child health Flashcards
viral - coryza symptoms, fever harsh stridor, barking cough usually presents middle of night normally clinically well age 6 months - 6 years coughing +++ acute onset rarely life threatening
croup presents middle of night when cortisol is at its lowest
bacterial soft stridor septic, toxic drooling can be any age (2-6yrs) absent cough 3-6 hrs onset classic tripod pose seriously life threatening
epiglotittis
bacterial (staph, strep. HIB) barking cough toxic, not drooling any age, mainly <6yrs croupy cough longer hx
bacterial tracheitis
epiglottitis - management
- keep child calm - call for anaesthetic and ENT support - O2 - IM/ nebulised adrenaline - can be repeated after 5 mins/ adrenaline infusion if still symptoms - once have control of airway - salbutamol for breathing - dexamethasone oral - budesonide nebs (if can’t take oral dex) - abx: ceftriaxone - fluid resuscitation
stridor more obvious when crying few week hx peaks around 6-9 months epiglottis floppy over larynx gaining weight and afebrile
laryngomalacia
which fluid regime is best for full maintenance fluids
0.9% NaCl + 5% dextrose always need dextrose in fluids for children
fluid calculations for maintenance fluids
for children under 16: 0.9% NaCl + 5% dextrose (or plasmalytte +5% dextrose) - 100mls/kg/day for each of first 10kg - 50ml/kg/day for each of next 10kg - 20ml/kg/day for every further kg e.g. 24kg = (100x10) + (50 x 10) + (20x4)
fluid calculations for bolus fluid
- 20ml/kg 0.9%NaCl in most situations (DKA + shock) - 10ml/kg when: for DKA, trauma, fluid overload, or heart failure
dehydration corrections calculations (and cheat formula)
usually over 24hrs MAINTENANCE FLUIDS PLUS %DEHYDRATION most of your body is water –> estimate % lost weigh the child if possible: 1kg weight loss = 1000ml lost estimate clinically if not possible: 3% dry lips 5% tachycardia 7% cap refill going 10% shock e.g. 3% weight loss in 20Kg child: 20kg = 20000g = 20000ml 1%= 200ml, therefore 3%= 600 ml CHEAT FORMULA: 10 x weight x %dehydration = correction
acute asthma/ viral acute wheeze management (4 steps)
burst step: 3-2-1 (at once) 1. salbutamol x3 (10 puffs each) 2. atrovent (ipatropium bromide) x 2 3. prednisone x 1 IV bolus step: after 1hr 1. MgSO4 (give over salbutamol if salbutamol toxicity) if not working after 10 mins then: 2. salbutamol 3. aminophylline - side effect of arrythmias - IV hydrocortisone if cannulated IV infusion step 1. aminophylline 2. salbutamol panic step 1. intubate and ventilate stretching out concept: once stable - start stretching out the salbutamol 1hr,2h,3hr,4hr (at 4hrly they can go home)
salbutamol toxicity
shivering vomiting high lactate
asthma prevention management (4 steps)
- very low dose inhaled steroid (or consider montelukast if <5) 2. very low dose inhaled steroid + LABA or montelukast if >5yrs montelukast if <5yrs 3. consider increasing steroid dose or add LABA/montelukast if not already on if <5, needs referral 4. REFERRAL consider theophylline salbutamol inhaler as required consider stepping up when needing 3x per week or waking once per week
shock not able to feel peripheral pulses (femoral) normal glucose, no indication for infection
co-arctation of the aorta
most likely causes for baby collapse
- sepsis 2. congenital heart disease- collapsing on day 3 - duct dependent lesion 3. metabolic
congenital heart disease - right atria?
cyanosis - tricuspid atresia - Epstein’s anomaly
tetralogy of fallot
- VSD 2. overriding aorta 3. right outflow tract obstruction (pushing over outflow tract causing right outflow tract obstruction) 4. right ventricular hypertrophy (right ventricle having to work harder so hypertrophy)
congenital disease - right ventricle
cyanosis pulmonary stenosis pulmonary atresia Fallot’s
congenital disease - mixed
VSD eisenmengers
congenital heart disease - left atria
in shock mild stenosis/ atresia
transposition of great arteries
transposition of the great arteries - two separate circuits if you have a duct or VSD with transposition can survive mixing between left to right and right to left not responding to O2 can get worse after 24hrs after birth when the duct closes
congenital heart disease - left ventricle
hypoplastic left heart coarctation (can present even if screening is normal) interrupted arch aortic stenosis
timing of presentation for congenital heart disease
first few hrs: - pulmonary /aortic atresia/ critical stenosis - hypo plastic heart syndrome first few days: - transposition, tetralogy, large PDA in premature infants - coarctation first few weeks: - aortic stenosis -co-arctation first few months: - any left to right shunt as pulmonary resistance falls e.g. VSD
management of duct dependent lesions
prostin IV infusion (prostaglandin E2)
wheeze and crepitations bilaterally in < 1 yrs
bronchiolitis almost exclusively under 1yrs viral infection premature babies more often affected RSV URTI, followed by cough peaks at day 5, lasts for 10-14days
bronchiolitis investigations
nasopharyngeal aspirate
bronchiolitis management
SUPPORTIVE TREATMENT nasal cannulae O2 and NG tube for feeds second line: CPAP, IV fluids third line: salbutamol doesn’t work under 1yrs so doesn’t work for bronchiolitis
wheeze >1yr
viral induced wheeze multi-trigger wheeze (viral, exertion, cold air) more likely to have asthma later on after 1yr – B receptors so can respond to salbutamol same management as asthma
wheeze >5yrs
asthma can only be diagnosed over 5yrs - show reversibility usually grown out of VIW over 5
sepsis management <1month
- admit - start IV amoxicillincillin (under 1 month - covers listeria) and ceftriaxone - full septic screen incl lumbar puncture (everyone gets LP <1month) - start maintenance fluids
foot and mouth disease - what virus?
