7 - Paediatrics Flashcards
How do you do a quick assessment of a child?
Airway: secretions, stridor, foreign body, check gag reflex to see if unprotected airway and jaw thrust if no gag
Breathing: resp rate, recession/accessory muscle use, oxygen sats if below 90 worry, auscultation
Circulation: colour, heart rate, cap refill, temp of hands and feet, bp
Disability: pupils, limb tone and movement, AVPU
Must do ENT for any child with fever
What else should you check when doing an abdominal exam on a child with abdominal pain apart from a normal abdominal exam?
- Testicles for torsion
- Groin for hernia
Newborn babies can get some of the following skin problems, how will a baby present with the following:
- Jaundice
- Mongolian spots
- Erythema Toxicum
- Milia
- Newborn dry skin
- Acne
- Cradle cap
- Heat rash
- Yellow skin and eyes
- Blue bruise from pinprick to up to 6 inches, often on back, sacrum or legs. Document early, birthmark but will fade at about 2 years
- Occurs in most babies 2-5 days old. Red spots with overlying papules or pustules. Resolves in 1-2 weeks
- White dots on babies nose, forehead, chin etc. Leave alone
- Dry skin that can be left alone
- 2-3 weeks after birth like adult acne because of mother’s hormones. Same as erythema toxicum
- Seborrheic dermatitis. Dandruff which will clear itself in a few weeks, may want to losen scales with baby shampoo or oil. If persists may give antifungal shampoo or hydrocortisone cream
- Occurs mainly in nappy and neck area
Women that are breastfeeding often present with the following complaints, what advice can you give them?
- Thrush
- Blocked milk duct
- Tongue tie
- Put on antifungal cream after feeding and possible 2-3days PO antifungals
- If engorgement continues this may occur and a small hard lump may form. Feed from this breast and face baby’s chin towards the hard lump. If left can lead to masititis and then a possible breast abscess which will need drainage
- May cause sore cracked nipples or baby may not be latching on properly and therefore not gaining weight. Can have tongue-tie division
Women that are breastfeeding often present with the following complaints, what advice can you give them?
- Sore nipples
- Not enough breast milk
- Breast engorgement
- Baby not latching on properly
- Baby not well positioned and latched, get advice from midwife
- Offer baby both breasts at each feed and alternate which breast you start with. Keep them skin to skin
- Wear a well fitting bra, possibly express milk, learn babies feeding habits
- Make sure babies face is facing the nipple so doesn’t have to turn head. Check they have rounded cheeks and not coming off and on
If a parent presents with a child with an itching head due to headlice what advice can you give them?
- Reassure it doesn’t mean they are dirty
- Check everyone in the house and start treatment on the same day for everyone
- Do wet combing on days 1, 5, 9 and 13 to catch any newly hatched head lice. Check again that everyone’s hair is free of lice on day 17. Lots of conditioner.
- Dimeticone 4% gel, lotion, or spray (Hedrin) Only treat if live lice found. Treat from root to tip of hair. Suffocates lice so not likely to form resistance. Safe for pregnant women
- No need to keep child off of school or put clothes on a hot wash or use tea tree oil
How does colic present in a child and what advice can you give to the parents?
Baby cries a lot for no obvious cause. If they cry more than 3 hours a day, 3 days a week for at least 1 week. Often will be very windy too and draw knees up to abdomen or arch back when crying
- Reassure parents they will grow out of it about 6 months
- Ask for support from friends, family or Cry-sis
- Check not crying for other reasons like a milk allergy
What advice would you give to a mother asking about weaning her baby?
- Start around 6 months alongside their milk
- Give mashed fruit or vegetables once a day or baby rice with their milk
- Introduce foods that are associated with allergies one at a time in little amounts so can pin point any reactions
- Offer child free flow cup with water in at meal times
- Baby will turn head away or close mouth if full
A 5 year old boy presents with a rash on his trunk, what are the differential diagnoses?
