General Child Health Flashcards
What is the definition of a febrile convulsion?
A seizure associated with a fever in a child aged 6 months to 6 years in the absence of intracranial infection due to bacterial meningitis or viral encephalitis.
What does ‘failure to thrive’ mean?
Sub-optimal weight gain in infants and toddlers
What is the Apgar score?
Used to assess condition at birth: Appearance (colour), Pulse, Grimace, Activity (i.e. tone), Respiratory effort
In necrotising enterocolitis, what are the characteristic appearances on x-ray?
Distended loops of bowel
Thickening of the bowel wall due to intramural gas
How might a baby with necrotising enterocolitis present?
Stops eating Aspirating milk Vomiting Distention of abdomen Blood in stools
What is the treatment for phenylketonuria?
Dietary restriction of phenylalanine
What are the two different types of presentation of Group B streptococcal infection?
Early onset (within 48 hours of birth) Late onset (at least 1 week after birth)
How does a late onset Group B streptococcal infection usually present?
Presents as a meningitis
How does an early onset Group B streptococcal infection usually present?
Septicaemia, respiratory distress
What are the two types of hearing impairment?
Sensorineural
Conductive
Which type of hearing loss may be present from birth, is often more severe, and may be progressive?
Sensorineural
What is the management of a child with sensorineural hearing loss?
Amplification device
Cochlear implant
What is Kawasaki disease?
A systemic vasculitis characterised by persistent fever and muco-cutaneous involvement
What is the presentation of Kawasaki Disease?
- Persistent fever for > 5 days
- Red mucous membranes
- Rash
- Non-purulent conjunctivitis
- Cervical lymphadenopathy
- Red palms or soles of feet
- Peeling of skin on fingers and toes
Why is Kawasaki disease an important disease not to miss?
It can cause coronary artery aneurysm which is devastating
What is the treatment for Kawasaki disease?
IV immunoglobulin
Aspirin
What is the most common type of cardiac arrhythmia affecting children?
Supraventricular tachycardia
What is the management for supra ventricular tachycardia in children?
- Vagal stimulation by using an ice pack to generate diving reflex (a way of doing vagal stimulation in children)
- IV adenosine
- Most resolve spontaneously within 1 year
- Flecanide
- RF ablation
What is phenylketonuria?
An ‘inborn error of metabolism’ where a lack of phenylalanine hydroxylase in the liver means phenylalanine cannot be converted into tyrosine
What is the pattern of inheritance of phenylketonuria?
Autosomal recessive
What is the treatment for phenylketonuria?
Dietary restriction of phenylalanine
What is medium-chain acyl-coA dehydrogenase deficiency?
Disorder of mitochondrial fatty acid oxidation
What are the red flags in a febrile child?
- Fever >38 degrees in child 39 degrees in 3-6 months
- Pale, mottled, blue appearance
- Signs of meningism e.g. reduced consciousness, neck stiffness, seizures, focal neurology, bulging fontanelle
- Bilious vomiting
- Severe dehydration
- Shock
What is the management of gastro-oesophageal reflux disease in infants?
- Advise parents to feed child in a more upright position
- Thickening agents to feed
- Infant Gaviscon
- Ranitidine
- Domperidone
At what age does pyloric stenosis present?
Infants aged 2 to 12 weeks
True / False: Pyloric stenosis is more common in boys
True
True / False: There is often a family history in cases of pyloric stenosis
True
What metabolic disturbance(s) may be present in pyloric stenosis?
Metabolic alkalosis (due to the loss of acid from the stomach)
Hypochloraemia
Hypokalaemia
How is pyloric stenosis diagnosed?
Suggestive history
Abdominal examination - palpable mass indicative of pylorus
‘Test feed’ shows visible peristalsis
Ultrasound may be used to confirm
What is the surgical management for pyloric stenosis?
Pyloromyotomy
What is the presentation of infantile colic?
Intermittent, inconsolable crying…often accompanied by drawing up of the legs due to pain
What is the most common cause of gastroenteritis in developed countries?
Rotavirus
What might lead you to suspect a bacterial rather than a viral cause for gastroenteritis?
If there is a history of blood in the stool
Give 3 bacterial causes for gastroenteritis in children
Salmonella
Shigella
Campylobacter
How do you assess severity of dehydration?
