CHILD'S HEALTH Flashcards
1
Q
benign ejection systolic murmur?
A
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
2
Q
Tetralogy of Fallot
A
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
3
Q
Nocturnal enuresis
A
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
4
Q
what are the Paediatric vital signs
A
< 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
5
Q
Presentation with acute limp differentials ?
A
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
6
Q
Differentials for child with limp
A
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
7
Q
Intussusception
What is this
Presentation/ features ?
A
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
8
Q
Intussusception
Investigation and management
A
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
9
Q
Asthma management in children
aged 5-16
A
- 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
10
Q
Thyroglossal cyst in children
Features
A
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)
11
Q
Neck lump Branchial cyst in children
features
A
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
12
Q
Dermoid cysts (thyroid) In children
A
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
13
Q
Posterior triangle mass -
A
Cystic hygroma
Infantile haemangioma
Lymphadenopathy
14
Q
cystic fibrosis - other life complications
A
Other features of cystic fibrosis short stature diabetes mellitus delayed puberty rectal prolapse (due to bulky stools) nasal polyps male infertility, female subfertility
15
Q
Edwards Syndrome (Trisomy 18) features
A
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
16
Q
Patau syndrome (trisomy 13) features
A
Microcephalic, small eyes
Cleft lip/palate
Polydactyly
Scalp lesions
17
Q
Fragile X features
A
Learning difficulties Macrocephaly Long face Large ears Macro-orchidism
18
Q
Noonan syndrome features
A
Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis
19
Q
Pierre-Robin syndrome* features
A
Micrognathia
Posterior displacement of the tongue (may result in upper airway obstruction)
Cleft palate
20
Q
Cri du chat syndrome (chromosome 5p deletion syndrome) features
A
Characteristic cry (hence the name) due to larynx and neurological problems
Feeding difficulties and poor weight gain
Learning difficulties
Microcephaly and micrognathism
Hypertelorism
21
Q
William’s syndrome features
A
Short stature Learning difficulties Friendly, extrovert personality Transient neonatal hypercalcaemia Supravalvular aortic stenosis
22
Q
Prader-Willi syndrome features
A
Hypotonia
Hypogonadism
Obesity
23
Q
pertussis - features and presentation
A
= 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
24
Q
Pertussis diagnosis and management
A
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 )
25
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)
```
26
Imms @ At birth
BCG if risk factors (see below)
27
Imms @ 2 months
'6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B)
Oral rotavirus vaccine
Men B
28
Imms @ 3 months
'6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B)
Oral rotavirus vaccine
PCV
29
Imms @ 5 months
'6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B)
Men B
30
Imms @ 12- 13 months
Hib/Men C
MMR
PCV
Men B
31
Imms @2-8 years
flu
32
Imms @ 3-4 years
'4-in-1 pre-school booster' (diphtheria, tetanus, whooping cough and polio)
MMR
33
Imms @ 12-13 years
HPV vaccination
34
Imms @ 13-18 years
'3-in-1 teenage booster' (tetanus, diphtheria and polio)
| Men ACWY
35
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
36
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
37
triad of the shaken baby syndrome
Retinal haemorrhages, subdural haematoma and encephalopathy
38
Pulmonary hypoplasia
| What & causes?
Pulmonary hypoplasia is a term used for newborn infants with underdeveloped lungs
Causes include
oligohydramnios
congenital diaphragmatic hernia
39
Scarlet fever - causative pathogen
Scarlet fever is a reaction to erythrogenic toxins produced by Group A haemolytic streptococci
40
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
```
41
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
42
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
43
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
```
44
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
45
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
46
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
```
47
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
48
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
49
Causes of dehydration in children
Reduced input - poor feeding,
| Increased loss - Diarrhoea • Vomiting • Fever
50
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
51
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
52
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)
53
Vomiting baby Ddx
GORD Post-tussive Pyloric stenosis Sepsis Obstruction Metabolic
54
Pyloric Stenosis: Clinical Features
* Projectile non-bilious vomiting •1 - 8 weeks
* Boys > girls
* First born children
* Positive FHx
•Hypochloraemic metabolic alkalosis
55
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)
56
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
57
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
58
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
59
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
60
Turner's syndrome associated mummer
ejection systolic murmur due to bicuspid aortic valve
61
Ddx for pelvic pain in children
-
62
ddx for stridor
Laryngomalacia
Croup
Acute epiglottitis
Inhaled foreign body
63
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.
64
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
```
65
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
```
66
Necrotising enterocolitis presentation
vomiting (bilious)
Distension
Premmy
Blood in stool
67
Ddx billions vomiting
malrotation
NEC
D/J atresia
Sepsis
68
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)
69
NEC treatment
Broad Antibiotics
Surgical resection
is pan - think palliative
70
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
```
71
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
72
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
73
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
74
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
75
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
76
Child health - continuous machinery murmur occurs with
patent ductus arteriosus.
77
Child health -A diastolic decrescendo murmur
aortic or pulmonary regurgitation.
