Child health 3 Flashcards
1
Q
Bacteraemia vs septicaemia
A
> bacteraemia = presence of bacteria in the BS
septicaemia = presence of pathogens in the BS -> sepsis
2
Q
Diagnosing infections
A
> urine
blood tests & culture
CXR
lumbar puncture for CSF
resp secretions
swabs
3
Q
Croup
A
> viral
hoarse voice
barking cough
resp distress
4
Q
Epiglottis
A
> Bacterial
child looks septic, drooling, soft stridor
avoid examining
call for senior help
5
Q
chemoprophylaxis
A
> refers to the administration of a medication for the purpose
of preventing disease or infection
6
Q
When should vaccines be avoided
A
during febrile illness
7
Q
absolute CI to vaccines
A
> Absolute CI: severe local or generalised reaction previously
Not given when on systemic steroids or immunosupression
8
Q
Gap between ig and live vaccine administration
A
12 week gap between human immunoglobulin and live vaccine administration
9
Q
vaccines: egg allergy
A
influenza, yellow fever, hepatitis A
10
Q
What could be causing a pyrexia of unknown origin
A
> Infectious diseases – bacterial, viral, fungal, parasitic
Connective tissue disorders
Malignancy
Miscellaneous
• Drug fever
• Inflammatory bowel disease
• Sarcoidosis
11
Q
Kawasaki disease
A
> fever lasting 5+ days without any other cause
at least 4 out of 5:
• Bilateral non-purulent conjunctivitis
• Polymorphous rash
• Cervical lymphadenopathy
• Peripheral peeling / oedema / erythema
• Oral mucous membrane changes
12
Q
Causes of stridor in children
A
> Croup
acute epiglottis
laryngomalacia
inhaled foreign body
13
Q
Features of inhaled foreign body
A
> Features are of sudden onset
coughing
choking
vomiting
stridor
14
Q
Laryngomalacia
A
> Congenital abnormality of the larynx.
Infants typical present at 4 weeks of age with:
stridor
15
Q
What is croup
A
> upper resp TI seen in infants and toddlers
stridor from laryngeal oedema and secretions
caused by parainfluenza viruses
more common in autumn
16
Q
CF of croup
A
> cough - barking, worse at night
stridor (do not examine throat at the risk of prec airway obstruction)
fever
coryzal symptoms
inc work of breathing e.g. retraction
17
Q
Grading severity of croup
A
> Image
18
Q
Ix for croup
A
> Most diagnosed clinically
if a CXR is done:
PA view will show subglottic narrowing - steeple sign
lateral view will show swelling of the epiglottis - thumb sign
19
Q
Mx of croup
A
> single dose of dexamethasone to all kids regardless of severity
predinsolone is the alt
20
Q
Emergency Tx of croup
A
> high-flow oxygen
nebulised adrenaline
21
Q
Epiglottitis
A
> caused by haemophilus influenza type B -> swelling can completely occlude airways -> life threatening
children vaccinated against haemophilus (higher risk in unvaccinated kids)
22
Q
Presentation of epiglottitis in exams
A
> unvaccinated child presenting with a fever, sore throat, difficulty swallowing that is sitting forward and drooling and suspect epiglottitis.
23
Q
Presentation Suggesting Possible Epiglottitis
A
> Patient presenting with a sore throat and stridor
Drooling
Tripod position, sat forward with a hand on each knee
High fever
Difficulty or painful swallowing
Muffled voice
Scared and quiet child
Septic and unwell appearance
24
Q
investigations for epiglottitis
A
> if ppt acutely unwell then do not perform Ix
XR of neck shows thumb sign - soft tissue shadow that looks like a thumb pressed into the trachea.
25
Mx of eoglottitis
> do not distress the child
> prepare to intubate
> once airway is secure:
> IV antibiotics (e.g. ceftriaxone)
> Steroids (i.e. dexamethasone)
26
Common complication of epiglottitis
A common complication to be aware of is the development of an epiglottic abscess, which is a collection of pus around the epiglottis. This also threatens the airway, making it a life threatening emergency. Treatment is similar to epiglottitis.
27
Mx of mild croup at home
> Symptoms usually resolve within 48 hours, although some episodes may last for up to one week.
> Parents/carers should be advised to give paracetamol or ibuprofen to control fever and pain and to seek urgent medical advice if there is any deterioration.
> Hospital admission may be required in some cases, for example if there is chronic lung disease, congenital heart disease, immunodeficiency, respiratory rate of over 60 breaths/minute, high fever, or inadequate fluid intake.
28
croup - what is an indicatio for admission
Croup: audible stridor at rest is an indication for admission
29
Mild croup
> Occasional barking cough with no stridor at rest
> No or mild recessions
> Well looking child
30
Moderate croup
> Frequent barking cough and stridor at rest
> Recessions at rest
> No distress
31
Severe croup
> Prominent inspiratory stridor at rest
> Marked recessions
> Distress, agitation or lethargy
> Tachycardia
32
most common cause of stridor in infants
laryngomalacia - made worse by eating
33
Bronciolotis
> acute bronchiolar inflammation
> Caused by RSV
> LTRI -> wheeze
> Peaks in winter
34
what can cause bronchiolitis to be more severe
> premature
> CF
> congenital HD
35
features of bronchiolitis
> coryzal symptoms (including mild fever) precede:
> dry cough
> increasing breathlessness
> wheezing, fine inspiratory crackles (not always present)
36
Immediate referral for bronchiolitis
> apnoea (observed or reported)
> child looks seriously unwell to a healthcare professional
> severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
> central cyanosis
> persistent oxygen saturation of less than 92% when breathing air.
