Mx Flashcards
Chronic Lung Disease of Prematurity
Proph 1 resp support 3 medications 3
• Prophylaxis:
o Corticosteroids for women in suspected, diagnosed or established preterm labour
<34 weeks (consider if 34-36 weeks)
• Respiratory support:
o High flow oxygen
Via nasal cannula or incubator oxygen If >2L per min humidify oxygen
o CPAP
o Invasive ventilation
Give surfactant
• Medications:
o Dexamethasone
If ≥ 8 days old and on ventilator
o Caffeine citrate
If ≤ 30 weeks corrected gestational age. Start within 3 days of birth Consider if preterm and apneic
o Nitric oxide
Only if pulmonary hypoplasia or pulmonary hypertensionDowns syndrome 3 Ix and 6 referrals incl. 1 support group
• Take blood for genetics and request urgent PCR for trisomy 21
• Full clinical examination paying particular attention to cardiovascular system
• Echocardiogram
o If abnormal then refer to cardiologist
o Congenital heart defects very common
Occur in 45% of Down syndrome babies (mainly AVSD)
• FBC and blood film
o 10% of Down syndrome babies will have transient abnormal myelopoiesis
Baby is higher risk of leukaemia
• Refer to haematologist
• MDT approach
• Hearing screening test
• Monitor for associated problems
o Duodenal atresia
o Hirschsprung disease
o Coeliac disease
o Hypothyroidism
o Epilepsy
o Hearing and visual defects
o Periodontal disease
o Atlantoaxial instability
• Speech and language therapist
o If difficulty swallowing
• Ophthalmologist (3-6 months)
• Parental counselling and education
o Recommend support groups to the parents
Charity: Down’s Syndrome Association
o Genetic counselling
• Early intervention therapies in childhood, refer to
o Physiotherapy
o Occupational therapy for fine motor skills
• Individualised educational plan (special schools)
Obesity. When is treatment considered? Main goal? 4 lifestyle modifications and pharmacological interventions and indications
• Managed in primary care, only refer for specialist paediatric assessment if there are any complications or an endogenous cause is suspected
• Treatment is considered if child’s BMI is above 98th decile
• Weight maintenance is the main goal, with BMI reduction achieved as height increases
• Lifestyle modification
o Healthier diet – regular meals, decreased portions, eating together as a family, nutrient- rich foods etc.
o Increase physical activity – aim for fun activities, family participation is encourages, structured physical activity
o Limiting television and other small screen recreational activities to less than 2 hours per day
o Counselling
• Pharmacotherapy is indicated in a small subgroup of children, over the age of 12 with extreme obesity
o Orlistat – lipase inhibitor
• Bariatric surgery is generally not considered
Septic arthritis
• Prolonged course of antibiotics (initially IV for 2 weeks, followed by 4 weeks of oral antibiotics)
o Suspected Gram-positive
Vancomycin
2nd line = clindamycin or cephalosporin
o Suspected Gram-negative
3rd generation cephalosporin (e.g. ceftriaxone) 2nd line = IV ciprofloxacin
• Joint aspiration - affected joints should be aspirated to dryness as often as required (through closed needle aspiration or arthroscopically)
• Washing out of the joint or surgical drainage may be required
Obesity organic causes 5
- Organic causes: o GH deficiency o Hypothyroidism o Down’s syndrome o Cushing’s syndrome o Prader-Willi syndrome
Septic arthritis vs transient synovitis criteria
Kocher Criteria Distinguishing transient synovitis from septic arthritis More likely to be due to septic arthritis if: • Temperature >38.5C • Unable to bear weight on limb • ESR >40 • WCC >12
0 = not likely 1 = 3% SA risk 2 = 40% SA risk 3 = 93% SA risk 4 = 100% SA risk
Septic Arthritis definition and aetiology
Septic Arthritis *
• Infectious arthritis of the synovial joint (vs osteomyelitis of bone); hip = 75% of cases
o Most common in children <2yo; often presents late
Septic arthritis MX
• Prolonged course of antibiotics (initially IV for 2 weeks, followed by 4 weeks of oral antibiotics)
o Suspected Gram-positive
Vancomycin
2nd line = clindamycin or cephalosporin
o Suspected Gram-negative
3rd generation cephalosporin (e.g. ceftriaxone) 2nd line = IV ciprofloxacin
• Joint aspiration - affected joints should be aspirated to dryness as often as required (through closed needle aspiration or arthroscopically)
• Washing out of the joint or surgical drainage may be required
Meningitis: eponymous signs
Kernig’s sign – pain on leg straightening
Brudzinski’s sign – supine neck flexion -> knee/hip flexion
Meningitis: cushings triad
o Raised ICP symptoms (late signs) = Cushing’s Triad:
High BP + Low HR + Irregular RR
Meningitis: Ix 8
o LP (CT head before LP if concerns of raised ICP – not routine however) – contraindications overleaf
o Blood culture (an LP would be done before this!)
