Extra Paediatrics Flashcards
Which vaccinations should be given below 2 months old? (4)
- 6 in 1
- Rotavirus
- Meng B (2 doses)
- Pneumococcal PCV
Which vaccinations should be given at 1 years old? (4)
- HIB/ Men C
- MMR (1st dose)
- PCV (2nd dose)
- MenB (3rd dose)
Which vaccinations should be given at 3.5 years old? (2)
- MMR (2nd dose)
- 4 in 1 pre-school booster
Which vaccination should be given between 2 and 10 years old?
Flu vaccine every year
Which vaccination should be given between 12 and 13 years old?
HPV
Which vaccinations should be given at 14 years old?
- Meningitis ACWY
- 3 in 1 teenage booster
What does the 6 in 1 vaccine protect against?
Diptheria
Hepatitis B
Haemophilus Influenza B (HIB) (acute epiglottitis)
Polio
Tetanus
Whooping Cough (pertussis)
What does the 4 in 1 vaccine protect against?
Diptheria
Tetanus
Polio
Whooping Cough
What does the HPV vaccine protect against?
Human Papillomavirus Strains: 6, 11, 16 and 18
What does the 3 in 1 teenage booster protect against?
Diptheria
Tetanus
Polio
What are the contraindications to vaccination?
Acute, febrile illness
Allergies to ingredients
Immunodeficiency/compromised - don’t give if primary immunodeficiency or on steroids
BUT GIVE ALL VACCINATIONS EXCEPT TB IF HAVE HIV
Can live vaccinations be given together?
Yes, live vaccines should be given together OR separated by > 3 weeks
Describe the rash seen with measles (4)
Morbiliform
Erythematous and maculopapular, can become confluent.
Starts specifically behind ears and then spreads to body
Kloplik’s Spots
Describe the onset of the rash seen with measles
- Prodromal Phase = 10-14 days after exposure
Kloplik’s Spots at end of prodromal phase
Symptoms for 2-4 days before rash
For how long should a child with measles be kept off school?
5 days after onset of rash
What are the other features associated with measles? (3)
Fever above 39 degrees
Coryzal symptoms
Conjunctivitis
What is the management of measles? (4)
Supportive as self limiting
Avoid contact with vulnerable people e.g. pregnant
Notifiable disease
MMR vaccine for prevention
What are the complications of measles? (4)
Otitis Media
Pneumonia
Encephalitis
Febrile seizures
How does mumps present?
Parotid swelling, usually bilateral
Prodromal malaise
Fever
What is the management of mumps?
Supportive as self limiting
MMR vaccine
What are 3 potential complications of mumps?
- Orchitis +/- infertility
- Arthritis
- Pancreatitis
Describe the rash associated with Rubella
Pink, maculopapular
Initially on face then spreads to body then fades after 3 days
What is the onset of the rash associated with Rubella?
2-3 weeks after infection
Rash lasts 5 days normally
How long should a child with Rubella be kept off school for?
4 days after rash appears
What are the associated symptoms of Rubella?
Arthralgia
Suboccipital and postauricular lymphadenopathy
Coryzal symptoms
What is the management of Rubella?
Supportive
Notifiable disease
MMR Vaccine
Avoid pregnant women + contact tracing
Avoid contact with vulnerable people
What is the triad of complications seen with Rubella?
Heart disease (PDA)
Congenital cataracts
Sensorineural hearing loss (triangle on a baby
Describe the rash associated with Varicella Zoster?
Chickenpox
Small macules over head, trunk and proximal limbs
Becomes vesicular and is ITCHY
Then crusts over
What is the onset of the rash associated with varicella zoster?
Has a prodrome
Rash progresses over 12-14 hours
Crusting = 5 days after onset
What is the management of varicella zoster virus?
Manage symptoms e.g. calamine lotion/chloramphenamine if >1yo
Oral Aciclovir if >14 yo
What is the causative organism of scarlet fever?
Group A Streptococcus
Describe the rash associated with scarlet fever?
Erythematous, blanching rash on abdomen and chest
Punctate, rough and sandpapery
Particularly visible in skin folds
Describe the onset of the rash associated with scarlet fever
Rash appears 12-48 hours after initial symptoms
What are the other symptoms of scarlet fever?
Strawberry tongue
Cervical lymphadenopathy
Pharyngitis
Fever (<38.3)
What is the management of scarlet fever?
Notifiable disease
Phenoxymethylpenicillin (GAS)
Symptom management
What is the causative organism of hand, foot and mouth disease?
