Child health Flashcards
What is perthes disease?
childhood orthopaedic condition characterized by idiopathic avascular necrosis of the femoral head
who does perthes disease occur in?
boys, aged 4-8
Aetiology of perthes disease?
HLA, genetic predis, vascular abn, trauma
staging of perthes disease?
Catteral staging
features of perthes disease
> Pain - most common.
limping - antalgic or trendeleburg
limited motion
leg length discrepency
what is trendeleburh due to?
abductor weakness
pain in perthes disease?
> pain localized to the hip, groin, or medial thigh.
The pain may be aggravated by activity and alleviated by rest.
In some cases, pain may be referred to the knee
radiological findings of perthes disease?
Findings include femoral head fragmentation, sclerosis, and flattening.
scans used for perthes?
> MRI - can detect early stages
bone scintigraphy
Cons management of perthes?
> pain management: analgesic, anti-inflammtories
physical therapy
orthotic devices
surgical management of perthes?
> Indications for surgery include persistent pain, progressive deformity, or failed conservative management
complications of perthes?
> residual deformaty
osteoarth
leg length discrepancy
femoracetabular impingement
avascular necrosis recurrence
DDH?
> Often picked up on newborn examination
Barlow’s test, Ortolani’s test are positive
Unequal skin folds/leg length
Transient synovitis (irritable hip)
> Typical age group = 2-10 years
Acute hip pain associated with viral infection
Commonest cause of hip pain in children
FEATURES OF PERTHES DISEASE xr
x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening
slipped femoral epiphysis epi?
> Typical age group = 10-15 years
More common in obese children and boys
how does slipped uppe femoral epiphysis present?
May present acutely following trauma or more commonly with chronic, persistent symptoms
features of slipped upper femoral epiphysis?
knee or distal thigh pain is common
loss of internal rotation of the leg in flexion
features of juvenile idiopathic arthirits?
joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows
JIA is?
limp
what can be positive in JIA?
ANA - assoc w anterior uveitis
septic arthi?
Acute hip pain associated with systemic upset e.g. pyrexia. Inability/severe limitation of affected joint
SUFE epi?
> head of femur slips along growth plate
more common in boys and obese children
presentation of SUFE?
The typical exam presentation is an adolescent, obese male undergoing agrowth spurt. There may be a history ofminor traumathat triggers the onset of symptoms. Suspect SUFE if the pain is disproportionate to the severity of the trauma.
Sx of SUFE?
> Hip, groin, thigh or knee pain
Restricted range of movement in the hip
Painful limp
SUFE examination?
When examining the patient, they will prefer to keep the hip inexternal rotation. They will have limited movement of the hip, particularlyrestricted internal rotation.
SUFE dx?
> XR
BTs normal
bone scan, CT, MRI
Mx of SUFE?
Surgery - returns femoral head to correct position
septic arthiritis is most common in?
kids under 4
septic arthiritis is a common comp of?
joint replacement
presentation of SA?
Septic arthritis usually only affects a single joint. This is often a knee or hip. It presents with a rapid onset of:
> Hot, red, swollen and painful joint
Refusing to weight bear
Stiffness and reduced range of motion
Systemic symptoms such as fever, lethargy and sepsis
Most common cause of SA?
> STAPH A
Neisseria gonorrhoea (gonococcus) in sexually active teenagers
Ix in SA?
> joint aspiration b4 ab if poss - send for gram staining, culture, ab sensitivities
Mx of SA?
> IV ab
surg drainage and washout of joint
what is osteomyelitis?
> inflammation of bone, usually due to bacteria - mostly staph aureus
key RF for osteomyelitis?
> open fractures
Orthopaedic operations, particularly with prosthetic joints
Diabetes, particularly with diabetic foot ulcers
Peripheral arterial disease
IV drug use
Immunosuppression
The typical presentation of osteomyelitis is with:
> Fever
Pain and tenderness
Erythema
Swelling
osteomyelitis XR findings?
> often normal in early disease
Periosteal reaction (changes to the surface of the bone)
Localised osteopenia (thinning of the bone)
Destruction of areas of the bone
Imaging for osteomyelitis?
> MRI
Blood tests will show raised inflammatory markers (e.g., WBC, CRP and ESR).
Blood cultures and bone cultures
Mx of osteomyelitis?
