Paediatrics Flashcards
Achondroplasia
Dwarfism
No treatment
Acute epiglottitis
A rare but serious infection caused by Haemophilus influenzae type B.
Features
-rapid onset
-high temperature, generally unwell
-stridor
-drooling of saliva
-‘tripod’ position: the patient finds it easier to breathe if they are leaning forward and extending their neck in a seated position
Investigations;
-Do not examine the neck if you suspect this
-Diagnosis is made by direct visualisation (only by senior/airway trained staff)
-X ray of neck may help (Thumb sign)- avoid! nothing that could compromise airway
Management;
-immediate senior involvement (those able to provide emergency airway support (e.g. anaesthetics, ENT))
- possible endotracheal intubation (don’t examine neck)
-oxygen
-IV antibiotics as per local policy
Acute lymphoblastic anaemia (ALL)
the most common malignancy affecting children and accounts for 80% of childhood leukaemias. The peak incidence is at around 2-5 years of age and boys are affected slightly more commonly than girls
Features may be divided into those predictable by bone marrow failure:
-anaemia: lethargy and pallor
-neutropaenia: frequent or severe infections
-thrombocytopenia: easy bruising, petechiae
And other features
-bone pain (secondary to bone marrow infiltration)
-splenomegaly
-hepatomegaly
-fever- (infection or constitutional symptom)
-testicular swelling
Poor prognostic factors
-age < 2 years or > 10 years
-WBC > 20 * 109/l at diagnosis
-T or B cell surface markers
-non-Caucasian
-male sex
APGAR Score
Activity (muscle tone)
Pulse
Grimace (reflex irritability)
Appearance (colour)
Respiratory effort
0-3 is very low score
4-6 is moderate low
7 - 10 means the baby is in a good state
Appendicitis in children
Appendicitis is one of the most common acute surgical problems facing children. Diagnosis is often made difficult by a presentation which is far from the classically history of:
-central abdominal pain which later radiates to the right iliac fossa
-low-grade pyrexia
-minimal vomiting
Children who are younger or have a retrocaecal/pelvic appendix are more likely to present in an atypical way
Appendicitis is uncommon in children under 4 years old but in this group often presents with perforation
List some autosomal dominant conditions
Huntington’s
Myotonic dystrophy
Osteogenesis imperfecta
Retinoblastoma
Tuberous sclerosis
Von Hippel-Lindau syndrome
Von Willebrand’s disease (type 3 is recessive)
List some autosomal recessive conditions
Albinism
Cystic fibrosis
Gilbert’s syndrome (sources differ)
Haemochromatosis
Sickle cell anaemia
Thalassaemias
Wilson’s disease
Benign rolandic epilepsy
Benign Rolandic epilepsy is a form of childhood epilepsy that typically occurs between the age of 4 and 12 years.
Features
-seizures characteristically occur at night
-seizures are typically partial (e.g. paraesthesia affecting face) but secondary generalisation may occur (i.e. parents may only report tonic-clonic movements)
-child is otherwise normal
EEG characteristically shows centro-temporal spikes
Prognosis is excellent, with seizures stopping by adolescence
Biliary atresia
a paediatric condition involving either obliteration or discontinuity within the extrahepatic biliary system, which results in an obstruction in the flow of bile. This results in a neonatal presentation of cholestasis in the first few weeks of life.
Patients typically present in the first few weeks of life with:
-Jaundice extending beyond the physiological two weeks
-Dark urine and pale stools
-Appetite and growth disturbance, however, may be normal in some cases
-Hepatomegaly with splenomegaly
-Possible cardiac murmurs
Investigations and management of biliary atresia
Investigations:
-Total bilirubin normal, conjugated bilirubin high
-Liver function tests (LFTs) usually raised
-Serum alpha 1-antitrypsin: Deficiency may be a cause of neonatal cholestasis
-Sweat chloride test: CF can involve biliary tract
-USS of the biliary tree and liver: May show distension and tract abnormalities
-Percutaneous liver biopsy with intraoperative cholangioscopy
Management:
-Surgical intervention (definitive)
-Medical intervention includes antibiotic coverage and bile acid enhancers following surgery
Complications:
-Unsuccessful anastomosis formation
-Progressive liver disease
-Cirrhosis with eventual hepatocellular carcinoma
Prognosis:
-Prognosis is good if surgery is successful
-In cases where surgery fails, liver transplantation may be required in the first two years of life
Bronchiolitis
a condition characterised by acute bronchiolar inflammation. Respiratory syncytial virus (RSV) is the pathogen in 75-80% of cases. It is the most common cause of a serious lower respiratory tract infection in < 1yr olds (more common in winter too)
Features
-coryzal symptoms (including mild fever) precede:
-dry cough
-increasing breathlessness
-wheezing, fine inspiratory crackles (not always present)
-feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission
NICE recommend immediate referral (usually by 999 ambulance) if they have any of the following:
-apnoea (observed or reported)
-child looks seriously unwell to a healthcare professional
-severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
-central cyanosis
-persistent oxygen saturation of less than 92% when breathing air.
NB- clinical diagnosis, but in AE would want CXR, ABG etc.
Management is largely supportive
-humidified oxygen is given via a head box and is typically recommended if the oxygen saturations are persistently < 92%
-nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth
-suction is sometimes used for excessive upper airway secretions
NB- the infection is more serious if bronchopulmonary dysplasia (e.g. Premature), congenital heart disease or cystic fibrosis
Caput succedaneum
describes oedema of the scalp at the presenting part of the head, typically the vertex. This may be due to mechanical trauma of the initial portion of the scalp pushing through the cervix in a prolonged delivery or secondary to the use of ventouse (vacuum) delivery.
Features
-soft, puffy swelling due to localised oedema
-crosses suture lines
No treatment is needed.
Cephalohaematoma
seen as a swelling on the newborns head. It typically develops several hours after delivery and is due to bleeding between the periosteum and skull. The most common site affected is the parietal region
Jaundice may develop as a complication.
A cephalohaematoma up to 3 months to resolve.
NB- does not cross the suture lines
Cerebral palsy
a disorder of movement and posture due to a non-progressive lesion of the motor pathways in the developing brain
Possible manifestations include:
-abnormal tone early infancy
-delayed motor milestones
-early hand dominance
-abnormal gait
-feeding difficulties.
Children with cerebral palsy often have associated non-motor problems such as:
-learning difficulties (60%)
-epilepsy (30%)
-squints (30%)
-hearing impairment (20%)
Management
-as with any child with a chronic condition a multidisciplinary approach is needed
-treatments for spasticity include oral diazepam, oral and intrathecal baclofen, botulinum toxin type A, orthopaedic surgery and selective dorsal rhizotomy
-anticonvulsants, analgesia as required
-physiotherapy, social work, occupational health and social workers, charity and support groups, SALT team
Chickenpox
caused by primary infection with varicella zoster virus. Shingles is a reactivation of the dormant virus in dorsal root ganglion
Chickenpox is highly infectious
-spread via the respiratory route
-can be caught from someone with shingles
-infectivity = 4 days before rash, until 5 days after the rash first appeared
Clinical features (tend to be more severe in older children/adults)
-fever initially
-itchy, rash starting on head/trunk before spreading. –Initially macular then papular then vesicular
systemic upset is usually mild
Management is supportive
-keep cool, trim nails
-calamine lotion
-school exclusion: NICE Clinical Knowledge Summaries state the following: Advise that the most infectious period is 1–2 days before the rash appears, but infectivity continues until all the lesions are dry and have crusted over (usually about 5 days after the onset of the rash).
-immunocompromised patients and newborns with peripartum exposure should receive varicella zoster immunoglobulin (VZIG). If chickenpox develops then IV aciclovir should be considered
Chickenpox complications
A common complication is secondary bacterial infection of the lesions
-NSAIDs may increase this risk
-whilst this commonly may manifest as a single infected lesion/small area of cellulitis, in a small number of patients invasive group A streptococcal soft tissue infections may occur resulting in necrotizing fasciitis
Rare complications include
-pneumonia
-encephalitis (cerebellar involvement may be seen)
-disseminated haemorrhagic chickenpox
-arthritis, nephritis and pancreatitis may very rarely be seen
Child abuse
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Child abuse presentations
Children may disclose abuse themselves. Other factors which point towards child abuse include:
-story inconsistent with injuries
-repeated attendances at A&E departments
-delayed presentation
-child with a frightened, withdrawn appearance - ‘frozen watchfulness’
Possible physical presentations of child abuse include:
-bruising
-fractures: particularly metaphyseal, posterior rib fractures or multiple fractures at different stages of healing
-torn frenulum: e.g. from forcing a bottle into a child’s mouth
-burns or scalds
-failure to thrive
-sexually transmitted infections e.g. Chlamydia, Gonorrhoea, Trichomonas
Neglect- Failure to thrive, Inadequate hygiene eg severe nappy rash, infestation, Poor development of emotional attachment to child’s caregiver, Delay in development and speech and language, Poor attendance for school and health appointments e.g. immunisations, Failure to supervise eg toddler hit by car while roaming, Unsupervised young children at home- law not clear
Sexual abuse- Disclosure (please believe the child), Sexually transmitted disease, Sexualised behaviour, Pregnancy, Soiling, dysuria and painful defecation
Fictitious illness- Often on background of existing disease, Bizarre illness events, Strange new symptoms, Parental reportage out of keeping with physical findings, Symptoms eg fits not witnessed by others e.g. school, Unneeded operations e.g. tonsils removed because parents kept requesting
Child health surveillance
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Childhood infections
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Childhood genetic syndromes
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Cleft lip
Pathophysiology
-polygenic inheritance
-maternal antiepileptic use increases risk
-cleft lip results from failure of the fronto-nasal and maxillary processes to fuse
-cleft palate results from failure of the palatine processes and the nasal septum to fuse
Problems
-feeding: orthodontic devices may be helpful
-speech: with speech therapy 75% of children develop normal speech
-increased risk of otitis media for cleft palate babies
Management
-cleft lip is repaired earlier than cleft palate, with practices varying from repair in the first week of life to three months
-cleft palates are typically repaired between 6-12 months of age
Features of coeliac disease in children
Features may coincide with the introduction of cereals (i.e. gluten)
-failure to thrive
-diarrhoea
-abdominal distension
-older children may present with anaemia
-many cases are not diagnosed to adulthood
Congenital diaphragmatic hernia
It is characterised by the herniation of abdominal viscera into the chest cavity due to incomplete formation of the diaphragm. This can result in pulmonary hypoplasia and hypertension which causes respiratory distress shortly after birth.
May hear tinkling bowel sounds in the chest/absence of breath sounds (typically on the LHS)- child will require intubation and ventilation
Only around 50% of new-borns with CDH survive despite modern medical intervention.
Congenital heart disease
Acyanotic - most common causes
-ventricular septal defects (VSD) - most common, accounts for 30%
-atrial septal defect (ASD)
-patent ductus arteriosus (PDA)
-coarctation of the aorta
-aortic valve stenosis
VSDs are more common than ASDs. However, in adult patients ASDs are the more common new diagnosis as they generally presents later.
Cyanotic - most common causes (3T’s)
-tetralogy of Fallot
-transposition of the great arteries (TGA)
-tricuspid atresia
Fallot’s is more common than TGA. However, at birth TGA is the more common lesion as patients with Fallot’s generally presenting at around 1-2 months
The presence of cyanosis in pulmonary valve stenosis depends very much on the severity and any other coexistent defects.
Congenital infections
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Children and consent
The law around consent in children is complicated. However, as a rough guide:
-patients less than 16 years old may consent to treatment if they are deemed to be competent (an example is the Fraser guidelines, previously termed Gillick competence), but cannot refuse treatment which may be deemed in their best interest
-between the ages of 16-18 years it is presumed patients are competent to give consent to treatment
-patients 18 years or older may consent to treatment or refuse treatment
With regards to the provision of contraceptives to patients under 16 years of age the Fraser Guidelines state that all the following requirements should be fulfilled:
-the young person understands the professional’s advice
-the young person cannot be persuaded to inform their parents
-the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment
-unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
-the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent
Constipation in children
Management;
Non-pharmacological- diet (fluid and fibre, reduce cows’ milk), behavioural training (encourage regular toileting, bowel diaries and reward systems), education: cause and involuntary nature of soiling
Pharmacological- Disimpaction (movicol- may get increased soiling initially, then senna if that doesn’t work), then maintenance dose (movicol)
Complications;
-faecal impaction
-bedwetting (always ask about stools in an enuresis history)
-anal fissure
-rectal prolapse
Cow’s milk protein intolerance/allergy (CMPI/CMPA)
Both immediate (IgE mediated) and delayed (non-IgE mediated) reactions are seen. The term CMPA is usually used for immediate reactions and CMPI for mild-moderate delayed reactions.
