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4th Year > Child Health > Flashcards

Child Health Flashcards

1
Q

diagnostic criteria from bronchiolitis

A

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

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2
Q

when should bronchiolitis be IMMEDIATELY referred to hospital

A 
apnoea 
child looks seriously unwell 
severe resp distress (grunting, marked chest recession, resp rate >70)
central cyanosis 
persistent sats <92% on air
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3
Q

when should you consider referring a child with bronchiolitis

A

resp rate >60
difficulty breast feeding or inadequate oral fluid intake
clinical dehydration

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4
Q

management of bronchiolitis

A

supplemental oxygen if persistently <92%

give fluids by naso- or oro-gastric tube if not feeding

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5
Q

what information must be passed on to parents if child is not admitted

A

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

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6
Q

differentials for bronchiolitis

A 
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
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7
Q

risk factors for severe bronchiolitis

A 
chronic lung disease 
haemodynamically significant congenital heart disease 
age <3 months 
premature birth, esp <32 weeks 
neuromuscular disorders 
immunodeficiency
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8
Q

discharge a child with bronchiolitis when

A

clinically stable
taking adequate oral fluids
maintained sats >92% in air for 4 hours, including a period of sleep

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9
Q

temperature measurement in <4 weeks

A

electronic thermometer in axilla

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10
Q

temperature measurement in 4 weeks to 5 years

A

electronic thermometer in axilla
chemical dot thermometer in the axilla
infra-red tympanic thermometer

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11
Q

high risk symptoms in feverish child

A

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

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12
Q

intermediate-risk symptoms in feverish child

A 
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
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13
Q

low-risk symptoms in feverish child (and no high or intermediate risk symptoms)

A 
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
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14
Q

cap refill over ____ is a sign of intermediate-risk illness

A

cap refill over 3 secs is a signs of intermediate-risk illness

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15
Q

temperature has different risk factors in different age groups
which temperatures are associated with which risk groups in <3 months and 3-6 months

A

<3 months: temp >38 = high risk group

3-6 months: temp 39 = at least intermediate risk group

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16
Q

fever lasting >5 days should be assessed for…

A

Kawasaki disease

duration of fever should not be used to predict likelihood of serious illness otherwise

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17
Q

definition of tachycardia in different age groups

A

<12 months = >160
12-24 months = >150
2-5 years = >140

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18
Q

signs of dehydration in children with fever

A 
prolonged cap refill
abnormal skin turgor 
abnormal resp pattern 
weak pulse 
cool extremities
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19
Q

when to consider meningococcal disease in a child with fever

A

non-blanching rash plus any of

  • ill looking child
  • lesions >2 mm (purpura)
  • cap refill >3 secs
  • neck stiffness
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20
Q

when to consider bacterial meningitis in a child with fever

A

neck stiffness
bulging fontanelle
decreased LOC
convulsive status epilepticus

classic signs (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants

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21
Q

when to consider herpes simplex encephalitis in feverish child

A

focal neurological signs
focal seizures
decreased LOC

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22
Q

when to consider pneumonia in child with fever

A 
tachypnoea 
crackles in chest 
nasal flaring 
chest undraping 
cyanosis 
sats <95% on air
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23
Q

definition of tachypnoea in different age groups

A

0-5 months = >60
6-12 months = >50
>12 months = >40

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24
Q

when to consider UTI in child with fever

A

in ALL children >3 months + fever

> 3 months

  • vomiting
  • poor feeding
  • lethargy
  • irritability
  • abdominal pain or tenderness
  • urinary frequency or dysuria
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25
Q

when to consider septic arthritis/osteomyelitis in a child with fever

A

swelling of a limb or joint
not using an extremity
non-weight bearing

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26
Q

when to consider Kawasaki disease in child with fever

A 
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

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27
Q

which investigations should be performed in infants younger than 3 months with fever

A 
FBC 
blood culture 
CRP
urine testing 
CXR if respiratory signs suggestive of pneumonia 
stool culture if diarrhoea present
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28
Q

indications of LP in feverish children <3 months

A

> 1 month
all infants 1-3 months who appear unwell
1-3 months with a WCC <5x10^9 or >15x10^9

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29
Q

which investigations should be performed in infants >3 months with fever

A

FBC
blood culture
CRP
urine testing

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30
Q

which investigations should be considered in children with red/high risk features with fever

A

LP
CXR
serum electrolytes and blood gas

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31
Q

how to investigate child with no apparent source of fever with 1 or more amber features

A

urine sample
bloods (FBC, CRP, cultures)
LP (if <1 year)
CXR (fever >39, WBC <20x10^9)

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32
Q

immediate management of children presenting with fever and shock

A

IV fluid boys of 20 ml/kg (normally 0.9% NaCl)

actively monitored and given further fluid boluses if necessary

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33
Q

when to give immediate parenteral abx to a feverish child

A

shock
unrousable
sign of meningococcal disease

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34
Q

which empirical IV abx should be given to feverish children

A

> 3 months: third generation cephalosporin (cefotaxime or ceftriaxone)
<3 months: add in listeria cover (ampicillin or amoxicillin)

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35
Q

what to give children with symptoms suggestive of herpes simplex encephalitis

A

IV aciclovir

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36
Q

which infections are covered by 3rd generation cephalosporin

A 
Neisseria meningitidis 
step pneumoniae
E coli 
staph aureus 
HiB
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37
Q

advice to parents caring of a feverish child at home

A 
regular fluids 
signs of dehydration 
non-blanching rash 
check during the night 
no nursery or school while fever persists but notify them of illness
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38
Q

when parents should seek help if caring of a feverish child at home

A

fits
non-blanching rash
they feel they are less well than when they first sought advice
fever lasts >5 days

