Paediatric core conditions 5 Flashcards
Testicular torsion- basics
- twist of the spermatic cord resulting in testicular ischaemia and necrosis.
- most common in males aged between 10 and 30 (peak incidence 13-15 years)
Testicular torsion- features
- pain is usually severe and of sudden onset
- the pain may be referred to the lower abdomen
- nausea and vomiting may be present
- on examination, there is usually a swollen, tender testis retracted upwards. The skin may be reddened
- cremasteric reflex is lost
- elevation of the testis does not ease the pain (Prehn’s sign)
- Lie of the testis may be horizontal (bell-clapper position)
- In neonatal torsion the patient may be asymptomatic and present as a firm, hard and enlarged testis in a blue scrotum
Testicular torsion: mangement
- treatment is with urgent surgical exploration with fixation of the testicles with bilateral orchidoplexy
- if a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.
- Manual detorsion can be performed if the patient presents early
- Post operatively the patient is provided with scrotal support and advised bed rest for 24 hours and refrain from heavy lifting or exercise for the first few weeks
Testicular torsion: investigations and complications
Investigations
* Doppler ultrasound scan: shows lack of blood flow to the testis
* Surgical exploration confirms the diagnosis
Complications: atrophy or necrosis of the testis, infection, subfertility
Neonatal hypoglycaemia
Normal term babies often have hypoglycaemia especially in the first 24hrs of life but without any sequelae as they can utilise alternate fuels like ketones and lactate. Normally <2.6 mmol/L. Transient hypoglycaemia in the first few hours after birth is common.
Persistent/severe hypoglycaemia may be caused by: Preterm birth (<37 weeks), maternal diabetes mellitus, IUGR, Hypothermia, Neonatal sepsis, Inborn errors of metabolism.
Neonatal hypoglycaemia: features
- May be asymptomatic
- Autonomic (hypoglycaemia -> changes in neural sympathetic discharge)= jitteriness, irritable, tachypnoea, pallor
- Neuroglycopenic= poor feeding/sucking, weak cry, drowsy, hypotonia, seizures
- Other features: apnoea, hypothermia
Neonatal hypoglycaemia: management
- Asymptomatic: encourage normal feeding (breast or bottle), monitor blood glucose
- Symptomatic or very low blood gas: admit to the neonatal unit, intravenous infusion of 10% dextrose.
Transient tachypnoea of the newborn: pathophysiology
- It is a parenchymal lung disorder characterised by pulmonary oedema resulting from delayed resorption and clearance of foetal alveolar fluid.
- It is the commonest cause of respiratory distress in the term baby.
- Commonly occurs after a C-section as passage through the birth canal applies external pressure on the thorax to help expel the fluid
- Some babies have delayed resorption of the fluid due to suboptimal epithelial clearance
Transient tachypnoea of the neonate: presentation, diagnosis, management
Presentation= respiratory distress (tachypnoea, increased work of breathing and potentially desaturated/cyanotic)
Diagnosis= TTN is diagnosed both clinically an by hyperinflated lungs and fluid level on the chest x-ray
Management= oxygen support. Should resolve in a couple of days with resorption of lung fluid within the first 3 days of life
Respiratory distress syndrome: surfactant
- Neonatal respiratory distress syndrome (NRDS) is caused by a lack of surfactant.
- Surfactant is a phospholipid-containing fluid produced by type 2 pneumocytes.
- It acts to lower the surface tension in the alveoli helping to keep them open. A lack of surfactant increases surface tension and causes alveoli to collapse, triggering respiratory distress.
- Surfactant is made from around 26 weeks gestation, although adequate levels are not achieved until about 35 weeks. This means premature babies are at increased risk of NRDS.
RDS: diagnosis
- Diagnosis of neonatal respiratory distress syndrome is principally through clinical evaluation.
- A ‘ground glass’ appearance may be seen on chest x-ray.
RDS: management and complications
Management
* Treatment of neonatal respiratory distress syndrome is with intratracheal instillation of artificial surfactant.
