CHILD'S HEALTH Flashcards
benign ejection systolic murmur?
Characteristics of an innocent ejection murmur include: soft-blowing murmur in the pulmonary area or short buzzing murmur in the aortic area may vary with posture localised with no radiation no diastolic component no thrill no added sounds (e.g. clicks) asymptomatic child no other abnormality
Tetralogy of Fallot
The severity of the right ventricular outflow tract obstruction determines the degree of cyanosis and clinical severity
Other features
cyanosis
causes a right-to-left shunt
ejection systolic murmur due to pulmonary stenosis (the VSD doesn’t usually cause a murmur)
a right-sided aortic arch is seen in 25% of patients
chest x-ray shows a ‘boot-shaped’ heart, ECG shows right ventricular hypertrophy
Management
surgical repair is often undertaken in two parts
cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm
*however, at birth transposition of the great arteries is the more common lesion as patients with TOF generally present at around 1-2 months
Nocturnal enuresis
NICE issued guidance in 2010. Management:
look for possible underlying causes/triggers (e.g. Constipation, diabetes mellitus, UTI if recent onset)
advise on fluid intake, diet and toileting behaviour
reward systems (e.g. Star charts). NICE recommend these ‘should be given for agreed behaviour rather than dry nights’ e.g. Using the toilet to pass urine before sleep
NICE advises: ‘Consider whether an alarm or drug treatment is appropriate, depending on the age, maturity and abilities of the child or young person, the frequency of bedwetting and the motivation and needs of the family’. Generally:
an enuresis alarm is first-line for children under the age of 7 years
desmopressin may be used first-line for children over the age 7 years, particularly if short-term control is needed or an enuresis alarm has been ineffective/is not acceptable to the family
please see the link for more details
what are the Paediatric vital signs
< 1 HR 110 - 160 RR 30 - 40 1 - 2 HR 100 - 150 RR 25 - 35 2 - 5 HR 90 - 140 RR 25 - 30 5 - 12 HR 80 - 120 RR 20 - 25 > 12 HR 60 - 100 RR 15 - 20
over 12 = adult
Presentation with acute limp differentials ?
child < 3 years presenting with an acute limp - needs inspection
Septic arthritis/osteomyelitis Juvenile idiopathic arthritis Development dysplasia of the hip Perthes disease Slipped upper femoral epiphysis
Differentials for child with limp
Septic arthritis/osteomyelitis. - Unwell child, high fever
Idiopathic arthritis - may be painless limp
Perthes disease - More common at 4-8 years
Due to avascular necrosis of the femoral head
Slipped upper femoral epiphysis - 10-15 years - Displacement of the femoral head epiphysis postero-inferiorly
Intussusception
What is this
Presentation/ features ?
ntussusception describes the invagination of one portion of bowel into the lumen of the adjacent bowel, most commonly around the ileo-caecal region.