> Surgical debridement of the infected bone and tissues
Antibiotic therapy
Ab req for acute osteomyelitis?
> 6 weeks of flucloxacillin, possibly with rifampicin or fusidic acid added for the first 2 weeks
Alt to flucloxacillin for osteomyelitis?
> Clindamycin in penicillin allergy
Vancomycin or teicoplanin when treating MRSA
chronic osteomyelitis?
usually requires 3 months or more of antibiotics.
diagnosis of SA?
> The Kocher criteria for the diagnosis of septic arthritis:
fever >38.5 degrees C
non-weight bearing
raised ESR
raised WCC
Red flags that may indicate an underlying serious disease or condition in a child presenting with an acute limp include
Pain waking the child at night — may indicate malignancy.
Redness, swelling, or stiffness of the joint or limb — may indicate infection or inflammatory joint disease.
Weight loss, anorexia, fever, night sweats, or fatigue — may indicate malignancy, infection, or inflammation.
Unexplained rash or bruising — may indicate haematological or inflammatory joint disease, or child maltreatment.
Limp and stiffness worse in the morning — may indicate inflammatory joint disease.
Unable to bear weight or painful limitation of range of motion — may indicate trauma or infection.
Severe pain, anxiety, and agitation after a traumatic injury — may indicate neurovascular compromise or impending compartment syndrome.
A palpable mass — may indicate malignancy or infection
What is muscular dystrophy?
umbrella term for genetic conditions that cause gradual weakening and wasting of muscles.
Gowers sign?
Children withproximal muscle weaknessuse a specific technique to stand up from a lying position. This is calledGower’s sign.
there is a 5 year old boy presenting with vague symptoms of muscle weakness and the description is that you notice them using their hands on their legs to help them stand up, the answer is probably
Duchennes muscular dystrophy. They may ask “what is the underlying genetic inheritance of the most likely cause?” The answer is X-linked recessive.
Mx of DMD?
> Imp QOL - occupational therapy, physiotherapy and medical appliances (such as wheelchairs and braces)
surgical and medical management of complications such as spinal scoliosis and heart failure.
What is DMD?
> Most common dystrophy
caused by defective gene for dystrophin on CX
X LINKED RECESSIVE
DMD presentation?
> Boys with Duchennes present around 3 – 5 years with weakness in the muscles around their pelvis.
The weakness tends to be progressive and eventually all muscles will be affected.
They are usually wheelchair bound by the time they become a teenager.
Beckers muscular dystrophy?
> dystrophin gene less affecred
symptoms appear 8-12 yrs
myotonic dystrophy presents in?
adulthood
TP of myotonic dystrophy?
> Progressive muscle weakness
Prolonged muscle contractions
Cataracts
Cardiac arrhythmias
key feature of myotonic dystrophy?
> prolonged muscle contraction - unable to let go of something, unable to release grip on something
Facioscapulohumeral Muscular Dystrophy
> usually presents in childhood
weakness around face> shoulders > arms
classical initial symptom of facioscuapulohumeral dystrophy?
> A classic initial symptom is sleeping with their eyes slightly open and weakness in pursing their lips.
They are unable to blow their cheeks out without air leaking from their mouth.
Oculopharyngeal Muscular Dystrophy pres?
usually presents in late adulthood with weakness of theocular muscles(around the eyes) andpharyn
Oculopharyngeal Muscular Dystrophy features?
bilateral ptosis, restricted eye movement and swallowing problems. Muscles around the limb girdles are also affected to varying degrees.
Limb girdle dystrophy?
Limb-girdle muscular dystrophy usually presents in teenage years with progressive weakness around the limb girdles (hips and shoulders).
Emery-Dreifuss Muscular Dystrophy
> Emery-Dreifuss muscular dystrophy usually presents in childhood with contractures, most commonly in the elbows and ankles.
Patients also suffer with progressive weakness and wasting of muscles, starting with the upper arms and lower legs.
gait in DMD?
waddling gait
DMD Ix?
CK - nearly always raised. Genetic testing uded to confirm diagnosus
DMD - what to check?
it is important to check thecreatine kinase levelin children whocannot walk by 18 months of ageto screen for MD
Predicted heigh calc?
> Boys: (mother height + fathers height + 14cm) / 2
Girls: (mothers height + father height – 14cm) / 2
complications of GORD in kids?
