Child Health Flashcards
What is the Aetiology of Meningococcal infection?
Caused by Neisseria Meningitidis (gram-negative intracellular diplococcus)
Transmission by respiratory droplet spread
Once bacteria enters circulation, initiates inflammatory process -> capillary leakage and intravascular thrombosis -> consumes clotting factor so basically intravascular coagulation
How does Infection with Neisseria Meningitidis present?
- Meningococcaemia
- Meningitis ( non-specific, lethargy, headache, fever, rigors, vomiting
- Rapidly developing purpuric skin rash
- Hypovolaemic shock - cold peripheries, poor Cap refill, tachycardia, poor urine output
- If presentation above associated with adrenal haemorrhage and septic shock = waterhouse-friderichsen syndrome
How is Diagnosis of Meningococcal Infection made?
Confirmed with blood or CSF culture
PCR testing for Neisseria Meningitidis is highly sensitive
What is the management of Meningococcal infection?
Early antibiotic treatment = broad spec IV antibiotics until confirmation of pathogen and then may be narrowed to penicillin-based drug
PICU admission if speticaemic
if Neisseria meningitidis, must notify close contacts
All household contacts should recieve ciprofloxacin or rifampicin as PEP
NM strains part of routine immunisations
How does Pyloric stenosis present?
Vomiting after feeds ( can be projectile)
May increase with intensity as obstruction becomes more sever
On examination during feeding, hypertrophic pyloric sphincter might be palpable as a smooth olive sized mass
Typically occuring in babies aged 6-8 weeks
What ion imbalance does pyloric stenosis cause?
Hypochloremic (low chloride) Hypokalemic (low Potassium) metabolic alkalosis
Dehydration
How is Pyloric Stenosis Diagnosed?
Through abdominal ultrasound to visualise hypertrophic sphincter
What is the management of Pyloric Stenosis?
Definitive management is surgical - laproscopic pyloromyotomy to cut pyloric sphincter
Before surgery should be kept nil-by-mouth and on IV fluids
If sever dehydration detected, fluid resus is needed
What are the Causes of Jaundice in babies?
Under 24 hours:
- Haemolytic disorders (Rhesus, ABO G6PD deficiency, spherocytosis)
- Congenital infection (TORCH)
- Sepsis
24 hours - 14 days
- Physiologic jaundice
- Breast milk jaundice
- Dehydration
- Infection, including sepsis
- Haemolysis
- Bruising
- Polycythaemia
- Crigler-Najjar Syndrome
Over 14 days ( 21 if preterm)
- Physiologic jaundice
- Breast milk jaundice
- Infection (if UTI perform a full septic screen)
- Hypothyroidism
- Bililary obstruction (incl. biliary atresia)
- Neonatal hepatitis
What is Slipped Upper Femoral Epiphsysis?
It occurs when weakness in the proximal femoral growth plate allows displacement of the capital femoral epiphysis
most common hip disorder in the adolescent age group, particularly in those who are obese
What are the risk factors for SUFE
Male
Adolescent
Obese
Hypothyroidism, hypogonadism
Afro-carribean or HIspanic
What is the presentation of SUFE?
Hip pain and limp
Pain may be referred to the knee
Reduced range of movement on hip flexion
Positive Trendelenburg gait (pelvis drops when lifting leg opposite to weak glute/hip)
How is diagnosis of SUFE made?
anterolateral and frog-leg X-rays, which may show characteristic features like a short displaced epiphysis and widened growth plate.
What is the management of SUFE?
Surgical management is typically via fixation with a screw
Prompt treatment is essential to avoid prolonged disruption to blood flow and subsequent progression to avascular necrosis of the femoral head.
What are the 3 major trisomy disorders with viable fetuses?
Patau’s = Puberty (puberty at age 13), Edward’s = Education (leave school at 18), Down’s = Degree (age of graduation at 21).
What are the features of Patau’s Syndrome?
Holoprosencephaly (failure of the 2 cerebral hemispheres to divide, which might present with only one eye and a nose with a single nostril)
Cleft lip and palate
Microcephaly
Polydactyly
Congenital heart disease
Not likely to survive for more than a few weeks
What are the features of Edward’s Syndrome?
Low-set ears
Micrognathia (undersized jaw )
Microcephaly
Overlapping 4th and 5th fingers
Rocked bottomed feet
Congenital heart disease
Think rat people
What are the features of Kawasaki’s Disease?
Fever > 5 days
Conjunctivitis (red eyes)
Rash
Erythema of hands and feet (red hands and feet)
Adenopathy (cervical, commonly unilateral)
Mucosal involvement (strawberry tongue, oral fissures)
What is the treatment for Kawasaki’s?
Treatment of Kawasaki disease is with aspirin and intravenous immunoglobulin (IVIG).
