GP paediatrics Flashcards
Red flags for jaundice in newborns
If not eating well
Hard to wake
More yellow than expected
Not urinating frequently
Mongolian spots
Common birthmarks that look like bruises
- painless
- eventually fade
- common on bottom, legs and back
- caused by a difference in skin colour and can range in size
Erythema toxicum
common in newborns 2 - 3 days after birth
- red and raised initially
- on face, legs and arms
- normal
- not hot to touch
- fades in a few days
Milia
Tiny white bumps on noe
- fade by itself
- on forehead, cheeks, nose and chin
Newborn dry skin
Normal, as was covered by placenta in vitro
Cradle cap
Like dandruff - scales on baby’s scalp
Resolves by itself
Appears in first several weeks
If severe can be treated
Baby acne
2 - 3 weeks of age due to hormones
- harmless and wont cause scarring
- keep area clean with warm water
Heat rash - prickly heat
If baby overheating
On neck, armpits and diaper area
May itch
Control temperature
Eczema
Environmental allergens and triggers
- itchy rash
- dry skin
- mostly on scalp, elbows, knees, diaper area and trunk
Treatment of eczema in newborns
Apply vaseline to prevent dryness
If severe - weak hydrocortisone
Sore or crackled nipples
Commonly caused when baby does not latch on in the correct position
- seek advice from midwife
- continue to use both nipples
Not enough breast milk mx
- Offer baby both breasts at each feed and alternating starting breast helps stimulate milk production
- exclusive breastfeeding recommended for 6 months
Signs baby is getting enough milk
- Wet and dirty nappies are good indication baby is feeding well
- Baby lets go by itself
- can hear swallowing
- mouth is moist
- baby gains weight
Breast engorgement
Breast gets too full of milk can be due to:
- producing more milk than baby requires
- milk duct blockage - feel small lump
- Mastitis
- breast abscess
Presentation of breast engorgement
Breast feels hard, tight and painful
Can occur when first starting to breastfeed
May occur when baby is older and eating solids
Breast engorgement mx
Express a little breast milk by hand
Use a well fitted breast feeding bra
Warm flannels on breast just before
Paracetamol (don’t use NSAIDs)
Milk duct blockage mx
Feed from the affected breast
Gently massage lump towards the nipple while baby is feeding
Warm flannel
Mastitis symptoms and tx
Symptoms:
- fever and flu symptoms
- hot and tender
- red and painful patch
- achy, tired and tearful
Breast abscess
Can be caused by untreated mastitis
Tx - drainage
Thrush presentation
Pain in both breasts
After period of pain-free breast feeding
Pain last up to 1 hour after a feed
Creamy white plaques on tongue, gums and roof of mouth of baby
Baby may have persistent nappy rash
Head lice presentation, risk factors and management
Presentation:
- itchy scalp - feels like something is moving
RF:
- Schools
Investigations:
- Use lice comb - find live lice
- check everyone in household
Management:
- Wet comb on days 1, 5, 9 and 13
- Apply lots of conditioner
- Medicated lotions and sprays
- cannot prevent lice, not due to hygiene
Colic presentation and management
Presentation: When baby cries a lot due to unknown cause
- Cries fro more than 3 hours a day, 3 days a week for more than 1 week
- hard to settle baby
- clench fists
- goes red
- brings knees to tummy or arches back
- windy and tummy rumbles
Mx :
- hold or cuddle when crying a lot
- wind baby after feeds
- hold upright during feed
- bathe in warm bath
- rock baby
Weaning
When introducing first solid foods alongside breastfeeding or formula milk after 6 months
- start with fruit and veg
- small amounts
- mashed, lumpy food
- progress to carbs and meats
- avoid ready-made food with added salt and sugar (bad for kidneys)
- wean when can sit up in high chair and hold head steady
- when can put spoon in mouth
Gait abnormalities
Antalgic gait - caused by pain, can be due to juvenile idiopathic arthritis (JIA)
Circumduction gait - excessive hip abduction as leg swings forwards.
