Paediatric Flashcards
Which babies should have ultrasound scan to check for hip dysplasia?
(PS: USS is only good for <6months due to insufficient ossification of hip. >6months will need hip radiograph)
- all babies that were breech at any point from 36 weeks (even if not breech by time of delivery)
- babies born before 36 weeks who had breech presentation
- all babies with a first degree relative with a hip problem in early life
- Multiple pregnancy - ie if one of a pair of twins is breech, both should be screened
What are the risk factors of developmental dysplasia of hip (old term: congenital dislocation of hip)?
female sex: 6 times greater risk
breech presentation
positive family history
firstborn children
oligohydramnios
birth weight > 5 kg
congenital calcaneovalgus foot deformity
?spina bifida
?metatarsus adduction
(the ? is from MCQBank)
Which side of the hip is most commonly affected by DDH (developmental dysplasia of hip)?
Left side
What is the name of the screening check for DDH (developmental dysplasia of hip)?
Barlow and Ortolani
This is done at 6 weeks.
Barlow - to dislocate
Ortolani - to relocate
How do you manage a baby with DDH (developmental dysplasia of hip)?
Nothing usually as the unstable hip should normally stabilise by 3-6 weeks of age
If less than 4 or 5 months, Pavlik harness (dynamic flexion-abduction orthosis)
If older - may require surgery.
What are the features of Patau syndrome? (trisomy 13)
Microcephalic (small head)
Small eyes (micro-ophthalmia)
Cleft lip/palate
Polydactyly
Cardiac defect
Scalp lesions
Neural tube defect
Learning difficulty
Does not survive past a few weeks
What are the features of Edward’s syndrome? (trisomy 18)
microcephaly
micropthalmia
microstomia
Micrognathia (small jaw)
Low-set ears
Rocker bottom feet
Overlapping of fingers/clenched fingers
VSD
unusual to live past 7 yo - many die in utero
What are the features of Fragile X syndrome?
X-linked chromosome disorder
Learning difficulties & autism
Macrocephaly (large head)
Long face
Large ears
Macro-orchidism
mitral prolapse
pes planus
What are the features of Noonan syndrome?
AKA ‘Turner-like’ syndrome
Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis
Hypertelorism
Low set ears
micrognathia
delayed puberty in males (but no change in females)
lymphoedema of hand and feet
low hairline
small chin
Autosomal dominant disease
What are the features of Pierre-Robin syndrome?
Micrognathia
Glossoptosis - Posterior displacement of the tongue (may result in upper airway obstruction)
Cleft palate
THis is not an inherited disease! patient often improves as they grow.
PS: this condition has many similarities with Treacher-Collins syndrome. One of the key differences is that Treacher-Collins syndrome is autosomal dominant so there is usually a family history of similar problems.
What are the features of Prader-Willi syndrome?
Complex genetic condition - usually not inherited!
Infants: Hypotonia, poor feeding, developmental delay
Children: hyperphagia, gross obesity
Learning difficulty, Hypogonadism, Short height with small hands and feet
What are the features of William’s syndrome (deletion of chromosome 7)?
Short stature
Learning difficulties
underdeveloped cheeks
short nose
broad forehead
Friendly, extrovert personality
Transient neonatal hypercalcaemia
Supravalvular aortic stenosis
What are the features of Cri du chat syndrome (chromosome 5p deletion syndrome)?
Characteristic cry (hence the name) due to larynx and neurological problems
Feeding difficulties and poor weight gain
Learning difficulties
Microcephaly and micrognathism
Hypertelorism- increased lateral distance between orbits
How to treat eczema in children?
simple emollients
topical steroids
wet wrapping (large amounts of emollient applied under wet bandages)
in severe cases: oral ciclosporin
What ‘Inattention’ features are associated with ADHD?
Does not follow through on instructions
Reluctant to engage in mentally-intense tasks
Easily distracted
Finds it difficult to sustain tasks
Finds it difficult to organise tasks or activities
Often forgetful in daily activities
Often loses things necessary for tasks or activities
Often does not seem to listen when spoken to directly
What ‘Hyperactivity/Impulsivity’ features are present in ADHD child?
Unable to play quietly
Talks excessively
Does not wait their turn easily
Will spontaneously leave their seat when expected to sit
Is often ‘on the go’
Often interruptive or intrusive to others
Will answer prematurely, before a question has been finished
WIll run and climb in situations where it is not appropriate
How many ‘inattention’ and ‘impulsive/hyperactive’ features needed to make a diagnosis of ADHD?
If below 16 years - 6 features
If 17 and above - 5 features
How manage a child with ADHD?
Watch and wait - observe for 10 weeks.
Referral to secondary care.
- Mild-moderate: parental education and training programmes
- Severe: methylphenidate (6 weeks trial first). 2nd line: lisdexamfetamine. 3rd line: Dexamfetamine
Peri-anal itching and seeing white stuff around anus. ?Diagnosis
Threadworm infection (Enterobius vermicularis, sometimes called pinworms)
Treatment of enterobius vermicularis (threadworm infection)?
Single dose of mebendazole to the whole household and advice personal hygiene.
Mebendazole can be used for >6 month old. Single dose is usually sufficient unless infestation persists.
Development Qs - what are the cut-off age to refer?
- Doesn’t smile
- Cannot sit unsupported
- Cannot walk
- Doesn’t smile : 10 weeks
- Cannot sit unsupported : 12 months
- Cannot walk : 18 months
If a baby develops hand preference before 12 months, is this normal?
No. This is a sign that baby may have cerebral palsy.
What is the meaning of enucleation?
Removal of all of the contents of the eye, optic nerve and leaving behind the scleral shell.
Used for ocular malignancy for example
Inheritance pattern for retinoblastoma
Autosomal dominant
10% are hereditary
Good prognosis >90% live to adulthood
What is the cause of retinoblastoma?
autosomal dominant
10% are hereditary
loss of function of the retinoblastoma tumour suppressor gene on chromosome 13
What are the features of retinoblastoma?
absence of red-reflex, replaced by a white pupil (leukocoria) - the most common presenting symptom
strabismus
visual problems
Management options for retinoblastoma
Enucleation
external beam radiation therapy
chemotherapy
photocoagulation
What is cephalohaematoma?