Aspirin is usually avoided in children due to the risk of Reye syndrome (liver and brain damage).
What is Duodenal atresia?
Duodenal atresia is a congenital malformation in which the duodenum does has a blind end, and so is not patent (basically opening in duodenum is too narrow or closed so food cannot pass)
25% of cases associated with down’s syndrome
How does Duodenal Atresia present?
Antenatally, associated with polyhydramnios (too much amniotic fluid around the baby) as the baby cannot ingest amniotic fluid properly
Distended abdomen
Vomiting may be bilious or non-bilious depending on the site of the atresia
How is the diagnosis of Duodenal atresia made?
X-Ray has characteristic double bubble
- one gas bubble visible in the stomach, and one gas bubble visible in the most proximal (patent) part of the duodenum prior to the atresia ( instead of moving onto the intestine)
What is the management of Duodenal Atresia?
Surgical repair. Duodenoduodenostomy involves reconnecting the closed proximal and distal segments of the duodenum in order to relieve the obstruction.
What are the signs of a sever asthma episode?
Respiratory distress (use of accessory muscles of respiration, breathlessness resulting in inability to complete sentences, tachypnoea with a respiratory rate ≥ 25/min)
Heart rate ≥ 110/min
Peak expiratory flow rate 33-50% of predicted
What are the signs of a life threatening asthma episode?
Peak exploratory flow rate is <33% predicted
Oxygen saturations <92%
Silent chest on auscultation
Weak or no respiratory effort
Hypotension
Exhaustion
Confusion/altered conscious level
Near fatal is when the PCO2 is also normal
What are the history signs of an acute asthma attack?
Widespread wheeze with exacerbation minutes to hours
confirmed by reduced peak expiratory flow rate and FEV 1 which improves with treatment
What is the management of an asthma attack?
- O2 mainted between 94-98% with high flow oxygen
- Inhaled salbutamol
- Nebulised salbutamol
- Add nebulised ipratropium bromide
- If O2 saturations remain <92% add magnesium sulphate
- Add intravenous salbutamol if no response to inhaled therapy
- If severe or life-threatening acute asthma not responsive to inhaled therapy, add aminophylline
- All patients should receive steroids. They should only be given IV if the patient is unable take the dose orally
- You should contact a senior if the patient is not responding to salbutamol or ipratropium.
What are the features of Coxsackie A virus (Hand-foot-mouth disease)
vesicular rash on the palms, soles and buccal mucosa along with a fever
What is the main feature of parvovirus B19?
Red rash across the cheeks (lace-like rash across the rest of the body)
Prodrome of fever, coryza (runny/stuffy nose), diarrhoea
What are the complications of Parvovirus B19?
- Red cell aplasia (decline in red blood cells)
- Infection in the first half of pregnancy can also cause severe foetal anaemia that can precipitate hydrops foetalis and subsequent miscarriage
- Cardiomyopathy
What is Necrotising Enterocolitis?
A condition in which the bowel of premature infants becomes ischaemic and infected
What are the risk factors for Necrotising Enterocolitis?
- Prematurity
- Low birth weight
- Non-breast-milk feeds
- Sepsis
- Acute hypoxia
- Poor intestinal perfusion
What is the presentation of Necrotising Enterocolitis?
- Presents in the first three weeks of life
- Vomiting (may be bile streaked - green stained)
- Bloody stools
- Abdominal distension
- Absent bowel sounds
- Signs of systemic compromise including acidosis on a blood gas
How is Necrotising Enterocolitis diagnosed?
Abdominal X-ray with following signs:
- Dilated Bowel Loops
- Pneumatosis intestinalis (gas within the bowel wall)
- Portal venous gas
- Pneumoperitoneum (air in abdominal cavity)
Staged using Bell’s classificiation - mix of clinical and radiological findings
What is the management of Necrotising enterocolitis?
- Nil-by mouth, nasogastric tube and admitted to the neonatal unit
- Broad-spectrum antibiotics
- Total parenteral nutrition to rest the bowel
- Supportive treatment with IV fluids and ventilation are also crucial
- Surgery to resect necrotic sections of bowel may be necessary, and is essential in cases of bowel perforation.
Mothers of premature babies are strongly encouraged to breastfeed as this reduces NEC risk
What is the management of Hydrocele?
Most hydroceles will spontaneously resolve by 12 months. Therefore, management includes observation initially and then surgical correction if they have not resolved by 1 year. This is because there is a significantly increased risk of an indirect inguinal hernia.
What is Turner’s Syndrome?
A condition that affects only females and results when one of the X chromosomes is missing or partially missing
What is the presentation of Turner’s Syndrome?