* Additionally, if preterm delivery is suspected, giving the mother glucocorticoids before delivery can increase surfactant production in the baby.
Complications= NRDS is a major cause of pre-term infant mortality and so prompt recognition and treatment is essential.
Overfeeding
Really common, uses feeding to settle babies. No sense of ‘fullness’
Signs:
* More than average weight gain
* 8 or more wet nappies per day
* Loose stool
* Milk regurgitation
* Irritability
* Sleep disturbances
What are the appropriate feeding volumes in babies
- 60 ml/kg day 1
- 90 ml/kg day 2
- 120 ml/kg day 3
- 150 ml/kg day 4 and onwards
Preemies and underweight babies may require more. Every 2-3h for 1st few weeks (up to 4h) then longer. Eventually they transition to feeding on demand (when hungry)
Self harm
Very common. 32% of 15 year old females, and 11% of 15yo males
Investigations= usually opportunistic. Full physical exam, opportunities to look for signs
PATHOS instrument to assess suicide risk after adolescent OD
- Have you had Problems for over a month?
- Were you Alone in the house at the time?
- Did you plan the overdose for longer than Three hours?
- Are you feeling HOpeless about the future?
- Were you feeling Sad for most of the time before the overdose?
High risk >2 but use clinical judgment.
Suicide risk- management per BMJ best practise
- ensure safety
- treat any self-harm or underlying physical illness
- determine treatment setting (opt for least restrictive that is also safe and effective)
- safety plan - collaborative, will belong to the patient
- psychotherapy (e.g. CBT, counseling, …)
- treat any underlying psychiatric illness (e.g. depression, anxiety)
How is weight faltering defined
- falling across 2 major weight centile lines
- or being at a weight centile 2+ centiles below length/height
- or head circumference or weight centile below 2nd centile for age
When is it normal for babies to loose weight
-Babies often lose up to 10% of birthweight in the first few days from fluid shifts but should have regained birthweight by 2 weeks.
-This is why the UK-WHO growth charts centile lines start at 2 weeks of age, rather than birth.
-Infants who become acutely ill often lose weight but usually regain their centile within 2-3w
-Some infants with severe IUGR remain small, though most exhibit catch-up growth
Weight faltering- investigations
Thorough feeding history
-Hx of milk feeding, age at weaning, range and type of foods, 3d food diary
-Mealtime routine, eating and feeding behaviors
Observed feeding if possible
Any psychosocial problems at home?
Further Ix only needed if faltering is severe and/or other comorbidities or red flags are identified:
-FBC, ferritin, U+E, coeliac screen, LFTs, bone panel, genetic, urinalysis/stools MCS
-Consider hospital admission to observe
Weight faltering- psyhosocial causes
inadequate feeding - feeding problems, insufficient or unsuitable food offered, no regular feeding times, conflict over feeding, parental intolerance of normal feeding behavior, food unavailable
psychosocial deprivation - mother-infant interaction, maternal depression or other mental health disorder, poor maternal cognitive function
neglect or child abuse - includes factitious illness - deliberate underfeeding to generate weight faltering
Psychosocial causes of weight faltering- management
- health visitor - observations, food diaries
- pediatric dietician or SALT may help
- input from clinical psychologist, social services
- nursery placement may help alleviate stress
- mothers’ and parents’ groups may help
Strategies for increasing food intake
Dietary
- 3 meals and 2 snacks /day
- Increase number + variety of foods
- Allow to self-feed, even if messy
- Increase energy density of foods (e.g. add cheese, butter, cream to fortify foods)
- Limit milk intake, use infant formula until 12 m
- Avoid XS fruit juice and diluted cordial drinks
Behavioral
- regular meal times
- praise when eating well, ignore when not
- limit mealtime to 30 min
- eat at same time as child
- avoid mealtime conflict
- never force feed
Caput succadeneum vs cephalohematoma
caput succedaneum - fluid collection on scalp outside periosteum. causes - pressure on an area of scalp during delivery. usually mild or no bruising. resolves in a few days, no treatment needed
cephalohematoma - blood collection below periosteum. center usually feels soft. resolves over w/m, risk of anemia and jaundice
Chignon and Subaponeurotic haemorrhage- birth injury
Chignon- oedema and bruising from ventouse delivery
Subaponeurotic haemorrhage- very uncommon. Diffuse, boggy swelling of scalp. Blood loss may be severe, can lead to hypovolaemic shock and coagulopathy
Facial paralysis and Erb’s palsy- birth injury
Facial paralysis- typically associated with forceps delivery. Normally function returns spontaneously within a few months. If it doesnt, may require neurosurgical input
Erb’s palsy- (C5/C6 injury) typically associated with shoulder dystocia, traumatic/instrumental delivery, large BW. Results in waiters tip
Fractured clavicle- birth injury
- Large shoulder dystocia, traumatic/instrumental delivery, large BW.