Coxsackie A16 Virus
Describe the rash seen with hand, foot and mouth disease
Ulcers within the oral cavity
Macules and papules on dorsum of hands and heel margins
Describe the onset of the rash seen with hand, foot and mouth disease
Prodrome of 12-36 hours
Mouth ulcers come first
Hands and feet follow
What are the associated symptoms of HFMD?
Sore throat
Low grade fever
What is the management of HFMD?
Supportive
Can attend school (enterovirus as faecal-oral)
Describe the rash seen with Parvovirus B19?
Erythematous
Looks like ‘slapped cheek’
What is the onset of the rash associated with parvovirus B19?
Prodromal phase = 2-5 days
Rash lasts 1-2 weeks
What are the associated symptoms with Parvovirus B19?
- Myalgia
- Low grade fever
- Runny nose
What is the management of Parvovirus B19?
Supportive
Avoid pregnant ladies
Follow up for FBC (susceptible individuals at risk of aplastic anaemia – get pancytopaenia)
What is the causative organism of Roseola Infantum?
Human Herpes Virus 6
Describe the rash seen with Roseola Infantum
Cranial erythema (like a halo)
Erythematous and maculopapular and on trunk.
Describe the onset of Roseola Infantum
Fever appears then goes away and then gets rash = often misdiagnosed
What are the associated symptoms of Roseola Infantum?
Really, really hot >40 – RoseohmygoditsHOT
Febrile seizures are v common
What are the management and complications of Roseola Infantum?
Supportive management
Encephalitis is a complication and can use antivirals in this case
What is the main complication of scarlet fever to be worried about and why?
Post-strep glomerulonephritis (most common cause of AKI in kids)
Can be caused by any group A strep
If a child has urinary symptoms ask about recent infections
What is other main complication of scarlet fever and how is this managed?
Rheumatic fever and therefore acquired valvular disorders
Give empirical abx (pen v)
What is the Jones’ Criteria for Rheumatic Fever?
J oints = Arthritis
O (heart) = Cardiac Disease
N odules = rheumatic
E rythema Marginatum (target rash)
S yndenhams Chorea ( sudden onset jerky movements and confusion)
What is a worrying complication of Parvovirus B19 in vulnerable individuals and why?
Can cause aplastic crisis
Affects reticulocytes (RBC precursor cells)
Bad for SCD/thalassaemia/haemaglobinopathy/G6PD as knocks out reticulocytes
Why should children infected with parvovirus B19 avoid pregnant women?
Can cross the placenta and infect susceptible babies = miscarriage
When should premature babies be vaccinated?
Should receive their routine vaccinations according to chronological age; there should be no correcting for gestational age.
Born prior to 28 weeks gestation should receive their first set of immunisations at hospital due to risk of apnoea.
Define a febrile convulsion
A single, tonic-clonic, symmetrical and generalised seizure lasting <15mins
Peak age is 6 months - 5 years
Why do febrile convulsions occur?
↑temperature, usually during the early stages of a viral infection.
There is no intracranial infection
Child is otherwise normal but there is a 1-2% chance they will go on to develop epilepsy
What advice should be given to the parent of a child who has had a febrile seizure?
Reassurance
Advice to give paracetamol/ibuprofen early in illness
Advice to put child in recovery position
Still drowsy after 1 hour is not normal and requires medical attention
What is the acute management of a epilepsy in children?
Lasts > 5mins = emergency ambulance
OR
Buccal Midazolam as rescue therapy if the seizure lasts >5mins and has been recommended by a specialist.
Then wait 10 mins and call an ambulance after if hasn’t stopped
What is a reflex anoxic seizure?
Seizure following cyanosis due to high emotional stimulation (provoked) ⇢ breath holding
Sleep for ~30 mins after and usually grow out of
Which cancer is most common in children?
Acute Lymphoblastic Leukaemia
Which children are more at risk of ALL?
Trisomy 21/Down’s syndrome
What is the typical epidemiology of ALL in children?