- Short stature
- Lymphoedema of hands and feet in neonate, may persist
- Spoon-shaped nails
- Webbed neck
- Widely space nipples
- Wide carrying angle
- Congenital heart defects - bicuspid aortic valve (most common), coarctation of the aorta (around 5% of all cases associated with Turner’s)
- Delayed puberty
- Ovarian dysgenesis causing infertility
- Hypothyroidism
- Recurrent otitis media
- Normal intellect
Increased risk of aortic stenosis (bicuspid valve defect) and aortic dissection (from coarctation of the aorta)
What is the management of Turner’s Syndrome?
Growth hormone therapy
Oestrogen replacement to allow development of secondary sexual characteristics
What is Rubella?
A condition caused by the rubella togavirus, which is transmitted via aerosols. Children are routinely vaccinated for Rubella as part of the MMR vaccine starting at 12 months of age.
What is the presentation of Rubella?
Nonspecific symptoms and signs such as fever, coryza, arthralgia, a rash, which classically starts on the face and moves down to the trunk, sparing the arms and legs), and lymphadenopathy (classically post-auricular - behind the ear)
Measles does not spare limbs
Confirmed with serological testing
What is the management of Rubella?
Supportive
What are the consequnces of Congenital Rubella infection?
Cataracts, deafness, patent ductus arteriosus, brain damage
What is nocturnal enuresis?
Wetting the bed at night is common in young children as they learn to gain voluntary control of the bladder sphincters. It is considered normal until children are 5 years old.
What is the difference between primary and secondary nocturnal enuresis?
Primary nocturnal enuresis is seen in children who have never achieved urinary continence overnight.
Secondary nocturnal enuresis is seen in children who have previously achieved urinary continence overnight.
What are the causes of Nocturnal Enuresis?
Diabetes mellitus
Urinary tract infections
Constipation - due to compression of the bladder
What is the management of Nocturnal Enuresis?
Star chart - initial conservative approach to reward good habits
First line - nocturesis alarm that detects water in the underwear and activates alarm
Over 7 years old can trial DDVAP (synthetic ADP) if alarm has failed
What is Biliary Atresia?
rare condition where the bile ducts of an infant are progressively fibrosed and destroyed, leading to conjugated hyperbilirubinaemia, liver failure and death if not treated
What is the presentation of Biliary Atresia?
Prolonged jaundice (i.e., jaundice that persists beyond 14 days of life)
Signs of biliary obstruction (e.g, dark urine and chalky white stool)
How is the diagnosis of Biliary Atresia made?
Bloods will show a raised conjugated bilirubin and deranged liver function tests
A hepatic scintigraphy (technetium-99) radioisotope scan will highlight the liver (takes up the isotope) but poor excretion into the bowel (as the bile ducts connecting the liver and the gut have been destroyed)
Abdominal ultrasound reveals echogenic fibrosis
Definitive diagnosis of biliary atresia is confirmed with cholangiography, which will fail to show normal architecture of the biliary tree
What is the management of Biliary Atresia?
Surgery is required: hepatoportoenterostomy (Kasai procedure), which creates a new pathway from the liver to the gut to bypass fibrosed ducts
What is the managment of acute epiglottitis?
Caused by Haemophilia Influenza B
This is an emergency - Senior ENT, anaesthetics and paediatric support is required as soon as possible alongside notifying PICU
- Do not examine or upset the child in the absence of senior support
- Securing the airway is the first priority.
- Endotracheal intubation may be necessary.
- Once the airway is secure, take cultures and examine the throat
- Treat with IV antibiotics: cefuroxime
What is cycstic fibrosis?
Cystic fibrosis is a progressive, autosomal recessive disorder that causes persistent lung infections and limits the ability to breathe over time
What is the cause of Cystic fibrosis?
Mutations affect the structure, processing or cellular transport of the CFTR protein (cystic fibrosis transmembrane conductance regulator)
The most common mutation, affecting Delta-F508, results in abnormal glycosylation and subsequent degradation of the CFTR protein before it reaches the cell membrane.
What are the complications of CF?
Thick mucus in the lungs causes cough, recurrent infections, and bronchiectasis (abnormal widening of the bronchi)
Sinusitis and nasal polyps are also very common. Patients usually are colonised with Pseudomonas in the lung by about age 20.
Reduced pancreatic lipase enzyme secretion inhibits fat absorption, causing steatorrhoea (fatty stools)
Poor fat absorption consequently contributes to deficiency of fat-soluble vitamins (A, D, E and K)
Poor weight gain
Diabetes mellitus
Seminiferous tubes also get blocked; most men with cystic fibrosis are unable to conceive naturally.
Fertility is also slightly lower than average in women due to thicker cervical mucus
How does Cystic fibrosis present?
- In neonates
Acutely with meconium ileus (blockage of small intestine) - diagnosed and treated with a gastrograffin enema
Delay in pasing meconium
Bilious green vomiting
- In infants
Salty sweat
Faltering growth
Malabsoprtion syndromes
- In Older children
Faltering growth
Recurrent chest infections
Malabsorption syndromes
Delayed onset puberty
How is a diagnosis of cystic fibrosis made?