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39
Q

initial assessment of under 12’s with suspected sepsis

A 
temperature 
heart rate 
resp rate 
O2 sats 
cap refill

assess BP too if heart rate or cap refill are abnormal

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40
Q

why is measuring blood pressure less prioritised in children

A

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

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41
Q

what skin signs should be assessed for in suspected sepsis

A 
mottled/ashen skin
cyanosis of skin, lip or tongue 
non-blanching rash 
breaches of skin integrity (cuts, burns, skin infections)
other rashes
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42
Q

features in history that are high risk for sepsis >12 yo

A

objective evidence of new altered mental state

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43
Q

features in history that are moderate-high risk for sepsis >12 yo

A

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

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44
Q

resp signs that are high risk for sepsis >12 yo

A

resp rate >25

new need for oxygen (40% FiOs or more) to maintain sats to 92%

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45
Q

resp signs that are mod/high risk for sepsis >12 yo

A

resp rate 21-24

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46
Q

circulatory signs that are high risk for sepsis >12 yo

A

HR >130

not passed urine in previous 18 hours

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47
Q

circulatory signs that are mod/high risk for sepsis >12 yo

A

HR 91-130

not passed urine for 12-18 hours

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48
Q

blood pressure that is high risk for sepsis >12yo

A

systolic >90 mmHg

or systolic >40 mmHg less than normal

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49
Q

blood pressure tat is mod/high risk for sepsis >12 yo

A

91-100 mmHg

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50
Q

behaviour signs that are high risk for sepsis 5-11 yo

A

objective evidence of altered behaviour or mental state
appears ill to a healthcare professional
does not wake or does not stay awake

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51
Q

behaviour signs that are mod-high risk for sepsis 5-11 yo

A

not behaving normally
decreased activity
parent or carer concern that child is behaving differently than normal

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52
Q

resp signs that are high risk of sepsis 5-11 yo

A

All ages: sats <90% on air
5 yo: resp rate >29
6-7 yo: RR >27
8-11 yo: RR >25

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53
Q

resp signs that are mod-high risk of sepsis 5-11 yo

A

all ages: sats <92% on air
5 yo: RR 24-28
6-7 yo: RR 24-26
8-11 yo: RR 22-24

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54
Q

circulatory signs that are high risk of sepsis 5-11 yo

A

all ages: HR <60
5 yo: HR >130
6-7: HR >120
8-11: HR >115

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55
Q

circulatory signs that are mod-high risk for sepsis 5-11 yo

A

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

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56
Q

temperature that is mod-high risk for sepsis 5-11 yo

A

all ages: temp <36

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57
Q

other signs that are mod-high risk for sepsis 5-11 yo

A

leg pain

cold hands or feet

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58
Q

management of patients with 1+ high risk sepsis factor

A

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

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59
Q

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:

A

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

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60
Q

when to consider inotropes or vasopressors in children 5-11 with suspected sepsis

A

any high risk criteria
lactate >4 mmol/L
ALSO give IV fluid bolus

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61
Q

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:

A

reduced LOC despite resuscitation
HR or RR fulfil high risk criteria
lactate remains >2 mmol/L

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62
Q

fluid resus guidelines in patients <16 with suspected sepsis

A

glucose-free crystalloids containing sodium in range of 130-154 mmol/l
bolus of 20 ml/kg over less than 10 mins

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63
Q

fluid resus guidelines in neonates with suspected sepsis

A

glucose-free crystalloids containing sodium in range of 130-154 mmol/l
bolus of 10-20 ml/kg over less than 10 mins

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64
Q

what are contraindication for LP

A 
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
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65
Q

define sepsis

A

life-threatening organ dysfunction due to a dysregulated host response to infection

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66
Q

define early onset neonatal bacterial infection

A

infection with onset within 72 hours of birth

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67
Q

signs that are suggestive of early onset neonatal infection

A 
abnormal behaviour 
unusually floppy 
difficulty feeding or tolerating feeds 
abnormal temperature (<36 or >38)
rapid breathing 
change in skin colour
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68
Q

when to offer intrapartum antibiotics and which abx should be used

A

previous baby with invasive group B strep infection
group B strep colonisation, bacteriuria or infection in the current pregnancy
IV benzpen

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69
Q

what is first line empirical treatment of early onset neonatal infection

A

IV benpen with gentamicin

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70
Q

investigations in suspected neonatal infection

A

CRP before starting abx

CRP after 18-24 hours

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71
Q

consider stopping abx after 36 hours if

A

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

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72
Q

risk factors for early onset neonatal infection

A

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

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73
Q

clinical indications of early onset neonatal infection

A 
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
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74
Q

investigations before starting antibiotics in neonatal infection

A

CRP

LP (strong clinical suspicion or signs of meningitis)

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75
Q

when should skin swabs be taken in neonatal infection and which empirical abx should be started in each instance

A

purulent eye discharge (chlamydia and gonococcus)
abx: cover gonococcus

purulent discharge or signs of periumbilical cellulitis
abx: IV fluclox and gentamicin

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76
Q

what is first line empirical abx for neonatal infection

A

IV benpen with gent

benpen: 25 mg/kg every 12 hours
gent: 5 mg/kg starting dose (every 36 hours)

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77
Q

consider stopping abx for neonatal infection after 36 hours if

A

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

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78
Q

how long should standard abx treatment be in babies with positive blood culture or with negative culture and strong clinical suspicion

A

7 days

longer if not yet recovered or advisable based on the pathogen

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79
Q

what is the trough concentration

A

gentamicin concentration just before giving another dose

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80
Q

what are the recommended thought concentrations for gentamicin

A

<2 mg/litre

if lasts more than 3 doses aim for <1 mg/litre

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81
Q

what features would cause you to withhold a gentamicin dose

A

evidence of renal dysfunction eg elevated serum urea or creatine concentration, or anuria

