Paediatrics Flashcards
How is chronic lung disease of prematurity managed?
prophylaxis / preventions: give mum IM steroids if <34 weeks and consider between 34-36 weeks
Respiratory support: A-E approach - high flow oxygen via nasal cannula or incubator oxygen - if >2L of oxygen then humidify CPAP Invasive ventilation Give surfactant
medications:
- dexamethasone if >/= 8 days and on ventilator
- caffeine citrate if =/<30 weeks corrected gestational age
- nitric oxide: only if pulmonary hypoplasia or pulmonary HTN
How are cleft lip and palate managed?
feeding: early assessment and intervention may be needed e.g. NG tube / specialised teat / dental palate
MDT team for CL / CP:
- early referra
potential airway problems (Pierre-Robin sequence) may occur and need management
pre-surgical: lip taping, oral appliances or pre surgical nasal alveolar moulding may be needed to narrow the cleft
surgery: at 3 months for CL, between 6-12 months for CP
seech and language therapy
may requires orthodontists
How is CMV in the newborn treated?
Urine for CMV and viral PCR
- definitive test for congenital CMV id done in the first 2 weeks of life
Barrier nursing - as CMV is shed in the urine and body secretions
CMV usually has no long term implications
Life threatening infection: IV ganciclovir or Oral valganciclovir
CNS infection: IV ganciclovir or oral valganciclovir (have been shown to prevent long term hearing loss in the babies)
How is a congenital diaphragmatic hernia in children managed?
In utero
o In utero surgical repair, and tracheal plugging or ligation have been attempted
- Outcomes have been variable
Resuscitation after birth o Intubate o Positive pressure ventilation o Wide-bore NG tube (8 Fr) - Aspirate and then leave on free drainage
o IV access
- Sedation and muscle relaxation
o HFOV and exogenous surfactant
- If respiratory failure severe
o Persistent pulmonary hypertension of the New-born
- Common and may require iNO
Surgery o Diaphragmatic defect is closed with primary repair or synthetic patch o Only done after baby is stabilised o Post-operative support may include: - HFOV - iNO - ECMO
How is conjunctivitis in the newborn managed?
all acute cases of bacterial conjunctivitis require an urgent same day referral to an ophthalmologist
Mild bacterial conjunctivitis:
o Chloramphenicol eye drops
• Moderate-severe bacterial conjunctivitis:
o Systemic antibiotics
- Chlamydial: Oral erythromycin
Gonococcal: Single dose of parenteral cefotaxime/ ceftriaxone
- Pseudomonal: Gentamicin eye drops plus systemic antibiotics
• Viral: no specific antiviral, may use topical antihistamine and artificial tears to relieve itching
How is Down syndrome managed?
Urgent PCR for trisomy 21
Full clinical exam especially of CVS
Echocariogram FBC and Blood film Hearing screening test SALT Opthalmologist MDT approach
Support: Down’s Syndrome Association
genetic counselling and early intervention therapies (physiotherapy and occupational therapy for fine motor skills)
individualised educational plan
monitor for associated problems
Why is an echocardiogram done in a suspected down syndrome case?
if abnormal send to cardiologist,
congenital heart defects very common, 45% of Down Syndrome babies have it, mainly AVSD
Why is a blood film and FBC done in a suspected case of Down Syndrome?
10% have transient abnormal myelopoiesis, so baby is at higher risk of leukaemia
polycythaemia also common and need to be excluded
refer to haematologist if suspicious
Which early intervention therapies are suggested in down syndrome?
physiotherapy
occupational therapy
What conditions needs to be monitored for in Down syndrome?
Duodenal atresia o Hirschsprung disease o Coeliac disease o Hypothyroidism o Epilepsy o Hearing and visual defects o Periodontal disease o Atlantoaxial instability
How is GBS prevented?
intrapartum ABx (IV benzylpenicllin / clindamycin if allergy) in women who have:
- a previous baby with an invasive group B streptococcal infection
-group B streptococcal colonisation, bacteriuria or infection in the current
pregnancy
Which medications are given if there are clinical signs of GBS?
Penicillin and gentamicin
If CSF fluid is positive for GBS, how is this managed?
Benzylpenicillin 50mg/kg every 12h (at least 14 days)
and Gentamicin in starting dosage of 5mg/kg every 36h (for 5 days)
- dose adjustments made based on clinical judgement
How is haemolytic disease of the new born prevented?
maternal Anti-D
- at 28 weeks, 34 weeks and birth
-rarely can be given as a single 1500iU between 28-30 weeks
How is haemolytic disease of the newborn managed in newborns?
Resuscitation
- A to E approach particularly if preterm, anaemic or hydropic
o Exchange transfusion
- Indicated if:
• Bilirubin rapidly rising (>8-10 μmol/l/hr) despite adequate phototherapy
• Severe hyperbilirubinaemia insufficiently responsive to phototherapy
and supportive care
• Significant anaemia (Hb <100 g/l)
o Phototherapy
- Do not delay if baby thought to clinically have significant jaundice
• Transcutaneous bilirubin measurement can be taken to confirm/ if
unsure
o IVIG
- Only for immune haemolysis
How is haemolytic disease of the newborn followed up?
check for late anaemia at 4-6 weeks
- consider folate supplementation to protect against this
hearing screen
counsel parents on recurrence in future pregnancies
Which neonates require the Hepatitis B vaccine?
Acute: supportive care
HBsAg positive should receive:
- monovalent hepatitis B vaccine within 24h of birth (also at 4 weeks and 1 year)
- hexavalent (6in1) at normal times
Which neonates require HBIG?
- If mum is HBsAg positive (even if HBeAg negative)
- if mum had acute hepatitis B during pregnancy
- mother had an HBV DNA level equal or above 1/10^6 in any antenatal sample during current pregnancy
HBIG should idealy be given simultaneously with Hep B vaccine but a different site
How is HSV in the neonate managed?
if mum has primary disease 6 weeks before delivery then elective c-section is indicated
if primary infection earlier in pregnancy then offer prophylactic oral aciclovir from 36 weeks until delivery
aciclovir / valaciclovir can be given prophylactically to baby during the ‘at-risk’ period
How is mild HIE managed?
Resucitate
Therapeutic hypothermia
ventilation - consider respiratory support early
Ensure PaCO2 4.5-6 kPa
Cardiovascular:
- consider invasive monitoring of BP and inotropic support early
- consider dobutamine to maintain BP ( > 40 MABP in term infants)
Fluids:
- 60-80% of maintenance
monitor urine output
How is moderate HIE managed?
- Prompt treatment of seizures
• EEG to be considered - Maintain normoglycaemia (2.6-8.0 mmol/l)
- Treat hypocalcaemia if present
- Measure LFTs to assess liver injury
- Ensure IM phytomenadione (vitamin K) is given
- Monitor coagulation
- Withold feeding for at least 48 hours (due to increased risk of NEC)
How is severe HIE managed?
