musculoskeletal/ neuro Flashcards
What AEDs for epilepsy w generalised tonic-clonic seizures?
Lamotrigine
sodium valproate
JIA complications
if uncontrolled, bone expansion from overgrowth
leg / digit length discrepancy
valgus deformity
advancement of bone age in wrists
chronic anterior uveitis - can lead to sever visual defect. ** regular ophthalmic screening using slit lamp indicated (esp those w oligoarticular disease)
joint flexion contracture (may lead to joint destruction/ need for replacement)
growth failure (generalised or local- premature fusion of epiphyses)
osteoporosis
infantile spasm (West syndrome)
4-6mths
triad of infantile spasm, interictal eeg pattern termed hypsarrhythmia, mental retardation
seizure pattern - violent flexor spasms of head, trunk and limbs followed by extension of arms (salaam spasms)
often multiple bursts of 20-30 spasms
Ix of osteomyelitis
FBC, WCC, CRP
Blood cultures
Xray
(may show subperiosteal new bone formation + multiple hypodense ares in metaphyseal regions)
USS
(may show periosteal elevation - ‘codmans triangle’)
MRI
(allows differentiation bewteen bone and soft tissue infection)
fitting mx
ABC DEFG
ABC approach
do not forget glucose!!
secure airway, give O2, assess B/C, check blood glucose, secure IV Access (large bore cannulae)
DDx
Infection- encephalitis, meningitis, cerebral abscess
malignancy
trauma
metabolic- hypoglycaemia, DKA
febrile convulsion
epileptic fit
pale -> falls to ground -> recovers rapidly
often after pain, discomfort, minor head injurites
due to reflex cardiac astystole secondary to increased vagal response
reflex anoxic seizure
Most common Osteomyelitis pathogen cause
Staph aureus
Strep / H influenzae also possible
Salmonella (assoc w Sickle cell anaemia - sees both staph and salmonella)
consider TB in immunodeficient child
characteristic skin rash, arthralgia, periarticular oedema, abdo pain and glomerulonephritis
often preceded by URTI
aetiology- antigen exposure increases IgA, which interacts w IgG to activate complement and are deposited in affected organs, precipitating an immune response w vasculitis
Henoch schonlein purpura
Clinical diagnosis. Ix includes FBC, renal function, urine dipstick and renal biopsy if indicated.
Risk factors for progressive renal disease are proteinuria, oedema, HTN and deteriorating renal function -> renal biopsy indicated
Most will resolve within 6 wks. NSAIDs help arthritic symptoms.
Generalised hypotonia and marked head lag.
small low set ears, upslanting palpebral fissures (upslanting eyes), prominent epicanthic folds, flat facial profile, protruding tongue
Short neck, single palmar crease, wide sandal gap between 1st and 2nd toe
Downs Syndrome T21
95% due to non-dysjunction, 2% robertsonian translocation, 2% mosaicism
learning disability
congenital heart disease- AVSD, TOF, ASD, VSD
GI - duodenal atresia, Hirschsprungs, anal atresia
increased risk of infection, DDH, OME, Alzheimers, epilepsy
diagnosis by karyotyping. By rapid FISH quicker results
Duchenne muscular dystrophy presentation
waddling gait
developmental delay (motor +/ language delay, may be global delay)
Acute painful limp differentials (3-10 yrs)
Infection (Septic arthritis, osteomyelitis)
Inflammation (Transient synovitis, JIA)
Trauma
Perthes
Malignancy (ALL)
Tx of osteomyelitis
Urgent systemic IV Abx
6 wk course
IV for 2 wks (until clinical recovery) then oral for 4
Surgical drainage if does not respond to abx therapy
affected limp initially rested in splint.
+ appropriate pain relief for child
infantile spasms prognosis
developmental regression
learning disability
may get epilepsy
Chronic intermittent limp differentials (1-3 yrs)
DDH
Talipes
Neuromuscular e.g. Cerebral palsy
JIA
EEG 3 spike wave complex cycles/ s
absence seizures
Benign intracranial HTN risk factors
obesity, triggered by drugs e.g tetracyclines, cocp, steroids
IX of reactive arthritis
FBC WCC CRP/ ESR
Xrays (normal)
Temp (low grade fever)
Benign intracranial HTN Mx
reduce weight, avoid precipitating drugs and avoid LP
Perthes Investigations
XRay of both hips (incl frog leg view)
(irregular, fragmented, sclerotic femoral head, with decreased size of head)
Bone scan
MRI
chondromalacia patellae
softening of the cartilage of the patella
teenage girls
anterior knee pain when walking up or down stairs, rising from sitting
reponds to physiotherapy
Learning difficulties, macroorchidism, macrocephaly, large ears, long face, mitral valve prolapse
Fragile X
more commonly in boys
CGG repeats
osteochondritis dissecans
pain after exercise
intermittent swelling and locking of knee
Treatment of DDH
Conservative (for newborns):
Pavlik harness.