78
Child health -mid-diastolic murmur
heard with mitral stenosis.
79
Referral points developmental mile stones
Referral points
doesn't smile at 10 weeks
cannot sit unsupported at 12 months
cannot walk at 18 months
80
hand preference before 12 months
abnormal and may indicate cerebral palsy
81
Innocent mumurs
ie
Venous hums
Still's 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
```
82
As per the NICE guidelines if any of the following are observed after any degree of meconium, then baby must be assessed by the neonatal team;
respiratory rate above 60 per minute
the presence of grunting
heart rate below 100 or above 160 beats/minute
capillary refill time above 3 seconds
temperature of 38°C or above, or 37.5°C on 2 occasions 30 minutes apart
oxygen saturation below 95%
presence of central cyanosis
83
features
Acute lymphoblastic leukaemia
anaemia: lethargy and pallor
neutropaenia: frequent or severe infections
thrombocytopenia: easy bruising, petechiae
And other features
bone pain (secondary to bone marrow infiltration)
splenomegaly
hepatomegaly
fever is present in up to 50% of new cases (representing infection or constitutional symptom)
testicular swelling
84
Acute lymphoblastic leukaemia - Poor prognostic factors
```
Poor prognostic factors
age < 2 years or > 10 years
WBC > 20 * 109/l at diagnosis
T or B cell surface markers
non-Caucasian
male sex
```
85
CH - DDX for fever
```
UTI
Covid
meningitis
sepsis
septic arthritis
osteomyelitis
Tb
Kawasis
JIA
rhematic fever
malignancy
```
86
initial priority when a child presents with an acute fever?
assess the risk of a serious illness that requires initiation of urgent treatment. The ABCDE approach is used as the initial assessment in the acutely unwell child
use the traffic light system
heart rate, respiratory rate, response to social cues, and capillary refill time,
87
Collapse Ddx in children
```
Generalised seizure
Vasovagal
anoxic seizure
Structural heart disease
Dehydration
hypoglymaia
```
88
Constipation in children
| causes
3 times per day for infants under 6 months old to once a day after 3 years of age.
NICE produced guidelines in 2010 on the diagnosis and management of constipation in children.
```
The vast majority of children have no identifiable cause - idiopathic constipation. Other causes of constipation in children include:
dehydration
low-fibre diet
medications: e.g. Opiates
anal fissure
over-enthusiastic potty training
hypothyroidism
Hirschsprung's disease
hypercalcaemia
learning disabilities
```
89
Constipation in children
| Management
If faecal impaction is present
polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated
inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain
Maintenance therapy
very similar to the above regime, with obvious adjustments to the starting dose, i.e.
first-line: Movicol Paediatric Plain
add a stimulant laxative if no response
substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated. Add another laxative such as lactulose or docusate if stools are hard
continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce dose gradually
Infants not yet weaned (usually < 6 months)
bottle-fed infants: give extra water in between feeds. Try gentle abdominal massage and bicycling the infant's legs
breast-fed infants: constipation is unusual and organic causes should be considered
Infants who have or are being weaned
offer extra water, diluted fruit juice and fruits
if not effective consider adding lactulose
90
Red flags Constipation in children
Reported from birth or first few weeks of life
'Ribbon' stools
Previously unknown or undiagnosed weakness in legs, locomotor delay
distention
91
GORD in children presentation
Gastro-oesophageal reflux is the commonest cause of vomiting in infancy. Around 40% of infants regurgitate their feeds to a certain extent so there is a degree of overlap with normal physiological processes.
Risk factors
preterm delivery
neurological disorders
Features
typically develops before 8 weeks
vomiting/regurgitation following feeds
92
GORD management in children
Management (partly based on the 2015 NICE guidelines)
advise regarding position during feeds - 30 degree head-up
infants should sleep on their backs as per standard guidance to reduce the risk of cot death
ensure infant is not being overfed (as per their weight) and consider a trial of smaller and more frequent feeds
a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum)
a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents
NICE do not recommend a proton pump inhibitor (PPI) or H2 receptor antagonists (H2RA), to treat overt regurgitation in infants and children occurring as an isolated symptom. A trial of one of these agents should be considered if 1 or more of the following apply:
unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
distressed behaviour
faltering growth
prokinetic agents e.g. metoclopramide should only be used with specialist advice
93
NICE do not recommend a proton pump inhibitor (PPI) or H2 receptor antagonists (H2RA) - when could they be considered
A trial of one of these agents should be considered if 1 or more of the following apply:
unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
distressed behaviour
faltering growth
94
Ddx Faltering growth in children
GI
- nutrition
- Coeliacs
- hirschsprungs
- consider developmental delays and genetics
Be aware that the following factors may be associated with faltering growth:
preterm birth
neurodevelopmental concerns
maternal postnatal depression or anxiety.