> reflux oesophagitis
recurrent aspiration pneumonia
recurrent otitis media
dental erosion
Tx of GORD in kids?
1) Gaviscon infant - dual satchets
2) Ranitidine/ Omeprazole – oral suspension (2mg/ml)
Sig of bile stained vomiting?
In neonates or infants it is an indication of bowel obstruction until proven otherwise
intussuption?
> v young - can have non billous vomiting/no pain/ well
Dance’s sign - empty RIF
USS usually +
double bubble sign?
duodenal atresia
bowel obst?
dilated bowel loops
air enema can be seen in?
inters
overflow soiling?
> v loose, smelly, passed without sensation or awareness
Hirscsprungs disease?
absence of air in bowel, constipation
Mx of const?
> bristol stool chart
bowel habit diary
ribbon stool pattern?
anal stenosis
GE is a ? Diseease
notifiable - let HPA know
assessing dehydration/ shock?
> unwell
lethargic
pale/ mottled skin
cold extremities
sunken eyes
dry membranes/ skin turgor
tachycardia/ tachypnoea
No dehydration?
continue BF, ORS as supplement, no fruit juices
Dehydrated but at home (under 5)
> less than 5 yrs = 50ml/kg for deficit over 4 hrs + maintenance ORS
Dehydrated but at home (over 5)
> 200ml ORS after each loose stool plus normal fluid intake
5 ml/kg ORS after each watery stool to prevent recurrence
avoid ? Until dehydration corrected?
solids
most common cause of coeliac disease?
coeliac
sign of coeliac?
dermatitis herpetiformis
eneuresis?
> considered normal under 5 yrs
over 5 at leasr 2x week
RF for enuresis?
> FH
males
const, faecal impaction
sleep apnoea
developmental delay
Mx of daytime wetting?
> double voiding bladder retraining
oxybutynin or imipramine (AM)
Mx noctural enuresis?
> first line: alarm system
desmopressin
How can constipation present?
> Less than 3 stools a week
Hard stools that are difficult to pass
Rabbit dropping stools
Straining and painful passages of stools
Abdominal pain
Holding an abnormal posture, referred to as retentive posturing
Rectal bleeding associated with hard stools
Faecal impaction causing overflow soiling, with incontinence of particularly loose smelly stools
Hard stools may be palpable in abdomen
Loss of the sensation of the need to open the bowels
what is encopresis?
> faecal inc
not pathological until 4
usually sign of chronic const
Large hard stools remain in the rectum and only loose stools are able to bypass the blockage and leak out, causing soiling.
what else can cause encopresis?
> spinal bfidia
hirschrpungs disease
CF
LF in const?
Habitually not opening the bowels
Low fibre diet
Poor fluid intake and dehydration
Sedentary lifestyle
Psychosocial problems such as a difficult home or school environment (always keep safeguarding in mind)
secondary causes of const?
> hirschprungs disease
CF - meconium ileus
hypothyroid
abuse
cows milk intolerance
anal stenosis
Constipation red flags - not passing…
Not passing meconiumwithin 48 hours of birth (cystic fibrosis or Hirschsprung’s disease)
Constipation red flags - neurological…
Neurologicalsigns or symptoms, particularly in the lower limbs (cerebral palsy or spinal cord lesion)
constipation red flags - vomiting?
Vomiting(intestinal obstruction or Hirschsprung’s disease)
constipation red flags - anb anus?>
anal stenosis, inflammatory bowel disease or sexual abuse)
constipation red flags - FTT?
oeliac disease, hypothyroidism or safeguarding)
Const red flags - acute severe abd pain and bloating?
obstruction or intussusception)
comps of constipation?
Pain
Reduced sensation
Anal fissures
Haemorrhoids
Overflow and soiling
Psychosocial morbidity
first line laxative?
Movicol
Faecal impaction may require a
disimpaction regimenwith high doses of laxatives at first
constipation lifestyle?
Correct any reversible contributing factors, recommend a high fibre diet and good hydration
Encourage and praise visiting the toilet. This could involve scheduling visits, a bowel diary and star charts.
It is normal for babies to have some reflux after larger feeds. It becomes more troublesome when this causes them to become distressed. Signs of problematic reflux include:
> Chronic cough
Hoarse cry
Distress, crying or unsettled after feeding
Reluctance to feed
Pneumonia
Poor weight gain
causes of vomiting?