(for 1-2 months. it is a soft positioning device that keeps the thighbone in the socket. helps tighten the ligaments around hip joint and promotes normal hip socket formation.)
Conservative (1-6 months):
Harness/ Craig’s splint
usually worn full time for at least 6 wks, then part-time for additional 6 wks.
risk factors for septic arthritis
immunocomp
joint problems/ damage
IVDU
diabetes
SCA (Salmonella)
beckers vs duchenne
some functional dystrophin produced
progresses more slowly
avg onset 11 yrs
life expectancy from late 40s to normal
Perthes Treatment
if identified early + <50% femoral head affected:
bed rest, analgesia and traction
severe/ late disease:
maintain hip in abduction w plaster or calipers
or
surgery (femoral or pelvic osteotomy)
whcih repositions femoral head within the acetabulum
Reactive arthritis most common pathogens
in adolescents: chlamydia trachomatis, neisseria gonorrhoea
in children:
campylobacter
yersinia
samonella
shigella
Also mycoplasma and lyme disease
skull xray shows characteristic rail road track calcification
MRI choice of imaging now
sturge weber
Hypotonia, hypogonadism, obesity
Prader-Willi
deletion on paternal chromosome 15
characteristic facies, floppy w feeding difficulties and FTT in infancy
rapid weight gain at 1-6 years old. typically have insatiable appetite w food foraging and other behavioural problems
diagnosis by molecular genetic analysis
Mx of JIA
aim to induce remission
Managed by specialist paediatric rheumatology MDTs (physio, GP, school, orthopaedics)
education and support for child and family
physio to maintain join function
NSAIDs to relieve symptoms during flares
Joint injections under USS guidance
Methotrexate (give weekly and regular blood monitoring required)
Systemic steroids - avoid if possible to minimize growth suppression and osteoporosis
Biologics - antiTNFa
hydrocephalus tx
minimised risk of neuro damage and symptomatic relief
mainstay: insertion of Ventriculoperitoneal VP shunt
ventriculostomy surgery
shunts can malfunction due to blockage or infection (usually w CNS)
perthes complications
may be commonly seen in SCA
degenerative osteoarthritis in early adult life
premature fusion of the growth plates
Acute painful limp differentials (11-16 yrs)
Mechanical (trauma, overuse, sport injuries)
SUFE
Perthes
Inflammation (RA, JIA)
Knee- osteochondritis dissecans
Malignancy (bone tumours)
Infection (SA, osteomyelitis)
drug side effects: rash, neutropenia, hypoNa, liver enzyme induction interfering w other meds
carbamazepine
NICE guidelines for refractory convulsive status epilepticus
IV Midazolam/ thopental sodium
+ adequate monitoring and blood levels of AEDs
Most common cause of headaches in children
Migraine
tension-type
refractory errors
cluster headaches
secondary:
benign intracranial HTN
raised ICP
infection- meningitis, encephalitis, sinusitis
ash leaf depigmented patches which fluoresce under UV light (woods light)
tuberous sclerosis
infantile spasm tx
1st line: AED vigabatrin
or steroids
neurofibromatosis type 1
features
6 or more cafe au lait spots >5mm in size before puberty, 15mm after puberty
1 or more neurofibroma
optic glioma - can cause visual impairment
port wine stain in distribution of trigeminal n
assoc w similar lesion intracranially
ophthalmic division of trigem n always involved
sturge weber syndrome
ethosuximide SE
N+V
short stature, learning difficulties, friendly, extroverted personality, transient neonatal hypercalcaemia, supravalvular aortic stenosis
Williams syndrome
septic arthritis investigations
FBC WCC CRP
Blood cultures
ALWAYS examine joint above and below
USS of joint- effusion
XRay to exclude other trauma/ lesions
MRI - may demonstrate adjacent osteomyelitis
JOINT ASPIRATION under USS guidance and culture is definitive (ideally immediately, before ABx)
osgood schlatter tx
rest and analgesia
most resolve w reduced activity and physio for quads strengthening, hamstring stretches and occasionally orthotics
Knee immobilised splint may be helpful
Perthes
Avascular necrosis of the femoral head