37
Ix for bronchiolitis
immunofluorescence of nasopharyngeal secretions may show RSV
38
Mx of bronchiolitis
> humidified O2 if sats under 92%
> nasogasrric feeding if can't feed enough by mouth
> suction if excessive upper airway secretions
39
peak incidence of bronchiolitis
> aged 3-6 months
40
what necessitates referral to hospital in bronchiolitis
In bronchiolitis, the presence of grunting necessitates immediate referral to hospital - grunting shows severe resp distress
41
red flags under 5
> Red flags in febrile under 5s; RUSH G! Recessions (moderate or severe) - indicating increased work of breathing
> Unarousable - indicating reduced consciousness
> Skin colour changes (blue/mottled) - indicating severe cyanosis
> Hydration - reduced skin turgor - indicating severe dehydration
> Grunting - increased work of breathing
42
perthes disease is more common in
boys. Primary school kids
43
what is the diagnosic test for hirschsprungs disease
rectal biopsy - definitive
44
GORD in babies presentation
Infant < 8 weeks, presents with milky vomits after feeds, often after being laid flat, excessive crying → ? GORD
45
duodenal atresia presentation
> ould typically present earlier in life, possibly a few hours after birth. It would present with projectile and bilious vomiting
46
GE pres in an infant
Gastroenteritis is commonly caused by a viral infection, typically resulting in a fever and tachycardia. This could be associated with stool changes,
47
cardiac deficit assoc w fragile X
MVP
48
What is associated w kartagners syndrome
bronchiectasis
49
Perthes disease classical presentation
> 4-8 year old boy
> irritable hip, limp (progressive), and reduced range of motion, despite no history of trauma or systemic symptoms
> X ray can demonstrate epiphyseal sclerosis
> usually unilateral
50
ToF features
> PROVE
> pulmonary stenosis
> RVH
> Overriding aorta
> VSD
> Ejection systolic murmur
51
What inc risk of autism
> Trinucleotide repeat disorder of X chromosome
> fragile X -> autism
52
what determines degree of cyanosis and severity in TOF
Right ventricular outflow obst
53
NSAIDs (ibuprofen) use in chicken pox
NSAIDs can increase the risk of necrotising fasciitis in patients with chicken pox
54
Mx of acute limp for kids
Urgent assessment should be arranged for a child < 3 years presenting with an acute limp - NICE guidance states transient synovitis is rare in this age group and septic arthritis more common - an urgent specialist assessment is therefore indicated for a child < 3 years with an acute limp.
55
Transient synovitis pres
> acute
> after viral infection normally
> more common in boys
56
Septic arthititis/ osteomyelitis
unwell child, high fever
57
Juvenile idiopathic arthiritis - limp
may be painless
58
DDH - diagnosis
> usually detected in neonates
> 6x more common in girls
59
Perthes vs SUFE
> Perthes - 4-8 (primary school kids)
> avascular necrosis
> SUFE - 10 -15 (secondary school), associated w obesity,
> displacement of femoral head posteriorly
60
first signs of puberty
> girls: breast development
> boys: testicular volume increases
61
ToF pres
: Cyanosis or collapse in first month of life, hypercyanotic spells. Ejection systolic murmur at left sternal edge
62
TGA vs TOF
> Cyanotic congenital heart disease presenting within the first days of life is TGA.
> Cyanotic congenital heart disease presenting at 1-2 months of age is TOF
63
Red flag pointing at hirschsprungs
delayed passage of meconium
64
Infant with bilious vomiting & obstruction → ?
intestinal malrotation
65
chickenpox CF
prodrome of raised temperature before the rash begins on the torso and face
66
What can be given for chickenpox
topical calamine lotion
67
first lines for GORD
Breastfed infants: Prescribe a 1-2 week trial of an alginate e.g. Gaviscon)
Bottle fed baby: Prescribe a 1-2 week trial of feed thickener i
68
prophylaxis for aspleic/ hypospleic ppts
> 5 yr pneumococcal booster
69
labetolol use in mother increases risk of
hypoglycaemia, measure BG levels of baby
70
Most common presentation of neonatal sepsis
Grunting and other signs of respiratory distress are the most common presentation of neonatal sepsis
71
triad of fat embolism
> Triad of symptoms:
> Respiratory
> Neurological
> Petechial rash (tends to occur after the first 2 symptoms)
72
Organisms causing post splenectomy sepsis:
> Streptococcus pneumoniae
> Haemophilus influenzae
> Meningococci
73
most common cause of neonatal sepsis
group B strep (strep agalactiae)
74
hypothermia - rapid rewarming can lead to
rapid rewarming can lead to peripheral vasodilation and shock
75
billous vomiting on first day is likely due to
atresia
76
referral for acute stridor
> moderate croup: paeds
> foreign body aspiration: ENT
> epiglottitis: A&E
> Anaphylaxis (IM adrenaline -> ED)
77
viral URTI symptoms
> nasal discharge, nasal obstruction, sore throat, headache, cough, tiredness and general malaise.
