4B Paediatrics Flashcards
Kawasaki disease
- Symptoms?
- Treatment?
- Complication?
‘CRASH + burn’
CONJUNCTIVITIS (bilat, non-exudative)
RASH
ADENOPATHY (lymph, cervical, painless)
STRAWBERRY TONGUE (+- red lips/oral mucosa)
HAND swelling / redness / desquamation.
BURN - fever >5 days (does not respond to antipyretics)
Treatment
- High dose aspirin
- IVIg
Complication
- Coronary artery aneurysm (screen with ECHO)
How is the presentation of Kawasaki disease and scarlet fever
- Similar
- Different
Similar: both present with
- Fever
- Adenopathy (swollen lymph glands)
- Strawberry tongue
- Rash
- Desquamation
Different: see image
(Pastia lines: bright red discolouration in creases eg. elbow, groin)
+ Kawasaki has conjunctivitis
+ Scarlet fever has sore throat
+ Kawasaki most common 0-5y, Scarlet fever 2-8y.
Scarlet fever management:
- Management
oral penicillin V for 10 days / azithromycin if pen allergic
BRONCHIOLITIS
1. Causative organism
2. Treatment?
3. Hospital admission criteria
- RSV - respiratory syncytial virus (80% - other mycoplasma, adenovirus)
Age: <1yo, peak 3-6m.
History: runny nose, dry cough turned to wheeze (URT → LRT), fever. breathless, feeding difficulties.
- Management - supportive only eg. oxygen, IV fluids, NGT feeds.
New - vaccine for pregnant women.
Cactus babies - hands off! - Hospital admission - if feeding <50% normal amount or SATS < 90%, or else discharge w/ safety netting (come back if colour change, not weeing, very sleepy, less than 50% milk) and 48hr open access.
CROUP
1. Causative organism?
2. Treatment?
3. Sign on CXR
- Parainfluenza virus
- Steroids
- Steeple sign (AP CXR)
Picture shoes tracheal tug
Avoid upsetting child
* Responsive to steroids
(PO dexamethasone/prednisolone or NEB budesonide) Dexamethsone 0.6mg/kg.
* Adrenaline if severe upper airway obstruction
(NEB 5ml 1:1000 adrenaline i inflamed airway in 20 mins
ACUTE EPIGLOTTITIS
1. Causative organism?
2. Treatment?
3. Vaccines what age?
4. Symptoms
5. Sign on CXR
- Haemophilus influenzae type B bacteria (Hib)
- Intubation if needed, IV antibiotics.
AVOID EXAMINATION. - Hib vaccine at 8w, 12w, 16w and 1y.
- ‘3 D’s - dysphagia, drooling, distress’ + tripoding
Neutrophilia - Thumb sign swelling of the epiglottis (lateral CXR)
WHOOPING COUGH
1. Causative organism
2. Treatment?
- Gram-negative bacterium Bordetella pertussis
- Azithromycin (if presenting < 21 days)
ROSEOLA INFANTUM
1. Causative organism
2. Symptoms?
- Herpes 6
- Rash (starts on trunk), seizure, high fever.
‘Rosie’ (roseola) hid ‘her 6 peas’ (herpes 6) in the ‘trunk’(rash starts on trunk) before anyone could ‘see her’ (seizure)
Causes of short stature?
Malnutrition
Turner’s (females). Increased carrying angle. Treatment with oestrogen to allow puberty.
Congenital hypothyroidism (cretinism) → low T4, high TSH. Failure to thrive. Thyroid scan, neonatal screening (heel prick test). Thyroxine. Irreversible cognitive impairment if not treated.
Juvenile hypothyroidism (autoimmune) short height, early menarche, weight gain, tired, cold, lethargy, low T4, high TSH.
Growth hormone deficiency. - tumour, congenital.
Familial short stature (short parents, not. problem).No treatment.
Cushing’s syndrome - rare in childhood. Excess steroid, obesity.
Prader-Willi syndrome. Hypotonia, floppy, not feed well as babies, then as toddler insatiable apetite. Learning disability. Genetic cause.
Info you want
- Preceding growth
- weight
- mid-parental height
- Bone age (X-ray of left hand and wrist) - look how open growth plates are, how many bones can you see. Plotted with triangle.
Causes of tall stature?
