaten breakfast that morning, and experienced a sensation of feeling hot, a black curtain coming in front of her eyes, sounds becoming distant and feeling dizzy. The school nurse did a blood glucose, which indicated a glucose level of 3.5 mmol/L (within the normal range). She has had two episodes similar to this in the past but has not presented to hospital before. She has no other medical problems.
Syncope
Syncope is often caused by prolonged standing or a prolonged fast. There are often pre-syncopal symptoms, including feeling hot, dizzy and/or visual disturbance. Syncope can lead to jerking movement (clonic movements), which can be mistaken for a seizure.
Blood glucose is normal so this isn't hypoglycaemia.
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Losing consciousness because of cardiac artyhmia vs seizures
Warning signs for a cardiac arrhythmia include collapse during exercise, early pallor and a family history of sudden premature death in otherwise fit and healthy relatives. Some types of cardiac arrhythmia (e.g. ventricular tachycardia) have abnormalities present on the ECG e.g long QT, and are provoked by a shock (e.g. diving into a swimming pool). Sometimes there is a structural heart problem (e.g. hypertrophic obstructive cardiomyopathy) that results in ECG changes.
109
Dora is an 8-year-old girl who attends the outpatient department. Her mother is worried because she used to be top of the class, but is not doing as well at school this year. Whilst in clinic, you notice that Dora has an episode where she suddenly stops what she is doing, stares ahead whilst flickering her eyelids for a couple of seconds and then resumes her previous activity as if nothing had happened. You ask her to blow out an imaginary candle, and the same thing happens again. She is growing normally and is otherwise fit and well.
Often affected children do not do well at school because of transient loss of consciousness, which impedes learning. They are often described as day-dreamers by their teachers. Absence seizures can be reproduced in the clinical setting by asking the child to hyperventilate for 2 minutes. Asking the child to blow on a toy windmill and keep it spinning quickly or blow out an imaginary candle is helpful (as well as fun).
110
Childhood Rolandic epilepsy
Childhood Rolandic epilepsy (benign epilepsy with centro-temporal spikes)
This classically presents between the age of 4–10 years, with tonic–clonic seizures in sleep or simple partial seizures, with abnormal feelings in the tongue and distortion of the face. It is also known as benign childhood epilepsy with centro-temporal spikes due to the EEG, which shows focal sharp waves from the Rolandic i.e. centro-temporal area.
Treatment is NOT usually given for childhood rolandic epilepsy
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Juvenile myoclonic epilepsy
Myoclonic jerks are worse in the morning, especially if the child is sleep deprived. These children may also have generalised tonic–clonic seizures and absences.
"Jude is a 14-year-old boy who is on treatment for generalised tonic–clonic and absence seizures. He attends a routine clinic appointment complaining of regularly spilling his tea in the morning because his arm jerks involuntarily. These jerks are worse if he has stayed up late the night before. He is doing relatively well at school."
112
Lennox–Gastaut syndrome
Lennox-Gastaut syndrome (LGS) is a severe form of epilepsy that typically becomes apparent during infancy or early childhood. Affected children experience several different types of seizures most commonly atonic, tonic and atypical absence seizures.
These children often have complex neurological problems and their prognosis is, sadly, very poor. It affects 4% of children with epilepsy and is more common in boys than girls.
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Gower sign
Normal until 3 years of age
Gowers' sign is classically seen in Duchenne muscular dystrophy where it is mostly evident at 4–6 years, but also presents itself in centronuclear myopathy, myotonic dystrophy and various other conditions associated with proximal muscle weakness, including Becker muscular dystrophy, dermatomyositis and Pompe disease.
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Sayeed is an 8-year-old Pakistani boy who has developed muscle weakness. His mother reports that he has poor coordination at home and at school. His speech has also recently become slurred. His problems have come on slowly over the last 12–18 months. He has no other medical history and is not taking any medications. On examination you notice that he has wasting of his calves.