due to interruption of blood supply,
followed by revascularisation and reossification
mainly affects boys (5:1) of 5-10 yrs
in community, if prolonged seizure (>5 min)
1st line; buccal midazolam
if buccal not avail, rectal diazepam
Max 2 doses of first line tx
If continuing seizures, IV phenytoin
and contact anaesthetist - child may need rapid anaesthesia for intubation and ventilation
increased ICP in absence of mass lesion
benign intracranial HTN
developmental dysplasia of the hip risk factors
female breech (esp vaginal delivery) oligohydramnios multiple pregnancy family history prematurity firstborn child
patellar subluxation
medial knee pain due to lateral subluxation of the patella
EEG- hysparrhythmia
salaam spasms
west syndrome
infantile spasms
DDH Surgical treatment
Surgical (> 6mths):
surgery (closed reduction) + hip spica cast
skin traction may be used for few wks before, as it prepares the soft tissues around the hip for the change in bone positioning.
Surgical (>2 yrs):
usually open surgery necessary + spica cast after
septic arthritis complications
adjacent osteomyelitis
sepsis
joint destruction
ankylosis
febrile convulsions investigations
examination - obs, temp
focus on cause of fever, exclude meningitis, encephalitis
Full septic/ infection screen may be necessary
febrile convulsion risk factors
family history
6mths-5yrs old
viral infection w temp rising rapidly
previous hx of febrile convulsion
(1 in 3 will have another febrile convulsion)
Duchennes Mx
appropriate physiotherapy and exercise to maintain muscle power and mobility
passive stretching and night splints to prevent contractures
orthoses to prolong walking
maintaing good posture and exercise reduces risk of scoliosis
scoliosis managed w truncal brace, moulded seat, surgical insertion of spinal rod
self help groups for parents
MDT care: specialist regional centre
Duchenne IX
serum CK (markedly elevated)
muscle biopsy showing decreased dystrophin is diagnostic
most common pathogen of septic arthritis
staph aureus
Hib was impt cause before Hib immunisation
First non febrile seizure IX
ECG - could be cardiac cause for fit e.g. prolonged QT
MRI if focal seizure <2 yo
after 2nd seizure: EEG
prominent occiput, small mouth and chin, low set ears, short sternum, overriding fingers, rocker bottom feet, cardiac (VSD) and renal malformations
Edwards Syndrome
Trisomy 18
majority caused by non dysjunction during maternal oogenesis
most do not survive beyond 1 yr
diagnosis - intitial rapid FISH followed by formal chromosomal analysis
median life expectancy around 4 days, although some live for several months
hydrocephalus different causes
obstruction to flow of CSF-> leading to dilation of ventricular system
obstruction may be within ventricular system or aqueduct (non communicating) or at arachnoid villi, the site of CSF absorption (communicating)
Causes:
non communicating: congenital malformation (e.g. aqueduct stenosis, stresia of outflow, chiari malformation)
communicating: subarachnoid haemorrhage, meningitis
systemic JIA features
fever
rash
lymphadenopathy
hepatosplenomegaly
serositis
anaemia, raised neut/pl, raised CRP/ESR
what is DDH?
ranging from dysplasia -> subluxation -> frank dislocation of hip checked in neonatal screening, thereafter presents with limp or abnormal gait. Look out for legs of different length + uneven skin folds on the thigh
DDH Complications
avascular necrosis of the femoral head
pain
osteoarthritis by early adulthood
even w appropriate tx: hip deformity and osteoarthritis may develop later. Esp when tx begins after 2 yrs.
webbed neck, pectus excavatum, short stature, pulmonary stenosis
Noonan syndrome
autosomal dominant disorder, karyotype normal
short stature, characteristic facies (hypertelorism -usually increased distance between eyes, ptosis, ear abnormalities), short webbed neck, pectus excavatum, undescended testes
associated pulmonary stenosis & ASD, cardiomyopathy, learning difficulties
diagnosis confirmed by mutation analysis of the PTPN11 gene
Duchenne muscular dystrophy - lack of what protein?