Info you want
- Preceding growth
- weight
- mid-parental height
- Bone age (X-ray of left hand and wrist) - look how open growth plates are, how many bones can you see. Plotted with triangle.
Obesity (high weight drives height - growth factors)
Precocious puberty
Congenital adrenal hyperplasia (pubic hair in 18 month old) - excess testosterone. Needs hydrocortisone, fludrocortisone, sodium chloride.
Newborn physical examination
- 4 main things to check?
Video : https://youtu.be/mvVgVlpdtbA?si=s9ZMTag0SCaPoRuj
Ask family hx of eye, heart or hip disease.
Do after 4 hours to allow for changes.
Babies with one problem often have something else too.
- Eyes (physiological squint - normal - eyepatch. Cataracts, retinoblastoma - white reflex/asymmetrical) Ophthalmoscope, check movement and red reflexes. 2-3/10,000 babies. DO FIRST while baby is happy.
- Heart - congenital cardiac disease (weak femoral pulses→ co-arctation of aorta, auscultate heart, o2 SATS. 1/200 babies.
- Hips (DDH - USS if concerned) 1-2/1000.
Risk factors - female, breech.
Symmetry, groin skin folds, abduction, rotation. Barlow (dislocate) and ortolani (relocate) tests.
Pavlov harness.. - Testes in boys (undescended testicle). Feel for both at the same time - check groin and inguinal canal -milk down Bilateral - concerning - USS/bloods.
Other
- pre-auricular skin tags
- milia
- congenital dermal melanocytosis (Mongolian blue spot / slate grey nevus) important to document - looks like bruise
- strawberry haemangioma - propranolol / timolol eye drops / laser therapy.
- Erythema toxic
- Imperforate anus (can accompany other problems)
-Cleft palate / lip
- hands, feet, spine, anus, face.
- Head: fontanelles
- Tone and reflexes
Prematurity
Extremely pre-term <? weeks
Very pre-term ?-?
Moderate to late pre-term ?-?
Neonate - 1st ? days.
Low birth weight <?kg
VLBW <?kg
Extremely LBW <?kg
Extremely pre-term <28 weeks
Very pre-term 28-32
Moderate to late pre-term 32-36
Neonate - 1st 28 days.
Low birth weight <2.5
VLBW <1.5kg
Extremely LBW <1kg.
< 28 weeks - 80% survival - high respiratory support, high risk of infection, no suck reflex, umbilical lines instead of cannulas.
28-32 weeks - 96% survival, incubator, NG tube. o2.
Resuscitation : system support.
- Respiratory support (surfactant, ventilation)
- Temperature control (incubator, plastic bag)
- Blood glucose
- Fluids, nutrition.
Respiratory Distress Syndrome
- signs on xray?
- Treatment?
Lack of surfactant
Structural immaturity
Prematurity - surfactant produced at 30/32 w.
Alveolar collapse, reduced compliance, increased dead space, inflammation.
Signs on X-ray
- Ground glass
- Air bronchograms
- Under aerated / low lung volume
Treatment
- Surfactant
IVH - intraventricular haemorrhage
- what is neuroprotective?
Retinopathy of prematurity
- Cause?
Magnesium given at least 4 hours before birth. Reduced rate of CP.
IVH grade I-IV.
Can lead to cyst - buildup of CSF due to blockage. Shunt.
ROP cause
- too much oxygen - increased vascularisation of retina.Aim sats 90-95%.
Developmental milestones
- What are the 4 domains?
- Give examples for each.
Gross motor
- Jumping, stand on one leg, hopping
Fine motor and vision
- Turning pages of a book, build tower of blocks, drawing, needle and thread.
Speech, language and hearing
- Sounds ‘Da’ ‘Ah’
- Words - single, two word sentences etc.
Social, emotional and behavioural
- smiling, eye contact
Foetal circulation changes
- What are the 3 shunts?
- Do prostaglandins vasodilate or vasoconstrict?
- Ductus venosus - bypasses the liver (umbilical vein / hepatic portal vein → vena cava)
Birth → in the days following birth progressive vasoconstriction of DV occurs and blood is diverted through the liver. - Foramen ovale - bypasses the lungs (right atrium → left atrium) high vascular resistance in non-functioning lungs allows this.