o FBC, CRP, U&E and glucose
o Coagulation profile
o Further immunological analysis (complement deficiency) if >1 episode of meningococcal meningitis
Meningitis: under 3 months over 3 months, 4 supportive therapies, Additional things 3
• <3 months old:
o Antibiotics: IV ampicillin/amoxicillin + cefotaxime
• >3 months old:
o IV ceftriaxone
• Supportive therapy:
o Analgesia and antipyretics
o Oxygen: reservoir rebreathing mask, unless
o IV fluids: 0.9% NaCl + 5% dextrose
o Vasopressors if hypotensive despite fluid resuscitation
• Presenting in primary care: single dose of IM/IV benzylpenicillin
o Arrange emergency medical transfer to hospital by telephoning 999
o Note: check for penicillin allergy (in which case you might consider moxifloxacin and vancomycin)
• Recent foreign travel: add vancomycin
• Dexamethasone may be given if >3 months old and presents with these in CSF analysis:
o Frankly purulent CSF
o CSF WBC > 1000/µL
o Raised CSF WBC + protein concentration > 1 g/L
o Bacteria on Gram stain
o Note: steroids should not be used in meningococcal septicaemia
• Notify the Health Protection Unit
• Discharge and Follow-Up
o All children should be reviewed by a paediatrician 4-6 weeks after discharge
o Offer formal audiological assessment
o Treating Contacts: ciprofloxacin is preferred over rifampicin
This includes anyone who has had close contact with the patients in the 7 days before onset
Meningitis: special medication considerations 3 and after discharge 3 things
o Note: check for penicillin allergy (in which case you might consider moxifloxacin and vancomycin)
• Recent foreign travel: add vancomycin
• Dexamethasone may be given if >3 months old and presents with these in CSF analysis:
o Frankly purulent CSF
o CSF WBC > 1000/µL
o Raised CSF WBC + protein concentration > 1 g/L
o Bacteria on Gram stain
o Note: steroids should not be used in meningococcal septicaemia
• Notify the Health Protection Unit
• Discharge and Follow-Up
o All children should be reviewed by a paediatrician 4-6 weeks after discharge
o Offer formal audiological assessment
o Treating Contacts: ciprofloxacin is preferred over rifampicin
This includes anyone who has had close contact with the patients in the 7 days before onset
PACES TIPS meningitis 6
- Explain the diagnosis (infection of the tissues surrounding the brain)
- Explain that it is a serious condition, but we have effective antibiotics that can treat the infection
- It will require hospital admission to administer the antibiotics and monitoring
- There can sometimes be long-term complications, the most common is hearing loss, and offer formal audiological assessment as follow up
- Follow-up with paediatricians in 4-6 weeks
- Offer ciprofloxacin prophylaxis for contacts
- Support: Meningitis Now
HSP follow up
o Follow-up (weekly for 1 month, 2-weekly for 2 months, 3 months, 6 months, 12 months):
BP measurements
Urine dipstick (haematuria)
UC scoring system 2
o Severity graded using: Paediatric Ulcerative Colitis Activity Index (PUCAI) N.B. be aware of coexistent depression • Severe = >65 points • Mild-Moderate = 10-64 points Truelove and Witts score
CD / UC Ix 8
o FBC (including iron, B12 and folate
CRP and ESR
o Faecal calprotectin
Upper GI and small bowel contrast scan
Colonoscopy and biopsy (cobblestones)
Assess impact on daily functioning (anxiety, depression)
o Stopping smoking (reduce risk of relapse)
Assess risk of osteoporosis
biopsy = non-caseating epithelioid cell granulomata
UC Mx Mild moderate steroid dependent and severe
• Severity in children is assessed using the Paediatric Ulcerative Colitis Activity Index (PUCAI) o Severe > 65 points o Moderate - 35-64 points o Mild – 10-34 points o Remission – 0-9 points
• Mild UC:
o 5-ASA
o Can be used topically (suppository or enema) initially and PO if remission not achieved within 4 weeks
o For extensive disease- topical and high-dose PO treatment is 1st line
o Continue as maintenance if no relapse
o Relapse = use oral prednisolone and taper
If they relapse with steroids, then it is called steroid dependent disease
• Moderate UC:
o Oral prednisolone for 2-4wks and taper
o If good response = treat with oral 5-ASA and continue for maintenance
o If relapse frequent, then steroid dependent disease
o If bad response to oral prednisolone, then IV can be given. Should be tapered off to oral and maintain remission.
