Intro Week Lectures 1 Flashcards
How do you calculate a child’s bladder capacity?
Up to 12 yrs old
(Child’s Age + 1) x 30
What can cause a neuropathic bladder in kids?
spinal cord injury
brain injury / nerve damage
spina bifida
bladder extrophy - protrusion of bladder through defect in abdominal wall
cloacal malformation - ‘common channel’
What are the sxs of neuropathic bladder in kids?
UTI
Kidney stones
Urinary incontinence
Frequency + urgency
Small urine vol during voiding
Dribbling
How can a neuropathic bladder be managed?
intermittent catheterisation
suprapubic catheter
Mitrofanoff
- A tube created using the appendix or small intestine which connects the bladder to the surface of the skin
Give some structural urological problems that may be seen in kids
vesico-ureteric reflux - ureter goes straight through bladder wall instead of at an angle = retrograde flow of urine = severe / frequent UTIs
uterocele - distal ureter balloons at opening into bladder forming a sac - can cause obstruction
PUJ obstruction - (1/1500 children)
Posterior urethral valves (PUV) - extra membranes cause narrowing of urethra in boys, often spotted at antenatal USS
Give some signs and sxs of PUV
Delayed urination
Weak stream / difficulty urinating
Palpable bladder
Urosepsis
Lethargy and poor feeding
UTIs
How can PUV be investigated?
micturating cystourethrogram
Mx of PUV?
catheterisation
mx of any UTI / fluid imbalance
cystoscopy and valve ablation
regular assessment of kidney function, growth and bladder training
What can cause urinary incontinence in kids?
constipation
reduced drinking
neuropathic bladder
structural urological problems
holding / delaying access to toilet
ADHD / autism
OverActive Bladder (OAB) causes a frequent and sudden urge to urinate that may be difficult to control. It may present with incontinence in children.
What can cause it?
Constipation
Reduced drinking
Certain drinks - artificial juices, caffeine (bladder irritants)
Holding / delaying toileting
UTI’s
An underactive bladder is also known as detrusor underactivity which is a bladder that has a contraction reduced in strength or duration.
What sxs may this present with?
Prolonged time required to PU
Frequency / Urgency
Requiring to double void
Needing to wait for the flow to start
What can cause underactive bladder in kids?
Bladder outlet obstruction (PUV)
Neurological disorders
Spinal cord injuries
Sxs of UTI in kids?
Dysuria
Nocturia
Frequency/urgency
Abdominal pain
Fever
Cloudy/dark urine
Causes of UTI in kids?
Constipation
Dehydration
Withholding urine
Reflux
Increased bladder pressure
Give some causes of nocturnal enuresis in kids
Small bladder (inability to hold a large amount of urine)
No awareness of a full bladder
Ongoing Constipation
Stress at school or home
Poor daytime toilet habits
How can nocturnal enuresis be managed in kids if lifestyle modification does not work?
enuresis alarm
desmospressin
What ix can you do for a child with urological problems ?
Physical exam – abdominal palpation (bladder distention, Faecal loading)
Renal scans – USS +XRAY
Uroflowmetry
* Uroflow measures the vol of urine released from the body, the speed at which it is released and how long it takes to release
MAG3
* A MAG3 Renogram scan is used to assess the structure and location of the kidneys and to check how well they are working
DMSA
* Identifies the shape of the kidney and how well its functioning
Urodynamics
* Identifies how well the bladder can hold and release urine.
General lifestyle advice for children with urological problems?
Treating underlying constipation
Drinking plenty
Accessing the toilet every 2-3hrs
Sitting and relaxing the bladder
Avoid withholding/delaying
Define asthma
a disease that includes the symptoms of wheeze, cough and breathing difficulty together with reversible airways obstruction, airway inflammation and bronchial hyper-responsiveness.
It demonstrates variability
Define wheeze
Continuous musical (whistling) sound , usually expiratory
Due to oscillation of opposing airway walls that are narrowed
◦ Bronchospasm
◦ Swelling of mucosal lining
◦ Excessive secretions
Give some causes of wheeze in children
Asthma
Respiratory infections - often viral infections
* Bronchiolitis
* Bronchiolitis obliterans
* LRTI
Excess secretions
* CF
* Ciliary disease
Airway abnormalities
* Bronchomalacia
* Chronic lung disease of prematurity
Foreign body inhalation
What is spirometry?
Physiological test
– Records volume/flow of air over time
There are three distinct phases to the forced exhalation manoeuvre as follows:
1) maximal inspiration
2) a ‘‘blast’’ of exhalation
3) continued complete exhalation to the end of test
How do you carry out bronchodilator reversibility testing?
4 puffs of salbutamol (100mcg) via spacer/MDI
Repeat spirometry after 10-15 minutes
Increase in FEV1 of ≥12% is positive
How would you instruct a child on how to do a FeNo test?
What classes as a positive test?
Empty lungs
Close lips around mouthpiece
Inhale deeply until full
Exhale slowly (over 10 secs) through filter at constant pace “keep cloud within limits”
≥ 20ppb = positive test in kids
What increases a child’s risk of an acute asthma attack?
Previous attacks
Over-reliance on SABA (relative to ICS)
Smoke exposure
Raised FeNO
Low FEV1
Key steps in the mx of an acute asthma attack?
ABC
Oxygen to keep saturations 94% and above
SABA - inhaled – (5 puffs) or nebulised
Ipratropium bromide
Corticosteroids (oral, IV)
ICU if severe
Questions to ask yourself to determine if a child has asthma?