Intussusception usually affects infants between 6-18 months old. Boys are affected twice as often as girls
Features
paroxysmal abdominal colic pain
during paroxysm the infant will characteristically draw their knees up and turn pale
vomiting
bloodstained stool - ‘red-currant jelly’ - is a late sign
sausage-shaped mass in the right upper quadrant
Intussusception
Investigation and management
Investigation
ultrasound is now the investigation of choice and may show a target-like mass
Management
the majority of children can be treated with reduction by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema
if this fails, or the child has signs of peritonitis, surgery is performed
Asthma management in children
aged 5-16
- Short-acting beta agonist (SABA) (salbutamol)
- SABA + paediatric low-dose inhaled corticosteroid (ICS)
- SABA + paediatric low-dose ICS + leukotriene receptor antagonist (LTRA)
- SABA + paediatric low-dose ICS + long-acting beta agonist (LABA)
In contrast to the adult guidance, NICE recommend stopping the LTRA at this point if it hasn’t helped
- SABA + switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a paediatric low-dose ICS
- SABA + paediatric moderate-dose ICS MART
OR consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA
- SABA + one of the following options:
increase ICS to paediatric high-dose, either as part of a fixed-dose regime or as a MART
a trial of an additional drug (for example theophylline)
seeking advice from a healthcare professional with expertise in asthma
Thyroglossal cyst in children
Features
Located in the anterior triangle, usually in the midline and below the hyoid (65% cases)
Derived from remnants of the thyroglossal duct
Thin walled and anechoic on USS (echogenicity suggests infection of cyst)
Neck lump Branchial cyst in children
features
Six branchial arches separated by branchial clefts
Incomplete obliteration of the branchial apparatus may result in cysts, sinuses or fistulae
75% of branchial cysts originate from the second branchial cleft
Usually located anterior to the sternocleidomastoid near the angle of the mandible
Unless infected the fluid of the cyst has a similar consistency to water and is anechoic on USS
Dermoid cysts (thyroid) In children
Derived from pleuripotent stem cells and are located in the midline
Most commonly in a suprahyoid location
They have heterogeneous appearances on imaging and contain variable amounts of calcium and fat
Posterior triangle mass -
Cystic hygroma
Infantile haemangioma
Lymphadenopathy
cystic fibrosis - other life complications
Other features of cystic fibrosis short stature diabetes mellitus delayed puberty rectal prolapse (due to bulky stools) nasal polyps male infertility, female subfertility
Edwards Syndrome (Trisomy 18) features
These include: Cardiac malformations Choroid plexus cysts Neural tube defects Abnormal hand and feet position: clenched hands, rocker bottom feet and clubbed feet Exomphalos Growth restriction Single umbilical artery Polyhydramnios Small placenta
Patau syndrome (trisomy 13) features
Microcephalic, small eyes
Cleft lip/palate
Polydactyly
Scalp lesions
Fragile X features
Learning difficulties Macrocephaly Long face Large ears Macro-orchidism
Noonan syndrome features
Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis
Pierre-Robin syndrome* features
Micrognathia
Posterior displacement of the tongue (may result in upper airway obstruction)
Cleft palate
Cri du chat syndrome (chromosome 5p deletion syndrome) features
Characteristic cry (hence the name) due to larynx and neurological problems
Feeding difficulties and poor weight gain
Learning difficulties
Microcephaly and micrognathism
Hypertelorism
William’s syndrome features
Short stature Learning difficulties Friendly, extrovert personality Transient neonatal hypercalcaemia Supravalvular aortic stenosis
Prader-Willi syndrome features
Hypotonia
Hypogonadism
Obesity
pertussis - features and presentation
= whooping cough (Notifiable disease)
Features, 2-3 days of coryza precede onset of:
coughing bouts: usually worse at night and after feeding, may be ended by vomiting & associated central cyanosis
inspiratory whoop: not always present (caused by forced inspiration against a closed glottis)
infants may have spells of apnoea
persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope & seizures
symptoms may last 10-14 weeks* and tend to be more severe in infants
marked lymphocytosis
Pertussis diagnosis and management
Diagnosis
per nasal swab culture for Bordetella pertussis - may take several days or weeks to come back
PCR and serology are now increasingly used as their availability becomes more widespread
Management
infants under 6 months with suspect pertussis should be admitted
in the UK pertussis is a notifiable disease
an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
household contacts should be offered antibiotic prophylaxis
antibiotic therapy has not been shown to alter the course of the illness
school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
Reflex anoxic seizure - What and features
Reflex anoxic seizure - a syncopal episode (or presyncope) that occurs in response to pain or emotional stimuli.