• Steroid dependent disease:
o #1: Thiopurine or infliximab
o If successful continue with medication as maintenance
o If inadequate:
Colectomy, adalimumab or vedolizmab Colectomy is the final treatment option
• Severe UC:
o Medical emergency
o High dose IV Methylprednisolone
o Oral 5-ASA should be stopped
o Antibiotics can be used with bacteraemia
o Parenteral nutrition needed until improvement or surgery
o Surgical Treatment
Colectomy with an ileostomy or ileojejunal pouch
UC PACES tip 7
- Explain the diagnosis (condition with unknown cause that leads to inflammation of the bowel, which leads to symptoms)
- Explain that it isn’t common but is a well-known disease (1 in 420
- Explain that there is no cure, and it is a condition that tends to come and go in flare- ups every so often
- Reassure that there are medications that can be used to reduce the likelihood of flare-ups and to treat flare-ups when they happen
- Explain the complications (growth issues, bowel cancer)
- Explain that they will be seen by a gastroenterologist
- Support: Crohn’s and Colitis UK
CD Mx inducing remission, if not tolerated, immunosuppressive/biologic therapies, maintaining remission, diet
• Assess impact of symptoms on daily functioning (anxiety, depression)
Replace diet with whole protein modular diet – excessively liquid, for 6-8 weeks
• Encourage stopping smoking (may reduce the risk of relapse)
• Assess risk of osteoporosis
• Inducing remission:
o Corticosteroid monotherapy (prednisolone, methylprednisolone or intravenous hydrocortisone): suitable for first presentation or first inflammatory exacerbation in a 12-month period
If not tolerated, budesonide or aminosalicylates (e.g. mesalazine) may be used If concerns about growth in children/young people, consider enteral nutrition as an alternative
o May add immunosuppressive drugs (azathioprine or methotrexate)
o Or biologic therapies: infliximab and adalimumab
o If disease is limited to the terminal ileum, consider resective surgery
• Maintaining remission:
o Offer azathioprine or methotrexate Including after surgery
• Using these medical therapies requires monitoring of certain biochemical measures (e.g. ferritin, B12, calcium and vitamin D)
• Educate about features of Crohn’s flare up (e.g. unintended weight loss)
• Patients on immunosuppressive therapies should not have live vaccines. They are at increased risk of influenza and pneumococcal infection so should receive these vaccines.