Cranial ultrasound scan
• Important in excluding other causes of encephalopathy e.g.
haemorrhage
-MRI brain
-Consider switching to palliative care
• Continuing efforts with intensive care may be futile
• Requires MDT approach and discussion with family
How is Listeria monocytogenes infection managed?
Amoxicillin and gentamicin (if blood cultures or CSF come back positive for Listeria)
How is meconium aspiration treated?
Use BMJ best practice flow chart
If normal term infant with meconium-stained amniotic fluid but no history of GBS, observation is recommended
• If there are risk factors or laboratory findings that are suggestive of infection, consider antibiotics:
o IV ampicillin AND gentamicin
- Oxygen therapy and non-invasive ventilation (e.g. CPAP) may be used in more severe cases
- Boluses of surfactant and inotropes given in moderate cases
How is necrotising enteroclitis managed?
• Stop enteral feeding and medications
o TPN may be required if feeds stopped >24 hours
o For confirmed NEC cases feeds stopped for 7 days
• NG tube
o Leave on free drain
o Monitor hourly gastric aspirates
• Broad-spectrum antibiotics
o Must cover both aerobic and anaerobic organisms
o For example: cefotaxime and vancomycin
• Respiratory support
o May require high ventilation pressures due to abdominal distension
• Fluids
o For cardiovascular support, may require addition of inotropes
• Surgery
o Indicated if:
- Perforation
- Failure to respond to medical treatment
o Laparotomy with resection of necrosed bowel with either a primary anastomosis or a
defunctioning stoma
How is neonatal hypoglycaemia prevented?
feed baby within 30 minutes of birth
subsequent frequent milk feeding (every 2-3hours)
How is a neoante with a blood glucose of <1.5 managed?
o Admit to neonatal unit (NNU)
o Confirm hypoglycaemia with laboratory blood glucose assay
o IV 10% glucose 2ml/kg bolus
o Followed by an infusion of 3.6ml/kg/hr of 10% glucose
o Frequently recheck glucose until stable
- Aim for 3-4mmol/l
How are neonates with a blood glucose of 1.5-2.5 managed?
Feed immediately
o Recheck glucose after 30 mins
- If glucose still low, consider admitting and starting IV glucose
- If hypoglycaemia persistent refer to endocrinology team for further investigation
- If hypoglycaemia is secondary to hyperinsulinism give one of:
o Glucagon infusion
o Diazoxide + chlorthiazide
o Somatastatin analogue
How is pathological unconjugated jaundice managed?
Acute bilirubin encephalopathy:
- Immediate exchange transfusion
- Phototherapy
- Hydration
- IVIG
o Total bilirubin >95th centile for phototherapy
- Phototherapy
- Hydration
o Total bilirubin >95th centile for exchange transfusion
- Exchange transfusion
- Phototherapy
- Hydration
- IVIG if ABO
How is pathological conjugated jaundice treated?
Treat the underlying cause e.g. surgery for biliary atresia
How is breast milk jaundice treated?
Temporary cessation of BF and supplemental feeding
phototherapy and hydration
exchange transfusion
PACES: neonatal jaundice
common
Will Ix if < 1 day or > 14 days
Explain what happens if physiological
Tx: light therapy, not harmful but regular blood samples
breastfeeding can continue as per usual, every 3h and wake baby to feed if required
explain need to stay after phototherapy to check for rebound hyperbilirubinaemia
resources: NHS choices and breastfeeding network, Bliss for premature and sick babies
How is persistent pulmonary hytertension of the newborn managed?
- Oxygen
- Aim to maintain relatively high PO2 (10-13kPa in infants born >34 weeks gestation or 7-9kPa for those born <34 weeks)
• Ventilation
- Use appropriate pressures to achieve and maintain good lung inflation
- Consider sedation and paralysis to optimise efficiency of ventilation
• Minimise handling
• Surfactant
- Consider so as to optimise lung inflation
• Treat underlying cause
• Suction of secretions from ETT
• Fluids and inotropes
- To optimise cardiac output
• Inhaled nitric oxide
- Used if severe hypoxic respiratory failure despite maximal respiratory support
• High-frequency oscillatory ventilation
- If oxygenation is still problematic despite optimal conventional ventilation and surfactant
How is a pneumothorax in the neonate managed?
• Small pneumothorax
o Close observation (even if ventilated)
o 100% oxygen for 1-2 hrs to ‘wash out’ nitrogen
• Needle drainage
o If urgent decompression is required e.g. infant at immediate risk of respiratory failure
• Chest drain insertion
o For all tension pneumothoraces
o For all ventilated or preterm infants with non-tension pneumothoraces who deteriorate
How is respiratory distress syndrome managed?
ABC resus
Review Hx and cause
Respiratory support o Ambient/headbox/ nasal cannula O2 - If baby: • Looks comfortable • FiO2 <0.3 • Blood gas normal
o Nasal continuous positive airway pressure (nCPAP) - If baby: • >30 wks and >1000g • Baby looks well • FiO2 <0.4 • pH <7.20, PCO2 <7.0-7.5
o Positive pressure ventilation
- If baby does not meet above parameters (e.g. <30 wks, looks unwell etc.)
• Fluids
o Usually 60ml/kg/day
o Initially dextrose
• IV antibiotics
o Broad spectrum combination
- Such as benzylpenicillin and gentamicin (unless listeria in which case start
amoxicillin and gentamicin)
• CXR
o Do ASAP unless mild respiratory distress where this can be delayed
How is SIDS prevented?
Infants should be put to sleep on their back
o Avoid overheating
o Place ‘feet to foot’ position i.e. feet at foot of cot
o No smoking exposure
o Baby at parents’ bedroom for the first 6 months
o Baby not in parents’ bed when they are tired, have taken alcohol, sedative medicines
or drugs
o Ideally infant should be breastfed
How is toxoplasmosis of the neonate managed?
Symptomatic babies
• Pyrimethamine + Sulfadiazine + Folinic acid
-Continue all 3 for 1 year
• Monitor LFTs and FBCs every 4-6 weeks
• Asymptomatic babies with positive serology
- No definitive guidelines present as treatment is controversial
- Discuss individual cases with infection and virology specialists
• Ophthalmology and audiology assessment recommended
How is TOF / Oesophageal atresia managed?
Primarily surgical correction
• Type A:
o Stabilisation and gastrostomy #1
o Oesophageal replacement
• Type B/D:
o Suction catheter and surgical correction
• Type C:
o Stabilisation and surgical correction
• Type E:
o NBM and surgical division of fistula
How is transient tachypnoea of the newborn managed?
Supportive therapy – O2 through hood/nasal cannula maintaining O2 sats >90%
- Maintain neutral thermal environment
- Provide nutrition – if respiratory rate 60-80 breaths per minute then use NGT or TPN
- If tachypnoea persists more than 4-6hrs begin antibiotics (ampicillin + gentamicin)
- Fluid restriction may be helpful in severe cases
How is aortic stenosis in the neonate managed?