dystrophin
causing excess of free radicals and myofibre necrosis
Tx for Reactive arthritis
complete recovery anticipated
only need pain relief, NSAIDs
clinical features of hydrocephalus
infants: as skull sutures not fused, HC disproportionately large, bulging ant fontanelle
advanced sign: fixed downward gaxe or sun setting of eyes
in older children: signs and symptoms of raised ICP
Hydrocephalus IX
antenatal USS
Cranial USS for infants
or Imaging with CT or MRI
Head circumferene should be monitored on centile charts
restriction of visual fields, sedation
Drug SEs
Vigabatrin
DDH neonatal screen test?
Barlow’s (whether hip can be dislocated posteriorly out of the acetabulum) - bring thighs to midline to adduct hip and push on knee backwards) Ortolanis (relocated back w abduction) Screened for at newborn first exam + thereafter (6-8wks)
Mx for epileptic seizure
always refer on to specialist asap!
must be diagnosed by paediatrician w expertise in epilepsy
discuss w parents what to do in next seizure:
First aid/ safety and injury prevention
safe spot, recovery position, time the seizure, take video if possible
if >5 min, come into hosp, give buccal midazolam
Liaise w school
Offer links to support groups / charities
social support
Most common cause of acute hip pain in children (2-12 yo)
following/ alongside viral infection
sudden onset of pain or limp.
pain on movement, decreased ROM, esp int rotation
pain may be referred to knee
Afebrile, does not look ill
transient synovitis
Chronic intermittent limp (11-16yrs)
SUFE (chronic)
JIA
tarsal coalition
Benign intracranial HTN features
headache, transient diplopia, papilloedema
SUFE complications
avascular necrosis
premature fusion of epiphyses
obese 10-15 yr old boy during adolescent growth spurt with insidious hip pain
(can be acute following minor trauma)
can also be limp, or referred knee pain
Slipped upper femoral epiphyses
epilepsy investigations
take collateral history.
pay attention to specific triggers
clinical exam: check skin for neurocutaneous syndromes and full neuro exam
EEG - after 2nd seizure
or 24h ambulatory eeg
MRI/CT imaging if focal neuro signs
Genetic studies for certain epileptic syndromes
if Barlows and ortolanis -ve, but many risk factors?
still do USS of hip +
if necessary, can seek specialist ortho surgeon opinion
Transient synovitis Tx
Rest and analgesia
+ Skin traction
usually resolves within 1 wk
~3% develop perthes
Mx of Turners syndrome
Refer to genetics team
MDT - paediatric endocrinologist, gynaecologist, psychologist, geneticist, nephrologist, cardiologist
Growth hormone therapy- can help child grow e.g. somatotropin
Oestrogen and Progesterone replacement tx- oestrogen to trigger puberty and then progesterone also started to help girl develop regular periods
If wanting fertility - likely IVF
Psychological therapies for low mood/ self esteem
Learning disability- support
Headache mx (when no red flags)
thorough history and exam
recurrent headaches common and cause no long term harm
advice on how to live with it
rescue tx- analgesia (paracetamol and NSAIDs) , antiemetics (prochlorperazine, metoclopramide), serotonic agonists (sumitriptan if >12yo)
but beware of medication overuse headache
psychosocial support- stressor ie bullying?
relaxation techniques
mx of congenital adrenal hyperplasia
during salt losing crisis - urgent tx with IV hydrocortisone, saline and glucose
long term - glucocorticoid replacement e.g. hydrocortisone with increased doses needed for illness/ stress
if salt wasting- also replace fludrocortisone
regular monitoring of growth, skeletal maturity, and androgens to ensure optimal growth and development
virilisation of external genitalia in females (clitoral hypertrophy)
virilisation in males (enlarged penis)
salt losing adrenal crisis (low Na)
vomiting, weight loss, floppiness and shock
Congenital adrenal hyperplasia
enzyme defect - deficiencies in 21a-hydroxylase (90%), 11B hydoxylase and 17a hydroxylase
decrease in cortisol production and aldosterone -> increased ACTH and subsequent adrenal hyperplasia
auto recessive
diagnosis by detecting biochemical abnormalities during salt wasting crisis- Low Na, High K, metabolic acidosis, hypoglycaemia
+ measuring high lvls of 17a-hydroxyprogesterone, etc
what AEDs for infantile spasms?