Birth → increased pressure in left atrium and decreased pressure in right atrium closes FO. - Ductus arteriosus - secondary right to left bypass to avoid circulation to non-functioning lungs. (pulmonary artery → aorta arch) caused by high pressure in pulmonary circuit. ‘Vasoactive - held in a state of vasodilation and mediated by prostaglandins)
Birth → increased pulmonary vascular resistance and decreased systemic vascular resistance → less blood flows through DA - > muscular wall constricts and it closes.
NB. At birth, removal of the placenta increases systemic vascular resistance, whereas lung expansion decreases pulmonary vascular resistance. (pulmonary hypoxic vasoconstriction ceases)
Prostaglandins VASODILATE.
What are some red flags for developmental milestones?
eg. not smiling by __ weeks
Not sitting by ___ months
Not smiling by 8 weeks
Not sitting by 9/10 months
Leading causes of Jaundice in…
1. First 24 hours
2. 2-14 days
3. > 2 weeks
- Haemolysis (Rh), Sepsis
- Usually physiological (not worrying), breast milk jaundice
- Biliary atresia
What are some signs of increased work of breathing?
NB. Tug happens last - bad sign esp in older children
Red flags in resp exam?
Causes of decreased consciousness?
Seizures - management. Steps 1 and 2?
IV Lorazepam (IV/IO) 0.1mg/kg(max 4mg)
OR
Buccal Midazolam
OR
Rectal diazepam
Seizure management. Step 3 onward?
Differences between simple and complex febrile convulsion?
Simple - GTCS.→ generalised tonic clonic seizure
NB Risk of further FC is 30%. higher if earlier age of onset, family history, lower provoking temp.
Risk of epilepsy 1% if no risk factors, 2% if one risk factor, 10% if 2 risk factors (abnormal neurology, faulty hx of afebrile seizures, complex febrile seizures).
What is reflex anoxic seizure?
How quick recovery?
Treatment?
Sudden unexpected shock/pain
Cardiac phenomenon causing hypoxia
Pallor
Quick recovery
No treatment needed
Headache reg flags?
Balance issues
Headache won’t go
Vision changes - children DON’T get double vision normally → brain tumour
Website - https://www.thebraintumourcharity.org
Symptoms of meningitis?
Diagnosis?
Treatment?
Diagnosis
- Clinical presentation
- Lumbar puncture (CSF microscopy/culture, blood cultures)
- PCR (CSF and blood)
Treatment
- IV Cefotaxime (neonates)
or Chloramphenicol for 7 days
(Do not use Chloramphenicol
for premature babies, neonates and young children up to age 2 due to “Gray Baby
syndrome”)
Spotting the sick child (SSC) 3 minute toolkit
- what steps does this involve?
A - Airway - Is it obstructed?
* eg secretions, foreign body, stridor
B - Breathing - Is the child struggling to breathe?
* Assess respiratory rate, look for recession/accessory muscle use, check oxygen saturation, auscultate the chest
C - Circulation - Is there evidence of poor circulation?
* Assess colour skin, heart rate, capillary refill time (on sternum and fingers/toes), blood pressure, warm or cold hands/feet?
D - Disability - What is the child’s neurological state?
* Assess pupil response to light, limb tone and movement, AVPU score/GCS.
* Temperature
* Glucose
E - Exposure - Have you exposed the child and examined top-to-toe?
* Rashes - viral rash, infectious disease rash, non-blanching rash (septicaemia?)
* Any evidence of injury/trauma
* Bruises - Always think Non-accidental injury in the non-mobile child
* Use any safeguarding skills you have learnt on accredited courses in child protection to identify any marks on the skin, or how a child is kept, or their interaction with the parent(s)/guardian(s).
ENT - Ears, Nose and Throat
T - Temperature - Use a tympanic or axillary thermometer.
* You may require a rectal thermometer in the very unwell child
T - Tummy - Is this soft? Distended? Tender? What are the bowel sounds like? Any masses? Any hernias?
* In boys, never forget to examine the testis (testicular torsion = surgical emergency)
* Urinalysis
DEF G - Don’t Ever Forget Glucose!
What are these genetic conditions?
