Child Health Flashcards
diagnostic criteria from bronchiolitis
coryzal prodrome lasting 1-3 days followed by;
persistant cough
tachypnoea and or chest recession
wheeze and or crackles on auscultation
REMEMBER <6 weeks may present with apnoea without other signs
when should bronchiolitis be IMMEDIATELY referred to hospital
apnoea child looks seriously unwell severe resp distress (grunting, marked chest recession, resp rate >70) central cyanosis persistent sats <92% on air
when should you consider referring a child with bronchiolitis
resp rate >60
difficulty breast feeding or inadequate oral fluid intake
clinical dehydration
management of bronchiolitis
supplemental oxygen if persistently <92%
give fluids by naso- or oro-gastric tube if not feeding
what information must be passed on to parents if child is not admitted
red flags: increased work of breathing (grunting, nasal flaring, marked chest recession), fluid intake is 50-75% normal or no wet nappy in 12 hours, apnoea or cyanosis, exhaustion
no smoking in the home
follow up if needed
differentials for bronchiolitis
pneumonia - high fever (>39) - persistently focal crackles viral-induced wheeze or early-onset asthma - persistent wheeze without crackles - recurrent episodic wheeze - personal or family history of atopy
risk factors for severe bronchiolitis
chronic lung disease haemodynamically significant congenital heart disease age <3 months premature birth, esp <32 weeks neuromuscular disorders immunodeficiency
discharge a child with bronchiolitis when
clinically stable
taking adequate oral fluids
maintained sats >92% in air for 4 hours, including a period of sleep
temperature measurement in <4 weeks
electronic thermometer in axilla
temperature measurement in 4 weeks to 5 years
electronic thermometer in axilla
chemical dot thermometer in the axilla
infra-red tympanic thermometer
high risk symptoms in feverish child
pale, mottled, ashen, blue skin lips or tongue
no response to social cues
appearing ill to health care professional
does not wake or if roused does not stay awake
weak, high-pitched or continuous cry
grunting
resp rate >60
moderate or severe chest indrawing
reduced skin turgor
bulging fontanelle
intermediate-risk symptoms in feverish child
pallor of skin, lips or tongue reported by parent or carer not responding normally to social cues no smile wakes only with prolonged stimulations decreased activity nasal flaring dry mucous membranes poor feeding in infants reduced urine output rigors
low-risk symptoms in feverish child (and no high or intermediate risk symptoms)
normal colour of skin, lips and tongue responds normally to social cues content/smiling stays awake or wakens quickly strong normal cry or not crying normal skin and eyes moist mucous membranes
cap refill over ____ is a sign of intermediate-risk illness
cap refill over 3 secs is a signs of intermediate-risk illness
temperature has different risk factors in different age groups
which temperatures are associated with which risk groups in <3 months and 3-6 months
<3 months: temp >38 = high risk group
3-6 months: temp 39 = at least intermediate risk group
fever lasting >5 days should be assessed for…
Kawasaki disease
duration of fever should not be used to predict likelihood of serious illness otherwise
definition of tachycardia in different age groups
<12 months = >160
12-24 months = >150
2-5 years = >140
signs of dehydration in children with fever
prolonged cap refill abnormal skin turgor abnormal resp pattern weak pulse cool extremities
when to consider meningococcal disease in a child with fever
non-blanching rash plus any of
- ill looking child
- lesions >2 mm (purpura)
- cap refill >3 secs
- neck stiffness
when to consider bacterial meningitis in a child with fever
neck stiffness
bulging fontanelle
decreased LOC
convulsive status epilepticus
classic signs (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants
when to consider herpes simplex encephalitis in feverish child
focal neurological signs
focal seizures
decreased LOC
when to consider pneumonia in child with fever
tachypnoea crackles in chest nasal flaring chest undraping cyanosis sats <95% on air
definition of tachypnoea in different age groups
0-5 months = >60
6-12 months = >50
>12 months = >40
when to consider UTI in child with fever
in ALL children >3 months + fever
> 3 months
- vomiting
- poor feeding
- lethargy
- irritability
- abdominal pain or tenderness
- urinary frequency or dysuria
when to consider septic arthritis/osteomyelitis in a child with fever
swelling of a limb or joint
not using an extremity
non-weight bearing
when to consider Kawasaki disease in child with fever
fever >5 days bilateral conjunctival injection without exudate erythema and craving of lips strawberry tongue erythema of oral and pharyngeal mucosa oedema and erythema in hands and feet polymorphous rash cervical lymphadenopathy
ask about presence of symptoms since onset of fever as they may have clears up by time of assessment
which investigations should be performed in infants younger than 3 months with fever
FBC blood culture CRP urine testing CXR if respiratory signs suggestive of pneumonia stool culture if diarrhoea present
indications of LP in feverish children <3 months
> 1 month
all infants 1-3 months who appear unwell
1-3 months with a WCC <5x10^9 or >15x10^9
which investigations should be performed in infants >3 months with fever
FBC
blood culture
CRP
urine testing
which investigations should be considered in children with red/high risk features with fever
LP
CXR
serum electrolytes and blood gas
how to investigate child with no apparent source of fever with 1 or more amber features
urine sample
bloods (FBC, CRP, cultures)
LP (if <1 year)
CXR (fever >39, WBC <20x10^9)
immediate management of children presenting with fever and shock
IV fluid boys of 20 ml/kg (normally 0.9% NaCl)
actively monitored and given further fluid boluses if necessary
when to give immediate parenteral abx to a feverish child
shock
unrousable
sign of meningococcal disease
which empirical IV abx should be given to feverish children
> 3 months: third generation cephalosporin (cefotaxime or ceftriaxone)
<3 months: add in listeria cover (ampicillin or amoxicillin)
what to give children with symptoms suggestive of herpes simplex encephalitis
IV aciclovir
which infections are covered by 3rd generation cephalosporin
Neisseria meningitidis step pneumoniae E coli staph aureus HiB
advice to parents caring of a feverish child at home
regular fluids signs of dehydration non-blanching rash check during the night no nursery or school while fever persists but notify them of illness
when parents should seek help if caring of a feverish child at home
fits
non-blanching rash
they feel they are less well than when they first sought advice
fever lasts >5 days
initial assessment of under 12’s with suspected sepsis
temperature heart rate resp rate O2 sats cap refill
assess BP too if heart rate or cap refill are abnormal
why is measuring blood pressure less prioritised in children
hypotension occurs much later in children as they are much better at peripheral constriction
correctly sized cuffs may not be available in non-paediatric settings
what skin signs should be assessed for in suspected sepsis
mottled/ashen skin cyanosis of skin, lip or tongue non-blanching rash breaches of skin integrity (cuts, burns, skin infections) other rashes