Define intussusception and the most common location
• Invagination of proximal bowel into distal component; 95% ileum through to caecum through ileocecal valve (ilio-colic)
o Most common cause of obstruction in infants of the neonatal period – 3 months to 2 years old (rarely <3m)
Intussusception
Mx of intussusception
• ABCDE approach
• IV fluids and NG tube aspiration may be needed
• Unless there are signs of peritonitis, reduction of the intussusception by rectal air insufflation
(with fluoroscopy guidance) is usually attempted by a radiologist
o Success rate is 75%
o Remaining 25% require an operation
• Clinically stable with no contraindications to contrast enema reduction
o Fluid resuscitation
o Contrast enema (air or contrast liquid e.g. Barium or Gastrograffin)
o Contraindications
Peritonitis Perforation Hypovolaemic shock
o Broad-spectrum antibiotics
Clindamycin + gentamicin OR tazocin OR cefoxitin + vancomycin
o 2nd line: surgical reduction with broad-spectrum antibiotics
• If recurrent intussusception - consider investigating for a pathological lead point (e.g. Meckel’s diverticulum)
Foreign body inhalation Mx conscious 5 unconscious 3
• Conscious
o Encourage coughing
o External maneuvers
Back blows (x 5)
Abdominal thrusts (Heimlich) (x 5)
• NOTE: these should NOT be done on infants and very young children
• Chest thrusts for infants (x 5)
o Removal of foreign body
1st line: Flexible bronchoscopy or rigid bronchoscopy
• Rigid bronchoscopy is preferred in cases of stridor, asphyxia, radio- opaque object seen on CXR, a history of foreign body aspiration associated with unilateral decreased breath sounds, localising wheeze, obstructive hyper-inflation, or atelectasis
• In all other cases, flexible bronchoscopy should be performed to confirm the diagnosis
• This is usually done with conscious sedation or general anaesthesia 2nd line: surgery, thoracotomy
• Unconscious
o Secure the airway immediately (endotracheal intubation)
Unless the foreign body can be seen and removed from the upper airway May need to do a cricothyroidotomy
o Removal of foreign body (as above)
MMR counselling
Counselling
I am glad you came in to discuss these things with me, I can see that you really want to do the best for your child and it is really difficult with so much information online and no way to police it, especially forums.
I want to start by talking about finns development. I think that he is doing very well. Every child is different and that is why there are such variations in the time that we expect children to achieve different milestones. In terms of his walking, we would expect him to walk any time now and only look into this further if it gets to 18 months. The same is true of him feeding himself and saying 6 words with meaning.
He was also born a bit early so we have to remember that when we look at him as an overall person.
So in summary, for his development I don’t see anything to be concerned about and he seems like a very happy boy
I want to address your concerns about the MMR vaccine.
Can you tell me exactly what you understand about it and the link to autism?
This link was first introduced by a man called Andrew Wakefield. He published a study that suggested a link between the vaccine and autism. However, the paper had a number of faults in it. In fact the paper has since been retracted, disproved by a number of large studies and the council that checks doctors are acting ethically actually took away his licence so he isn’t allowed to practice medicine in the UK any more.
The specific issues with his study was that it only looked at 12 cases.
He also had a lot to benefit from this – he had a patent for MMR alternative vaccines which means that if people used these vaccines more he would earn more money.
He also didn’t include some of his data in his publication, this data went against his conclusions.
There have since been larger studies which have disproved the link between autism and any link between MMR and bowel disease.
The vaccine has never had mercury in it.
There are sometimes additives put into the vaccine in tiny doses that are checked to be safe. The reason they are added is because they help the immune system see the virus and build a stronger level of immunity towards it.
The concept of herd immunity is true however WHO say that 95% of people have to receive the MMR vaccine to ensure herd immunity. This has to include those who have weak immune systems that can’t tolerate a vaccine. In fact in 2018 only 91% of babies had received the vaccine so herd immunity doesn’t apply here unfortunately.
Why MMR is important
Protects against three illnesses in 2 separate doses. It protects against measles mumps rubella. These have a lot of nasty complications but the most worrying is called encephalitis. This is an infection of the brain tissue.
Side effects of MMR
- Ill for a few days – mild temperature
Obesity Mx 5 and 1 Pharmacological
Most obese children can be managed in primary care. MDT approach
Diet
NICE does not recommend using a dietary approach alone.
Tailor any dietary changes to individual preferences. Allow a flexible, individual approach.
Do not recommend unduly restrictive, nutritionally unbalanced diets.
It may be helpful to keep a food diary (assists cognitive approach). Do not forget snacks and
drinks.
It is very unpleasant being hungry and, rather than just cutting back on all food, it may be easier to move to a diet with less fat and more fibre in it.
NICE advises that calorie intake should be below energy expenditure, but gives no specifics
about diet or numbers of calories. It emphasises the general benefits of healthy eating.