Affects children of all ages but the main peak is between 2-5 years old
Boys > Girls
Describe the clinical presentation of ALL in children
Insidious presentation and depends on where is infiltrated:
Differential Diagnosis
Bruising = ITP, trauma, non-accidental injury
Recurrent infections = immunocompromised
Lymphadenopathy = Reactive + hx of infection
Pancytopenia = other malignancy or aplastic anaemiaGeneral = fatigue and malaise
Bone Marrow =
Bone Pain
Pancytopenia
Anaemia = pallor
Neutropenia = ↑infections
Thrombocytopenia = epistaxis, brusing, petechiae
Reticulo-Endothelial System - precursors settle in these tissues
Hepatosplenomegaly
Lymphadenopathy
Give 4 differentials for ALL and how they might present
Bruising = ITP, trauma, non-accidental injury
Recurrent infections = immunocompromised
Lymphadenopathy = Reactive + hx of infection
Pancytopenia = other malignancy or aplastic anaemia
Which blood tests should be done if ALL is suspected?
FBC
Pancytopenia: low Haemaglobin (anaemia), WBC (neutropenia) and platelets (thrombocytopenia)
OR Anaemia + lymphocytosis
Blood Film
Presence of blast cells
What imaging/invasive tests should be done if ALL is suspected?
Bone Marrow aspirate is needed to diagnose
CXR - exclude a mediastinal mass (may obstruct airway)
LP is CNS is involved
What is the acute management of ALL in children?
Stabilise patient - blood transfusion, abx, platelets
?TLS protection
?Steroids if mediastinal mass present
What is the long term management of ALL in children?
Combination Chemo + steroid
Supportive care - platelets + red cells
Prophylactic antifungals - prevents Pneumocystis Pneumonia
Why give Allopurinol/Rasburicase in tumour lysis syndrome?
Rapid cell lysis = hyperuricaemia
Allopurinol prevents Uric Acid formation by acting on Xanthine Oxidase so prevents hyperuricaemia SO prevents kidneys from rapid cell lysis
Rasburicase = urate oxidase so converts uric acid to allantoin = more easily excreted
Define hypersensitivity
The objectively reproducible symptoms or signs following exposure to a specific stimulus at a dose that is tolerated by a normal person
What are the 4 types of hypersensitivity reaction and the antibodies that mediate them
I = A - Acute or Allergy. IgE mediated
II = B - AntiBody - IgG or IgM mediated
III = C - immune Complex (depositions of antibody-antigen complexes)
VI = D = Days/Delayed - Cell-mediated by T cells and Macrophages
Define allergy
A hypersensitivity reaction initiated by specific immunological mechanisms leading to disease.
Can be IgE mediated or non-IgE mediated
Define atopy
A personal or familial tendency to produce IgE in response to ordinary exposure to potential allergens
Define anaphylaxis
A severe, potentially life threatening generalised or systemic hypersensitivity reaction.
The onset is rapid and has a multi system involvement (airway/breathing/ circulation + skin/mucosal changes)
Give 4 examples of IgE mediated allergies
Anaphylaxis
Urticaria
Acute Asthma
Acute Rhinitis
Give 3 examples of non-IgE mediated allergies
Coeliac Disease
Contact Dermatitis
Dermatitis herpetiformis
Describe the main differences between IgE and non-IgE mediated allergies
IgE = Acute onset + fast resolution with SPECIFIC symptoms
Non-IgE = Longer onset post ingestion, symptoms are NON-SPECIFIC
How does a food intolerance occur?
No immunological mechanism behind it
Lack of enzyme to digest
Sensitivity to additives e.g. sulphites
Psychological stress response to a certain food
What happens during sensitisation (first stage of allergy timeline)?
Antigen taken up by APCs (macrophage or dendritic cell) and presented to T cellss
T cells become TH2s and release interleukines
ILs activate Eosinophils and cause B cell class switching to produce specific IgE
IgE can attach to mast cells
What happens during the early part of the second stage of the allergy timeline?
IgE attaches to mast cells = degranulation
Histamine, protease/tryptase and leukotriene release
What happens during the late part of the second stage of the allergy timeline?
TH2, eosinophils and basophils etc are recruited to the site of exposure
More immune cells are therefore attracted even after the allergen has gone
What are the long term investigations for allergy?
Bloods
Skin Prick Test
Immunoassay - Western Blot/ELISA that are specific for IgE
What is the long term, conservative management for allergy?
Patient/Parent = Allergy Education (avoidance of food/cross allergens) and an Allergy Plan/ ID
Clinician = Risk Assessment and consider an Adrenaline Auto-Injector (AAI)
+ give information on biphasic response*.
Give info on support websites
Involve dietician and allergy nurse
What is the long term medical management for allergy?
Adrenaline Auto-Injector
Immunomodulation/glucocorticoids?
What is the MOA for adrenaline during anaphylaxis?