Swelling due to bleeding between the periosteum and the skull.
Most commonly noted in the parietal region and is associated with instrumental deliveries.
The swelling usually appears 2-3 days following delivery and does not cross suture lines.
Jaundice may develop as a complication
It gradually resolves over a number of weeks.
What is caput succadeneum?
bleed in the subcutaneous tissue
generalised superficial scalp oedema, which crosses suture lines.
commonly seen in newborns immediately after birth. It is associated with prolonged labour.
rapidly resolve over a couple of days.
What is subaponeurotic haematoma?
rare condition where bleeding occurs that is not bound by the periosteum.
It can be life threatening and presents as a fluctuant scalp swelling, which is not limited by suture lines.
what is subgaleal bleed?
bleeding in the subaponeurotic space (between periosteum and the epicranial aponeurosis)
typically presents as swelling 12-72hours post-delivery and associated with ventouse deliveries.
What is craniosynostosis?
uncommon and is where there is premature closure of cranial sutures, causing deformity of the skull. It can be evident at birth and may be associated with genetic syndromes.
The shape of the skull will depend upon which sutures are involved.
Other clinical features include early closure of the anterior fontanelle and raised ridge along the fused suture.
What type of diseases follow inheritance pattern of:
- autosomal recessive
- autosomal dominant
autosomal recessive - usually metabolic diseases (exceptions: structural causes such as ataxia telangiectasia and Freiderich’s ataxia)
autosomal dominant - usually structural diseases (exceptions: Gilbert’s, hyperlipidaemia type II)
HERE ARE THE ANOMALIES:
Some ‘metabolic’ conditions : Hunter’s and G6PD are X-linked recessive whilst hyperlipidaemia type II and hypokalaemic periodic paralysis are autosomal dominant
Emergency treatment for severe croup
Oxygen
Nebulised adrenaline
(adrenaline causes vasoconstriction in the upper airway mucosa -> reduces airway oedema and improve airflow)
What is the cause of croup?
Parainfluenza virus
What is peak incidence age for croup?
6 months to 3 years
How to classify the severity for croup?
Mild - no symptoms or signs apart from barking cough.
Moderate - frequent barking cough, easily audible stridor at rest, at rest, suprasternal and sternal wall retraction at rest, no to little distress when agitated, child is happy & playing
Severe - Frequent barking cough
Prominent inspiratory (and occasionally, expiratory) stridor at rest
Marked sternal wall retractions
Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
GP management of croup
single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity
prednisolone is an alternative if dexamethasone is not available
2nd line: pulmincort (budesonide) inhaler
SUFE vs Perthe’s disease
(Age of patients)
SUFE: 10-15 y/o
Perthe’s: 4-8 y/o
How does surfactant help breathing?
reduced surface tension in the alveoli
(leading to)
increase compliance
(leading to)
reduce work of breathing
Why do we give dexamethasone to premature labour mother?
Natural maternal glucocorticosteroids are very important for surfactant production in the foetus, and therefore synthetic steroids are the first line agents for preventing NRDS in pregnancies at risk of pre-term birth.
What is the disease caused by lack of surfactant for newborns?
Surfactant deficient lung disease (SDLD, also known as respiratory distress syndrome and previously as hyaline membrane disease)
What is the risk of a premature newborn not producing surfactant?
26-28 weeks: 50%
30-31 weeks: 25%
Risk factor of surfactant deficient lung disease?
male sex
diabetic mothers
Caesarean section
second born of premature twins
If a baby is born prematurely, when should vaccinations be given?
Gestational age OR chronological age?
Chronological age (ie from when they are born & NOT their predicted gestational date).
What situation should delay vaccination?
Febrile illness/intercurrent infection
Contraindication to vaccine
Anaphylaxis
Contraindication to live vaccine
Pregnancy
immunosuppression
Transient synovitis VS septic arthritis in child
(Hint: presenting complaint differences)
hip pain, limp and recent infective/autoimmune illness : transient synovitis
- ALSO, don’t need to aspirate the joint
if child has full-raging fever - think septic arthritis! (there may be mild fever in transient synovitis)
- ALSO, aspirate the joint to rule this out!
Transient synovitis
AKA irritable hip
most common in children between age 2 and 8 years old & usually following viral infection
There are no x-ray changes. But USS can show fluid inside the joint capsule (but not always present)
Symptoms usually last a few days to 1 week and is self-limiting.
Management is conservative with rest and analgesia.
Immunisation schedule
8 weeks: DTaP, IPV, HiB, HepB, MenB, Rotavirus
12 weeks: DTaP, IPV, HiB, HepB, PCV, Rotavirus
16 weeks: DTaP, IPV, HiB, HepB, MenB
1 yr: HiB, MenC, PCV booster, MMR, MenB booster
3 yrs 4 months: DTaP, IPV, MMR
12-13 years: HPV
14 yrs: Td, IPV, MenACWY
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/899422/PHE_Routine_Childhood_Immunisation_Schedule_Jun2020_03.pdf
What is the treatment for newborns who have patent ductus arteriosus?
Indomethacin / Ibuprofen
Given to the neonate
NOT prostaglandin (as this would make the ductus arteriosus patent). Hence, prostaglandin inhibitor is given.
Gross motor milestones
3 months - Little or no head lag on being pulled to sit, Lying on abdomen, good head control, Held sitting, lumbar curve
6 months- Lying on abdomen, arms extended, Lying on back, lifts and grasps feet, Pulls self to sitting, Held sitting, back straight, Rolls front to back
7-8 months- Sits without support (Refer at 12 months)
9 months- Pulls to standing, Crawls
12 months- Cruises, Walks with one hand held
13-15 months- Walks unsupported (Refer at 18 months)
18 months- Squats to pick up a toy
2 years- Runs, Walks upstairs and downstairs holding on to rail
3 years - Rides a tricycle using pedals, Walks up stairs without holding on to rail
4 years- Hops on one leg
When is normal puberty for girls/boys?