features in history that are high risk for sepsis >12 yo
objective evidence of new altered mental state
features in history that are moderate-high risk for sepsis >12 yo
reports of new onset altered behaviour or mental state
history of acute deterioration of functional ability
impaired immune system (illness or drugs)
trauma, surgery or invasive procedure in the last 6 weeks
resp signs that are high risk for sepsis >12 yo
resp rate >25
new need for oxygen (40% FiOs or more) to maintain sats to 92%
resp signs that are mod/high risk for sepsis >12 yo
resp rate 21-24
circulatory signs that are high risk for sepsis >12 yo
HR >130
not passed urine in previous 18 hours
circulatory signs that are mod/high risk for sepsis >12 yo
HR 91-130
not passed urine for 12-18 hours
blood pressure that is high risk for sepsis >12yo
systolic >90 mmHg
or systolic >40 mmHg less than normal
blood pressure tat is mod/high risk for sepsis >12 yo
91-100 mmHg
behaviour signs that are high risk for sepsis 5-11 yo
objective evidence of altered behaviour or mental state
appears ill to a healthcare professional
does not wake or does not stay awake
behaviour signs that are mod-high risk for sepsis 5-11 yo
not behaving normally
decreased activity
parent or carer concern that child is behaving differently than normal
resp signs that are high risk of sepsis 5-11 yo
All ages: sats <90% on air
5 yo: resp rate >29
6-7 yo: RR >27
8-11 yo: RR >25
resp signs that are mod-high risk of sepsis 5-11 yo
all ages: sats <92% on air
5 yo: RR 24-28
6-7 yo: RR 24-26
8-11 yo: RR 22-24
circulatory signs that are high risk of sepsis 5-11 yo
all ages: HR <60
5 yo: HR >130
6-7: HR >120
8-11: HR >115
circulatory signs that are mod-high risk for sepsis 5-11 yo
all ages: cap refill >3 secs, reduced urine output
5 yo: HR 120-129
6-7 yo: HR 110-119
8-11 yo: HR 105-114
temperature that is mod-high risk for sepsis 5-11 yo
all ages: temp <36
other signs that are mod-high risk for sepsis 5-11 yo
leg pain
cold hands or feet
management of patients with 1+ high risk sepsis factor
arrange for immediate senior review
venous blood test for: blood gas (glucose and lactose), culture, FBC, CRP, U&E, creatinine, clotting screen
broad spectrum abx
fluid bolus if lactate >2 mmol/L or systolic BP <90 mmHg
when managing a patient >12 yo with sepsis a consultant should be alerted if the patient fails to respond to initial abx/fluid resuscitations in 1 hour
failure to respond includes:
systolic BP persistently <90 mmHg
reduced LOC despite resuscitation
resp rate >25 or new need for mechanical ventilation
lactate not reduced by >20% of initial value
when to consider inotropes or vasopressors in children 5-11 with suspected sepsis
any high risk criteria
lactate >4 mmol/L
ALSO give IV fluid bolus
when managing a patient <12 yo with sepsis a consultant should be alerted if the patient fails to respond to initial abx/fluid resuscitations in 1 hour
failure to respond includes:
reduced LOC despite resuscitation
HR or RR fulfil high risk criteria
lactate remains >2 mmol/L
fluid resus guidelines in patients <16 with suspected sepsis
glucose-free crystalloids containing sodium in range of 130-154 mmol/l
bolus of 20 ml/kg over less than 10 mins
fluid resus guidelines in neonates with suspected sepsis
glucose-free crystalloids containing sodium in range of 130-154 mmol/l
bolus of 10-20 ml/kg over less than 10 mins
what are contraindication for LP
suggested raised ICP reduced or fluctuating LOC relative bradycardia and hypertension focal neuro sings abnormal posture or posturing unequal, dilated or poorly responsive pupils abnormal 'doll's eye' movements shock extensive or spreading purpura after convulsion until stabilised coagulation abnormalities local superficial infection at LP site resp insufficency
define sepsis
life-threatening organ dysfunction due to a dysregulated host response to infection
define early onset neonatal bacterial infection
infection with onset within 72 hours of birth
signs that are suggestive of early onset neonatal infection
abnormal behaviour unusually floppy difficulty feeding or tolerating feeds abnormal temperature (<36 or >38) rapid breathing change in skin colour
when to offer intrapartum antibiotics and which abx should be used
previous baby with invasive group B strep infection
group B strep colonisation, bacteriuria or infection in the current pregnancy
IV benzpen
what is first line empirical treatment of early onset neonatal infection
IV benpen with gentamicin
investigations in suspected neonatal infection
CRP before starting abx
CRP after 18-24 hours
consider stopping abx after 36 hours if
blood culture is negative
initial clinical suspicion of infection was not strong
clinical condition is reassuring with no clinical indicators of possible infection
levels and trends of CRP are reassuring
risk factors for early onset neonatal infection
invasive group B strep in previous baby
maternal group B strep colonisation, bacteriuria or infection in current pregnancy
PROM
preterm birth following spontaneous labour (<37 weeks)
suspected or confirmed ROM for more than 18 hours in a preterm birth
intrapartum fever >38
parenteral abx given to woman during labour or in 24 hours before or after
infection in another baby if multiple pregnancy
clinical indications of early onset neonatal infection
altered behaviour or responsiveness altered muscle tone eg floppy feeding difficulties feed intolerance (vomiting, excessive gastric aspirates, abdominal distension) abnormal HR signs of resp distress resp distress starting more than 4 hours after birth hypoxia jaundice within 24 hours of birth apnoea neonatal encephalopathy seizures need for CPR need for mechanical ventilation temp shock bleeding oliguria >24 hr after birth altered glucose homeostasis Metabolic Acidosis local signs of infection
investigations before starting antibiotics in neonatal infection
CRP
LP (strong clinical suspicion or signs of meningitis)
when should skin swabs be taken in neonatal infection and which empirical abx should be started in each instance
purulent eye discharge (chlamydia and gonococcus)
abx: cover gonococcus
purulent discharge or signs of periumbilical cellulitis
abx: IV fluclox and gentamicin
what is first line empirical abx for neonatal infection
IV benpen with gent
benpen: 25 mg/kg every 12 hours
gent: 5 mg/kg starting dose (every 36 hours)
consider stopping abx for neonatal infection after 36 hours if
blood culture is negative
initial clinical suspicion of infection was not strong
baby’s clinical condition is reassuring with no clinical indicators of possible infection
levels and trends of CRP concentration are reassuring
how long should standard abx treatment be in babies with positive blood culture or with negative culture and strong clinical suspicion
7 days
longer if not yet recovered or advisable based on the pathogen
what is the trough concentration
gentamicin concentration just before giving another dose
what are the recommended thought concentrations for gentamicin
<2 mg/litre
if lasts more than 3 doses aim for <1 mg/litre
what features would cause you to withhold a gentamicin dose
evidence of renal dysfunction eg elevated serum urea or creatine concentration, or anuria
when would you measure peak gentamicin concentrations
1 hour after starting infusion
when would you measure peak blood gentamicin