1. (45,X)
2. (47,XXY)
3. Trisomy 21 (47,XX+21 or 47,XY+21)
4. Trisomy 13
5. Trisomy 18
- Turner syndrome
- Kleinfelter syndrome
- Down’s syndrome
- Pateau syndrome (fatal)
- Edwards’ syndrome (fatal)
Aneuploidy refers to an abnormal chromosome number. Aneuploidies are relatively common at conception, but the great majority of affected conceptuses are lost in early pregnancy. Sex chromosome aneuploidies such as Turner (45,X), or Klinefelter (47,XXY) Syndromes are compatible with life and may only be recognised due to growth or fertility problems.
Autosomal trisomies are incompatible with life in most cases. Trisomy 21 (47,XX+21 or 47,XY+21) - Down Syndrome - is the exception. Infants with Pateau Syndrome (Trisomy 13) or Edwards’ Syndrome (Trisomy 18) may be born alive but survival beyond infancy is exceptional.
- What is genetic anticipation?
- Give two examples of disease what experience anticipation?
- Worsening severity, and earlier age of onset with successive generations.
- Anticipation - the tendency of a disease to become worse with each generation - is a characteristic of trinucleotide (or triplet) repeat disorders such as Fragile X or Huntington’s Disease.
What is the genetic inheritance of the following conditions?
1. Marfan syndrome
2. Cystic fibrosis
3. Haemophilia A (deficiency factor VIII) and B (deficiency factor IX)
4. Duschene muscular dystrophy
5. Red/green colour blindness
6. Hypertrophic cardiomyopathy (HOCM)
- Autosomal dominant (50% chance child will inherit the disease)
- Autosomal recessive (depends on partner - if both are carriers Ff Ff- children have 25% chance getting disease ff, 50% carriers Ff, 25% unaffected FF. If affected parent with carrier ff Ff - 50% affected ff, 50% carriers Ff).
- X linked recessive. Much more common in males. No male to male transmission. Women are carriers and can have carrier daughters or affected sons.
- X linked recessive.
- X linked recessive.
- Autosomal dominant - causes sudden death in young people
Drawing a family pedigree
1. What symbol for unknown sex?
2. Miscarriage?
- Unknown sex - diamond
- Miscarriage - triangle
Notes on good practice when taking a genetic family history
1. Gain consent from the person giving the genetic family history for
information to be shared with family members and health
professionals and note this on your paperwork.
2. Date and write your name on the pedigree diagram
3. Explain any abbreviations used on the diagram
Good online resource - https://www.genomicseducation.hee.nhs.uk/education/online-courses/genomics-101-taking-and-drawing-a-family-history/
Mitochondrial inheriance - what genders affected?
- what gender passes it on?
- example of a disease transmitted via mitochondrial inheritance?
Both genders affected
But only passed on through females - Matrilineal lineage -
Variable phenotype
example of disease transmitted this way is MCAD (medium-chain acyl Co-A dehydrogenase) deficiency - tested in newborn heel-prick test
how to examine the respiratory system
- ‘Hands off’ steps?
- ‘Hands on’ steps?
WHEEZE
- feature of asthma & bronchiolitis & lower respiratory tract foreign body
- noise from lower airways expiratory
- due to bronchoconstriction
- can be audible without stethoscope
* STRIDOR (harsh sound from upper airways inspiratory +/- expiratory “seal noise”)
- Its present suggests significant obstruction of airflow in the larynx or
extra -thoracic trachea
* GRUNTING
- most often in infants with significant respiratory distress e.g bronchiolitis
- due to glottis closure in expiration to h end expiratory pressure to keep alveoli open
AUSCULTATION
* auscultation of chest can be limited in emergency setting
- amount of wheeze & air entry does not relate to how ill a child is
- misleading noises transmitted all over small chest
- child crying when attempted
* typical sounds
- asthma wheezy
- bronchiolitis
bilateral crepitation/ fine crackles
or/and wheezy
- pneumonia (19-33% Normal sounds!!)
Crackles/ rales Crepitations
(- unilateral - bilateral
bronchial breathing – usually > 3 years of age
(harsh blowing noise above area of consolidation)
PNEUMONIA in kids
- Most common organism?
- Vaccine?
