MCQS Flashcards
Does fever reduce length of illness in children?
Yes
Fever is thought to be a generally
beneficial adaptive response that promotes the immune response and inhibits the invading pathogen, potentially
reducing the duration of certain infections
What % of children with fever will have an identifiable source?
80%
Can teething cause a fever >38.5?
NO
What % of children <5yo with fever have a serious bacterial infection and which ones are they?
7.5%
Of this:
3.4% UTI
3.4% Pneumonia
**0.4% bacteraemia
**0.1% Meningitis
Bacteraemia causes: osteomyelitis | septic arthritis | cellulitis | bacterial enteritis etc.
What non-bacterial diagnoses can present with fever in children?
Kawasaki disease
Vaccination reactions
Arthritis
Connective tissue disorders
Malignancies
Drug fever
Inflammatory bowel disease
What % of infants <3 months with fever have a serious bacterial infection?
7-25%!
What are common pathogens for infants <3 months?
Group B strep
E. Coli
HSV
Listeria
What are the empiric antibiotics for neonatal sepsis?
<2 months of age
BENPEN 60mg/kg IV
Cefotaxime 50mg/kg IV
What antibiotic should be added to routine sepsis treatment if there is evidence of umbilical infection?
<2 months of age
Flucloxacillin 50mg/kg
Suspect staph aureus
What are the empiric antibiotics for neonatal sepsis suspected to be from an abdominal source?
<2 months of age
Ampicillin 50mg/kg
Metronidazole 15mg/kg
Gentamicin 5mg/kg
What are the common pathogens in sepsis in children >2 months?
Strep pneumoniae
Neisseria meningitidis
Staph Aureus
Group A strep
What are the empiric antibiotics for sepsis in infants/children?
> 2 months
Ceftriaxone 50mg/kg
Flucloxacillin 50mg/kg
What change would you make to the empiric antibiotics for sepsis regimen in infants/children who return a normal CSF result on LP?
> 2 months
Remove ceftriaxone
Add gentamicin 7.5mg/kg
List some risk factors for MRSA in Australia?
Aboriginal and Torres Strait Islander or Pacific Islander child
Recent travel/live in NT or remote QLD
Previous colonisation with MRSA
Which antibiotics could you substitute for flucloxacillin if there was concern for MRSA or the patient had a penicillin allergy?
Vancomycin 15mg/kg
Clindamycin 15mg/kg
Trimethoprim/sulfamoxazole 4/20mg/kg BD
“Pain unlocks a secret doorway in the mind, one that leads to both peak performance, and beautiful silence.”
Who said this?
David Goggins
What are the target trough levels for gentamicin(pre-third dose) and vancomycin?
Gent = <1mg/L
Vanc = 15-20mg/L
What is the concomitant UTI rate in infants < 3months with bronchiolitis?
5%
What is the % of bacteraemia for UTI patients <3months?
50%!
Name some paediatric risk factors for serious bacterial infection
Congenital immune deficiency syndrome
Indigenous demographic
Sickle cell
Asplenia
Cancer
Nephrotic syndrome
Intracranial shunt
HIV
What CRP levels in children represent a 70% and 5% risk of serious bacterial infection and when should it be taken?
At least 12 hours AFTER first fever
CRP > 80 = 70%
CRP < 20 = 5%
What is the concomitant serious bacterial infection rate with a positive viral swab?
7%
Mostly UTI (hence CRP < 20 being 5% risk = better test but harder to perform)
What are the difference between normal neonatal and infant LP results?
What is the sensitivity of the “step-by-step” score in infants < 3 months and what are the criteria?