oedema
macrosomia (BW >4.5 kg)
unsatisfactory response to treatment
proven gram-negative infection
most common cause of meningitis in children
Neisseria meningitidis
strep pneumo
HiB
most common cause of meningitis in <3 months
group B strep
E coli
strep pneumo
listeria monocytogenes
describe IV fluid resus in children with suspected/confirmed meningococcal sepsis
immediate fluid bolus 20 ml/kg NaCl 0.9% over 5-10 mins
give second bolus 20 ml/kg NaCl or albumin 4.5% over 5-10 mins
if still shocked after 40 ml/kg:
- give third bolus
call anaesthetics for urgent tracheal intubation and mechanical ventilation
start vasoactive drugs
investigations in a child/young person with unexplained petechial rash and fever
FBC CRP coagulation screen blood culture PCR for N meningitidis blood glucose blood gas
abx in child/young person with suspected meningitis
IV ceftriaxone
abx in infant <3 months with suspected meningitis
IV cefotaxime plus amoxicillin
when should vancomycin be added in meningitis
recent travel outside the UK or have had prolonged exposure to antibiotics within the past 3 months
in which patient group should ceftriaxone not be used and why
premature babies or babies with jaundice, hypoalbuminaemia or acidosis
may exacerbate hyperbilirubinaemia
which metabolic disturbances should be monitored for in children with bacterial meningitis
hypoglycaemia acidosis hypokalaemia hypocalcaemia hypomagnesaemia anaemia coagulopathy
in a child/young person with meningitis what are the indications fo intubation
threatened or actual loss of airway patency
need for assisted ventilation
clinical observation of increasing work of breathing
hypoventilation or apnoea
features of resp failure
along with abx, which drug should be given in meningitis
dexamethasone before or with first dose of abx
do not start more than 12 hours after abx started
possible long term complications of meningitis
hearing loss orthopaedic complications skin complications (scarring from necrosis) psychosocial problems neurological and developmental problems renal failure
sings of UTI in infants <3 months
most common:
fever, vomiting, lethargy, irritability
less common:
poor feeding, failure to thrive
least common:
abdominal pain, jaundice, haematuria, offensive urine
signs of UTI in preverbal children
most common:
fever
less common:
abdominal pain, loin tenderness, vomiting, poor feeding
least common:
lethargy, irritability, haematuria, offensive urine, failure thrive
signs of UTI in verbal children
most common:
frequency, dysuria
less common: dysfunctional voiding, changes to continence, abdominal pain, loin tenderness
least common:
fever, malaise, vomiting, haematuria, offensive urine, cloudy urine
what is the recommended way to collect a urine sample from children?
if this is not possible which other methods are available?
clean catch urine sample
urine collection pads
catheter samples
suprapubic aspiration
which tests should be performed on urine samples in children:
<3 months
3 months - 3 years
over 3 years
<3 months:
send sample for urgent microscopy and culture
3 months - 3 years:
dipstick testing
> 3 years:
dipstick testing
indications for antibiotic treatment in suspected UTI age <3 months
start empirical abx if clinical suspicion
IV amoxicillin and gent
send urine for culture but do not delay abx
indications for abx in suspected UTI age 3 months - 3 years
leukocyte esterase, nitrite or both are positive on dipstick start abx and send urine for culture
trimethoprim PO or nitrofurantoin PO
indications for abx in suspected UTI age >3 years
leukocytes + nitrite positive:
abx
leukocyte negative + nitrite positive:
abx
leukocyte postive + nitrite negative:
abx started only if there are clinical signs of UTI (may be indicative of infection elsewhere)
both negative:
no abx, no UTI
when should urine sample be sent for culture
suspicion of acute pyelonephritis or upper UTI
high-intermediate risk of serious illness
<3 months
positive result for leukocyte or nitrite
recurrent UTI
doesn’t respond to treatment in 24-48 hours
clinical symptoms and negative dipstick
what are risk factors for UTI and may indicate serious underlying pathology
poor urine flow previous UTI recurrent fever of uncertain origin antenatally diagnosed renal abnormality Fix of vesicoureteric reflux or renal disease constipation dysfunctional voiding enlarged bladder abdominal mass evidence of spinal lesion poor growth high BP
how to differentiate between acute pyelonephritis/upper UTI and cystitis/lower UTI
bacteriuria and fever >38 = pyelonephritis/upper UTI
fever <38,loin pain/tenderness and bacteriuria = pyelonephritis/upper UTI
bacteriuria - systemic signs or symptoms = cystitis/lower UTI
DO NOT USE CRP ALONE
investigation of UTI in children <6/12
US in all to detect structural abnormality
VCUG and venogram (after 4/12) if US abnormal
atypical UTI (non E Coli, no response to abx)
recurrent UTI
investigation of UTI in children 6 months to 3 years
no imaging if uncomplicated UTI
US and venogram if atypical or recurrent
no VCUG
investigation of UTI in children >3 years
US and renogram only if recurrent UTI
features of atypical UTI
seriously ill poor urine flow abdominal or bladder mass raised creatinine sepsis failure to respond to abx in 48 hours infection with E coli
define recurrent UTI
2 or more episodes of UTI with acute pyelonephritis/upper UTI
1 episode of UTI with acute pyelonephritis/upper UTI PLUS one or more episode of lower UTI
3 or more episodes of lower UTI
when is referral to a paediatric nephrologist necessary in children with UTI
bilateral renal abnormalities
impaired kidney function
raised blood pressure
proteinuria
when should stool samples be performed on children with diarrhoea
suspicion of sepsis
blood/mucous in stool
immunocompromised
consider them if;
recent travel abroad
diarrhoea not improved in 7 days
uncertainty about diagnosis
fluid management in children with gastroenteritis but no clinical dehydration
continue breast feeding/other milk feeds
encourage fluid intake
discourage drinking fruit juices and carbonated drinks
oral rehydration solutions if increased risk of dehydration
fluid management in children with gastroenteritis and clinical dehydration
low osmolarity oral rehydration solution
(50 ml/kg over 4 hours as well as maintenance fluid)
consider using NG tube if unable to drink/persistent vomiting
when to use IV fluid in fluid management in gastroenteritis
shock is suspected/confirmed
evidence of deterioration despite oral rehydration therapy
persistent vomiting of ORS (orally or NG)
questions to ask in suspected gastroenteritis
recent contact with someone with acute diarrhoea and/or vomiting
exposure to known source of enteric infection (contaminated water or food)
recent travel abroad
signs that suggest diagnosis other that simple gastroenteritis
fever SOB/tachyp altered conscious state meningism bulging fontanelle blood/mucous in stool bilious green vomit severe or localised abdominal pain abdominal distension or rebound tenderness
which children are at greater risk of dehydration due to diarrhoea/gastroenteritis
<1 year, particularly <6 months
low birth weight
>5 diarrhoeal stools in previous 24 hours
>2 vomits in previous 24 hours
not been offered/tolerate supplementary fluids
stopped breastfeeding
malnutrition
red flags for dehydration