QISS QIQ
At normal concentrations, adrenaline has a higher affinity for β2 adrenoceptors than for α1 receptors
At higher concentrations i.e. therapeutic dose it also activates α1
This causes:
Bronchodilation via stimulation of B2 adrenoceptors
Vasoconstriction (and therefore increasing BP as peripheral vascular resistance increases) via stimulation of A1 adrenoceptors
Give 3 indications for adrenaline
Anaphylaxis/angioedema +/- circulatory involvement
Acute hypotension
Can be nebulised for treatment of Croup (if not managed with corticosteroids)
Give 4 indications for 1 Adrenaline Auto-Injector
Allergy to high risk foods e.g. nuts (does this mean you????)
Previous Hx of anaphylaxis
Idiopathic anaphylaxis
Moderate - severe asthma + food allergy
Give 5 indications for a second Adrenaline Auto-injector
Moderate - severe asthma + food allergy
Can’t get to hospital easily e.g. live very rural
Have concurrent mast cell disease
Previous history of anaphylaxis + more than 1 dose adrenaline needed
Previous near death anaphylaxis
When should a child with a fever be admitted? (5)
Temp >38
> 5 days in duration
<3 months
Non-blanching rash
Bulging fontanell
What characterises nephrotic syndrome?
Triad of:
Proteinuria
Hypoalbuminaemia
Oedema
What is the most common cause of nephrotic syndrome in children?
Minimal change glomerulonephritis
+ hyperlipidaemia + hyper coagulable state + predisposition to infections
What is the most common cause of hypothyroidism in children?
Autoimmune thyroiditis
What are the Fraser guidelines?
Guidelines that are used to assess if a patient who has not yet reached 16 years of age is competent to consent to treatment, e.g. contraceptions
What are the 5 components of the Fraser guidelines?
- Understands professional advice
- Can’t be persuaded to inform parents/professional can inform parents
- Likely to begin/continue to have sex anyway regardless
- Physical/mental health will suffer without the contraception
- Best interests require the contraception
Does a 16 year old person have capacity to consent?
Yes if 16+
under can also have capacity if they can understand what is involved
What happens if the parent does not consent but the child (~14-16) does consent?
Do what the child wants but get it in writing
What happens if a competent child does not consent to treatment?
The person with parental responsibility/the court can authorise the treatment if it is within the best interests of the child (unless you’re in Scotland but good thing you aren’t)
What is the pathophysiology of a slipped upper femoral epiphysis?
Growth of the femur occurs at the end of the bone around the developing cartilage surrounding the growth plate (physis = metaphysis = widened shaft + epiphysis = end of bone)
SUFE = epiphysis is displaced posteroinferiorly and therefore moves off the physis which is weaker and underdeveloped
How does a SUFE normally present?
Fat boys aged 10-16
Normally unilateral but 20% = bilateral
Pain in: Hip, ant thigh, groin +/- knee
Loss of internal rotation
Stable can usually weight bear but unstable cannot
What is the difference between a stable and unstable SUFE?
LODER classification
stable = can walk with or without crutches unstable = cannot walk no matter what + higher risk of complications
What are the complications of a SUFE?
Epiphyseal slip progresses = early osteoarthritis
Avascular necrosis of the femoral head
Malunion = poor growth?
What is the pathophysiology behind perthes disease?
Interruption of the blood supply to the femoral head leading to avascular necrosis
Some self healing after initial ischaemia and subsequent remodelling of the bone = distortion and abnormally shaped epiphysis
Leads to abnormal ossification
Describe the blood supply to the femoral head
Intracapsular = medial femoral circumflex
Extracapsular = ?
What are the investigations and definitive treatment of a SUFE?
Ix = Frog leg lateral x-ray of BOTH hips
Tx = Surgery. Internal fixation of the affected hip
What is the presentation of Perthes’ Disease?
Boys aged 3-11
Usually unilateral but 15% are bilateral
Pain = hip, knee + limp. Pain is worsened by activity and relieved by rest
Limited internal rotation and abduction
What is the management of Perthes’ Disease?
Hip Xray - widening of joint space + reduced femoral head that is also flattened
Self limiting so just focus on symptom reduction
What is osteomyelitis and what is the pathophysiology in children?
Infection within the bone that either spreads:
Haematogenously (acute) e.g. staph aureus, GBS, E. Coli, Secondary to nearby infections/vascular disease or directly from trauma/surgery e.g. staph aureus
Pus lifts the periosteum which interrupts blood supply leading to the formation of necrotic fragments
What is the most common causative agent of osteomyelitis in children with sickle cell disease?