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82
Q

when would you measure peak gentamicin concentrations

A

1 hour after starting infusion

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83
Q

when would you measure peak blood gentamicin

A

oedema
macrosomia (BW >4.5 kg)
unsatisfactory response to treatment
proven gram-negative infection

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84
Q

most common cause of meningitis in children

A

Neisseria meningitidis
strep pneumo
HiB

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85
Q

most common cause of meningitis in <3 months

A

group B strep
E coli
strep pneumo
listeria monocytogenes

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86
Q

describe IV fluid resus in children with suspected/confirmed meningococcal sepsis

A

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

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87
Q

investigations in a child/young person with unexplained petechial rash and fever

A 
FBC 
CRP
coagulation screen 
blood culture 
PCR for N meningitidis 
blood glucose 
blood gas
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88
Q

abx in child/young person with suspected meningitis

A

IV ceftriaxone

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89
Q

abx in infant <3 months with suspected meningitis

A

IV cefotaxime plus amoxicillin

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90
Q

when should vancomycin be added in meningitis

A

recent travel outside the UK or have had prolonged exposure to antibiotics within the past 3 months

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91
Q

in which patient group should ceftriaxone not be used and why

A

premature babies or babies with jaundice, hypoalbuminaemia or acidosis
may exacerbate hyperbilirubinaemia

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92
Q

which metabolic disturbances should be monitored for in children with bacterial meningitis

A 
hypoglycaemia 
acidosis 
hypokalaemia 
hypocalcaemia 
hypomagnesaemia 
anaemia 
coagulopathy
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93
Q

in a child/young person with meningitis what are the indications fo intubation

A

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

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94
Q

along with abx, which drug should be given in meningitis

A

dexamethasone before or with first dose of abx

do not start more than 12 hours after abx started

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95
Q

possible long term complications of meningitis

A 
hearing loss 
orthopaedic complications 
skin complications (scarring from necrosis)
psychosocial problems 
neurological and developmental problems 
renal failure
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96
Q

sings of UTI in infants <3 months

A

most common:
fever, vomiting, lethargy, irritability

less common:
poor feeding, failure to thrive

least common:
abdominal pain, jaundice, haematuria, offensive urine

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97
Q

signs of UTI in preverbal children

A

most common:
fever

less common:
abdominal pain, loin tenderness, vomiting, poor feeding

least common:
lethargy, irritability, haematuria, offensive urine, failure thrive

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98
Q

signs of UTI in verbal children

A

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

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99
Q

what is the recommended way to collect a urine sample from children?
if this is not possible which other methods are available?

A

clean catch urine sample
urine collection pads
catheter samples
suprapubic aspiration

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100
Q

which tests should be performed on urine samples in children:
<3 months
3 months - 3 years
over 3 years

A

<3 months:
send sample for urgent microscopy and culture

3 months - 3 years:
dipstick testing

> 3 years:
dipstick testing

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101
Q

indications for antibiotic treatment in suspected UTI age <3 months

A

start empirical abx if clinical suspicion
IV amoxicillin and gent
send urine for culture but do not delay abx

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102
Q

indications for abx in suspected UTI age 3 months - 3 years

A

leukocyte esterase, nitrite or both are positive on dipstick start abx and send urine for culture

trimethoprim PO or nitrofurantoin PO

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103
Q

indications for abx in suspected UTI age >3 years

A

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

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104
Q

when should urine sample be sent for culture

A

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

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105
Q

what are risk factors for UTI and may indicate serious underlying pathology

A 
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
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106
Q

how to differentiate between acute pyelonephritis/upper UTI and cystitis/lower UTI

A

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

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107
Q

investigation of UTI in children <6/12

A

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

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108
Q

investigation of UTI in children 6 months to 3 years

A

no imaging if uncomplicated UTI
US and venogram if atypical or recurrent
no VCUG

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109
Q

investigation of UTI in children >3 years

A

US and renogram only if recurrent UTI

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110
Q

features of atypical UTI

A 
seriously ill
poor urine flow 
abdominal or bladder mass 
raised creatinine 
sepsis 
failure to respond to abx in 48 hours 
infection with E coli
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111
Q

define recurrent UTI

A

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

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112
Q

when is referral to a paediatric nephrologist necessary in children with UTI

A

bilateral renal abnormalities
impaired kidney function
raised blood pressure
proteinuria

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113
Q

when should stool samples be performed on children with diarrhoea

A

suspicion of sepsis
blood/mucous in stool
immunocompromised

consider them if;
recent travel abroad
diarrhoea not improved in 7 days
uncertainty about diagnosis

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114
Q

fluid management in children with gastroenteritis but no clinical dehydration

A

continue breast feeding/other milk feeds
encourage fluid intake
discourage drinking fruit juices and carbonated drinks
oral rehydration solutions if increased risk of dehydration

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115
Q

fluid management in children with gastroenteritis and clinical dehydration

A

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

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116
Q

when to use IV fluid in fluid management in gastroenteritis

A

shock is suspected/confirmed
evidence of deterioration despite oral rehydration therapy
persistent vomiting of ORS (orally or NG)

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117
Q

questions to ask in suspected gastroenteritis

A

recent contact with someone with acute diarrhoea and/or vomiting
exposure to known source of enteric infection (contaminated water or food)
recent travel abroad

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118
Q

signs that suggest diagnosis other that simple gastroenteritis

A 
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
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119
Q

which children are at greater risk of dehydration due to diarrhoea/gastroenteritis