- Scarlet fever may have strawberry tongue. S.Pyogenes
- Slapped cheek syndrome is erythema infectiosum. Parvovirus
- Roseola has prefever. HHV-6
- Varicella can be on scalp. Pustules then scabs. Starry sky
How would eczema in a child present and how would you treat it?
- Flexural dermatitis (red, itchy dry) in skin creases like elbows and back of knees
- History of atopy
- Flare ups causd by allergens, stress, diet etc
- In Asian and African children can affect extensor surfaces
- Use steroids for flares but not potent ones on neck and face
How would you rule out scabies and urticaria when considering a diagnosis of eczema?
What is functional conspitation in children?
- Chronic constipation not due to a secondary cause
- Often psychosomatic: witholding stool (e.g due to being in unfamiliar place), emotional, or diet
- Need to have straining, hard stools, pellet stools, manual evacuation etc for 3 months for a diagnosis
What are some congenital and physical causes of constipation in children?
- Hirschsprung’s Disease: presents early in life with failure to thrive, no meconium in first 24 hours, swollen abdomen, constipation doesn’t respond to treatment
- CF
- Hypothyroidism
- Anorectal malformation: faeces coming out of urethra
- Colonic atresia: often billous vomiting
How do we treat functional constipation in children?
- Laxatives (stimulants like docusate sodium or osmotics like lactulose and laxido) until a few weeks after it has resolved
- Increase fibre in diet e.g porridge, whole grain bread, food
- Avoid dairy, apples and bananas due to pectin content
- Encourage lots of fluids
- Praise child for going to the toilet, give them plenty of time, do not punish accidents
How may a viral wheeze present in a child and how can we treat it?
- Child may have SOB, recession and an expiratory wheeze
- Wheeze can continue for some time after virus and reoccurs with viruses
- Most common between 12 months to 5 years
Treatment: same as acute asthma with reliever inhaler and spacer
If a child is wheezy before 12 months or after 5 years, what is the likely diagnosis?
NOT VIRAL WHEEZE
<12 months think bronchiolitis
>5 years think asthma
How can a wheezing child due to a viral wheeze be distinguished from asthma, a respiratory infection and an inhaled foreign body?
Asthma: history of atopy, no history of viral infection, often after 3 years, has triggers like allergens and the cold
Resp Infection: will usually have a fever and a cough, more sudden onset, coryzal symptoms
Inhaled foreign body: sudden onset, initial coughing/choking, stridor, no coryzal symptoms, reduced chest wall movement on affected side, decreased/abnormal breath sounds
How does Osgood-Schlatter’s disease present in children?
- Small avulsion fractures of the patella tendon on the tibial tuberosity during forceful contractions of the quads. Happens before tibial tuberosity has undergone ossification
- Ossicles or enlarged tubercle may form so pain and swelling/lump occurs below kneecap which is worse on activity like running and jumping
- Develops slowly and severe exacerbations
- Usually unilateral
- More common in boys and with skeletal maturity it will disappear. Exacerbation usually settles after a few weeks to months
How is Osgood-Schlatters diagnosed?
- Exclude alternative causes of knee pain
- Do not X-ray as will not show anything except a possible ossicle when the epiphysis has ossified
What is the treatment for Osgood Schlatters?
- Analgesia
- Ice packs 10-15mins TDS
- Knee pads
- Reassure parent symptoms will settle but may persist until growth spurt
- Reassure sporting activity can still continue or can modify activity to level of pain
- Muscle stretching before and after exercise
- Reassess if persisting or getting worse
How can you distinguish Osgood Schlatter’s from the following:
- Injury
- Perthes
- SUFE
Injury: pain suddenly starts after trauma not gradual. Often abdnormal exam such as ligament injuries
Perthes: Femur head loses blood supply so AVN and head collapses. Pain in hip/groin or referred to knee/thigh. Painful muscle spasms and limited abduction/internal rotation. X-ray to diagnose
SUFE: head of femur slips off backwards, more common in boys aged 11-17. Pain in knee, limp, leg appears shorter or turned outwards, limited movement, possible Trendelenberg gait
How does hayfever present in children and how can it be treated?