Overfeeding
Gastro-oesophageal reflux
Pyloric stenosis (projective vomiting)
Gastritis or gastroenteritis
Appendicitis
Infections such as UTI, tonsillitis or meningitis
Intestinal obstruction
Bulimia
Vomiting - red flags - not keeping down food?
pyloric stenosis or intestinal obstruction
Vomiting - red flags - projectile/ or forceful vomiting?
pyloric stenosis or intestinal obstructio
vomiting - bile stained?
IO
vomiting - haematemsis/ melena?
peptic ulcer, oesophagitis or varices
vomiting - abd distension?
(intestinal obstruction
vomiting - Reduced consciousness, bulging fontanelle or neurological signs
meningitis or raised intracranial pressure)
vomiting - blood in stool?
astroenteritis or cows milk protein allerg
vomiting, rashing, angioedema?
cows milk protein allergy
Advice on managing vomiting?
> Small, frequent meals
Burping regularly to help milk settle
Not over-feeding
Keep the baby upright after feeding (i.e. not lying flat)
Tx of severe vomiting?
> Gaviscon mixed with feeds
Thickened milk or formula (specific anti-reflux formulas are available)
Proton pump inhibitors (e.g., omeprazole) where other methods are inadequate
Sandifer’s Syndrome
> causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants.
torticollis - forceful contraction of the neck -> twisting
dystonia - abnormal muscle contractions causing twisting movements, arching of the back or unusual postures
Pyloric stenosis presentation?
> typically presents in the first few weeks of life, with a hungry baby that is thin, pale and generally failing to thrive.
projectile vomiting
examination findings in pyloric stenosis?>
f examined after feeding, often the peristalsis can be seen by observing the abdomen. A firm, round mass can be felt in the upper abdomen that “feels like a large olive”. This is caused by thehypertrophicmuscle of thepylorus.
PS ABG?
hypochloric(low chloride)metabolic alkalosisas the baby is vomiting thehydrochloric acidfrom the stomach.
diagnosis of PS?
abd US - shows thickened pylorus
Tx of PS?
Treatmentinvolves alaparoscopic pyloromyotomy(known as “Ramstedt’s operation“). An incision is made in the smooth muscle of the pylorus to widen the canal allowing that food to pass from the stomach to the duodenum as normal.P
Key conditions to think about in patients with loose stools are:
> Infection (gastroenteritis)
Inflammatory bowel disease
Lactose intolerance
Coeliac disease
Cystic fibrosis
Toddler’s diarrhoea
Irritable bowel syndrome
Medications (e.g. antibiotics)
Most common cause of GE?
Rotavirus
E coli GE?
> Abd cramps, vomiting, bloody diarrgoea
HUS?
> E coli
use of ab inc risk
how is e coli spread?
It is spread through contact with infected faeces, unwashed salads or contaminated water.
Camplyobacter jejuni?
> most common cause of bac GE worldwide
spread by:
Raw or improperly cooked poultry
Untreated water
Unpasteurised milk
Symptoms of Camp GE?
> Incubation is usually 2 to 5 days. Symptoms resolve after 3 to 6 days. Symptoms are:
> Abdominal cramps
Diarrhoea often with blood
Vomiting
Fever
How is shigella spreaD?
spread by faeces contaminating drinking water, swimming pools and food
inc period for shigella?
he incubation period is 1 to 2 days and symptoms usually resolve within 1 week without treatmen
shigella GE?
causes bloody diarrhoea, abdominal cramps and fever
Which toxins produce HUS?
Shigella and E coli
salmonella spread?
Salmonellais spread by eating raw eggs or poultry, or food contaminated with the infected faeces of small animals.
salmonella inc period?
Incubation is 12 hours to 3 days and symptoms usually resolve within 1 week.
salmonella symptoms?
Symptoms are watery diarrhoea that can be associated with mucus or blood, abdominal pain and vomiting
bac cereus spread?
Bacillus cereus is agram positive rodspread through inadequately cooked food. It grows well on food not immediately refrigerated after cooking. The typical food isfried riceleft out at room temperature.
bac cereus time frame?
The typical course is vomiting within 5 hours, then diarrhoea after 8 hours, then resolution within 24 hours.
yersinia?
