Paediatric Common Conditions 3

Question 1

What is Laryngomalacia?

Answer 1

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

Question 2

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

Answer 2

Chondromalacia patellae

Question 3

Spot diagnosis:
Pain, tenderness and swelling over the tibial tubercle
Seen in sporty teenagers

Answer 3

Osgood-Schlatter disease
(tibial apophysitis)

Question 4

Spot diagnosis:
Knee pain after exercise
Intermittent swelling and locking

Answer 4

Osteochondritis dissecans

Question 5

Spot diagnosis:
Medial knee pain due to lateral subluxation of the patella
Knee may give way

Answer 5

Patellar sublaxation

Question 6

Spot diagnosis:
More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination

Answer 6

Patellar tendonitis

Question 7

Differentials for a limping child?

Answer 7

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

Question 8

What organism causes measles? What is the incubation period?

Answer 8

RNA paramyxovirus

infective from prodrome until 4 days after rash starts
incubation period = 10-14 days

Question 9

What features does measles present with?

Answer 9

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

Question 10

How can measles be investigated and managed?

Answer 10

Ix: IgM antibodies
Mx: mainly supportive
notifiable disease → inform public health

Question 11

Complications of measles?

Answer 11

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)

Question 12

What is Meckel’s diverticulum?

Answer 12

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

Question 13

How should a non-immunised child be managed if they come into contact with measles?

Answer 13

MMR within 72 hours

Question 14

What is the most common cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years?

Answer 14

Meckel’s diverticulum

Question 15

How does Meckel’s diverticulum present?

Answer 15

abdominal pain mimicking appendicitis
rectal bleeding
intestinal obstruction
- secondary to an omphalomesenteric band (most commonly)

Question 16

How should Meckel’s diverticulum be investigated and managed?

Answer 16

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

Question 17

What is meconium aspiration syndrome?

Answer 17

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

Question 18

Contraindications to lumbar puncture in children with suspected meningitis?

Answer 18

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

Question 19

What abx should be used to treat meningitis?

Answer 19

< 3 months: IV amoxicillin (or ampicillin) + IV cefotaxime
> 3 months: IV cefotaxime (or ceftriaxone)

Question 20

What are the 5 key components of meningitis management in children?

Answer 20

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

Question 20

What can be given to cover for possible herpetic meningoencephalitis (HSV-1)?

Answer 20

Acyclovir

Question 21

When should steroids be given to children with meningitis?

Answer 21

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

Question 22

Causes of meningitis in <3 month olds?

Answer 22

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

Question 23

Causes of meningitis in the 1 month to 6 years category?

Answer 23

Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae

Question 24

Causes of meningitis in children > 6 years ?

Answer 24

Neisseria meningitidis Streptococcus pneumoniae

Question 25

What is mesenteric adenitis?

Answer 25

inflamed lymph nodes within the mesentery presents similarly to appendicitis, occurs post viral infection no tx required

Question 26

What is microcephaly?

Answer 26

occipital-frontal circumference < 2nd centile

Question 27

What can cause microcephaly?

Answer 27

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

Question 28

Give some examples of diseases with a mitochondrial inheritance pattern

Answer 28

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

Question 29

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?

Answer 29

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

Question 30

Mumps is a caused by RNA paramyxovirus and tends to occur in winter and spring. What is the incubation period?

Answer 30

14-21 days

Question 31

What clinical features does mumps typically present with?

Answer 31

fever malaise, muscular pain parotitis ('earache', 'pain on eating'): unilateral initially then becomes bilateral in 70%

Question 32

How can mumps be investigated and managed?

Answer 32

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

Question 33

What are the potential complications of mumps?

Answer 33

orchitis - occurs four or five days after the start of parotitis hearing loss - usually unilateral and transient meningoencephalitis pancreatitis

Question 34

What can cause a napkin (nappy) rash?

Answer 34

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

Question 35

How should nappy rash be managed?

Answer 35

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

Question 36

What can cause neck masses in children?

Answer 36

Thyroglossal cyst , Branchial cyst , Dermoid cyst Thyroid gland Lymphatic malformations e.g. cystic hygroma Infantile haemangioma Lymphadenopathy

Question 37

How do thyroglossal cysts present?

Answer 37

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)

Question 38

How do branchial cysts present?

Answer 38

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

Question 39

How do dermoid cysts present?

Answer 39

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

Question 40

Causes of an enlarged thyroid in children?

Answer 40

True thyroid lesions are rare in children and usually represent thyroglossal cysts or tumours like lymphoma

Question 41

How do cystic hygromas present?

Answer 41

result from occlusion of lymphatic channels painless fluid filled lesions usually present prior to the age of 2 hypoechoic on USS

Question 42

How do infantile hemangiomas present?

Answer 42

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

Question 43

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?

Answer 43

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)

Question 44

Neonatal blood spot screening is performed at 5-9 days of life. What conditions does it screen for?

Answer 44

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

Question 45

Transient hypoglycaemia in the first hours after birth is common. What may cause persistent neonatal hypoglycaemia?

Answer 45

preterm birth (< 37 weeks) = MAJOR IUGR maternal diabetes mellitus hypothermia neonatal sepsis inborn errors of metabolism

Question 46

What symptoms may neonatal hypoglycaemia present with?

Answer 46

autonomic (hypoglycaemia → changes in neural sympathetic discharge) 'jitteriness' irritable tachypnoea pallor neuroglycopenic: poor feeding/sucking weak cry drowsy hypotonia , seizures

Question 47

How should neonatal hypoglycaemia be managed?