- Seasonsal allergic rhinitis that happens at the same time every year due to grass and tree pollen
- Allergen avoidance
- Nasal irrigation with saline
- Oral non-sedating antihistamine
- Nasal antihistamine, steroid, decongestant, chromones
How can you distinguish hayfever from an infection and allergic rhinitis?
Infection: high temperature, green/yellow mucus from the nose, may occur after cold/flu
Allergic rhinitis: symptoms the same but not seasonal, triggered by any allergen not just pollen
What is toddler’s diarrhoea and what advice can you give to parents about this?
- Chronic diarrhoea usually in boys aged 1-5 years
- 3 or more loose stools a day that are often smelly, pale, bits of vegetable in and abdominal cramps
- Reassure parent child will grow out of it by age 5-6
- Encourage parent to increase fat, lower fibre, decrease amount of fruit juice in childs diet
How can you distinguish toddler’s diarrhoea from the following:
- Infection
- Dietary intolerance
- IBD
- Coeliac disease
How may a child with threadworms present?
- Parasite enterobius vermicularis has faecal-oral transmission e.g from scratching anus then touching toy
- Perianal itching, worse at night which can wake
- Visible worms in stool or seen on perianal area
- Can cause vaginal itching in females
- Do tape test if uncertain but stool sample not necessary
How are threadworms treated?
- Give all household members the OTC antihelminthic Mebendazole on the same day
- If pregnant or under 6 months old, hygiene measures for 6 weeks
- Strict hygiene measures to prevent re-infection
What is the difference between GOR and GORD?
GOR: usually begins before 8 weeks and is normal physiological if symptoms not affecting child. 90% will resolve by 1st year
GORD: when the symptoms are affecting the child e.g discomfort, pain, oesophagitis. Consistent projectile vomiting, failure to thrive, dysphagia, fever, cough, retrosternal pain, irritability
What are some risk factors and complications of GORD in children?
Risk factors: premature birth, FH of heartburn, obesity, hiatal hernia, neurodisability
Complications: reflux oesophagitis, recurrent aspiration pneumonia, frequent otitis media (>3eps in 6 months), dental erosion
How is GORD treated in children?
- Reassure parents symptoms will improve over time
- Give Gaviscon infant to breast fed infants for 1-2 weeks
- Reduce the volume of feeds/thicken the feeds with Carobel if formula fed then Gaviscon
- If treatment doesn’t work try a 4 week trial of omeprazole or ranitidine
How can you differentiate GORD from mesenteric adenitis, abdominal migraine, and psychological reflux?
Mesenteric adenitis: sore throat/cold precursor, fever, pain in abdomen usually RIF, nausea and diarrhoea. Self-limiting
Abdominal Migraine: ab pain, N+V, paroxysmal episodes>1h, symptom free between episodes, photo/phonophobia
Psychological: usually 5-14 years, stress, depression, anxiety, myalgia, head-aches, IBS like symptoms
How do you do a newborn baby check?
Done within first 24 hours then repeated at 6 weeks but advise vaccinations and ask how feeding
https: //geekymedics.com/wp-content/uploads/2020/09/OSCE-Checklist-Newborn-Baby-Assessment-NIPE.pdf
https: //geekymedics.com/newborn-baby-assessment/
What are some primitive reflexes in newborn babies?
If reflexes don’t disappear when they are supposed to this is a developmental delay
What are child developmental milestones up to age 3?
https://www.cdc.gov/ncbddd/actearly/milestones/milestones-2mo.html
What are some gross motor development milestones?
When born there is head lag when picking baby up as cannot support its own head
What are some vision and fine motor developmental milestones in children?
Draws without seeing:
Line – 2 years
Circle – 3 years
Cross – 3.5 years
Square – 4 years
Triangle – 5 years
Brick building between 14 months and 2 years
What are some hearing, speech and language milestones in children?