coxackie virus
hand foot and mouth disease presentation
blanching papular rash - palms and soles, face, nappy area fever tonic-clonic seizure
macular
flat to skin erythematous skin think measles
maculopapular
bobles background of erythematous skin
vesicles
raised fluid filled herpes - varicella, zoster, simplex
non-blanching rash
petechial purpuric - meningococcal sepsis/DIC - ITP - idiopathic thrombocytopaenic Purpura - low platelets - HSP - Henoch-Schonlein Purpura - ?leukaemia
NON-BLANCHING rash developed over 24hrs rash on BUTTOCKS AND DOWN LEGS* blood in urinalysis* runny nose and mild cough tummy pain joint pain otherwise well and bloods normal
henoch- Schonlein purpurn multi-system vasculitis blood in urinalysis: develop glomerular nephritis –> blood in urine
croup management
supportive treatment - oral dexamethasone 0.1/kg - taken immediately regardless of severity
bacterial tracheitis - management
80% need intubation ceftriaxone + flucoxacillin
laryngomalacia management
management: anti-reflux, no treatment needed if gaining weight
8-month old crying inconsolably vomiting recurrent jelly like diarrhoea * diagnosis?
intussusception
bilious vomiting (green)
volvulus obstruction below level of ampulla
4 yrs 2hrs * abdo pain unilateral swollen and tender testis * fever diagnosis and most appropriate management
testicular torsion at two hrs still salvageable –> EMERGENCY SURGERY ultrasound in children insensitive appendicitis would develop over a day or so
12 yr old girl sharp abdo pain 12hrs most important investigation?
pregnancy test rule out ectopic think about pregnancy from ~10yrs
causes of acute abdo pain <1yrs
pyloric stenosis intussusception obstruction
4-6wks old milky projectile vomiting non bilious hungry after vomiting hyperc diagnosis?
pyloric stenosis
causes of acute abdo pain 1-4yrs
intussusception (appendicitis)
pyloric stenosis management
investigation: ultrasound hypokalemic hypochloremic metabolic alkalosis - correct potassium correct chloride high bicarb - correct rehydration
non-organic pathology - recurrent abdominal pain
change of school periumbilical pain changes to home pain associated with headache
causes of acute abdo pain 5-11yrs
intussusception appendicitis testicular torsion
causes of acute abdo pain 12yrs +
appendicitis testicular torsion/ectopic pregnancy
8yrs old 12hr diffuse abdo pain vomiting background 2 weeks of polyuria and weight loss glucose + ketones in urine diagnosis and management
DKA diagnosis: - diabetic - blood glucose >11 - ketones –> metabolic acidosis - acidosis management: - most important: refer for urgent admission under medical team - resus fluids - give insulin to turn off acidosis and correct glucose - VTE prophylaxis - electrolyte monitoring - education about diabetes
henoch-Schonlein purpura investigations and management
investigations: - urine dipstick - blood pressure - assessment for fluid overload and nephrosis to detect signs of renal impairment (develop glomerular nephritis (blood in urine) management: - usually self limiting - immunosupression - steroids
recurrent UTI
recurrent: - 2 or more upper tract - 1 upper and 1 or more lower tract - 3 or more lower tract
atypical UTI
- poor urine flow - abdominal/bladder mass - rise in creatinine - sepsis - unresponsive - non E.coli UTI
atypical UTI investigations
<6 months - ultrasound during infection - DMSA within 4-6 months - MCUG 6months-3yrs: - USS during infection - DMSA 4-6months >3yrs: USS during infection
simple UTI investigations
simple UTI: responds to Tx within 48hrs < 6 months - USS within 6 weeks - if abnormal: MCUG 6months- 3yrs: - none >3yrs none
recurrent UTI investigations
< 6months: - USS during infection - DMSA 4-6 months - MCUG 6months-3yrs: - USS 6 weeks - DMSA 4-6months >3yrs: - USS 6 weeks DMSA 4-6 months given to all ages with recurrent UTI
DMSA VCUG
DMSA: radioactive isotope - shows longer damage - to detect renal parenchymal defect VCUG: fluoroscopy, diagnosis of vesicoureteral reflux (urine up from bladder to kidneys)
space occupying lesion red flags
signs of raised ICP - early morning headache and vomiting - worsening headaches over time - changes in personality/ behaviour - papilloedema - seizure
headaches with aura unilateral throbbing
migraine
previously well fever tonic-clonic seizure blood sugar normal diagnosis and management
febrile seizure (normally resolve at 5 mins) management: - 0 mins: O2, BM, IV access - 5mins: benzo (midazolam, diazepam) (IV/IO/buccal/PR) - 15mins: benzo (IV/IO) - 25mins: phenytoin IV - 45mins: anaesthesia if no IV access: buccal midazolam/ rectal diazepam
24hr hx limp no hx trauma preceding viral illness limited internal rotation of hip*
transient synovitis investigations: - normal WCC - normal ESR - normal x-ray - USS: fluid in joint management: - rest - analgesia
24hr hx limp no hx trauma preceding viral illness limited internal rotation of hip* diagnosis, investigations and management
transient synovitis investigations: - normal WCC - normal ESR - normal x-ray - USS: fluid in joint management: - rest - analgesia
fever and limp fever, unwell erythematous and tender with effusion unwilling to weight bare hip held flexed diagnosis and investigations
septic arthritis investigations: - URGENT bloods - blood culture - ESR raised WCC normal/high USS: fluid in joint x-ray: normal/ widened joint space management: - joint aspiration - IV abx - analgesia, rest
developmental dysplasia of the hip
age 1-4yrs suspect if limp
developmental dysplasia of the hip …..
age 1-4yrs suspect if limp …
perches disease …..
age 5-10 incideous onset pain + limp leg length discrepancies diagnosis on plain X-ray and MRI
slipped upper femoral epiphysis - SUFE …..