95
What is faltering growth via NICE
Consider using the following as thresholds for concern about faltering growth in infants and children (a centile space being the space between adjacent centile lines on the UK WHO growth charts):
a fall across 1 or more weight centile spaces, if birthweight was below the 9th centile
a fall across 2 or more weight centile spaces, if birthweight was between the 9th and 91st centiles
a fall across 3 or more weight centile spaces, if birthweight was above the 91st centile
when current weight is below the 2nd centile for age, whatever the birthweight.
96
Therapeutic hypothermia in preterm is used to treat?
hypoxic ischaemic encephalopathy
97
Erythema toxicum neonatorum treatment
a very common skin condition in neonates. The condition can be alarming to parents, but resolves spontaneously and does not require any treatment
98
Breast feeding benefits
eduction in risk of otitis media, respiratory tract infections, gastrointestinal infections and potentially also for reduction in risk of type 2 diabetes and obesity (evidence base less clear for these latter two conditions).
Maternal benefits include a reduction in risk of triple negative breast cancer
Victoria et al 2016
protection against child infections and malocclusion, increases in intelligence, and probable reductions in overweight and diabetes.
99
Breast feeding WHO and NICE guidance
| when and how long should you breast feed
WHO and UNICEF recommendations:
- early initiation of breastfeeding within 1 hours of birth
- exclusive breastfeeding for the first 6 months of life
- introduction of nutritionally-adequate and safe complementary foods at 6 months together with continued breastfeeding up to 2 years or beyond
UK Department of Health recommendations:
- adoption of WHO guidance recommending exclusive breastfeeding for the first six months of life
- breastfeeding should continue beyond six months, alongside the introduction of appropriate solid foods.
- infant formula is the only recommended alternative to breastfeeding for babies who are under 12 months old
100
Key points for advice on bottle feeding:
Key points for advice on bottle feeding:
- First infant formula (whey-based) is the only formula needed in the first year of life
- Full fat cows milk can be used after 12 months of age
- There is no evidence to support the use of formulas advertised for colic/reflux/constipation/hungry babies
- UK law and The WHO International Code of Marketing of Breastmilk Substitutes precludes the advertising of first infant formula. “Follow on formulas” were developed to bypass this – there is no nutritional reason to use these formulas after 6 months, and so parents can safely continue on first milk
101
Transposition of the great arteries (TGA) presentation
```
linical features
cyanosis
tachypnoea
loud single S2
prominent right ventricular impulse
'egg-on-side' appearance on chest x-ray
```
102
Transposition of the great arteries (TGA) management
Management
maintenance of the ductus arteriosus with prostaglandins such as alprostadil
surgical correction is the definite treatment.
103
Retinoblastoma presentation (children)
Possible features
absence of red-reflex, replaced by a white pupil (leukocoria) - the most common presenting symptom
strabismus
visual problems
104
Retinoblastoma management
Management
enucleation is not the only option
depending on how advanced the tumour is other options include external beam radiation therapy, chemotherapy and photocoagulation
Prognosis
excellent, with > 90% surviving into adulthood
105
Newborn resuscitation
ewborn resuscitation
1. Dry baby and maintain temperature
2. Assess tone, respiratory rate, heart rate
3. If gasping or not breathing give 5 inflation breaths*
4. Reassess (chest movements)
5. If the heart rate is not improving and <60bpm start compressions and ventilation breaths at a rate of 3:1
106
RF for preterm labour
a. Sepsis
b. Preterm rupture of membranes
c. Cervical shortening
d. Maternal illness- pre-eclampsia, diabetes, blood pressure or renal problems
e. Multiple pregnancy
f. Placental problems such as placenta praevia, leading to APH
g. Fetal anomaly
h. Social/lifestyle factors such as smoking, illegal drugs, alcohol, suboptimal antenatal care.
107
What is the purpose of giving dexamethasone and magnesium sulphate to a mother in preterm labour?
. Antenatal steroids are given to reduce risk of respiratory distress syndrome and intraventricular haemorrhage in the preterm infant. Steroids have been shown to accelerate the development of type 1 and type 2 pneumocytes, thereby increasing surfactant production and improving lung mechanics. They also stabilise circulatory changes at birth lowering the risk of IVH and NEC.
b. Magnesium sulphate is routinely given to imminent preterm delivery under 30 weeks gestation for neuroprotection- reduced risk of cerebral palsy and motor function defecit.
108
caffeine in prematurity
Caffeine is a respiratory stimulant and treats apnoea of prematurity. It also has been shown to reduce frequency of BPD
109
Roseola infantum
Cause
Features
HHSV-6
Features
high fever: lasting a few days, followed later by a
maculopapular rash
Nagayama spots: papular enanthem on the uvula and soft palate
febrile convulsions occur in around 10-15%
diarrhoea and cough are also commonly seen
110
Pyloric stenosis blood
Pyloric stenosis classically leads to hypochloraemic, hypokalaemic alkalosis
111
A 8-year-old boy presents to the GP as his mother is worried about a fever that is not settling with regular paracetamol and ibuprofen. He has had the fever for 7 days now.
