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