Trinucleotide repeat disorder mutation in FXN gene
PC: Worsening ataxia
Romberg's sign positive.
115
Jane is an 11-year-old girl who presents to the outpatient department. She complains that she finds it difficult to play sports such as basketball. In particular, she finds it difficult to run and coordinate her arm movements. She was born at 32 weeks’ gestation and discharged from the neonatal service at 2 years of age as her development was normal. Her neurological examination appears to be normal except when you are examining her gait. On heel walking her left arm moves into a flexed position.
Subtle asymmetries in gait may be revealed by Fogs’ test – children are asked to walk on their heels, the outside of their feet and then the inside of their feet. Watch for the pattern of abnormal movement in the upper limbs. Observe them running. This girl probably has subtle cerebral palsy, which may be related to her premature birth.
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Ribbon Stool
Anal Stenosis
117
James, aged 11 years, has type 1 diabetes mellitus. While playing football during the mid-morning break at a holiday camp, he suddenly feels faint. His classmates call the supervisor who finds him lying unresponsive in the playground.
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What should be his immediate management?
A) Call Ambulance
B) Check blood glucose
C) Give glucose drink
D) Give buccal gel
E) Give insulin
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Buccal gel as if James recovers ambulance wont be needed.
118
T1DM Annual screens
o Diabetic retinopathy, nephropathy and hypertension – monitor annually from 12 years (BP measurement)
o Thyroid disease - annual screens
o Coeliac - screen at diagnosis and again after 3 years or if weight gain is poor
o Delayed puberty onset
(GH, oestrogen and testosterone antagonise insulin action and therefore there is a requirement of 0.5 - 1.0 U/kg per day up to 2.0/kg/d.
Psychological changes accompanying puberty may make this a time of rebellion and decrease adherence to insulin therapy_
119
Mohammed, a 12-year-old boy with type 1 diabetes mellitus, is reviewed in the outpatient clinic. In spite of maintaining good control of his diabetes, his height has remained static for 9 months. He says his appetite is alright, but he has lost interest in football, which is his passion, as he says he can't keep up with the other boys any more. He just stays at home and watches TV, but wants to be out playing football and getting back his energy. A full blood count and C-reactive protein are normal and his HbA1C is satisfactory.
Hypothyroidism can cause short stature because thyroid hormone mediates growth and development of skeleton through its direct effects, as well as through permissive effects on growth hormone.
DDx:
Depression - but he wants to be out playing / wouldn't explain short stature
Crohn's is ruled out by normal CRP
GH deficiency - wouldn't explain him not being able to keep up with other boys
Anorexia - less likely.
120
CAH crisis mx short term and long term
Short term:
saline bolus, nebulised salbutamol, calcium gluconate and hydrocortisone, glucose
discharged home with hydrocortisone, fludrocortisone and sodium chloride.
The dose of glucocorticoid needs to be increased at times of illness.
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Which kids are at risk of Cushing's?
Those receiving exogenous steroids (ACTH tumour are very rare in kids)
Children requiring high dose oral corticosteroid therapy, e.g. for Crohn’s disease/UC or nephrotic syndrome, may develop the features of Cushing syndrome. Minimized by decreasing the dose as soon as possible.
Eczema, long term inhaled steroids are not sufficient enough to cause Cushing's.
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Addisons biochemical features
Hyperkalaemia Hyponatrameia
LOW Cortisol
High ACTH
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CAH presentations
1. Classical CAH: salt-waster
Most severe form of the disease
Approximately 75% of classical cases
May present with ambiguous genitalia in females
Characterised by glucocorticoid and mineralocorticoid deficiency, leading to life-threatening adrenal crises and salt-wasting crises with vomiting and dehydration occurring early in infant life.
2. Classical CAH: simple viriliser
Enzyme defect is moderate
Approximately 25% of classical cases
Retain ability to conserve salt.