On examination, he has a widespread erythematous rash on his torso and arms. In particular, his palms and soles of his feet are very red. There is conjunctival injection with no discharge. Tender cervical lymphadenopathy is palpated. You measure his temperature at 38ºC.
Following resolution of this condition, which of the following investigations should be used to screen for potential complications?
Coronary artery aneurysms are a complication of Kawasaki disease and this should be screened for with an echocardiogram
112
Kawasaki disease
| Features
Features
high-grade fever which lasts for > 5 days. Fever is characteristically resistant to antipyretics
conjunctival injection
bright red, cracked lips
strawberry tongue
cervical lymphadenopathy
red palms of the hands and the soles of the feet which later peel
113
Kawasaki disease
| management
Kawasaki disease is a clinical diagnosis as there is no specific diagnostic test.
Management
high-dose aspirin
Kawasaki disease is one of the few indications for the use of aspirin in children. Due to the risk of Reye's syndrome aspirin is normally contraindicated in children
intravenous immunoglobulin
echocardiogram (rather than angiography) is used as the initial screening test for coronary artery aneurysms
114
Perthes' disease,
| management
Surgical repair of Perthes' disease is only indicated in children age >6. In those age <6, the prognosis is good with no intervention.
Older: surgical management with moderate results
Operate on severe deformities
115
description that is classical of a venous hum
benign murmur heard in children and sounds like a continuous blowing noise heard below the clavicles
116
Still's murmur
low-pitched sound on the lower left sternal edge.
117
snoring in children causes
```
Causes
obesity
nasal problems: polyps, deviated septum, hypertrophic nasal turbinates
recurrent tonsillitis
Down's syndrome
hypothyroidism
```
118
Turner syndrome (45 XO) is associated with:
Bicuspid aortic valve
Aortic root dilatation
Coarctation of the aorta
119
promote duct closure?
Indomethacin or ibuprofen is used in patent ductus arteriosus to promote duct closure
120
Management of a SCFE: (slipped upper femoral epiphysis)
internal fixation (across growth plate)
121
Gastroschisis vs omphalocele
Gastroschisis = defect lateral to the umbilicus
| omphalocele refers to a defect in the umbilicus itself.
122
Gastroschisis
management
Gastroschisis describes a congenital defect in the anterior abdominal wall just lateral to the umbilical cord.
Management
vaginal delivery may be attempted
newborns should go to theatre as soon as possible after delivery, e.g. within 4 hours
123
Gastroschisis
| associated risk factors
socioeconomic deprivation (maternal age <20, maternal alcohol/tobacco use)
124
APGAR scores timings
1, 5 and 10 minutes of age
125
Varicocele - sign of?
can be a sign of malignancy due to compression of the renal vein between the abdominal aorta and the superior mesenteric vein - known as the nutcracker angle
126
Umbilical hernias: management in children
Umbilical hernias: Usually self-resolve, but if large or symptomatic perform elective repair at 2-3 years of age. If small and asymptomatic peform elective repair at 4-5 years of age.
127
Seizures: acute management
Basics
check the airway and apply oxygen if appropriate
place the patient in the recovery position
if the seizure is prolonged give benzodiazepines ( rectal diazepam or Midazolam oromucosal solution may also be used)
128
Absence seizures features
The typical age of onset of 3-10 years old
girls 2x vs boys
absences last a few seconds and are associated with a quick recovery
seizures may be provoked by hyperventilation or stress
the child is usually unaware of the seizure
they may occur many times a day
EEG: bilateral, symmetrical 3Hz spike and wave pattern
129
Absence seizures management
Management
sodium valproate and ethosuximide are first-line treatment
good prognosis - 90-95% become seizure free in adolescenc
130
Reflex anoxic seizure features
```
Typical features
child goes very pale
falls to floor
secondary anoxic seizures are common
rapid recovery
response to pain or emotional stimuli.