10-15yrs displacement of femoral epiphyseal head plain radiography surgical fixation
18months bottom shuffling unable to walk crawled at 10 months other development normal
bottom shuffling alternative to walking - delays walking discharge arranging for further review in 6 months if still not walking at 2yrs then arrange further assessment
developmental milestones: smiling sitting words walking
smiling: 6 weeks sitting: 6/7 months few words: 1 yr walking: 1 yr
pale
anaemic/ shocked
pale and jaundiced
haemolytic anaemia
drooling
epiglottitis
recently moved from abroad and don’t have red book. what vaccinations are they missing? and what screening?
unimmunised: measles/ epiglottitis/ meningitis no Guthrie screening: thyroid, PKU, cystic fibrosis
mum has a new boyfriend
child abuse
unsupervised
foreign body aspiration wasn’t there to see it be inhaled
6 or more days of fever
Kawasaki disease
mum unable to let go of your hand
myotonic dystrophy hereditary so mum may have it too
rash with amoxicillin
Epstein barr virus
irritability
meningitis
white spots inside of cheek
measles (Koplick spots)
fat teenager limping
slipped upper femoral epiphysis SUFE
gower’s sign positive (struggling to stand up and having to walk up their legs)
Duchenne’s
egg on side appearance on heart
Transposition of great arteries
heart appears boot shaped on CXR
tetralogy of fallout
double buble AXR
duodenal atresia
confusion/ hallucinating
encephalitis/opathy
barking cough
croup
birthday party
anaphylaxis - eg to peanut butter sandwhich parent wasn’t there to tell them they can’t have it
back arching in neonate
reflux
boy unwell but sister unaffected
x-linked condition?
causes of stertor (snoring noise)
- tonsilitis - retropharyngeal abscess - decreased consciousness
causes of stridor (inspiratory)
- anaphylaxis - croup - epiglottitis - foreign body - diphtheria - laryngomalacia - subglottic stenosis (after extended intubation)
- web at back of throat - ball neck - inflammation which can be seen from outside the neck - stridor - abroad
diphtheria
causes of wheeze
asthma viral induced wheeze bronchiolitis pneumonia
5yrs stop and stares 20-30 times a day for the past month can last btwn 5-15secs can happen even when she is actively playing diagnosis and investigations
absence seizures EEG - expected to show 3Hz generalised spike-and-wave pattern on EEG
septic screen in <3 months old
- bloods: FBC, lactate - blood culture - urinalysis - LUMBAR PUNCTURE - IV ABX - fluids - O2 if needed
- generalised tonic - clonic seizure - brief (1-2 mins) - viral infection - 6months - 3yrs diagnosis
febrile convulsion
slapped cheeks rash: virus?
parovirus B19
roseola: virus?
HHV6
purpuric rash with fever and weight loss for a month diagnosis?
leukaemia
average age of menarche in the UK
13yrs
sexual precocity before what age in girls and boys
girls: before 8 boys: before 9
what staging system measures breast, pubic hair and genital development
tanner staging
what stage of breast development is at the peak height velocity for girls
breast stage 2-3 (early)
what stage of testes development is at the peak height velocity for boys
12-15ml testes (late) (stage 3/4)
calculation for mid parental height for boy and girl
mothers height plus fathers height in cm divide by 2 - then add 7cm for boy - then minus 7cm for girl
target parental range calculation
to mid parental height: +/- 10cm for boys +/- 8.5cm for girls
factors affecting height
- familial short stature - intrauterine growth retardation - constitutional delay in growth and puberty (commonest reason) - later developers - familial
delayed puberty can be diagnosed at what age
absence of puberty by: - 14yrs for girls - 15yrs for boys
commonest cause of delayed puberty
constitutional delay
management for constitutional delay
girls: oestradiol boys: - testosterone injection for 4 months once a month
- hypogonadotrophic hypogonadism (low gonadotrophs - LH & FSH) - absence of smell - doesn’t respond to testosterone diagnosis
Kallmans syndrome
- hypergonadotrophic hypogonadism - doesnt respond to testosterone - XXY chromosomes
Kleinfelters syndrome
what is hypogonadotrophic hypogonadism
low gonadotrophs - LH & FSH
what is Hypergonadotrophic hypogonadism
- testes not responding to gonadotrophs - leads to +ve feedback on pituitary gland which produces excess gonadotrophs to try compensate
investigations for short stature
- record birth weight - record both parental final heights - measure height velocity - if poor: - FBC (iron deficiency anaemia, macro cystic anaemia), U&Es, TFTs (hypothyroidism), coeliac scan - karyotype in alll girls (turners syndrome - XO)
central precocious puberty how to diagnose
- onset of breast development before 8yrs - onset of testicular development (vol >4ml) before 9yrs - due to early activation of HPG axis
most common cause of central precocious puberty in boys and girls
girls 90% idiopathic boys - 75% structural CNS abnormality -> craniofaringioma - excess FSH & LH –> testes growth –> precocious puberty
pseudo- precocious puberty what is it and causes
showing secondary sexual characteristics but not from testes (from adrenal gland) causes sex steroids from adrenal: - congenital adrenal hyperplasia - adrenal tumour - premature adrenarche - cushings syndrome sex steroids from gonad: - ovarian tumour, cyst - McCune-Albright syndrome - testotoxicosis - HCG - secreting tumours
congenital adrenal hyperplasia most common deficiency disorder?