3. Non-classical CAH
Mild to moderate enzyme deficiency
Present postnatally with signs of hyperandrogenism
Females do not have virilised genitalia at birth
May present in a child as precocious development of axillary hair or odour, pubic hair, acne, or tall stature with an advanced bone age that may eventually result in short stature
Adolescent and adult females may also present with oligomenorrhoea, amenorrhoea, polycystic ovaries, acne, hirsutism, alopecia, and impaired fertility.
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CAH investigations
In CAH Due to 21ohdeficency
17-hydroxyprogesterone is raised (as is precursor)
11 deoxycortisol is raised
Hyperkal hyponatraemia, met acidosis
Rapid ACTH test
An IV injection of 250 micrograms of ACTH is given. 17-hydroxyprogesterone levels are measured at baseline and then 60 minutes later. Should remain high in CAH. (because it can't go downstream as it would in normal people)
NB In addison's, they wouldn't have high 17hydroxy after ACTH stimulation they would just have low/absent coritsol. Also addisons would present with muscle weakness/fatigue
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Causes of disorders of sexual differentiation
What can DSD be secondary to?
(APPEARS MALE) Excessive androgens producing virilisation in a female (commonest cause is CAH)
(APPEARS FEMALE) Inadequate androgen action producing under virilisation in a male, can be due to:
- Not having the receptor for androgens (androgen insensitivity syndrome, can be partial or complete) (increased risk of testicular cancer - house episode)
- Unable to produce the DHT (imperative for sexual differentiation) (due to 5alpha-reductase deficiency) (5areductase converts the less potent testosterone to DHT- dihydrotestosterone)
- Abnormal synthesis of androgen from cholesterol
Gonadotropin insufficiency (PW Syndrome or congenital hypopituitarism, resulting in small penis and cryptorchidism)
Previously known as true hermaphroditism, but now as ovo-testicular disorder of sex developement, the fetus has XX and XY containg cells leading to both testicular and ovarian tissue.
126
Sophie, a 9-year-old girl with type 1 diabetes mellitus, develops a fever along with vomiting and diarrhoea. After 2 days her mother takes her to the local paediatric assessment unit as she continues to vomit. On examination her temperature is 37.5° C. She is able to talk to her mother. She has clinical dehydration. Her pulses, capillary refill time and blood pressure are normal. Her blood glucose is 16 mmol/L.
IV saline infusion is still needed here despite not being in shock.
127
Causes of erythema nodosum + Arthralgia
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Strep pneumococcus
Primary tuberculosis
IBD
Drug reaction
Idiopathic
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128
Steven Johnson Syndrome
This boy has Stevens–Johnson syndrome, which is a severe bullous form of erythema multiforme. Its relative frequency in children treated with co-trimoxazole has led to this antibiotic rarely being used. It is still helpful for the treatment or prevention of Pneumocystis jirovecii (carinii) in children with immunosuppression. The eye involvement may include conjunctivitis, corneal ulceration and uveitis, and ophthalmological assessment is required. It may also be caused by sensitivity to other drugs or infection, with morbidity and sometimes even mortality from infection, toxaemia or renal damage.
129
Atopic Keratoconjunctivitis
Atopic keratoconjunctivitis is a chronic (long-term) allergic condition of the eyelids and front surface of the eye. It is present in a high percentage of patients who have the skin condition, atopic dermatitis.
It is a chronic, bilateral disease that relapses and remits with little to no seasonal correlation (as opposed to vernal keratoconjunctivitis).
Both eyes are red and the conjunctiva have a yellow lining.
130
Langerhan cell histiocytosis
Langerhans cell histiocytosis is a disorder in which excess immune system cells called Langerhans cells build up in the body.
It is a disorder that primarily affects children, but is also found in adults of all ages.
Most common lesion in the first few months of life is a papulosquamous rash that affects the scalp.
Can also cause symptoms of diabetes e.g. polyuria/polydip
131
Candida napkin rash vs irritant dermatitis (+Mx)
Candida napkin rash - In this condition the flexures are involved and there are satellite lesions (isolated erythematous lesions away from the main rash area)
Mx: Clotrimoxazole cream.