Organisms
- Viral (severe)
- Streptococcus pneumoniae
-Haemophilus Influenza type b (HiB)
- 20% Mycoplasma pneumoniae (Atypical)
- Presentation in children < 3 years notoriously subtle
- appear more unwell & lethargic
- fever > 38.5OC
- anorexia/vomiting
- abdominal pain*
- cough less reliable symptom than in adults
- small chest transmits sounds all over so focal sounds hard to detect
Significant effect after pneumococcal
Conjugated vaccine - Treatment: amoxicillin, 2nd choice - macrolide eg clarithromycin if no response to 1.
Pneumococcal Vaccine - 12 weeks and 1 year
ASTHMA in children
Exacerbation of asthma treatment steps?
Exacerbation of asthma treatment steps:
1. Back to back nebs - salbutamol and ipratropium bromide
(with high flow oxygen via mask if sats < 92%)
2. STEROIDS - Stat dose soluble prednisolone 10mg OR IV hydrocortisone
IV fluids
HDU
IV aminophylline and magnesium sulphate
Advise parents to stop smoking
NB. Montelukast can cause personality change (warn parents).
DIABETES in children
1. Symptoms?
2. Blood gas
3. Physiology
4. What level must blood glucose be for diagnosis? a) fasting b) random.
- Thirsty, tired, lots of wet nappies, kussmaul breathing, unwell, decreased consciousness, sunken eyes, signs of dehydration. weight loss.
Toilet
Tired
Thirsty
Thinner - High pH, high glucose, low base excess.
- Impaired insulin action, secretion or both. B cells islets of Langerhan’s.
Low blood sugar → glucagon released → breaks down glycogen in liver → blood glucose goes up.
High blood sugar → insulin released → stimulates glucose uptake from blood → blood glucose goes down.
- Fasting Blood
glucose >7mmol/L
2 hours post glucose
load >11mmol/L
Random blood
glucose + symptoms >11mmol/L
MODY - maturity onset diabetes of the young
1. Inheritance?
2. Age at onset
- Cause is genetic. Monogenic inheritance (single gene mutation)
- < 25 years old.
DKA in Children
Criteria for diagnosis? (3)
BG >11
Ketones > 3mmol/L
pH < 7.3 (or? HCO3 < 15)
DKA in children
Treatment?
Aims:
To slowly restore metabolic homeostasis
Correct dehydration over 48 hours
To correct lack of insulin
Switch off lipolysis and hence acidosis
Reduce hyperglycaemia
(SPIDER)
Saline
Potassium
Insulin:
Dextrose: with Insulin
Eat nothing: NBM
Reason: find the underlying
reason & treat
- IV fluids (0.9% saline) 10ml/kg bolus
eg for 30 kg child ->
0.9% sodium chloride 300ml over 1 hour - IV fluids with Potassium (0.9% saline with 40 mmol/L KCl)
- Insulin infusion (50 units actrapid in 50ml N/S) at 0.1 ml/kg/hr.
Complications of DKA in children
- Wha observations are needed?
- Risk factors for cerebral oedema
- Symptoms
- Signs
- Treatment
- What is Cushings triad of raised intracranial pressure?
Monitor for
- Hyper/hypoglycaemia
- Hyper/hypokalaemia
- Cerebral oedema (HOURLY neuro obs)
Risk factors for cerebral oedema
- Severe presentation
- large amounts IV fluids
- age < 5
- sudden drop in osmolality
- use of bicarbonate (not used anymore)
Symptoms of cerebral oedema
- Headache
- Drowsiness
- Incontinence
- Vomiting
Signs
- LOC
- Rising BP
- Bradycardia
- Decreasing SATS
- Abnormal posturing
- Abnormal pupil responses
Treatment
* Mannitol 0.5g to 1.5g / kg (= 2.5 to 7.5ml / kg
20% Mannitol) over 30mins
* 3% saline
What are the chronic complications of diabetes?
3 microvascular
3 microvascular
Hypoglycaemia in children
1. Signs?
2. Treatment?
HEADACHE
- red flags
- things check in history
Red flags
- Vision changes
- Vomiting
- worse in morning (raised ICP)
- Neurological changes
- Meningism
- weight loss
Things to check in history
- Had eyes checked?
- Problems at school /friends / bullying?
Paeds history taking
- Sections?
What is the assessment tool for teenagers?