Features
-regurgitation and vomiting
-diarrhoea
-urticaria, atopic eczema
-‘colic’ symptoms: irritability, crying
-wheeze, chronic cough
-rarely angioedema and anaphylaxis may occur
Diagnosis is often clinical (e.g. improvement with cow’s milk protein elimination). Investigations include:
-skin prick/patch testing
-total IgE and specific IgE (RAST) for cow’s milk protein
If the symptoms are severe (e.g. failure to thrive) refer to a paediatrician.
Management if formula-fed;
-extensive hydrolysed formula (eHF) milk is the first-line replacement formula for infants with mild-moderate symptoms
amino acid-based formula (AAF) in infants with severe CMPA or if no response to eHF
Management if breastfed;
-continue breastfeeding
-eliminate cow’s milk protein from maternal diet.
-use eHF milk when breastfeeding stops, until 12 months of age and at least for 6 months
Croup
a form of upper respiratory tract infection seen in infants and toddlers. It is characterised by stridor which is caused by a combination of laryngeal oedema and secretions. Parainfluenza viruses account for the majority of cases. (bronchiolitis is lower, croup and epiglottis are upper)
Epidemiology
-peak incidence at 6 months - 3 years
-more common in autumn
Features
-stridor
-barking cough (worse at night)
-fever
-coryzal symptoms
CKS suggest admitting any child with moderate or severe croup. Other features which should prompt admission include:
-< 6 months of age
-known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
-uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
Investigations
-diagnosed clinically
however, if a chest x-ray is done:
-a posterior-anterior view will show subglottic narrowing, commonly called the ‘steeple sign’
Management
-a single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity (check max dose, and uses BNF children)
-prednisolone is an alternative if dexamethasone is not available
Emergency treatment
-high-flow oxygen
-nebulised adrenaline (for severe croup)
Grading of croup
Mild;
Occasional barking cough
No audible stridor at rest
No or mild suprasternal and/or intercostal recession
The child is happy and is prepared to eat, drink, and play
Moderate;
Frequent barking cough
Easily audible stridor at rest
Suprasternal and sternal wall retraction at rest
No or little distress or agitation
The child can be placated and is interested in its surroundings
Severe;
Frequent barking cough
Prominent inspiratory (and occasionally, expiratory) stridor at rest
Marked sternal wall retractions
Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
Cyanosis in neonatal period
The nitrogen washout test (also known as the hyperoxia test) may be used to differentiate cardiac from non-cardiac causes. The infant is given 100% oxygen for ten minutes after which arterial blood gases are taken. A pO2 of less than 15 kPa indicates cyanotic congenital heart disease
Initial management of suspected cyanotic congenital heart disease
-supportive care
-prostaglandin E1 e.g. alprostadil (used to maintain a patent ductus arteriosus in ductal-dependent congenital heart defect, this can act as a holding measure until a definite diagnosis is made and surgical correction performed)
NB- Acrocyanosis is often seen in healthy newborns and refers to the peripheral cyanosis around the mouth and the extremities (hands and feet)
Cystic Fibrosis (CF)
An autosomal recessive disorder causing increased viscosity of secretions (e.g. lungs and pancreas). It is due to a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which codes a cAMP-regulated chloride channel
Presenting features
-neonatal period (around 20%): meconium ileus, less commonly prolonged jaundice
-recurrent chest infections (40%)
-malabsorption (30%): steatorrhoea, failure to thrive
-other features (10%): liver disease
Many patients are picked up during newborn screening programmes (raised IRT) or early childhood, but some are picked up after 18 years. If IRT is raised, then they undergo a sweat test (raised in CF)
Other features of cystic fibrosis
-short stature
-diabetes mellitus
-delayed puberty
-rectal prolapse (due to bulky stools)
-nasal polyps
-male infertility, female subfertility
Management of CF
-Lifestyle- regular (at least twice daily) chest physiotherapy and postural drainage. Deep breathing exercises, high calorie diet, including high fat intake
NB- minimise contact with each other CF patients to prevent cross infection with Burkholderia cepacia complex and Pseudomonas aeruginosa
-Medical- vitamin supplementation, pancreatic enzyme supplements, lumacaftor (patients who are homozygous for the delta F508 mutation), long term prophylactic flucloxacillin to prevent staph aureus infection
-Surgery- lung transplantation
(chronic infection with Burkholderia cepacia is an important CF-specific contraindication to lung transplantation)
Development Problems
Referral points
-doesn’t smile at 10 weeks
-cannot sit unsupported at 12 months
-cannot walk at 18 months
Fine motor skill problems
-hand preference before 12 months is abnormal and may indicate cerebral palsy
Gross motor problems
-most common causes of problems: variant of normal, cerebral palsy and neuromuscular disorders (e.g. Duchenne muscular dystrophy)
Speech and language problems
-always check hearing
-other causes include environmental deprivation and general development delay
Developmental dysplasia of the hip (DDH)
Risk factors
-female sex: 6 times greater risk
-breech presentation
-positive family history
-firstborn children
-oligohydramnios
-birth weight > 5 kg
Screening for DDH
the following infants require a routine ultrasound examination
-first-degree family history of hip problems in early life
-breech presentation at or after 36 weeks gestation, irrespective of presentation at birth or mode of delivery
-multiple pregnancy
NB- all infants are screened at both the newborn check and also the six-week baby check using the Barlow and Ortolani tests (and USS)
Clinical examination
-Barlow test: attempts to dislocate an articulated femoral head
-Ortolani test: attempts to relocate a dislocated femoral head
other important factors include:
-symmetry of leg length
-level of knees when hips and knees are bilaterally flexed
-restricted abduction of the hip in flexion
Imaging
-ultrasound is generally used to confirm the diagnosis if clinically suspected
-however, if the infant is > 4.5 months then x-ray is the first line investigation
Management
-most unstable hips will spontaneously stabilise by 3-6 weeks of age
-Pavlik harness (dynamic flexion-abduction orthosis) in children younger than 4-5 months
-older children may require surgery
Developmental milestones
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Diarrhoea
Gastroenteritis
-main risk is severe dehydration
-most common cause is rotavirus - typically accompanied by fever and vomiting for the first 2 days. The diarrhoea may last up to a week
-treatment is rehydration
Chronic diarrhoea
-most common cause in the developed world is cows’ milk intolerance
-toddler diarrhoea: stools vary in consistency, often contain undigested food
-coeliac disease
-post-gastroenteritis lactose intolerance
Disorders of sex hormones
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Down syndrome features
Clinical features;
face: upslanting palpebral fissures, epicanthic folds, Brushfield spots in iris, protruding tongue, small low-set ears, round/flat face
flat occiput
single palmar crease, pronounced ‘sandal gap’ between big and first toe
hypotonia
congenital heart defects (40-50%, see below)
duodenal atresia
Hirschsprung’s disease
Cardiac complications
multiple cardiac problems may be present
endocardial cushion defect (most common, 40%, also known as atrioventricular septal canal defects)
ventricular septal defect (c. 30%)
secundum atrial septal defect (c. 10%)
tetralogy of Fallot (c. 5%)
isolated patent ductus arteriosus (c. 5%)
Later complications
subfertility: males are almost always infertile due to impaired spermatogenesis. Females are usually subfertile, and have an increased incidence of problems with pregnancy and labour
learning difficulties
short stature
repeated respiratory infections (+hearing impairment from glue ear)
acute lymphoblastic leukaemia
hypothyroidism
Alzheimer’s disease
atlantoaxial instability
Duchenne muscular dystrophy
an X-linked recessive inherited disorder in the dystrophin genes required for normal muscular function.
Features;
-progressive proximal muscle weakness from 5 years
-calf pseudohypertrophy
-Gower’s sign: child uses arms to stand up from a squatted position
-30% of patients have intellectual impairment
Investigation;
-raised creatinine kinase
-genetic testing has now replaced muscle biopsy as the way to obtain a definitive diagnosis
Management
-is largely supportive as unfortunately there is currently no effective treatment
Prognosis
-most children cannot walk by the age of 12 years
-patients typically survive to around the age of 25-30 years
-associated with dilated cardiomyopathy
Ebstein’s anomaly
Ebstein’s anomaly is a congenital heart defect characterised by low insertion of the tricuspid valve resulting in a large atrium and small ventricle. It is sometimes referred to as ‘atrialisation’ of the right ventricle.
Ebstein’s anomaly may be caused by exposure to lithium in-utero.
Associations
-patent foramen ovale (PFO) or atrial septal defect (ASD) is seen in at least 80% of patients, resulting in a shunt between the right and left atria
-Wolff-Parkinson White syndrome
Clinical features
-cyanosis
-prominent ‘a’ wave in the distended jugular venous pulse,
-hepatomegaly
-tricuspid regurgitation (pansystolic murmur, worse on inspiration)
-right bundle branch block → widely split S1 and S2
Using emollients
-if a topical steroid is also being used the emollient should be applied first followed by waiting at least 30 minutes before applying the topical steroid
-creams soak into the skin faster than ointments
-emollients can become contaminated with bacteria - fingers should not be inserted into pots (many brands have pump dispensers, or you can use a spatula/spoon)
Epstein’s pearl
A congenital cyst found in the mouth. They are common on the hard palate, but may also be seen on the gums where the parents may mistake it for an erupting tooth. No treatment is generally required as they tend to spontaneously resolve over the course of a few weeks.
Febrile convulsions
Management following a seizure
-children who have had a first seizure OR any features of a complex seizure should be admitted to paediatrics
Prognosis
-the overall risk of further febrile convulsion = 1 in 3. -
-if recurrences, try teaching parents how to use rectal diazepam or buccal midazolam. Parents should be advised to phone for an ambulance if the seizure lasts > 5 minutes
-regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring
Link to epilepsy
-risk factors for developing epilepsy include a family history of epilepsy, having complex febrile seizures and a background of neurodevelopmental disorder
-children with no risk factors have 2.5% risk of developing epilepsy
-if children have all 3 features the risk of developing epilepsy is much higher (e.g. 50%)
Foetal alcohol syndrome
Baby may show symptoms of alcohol withdrawal at birth e.g. irritable, hypotonic, tremors
Features
-short palpebral fissure
-thin vermillion border/hypoplastic upper lip
-smooth/absent filtrum
-learning difficulties
-microcephaly
-growth retardation
-epicanthic folds
-cardiac malformations
Assessment of feverish children
The following should be recorded in all febrile children:
-temperature
-heart rate
-respiratory rate
-capillary refill time
Signs of dehydration (reduced skin turgor, cool extremities etc) should also be looked for
NB- print off feverish illness in children passmedicine
Fragile X syndrome
Features in males
-learning difficulties
-large low set ears, long thin face, high arched palate
-macroorchidism
-hypotonia
-autism is more common
-mitral valve prolapse (“fragile” mitral valve)
Features in females (who have one fragile chromosome and one normal X chromosome) range from normal to mild
Diagnosis
-can be made antenatally by chorionic villus sampling or amniocentesis
-genetic testing
GORD in children
Gastro-oesophageal reflux is the commonest cause of vomiting in infancy. Around 40% of infants regurgitate their feeds to a certain extent so there is a degree of overlap with normal physiological processes.
Risk factors
-preterm delivery
-neurological disorders
Features
-typically develops before 8 weeks
-vomiting/regurgitation following feeds
Diagnosis is usually made clinically
Complications
-distress
-failure to thrive
-aspiration
-frequent otitis media
-in older children dental erosion may occur
Management of GORD in children
Lifestyle- feed child with head up at 30 degrees, sleep on back, don’t overfeed (smaller, more frequent feeds), thicker formulas if bottle-fed
Medical- alginates (Gaviscon, not with thickeners), PPI if severe (see criteria below), rarely metoclopramide
Specialist- refer to paediatrics if unsuccessful (may require surgery)
NB- alginate before PPI. PPI criteria;
-unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
-distressed behaviour
-faltering growth
NB- If there are severe complications (e.g. failure to thrive) and medical treatment is ineffective then fundoplication may be considered
Gastroschisis
A congenital defect in the anterior abdominal wall just lateral to the umbilical cord. The abdominal contents are NOT covered
Management
-vaginal delivery may be attempted
-newborns should go to theatre as soon as possible after delivery, e.g. within 4 hours
Exomphalos (omphalocoele)
the abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum.