A

<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

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120
Q

red flags for dehydration

A 
appears unwell/deteriorating 
altered responsiveness 
sunken eyes 
tachycardia/tachyp
reduced skin turgor
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121
Q

which features suggest Hypernatraemia dehydration

A 
jittery movements 
increased muscle tone 
hyperreflexia 
convulsions 
drowsiness or coma
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122
Q

when to give abx in gastroenteritis

A

suspected/confirmed sepsis
extra-intestinal spread of bacterial infection
<6 months, malnourished or immunocompromised with salmonella
C diff, giardiasis, shigella

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123
Q

abx in C diff in children

A

1st line PO met

2nd line PO vanc

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124
Q

when to suspect croup

A 
sudden onset, seal-like barking cough 
stridor 
chest wall or sternal undraping 
worse at night 
increase with agitation
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125
Q

differentials for croup

A 
bacterial tracheitis 
epiglottitis 
foreign body 
quinsy 
allergic reaction
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126
Q

features of epiglottitis

A 
sudden onset fever 
dysphagia 
drooling 
anxiety 
non-barking cough 
preferred posture if upright with head extended
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127
Q

features of foreign body in upper airway

A

sudden onset dyspnoea and stridor
usually history of inhalation of object
no prodrome or viral symptoms

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128
Q

features of quinsy

A 
dysphagia 
drooling 
stridor (occasionally)
dyspnoea 
tachyp 
neck stiffness 
unilateral cervical adenopathy 
more gradual onset
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129
Q

what is croup

A

laryngotracheobronchitis
symptoms caused by upper airway obstruction due to generalised inflammation of the airways
typically parainfluenza virus types 1 or 3

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130
Q

risk factors for croup

A

6 months - 6 years
male sex
previous intubation

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131
Q

how to categorise severity of croup symptoms

A

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

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132
Q

signs of impending resp failure in croup

A 
increasing upper airway obstruction 
sternal/intercostal recession
asychronus chest wall and abdominal movement 
fatigue 
pallor/cyanosis 
decreased level of consciousness 
tachycardia 
resp rate >70
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133
Q

when to consider hospital admission for children with croup

A 
moderate or severe illness 
resp rate >60
<3 months 
inadequate fluid intake 
immunodeficiency
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134
Q

pre-hospital management of moderate/severe croup

A

supplementary O2 if severe

oral dexamethasone or inhaled budesonide

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135
Q

management of mild croup (at home)

A

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

136
Q

children and young people presenting with suspected seizure should be seen by a specialist in the diagnosis and management of epilepsy within _______ of presentation

A

2 weeks

137
Q

define suspected epileptic seizure

A

acute episode of altered functioning, presumed to be the direct result of a change in electrical activity in the brain

138
Q

what is SUDEP

A

sudden unexpected death in epilepsy

139
Q

how is the risk of SUDEP reduced

A

optimising seizure control

being beware of the potential consequences of nocturnal seizures

140
Q

investigations in suspected epilepsy

A

EEG
MRI
CT if not MRI

141
Q

MRI is particularly important in the diagnosis of epilepsy in which population

A

<2 years
focal onset on history, examination or EEG
continued seizures in spite of first-line medication

142
Q

treatment of generalised seizures

A

first line: sodium valproate, lamotrigine, levetiracetam or topiramate

143
Q

treatment of focal seizures with or without secondary generalisation

A

first line: lamotrigine, carbamazepine or levetiracetam

second line: sodium valproate or topiramate

144
Q

which epileptic drugs are hepatic enzyme inducers and therefore reduce the effectiveness of hormonal contraceptives

A

carbamazepine
topiramate >200 mg/day

sodium valproate is teratogenic

145
Q

define focal seizure

A

originate in networks limited to one hemisphere, and may be localised or more widely distribution

divided into retained awareness or impaired awareness

146
Q

define generalised seizures

A

originate in bilaterally distributed networks and can include cortical and subcortical structures
divided into motor and non-motor (absence) seizures

147
Q

risk factors for epilepsy

A 
premature birth 
complicated febrile seziures 
brain development malformations 
family history 
head trauma, infections or tumours 
CVD or stroke (older people)
dementia and neurodegenerative disorders
148
Q

what should history include when assessing possible seizure

A

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)

149
Q

describe a tonic seizure

A

short lived (<1 min)
abrupt, generalised muscle stiffening (may cause a fall)
rapid recovery

150
Q

describe a generalised tonic-clonic seizure

A

generalised stiffening and subsequent rhythmic jerking of the limbs
urinary incontinence
tongue biting

151
Q

describe an absence seizure

A

behavioural arrest

152
Q

describe atonic seizure

A

sudden onset of loss of muscle tone

153
Q

describe myoclonic seizure

A

brief, ‘shock-like’ involuntary single or multiple jerks

154
Q

what is the differential for epileptic seizure in children

A

febrile convulsions
breath-holding attacks
night terrors
stereotyped/ritualistic behaviour (LD)

155
Q

what long term monitoring is needed for people taking anti-epileptic drugs

A

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

156
Q

define simple febrile seizure

A

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

157
Q

define complex febrile seizure

A

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

158
Q

define febrile status epilepticus

A

> 30 mins

series of seizures without full recovery in between lasting 30 mins or more

159
Q

typical features of simple febrile seizure

A

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

160
Q

typical features of complex febrile seizure

A

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)

161
Q

differential diagnosis of febrile convulsion

A

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
162
Q

what is the most common cause of bacterial pneumonia in children

A 
strep pneumoniae
also;
group A strep
staph aureus 
haem influenzae
163
Q

when to consider pneumonia in a child

A 
high fever 
cyanosis 
raised resp rate 
signs of increased work of breathing 
persistently focal crackles 
sats <95%
164
Q

features of pneumonia in children

age, resp rate, hyperflation, wheeze, crackles

A

age: any age

resp rate: usually increased

hyperinflation: not present
wheeze: not usually present
crackles: course crackles, usually focal