When is precocious puberty for girls/boys?
when is delayed puberty?
Precoccious:
Girls:before 8 y/o
Boys: before 9 y/o
Therefore, normal puberty is after these ages.
Delayed:
Girls: not begun thelarche by 13 or menarche by 15
Boys:
Labial adhesions - what can you find on examination?
thin semitranslucent adhesions completely covering the vaginal opening between the labia minora but not the urethra opening.
patient normally presents with micturition due to urine pooling in the vagina
common age for labial adhesions
3 months and 3 years
treatment for labial adhesions
conservative
if causing too many UTI - oestrogen cream may help
if that fails, surgery
treatment for whooping cough
azithromycin or clarithromycin for non-pregnant OR erythromycin for pregnant adults (if onset of cough is within 21 days)
what causes whooping cough
Bordetella pertussis
(gram negative)
what defines maternal mortality?
during pregnancy, labour or six weeks post-partum
what defines stillbirth
20 (?24) weeks gestation and onwards death
https://www.nhs.uk/conditions/stillbirth/#:~:text=A%20stillbirth%20is%20when%20a,miscarriage%20or%20late%20foetal%20loss
School exclusion for:
- rubella
- whooping cough
- measles
- chicken pox
- mumps
- infectious gastroenteritis
- impetigo
- scarlet fever
Rubella: 6 days from onset of rash
Whooping cough: 2 days after commencing abx or 21 days from onset of symptoms if no abx
Measles: 5 days from onset of rash
Chicken pox: all lesions crusted over
Mumps: 5 days from onset of swollen glands
IG: symptoms have settled for 48hours
Impetigo: until lesions have crusted over OR 48hours after abx started
Scarlet fever: 24 hours after abx started
Which diseases doesn’t need school exclusion?
Conjunctivitis, slapped cheek, roseola, infectious mononucleosis, head lice, threadworms, hand foot and mouth
A 6-year-old boy presents with a 3-day history of fever, mild coryzal symptoms, rash and cervical lymphadenopathy. He has an erythematous, maculopapular rash on his face and neck that has started spreading down his body. Diagnosis?
Rubella
8-year-old girl presents with a 2-day history of fever, lethargy and a sore throat. Over the last few hours, she has developed a pinpoint, sandpaper-like blanching rash that initially appeared on her trunk before spreading to the rest of the body. The area around her mouth is noted to be spared. Her pharynx is inflamed with petechiae noted on the hard and soft palate. Cervical lymphadenopathy is palpable. Diagnosis?
Scarlet fever
- rash with circumoral pallor
- Forchheimer spots
- strawberry tongue (initially white and then red)
- due to Group A strep.
A 5-year-old girl presents with a 2-day history of fever, reduced appetite, abdominal discomfort and a sore mouth. She has scattered ulcerative lesions in her mouth and an erythematous maculopapular rash on the sides of her fingers, dorsum of her hands and margins of her heels. Diagnosis?
Hand, Foot and Mouth
- due to Coxackie virus A16
- incubation period 3 days
- affect children <10y/o
what is the presentation of osteochondritis dissecans?
Joint pain, locking and swelling
It tends to present in older children with a more insidious onset.
When small segments of articular cartilage and bone come loose into the joint due to reduced blood supply.
what is Kocher’s criteria?
Kocher’s criteria is used to assess the probability of septic arthritis in children using 4 parameters:
Non-weight bearing - 1 point
Fever >38.5ºC - 1 point
WCC >12 * 109/L - 1 point
ESR >40mm/hr
The probabilities are calculated thus:
0 points = very low risk
1 point = 3% probability of septic arthritis
2 points = 40% probability of septic arthritis
3 points = 93% probability of septic arthritis
4 points = 99% probability of septic arthritis
Developmental Qs-
think about what babies can say at this age: 3months, 6 months, 9 months, 12 months, 12-15 months, 2 years, 2.5 years, 3 years, 4 years.
3 months- Quietens to parents voice, Turns towards sound. Squeals
6 months- Double syllables ‘adah’, ‘erleh’
9 months- Says ‘mama’ and ‘dada’, Understands ‘no’
12 months- Knows and responds to own name
12-15 months- Knows about 2-6 words (Refer at 18 months), Understands simple commands - ‘give it to mummy’
2 years- Combine two words, Points to parts of the body
2½ years- Vocabulary of 200 words
3 years- Talks in short sentences (e.g. 3-5 words), Asks ‘what’ and ‘who’ questions, Identifies colours, Counts to 10 (little appreciation of numbers though)
4 years- Asks ‘why’, ‘when’ and ‘how’ questions
what vitamins are ALL newborns deficient in?
vitamin K
this can cause haemorrhagic disease of the newborn (HDN). Breast-fed babies are at risk as breast milk is a poor source of vitamin K. Maternal antiepileptic use also increases risk of HDN. THerefore, IM or PO vitamin K to all newborns
what diseases are checked by the heel prick test in the first month of life?
congenital hypothyroidism
PKU
sickle cell
CF
MCADD (medium chain acyl CoA dehydrogenase deficiency)
maple syrup urine disease (MSUD)
isovaleric acidaemia (IVA)
glutaris aciduria type 1 (GA1)
homocystinuria (pyridoxine unresponsive) (HCU)
what type of checks are done to a newborn?
clinical examination
heel prick test at 5-9 days of life
newborn hearing screening programme
give the ‘Personal Child Health Record’ book to mother
what antenatal test are done to the foetus as part of the Child Health Surveillance in UK?
intrauterine growth
maternal infections such as HIV
USS for fetal abnormalities
blood test for neural tube defects
when would health visitor visit the mom + new baby?
when would GP need to examine the new baby?
Health visitor: after 1 month post-delivery
GP: 6-8 weeks
what type of vaccine is MMR?
live attenuated
when would one get MMR vaccine?
12-15months
3-4 years
what is genetic anticipation?
what diseases exhibit genetic anticipation?