Associations
-Beckwith-Wiedemann syndrome
-Down’s syndrome
-cardiac and kidney malformations
Management
-caesarean section is indicated to reduce the risk of sac rupture
-a staged repair may be undertaken as primary closure may be difficult due to lack of space/high intra-abdominal pressure
Growing pains
Growing pains are equally common in boys and girls and occur in the age range of 3-12 years.
Features of growing pains
-never present at the start of the day after the child has woken
-no limp
-no limitation of physical activity
-systemically well
-normal physical examination
-motor milestones normal
-symptoms are often intermittent and worse after a day of vigorous activity
-bilateral symptoms
Growth
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Haemorrhagic disease of the newborn
Newborn babies are relatively deficient in vitamin K. This may result in impaired production of clotting factors which in turn can lead to haemorrhagic disease of the newborn (HDN). Bleeding may range from minor brushing to intracranial haemorrhages
Breast-fed babies are particularly at risk as breast milk is a poor source of vitamin K. Maternal use of antiepileptics also increases the risk
Because of this all newborns in the UK are offered vitamin K, either intramuscularly or orally
Head injury paediatrics
Criteria for immediate request for CT scan of the head (children);
Loss of consciousness lasting more than 5 minutes (witnessed)
Amnesia (antegrade or retrograde) lasting more than 5 minutes
Abnormal drowsiness
Three or more discrete episodes of vomiting
Clinical suspicion of non-accidental injury
Post-traumatic seizure but no history of epilepsy
GCS less than 14, or for a baby under 1 year GCS (paediatric) less than 15, on assessment in the emergency department
Suspicion of open or depressed skull injury or tense fontanelle
Any sign of basal skull fracture (haemotympanum, panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
Focal neurological deficit
If under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head
Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 m, high-speed injury from a projectile or an object)
Management of headlice
School exclusion is not advised for children with head lice
fine-toothed combing of wet or dry hair
treatment is only indicated if living lice are found
a choice of treatments should be offered - malathion, wet combing, dimeticone, isopropyl myristate and cyclomethicone
household contacts of patients with head lice do not need to be treated unless they are also affected
Hearing testing in children
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Most common cause of primary headache in children.
Migraine with aura
Hirschsprung’s disease
Caused by an aganglionic segment of bowel due to a developmental failure of the parasympathetic Auerbach and Meissner plexuses.
Risk factors;
-3 times more common in males
-Down’s syndrome
Features;
-neonatal period e.g. failure or delay to pass meconium
-older children: constipation, abdominal distension
Investigations;
-abdominal x-ray
-rectal biopsy: gold standard for diagnosis
Management;
-initially: rectal washouts/bowel irrigation
-definitive management: surgery to affected segment of the colon
NB- Hirschsprung-associated enterocolitis (HAEC) is inflammation and obstruction of the intestine occurring in around 20% of neonates with Hirschsprung’s disease. It typically presents within 2-4 weeks of birth with fever, abdominal distention, diarrhoea (often with blood) and features of sepsis
Hypospadias
a congenital abnormality of the penis
It is usually identified on the newborn baby check. If missed, parents may notice an abnormal urine stream.
Hypospadias most commonly occurs as an isolated disorder. However, associated conditions include cryptorchidism (present in 10%) and inguinal hernia.
Management;
-refer to specialist
-corrective surgery at 12 months (no circumcision prior, may be required in the repair)
NB- in boys with very distal disease, no treatment may be needed.
Hypothyroidism in children
The most common cause of hypothyroidism in children (juvenile hypothyroidism) is autoimmune thyroiditis.
Other causes include
-post total-body irradiation (e.g. in a child previous treated for acute lymphoblastic leukaemia)
-iodine deficiency (the most common cause in the developing world)
Causes of hypotonia
Central causes
-Down’s syndrome
-Prader-Willi syndrome
-hypothyroidism
-cerebral palsy (hypotonia may precede the development of spasticity)
Neurological and muscular problems
-spinal muscular atrophy
-spina bifida
-Guillain-Barre syndrome
-myasthenia gravis
-muscular dystrophy
-myotonic dystrophy
ITP
an immune-mediated reduction in the platelet count.
ITP in children is typically more acute than in adults and may follow an infection or vaccination ( ask about recent URTI)
Features
-bruising
-petechial or purpuric rash
-bleeding is less common and typically presents as epistaxis or gingival bleeding
Investigation;
- FBC (isolated thrombocytopenia)
-blood film
bone marrow examinations is only required if there are atypical features e.g. lymph node enlargement/splenomegaly, high/low white cells
-failure to resolve/respond to treatment
Management;
usually, no treatment
EXCLUDE MENINGITIS (RASH)
advice to avoid activities that may result in trauma (and avoid NSAIDs, aspirin, blood thinners)
other options may be indicated if the platelet count is very low (e.g. < 10 * 109/L) or there is significant bleeding. Options include:
-oral/IV corticosteroid
-IV immunoglobulins
Immunisations/Immunisation schedule
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Infantile colic
Infantile colic describes a relatively common and benign set of symptoms seen in young infants. It typically occurs in infants less than 3 months old and is characterised by bouts of excessive crying and pulling-up of the legs, often worse in the evening.
Innocent murmurs in children
Ejection murmurs- due to turbulent blood flow at the outflow tract of the heart
Venous hums- due to the turbulent blood flow in the great veins returning to the heart. Heard as a continuous blowing noise heard just below the clavicles
Still’s murmur- low-pitched sound heard at the lower left sternal edge
Characteristics of an innocent ejection murmur include:
Soft, Systolic, Short, Symptomless, Standing/Sitting (vary with position), Solitary site (no radiation)
Intussusception
The invagination of one portion of bowel into the lumen of the adjacent bowel, most commonly around the ileo-caecal region. Usually affects infants between 6-18 months old. Boys are affected twice as often as girls
Features;
-paroxysmal abdominal colic pain
-during paroxysm the infant will characteristically draw their knees up and turn pale
-vomiting
-bloodstained stool - ‘red-currant jelly’ - is a late sign
-sausage-shaped mass in the right upper quadrant
Associated conditions:
Concurrent viral illness
Henoch-Schonlein purpura
Cystic fibrosis
Intestinal polyps
Meckel diverticulum
Investigation
-USS is the investigation of choice (target-like mass)
Management;
-the majority of children can be treated with reduction by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema
-if this fails, or the child has signs of peritonitis, surgery is performed
Jaundice in newborns
First 24 hours- always pathological
Causes of jaundice in the first 24 hrs
-rhesus haemolytic disease
-ABO haemolytic disease
-hereditary spherocytosis
-glucose-6-phosphodehydrogenase (G6PD)
2-14 days
Jaundice in the neonate from 2-14 days is common (up to 40%) and usually physiological. It is due to a combination of factors, including more red blood cells, more fragile red blood cells and less developed liver function. More common if breastfed
14 days + (prolonged)
If there are still signs of jaundice after 14 days (21 days if premature) a prolonged jaundice screen is performed, including:
-conjugated and unconjugated bilirubin: the most important test as a raised conjugated bilirubin could indicate biliary atresia which requires urgent surgical intervention
-direct antiglobulin test (Coombs’ test)
-TFTs
-FBC and blood film
-urine for MC&S and reducing sugars
-U&Es and LFTs
Causes of prolonged jaundice;
-biliary atresia
-hypothyroidism
-galactosaemia
-urinary tract infection
-breast milk jaundice
-prematurity
-congenital infections e.g. CMV, toxoplasmosis
Juvenile idiopathic arthritis
describes arthritis occurring in someone who is less than 16 years old that lasts for more than 6 weeks
Pauciarticular JIA refers to cases where 4 or less joints are affected. It accounts for around 60% of cases of JIA
Features of pauciarticular JIA
-joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows
-limp
-ANA may be positive in JIA - associated with anterior uveitis
Systemic onset JIA is a type of JIA which is also known as Still’s disease
Features of systemic onset JIA include
-pyrexia
-salmon-pink rash
-lymphadenopathy
-arthritis
-uveitis
-anorexia and weight loss
Investigations
-ANA may be positive, especially in oligoarticular JIA
-rheumatoid factor is usually negative
Kawasaki disease
a type of vasculitis which is predominately seen in children.
Features
-high-grade fever which lasts for > 5 days. Fever is characteristically resistant to antipyretics
-conjunctival injection
-bright red, cracked lips
-strawberry tongue
-cervical lymphadenopathy
-red palms of the hands and the soles of the feet which later peel
Clinical diagnosis
Management
-high-dose aspirin (one of the few indications for the use of aspirin in children. Due to the risk of Reye’s syndrome aspirin is normally contraindicated in children)
-intravenous immunoglobulin
-echocardiogram (rather than angiography) is used as the initial screening test for coronary artery aneurysms
Complications
-coronary artery aneurysm
Knee problems: children and young adults
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Limping child
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McCune-Albright syndrome
Features
-precocious puberty
-cafe-au-lait spots
-polyostotic fibrous dysplasia
-short stature
Measles
Features
-prodromal phase
-irritable
-conjunctivitis
-fever
-Koplik spots (white spots (‘grain of salt’) on the buccal mucosa)
-rash (starts behind ears then to the whole body
discrete maculopapular rash becoming blotchy & confluent)- think M for Mastoid (&Measles- that’s where it starts)
-desquamation that typically spares the palms and soles may occur after a week
-diarrhoea occurs in around 10% of patients
Management
-mainly supportive
-admission may be considered in immunosuppressed or pregnant patients
-notifiable disease → inform public health
Complications
-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)
-subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness
-febrile convulsions
-keratoconjunctivitis, corneal ulceration
-diarrhoea
-increased incidence of appendicitis
-myocarditis
Osgood-Schlatter disease
Osgood-Schlatter disease (tibial apophysitis) is a type of osteochondrosis characterised by inflammation at the tibial tuberosity. It is a traction apophysitis thought to be caused by repeated avulsion of the apophysis into which the patellar tendon is inserted
Management is supportive
Paediatric BLS
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Paediatric gastrointestinal disorders
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Paediatric orthopaedic disorders
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Paediatric umbilical disorders
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Patent ductus arteriosus
usually, the ductus arteriosus closes with the first breaths due to increased pulmonary flow which enhances prostaglandins clearance
Features
-left subclavicular thrill
-continuous ‘machinery’ murmur
-large volume, bounding, collapsing pulse
-wide pulse pressure
-heaving apex beat
Management
-indomethacin or ibuprofen to close PDA
-if associated with another congenital heart defect amenable to surgery then prostaglandin E1 is useful to keep the duct open until after surgical repair
Patent ductus arteriosus
usually, the ductus arteriosus closes with the first breaths due to increased pulmonary flow which enhances prostaglandins clearance
Features
-left subclavicular thrill
-continuous ‘machinery’ murmur
-large volume, bounding, collapsing pulse
-wide pulse pressure
-heaving apex beat
Management
-indomethacin or ibuprofen
-if associated with another congenital heart defect amenable to surgery then prostaglandin E1 is useful to keep the duct open until after surgical repair
Perthe’s disease
A degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years. It is due to avascular necrosis of the femoral head, specifically the femoral epiphysis. Perthes’ disease is 5 times more common in boys. Around 10% of cases are bilateral
Features
-hip pain: develops progressively over a few weeks
limp (chronic, not acute)
-stiffness and reduced range of hip movement
-x-ray: early changes include widening of joint space, -later changes include decreased femoral head size/flattening
NB- hyperactivity and short stature are associated
Diagnosis
-plain x-ray
-technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist
Complications
-osteoarthritis
-premature fusion of the growth plates
NB- Catterall staging
Management
-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
Prognosis
-Most cases will resolve with conservative management. Early diagnosis improves outcomes. Make sure to exclude SA (hip pain and fever in child- refer urgently)
Phenylketonuria (PKU)
Features
-usually presents by 6 months e.g. with developmental delay
-child classically has fair hair and blue eyes
-learning difficulties
-seizures, typically infantile spasms
-eczema
-‘musty’ odour to urine and sweat*
Pneumonia in children
S .pneumoniae is the most likely causative agent of a bacterial pneumonia in children
Management;
-Amoxicillin is first-line for all children with pneumonia
-Macrolides (erythro/clarithromycin) may be added if there is no response to first line therapy (should be used if mycoplasma or chlamydia is suspected)
-In pneumonia associated with influenza, co-amoxiclav is recommended
Prader-willi syndrome
Features
-hypotonia during infancy
-dysmorphic features
-short stature
-hypogonadism and infertility
-learning difficulties
-childhood obesity
-behavioural problems in adolescence
-Constant insatiable hunger that leads to obesity
Management;
Supportive- limit access to food, dieticians, occupational therapists, special educators
Medical- GH (improves muscle development and body composition)
Pre-school wheeze in children
Usually viral induced (commonly RSV or rhinovirus)
Other causes of wheeze;
-asthma, bronchiolitis, FBA, CF, laryngomalacia, mediastinal mass
Parents who are smokers should be strongly encouraged to stop.