. It typically occurs in young children aged 6 months to 3 years
Typical features child goes very pale falls to floor secondary anoxic seizures are common rapid recovery ( this diffs from epilispey)
Imms @ At birth
BCG if risk factors (see below)
Imms @ 2 months
‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B)
Oral rotavirus vaccine
Men B
Imms @ 3 months
‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B)
Oral rotavirus vaccine
PCV
Imms @ 5 months
‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B)
Men B
Imms @ 12- 13 months
Hib/Men C
MMR
PCV
Men B
Imms @2-8 years
flu
Imms @ 3-4 years
‘4-in-1 pre-school booster’ (diphtheria, tetanus, whooping cough and polio)
MMR
Imms @ 12-13 years
HPV vaccination
Imms @ 13-18 years
‘3-in-1 teenage booster’ (tetanus, diphtheria and polio)
Men ACWY
Ebstein’s anomaly what is this?
Causes
Ebstein’s anomaly is a congenital heart defect characterised by low insertion of the tricuspid valve resulting in a large atrium and small ventricle. It is sometimes referred to as ‘atrialisation’ of the right ventricle.
Associations
tricuspid incompetence (pan-systolic murmur, giant V waves in JVP)
Wolff-Parkinson White syndrome
Ebstein’s anomaly may be caused by exposure to lithium in-utero
Mesenteric adenitis
Mesenteric adenitis is inflamed lymph nodes within the mesentery. It can cause similar symptoms to appendicitis and can be difficult to distinguish between the two. It often follows a recent viral infection and needs no treatment
triad of the shaken baby syndrome
Retinal haemorrhages, subdural haematoma and encephalopathy
Pulmonary hypoplasia
What & causes?
Pulmonary hypoplasia is a term used for newborn infants with underdeveloped lungs
Causes include
oligohydramnios
congenital diaphragmatic hernia
Scarlet fever - causative pathogen
Scarlet fever is a reaction to erythrogenic toxins produced by Group A haemolytic streptococci
Scarlet fever presentation
Scarlet fever has an incubation period of 2-4 days and typically presents with: fever: typically lasts 24 to 48 hours malaise, headache, nausea/vomiting sore throat 'strawberry' tongue rash
Scarlet feverManagement
Management
oral penicillin V for 10 days
patients who have a penicillin allergy should be given azithromycin
children can return to school 24 hours after commencing antibiotics
scarlet fever is a notifiable disease
Scarlet fever complications
Scarlet fever is usually a mild illness but may be complicated by:
otitis media: the most common complication
rheumatic fever: typically occurs 20 days after infection
acute glomerulonephritis: typically occurs 10 days after infection
invasive complications (e.g. bacteraemia, meningitis, necrotizing fasciitis) are rare but may present acutely with life-threatening illness
Risk factors for Developmental dysplasia of the hip (DDH)
Risk factors female sex: 6 times greater risk breech presentation positive family history firstborn children oligohydramnios birth weight > 5 kg congenital calcaneovalgus foot deformity
Exam for Developmental dysplasia of the hip (DDH)
Clinical examination
Barlow test: attempts to dislocate an articulated femoral head
Ortolani test: attempts to relocate a dislocated femoral head
other important factors include:
symmetry of leg length
level of knees when hips and knees are bilaterally flexed
restricted abduction of the hip in flexion
Developmental dysplasia of the hip (DDH) Management
Management
most unstable hips will spontaneously stabilise by 3-6 weeks of age
Pavlik harness (dynamic flexion-abduction orthosis) in children younger than 4-5 months
older children may require surgery
Daily milk/fluid Requirement (< 3 months)(first 4 days of life)