Associated with Williams syndrome
Balloon valvulotomy:
- if high resting pressure gradient (>65mmHg)
- If symptomatic
- Sometimes used as a temporising measure surgery before or TAVR
Transcatheter aortic valve replacement (TAVR):
- most children with significant stenosis will require this
How is an atrial septal defect in the newborn managed?
(Ejection systolic murmur best heard at the upper left sternal edge and fixed wide-split second heart sound)
• Observation
o Main management strategy as the defect may close or shrink with time
• Measurement ratio of pulmonary to systemic blood flow (Qp:Qs)
o If <1.5 then does not require closure
o If >1.5 or ASD is large enough to cause right ventricular dilatation will require closure
• Closure of ASD o Usually undertaken pre-school age o Approaches: - Transcatheter closure • Secundum ASD
- Open heart surgery
• Primum ASD (and sometimes Secundum ASD)
How is coarcatation of the aorta managed in the newborn?
98% occur in the left subclavian artery
most common presentation is at 48 hours when the ductus arteriosus closes
prostaglandin E1 infusion: given to maintain duct patency
surgical repair:
End-to-end anastomosis or arch reconstruction with patch placement or bypass graft
o Older patients may require stent insertion or surgical resection
How is congenital cyanotic heart disease managed?
• Stabilise the airway, breathing and circulation (ABC), with artificial ventilation and
supplemental oxygen if necessary
o Place UVC/UAC
• Prostaglandin E1 infusion
o 0.05mcg/kg per minute
o Most infants with cyanotic heart disease presenting in the first week of life, are ductdependent
o Maintaining duct patency is key to early survival
o Prostaglandins help maintain duct patency
o Side-effects of prostaglandins: apnoea, jitteriness and seizures, flushing, vasodilation,
hypotension
• Start IV broad-spectrum antibiotics
What are the main aims of managing heart failure?
reduce preload (diuretics)
enhance contractility (IV dopamine, digoxin)
Reduce afterload (ACEi, IV hydralazine)
Improving oxygen delivery (beta blockers)
enhance nutirion (increase caloric diet)
Exercise and physical activity (depends on capacity)
How is infective endocarditis managed in the neonate?
Antibiotic prophylaxis
MDT
Surgery
When is ABx prophylaxis recommended for infective endocarditis?
Recommended for patients at highest risk of IE:
- Patients with any prosthetic valve, including a transcatheter valve, or those in whom any prosthetic material was used for cardiac valve repair
- Patients with a previous episode of IE
- Patients with CHD:
• Any type of cyanotic CHD
• Any type of CHD repaired with a prosthetic material, whether placed surgically or by percutaneous techniques, up to 6 months after the procedure or lifelong if residual shunt or valvular regurgitation remains
Which antibiotics are used in infective endocarditis in native valves?
Penicillin-sensitive Streptococcus viridans
• Beta-lactam +/- gentamicin or vancomycin
Methicillin-sensitive Staphylococcus aureus
• Beta-lactam or vancomycin or daptomycin or co-trimoxazole and
clindamycin
Which antibiotics are used in prosthetic valve infective endocarditis?
Penicillin-sensitive Streptococcus viridans:
• Beta-lactam +/- gentamicin or vancomycin
Methicillin-sensitive Staphylococcus aureus
• Nafcillin or oxacillin or cefazolin or vancomycin and rifampicin and
gentamicin
When is surgery indicated in infective endocarditis?
for removal of infected prosthetic material
Why should a PDA be closed?
to abolish lifelong risk of bacterial endocarditis and pulmonary vascular disease
When should a prostaglandin infusion be given?
If cyanosis is dependent on the PDS
How can a PDA be closed?
1st - IV indomethacin
Prostacyclin synthetase inhibitor
Ibuprofen (in premature / VLBW infants)
If pharmacological methods of closing a PDA are unsuccessful what can be done?
surgical ligation or percutaneous catheter device closure
Term infants:
o Symptomatic >6mo, percutaneous catheter device closure ASAP
o Usually closed using a coil or occlusive device introduced through a cardiac catheter at about 1 year of age, or delayed until 1yo
o Diuretics can be given if delay of closure, to manage symptoms
How is pulmonary stenosis in the neonate treated?
mild - asymptomatic and rarely progressive so just follow up
Moderate and severe:
- Transcatheter balloon dilatation is the treatment of choice
o Surgical valvuloplasty is 2nd line
o Endocarditis prophylaxis given before high-risk procedures
How is acute rheumatic fever managed?
Bed rest nad anti-iniflammatory agents
(aspirin, high dose for 1-2 weeks or 6-8 weeks)
anti-streptococcal ABx if there is sign of infection e.g. penicillin V, benzathine benzypenicillin or amoxicillin)
How is symptomatic heart failure following rheumatic fever treated?
diuretics and ACEi
-prednisolone may be required
How is rheumatic fever prevented from recurring?
prophylaxis
monthly injections of benzathine penicillin (or oral pencillin OD)
prophylaxis for 10 years after last episode of until age of 21
lifelong for those with severe valvular disease
surgical treatment and valve repair may be needed
How is supraventricular tachycardia managed?
• If haemodynamically stable:
o 1st line: vagal manoeuvres preferably in the supine position with legs raised
o 2nd line: adenosine
-50-100mcg/kg then 100-200mcg/kg then increase in increments up to a single
dose of 500mcg/kg)
o 3rd line is a choice of one of the following:
- DC cardioversion
- Amiodarone 5 mg/kg
- Procainamide 15mg/kg
- Fleicainide 2mg/kg
• If haemodynamically unstable:
o Attempt vagal manoeuvres and adenosine as above but do not delay DC
cardioversion
• Catheter ablation is recommended if recurrent/ accessory pathway
How are hypercyanotic spells in tetraology of fallot treated?
- Place the patient in the knee-to-chest position
- Administer oxygen
- Insert IV line and administer phenylpephrine, morphine sulphate and
propranolol - Prolonged attacks require sodium bicarbonate
- Refer to cardiac centre
How is transposition of the great arteries managed?
maintain body temperature
correct acidosis / hypoglycaemia
prostaglanding E1 infusion
Balloon atrial septostomy
- give heparin bolus before
How is tricuspid atresia managed initially?
medical:
given prostaglandin E1 infusion to maintain adequate flow through PDA
cardiorespiratory support: O2 and mechanical ventilation, inotropes, IV fluid
How is tricuspid atresia managed surgically?
First stage in neonates:
§ Early palliation to maintain a secure supply of blood to the lungs at low pressure by:
• Blalock-Taussig shunt insertion (between subclavian and pulmonary
arteries)
• Pulmonary artery banding operation to reduce pulmonary blood flow if breathless
o Second stage at 3-6m old:
- Removal of shunt and direct anastomosis of SVC to Right pulmonary artery = Glenn
o Third stage at 2-5yo:
§ Direct venous pathway from IVC into pulmonary arteries = Fontan
o Needs antibiotic prophylaxis
How is vasovagal syncope managed?