appears unwell/deteriorating altered responsiveness sunken eyes tachycardia/tachyp reduced skin turgor
which features suggest Hypernatraemia dehydration
jittery movements increased muscle tone hyperreflexia convulsions drowsiness or coma
when to give abx in gastroenteritis
suspected/confirmed sepsis
extra-intestinal spread of bacterial infection
<6 months, malnourished or immunocompromised with salmonella
C diff, giardiasis, shigella
abx in C diff in children
1st line PO met
2nd line PO vanc
when to suspect croup
sudden onset, seal-like barking cough stridor chest wall or sternal undraping worse at night increase with agitation
differentials for croup
bacterial tracheitis epiglottitis foreign body quinsy allergic reaction
features of epiglottitis
sudden onset fever dysphagia drooling anxiety non-barking cough preferred posture if upright with head extended
features of foreign body in upper airway
sudden onset dyspnoea and stridor
usually history of inhalation of object
no prodrome or viral symptoms
features of quinsy
dysphagia drooling stridor (occasionally) dyspnoea tachyp neck stiffness unilateral cervical adenopathy more gradual onset
what is croup
laryngotracheobronchitis
symptoms caused by upper airway obstruction due to generalised inflammation of the airways
typically parainfluenza virus types 1 or 3
risk factors for croup
6 months - 6 years
male sex
previous intubation
how to categorise severity of croup symptoms
mild: seal-like barking cough, no stridor or recession at rest
moderate: seal-like barking cough with stridor/recession at rest; no agitation/lethargy
severe: like moderate but with agitation/lethargy
signs of impending resp failure in croup
increasing upper airway obstruction sternal/intercostal recession asychronus chest wall and abdominal movement fatigue pallor/cyanosis decreased level of consciousness tachycardia resp rate >70
when to consider hospital admission for children with croup
moderate or severe illness resp rate >60 <3 months inadequate fluid intake immunodeficiency
pre-hospital management of moderate/severe croup
supplementary O2 if severe
oral dexamethasone or inhaled budesonide
management of mild croup (at home)
single dose of oral dexamethasone
advise symptoms should resolve in 48 hours
take to hospital if continuous stridor, undraping, restless or agitated
ambulance if very pale/blue/grey, unusually sleepu or unresponsive, struggling to breath, want to sit instead of lie down etc
children and young people presenting with suspected seizure should be seen by a specialist in the diagnosis and management of epilepsy within _______ of presentation
2 weeks
define suspected epileptic seizure
acute episode of altered functioning, presumed to be the direct result of a change in electrical activity in the brain
what is SUDEP
sudden unexpected death in epilepsy
how is the risk of SUDEP reduced
optimising seizure control
being beware of the potential consequences of nocturnal seizures
investigations in suspected epilepsy
EEG
MRI
CT if not MRI
MRI is particularly important in the diagnosis of epilepsy in which population
<2 years
focal onset on history, examination or EEG
continued seizures in spite of first-line medication
treatment of generalised seizures
first line: sodium valproate, lamotrigine, levetiracetam or topiramate
treatment of focal seizures with or without secondary generalisation
first line: lamotrigine, carbamazepine or levetiracetam
second line: sodium valproate or topiramate
which epileptic drugs are hepatic enzyme inducers and therefore reduce the effectiveness of hormonal contraceptives
carbamazepine
topiramate >200 mg/day
sodium valproate is teratogenic
define focal seizure
originate in networks limited to one hemisphere, and may be localised or more widely distribution
divided into retained awareness or impaired awareness
define generalised seizures
originate in bilaterally distributed networks and can include cortical and subcortical structures
divided into motor and non-motor (absence) seizures
risk factors for epilepsy
premature birth complicated febrile seziures brain development malformations family history head trauma, infections or tumours CVD or stroke (older people) dementia and neurodegenerative disorders
what should history include when assessing possible seizure
subjective symptoms at the start of the seizure (aura)
potential triggers (sleep deprivation, stress, light sensitivity, alcohol use)
specific features of the seizure
residual symptoms after the attack (post-ictal)
describe a tonic seizure
short lived (<1 min)
abrupt, generalised muscle stiffening (may cause a fall)
rapid recovery
describe a generalised tonic-clonic seizure
generalised stiffening and subsequent rhythmic jerking of the limbs
urinary incontinence
tongue biting
describe an absence seizure
behavioural arrest
describe atonic seizure
sudden onset of loss of muscle tone
describe myoclonic seizure
brief, ‘shock-like’ involuntary single or multiple jerks
what is the differential for epileptic seizure in children
febrile convulsions
breath-holding attacks
night terrors
stereotyped/ritualistic behaviour (LD)
what long term monitoring is needed for people taking anti-epileptic drugs
adverse effects and compliance
osteoporosis risk
- long term carbamazepine, phenytoin, primidone, phenobarbital, sodium valproate
- calcium and vit D supplements if appropriate
women of child-bearing age
- contraception, AEDs during pregnancy etc
define simple febrile seizure
isolated, generalised, tonic-clonic seizures
lasts less than 15 mins
do not recur within 24 hours or within same febrile illness
complete recovery within 1 hour
define complex febrile seizure
one or more of;
partial (focal) seizure (movement limited to one side of the body or one limb)
duration >15 mins
recurrent within 24 hours or within same febrile illness
incomplete recovery within 1 hr
define febrile status epilepticus
> 30 mins
series of seizures without full recovery in between lasting 30 mins or more
typical features of simple febrile seizure
6 months - 6 years
2-3 minutes, rarely >10 mins
generalised tonic-clonic
may be foaming at the mouth, difficulty breathing, pallor, cyanosis
brief post-ictal drowsiness, irritability, confusion
complete recovery within 1 hour
typical features of complex febrile seizure
partial onset or focal features
>15 mins
recurrent within 24 hours or same febrile illness
incomplete recovery within 1 hour
prolonged post-ictal drowsiness or transient hemiparesis (Todd’s palsy)
differential diagnosis of febrile convulsion
with fever
- CNS infection eg meningitis/encephalitis
- rigors/delirium
- shivering
- febrile myoclonus
without fever - syncope - breath-holding attacks or reflex anoxic seizure - head injury - hypoglycaemia/metabolic drug use/withdrawal epilepsy
what is the most common cause of bacterial pneumonia in children
strep pneumoniae also; group A strep staph aureus haem influenzae
when to consider pneumonia in a child
high fever cyanosis raised resp rate signs of increased work of breathing persistently focal crackles sats <95%
features of pneumonia in children
age, resp rate, hyperflation, wheeze, crackles
age: any age
resp rate: usually increased
hyperinflation: not present
wheeze: not usually present
crackles: course crackles, usually focal
features of bronchiolitis in infants
age, resp rate, hyperflation, wheeze, crackles