> raw/ undercooked porj
also spread through contamination with the urine or faeces of other mammal such as rats and rabbits.
most commonly affects kids
inc of yersinia?
Incubation is 4 to 7 days and the illness can last longer than other causes of enteritis with symptoms lasting 3 weeks or more.
how can yersinia present in older kids?
Older children or adults can present with right sided abdominal pain duemesenteric lymphadenitis(inflammation in the intestinal lymph nodes) and fever. This can give the impression ofappendicitis.
staph a foods?
Staphylococcus aureuscan produceenterotoxinswhen growing on food such as eggs, dairy and meat.
staph a time course?
start within hours of ingestion and settle within 12 to 24 hours
Giardiasis?
> parasite
faecal oral transmission
RF for giardiasis?
> foreign travel
swimming/drinking water from a river or lake
male-male sexual contact
most common cause of travellers diarrhoea?
E coli
E coli summary?
> Common amongst travellers
Watery stools
Abdominal cramps and nausea
Giardiasis?
Prolonged, non-bloody diarrhoea
Cholera?
> Profuse, watery diarrhoea
Severe dehydration resulting in weight loss
Not common amongst travellers
Shigella?
> Bloody diarrhoea
Vomiting and abdominal pain
Staph A?
> Severe vomiting
Short incubation period
campb?
> A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which may be bloody
May mimic appendicitis
comp of campb?
GBS
bac cereus?
> Two types of illness are seen
vomiting within 6 hours, stereotypically due to rice
diarrhoeal illness occurring after 6 hours
Amoebiasis?
Gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several weeks
1-6 hrs incubation ?
Staphylococcusaureus and Bacillus cereus
12-48 hrs?
Salmonella,Escherichia coli
48-72 hrs
Shigella,Campylobacter
> 7 days?
giardiasis, amoebiasis
Mx of giardiasis?
Metronidazole
Mx of cholera?
- Doxycycline or 2. Ciprofloxacin
Mx of shigella?
- Ciprofloxacin or 2. Azithromycin
Mx of campb?
Clarithromycin
Mx of Bac cerus?
Self Limiting OR Severe = Vancomycin
Mx of amoebiasis?
Metronidazole + + Diloxanide Furoate
Bloody diarrhoea?
> Bloody diarrhoea (Blood SAC)
- Shigella
- Amoebiasis (gradual onset)
- Campy (flu s+s)
ab in coeliac?
anti-TTG abd anti EMA
inflammation in coeliac?
Inflammation affects the small bowel, particularly thejejunum. It causesatrophyof theintestinal villi.
Sx of coeliac?
> Failure to thrive in young children
Diarrhoea
Fatigue
Weight loss
Mouth ulcers
Anaemia secondary to iron, B12 or folate deficiency
Dermatitis herpetiformis is an itchy blistering skin rash that typically appears on the abdomen
watery diarrhoea?
Watery diarrhoea (Water CCCEG)
- Cholera (rice water diarrhoea)
- Cryptosporidiosis (most common protozoal cause in UK)
- Can be Campy
- E.coli (traveller)
- Giardiasis (fatty stool)
Neuro symptoms of coeliac?
> Peripheral neuropathy
Cerebellar ataxia
Epilepsy
Test all T1D patients for…
coeliac
gene is coeliac?
HLA-DQ2
Testing for coeliac ab?
test for TTG and EMA, test total IgA levels as some ppts have igA deficiency
Endoscopy and intestinal biopsy show (coeliac)
“Crypt hypertrophy”
“Villous atrophy”
Comps of untreated coeliac?
> osteoporosis
EATL
non hodgkins lymphoma
Tx of coeliac?
lifelong gluten free diet
causes of intestinal obst?
> Meconium ileus
Hirschsprung’s disease
Oesophageal atresia
Duodenal atresia
Intussusception
Imperforate anus
Malrotation of the intestines with a volvulus
Strangulated hernia
Presentation of intestinal obst?
> pers vomiting, might be billous (containing bright green bile)
abd pain & distention
high pitched, tinkling bowel sounds, absent later
Ix of intestinal obst?
> abd XR
This may show dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction.
There will also be absence of air in the rectum.
Mx of intest obst?
> paeds surgical unit as an emergency
make them nbm abd insert nasogastric tube
IV fluids to correct dehydration
Hirscsprungs disease is caused by?