78
signs of URTI
> Erythema or injection of the back of the throat
> Nasal discharge
> Tender cervical lymphadenopathy
> Mild fever
79
chickenpox CF
> Fever initially
> Itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular
> Systemic upset is usually mild
80
Measles CF
> Prodrome: irritable, conjunctivitis, fever
> Rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent
81
Spots seen in measles
koplik spots - white spots on buccal mucosa
82
mumps CF
> Fever, malaise, muscular pain
> Parotitis ('earache', 'pain on eating'): unilateral initially then becomes bilateral
83
rubella CF
> Rash: pink maculopapular, initially on face before spreading to whole body, usually fades by the 3-5 day
> Lymphadenopathy: suboccipital and postauricular
84
Erythema infectiosum
> slapped cheek syndrome
> caused by parovirus B19
> Lethargy, fever, headache
85
rash in erythema infectosum
'Slapped-cheek' rash spreading to proximal arms and extensor surfaces
86
scarlet fever CF
> Reaction to erythrogenic toxins produced by Group A haemolytic streptococci
> Fever, malaise, tonsillitis
> 'Strawberry' tongue
87
Rash in scarlet fever
> fine punctate erythema sparing the area around the mouth (circumoral pallor)
88
hand, foot and mouth disease is caused by
Caused by the coxsackie A16 virus
89
H F and M features
> Mild systemic upset: sore throat, fever
> Vesicles in the mouth and on the palms and soles of the feet
90
infectivity of chicken pox
> 4 days before rash
> infectious until all lesions crusted over (isolate from school)
91
newborns and IC patients and chicken pox
> IC and newborns w peripartum exposure should get varicella zoster immunoglobulin
> consider IV aciclovir if CP develops
92
post exposure prophylaxis for CP
> sign exposure
> risk of severe infection: IS, pregnancy, neonates
> no ab to VZV
. Give varicella zoster immunoglobulin
93
Rf for shingles
> age
> HIV
> immunosuppression - steroids, chemo
94
features of shingles
> most commonly affects T1-L2 dermatomes
> burning pain over affected deratome, may be severe enough to interfere w sleep
> rash - macular but then becomes vesicular
> rash does nort cross the midline - stays within dermatome
95
Mx of shingles
> paracteamol/ NSAIDs first line for pain relief
> Amitryptine can be used second
> oral steroids if severe pain as 3)
96
Antivirals in shingles
> if moderate/ severe w RD
> aciclovir or famciclovir
> reduced incidence of post herpertic neuralgia
97
complications of shingles
> post herpetic neuralgia - most common
> herpes zoster ophthalmicus
> herpes zoster oticus (Ramsay Hunt syndrome): may result in ear lesions and facial paralysis
98
NSAIDs can be used in
shingles but not CP
99
features of kawasaki disease
> high fever, lasts more than 5 days - resistant to AP
> conjunctivitis
> bright red cracked lips
> strawberry tongue
> cervical lymphadenopathy
> red palms of the hands and the soles of the feet which later peel
100
complication of kawasaki
coronary artery aneurysm - screened for using echo
101
Mx of kawasaki
> high dose aspirin
> IV immunoglobulin
102
Measles pathogen
> RNA virus
> aerosol transmission
> incubation period 10-14 days
103
Ix of measles
> IgM antibodies can be detected within a few days of rash onset
104
Mx of measles
> admission may be considered in immunosuppressed or pregnant patients
> notifiable disease → inform public health
105
Comps of measles
> otitis media: most common
> pneumonia: most common cause of death
> encephalitis - usually 1-2 weeks after onset
106
unvaccinated child who has come into contact w measles
give MMR vaccine within 72 hrs
107
when does mumps tend to occur
> RNA virus
> winter and spring
108
Spread of measles?
> by droplets
> respiratory tract epithelial cells → parotid glands → other tissues
> infective 7 days before and 9 days after parotid swelling starts
109
Mx of measles
> rest
> paracetamol for high fever/discomfort
> notifiable disease
110
complications of measles
> orchitis (mainly post-pubertal males)
> hearing loss - usually unilateral and transient
111
comps of rubella
> arthiritis
> myocarditis
> thrombocytopenia
112
incubation period for rubella
> incubation period is 14-21 days and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.
113
rubella in pregnancy: congenital rubella syndrome
> sensorineural deafness
> congenital cataracts
> congenital HD - e.g. patent DA
> Cerebral palsy
114
diagnosis of rubella
> IgM ab raised
> check serology for parovirus b19
115
Mx of rubella
> suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit
> non immune mothers should be offered MMR in post natal period
> MMR should not be given to women known to be pregnant/ attempting to be (avoid pregnancy 28 days after MMR)
116
Eryrthema infecriosum - school exclusion
not required - no longer infectious by the time rash occurs
117
scarlet fever pathogen
Group A haemolytic streptococci (usually Streptococcus pyogenes
118
Rash of scarlet fever
> pinhead rash - usually on torso and spares palms and soles
> children often have a flushed appearance with circumoral pallor. The rash is often more obvious in the flexures
> rough sandpaper texture
> desquamination occurs later in the course of the illness, particularly around the fingers and toes
119
Mx of scarlet fever
> oral penicillin V for 10 days
> patients who have a penicillin allergy should be given azithromycin
> children can return to school 24 hours after commencing antibiotics
> scarlet fever is a notifiable disease
120
comps of scarlet fever
> otitis media: most common
> rheumatic fever
> acute glomerulonephritis
121
Mx of HFM
> symptomatic Tx
> school exclusion not required
122
pneumonia CF
> Cough (typically wet and productive)
> High fever (> 38.5ºC)
> Tachypnoea
> Tachycardia
> Increased work of breathing
> Lethargy
> Delirium (acute confusion associated with infection)
123
Signs of pneumonoa
> can indicate sepsis secondary to pneumonia
> tachycardia, tachypnoea, hypoxia, hypotension, fever, confusion
124
exam findings of pneumonia
> crackles - coarse
> dull to percussion
> bronchial breath sounds
125
pathogen causing pneumonia in pre-vaccinated infants
Group B strep occurs in pre-vaccinated infants, often contracted during birth as it often colonises the vagina.