age: <2 yo, peak at 3-6 months
resp rate: usually increased
hyperinflation: often present (difficult to detect in infants <6 months)
wheeze: may be present
crackles: fine crackles present throughout lung fields
features of viral-induced wheeze
age, resp rate, hyperflation, wheeze, crackles
age: under 5 yo
resp rate: may be normal of increased
hyperinflation: may be present
wheeze: present
crackles: not usually present
features of infective exacerbation of asthma
age, resp rate, hyperflation, wheeze, crackles
age: any age
resp rate: may be normal or increased
hyperinflation: may be present
wheeze: present
crackles: not usually present
abx for non-severe CAP in children
amoxicillin PO (7 days)
clarithromycin if penicillin allergic
<1 year use co-amoxiclav PO
abx for severe CAP in children
co-amoxiclav IV then PO (10 days)
add clarithromycin if features of atypical pneumonia or pertussis
risk factors for asthma
personal or family history of aortic disease
respiratory infections in infancy
exposure (including prenatally) to tobacco smoke
premature birth and low birth weight
obesity
features of ciliary dyskinesia
persistent moist cough present from birth
features of cystic fibrosis
persistent moist cough and GI symptoms that are often present from birth
finger clubbing
failure to thrive
first line management of asthma in children
SABA reliever inhaler
second line management of asthma in children
why would it be indicated
inhaled corticosteroids
SABA use 3+ times a week
asthma symptoms 3+ times a week
woken at night by asthma symptoms 1+ times a week
third line management of asthma in children
leukotriene receptor antagonist (montelukast)
then LABA
features of a moderate asthma exacerbation in children
PEFR at least 50% best or predicted
normal speech
no features of severe/life-threatening asthma
features of acute severe asthma exacerbation in children
PEFR <50% best or predicted resp rate >25/30/40 heart rate >110/125/140 inability to complete full sentences in one breath accessory muscle use inability to feed (infants) sats <92%
features of life-threatening asthma exacerbation in children
PEFR <33% best or predicted sats <92% altered consciousness exhaustion cardiac arrhythmia hypotension cyanosis poor respiratory effort silent chest confusion
management of acute asthma attack while awaiting admission to hospital
O2: aim for sats 94-98
nebuliser salbutamol
can add in nebuliser ipratropium bromide
PO prednisolone, IM methylprednisolone, IV hydrocortisone
what would be defined as a dangerous mechanism or high-energy head injury
fall from >1 m or 5 stairs
car crash
important symptoms to ask about after a head injury
loss of consciousness amnesia vomiting headache neck pain
what signs are suggestive of basal skull fracture
clear fluid (possible CSF) leaking from the ear/nose
periorbital haematomas with no associated damage around the eyes
bleeding from one of both ears, blood behind ear drum, new deafness
battle’s sign: bruising behind one or both ears over the mastoid process
suspect NAI as cause of head injury if
child is not yet independently mobile
injury/brusie over non-bony part of face or on both sides
bruises that are disproportionate, present in multiple sites/clusters, similar size/shape
retinal haemorrhages
explanation is implausible, inadequate or inconsistent
delay in presentation
typical symptoms of appendicitis
abdo pain:
periumbilical or epigastric pain that worsens, migrates to right lower quadrant
fever (low grade), general malaise, anorexia
nausea and vomiting
constipation
examination signs of appendicitis
tenderness in LQ
abdo dissension, guarding, rebound tenderness
which investigations may be performed to rule out alternative cause of appendicitis
FBC
CRP
urine dipstick
pregnancy test (ectopic pregnancy)
GI differentials for appendicitis
gastroenteritis intestinal obstruction incarcerated inguinal hernia intussusception malrotation of gut meckel diverticulum biliary colic perforated ulcer IBD constipation
features of intussusception
right lower quadrant tenderness
sausage shaped mass in abdo
redcurrant jelly stool
urological differentials for appendicitis
ureteric colic pyelonephritis UTI retention testicular torsion
what is mesenteric adenitis
enlarged mesenteric lymph nodes caused by viral infection
signs of testicular torsion
acute onset unilateral scrotal pain (may be abdominal)
nausea and vomiting
high-riding or transverse testis
blue dot sign
signs of epididymo-orchitis
pain/swelling
symptoms of lower UTI/urethral discharge
tender on palpation
which virus causes slapped cheek
human parvovirus B19
symptoms of slapped cheek
fever headache, runny nose rash on arms, legs, trunk red rash on cheeks rash fades from centre outwards - lacy appearance
risks of parvovirus in pregnancy
anaemia
hydrops fetalis
miscarriage
fluid management in paediatrics: maintenance volume (volume/kg)
1st 10 kg = 100 ml/kg
2nd 10 kg = 50 ml/kg
further kg = 20 ml/kg
fluid management in paediatrics: bolus
20 ml/kg
what is tested for on the new born bloodspot screening programme
cystic fibrosis congenital hypothyroidism phenylketonuria MCADD sickle cell disease maple syrup urine disease homocystinuria clutaric acuduria type 1 isovaleric aciduria
in which patients might faecal elastase be measured and why
infants with CF
marker of exocrine pancreatic function
pancreatic duct becomes obstructed with thick secretions leading to malabsorption or fats (failure to thrive)
can be given pancreatic enzyme replacement to maintain growth
which vitamins need to be supplemented in children with cystic fibrosis
fat soluble vitamins
A, D, E, K
common presentations of cystic fibrosis in infants/children
recurrent resp infections:
sticky secretions are difficult to clear, allowing bacteria to colonise them
can lead to bronchiectasis
meconium ileus:
intestinal obstruction due to excessively sticky stool in neonatal period
failure to thrive:
pancreatic insufficiency leads to malabsorption with pale, offensive stools that float and poor growth
why is cystic fibrosis associated with diabetes
causes endocrine pancreatic dysfunction as well as exocrine
relative insufficiency of insulin results in high fasting blood glucose levels
who would be part of an MDT for a child with cystic fibrosis
physio
dietitian
GP
as they get older will also transition with adult CF services
what are the main organs affected by cystic fibrosis
lungs
GI tract
pancreas
what are common late complications of cystic fibrosis
bronchiectasis (due to recurrent RTI) diabetes distal intestinal obstruction syndrome cirrhotic liver disease (blockage of ducts in liver) infertility
what is the cause of respiratory distress syndrome in neonates
lack of surfactant
underdeveloped alveoli
risk factors for respiratory distress syndrome in neonates
male gender maternal diabetes and HTN IGUR <29 weeks sepsis hypothermia delivery be c-section second twin
pathology of RDS
surfactant deficiency leads to
alveolar collapse
low lung volumes
low lung compliance
stiffer lungs = poorer gas exchange
how is surfactant given
via catheter down an ET tube
which drugs may be given in the neonatal period and why
vitamin K: prevent haemorrhage disease of the newborn (IM injection)
caffeine: early Peter babies to prevent apneoic episodes and also neuroprotection
ABIDEC: multivitamin
sytron: iron
multivitamins added once fully enterally fed