Use %age body weight lost, together with clinical features, to define whether dehydration is mild, moderate or severe (shock)
What is the maintenance fluid requirement for children?
100ml / kg for first 10kg
50ml / kg for second 10kg
20ml / kg for all kg after that
What triad of features are present in intussusception?
Abdominal pain
Mass in RUQ
Bloody stools ('red current jelly')What is the treatment for intussusception?
- Fluid resus +++
- Rectal air insufflation
- Surgical reduction
What is a Meckel diverticulum and how might it present?
An ileal remnant present in 2% of individuals. May be asymptomatic but may cause severe rectal bleeding.
What is the diagnosis and management of Meckel diverticulum?
Technitium scan will show increased uptake by ectopic mucosa, treatment is surgical resection
What are the parameters required for diagnosing DKA in children?
- Hyperglycaemia (blood glucose > 11.1)
- Presence of ketones in blood (>3mmol/L) or urine
- Acidosis on blood gas i.e. pH
List some organisms which commonly cause meningitis in babies and children
Group B streptococcus E. Coli Listeria monocytogenes Strep pneumoniae Neisseria meningitides Haemophilus influenzae
What is the antibiotic of choice for suspected bacterial meningitis?
IV ceftriaxone 50-80mg/kg (max 2-4g)
What antibiotic could you add if you suspect a meningitis which is caused by Listeria?
Ampicillin
Which cells are affected by a neuroblastoma?
Neural crest cells in adrenal medulla and sympathetic nervous system
What is the most common presenting features of a neuroblastoma?
Abdominal mass Systemic signs e.g. weight loss, bone pain, pallor Proptosis (unilateral) Hepatomegaly Lymphadenopathy
What diagnosis might you suspect in a child with an absent red reflex on ophthalmoscopy?
Retinoblastoma
True / False: Retinoblastoma only ever affects one eye
False - It can be bilateral
What is the most common childhood malignancy, accounting for over 80%?
Acute lymphoblastic leukaemia
What will bone marrow biopsy show in acute lymphoblastic leukaemia?
High levels of blast cells and high WCC
How might a child with acute lymphoblastic leukaemia present?
Signs of bone marrow failure (pancytopenia): Anaemia, fatigue, bleeding, fever, infection
Signs of bone infiltration: Lymphadenopathy, hepatosplenomegaly, orchidomegaly
True / False: Testing for congenital hypothyroidism is done as part of the newborn screening programme in the UK
True
How do you treat congenital hypothyroidism?
Lifelong thyroid hormone replacement with levothyroxine
What is the most common abnormality in congenital adrenal hyperplasia?
21-hydroxylase deficiency
What is the classic presentation of 21-hydroxylase deficiency in males and females
Males = Precocious puberty Females = Masculinisation of genetalia
What is the most common cause of anaemia in childhood?
Iron deficiency anaemia
Give 3 causes of aplastic anaemia in childhood
Congenital red cell aplasia (Diamond-Blackman anaemia)
Transient erythroblastopaenia of childhood
Parvovirus B19 (in children with existing inherited haemolytic anaemia)
What might investigations reveal in aplastic anaemia?
Low Hb, low reticulocytes
Normal bilirubin
Negative Coombs test
Absent red cell precursors on bone marrow examination
What is the inheritance pattern of hereditary spherocytosis
Autosomal dominant in about 75% of cases
What is the treatment for hereditary spherocytosis?
Usually only requires folic acid supplementation as these children have increased requirement for folate due to increased RBC production. Splenectomy is indicated if faltering growth due to anaemia or if severe symptoms.
What is the glucose-6-phosphate dehydrogenase enzyme required for?
Protects RBCs against oxidative damage
True / False: All pregnant women are screened for Hepatitis B infection
True
Which type of cerebral palsy is classically caused by hyperbilirubinaemia (Kernicterus)?
Choreoathetoid (dyskinetic)
List 4 organisms which commonly cause UTIs in children
E. coli
Proteus
Klebsiella
Pseudomonas
What is West syndrome?
Infantile spasms in the first year of life, often associated with generalised organic disease e.g. tuberous sclerosis
What is the triad of features in West syndrome?
Infantile (flexor) spasms
Hypsarrhythmia (chaotic pattern on EEG)
Developmental delay or even regression
What is the treatment for West syndrome?
Steroids or vigabatrin
What is the appearance of an absence seizure on EEG?