Education: teach them to spot warning signs, avoid triggers and learn how to abort attacks
physical techniques e..g physical counter-pressure manoeuvres and tilt training stop the faint when warning signs appear
increase volume e.g. salt in diet and electrolyte rich sports drinks, may give fludrocortisone
What murmur is heard in a ventricular septal defect managed?
loud pansystolic murmur at the lower left sternal edge, quiet pulmonary second heart
sound
How are small VSDs managed?
observation as they usually disappear by themselves
What should be given while the VSD is present?
prophylactic ABx to prevent bacterial endocarditis (amoxicillin)
How is a large VSD managed?
Heart failure is treated with diuretics (furosemide), or may need furosemide + captopril + digoxin
o Additional calorie input
o Open surgery is usually performed to:
- Prevent permanent lung damage from pulmonary hypertension and high blood flow (i.e. prevent Eisenmenger syndrome)
- Manage heart failure and faltering growth
How is an AVSD managed?
Treat heart failure medically and surgical repair at 3-6 months
Which children with otitis media need to be admitted?
severe sytemic infection
complications (e.g. meningitis, mastoiditis and facila nerve palsy)
Children < 3 months with a temperature > 38 degrees
When should parents of a child seek help?
if symptoms show no improvement after 3 days
When should back up antibiotics be prescribed in acute otitis media?
advise that it is not needed immediately but should use if symptoms have no improvement after 3 days
When should antibiotics be prescribed immediately in acute otitis media?
children with otorrhoea or children < 2 with bilateral OM
and advise to seek seek if they worsen or become systemically unwell:
-amoxicillin 5-7 days is first-line
Penicllin allergy: clarithromycin / erythromycin
Which children with otitis media should be referred to ENT?
Structural defects e.g. cleft palate or Down syndrome
PACES: otitis media
infection of middle ear
common in young children, usually lasts up to a week with improvement after 3 days
urgent help if they become systemically unwell
ABx if no improvement after 3 days
symptomatic management with fluids, paracetamol
How is acute epiglottitis treated?
admit and ICU
intubate and give supplemental oxygen blood culture
IV 2nd / 3rd generation cephalosporins for 7-10 days e.g. ceftriaxone
steroids and adrenaline may be used to reduce inflammation in some cases
prolonged intubation may be needed
usually recover within 2-3 days
What medication is given to close contacts of patients with acute epiglottitis?
Rifampicin
How is intermittent mild allergic rhinitis managed?
allergen advice
oral / intranasal antihistamine
2nd: LTRA (leukotriene receptor antagonist)
How is persistent mild / intermittent moderate or severe allergic rhinitis treated?
allergen avoidance
oral =/- intranasal antihistamine OR LTRA
2nd: intranasal corticosteroid
3rd sublingual / SC immunotherapy
adjuncts: intranasal decongestant or nasal saline irrigation
How is persistent moderate to severe allergic rhinitis managed?
allergen avoidance
intranasal corticosteroid =/- anti-histamine
2nd: sublingual / SC immunotherapy
adjuncts:
- intranasal decongestant
- nasal saline irrigation
- intranasal ipratropium
- oral antihistamine
How is rapidly developing angio-oedema without anaphylaxis managed?
Chlorphenamine and hydrocortisone:
- given rapidly as IV or IM
- emergency admission
How is stable angioedema without anaphylaxis managed?
identify underlying causes
What treatment if given to people with angio-oedema that requires treatment?
Cetrizine (or other non-sedatine antihistamines such as fexofenadine or loratidine) for up to six weeks
oral corticosteroid (e.g. prednisolone 40mg for up to 7 days) if sever Sx, in addition to non-sedating oral antihistamine
safety net: call 999 if they are unable to breathe
resources: british association of dermatologists
How is asthma in children <5 managed?
- SABA
- moderate dose ICS (this is first step if child is waking at night from asthma or having Sx more than 3 times a week)
- if Sx resolve at 8 weeks but recur within 4, LOW DOSE ICS
- if Sx resolve and recur after 4 weeks repeat moderate dose 8 week trial - LTRA to LOW dose ICS
- STOP LTRA and refer to specialist
How is asthma in children 5-16 managed?
- SABA
- LOW dose ICS (first step if waking at night from asthma or Sx 3 times a week)
- LTRA
- Stop LTRA and add LABA
- Switch ICS and LABA to MART with LOW dose ICS
- Increase this to moderate dose ICS
- Seek advice from specialist, consider either high dose ICS or theophylline
What are the non pharmacological aspects of asthma management?
assess baseline status using asthma control questionnaire or spirometry
personalised action plan from asthma uk
ensure all vaccines are up to date
advise about trigger avoidance e..g NSAIDs
assess for depression / anxiety
ensure patient has peak flow meter and assess inhaler technique
resources: Asthma UK
What needs to be addressed at an asthma review?
Confirm medication adherence
review inhaler technique
consider medication change
ask about occupational asthma and triggers
PACES: asthma
explain it is a condition where the airways are sensitive and can tighten suddenly and make it hard to breathe
explain the steps of treatment
discuss action plan, (blue inhaler carried everywhere, 10 puffs every 30-60s if breathless and ambulance if no presonse)
explain how to use a peak flow meter
advise on identifying triggers
support: Asthma UK and itchywheezysneezy
How is bronchiectasis investigated in secondary care?
Bronchiectasis severity index: calculated to gauge severity of disease
sweat chloride test or genetic testing for CF: offered to all children
Screen for antibody deficiency: done for all patients with a confirmed diagnosis
test for primary ciliary dyskinesia ( if no other cause)
How is bronchiectasis managed?
treat underlying cause e.g. CF
Vaccination against streptococcus pneumoniae and seasonal influenza
Which antibiotics are given to children aged 1 month - 11 years for non CF bronchiectasis exacerbation?
1st line
• Amoxicillin
• Clarithromycin
- 2nd line
• Co-amoxiclav
Which antibiotics are given to children aged 12 - 17 years for non CF bronchiectasis exacerbation?
1st line: • Doxycycline • 2nd line: • Co-amoxiclav • Ciprofloxacin can be started following specialist advice if co-amoxiclav cannot be used
Which antibiotics are given empirically if child is unwell / unable to take oral medication?
- 1 month to 17 yrs
- Co-amoxiclav
- Piperacillin and tazobactam
- 1yr to 17yrs
- Ciprofloxacin (following specialist advice)
When should children with bronchiectasis be referred to secondary care?
3 or more exacerbations in 1 year
they have had a severe infection
symptoms not responding to repeat courses of ABx
cardiorespiratory failure or sepsis should be referred
British Lung Foundation patient information leaflet
When should children with bronchiolitis be referred via 999?
- apnoea
- child looks unwel
- signs of respiratory distress
- central cyanosis
- persistent oxygen saturation < 92% on air
How is bronchiolitis managed?