Genetic anticipation: earlier age of onset through successive generations
Examples: Huntingdon’s disease, myotonic dystrophy (CTG repeat sequence)
risks of Down syndrome?
1 in 1000 (when at 30 years)
Then divide by 3 for every 5 years after 30y/o. (ie 1:270 at 35yo, 1:100 at 40yo, 1:50 at 45yo)
what are the different types of vaccine?
live attenuated (organism that is still alive but weakened)
inactivated (organism that is dead but contain particles that can allow pick up into the cells)
subunit (uses the antigenic protein from the organism without any genetic material)
toxoid
examples of live attenuate vaccine is used for?
MMR
Chicken pox
BCG
yellow fever
oral polio
typhoid
rotavirus
infuenza
examples of inactivated /killed whole organism vaccine
polio
whole cell pertussis
influenza
Japanese encephalitis
hepatitis A
rabies
examples of subunit vaccine?
HPV
Pertussis
Hep B
influenza
meningoccocal
pneumococcal
examples of toxoid vaccine?
diptheria
tetanus
poor prognostic factors for ALL
age < 2 years or > 10 years
WBC > 20 * 109/l at diagnosis
T or B cell surface markers
non-Caucasian
male sex
Developmental Qs-
think about what babies can do (gross motor): 3months, 6 months, 7-8 months, 9 months, 12 months, 13-15 months, 18 months, 2 years, 3 years, 4 years.
Smile (0-3months)
3 months: Little or no head lag on being pulled to sit, Lying on abdomen, good head control, Held sitting, lumbar curve, transfer object from one hand to another
6 months: Lying on abdomen, arms extended, Lying on back, lifts and grasps feet, Pulls self to sitting, Held sitting, back straight, Rolls front to back
7-8 months: Sits without support (Refer at 12 months)
9 months: Pulls to standing, Crawls
12 months: Cruises, Walks with one hand held
13-15 months: Walks unsupported (Refer at 18 months)
18 months: Squats to pick up a toy
2 years: Runs. Walks upstairs and downstairs holding on to rail, kick ball
3 years: Rides a tricycle using pedals, Walks up stairs without holding on to rail
4 years: Hops on one leg
most common cause of headaches in children
migraine
treatment for migraine in paeds
ibuprofen
oral triptans for >18y/o
nasal sumatriptan is the only triptan with proven efficacy but children do not tolerate the taste in the back of the throat
prophylaxis for paeds migraine
GOSH website states: ‘in practice, pizotifen and propranolol should be used as first line preventatives in children. Second line preventatives are valproate, topiramate and amitryptiline’
what is the inheritance pattern for G6PD deficiency?
X-linked recessive
treatment of scarlet fever
phenoxymethylpenicillin OR azithromycin
A 4-year-old girl presents to the GP with a persistent fever and rash for the last 5 days. She is noted to have cracked, dry lips and peeling hands and fingers. Her mother is concerned and has been giving her regular paracetamol which has not helped. Diagnosis?
Kawasaki disease
- high fever lasting >5 days
- red palms with desquamation
- strawberry tongue
treatment of kawasaki disease
high dose aspirin
(but this may be contraindicated due to risk of Reye’s syndrome)
IV immunoglobulin
echo to screen for coronary artery aneurysm (at diagnosis, then 1-2 weeks and 6-8 weeks after treatment)
inheritance pattern for CF
autosomal recessive
carrier frequency 1 in 25
prevalence 1 in 2500 newborns
what are the organisms that colonise CF patients?
Staph aureus
Pseud aeruginosa
Burkholderia capacia (formerly known as Pseudomonas cepacia)
Aspergillus
what does it mean by ‘low penetrance’ genetic disease
there is abnormal genotype but normal/mild phenotype
puberty for girls - which ones first?
androgens production (adrenarche)
breast development (thelarche) at around 11.5y/o (range from 9-13y/o)
pubic hair development (pubarche)
height spurt - maximum at 12
menarche/menstruation at 13y/o (range 11-15y/o)
puberty in boys - which ones start first?
testicular growth at 12y/o (range 10-15 y/o)
maximum height spurt at 14
management of paeds umbilical hernia
observation (typically resolve by 3y/o)
may consider surgery if persist beyond 3y/o
Associations: Afro-Caribbean infants, Down’s syndrome, mucopolysaccharide storage diseases
Dose of IM benzylpenicillin for suspected meningococcal septicaemia
< 1 year 300 mg
1 - 10 years 600 mg
> 10 years 1200 mg
what ear pathology is common for Down’s patients?
acute otitis media
glue ear
features of Down’s syndrome
upslanting palpebral fissures
prominent epicanthic folds
low-set ears
protruding tongue
what visual problems occur in patients with Down’s?
refractive errors are more common
strabismus: seen in around 20-40%
cataracts: congenital and acquired are both more common
recurrent blepharitis
glaucoma
chest x-ray findings for transient tachypnoea of the newborn
hyperinflation
fluid in the horizontal fissure
chest xray findings in respiratory distress syndrome
ground glass appearance
low volume lungs
chest xray findings in meconium aspiration syndrome
asymmetric patchy opacities
when does transient tachypnoea of newborn usually resolve?
24-48 hours
treatment of 3 month old with regurgitation problems and weight loss
trial 1-2weeks of alginate (eg Gaviscon)
if symptom persist after this- 4 week trial of PPI or H2antagonist
if symptom persist after this, referral to paeds
A 6-week-old baby boy presents to his GP with symptoms of regurgitation and vomiting after feeding. His mother also reports ongoing issues with diarrhoea. He is generally irritable; his mother has also noticed some dry patches of skin on the insides of his elbows. The mother reports that he is formula-fed.
His examination is unremarkable aside from mild eczema of the elbow flexures.
Diagnosis?