```
There is no specific treatment and prognosis is excellent
131
Psychogenic nonepileptic seizures features
```
Factors favouring pseudoseizures
pelvic thrusting
family member with epilepsy
much more common in females
crying after seizure
don't occur when alone
gradual onset
```
Factors favouring true epileptic seizures
tongue biting
raised serum prolactin*
132
Temporal lobe seizure
allucinations (auditory/gustatory/olfactory), Epigastric rising/Emotional, Automatisms (lip smacking/grabbing/plucking), Deja vu/Dysphasia post-ictal)
133
Frontal lobe seizure
Head/leg movements, posturing, post-ictal weakness, Jacksonian march
134
Parietal lobe seizure
Paraesthesia
135
major gross motor developmental milestones
| 3 months
3 months
Little or no head lag on being pulled to sit
Lying on abdomen, good head control
Held sitting, lumbar curve
136
major gross motor developmental milestones
| 6 months
```
6 months
Lying on abdomen, arms extended
Lying on back, lifts and grasps feet
Pulls self to sitting
Held sitting, back straight
Rolls front to back
```
137
major gross motor developmental milestones
| 7/8 months
7-8 months Sits without support (Refer at 12 months)
138
major gross motor developmental milestones
| 9 and 12 months
```
9 months
Pulls to standing
Crawls
12 months
Cruises
Walks with one hand held
```
139
major gross motor developmental milestones
| 13-15 months
13-15 months Walks unsupported (Refer at 18 months)
140
major gross motor developmental milestones
| 2,3 and 4 years
```
2 years
Runs
Walks upstairs and downstairs holding on to rail
3 years
Rides a tricycle using pedals
Walks up stairs without holding on to rail
4 years
Hops on one leg
```
141
Developmental milestones: fine motor and vision
| 3 months
```
3 months
Reaches for object
Holds rattle briefly if given to hand
Visually alert, particularly human faces
Fixes and follows to 180 degrees
```
142
Developmental milestones: fine motor and vision
| 6 months
6 months Holds in palmar grasp
Pass objects from one hand to another
Visually insatiable, looking around in every direction
143
Developmental milestones: fine motor and vision
| 9 n 12 months
```
9 months
Points with finger
Early pincer
12 months
Good pincer grip
Bangs toys together
```
144
Developmental milestones: speech and hearing
| 3 and 6 months
3 months
Quietens to parents voice
Turns towards sound
Squeals
6 months
Double syllables 'adah', 'erleh'
145
Developmental milestones: speech and hearing
| 9 and 12 months
```
9 months
Says 'mama' and 'dada'
Understands 'no'
12 months
Knows and responds to own name
```
146
Developmental milestones: speech and hearing
| 12-15 months
12-15 months Knows about 2-6 words (Refer at 18 months)
| Understands simple commands - 'give it to mummy'
147
developmental ref points
Referral points
doesn't smile at 10 weeks
cannot sit unsupported at 12 months
cannot walk at 18 months
148
developmental hip dyslspia imaging
Imaging
ultrasound is generally used to confirm the diagnosis if clinically suspected
however, if the infant is > 4.5 months then x-ray is the first line investigation
149
Developmental dysplasia of the hip 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
150
Precocious puberty definition
Definition
'development of secondary sexual characteristics before 8 years in females and 9 years in males'
more common in females
151
bruising in children ddx
```
malignancy
Haemophilia
VWD
Thrombocytopenia
Idiopathic thrombocytopenic purpura
Henoch-Schonlein purpura (HSP)
vit k def
```
152
Acute myeloid leukaemia
Features are largely related to bone marrow failure:
anaemia: pallor, lethargy, weakness
neutropenia: whilst white cell counts may be very high, functioning neutrophil levels may be low leading to frequent infections etc
thrombocytopenia: bleeding
splenomegaly
bone pain
More common in adults
153
Acute myeloid leukaemia poor prognosis
Poor prognostic features
> 60 years
> 20% blasts after first course of chemo
cytogenetics: deletions of chromosome 5 or 7
154
Acute lymphoblastic leukaemia presentation
Most common malignancy affecting children and accounts for 80% of childhood leukaemias. The peak incidence is at around 2-5 years of age and boys are affected slightly more commonly than girls
Features may be divided into those predictable by bone marrow failure:
anaemia: lethargy and pallor
neutropaenia: frequent or severe infections
thrombocytopenia: easy bruising, petechiae
And other features
bone pain (secondary to bone marrow infiltration)
splenomegaly
hepatomegaly
fever is present in up to 50% of new cases (representing infection or constitutional symptom)
testicular swelling
155
Chronic lymphocytic leukaemia: complications
Complications
anaemia
hypogammaglobulinaemia leading to recurrent infections
warm autoimmune haemolytic anaemia in 10-15% of patients
transformation to high-grade lymphoma (Richter's transformation)
Richter's transformation
Ritcher's transformation occurs when leukaemia cells enter the lymph node and change into a high-grade, fast-growing non-Hodgkin's lymphoma. Patients often become unwell very suddenly.
```
Ritcher's transformation is indicated by one of the following symptoms:
lymph node swelling
fever without infection
weight loss
night sweats
nausea
abdominal pain
```
156
Causes of moderate thrombocytopenia
```
heparin induced thrombocytopenia (HIT)
drug-induced (e.g. quinine, diuretics, sulphonamides, aspirin, thiazides)
alcohol
liver disease
hypersplenism
viral infection (EBV, HIV, hepatitis)
pregnancy
SLE/antiphospholipid syndrome
vitamin B12 deficiency
```
157
Immune thrombocytopenia (ITP) in children
Immune (or idiopathic) thrombocytopenic purpura (ITP) is an immune-mediated reduction in the platelet count. Antibodies are directed against the glycoprotein IIb/IIIa or Ib-V-IX complex.