steroids
vigabatrin
Gowers sign
duchenne muscular dystrophy
SUFE investigations
XRAY esp lateral view
shows ice cream cone sign
micrognathia, posterior displacement of tongue (may cause upper airway obstruction), cleft palate
pierre-robin syndrome
EEG high amplitude spikes in L centrotemporal region
benign rolandic epilepsy
lamotrigine SE
rash
What AED if myoclonic seizures?
sodium valproate
consider levetiracetam or topiramate
Febrile convulsions Mx
reassure parents and provide advice sheet
antipyretics not effect
first aid mx of seizures taught to family:
safe spot, put them in recovery position, don’t restrain them/ put anything in their mouth
if prolonged >5 min, rescue therapy w rectal diazepam/ buccal midazolom
if first episode, MUST be reviewed by consultant paediatrician
tuberous sclerosis inheritance
auto dominant
Head injury mx?
ABC
cervical spine immobilisation unless suspiscion of neck injury
Transient synovitis ix
difficult to differentiate from early septic arthritis
if suspicious, joint aspiration and blood cultures
FBC, WCC, CRP
USS of hip (shows mild effusion)
XRay shows normal joint
infantile spasms ix
EEG
MRI/CT head- shows diffuse/ localised brain disease in 70%
topiramate SEs
drowsiness, wtihdrawal, weight loss
features that suggest SOL
worse in morning/ when lying down/ straining/ coughing
vomiting in the morning
change in mood/ personality/ educational performance
visual field defects
focal neurological signs (e.g. cranial n abnormalities)
papilloedema
neurofibromatosis type I inheritance
auto dom
If on AED and pregnant? Advice?
risk of AEDs causing malformations and neuro impairments in unborn child, esp Sodium valproate
offer 5mg/day of folate before/ if any possibility of pregnancy
aim for seizure freedom
presentation of septic arthritis
acutely unwell, febrile child
with erythematous, warm, acutely tender joint
w reduced or ‘no’ ROM
infant may hold limb still (pseudoparalysis)
may be referred to knee pain
What is osgood-schlatter?
transient inflammation of the (patellar tendon insertion) growth plate of the tibial tuberosity
often affects adolescent males
worse after exercise (knee pain esp on leg extension)
localised tenderness and swelling over the tibial tuberosity
may be bilateral
Markedly painful, immobile limb with fever.
swelling and exquisite tenderness over thigh.
+ skin is erythematous and warm
osteomyelitis
temporal focal seizures
most common
aura, strange warning feelings
lip smacking
automatism (walking in non purposeful manner)
deja vu
jamais vu
consciousness impaired
hair loss, weight gain, idiosyncratic liver failure (drug side effects)
sodium valproate
JIA presentation
stiffness after rest (gelliing)
morning joint stiffness and pain
intermittent limp/ avoidance of activities
mono/oligo/polyarticular
joint swelling due to fluid, inflammation
Chronic intermittent limp differentials (3-10 yrs)
Perthes (chronic)
neuromuscular e.g. CP, Duchenne’s muscular dystrophy
JIA
Trauma (old unidentified fracture)
JIA
most common chronic inflammatory joint disease in children and adolescents
persistent >6wks joint swelling in absence of infection or any other cause
pseudohypertrophy of calves
duchenne muscular dystrophy
(replacement of muscle w fat and fibrous tissue)
what AEDs used in absence epilepsy/ seizure?