- Conservative management (usually immobilization) – usually heals well
- Main complication – injury to brachial plexus and subsequent nerve palsy
What are some potential manifestations of HSV infections
- Most are asymptomatic.
- Gingivostomatitis – may need IV fluids and aciclovir.
- Skin manifestations – mucocutaneous junctions, e.g. lips and damaged skin.
- Eczema herpeticum – may result in secondary bacterial infection and sepsis.
- Herpetic whitlows – painful pustules on the fingers.
- Eye disease – blepharitis, conjunctivitis, and corneal ulceration.
- CNS – aseptic meningitis, encephalitis.
- Pneumonia and disseminated infection in the immunocompromised
Chicken pox (VZV)- features and treatment
- Clinical features – fever and itchy, vesicular rash, crops of lesions arising at different times for up to 7 days.
- Treatment is mainly supportive; IV aciclovir for severe chickenpox and for immunocompromised children
- Human varicella zoster immunoglobulin – if immunocompromised and in contact with chickenpox or if there is maternal chickenpox shortly before or after delivery
Complications and transmission of chicken pox
Rare but serious complications incl.
Encephalitis, 2ndary bacterial infection, purpura fulminans, pneumonia, disseminated haemorrhagic chickenpox
Transmission: respiratory droplets, contact with lesions
Chicken pox- red flags
- Child with chickenpox whose fever settles but then recurs a few days later: Secondary bacterial infections
- Beware of admitting a chickenpox contact to a clinical area with immunocompromised children: can disseminate and cause potentially fatal disease
EBV
- Infectious mononucleosis (aka glandular fever)
- Also involved in Burkitt lymphoma, lymphoproliferative disease (immunocomp), and nasopharyngeal carcinoma
- A lymphotropism of B cells (also epithelial cells of the oropharynx)
- Transmission: saliva
Features of infective mononucleosis
Main features:
- fever
- malaise
- lymphadenopathy
- tonsillitis/pharyngitis
Other features:
- petechiae on soft palate
- hepatosplenomegaly
- maculopapular rash
- jaundice
Sx may persist for 1 to 3m
Infectious mononucleosis management
supportive
if airway compromised, corticosteroids
note= ampicillin or amoxicillin can cause a florid maculopapular rash in children infected with EBV and should therefore be avoided
CMV: transmission, features and treatment
- Transmission: saliva, genital secretions, breastmilk, rarely blood products, organ transplants and transplacentally
- Features: may cause mild mononucleosis like syndrome. Main risk is congenital CMV infection and infection in the immunocompromised
- Treatment: may include IV ganiclovir, oral valganiclovir, foscarnet or cidofovir
HHV- 6 and HHV-7
- Closely related and have similar presentations, although HHV-6 is more prevalent.
- Most kids infected by age 2, usually from oral secretions of a family member.
- Classically cause roseola infantum (aka exanthema subitum) - high fever, malaise lasting a few d, followed by generalized macular rash
- Frequently misdiagnosed as measles or rubella - should confirm by PCR or serology.