Irritant napkin rash - flexures spared! 'scalded' appearance
Mx: mild, topical corticosteroids if severe (1% hydrocortisone cream
132
Infantile Seb Dermatitis (+Mx)
A condition that usually arises in the first 2 months of life with unknown cause, commonly referred to as cradle cap. Children develop an erythematous scaly eruption, which forms a thick yellow adherent layer.
Softening the scales with baby oil first, followed by gentle brushing, then washing off with baby shampoo
Soaking the crusts overnight with white petroleum jelly or slightly warmed vegetable/olive oil, and shampooing in the morning
Emulsifying ointment can be used if these measures don’t work
Medical - clotrimoxazole if severe
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Most common type of psoriasis in kids?
| (+ Risk factors
Well demarcated, erythematous, silver scaled plaque (raised skin) usually on trunk or upper limbs. There are different types e.g. guttate, plaque, erythematous etc. but guttate is most common in kids.
Rf: FHx, for children post-infection psoriasis can occur (post strep/viral/ear infection!! Vert common post infec)
Usually resolves in 2-3 months and can re-occur in next 3-5 years.
Guttate: Reassure that it is usually a self-limiting condition that typically resolves within 3–4 months of onset, and reassure that it is not infectious.
Guttate: Coal tar preparations are useful for plaque psoriasis in > 6 yrs. Dithranol preparations are very effective in resistant plaque psoriasis. Calcipotriol, a vitamin D analogue, is useful for plaque psoriasis in > 6 yrs
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Oval, scaly macule
Pityriasis Rosea
This acute, benign self-limiting condition is thought to be of viral origin.
Begins with a single round or oval scaly macule, the herald patch, 2–5 cm in diameter, on the trunk, upper arm, neck or thigh.
After a few days, numerous smaller dull pink macules develop on the trunk, upper arms and thighs. The rash tends to follow the line of the ribs posteriorly, described as the ‘fir tree pattern’. Sometimes the lesions CAN BE ITCHY.
Resolves 4-6 weeks, no treatment required
135
Viral dermatological conditions
1. Molluscum Contagiosum. Pox virus. Dome shaped papules with central indentations ‘belly button’ anywhere on body except palm + soles. Self limiting - but can persist for 2 years.
2. HSE - golden lesions but with SATELLITE lesions (unlike impetigo) and slightly more scaley. IV Aciclovir 2-3wks.
3. Viral warts - Firm, rough nodule which is often keratinised. They disrupt natural skin lines. HPV Type 1. Resolves in 2 years, cryo if not.
4. Pityariasis Rosea - thought ot be of viral origin.
136
Impetigo Mx
Localised Infection = topical fusidic acid (3-4/day for 7 days)
Extensive Infection = oral flucloxacillin (4/day for 7 days)
Bullous Infection = oral flucloxacillin or clarithromycin/erythromycin
137
Mikey is a 2-year-old boy who has eczema. He comes to his family doctor with his mother, as his eczema has become troublesome over the last few weeks. His mother had been using emollients twice a day, but for the last few months during the summer she stopped as she did not think his eczema had been sufficiently bad. Today he has erythematous, weeping areas of skin in the flexor surfaces of his knees and ankles. There are also some areas of yellow crusting and he is pyrexial.
What is most likely to have caused his eczema to flare-up?
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The yellow crusting and pyrexia are suggestive of infection with Staphylococcus, therefore a bacterial cause for the exacerbation.
Other causes of flares:
• ingestion of an allergen, e.g. egg
• contact with an irritant or allergen
• environment: heat, humidity
• change or reduction in medication
• psychological stress.
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NB This is not herpes simplex because it isn't vesicular.