165
Q

features of bronchiolitis in infants

age, resp rate, hyperflation, wheeze, crackles

A

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

166
Q

features of viral-induced wheeze

age, resp rate, hyperflation, wheeze, crackles

A

age: under 5 yo

resp rate: may be normal of increased

hyperinflation: may be present
wheeze: present
crackles: not usually present

167
Q

features of infective exacerbation of asthma

age, resp rate, hyperflation, wheeze, crackles

A

age: any age

resp rate: may be normal or increased

hyperinflation: may be present
wheeze: present
crackles: not usually present

168
Q

abx for non-severe CAP in children

A

amoxicillin PO (7 days)

clarithromycin if penicillin allergic

<1 year use co-amoxiclav PO

169
Q

abx for severe CAP in children

A

co-amoxiclav IV then PO (10 days)

add clarithromycin if features of atypical pneumonia or pertussis

170
Q

risk factors for asthma

A

personal or family history of aortic disease
respiratory infections in infancy
exposure (including prenatally) to tobacco smoke
premature birth and low birth weight
obesity

171
Q

features of ciliary dyskinesia

A

persistent moist cough present from birth

172
Q

features of cystic fibrosis

A

persistent moist cough and GI symptoms that are often present from birth
finger clubbing
failure to thrive

173
Q

first line management of asthma in children

A

SABA reliever inhaler

174
Q

second line management of asthma in children

why would it be indicated

A

inhaled corticosteroids

SABA use 3+ times a week
asthma symptoms 3+ times a week
woken at night by asthma symptoms 1+ times a week

175
Q

third line management of asthma in children

A

leukotriene receptor antagonist (montelukast)

then LABA

176
Q

features of a moderate asthma exacerbation in children

A

PEFR at least 50% best or predicted
normal speech
no features of severe/life-threatening asthma

177
Q

features of acute severe asthma exacerbation in children

A 
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%
178
Q

features of life-threatening asthma exacerbation in children

A 
PEFR <33% best or predicted 
sats <92%
altered consciousness 
exhaustion 
cardiac arrhythmia 
hypotension 
cyanosis 
poor respiratory effort 
silent chest 
confusion
179
Q

management of acute asthma attack while awaiting admission to hospital

A

O2: aim for sats 94-98

nebuliser salbutamol

can add in nebuliser ipratropium bromide

PO prednisolone, IM methylprednisolone, IV hydrocortisone

180
Q

what would be defined as a dangerous mechanism or high-energy head injury

A

fall from >1 m or 5 stairs

car crash

181
Q

important symptoms to ask about after a head injury

A 
loss of consciousness 
amnesia 
vomiting 
headache 
neck pain
182
Q

what signs are suggestive of basal skull fracture

A

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

183
Q

suspect NAI as cause of head injury if

A

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

184
Q

typical symptoms of appendicitis

A

abdo pain:
periumbilical or epigastric pain that worsens, migrates to right lower quadrant
fever (low grade), general malaise, anorexia
nausea and vomiting
constipation

185
Q

examination signs of appendicitis

A

tenderness in LQ

abdo dissension, guarding, rebound tenderness

186
Q

which investigations may be performed to rule out alternative cause of appendicitis

A

FBC
CRP
urine dipstick
pregnancy test (ectopic pregnancy)

187
Q

GI differentials for appendicitis

A 
gastroenteritis 
intestinal obstruction 
incarcerated inguinal hernia 
intussusception 
malrotation of gut 
meckel diverticulum 
biliary colic 
perforated ulcer 
IBD
constipation
188
Q

features of intussusception

A

right lower quadrant tenderness
sausage shaped mass in abdo
redcurrant jelly stool

189
Q

urological differentials for appendicitis

A 
ureteric colic 
pyelonephritis 
UTI 
retention 
testicular torsion
190
Q

what is mesenteric adenitis

A

enlarged mesenteric lymph nodes caused by viral infection

191
Q

signs of testicular torsion

A

acute onset unilateral scrotal pain (may be abdominal)
nausea and vomiting
high-riding or transverse testis
blue dot sign

192
Q

signs of epididymo-orchitis

A

pain/swelling
symptoms of lower UTI/urethral discharge
tender on palpation

193
Q

which virus causes slapped cheek

A

human parvovirus B19

194
Q

symptoms of slapped cheek

A 
fever
headache, runny nose 
rash on arms, legs, trunk
red rash on cheeks 
rash fades from centre outwards - lacy appearance
195
Q

risks of parvovirus in pregnancy

A

anaemia
hydrops fetalis
miscarriage

196
Q

fluid management in paediatrics: maintenance volume (volume/kg)

A

1st 10 kg = 100 ml/kg

2nd 10 kg = 50 ml/kg

further kg = 20 ml/kg

197
Q

fluid management in paediatrics: bolus

A

20 ml/kg

198
Q

what is tested for on the new born bloodspot screening programme

A 
cystic fibrosis 
congenital hypothyroidism 
phenylketonuria 
MCADD
sickle cell disease 
maple syrup urine disease 
homocystinuria 
clutaric acuduria type 1
isovaleric aciduria
199
Q

in which patients might faecal elastase be measured and why

A

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

200
Q

which vitamins need to be supplemented in children with cystic fibrosis

A

fat soluble vitamins

A, D, E, K

201
Q

common presentations of cystic fibrosis in infants/children

A

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

202
Q

why is cystic fibrosis associated with diabetes

A

causes endocrine pancreatic dysfunction as well as exocrine

relative insufficiency of insulin results in high fasting blood glucose levels

203
Q

who would be part of an MDT for a child with cystic fibrosis

A

physio
dietitian
GP

as they get older will also transition with adult CF services

204
Q

what are the main organs affected by cystic fibrosis

A

lungs
GI tract
pancreas

205
Q

what are common late complications of cystic fibrosis

A 
bronchiectasis (due to recurrent RTI)
diabetes 
distal intestinal obstruction syndrome 
cirrhotic liver disease (blockage of ducts in liver)
infertility
206
Q

what is the cause of respiratory distress syndrome in neonates

A

lack of surfactant

underdeveloped alveoli

207
Q

risk factors for respiratory distress syndrome in neonates

A 
male gender 
maternal diabetes and HTN 
IGUR <29 weeks 
sepsis 
hypothermia 
delivery be c-section 
second twin
208
Q

pathology of RDS

A

surfactant deficiency leads to
alveolar collapse
low lung volumes
low lung compliance

stiffer lungs = poorer gas exchange

209
Q

how is surfactant given

A

via catheter down an ET tube

210
Q

which drugs may be given in the neonatal period and why

A

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

211
Q

fluid management/feeding in preterm babies

A

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)