fluid management/feeding in preterm babies
75 ml/kg/day 10% dextrose initially
introduce trophic feeds of EMB
gradually work up on enteral feeds to 120-150 ml/kg/day
around 34 weeks introduce suck feeds (breast feeding/bottles)
which type of IBD: affects whole GI tract skip lesions transmural involvement granulomas cobble stone appearance
Crohn’s
which type of IBD: affects colon only diffuse progression from rectum upwards mucosal involvement crypt abscesses pseudopolyps
ulcerative colitis
gold standard investigation for IBD
upper and lower GI endoscopy preferably including terminal ileum and multiple biopsies
as well as endoscopy, which other investigations should be considered in diagnosis of IBD
barium meal and follow through
MRI abdo
which autoantibody is associated with UC
pANCA
the following complications are more likely in UC or Crohn's: risk of bowel cancer fistulae toxic megacolon abscesses primary sclerosis cholangitis strictures infective colitis perforation
Crohn’s:
fistulae
abscesses
UC:
risk of bowel cancer
toxic megacolon
primary scelrosing cholangitis (HLA-B27)
both:
strictures
infective colitis
perforation
extra-intestinal manifestations of IBD
growth failure delayed puberty erythema nodosum/pyoderma gangrenous arthritis ank spon/sacroiliitis osteoporosis iritis/uveitis psychological impact
management of crohn’s
induce remission:
exclusive enteral nutrition (EEN) for 6 weeks
steroids
maintenance: aminosalicylates (sulfasalazine/mesalazine) thiopurines (azathioprine) anti-TNF (infliximab/adalimumab) methotrexate surgery if needed
management of UC
mild:
mesalazine
steroids
mod/severe:
corticosteroids
cyclosporin
anti-TNF (infliximab)
what is a toxic megacolon
acute life threatening toxic colitis with colonic distension
management of toxic megacolon
IV fluids and NBM IV antibiotics IV steroids blood transfusion if necessary urgent surgical review
common causes of limp in children
trauma
transient synovitis/irritable hip
septic arthritis or osteomyelitis
developmental dysplasia of the hip
less common causes of limp in children
leg length discrepancy neuromuscular disorders (cerebral palsy, Spina Bifida, muscular dystrophy) cellulitis slipped upper femoral epiphysis perthes disease cancer
what is SUFE
slipped upper femoral epiphysis
top portion of femur moves
most commonly in overweight, adolescent boys
what is perthes’ disease
idiopathic avascular necrosis of the femoral head
why do children with leukaemia complain of bone pain
bone marrow is working harder because of uncontrolled proliferation of leukaemia clone of WBCs
why is there recurrent infection in leukaemia
despite increased WBCs they do not function normally as they are the mutated clone
which type of cells are indicative of leukaemia on blood film
blast cells
which investigations should be done in the investigation of suspected leukaemia
bone marrow aspiration
renal function (chemo can damage kidneys so baseline function is important)
chicken pox serology (may be given chicken pox immunoglobulin)
LP (look for leukaemia cells in CSF)
CXR (look for mediastinal masses)
common chemo side effects
mucositis: can affect all mucous membranes, makes eating painful, can require NG or TPN
N+V: give anti-emetics with chemo
abscess/neutropenic sepsis: chemo causes chronic neutropenia, any fever needs blood, throat and urine cultures and IV abx
bruising/bleeding: may need PLT transfusions
what is the most common type of leukaemia in children
acute lymphoblastic leukaemia (ALL)
acute myeloid is 2nd common
management of cardiac failure in congenital cardiac defect
reduce pulmonary blood flow: lower volume, high calorie formulas, may need NG tube
diuretics: furosemide/spironolactone
ACEI: captorpil
pulmonary artery band
why is a combination of furosemide and spironolactone commonly used in heart failure in congenital heart defects
furosemide used to inhibit water reabsorption and treat pulmonary oedema
spironolactone is weak diuretic but prevents hypokalaemia
how is captopril (ACEI) useful in heart failure in congenital cardiac defects
peripheral vasodilation
reduces vascular resistance and reduces the left to right shunt
what are indications for surgical management of congestive heart failure
medical management is not enough to control symptoms or allow adequate weight gain
what is Eisenmenger syndrome
chronic pulmonary over circulation causes irreversible hypertrophy of the pulmonary arterioles increasing pulmonary vascular resistance
causes increase in pressure in right ventricle above the pressure in the left ventricle
reverses the shunt to right-to-left, causes cyanosis
differentials for “fits, faints, funny turns”
neuro, cardiac, metabolic, ENT, general, infection, behavioural/psych
neuro: seizures, febrile convulsions, migraine
cardiac: vaso-vagal syncope, cardiac arrhythmias
metabolic: hypoglycaemia, electrolyte imbalances
ENT: vertigo
general: rigor, NAI, reflex anoxic seizures
infection: meningitis, encephalitis
behavioural/psych: pseudo-seizures, anxiety, self gratification, breath holding, benign myoclonus, daydreaming, night terrors
when is an EEG indicated after a first seizure
a focal seizure
not after a generalised seizure
which investigations may be useful after a first afebrile generalised seizure
ECG
blood sugar/blood gas: metabolic cause
how would you describe an EEG to a parent
involves attaching small sensors to the scalp that pick up electrical signals that brain cells send to each other
these are recorded and analysed
child doesn’t need to do anything special beforehand
the electrodes are stuck on with a special glue
takes about 30 minutes
will an EEG give a guaranteed diagnosis about epilepsy in a child
some types of epilepsy have a characteristic EEG pattern
but children without may have abnormal EEG and children with can have normal EEG
EEG will give more information but diagnosis will be made on clinical info
EEG should not be used to exclude epilepsy or used in isolation to diagnose epilepsy
clinical features of non-QT syndromes
pallor, LOC, stiffness, anoxic seizures
associated with exercise, fright, emotional or auditory stimuli
can occur in sleep
how is long QT syndrome diagnosed
family history
12 lead ECG
ion channel mutational analysis
what can cause jitteriness in a young infant
hypoglycaemia
hypocalcaemia
hypomagnesaemia
drug withdrawal
what is measured in the Apgar score
appearance (colour) pulse (heart rate) grimace (reflex) activity (muscle tone) respiratory effort
how is the APGAR score calculated
appearance:
0 = white
1 = blue peripheries, pink central
2 = pink all over
pulse:
0 = absent
1 = <100
2 = >100
grimace:
0 = no response
1 = grimace, feeble cry
2 = active, spontaneous movements
activity:
0 = floppy
1 = flexion
2 = strong
respiration:
0 = none
1 = irregular respirations
2 = lusty cry
briefly describe the changes in cardiorespiratory system after birth
in utero oxygenated blood travels via the umbilical vein to the heart (via the portal circulation), bypassing the lungs to reach the systemic circulation
lungs are filled with fluid, pulmonary vessels constricted
during birth liquid is pushed out of the lungs and after first breath the rest is absorbed
breathing causes dilatation of pulmonary circulation and decreased PVR
clamping the cord caused a rise in systemic pressures causing closure of ductus arterioles and foramen ovale
