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Paediatrics > Miscellaneous > Flashcards

Miscellaneous Flashcards

1
Q

Osgood-Schlatter Disease

A

Traction Apophysitis of the tibial tubercle
Inflammation at patellar tendon insertion on tibial tubercle
- Occurs in late childhood and early adolescence
- More common in boys ?Sport activity
- Bilateral in 1/3rd of cases
- Worse when going through vertical deceleration (jumping or running) or climbing up stairs
- Clinical diagnosis. No imaging required.
- Tenderness and lump on palpation to tibial tubercle.

Treatment
- Quadriceps strengthening exercises
- Taping or protective sleeve worn over knee
- Ice packs to reduce pain or inflammation post-activity
- Modification of patient activities

Pain goes away when growth is finished. Conservative management between 6-18 months with average of 12 months

Lump may remain prominent and can cause discomfort when kneeling.

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2
Q

Croup

A

Laryngotracheobronchitis
Inflammation of upper airway (larynx, trachea, bronchi) usually triggered by a virus
6/12 - 6yo
Often worse at night

Differential - Think of other causes of upper airway obstruction such as - Inhaled foreign body, bacterial tracheitis, anaphylaxis

Assessment - Minimal examination. Do not examine throat. Do not upset child.
- Barking cough, inspiratory stridor, hoarse voice, increased work of breathing.

  • Severity - Mild/Mod/Severe
  • Review behaviour, stridor, resp rate, accessory muscle use, oxygen saturations (check sats only in severe croup)
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3
Q

Pharmacological management of croup

A

Mild / Mod
- Dexamethasone 0.15mg/kg PO once only
- Prednisolone 1mg/kg PO once only (RCH says 2 days)
- Oral not possible? Budesonide 2mg NEB BD up to 2 days

Severe
- Nebulised adrenaline 0.5ml/kg 1:1000 to max 5mL undiluted
PLUS
- Dexamethasone 0.6mg/kg (Max 12mg) IM/IV/PO

Life threatening
- Nebulised adrenaline + 15L/min non-rebreather + Systemic corticosteroids.

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4
Q

Concerning potential causes of crying in babies

A

Raised intracranial pressure
Non-accidental injury
Incarcerated inguinal hernia
Urinary tract infection
Hair tourniquet
Corneal foreign body / abrasion

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5
Q

Scarlet Fever

A

Group A Strep Pyogenes infection with creation of erythrogenic toxin.
Common between 5-15 yo.

Prodrome - Malaise, sore throat, vomiting
Exanthem - Circumoral pallor, strawberry tongue, Punctate, red ‘boiled lobster’ skin appearance that feels like sandpaper with prominence in axillae, cubital fossae, groin - Lasts for about 5 days.

Investigation
- Throat swab for culture of GAS

Management
- Phenoxymethylpenicillin 500mg (15mg/kg) PO BD x 10 days.
- Rural? Benzathine benzylpenicillin up to 1.2million units IM once only,.

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6
Q

Erythema toxicum neonatorum

A

Common condition affecting half of all full-term neonates
- Most prominent Day 2 and can last up to 2 weeks
- Erythematous macule, papules and pustules.

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7
Q

Management of Pinworm

A

Mebendazole 100mg PO single dose
Albendazole 400mg PO single dose

Halve both doses if patient < 10kg

Consider treatment of all household contacts and repeat treatment in 2 weeks.

Non-pharmacological
- Wash hands, Avoid scratching around the anus, keep fingernails short, take a shower or bath daily, wash clothing, towels and linen in hot water.

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8
Q

Diagnostic criteria for Kawasaki Disease

A

Fever lasting at least 5 days combined with at least 4 of 5 of following
- Bilateral bulbar conjunctivitis
- Oral mucous membrane changes (fissured lips, injected pharynx, strawberry tongue)
- Peripheral extremity changes - Erythema on palms and soles, oedema of hands, periungual desquamation
- Polymorphous rash
- Cervical lymphaedenopathy (at least 1 lymph node > 1.5cm diameter)

Differential Diagnosis
- Scarlet Fever
- ARF
- Bacterial Tonsillitis
- EBV
- Adenovirus
- Drug reaction
- JIA
- Stevens-Johnson Reaction

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9
Q

Management of Kawasaki Disease

A

IVIg - Ideally within 10 days of symptom onset
- Note: Delay live vaccines for 11 months post IvIg as reduced immune response.