There may be occasions where there is benefit in referral to a dietician, particularly where
there is a large amount of weight to be lost and caloric cut has to be balanced by adequate
nutrition for ongoing developmental needs.
This is not easy for the patient and it is important to be positive and reinforcing.
Exercise
The value of exercise is more than just the calories expended in the session. It tends to increase basal metabolic rate and, after vigorous exercise, metabolism is stimulated for the subsequent 36 hours. It has cardiovascular benefit, and reduces the risk of diabetes. It also promotes a sense of well-being.
Overweight children often shun exercise because of poor mobility, ready fatigue and “being no good at games”. It is important to discuss the options to find something appropriate and sustainable. The age and aptitudes of the individual must be taken into account. It must be something that the individual will enjoy or he or she will not persevere. This is very important, as the ethos of exercise is not just for the duration of weight loss but for life.
NICE recommends a total of 60 minutes of at least moderate exercise each day (in one session, or more, shorter sessions lasting a minimum of 10 minutes). Overweight children may need more than 60 minutes.
Exercise need not always be ‘formal’ - walking, using stairs, cycling and active play all count.
Reduce time spent on inactive pursuits, such as watching television and playing video games.
It is very helpful to involve all the family in development of an active lifestyle
Behavioural therapy should involve Stimulus control Self-monitoring Goal setting Rewards for reaching goals Problem solving
Pharmacological
Orlistat is the only licensed obesity drug in the UK – pancreatic lipase inhibitor
Reserved for children 12 years or older if co-morbidities present and lifestyle
management is not sufficient
Bariatric surgery is only considered once child has reached physical/psychological maturity , in extreme cases with complications and all other methods have failed
Pyloric stenosis Mx 2
• IV fluid resuscitation
o This is essential to correct the fluid and electrolyte disturbance before surgery
o This should be provided at 1.5 x maintenance rate with 5% dextrose + 0.45% saline
o Add potassium once urine output is adequate
• Definitive treatment is by performing a Ramstedt pyloromyotomy
o This involves dividing the hypertrophied muscle down to but not including the mucosa
o Can be open or laparoscopic
GOR Mx breast 2 formula 3 and positional 2
Gastro-oesophageal Reflux
• Reassure
o It is very common
o Begins early (< 8 weeks) and may be frequent
o It usually becomes less frequent with time
o Treatment and investigation are not usually needed
• Review infant or child if:
o Projectile regurgitation
o Bile-stained vomit or haematemesis
o New concerns (e.g. faltering growth, feeding difficulties)
o Persistent, frequent regurgitation beyond the first year of life
• Same day referral if: haematemesis, melaena or dysphagia present
• Initial Management
o If breastfed:
Carry out a breastfeeding assessment
If issue persists despite advice, consider trial of alginate therapy for 1-2 weeks (stop at intervals to check whether the infant has recovered)
o If formula-fed:
Review feeding history
Reduce feed volumes if excessive for infant’s weight (aim for 150-180 mL/kg/day)
FIRST: Offer a trial of smaller, more frequent feeds
SECOND: Offer a trial of thickened formula or anti-regurgitant formula
THIRD: Offer alginate therapy without feed thickeners if the above hasn’t worked (stop at 2-week intervals to see if the infant has recovered)
Trials are recommended to last 1-2 weeks
o Positional:
Advise about upright positioning after feeds and avoiding overfeeding
Prone and left-lateral positioning helps but should be used when awake
Do NOT use positional management in a sleeping infant (they should sleep on their back)
o Pharmacological Management
Consider 2-4-week trial of PPI or histamine antagonist in children who have 1 or more of the following:
• Unexplained feeding difficulties (refusing feeds, choking)
• Distressed behaviour
• Faltering growth
• No resolution respite 1-2 week trial of alginate therapy Consider specialist referral if still no resolution
• Last Resort Options
o Enteral feeding (if failure to thrive)
o Nissen fundoplication
The fundus of the stomach is wrapped around the intra-abdominal oesophagus Abdominal or laparoscopic procedure
• If the child fails to respond to these measures, other diagnoses e.g. cow’s milk protein allergy should be considered