138
Acne escalation Mx
1. Topical Benzoyl peroxide
2. Topical benzoyl peroxide and oral tetracycline
Refractory: Oral retinoid isotretinoin
139
Kerion
Is another name for tinea capitis (scalp ringworm). Topical treatment is usually tried first but oral antifungals may be required for very severe cases
e.g. griseofulvin or terbinafine)
Pets who are infected need treatment too.
140
Causes of erythema mulitforme (Google image it)
Although amoxicillin can cause this rash, it can be due to herpes simplex virus or idiopathic or Mycoplasma pneumoniae infection.
141
Most common cause of UTI causing renal stones
Proteus sp
142
Freddie is a 3-year-old boy. He is referred to the hospital as his mother has noticed that his face is swollen (Fig. 19.1). His mother was concerned that he had an allergic reaction to some peanuts he ate at a party. Examination reveals abdominal distension, bilateral scrotal swelling and pitting oedema of his lower limbs. Urine dipstick had 4+ protein, 2+ blood and nitrite and leucocyte negative. His blood pressure is normal for his age. You perform renal function tests, which reveal normal levels of sodium, potassium, urea, and creatinine. His complement levels (C3 and C4) are normal.
What is the most likely diagnosis? and treatment?
Nephrotic Syndrome - treat with oral prednisolone
Anaphylaxis would cause angioedema
143
Finlay, a 5-year-old boy, recently had a birthday party at his local farm. Since then he has had 3 days of diarrhoea. The loose stool had some blood in it. His mother is concerned as he is still not himself. He appears to be very pale and has not passed urine for 12 hours. He has no other medical problems and is not normally on any medication. On examination you note that he has pale conjunctivae. His blood pressure is 120/70 mmHg. You decide to take some blood tests and get the following results:
* haemoglobin: 76 g/L; white blood cells: 14.2 × 109/L; platelet count: 50 × 109/L
* creatinine: 200 µmol/L (normal: 20–80 µmol/L)
* prothrombin time: 13 seconds (control: 12–15 s)
* activated partial thromboplastin time: 34 seconds (control: 25–35 s)
What is the most likely diagnosis?
This is a characteristic presentation with the triad of acute renal failure, microangiopathic haemolytic anaemia and thrombocytopenia. Typical haemolytic-uraemic syndrome is secondary to gastrointestinal infection with verocytotoxin-producing Escherichia coli O157:H7 acquired through contact with farm animals or eating uncooked beef, or, less often, Shigella.
Treat with IV Fluids. If atypical HUS you can give PEX or ecluzimab
144
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A 3-year-old boy attends the Paediatric A+E Department because he has developed an itchy rash whilst at a birthday party. Of the following features, which requires immediate treatment with 0.01 ml/kg of 1:1000 adrenaline i.m.?
a.
Blood pressure of 88/50
b.
Generalised urticaria
c.
Lip swelling
d.
Respiratory rate of 22/minute
e.
Wheeze on auscultation
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E - Wheeze on auscultation
145
A 3-year-old boy has just started fitting in A+E. You are the F1 doctor. The nurses are all busy with other children. Of the following actions which should you do first?:
GIVE HIM HIGH FLOW OXYGEN
| before measuring blood glucose/giving oral midaz etc
146
A 15-month-old girl presents with a 3-day history of intermittent fevers and vomiting and poor feeding. On examination her temperature is 38.6 C but there are no localising signs. What is the most likely cause?
UTI
147
An eight year old boy presents with nocturnal cough and early morning tiredness. He has a past history of serous otitis media. On examination, he has noisy breathing, is overweight and is inattentive during consultation. What is the most likely diagnosis? Ix and Mx?
OSA
all children should be screened for snoring;
gold standard being polysomnography;
adenotonsillectomy is the first line of treatment for most children, and CPAP is an option for those who are not candidates for surgery or do not respond to surgery;
148
A term baby is born normally at 38 weeks gestation at 2.3 kg. Labour was difficult with prolonged rupture of membranes. At 35 minutes of age the infant was noted to have an increasing oxygen requirement with grunting and respiratory distress. On examination he was floppy with an oxygen saturation of 95% in 2L/min of oxygen. A CXR showed reticulonodular shadowing. What is the most likely diagnosis?