Definitive diagnosis is via a sweat test
screened for on the neonatal blood spot test within the first few days of life; they have a raised blood immunoreactive trypsinogen
What is the management of Cystic Fibrosis?
Daily chest physiotherapy techniques are necessary to help clear mucus and prevent pneumonias.
prophylactic antibiotics, bronchodilators, and medicines to thin secretions (e.g. dornase alfa)
Pancreatic enzyme replacement (creon) and fat-soluble vitamin supplementation (ADEK) are also useful.
Patients should also have influenza and pneumococcal vaccines
A last-resort for patients with end-stage pulmonary disease in cystic fibrosis may be a bilateral lung transplant.
What are the features of Foetal Alcohol Syndrome?
functional or structural nervous system abnormalities e.g. decreased cranial size, structural brain abnormalities, problems with attention, cognitive difficulties
growth impairment e.g. low birth weight, decelerating weight over time
specific facial abnormalities (e.g. short palpebral fissures, smooth philtrum and thin upper lip)
How does Scarlet fever present and what casues it?
coarse red rash (sandpaper texture)
Sore Throat
Headache
Fever
Bright red tongue
Caused by a streptococcus
What is the management of scarlet fever?
It is treated with antibiotics (usually 10 days of phenoxymethylpenicillin)
Children remain infectious until 24 hours after the first dose of antibiotics
What are the features of Roseola?
Roseola (Human Herpes Virus 6) causes a lace-like red rash (rose-pink macular with surrounding pale halos) across the whole body with a high fever.
It is self limiting and management is supportive
What is chicken pox?
Chickenpox presents with a maculopapular vesicular rash that crust over and form blisters, which can be itchy
caused by varicella zoster virus (Human Herpes Virus 3)
Children are infectious from 1-2 days before the rash until every single lesion has crusted over
Treatment is supportive unless the patient is in one of the categories below in which case antiviral treatment (and potentially hospital admission following discussion with a specialist) is indicated.
A neonate
Immunocompromised
An adolescent presenting within the first 24 hours of rash onset
Pregnant
Complications include pneumonitis and encephalitis.
What are the features of measles?
Measles presents with a characteristic erythematous, blanching maculopapular rash all over the body.
It is preceded by a fever, cough, runny nose or conjunctivitis.
Koplik spots (white spots inside the buccal cavity) may also be seen alongside the preceding symptoms.
Children are infectious from 4 days before the rash to around 4 days after. It is highly infectious.
What is neonatal respiratory distress syndrome?
Neonatal respiratory distress syndrome (NRDS) is caused by a lack of surfactant.
Surfactant is produced by type 2 pneumocytes
May show ground glass appearance on chest x-ray
What is the management of NRDS?
Treatment of neonatal respiratory distress syndrome is with intratracheal instillation of artificial surfactant.
Additionally, if preterm delivery is suspected, giving the mother glucocorticoids (dexamethasone) before delivery can increase surfactant production in the baby.
How is a diagnosis of hydrocele made?
Hydroceles are confirmed with an ultrasound scan, which demonstrate simple fluid accumulated around the testicle.
How is the diagnosis of asthma made in children?
Serial peak flow readings, both when symptomatic and asymptomatic, as the airflow obstruction is reversible
Those suspected of having a high probability of asthma can be started on a trial of a short acting beta agonist (SABA) inhaler
Where possible, spirometry should be performed in children
Where cases are unclear, FeNO testing may be helpful
Detailed History
What is the stepwise management of chronic asthma?
All patients should receive a personalised written asthma plan. This should be regularly checked and updated.
Use of a spacer is the preferred method method of delivery for inhaled treatments from a metred dose inhaler
Step 1: Inhaled SABA PRN and consider monitored initiation of very low to low dose inhaled corticosteroid (ICS)
Step 2: Add very low dose ICS (or leukotriene receptor antagonist (LTRA) if <5 years)
Step 3: Very low dose ICS and:
Age < 5 years old: add LTRA
Age > 5 years old: add LTRA or LABA
Additional add-on therapies:
No response to LABA: Consider stopping LABA and increase ICS to low-dose
If some benefit from LABA but still inadequate: increase ICS to low-dose
If benefit from LABA and low-dose ICS but still inadequate: Consider trial of LTRA
High dose therapies:
Consider increasing ICS to medium dose ICS
Addition of fourth drug e.g. theophylline
Refer to patient for specialist care
If the above is inadequate, use daily steroid tablet and maintain medium-dose ICS. Consider other treatments to minimise use of steroid tablets.
What is Minimal Change Disease?
Minimal change disease is the most common cause of nephrotic syndrome in children (~70%) and is characterised by minimal histological changes to nephrological structures on light microscopy. It can be associated with a viral upper respiratory tract infection in the preceding weeks.
