Paediatric Common Conditions 3 Flashcards
What is Laryngomalacia?
seen in infants - the supraglottic larynx is structured in a way that allows it to cause partial airway obstruction. This leads to a chronic stridor on inhalation, when the larynx flops across the airway as the infant breathes in
may resolve on its own or rarely requires tracheostomy
Spot diagnosis:
Softening of the cartilage of the patella
Common in teenage girls
Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting
Usually responds to physiotherapy
Chondromalacia patellae
Spot diagnosis:
Pain, tenderness and swelling over the tibial tubercle
Seen in sporty teenagers
Osgood-Schlatter disease
(tibial apophysitis)
Spot diagnosis:
Knee pain after exercise
Intermittent swelling and locking
Osteochondritis dissecans
Spot diagnosis:
Medial knee pain due to lateral subluxation of the patella
Knee may give way
Patellar sublaxation
Spot diagnosis:
More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination
Patellar tendonitis
Differentials for a limping child?
Trauma
Transient synovitis:
Acute onset, accompanies viral infections, but the child is well or has a mild fever
Mostly in boys aged 2-12 years
Septic arthritis/osteomyelitis
Unwell child, high fever
Juvenile idiopathic arthritis
Limp may be painless
Development dysplasia of the hip
diagnosed as neonate, more common in girls
Perthes disease
More common at 4-8 years, due to AVN of the femoral head
Slipped upper femoral epiphysis
10-15 years - Displacement of the femoral head epiphysis postero-inferiorly
What organism causes measles? What is the incubation period?
RNA paramyxovirus
infective from prodrome until 4 days after rash starts
incubation period = 10-14 days
What features does measles present with?
prodromal phase:
irritable, conjunctivitis, 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 spares the palms and soles may occur after a week
How can measles be investigated and managed?
Ix: IgM antibodies
Mx: mainly supportive
notifiable disease → inform public health
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)
What is Meckel’s diverticulum?
a congenital diverticulum of the small intestine
Rule of 2s
occurs in 2% of the population
is 2 feet from the ileocaecal valve
is 2 inches long
How should a non-immunised child be managed if they come into contact with measles?
MMR within 72 hours
What is the most common cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years?
Meckel’s diverticulum
How does Meckel’s diverticulum present?
abdominal pain mimicking appendicitis
rectal bleeding
intestinal obstruction
- secondary to an omphalomesenteric band (most commonly)
How should Meckel’s diverticulum be investigated and managed?
Ix: Meckel’s scan (technetium scan)
mesenteric arteriography may also be used in more severe cases e.g. transfusion is require
Mx: removal if narrow neck or symptomatic
What is meconium aspiration syndrome?
respiratory distress in the newborn as a result of meconium in the trachea
occurs in the immediate neonatal period
more common in post-term deliveries
Contraindications to lumbar puncture in children with suspected meningitis?
Any signs of raised ICP:
focal neurological signs
papilloedema
significant bulging of the fontanelle
DIC
signs of cerebral herniation
meningococcal septicaemia:blood cultures and PCR for meningococcus instead
What abx should be used to treat meningitis?
< 3 months: IV amoxicillin (or ampicillin) + IV cefotaxime
> 3 months: IV cefotaxime (or ceftriaxone)
What are the 5 key components of meningitis management in children?
Antibiotics
Steroids
Fluids
treat any shock, e.g. with colloid
Cerebral monitoring
mechanical ventilation if respiratory impairment
Public health notification and antibiotic prophylaxis of contacts - ciprofloxacin
What can be given to cover for possible herpetic meningoencephalitis (HSV-1)?
Acyclovir
When should steroids be given to children with meningitis?
NICE advise against giving corticosteroids in children younger than 3 months
dexamethsone should be considered if the lumbar puncture reveals any of the following:
purulent CSF
CSF white blood cell count > 1000/microlitre
raised CSF white blood cell count with protein concentration greater than 1 g/litre
bacteria on Gram stain
Causes of meningitis in <3 month olds?
Group B Streptococcus: usually acquired from the mother at birth. More common in low birth weight babies and following prolonged rupture of the membranes
E. coli and other Gram -ve organisms
Listeria monocytogenes
Causes of meningitis in the 1 month to 6 years category?
Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae
Causes of meningitis in children > 6 years ?