Episodic viral wheeze
-treatment is symptomatic only
-first-line is treatment with short acting beta 2 agonists (e.g. salbutamol) or anticholinergic via a spacer
-next step is intermittent leukotriene receptor antagonist (montelukast), intermittent inhaled corticosteroids, or both
NB- if severe, senior review, and very similar to asthma ladder treatment
NB- Neither viral-induced wheeze or asthma cause a focal wheeze (they are usually widespread). If you hear a focal wheeze be very cautious and investigate further for a focal airway obstruction such as an inhaled foreign body or tumour. These patients will require an urgent senior review.
Precocious puberty
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Primitive reflexes
Moro
Head extension causes abduction followed by adduction of the arms
Present from birth to around 3-4 months of age
Grasp
Flexion of fingers when object placed in palm
Present from birth to around 4-5 months of age
Rooting
Assists in breastfeeding
Stroke cheek and they turn head in that direction and start sucking
Present from birth to around 4 months of age
Stepping
Also known as walking reflex
When child is held up and heels touch surface, legs will start marching
Present from birth to around 2 months of age
Puberty
Males
-first sign is testicular growth at around 12 years of age (range = 10-15 years)
-testicular volume > 4 ml indicates onset of puberty
-maximum height spurt at 14
Females
-first sign is breast development at around 11.5 years of age (range = 9-13 years)
-height spurt reaches its maximum early in puberty (at 12) , before menarche
-menarche at 13 (11-15)
-there is an increase of only about 4% of height following menarche
Normal changes in puberty
-gynaecomastia may develop in boys
-asymmetrical breast growth may occur in girls
-diffuse enlargement of the thyroid gland may be seen
Pulmonary hypoplasia
Pulmonary hypoplasia is a term used for newborn infants with underdeveloped lungs
Causes include
-oligohydramnios (eg. due to renal agenesis)
-congenital diaphragmatic hernia
Pyloric stenosis
typically presents in the second to fourth weeks of life with vomiting, although rarely may present later at up to four months. It is caused by hypertrophy of the circular muscles of the pylorus.
Features
-‘projectile’ vomiting, typically 30 minutes after a feed
-constipation and dehydration may also be present
-a palpable mass may be present in the upper abdomen
-hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
Diagnosis- USS
Management- Ramstedt pyloromyotomy.
Reflex anoxic seizures
describes a syncopal episode (or presyncope) that occurs in response to pain or emotional stimuli. It is thought to be caused by neurally-mediated transient asystole in children with very sensitive vagal cardiac reflexes. It typically occurs in young children aged 6 months to 3 years
Typical features;
-child goes very pale
-falls to floor
-secondary anoxic seizures are common
-rapid recovery
There is no specific treatment and prognosis is excellent
Retinoblastoma
The most common ocular malignancy found in children. The average age of diagnosis is 18 months. Autosomal dominant
Features
-absence of red-reflex, replaced by a white pupil (leukocoria) - the most common presenting symptom
-strabismus
-visual problems
Management
-enucleation is not the only option
-other options include external beam radiation therapy, chemotherapy and photocoagulation
Prognosis
-excellent, with > 90% surviving into adulthood
Roseola infantum
a common disease of infancy caused by the human herpes virus 6 (HHV6).
Features
-high fever: lasting a few days, followed later by a
-maculopapular rash
-Nagayama spots: papular enanthem on the uvula and soft palate
-febrile convulsions occur in around 10-15%
-diarrhoea and cough are also commonly seen
Other possible consequences of HHV6 infection
-aseptic meningitis
-hepatitis
School exclusion is not needed.
Rotavirus vaccine
it is an oral, live attenuated vaccine
2 doses are required, the first at 2 months, the second at 3 months
the first dose should not be given after 14 weeks + 6 days and the second dose cannot be given after 23 weeks + 6 days due to a theoretical risk of intussusception
Scarlet fever
a reaction to erythrogenic toxins produced by Group A haemolytic streptococci (usually Streptococcus pyogenes).
Scarlet fever has an incubation period of 2-4 days and typically presents with:
-fever: typically lasts 24 to 48 hours
-malaise, headache, nausea/vomiting
-sore throat
-‘strawberry’ tongue
-rash;
fine punctate erythema (‘pinhead’) which generally appears first on the torso and spares the palms and soles
children often have a flushed appearance with circumoral pallor. The rash is often more obvious in the flexures
it is often described as having a rough ‘sandpaper’ texture
desquamination occurs later in the course of the illness, particularly around the fingers and toes
Diagnosis
a throat swab is normally taken but antibiotic treatment should be commenced immediately, rather than waiting for the results
Management
-oral penicillin V for 10 days
-patients who have a penicillin allergy should be given azithromycin
-children can return to school 24 hours after commencing antibiotics
-scarlet fever is a notifiable disease
Scarlet fever is usually a mild illness but may be complicated by:
-otitis media: the most common complication
-rheumatic fever: typically occurs 20 days after infection
-acute glomerulonephritis: typically occurs 10 days after infection
-invasive complications (e.g. bacteraemia, meningitis, necrotizing fasciitis) are rare
School exclusion in children
Whooping cough- 2 days after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics)
Chickenpox- all lesions crusted over (usually takes 5 days)
D&V- Until symptoms have settled for 48 hours
Impetigo- Until lesions are crusted and healed, or 48 hours after commencing antibiotic treatment
Influenza- Until recovered
Sebhorrhoeic dermatitis
Seborrhoeic dermatitis is a relatively common skin disorder seen in children. Due to a yeast that lives n our skin and is typically harmless. It typically affects the scalp (‘Cradle cap’), nappy area, face and limb flexures.
Cradle cap is an early sign which may develop in the first few weeks of life. It is characterised by an erythematous rash with coarse yellow scales.
Management;
-mild-moderate: baby shampoo and baby oils
-severe: mild topical steroids e.g. 1% hydrocortisone
Seborrheic dermatitis in children tends to resolve spontaneously by around 8 months of age
Septic arthritis
Symptoms;
joint pain
limp
fever
systemically unwell: lethargy
Signs;
swollen, red joint
typically, only minimal movement of the affected joint is possible
Investigations;
joint aspiration: for culture. Will show a raised WBC
raised inflammatory markers
blood cultures
The Kocher criteria for the diagnosis of septic arthritis:
fever >38.5 degrees C
non-weight bearing
raised ESR
raised WCC
Sexual Abuse Features
Features which may be present in a sexually abused child;
pregnancy
sexually transmitted infections, recurrent UTIs
sexually precocious behaviour
anal fissure, bruising
PV/PR bleeding
reflex anal dilatation
enuresis and encopresis
behavioural problems, self-harm
recurrent symptoms e.g. headaches, abdominal pain
Shaken baby syndrome
This syndrome encompasses the triad of retinal haemorrhages, subdural haematoma, and encephalopathy. This is caused by the intentional shaking of a child (0-5 years old). The diagnosis of shaken baby syndrome has often made the headlines due to the controversy amongst physicians as to whether the mechanism of injury is definitely an intentional shaking of a child. This has often resulted in difficulty for the courts to convict suspects of causing shaken baby syndrome to a child.
Slipped upper (capital) femoral epiphysis
A rare hip condition seen in children, classically seen in obese boys. It is also is known as slipped upper femoral epiphysis.
NB- more common in obese children and boys
Displacement of the femoral head epiphysis postero-inferiorly
Features;
hip, groin, medial thigh or knee pain
loss of internal rotation of the leg in flexion
bilateral slip in 20% of cases
Investigation;
AP and lateral (typically frog-leg) views are diagnostic
Management;
internal fixation
Causes of stridor in children
Croup
Acute epiglottitis
Inhaled foreign body
Laryngomalacia
Sudden infant death syndrome (SIDS)
The commonest cause of death in the first year of life. It is most common at 3 months of age.
Major risk factors;
putting the baby to sleep prone
parental smoking
prematurity
bed sharing
hyperthermia (e.g. over-wrapping) or head covering (e.g. blanket accidentally moves)
Other risk factors;
male sex
multiple births
social classes IV and V
maternal drug use
incidence increases in winter
NB- these odds are additive.
Protective factors;
breastfeeding
room sharing (but not bed sharing, which is a significant risk factor)
the use of dummies (pacifiers)
Following a cot death siblings should be screened for potential sepsis and inborn errors of metabolism.
Surfactant deficient lung disease
A condition seen in premature infants. It is caused by insufficient surfactant production and structural immaturity of the lungs
Risk factors;
prematurity
male sex
diabetic mothers
Caesarean section
second born of premature twins
Features;
tachypnoea
intercostal recession
expiratory grunting
cyanosis
NB- AKA respiratory distress
Chest x-ray characteristically shows ‘ground-glass’ appearance with an indistinct heart border
Management;
prevention during pregnancy: maternal corticosteroids to induce fetal lung maturation
oxygen
assisted ventilation
exogenous surfactant given via endotracheal tube
Tetralogy of Fallot (TOF)
The most common cause of cyanotic congenital heart disease. It typically presents at around 1-2 months, although may not be picked up until the baby is 6 months old
TOF is a result of anterior malalignment of the aorticopulmonary septum. The four characteristic features are:
-ventricular septal defect (VSD)
-right ventricular hypertrophy
-right ventricular outflow tract obstruction, pulmonary stenosis
-overriding aorta
Features;
cyanosis (expanded upon below)
-unrepaired TOF infants may develop episodic hypercyanotic ‘tet’ spells due to near occlusion of the right ventricular outflow tract
-features of tet spells include tachypnoea and severe cyanosis that may occasionally result in loss of consciousness
-they typically occur when an infant is upset, is in pain or has a fever
causes a right-to-left shunt
ejection systolic murmur due to pulmonary stenosis (the VSD doesn’t usually cause a murmur)
a right-sided aortic arch is seen in 25% of patients
chest x-ray shows a ‘boot-shaped’ heart, ECG shows right ventricular hypertrophy
Management
-surgical repair is often undertaken in two parts
-cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm
NB- the severity of the right ventricular outflow tract obstruction (pulmonary stenosis) determines the degree of cyanosis and clinical severity
Threadworms
Extremely common amongst children in the UK. Infestation occurs after swallowing eggs that are present in the environment.
Threadworm infestation is asymptomatic in around 90% of cases, possible features include:
-perianal itching, particularly at night
-girls may have vulval symptoms
Diagnosis may be made by the applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs. However, most patients are treated empirically and this approach is supported in the CKS guidelines.
Management
-CKS recommend a combination of anthelmintic with hygiene measures for all members of the household
-mebendazole is used first-line for children > 6 months old. A single dose is given unless infestation persists
Transient synovitis (irritable hip)
It generally presents as acute hip pain following a recent viral infection. It is the commonest cause of hip pain in children. The typical age group is 3-8 years.
Features;
limp/refusal to weight bear
groin or hip pain
a low-grade fever (high fever- think septic arthritis)
Management;
Child with fever and limp/hip pain- same day assessment
Transient synovitis is self-limiting, requiring only rest and analgesia.
Transient tachypnoea of the newborn
The commonest cause of respiratory distress in the newborn period. It is caused by delayed resorption of fluid in the lungs
It is more common following caesarean sections, possibly due to the lung fluid not being ‘squeezed out’ during the passage through the birth canal
Chest x-ray may show hyperinflation of the lungs and fluid in the horizontal fissure.