99% rule out serious bacterial infection
NOT “ill-appearing” including normal WOB
>21 days old
No leukocyturia
Procalcitonin <0.5
CRP <20
The astute amoung you will realised how utterly useless this is given procalitonin is not a widely available test so until it is you can’t use this. Also the infant/neonate has to appear completely well : /
List methods of urine capture in infants from most to least sensitive
In/out catheter (lowest failure rate)
Suprapubic aspirate (20-90% success)
Clean catch
Bag urine
Most kids and parents can manage a clean catch
What are the NICE guidlines for starting antibiotics in neonates/infants based on urine dipstick?
Start antibiotics IF:
Nitrates & leukocytes +
Only Nit +
Do a urine MCS if:
Only Leuk +
Leuk/nit -ve = look elsewhere
According to NICE when should antibiotics be started for UTI based on urine MCS results?
Start Abx if:
Pyuria & bacteruria +
Only bacteruria +
Only Pyruria + (if they clinically have a UTI)
PYURIA MAY BE ABSENT IN EARLY UTI IN VERY YOUNG CHILDREN
Pyuria = WBCs
Bacteriuria you can see the bugs ennit
When should a UTI be considered pyelonephritis in an infant?
Fever >38
Unwell
Malaise
Vomiting
Loin tenderness
What are common UTI pathogens <2 months and >2 months
<2 months :
E.coli
Klebsiella
> 2 months:
E.coli!
Proteus
Enterobacter
Morganella
Serratia
(PEMS lol)
What antibiotics should be given for UTI + pyelonephritis in children?
RCH guidelines:
Cefalexin 33mg/kg PO BD 3-7 days (max 500mg)
Pyelo = 45mg/kg oral TDS 7-10 days (max 1.5grams)
UTI sepsis = gent and benpen (60mg/kg)
List 3 risk factors for UTI in children
Constipation
Failure to thrive
Vesico-ureteric reflux
These are just the ones from the NICE guideline. Im sure there’s plenty more
List features associated with atypical UTI
NON E.coli organisms
Treatment failure after 48 hrs
Seriously ill e.g. sepsis
Poor urine flow
Abdo or bladder mass
Raised creatinine
What is the definition of recurrent UTI?
> 3 episodes of cystitis
OR
2 episodes of pyelo
OR
1 cystitis + 1 pyelo
What imaging is required in children with UTI under 6 months
Normal UTI = ALL get USS at 6 weeks
ATYPICAL or RECURRENT:
Acute phase USS
PLUS MCUG and DMSA (4-6 months post)
Normal UTI = responds to therapy within 48 hours
What imaging is required in children with UTI 6 months - 3 years
Normal UTI = No imaging
Atypical = acute USS + DMSA
Recurrent = 6 week USS + DMSA
Normal UTI = responds to therapy within 48 hours
What imaging is required in children with UTI >3 years
Normal UTI = no imaging
Atypical = acute USS only
Recurrent = USS 6 weeks
Normal UTI = responds to therapy within 48 hours
What is HUS?
Haemolytic uraemic syndrome
The most common cause of AKI in children
Non-immune, coombs negative microangiopathic haemolytic anaemia with thrombocytopaenia
What are the two types of HUS?
Shiga-toxin HUS (90% cases)
E.coli O157 produces shiga
0-4 yo
75% have diarrhoea
85% will recover renal function with supportive care
Non-shiga HUS (10% cases)
Mostly adults: sporadic or familial
Strep Pneumonia = 40%
Other causes: drugs | malignancies | antiphospholipid | pregnancy
HIGH mortality rate (25% in acute phase)
What are some complications of HUS?
- Renal failure
- Stroke
- Coma
- Seizures
- Bleeding
- Chronic hypertension
50% of non-stx HUS patients develop ESRD
What investigations for HUS?
MAHA
Thrombocytopaenia
Coombs negative (no autoantibodies)
Positive O157 stool/blood culture
Low ADAMST13 (cleaves vWF)
What are differentials for HUS?
- Disseminated Intravascular Coagulation
- Malignant Hypertension
- Pediatric Antiphospholipid Antibody Syndrome
- Preeclampsia
- Thrombotic Thrombocytopenic Purpura (TTP)
What are treatments for HUS?