Neisseria meningitidis
Streptococcus pneumoniae
What is mesenteric adenitis?
inflamed lymph nodes within the mesentery
presents similarly to appendicitis, occurs post viral infection
no tx required
What is microcephaly?
occipital-frontal circumference < 2nd centile
What can cause microcephaly?
normal variation
familial e.g. parents with small head
congenital infection
perinatal brain injury e.g. hypoxic ischaemic encephalopathy
fetal alcohol syndrome
syndromes: Patau
craniosynostosis
Give some examples of diseases with a mitochondrial inheritance pattern
Leber’s optic atrophy
MELAS syndrome: mitochondrial encephalomyopathy lactic acidosis and stroke-like episodes
MERRF syndrome: myoclonus epilepsy with ragged-red fibres
Kearns-Sayre syndrome
sensorineural hearing loss
Whilst most DNA is found in the cell nucleus, a small amount of double-stranded DNA is present in the mitochondria.
What are the characteristics of mitochondrial inheritance?
inheritance is only via the maternal line
none of the children of an affected male will inherit the disease
all of the children of an affected female will inherit the disease
Mumps is a caused by RNA paramyxovirus and tends to occur in winter and spring. What is the incubation period?
14-21 days
What clinical features does mumps typically present with?
fever
malaise, muscular pain
parotitis (‘earache’, ‘pain on eating’): unilateral initially then becomes bilateral in 70%
How can mumps be investigated and managed?
Ix:
PCR testing on a saliva swab. The blood or saliva can also be tested for antibodies to the mumps virus
Mx:
rest
paracetamol for high fever/discomfort
notifiable disease
What are the potential complications of mumps?
orchitis - occurs four or five days after the start of parotitis
hearing loss - usually unilateral and transient
meningoencephalitis
pancreatitis
What can cause a napkin (nappy) rash?
Irritant dermatitis
most common cause, irritant effect of urinary ammonia and faeces, creases are characteristically spared
Candida dermatitis
erythematous rash which involve the flexures and has characteristic satellite lesions
Seborrhoeic dermatitis
erythematous rash with flakes, may be coexistent scalp rash
Psoriasis
erythematous scaly rash also present elsewhere on the skin
Atopic eczema
Other areas of the skin will also be affected
How should nappy rash be managed?
disposable nappies are preferable to towel nappies
expose area to air when possible
apply barrier cream (e.g. Zinc and castor oil)
mild steroid cream (e.g. 1% hydrocortisone) in severe cases
management of suspected candidal nappy rash is with a topical imidazole. Cease the use of a barrier cream until the candida has settled
What can cause neck masses in children?
Thyroglossal cyst , Branchial cyst , Dermoid cyst
Thyroid gland
Lymphatic malformations e.g. cystic hygroma
Infantile haemangioma
Lymphadenopathy
How do thyroglossal cysts present?
Located in the anterior triangle, usually in the midline and below the hyoid
Derived from remnants of the thyroglossal duct
Thin walled and anechoic on USS (echogenicity suggests infection of cyst)
How do branchial cysts present?
Usually located anterior to the sternocleidomastoid near the angle of the mandible
Unless infected the fluid of the cyst has a similar consistency to water and is anechoic on USS
How do dermoid cysts present?
Derived from pleuripotent stem cells and are located in the midline
Most commonly in a suprahyoid location
They have heterogeneous appearances on imaging and contain variable amounts of calcium and fat
Causes of an enlarged thyroid in children?
True thyroid lesions are rare in children and usually represent thyroglossal cysts or tumours like lymphoma
How do cystic hygromas present?
result from occlusion of lymphatic channels
painless fluid filled lesions
usually present prior to the age of 2
hypoechoic on USS
How do infantile hemangiomas present?
May present in either triangle of the neck
Grow rapidly initially and then will often spontaneously regress
Plain x-rays will show a mass lesion, usually containing calcified phleboliths
As involution occurs the fat content of the lesions increases
Necrotising enterocolitis is one of the leading causes of death in premature infants. Initial symptoms can include feeding intolerance, abdominal distension and bloody stools.