ethosuximide
sodium valproate
Management of Downs Syndrome
Refer to genetics team
refer for dated cardiac assessment, Hip USS, audiology
Long term follow up with MDT team including developmental paediatrician, physiotherapist, specialist nurse etc
Genetic counselling
Parental support e.g. Downs Association
+ education on short term and long term implications of the diagnosis
Test TFTs, audiology, opthalmic assessment yearly
Appropriate education support
short stature, webbed neck, wide carrying angle, widely spaced nipples, lymphoedema of hands and feer, spoon shaped nails, excessive pigmented moles
Turners Syndrome 45XO
caused by non dysjunction
short stature (cardinal feature)
heart conditions- Coarctation of the arorta and VSD, aortic root dilation + bicuspid aortic valve, renal anomalies
ovarian dysgenesis resulting in delayed puberty, amenorrhoea and infertility
diagnosis by chromosome analysis
Migraine common triggers
cheese, chocolate, caffeine
menstruation, cocp
stress, late nights
angiofibromas in butterfly distribution over bridge of nose and cheeks
tuberous sclerosis
tonic clonic seizures
limb jerking, breathing irregular, cyanosis, tongue biting, urinary incontinence
unconscious or deep sleep to up to several hours later
microcephaly, polydactyly, cleft lip/ palate, scalp lesions, small eyes
Patau syndrome (trisomy 13)
75% by non dysjunction, 20% robertsonian translocation, 5% mosaicism
usually diagnosed on antenatal scan due to multiple congenital abnormalities incl SGA, microcephaly, cleft lip, polydactyly, micropthalmia (small eyes), cardiac (VSD, ASD), and renal anomalies (fused kidneys) and severe mental retardation
diagnosis via chromosome analysis by amniocentesis, but rapid FISH done to confirm diagnosis quickly
tall stature, gynaecomastia in puberty, infertility, small testes
Klinefelter’s syndrome 47XXY
infertility most common presentation
hypogonadotrophic hypogonadism - small testes and decreased testosterone production
diagnosis by chromosome analysis
what examinations are important in investigating epilepsy?
cardiac
neurological
development assessment
next step if barlows and ortolani’s postive?
USS of hip - allows detailed hip assessment
epilepsy mx
NICE guidelines or follow individually agreed protocol drawn up by specialist
MDT- specialist epileptic nurse + consultant paediatric neurologist
duchenne prognosis
life expectancy reduced to late twenties
from resp failure or assoc cardiomyopathy
complications: scoliosis, learning difficulties
Septic Arthritis Tx
Prolonged course of ABx, initially IV
recommendations vary from 1 -6 wks
Fluclox and Benpen
washing out of joint or surgical drainage may be required
If prolonged seizure (>5 min), IV access in place
IV lorazepam 1st line
2nd line: iv diazepam or buccal midazolam
+ ABC
MAX 2 doses
If continuing seizures, IV phenytoin
and contact anaesthetist - child may need rapid anaesthesia for intubation and ventilation
Duchenne muscular dystrophy
what is it?
inherited disorder X-linked recessive
progressive muscle degeneration
baby crying, holding breath til blue then losing consciousness
recovers fully and rapidly
breath holding attacks
occurs in toddlers when they are upset
behaviour modification therapy, with distraction, may help
SUFE assoc w endocrine abnormalities
hypothyroidism
hypogonadism
Acute painful limp differentials (1-3 yrs)
1-3 yrs:
Infection (Osteomyelitis, septic arthritis)
Inflammation (transient synovitis)
Trauma (NAI/ accidental)
Malignancy (Leukaemia, neuroblastoma) - pain may be primarily at night
odd sensation at corner of mouth -> twitching of mouth -> rest of ipsilateral face twitches
assoc w excessive salivation, grunting and slurred speech
benign rolandic epilepsy
traffic light system for fever <5
other
Amber - intermediate risk:
age 3-6 months and temp >39
fever >5 days
Rigors
Swelling of limb/ joint
non weight bearing limb
Red - high risk:
Age <3 and temp >38
non blanching rash
bulging fontanelle
neck stiffness
status epilepticus
focal neuro signs
focal seizures
Risk factors for slipper upper femoral epiphyses
obese children and boys
growth spurt
may present acutely following trauma
what should be recorded in all febrile children?
Obs
temp, heart rate, resp rate, cap refill time
signs of dehydration (reduced skin turgor, cool extremities) should be looked for
then use NICE traffic light system to determine risk and subsequent mx
Traffic Light system
Colour
Green - low risk:
Normal colour
Amber - intermediate risk:
pallor reported by parent/ carer
Red - high risk:
pale/ mottled/ ashen/ blue
Traffic light system for feverish under 5 children
Activity
Green - low risk:
responds normally to social cues, smiles, stays awake, strong normal crying/ not crying
Amber - intermediate risk:
not responding normally to social cues, no smile, decreased activity, wakes only w prolonged stimulation
Red - high risk:
no response to social cues, appears ill to a healthcare professional, does not wake or if roused does not stay awake, weak high pitched or continous cry
traffic light system for feverish illness <5
respiratory
Amber - intermediate risk:
nasal flaring, RR >50 if aged 6-12 months, RR>40 if > 1yr, SaO2 <95% in air, crackles in the chest
Red - high risk:
RR >60
grunting
]moderate or severe chest indrawing
traffic light system for feverish <5
circulation and hydration
Amber - intermediate risk:
tachycardia >140 if age 2-5, >150 if 1-2 yrs, >160 if <1 yr
CRT >3s
Dry mucus membranes, poor feeding, reduced UO
Red - high risk:
reduced skin turgor
Presentation of acute glomerulonephritis
reduced GFR -> decreased urine output and volume overloaded, haematuria and proteinuria.