Aspirin 3-5mg/kg PO OD until normal echo. Minimum 6 weeks
- Be mindful of possibility of Reye Syndrome

Prednisolone 2m/kg PO OD for minimum 5 days - Evidence for this is limited. Consider in consultation with specialist

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10
Q

Differential diagnosis of Kawasaki disease

A

GAS infection (tonsillitis, scarlet fever, acute rheumatic fever)
EBV
Adenovirus
Systemic juvenile idiopathic arthritis
Sepsis
Stevens-johnson syndrome
Drug reaction

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10
Q

Enuresis - Non-pharmacological management

A

Consider treatment at 6 years of age
- Manage constipation
- Encourage regular fluids and toileting during the day
- Eliminate caffeinated beverages in the evening
- Bedwetting alarm system

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11
Q

Enuresis - Pharmacological management

A

Desmopressin 120microg subling Nocte

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12
Q

Adrenaline dose in anaphylaxis

A

Adrenaline 1:1000 0.01ml/kg (Max 0.5.ml) IM . Repeat if nil response after 5 minutes.

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13
Q

Constipation - Non-pharmacological management

A

Positioning with footstool
Sit on toilet for up to 5 minutes 3 times a day. Ensure toileting remains a positive experience
Exercise
Review toilet access availability
Increase dietary fibre
Do not recommend change in fluid intake in children

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14
Q

Constipation - Pharmacological

A

Infants < 1/12 - Coloxyl drops
Infants 1/12-12/12 - Movicol, Osmolax, Lactulose
Children - Paraffin oil
Vaseline for anal fissures

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15
Q

Live vaccines

A

Japanese Encephalitis (Imojev)
MMR
MMRV
Rotavirus (Oral)
Varicella
Zoster
BCG
Typhoid (Oral)

Re-administration if required after mistake should occur at least 28 days after initial immunisation to reduce risk of interference from interferon on subsequent doses

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16
Q

Optimal times for surgical intervention of children’s surgical disorders

A

Tongue tie - 3-4months or 2-6 years
Cleft lip - < 3 months
Cleft palate - 6-12months
Undescended testes - 6-12months
Inguinal hernia (6-2 rule) for days/weeks/months
Femoral hernia - ASAP
Hydrocoele - 12 months
Umbilical hernia - 4 years
Squint - 12-24 months
Ear deformity - 6yo+

17
Q

Common Differential for Childhood hip pain and limping

A

Toddler (0-4 year)
- Transient Synovitis
- Acute myositis
- Developmental Dysplasia of the hip

Child (5-10 years)
- Transient synovitis
- Acute myositis
- Developmental dysplasia of the hip
- Perthes disease

Adolescent (>10 years)
- Stress fractures or sprains
- Traction apophysitis of tibia (Osgood Schlatter disease), or calcaneus (severs disease)
- Slipped upper femoral epiphysis

Red flags
- Symptoms > 7 days
- History of trauma
- change to urinary or bowel habit
- Nocturnal pain
- Fever, night sweats, chills
- Weight loss / lethargy / anorexia
- Petechiae or purpura

18
Q

Concerning differentials for limping or non-weight bearing child.

A

Infection (Osteomyelitis, septic arthritis)
Trauma
Non-accidental injury
Malignancy (Bone, soft tissue)
Rheumatological (Reactive arthritis, idiopathic juvenile arthritis, vasculitis
Haematological - Haemophilia
Intra-abdominal or genitourinary - Appendicitis, ovarian or testicular torsion

19
Q

Imaging considerations for limping or non-weight bearing child

A

Xray Pelvis AP or frog leg - DDH, SUFE, Perthes
US Hip - Drainable effusion for ?septic arhritis
Bone scan or MRI ?Osteomyelitis / cancer

19
Q

SUFE Klein Line

A

On Xray Pelvis. Line along superior aspect of neck of femur should transect the epiphysis. If this does not occur, can diagnose SUFE

20
Q

Phimosis in children

A

Non-retractable foreskin is normal variant and needs no intervention.
Foreskin should never be forcibly retracted for cleaning
Red flags to consider - Urinary retention, swollen penis, pain
- Retractabiliy
- 10% of boys by 1 year
- 50% of boys by 10 years
- 99% of boys by 17 years

Treatment in children if indcated
- topical betamethasone 0.05% TDS x 6-12 weeks

21
Q

What is HEEADSSSS

A

Social history review of child or adolescent.

Home
Education and Employment
Eating and Exercise
Activity
Drugs, Alcohol and Smoking
Sex and relationships
Self-harm, depression and self-image
Safety and abuse
Spirituality

22
Q

Chronic diarrhoea > 6/12 of age

A

Coeliac Disease?
- Screen with serum IgA-tTG (Immunoglobulin A to tissue transglutaminase) + Serum IgA

Functional Diarrhoea
- Daily painless, recurrent passage of >=4 large, unformed stools, symptoms > 4/52, No failure to thrive
- Can sometimes be caused by excessive intake of osmotically active carbohydrates (apple, prune, pear, sorbitol, fructose)
- Restrict above to 35-50% of total daily calories.