what is transient tachypnoea of the newborn
self-limiting period of respiratory distress most often seen in babies following C-section
due to delayed absorption of lung fluid
may require oxygen therapy
what is meconium aspiration syndrome
hypoxic infant begins to gasp in utero and aspirate meconium stained liquor
pulmonary vasodilation is delayed and results in persistent pulmonary hypertension
what is haemorrhage disease of the newborn caused by
relative deficiency of factors II, VII, IX, X
vitamin K deficiency
why are babies given a vitamin K injection after birth
to prevent haemorrhagic disease of the newborn
how does haemorrahgic disease of the newborn present
early (24 hours):
mucosal bleeding, GI bleeding, cephalohaematoma, shock, intracranial bleeding
classic (1-7 days)
mucosal bleeding, circumcision bleeding
late (7+ days)
intracranial bleeding
what is a cephalohaematoma
what cause them (in birth)
what are they like
cephalohaematoma = subperiosteal haematoma
prolonged labour, instrumental delivery
usually over parietal bone, cannot cross a suture line
if you notice a cephalohaematoma during a baby check what should you tell the parent
like a bruise around the bone not harmful should resolve in a few days-weeks calcification can lead to a prominent ring of bone around a central defect after resolution may cause/exacerbate jaundice
what is caput
what type of delivery is most likely to cause it
what are its features on examination
oedema and bruising over the scalp
commonly caused by ventouse deliveries
can cross suture lines, pitting oedema
what are (Mongolian) blue spots where/in who are they most common why are they important to document
dark blue/grey lesions
over the sacrum
in afro-caribbean and asian parents
tend to fade but should be carefully documented as they can be confused with bruising in later life, and can cause concerns re NAI
describe the course of erythema toxicum
lesions generally appear on day 1/2 and increase in number over the next several days
spontaneous resolution in about a week
describe the lesions in erythema toxicum
central yellow plaque with a halo of erythema
not itchy
what causes neonatal gynaecomastia
when should you consider another cause of breast enlargement
due to falling levels of maternal oestrogen, baby’s release prolactin causing enlargement of breast tissue
unilateral enlargement consider breast abscess or mastitis (esp if unwell, heat/erythema at site)
apart from neonatal gynaecomastia, what other effects can maternal oestrogen have on newborns
withdrawal bleeding/discharge in females
swelling of labia/clitoris
what are the feeding recommendations for newborns
exclusive breast feeding for 6 months
no solids before 4 months
why do babies get jaundiced
breakdown of fatal Hb and immature liver can handle it
UNconjugated bilirubin
what is a possible complication of hyperbilirubinaemia in babies
kernicterus
what is the definition of prolonged jaundice in term and preterm infants
> 14 days in term
> 21 days in preterm
what is a benign and a pathologic cause of prolonged jaundice in babies
breast milk jaundice (reabsorption of unconjugated bilirubin from the gut)
biliary atresia (absence of biliary tree) - elevated conjugated bilirubin
which babies are more prone to severe jaundice
preterm
sepsis
severe haemolysis (Rh-incompatibility, AO incompatibility, G6PD deficiency, spherocytosis)
bruising (cephalohaematoma)
which infants are most at risk of group B strep infection
premature mother is colonised by GBS previous child with GBS infection evidence of maternal infection (pyrexia or elevated CRP) prolonged rupture of membranes evidence of fatal distress
when is the best time to screen Down’s syndrome antenatally
11+0 - 14+1 weeks
combined test
US nuchal transparency measurement plus serum biochemistry to measure beta hCG and PAPP-A
how is definitive antenatal diagnosis of Down’s syndrome carried ut
chorionic villous sampling or amniocentesis
when does the fatal anomaly scan take place
18-21 weeks
which blood infections are routinely screened for in pregnant women
hep B
HIV
syphilis
rubella susceptibility
when does hearing screening take place in newborns
within first 2 weeks of life
what is PKU?
inability to metabolise phenylalanine
untreated leads to LD, behavioural problems
dietary management
what is MCADD and why is it screened for in the bloodspot test
medium chain acyl-coA dehydrogenase deficiency
autosomal recessive condition
inability to metabolise a type of fat
can become acutely unwell when starved or stressed
diagnosis allows education and planning
what is the marker for CF on the bloodspot test
immunoreactive trypsin (IRT)
what is a risk factor for retinopathy of prematurity
excessive oxygen therapy in infants borns before 32 weeks
causes neovascularisation of the retina which then is at risk of bleeding
infants born before ______ are likely to have problems feeding as they have not yet developed suck, swallow and breathing coordination
32-34 weeks
what are prem babies at increased risk of infection
immunodeficiency
readily broken down skin
increased medical input with indwelling devices
describe the action of fast acting insulin and give some examples
start acting in 15 minutes, last 2-3 hours
novorapid, Humalog, actrapid
describe the action of long acting insulin and give some examples
slower onset, last 20-24 hours
glargine, levemir, insulatard
which types of insulin are used in mixtures and give some examples
fast and medium acting insulins
mixtard30, Humalog mix 25, novomix 30
what are the main differences between a basal bolus and mixed insulin regime
basal bolus
long acting insulin given at night, with a bolus of fast acting insulin given before each meal time
mixed
2 injections of mixture of fast and slower acting insulin given at about 10 hours apart
which type of insulin is used in insulin pumps
fast acting
what is the definition of DKA
blood glucose >11 mmol/L
ketones and glucose on urine dipstick
metabolic acidosis (pH <7.3 or bicarb <14 mmol/L)
how does DKA cause dehydration (2 ways)
increased stress hormones leading to increased glucose mobilisation from body stores and gluconeogenesis in the liver as well as absorption from the gut –> high blood glucose causes osmotic diuresis with increased urine production
low intracellular glucose leads to ketosis, which act on emesis centres causing N+V
what are the common presenting features of DKA in children
breathlessness
N+V
abdo pain
constipation
complications of DKA
cerebral oedema:
can be exacerbated by rapid fluid resuscitation or beginning insulin therapy too early
hypoglycaemia:
giving too much insulin without monitoring blood sugar (switch to insulin/dextrose infusions)
hypokalaemia:
insulin drives K+ into cells leading to reduced blood levels
what is the difference between primary and secondary nocturnal enuresis
primary: child has never been dry at night
secondary: child has been dry for at least 6 months
what are differentials for primary nocturnal enuresis
delayed development: mature CNS so not aware when they need to go
small bladder capacity
too little ADH: normally there is increased ADH over night to reduce urine production
sound sleeping: may not be woken by urge to pee
psychosocial
FHx
what are differentials for secondary nocturnal enuresis