Immune thrombocytopenia (ITP) in children
it is typically more acute than in adults
equal sex incidence
may follow an infection or vaccination
usually runs a self-limiting course over 1-2 weeks
158
Henoch-Schonlein purpura Features
Features
palpable purpuric rash (with localized oedema) over buttocks and extensor surfaces of arms and legs
abdominal pain
polyarthritis
features of IgA nephropathy may occur e.g. haematuria, renal failure
159
Henoch-Schonlein purpura treatment
Treatment
analgesia for arthralgia
treatment of nephropathy is generally supportive. There is inconsistent evidence for the use of steroids and immunosuppressants
160
Nephrotic syndrome is classically defined as a triad of
Nephrotic syndrome is classically defined as a triad of
proteinuria (> 1 g/m^2 per 24 hours)
hypoalbuminaemia (< 25 g/l)
oedema
161
IgA nephropathy features
It classically presents as macroscopic haematuria in young people following an upper respiratory tract infection.
Associated conditions
alcoholic cirrhosis
coeliac disease/dermatitis herpetiformis
Henoch-Schonlein purpura
Presentations
young male, recurrent episodes of macroscopic haematuria
typically associated with a recent respiratory tract infection
nephrotic range proteinuria is rare
renal failure is unusual and seen in a minority of patients
162
COPD LTOT
Assess patients if any of the following:
very severe airflow obstruction (FEV1 < 30% predicted). Assessment should be 'considered' for patients with severe airflow obstruction (FEV1 30-49% predicted)
cyanosis
polycythaemia
peripheral oedema
raised jugular venous pressure
oxygen saturations less than or equal to 92% on room air
163
Spider naevi. vs telangiectasia
Spider naevi can be differentiated from telangiectasia by pressing on them and watching them fill. Spider naevi fill from the centre, telangiectasia from the edge
164
Major bleeding on warfarin
stop warfarin, give intravenous vitamin K 5mg, prothrombin complex concentrate
165
management for patients with INR > 8 and minor bleeding.
intravenous vitamin K 1-3mg and repeat dose of vitamin K after 24 hours if INR still high, restart warfarin when INR <5 is incorrect,
166
INR 5.0-8.0
| Minor bleeding
Stop warfarin
Give intravenous vitamin K 1-3mg
Restart when INR < 5.0
167
Painful third nerve palsy
posterior communicating artery aneurysm
168
Causes
| of third nerve palsy
Causes
diabetes mellitus
vasculitis e.g. temporal arteritis, SLE
false localizing sign* due to uncal herniation through tentorium if raised ICP
posterior communicating artery aneurysm
pupil dilated
often associated pain
cavernous sinus thrombosis
Weber's syndrome: ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain strokes
other possible causes: amyloid, multiple sclerosis
169
third nerve palsy
Features
eye is deviated 'down and out'
ptosis
pupil may be dilated (sometimes called a 'surgical' third nerve palsy)
170
Pneumocystis jiroveci penumonia is treated with
co-trimoxazole, which is a mix of trimethoprim and sulfamethoxazole
171
Felodipine
A calcium channel blocker is a first-line treatment for hypertension in patients > 55 and a common side effect is peripheral oedema.
172
Behcet's syndrome
Features
classically: 1) oral ulcers 2) genital ulcers 3) anterior uveitis
thrombophlebitis and deep vein thrombosis
arthritis
neurological involvement (e.g. aseptic meningitis)
GI: abdo pain, diarrhoea, colitis
erythema nodosum
173
Cautions and contraindications of ACE inhibitors
Cautions and contraindications
pregnancy and breastfeeding - avoid
renovascular disease - may result in renal impairment
aortic stenosis - may result in hypotension
hereditary of idiopathic angioedema
specialist advice should be sought before starting ACE inhibitors in patients with a potassium >= 5.0 mmol/L
174
man presenting with dyspnoea, peripheral oedema and a positive Kussmaul's sign (the raised JVP that doesn't fall with inspiration).
constrictive pericarditis.
175
Recommend Adult Life Support (ALS) adrenaline doses
anaphylaxis: 0.5mg - 0.5ml 1:1,000 IM
| cardiac arrest: 1mg - 10ml 1:10,000 IV or 1ml of 1:1000 IV
176
allergy history
This should include:
any personal or family history of atopic disease (asthma, eczema or allergic rhinitis)
food allergy in parents or siblings
details of any foods that are avoided and the reasons why
an assessment of presenting symptoms and other symptoms that may be associated with food allergy (see signs and symptoms of possible food allergy), including questions about:
the age of the child or young person when symptoms first started
speed of onset of symptoms following food contact
duration of symptoms
severity of reaction
frequency of occurrence
setting of reaction (for example, at school or home)
reproducibility of symptoms on repeated exposure
what food and how much exposure to it causes a reaction
cultural and religious factors that affect the foods they eat
who has raised the concern and suspects the food allergy
what the suspected allergen is
the child or young person's feeding history, whether they were breastfed or formula-fed and the age of weaning
the mother's diet, if the child is currently being breastfed
details of any previous treatment, including medication, for the presenting symptoms and the response to this
177
allergy diagnosis pathway
diagnostic process, which may include:
an elimination diet followed by a possible planned rechallenge or initial food reintroduction procedure (see suspected non-IgE-mediated food allergy)
skin prick tests and specific IgE antibody testing, including the safety and limitations of these tests (see suspected IgE-mediated food allergy)
referral to secondary or specialist care.