Human parvovirus B19 features and treatment
- usually asymptomatic
- if symptomatic, mild fever, coryza, myalgia, lethargy then slapped cheek rash spreading to limbs
- supportive treatment; it is contagious so stay home
- pregnant, immunocomp, hematological conditions are at risk
- Slapped cheek syndrome
Enterovirus: possible features
- mostly asymptomatic and self-limiting with rash, which may be petechial
- hand, foot, and mouth disease (coxsackie A16 - mild systemic upset, oral ulcers followed by vesicles on the palms and soles)
- eczema coxsackium (affects kids with eczema; causes vesicles, bullae, erosions)
- Supportive treatment
Measles- clinical features
- fever, cough, runny nose, conjunctivitis, marked malaise, Koplik spots, and maculopapular rash.
- Viral resp illness with cold-like symptoms, conjunctivitis, cough, fever
- Incubation 10-14d -> sx -> 2-3 d after sx onset Koplik spots -> 3-5d after sx onset measles rash
Measles- investigations, management and complications
- Investigations: measles specific IgM and IgG and PCR
- Management: self-limiting, supportive, paracetaml/ibuprofin
- Complications: Ear infections followed by HL, diarrhea, pneumonia, encephalitis, SSPE (years later, quite rare). Complications common if malnourished or immunocompromised, still major cause of death in low-income countries
Mumps features
Acute infectious disease caused by paramyxovirus, spread by droplets, fomites, saliva
-Incubation – 2-3 w and then sx last about 9 days
-Not very common now due to MMR vaccine
-Sx – parotitis, tender glands, earache, difficulty chewing, systemic (fever, headache, appetite loss, fatigue)
Mumps: investigations and management
-Ix – clinical diagnosis, confirmed by saliva sample (IgM)
-Mx – notifiable, self-limiting, supportive care, follow-up, isolation
-Complications – rare, epididymo-orchitis, oophoritis, meningitis, encephalitis, deafness, pancreatitis
-Dx – parotid duct obstruction, metabolic disorders
Rubella- features and diagnosis
- Respiratory spread - Incubation - 2-3 w
- Mild disease - lymphadenopathy -> erythematous maculopapular rash (3-5d) (usually) and non-specific symptoms
- Rash is face and neck then spreads down body
- Infectious from 1w before sx to 4d after rash
- Diagnosis: clinical suspicion and saliva swab to confirm
Congenital rubella syndrome
Classic triad:
- congenital cataracts (white pupils)
- SN deafness
- Patent ductus arteriosus (could be pulmonary artery stenosis as well)
Could potentially also result in microcephaly and mental retardation - non-pregnant females should be vaccinated with the live MMR vaccine prior to pregnancy.
Small bowel obstruction in neonates- causes
atresia or stenosis of duodenum, jejunum, or ileum- duodenal atresia is common in Down syndrome. associated with other congenital malformations
meconium ileus- almost all affected neonates have CF
malrotation with volvulus- dangerous, may lead to infarct of entire midgut
Small bowel obstruction in neonates- presentation
May be recognized antenatally on US. Otherwise - persistent, vomiting, bilious (unless above the ampulla of Vater)
- meconium may be passed initially
- then no normal stool
- abdominal distension
Depending on where the obstruction is, presentation may be soon after birth or some days after
Small bowel obstruction in neonates- investigation, diagnosis and management
- Diagnosis made on clinical features and AXR
- If atresia, stenosis, malrotation: fluids and electrolytes then surgery
- If meconium ileus: gastrografin contrast medium, surgery if unsuccessful
Large bowel obstruction in neonates: causes
1) meconium plug - usually passes spontaneously
2) imperforate anus- complex anatomy requiring surgery - initially colostomy then reconstruction when older
3) Hirschsprung disease - absent myenteric nerve plexus in the rectum (may extend along colon). M>F, Down syndrome. Often don’t pass meconium in first 48h, then abdo distension
Causes of bilious vomiting
1) Neonates: volvulus, Hirschsprungs disease, Necrotising enterocolitis, upper GI obstruction including duodenal atresia
2) Infants: upper GI obstruction including strangulated hernia, intussusception, adhesions