Giardiasis
- Review if international traveller.

23
Q

Indications for Abx therapy in AOM

A
  • ATSI
  • < 6/12
  • Bilateral infection < 2yo
  • Systemically unwell (lethargy, pain, irritability)
  • Otorrhoea present
  • Immunocompromised
24
Q

Thyroglossal Duct Cyst

A

Midline neck mass at level of thyrohyoid membrane
- Non-tender mass within 2cm of midline.
- Moves with swallowing and protrusion of tongue.
- Most have some degree of infection or inflammation present.

25
Q

Approach to Short stature in children

A

Differential
- Constiutional Delay
- Familial Short stature
- Pathological causes in 15% of cases
- Growth hormone deficiency
- Hypothyroidism
- Malnutrition
- Intrauterine growth retardation.
- Chronic systemic disease
- Congenital adrenal hyperplasia
- Genetic (Turner, Syndrome)

  • Consider blood testing if child is significantly short relative to their family or is growing slowly.
  • Random growth hormone is not useful due to pulsatile nature of secretion. Test with plasma insulin-like growth factor 1 (IGF-1)
    • Cushing Syndrome

Consider specialist referral if:
- Height is below 1st percentile
- Significantly shorter than expected in context of parental height
- Growth velocity is abnormally low.

Mid-parental height measurement is indication of child’s final adult height.

For boy - (father+ mother + 13 )/2
For girls - (father + mother - 13)/2

26
Q

Slipped Upper Femoral Epiphysis

A

Displacement of capital femoral epiphysis from metaphysis
- Characterisation
- Stable or unstable (unable to weightbear even with crutches)
- Acute, Chronic (Progression of symptoms > 3 weeks.)
- Risk
- M > F, Mean age 13.5 years for bys and 12 for girls
- Weight (95th percentile) have 50% of cases.
- Can happen bilaterally in 20-50% of cases.

Clinical presentation
- Antalgic gait.
- Out-toeing and shortening of affected limb.
- Obligatory external rotation and abduction during flexion of the hip.
- Vague pain in groin, thigh or knee

Ix
- Pelvic xray, cross-table lateral x-ray in acute slip, frogleg lateral xray in chronic slip (Frog-leg can disrupt vascular supply to head of femur in acute slip)

Complications
- Osteonecrosis in 50% of unstable SUFE even with treatment
- Chondrolysis
- Osteoarthritis
- Femoral acetabular impingement

Treatment
- Make non-weightbearing to reduce likelihood of further slippage.
- Urgent review by Ortho to discuss internal fixation with in-situ pinning of the hip.

27
Q

Vulvovaginitis

A

Symptoms
- Itchy vaginal area
- Some discharge
- Redness of skin between labia majora
- Dysuria

Increased likelihood in female children as lining of vagina and vulva are thin and can be easily irritated.

Risk factors
- Tight clothing
- Obesity
- Irritants - Soap residue, bubble baths, antiseptics
- Concomitant threadworms

Management
- Loss cotton underwear / Avoid tight jeans
- Maintain healthy weight
- Avoid use of soap in bath or shower. / Ensure vulva is well-rinsed
- Vinegar sitz baths 15mins daily for a few fays
- Sudocreme use daily

28
Q

Straddle Injuries

A

Impact to genital area in children.
- In pre-pubertal females, genital tissue is friable with excellent blood flow. Minor injury can cause bleeding

History questions to ask
- Mechanism of injury
- Timing and setting of injury
- First aid provided
- Inability to pass urine or faeces
- Other injuries
- Witnesses
- Consider if injury is consistent with history or if there is suspicion of NAI

Management
- Sitz bath
- Avoid strenuous activity for 24 hours (re-injury minimisation)
- Minimise direct pressure to area
- Ice pack to minimise swelling.
- Analgesia
- Ibuprofen / Paracetamol
- Topical anaesthetic cream.

Non-minor injuries?
- Ongoing bleeding, laceration borders not visualised, labia minora tear, unable to void, clinical concern
-> Admission to hospital under paediatrics and consider urethral catheter if inability to void or large vulval haematoma.

29
Q

Purple Crying

A

Acronym
- P - Peak of crying at 6-8 weeks and improves by 3-4 months
- U - Unexpected - Crying can come and go and you don’t know why
- R - Resists Soothing -
- P - Pain-like Face - May look like they are in pain even when they are not
- L - Long-lasting - Lasts as much as 5 hours a day
- E - Evening - Worse in late afternoon and Evening

Educational Notes to discuss with parents
- Crying is normal physiological behaviour in young infants.
- At 6-8 weeks of age, babies are expected to cry for 2-3 hours in 24 hours.