How does Minimal Change disease present?
Patients suffering from minimal change disease typically present with oedema, including facial swelling
Patients will also produce frothy urine
If a child presents with nephrotic syndrome, they are presumed to have minimal change disease and treated for it empirically
What is the initial investigation for minimal change disease?
Urine Dipstick - If the urinalysis is strongly positive for protein 3+ or 4+ in the absence of haematuria then nephrotic syndrome is very likely.
What is the managment of Minimal Change Disease?
- Corticosteroid therapy: prednisolone
- Second line therapy includes other oral immunosuppressive agents such as ciclosporin
- Fluid restriction and reduced salt intake
- Human albumin and furosemide
What are the complications of minimal change disease?
Spontaneous peritonitis
Thrombosis
Renal damage
Increased risk of infections
Where do you measure pulse on paeds?
Carotid pulse in children aged >1 years old
Brachial or femoral pulses in infants
When should resuscitation be stopped?
Child shows signs of life
Further help arrives
Rescuer becomes exhausted
What is Acute Lymphocytic Leukaemia?
ALL is a malignant clonal disease that develops when a lymphoid progenitor cell becomes genetically altered through somatic changes and undergoes uncontrolled proliferation. This eventually leads to ALL, characterised by early lymphoid precursors replacing the normal haematopoietic cells of the bone marrow and further infiltrating various body organs.
Associated with Down’s syndrome
How does ALL present?
Any children presenting in GP with bruising, enlarged lymph nodes and systemic illness should be referred for specialist assessment.
Lymphadenopathy is the most common sign in ALL.
Other symptoms which may be present include: hepatosplenomegaly, pallor or petechiae, fever, fatigue, dizziness, weakness, and epistaxis
THREE CORE SIGNS: Neutropaenia (recurrent infections), Anaemia (pallor, fatigue), and thrombocytopaenia (purpuric rash)
How is diagnosis of ALL made?
diagnosed definitively through bone marrow biopsy
What are the normal gross motor milestones?
Six weeks: Good head control - raises head to 45 degrees when on tummy
Six months: Sit without support - rounded back; rolls tummy (prone) to back (supine) - vice versa slightly later.
9 months: Stands holding on
12 months: Walks alone (12-18m). 18 months is threshold for concern.
18 months: Runs
2 years: Runs on tiptoes; walks up stairs - 2 feet per step
2.5 years: Kicks ball
3 years: Hops on one foot for 3 steps; walks up stairs 1 foot per step but still 2 feet per step on the way down.
4 years: Walks up and down stairs in an adult fashion
What is tetralogy of fallot?
Tetralogy of Fallot is a relatively rare form of congenital cardiac disease
Tetrad compromised of:
- Ventricular septal defect (VSD)
- Overriding aorta - i.e., an aorta that overrides the right and left ventricles as a result of the VSD
- Right ventricular outflow tract obstruction (RVOTO), this is the main determinant of the severity of cyanosis
- Right ventricular hypertrophy
How does tetralogy of fallot present?
Tetralogy of Fallot is most commonly diagnosed antenatally, or on detection of a murmur in the first few months of life.
May also present with cyanosis
Babies can present with tet spells, which are acute episodes of cyanosis. During a tet spell, there is reversal of the shunt across the VSD, resulting in a right-to-left shunt and worsening cyanosis.
What is the management of Tet Spells?
This is an emergency and can be fatal
Acutely: lie babies on their back and bend their knees. In hospital, oxygen should also be provided.
Prophylaxis: propranolol may be used by some centres
What is the management of Tetralogy of Fallot?
Definitive management is via surgery where the RVOTO is corrected and the VSD is closed
What is Hypoxic Ischaemic encephalopathy?
brain damage resulting from ante- or perinatal hypoxia
What is the aetiology of Hypoxic Ischaemic encephalopathy?
Any poor oxygentation can cause HIE
- Pre-partum (e.g., placental abruption)
- During delivery (e.g., cord compression)
- Post-partum (e.g., prolonged respiratory arrest).
How is the diagnosis of HIE made?
Investigation of HIE is with EEG monitoring and multiple MRI brain scans
Presentation ranges depending on degree of neurological damage ranging from mild (irritability) to severe (hypotonia, poor responses, prolonged seizures)
What is the management of HIE?
Management includes respiratory support, anticonvulsant therapy, careful fluid balance and electrolyte monitoring, and potentially the use of inotropes.
Cooling the baby (to around 34 degrees) to induce mild hypothermia can also prevent further damage by secondary reperfusion injury.
What is the presentation of Testicular torsion?
Sudden onset, severe pain in one testicle
Often follows minor trauma
High riding in the scrotum
Unilateral loss of cremaster reflex
No relief in pain on elevation of the testicle (negative Prehn’s sign)
What is the management of Testicular Torsion?