- can be due to leg length discrepancy with stiff joint i.e. JIA or unilateral spasticity
Spastic gait: stiff foot-dragging with inversion, in UMN, disease
Ataxic gait - instability with an alternating narrow to wide base, cerebral palsy
History of newborn
Establish parent’s concerns (ICE)
Detailed pregnancy, birth and development hx
FHx
Vaccinations
When does walking delay require investigation
Beyond 18 months
Measles
Partially confluent dark red rash
Starts behind ears and spreads to rest of body
Koplik’s spots - white patches in mouth
Conjunctivitis
Scarlet fever
Fine, light red, confluent rash On face, armpits and groin Begins on neck Non-blanching petechiae Strawberry tongue - bright red tongue with papillae
Rubella
Non confluent
pink
Begins behind ears and extends to rest of body
Erythema infectiosum
Asymptomatic
may not develop rash
red patches may develop on body and limbs
Slapped cheek syndrome
Roseola infanctum
Patchy
Rose pink
More pronounced on torso
3 days fever followed by sudden decrease in temperature
Chickenpox rash - varicella zoster
Widespread rash
Small lumps develop into pustules and form scabs
Different stage of blister formation
Highly contagious
Chickenpox presentation and mx
Symptoms:
- nausea
- myalgia
- malaise
- loss of appetite
Conservative:
- Fluid intake, keep nails short
- avoid pregnant women and newborns
- Paracetamol
- Chlorphenamine - treats itch
If immunocompromised:
- aciclovir
Croup presentation
Presentation:
- sudden onset, seal - like barking cough
- accomponied by stridor and intercostal indrawing
- URTI symtpoms e.g. fever and cough present for 12 - 48 hrs
- hoarse voice
Moderate/ severe:
- lethargy and fatigue
- pallor/ cyanosis
- decreased level of consciousness
Croup severity
Mild – seal-like barking cough
Moderate – seal-like barking cough with stridor and sternal recession at rest
Severe – seal-like barking cough with stridor and sternal/intercostal recession associated with agitation or lethargy.
Impending respiratory failure – increasing upper airway obstruction
- sternal/intercostal recession
- asynchronous chest wall and abdominal movement
- fatigue
- pallor or cyanosis
- decreased level of consciousness or tachycardia.
- RR over 70 breaths/minute
When to admit croup pt to hospital
Moderate/ severe illness, or impending respiratory failure.
Croup mx
If mild:
Pharmacological:
- 1 dose of oral dexamethasone (0.15 mg/kg) taken immediately
- Should resolve in 48 hours
If severe +:
- Give controlled supplementary oxygen whilst waiting for hospital admission
- a dose of oral dexamethasone (0.15 mg/kg).
- OR inhaled budesonide (2 mg nebulised as a single dose)
- OR intramuscular dexamethasone
Croup
laryngotracheobronchitis synptomatic due to upper airway obstruction
Bronchiolitis
- commonly affects infants less than 12 months up to 2 years
- caused by respiratory syncytial virus, of the epithelial lining of the lower bronchial tree
- Infected epithelial cells slough off into the small airways and the alveolar spaces.
- mucus and sloughing causes obstruction of the small airways
- Impaired gas exchange leading to hypoxia and breathlessness
Viral induced wheeze
Considered in children between the ages of six months and five years with wheezing associated with infection only
Ix:
- PEFR
- Obs
Mx:
- assess severity
- if not severe - self limiting
- can give a SABA via a large-volume spacer to relieve acute symptoms. Give a puff every 30–60 seconds, up to 10 puffs
Symptoms of bronchiolitis
Coryzal prodrome - due to inflammation of mucous membranes
Fever
Cough
Dehydration
Followed by:
- tachypnoea
- wheeze
Bronchiolitis mx
Self limiting - symptoms peak between 3 - 5 days
- paracetamol
- fluids
6 week baby check
- History
- Inspect
- Head
- shape, fontanelles and suture lines
- eyes - ophthalmoscope
- mouth - cleft
- ears - Chest
- clavicles
- auscultate
- HR and RR
- oxygen saturation - abdomen
- femoral pulses
- resp movements
- shape - External genitalia
- Limbs , hips and back
- all digits
- grasp reflex
- hips dysplasia
- spine - Reflexes
- moro’s reflex - sudden loud noise
- stepping reflex
APGARS
Screening tool for general health at birth
Hayfever
Common allergy to pollen
Seasonal rhinitis - spring/summer
Sx:
- sneezing
- rhinorrhoea
- itchy eyes
- itchy nose
Tx:
- Avoid allergens
- Antihistamine - non sedative (cetirizine)
Threadworm summary
- Common parasitic worm which infests the gut
- White and thread like, can be found in stool
- Transmission via faeco - oral route
Sx:
- Perianal itching
- worse during night
Tx:
- anti-helminthic - mebendazole
- dose may need to be repeated in 2 weeks if infection persists
- Children under 6 months and pregnant/breastfeeding women - treated with hygiene methods alone
GORD summary
- Passage of gastric contents into the oesophagus
- Reflux is common in under 1 yo
- Physiological in infants if asymptomatic
- Does not usually need investigation or treatment
- Mx - advising and reassuring patients
When to suspect GORD
Distressed behaviour
- excessive crying
- crying while feeding
- adopting unusual neck postures.