Cow’s milk protein intolerance
management of mild to moderate cow’s milk protein intolerance
switch from normal formula to extensive hydrolysed formula
if this does not work, then switch to amino-acid formula
management of child with nocturnal bed-wetting and age less than 5 y/o
reassurance and advice (good fluid intake during the day, avoiding caffeine-containing drinks, ensuring a balanced diet with enough fibre to avoid constipation (which can exacerbate enuresis), encouraging regular daytime toilet use and establishing a routine for emptying the bladder before bedtime)
star reward system
if not working - enuresis alarm
management of child with nocturnal bed-wetting and age more than 7 y/o
tx of overactive bladder >=5yo
desmopression (but only if initial advice/star reward system/enuresis alarm has been trialled and failed) - vasopressin analogue
2nd line: imipramine (TCA) - NOT PRESCRIBED ANY LONGER!
tx of overactive bladder >+5yo : oxybutynin
diagnosis for lack of red reflex in one eye
retinoblastoma
urgent opthalmology referral
can pregnant ladies get the pertussis vaccine?
yes - at 16-32 weeks pregnancy
at what age does pyloric stenosis typically present?
2-6weeks old
investigation and treatment of pyloric stenosis?
Ix: ultrasound
Tx: Ramstedt pyloromyotomy
what is Kallman syndrome?
delayed puberty due to hypogonadotrophic hypogonadism
peripheral cyanosis is common & normal in neonates up to how old? what is the special name for this type of cyanosis?
first 24 to 48 hours of life
acrocyanosis
It is caused by benign vasomotor changes that result in peripheral vasoconstriction and increased tissue oxygen extraction and is a benign condition
what is the test that is used to differentiate cardiac from non-cardiac cause of cyanosis?
nitrogen washout test (AKA hyperoxia test)
- give 100% oxygen for 10 minutes
- ABG done
- pO2 less than 15kPa indicated cyanotic congenital heart disease
treatment of suspected cyanotic heart disease?
supportive
prostaglandin E1 eg alprostadil (this is used to maintain patent ductus arteriosus)
butfinally need to find cause of cyanosis - surgical repair is definitive treatment
what is the typical presentation of turner syndrome?
lymphoedema of hand/feet
short stature
webbed neck
shield chest
widely spaced nipples
high arched palate
short 4th metacarpal
bicuspid aortic valve - thererfore, ejection systolic murmur
horseshoe kidney (most common renal pathology here)
amenorrhoea
also increased incidence of autoimmune disease (esp thyroiditis) and Crohn’s disease.
presentation/signs of Perthe’s disease
hip/groin pain
limited range of movement of affected hip
limited internal rotation and abduction
common presenting complaint of osteoid osteoma
localized pain that is worse at night and relieved by nonsteroidal anti-inflammatory drugs (NSAIDs).
what extra tests are done for paeds UTI case?
urine MSU (only sent as only 50% have pyuria)
DNSA (static isotope scan) to identify scars. Should be done 4-6 months after initial infection.
MCUG (micturating cystourethrography) to identify vesicoureteric reflux. For infants <6months who present with atypical or recurrent infections.
serum IL-6 and matrix metalloproteinase 9 (MMP9) are used for what?
assessment of severe asthma
investigation for developmental dysplasia of hip (aka congenital dislocation of hip)?
ultrasound of newborn hips
if infant is >4.5 months, then x-ray is first line
complications of measles?
otitis media: the most common complication
pneumonia: the most common cause of death
encephalitis: typically occurs 1-2 weeks following the onset of the illness)
subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness
febrile convulsions
keratoconjunctivitis, corneal ulceration
diarrhoea
increased incidence of appendicitis
myocarditis
features of measles
Incubation: 8-12 days
prodromal phase: irritable, conjunctivitis, cough, coryza (3C), fever
Koplik spots: typically develop before the rash, white spots (‘grain of salt’) on the buccal mucosa
rash: starts behind ears then to the whole body, discrete maculopapular rash becoming blotchy & confluent, desquamation that typically spares the palms and soles may occur after a week
diarrhoea occurs in around 10% of patients
Tx: supportive
inheritance pattern for haemophilia A?
X-linked recessive
bow-legs: what is the medical term for this? is this normal for paeds?
genu varum
common in 1-3y/o
resolves spontaneously by 4y/o
(to check for this, the intercondylar distance is increased)
knock knees: what is the medical term for this? is this normal for paeds?
genu valgum
common in 3-4y/o
typically resolves spontaneously
(to check for this, the intermalleolar distance is increased)
In-toeing / Out-toeing
(is this normal for paeds?)
In-toeing: typically presentation for 1 y/o
Out-toeing: Common in early infancy and usually resolves by the age of 2 years
causes of in-toeing
metatarsus adductus: abnormal heel bisector line. 90% of cases resolve spontaneously, severe/persistent cases may require serial casting
internal tibial torsion: difference the thigh and foot ankle: resolves in the vast majority
femoral anteversion: ‘W’ sign resolves in around 80% by adolescence, surgical intervention in the remaining not usually advised
causes of out-toeing
external tibial torsion
flat feet: what is the medical term for this? is this normal for paeds?
pes planue
common for all ages and resolves between 4-8y/o
Orthotics are not recommended
Parental reassurance appropriate
(to check for this, you can see absent medial arch on standing)
xray findings for Perthe’s disease
early changes: widening of joint space
late changes: decreased femoral head and flattening
at what age/stage would you worry about neonatal jaundice?
in the first 24 hours post-delivery
physiological jaundice develops 2-3 days post-delivery and should resolve by 14 days. (and level does not reach higher than 200micromol/L)
causes of neonatal jaundice in the first 24 hours
Haemolytic disease: rhesus haemolytic disease, ABO haemolytic disease, hereditary spherocytosis,glucose-6-phosphodehydrogenase
Infection : CMV, toxoplasmosis, CMV, Herpes Simplex, Syphilis
Increased haemolysis due to haematoma - ie ventouse delivery
Maternal autoimmune haemolytic anaemia: eg SLE
Enzyme deficiencies: Criggler-Najjar, Dubin Johnson, Gilbert’s syndrome
causes of neonatal jaundice from 2-14days
more red blood cells, more fragile red blood cells and less developed liver function.