Management involves expedited surgical exploration with fixation of the testicles with orchidoplexy.
How do you monitor for complications of Kawasaki’s disease?
Associated with future development of coronary aneurysms - echocardiogram recommended to assess long term risk of myocardial ischaemia secondary to coronary aneurysm
What is Hirchsprung’s disease?
Can cause chronic constipation
As the baby develops in utero, the distal colon is not innervated correctly. The resulting aganglionic colon is shrunken and not able to distend properly. This causes a back pressure of stool trapped in the more proximal colon.
What is the presentation of Hirchsprung’s Disease?
Presents at brith with:
- a delay in passing meconium (>48 hours)
- a distended abdomen
- forceful evacuation of meconium after digital rectal examination
In later childhood, will have chronic history of constipation, poor response to movicol disimpaction regimes (laxatives) and poor weight gain
What is the diagnosis and management of hirchsprung’s disease?
Confirmed with a rectal suction biopsy - will show an absence of ganglion cells in colonic submucosa
Definitive management of Hirschsprung’s disease is through removal of the section of aganglionic colon and the healthy bowel is pulled through.
What is Juvenile Idiopathic Arthritis?
Juvenile idiopathic arthritis (JIA) is an umbrella term for a range of arthritides affecting children and young people where the cause is not clear. JIA is a diagnosis of exclusion for children <16 years old who have persistent joint swelling (>6 weeks). Different kinds of JIA include polyarthritis, oligoarthritis and systemic forms.
What is the presentation and diagnosis of JIA?
Systemic signs followed by joint pain:
- Fevers
- Malaise
- Salmon Pink rash
- Joing involvement can be in one or multiople joints
Diagnosis of exclusion (e.g exclude infections, malignancy and lupus)
What are the complications of JIA?
- Flexion contractures (requiring physio and splints)
- Joint destruction (requiring prostheses at young ages)
- Growth failure (from steroids and chronic disease)
- Anterior uveitis (causing visual impairment)
What is the management of JIA?
Psychological support to help coming to terms with using walking aids so early on in life
medical management:
- NSAIDs (symptom control only)
- Steroids (intra-articular or oral)
- Steroid-sparing agents e.g., methotrexate or biologics such as TNF-a inhibitors
What is the presentation of Measles?
Development of a fever above 40 degrees
Coryzal symptoms
Conjunctivitis followed by a rash about 2-5 days after onset of symptoms
Koplik spots are small grey discolourations of the mucosal membranes in the mouth and appear 1-3 days after symptoms begin during the prodrome phase of infection. They are pathognomonic for measles infection.
How is the diagnosis of Measles made?
1st: measles specific IgM and IgG serology (ELISA) is most sensitive 3-14 days after onset of the rash
2nd: measles RNA detection by PCR best for swabs taken 1-3 days after rash onset
What are the complications of Measles?
Acute otitis media
Bronchopneumonia
Encephalitis
Subacute sclerosing panencephalitis is a possible long-term complication, which can occur up to 10 years after initial measles infection
What sort of vaccine is the MMR vaccine?
LIve attenuated vaccine
What is the management of measles?
Supportive care which will normally include an antipyrexial
Vitamin A in all children under 2
Ribavarin may reduce the duration of symptoms but its use is not routinely recommended
What sort of murmur does a ventricular spetal defect cause?
Pan-systolic murmur most likely VSD
What is Eisenmenger syndrome?
Eisenmenger syndrome describes the reversal of a left-to-right shunt to a right-to-left shunt. It is thus an acquired right-to-left shunt.
What is the cause of Eisenmenger syndrome?
Increased pulmonary pressures cause changes in the pulmonary vasculature resulting in pulmonary hypertension
This results in the shunt reversing and is accompanied with right ventricular hypertrophy
What is the presentation and prognosis of Eisenmenger syndrome?
Typically occurs in late teens
Cyanosis
May develop right heart failure
rreversible and generally progresses to severe cardiac failure, often fatal by around age 40
What is the management of Eisenmenger syndrome?
Eisenmenger syndrome is best treated by prevention - i.e. identifying and promptly treating causes of left-to-right shunts
Otherwise, the treatment for Eisenmenger syndrome would be a heart-lung transplant, or palliation if this is not an option
What is transient synovitis?
Transient synovitis is a benign cause of limp in children from inflammation of the synovial lining of the hip joint.
What is the cause of transient synovitis?
Transient synovitis is generally preceded by a viral infection (particularly upper respiratory tract infections) 1-2 weeks before the onset of pain and limp.
The child may complain of pain in the hip itself or of knee pain (referred from the hip) and may have a low-grade fever.
What is the presentation of Tranisent Synovitis?
Distinguishing transient synovitis (‘irritable hip’ as an inflammatory reaction after a viral infection) and early septic arthritis (bacterial infection of the joint) can be a clinical challenge.