HEADSSS
Home
Education & Employment
Activities
Drugs/Drinking
Sex
Self-harm, depression, & Suicide
Safety (including Social media / online)
Shared decision making
See independently
Prioritise listening
PAEDIATRIC fluids
Normal requirements
0-10kg
10.1-20kg
>20kg
SCARLET FEVER
1. Causative organism?
2. Symptoms
3. Treatment
4. Exclude from school?
- Group A beta-haemolytic streptococci (GABHS), specifically the bacterium Streptococcus pyogenes.
- sore throat, fever, strawberry tongue (white coat or red with lumps) and a fine sandpaper-like rash (rash first appears on torso, leads to desquamation around fingers and toes, pastia lines - red lines in creases) prodrome of headache, nausea/vomiting. Lymphadenopathy.
- Penicillin V for 10 days
Common in 2-6 year olds.
NOTIFIABLE disease.
Exclude from school until 24 hours after starting antibiotics.
APGAR score
1. 3. What is the maximum / minimum score?
2. At what minutes after birth is it calculated?
3. What are the 5 things measured?
Minimum score = 0
Maximum score = 10
Calculated at 1 and 5 minutes post birth (and 10 mins if score is low)
5 criteria
A - Appearance (Colour)
P - Pulse
G - Grimace (Reflex irritability)
A - Activity (Tone)
R - Respiratory effort.
Pain associated with 9 regions of the abdomen - in paediatrics
Right hypochondriac - liver, gallbladder, pancreas, lower lobe pneumonia
Epigastric - (very common), GORD, oesophagus, gastritis, pancreatitis (very severe), duodenum, liver.
Left hypochondriac - left lower lobe pneumonia, splenic infarction (sickle cell)
Right lumbar - Kidneys
Let lumbar - kidneys
Right iliac fossa - appendicitis (Rosving;s sign = press on left get pain in right = perforated appendix) NB. Pain occurs first then vomiting in appendicitis. Painful tapping / rebound tenderness, painful drive to hospital? Bumps = pain.
Suprapubic - UTI, urine retention (percuss bladder)
Left iliac fossa - constipation
Lower abdomen - gynae -PID, ovarian cyst, testicular tortion (DONT MISS - always examine testes) look for loose/lax testes, vertically orientated, redness, oedema, cremasteric reflex, smooth surface, sore, cord thickening / tenderness?
No DRE except acute intersusseption, hirchspung’s disease.
Blood tests for abdomen pain?
1. Basic
2. unwell
- Next test?
1.Basic abdo pain, not unwell - FBC, U&Es, CRP
- Very unwell - FBC, U&Es, LFTs (inc bilirubin, albumin), amylase & lipase, CRP (acute phase protein), clotting, group & save.
Blood gas, blood cultures if ?septic
Not ESR as that’s chronic inflammation marker
- ALAR principle - as low as reasonably acceptable - > USS rather than AXR.
NB. Bilious vomiting is dark green (bile turns green when reacts with intestinal juice, its golden colour in gallbladder), stomach acid is yellow.
Paediatric gastro red flags
Haematemesis
Failure to thrive
severe symptoms
severe eczema
Allergies - CMPO → specialist hydrolysed formula or breastfeeding mum cuts out dairy completely (takes 3-4 weeks to clear)
IBD- what tests to order if sx > 6w?
Faecal calprotectin - what is?
FBC, CRP, faecal calprotectin.
Faecal calprotectin - presence of eosinophils in the stool
Inv. Crohn’s / IBD - endoscopy, small bowel imaging.
Coeliac
1. Signs on microscopy
2. Doesn’t need biopsy if?
- Villous atrophy
- Doesn’t need biopsy if - see image
IgE mediated vs non IgE mediated food allergy
- Lactose intolerance
- Cows milk protein allergy
1.All GI symptoms - diarrhoea, bloating, cramps. Not common in babies.
- Non-IgE mediated - eczema, unsettled, vomiting, constipated, formula fed. - switch to extensively hydrolysed formula.
Paeds Renal
www.emeesykidney.nhs.uk
- Nottingham
**Baby <3m with temp do full septic screen, admit, antibiotics within 1 hour **
urine sample should be sent in all children with unexplained fever > 38.
Nitrites present when bacteria convert nitrates > nitrites. Gram - or +.
DMSA - what does it show?