126
most common cause of pneumonia
strep
127
most common viral cause of pneumonia
rsv
128
acute bronchitis vs pneumonia
> History: Sputum, wheeze, breathlessness may be absent in acute bronchitis whereas at least one tends to be present in pneumonia.
> Examination: No other focal chest signs (dullness to percussion, crepitations, bronchial breathing) in acute bronchitis other than wheeze. Moreover, systemic features (malaise, myalgia, and fever) may be absent in acute bronchitis, whereas they tend to be present in pneumonia.
129
When should ab be used for acute brochitis
> systemically unwell, co-morbidities, CRP 20-100 (delayed prescription) or CRP > 100 - immediate
> use doxycycline
130
Traffic light system - green
> normal colour, normal response to cues, awake
> normal skin and eyes
> no amber or red signs
131
Mx of fever - green
managed at home
132
Traffic light system - amber
> pallor
> no smile, not responding to cues, decreased activity, wakes only w prolonged stimulation
> nasal flaring, tachpnoea,
> O2 sats less than 95% on air
> crackles
> reduced urine output
> CRT over 3 seconds
> dry mucous membranes
> poor feeding
133
RR in amber kids (fever)
> > 50 in kidsaged 6 -12 months
> > 40 In kids over 12 months
134
pulse in amber kids
> >160 beats/minute, age <12 months
> >150 beats/minute, age 12-24 months
> >140 beats/minute, age 2-5 years
135
other features of the amber kid
• Age 3-6 months, temperature >=39ºC
• Fever for >=5 days
• Rigors
• Swelling of a limb or joint
• Non-weight bearing limb/not using an extremity
136
red (high risk) fever
> pale/ mottled/ ashen/ blue
> no resp to cues, appears ill, does not wake or does not stay awake
> weak cry
> reduced skin turgor
137
resp signs of red fever
> resp rate > 60
> moderate/ severe chest indrawing
138
red fever - other criteria
> under 3 months w a fever over 38 degrees
> bulging foantanella
> neck stiffness
> non blanching rash
> status epilepticus
> focal neuro signs/ seizures
139
Mx of amber fever
> safety net or refer to paeds
140
red fever Mx
urgent referral to paeds
141
immunisation for whooping cough
> immunised at 2, 3, 4 months
> and 3-5 yrs
> immunisation does not offer lifelong protection
> pregnant women
142
Features of whooping cough
> catarrhal phase: sim to VURTI, lasts 1-2 weeks
> Paroxysmal phase: cough increases in severity
> covalescent phase: cough subsides over weeks to months
143
Cough In whooping cough
> coughing bouts are usually worse at night and after feeding, may be ended by vomiting & associated central cyanosis
> inspiratory whoop
> may be spells of apnoea
> persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope & seizures
144
diagnostic criteria for whooping cough
Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:
> Paroxysmal cough.
> Inspiratory whoop.
> Post-tussive vomiting.
> Undiagnosed apnoeic attacks in young infants.
145
diagnosis of whooping cough
> nasal swab culture
> PCR and serology
146
Mx of whooping cough
> infants under 6 months with suspect pertussis should be admitted
> in the UK pertussis is a notifiable disease
> an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
> ab prophylaxis for household conacts
147
school exclusion for whooping cough
school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
148
whooping cough vaccine is offered to pregnant women in weeks
Women who are between 16-32 weeks pregnant will be offered the vaccine.
149
meningitis vs meningococcal septicaemia vs meningococcal meningitis
> meningitis: inflammation of meninges
> Meningococcal septicaemia refers to the meningococcus bacterial infection in the bloodstream.
>Meningococcal meningitis is when the bacteria is infecting the meninges and the cerebrospinal fluid
150
Pathogens in meningitis
> meningococcus (neisseria)
> strep pneumonia
> neonates: group B strep - susually contracted during birth
151
presetation of meningitis
> fever
> neck stiffness
> vomiting
> headache
> photophobia
> altered consciousness
> seizures
152
what is a sign of meningococcal septicaemia
non blancing rash
153
signs of meningitis in neonates/ infants
non-specific signs and symptoms, such as hypotonia, poor feeding, lethargy, hypothermia and a bulging fontanelle.
154
Ix for meningitis
> lumbar puncture:
> Under 1 month presenting with fever
> 1 to 3 months with fever and are unwell
> Under 1 year with unexplained fever and other features of serious illness
155
Tests in meningitis
Kernigs, Brudzinkis
156
Kernigs test
involves lying the patient on their back, flexing one hip and knee to 90 degrees and then slowly straightening the knee whilst keeping the hip flexed at 90 degrees. This creates a slight stretch in the meninges. Where there is meningitis it will produce spinal pain or resistance to movement.
157
Brudzinskis test
involves lying the patient flat on their back and gently using your hands to lift their head and neck off the bed and flex their chin to their chest. In a positive test this causes the patient to involuntarily flex their hips and knees.