HTN which may cause seizures.
Oedema, characteristically around the eyes.
why is Downs associated with sleep apnoea and snoring?
This is due to the low muscle tone in the upper airways and large tongue/adenoids. There is also an increased risk of obesity which in people with Down’s syndrome which is another predisposing factor to snoring.
causes of snoring in children
- obesity
- nasal problems: polyps, deviated septum, hypertrophic nasal turbinates
- recurrent tonsillitis
- Down’s syndrome
- hypothyroidism
at what age should a child be smiling?
6 wks
refer at 10 wks
at what age should a child be laughing and enjoing friendly handling
3 months
at what age should a child be shy and takes everything to mouth
9 months
at what age should a child be able to use knife and fork
5 years
at what age should a child be able to use spoon and fork
3 years
at what age should a child be competent w spoon and doesnt spill w cup
2 years
at what age does child develop skills of drinking from cup and using spoon, over a 3 month period
12-15 months
at what age will child get dressed and undressed independently except for laces and buttons
4 years
periorbital oedema, leg and ankle oedema, ascites, breathless due to pleural effusions and abdo distension
nephrotic syndrome - proteinuria, low plasma albumin and oedema
Ix- Urine dip for protein
possible causes: minimal change disease, secondary to HSP, SLE, infections e.g. malaria, or allergens e.g. bee sting
Mx of nephrotic syndrome
85-90% steroid sensitive -> resolves with steroid therapy
Give oral steroid (prednisolone) for 4 wks then reduce dose for another 4 wks then stop.
if steroid resistant, refer to paediatric nephrologist. Mx by diuretic therapy, salt restriction, ACEi and sometimes NSAIDs.
Complications of nephrotic syndrome
Clots - loss of antithrombin III in urine
Infections - loss of Ig -> risk of encapsulated bacteria.
Hypovolaemia - intravasc compartment vol depleted. urinary sodium retention -> low urinary Na (<20mm/L). requires urgent tx w IV albumin as child is at risk of vascular thrombosis and shock
Hypercholesterolaemia - correlates inversely w serum albumin
Ix /MX for primary nocturnal enuresis
Urine always tested for glucose and protein and for infection.
Mx:
explanation to child and parent. stop punitive measures.
star chart
enuresis alarm - if star chart does not work
desmopressin - short term relief. used first line for >7 who wish to achieve dryness v quickly.
self- help groups - advice and assistance to parents
USS of kidneys can look for?
urinary tract dilatation, stones, nephrocalcinosis
downward slanting palpebral fissures, underdevelopment of lower jaw, + tongue being retracted. external ear is small, rotated, malformed or absent. -> majority have conductive hearing loss
treacher collins syndrome
acute, unilateral facial n palsy around 2 wks following a viral infection.
mouth droops, pt cannot close one eye.
Bells palsy
tx: maintiaining moisture to the affected eye to prevent keratitis. complete spontaneous resolution occurs in about 85% of cases.
by what age should infants be able to smile and coo when smiled at or being talked to
2 months
by what age would a child be able to help dress and undress themselves, with the exception of shoelaces/ buttons. can ride a tricycle and can alternate feet when climbing stairs.
they know their age and gender, but have not porgressed beyond copying a circle.
3 years
complication of juvenile rheumatoid arthritis
iridocyclitis
-> all children should have frequent slit lamp eye examinations.
staphylococcal scalded skin disease
aka
Ritter’s Disease of the newborn
most commonly in children <5 yrs
due to epidermolytic exotons released by s aureus-> breaking down of the desmosomes. they cleave desmoglein-1 (similar to pemphigus vulgaris)
rash preceded by fever, irritability, erythema and extraordinary tenderness of the skin.
circumoral erythema, crusting of the eyes, mouth and nose, and blisters of the skin can develop. intraoral mucosal surfaces are not affected. (unlike toxic epidermal necrolysis, mucous membranes are spared)
Nikolskys sign positive.