> absence of parasympathetic ganglion cells
occurs when the parasympathetic ganglion cells do not travel all the way down the colon, and a section of colon at the end is left without these parasympathetic ganglion cells.
pathophys of hirscprungs disease?
> aganglionic sections become constricted as they cannot relax
loss of movement of faeces -> bowel obst
Genetic associations of hirschsprungs disease?
> downs
neurofiromatosis
waardenburg syndrome
MEN 2
Waardenburg syndrome
a genetic condition causing pale blue eyes, hearing loss and patches of white skin and hair
Symptoms of hirscprungs?
> Delay in passing meconium (more than 24 hours)
Chronic constipation since birth
Abdominal pain and distention
Vomiting
Poor weight gain and failure to thrive
Hirschsprung-Associated Enterocolitis
> inflammation abd obst of intestine
ypically presents within 2-4 weeks of birth with fever, abdominal distention, diarrhoea (often with blood) and features of sepsis.
what can HAEC lead to?
> It is life threatening and can lead to toxic megacolon and perforation of the bowel.
It requires urgent antibiotics, fluid resuscitation and decompression of the obstructed bowe
Ix of hirschspring
> Abd XR - bowel obst
rectal biopsy
Mx of hirschsprung?
> Unwell children and those with enterocolitis will require initial fluid resuscitation and management of the intestinal obstruction.
IV antibiotics are required in HAEC.
def Mx of hirschsprung?
Definitive management is bysurgical removalof theaganglionicsection of bow
Intussusception occurs in?
> infants 6 months - 2 yrs
more common in boys
What is Intussusception assoc w ?
> concurrent vital illness
HSP
CF
key feature of intussuception?
Redcurrantjelly stool
Presentation of tussuscepeption?
> severe, colicky abd pain
pale, lethargic, unwell
RUQ mass on palpation - sausage shaped
intest obstruction and vomiting
Ix of intussception?
US
Mx of intussception?
> therapeutic enemas
surgical reduction if enemas don’t work
surgical resection if bowel becomes gangerenous
comps of intussception?
> Obstruction
Gangrenous bowel
Perforation
Death
appendicitis?
> abd pain - starts central then moves to RIF
appendicitis - palpation?
> On palpation of the abdomen there is tenderness in McBurney’s point.
This is a localised area one third the distance from the anterior superior iliac spine (ASIS) to the umbilicus.
CFs of appendicitis?
> anorexia
N and V
Rosvings sign
rebound tenderness and guarding (peritonitis)
percussion tenderness
Rosvings sign?
> palpation of the left iliac fossa causes pain in the RIF
Diagnosis of appendicitis?
> CP and raised inflammatory markers
CT can be done to confitm
US in female patients to exclude gynae
signs of appendicitis but Ix negative means….
> diagnostic laparoscopy
DDs of appendicitis?
> ectopic pregnancy
ovarian cysts
meckles diverticulum
appendix mass
Meckel’s Diverticulum
Meckel’s diverticulum is a malformation of thedistal ileum. It is usually asymptomatic, however it can bleed, become inflamed, rupture or cause avolvulusorintussusception.
Mesenteric Adenitis
> Mesenteric adenitis describes inflamed abdominal lymph nodes.
This presents with abdominal pain, usually in younger children.
This is often associated with tonsillitis or an upper respiratory tract infection.
Mx of appendicitis?
> appendicectomy
laparoscopic fewer SE vs laparotomy
PS summary?
> Projectile non bile stained vomiting at 4-6 weeks of life
Diagnosis is made by test feed or USS
Mesenteric Adenitis?
> Central abdominal pain and URTI
Conservative management
intestinal malrotation?
> High caecum at the midline
Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia
May be complicated by the development of volvulus, an infant with volvulus may have bile stained vomiting
Oesophageal atresia
> Associated with tracheo-oesophageal fistula and polyhydramnios
May present with choking and cyanotic spells following aspiration
Necrotising enterocolitis main RF?
PREMATURITY. Also Increased risk when empirical antibiotics are given to infants beyond 5 days
features of nec enterocolitis?
> abd distension
passage of bloody stools
XR of nec enterocolitis?
> X-Rays may show pneumatosis intestinalis and evidence of free air
Tx of nec enterocolitis?