Bacterial Pneumonia
149
A 5-year-old girl who never received MMR was exposed to chicken pox last week at school. She now presents with a 12 hour history of rash and abdominal pain and is reluctant to walk. On examination, she is unwell with cold hands and feet, and a widespread blanching maculopapular rash with spots of different sizes sparing the head and neck. What is the most likely diagnosis?
Meningococcal sepsis
150
A 3-year-old child presents with acute onset abdominal pain for 4 hours. She has had 3 similar episodes in the past, which were all self-resolving. This time the vomiting is bile-stained. What is the most likely cause?
Malrotation
151
A 15-month-old Muslim girl is not meeting her gross motor developmental milestones and is generally very irritable. She was growing on the 50th centile, but is now on the 25th. She has 2-hourly breast feeds and consumes minimal solids with no additional dairy products. What is the most likely diagnosis?
Nutritional rickets
152
Congenital hypohtyroidism typical case
A 7-month-old girl adopted from an orphanage in Nepal is below 0.4th centile for length and weight. The birth history was apparently normal, apart from prolonged jaundice postnatally. She is not yet sitting. On examination she is hypotonic and flaccid. The lower limb reflexes are hard to elicit.
153
Which of these require prompt surgical referral?
a. A right testis which can be manipulated to the base of the scrotal sac
b. An acute episode of balanitis
c An irreducible firm lump which extends from the inguinal canal to the scrotum
d. Bilateral nontender scrotal swellings which transilluminate
e. Glandular hypospadias
C
154
A 10-month-old girl has grown along the 50th centile for weight until around 6 months but is now on the 25th centile. The mother has noticed a distended abdomen and says her stools are more frequent and bulky. What is the most likely underlying condition?
Coeliac
155
Two infants are born at 36 weeks’ gestation. One infant weighs 2600g at birth and an unrelated second infant weighs 1600g. Which of the following conditions is the second baby more likely to have?
a.
Congenital malformations
b.
Hyperglycaemia
c.
Low haematocrit
d.
Occipito-frontal (head) circumference that is small compared to body weight
e.
Surfactant deficiency
a - congenita l malformation
156
A 2 year old presents with frank haematuria, some abdominal pain and rigors. Which investigation is most likely to reveal the underlying diagnosis?
Urine mc&S
157
Functional Dyspepsia vs RAP
FD- non-ulcer dyspepsia, issues with functioning of GI tract, belching, cramping etc. Normal GI tract refractory to PPI treatment.
RAP - Recurrent abdominal pain (RAP) in children is defined as at least three episodes of pain that occur over at least three months and affect the child's ability to perform normal activities.
158
Toddler's Diarrhoea causes and differentials
Foods which are high in fibre or
sugar, and drinking plenty of fluid can lead to
toddler diarrhoea. A low fat diet can also
contribute to it.
Chronic diarrhoea Distinguish between faecal overflow (due to constipation) and true diarrhoea by abdominal and rectal examination.
If growth is normal, toddler diarrhoea or post-gastroenteritis food intolerance are most likely. If growth is faltering, consider malabsorption. Inflammatory bowel disease is rare
The most common cause of acute diarrhoea is gastroenteritis, which may be accompanied by fever. In the UK, most gastroenteritis is viral, mostly rotavirus and mostly in infants and toddlers.
Bloody diarrhoea suggests a bacterial infection (most commonly Campylobacter or E coli); a surgical cause (for example intussusception) in a young child; or the onset of inflammatory bowel disease in an older child. All such children should be referred to hospital urgently.
Certain strains of E coli can cause haemolytic uraemic syndrome, which can lead to renal failure and coagulopathy. 'Redcurrant jelly' stools, abdominal distension and bilious vomiting suggest intussusception, usually in children aged three months to three years.