21-hydroxylase deficiency
congenital adrenal hyperplasia what is it
- autosomal recessive disorder - pituitary picks up that not making cortisol - however the only thing that can be made is male androgens at the cost of aldosterone - EXCESSIVE ANDROGEN AND ALDOSTERONE DEFICIENCY
diagnosis of CAH
raised levels of 17 alpha
girl presentation of CAH
girls: - clitoromegaly - fused labia majora - bones more ossified - initially tall then short
boy presentation of CAH
- classically with SALT LOSING CRISIS at 6 weeks (low Na, high K (low aldosterone –> low Na + high K), acidosis, low glucose, and shocked) vomiting, weight loss and circulatory collapse
management of salt losing crisis in baby with CAH
IV hydrocortisone STAT
simple virilising CAH
excessive growth and precocious puberty with no aldosterone deficiency
- bitemporal hemianopia - increased growth with no other signs of increased androgen - acromegalic symptoms
cerebral gigantism impinging on optic nerve gives bitemporal hemianopia
- webbed neck - shield chest - nipples pointing outward - left heart lesions - bicuspid aortic valve - kidney abnormalities - intellectual development delay - gain weight and lose height
turners syndrome XO
horseshoe kidney
hypothyroidism
gonadotrophins elevated
investigation management of turners syndrome
- test with carrier type: XO - oestrogen replacement therapy for life - ovaries don’t develop - ovarian failure - growth hormone - epithelial dysplasia –> growth hormone replacement
- off feeds - prolonged jaundice - constipation - coarse voice - coarse facies - large tongue - hoarse cry diagnosis
congenital hypothyroidism
how is congenital hypothyroidism normally picked up
screening on day 5 - Guthrie test (heel prick) (high TSH, low T4) will not pick up central hypothyroidism (low TSH)
most common cause of congenital hypothyroidism
maternal iodine deficiency
levels of TFTs for hashimotos thyroiditis
low T4 high TSH positive thyroid peroxidase antibodies
- more common in Down’s & turners children - more common in females - goitre is common - classical features of growth failure and delayed bone age - underperformance at school
acquired hypothyroidism
if goitre what investigation should be done
USS goitre as well as TFTs
management of hypothyroidism
levothyroxine
hyperthyroidism and graves disease diagnosis TFTs
high T4 low TSH USS if goitre graves: autoantibodies against TSH receptor
management for hyperthyroidism
- carbimazole - beta-blockers for acute symptom relief - surgery or radioiodine
- postural hypotension - increased pigmentation of skin and mucosa (ACTH build up) - hypoglycaemia - changes in body hair distribution diagnosis
Addison’s disease
adrenal crisis:
vomiting dehydration shock hypoglycaemia vascular collapse (low BP) renal shut down low Na high K
investigations for Addison’s disease
U&Es synacthen test cortisol measurement
management for Addison’s disease
IV hydrocortisone saline glucose in acute adrenal crisis
management of type 2 diabetes
weight loss metformin
management for type 1 diabetes
MDI - short acting insulin for meals - insulin pump therapy continuous glucose sensors - aim to maintain glycerinated haemoglobin <48
familial tall stature
excentuated tall genes - tall women tend to marry tall men no treatment
atopy triad
asthma eczema allergic rhinitis (hay fever)
how to diagnose asthma
spirometry gold standard - test with salbutamol
management of chronic asthma under 5s
- SABA - inhaled corticosteroid (budesonide, beclometasone) or/and leukotriene (monteleukast) - refer
chronic asthma management - 5-12yrs
- SABA - inhaled corticosteroid (200-400mcg) - LABA (salmeterol) - max dose ICS (800mcg) - theophylline + referral - oral corticosteroids + referral
acute asthma staging: mild, moderate, severe and life threatening
mild: PERF>75%, SaO2>92% moderate: PERF>50%, SaO2>92% severe: PERF<50%, SaO2<92% heart rate: >125 (>5yrs), >140 (1-5yrs) RR: >30 (>5yr), >40 (1-5) life threatening: PERF <33% SaO2 <92%, cyanosed, tachycardia, hypotensive, exhaustion, silent chest
management for acute asthma - dependent on mild, moderate, severe and life threatening
O2 face mask mild-moderate: - SABA - if improving 30-40mg oral prednisolone - discharge with 3 days steroids, review inhalers and technique severe: - neb salbutamol (5mg) - neb terbutaline (10mg) (SABA) - oral prednisolone 30-40mg (IV hydrocortisone alt) - consider admission life threatening: - ABG - CXR - PICU - IV salbutamol bolus - IV hydrocortisone 100mg
wheeze triggered by coryzal illness fever common in first 2-3yrs diagnosis
viral induced wheeze
what virus causes croup
parainfluenza virus
management for croup
oral dexamethasone (or prednisolone) if severe: neb adrenaline and O2
most common autosomal recessive mutation in cystic fibrosis
F508
infant poor weight gain steatorrhoea (bulky and pale) recurrent chest infections pancreatic insufficiency prolonged jaundice diagnosis
cystic fibrosis
diagnostic tests for cystic fibrosis
- Guthrie tet - at 5days - sweat test ([Cl-]>60) - genetic testing
management for cystic fibrosis
medical: - mucolytics: neb hypertonic saline/ DNase - ivacaftor/lumacaftor microbiology: - abx prophylaxis - H.influenza, s.aureus, p.aeruginosa physiology: - chest & exercise physio dietician: - signs of diabetes - croon supplements for pancreatic dysfunction - high calorie diets surgical: - lung or liver transplant
what bacteria causes epiglottitis and therefore what is used to prevent it
haemophilus influenza haemophilus influenza vaccine
management for epiglottitis
ceftriaxone rifampicin for household contacts fluids
investigations for laryngomalacia
barium/ contrast swallow - check for inhaled foreign body - vascular ring - pushing into oesophagus
moro reflex and when is it present?
head extension causes abduction followed by adduction of arms present from birth to around 3-4 months
grasp reflex and when is it present?
flexion of fingers when object placed in palm present from birth to around 4-5months
which virus causes respiratory syncytial virus
bronchiolitis
test for bronchiolitis
nasopharyngeal aspirate for RSV PCR
management for bronchiolitis
hydration nutrition analgesia O2
coryza symptoms fever dry cough course crackles in one area on respiratory exam CXR - local consolidation diagnosis?
pneumonia
bacteria and viruses causing community acquired pneumonia <3wks 3wks - 3mnths 4mnths - 5yrs 5yrs - adolescence
<3wks: - bacteria: e.coli, GBS, L.monocytogenes (maternal transmission) 3wks - 3mnths: - bacteria: chlamydia trachomatis (maternal transmission - also have sticky eye (conjunctivitis) that doesn’t go away with topical abx - give macrolides), s.pneumoniae - virus: adeno, influenza, parainfluenza, RSV 4mnths - 5yrs: - c.pneumoniae, m.pneumoniae, s.pneumoniae, H.influenza virus: same 5yrs - adolescence bacteria: same as above
CAP management
amoxicillin alternatives: co-amoxiclav, erythromycin, azithromycin, clarithromycin second line: macrolide if no response to first line - used if mycoplasma or chlamydia pneumonia pneumonia associated with influenza: co-amoxiclav
from underdeveloped country/ recently visited few week hx anorexia, weight loss, dry cough diagnosis?