158
Community management of menigitis AND non blanching rash
immediately give IV or IM benzylpenicillin and transfer to hospital (in the case of penicillin allergy focus on transferring to hosp)
159
Hospital Mx of meningitis
> lumbar puncture for CSF
> Blood culture
> tests for meningococcal PCR
> Ab
160
abs used in meningitis in the hosp
> Under 3 months – cefotaxime plus amoxicillin (the amoxicillin is to cover listeria contracted during pregnancy)
> Above 3 months – ceftriaxone
> add vancomyci if recent travel or prolonged ab exposure
> steroids (to reduce hearing damage) - dexamethasone
161
Mx of menigitis - inform
PHE - notifiable disease
162
Post exposure prophylaxis for meningitis
> highest risk for those in contact w the child 7 days before symptom onset
> single dose of ciprofloxacin or rifampicin
163
viral meningits causes
> HSV
> VZV
> enterovirus
164
Tx of viral meningitis
aciclovir
165
CSF analysis for meningitis
> the immune system releases neutrophils in response to bacteria and lymphocytes in response to viruses.
> image
166
Bacterial meningitis results
> Cloudy appearance (bacteria swimming in CSF)
> high protein, low glucose (eating glucose)
> high neutrophils
167
Viral meningitis results
> clear appearance (viruses aren't alive)
> proteins midly raised/ normal
> normal glucose
> high lymphocytes
> negative culture
168
meningitis comps
> hearing loss
> cerebral palsy
> epilepsy
169
Mx of septic shock in kids
> IV fluids aggressively
> if this fails, transfer to high dependency unit or ICU where ionotropes like noradrenaline can be used
170
Signs if sepsis
> prolonged CRT
> fever or hypothermia
> poor feeding
> inconsolable/ high pitched cry/ weak cry
> floppy
> skin changes - cyanosis, mottled, pale, ashy
171
It is worth remembering that all infants under 3 months with a temperature of 38ºC or above
need to be treated urgently for sepsis, until proven otherwise.
172
immediate management of paed sepsis
> O2 if shock or levels under 94%
> IV access
> blood tests and culture (FBC, U&E, CRP, clotting screen (INR), blood gas for lactate and acidosis)
> urine dipstick
> ab - within 1 hr
> fluids if shock or if lactate above 2mmol/L
173
additional tests in sepsis
> CXR: pneumonia
> abd US
> LP: meningitis
> Meningococal PCR
> Serum cortisol: adrenal crisis
174
Sepsis - ab use
> continue for 5-7 days
> stop when there is low suspicion of bacterial infection, patient is well, blood cultures and CRP results are negative at 48 hrs
175
Which vaccines are given to neonates at risk
> BCG if RF - (e.g. Tuberculosis in the family in the past 6 months).
> hep B - birth, 4 weeks, and 1 yr
176
2 months - vaccines
> '6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B)
> Oral rotavirus vaccine
> Men B
177
3 months - vaccine
> 6 in 1
> oral rotavirus vaccine
> PCV
178
4 months - vaccibe
> 6 in 1
> men B
179
12-13 months vaccines
> Hib / men c
> MMR
> PCV
> men B
180
2-8 yrs vaccines
flu - annual
181
3-4 yrs vaccines
4-in-1 pre-school booster' (diphtheria, tetanus, whooping cough and polio)
MMR
182
12-13 yrs vaccine
HPV
183
13-18 yrs vaccie
> 3 in 1 teenage booster - tetanus, diptheria, polio
> men ACWY
184
females of child bearing age susceptible to rubella vaccine
mmr - exclude pregnancy before vaccinating and avoid pregnancy for one month after
185
pregnant females vaccies
> pertussis
> DPT
> influenza - inactivates
186
over 65s vaccines
> influenza - annual
> pneumococcal
187
herpes zoster vaccine
> aged 65 and 70-79
188
which vaccine is not routinely given in the first 6 months of life
mmr
189
Most common cause of viral meningitis in adults
enterovirus (e.g. coxsackie)
190
men B schedule mneumonic
> B is second letter of the alphabet = 2 months
> second dose = double this -> 2 x 2 = 4 months
> Third dose = triple this -> 4 x 3 = 12 months
191
when not to do a LP
Suspected bacterial meningitis: an LP should not be done if there signs of severe sepsis or a rapidly evolving rash - possible raised ICP
> Do LP for meningitis BUT NOT meningococcal septicaemia
192
Cushings reflex
> bradycardia
> HTN
> CI TO LP!!!