Salmonella
Which bones are more at risk of osteomyelitis?
Highly vascular ones e.g. long bone metaphases like the distal femur
What is the presentation of osteomyelitis?
Gradual pain + warm, swollen erythematous joint
+ systemic signs of infection
What are the investigations for osteomyelitis?
Bed - baseline obs for A to E
Bloods - FBC, blood culture, CRP
Imaging - Diagnosis confirmation = MRI but changes don’t show for ~12 days
What is the treatment for osteomyelitis?
Conservative
Medical = 6 weeks of abx! Vancomycin + Cefotaxime until culture is known
Surgical = abscess drainage/removal of sequestra
What are the causes of anaemia in children that have a LOW reticulocyte count?
Parvovirus B19 (slapped cheek) so do serology
Diamond Blackfan (v v v v v rare) BM aspirate?
What are the causes of anaemic children that have a HIGH reticulocyte? How can they be further classified?
Raised bilirubin = haemolysis (Membrane disorder = h. spherocytosis, Enzyme disorder = G6PD, Haemaglobinopathy = SCD, thallassaemia)
Normal bilirubin = Blood loss (acute = fetomaternal, chronic = VWB, Meckels), Impaired production = Fe/Folate - coeliac/IBD/B12 - vegan mother deficiency)
What are the risk factors for anaemia in children?
NM = Age (adolescent females), a baby from a multiple pregnancy
M = Delayed intro of iron containing foods, poor diet (poverty, veganism), preterm, LBW
What is the management of anaemia in children?
Oral Fe supplements for 3 months
Max 200mg per day in 2-3 divided doses
Don’t take with milk/tea/eggs/chappatis
Take with OJ as vitamin C increases iron intake
What is the definition of Idiopathic Thrombocytopenic Purpura?
A type of thrombocytopenic purpura defined as an isolated LOW platelet count with a NORMAL bone marrow in the absence of other causes of low platelets.
Platelets are destroyed by IgG
What are the definitions of mild, moderate and severe thrombocytopenia?
Mild = Platelet levels between 50-150 Moderate = 20-50 + increased risk of bleeding in surgery or trauma Severe = <20 + increased risk of spontaneous bleeding
What is the usual presentation of ITP?
Age 2-10 years
1-2 weeks after a viral illness
Petechiael rash/purpuric/bleeding/bruising/epistaxis
V rarely = intracranial haemorrhage
What are the investigations that should be done for a child presenting with ITP?
Mainly a clinical diagnosis but want to rule out ALL
Bloods = FBC and blood film to rule out malignancy. Also serology e.g. viral, autoimmune, Anti-platelet if non-accidental injury suspected
BM aspirate if abnormal signs/steroids part of management
What is the treatment for acute ITP?
Conservative = self limiting but avoid NSAIDs and contact sports as these prevent platelet aggregation. Give 24hr access to hospital
Medical = Oral prednisolone/IV Anti-D/ IVIG if significant bleeding or affecting QOL
What is the treatment for chronic ITP?
Counted as low platelets after 6 months
Screen for SLE and follow medical management
What is Henoch Schonlein Purpura? What type of hypersensitivity reaction is it?
An acute immune complex-medicated reaction (small vessel vasculitis) so is type 3 hypersensitivity
What is the common presentation of HSP?
Rash = purpuric + blanching
Arthralgia = usually knees/ankles
Abdominal pain
More common in girls
Preceding URTI
What are the bedside and blood tests to investigate HSP?
ESR, U&E (renal involvement is common), IgA
Urinalysis = proteinuria
BP
What is the management of HSP?
Self limiting so supportive
Can give steroids but not usually
Important thing is detection and prevention of CKD so need follow up urinalysis for ~8 weeks
How could a migraine present in a child?
Bilateral/frontal headache lasting 1-48hr
Nausea and vomiting
any 2 of photophobia, phonophobia, visual/sensory aura, +/- vertigo/abdo pain
Made worse by physical activity
What is the acute management of migraine in a child?
Paracetamol/Ibuprofen
Domperidone for nausea or sumatriptan if >12
WHAT IS the prophylactic management of migraine in a child? When would this be started?
3 month trial of pizotifen then propranolol if that doesn’t work
Disrupting school/social activity on a regular basis
also work on stress management/sleep/triggers