tuberculosis
investigations for tuberculosis
- CXR, CT thorax - tuberculin/ Mantoux skin test - interferon -gamma release assay
vaccine for tuberculosis
BCG vaccine
difference between hydrocele and hernia and how to distinguish
hydrocele is fluid when the gap is too small to allow the loop of gut through. hernia is when the gap is bigger so allows gut to pass through hydrocele: - slow to fill, slow to empty - due to small channel (small in morning and gets bigger throughout day) - can get above the swelling - it transilluminates
what side are inguinal hernias more common on and which type of inguinal hernia is more common in children/adults
R:L 3:1 more common in males indirect hernias more common in children direct hernias more common in adults
inguinal hernia management
herniotomy prems: within 2 wks infants: within 1 month child: elective incarcerated hernias which have been reduced: same admission Incarcerated and unable to reduce: emergency repair
investigation for hydrocele
transillumination
when should testes have fully descended by?
continue to descend with first couple months should have descended by 1st yr
complications of undescended testes
- infertility - tumours (less likely to feel abnormalities) - torsion - cosmetic
management for UNILATERAL undescended testes
- palpable - orchidopexy (surgery to move testicle) - impalpable - laparoscopy - first line orchidopexy staged procedure
management for BILATERAL undescended testes
- palpable - orchidopexy - impalpable IS IT A BOY? - genetic testing laparoscopy orchidopexy microvascular transplant
umbilical hernia when are they common in childhood management
usually few weeks after birth most get better by themselves if complicate –> surgery
non- bilious projectile vomits after every feed hungry baby 2-8 weeks of age
hypertrophic pyloric stenosis - gastric outlet obstruction
investigations for hypertrophic pyloric stenosis
gold standard - USS - clinical exam (to feel stenosis), test feed - blood gas: metabolic hypochloraemic alkalosis (as throwing up gastric acid)
management for hypertrophic pyloric stenosis
- rehydration, NG tube, correct electrolyte abnormalities - Ramstedt pyloromyotomy - splitting muscle - can be done laparoscopically
what is the blood gas result in pyloric stenosis
metabolic hypochloraemic alkalosis
what is a test feed
test for pyloric stenosis pass NG tube examine from left feed/put air down watch for visible peristalsis feel for tumour
what is physiological phimosis
tight foreskin unable to retract foreskin very common in babies (should be able to retract by puberty) not an indication for circumcision
how to distinguish between pathological phimosis and a normal physiological phimosis
pull foreskin back and seeing inner mucosa everting out with no scar tissue - physiological phimosis
irretractable foreskin urine spraying when urinating the foreskin balloons
phimosis
definite indications for circumcision
- pathological phimosis - BXO - Balantis Xerotica Obliterans - inflammatory –> scarring of foreskin that it can’t be retracted
relative indications for circumcision
- single kidney and recurrent UTI - recurrent balanoposthitis - infection of foreskin and glands - paraphimosis - when you pull back the foreskin and it can’t go back forwards if left long enough due to oedema (ring constriction) - trauma - viral warts
what is BXO
- bzalantis xerotica obliterans - inflammatory –> scarring of foreskin that it can’t be retracted - can cause urinary retention if left untreated as scar tissue can completely cover the penis tip
from what age can you get BXO
does not occur before 5yrs
differentials for pain in scrotum and management
- torsion of hydatid of Morgagni - most common - testicular torsion - epididymo-orchitis - idiopathic scrotal oedema - incarcerated hernia management: - scrotal exploration procedure if testicular torsion likely or if any doubt of diagnosis
unilateral acute pain in scrotum oedema erythema black dot beneath skin on pressing that point it is the most tender spot
Hydatid of Morgagni – appendix testes - sits by epidemics - can twist on itself and become ischaemic and necroses and fall off – presents in same way as testicular torsion - can see a black dot beneath the skin and if you press it and that is the most tender spot then can confirm diagnosis
treatment for Hydatid of Morgagni
analgesia - pain should go in 1 to 2 days
- unilateral acute sudden onset testicular pain - oedema - erythema - one testicle higher than the other - absent cremasteric reflex - testes with abnormal orientation diagnosis?
testicular torsion cremasteric reflex - rub inside of thigh and see if cremasteric muscles contracting
oedema, erythema on scrotum - erythema extends beyond scrotum diagnosis and treatment
idiopathic scrotal oedema doesn’t need any treatment, will go away in a few days
differentials for child with bilious vomiting
malrotation and volvulus intussusception
what does malrotation of the gut increase the risk of
volvulus
what causes primary idiopathic intussuception
secondary to lymphoid hyperplasia of Peyers Patches in terminal ileum following a viral infection
colicky abdo pain abdo mass vomiting distension red current jelly stool dehydration SHOCK diagnosis?
intussusception
investigations for intussusception
- clinical examination - sausage-shaped right hypochondrium and emptiness in right lower quadrant (Dance’s sign) - USS - diagnostic – transverse - TARGET sign – longitudinal - tubular mass if still in any doubt - contrast enema
management of intussusception
resus (before air enema) - IV fluids - NG tube - Abx pneumatic reduction (air enema- pump air into anus to push intussusception back into place)
contraindications to pneumatic reduction in intussusception? alternative management?
contraindications: - peritonitis - shock - perforation - known pathological lead point NEVER IGNORE BILE STAINED VOMITING - SURGICAL EMERGENCY until proven otherwise (acute perforation - put needles into abdo to relieve pressure) if contraindication then go straight to theatre - surgical reduction: manual reduction necrotic or perforation -> resection
three most common childhood cancers
leukaemia brain & spinal lymphoma
what cancers are you predisposed to with downs syndrome which cancer does it help with
more likely to get leukaemias less likely to get brain tumours
which cells does acute lymphoblastic leukaemia (85% of acute leukaemia) affect?
B cell 85% T cell 15%
fever off food swollen glands - cervical LYMPHADENOPATHY no improvement with abx new BRUISES not wanting to walk - BONE PAIN examination: - SPLENOMEGALY - HEPATOMEGALY - PETECHIAL RASH diagnosis?
acute lymphoblastic leukaemia (ALL) petechial rash - reduced platelet count –> haemorrhage –> DIC
investigations and management for ALL
investigations: - microscopy management: - chemotherapy - 99% cure rate - long term side effects of treatment
B symptoms: - fever - night sweats - weight loss - unexplained persistent supraclavicular lymphadenopathy - non tender, firm, growing mediastinal involvement - 60% axillary nodes palpable diagnosis?