3Hz spike and wave pattern
Give some suitable treatment options for a tonic-clonic seizure
Sodium valproate
Lamotrigine
Carbamazepine
For which type of seizures is carbamazepine an inappropriate choice of treatment? Why?
Myotonic
Absence
It can make these seizures worse
Give some suitable treatment options for management of an absence seizure
Ethouximide
Sodium valproate
Lamotrigine
Give some suitable treatment options for management of myoclonic or atonic seizures
Sodium valproate
Levetiracetam
Topiramate
Give some suitable treatment options for management of a partial seizure
Carbamazepine
Lamotrigine
Sodium valproate
Give some viral causes of meningitis
Echovirus
Coxackie virus A and B
Poliovirus
What is opisthotonus? When might you see it?
Arching of back in infant - seen in meningitis
What is given as prophylaxis to the contacts of those with meningitis?
Rifampicin
True / False: Meningitis is a notifiable disease
True
Which type of meningitis is more common, Men C or Men B?
Meningitis B
What are the common causative organisms of bacterial meningitis in infants under 3 months old?
Group B streptococcus
E. coli
Listeria monocytogenes
What are the common causative organisms of bacterial meningitis in the 3 months to 6 years age group?
Neisseria meningitides
Strep. pneumoniae
Haemophilus influenzae
What are the common causative organisms of bacterial meningitis in children over 6 years old?
Neisseria meningitides
Strep. pneumoniae
What is the leading cause of death in infants over 1 week old?
Sudden infant death syndrome (SIDS)
List some risk factors for sudden infant death syndrome
Low socioeconomic class Parents are smokers Male infant Prematurity Co-sleeping Co-existing minor URTI Previous sibling affected by SIDS Winter months
What advice would you give to parents to prevent sudden infant death syndrome?
- ‘Back to sleep’ i.e. lie baby supine when asleep
- Prevent cigarette exposure…ideally by stopping completely!
- Prevent overheating - don’t cover baby too much whilst asleep, avoid heaters / hats etc. whilst asleep, put feet down at the bottom of the cot to prevent blanket migrating down (the face is an important source of heat loss so should be exposed)
What is the most common cause of intestinal obstruction in infants, after neonatal period?
Intussusception
In which paediatric condition might you see a ‘doughnut’ sign on ultrasound?
Intussusception
What is the most common surgical emergency in childhood?
Pyloric stenosis
What causes pyloric stenosis?
Hypertrophy of the pyloric sphincter which causes obstruction of the gastric outlet
How does pyloric stenosis present?
Projectile, non-bilious vomiting after feeds
Baby appears hungry after feeds
Abdominal mass - olive shaped mass in RUQ
Weight loss
Dehydration
What is Hirschsprung’s disease?
Rare, genetic disorder where there is absence of ganglion cells in the myenteric and submucosal plexuses. This results in a narrow, contracted segment of bowel. It always includes the rectum, and extends up proximally from there.
How do you diagnose Hirschsprung’s disease?
Demonstrating absence of ganglion cells in via suction biopsy
What is the management of Hirschsprung’s disease?
Surgical resection of affected segment
Anastomosis of innervated bowel
What is the presentation of Hirschsprung’s disease?
Failure to pass meconium in first 24 hours of life
Abdominal distension
Bilious vomiting
What investigations should be carried out in suspected leukaemia?
FBC
Blood film
Bone marrow aspirate
Chest x-ray to look at mediastinal involvement
May have lumbar puncture to assess CNS involvement
What is the likely result on FBC in acute lymphoblastic leukaemia?
Normochromic, normocytic anaemia
WCC may be low, normal or high
Low platelets
Why is chemotherapy in ALL given to boys for longer than girls?
ALL can remain in the testes so boys need longer treatment course
Give 3 important complications of ALL in children
Bone marrow failure
Neutropenic sepsis
Tumour lysis syndrome
What are the stages of chemotherapy in the treatment for ALL?
Induction
Early CNS protection
Consolidation
Maintenance
List some good prognostic factors in ALL
Age under 10 years old Low WCC at diagnosis Good response to induction chemo Minimal residual disease burden 'Non T cell, non B cell' lineage No translocation mutation
Which type of lymphoma is more common in young children, and which is more common in adolescents / young adults?
Children = Non-Hodgkin’s
Adolescents / young adults = Hodgkin’s
What is the malignant cell type in lymphomas?