Management
-observation, supportive care
-supplementary oxygen may be required to maintain oxygen saturations
Transient tachypnoea of the newborn usually settles within 1-2 days
Difference between TTN and neonatal respiratory distress syndrome;
Neonates with NRDS usually present with respiratory distress shortly after birth which usually worsens over the next few days. In contrast, TTN usually presents with tachypnoea shortly after birth and often fully resolves within the first day of life. A chest radiograph can be useful. In NRDS the characteristic features are a diffuse ground glass lungs with low volumes and a bell-shaped thorax. In TTN the CXR depicts a heart failure type pattern (e.g. interstitial oedema and pleural effusions) but key distinguishing features from congenital heart disease are a normal heart size and rapid resolution of the failure type pattern within days.
Transposition of the great arteries (TGA)
a form of cyanotic congenital heart disease. It is caused by the failure of the aorticopulmonary septum to spiral during septation. Children of diabetic mothers are at an increased risk of TGA.
Clinical features;
cyanosis
tachypnoea
loud single S2
prominent right ventricular impulse
‘egg-on-side’ appearance on chest x-ray
Management;
maintenance of the ductus arteriosus with prostaglandins
surgical correction is the definite treatment.
Turners syndrome
A chromosomal disorder caused by either the presence of only one sex chromosome (X) or a deletion of the short arm of one of the X chromosomes. Turner’s syndrome is denoted as 45,XO or 45,X.
Features;
short stature
shield chest, widely spaced nipples
webbed neck
bicuspid aortic valve (15%), coarctation of the aorta (5-10%)
primary amenorrhoea
cystic hygroma (often diagnosed prenatally)
high-arched palate
short fourth metacarpal
multiple pigmented naevi
lymphoedema in neonates (especially feet)
gonadotrophin levels will be elevated
hypothyroidism is much more common in Turner’s
horseshoe kidney: the most common renal abnormality in Turner’s syndrome
NB- there is also an increased incidence of autoimmune disease (especially autoimmune thyroiditis) and Crohn’s disease
Management;
Medical- GH (short stature), fertility treatments, oestrogen and progesterone (secondary sexual characteristics)
NB- females with 1 X chromosome, this means they are more likely to exhibit X-linked recessive conditions eg. haemophillia
Undescended testes
Complications of undescended testis
-infertility
-torsion
-testicular cancer
-psychological
Management
Unilateral undescended testis;
-NICE CKS now recommend referral should be considered from around 3 months of age, with the baby ideally seeing a urological surgeon before 6 months of age
-Orchidopexy: Surgical practices vary although the majority of procedures are performed at around 1 year of age
Bilateral undescended testes
-Should be reviewed by a senior paediatrician within 24hours as the child may need urgent endocrine or genetic investigation
Causes of UTI in children
Predisposing factors;
Incomplete bladder emptying
infrequent voiding
hurried micturition
obstruction by full rectum due to constipation
neuropathic bladder
Vesicoureteric reflux;
a developmental anomaly found in around 35% of children who present with a UTI
Poor hygiene;
e.g. not wiping from front to back in girls
Typical organisms- e coli, proteus, pseudomonas
Vesicoureteric reflux (VR)
the abnormal backflow of urine from the bladder into the ureter and kidney. It is a relatively common abnormality of the urinary tract in children and predisposes to urinary tract infection (UTI), being found in around 30% of children who present with a UTI. As around 35% of children develop renal scarring it is important to investigate for VUR in children following a UTI
Possible presentations;
-antenatal period: hydronephrosis on ultrasound
-recurrent childhood urinary tract infections
-reflux nephropathy (term used to describe chronic pyelonephritis secondary to VUR)
Investigation;
-micturating cystourethrogram
-DMSA (nuclear medicine scan of kidney) scan: look for renal scarring
Features of UTI in children
-infants: poor feeding, vomiting, irritability
-younger children: abdominal pain, fever, dysuria
-older children: dysuria, frequency, haematuria
features which may suggest an upper UTI include: temperature > 38ºC, loin pain/tenderness
Investigations for UTI in children
NICE guidelines for checking urine sample in a child;
-if there are any symptoms or signs suggestive or a UTI
-with unexplained fever of 38°C or higher (test urine after 24 hours at the latest)
-with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest)
Urine collection method;
-clean catch is preferable
-if not possible then urine collection pads should be used
-cotton wool balls, gauze and sanitary towels are not suitable
-invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible
Management of UTI in children
-infants less than 3 months old should be referred immediately to a paediatrician
-upper UTI- should be considered for admission to hospital. If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
-3+ months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin (bring the children back if they remain unwell after 24-48 hours)
NB- antibiotic prophylaxis should be considered with recurrent UTIs
Whooping cough
an infectious disease caused by the Gram-negative bacterium Bordetella pertussis. It typically presents in children
Immunisation;
-2, 3, 4 months and 3-5 years. Newborn infants are particularly vulnerable- pregnant women vaccinated
-neither infection nor immunisation results in lifelong protection (adolescents and adults may develop whooping cough)
Features;
-2-3 days of coryza precede onset of:
-coughing bouts: usually worse at night and after feeding, may be ended by vomiting & associated central cyanosis
-inspiratory whoop: not always present (caused by forced inspiration against a closed glottis)
-infants may have spells of apnoea
-persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope & seizures
-symptoms may last 10-14 weeks* and tend to be more severe in infants
-marked lymphocytosis
Diagnosis;
-per nasal swab culture for Bordetella pertussis (days-weeks)
-PCR and serology
Management;
Infants under 6 months with suspect pertussis should be admitted
in the UK pertussis is a notifiable disease
an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
household contacts should be offered antibiotic prophylaxis
antibiotic therapy has not been shown to alter the course of the illness
school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
William’s syndrome
an inherited neurodevelopmental disorder caused by a microdeletion on chromosome 7
Features;
elfin-like facies
characteristic like affect - very friendly and social
learning difficulties
short stature
transient neonatal hypercalcaemia
supravalvular aortic stenosis
Diagnosis is made by FISH studies
NB- the distinctive features to remember with William syndrome are the very sociable personality, the starburst eyes and the wide mouth with a big smile. It is worth remembering the association with supravalvular aortic stenosis and hypercalcaemia
Management;
Supportive- physiotherapists, social workers, occupational therapists, educational support, monitoring for cardiac complications
Medical- low calcium diet
Wilms tumour/nephroblastoma
one of the most common childhood malignancies. It typically presents in children under 5 years of age
Associations;
Beckwith-Wiedemann syndrome
as part of WAGR syndrome with Aniridia, Genitourinary malformations, mental Retardation
hemihypertrophy
Features;
abdominal mass (most common presenting feature)
painless haematuria
scrotal swelling
flank pain
other features: anorexia, fever
unilateral in 95% of cases
metastases are found in 20% of patients (most commonly lung)
Referral;
children with an unexplained enlarged abdominal mass in children - possible Wilm’s tumour - arrange paediatric review with 48 hours
Management;
nephrectomy
chemotherapy
radiotherapy if advanced disease
prognosis: good, 80% cure rate
X-linked recessive conditions
Becker muscular dystrophy
Colour blindness
Duchenne muscular dystrophy
G6PD deficiency
Haemophilia A,B
Nephrogenic diabetes insipidus
Signs of poor ventilation
Rising pCO2- airways have collapsed and can’t clear waste carbon dioxide
Falling pH- CO2 is building up and they are not able to buffer the acidosis this creates. This is a respiratory acidosis. If they are also hypoxic, this is classed as type 2 respiratory failure.
Laryngomalacia
a congenital abnormality that predisposes to dynamic supraglottic collapse during the inspiratory phase of respiration, resulting in intermittent upper airway obstruction and stridor.
Features;
Usually happy and thriving infants
Inspiratory stridor: worsens in supine position, during crying, upper respiratory tract infections, agitation, and feeding (the noise steadily increases over the first 6 months, as inspiratory airflow increases with age)
Reflux may be present (as a result of higher intrathoracic pressures necessary to overcome the inspiratory obstruction)
Failure to thrive and sleep-disordered breathing in severe cases
NB- symptoms begin within the first 2 months of life and peak at 6–8 months
NB- no respiratory distress
Investigations- bronchoscopy
Management;
90% resolve
Some need surgery
Anaphylaxis
Used to describe Hypotension, Bronchoconstriction or Airway compromise in the setting of an allergic reaction
Clinical diagnosis (but serum tryptase at 6 hours can hep confirm whether anaphylaxis occurred or not)
Management;
1- A-E assessment
2- 3 medications must be given; intramuscular adrenalin, repeated after 5 minutes if required, antihistamines, such as oral chlorphenamine or cetirizine, and steroids
NB- need to know doses of the 3 drugs (wont have time to look up in an emergency)
3 things to check in unwell children
Ammonia glucose and gas
Fever in unwell child
Always treat as sepsis until proven otherwise
Bacteria in CF
S. aureus is the most common cause of recurrent pulmonary infection in infancy and childhood.
P. aeruginosa is the most common cause of recurrent pulmonary infections in adulthood.
Shaken baby syndrome
encompasses the triad of retinal haemorrhages, subdural haematoma, and encephalopathy
Features of anorexia
Excessive weight loss
Amenorrhoea
Lanugo hair- fine, soft hair across most of the body (and then scalp hair loss/ thinning)
Hypokalaemia
Hypotension
Hypothermia, cold peripheries
Constipation
Dry skin
Lethargy, tiredness
Peripheral oedema
Psychosocial
Cardiac complications include arrhythmia (bradycardia), cardiac atrophy, and sudden cardiac death
Physiological Abnormalities;
Hypokalaemia
Low FSH, LH, oestrogens, and testosterone
Raised cortisol and growth hormone
Hypercholesterolaemia
NB- always rule out coeliac and malignancy
NB- most things low, G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
Management of anorexia
- Short term- physical stabilisation, thiamine, Vitamin B complex and multivitamins, diet plan
- MDT approach- child psychiatrist diagnosis, treatment of co-morbidities eg. anxiety, dietician input, support from community mental health team, paediatrician to monitor physical health eg. DEXA scan for bone mineral density
- Long term- prevention of relapse, continuing support etc. eg. BEAT charity
Bulimia nervosa
Normal body weight (usually)
Alkalosis, due to vomiting hydrochloric acid from the stomach
Hypokalaemia
Erosion of teeth
Swollen salivary glands
Mouth ulcers
Gastro-oesophageal reflux and irritation
Calluses on the knuckles where they have been scraped across the teeth. This is called Russell’s sign.
What conditions can cause rapid weight loss in children
Coeliac disease
Type 1 diabetes mellitus
Hyperthyroidism
Malignancy
Anorexia nervosa
Inflammatory bowel disease
Oesophageal problems eg achalasia
Severe depression/OCD/autism
Juvenile arthritis
Addison’s
Pyloric stenosis
Features;
Frequent regurgitation progressing to projectile, nonbilious vomiting immediately after feeding
An enlarged, thickened, “olive-shaped”, non-tender pylorus (diameter of 1–2 cm) should be palpable in the epigastrium
A peristaltic wave, moving from left to right, may be evident in the epigastrium
“Hungry vomiter”: demands re-feeding after vomiting; demonstrates a strong rooting and sucking reflex, irritable
If left untreated: dehydration, weight loss, failure to thrive
Blood gas analysis will show a hypochloric (low chloride) metabolic alkalosis as the baby is vomiting the hydrochloric acid from the stomach.
NB- USS is investigation of choice (thickened pylorus)
Management;
Supportive- IV fluids
Surgical- laparoscopic pyloromyotomy
Staphylococcal Scalded Skin Syndrome (SSSS)
a potentially serious acute skin condition caused by the exfoliative toxins of Staphylococcus aureus and typically affects infants and young children (history will usually point to a local staph infection eg. pharyngitis or bullous impetigo)
NB- Stevens-Johnson syndrome and toxic epidermal necrolysis manifest with mucosal involvement, SSSS does not
Toxic shock syndrome (TSS)
a rare toxin-mediated life-threatening acute condition caused by toxin-producing strains of Streptococcus pyogenes and Staphylococcus aureus (MRSA)
Features;
fever: temperature > 38.9ºC
hypotension: systolic blood pressure < 90 mmHg
diffuse erythematous rash
desquamation of rash, especially of the palms and soles
involvement of three or more organ systems: e.g. gastrointestinal (diarrhoea and vomiting), mucous membrane erythema, renal failure, hepatitis, thrombocytopenia, CNS involvement (e.g. confusion)
Complications of DKA
VTE
Cerebral oedema
Hypokalaemia
Monitoring for children with DM
Thyroid disease at diagnosis and annually thereafter until transfer to adult services
Diabetic retinopathy- annually from 12 years
Moderately increased albuminuria (albumin:creatinine ratio [ACR] 3–30 mg/mmol; ‘microalbuminuria’) to detect diabetic kidney disease- annually from 12 years
Hypertension- annually from 12 years.