212
Q 
which type of IBD:
affects whole GI tract 
skip lesions 
transmural involvement 
granulomas
cobble stone appearance
A

Crohn’s

213
Q 
which type of IBD:
affects colon only 
diffuse progression from rectum upwards 
mucosal involvement 
crypt abscesses 
pseudopolyps
A

ulcerative colitis

214
Q

gold standard investigation for IBD

A

upper and lower GI endoscopy preferably including terminal ileum and multiple biopsies

215
Q

as well as endoscopy, which other investigations should be considered in diagnosis of IBD

A

barium meal and follow through

MRI abdo

216
Q

which autoantibody is associated with UC

A

pANCA

217
Q 
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
A

Crohn’s:
fistulae
abscesses

UC:
risk of bowel cancer
toxic megacolon
primary scelrosing cholangitis (HLA-B27)

both:
strictures
infective colitis
perforation

218
Q

extra-intestinal manifestations of IBD

A 
growth failure 
delayed puberty 
erythema nodosum/pyoderma gangrenous 
arthritis 
ank spon/sacroiliitis 
osteoporosis 
iritis/uveitis 
psychological impact
219
Q

management of crohn’s

A

induce remission:
exclusive enteral nutrition (EEN) for 6 weeks
steroids

maintenance:
aminosalicylates (sulfasalazine/mesalazine)
thiopurines (azathioprine)
anti-TNF (infliximab/adalimumab)
methotrexate 
surgery if needed
220
Q

management of UC

A

mild:
mesalazine
steroids

mod/severe:
corticosteroids
cyclosporin
anti-TNF (infliximab)

221
Q

what is a toxic megacolon

A

acute life threatening toxic colitis with colonic distension

222
Q

management of toxic megacolon

A 
IV fluids and NBM
IV antibiotics
IV steroids 
blood transfusion if necessary 
urgent surgical review
223
Q

common causes of limp in children

A

trauma
transient synovitis/irritable hip
septic arthritis or osteomyelitis
developmental dysplasia of the hip

224
Q

less common causes of limp in children

A 
leg length discrepancy 
neuromuscular disorders (cerebral palsy, Spina Bifida, muscular dystrophy)
cellulitis 
slipped upper femoral epiphysis 
perthes disease
cancer
225
Q

what is SUFE

A

slipped upper femoral epiphysis

top portion of femur moves

most commonly in overweight, adolescent boys

226
Q

what is perthes’ disease

A

idiopathic avascular necrosis of the femoral head

227
Q

why do children with leukaemia complain of bone pain

A

bone marrow is working harder because of uncontrolled proliferation of leukaemia clone of WBCs

228
Q

why is there recurrent infection in leukaemia

A

despite increased WBCs they do not function normally as they are the mutated clone

229
Q

which type of cells are indicative of leukaemia on blood film

A

blast cells

230
Q

which investigations should be done in the investigation of suspected leukaemia

A

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)

231
Q

common chemo side effects

A

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

232
Q

what is the most common type of leukaemia in children

A

acute lymphoblastic leukaemia (ALL)

acute myeloid is 2nd common

233
Q

management of cardiac failure in congenital cardiac defect

A

reduce pulmonary blood flow: lower volume, high calorie formulas, may need NG tube

diuretics: furosemide/spironolactone

ACEI: captorpil

pulmonary artery band

234
Q

why is a combination of furosemide and spironolactone commonly used in heart failure in congenital heart defects

A

furosemide used to inhibit water reabsorption and treat pulmonary oedema

spironolactone is weak diuretic but prevents hypokalaemia

235
Q

how is captopril (ACEI) useful in heart failure in congenital cardiac defects

A

peripheral vasodilation

reduces vascular resistance and reduces the left to right shunt

236
Q

what are indications for surgical management of congestive heart failure

A

medical management is not enough to control symptoms or allow adequate weight gain

237
Q

what is Eisenmenger syndrome

A

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

238
Q

differentials for “fits, faints, funny turns”

neuro, cardiac, metabolic, ENT, general, infection, behavioural/psych

A

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

239
Q

when is an EEG indicated after a first seizure

A

a focal seizure

not after a generalised seizure

240
Q

which investigations may be useful after a first afebrile generalised seizure

A

ECG

blood sugar/blood gas: metabolic cause

241
Q

how would you describe an EEG to a parent

A

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

242
Q

will an EEG give a guaranteed diagnosis about epilepsy in a child

A

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

243
Q

clinical features of non-QT syndromes

A

pallor, LOC, stiffness, anoxic seizures

associated with exercise, fright, emotional or auditory stimuli

can occur in sleep

244
Q

how is long QT syndrome diagnosed

A

family history
12 lead ECG
ion channel mutational analysis

245
Q

what can cause jitteriness in a young infant

A

hypoglycaemia
hypocalcaemia
hypomagnesaemia
drug withdrawal

246
Q

what is measured in the Apgar score

A 
appearance (colour)
pulse (heart rate)
grimace (reflex)
activity (muscle tone)
respiratory effort
247
Q

how is the APGAR score calculated

A

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

248
Q

briefly describe the changes in cardiorespiratory system after birth

A

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

249
Q

what is transient tachypnoea of the newborn

A

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

250
Q

what is meconium aspiration syndrome

A

hypoxic infant begins to gasp in utero and aspirate meconium stained liquor
pulmonary vasodilation is delayed and results in persistent pulmonary hypertension