Hodgkins disease (lymphoma)
management of Hodgkins lymphoma
- radiotherapy
side effects of radiotherapy
- thyroid disease – hypothyroidism - 30% – hyperthyroidism - 5% - heart disease - growth - great tissue - increased breast cancer - screen at 30 instead of 40
- cough and wheeze - orthopnoea - no hx asthma - SWOLLEN FACE - reduced appetite, weight loss diagnosis?
high grade non-hodgkins lymphoma - T cell SVC obstruction by lymph nodes –> can’t get fluid out of head –> significant oedema
management for high-grade non-hodgkins lymphoma
steroids
investigation for high-grade non-hodgkins lymphoma
CXR - MEDIASTINAL wide - swollen lymph nodes in mediastinal region LYMPHOMA UNTIL PROVEN OTHERWISE
intussusception above 2/3yrs diagnosis?
LYMPHOMA (NON-HODGKINS B cell) UNTIL PROVEN OTHERWISE head, neck, abdo
most common malignant CNS tumour
medulloblastoma - brain tumour
2 wk hx vomiting: early morning no diarrhoea headaches: worse in morning clumsy: poor coordination, avoiding activities examination: - truncal ataxia (like drunk) - diplopia - double vision - lateral gaze paresis - papilloedema diagnosis?
brain tumour - medulloblastoma - most common type typical age: 7-10yrs
investigations for medulloblastoma
CT head - mass - transependymal oedema - sign of raised pressure (typically very anterior)
types of medulloblastoma in order of prognosis
WNT - wingless good prognosis (leaky blood brain barrier so chemo gets in) SHH - sonic hedgehog childhood prognosis better than adults Group 4 Group 3 worst prognosis
- back pain - - extremity weakness - sensory dysfunction - bowel/bladder dysfunction
spinal cord tumour back pain uncommon in healthy children EMERGENCY
investigations for spinal cord tumour
MRI
presentation of CNS tumours - infants
- MACROCEPHALY - failure to thrive - lethargy - vomiting - head tilt - tumour in foramen magnum - development - delay or regression
- constipation/ diarrhoea - fever - off legs/ screams when changing nappy - painful examination: - DISTENDED ABDO - MASS - wasted limbs - elevated BP - PANDA EYES diagnosis? and differential?
neuroblastoma differential: non-accidental injury
investigations for neuroblastoma
MRI - mass with section going posteriorly - can lead to cord compression USS LDH/ uric acid check BP urine catecholamines AFP/B HCG
management of neuroblastoma
- CHEMOTHERAPY - high dose intensity every 10 days - then SURGICAL reduction - then high dose CHEMO (all at same time) and STEM CELL RESCUE (bone marrow transplant) - then RADIOTHERAPY - then DIFFERENTIATION therapy and IMMUNOTHERAPY
well distended abdomen haematuria HTN non-tender unilateral abdo mass diagnosis and differentials
Wilms tumour tumour tends to take up all free space differentials: UTI nephritis
longstanding knee pain tender tibia regular analgesia unable to sleep - PAIN AT NIGHT examination: tender tibial tuberosity restricted knee flexion swelling proximal tibia diagnosis
bone tumours - osteosarcoma, Ewings sarcoma
investigations for bone tumour
- X-ray - MRI - significant soft tissue madd around tumour, lots of blood vessels coming out into mass - bone scan - can see primary lesion due to high turnover of bone - CXR - CT chest - mets in chest - bloods
what kind of tumour comes from mesenchymal cells with characteristics of striated muscle - worse prognosis in legs as can grow large before being seen - good prognosis in vagina - less mets
rhabdomyosarcoma
management for rhabdomyosarcoma
brachytherapy - high dose radiotherapy for localised target action
- well child - non-articular and poorly localised (shins, calves, backs of knees) - bilateral - intermittent with pain free intervals - normal Gait - occur late in day/ night - normal clinical examination diagnosis?
growing Pains can’t say its growing pains if associated with swelling or specific point tenderness
exaggerated response to pain
chronic regional pain syndrome
- prior to 16yrs - persisting for at least 6 weeks - arthralgia: pain in joint - arthritis: swelling, tenderness, limited range of motion - enthesitis: inflammation at insertion of tendon, ligament, joint capsule diagnosis
juvenile idiopathic arthritis long term joint damage
which genetics are associated with juvenile idiopathic arthritis
HLA (e.g. HLA B27) and non-HLA related genes (cytokine TNFa)
difference between JIA and systemic JIA
JIA: auto-immune systemic: auto-inflammatory
most common type of juvenile idiopathic arthritis
oligoarticular JIA
- 2-12 yrs - less than 5 joints affected - large joints - limping - worse in morning - lasts a few hrs each day - FHx psoriasis - +/- Uveitis - ANA +ve diagnosis
oligoarticular JIA
investigations for oligoarticular JIA
- X-ray: soft tissue swelling - CRP, ESR, FBC, U&Es, LFTs all normal - screen for ANA - with ANA+ve oligoarticular JIA –> uveitis –> if left can be sight threatening
two peaks - 2-12 yrs - adolescence - more than 5 joints affected - several yrs of joint pain - knees, ankles, hands, shoulders, hip -worse at end of day after activity - unable to walk long distances - joint often click - otherwise well investigations: bloods normal can be RF+ve diagnosis?