- USS - during acute infection, within 6w.
- DMSA - isotope scan, looks for renal scaring. 4-6m following infection. Dimercapto succinic acid.
In photo - left kidney normal, right renal scaring.
MCUG
1st imagine - normal
2nd image - Posterior urethral valve.
Catheter insertion, dye injected, will show any obstructions / back flow.
A micturating cystourethrogram is an x-ray test which is used to identify any abnormalities in your child’s urinary system and so help to identify why your child may have urinary tract infections.
The urinary tract includes the parts of the body that are involved in making and passing urine ie the kidneys (which make urine), ureters (that take urine from the kidneys to the bladder), the bladder (which stores urine) and urethra (the tube which carries urine from the bladder to outside of the body).
Triad of nephrotic syndrome?
Complications ?
Management?
- Oedema
- Proteinuria
- Hypoalbuminaemia
90% of nephrotic syndrome in children due to minimal change disease
Complications:
Hypovolemia
Infection
Hyperlipidaemia
Hypercoagulability
Anaemia
Progression to ESRF
Management:
Fluid resuscitation
20% albumin and frusemide if needed
Intravenous antibiotics
Corticosteroids (prednisolone)
2nd line - tacrolimus, cyclosporin, MMF etc.
Steroid resistant nephrotic syndrome (SRNS)
- Biopsy
- Genetics
Signs of hypernatraemic dehydration in children?
Paediatric IV fluids maintenance
- How much for 10kg baby?
2.How much for 25 kg child?
- 10 x 100 = 1000ml / day
- 10 x 100 + 10 x 50 + 5 x 20
= 1000 + 500 + 100 = 1600ml / day
Paediatric IV fluids
- 10kg baby, with shock?
Maintenance PLUS :
100ml/kg (=10% body weight) for those initially shocked
50ml/kg (5%) for those not shocked
Cardiac conditions - heart murmurs. What murmer with what defect?
1. VSD (most common)
2. ASD
3. Complete AVSD (hallmark lesion for DS)
4. Co-arctation of aorta
5. Aortic valve stenosis
- Pansystolic
- Ejection systolic murmer, widely split and often fixed 2nd HS (RV enlargement)
- Femorals not palpable, Ejection systolic murmer, radiates to back.
- harsh ejection systolic murmer.
Cyanotic heart conditions
Tetralogy of fallot (boot shaped heart on CXR - apex lifted) hyper cyanotic spells (O2, morphine, propranolol)
Transposition of great arteries (egg shaped heart on CXR)
Approach to ‘blue baby’
measure sats
CXR
Blood gas - arterial on room air
ECG
Pre & post ductal SATS
Start PGE1 - prostaglandins
Urgent echo
Children’s cancer red flags
Pain that wakes you from sleep at night - always sinister unless proven otherwise. (low cortisol → inflammation increases → pain increases)
Headache that wakes you from sleep
Night sweats - full body drenching
2 deep proven bacterial infections eg. pneumonia, appendicitis, septic joint.
Lymphadenopathy most common reason for referral refer if raised > 2cm for 6 weeks
Double vision (big red flag in a child)
Brain tumours
Normal CT doesn’t rule out brain tumour, still need MRI
Raised ICP → opposite of sepsis, you get high BP and low HR.
Puberty
- What tests for endocrine evaluation?
- cut offs for precocious puberty?
- Treatment for precocious puberty?
girls <8, boys <9 (be more worried with boys - commonly CNS pathology)
oestrodial > 92 is abnormal
FSH
LH > 0.6 strongly suggests puberty
Treatment (central) - GnRH analogues eg. gosrelin. Stop at about 10.5 years - 1 year for hormonal axis wake up.
(not central) anti androgens
Congenital adrenal hyperplasia
1. presents how?
2. Pathophysiology
3. Treatment
Picked up at birth w/ ambiguous genetalia- fused labia looks like scrotum but empty
Inborn error of cortisol +- aldosterone synthesis
Treatment - hydrocortisone replacement
Delayed puberty
- Causes?
Causes of delayed puberty - Crohn’s, coeliac, asthma, cystic fibrosis, juvenile arthritis, malnutrition, Turner’s, Kleinfelter’s, Prada-willi, constitutional delay.
Treatment - sex steroid replacement
Duschenne muscular dystrophy - what marker in the blood do we test for?