251
Q

what is haemorrhage disease of the newborn caused by

A

relative deficiency of factors II, VII, IX, X

vitamin K deficiency

252
Q

why are babies given a vitamin K injection after birth

A

to prevent haemorrhagic disease of the newborn

253
Q

how does haemorrahgic disease of the newborn present

A

early (24 hours):
mucosal bleeding, GI bleeding, cephalohaematoma, shock, intracranial bleeding

classic (1-7 days)
mucosal bleeding, circumcision bleeding

late (7+ days)
intracranial bleeding

254
Q

what is a cephalohaematoma
what cause them (in birth)
what are they like

A

cephalohaematoma = subperiosteal haematoma

prolonged labour, instrumental delivery

usually over parietal bone, cannot cross a suture line

255
Q

if you notice a cephalohaematoma during a baby check what should you tell the parent

A 
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
256
Q

what is caput
what type of delivery is most likely to cause it
what are its features on examination

A

oedema and bruising over the scalp
commonly caused by ventouse deliveries
can cross suture lines, pitting oedema

257
Q 
what are (Mongolian) blue spots
where/in who are they most common 
why are they important to document
A

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

258
Q

describe the course of erythema toxicum

A

lesions generally appear on day 1/2 and increase in number over the next several days
spontaneous resolution in about a week

259
Q

describe the lesions in erythema toxicum

A

central yellow plaque with a halo of erythema

not itchy

260
Q

what causes neonatal gynaecomastia

when should you consider another cause of breast enlargement

A

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)

261
Q

apart from neonatal gynaecomastia, what other effects can maternal oestrogen have on newborns

A

withdrawal bleeding/discharge in females

swelling of labia/clitoris

262
Q

what are the feeding recommendations for newborns

A

exclusive breast feeding for 6 months

no solids before 4 months

263
Q

why do babies get jaundiced

A

breakdown of fatal Hb and immature liver can handle it

UNconjugated bilirubin

264
Q

what is a possible complication of hyperbilirubinaemia in babies

A

kernicterus

265
Q

what is the definition of prolonged jaundice in term and preterm infants

A

> 14 days in term

> 21 days in preterm

266
Q

what is a benign and a pathologic cause of prolonged jaundice in babies

A

breast milk jaundice (reabsorption of unconjugated bilirubin from the gut)

biliary atresia (absence of biliary tree)
- elevated conjugated bilirubin
267
Q

which babies are more prone to severe jaundice

A

preterm
sepsis
severe haemolysis (Rh-incompatibility, AO incompatibility, G6PD deficiency, spherocytosis)
bruising (cephalohaematoma)

268
Q

which infants are most at risk of group B strep infection

A 
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
269
Q

when is the best time to screen Down’s syndrome antenatally

A

11+0 - 14+1 weeks
combined test
US nuchal transparency measurement plus serum biochemistry to measure beta hCG and PAPP-A

270
Q

how is definitive antenatal diagnosis of Down’s syndrome carried ut

A

chorionic villous sampling or amniocentesis

271
Q

when does the fatal anomaly scan take place

A

18-21 weeks

272
Q

which blood infections are routinely screened for in pregnant women

A

hep B
HIV
syphilis
rubella susceptibility

273
Q

when does hearing screening take place in newborns

A

within first 2 weeks of life

274
Q

what is PKU?

A

inability to metabolise phenylalanine
untreated leads to LD, behavioural problems
dietary management

275
Q

what is MCADD and why is it screened for in the bloodspot test

A

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

276
Q

what is the marker for CF on the bloodspot test

A

immunoreactive trypsin (IRT)

277
Q

what is a risk factor for retinopathy of prematurity

A

excessive oxygen therapy in infants borns before 32 weeks

causes neovascularisation of the retina which then is at risk of bleeding

278
Q

infants born before ______ are likely to have problems feeding as they have not yet developed suck, swallow and breathing coordination

A

32-34 weeks

279
Q

what are prem babies at increased risk of infection

A

immunodeficiency
readily broken down skin
increased medical input with indwelling devices

280
Q

describe the action of fast acting insulin and give some examples

A

start acting in 15 minutes, last 2-3 hours

novorapid, Humalog, actrapid

281
Q

describe the action of long acting insulin and give some examples

A

slower onset, last 20-24 hours

glargine, levemir, insulatard

282
Q

which types of insulin are used in mixtures and give some examples

A

fast and medium acting insulins

mixtard30, Humalog mix 25, novomix 30

283
Q

what are the main differences between a basal bolus and mixed insulin regime

A

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

284
Q

which type of insulin is used in insulin pumps

A

fast acting

285
Q

what is the definition of DKA

A

blood glucose >11 mmol/L

ketones and glucose on urine dipstick

metabolic acidosis (pH <7.3 or bicarb <14 mmol/L)

286
Q

how does DKA cause dehydration (2 ways)

A

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

287
Q

what are the common presenting features of DKA in children

A

breathlessness
N+V
abdo pain
constipation

288
Q

complications of DKA

A

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

289
Q

what is the difference between primary and secondary nocturnal enuresis

A

primary: child has never been dry at night
secondary: child has been dry for at least 6 months

290
Q

what are differentials for primary nocturnal enuresis

A

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

291
Q

what are differentials for secondary nocturnal enuresis

A 
UTI
constipation 
DM 
seizure disorder 
medication side effect 
emotional, sexual or physical abuse
292
Q

what is the single most useful investigation in a child presenting with secondary enuresis