193
who gets the HPV vaccine
All boys aged 12-13 (school year 8) are now offered the HPV vaccine as well as girls
194
when not to use dexamethasone in meningitis
> child under 3
> meningococcal septicaemia: non blanchig rash
195
Prematurity =
> birth before 37 weeks gestation
> under 28 weeks: extreme pretrm
> 28-32 weeks: very preterm
> 32-37 weeks: moderate-late preterm
196
associations of prematurity
> social deprivation, smoking, alc, drugs
> overweight, underweight mother
> twins
197
In women with a history of preterm birth or an ultrasound demonstrating a cervical length of 25mm or less before 24 weeks gestation there are two options of trying to delay birth:
> prophylactic vaginal progesterone: discourages labour
> prophylactic cervucal cerclage - putting a suture in cervix to hold it closed
198
options to improve outcomes for preterm labour
> tocolysis with nifedepine
> maternal corticosteroids
> IV Mg sulphate
199
risks of prematurity
> resp distress syndrome
> intraventricular haemorrhage
> NEC
> chronic lung disease, hypothermia, feeding problems, infection, jaundice
> Hearing problems
200
retinopathy of prematurity
> imp cause of visual impairment in babies born before 32 weeks
> overoxygenation e.g. during ventilation -> proliferation of retinal blood vessels (neovascularisation)
201
long term effects of prematurity
> chronic lung disease of prematurity
> LDs
> resp tract infections
> CP
202
Neonatal apnoea
> very common in premature neonates
> occurs in almost all babies under 28 weeks
> brief periods of stopping breathing, oxygen desat, bradycardia
203
management of neonatal apnoea
> apnoea monitors
> tactile stim to prompt baby to breathe
> IV caffiene can be used to treat recurrent episodes
204
CXR of resp distress syndrome
> ground glass appearance
205
what is resp distress syndrome
> ffects premature neonates, born before the lungs start producing adequate surfactant - commonly below 32 weeks
> not enough surfactant -> lung collapse -> inadequate gas exchange -> resp distress
206
incidence of resp distress reduced by
antenatal steroids ie. Dexamethasone in mother -> inc surfactant
207
Mx of resp distress
> intubation and V if severe
> endotracheal surfactant
> CPAP
> O2
208
comps of neonatal resp distress
> pneumothorax
> apnoea
> retinopathy of prem more common
> hearing and visual impairment
209
neonatal abstinence syndrome
> withdrawal symptoms happen in neonates of mothers who used substances in pregnancy
210
Withdrawal from most opiates, diazepam, SSRIs and alcohol occurs between after birth
3 – 72 hours
211
withdrawal from methadone and other benzos occurs between
24 hrs and 21 days
212
Symptoms of neonatal withdrawal
> tachypnoea
> sweating
> unstable T and pyrexia
> poor feeding, vomiting, hypoglycaemia
> irritable, high pitched cry, tremors, seizures
213
medical management of NAS
> Oral morphine sulphate for opiate withdrawal
> Oral phenobarbitone for non-opiate withdrawal
> SSRIs don’t need medical Tx
214
risks of SIDs
> usually within first 6 months
> prematurity
> Low birth weight
> male baby
> smoking in pregnancy
215
reducing risk of SIDS
> Baby on their back
> keeping head uncovered
> cot clear of toys and blankets
> avoid smoking
> avoid co sleeping
> If co-sleeping avoid alcohol, drugs, smoking, sleeping tablets or deep sleepers
216
major RF for SIDs
> sleeping baby prone
> bed sharing
> prematurity
> paternal smoking
> hyperthermia - overwrapping or head covering
217
protective factoirs against SIDS
> BF
> room charing but not bed sharing
> use of dummies
218
MMR and pregnancy
> Pregnant women should not receive the MMR vaccination, as this is a live vaccine. Non-immune women should be offered the vaccine after giving birth.
219
features of congenital rubella syndrome
> Congenital cataracts
> Congenital heart disease (PDA and pulmonary stenosis)
> Learning disability
>Hearing loss
220
chickenpox in pregnancy
> can lead to varicella pneumonitis, hepatitis or encephalitis
> fetal varicella syndrome
> severe neonatal varicella infection
221
checking for immunity to VZV in pregnancy
> prev CP: safe and immune
> check IgG levels if doubt: positive indicates immunity
> not immune: give IV VZV ab within 10 days of exposure
222
when is aciclovir used for CP in pregnancy
If the chickenpox rash starts in pregnancy, they may be treated with oral aciclovir if they present within 24 hours and are more than 20 weeks gestation.
223
congenital varicella syndrome
> cp within 28 weeks of gestation
> fetal growth restriction
> microcephaly, hydrocephalus, LDs
> scars and skin issues following dermatomes
> limb hypoplasia
> cataracts
224
congenital CMV symptoms
> growth restriction
> seizures
> microcephaly
> hearing loss and vision loss
225
triad of congenital toxoplasmosis
> intracranial calcification
> Hydrocephalus
> Chorioretinitis
226
congenital zika syndrome features
> Microcephaly
> Fetal growth restriction
> Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy
227
congenital rubella, toxoplasmosis, CMV can all cause
Cerebral palsy
228
Newborn physical examination
> first by 72 hrs
> second at 6-8 weeks old
> The examinations include a full general physical examination & detailed examination of: eyes, heart, hips, and testes
229
physical exam of the newborn should involve
> congenital cataracts
> congenital hd
> ddh
> undescended testes
230
At 6 to 8 weeks, assess the baby's
social smiling and visual fixing and following.
231
newborn blood spot
> at 5 days
> sickle cell, CF, congenital hypothyroidism, PKU, MCADD, MSUD, IVA, GA1, HCU
232
Hearing test used in newborns
> otoacoustic emission
> The presence of a soft echo indicates a healthy cochlea
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if otoacoustic emission test is anbormal,
use auditory brainstem response test
234
jaundice in the first 24 hrs
> always pathological
> can be caused by: rhesus haemolytic disease, ABO haem disease, GDP6 def, hereditary spherocytosis
235
jaundice in days 2-14
> common, usually physiological
> more common in breastfed babies
236
If there are still signs of jaundice after 14 days (21 days if premature) a prolonged jaundice screen is performed, raised conjugated bilirubin could indicate
Biliary atresia
237
causes of prolonged jaundice (after 14 days)
> biliary atresia
> hypothyroidism
> breast milk jaundice
> prematurity
> congenital infections such as CMV
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physiologyical jaundice
> fetuses have more fragile rbcs
> can no longer excrete via placenta
> This leads to a normal rise in bilirubin shortly after birth, causing a mild yellowing of skin and sclera from 2 – 7 days of age.
239
Babies with jaundice within 24 hours of birth need treatment for
sepsis if they have any other clinical features or risk factors.