- 2.5-3 years can talk in 3 to 4 word sentences
- Understands 2 joined commands also e.g push me fast daddy
What are some social, emotional and behavioural development milestones in children?
How does adult gait differ to paediatric gait?
- Flat feet are common up to 6-7 years
- Toe walking common up to 3 years
- Knock knees associated with in toeing mostly resolve by 7 years
If persisting after normal ages consider referral
What are the gait milestones in a child?
What antenatal appointments is a woman given?
1. First contact: tell GP as soon as pregnant so can give advice on folic acid supplements. Screening for sickle cell and thalassemia needs to take place before 10 weeks
2. 8-12 weeks: (see image)
3. 8-14 weeks: dating scan
4. 16 weeks: discuss screening results, measure bp, test urine for proteinuria, give iron supplement if anaemic
5. 18-20 weeks: whooping cough vaccine and USS for structural abnormalities
6. 25 weeks nulliparous: measure BP and test urine for protein, symphis fundal height
7. 28 weeks: same as before plus anti-d prophylaxis, second anaemia screen
8. 31 weeks nulliparous: same as 25 weeks
9. 34 weeks: same again, seond anti-d injection, prep for labour and info about c-section
10. 36 weeks: same again, offer ECV if baby breech, given info on breast feeding, baby blues, vit k deficiency
11. 38 weeks: same again and discuss what will happen with prolonged pregnancy
12. 41 weeks: membrane sweep
13. 42 weeks: induction
6 weeks after birth a mother is checked by the GP as well as the baby, what is the GP checking for?
What are some post natal appointments that occur in the community?
- Newborn baby check within 72 hours
- Heel prick screening 5-8 days
- Health visitor will come to advise safe sleeping, vaccines, feeding after 1-2 weeks
What is bronchiolitis?
- Viral infection of bronchioles usually by resp syncitial virus, adenovrus or influenza
- Usual onset less than 2
- Subcostal recession/nasal flaring/grunting are serious signs
- Fever
- Cough
- Wheeze
- Tachypnea
- Crackles
What are risk factors for bronchiolitis?
- Smoking
- Not being breast fed
- Premature
- Crowded living
What is the treatment for bronchiolitis?
If the child does not require hospital admission:
- Advise the parents self-limiting illness and that symptoms tend to peak between three and five days of onset. Advise of red flags like grunting, poor feeding, apnoea, lack of wet nappies etc
- Advice parents not to smoke in the house
Hospital admission:
Give oxygen if sats <92%
If resp failure CPAP
How does croup present?
- Usually between 6months to 6 years
- Inspiratory stridor
- Barking seal like cough
- Hoarseness
- Resp distress
- Worse at night
- +/- fever
- Subcostal recession
How should croup be treated?
- If mild can be managed at home if not under 3 months or no immunodeficiency. Symptoms usually get better within 48 hours
- Advise regular fluids, paracetamol/ibuprofen
- Need single dose PO dexamethasone regardless of the severity
What is the presentation of chicken pox?
- Varicella Zoster Virus
- Incubation 1-3 weeks with most infectious a few days before rash
- Starts with nausea, malaise, headache, myalgia, anorexia, high temp and flu like symptoms before rash
- Small erythmatous macules that progress to itchy vesicles/pustules which then crust at 5 days and fall off in 1-2 weeks
- Rash more pronounced in flexures
How should chicken pox be managed?
- Paracetamol but not NSAIDs
- Topical calamine lotion for itch
- Chlorphenamine for itch if >1year
- Possible aciclovir within 24hrs of rash in immunocompromised or those at risk of complications
- Keep child away from immunocompromised pregnant, or nursery until vesicles have crusted over
- Keep nails short to minimise scratching
- Keep hydrated
Why should ibuprofen not be taken when a patient has chicken pox?
Increases the risk of necrotising fascitis
What are the diseases from 1-7 e.g first, second, third?
Seventh is Kawasaki’s