polyarticular JIA
extra features when polyarticular JIA is RF+ve
- more erosive changes: rheumatoid nodules - RF+ve more likely to go into adulthood - more symmetric - needs more aggressive treatment
child FEVER- intermittent systemic symptoms RASH - trunk & armpits JOINT PAIN markedly raised CRP AND ESR - triple normal value FBC - normocytic anaemia and thrombocytosis lymphadenopathy hepatosplenomegaly
systemic JIA
child FHx psoriasis psoriasis + joint pain nail pitting dactylitis psoriatic ski lesions 50% ANA +ve 30% HLA B27 +ve
psoriatic JIA
adolescence single joint pain, swelling inflammatory bowel disease HLA B27 +ve linked to juvenile ankylosing spondylitis aortitis
enthesitis -related arthritis
investigations for JIA
first line blood tests: - FBC (including blood film) - U&Es, creatinine, LFTs - CRP, ESR specialist tests: - ANA - oligoarticular, SLE - HLA B27 - enthesitis, psoriatic - RF - polyarticular synovial fluid aspirate - non/ infective X-ray, USS, bone scan, CT, MRI
which JIA is uveitis most common with? treatment for JIA uveitis? complications of uveitis?
most common: oligoarticular (with ANA+ve) treatment: - local steroids - DMARDs - BDMARDs complications: - cataract - keratin precipitates - synechiae - vision impairment - blindness
treatment for JIA
non-pharmacological: - healthy diet - vit D - exercise - physio, OT - heat packs, warm baths - footwear, orthotics pharmacological: - NSAIDs - steroids (oral, intravenous, intra-articular) - DMARDs (methotrexate,leflunomide, sulfasalazine) - bDMARDs (etanercept, infliximab & adalimumab- anti TNF), (tocilizumab- antil IL6), (anakinra - antil IL1)
3 risk factors for chronic fatigue?
- socioeconomic deprivation - mood - infection EBV - glandular fever –> chronic fatigue
screening investigations to exclude differentials for chronic fatigue
FBC, ESR, CRP, U&Es, creatinine, TFTs
management for chronic fatigue
advice about sleep and activity: - do not oversleep 7-8hrs - anchor wake up time activity management: - monitor activity - should be halfway btwn what you do in a good day and a bad day consider referral to specialist: - refer to paediatrician 6 weeks
chronic disabling pain - extreme pain even on light touch stop using part of body that is painful diagnosis and management
allodynia - chronic pain syndrome management: - antidepressant (amitriptyline, duloxetine) - neuropathic pain (gabapentin, pregabalin) not opioids for children - will get addicted
what does stridor suggest
URT obstruction
stridor management
don’t upset child O2 adrenaline neb dexamethasone remove any foreign body
what does a delayed cap refill suggest?
shock
what is decorticate posture and what does it mean
hands into CORE damage to corticospinal tracts in brain
what is decerebrate posture and what does it mean
hands out damage to brain stem
what is unilateral dilated pupil a sign of
brainstem coning through foramen magnum - from bleeding, tumours in brain
what does bum shuffling of a baby lead to in walking development
slower walking development
at what age would a child be rolling
4/5 months
at what age should a child be sitting
6 months
stroke in developing brain before the age of two affecting Childs movement and posture speech might be affected hand pronated, foot extended and pronated tone increased reflexes increased diagnosis
cerebral palsy
one shoulder higher than the other or pelvis tilted
scoliosis
when is scoliosis of less concern when does scoliosis get worse
- when the head is above their bottom - when you can put them back int a straight line gets worse: - growth spurt - gastroscopy inserted - good nutrition
what is usually the first sign of Duchenne muscular dystrophy
speech delay
spina bifida is a lower motor neurone disease. what condition is it associated with
hydrocephalus
what is Gower’s manoeuvre and what is it a sign of
muscle weakness around hip gurdle climbing up legs longer time to stand up
speech development milestones for making and understanding language
1 year = 1 word 2 yrs = two word sentences 3 yrs = 3 word sentences 1 yr = 1 step command (put that under the chair) 2 yrs = 2 step command (put that under Lauras chair)
what is Landau-Kleffner syndrome and how does it affect speech
epilepsy where you start to lose language after 4yrs due to seizures
- hypopigmented spot - seborrheic acne - tubers - blobs on CT (calcified nodules in brain) - fibroma - on nail - leash nodules - refer to ophthalmologist - shagreen patch cause autism like phenotype diagnosis
tuberous sclerosis
chromosome 46 xx del 15q11-13 uniparental dysomy for chromosome 15 from dad- (two copies from dad) ataxic gait giggly lack of language severe seizures diagnosis
Angelman syndrome
two copies of chromosome 15 from mum
Prader-Willi syndrome
places to measure temperature in a child - under 4 weeks - over 4 weeks
under 4 wks: electronic under axilla over 4 wks: infrared tympanic temperature
red - high risk for fever - emergency care presentation
- pale/mottled/ ashen/ blue skin, lips or tongue - no response - appearing ill - grunting - RR > 60 - moderate/ severe chest undrawing - reduced skin turgor - bulging fontanelle
amber - intermediate risk for fever - emergency care presentation
- pallor of skin, lips or tongue - wakes only with prolonged stimulus - nasal flaring - dry mucous membranes - reduced urine output - rigors
green - low risk fever - emergency care presentation
- fever but otherwise well - normal colour of ski, lips and tongue - awake - normal skin, eyes
which groups do these belong to in the traffic light risk system: - fever + tachycardia - fever + tachypnoea
amber group
fever non blanching pietichial rash lesions >2mm in diameter (purpura) off food cap refill time >3s neck stiffness
meningococcal disease
fever neck stiffness bulging fontanelle decreased level of consciousness convulsive status epilepticus
meningitis
fever focal neurological signs focal seizures decreased level of consciousness
herpes simplex encephalitis
fever tachypnoea crackles nasal flaring chest indrawing cyanosis O2 sats <95%
pneumonia
fever vomiting poor feeding lethargy irritability abdo pain/ tenderness urinary frequency or dysuria offensive urine or haematuria
UTI
fever swelling of a limb or joint not using an extremity non-weight bearing
septic arthritis
what is the commonest cause of acquired heart disease in childhood in developing countries
Kawasaki disease
ADHD
inattention hyperactivity impulsivity persistent