Humidified oxygen is < 92%
CPAP if impending respiratory failure
upper airway suction (do not perform routinely)
Fluids (by NG tube if cannot take fluid by mouth, IV cannot tolerate oral)
How can bronchiolitis be prevented?
infection control measures are required in the ward the patient is placed as RSV is highly infectious,
pavlizumab reduces the number of hospital admission in high risk preterm infants
PACES: bronchiolitis
explain it is a common chest infection that affects about 1 in 3 children < 1 year, and usually resolves by itself over 2 weeks
advise on maintaining good hydration and using paracetamol if child over 3 months old and distressed
safety net about A&E if apnoea or respiratory distress
NHS page on bronchiolitis
How is mild-moderate IgE-mediate CMPA?
onset minutes - 2 hours of ingestion
- Allergy testing at specialist allergy clinic
- Paediatric dietician referral
- Exclusively breast feeding mother
• Exclusion of all cow’s milk protein from mother’s diet
• Mother to take calcium and vitamin D supplements
-Formula fed or mixed feeding
• Trial of extensively hydrolysed formula
How is severe IgE-mediate CMPA?
As mild and:
- Consider elemental (amino acid) formula if extensively hydrolysed formula not
effective
- Refer to A&E if severe respiratory or CVS signs present – risk of anaphylaxis
How is mild/moderate non IgE mediated CMPA managed?
Be wary of diagnosing infant with CMA as GI symptoms of vomiting and
diarrhoea are very common
- Exclusively breast feeding mother
• Exclusion of all cow’s milk protein from mother’s diet
• Mother to take calcium and vitamin D supplements
-Formula fed or mixed feeding
• Trial of extensively hydrolysed formula
How is severe non IgE mediated CMPA managed?
Classified as severe if above measures taken and symptoms persist and are severe – symptoms to look out for:
• Skin: prurits/ erythema/ atopic eczema
• GI: GORD/ vomiting/ loose stools/ blood or mucus in stools/ abdominal
pain or discomfort/ infantile colic/ food refusal or aversion/ constipation/
perianal redness/ pallor or tenderness/ faltering growth
• Resp: cough/ chest tightness/ wheezing/ shortness of breath
Continue management as per mild/moderate non-IgE mediated CMA plus:
• Urgent referral to local paediatric allergy service
• Urgent referral to dietician
How are infants / older children with a CMPA managed?
Exclude cows’ milk protein from their diet
o Offer nutritional counselling with a paediatric dietician
o Regularly monitor growth
o Re-evaluate the child to assess for tolerance to cows’ milk protein (every 6-12 months)
- this involves re-introducing cows’ milk protein into the diet
§ If tolerance is established, greater exposure of less processed milk is advised
following a ‘Milk Ladder’ (available from Allergy UK)
PACES: CMPA
explain it is an allergic reaction to some of the proteins in milk
5-15% of infants have this
treatment is simply to avoid cow’s milk in maternal diet / switch to formula and add vitamin D for mum (takes 2-3 weeks to fully eliminate cows milk from breastmilk)
many children grow out of it between 6 months - 12 months (reintroduce using milk ladder)
monitor growth regularly
resources: british dietetic association
How is croup managed?
Oral dexamethasone (0.15mg/kg)
if oral not possible:
- inhaled beclomethasone (2mg)
- IM dexamethasone (0.6mg/kg)
How is mild croup managed?
admission not required
safety net:
- take to hospital if stridor or pulling between ribs
-ambulance if pale, blue, grey for more than a few seconds, sleepy, breathing trouble, upset and cannot be calmed, unable to talk or drooling
How is moderate croup treated?
oxygen
How is severe croup treated?
oxygen and nebulised adrenaline (1 in 1000 (1mg/ml))
PACES: croup
common infection of airways
explains it improves over 48h and steroids have been given to help that
if it worsens, come back
if child becomes blue, pale for more than a few seconds, unusually sleepy or unresponsive or serious breathing difficulties call and ambulance
paracetamol or ibuprofen if feerish
fluid intake
regularly checking on child at night as it worsens
What is the common mutation identified in cystic fibrosis and how is this treated?
delta F508 (specific mutation can be treated with lumacaftor / ivacaftor which increase CFTR protein trafficking to cell membrane)
What are the common pulmonary complications of cystic fibrosis?
pneumonia
nasal polyps
sinusitis
What is the general prophylactic management of the pulmonary complications of CF?
airway clearance techniques
mucoactive agents:
- rhDNAase
- hypertonic sodium chloride +/- rhDNAse
- mannitol dry powder for inhalation
How is staphylococcus pneumonia in CF treated?
flucloxacillin (prophylaxis)
given between 3-6 years of age
How is acute pseudomonas aerguinosa pneumonia treated in CF?
local guidelines with oral / inhaled ABx (IV if unwell)
How is chronic pseudomonas aerguinosa pneumonia treated in CF?
1st line: nebulised/ inhaled Colistimethate sodium
• Plus oral antibiotic/ 2 IV antibiotics of different classes if clinically
unwell with a pulmonary disease exacerbation
2nd line: Tobramycin DPI
How are GI complications of CF managed?
High calorie diet
o Pancreatic enzyme replacement therapy (e.g Creon)
- Insufficiency of pancreatic enzymes can be tested with faecal elastase
o H2 receptor antagonist or PPI
- If malabsorption persistent despite optimal pancreatic enzyme replacement therapy
PACES: CF
lifelong genetic condition characterised by recurrent respiratory infections and malabsorption
management requires MDT approach
will be referred to a specialist CF centre to discuss the ongoing management
aspects:
- pulmonary: physio and mucolytics
- infection: prophylactic ABx and monitoring
- Nutrition: enzyme tablets, high calorie diet and monitor growth
- psychosocial: support for child and carers
genetic counselling if considering more children / other siblings
What are the 3 aspects of managing a food allergy?
Dietary treatment:
- excluding offending foods
- paediatric dietician referral
- exclusion in mum if breastfeeding
drug treatment:
- mild - non-sedating antihistamines (diphenhydramine)
- severe (CVS, airways involvement): IM adrenaline and salbutamol if bronchospasm
education child and parent with allergy action plan:
- epi-pens for home use, 2 doses with them and one for school
food challenge may be considered after 6-12 months of being symptom free
PACES: food allergy
explain immune system reacts to parts of the food that other people do not
mainstay is to avoid
allergy action plan needed
some grow out of it
using of non sedating antihistamines and adrenaline
CMPA / egg often resolves in early childhood so gradual reintroduction may be possible
nuts and seafood usually persist to adulthood
How is hereditary lactose intolerance managed?
Dietary modification by avoidance and trialling different foods to discover their lactose
threshold
- Should be done with a dietician
o Can use lactase-treated dairy products or oral lactase supplementation
o Supplementation of calcium and vitamin D is required
How is acquired lactose intolerance managed?
Treat the underlying cause
o Consult a dietician to do dietary modification
o Can use lactase-treated dairy products or oral lactase supplementation
o Supplementation of calcium and vitamin D is required
How is laryngitis with airway compromised managed?