culture of bullae are negative, but source site often positive.
tx: antibiotics to cover s aureus and localized skin care.
human bite
- what organisms may infect it
- what mx
oropharyngeal bacteria, including staphylococcus aureus, viridans streptococci, bacteroides spp and anaerobes.
a patient w infected human bite of the hand requires hospitalization for appropriate drainage procedures, gram stain and culture of the exudate, vigorous cleaning, debridement and appropriate antibiotics.
tx usually w oral coamoxiclav or erythromycin.
the would should be left open and allowed to heal by secondary intention.
presents w a herald patch, a single round or oval lesion appearing anywhere on the body. usually about 5-10 days after, a more diffuse rash involving upper extremities and trunk appears.
the rash can appear in a christmas tree pattern on the back.
Pityriasis rosea
tx is usually unnecessary but can consist of topical emollients and oral antihistamines
neonatal acne
peaks at 2-4 wks of age.
the condition results from maternal hormone transmission.
it resolves in a few wks to months, and occasionally is severe enough to require tx w agents such as 2.5% benzoyl peroxide.
constricted pupils, bradycardia, muscle fasciculations assoc w sudden onset neurologic symptoms, progressive resp distress, diaphoresis, diarrhoea and overabundant salivation
organophosphate poisoning
intake can occur by ingestion, inhalation, or absorption through skin or mucosa.
toxicity depends primarily on the inactivation or inhibition of acetylcholinesterase
tx includes gastric lavage if poison was ingested.
if exposure through contact, maintenance of adequate ventilation and fluid and electrolyte balance.
all symptomatic children should receive atropine.
mx of scabies in infants
usually present w bullae and pustules.
5% permethrin cream
factors that confer high risk to hearing impairments in neonates
craniofacial defects (including abnormal ear structure),
neonatal asphyxia,
bacterial meningitis,
congenital infections,
significant hyperbilirubinaemia,
use of ototoxic medications >5 days,
Fhx,
birth weight <1500g,
mechanical ventilation for more than 10days.
strabismus tx
persistence of a transient or fixed deviation of an eye beyond 4 months requires referral to an ophthalmologist.
infants screened for strabismus by observing the location of a light reflection in the pupils when the pt fixes on a light source.
to prevent monocular blindness and to ensure the development of normal binocular vision, early recognition and treatment of strabismus are essential.
TX: to prevent loss of central vision, accomplished by surgery, eyeglasses, or patching of the normal eye.
finding pus in the joint in septic arthritis indicates?
immediate surgical drainage and prompt institution of IV abx to avoid serious damage to the joint and permanent loss of function.
most common organism found in staph aureus.
in sexually active adolescents, neisseria gonorrhoea is a common cause.
dog bite mx
antibiotic prophylaxis should be considered in cat, human, or monkey bites too, and should be given to any bite sustained by an infant, diabetic or immunocompromised person.
erythema toxicum neonatorum
lesions (1-2mm) are yellow-white and w a surrounding edge of erythema.
examination of the fluid from these lesions demonstrates eosinophils.
No therapy is indicated.
Salmon patches aka stork bites
flat vascular lesions that appear more prominent when crying.
lesions on the face fade over the first few wks of life.
lesions found over the nucal and occipital areas often persist.
no tx indicated.
Pustular melanosis
benign self limited disease
more common in darker skin tones.
lesions usually found at birth and consist of 1 -2mm pustules that result in a hyperpigmented lesion upon rupture of the pustule.
the pustular stage of these lesions occur during the first few days of life, w the hyperpigmented stage lasting weeks to months.
no tx indicated.
sebaceous naevi
small, sharply edged lesions that occur most commonly on the head and neck of infants. yellow orange in color and are slightly elevated. usually hairless.
seborrhoeic dermatitis
frequently presents as cradle cap in the newborn period.
this rash is commonly greasy, scaly, and erythematous and in smaller children, involve the face, neck, axilla and diaper area. in older children, the rash can be localized to the scalp and intertriginous areas.
pruritus can be marked.
SUFE - surgery w internal fixation or open reduction?
internal.
open reduction assoc w increased incidence of avascular necrosis of femoral head.
osteogenesis imperfecta
inheritance?
auto dominant
Ash leaf macules + subependymal nodules + infantile spasms
Tuberous sclerosis
- a cause of infantile spasms - treated w vigabatrin