Answer 47

asymptomatic = encourage normal feeding, monitor BM symptomatic or very low blood glucose = admit to the neonatal unit, IV infusion of 10% dextrose

Question 48

What can cause neonatal hypotonia?

Answer 48

neonatal sepsis Werdnig-Hoffman disease (spinal muscular atrophy type 1) hypothyroidism Prader-Willi Maternal causes: maternal drugs e.g. benzodiazepines maternal myasthenia gravis

Question 49

How does neonatal sepsis present? What causes it?

Answer 49

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

Question 50

How should neonatal sepsis be investigated and managed?

Answer 50

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

Question 51

Define nephrotic syndrome

Answer 51

a triad of: proteinuria (> 1 g/m^2 per 24 hours) hypoalbuminaemia (< 25 g/l) oedema usually caused by minimal change disease in kids

Question 52

How should nephrotic syndrome in children be managed?

Answer 52

oral prednisolone Dose: 60 mg/sq.m for 4 weeks, followed by 40 mg/sq.m on alternate days for 4 weeks

Question 53

What is remission of nephrotic syndrome?

Answer 53

Urine protein negative or trace for 3 consecutive days

Question 54

What is relapse of nephrotic syndrome? Who is considered to be a frequent relapser?

Answer 54

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

Question 55

What are the 5 steps of newborn resus?

Answer 55

1. Dry baby and maintain temperature 2. Assess tone, respiratory rate, heart rate 3. If gasping or not breathing give 5 inflation breaths 4. Reassess (chest movements) 5. If the heart rate is not improving and <60bpm start compressions and ventilation breaths at a rate of 3:1

Question 56

Define eneuresis

Answer 56

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'

Question 57

How can nocturnal enuresis (bed wetting) be classified?

Answer 57

primary (the child has never achieved continence) or secondary (the child has been dry for at least 6 months before)

Question 58

How should nocturnal enuresis be managed?

Answer 58

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)

Question 59

What is Noonan syndrome?

Answer 59

'male Turner's' autosomal dominant cardiac: pulmonary valve stenosis ptosis triangular-shaped face low-set ears coagulation problems: factor XI deficiency

Question 60

Flat feet (pes planus) present with an absent medial arch on standing. How should they be managed?

Answer 60

Typically resolves between the ages of 4-8 years Orthotics are not recommended Parental reassurance appropriate

Question 61

How do bow-legs present?

Answer 61

Bow legs (genu varum) 1st-2nd year Increased intercondylar distance Typically resolves by the age of 4-5 years

Question 62

How do Knock knees (genu valgum) present?

Answer 62

3rd-4th year Increased intermalleolar distance Typically resolves spontaneously

Question 63

What can cause childhood obesity?

Answer 63

lifestyle factors growth hormone deficiency hypothyroidism Down's syndrome Cushing's syndrome Prader-Willi syndrome associations: Asian, female, taller children

Question 64

What are the consequences of childhood obesity?

Answer 64

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

Question 65

What is Ophthalmia neonatorum? Mx?

Answer 65

infection of the newborn eye organisms include: Chlamydia trachomatis Neisseria gonorrhoeae should be referred for same-day ophthalmology/paediatric assessment

Question 66

What is Osgood Schlatter disease?

Answer 66

osteochondrosis characterised by inflammation at the tibial tuberosity mx is supportive

Question 67

How does pyloric stenosis present? Ix? Mx?

Answer 67

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)

Question 68

How does intestinal malrotation present? Ix? Mx?

Answer 68

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

Question 69

How does Slipped upper femoral epiphysis present? Mx?

Answer 69

typically obese male adolescents pain is often referred to the knee limitation to internal rotation Bed rest and non-weight bearing

Question 70

What is Omphalitis? Mx?

Answer 70

infection of the umbilicus - most commonly Staphylococcus aureus risk of portal pyaemia topical and systemic antibiotics

Question 71

What are Umbilical granuloma? Mx?

Answer 71

cherry red lesions surrounding the umbilicus, they may bleed on contact and be a site of seropurulent discharge chemical cautery w silver nitrate

Question 72

What is a Persistent urachus?

Answer 72

urachus is the tube which attaches the umbilicus to the bladder peristent urachus is characterised by urinary discharge from the umbilicus

Question 73

How do persistent vitello-intestinal ducts present? Ix and mx?

Answer 73

umbilical discharge of small bowel content contrast study and laparotomy and surgical closure

Question 74

What are the reference ranges for vital signs at: <1 year 1-2 2-5 5-12 >12 ?

Answer 74

................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

Question 75

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?

Answer 75

left subclavicular thrill continuous 'machinery' murmur large volume, bounding, collapsing pulse wide pulse pressure heaving apex beat dx confirmed on echo

Question 76

How should a patent ductus arteriosus be managed?

Answer 76

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

Question 77

What is the Perinatal mortality rate?

Answer 77

stillbirths + early neonatal deaths (within 7 days) per 1,000 births after 24 weeks gestation

Question 78

How do you calculate maternal mortality rate?

Answer 78

Maternal mortality rate = deaths in pregnancy, labour & 6 weeks afterwards / total maternities * 1000

Question 79

How do you calculate stillbirth death rate?

Answer 79

Stillbirth rate = babies born dead after 24 weeks / total births (live + stillborn) * 1000

Question 80

How do you calculate neonatal death rate?

Answer 80

Neonatal death rate = babies dying between 0-28 days / total live births * 1000

Question 81

What is Perthe's disease? Presenting features?

Answer 81

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

Question 82

Complications of Perthe's disease?

Answer 82

osteoarthritis premature fusion of the growth plates

Question 83

How should Perthe's disease be managed ?

Answer 83

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