Both cause acute onset limp where the child avoids bearing weight and present with fever. Generally, the features of transient synovitis are milder than septic arthritis (mild/absent fever versus high fever, mild vs severe pain).
How is a diagnosis of transient synovitis made?
Investigations such as blood tests and imaging may be useful in providing evidence towards a diagnosis.
For example, raised white cell counts and raised inflammatory markers point towards septic arthritis, but may be normal or raised in either condition.
Similarly, ultrasound of the joint may show effusion and X-rays may be normal in either condition.
If the history, examination, bloods and X-ray do not give a clear diagnosis, or if there is a high index of clinical suspicion for septic arthritis, a joint aspirate under ultrasound guidance and blood cultures should be taken.
Microscopy, culture and sensitivity of the joint aspirate will distinguish between the two, as bacteria within the joint space confirms septic arthritis.
What is the management of Transient Synovitis?
Transient synovitis is managed with supportive treatment. Transient synovitis generally resolves in around 7 days with minimal risk of long-term damage to the joint.
What is the management of neonatal sepsis?
Initial investigations should include:
FBC, CRP and blood culture. A blood culture should be taken before the first dose of antibiotics
Strongly consider a lumbar puncture (LP). An LP is essential if neonatal meningitis is suspected.
Chest X-rays should only be performed if there is a strong suspicion of a chest source
NICE advises against a urine culture in early onset neonatal sepsis
CRP should be repeated by 24-36 hours after the initial dose of antibiotics
Empirical treatment: benzylpenicillin and gentamicin
This is further adjusted based on culture results and the clinical picture
Gentamicin levels require monitoring
What is Henoch Schonlein Purpura?
Henoch-Schonlein Purpura (HSP) is the most common small vessel vasculitis in children. It most commonly affects children aged 3-5 years old.
How does Henoch Schonlein Purpura present?
Purpura or petechiae on the buttocks and lower limbs
Abdominal pain
Arthralgia
Nephritis (haematuria +/- proteinuria)
May be pyrexial
HSP is commonly preceded by a viral upper respiratory tract infection
What is the management of Henoch Schonlein Purpura?
NSAIDs for analgesia and their anti-inflammatory effect
Antihypertensives may be needed to control blood pressure
After an episode of HSP, children should have regular urine dips for 12 months to check for renal impairment.
What is Transposition of great arteries?
Transposition of the great arteries (TGA) is a cyanotic congenital cardiac defect where the origins of the aorta and pulmonary artery are swapped
The most common form of congenital heart defect in infants of diabetic mothers
What is the aetiology of Transposition of great arteries?
In normal development, the aortopulmonary septum spirals
In TGA, this spiral doesn’t happen, which means that the aorta leaves the right ventricle and supplies the body while the pulmonary artery leaves the left ventricle and supplies the lungs
This in effect creates two parallel circulations and is not compatible with life without shunting via the ductus arteriosus and sometimes septal defects
How is the diagnosis of Transposition of the great arteries amde?
Most diagnoses are made antenatally
Neonates may be diagnosed postnatally when they are cyanotic at birth or may become cyanotic upon closure of the ductus arteriosus
What is the management of Transpositiong of great arteries?
Transposition of the great arteries requires surgery within the first few months of life to correct the defect
Patients may be started on Prostaglandin E infusions while they await surgery
What common x-ray fracture is found. in non-accidental injury?
Spiral fractures are complete fractures of long bones that result from a rotational force being applied along the axis of a bone while the other extremity is planted. Spiral fractures in children are a common sign of physical abuse because they are a result of forceful jerking or twisting of a limb
What is Impetigo?
Impetigo is a bacterial skin infection most often caused by Staphylococcus aureus or Streptococcus pyogenes. It can occur as a primary infection or as a complication of an existing condition, such as eczema. Impetigo presents with golden, crusted skin lesions usually around the mouth and nose.
What is the first line treatment of Impetigo?
With localised disease, first line treatment would be topical fusidic acid
What is Tonsilitis?
Tonsillitis is a form of pharyngitis where there is intense acute inflammation of the tonsils, often with a purulent exudate in bacterial tonsillitis.
Strep. Pneumoniae most common organism in recurrent tonsillitis. inchildren - EBV is another common cause
How do you differenetiate between bacterial and viral tonsilitis?
Bacterial more associated with cervical lymphadenopathy
Viral more associated with headache, apathy and abdominal pain
How do you diagnose Tonsilitis due to bacterial infection?
CENTOR criteria: 1 point for each of the following
- Tonsillar exudate
- Tender anterior cervical lymphadenopathy
- Fever over 38
- Absence of cough
What is the management of bacterial tonsillitis?