240
jaundice in pre-emies
> higher risk of kernicterus - brain damage due to high levels of bilirubin
> immature liver
241
what is hemolytic disease of the newborn
> Hemolysis and jaundice in the neonate caused by incompatibility between rhesus >antigens
> When a woman that is recessed D negative becomes pregnant with a recess D positive child the mother will produce antibodies against this and has then become sensitized
> This normally does not cause problems during the first pregnancy during subsequent pregnancies the anti D antibodies can cross a placenta if the if the fetus is rhesus positive this can lead to hemolysis
242
What occurs during hemolytic disease of the newborn
hemolysis which leads to anemia and high bilirubin levels
243
What are three important causes of prolonged jaundice
Billy Atresia hypothyroidism and GDP 6 deficiency
244
Investigations for neonatal jaundice
Full blood count and blood film for polycythaemia or anaemia
Conjugated bilirubin: elevated levels indicate a hepatobiliary cause
Blood type testing of mother and baby for ABO or rhesus incompatibility
Direct Coombs Test (direct antiglobulin test) for haemolysis
Thyroid function, particularly for hypothyroid
Blood and urine cultures if infection is suspected. Suspected sepsis needs treatment with antibiotics.
Glucose-6-phosphate-dehydrogenase (G6PD) levels for G6PD deficiency
245
Management of neonatal jaundice
> Management of neonatal jaundice depends on treatment threshold charts
> Phototherapy is normally enough to correct it but exchange transfusions may be required (removing blood from the neonatal and replacing it with Donna blood )
246
kernecticus
> Type of brain damage that results from excessive bilirubin
> Presents with a less responsive floppy drowsy baby with poor feeding
> Causes permanent damage to the central nervous system causing cerebral palsy learning difficulties and deafness
247
Extra hepatic biliary atresia is more common in
Females than males
248
What is the most common type of bilibi atresia
Atresia of the left and right ducks to the level of the Porter Hepatis
249
what is the typical presentation of biliary atresia
> Patients typically present in the first few weeks of life with:
> Jaundice extending beyond the physiological two weeks
> Dark urine and pale stools
> Appetite and growth disturbance
250
Signs of biliary atresia
> Jaundice
> Hepatomegaly with splenomegaly
> cardiac murmurs
251
Test results in Billery Atresia
> Total bilirubin may be normal, whereas conjugated bilirubin is abnormally high
> Alpha 1 antitrypin deficiency may be a cause of cholesterol
> Sweat chloride test cystic fibrosis
252
Management of Billy Atresia
Surgical intervention is the only definitive treatment - Kasai procedure. Liver transplanation may be required if this fails
253
Neonat and lung surfactant
> type two alveola cells start producing subactone between 24 and 34 weeks gestation - Free time babies have problems with reduced pulmonary surfactant
254
Cardio respiratory treat changes at birth
> A strong First breath is needed to expand previously collapsed alveoli adrenaline and cortisol are released in response to labor to stimulate respiratory effort
> The baby's first breath expands alveoli reducing pressure in the right atrium -> this then caused his closure of the foramen ivale
255
What drops after birth cause enclosure of the ductus arteriosus
> Prostaglandins drop after birth which causes closure of the ductus arteriosus which then becomes a ligamentum arteriosum
256
ductus venosus Closure
The ductus venosis stops functioning immediately after birth because the umbilical cord is clamped so there is no blood flow to umbilical veins . The doctors of the Gnosis clauses a few days later to become the ligamentum venosum
257
Features of congenital hypothyroidism
Prolonged neonatal jaundice, Paul feeding , Constipation tiredness slow growth and development
258
Management of congenital hypothyroidism
> Investigations include TFT thyroid ultrasound and thyroid antibodies
> Levothyroxine in once a day
259
What kind congenital growth hormone deficiency be a result of
Growth hormone is produced by the anterior pituitary gland . Deficiency can be from genetic mutation GH1 or empty sella syndrome
260
Growth hormone deficiency may present at birth or in neonates with:
> Micropenis (in males)
> Hypoglycaemia
> Severe jaundice
261
GH def in older kids presents as:
> Poor growth, usually stopping or severely slowing from age 2-3
> Short stature
> Slow development of movement and strength
> Delayed puberty
262
Growth hormone stimulation test
Measures response to medications that normally stimulate growth hormone release for example insulin glucagon
263
Management of GH deficiency
Daily subcutaneous injections of growth hormone (somatropin)
264
Is what is congenital adrenal hyperpleasure caused by
> Congenital deficiency of 21 hydroxylase
> This leads to under production of cortisol and aldosterone under too much androgens from birth
> Inherited in an autosomal recessive pattern
265
What is the action of aldosterone
Released by the adrenal gland in response to renin. actson the kidneys to increase sodium resorption and increase potassium secretion into the urine
266
CAH pathophys
> 21-hydroxylase is the enzyme responsible for converting progesterone into aldosterone and cortisol
> Extra progesterone is converted into testosterone instead -> Patient has low aldosterone low cortisol but abnormally high testosterone
267
severe CAH presentation
> females - ambiguous genitals w enlarged clitorus
> Patients with more severe CAH present shortly after birth with hyponatraemia, hyperkalaemia and hypoglycaemia.
268
CAH pres in females
> tall, Facial hair, Absent peroidsDeep voice and early puberty
269
CH presentation in males
Tall, deep voice, Large penis, small testicles, early puberty
270
What are skin change to people with CAH get
hyperpigmentation because AP produces extra ACTH which is structurally similar to melanin
271
Management of CAH
> Hydrocortisone, fludrocortisone to replace aldosterone 4
272
what is associated w increased morbidity for CF
Chronic infection with Pseudomonas and Bulkholderia in CF are associated with increased morbidity and mortality - Bulkholderia is a CI against lung transplantation
273
rotavirus timings
Two months + three months
274
How does androgen insensitivity syndrome present
Groin swellings from undescended testes primary amenaria nor pubic hair. Breast development occurs
275
most common cause of ambiguous genitalia
CAH, AIS does not cause amb genitals
276
congenital rubella is associated w ? Murmur
patent ductus arteriosus, causing a machinery murmur.