Breath holding spells
involuntary episodes during which a child holds their breath, usually triggered by something upsetting or scaring them. They typically occur between 6 and 18 months of age. The child has no control over the breath holding spells. They are not harmful in the long term, do not lead to epilepsy and most children outgrow them by 4 or 5 years.
They are often divided into two types: cyanotic breath holding spells and pallid breath holding spells (also known as reflex anoxic seizures).
Management;
After excluding other pathology and making a diagnosis, educating and reassuring parents about breath holding spells is the key to management.
Breath holding spells have been linked with iron deficiency anaemia. Treating the child if they are iron deficiency anaemic can help minimise further episodes.
Types of breath-holding spells
Cyanotic breath holding spells occur when the child is really upset, worked up and crying. After letting out a long cry they stop breathing, become cyanotic and lose consciousness. Within a minute they regain consciousness and start breathing. They can be a bit tired and lethargic after an episode.
Reflex anoxic seizures occur when the child is startled. The vagus nerve sends strong signals to the heart that causes it to stop beating. The child will suddenly go pale, lose consciousness and may start to have some seizure-like muscle twitching. Within 30 seconds the heart restarts and the child becomes conscious again.
Hydrocephalus
describes cerebrospinal fluid (CSF) building up abnormally within the brain and spinal cord. This is a result of either over-production of CSF or a problem with draining or absorbing CSF.
Congenital Causes;
The most common cause of hydrocephalus is aqueductal stenosis, leading to insufficiency drainage of CSF. The cerebral aqueduct that connects the third and fourth ventricle is stenosed (narrowed). This blocks the normal flow of CSF out of the third ventricle, causing CSF to build up in the lateral and third ventricles.
Other causes:
Arachnoid cysts can block the outflow of CSF if they are large enough
Arnold-Chiari malformation is where the cerebellum herniates downwards through the foramen magnum, blocking the outflow of CSF
Chromosomal abnormalities and congenital malformations can cause obstruction to CSF drainage.
Presentation;
-enlarged and rapidly increasing head circumference (occipito-frontal circumference).
-Bulging anterior fontanelle
-Poor feeding and vomiting
-Poor tone
-Sleepiness
Definitive management- VP shunt
Complications of a VP Shunt;
-Infection
-Blockage
-Excessive drainage
-Intraventricular haemorrhage during shunt related surgery
-Outgrowing them (they typically need replacing around every 2 years as the child grows)
Spinal muscular atrophy
a rare autosomal recessive condition that causes a progressive loss of motor neurones, leading to progressive muscular weakness.
Spinal muscular atrophy affects the lower motor neurones in the spinal cord. This means there will be lower motor neurone signs, such as fasciculations, reduced muscle bulk, reduced tone, reduced power and reduced or absent reflexes.
Management (no cure)
-MDT approach
-Supportive- physiotherapy, mobility aids, NIV
-Medical/surgical- tracheostomy or PEG insertion
Severe combined immunodeficiency (SCID)
SCID will present in the first few months of life with:
Persistent severe diarrhoea
Failure to thrive
Opportunistic infections that are more frequent or severe than in healthy children, for example severe and later fatal chickenpox, Pneumocystis jiroveci pneumonia and cytomegalovirus
Unwell after live vaccinations such as the BCG, MMR and nasal flu vaccine
Omenn syndrome (see below)
classic features of Omenn syndrome:
A red, scaly, dry rash (erythroderma)
Hair loss (alopecia)
Diarrhoea
Failure to thrive
Lymphadenopathy
Hepatosplenomegaly
Management (fatal unless successfully treated)
-supportive- treat any infections, sterile environment, avoid live vaccines
-medical- immunoglobulin therapy
-surgical- haematopoietic stem cell transplantation
DiGeorge Syndrome
also called 22q11.2 deletion syndrome, results from a microdeletion in a portion of chromosome 22 that leads to a developmental defect in the third pharyngeal pouch and third branchial cleft. One of the consequences of this is incomplete development of the thymus gland. An underdeveloped thymus gland results in an inability to create functional T cells.
Features of DiGeorge syndrome can be remembered with the CATCH-22 mnemonic:
C – Congenital heart disease
A – Abnormal facies (characteristic facial appearance)
T – Thymus gland incompletely developed
C – Cleft palate
H – Hypoparathyroidism and resulting Hypocalcaemia
22nd chromosome affected
Chronic childhood asthma
Presentation;
Episodic symptoms with intermittent exacerbations
Diurnal variability, typically worse at night and early morning
Dry cough with wheeze and shortness of breath
Typical triggers
A history of other atopic conditions such as eczema, hayfever and food allergies
Family history of asthma or atopy
Bilateral widespread “polyphonic” wheeze heard by a healthcare professional
Symptoms improve with bronchodilators
Presentation Indicating a Diagnosis Other Than Asthma;
Wheeze only related to coughs and colds, more suggestive of viral induced wheeze
Isolated or productive cough
Normal investigations
No response to treatment
Unilateral wheeze suggesting a focal lesion, inhaled foreign body or infection
Typical Triggers;
Dust (house dust mites)
Animals
Cold air
Exercise
Smoke
Food allergens (e.g. peanuts, shellfish or eggs)
Investigations;
NB- typically clinical diagnosis, but the below can help;
-Spirometry with reversibility testing (in children aged over 5 years)
-Direct bronchial challenge test with histamine or methacholine
-Fractional exhaled nitric oxide (FeNO)
-Peak flow variability measured by keeping a diary of peak flow measurements several times a day for 2 to 4 weeks
Management of chronic childhood asthma
Medical Therapy in Under 5 Years;
1. SABA
2. ICS + SABA
3. ICS + SABA + LTRA
4. Stop LTRA and refer to specialist
Medical Therapy 5-16;
1. SABA
2. ICS + SABA
3. ICS + SABA + LTRA
4. ICS + SABA + LABA
NB- yearly review, vaccinations, always check inhaler technique and adherence at each review etc. (same stuff as for adults)
Acute childhood asthma
Presentation;
Progressively worsening shortness of breath
Signs of respiratory distress
Fast respiratory rate (tachypnoea)
Expiratory wheeze on auscultation heard throughout the chest
The chest can sound “tight” on auscultation, with reduced air entry
NB- A silent chest is an ominous sign. This is where the airways are so tight it is not possible for the child to move enough air through the airways to create a wheeze.
Severity- see print out
Staples of management in acute viral induced wheeze or asthma are:
-Supplementary oxygen if required (i.e. oxygen saturations less than 94% or working hard)
-Bronchodilators (e.g. salbutamol, ipratropium and magnesium sulphate)
-Steroids to reduce airway inflammation: prednisone (orally) or hydrocortisone (intravenous)
-Antibiotics only if a bacterial cause is suspected (e.g. amoxicillin or erythromycin)
NB- If you haven’t got control after working down the ladder the situation is very serious. Call an anaesthetist and the intensive care unit. They may need intubation and ventilation. This call should be made earlier to give the best chance of successfully intubating them before the airway becomes too constricted.
NB- Consider monitoring the serum potassium when on high doses of salbutamol as it causes potassium to be absorbed from the blood into the cells.
Look for evidence of cyanosis (central or peripheral), tracheal tug, subcostal recessions, hypoxia, tachypnoea or wheeze on auscultation.
Discharge following acute childhood asthma
Generally, discharge can be considered when the child well on 6 puffs 4 hourly of salbutamol. They can be prescribed a reducing regime of salbutamol to continue at home, for example 6 puffs 4 hourly for 48 hours then 4 puffs 6 hourly for 48 hours then 2-4 puffs as required.
A few other steps to consider:
Finish the course of steroids if these were started (typically 3 days total)
Provide safety-net information about when to return to hospital or seek help
Provide an individualised written asthma action plan
Abdominal pain in children
Medical Causes of Abdominal Pain
Functional
Constipation is also very common
Urinary tract infection
Coeliac disease
Inflammatory bowel disease
Irritable bowel syndrome
Mesenteric adenitis
Abdominal migraine
Pyelonephritis
Henoch-Schonlein purpura
Tonsilitis
Diabetic ketoacidosis
Infantile colic
There are addition causes in adolescent girls:
Dysmenorrhea (period pain)
Mittelschmerz (ovulation pain)
Ectopic pregnancy
Pelvic inflammatory disease
Ovarian torsion
Pregnancy
Surgical Causes of Abdominal Pain
Appendicitis causes central abdominal pain spreading to the right iliac fossa
Intussusception causes colicky non-specific abdominal pain with redcurrant jelly stools
Bowel obstruction causes pain, distention, absolute constipation and vomiting
Testicular torsion causes sudden onset, unilateral testicular pain, nausea and vomiting
Red Flags for Serious Abdominal Pain
Persistent or bilious vomiting
Severe chronic diarrhoea
Fever
Rectal bleeding
Weight loss or faltering growth
Dysphagia (difficulty swallowing)
Nighttime pain
Abdominal tenderness
Initial investigations that may indicate the pathology pathology:
Anaemia can indicate inflammatory bowel disease or coeliac disease
Raised inflammatory markers (ESR and CRP) can indicate inflammatory bowel disease
Raised anti-TTG or anti-EMA antibodies indicates coeliac disease
Raised faecal calprotectin indicates inflammatory bowel disease
Positive urine dipstick indicates a urinary tract infection
Recurrent abdominal pain
A diagnosis of recurrent abdominal pain is made when a child presents with repeated episodes of abdominal pain without an identifiable underlying cause. The pain is described as non-organic or functional. This is common and can lead to psychosocial problems, such as missed days at school and parental anxiety. There is overlap between the diagnoses of recurrent abdominal pain, abdominal migraine, irritable bowel syndrome and functional abdominal pain.
Recurrent abdominal pain often corresponds to stressful life events, such as loss of a relative or bullying. The leading theory for the cause is increased sensitivity and inappropriate pain signals from the visceral nerves (the nerves in the gut) in response to normal stimuli.
Management involves careful explanation and reassurance. Measures that can help manage the pain are:
Distracting the child from the pain with other activities or interests
Encourage parents not to ask about or focus on the pain
Advice about sleep, regular meals, healthy balanced diet, staying hydrated, exercise and reducing stress
Probiotic supplements may help symptoms of irritable bowel syndrome
Avoid NSAIDs such as ibuprofen
Address psychosocial triggers and exacerbating factors
Support from a school counsellor or child psychologist
Causes of global developmental delay
Down’s syndrome
Fragile X syndrome
Fetal alcohol syndrome
Rett syndrome
Metabolic disorders
Causes of fine motor delay
Dyspraxia
Cerebral palsy
Muscular dystrophy
Visual impairment
Congenital ataxia (rare)
Causes of Gross Motor Delay
Cerebral palsy
Ataxia
Myopathy
Spina bifida
Visual impairment
Causes of language delay
Specific social circumstances, for example exposure to multiple languages or siblings that do all the talking
Hearing impairment
Learning disability
Neglect
Autism
Cerebral palsy
Causes of personal and social delay
Emotional and social neglect
Parenting issues
Autism
NB
Keep looking at 0-final notes printed, not all of them have been made into flashcards
Haemolytic uraemic syndrome (HUS)
classic triad of:
-Haemolytic anaemia
-Acute kidney injury
-Thrombocytopenia
The most common cause is a toxin produced by the e. coli 0157 bacteria, called the shiga toxin. Shigella also produces this toxin. The use of antibiotics and anti-motility medications such as loperamide to treat gastroenteritis caused by these pathogens increases the risk of developing HUS.
Presentation;
E. coli 0157 causes a brief gastroenteritis, often with bloody diarrhoea. The symptoms of haemolytic uraemic syndrome typically start around 5 days after the onset of the diarrhoea.