Malignant proliferation of lymphocytes
Which is more aggressive / rapidly growing - Non-Hodgkin’s or Hodgkin’s lymphoma?
Non-Hodgkin’s
Which type of lymphoma is associated with Reed-Sternberg cells?
Hodgkin’s lymphoma
True / False: Acute lymphoblastic leukaemia is associated with the Philadelphia chromosome…a mutation in the 9,22 chromosomes
FALSE - This is characteristic of chronic myeloid leukaemia (see in elderly) and NOT ALL.
Describe the presenting features of Hodgkin’s lymphoma
2 peak incidences - Young adults and the elderly
Enlarged, non-tender, ‘rubbery’ superficial lymph nodes (typically cervical)
B symptoms: Night sweats, fever, weight loss, lethargy
How is Hodgkin’s lymphoma diagnosed, and how is the disease staged?
Tissue diagnosis by lymph node biopsy…staging done by CT chest/abdo/pelvis
What is the treatment for Hodgkin’s lymphoma?
Chemoradiotherapy
Why is thyroid hormone important in children?
Neurological development and growth
Give some causes of congenital hypothyroidism
Developmental defect: Thyroid agenesis, failure of thyroid migration
Dyshormonogenesis: Failure of production of thyroid hormones
Maternal iodine deficiency (Most significant worldwide cause)
TSH deficiency due to hypopituitarism (lack of all pituitary hormones)
Give some features of congenital hypothyroidism
Prolonged neonatal jaundice Feeding problems, including failure to thrive Constipation Coarse facial features Protruding tongue Large posterior fontanelle Delayed development Inactivity, sleepiness Hypotonia
Describe a typical insulin regime commenced in children diagnosed with TIDM
Dose: Pre-pubertal = 0.8-1.0units/kg/24hrs, pubertal = 1.5units/kg/24hrs
Give 2/3 before breakfast of long-acting, and 1/3 before dinner of short-acting
What are some symptoms of DKA?
Vomiting Dehydration Kussmaul's breathing Confusion Weight loss Disturbance of consciousness Breath smells of ketones
What is the treatment for cerebral oedema as a consequence of fast fluid replacement in DKA?
Admit to PICU
Hypertonic saline or mannitol
Slow down fluid replacement
What is the management of DKA?
DR ABCDE approach:
- Administer oxygen
- IV access: Take bloods for glucose, venous gas, U+E, ketones
- Fluid bolus of 100mL/kg if patient is shocked
- Calculate amount of dehydration and replace fluids accordingly: Use 0.9% saline + 200mmo/500mL K+
- Replace fluids over 48 hours
- Add insulin replacement when fluids have been running for 1hr: Start with 1unit/mL of Actrapid and run at 0.1units/kg/hr
What is leukocoria?
White pupillary reflex (instead of red) seen in neonates with retinoblastoma
What is immune thrombocytopenic purpura?
Destruction of platelets caused by autoantibody to antigen on the platelet surface
What is the different in presentation in immune thrombocytopenic purpura in adults and children?
Adults: Slow onset, no identified infective cause, requires treatment, chronic / relapsing
Children: Acute onset usually of bruising, usually follows viral infection, usually self-limiting and not requiring treatment
What is the treatment for immune thrombocytopenic purpura?
- Doesn’t require treatment in children unless bleeding as usually self-limiting condition
- Oral corticosteroids e.g. prednisolone (produces response in 60-80% of patients)
- Immunoglobulin infusion e.g. IV IgG
- Splenectomy (because platelets are destroyed in the spleen)
- Thrombopoeitin agonist
- Rituximab
Give 6 red flags for dehydration in infants and children
Appears unwell Decreased responsiveness Sunken eyes Decreased skin turgor Tachycardia Tachypnoea
What key points would you focus on in a history of a child with acute gastroenteritis
Eliciting level of dehydration
What percentage of weight loss corresponds to mild dehydration in children?
Less than 5% weight loss
What percentage of weight loss corresponds to moderate dehydration in children?
5-10% weight loss
What percentage of weight loss corresponds to severe dehydration in children?
More than 10% weight loss
What is the diagnostic blood test result in congenital adrenal hyperplasia?
Raised plasma 17-hydroxyprogesterone
What is the inheritance pattern of congenital adrenal hyperplasia?
Autosomal recessive