If patient doesn’t have diptheria then can give:
- Dexamethasone sodium phosphate: to reduce oedema
- Cefalozin and cefalexin: administered IV to start and then changed to oral antibiotics
o If patient has diptheria:
- Patient needs to be isolated
- Benzylpenicillin sodium IV/IM for 14d
- Diptheria antitoxin
How is laryngitis without airway compromised managed?
Viral:
- Analgesia as required: paracetamol
- Vocal hygiene: voice rest for 3-7d, increase hydration, humidification,
decreased caffeine intake
- Mucolytic can be given to help lubricate the vocal folds
o Bacterial:
-Phenoxymethylpenicillin for 14d
- Analgesia as required: paracetamol
-Vocal hygiene: voice rest for 3-7d, increase hydration, humidification,
decreased caffeine intake
- Mucolytic can be given to help lubricate the vocal folds
how is bacterial otitis externa treated?
Initial treatment:
- Antibacterial ear drops: ciprofloxacin and dexamethasone otic (0.3%/0.1%) 2x day for 7-10 days
• Ear needs to be cleaned of wax first and may need a wick to deliver the drops if the ear is too swollen
- Ibuprofen/paracetamol can be used for pain management. If severe pain and
>12yo, then can use codeine with the paracetamol
o If infection hasn’t responded to treatment, then can give oral ciprofloxacin
How is fungal otitis externa managed?
Non-perforated tympanic membrane:
-Topical acetic acid/hydrocortisone otic (2%/1%) 3x day for 7-10d
§ Ibuprofen/paracetamol can be used for pain management. If severe pain and >12yo, then can use codeine with the paracetamol
o Perforated tympanic membrane:
- Tolnaftate topical (1%) 3-4x day for 7d, with frequent ear cleaning
- Ibuprofen/paracetamol can be used for pain management. If severe pain and >12yo, then can use codeine with the paracetamol
How is pneumonia (not requiring admission) treated?
Most children can be managed at home
o Prescribe Amoxicillin is first-line for 7-14 days
- Alternatives: co-amoxiclav, cefaclor or macrolides (e.g. erythromycin)
- Macrolides can be added at any stage if there is no response to first-line treatment
- Bacterial and viral pneumonia are difficult to differentiate so all children should be given antibiotics.
o Paracetamol or ibuprofen can be used as antipyretics
o Keep adequate hydration
o Seek medical advise if RR increases, dehydration occurs or worsening of fever
When should children with pneumonia be referred for hospital admission?
Persistent SpO2 < 92% on air
o Grunting, marked chest recession, RR > 60/min
o Cyanosis
o Child looks seriously unwell, does not wake, or does not stay awake if roused or does
not respond to normal social cues
o Temperature > 38 degrees in a child < 3 months
o Consider admission if: dehydration, decreased activity, nasal flaring, predisposing
diseases (e.g. chronic lung disease)
o Whilst awaiting hospital admission
§ Give controlled supplemental oxygen if SpO2 < 92%
PACES: pneumonia
explain it is a chest infection
explain whether admission is needed
explain treatment (ABx) - amoxicillin for non-severe 5 days
advise to use paracetamol and maintain fluid intake
advise against smoking
check on child regularly during day and night
medical advice if child deteriorates
How is scarlett fever managed?
Notify the Health Protection Unit (HPU)
• Antibiotics
o Phenoxymethylpenicillin (penicillin V) - 4/day for 10 days
o Azithromycin (if penicillin allergy)
o Stay away from nursery/school for 24 hours after starting antibiotics
- Paracetamol or ibuprofen can be given for symptomatic relief
- Symptoms should settle down after around 1 week
- Treatment for 10 days is needed to prevent complications such as acute glomerulonephritis and rheumatic fever
How is sinusitis (<10 days) managed?
Do NOT offer an antibiotic
o Advice
-Acute sinusitis is usually caused by a virus and takes 2-3 weeks to resolve
- Symptoms, such as fever, can be managed using paracetamol or ibuprofen
-Some people may find some relief using nasal saline or nasal decongestants
• Can be given intranasal corticosteroid for congestion
-Medical advice should be sought if symptoms worsen rapidly, if they do not improve in 3 weeks or become systemically unwell
How is sinusitis >10 days but < 4 weeks managed?
Commonly bacterial infection
o Consider high-dose nasal corticosteroid for 14 days for adults and children > 12
years old (e.g. mometasone)
- May improve symptoms but unlikely to affect duration of illness
- Could cause systemic side-effects
o Consider NO antibiotic prescription or back-up prescription
-Watchful waiting for up to 10d and then give amoxicillin
- Antibiotics are unlikely to change the course of the illness
- The back-up prescription should be used if symptoms get considerably worse
of it is still has not improved by 7 days
-1st line: phenoxymethylpenicillin
• NOTE: clarithromycin if penicillin allergy
2nd line: co-amoxiclav
o Advise patients to seek medical advice if they develop complications or their symptoms
don’t improve/worsen
How is sleep disordered breathing managed?
Children with adenotonsillar hypertrophy may need adenotonsillectomy which usually
causes a dramatic improvement in symptoms
- Other children may benefit from CPAP or BiPAP to maintain their upper airway at night
- Can use montelukast +/- intranasal budesonide if surgery didn’t improve the obstruction
When are children with pharyngitis / sore throat admitted?
Difficulty breathing
o Clinical dehydration
o Peri-tonsillar abscess or cellulitis
o Signs of marked systemic illness or sepsis
o A suspected rare cause (e.g. Kawasaki disease, diphtheria)
When are antibiotics given in pharyngitis?
Given if either
Group A Streptococcus has been confirmed:
• FeverPAIN score (4 or 5) or Centor scor (3 or 4)
• Throat cultures
• Rapid antigen testing
OR Person is experiencing severe symptoms
o Phenoxymethylpenicillin
- Given for 10 days
o Clarithromycin - If penicillin allergy
o Avoid amoxicillin because it may cause a widespread maculopapular rash if the tonsillitis is due to infectious mononucleosis
PACES: pharyngitis and tonsillitis
explain that it is tonsillitis
explain the ABx need to be taken correctly for ten days even if symptoms improve
avoid school for 24h until
ABx have been taken
advise to use paracetamol, lozenges, salt water gargling and difflam for symptomatic treatment
How is urticaria managed?
avoid triggers: identify triggers and if possible avoid
symptom diaries: determine frequency, duration and severity of urticarial episodes
UAS7 score (<7 in 1 week indicates control of disease, whereas more than 28 in a week is severe disease)
How is urticaria in people with symptoms requiring treatment managed?
Cetirizine (or other non-sedating antihistamine e.g. fexofenadine or loratadine)
- Usually given for up to 6 weeks
• Can be given for up to 3-6 months if it is likely that symptoms will recur
o Prednisolone (or other oral corticosteroid) -If symptoms severe
When are children with urticaria referred to the dermatologist or immunologist?