more commonly seen in breastfed babies
causes of neonatal jaundice after 14 days
biliary atresia
hypothyroidism
galactosaemia
urinary tract infection
breast milk jaundice: jaundice is more common in breastfed babies, mechanism is not fully understood but thought to be due to high concentrations of beta-glucuronidase → increase in intestinal absorption of unconjugated bilirubin
prematurity: due to immature liver function
increased risk of kernicterus
congenital infections e.g. CMV, toxoplasmosis
treatment of paeds pneumonia
Amoxicillin is first-line for all children with pneumonia
Macrolides may be added if there is no response to first line therapy
Macrolides should be used if mycoplasma or chlamydia is suspected
In pneumonia associated with influenza, co-amoxiclav is recommended
treatment of paeds meningitis
Abx: < 3 months: IV amoxicillin (or ampicillin) + IV cefotaxime; > 3 months: IV cefotaxime (or ceftriaxone)
Steroids: < 3 months- don’t give steroids! dexamethsone should be considered if the lumbar puncture reveals any of the following: frankly purulent CSF, CSF white blood cell count greater than 1000/microlitre, raised CSF white blood cell count with protein concentration greater than 1 g/litre, bacteria on Gram stain
colloid IV fluids
cerebral monitoring: mechanical ventilation if respiratory impairment
public health notification and abx prophylaxis of contacts: ciprofloxacin is preferred over rifampicin
what is an Epstein’s pearl?
A congenital cyst found in the mouth. They are common on the hard palate, but may also be seen on the gums where the parents may mistake it for an erupting tooth. No treatment is generally required as they tend to spontaneously resolve over the course of a few weeks.
what is bohn’s nodule?
Bohn’s nodules are mucous gland cysts, frequently located on the buccal or lingual aspects of the alveolar ridges and rarely on the palate.
what is a congenital ranula?
A congenital ranula is a translucent, firm papule or nodule found on the anterior floor of mouth, lateral to lingual frenulum.
Due to rupture of sublingual gland ducts OR obstruction of the sublingual gland
what is alveolar lymphangioma?
Alveolar lymphangioma is bluish fluid-filled lesions on the alveolar ridges, not seen on the palate.
common causes of snoring for children?
obesity
nasal problems: polyps, deviated septum, hypertrophic nasal turbinates
recurrent tonsillitis
Down’s syndrome
hypothyroidism
ALS algorithm for paeds
unresponsive?
shout for help
open airway
look, listen, feel for breathing
give 5 rescue breaths
check for signs of circulation: infants use brachial or femoral pulse, children use femoral pulse
15 chest compressions:2 rescue breaths (see above)
chest compressions should be 100-120/min for both infants and children
depth: depress the lower half of the sternum by at least one-third of the anterior–posterior dimension of the chest (which is approximately 4 cm for an infant and 5 cm for a child)
in children: compress the lower half of the sternum
in infants: use a two-thumb encircling technique for chest compression
which babies normally get transient tachypnoea of newborn?
born via C-section
which babies normally get respiratory distress syndrome post-birth?
premature neonates
low birth weight babies
Male infants
C-section
Hypothermia
Maternal diabetes
Multiple pregnancy
Fhx
feeding intolerance, abdominal distension and bloody stools of preterm neonate - diagnosis to rule out?
necrotising enterocolitis
abdominal xray findings for necrotising enterocolitis
dilated bowel loops (often asymmetrical in distribution)
bowel wall oedema
pneumatosis intestinalis (intramural gas)
portal venous gas
pneumoperitoneum resulting from perforation
air both inside and outside of the bowel wall (Rigler sign)
air outlining the falciform ligament (football sign)
what is roseola infantum?
Exanthem subitum or sixth disease. It is a common childhood illness caused by human herpesvirus 6 (HHV-6) or sometimes human herpesvirus 7 (HHV-7).
affects 6months to 2y/o
The disease usually presents with a sudden high fever lasting for around three days, followed by a characteristic rash consisting of rose-pink macules and papules that appear once the fever subsides. The rash typically starts on the trunk and may spread to the limbs and face. Nagayama spots: papular enanthem on the uvula and soft palate. febrile convulsions occur in around 10-15%. diarrhoea and cough are also commonly seen.
prognosis for cows milk protein intolerance patients?
in children with IgE mediated intolerance around 55% will be milk tolerant by the age of 5 years
in children with non-IgE mediated intolerance most children will be milk tolerant by the age of 3 years
how to reintroduce milk for cows milk protein intolerance patients?
malted milk biscuits
then digestives
then chocolate and yogurt
in GP practice, child presenting with large abdominal mass - you suspect Wilm’s tumour. what should you do next?
paeds review in 48hours
what is hypospadias?
a ventral urethral meatus
a hooded prepuce
chordee (ventral curvature of the penis) in more severe forms
the urethral meatus may open more proximally in the more severe variants. However, 75% of the openings are distally located.
associated conditions include cryptorchidism (present in 10%) and inguinal hernia.
risk of subsequent siblings having the condition is 12%
management of hypospadias
once hypospadias has been identified, infants should be referred to specialist services
corrective surgery is typically performed when the child is around 12 months of age
it is essential that the child is not circumcised prior to the surgery as the foreskin may be used in the corrective procedure
in boys with very distal disease, no treatment may be needed.
causes of obesity in children
growth hormone deficiency
hypothyroidism
Down’s syndrome
Cushing’s syndrome
Prader-Willi syndrome
examples of innocent murmurs in children
Ejection murmurs - Due to turbulent blood flow at the outflow tract of the heart
Venous hums- Due to the turbulent blood flow in the great veins returning to the heart. Heard as a continuous blowing noise heard just below the clavicles
Still’s murmur- Low-pitched sound heard at the lower left sternal edge
why would you prescribe caffeine to a newborn?
as a respiratory stimulant ie weaning off the ventilator
what is osgood schlatter disease?
Inflammation of the area just below the knee where the tendon from the kneecap (patellar tendon) attaches to the shinbone (tibia).
It’s most common in teenagers who participate in sports involving running or jumping but typically presents with localised tenderness over tibial tuberosity and visible enlargement of it rather than joint swelling or locking. Also, Osgood-Schlatter disease causes discomfort on activity but rarely causes pain at rest unlike osteochondritis dissecans.
what developmental aspects would make you think that the child may have cerebral palsy?