178
cow milk intolerance advice
For babies and young children with suspected allergy to cows' milk protein, offer:
food avoidance advice to breastfeeding mothers
information on the most appropriate hypoallergenic formula or milk substitute to mothers of formula-fed babies.
Seek advice from a dietitian with appropriate competencies.
179
IgE mediated allergy vs non IGe clinical presentation
IgE mediated allergy often occur immediately after ingestion - cute angioedema or urticaria
Non IGE - characterised by delayed reactions
180
IgE mediated allergy investigations
IgE-mediated allergy is suspected, offer the child or young person a skin prick test and/or blood tests for specific IgE antibodies to the suspected foods and likely co-allergens.
181
non-IgE-mediated food allergy investigations
if non-IgE-mediated food allergy is suspected, trial elimination of the suspected allergen (normally for between 2-6 weeks) and reintroduce after the trial. Seek advice from a dietitian with appropriate competencies, about nutritional adequacies, timings of elimination and reintroduction, and follow-up. (For people undergoing investigation for coeliac disease see the NICE Pathway on coeliac disease.)
182
consider referral to secondary or specialist care in any of the following circumstances. in allergy
The child or young person has:
faltering growth in combination with one or more of the gastrointestinal symptoms described in signs and symptoms of possible food allergy
not responded to a single-allergen elimination diet
had one or more acute systemic reactions
had one or more severe delayed reactions
confirmed IgE-mediated food allergy and concurrent asthma
significant atopic eczema where multiple or cross-reactive food allergies are suspected by the parent or carer.
There is:
persisting parental suspicion of food allergy (especially in children or young people with difficult or perplexing symptoms) despite a lack of supporting history
strong clinical suspicion of IgE-mediated food allergy but allergy test results are negative
clinical suspicion of multiple food allergies.
183
NAI - non acidental injury presentation
Worrying bruises are those shaped like hands, linear bruises, ligatures or an identifiable implement.
Bruises around the Pinna
Always be suspicious of bruises in a child who cannot mobilise
Remember “if they can’t cruise they don’t bruise”
acerations or abrasions are seen:
In non-mobile children
Symmetrically
Around the face
Around the ankles or wrists, in the position a ligature could be applied
Fractures of different ages, especially where there is no documentation of caregivers seeking medical attention, are highly suspicious of NAI.
Metaphyseal corner fractures
Evidence of occult rib fractures is also a common finding in infants/children who have been grabbed by the chest and squeezed/shaken.
Spiral fractures are a result of twisting forces so cannot be caused by simple falling, and are highly suspicious of NAI
Retinal haemorrhages with no medical explanation are highly suspicious for NA
184
imaging requirements when NAI is suspected,
Skeletal Survey
```
Head/chest (including AP and lateral skull)
Spine/pelvis
Upper limbs
Lower limbs
Follow-up Imaging
```
Skeletal survey should be repeated at 11-14 days.
This is to ensure that injuries too new to appear on the initial skeletal survey are detected.
11-14 days is used as this is the maximal time take for the periosteal reaction to occur, allowing fractures to be visualised on X-ray.
185
imaging requirements when NAI is suspected, RcR guidelines
Imaging should always include skeletal survey in children under two years old and skeletal survey and computed tomography (CT) head scan in children under one year old. See Appendix A for the standard views to be obtained.
2. Children who are older than one year and have external evidence of head trauma and/or abnormal neurological symptoms or signs should also have a CT head scan.
3. Skeletal survey may occasionally be indicated in older children; this should be considered on a case-by-case basis.
186
classical presentation of croup
coryzal type illness (i.e. runny nose, nasal congestion, fever) associated with a hoarse voice, characteristic barking cough and stridor. Stridor describes the harsh sound heard on inspiration due to obstruction of the upper airways.
187
VSD in children
SDs may be asymptomatic if they are small, and may simply be noted on routine scans. Large VSDs present with shortness of breath on exertion (for example, whilst breastfeeding in infancy). As the work of breathing is greatly increased, there might be poor weight gain as energy is diverted to breathing instead of growing.
Diagnosis
VSDs are definitively diagnosed with echocardiogram scans, which allow visualisation of the defect and characterisation of its severity. Chest X-ray and ECG are also useful in assessment.
Management
The majority of ventricular septal defects self-resolve, so infants may be managed conservatively with increased caloric intake and observation with follow up. For VSDs that are causing signs and symptoms of heart failure, diuretics such as captopril may be useful. Corrective surgery may be required in very severe cases.