Signs and symptoms of HUS may include:
Reduced urine output
Haematuria or dark brown urine
Abdominal pain
Lethargy and irritability
Confusion
Oedema
Hypertension
Bruising
Management;
HUS is a medical emergency and has a 10% mortality. It needs to be managed by experienced paediatricians under the guidance of a renal specialist. The condition is self limiting and supportive management is the mainstay of treatment:
-Urgent referral to the paediatric renal unit for renal dialysis if required
-Antihypertensives if required
-Careful maintenance of fluid balance
-Blood transfusions if required
Failure to thrive
Anything that leads to inadequate energy and nutrition can lead to failure to thrive. The causes can be categorised as:
-Inadequate nutritional intake
-Difficulty feeding
-Malabsorption
-Increased energy requirements
-Inability to process nutrition
Causes of Inadequate Nutritional Intake
Maternal malabsorption if breastfeeding
Iron deficiency anaemia
Family or parental problems
Neglect
Availability of food (i.e. poverty)
Causes of Difficulty Feeding
Poor suck, for example due to cerebral palsy
Cleft lip or palate
Genetic conditions with an abnormal facial structure
Pyloric stenosis
Causes of Malabsorption
Cystic fibrosis
Coeliac disease
Cows milk intolerance
Chronic diarrhoea
Inflammatory bowel disease
Causes of Increased Energy Requirements
Hyperthyroidism
Chronic disease, for example congenital heart disease and cystic fibrosis
Malignancy
Chronic infections, for example HIV or immunodeficiency
Inability to Process Nutrients Properly
Inborn errors of metabolism
Type 1 diabetes
Investigations;
-Urine dipstick, for urinary tract infection
-Coeliac screen (anti-TTG or anti-EMA antibodies)
-Further investigations are usually not necessary where there are no other clinical concerns. Focused investigations should be considered where additional signs or symptoms suggest an underlying diagnosis, such as cystic fibrosis or pyloric stenosis.
Management of failure to thrive
Management depends on the cause and may involve input from the multidisciplinary team. All children with faltering growth should have regular reviews to monitor weight gain. Reviews that are too frequent can increase parental anxiety.
Where difficulty with breastfeeding is the cause, there are lots of ways for the mother to get support, including midwives, health visitors, peers groups and “lactation consultants”. Supplementing with formula milk is likely to successfully improve growth, however it often results in breastfeeding stopping. Mother should be encouraged to feed with breastmilk prior to top-up feeds, and express when not breastfeeding to encourage lactation to continue.
Where inadequate nutrition is the cause there are several management options based on individual circumstances:
Encouraging regular structured mealtimes and snacks
Reduce milk consumption to improve appetite for other foods
Review by a dietician
Additional energy dense foods to boost calories
Nutritional supplements drinks
Where other measures fail and there are serious concerns the multidisciplinary team may consider enteral tube feeding. This needs to have clear goals and a defined end point.
Recurrent UTI
Recurrent UTIs should be investigated for an underlying cause and renal damage. This is a summary of the NICE guidelines on urinary tract infections in under 16s. Please read the full guidelines before treating patients.
Ultrasound Scans
-All children under 6 months with their first UTI should have an abdominal ultrasound within 6 weeks, or during the illness if there are recurrent UTIs or atypical bacteria
-Children with recurrent UTIs should have an abdominal ultrasound within 6 weeks
-Children with atypical UTIs should have an abdominal ultrasound during the illness
DMSA (Dimercaptosuccinic Acid) Scan
DMSA scans should be used 4 – 6 months after the illness to assess for damage from recurrent or atypical UTIs. This involves injecting a radioactive material (DMSA) and using a gamma camera to assess how well the material is taken up by the kidneys. Where there are patches of kidney that have not taken up the material, this indicates scarring that may be the result of previous infection.
Vesico-Ureteric Reflux (VUR)
Vesico-ureteric reflux (VUR) is where urine has a tendency to flow from the bladder back into the ureters. This predisposes patients to developing upper urinary tract infections and subsequent renal scarring. This is diagnosed using a micturating cystourethrogram (MCUG).
Management of vesico-ureteric reflux depends on the severity:
Avoid constipation
Avoid an excessively full bladder
Prophylactic antibiotics
Surgical input from paediatric urology
Micturating Cystourethrogram (MCUG)
Micturating cystourethrogram (MCUG) should be used to investigate atypical or recurrent UTIs in children under 6 months. It is also used where there is a family history of vesico-ureteric reflux, dilatation of the ureter on ultrasound or poor urinary flow. A MCUG is used to diagnose VUR.
It involves catheterising the child, injecting contrast into the bladder and taking a series of xray films to determine whether the contrast is refluxing into the ureters. Children are usually given prophylactic antibiotics for 3 days around the time of the investigation.
Signs of respiratory distress
Raised respiratory rate
Use of accessory muscles of breathing, such as the sternocleidomastoid, abdominal and intercostal muscles
Intercostal and subcostal recessions
Nasal flaring
Head bobbing
Tracheal tugging
Cyanosis (due to low oxygen saturation)
Abnormal airway noises
Abnormal Airway Noises
-Wheezing is a whistling sound caused by narrowed airways, typically heard during expiration
-Grunting is caused by exhaling with the glottis partially closed to increase positive end-expiratory pressure (NB- isolated grunting in an unwell child is more likely to indicate sepsis rather than bronchiolitis)
-Stridor is a high pitched inspiratory noise caused by obstruction of the upper airway, for example in croup
Primary Ciliary Dyskinesia (Kartagner’s syndrome)
An autosomal recessive condition affecting the cilia of various cells in the body. PCD causes dysfunction of the motile cilia around the body, most notably in the respiratory tract
NB- there is a strong link between primary ciliary dyskinesia and situs inversus.
Kartagner’s Triad;
Kartagner’s triad describes the three key features of PCD. Not all patients will have all three features. These are:
-Paranasal sinusitis
-Bronchiectasis
-Situs Inversus
Investigations;
-CXR (situs invertus and bronchiectasis)
-Bronchoscopy with biopsy
-Semen analysis (male infertility)
Management;
Similar to cystic fibrosis and bronchiectasis with daily physiotherapy, a high calorie diet and antibiotics.
Inflammatory Bowel Disease (Crohn’s/UC)
Suspect inflammatory bowel disease in children and teenagers presenting with perfuse diarrhoea, abdominal pain, bleeding, weight loss or anaemia. They may be systemically unwell during flares, with fevers, malaise and dehydration.
See 3rd year notes for more detail (management/ investigations etc.)
Intestinal Obstruction
Where a physical obstruction prevents the flow of faeces through the intestines. This blockage will lead to a back-pressure through the gastrointestinal system, causing vomiting. It also causes absolute constipation, where the patient is unable to pass stools or wind.
Causes;
Meconium ileus
Hirschsprung’s disease
Oesophageal atresia
Duodenal atresia
Intussusception
Imperforate anus (ARM)
Malrotation of the intestines with a volvulus
Strangulated hernia
Features;
-Persistent vomiting. This may be bilious, containing bright green bile.
-Abdominal pain and distention
-Failure to pass stools or wind
-Abnormal bowel sounds. These can be high pitched and “tinkling” early in the obstruction and absent later.
Investigations;
Bedside- obs, exam
Blood- metabolic panel etc.
Specialist- Abdominal X-ray (dilated loops, absence of air in rectum)
Management;
Conservative- nil by mouth (NG tube), IV fluids
Medical- analgesia
Surgical- repair underlying cause (if necessary)
Growth hormone deficiency
Congenital growth hormone deficiency- congenital underproduction
Acquired growth hormone deficiency- secondary to infection, trauma or interventions such as surgery
NB- can occur in isolation or in combination with other pituitary hormone deficiencies like hypothyroidism, adrenal insufficiency
Features;
Growth hormone deficiency may present at birth or in neonates with:
-Micropenis (in males)
-Hypoglycaemia
-Severe jaundice
Older infants and children can present with:
-Poor growth, usually stopping or severely slowing from age 2-3
-Short stature
-Slow development of movement and strength
-Delayed puberty
Investigations;
Bedside-
Bloods- other pituitary deficiencies (thyroid/adrenal)
Specialist- GH stimulation test (poor response), genetic counselling (if necessary), MRI head (pituitary/hypothalamus abnormalities), X-ray or DEXA (bone age, determine final height)
Management;
Conservative- paediatric endocrinology referral
Medical- s/c injections of GH (somatropin)
Posterior urethral valve
Where there is tissue at the proximal end of the urethra (closest to the bladder) that causes obstruction of urine output. The obstruction to the outflow of urine causes hydronephrosis. A restriction in the outflow of urine prevents the bladder from fully emptying, leading to a reservoir of urine that increases the risk of urinary tract infections.
Features;
Difficulty urinating
Weak urinary stream
Chronic urinary retention
Palpable bladder
Recurrent urinary tract infections
Impaired kidney function
NB- severe cases can cause bilateral hydronephrosis in the foetus and oligohydramnios. The oligohydramnios leads to underdeveloped fetal lungs (pulmonary hypoplasia) with respiratory failure shortly after birth.
Investigations;
NB- usually picked up on antenatal scans (bilateral hydronephrosis)
Bedside-
Bloods-
Specialist- abdominal USS, micturating cystourethrogram (MCUG),Cystoscopy
Management;
Conservative- watchful waiting, urinary catheter
Surgical- ablation of tissue (during cystoscopy)
Simple hydrocele
Simple hydroceles are common in newborn males. They occurs where fluid is trapped in the tunica vaginalis. Usually this fluid gets reabsorbed over time and the hydrocele disappears.
The key differential diagnoses of a scrotal or inguinal swelling in a neonate are:
Hydrocele
Partially descended testes
Inguinal hernia
Testicular torsion
Haematoma
Tumours (rare)
Management;
-USS
-Simple hydroceles will resolve, communicating: surgery
Simple hydrocele
Simple hydroceles are common in newborn males. They occurs where fluid is trapped in the tunica vaginalis. Usually this fluid gets reabsorbed over time and the hydrocele disappears.
The key differential diagnoses of a scrotal or inguinal swelling in a neonate are:
Hydrocele
Partially descended testes
Inguinal hernia
Testicular torsion
Haematoma
Tumours (rare)
Management;
-USS
-Simple hydroceles will resolve, communicating: surgery
Klinefelter Syndrome
see previous notes
Kallman syndrome
see previous notes
Noonan Syndrome
Features
Short stature
Broad forehead
Downward sloping eyes with ptosis
Hypertelorism (wide space between the eyes)
Prominent nasolabial folds
Low set ears
Webbed neck
Widely spaced nipples
Associated Conditions
Congenital heart disease, particularly pulmonary valve stenosis, hypertrophic cardiomyopathy and ASD
Cryptorchidism (undescended testes) can lead to infertility. Fertility is normal in women.
Learning disability
Bleeding disorders
Lymphoedema
Increased risk of leukaemia and neuroblastoma
Management;
Conservative- supportive, MDT, monitor cardiac complications
Fragile X syndrome
Fragile X syndrome usually presents with a delay in speech and language development. Other features are:
Intellectual disability
Long, narrow face
Large ears
Large testicles after puberty
Hypermobile joints (particularly in the hands)
Attention deficit hyperactivity disorder (ADHD)
Autism
Seizures
Management;
Conservative- supportive, deal with autism and ADHD (special school etc.)