Not sitting by 8 months (corrected for gestational age)
Not walking by 18 months (corrected for gestational age)
Early asymmetry of hand function (hand preference) before 1 year (corrected for gestational age)
Persistent toe-walking
what age would most children achieve day continence and night continence?
day continence 2-3 y/o
both day and night continence 3-4 y/o
Treatment of SUFE
SURGERY with insitu screw fixation
Not weight bear on the affected hip.
(We are aiming to prevent osteonecrosis)
Controversy in terms of prophylactic pinning of contralateral side (to avoid SUFE on the other side). Usually do this for patients with global metabolic disease.
What is the fifth disease?
Parvovirus B19
AKA slapped cheek disease, erythema infectiosum
What is the criteria for atypical UTI?
- infected with non-E.coli organisms
- does not respond within 48 hours of abx
- seriously ill or septic
- poor urine flow or raised creatinine
- abdominal or bladder mass
Diet that contained gluten
Wheat (includes kamut and spelt)
Barley
Rye
Triticale
?oats
Simple febrile seizure VS complex febrile seizure VS febrile status epilepticus
Simple: <15min, do not recur in 24hr, complete recovery in 1 hr
Complex: >=1 of the following: partial focal seizure, >15min, recurrence within 24hr, incomplete recovery in 1 hr
Febrile status epilepticus: >=30min or series of full seizure without full recovery that lasts >=30min
young boy scratching peri-anal region - ?diagnosis
Pinworm infection
(enterobius vermicularis)
affect children 5-9y/o
Tx: mebendazole
what is the acid-base balance disturbance for pyloric stenosis?
hypochloraemic hypokalaemia metabolic alkalosis
Tx of chicken pox
bathe lesions with calamine lotion as anti-pruritic
oral aciclovir to immunocompetent adult and older adolescent
antibiotics for secondary infection
complications of chicken pox
secondary infections such as pneumonia, encephalitis
features of fifth disease
incubation period 7-10days
mild prodromal symptoms: 1 week post-exposure and lasts 2-3 days
- headache, fever, sore throat, pruritus, coryza, abdo pain, arthralgia
then symptom free for 7-10 days and then typical exanthem follows:
- bright red, raised, slapped-cheek rash with circumoral pallor and sparing of nasolabial folds
- erythematous maculopapular rash on proximal extremities
- frequent clearing and recurrences for weeks due to stimuli such as exercise, irritation, overheating of skin from bathing or sunlight
Infant breathing : abdominal or diaphragmatic breathing - is this normal?
Yes!
what are the features to show respiratory distress in infant?
RR>60 for at least an hour.
Recession.
Grunting.
Flaring of nasal alae.
Increased oxygen requirement.
Raised anti-streptolysin O titres. ?diagnosis
Can be found in 20-50% of paedatric patients with Henoch Schonlein purpura (HSP)
For adults: Post-streptococcal glomerulonephritis
Normal baseline observation for infant (<1y/o)
RR 30-40
HR 110-160
systolic BP 70-90
Treatment of UTI for >3y/o
Upper UTI: 7-10 days of either cefalexin or co-amoxiclav
Lower UTI: 3 days of either trimethprim (if low risk of resistance), nitrofurantoin (eGFR>45), cefalexin, amoxicillin
what is considered tachycardia for
- newborn
- neonate
- infant
<12 month: >160
12-24month: >150
2-5y/o: >140
What is Forchheimer spots?
small red spots or petechiae seen at the soft palate (usually near the uvula) of patients with rubella, measles and scarlet fever
Tx of nappy rash
Skin care: frequent nappy changes, careful washing with warm water, clean the skin from urine/faeces residue
Barrier cream (eg zinc or metanium ointment)
top hydrocortisone if causing discomfort
topical imidazole cream if candidal infection suspected/confirmed
may need antibiotics if bacterial infection
How to work out the amount of normal saline to give?
10ml/kg
what is impetigo?
infection due to staph aureus OR group a beta-haemolytic strep
-usually in children <6y/o
- multiple itchy macules on face/extremities -> quickly evolve into vesicles/pustules -> rupture leaving honey-coloured crusts
Tx: topical hydrogen peroxide OR topical fusidic acid -> then oral fluclox / erythromycin
Tx of impetigo
good hand hygiene
stay away from schools for 48hours after abx started OR lesions are healed, dry and crusted over
For localised, no-bullous impetigo: hydrogen peroxide 1% cream. If not, fusidic acid 2%. If fusidic acid resistant, use mupirocin 2%
For widespread non bullous impetigo: short course of topical or oral antibiotic
Tx: hygiene, stay away from school for 48hrs post-abx or lesions healed
- localised non-bullous: hydrogen peroxide 1% cream -> fusidic acid 2% -> mupirocin 2%
- widespread non-bullous: TOP/PO antibiotic + topical fusidic acid/mupirocin
(PO fluclox or clari for pen allergic or erythromycin for pregnancy)
How to estimate weight of a child quickly?
(Age +4) * 2
which virus normally causes the following:
- croup
- bronchiolitis
- influenza
- whooping cough
- common cold
Croup: parainfluenza virus
Bronchiolitis: respiratory synctial virus
Influenza
Whooping cough: Bordetella pertussis
Common cold
what is the cxr sign for croup?
Steeple sign - subglottic narrowing
risk factors for necrotising faciitis
maternal use of illicit drugs, chorioamnionitis, HIV positive.
premature infants & low birth weight
congenital abnormalities esp heart and GI
gut dysbiosis
low flow & perfusion states during perinatal events such as placental abruption
respiratory support, feeding type and pharmacological interventions in neonatal stage
x-ray findings of necrotising faciitis
pneumatosis intestinalis, portal venous gas, dilated loops of bowel, extra-luminal air
what is the most common childhood epilepsy?
benign rolandic epilepsy (BRE)
- age 7-10y/o
- focal motor aware seizure, occur at night, one side of face +/- muscles involving with speech/swallowing.
