Miscellaneous Flashcards
Osgood-Schlatter Disease
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.
Croup
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)
Pharmacological management of croup
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.
Concerning potential causes of crying in babies
Raised intracranial pressure
Non-accidental injury
Incarcerated inguinal hernia
Urinary tract infection
Hair tourniquet
Corneal foreign body / abrasion
Scarlet Fever
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,.
Erythema toxicum neonatorum
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.
Management of Pinworm
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.
Diagnostic criteria for Kawasaki Disease
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
Management of Kawasaki Disease
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
Differential diagnosis of Kawasaki disease
GAS infection (tonsillitis, scarlet fever, acute rheumatic fever)
EBV
Adenovirus
Systemic juvenile idiopathic arthritis
Sepsis
Stevens-johnson syndrome
Drug reaction
Enuresis - Non-pharmacological management
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
Enuresis - Pharmacological management
Desmopressin 120microg subling Nocte
Adrenaline dose in anaphylaxis
Adrenaline 1:1000 0.01ml/kg (Max 0.5.ml) IM . Repeat if nil response after 5 minutes.
Constipation - Non-pharmacological management
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
Constipation - Pharmacological
Infants < 1/12 - Coloxyl drops
Infants 1/12-12/12 - Movicol, Osmolax, Lactulose
Children - Paraffin oil
Vaseline for anal fissures
Live vaccines
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
Optimal times for surgical intervention of children’s surgical disorders
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+
Common Differential for Childhood hip pain and limping
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
Concerning differentials for limping or non-weight bearing child.
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
Imaging considerations for limping or non-weight bearing child
Xray Pelvis AP or frog leg - DDH, SUFE, Perthes
US Hip - Drainable effusion for ?septic arhritis
Bone scan or MRI ?Osteomyelitis / cancer
SUFE Klein Line
On Xray Pelvis. Line along superior aspect of neck of femur should transect the epiphysis. If this does not occur, can diagnose SUFE
Phimosis in children
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
What is HEEADSSSS
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
Chronic diarrhoea > 6/12 of age
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.
Indications for Abx therapy in AOM
- ATSI
- < 6/12
- Bilateral infection < 2yo
- Systemically unwell (lethargy, pain, irritability)
- Otorrhoea present
- Immunocompromised
Thyroglossal Duct Cyst
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.
Approach to Short stature in children
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
Slipped Upper Femoral Epiphysis
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.
Vulvovaginitis
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
Straddle Injuries
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.
Purple Crying
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.
Examination findings in Strabismus
- 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)
Balanitis
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.
Indications for paediatric circumcision
-pathological phimosis
- Recurrent UTIs
- Parent preference
Complications
- Infection
- Bleeding
Severs Disease
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.
Tic Disorders
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.
Bow legs and Knock Knees in Children
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.
Night Terrors
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
Pulled Elbow
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.
Food Protein-Induced Allergic Proctocolitis
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.
Lactose Intolerance
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.