Treatment is with total gut rest and TPN, babies with perforations will require laparotomy
Arrange same-day hospital admission if there is associated:
Bile-stained (green or yellow-green) vomiting, abdominal tenderness, mass, and/or distension — suggesting intestinal obstruction or another acute surgical condition needing paediatric surgery assessment.
SBO features on abd XR?
> Dilated bowel
central abd location
lines completely crossing bowel
LBO features on XR?
> Dilated bowel
peripheral location
and haustral lines visible (lines not completely crossing the bowel, ‘indents that go Halfway are Haustra’)
Mx of child constipation - faecal impaction?
> Movicol paed plain - first line
2) stimulant laxative if disimpaction not achieved within 2 weeks
Mx of child const?
1) movicol
2) add stimulant laxative
3) substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated.
Mx of constipation in babies < 6 months?
> bottle-fed infants: give extra water in between feeds. Try gentle abdominal massage and bicycling the infant’s legs
breast-fed infants: constipation is unusual and organic causes should be considered
Infants who have been weaned - constipation Mx?
> offer extra water, diluted fruit juice and fruits
if not effective consider adding lactulose
Children at inc risk of dehydration?
> children under 1
low birth weight
vomited more than 3x in 24 hrs
6x+ diarrhoea in 24 hrs
stoooed breastfeeding in illness
features suggestive of hypernatreamic dehydration?
> jittery movements
increased muscle tone
hyperreflexia
convulsions
drowsiness or coma
For children with no evidence of dehydration
> continue breastfeeding and other milk feeds
encourage fluid intake
discourage fruit juices and carbonated drinks
If dehydration is suspected:
> give 50 ml/kg low osmolarity oral rehydration solution (ORS) solution over 4 hours, plus ORS solution for maintenance, often and in small amounts
continue breastfeeding
consider supplementing with usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks)
most common cause of chronic diarrhoea in children?
cows milk intolerance
CF of toddlers diarhoea?
> frequent, poorly formed brown and slightly offensive stools
food material easily recognisable in the stools is a hallmark feature
what is the child normally like in toddlers diarrhoea?
Despite persisting diarrhoea the child is constitutionally well, normally active and has unimpaired growth. The child has a normal appetite and a normal or increased fluid intake.
diet in toddlers diarrhoea?
high fruit intake of fruit juices
Mx of toddlers diarrhea?
reassurance & avoidance of fulll strength fruit juices
always consider UTI in children w?
Fevermay be the only symptom of a urinary tract infection, especially in young children. Always consider (and exclude) a urinary tract infection in a child with a temperature, unless there is a clear alternative source of infection.
Symptoms of UTI in babies?
non specific: Fever
Lethargy
Irritability
Vomiting
Poor feeding
Urinary frequency
Signs and symptoms in of UTIs older infants and children are more specific:
> Fever
Abdominal pain, particularly suprapubic pain
Vomiting
Dysuria (painful urination)
Urinary frequency
Incontinence
Diagnosis of Pyelo is made if there is either:
> A temperature greater than 38°C
Loin pain or tenderness
Urine dipstick results in UTI?
> Nitrite + - best measure
leucocyte esterase + - don’t treat as UTI if only this is present
tests in UTI?
> Dipsrick > send to microbiology if positive
MSU sent for culture and sensitivity testing
Mx of a UTI - all children under 3 should have…
> All children under 3 months with a fever should start immediate IV antibiotics (e.g. ceftriaxone) and have a full septic screen, including blood cultures, bloods and lactate.
A lumbar puncture should also be considered.
Mx of UTI - children over 3 months?
> oral ab if othewise well
if features of sepsis or pyelo, treat w IV ab
Typical antibiotic choices in urinary tract infections in children are:
> Trimethoprim
Nitrofurantoin
Cefalexin
Amoxicillin
All childrenunder 6 monthswith their firstUTI should have an abdominal ultrasound within ? weeks
All childrenunder 6 monthswith their firstUTI should have an abdominal ultrasound within 6 weeks, or during the illness if there are recurrent UTIs or atypical bacteria
children w recurrent UTIs should have ? Within ? Weeks
abdominal ultrasound within 6 weeks
Children withatypical UTIsshould have an abdominal ultrasound
during the illness
DMSA scan?
> DMSA scans should be used 4 – 6 months after the illness to assess for damage from recurrent or atypical UTIs.
patches of reduced uptake -> scarring
VUR?