- Hoarseness and/or chronic cough.
- A single episode of pneumonia.
- Unexplained feeding difficulties i.e. refusing to feed, gagging, or choking.
- Faltering growth
Pharmacological management of GORD
Gaviscon® Infant
if not better after 1 - 2 weeks - 4-week trial of liquid proton pump inhibitor
Functional constipation summary
Fewer than 3 complete stools per week in children
Type 3/4 stools - semi soft
sx:
- straining
- pain
- blood due to hard stool
Mx: Conservative: - increase fibre - fruit and veg - increase fluid intake - increase activity - bowel diary
Pharmacological:
- laxatives
Red flags for constipation
Constipation appearing from birth or during the first few weeks of life — may indicate Hirschsprung’s disease
Delay in passing meconium for more than 48 hours after birth, in a full-term baby
Abdominal distention with vomiting — may indicate intestinal obstruction
Family history of Hirschsprung’s disease.
Ribbon stool pattern — may indicate anal stenosis (more likely to present in a child younger than 1 year of age).
Leg weakness or motor delay — may indicate a neurological or spinal cord abnormality.
Faecal impaction
A history of severe symptoms of constipation.
The presence of overflow soiling.
Faecal mass palpable on abdominal examination
Tx - initially increases soiling
- macragol - movicol
- 2nd line - senna
Hirschsprung’s disease
Pathophysiology : absence of parasympathetic ganglion cells in the myenteric and submucosal plexus of the rectum
Presentation:
- Abdominal distention
- failure of passage of meconium within the first 48 hours of life
- repeated vomiting
Older infants:
- chronic constipation that is resistant to the usual treatments (daily enema may be required)
- Rare - soiling and overflow incontinence.
- Early satiety, abdominal discomfort and distension
- Poor nutrition and poor weight gain.
Ix:
- Bloods WCC - may be raised if enterocolitis
- AXR
- Rectal biopsy - gold standard
Mx: surgery
Osgood Schlatter summary
Pathophysiology: apophysitis of the tibial tuberosity that causes anterior knee pain during adolescence and is usually self-limiting
Causes: repetitive strain on patella tendon ( common in active children undergoing growth spurt.g. football)
Presentation:
- unilateral but can be bilateral
- gradual onset
- worse with activity
- tender over tibial tuberosity
Mx:
- Analgesia
- exercise modification
Eczema (atopic dermatitis)
chronic, itchy, inflammatory skin condition that is episodic
- normally flexor distribution (in infants, can be extensor)
- atopy
Eczema Tx
Mx: - corticosteroid - emollient - antihistamine for pruritis Mild - mild topical corticosteroid i.e. hydrocortisone 1% continue 2 days after controlled
Moderate:
- betamethasone valerate 0.025% or clobetasone butyrate 0.05%
Severe:
- betamethasone valerate 0.1%
Infective exacerbation: flucloxacillin
Perthe’s disease
Pathophysiology: idiopathic ischaemia and subsequent necrosis of the femoral head
Presentation:
- no history of trauma
- limited hip rotation and limp
- typically unilateral
- systemically well
Ix:
- FBC and ESR.
- Early X-rays may show widening of the joint space or may be normal. Seen later
- Technetium bone scan or MRI scanning can be used to identify pathology
Mx:
- Restriction of activities and weight-bearing until ossification is complete
- Physiotherapy
- NSAIDs can be prescribed for pain relief.
- Operation if 6 + yo