STX-HUS:
Supportive
Renal transplant (5-10% recurrence)
Non-STX HUS that is NOT strep pneumonia driven:
plasma exchange
AND
Eculizumab
Renal transplant not an option in non-stx HUS due to high recurrence rate
plasma exchange worsens strep pneumonia HUS
becaudse adult plasam contains antibodies against the Thomsen-Friedenreich antigen
What is the definition of paediatric hypoglycaemia?
<3.3mmol/L
<2.6mmol/L = severe
What is the most common cause of hypoglycaemia in children?
Ketotic hypoglycaemia
RCH calls it “accelerated starvation”
Diagnosis of exclusion
What are paediatric causes of hypoglycaemia by age other than sepsis/T1DM complication?
Sepsis + T1DM all ages
Neonate <72hrs: PREM | IUGR | diabetic mom | perinatal asphyxia
72-hrs - 2 years: Congenital hyperinsulinism | inborn erros of metabolism | Gh deficiency
> 2: Accelerated starvation | hypopituitarism | GH deficiency
Adolescent: insulinoma | adrenal insufficiency |
TOXIN ingestion: sulfonuylureas | EtOH | beta-blockers | Aspirin
Congenital hyperinsulinism = most common cause in age group
What is the treatment for severe hypoglycaemia with reduced GCS?
2ml/kg of 10% dextrose stat
THEN
Full maintenance
Neonate: 10% dextrose 60mls/kg/day
Child: 10%Dex/0.9% NaCl
No IV access = IM glucagon
<25kg = 0.5 units
>25kg = 1 unit
Replace deficit if dehydrated as well (add to maintenance)
4:2:1 ml/kg 0-10, 0-20, >20 kg rule
How do you calculate paediatric fluid deficit?
Weight x % dehydration + 10
(add to full maintenance 24hr requirments)
E.g. 30kg, 5% dehydration = 30 x 5 + 10
What are the discharge criteria for neonates and infants?
Neonates: >2.6 for 3 consecutive feeds
Infants/children: >3 4 hrs post meal
Discharge them with a glucose gel if unclear
What is a “sick day” plan for a child who’s had a hypoglycaemia?
When sick: pause normal diet and:
1 - 4 yo
10% carbohydrate solution for meals
> 4 = 15%
> 12 = 20%
What is included on a hypoglycaemia panel?
Insulin and c-peptide
FFAs
Carnitine
Ammonia
GH
Cortisol
Amino acids
What causes high c-peptide?
T2DM
Cushings
Insulinoma
Sulfonylureas
What causes low c-peptide?
T1DM
Insulin therapy
Diuretics
Addisons
Palpable pulses paradoxus if present in which severity of asthma?
Severe & life-threatening
What are the four best indicators of asthma severity on examination?
General appearance
Mental state
Activity level
Work of breathing: RR | recession | tug
What is the main difference in treatment of moderate asthma in the 1-5 age group vs >6?
> 6 give 1mg/kg of steroids
What is the treatment for life-threatening asthma?
Life-threatening = B2B nebs, severe i.e. can still inhale MDIs
Learn this
Ciclesonide instead of fluticasone is cheaper, once daily and has lower side effect profile
What features are consistent with a simple febrile seizure?
6months - 6 years
Generalised tonic clonic seizure <15mins
No signs of CNS infection
Complete recovery within 1 hour
No recurrence within same illness
Whats the seizure treatment guideline?
> 5 mins, new dose every 5 minutes
Midazolam 0.15mg/kg IV/IM (x2 for buccal)
Repeat midaz
Leviteracetam 40mg/kg Levit-er-forty-am
Phenytoin 20mg/kg (Phenytwenty)
Phenobarb 20mg/kg Phwends (same dose)
Thiopentone or Propofol 2.5mg/kg then 1-3mg/kg/hr if ready to intubate
GIVE pyridoxine 100mg if refractory
Always check BSL!