277
congenital sensorineural deafness
> CMV: deafness, rubella: cataracts and deafness
278
what other causes of cyanotic heart disease
> right to left shunt
> ASD, VSD, Patent ductus arteriousus, transposition if the great arteries
279
Eisenmenger syndrome.
Patients with ventral septal defect atrial septal defect or a patent doctors arteriosus are usually not cyntotic because the pressure on the left side of the heart is greater than the right side so blood flows into the right side. If pulmonary pressure increases beyond systemic pressure blood flows from right to left across the defect causing cyanosis
280
What are the complications of congenital heart disease
> Heart failure arrhythmias endorcarditis pulmonary hypertension eisenmenger syndrome
281
types of ASD
> Patent foramen ovale
> ostium secondum and osteiyn primum
282
ASD
> blood moves from left -> RA
> Overload in RA
> blood still goes to lungs to get oxygenated si no cyanosis
> right heart strain and pulmonary HTN
283
How does ASD lead to eismengers
> Pulm HTN -> increased right pressure -> pulm pressure > systemic pressure -> blood moves in opposite direction from right to left -> blood bypasses lungs leading to cyanosis
284
atrial septal defect pres
> often picked up on antenatal scans or newborn examination
> can present in adulthood
> dyspnoea secondary to pulm HTN and right sided HF
> AF ir flutter
285
stroke in DVT patients
> ASD causes stroke in patients w DVT (clot enters systemic circulation and goes straight to brain)
286
ASD murmur
> systolic cresendo decresendo murmur loudesr at upper left sternal edge
> fixed split second heart sound
287
Mx of ASD
> can be corrected surgically percutaneous transvenous catheter closure or open heart surgery
> AC such as aspirin, warfarin, DOACs used to reduce risk of clots
288
conditions associated VSD
downs syndrome and turners syndrome
289
VSD murmur
> pansystolic mumur heard at left lower sternal edge in third and 4th ICS
290
increased risk of ? With VSD
IE. Give antibiotic prophylaxis during surgical
291
coarctation of the aorta =
> narrowing of the aorta usually around the DA
> associated turners syndrome
292
pres of coarctation of the aorta
> systolic murmur below left infraclavicular area
> four limb blood pressure: difference in BPs
> left ventricular heave
293
ix for coarctation
CT angio
294
how can coarctation of the aorta present
> Percutaneous balloon angioplasty (stretching the stenosis), potentially with a stent inserted
> Open surgical repair
> medical management of HTN
295
Peripheral cyanosis vs central cyanosis
> peripheral: looking blue
> central cyanosis when conc of hb exceeds 5g/dl
296
nitrogen washout test
> differentiate between cardiac vs non cardiac causes
> The infant is given 100% oxygen for ten minutes after which arterial blood gases are taken.
> A pO2 of less than 15 kPa indicates cyanotic congenital heart disease
297
causes of cyanosis congenital HD
> TOF
> transposition of the great arteries
> tricuspid atresia
298
mx of cyanotic congenital heart disease
> supportive care
> prostaglandin E1 e.g. alprostadil - used to maintain patent ductus arteriosus
299
acrocyanosis
> often seen in healthy newborns
> cyanosis around mouth and hands/ feet
> occurs immediately after birth in healthy infants
300
features of TOF
> ventricular septal defect (VSD)
> right ventricular hypertrophy
> right ventricular outflow tract obstruction, pulmonary stenosis
> overriding aorta
301
TOF - clinical features
> cyanotic episodes
> ejection systolic murmur
302
cyanotic spells in TOF
> unrepaired TOF infants may develop episodic hypercyanotic 'tet' spells due to near occlusion of the right ventricular outflow tract
> features of tet spells include tachypnoea and severe cyanosis that may occasionally result in loss of consciousness
> they typically occur when an infant is upset, is in pain or has a fever
303
Chest XR findings of TOF
> CXR: Boot shaped heart
> ECG: LVH
304
Mx of TOF
> Surgical repair
> cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm
305
when is patent DA more often
> usually, the ductus arteriosus closes with the first breaths due to increased pulmonary flow which enhances prostaglandins clearance
> more common in premature babies, born at high altitude or maternal rubella infection in the first trimester
306
features of patent DA
> Left subclavian thrill
> continuous 'machinery' murmur
> large volume, bounding, collapsing pulse
> heaving apex beat
307
Mx of patent DA
> Indomethacin or ibuprofen - given to the neonate inhibits prostaglandin synthesis (closes connection)
308
what is ebsteins anomaly
> low insertion of the tricuspid valve -> large atrium and large ventricles - atrialisation of the RV
309
lithium exposure in utero can cause
ebsteins anomaly
310
associations w ebsteins anomaly
> PFO, ASD, WPW
311
CFs of ebsteins anomaly
> cyanosis, prominent a waves in the distended JVP
> hepatosplenomeg
> tricuspid regurg
312
murmur of ebsteins anomaly
pansystolic murmur, worse on inspiration
313
ECG finding of ebsteins anomaly
RBBB -> widely split S1 and S2
314
ACEi as a teratogen
Renal dysgenesis
Craniofacial abnormalities
315
alcohol as a teratogen
Craniofacial abnormalities
316
aminoglycosides as a teratogen
Ototoxicity