- anti-epileptics may not be needed but can be helpful if tonic-clonic or more frequent
childhood absent seizure
age 4-10y/o
can happen up to 100 times per day
very brief - lasting seconds
will become unconscious
responds well to medication
90% will grow out of the seizure by adulthood
juvenile myoclonic seizure
12-18y/o
different type of seizure - myotonic or tonic-clonic
seizure happen shortly as or after waking up
medication can be needed for life
triggered by flashing light
infantile spasms (West syndrome)
1st year of life
brief spasms or jerks that happens in clusters
each cluster can include 10-100 individual spasms
25% do not respond well to tx (anti-epileptics and steroids)
Lennox-Gastaut syndrome
3-5y/0
most commonly tonic (stiff muscles), atonic (muscles relax) and atypical absences (last longer and child may be responding/aware of surroundings)
very difficult to treat with anti-epileptics
present all the way into adulthood
Chromosome 11 single gene disorder. Autosomal recessive. Causing childhood anaemia and jaundice.
Sickle cell disease
Decreased crown pubis; pubis-heel ratio, libido. Infertility. Gynaecomastia. Poorly developed testes. Learning difficulty. ?diagnosis
Klinefelter syndrome 47XXY, 48XXXY
Intussusception what is it
Small bowel telescope on itself
Sausage shaped abdominal mass
Red currant jelly stool
A good baby who sleeps most of the time, rarely cries, doesn’t drink milk all the time, coarse facial features, macroglossia, hypotonic, large frontal frontanelles, umbilical hernia.
?diagnosis
Congenital hypothyroidism
Digeorge syndrome - features?
hypertelorism
tetralogy of fallot, type B interrupted aortic arch, truncus arteriosus, ventricular septal defect
abnormal ears
shortened philtrum
micrognathia
cleft palate
abnormal T-cells function with recurrent infections
5/7 fever, conjunctival injection, polymorphous rash, strawberry tongue, cracked lips, peripheral oedema, cervical lymphadenopathy
?diagnosis
Kawasaki disease
also can find:
- anaemia
- neutrophilia
- thrombocytosis
- elevated CRP and ESR
what virus causes pancreatitis in children?
measles, varicella
tx of salmonella diarrhoea
no need for abx but notifiable disease in UK
consider abx if <6months, malnourished or immunocompromised
Benign rolandic epilepsy - what is it?
AKA childhood epilepsy with centrotemporal spikes
seizure usually during sleeping or just before waking
- paraesthesia on their lips, tongue, inside of mouth
- seizure interfere with speech and causes drooling
- last for 2 minutes
- conscious
tx of mastoiditis
IV ceftriaxine OD
IV metronidazole TDS
what type of heart defect are these:
- cyanosed newborn baby, no murmur, oligaemic lungs
- 3 month, cyanosis, short systolic murmur at upper left sternal edge, boot shaped heart with oligaemic lungs
- newborn, difficult to feel pulses, short ejection systolic murmur at right upper sternal edges
- 8 week, breathless, sweating, poor feeding. machinery continuous murmur.
- pulmonary atresia
- tetralogy of fallot
- aortic stenosis
- patent ductus arteriosus
signs of risk of dehydration (& hence needing oral rehydration solution)
age <1yo
low birth weight
>5 diarrhoeal stool or >2 vomit in 24hours
unable to tolerate fluids/breastfeed
signs of malnutrition
cause of scarlet fever
streptococcus (group A haemolytic) - eg strep pyogenes
paraquat poisoning - ?presentation
starts after 12 hours
pulmonary haemorrhage oedema
progressive pulmonary fibrosis
liver and renal failure
stages of sickle cell
Splenic sequestration crisis: acute intrasplenic pooling/trapping of large volumes of blood. may be associated with parvovirus B19.
Haemolytic crisis:
hirschsprung’s disease - usually associated with which type of genetic disorder?
trisomy 21
bronchiolitis - ? presenting features
coryzal symptoms for 1-3 days followed by:
- persistent cough
- tachypnoea and/or chest recession
- wheeze and/or crepitations on ausculatation
low grade fever (<39) and reduced feeding can also be seen
ITP vs haemorrhagic disease of newborn
?age of typical patient
ITP: 2-4 yo
Haemorrhagiv disease: newborn
symptoms/signs of lead poisoning
GI disturbance: constipation, n&V, abdo pain
Raised ICP : headache, n&V, drowsiness
symptoms/signs of iron overdose
GI disturbance & haemorrhage
leading to haemodynamic compromise
newborn - unconjugated hyperbilirubinaemia - 12 hours post birth
?diagnosis
ABO incompatibility
at birth - jaundice - distended abdomen - organomegaly - microcephaly
?diagnosis
CMV infection
congenital rubella
toxoplasma
full term infant - breastfed - jaundice day 5 to week 2 - unconjugated - baby is well - no derangement of LFT
?diagnosis
breast milk jaundice
what is haematocolpos?
menstrual blood pooling around the vagina due to imperforate hymen or vaginal or cervical atresia.
6month old - feeding & recurrent chest infection - poor weight gain - pansystolic murmur with loss of second heart sound
?diagnosis
VSD (for pan-systolic murmur)
5 months - irritability, cyanosis, loss of consciousness - CXR: right aortic arch with oligaemic lung fields
?diagnosis
tetralogy of fallot
1 day olf - blue - cardiac failure - no murmur - pulse feels full
?diagnosis
transposition to great areteries
In the order of age, state the type of epilepsy syndromes that can be found:
1st year: infantile spasms
3-5 y/o : Lennox-Gestaut syndrome (diff typse of seizure - atonic, tonic, absence)
4-10y/o : childhood absence epilepsy
7-10 y/o : benign rolandic epilepsy (focal motor seizures occur at night and involve part of the face or swallowing)
12-18 y/o : juvenile myoclonic eplepsy : myoclonic ortonic clonc.
small, erythematoud papules and vesicles
occasionally pustules
lesions are surrounded by diffuse blotchy erythema - giving the appearance of distinct halo.
?diagnosis
erythema toxicum neonatorum