Techniques to assist with comfort of child
- Establish pattern to feeding/settling/sleep
- Predictable settling for naps e.g. Quiet play -> Move to bedroom -> Give baby cuddle -> Settle in cot whilst awake
- Avoid excessive stimulation - Noise / light / handling
- Darken the room for daytime sleeps
- Baby massage / rocking / patting
- Respond before the baby is too worked up.
- Give primary carer respite once a day

Recommend against following empiric treatment for crying
- Anti-reflux medication - Not effective compared to placebo
- Anticholinergics - Effective by SE of apnoeas and seizures
- Gripe water - No proven benefit
- Simethicone - No effect compared to placebo
- Limited evidence to support probiotic use.

30
Q

Examination findings in Strabismus

A
  • Positive cover test
  • Unequal corneal light reflex
  • Unequal red reflex
  • Abnormal head tilt
  • Impaired extraocular movement
  • Positive cover/uncover test (Use to find latent strabismus)
31
Q

Balanitis

A

Inflammation at the tip of the foreskin. and glans of the penis

Causes
- Chemical irritation (urine trapping, soiled nappies, soap residue
- Physical trauma - Forcible Retraction
- Candida

Treatment
- Soaking in salt water bath settles swelling and discomfort
- Consider barrier cream or 1% hydrocortisone if concern for nappy rash
- Consider clotrimazole if candida suspected
- Oral analgesia
- Avoid retraction of foreskin.

32
Q

Indications for paediatric circumcision

A

-pathological phimosis
- Recurrent UTIs
- Parent preference

Complications
- Infection
- Bleeding

33
Q

Severs Disease

A

Calcaneal Traction Apophysitis
- Common cause of heel pain in childhood and early adolescence.
- Increased risk with high activity level with sports that involve running and jumping.

Symptoms
- Limp. Complain of pain during or after activity.
- Can be unilateral or bilateral

Imaging not necessary. Clinical diagnosis.

Management
- Modify activities that cause pain.
- Ice packs
- Insert gel heel pad into shoes
- Daily calf-stretching exercises.

Pain normally settles in 6-12 months but can last up to 2 years.

34
Q

Tic Disorders

A

Sudden, rapid, recurrent involuntary vocalisations or movements

Included behaviours
- Grunting, blinking, shrugging shoulders, humming, yelling out a word or phrase, clearing the throat

Classification
- Tourette Syndrome - Motor and vocal tics for > 1 year
- Provisional Tic Disorder - Motor or vocal tics for < 1 year
- Persistent motor or vocal tic disorder - Motor or vocal tics for > 1 year

  • Average age of onset 5-6 years
  • Associated with psychosocial distress and poor functioning.
  • Strong genetic component.
  • Associated with ADHD or OCD.

No treatment other than psychosocial support and treating co-morbidities.

35
Q

Bow legs and Knock Knees in Children

A

Normal physiological development of legs in children

Bow legs (Genu Varum)
- Toddlers -> 3yo
- Monitor intercondylar (medial condyle of knees) separation. if > 6cm at 4 years, refer.

Knock knees (Genu valgum)
- Normal 2-8yo
- Running is awkward but improves with time.
- Refer if intermalleolar separation is > 8cm.

36
Q

Night Terrors

A

Dramatic awakening during the night in the first few hours of sleep
- 5% of children will have night terrors.
- Usually occur in pre-school and primary school.
- No long-term effects

37
Q

Pulled Elbow

A

Radial Head Subluxation

Signs
- Not using affected limb
- Elbow in extension and forearm in pronation
- Distressed only on elbow movement
- No associated swelling, deformity or bruising.
- Resistance and pain on supination of forearm

Rx
- Reduction manoeuvre
- Supination and flexion - Thumb on radial head. Fully supinate arm and then flex arm. Should feel a click with relocation.

38
Q

Food Protein-Induced Allergic Proctocolitis

A

Inflammation of distal colon in response to food proteins.
- Common triggers - Cow’s milk, soy.

Clinical Signs
- Haematochezia in otherwise healthy infant.
- Anal fissures

Rx
- Elimination diet.

39
Q

Lactose Intolerance

A

Lack of activity of enzyme lactase used to digest disaccharide lactose. Instead, lactose is converted by bacteria in colon to hydrogen gas and short-chain fatty acids.

High prevalence in African Americans, hispanics, Asians, Native Americans.

Symptoms
- Abdominal pain, bloating, flatulence.

Clinical diagnosis based upon suspicion of symptoms.
- Ix - Can consider Lactose hydrogen breath test

Rx
- Restriction of lactose to two cups of milk per day taken in divided doses.
- Can consider use of lactase supplements.
- Consider calcium supplementation due to inadequate dietary calcium intake through restriction.

Paediatrics (9 decks)

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