A Centor criteria score of 3/4 would warrant prescribing antibiotics or evidence of systemic upset/immunosuppression would warrent a course of antibiotics:
1st line: Penicillin V 500mg PO QDS for 5-10 days
Alternative in penicillin allergy: Clarithromycin/Erythromycin 250-500mg PO BD for 5 days
What are the main factors in constipation within children?
Low fibre diet
Dislike of using toilet
Pain on passing stool e.g., secondary to an anal fissure or very hard stool
Not recognising sensation of needing to pass stool
What is the best initial management of chronic constipation?
Initial treatment of chronic constipation is with a movicol disimpaction regimen
This is followed by maintenance movicol, alongside a high fibre diet and advice about encouraging good toileting habits
What is the management of ADHD?
Conservative:
Behavioural techniques
Extra support at school. However, ADHD does not generally affect intellectual ability.
Medical:
Stimulant medication such as methylphenidate. These medicines have some activity in the frontal lobe thus increasing executive function, attention, and reducing impulsivity.
What is muscular dystrophy?
Muscular dystrophy includes a range of conditions where muscles gradually break down and get progressively weaker over time. The most common form of muscular dystrophy is Duchenne muscular dystrophy (DMD). Becker’s muscular dystrophy is the second most common form, and one may view it as a milder version of Duchenne’s muscular dystrophy.
Caused by mutations that reduce expression of dystrophin - in duchenne its not expressed, in beckers. its at low level
Both inherited by X-link recessive mechanisms so vast majority of cases are male
What is the presentation of Duchenne’s muscular dystrophy?
Muscle wasting and weakness in early childhood
Usually wheelchair-bound before puberty and die from respiratory failure by their early twenties.
Children may have bulky-appearing muscles, as degenerated muscle is replaced by fat.
Parents may notice that the child ‘slips through their hands’ when they pick them up (due to loose muscles in the shoulder), and that they walk their arms up their legs when getting up from the floor (Gower’s manoeuvre, sign of proximal muscle weakness).
What is the presentation of Becker’s muscular dystrophy?
Muscle wasting and weakness presents in late childhood - Usually become wheelchair-bound in their teens commonly survive into their thirties.
How do you diagnose Muscualar dystrophy?
Genetic testing detects Duchenne’s muscular dystrophy in most cases. It has replaced muscle biopsy as the gold standard diagnostic test.
Muscle biopsies are sometimes performed, but they are not usually needed now that genetic testing is readily available
A creatinine kinase (CK) can be used as a first-line test to screen for muscular dystrophy
What is retinopathy of prematurity?
Retinopathy of prematurity is a cause of visual impairment in premature babies.
The mechanism of retinopathy of prematurity is thought to involve free radicals. Supplemental oxygen therapy creates free radicals which damage the retina and trigger proliferation of blood vessels on the retina. This can lead to retinal fibrosis, retinal detachment and ultimately blindness.
What is the indications and management of retinopathy of prematurity?
Indications for referral: Babies born at less than 32 weeks gestation or less than 1.5kg birth weight should be screened for retinopathy of prematurity with fortnightly fundoscopy by an ophthalmologist
Treatment: laser therapy
What is a characteristic sign of retinoblastoma?
Children with retinoblastoma present with a white eye reflex (loss of the normal red reflex) which parents might note on flash photography.
What is the ratio of breaths to rescue breaths in paeds?
5 rescue breaths initially then 15 chest compressions followed by 2 breaths and repeat 2 breaths 15 comrpessions
depth - 5 cm in adult sized children - babies and young children 2/3 chest depth
What is a contraindication to LP
Septicaemia - risk of coning
What is Ebstein’s anomaly?
Caused by lithium monotherapy normally
large right atrium and small right ventricle, usually due to low insertion of the tricuspid valve, which also causes tricuspid incompetence
How does Rickets present?
Vitamin D is required for bone mineralisation. Inadequate mineralisation causes soft bones, e.g. ‘bowed femurs’. Children with rickets can present with:
Aching bones and joints
Poor growth and development
Delayed dentition
Weakness
Constipation
Prematurity is a risk factor for vitamin D deficiency.
The diagnosis of rickets is made through a low blood level of vitamin D
There may be additional radiological evidence such as bowed femurs and widened epiphyseal plates
Management is oral vitamin D supplementation
What is Meconium aspiration syndrome?
The presence of meconium in the amniotic fluid may lead to development of meconium aspiration syndrome (MAS).
MAS is caused by passage of the meconium from the amniotic fluid into the foetal lungs.
This can cause blockage and inflammation of the airways and is associated with significant morbidity and mortality.
Can stain the skin of a baby and aspiration can result in respiratory distress
What are high risk objects that could be inhaled?
Batteries
Large objects that may become trapped at the pylorus
Absorbent materials that may cause obstruction
Magnets swallowed with metal objects
Lead-based objects
Objects containing toxins