Is there airway obstruction?
Is it variable?
Do they respond to asthma medication?
How can you monitor how well controlled a child’s asthma is?
- Asthma control tests
- SABA use
- Time off school
- Exercise limitation
- Daytime/nighttime symptoms
What are the key side effects of asthma medications in kids?
Steroids
* Height, adrenal suppression
Montelukast
* Sleep disturbance, aggressive behaviour
What plan should be made upon discharge for a child who has had an asthma attack?
Check inhaler technique
(Update) Personalised written asthma action plan
Ask family to make appointment with GP within 2 working days
What is the long term mx of recurrent viral wheeze?
Encourage parents to stop smoking
IV treatment or ICU admission = treat
More than 4 hospital admissions/year or frequent need for oral CS = trial of treatment
SABA / anticholinergic via a spacer
intermittent LTRA, intermittent ICS
Commonest cause of recurrent viral wheeze?
rhinovirus - type C
What ix are useful for a child with suspected foreign body obstruction?
CXR: expiratory film - because obstructed lung cannot empty properly and will remain hyper inflated
if CXR unclear - have to do bronchoscopy
Are corticosteroids helpful for pre-school wheeze?
not generally
How can you manage rhinitis with post natal drip in kids?
steroid nasal spray and antihistamines
Define neonate
Define infant
neonate - first 28 days of life
infant - first 12 months of life
Common causes of vomiting after feeds?
reflux - GORD
CMP allergy - may also have rashes, problems with stool
Causes of recurrent abdo pain with normal test results in kids?
constipation
RAPS- recurrent abdo pain syndrome (psychosomatic)
abdominal migraine
What location of pain is suggestive of RAPS?
periumbilical - with tummy pain due to stress, kids tend to point at their belly button when asked where it is, a very localised pain that is not central makes a dx of RAPS less likely
Define acute cough
What can cause this in kids?
recent onset of cough lasting < 3 weeks
Infection – viral, bacterial
non-infective – foreign body, irritant toxin
Define subacute cough
What can cause it in kids?
also known as ‘prolonged acute cough’
3-8 weeks duration
Post viral cough – (can persist for 3 weeks following resolution)
Pertussis and similar infections
Children recovering from complicated pneumonia
Define chronic cough
What can cause it in kids?
a cough lasting > 8 weeks
Persistent bacterial bronchitis (PBB) - dx of exclusion
Rhinitis and post-nasal drip
GORD
Recurrent aspiration - NM weakness
Bronchiectasis
Cystic fibrosis
Define persistent / protracted bacterial bronchitis
1) Presence of wet cough (>4 weeks’ duration)
2) absence of symptoms or signs (i.e. specific cough pointers) suggestive of other causes
3) cough resolves following a 2–4 week course of an appropriate oral antibiotic i.e. co-amoxiclav
Define bronchiectasis. How is it diagnosed?
Abnormal dilation and distortion of the bronchial tree
dx with High Resolution CT - signet ring sign
What can cause bronchiectasis in kids?
Cystic fibrosis
Ciliary dyskinesia
Post infectious
Immunodeficiency
Aspiration
Mx of bronchiectasis in kids?
Prophylactic Abx
Physiotherapy
Aggressive treatment of LRTI
Nutrition
Regular monitoring, inc. lung function
Define recurrent cough
> 2 episodes of cough / year not associated with specific illness
When should you consider CXR in a child with a cough?
suspicion of lower respiratory infection, persistent/non resolving cough, haemoptysis or features of chronic disorders
Most common cause of CAP in children?
viral - RSV
Mx of CAP in children?
Non-severe – oral antibiotics (amoxicillin) for 5 days
Severe – IV (amoxicillin or cefuroxime) antibiotics
When would you consider pneumonia in a child to be ‘complicated’?
Parapneumonic effusion (pleural fluid collection in association with underlying pneumonia)- transudate/ exudate
Empyema (the presence of pus in the pleural space)
How should you manage complicated pneumonia in a child?
Antibiotics (long course)
Chest drain + Intrapleural fibrinolytic agents (urokinase)
VATS (video assisted thoracoscopic surgery)
What initial investigations might you do for a child with chronic wet cough?
Spirometry + Bronchodilator reversibility
Microbiology of respiratory tract – sputum/ induced sputum (if possible), swab
CXR
Sweat test, pancreatic function
Immune function testing – immunoglobulins, functional antibodies, allergy markers e.g. IgE and eosinophils
Primary ciliary dyskinesia results in the lack of effective ciliary motility, causing abnormal mucociliary clearance. What clinical features does it present with?
Chronic wet cough
Sinusitis/ rhinitis, persistent nasal discharge
Situs inversus (40-50% - kartagener syndrome)
Associations- congenital heart lesions, asplenia, hydrocephalus, renal disease
How is primary ciliary dyskinesia diagnosed?
Ciliary studies
Nasal nitric oxide
How can sleep disordered breathing be investigated in kids?
Polysomnography (gold standard)
- Respiratory effort, nasal flow/pressure analysis, EEG for sleep staging
What can cause obstructive sleep apnoea in kids?
Obesity
Adenotonsillitis, Allergic rhinitis,
Down syndrome, craniofacial syndromes, mps, neuromuscular disorders
Complications of NIV in kids?
Pressure sore
Dry nose/mouth/conjunctivitis
Rhinitis
Increased flatulence (swallowing air)
Complications of invasive ventilation in kids?
Loss of humidification system, thick secretions
Loss of natural defence, recurrent chest infection
Tracheostomy related effects e.g. granulations