How can it be investigated?
abdo x-ray
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)
Neonatal blood spot screening is performed at 5-9 days of life. What conditions does it screen for?
congenital hypothyroidism
cystic fibrosis
sickle cell disease
phenylketonuria
medium chain acyl-CoA dehydrogenase deficiency (MCADD)
maple syrup urine disease (MSUD)
isovaleric acidaemia (IVA)
glutaric aciduria type 1 (GA1)
homocystinuria
Transient hypoglycaemia in the first hours after birth is common. What may cause persistent neonatal hypoglycaemia?
preterm birth (< 37 weeks) = MAJOR
IUGR
maternal diabetes mellitus
hypothermia
neonatal sepsis
inborn errors of metabolism
What symptoms may neonatal hypoglycaemia present with?
autonomic (hypoglycaemia → changes in neural sympathetic discharge)
‘jitteriness’
irritable
tachypnoea
pallor
neuroglycopenic:
poor feeding/sucking
weak cry
drowsy
hypotonia , seizures
How should neonatal hypoglycaemia be managed?
asymptomatic =
encourage normal feeding, monitor BM
symptomatic or very low blood glucose =
admit to the neonatal unit, IV infusion of 10% dextrose
What can cause neonatal hypotonia?
neonatal sepsis
Werdnig-Hoffman disease (spinal muscular atrophy type 1)
hypothyroidism
Prader-Willi
Maternal causes:
maternal drugs e.g. benzodiazepines
maternal myasthenia gravis
How does neonatal sepsis present?
What causes it?
Grunting and other signs of respiratory distress are the most common presentation
Early-onset neonatal sepsis is most commonly caused by group B streptococcus
Late- onset can be caused by Staphylococcus epidermidis, Pseudomonas aeruginosa, Klebsiella and Enterobacter
How should neonatal sepsis be investigated and managed?
Ix:
- Urine MCS
- FBC, CRP
- Blood culture
- Blood gases: metabolic acidosis is particularly concerning for neonatal sepsis, particularly a base deficit of ≥10 mmol/L
- LP
Mx:
IV benzylpenicillin with gentamicin
Define nephrotic syndrome
a triad of:
proteinuria (> 1 g/m^2 per 24 hours)
hypoalbuminaemia (< 25 g/l)
oedema
usually caused by minimal change disease in kids
How should nephrotic syndrome in children be managed?
oral prednisolone
Dose: 60 mg/sq.m for 4 weeks, followed by 40
mg/sq.m on alternate days for 4 weeks
What is remission of nephrotic syndrome?
Urine protein negative or trace for 3 consecutive days
What is relapse of nephrotic syndrome? Who is considered to be a frequent relapser?
Relapse – Urine protein 3+ or more for 3 consecutive days
Frequent relapser – 2 or more relapses in 6 months, or 4 or more in 12 months
What are the 5 steps of newborn resus?
- Dry baby and maintain temperature
- Assess tone, respiratory rate, heart rate
- If gasping or not breathing give 5 inflation breaths
- Reassess (chest movements)
- If the heart rate is not improving and <60bpm start compressions and ventilation breaths at a rate of 3:1
Define eneuresis
involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract’
How can nocturnal enuresis (bed wetting) be classified?
primary (the child has never achieved continence) or secondary (the child has been dry for at least 6 months before)
How should nocturnal enuresis be managed?
look for possible underlying causes/triggers
constipation, diabetes mellitus, UTI
general advice:
fluid intake
toileting patterns: encourage to empty bladder regularly during the day and before sleep
reward systems (e.g. Star charts)
should be given for agreed behaviour rather than dry nights e.g. Using the toilet to pass urine before sleep
enuresis alarm : first line after general measures
have sensor pads that sense wetness
desmopressin
particularly if short-term control is needed (e.g. for sleepovers)
What is Noonan syndrome?
‘male Turner’s’
autosomal dominant
cardiac: pulmonary valve stenosis
ptosis
triangular-shaped face
low-set ears
coagulation problems: factor XI deficiency
Flat feet (pes planus) present with an absent medial arch on standing. How should they be managed?
Typically resolves between the ages of 4-8 years
Orthotics are not recommended
Parental reassurance appropriate
How do bow-legs present?
Bow legs (genu varum)
1st-2nd year
Increased intercondylar distance
Typically resolves by the age of 4-5 years
How do Knock knees (genu valgum) present?