What inheritance pattern?
Treatment?
Creatine kinase - in 1000’s suggests DMD
(if normal then MRI test for cerebral palsy)
Predominantly affects boys - X linked recessive
Glucocorticoids, diltiazam, physiotherapy, braces
Cafe au lait macule suggest what illness?
Other symptoms of this illness?
Neurofibromatosis (but not always)
Associated with learning difficulties, epilepsy.
2 types
NF1 - benign tumours on nerves. Neurofibromas. More common.
NF2- much less common. Hearing loss, tinnitus, and balance problems.
Clinical diagnosis, criteria:
- Cafe au lait macules
- Lisch nodules (in the eyes, aka iris hamartoma - dendritic melanocytes) refer to ophthalmologist for slit lamp examination
Breaking bad news eg. leukaemia
Side room
Warning shot - We have run some tests, and the results are very concerning.
The results indicate X has leukaemia.
Summary - you came in today as you were worried about his bruising. We’ve run some tests looking for causes some of which are serious and some are not serious.
22kg child with severe dehydration. What should be prescribed for resuscitation fluid bolus?
220ml 0.9% sodium chloride over 10 mins or less. (10ml/kg).
‘bolus of 10 ml/kg over less than 10 minutes for children and young people, and 10–20 ml/kg over less than 10 minutes for term neonates’
Three types of situation for paediatric IV fluid prescribing, what are the formulas for each?
- Resuscitation eg. if shocked
- Replacement eg. prolonged fluid deficit, D&V.
- Routine maintenance eg. Nil By Mouth.
Where possible, oral fluids (e.g. oral rehydration solution) via the oral or nasogastric route should be used.
IV fluids used where oral fluids are contra-indicated or impractical.
Total fluid requirement (mL) = 2 + 3
replacement/fluid deficit + routine maintenance fluids (mL)
- Resuscitation - 10ml/kg 0.9% sodium chloride over 10 mins.
eg. 18kg child = 18 x 10 = 180ml 0.9% sodium chloride over 10 mins.
- Replacement fluids
0.9% sodium chloride + 5% glucose
OR
0.9% sodium chloride + 5% glucose + 10mmol KCl
(add KCl if there are ongoing losses e.g. diarrhoea, vomiting)
The U&Es and plasma glucose should be monitored at least every 24 hours, or more frequently if there are electrolyte abnormalities
- Routine maintenance - Holliday-Segar formula:
100 ml/kg/day for the first 10kg of weight
50 ml/kg/day for the next 10kg of weight
20 ml/kg/day for weight over 20kg
eg.
5kg child = 500ml/day
18 kg child = 1000 + 400 = 1400ml/day.
27 kg child = 1000 + 500 + 140 = 1640ml/day.
Infusion rate = daily volume/24 eg 1640 /24 = 68 ml/hr (to the nearest ml is fine)
Paediatric IV fluids - Replacement fluids
Calculate the fluid deficit for the following cases
- 5% dehydration of 18kg child (dehydrated but not clinically shocked)
- 10% dehydration of 30kg child
(clinically shocked)
Formula
Fluid deficit (mL) = % dehydration x weight (kg) x 10
- 5 x 18 x 10 = 900 ml.
- 10 x 30 x 10 = 3000 ml.
Fluids to use for paeds replacement:
0.9% sodium chloride + 5% glucose
OR
0.9% sodium chloride + 5% glucose + 10mmol KCl
(add KCl if there are ongoing losses e.g. diarrhoea, vomiting)
Total fluid requirement (mL) = maintenance fluids (mL) + fluid deficit (mL)
Paeds IV fluids - calculating percentage dehydration
Calculate the percentage dehydration via weight change.
- Initial weight = 30kg
Current weight = 28kg - Initial weight = 6kg
Current weight = 5kg
weight change / original weight x 100
- 30-28 = 2.
2/30 x 100 = 7% dehydration - 6-5 = 1
1/6 x 1000 = 17% dehydration
https://geekymedics.com/intravenous-iv-fluid-prescribing-in-paediatrics/
Paediatric respiratory examination
- Auscultation positions?
- Percussion positions?
NB Percussion may not be performed in small children
Vocal resonance can only be performed if child is old enough to follow instructions