188
Migraine without Aura
1. At least 5 headaches lasting 1 – 72 hours
2. Two of following
a. Unilateral location
b. Pulsating Quality
c. Moderate or Severe Intensity
d. Aggravation by walking or similar routine activity
• 3. One of following
a. Nausea and/or vomiting
b. Photophobia and Phonophobia
189
Migraine with aura
Migraine with aura
• 1. At least 2 attacks
• 2. At least 3 of following
a. one or more reversible aura symptoms (Visual- flushing lights, blurred vision, blind spots; Sensory- pins & needles, numbness; Motor- weakness, dysarthria; Atypical or prolonged aura)
b. Aura develops gradually over 5 min c. No aura lasts more than 60 min
d. Headache follows aura within 60 min
190
Benign Paroxysmal Torticollis
* Episodic attacks in a young child (< 1 year) with all of the following:
* Tilt of the head to one side lasting minutes or days, remmiting spontaneously
* Tending to re-occur monthly
* With pallor, irritability, malaise, vomiting, ataxia
* Normal neurological examination between attacks
* Not attributed to another disorder
191
Prophylaxis of Migraine
* Pizotifen (not enough studies showed an evidence of good effect in Migraine but evidently effective in Abdominal Migraine)
* Propranolol (NICE number 1 and 2)
* Topiramate (NICE number 1 and 2)
* Amitriptyline (effective but plenty of side effects) (use in astmatics)
* Clonidine
* Gabapentine
* Vaproate
* Flunarizine for Hemiplegic Migraine
192
Idiopathic Intracranial Hypertension (Dandy criteria)
* Clinical features if raised ICP: headache, nausea, vomiting, transient visual symptoms, papilloedoema
* No localisation signs (except VI nerve palsy)
* Patient awaike and alert
* No other explanation for raised ICP
* Normal brain imaging
* CSF opening pressure > 25 mm H2O with normal CSF. (modified Dandy criteria 2014)
193
Management of Vaso-occlusive Crisis
Paracetamol PO qds + Ibuprofen PO tds
+ Dihydrocodeine if analgesia given at home within 6 hours)
Ensure good hydration. IV fluids if reduced oral intake
• Cover with broad spectrum antibiotics in presence of fever while screening for infection
194
Acute Chest Syndrome
Peak incidence 2-4 years
• Fever and/or respiratory symptoms with new pulmonary infiltrate on chest X-ray in a child with SCD
• Occlusion of lung microvasculature by sickled cells causing pulmonary infarction , reduction in oxygen tension leading to further sickling.
• Often mutifactorial
• Most common cause in children under 10 years is respiratory viral infection.
• Non infectious causes includes fat embolism, hypoventilation secondary to pain or reduced respiratory drive
195
Management of ACS
All children should admitted to hospital
• Close monitoring with early escalation to HDU/PICU
• Optimal oxygenation, aiming 100% saturations
• Daily FBC UES CRP until stable
• IV fluids
• Physiotherapy
• IV antibiotics according to trust guidelines (ceftriaxone+Clarithymomycin here)
• Anti viral in flu season
• Top up transfusion if Hb <70 ( discussion with haematology) Exchange transfusion in deteriorating patients with severe disease
196
HYPOGLYCAEMIA: <4MMOL/L
• If Blood Glucose <4mmol/L
1. Give 5-15g fast acting carbs
2. Wait 15 mins and re-check blood glucose levels
• If Blood Glucose level still <4mmol/Lrepeat above step 1+2
• If Blood Glucose level is >4mmol/L give longer acting carb if on pen injections
• If Hypo and drowsy give 1⁄2 (<5yrs old) / 1 tube (>5yrs old) of dextrogel/ Glucogel
197
HYPERGLYCAEMIA: >14MMOL/L
* If blood glucose is >14mmol/L on 2 consecutive checks
* Check for ketones. Levels >0.6mmol/L are positive
* Administerinsulinasguidedbysmartmeterorpump
* Repeated episodes raises HbA1c – a marker of longer term control • Longer term complications more likely
198
Risk factors for neonatal sepsis
Risk factors
Mother who has had a previous baby with GBS infection, who has current GBS colonisation from prenatal screening, current bacteruria, intrapartum temperature ≥38ºC, membrane rupture ≥18 hours, or current infection throughout pregnancy
Premature (<37 weeks): approximately 85% of neonatal sepsis cases are in premature neonates
Low birth weight (<2.5kg): approximately 80% are low birth weight
Evidence of maternal chorioamnionitis
199
typhoid treatment
Option include ciprofloxacin if acquired from outside the Indian subcontinent, otherwise ceftriaxone.
200
reyes syndrome - diagnosis
liver biopsy - shows with 'hepatocyte microvesicular steatosis
201
West Syndrome
```
Infantile spasms (West syndrome) is a form of epilepsy which starts around age 4-8 months.
Infantile spasms are is associated with developmental regression and has a high morbidity.
```
202
Benign rolandic seizures
Benign rolandic seizures affect children aged 3-10 and occur almost exclusively during sleep.
benign rolandic seizures, children characteristically have a tonic seizure overnight. This might be noticed by the parents if the child makes noises, or the child falls out of bed.