Painful and persistent
o Symptoms not well controlled with antihistamines
o Acute severe urticaria due to food or latex allergy
How is viral episodic wheeze treated?
DO NO DIAGNOSE AS ASTHMA AS MANY PRESCHOOL CHILDREN WILL GROW OUT OF THEIR ILLNESS BY AGE 6 AND CAN AFFECT THEIR LIFE E.G. PILOTS
how is viral episodic wheeze managed?
1st line: salbutamol
-Inhaler used with a spacer
- Burst Therapy is often used for viral-induced wheeze
• The child is given 10 puffs of salbutamol using a spacer
• They are then assessed for a response to treatment
• If they can last 4 hours without the symptoms reappearing, they can be discharged
• They will be given a weaning regime for the salbutamol inhaler with a
spacer
o 2nd line: leukotriene antagonist and/or intermittent inhaled glucocorticoids
- Can be used at the start of an URTI and continued up to 10d
- This can also be used as continuous prevention
• Encourage parents who are smokers to stop
PACES: viral episodic wheeze
Explain the diagnosis (narrowing of the airways due to a viral chest infection causes
difficulty breathing)
- Inhaled medication helps to open up the airways and make you breathe easier
- Explain that the child will be monitored for 4 hours to see whether they can be symptomfree for 4 hours after the episode
• Discharge with salbutamol and spacer
o 10 puffs through spacer maximum of every 4 hours
o If no response after 10 puffs, seek help
o If symptomatic 48 hours after discharge, seek help
How is whooping cough managed?
Admit in isolation if:
o < 6 months old or acutely unwell
o Significant breathing difficulties (e.g. apnoea, severe paroxysms, cyanosis)
o Significant complications (e.g. seizures, pneumonia)
• Pharmacological Treatment - if admission is not needed, prescribe an antibiotic if the onset
of the cough is within 21 days.
o < 1 month old = clarithromycin
o >1 months old and not pregnant = azithromycin
o If pregnant = erythromycin
- Recommended >32 weeks gestation without vaccination to reduce the risk of
transmission to the newborn
• Advice
o Rest, adequate fluid intake and the use of paracetamol or ibuprofen for symptomatic relief
o Inform the parents that, despite antibiotic treatment, the disease is likely to cause a protracted non-infectious cough that may take weeks to resolve
o Advise that children should avoid nursery until 48 hours of appropriate antibiotic treatment has been completed or until 21 days after the onset of the cough if it was not treated
o Once the acute illness has been dealt with, advice parents to complete any outstanding immunisations
PACES: whooping cough
Explain the diagnosis (cough that lasts for a reasonably long time)
• Explain that it isn’t seen very often because of the immunisation programme (and discuss concerns about immunisation with the parent)
• Explain that having it once does not mean you can’t have it again
• Explain that antibiotics can help treat the condition, but the cough often persists for a long time
• Exclude from school until 48 hours after starting antibiotics
How are anal fissures managed?
Ensure stools are soft and easy to pass o Increase dietary fibre (include foods containing whole grains, fruits and vegetables) o Increase fluid intake o Consider constipation treatment o Stool softeners
• Manage pain
o Glyceryl trinitrate intra-anally
o Offer simple analgesia (paracetamol or ibuprofen)
o Sitting in a shallow, warm bath can help relieve the pain
- Advise on the importance of anal hygiene
- Advise against stool withholding
• Advise the parents that if it has NOT healed after 2 weeks or the child remains in a great deal
of pain, they should seek help
How is acute appendicitis managed?
Surgical emergency
• The patient should be nil-by-mouth from the time of diagnosis
- IV fluids should be started
- Requires immediate hospital admission
• Appendectomy performed without delay - open/laparoscopic
o Consider IV antibiotics (cefoxitin)
How is coeliac disease managed?
All products containing gluten (wheat, rye and barley) are removed from the diet
- Consider referral to dietician if there are problems with adhering to the diet
- Calcium and Vit D supplements +/- Iron should be given
• Arrange annual review
o Check height, weight and BMI
o Review symptoms
o Review adherence to diet - IgA-tTG titre every 3m until normalised and then yearly
o Consider blood tests (coeliac serology, FBC, TFT, LFT, vitamin D, B12, folate, calcium, U&E)
o Bone mineral density evaluated after 1yr
PACES: coeliac disease
Explain the diagnosis (caused by an inability to digest gluten (present in barley, rye and
wheat)
• Reassure that it is a common condition (1 in 100) and the treatment is fairly straight forward
(gluten-free diet)
• Explain that they will be put in touch with a dietician
• Explain the importance of keeping to a strict gluten-free diet (complications include
malnutrition and cancer)
• Explain that follow-up is usually necessary every 6-12 months
• Advise regular measurements of height and weight on centile charts
• Support: Coeliac UK
How is constipation managed?
Exclude red flag symptoms
• Reassure that underlying causes of constipation have been excluded
• Laxatives - may have to be taken for several months
• Check for faecal impaction - if present, recommend disimpaction regimen
o Osmotic laxative + dietary/lifestyle modification
o May need other laxatives too (stimulant, faecal softener)
• Start maintenance laxative treatment if impaction is not present/has been treated
o Dietary modification + osmotic laxative
- Advise behavioural interventions (scheduled toileting, bowel habit diary, reward system)
- Follow up to assess adherence and response to treatment
- Secondary behavioural problems are common
What are the different types of laxative?
Bulk-forming: fybogel, methylcellulose
o Osmotic: lactulose, Movicol
o Stimulant: Bisacodyl, senna, sodium picosulphate
o Stool-softener: arachis oil, docusate sodium
PACES: constipation
Explain that this is simple constipation and that it is very common
• Explain treatment (want to break the cycle of a hard stool being difficult to pass)
• Explain that Movicol takes time to work
o Disimpaction: escalating dose for 2 weeks
o Maintenance: can be used for a long time until bowel habits are re-established (no dangers)
• Advise encouraging the child to sit on the toilet after mealtimes (reflex)
• Advise behavioural intervention (star chart) to aid motivation
What is the medical management of Crohn’s disease?
Steroids (prednisolone) may be used to induce and maintain remission
o Immunosuppressive drugs (azathioprine, methotrexate)
o Biologic therapies (e.g. infliximab)
o Aminosalicylates (e.g. mesalazine)
PACES: crohn’s
Explain the diagnosis (a disease with an unknown cause that causes inflammation of the
digestive system leading to malabsorption and bloody diarrhoea)
• Explain that it is a life-long condition and there is always a risk of relapse
• Reassure that there are many medications that can be used to settle down the inflammation
any time it flares up (and explain that they will be seen by a gastroenterologist)
• Explain complications (malabsorption and bowel cancer)
• There is no special diet but you may find that certain foods will make it worse
• Support: Crohn’s and Colitis UK
How is GOR managed in breastfed infants?
-Carry out a breastfeeding assessment
-positional!