A

urine dipstick
assessment of glycosuria and ketonuria (DM)
assessment of leucocytes and nitrites (UTI)

293
Q

after diagnosis of DM is confirmed which other investigations should be carried out

A

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

294
Q

what are the general sick day rules of diabetics

A

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

295
Q

when should a diabetic child who is unwell (generally not DKA-y) be admitted

A

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

296
Q

which fluids should be given in DKA

A

NaCl with KCl

when glucose lowers, give dextrose too to prevent hypokalaemia

297
Q

what are the three main phases of growth

A

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

298
Q

when should a child be referred for poor growth

A

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

299
Q

what is precocious puberty

A

onset before 8 in girls and 9 in boys

300
Q

features of turners

A 
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
301
Q

definition of chronic lung disease in the neonatal period

A

oxygen requirement beyond 36 weeks corrected gestation PLUS pulmonary parenchymal disease on CXR

302
Q

causes of bilious vomiting

A 
malrotation/volvulus 
intussusception 
ileus (post-op, sepsis)
duodenal/intestinal atresia 
Hirschsprungs disease 
meconium ileus 
adhesions/obstructions
303
Q

causes of non-bilious vomiting

A 
pyloric stenosis 
gastroenteritis 
GORD 
intolerance 
intoxication 
UTI 
meningitis
304
Q

what is pyloric stenosis

A

thickening of the pyloric muscle

305
Q

features of pyloric stenosis

A

projectile non-bilious vomiting
dehydration
tired/sleeping more
not passing stool

306
Q

how to diagnose pyloric stenosis

A

test feed

abdominal USS

307
Q

how to manage pyloric stenosis

A

stop oral feeds and site NG tube
fluids and electrolyte replacement/monitoring
surgery

308
Q

what is intussusception

A

proximal part of bowel slips inside a more distal part

commonly at ileocaecal valve

309
Q

diagnosis of intussusception

A

abdominal US: target sign

310
Q

management of intussusception

A

fluid resus
IV antibiotics
surgery = rectal insufflation

311
Q

what are malrotation and volvulus

A 
malrotation = failure of gut to complete normal rotation during gestation 
volvulus = mesentery twists around itself
312
Q

presentation of malrotation/volvulus

A

previously well develops bilious vomiting
distended tender abdomen
peritonitis

313
Q

why is identification of malrotation or volvulus time critical

A

time = gut

delayed diagnosis leads to ischaemia and possible necrosis of gut

314
Q

diagnosis and management of malrotation/volvulus

A

urgent upper GI contrast study

agressive fluid resus
IV abx
emergency laparotomy

315
Q

projectile vomiting, olive-shaped mass

A

pyloric stenosis

316
Q

child born with Down syndrome, AXR shows double bubble

A

duodenal atresia

317
Q

intermittent crying, drawing legs up to chest, red-currant stool

A

intussusception

318
Q

failure to pass meconium in 48 hours

  • with cystic fibrosis
  • PR causes explosive air and faeces
A

CF = meconium ileus

explosive air/faeces = hirschprungs

319
Q

common and uncommon causes of neonatal respiratory distress

A 
common
transient tachypnoea of the newborn 
surfactant deficiency 
pneumonia 
meconium aspiration

uncommon
pulmonary aplasia
congenital cystic adenoid malformation
congenital diaphragmatic hernia

320
Q

radiological finding of surfactant deficiency

A

small volume lungs (bell shaped thorax)
diffuse granular opacification, progressing to opaque lungs, with bronchograms
no effusion unless complications arise

321
Q

CXR findings of TTN

A

normal or overinflated lungs
interstitial lines and effusions
fluid in fissures
air space opacification

322
Q

CXR findings of meconium aspiration

A

patchy opacities
overinflated lungs due to air trapping
air leaks
atelectasis

323
Q

what is the cause of resp distress

31 weeks, premature rupture of membranes, vaginal delivery, no meconium, resp distress, ventilated

A

surfactant deficiency

324
Q

what is the cause of resp distress

37 weeks, elective C-section for pre-eclampsia, no meconium, mild resp distress as 12 hours

A

TTN

325
Q

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

A

neonatal pneumonia

326
Q

what is the correct tip position for an endotracheal tube in a neonate

A

at or just below the carina
in the left main bronchus
2 cm above the carina at about T2/3
at the cricoid cartilage

327
Q

what is the correct tip position for a nasogastric tube

A

stomach, should travel in midline until reaches the stomach

328
Q

how many umbilical veins and arteries should a baby have

A

1 vein

2 arteries

329
Q

where is the normal endpoint of an umbilical vein catheter

though which vessels does it pass

A

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

330
Q

where is the normal endpoint of an umbilical artery catheter

through which vessels does it pass

A

low tip: L3/4, below renal arteries

high tip: T6-10

from umbilicus –> right or left internal iliac artery –> common iliac artery –> aorta

331
Q

CXR signs of bronchiolitis

A

overinflated lungs
perihilar haze
scattered atelectasis
rarely more diffuse opacification

332
Q

CXR signs of bacterial pneumonia

A

fluffy consolidation with air bronchograms
rounded, lobar or multifocal patterns
effusion
pneumothorax

333
Q

CXR signs of inhaled foreign body

A

Lucent lung due to air trapping is common due to ball valve effect

mediastinum displaces away from he affected side

pattern exaggerated in expiration

334
Q

which fracture patterns are suspicious of NAI

A

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

335
Q

which fracture patterns are specific to children and adolescents

A

buckle fracture
green stick fracture
plastic bowing
growth plate injury

336
Q

what is the grading system for growth plate injuries

A

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

4th Year (3 decks)

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