3rd-4th year
Increased intermalleolar distance
Typically resolves spontaneously
What can cause childhood obesity?
lifestyle factors
growth hormone deficiency
hypothyroidism
Down’s syndrome
Cushing’s syndrome
Prader-Willi syndrome
associations: Asian, female, taller children
What are the consequences of childhood obesity?
orthopaedic problems: slipped upper femoral epiphyses, Blount’s disease (a development abnormality of the tibia resulting in bowing of the legs), musculoskeletal pains
psychological consequences: poor self-esteem, bullying
sleep apnoea
benign intracranial hypertension
long-term consequences: increased incidence of type 2 diabetes mellitus, hypertension and ischaemic heart disease
What is Ophthalmia neonatorum? Mx?
infection of the newborn eye
organisms include:
Chlamydia trachomatis
Neisseria gonorrhoeae
should be referred for same-day ophthalmology/paediatric assessment
What is Osgood Schlatter disease?
osteochondrosis characterised by inflammation at the tibial tuberosity
mx is supportive
How does pyloric stenosis present?
Ix? Mx?
M>F
5-10% Family history in parents
Projectile non bile stained vomiting at 4-6 weeks of life
Diagnosis is made by test feed or USS
Treatment: Ramstedt pyloromyotomy (open or laparoscopic)
How does intestinal malrotation present? Ix? Mx?
High caecum at the midline
bilious vomiting and obstruction (volvulus)
Ix: upper GI contrast study and USS
Mx: laparotomy, if volvulus is present (or at high risk of occurring) then a Ladd’s procedure is performed
How does Slipped upper femoral epiphysis present? Mx?
typically obese male adolescents
pain is often referred to the knee
limitation to internal rotation
Bed rest and non-weight bearing
What is Omphalitis? Mx?
infection of the umbilicus - most commonly Staphylococcus aureus
risk of portal pyaemia
topical and systemic antibiotics
What are Umbilical granuloma? Mx?
cherry red lesions surrounding the umbilicus, they may bleed on contact and be a site of seropurulent discharge
chemical cautery w silver nitrate
What is a Persistent urachus?
urachus is the tube which attaches the umbilicus to the bladder
peristent urachus is characterised by urinary discharge from the umbilicus
How do persistent vitello-intestinal ducts present? Ix and mx?
umbilical discharge of small bowel content
contrast study and laparotomy and surgical closure
What are the reference ranges for vital signs at:
<1 year
1-2
2-5
5-12
>12 ?
…………….HR………………RR
< 1 110 - 160 30 - 40
1 - 2 100 - 150 25 - 35
2 - 5 90 - 140 25 - 30
5 - 12 80 - 120 20 - 25
> 12 60 - 100 5 - 20
A patent ductus arteriosus is a congenital heart defect that results in a connection between the pulmonary trunk and descending aorta.
What features does it present with?
How is diagnosis confirmed?
left subclavicular thrill
continuous ‘machinery’ murmur
large volume, bounding, collapsing pulse
wide pulse pressure
heaving apex beat
dx confirmed on echo
How should a patent ductus arteriosus be managed?
indomethacin or ibuprofen
- given to the neonate , inhibits prostaglandin synthesis
After 1 year of age it is highly unlikely that the PDA will close spontaneously and trans-catheter or surgical closure can be performed
What is the Perinatal mortality rate?
stillbirths + early neonatal deaths (within 7 days) per 1,000 births after 24 weeks gestation
How do you calculate maternal mortality rate?
Maternal mortality rate = deaths in pregnancy, labour & 6 weeks afterwards / total maternities * 1000
How do you calculate stillbirth death rate?
Stillbirth rate = babies born dead after 24 weeks / total births (live + stillborn) * 1000
How do you calculate neonatal death rate?
Neonatal death rate = babies dying between 0-28 days / total live births * 1000
What is Perthe’s disease? Presenting features?
degenerative condition affecting the hip joints of children (typically 4-8 years) , due to avascular necrosis of the femoral head
hip pain: develops progressively over a few weeks
limp
stiffness and reduced range of hip movement
x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening
Complications of Perthe’s disease?
osteoarthritis
premature fusion of the growth plates
How should Perthe’s disease be managed ?
To keep the femoral head within the acetabulum: cast, braces
If less than 6 years: observation
Older: surgical management with moderate results
Operate on severe deformities