> Vesico-ureteric reflux (VUR) is where urine has a tendency to flow from the bladder back into the ureters.
This predisposes patients to developing upper urinary tract infections
MCUG used to diagnose
when should an MCUG be used?
(MCUG) should be used to investigate atypical or recurrent UTIs in childrenunder 6 months. It is also used where there is a family history ofvesico-ureteric reflux,dilatation of the ureteron ultrasound orpoor urinary flow.
Mx of UTIs?
> children less than 3 months - refer to paeds
ab prophylaxis for recurrent UTIs
children aged more than 3 months old with a lower UTI should be treated
with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin
children aged more than 3 months old with an upper UTI should be
considered for admission to hospital. If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
Ix for haematuria and proteinuria?
> urinalysis
FBC, u&Es, clotting
ACR
GFR
Primary nocturnal enuresis
where the child has never managed to be consistently dry at night.
Causes of PNE?
> Most common: variation of normal development
OAB
Fluids before bed
failure to wake
secondary causes of PNE?
chronic constipation, urinary tract infection, learning disability or cerebral palsy
first line PNE?
The initial step in management of primary nocturnal enuresis is to establish the underlying cause. It can be helpful to keep a2 week diaryof toileting, fluid intake and bedwetting episodes
management of PNE?
> Reassurance of under 5s that it is likely to resolve w/o Tx
lifestyle changes
treat underlying causes like constipation
eneuresis alarms
what is secondary NE?
> where a child begins wetting the bed when they have previously been dry for at least 6 months. This is more indicative of an underlying illness than primary enuresis.
Causes of secondaru NE?
> UTI
const
T1D
psych problems or maltreatment
what is diurnal enuresis?
daytime incontinence. Dry at night but episodes of incontinence during the day
2 types of diurnal eneuresis?
> Urge incontinence is an overactive bladder that gives little warning before emptying
Stress incontinence describes leakage of urine during physical exertion, coughing or laughing.
meds for eneuresis?
> desmopressin
oxybutinin
imipramine
primary assessment of child w decreased LOC?
> ABCDE
D: use GCS or ACVPU
What would suggest ICP in a previously normal child?
decorticate or decerebrate positioning
CI of LP?
> Signs of raised ICP
neurological signs
prolonged/ focal seizures
GCS under 13
dilated pupils
Dolls eye reflex
abn posture - decorticate or decerebrate
coag disorder
dolls eye reflex?
> CI of LP
eyes should move opp to head movement
if dolls eye reflex is absent and eyes move W the head -> BS dysfunction
cushings triad?
> slow HR
abn breathing
Widening pulse pressure (raised bp)
> late sign of raised ICP
Mx of ICP?
> reduce pCO2 by hyperventillating
Head elevation to 30
mannitol or hypertonic saline
catheter and monitor u/o
Mx of oedema in a SOL?
Dexamethasone
cerebral perfusio pressure?
> cerebral perfusion pressure (CPP) is the net pressure gradient causing cerebral blood flow to the brain
CPP = mean arterial pressure - ICP
causes of raised ICP?
> Idiopathic intercranial HTN
traumatic head injuries
hydrocephalus
meningitis
tumours
features of raised ICP?
> headache
vomiting
reduced levels of consciousness
papilloedema
Ix for raised ICP?
> CT/MRI - looking for underlying cause
ICP - removing CSF?
> repeated lumbar puncture (e.g. idiopathic intracranial hypertension)
ventriculoperitoneal shunt (for hydrocephalus)
Immediate management of a child with raised ICP?
> abc assessment
Oxygen
GCS
tilt head up
O2
Mannitol
Dexamethasone
A?
> Consider intubation if GCS is <8 (or patient is unresponsive to pain on the AVPU), unless the child is showing signs of improvement.
> Give 100% oxygen if oxygen saturations are ≤95%.
Circ?
Circulatory compromise should be considered if one or more of the following are present:
> mottled, cool extremities
diminished peripheral pulses.
Consider circulatory shock if one or more of the following are present:
> systolic blood pressure is less than fifth percentile for age
decreased urine output <1 mL/kg/hour
differentials for decreased LOC?
> Meningitis
acute hydrocephalus
hypoglycaemia
intoxication
HTN
Sepis?
> htn
tachycardia
tachypnoea
WCC raised
non blanching rash