first line mx ADHD
methylphenidate (for children over 5)
side effect of methylphenidate
stunted growth weight and height should be monitored every 6 months cardiotoxic baseline ECG
child on SABA + ICS + LRTA for asthma next line
swap LRTA for LABA
causes of heart failure in children <2 weeks old
coarctation of aorta left-to-right shunts
causes of heart failure in children >2 weeks old
VSD as the pulmonary vasculature resistance begins to fall
most common causes of acyanotic congential heart disease
- ventricular septal defects (most common) - atrial septal defect - patent ductus arteriosus - coarctation of aorta - aortic valve stenosis
most common causes of cyanotic congential heart disease
- tetralogy of fallot - transposition of great arteries - tricuspid atresia
when does tetralogy of fallot present
1-2 months
when does transpotition of great arteries present
at birth
repeated flexion of head/arms/trunk followed by extension of arms 4-8months
infantile spasms salaam attacks 1-2seconds but may be repeated up to 50 times
drawing up of legs
infantile colic
pneumatosis intestinalis on AXR
pneumatosis intestinalis on AXR is a hallmark of necrotising enterocolitis usually in 2-3 days following birth pneumonitis intestinalis (gas cysts in bowel wall) abdo distension
scarlet fever mx
phenoxymethylpenicillin 5 days
to treat strep pyogenes
fever responds to antipyretics
can lead to rheumatic fever and post strep glomerulonephritis
hirschsprung’s disease
neonatal period: failure or delay to pass meconium older children: constipation, abdominal distension failure of parasympathetic - bowels dont contract more common in males downs syndrome
downs syndrome features
face:
- upslanting palpebral fissures
- epicanthic folds
- brushfield spots in iris
- protruding tongue
- small low-set ears
- round/flat face
flat occiput
single palmar crease
pronounced ‘sandal gap’ btwn big and first toe
hypotonia
congenital heart defects
duodenal atresia
hirschsprung’s disease
cardiac complications of downs syndrome
- endocardial cushion defect (atrioventricular septal defect) - most common - ventricular septal defect - secundum atrial septal defect - tetralogy of fallot isolated patent ductus arteriosus
later complications of downs syndrome
subfertility learning difficulties short stature repeated respiratory infections acute lymphoblastic leukaemia hypothyroidism alzheimer’s disease atlantoaxial instability
diagnosis
DiGeorge
CATCH 22
C - cleft palate
A - abnormal fascies
T- thymic hypoplasia
C- cardiac defects
H - hypocalcaemia
22 - chromosome 22 deletion
abnormal facies: small jaw, small upper lip, low set ears, short stature, learning difficulties
Fragile X syndrome
gross motor developmental milestones
sits without support: 7-8 months (refer at 12)
crawls: 9 months
walks unsupported: 13-15 months (refer at 18)
runs: 2yrs
rides a tricycle using pedals, walks up stairs without rail: 3yrs
hops on one leg: 4yrs
measles features
RNA paramyxovirus
prodrome: irritable, conjunctivitis, fever
koplik spots ( before rash): white spots (grain of salt) in mouth
rash: starts behind ears then to whole body - discrete maculopapular rash
ix and mx measles
ix: IgM antibodies
Mx: supportive
notifiable disease: inform public health
high grade fever > 5 days
resistant to antipyretics
bright red, cracked lips
strawberry tongue
red palms and soles which later peel
conjunctivitis
kawasaki disease
clinical diagnosis
mx kawasaki disease
high-dose aspirin
IVIG
echo - screen for coronary artery aneurysms
most common cause of gastroenteritis in children
rotavirus
diarrhoea + vomiting and fever for the first 2 days
causes of chronic diarrhoea in infants
most common cause in the developed world is cows’ milk intolerance
toddler diarrhoea: stools vary in consistency, often contain undigested food
coeliac disease
post-gastroenteritis lactose intolerance
continous machinery murmur
patent ductus arteriosis
mx: indomethacin - closes connection
disorders of sex hormones
primary hypogonadism
XXY
Klinefelter’s syndrome
primary hypogonadism: low testosterone, high LH
features:
- taller
- lack of secondary sexual characteristics
- small firm testes
- infertile
- gynaecomastia
Kallmans syndrome
hypogonadotrophin hypogonadism
low LH causes low testosterone
features:
- boy
- delayed puberty
- anosmia: loss of smell
androgen insensitivity syndrome
x-linked recessive
46XY but female phenotype
high LH, normal/high testosterone
have end organ resistance to testosterone
features:
- primary amenorrhoea
- undescended testes - groin swelling
- breast development
cytomegalovirus - congenital
growth retardation
purpuric skin lesions
sensorineural deafness
seizures
congenital toxoplasmosis
cerebral calcification
chorioretinitis
hydrocephalus
congenital rubella
sensorineural deafness
congenital cataracts
congenital heart disease (patent ductus arteriosus)
glaucoma
speech and hearing developmental milestones
fine motor and vision milestones
faecal impaction mx children
polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain)
maintenance therapy: Movicol Paediatric Plain
meckel’s diverticulum
abdo pain
rectal bleeding - most common cause of painless massive GI bleed btwn 1-2yrs
intestinal obstruction
fifth disease (erythema infectiosum)
slapped-cheek syndrome
caused by parvovirus B19
lethargy, fever, headache
slapped-cheek rash spreading to proximal arms and extensor surfaces
intussusception features
paroxysmal abdominal colic pain
during paroxysm - draw knees up and turn pale
vomiting
bloodstained stool - red-current jelly - late sign
sausage-shaped mass in RUQ
ix and mx for intussusception
Ix: USS - target-like mass
mx: first line: reduction by air insufflation under radiological control
used to be barium enema
if this fails or child has signs of peritonitis - surgery
GORD first line medical treatment in infants
alginate therapy e.g. gaviscon
child <5
haematuria
unilateral loin mass
Wilms tumour
nephroblastoma
children <5yrs - median age of 3yrs
unexplained enlarged abdo mass in children - Wilms tumour - review in 48hrs
Mx: nephrectomy, chemo, radio if advanced
child immunisation schedule
childhood syndromes
phenylketonuria (PKU) features
autosomal recessive
chromosome 12
usually presents by 6months with developmental delay
child classically has fair hair and blue eyes
learning difficulties
seizures
eczema
‘musty’ odour to urine and sweat
screened in Guthrie ‘heel prick’ test 5-9 days of life
fluids for children