Day of Life 1 60ml/kg/day 2 90 ml/kg/day 3 120 ml/kg/day 4+ 150ml/kg/day
Daily Fluid Requirement (> 6 months)
by body weight
• 1st 10 kg:100 ml/kg/day
• 2nd 10 kg: 50 ml/kg/day
• each kg above 20kg:20 ml/kg/day
Daily Fluid Requirements in Small Infants
for 1-3 m
Term
Preterm
Very preterm
Term infants, 1 week to 3 months: • 150 ml/kg/day
• Preterm infants (<37 weeks): • 150-180 ml/kg/day
• Very preterm infants (<32 weeks): • up to 200 ml/kg/day
Causes of dehydration in children
Reduced input - poor feeding,
Increased loss - Diarrhoea • Vomiting • Fever
Dehydration Classified by ECF Tonicity
• Isotonic (isonatraemic) dehydration – Na 130-150 mmol/l
Hypotonic (hyponatraemic) dehydration – Na <130 mmol/l
• Hypertonic (hypernatraemic) dehydration – Na >150 mmol/l
Intravenous fluids rehydration in children
- Assess dehydration clinically
- Use isotonic fluid (0.9% saline with added dextrose)
- Avoid rapid correction of hypernatremia or hyponatraemia (approx 10mmol/L/day rate of change)
- Maintenance + deficit over 24-48hrs
- Re-establish feeding as soon as possible
IV calculation of fluids IN CHILDREN
by body weight
• 1st 10 kg:100 ml/kg/day
• 2nd 10 kg: 50 ml/kg/day
• each kg above 20kg:20 ml/kg/day
+ Deficit (weight x %dehydration) = 5% x 15 = 750 – over 24 hrs (in this case)
/24 (caluate ml per hr)
Vomiting baby Ddx
GORD Post-tussive Pyloric stenosis Sepsis Obstruction Metabolic
Pyloric Stenosis: Clinical Features
- Projectile non-bilious vomiting •1 - 8 weeks
- Boys > girls
- First born children
- Positive FHx
•Hypochloraemic metabolic alkalosis
Infantile Hypertrophic Pyloric Stenosis:
Preliminary Treatment
• Treat shock
• IV correction of the electrolyte and acid-base abnormality over
24-48 hours
• Maintenance fluids
• Add Potassium to the infusion fluid (~20 mmol/L)
Blood in the Vomitus children ddx
• Newborn
• ingested maternal blood, drug induced, gastritis, maternal
nipples
• Toddler and older
• ulcers, gastritis, esophagitis, Henoch Shonlein Purpura, foreign Body
Blood in the Stool ddx
Newborn
• ingested maternal blood, CMPI, NEC, volvulus, Hirschsprung’s
• Toddler
• anal fissures, infectious colitis, Meckel’s, CMPI, juvenile polyps, HUS,
IBD
• 2 to 6 years
• infectious colitis, juvenile polyps, anal fissures, intussusception, Meckel’s, IBD, HSP
• 6 years and older
• IBD, colitis, polyps, hemorrhoids
Fragile X syndrome features
Features in males learning difficulties large low set ears, long thin face, high arched palate macroorchidism hypotonia autism is more common mitral valve prolapse
Features in females (who have one fragile chromosome and one normal X chromosome) range from normal to mild
Diagnosis
can be made antenatally by chorionic villus sampling or amniocentesis
analysis of the number of CGG repeats using restriction endonuclease digestion and Southern blot analysis
Juvenile idiopathic arthritis (JIA),
Features of systemic onset JIA include pyrexia salmon-pink rash lymphadenopathy arthritis uveitis anorexia and weight loss
Investigations
ANA may be positive, especially in oligoarticular JIA
rheumatoid factor is usually negative
Turner’s syndrome associated mummer
ejection systolic murmur due to bicuspid aortic valve
Ddx for pelvic pain in children
-
ddx for stridor
Laryngomalacia
Croup
Acute epiglottitis
Inhaled foreign body
Laryngomalacia
present
Congenital abnormality of the larynx.
Infants typical present at 4 weeks of age with:
stridor
normally a self-limiting condition, but if the stridor becomes severe with signs of respiratory distress, or if there is failure to thrive (due to poor feeding), then surgery is recommended to improve the airway.