Pyridoxine for the rare pyridoxine dependent epilepsy
What are important acute side effects of AEDs?
Respiratory depression
Negative inotropes (monitor BP)
Arryhthmogenic
What disadvantages does diazepam have versus midazolam in seizures?
Can’t give IM
Longer half-life (for assessing neurology and d/c)
What are the main differences when treating neonatal seizures?
Give anticonvulsants if:
> 3minutes
> 2-3 seizures/hr
All should get a CT head to exclude ICH
List neonatal anti-seizure medication in order of effectiveness
Clonazepam 0.2mg IV (total)
Phenytoin 20mg/kg
Phenobarbitone 20mg/kg
Clonaz = 90-100%
phenytoin = 85%
Phenobarbitone = 70%
What are common causes of neonatal seizures?
Hypoxic ischaemic encepahlopathy (50%)
Cerebral infarction
Cerebral trauma
CNS infection
Narcotic drug withdrawal
Hypoglycaemia
Most to least common
HIE most common
What are the 3 main neonatal differentials for seizures?
Seizures/infantile spasms
Jitteriness
Benign neonatal sleep myoclonus
Infantile spasms = 3-7 months is peak: clusters of flexor/extensor spasms (can be head nodding)
Jitteriness = Stimulus sensitive symmetrical movements of hands and feet that stop when limb held
BNSM = Bilateral or unilateral jerking during sleep
What are the 4 main types of neonatal/infant seizures?
Subtle: oral (chewing sucking/lip smacking), cycling/rowing, apnoea
Clonic: one limb or one side 1-4beats/second
Myoclonus: Focal or multifocal muscle jerking
Subtle = includes infantile spasms
Clonic = assoc with ICH/CVA
Myoclonic = drug withdrawal
Tonic = sustained posturing of the limbs
What’s the treatment of infantile spasms?
10mg QID for 1 week then wean if seizures persist
Increase to 20mg TDS if persisting
What is the treament of tuberous sclerosis seizures?
Vigabatrin
GABA transminase inhibitor (increases GABA)
What are the risk factors for severe bronchiolitis?
Gestational age <37 weeks
Corrected age <10 weeks
Failure to thrive
Indigenous ethniticity
Breast feeding for <2months
Congenital heart disease
What are 2 types of benign jaundice and when do they occur?
Physiological (>24hrs - 10 days)
Breast milk jaundice (5-14 days)
Physiological = higher conc of RBCs and shorter lifespan = increased bili
Breast = B-glucornidase in breast milk = increased deconj and reabsorption of bili
What are the two types of pathological jaundice and when do they occur?
Jaundice within 24 hrs (always pathological)
Prolonged jaundice or ONSET of jaundice >10 days
There will be pathological jaundice within 24hr-10day group but physiological most common
Why is hyperbilirubinaemia an issue in neonates?
Causes kernicterus: staining on basal nuclei
Encompassess acute and chronic bilirubinaemia
Acute = Hypotonia/lethargy/irritability/poor feeding
Chronic = Developmental delay/hearing deficit/parinaud’s sign/intellectual impairment
What is parinaud’s sign?
Upward gaze paralysis
Lid retraction
Nystagmus
Tectal plate lesion - think MS in adult
What are the 4 main risk factors for severe hyperbilirubinaemia?
Gestational age <38wks
Exclusive breast feeding
Jaundice within first 24 hours
Previous sibling requiring phototherapy
What are the risk factors for neurotoxicity in jaundice?
Preterm
Rapid rate of rise in bili
Hypoalbuminaemia
Sepsis | asphyxia | acidosis
Ultrasound in shocked infants secondary to trauma is useful?
“Doesn’t change outcomes”
Exam answer
The study quoted for this MCQ was on the PEM revision course was on 975 haemodynamically stable patients!!!! Also not indicated in adults looool