UTI constipation DM seizure disorder medication side effect emotional, sexual or physical abuse
what is the single most useful investigation in a child presenting with secondary enuresis
urine dipstick
assessment of glycosuria and ketonuria (DM)
assessment of leucocytes and nitrites (UTI)
after diagnosis of DM is confirmed which other investigations should be carried out
HbA1c
thyroid function and thyroid peroxidase antibodies: autoimmune
coeliac screen: autoimmune
C-peptide: also made in beta-cells in pancreas so can distinguish between T1DM and T2DM
what are the general sick day rules of diabetics
never stop insulin completely: may need to be increased or decreased
check (blood) ketones is blood glucose is >14 mmol/L: if raised ketones and glucose give fast insulin, if raised ketones but low/normal glucose give sugar then insulin
if not eating give sugary drinks
when should a diabetic child who is unwell (generally not DKA-y) be admitted
does not have a blood glucose testing kit at home
high blood glucose and is vomiting or does not have ketone testing kit at home
vomiting and unable to keep fluids down
parents are worried
which fluids should be given in DKA
NaCl with KCl
when glucose lowers, give dextrose too to prevent hypokalaemia
what are the three main phases of growth
infant stage (0-2)
rapid linear growth
nutrition dependent
childhood stage
steady growth
hormone dependent
pubertal stage
rapid linear growth
depends on pubertal hormones and growth hormone
start of puberty in girls and end of puberty in boys
when should a child be referred for poor growth
when a child is short for parent’s height
height velocity is below expected for age
height has crossed >2 centile lines (up or down)
height >3 SDs below mean (<0.4th centile)
child is at risk of poor growth
known to have a condition associated with poor growth
known to have treatment likely to affect growth
what is precocious puberty
onset before 8 in girls and 9 in boys
features of turners
short ovarian dysgensis congenital lymphedema low posterior hair line neck webbing ear abnormalities deafness broad chest with widely space nipples cubitus valgus hypoplastic nails renal abnormalities cardiac abnormalities
definition of chronic lung disease in the neonatal period
oxygen requirement beyond 36 weeks corrected gestation PLUS pulmonary parenchymal disease on CXR
causes of bilious vomiting
malrotation/volvulus intussusception ileus (post-op, sepsis) duodenal/intestinal atresia Hirschsprungs disease meconium ileus adhesions/obstructions
causes of non-bilious vomiting
pyloric stenosis gastroenteritis GORD intolerance intoxication UTI meningitis
what is pyloric stenosis
thickening of the pyloric muscle
features of pyloric stenosis
projectile non-bilious vomiting
dehydration
tired/sleeping more
not passing stool
how to diagnose pyloric stenosis
test feed
abdominal USS
how to manage pyloric stenosis
stop oral feeds and site NG tube
fluids and electrolyte replacement/monitoring
surgery
what is intussusception
proximal part of bowel slips inside a more distal part
commonly at ileocaecal valve
diagnosis of intussusception
abdominal US: target sign
management of intussusception
fluid resus
IV antibiotics
surgery = rectal insufflation
what are malrotation and volvulus
malrotation = failure of gut to complete normal rotation during gestation volvulus = mesentery twists around itself
presentation of malrotation/volvulus
previously well develops bilious vomiting
distended tender abdomen
peritonitis
why is identification of malrotation or volvulus time critical
time = gut
delayed diagnosis leads to ischaemia and possible necrosis of gut
diagnosis and management of malrotation/volvulus
urgent upper GI contrast study
agressive fluid resus
IV abx
emergency laparotomy
projectile vomiting, olive-shaped mass
pyloric stenosis
child born with Down syndrome, AXR shows double bubble
duodenal atresia
intermittent crying, drawing legs up to chest, red-currant stool
intussusception
failure to pass meconium in 48 hours
- with cystic fibrosis
- PR causes explosive air and faeces
CF = meconium ileus
explosive air/faeces = hirschprungs
common and uncommon causes of neonatal respiratory distress
common transient tachypnoea of the newborn surfactant deficiency pneumonia meconium aspiration
uncommon
pulmonary aplasia
congenital cystic adenoid malformation
congenital diaphragmatic hernia
radiological finding of surfactant deficiency
small volume lungs (bell shaped thorax)
diffuse granular opacification, progressing to opaque lungs, with bronchograms
no effusion unless complications arise
CXR findings of TTN
normal or overinflated lungs
interstitial lines and effusions
fluid in fissures
air space opacification
CXR findings of meconium aspiration
patchy opacities
overinflated lungs due to air trapping
air leaks
atelectasis
what is the cause of resp distress
31 weeks, premature rupture of membranes, vaginal delivery, no meconium, resp distress, ventilated
surfactant deficiency
what is the cause of resp distress
37 weeks, elective C-section for pre-eclampsia, no meconium, mild resp distress as 12 hours
TTN
what is the cause of resp distress?
37 weeks, premature rupture of membranes at 35 weeks, spontaneous labour at 37 weeks, normal vaginal delivery, increasing respiratory distress on day 3
neonatal pneumonia
what is the correct tip position for an endotracheal tube in a neonate
at or just below the carina
in the left main bronchus
2 cm above the carina at about T2/3
at the cricoid cartilage
what is the correct tip position for a nasogastric tube
stomach, should travel in midline until reaches the stomach
how many umbilical veins and arteries should a baby have
1 vein
2 arteries
where is the normal endpoint of an umbilical vein catheter
though which vessels does it pass
at or just above the right hemidiaphragm
from umbilicus –> umbilical vein –> left portal vein –> ductus venosus –> middle/left hepatic veins –> into IVC and right atrium
where is the normal endpoint of an umbilical artery catheter
through which vessels does it pass
low tip: L3/4, below renal arteries
high tip: T6-10
from umbilicus –> right or left internal iliac artery –> common iliac artery –> aorta
CXR signs of bronchiolitis
overinflated lungs
perihilar haze
scattered atelectasis
rarely more diffuse opacification
CXR signs of bacterial pneumonia
fluffy consolidation with air bronchograms
rounded, lobar or multifocal patterns
effusion
pneumothorax
CXR signs of inhaled foreign body
Lucent lung due to air trapping is common due to ball valve effect
mediastinum displaces away from he affected side
pattern exaggerated in expiration
which fracture patterns are suspicious of NAI
metaphysical corner fractures
posterior or lateral rib fractures
multiple fractures in different healing stages
sternal, scapular and spinous process fractures
spinal injuries with no clear history of major trauma
which fracture patterns are specific to children and adolescents
buckle fracture
green stick fracture
plastic bowing
growth plate injury
what is the grading system for growth plate injuries
salter Harris
I: along the growth plate
II: along the growth plate, with a small part of the proximal bone
III: fracture vertically through the distal end, then along the growth plate (proximal bone not fractured)
IV: vertical fracture through the distal end, growth plate and proximal bone
V: compression of growth plate