Acute epiglottitis
Acute epiglottitis is rare but serious infection caused by Haemophilus influenzae type B. Prompt recognition and treatment is essential as airway obstruction may develop. Epiglottitis generally occurs in children between the ages of 2 and 6 years. The incidence of epiglottitis has decreased since the introduction of the Hib vaccine
Features rapid onset unwell, toxic child stridor drooling of saliva
Croup
Croup is a form of upper respiratory tract infection seen in infants and toddlers. It is characterised by stridor which is caused by a combination of laryngeal oedema and secretions. Parainfluenza viruses account for the majority of cases.
Epidemiology
peak incidence at 6 months - 3 years
more common in autumn
Features stridor barking cough (worse at night) fever coryzal symptoms
Necrotising enterocolitis presentation
vomiting (bilious)
Distension
Premmy
Blood in stool
Ddx billions vomiting
malrotation
NEC
D/J atresia
Sepsis
NEC Xray
Abdominal x-rays are useful when diagnosing necrotising enterocolitis, as they can show:
dilated bowel loops (often asymmetrical in distribution)
bowel wall oedema
pneumatosis intestinalis (intramural gas)
portal venous gas
pneumoperitoneum resulting from perforation
air both inside and outside of the bowel wall (Rigler sign)
air outlining the falciform ligament (football sign)
NEC treatment
Broad Antibiotics
Surgical resection
is pan - think palliative
Billary atresia presentation
Patients typically present in the first few weeks of life with:
Jaundice extending beyond the physiological two weeks
Dark urine and pale stools
Appetite and growth disturbance, however, may be normal in some cases
Signs: Jaundice Hepatomegaly with splenomegaly Abnormal growth Cardiac murmurs if associated cardiac abnormalities present
Billiary atresia investation and management
Investigations:
Serum bilirubin including differentiation into conjugated and total bilirubin: Total bilirubin may be normal, whereas conjugated bilirubin is abnormally high
Liver function tests (LFTs) including serum bile acids and aminotransferases are usually raised but cannot differentiate between biliary atresia and other causes of neonatal cholestasis
Serum alpha 1-antitrypsin: Deficiency may be a cause of neonatal cholestasis
Sweat chloride test: Cystic fibrosis often involves the biliary tract
Ultrasound of the biliary tree and liver: May show distension and tract abnormalities
Percutaneous liver biopsy with intraoperative cholangioscopy
Management:
Surgical intervention is the only definitive treatment for biliary atresia: Intervention may include dissection of the abnormalities into distinct ducts and anastomosis creation
Medical intervention includes antibiotic coverage and bile acid enhancers following surgery
Hirschsprung’s disease presentation
Possible presentations
neonatal period e.g. failure or delay to pass meconium
older children: constipation, abdominal distension
Associations
3 times more common in males
Down’s syndrome
Caput succedaneum presentation
Caput succedaneum is a subcutaneous, extraperiosteal, collection of fluid that collects as the result of pressure on the baby’s head during delivery.
(C)aput (S)uccedaneum= (C)rosses (S)uture lines - Passmed user Ava Maria
cephalhaematoma
A cephalhaematoma is a haemorrhage between the skull and periosteum. Because the swelling is subperiosteal, it’s limited by the boundaries of the baby’s cranial bones.
Doesn’t cross suture lines
Febrile convulsions advice
the overall risk of further febrile convulsion = 1 in 3. However, this varies widely depending on risk factors for further seizure. These include: age of onset < 18 months, fever < 39ºC, shorter duration of fever before seizure and a family history of febrile convulsions
if recurrences, try teaching parents how to use rectal diazepam or buccal midazolam. Parents should be advised to phone for an ambulance if the seizure lasts > 5 minutes
regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring
Child health - continuous machinery murmur occurs with
patent ductus arteriosus.
Child health -A diastolic decrescendo murmur
aortic or pulmonary regurgitation.
Child health -mid-diastolic murmur
heard with mitral stenosis.
Referral points developmental mile stones
Referral points
doesn’t smile at 10 weeks
cannot sit unsupported at 12 months
cannot walk at 18 months
hand preference before 12 months
abnormal and may indicate cerebral palsy