- If issue persists despite advice, consider trial of alginate therapy for 1-2 weeks
(stop at intervals to check whether the infant has recovered)
How is GOR managed in formula fed infants?
Review feeding history
- positional!
- Reduce feed volumes if excessive for infant’s weight (aim for 150-180mL/kg/day)
- Offer a trial of smaller, more frequent feeds
- Offer a trial of thickened formula or anti-regurgitant formula
- Offer alginate therapy without feed thickeners (stop at intervals to see if the infant has recovered)
What pharmacological options are available for the management of GOR?
-Consider 2-4-week trial of PPI or histamine antagonist in children who have 1 or more of the following:
• Unexplained feeding difficulties (refusing feeds, choking)
• Distressed behaviour
• Faltering growth
- Consider specialist referral if still no resolution
PACES: GORD
Explain the diagnosis (due to immaturity of the gullet leading to food coming back the wrong
way)
• Reassure that this is common and usually gets better with time
• Breastfeeding: offer assessment -> alginate therapy
• Formula: review feeding history -> smaller, more frequent feeds -> thickeners -> alginate
therapy
• Safety net: keep an eye on the vomitus (if it’s blood-stained or green seek medical attention)
How are hernias managed?
- # 1: surgical repair for inguinal hernia. Timing is based on whether hernia is reducible
- If it is reducible, then manual reduction is preferred, with elective surgery being scheduled for repair
- If it is incarcerated, manual reduction is attempted if no signs of peritonitis, intestinal obstruction or toxicity and then surgery is scheduled to repair it
How is Hirschsprung disease managed?
Initial management involves bowel irrigation
• Surgical - usually involves an initial colostomy followed by anastomosing normally innervated
bowel to the anus (anorectal pull-through)
• Total colonic agangliosis would require initial ileostomy with later corrective surgery
How is infant colic in a breast fed infant managed?
continue and mother may benefit from following a hypoallergenic diet
How is infant colic in a formula fed infant managed?
Check bottle teat size is correct for infant
o Hypo-allergenic formula may be beneficial but should have food challenges periodically
to check if it has resolved naturally
o Avoid Soy formula
support: NHS Choices leaflet, health visitor (help with feeding
techniques etc.)
• Strategies to sooth a crying infant: holding the baby, gentle motion, white noise
• Encourage parents to look after themselves: get support from family and friends, meet
other parents at a similar state (NCT), resting, putting the baby in a safe place to give yourself
a time out
• Do not recommend things like Infacol and Colief because there is an insufficient evidence base
How is intussussception managed?
ABCDE approach
• IV fluids and NG tube aspiration may be needed
• Unless there are signs of peritonitis, reduction of the intussusception by rectal air insufflation (with fluoroscopy guidance) is usually attempted by a radiologist
• Clinically stable with no contraindications to contrast enema reduction
o Fluid resuscitation
o Contrast enema (air or contrast liquid)
o Contraindications
- Peritonitis
- Perforation
- Hypovolaemic shock
o Broad-spectrum antibiotics
- Clindamycin + gentamicin OR tazocin OR cefoxitin + vancomycin
o 2nd line: surgical reduction with broad-spectrum antibiotics
• If recurrent intussusception - consider investigating for a pathological lead point (e.g. Meckel’s diverticulum)
PACES: intussussception
Explain that it is caused by telescoping of the bowel and typically occurs in young children
• If needing reduction, explain the procedure
• Explain that NG tube aspiration may be required
• Explain the supportive treatment (fluids and antibiotics)
• Explain about the possibility of needing an operation if rectal air insufflation is unsuccessful (75% success rate)
• 5% risk of recurrence (usually within a couple of days of treatment)
How is Meckel’s diverticulum managed?
Asymptomatic
o Incidental imaging finding - no treatment required
o Detected during surgery for other reasons - prophylactic excision
• Symptomatic
o Bleeding - excision of diverticulum with blood transfusion (if hemodynamically unstable)
o Obstruction - excision of diverticulum and lysis of adhesions
o Perforation/peritonitis - excision of diverticulum or small bowel segmental resection with perioperative antibiotics
How is malrotation managed?
If there are signs of vascular compromise, an Emergency laparotomy is needed
• Ladd procedure - detorting the bowel and surgically dividing the Ladd bands
o This is either done laparoscopically (if elective or non-urgent) or during open laparotomy (emergency or urgent)
o The bowel is placed in the non-rotated position with the duodenojejunal flexure on the right and the caecum and appendix on the left
o Note: the appendix is usually removed to avoid diagnostic confusion in case the child presents again with an acute abdomen
• Antibiotics (cefazolin)
How is Mesenteric Adenitis managed?
Self-limiting condition, so supportive care:
o Pain management and adequate hydration
How is acute bleeding peptic ulcer managed?
Endoscopy +/- blood transfusion
• And PPI
Surgery or embolization
How is a non-bleeding h pylori negative peptic ulcer disease managed?
Treat underlying cause + PPI
2nd line: H2 antagonist
How is a non bleeding, pylori positive peptic ulcer disease managed?
H. pylori eradication triple therapy for 7d:
• PPI BD + clarithromycin 500mg BD + amoxicillin 1g BD
How should children with a suspected peptic ulceration be treated?
treated with proton-pump inhibitors
(e.g. lansoprazole 30 mg)
• If they fail to respond to treatment, an upper GI endoscopy should be performed
o If this is normal, functional dyspepsia is diagnosed
o Note: functional dyspepsia is probably a variant of IBS
How is pyloric stenosis mamanged?
IV fluid resuscitation
o This is essential to correct the fluid and electrolyte disturbance before surgery
o This should be provided at 1.5 x maintenance rate with 5% dextrose + 0.45% saline
o Add potassium once urine output is adequate
• Definitive treatment is by performing a Ramstedt pyloromyotomy
o This involves dividing the hypetrophied muscle down to but not including the mucosa
o Can be open or laparoscopic
How is recurrent abdominal pain managed?
Important to say that pain is real, not faked.
• Reassurance and continuation with physical activities
• Psych interventions may be helpful – CBT, family therapy
How is small bowel atresia managed?
Initially: nil by mouth, NGT placed for suction, IV hydration, broad spectrum antibiotics given.
• Surgical approach depends on the atresia site, mainly end-to-end attachment to form an anastomosis.
How is mild UC managed?
Oral 5-ASA
o Continue as maintenance if no relapse
o Relapse = use oral prednisolone and taper
- If they relapse with steroids, then it is called steroid dependent disease
How is moderate UC managed?
Oral prednisolone for 2-4wks and taper
o If good response = treat with oral 5-ASA and continue for maintenance
o If relapse frequent, then steroid dependent disease
o If bad response to oral prednisolone, then IV can be given. Should be tapered off to oral and maintain remission.
How is steroid dependent UC managed?
1: Thiopurine or infliximab
o If successful continue with medication as maintenance
o If inadequate:
- Colectomy, adalimumab or vedolizmab
- Colectomy is the final treatment option