Angelman Syndrome
Features;
Delayed development and learning disability
Severe delay or absence of speech development
Coordination and balance problems (ataxia)
Fascination with water
Happy demeanour
Inappropriate laughter
Hand flapping
Abnormal sleep patterns
Epilepsy
Attention-deficit hyperactivity disorder
Dysmorphic features
Microcephaly
Fair skin, light hair and blue eyes
Wide mouth with widely spaced teeth
Management;
Supportive- physiotherapists, social workers, occupational therapists, educational support
CAMHS
See zero to finals (need to go over- MH can come up in F&C (also with postnatal depression))
Anaemia in Childhood
Causes in infancy;
-Physiological anaemia
-Anaemia of prematurity
-Blood loss
-Haemolysis (haemolytic disease of newborn, Hereditary spherocytosis, G6PD deficiency)
-Twin-twin transfusion, where blood is unequally distributed between twins that share a placenta
Causes in older children;
-Iron deficiency anaemia secondary to dietary insufficiency. This is the most common cause overall
-Malabsorption ie. coeliac, IBD (can be Fe,B12, or folate anaemia)
-Blood loss, most frequently from menstruation in older girls
-Sickle cell anaemia
-Thalassaemia
-Leukaemia
-Hereditary spherocytosis
-Hereditary eliptocytosis
-Sideroblastic anaemia
Symptoms of anaemia
Tiredness
Shortness of breath
Headaches
Dizziness
Palpitations
Worsening of other conditions
Pica, hair loss (iron-deficiency specific)
Signs of anaemia;
Pale skin
Conjunctival pallor
Tachycardia
Raised respiratory rate
Signs of specific causes of anaemia:
Koilonychia refers to spoon shaped nails, which can indicate iron deficiency
Angular chelitis can indicate iron deficiency
Atrophic glossitis is a smooth tongue due to atrophy of the papillae and can indicate iron deficiency
Brittle hair and nails can indicate iron deficiency
Jaundice occurs in haemolytic anaemia
Bone deformities occur in thalassaemia
Investigations;
Bedside- observations, physical examination
Bloods- FBC, blood film, haemanitics, reticulocyte count LFT (bilirubin), direct coombs (autoimmune haemolytic), haemoglobin electrophoresis (haemoglobinopathies)
Specialist-
NB- increased reticulocytes: due to haemolysis or blood loss.
Mumps
a viral infection spread by respiratory droplets
Features;
Fever
Muscle aches
Lethargy
Reduced appetite
Headache
Dry mouth
Parotid gland swelling, either unilateral or bilateral, with associated pain is the key feature that should make you consider mumps.
It can also present with symptoms of the complications, such as:
Abdominal pain (pancreatitis)
Testicular pain and swelling (orchitis)
Confusion, neck stiffness and headache (meningitis or encephalitis)
Investigations and Management;
-PCR testing on a saliva swab
-Supportive management (rest, fluid, analgesia, self-limiting)
Complications;
Complications
Pancreatitis
Orchitis (most common in post-pubertal males)
Meningitis
Sensorineural hearing loss
Paediatric ENT
See ENT notes
HSP
see previous notes
Paediatric dermatology
see previous notes
NB- go through 0-finals before exams (some notes will be in sections from M&M that I may have missed)
Causes of a non blanching rash
ITP
HSP
HUS (low platelets causes the rash, after diarrhoeal illness)
NAI
Meningococcal septicaemia
Haematological malignancy (low platelets)
DIC (due to sepsis)
Forceful coughing or vomiting
Routine fluid maintenance formula
Needed if patient cannot meet fluid needs orally (eg. NBM)
Holliday-Segar formula; (this is total volume needed in 24 hours);
100ml/kg for first 10kg
50ml/kg for next 10kg
20ml/kg for anything over 20kg
Rate of infusion = total amount in ml / 24
NB- fluid of choice: 0.9% sodium chloride + 5% glucose
Replacement fluid formula
%dehydration x weight (kg) x 10 = mls of fluid to replace
%dehydration = well weight-current weight/ well weight x 100
Total fluid requirement formulas
Total fluid in 24 hours (ml) = routine maintenance + replacement fluid
Rate of infusion (ml/hr) = total amount (ml) / 24
Duration (minutes) = (volume of fluid bag (eg. 500ml)/ rate) x 60
Features of congenital infections
Rubella- congenital sensorineural deafness and cataracts
Toxoplasmosis- Cerebral calcification, Chorioretinitis, Hydrocephalus
CMV- Low birth weight, Purpuric skin lesions, congenital sensorineural deafness, Microcephaly, seizures
Disorders of sex hormones
Primary hypogonadism (Klinefelter’s syndrome)- High LH Low testosterone
Hypogonadotropic hypogonadism (Kallman’s syndrome) Low LH Low testosterone
Androgen insensitivity syndrome High LH Normal/high testosterone
Testosterone-secreting tumour Low LH High testosterone
Hearing tests in children
Newborn- Otoacoustic emission test: All newborns should be tested as part of the Newborn Hearing Screening Programme
Newborn & infants- Auditory Brainstem Response test: May be done if otoacoustic emission test is abnormal
6-9 months- Distraction test: Performed by a health visitor, requires two trained staff
Knee problems in young people
Chondromalacia patellae
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
Osgood-Schlatter disease
Seen in sporty teenagers
Pain, tenderness and swelling over the tibial tubercle
Osteochondritis dissecans
Pain after exercise
Intermittent swelling and locking
Patellar subluxation
Medial knee pain due to lateral subluxation of the patella
Knee may give way
Patellar tendonitis
More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination
Causes of a limping child
Transient synovitis
Septic arthritis/osteomyelitis
Juvenile idiopathic arthritis
Trauma
Development dysplasia of the hip
Perthes disease
Slipped upper femoral epiphysis
Paediatric GI disorders
Pyloric stenosis
Acute appendicitis
Intussusception
Hirschsprung’s disease
Meconium ileus
Biliary atresia
Necrotising enterocolitis
There are some cards
In case 4 year 3
What does the 6-1 vaccine cover?
Diphtheria
Tetanus
Polio
Whooping cough (Pertussis)
Haemophilus influenzae type B
Hepatitis B
DTWPHH- don’t tango pio when he’s h
NB- thats the order that they feature in (ie. 3-1 teenage is d t p)
2 months
6-1
Rotavirus
Meningitis B
3 months
6-1
Rotavirus
Pneumococcal (PCV) vaccine
4 months
6-1
Meningitis B vaccine
1 year
Hib/Meningitis C booster
MMR
Pneumococcal PCV vaccine
Meningitis B vaccine
2-10 years
Annual flu vaccine
3 years and 4-months
4-1
MMR
What does the 4-1 vaccine (DTaP/ IPV (4-in-1 pre-school booster) cover?
Diphtheria
Tetanus
Whooping cough (Pertussis)
Polio
12/13 years
HPV vaccine- two jabs are given at 6-24 months apart
14 years
3-in-1 teenage booster
Meningitis ACWY vaccine
What does the 3-1 teenager booster vaccine cover?
Diphtheria
Tetanus
Polio
Breastfeeding and poor weight gain
Around 1 in 10 breastfed babies lose more than the ‘cut-off’ 10% threshold in the first week of life. This should prompt consideration of the above breastfeeding problems. The infant should also be examined to look for any underlying problems. NICE recommends an ‘expert’ review of feeding if this occurs (e.g. midwife-led breastfeeding clinics) and monitoring of weight until weight gain is satisfactory
NB- infants can lose less than 10% of their body weight in the first week of life
Management of meningitis
Supportive- IV fluids, notify PHE
Medical- IV cefotaxime (add IV amoxicillin if younger than 3 months or older than 50 years), IV steroids if older than 3 months, PEP for any contacts of meningococcal disease within 7 days of onset (oral ciprofloxacin)
NB- in community IM benzylpenicillin should be used
Contraindications to steroids;
-Septic shock
-Meningococcal septicaemia
-Meningitis post-surgery
-Immunocompromised
Patau syndrome (trisomy 13)
Microcephalic, small eyes
Cleft lip/palate
Polydactyly
Scalp lesions
Edwards syndrome (trisomy 18)
Micrognathia (small chin)
Low-set ears
Rocker bottom feet
Overlapping of fingers
Fragile X
Learning difficulties
Macrocephaly
Long face
Large ears
Macro-orchidism
Noonan syndrome
Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis
Pierre-Robin syndrome
Micrognathia
Posterior displacement of the tongue (may result in upper airway obstruction)
Cleft palate
Cri du chat syndrome (chromosome 5p deletion syndrome)
Characteristic cry (hence the name) due to larynx and neurological problems
Feeding difficulties and poor weight gain
Learning difficulties
Microcephaly and micrognathism
Hypertelorism
Differential diagnoses for NAI
Bruises- accidental injury, non-accidental injury eg. physical abuse, coagulopathy (VWD), haematological malignancy, DIC (meningococcal septicaemia (meningitis or sepsis)), ITP, HSP, ED (or other hypermobility syndrome)
Fractures- Accidental Injury, Osteogenesis Imperfecta, vitamin D deficiency, ED or other hypermobility syndrome
Burns- SSSS, accidental, bullous impetigo
Neglect- Failure to thrive, Inadequate hygiene eg severe nappy rash, infestation, Poor development of emotional attachment to child’s caregiver, Delay in development and speech and language, Poor attendance for school and health appointments e.g. immunisations, Failure to supervise eg toddler hit by car while roaming, Unsupervised young children at home- law not clear
Imaging required in suspected NAI
Skeletal Survey- full body CT
Neurological Imaging- head CT acutely, head MRI once stable
Reporting NAI
Discuss with team/seniors
Refer to children’s services/safeguarding officer on the ward
Identify any other children who may be at risk at home
Epilepsy vs acute symptomatic seizures
Acute symptomatic seizures are a result of acute insults, including hypoglycaemia, hypoxia, electrolyte derangements, infection, and trauma.
Focus on any known triggers in the history, think ‘before’, not ‘after’.
They may also be recurrent (e.g recurrent febrile seizures).
Types of paediatric seizures
Infantile spasms (West syndrome)- brief spasms with severe distress afterwards (not to be confused with infantile colic where the child is distressed during the “spasms” (bringing the legs to the chin))
Rolandic epilepsy- on waking, facial involvement
Absence epilepsy/seizures
Juvenile myoclonic epilepsy- awareness retained, myoclonic episodes
Febrile seizures
Vasovagal syncope
Reflex anoxic seizures
Cataplexy- sudden, strong emotion causes loss of tone
When to investigate centile abnormalities
A sustained drop through two or more weight/height centiles is unusual and should be investigated. (ie. a child that was once on the 75th percentile is now on the 25th (that’s 2 centiles))
Weight or height or BMI is below the 0.4th centile
Weight and centiles
Overweight is defined as a body mass index (BMI) above the 85th percentile and obese as above the 95th percentile.
Mesenteric adenitis
inflamed lymph nodes within the mesentery. It can cause similar symptoms to appendicitis and can be difficult to distinguish between the two. It often follows a recent viral infection and needs no treatment
Mesenteric adenitis
inflamed lymph nodes within the mesentery. It can cause similar symptoms to appendicitis and can be difficult to distinguish between the two. It often follows a recent viral infection and needs no treatment
Rubella
Features
prodrome, e.g. low-grade fever
rash: maculopapular, initially on the face before spreading to the whole body, usually fades by the 3-5 day
lymphadenopathy: suboccipital and postauricular
Complications
arthritis
thrombocytopaenia
encephalitis
myocarditis
erythema infectiosum
Also known as fifth disease or ‘slapped-cheek syndrome’
Caused by parvovirus B19
Lethargy, fever, headache
‘Slapped-cheek’ rash spreading to proximal arms and extensor surfaces
VSD
Heart failure
Pan systolic murmur
ASD
Ejection systolic murmur
Fixed splitting of S2
Compensated vs decompensated shock
Compensated
Normotensive
Tachycardia
Tachypnoea
Pale/mottled extremities
Oliguria
Decompensated
Hypotension
bradycardia
acidotic (Kussmaul)
blue
anuria
Head injury paediatrics
Criteria for immediate request for CT scan of the head (children)
Loss of consciousness lasting more than 5 minutes (witnessed)
Amnesia (antegrade or retrograde) lasting more than 5 minutes
Abnormal drowsiness
Three or more discrete episodes of vomiting
Clinical suspicion of non-accidental injury
Post-traumatic seizure but no history of epilepsy
GCS less than 14, or for a baby under 1 year GCS (paediatric) less than 15, on assessment in the emergency department
Suspicion of open or depressed skull injury or tense fontanelle
Any sign of basal skull fracture (haemotympanum, panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
Focal neurological deficit
If under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head
Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 m, high-speed injury from a projectile or an object)
Paediatric abdominal wall hernias
Congenital inguinal hernia
-Should be surgically repaired soon after diagnosis as at risk of incarceration (<6 weeks do in 2 days, <6 months do in 2 weeks, <6 years do in 2 months)
Infantile umbilical hernia
-The vast majority resolve without intervention before the age of 4-5 years
Complications are rare
Bilious vomiting within 24 hours of birth
Intestinal atresia, which can be subdivided into duodenal atresia, jejunal atresia, or ileal atresia is the most common cause
Other causes of neonatal bilious vomiting;
Malrotation with volvulus (distention, bowle sounds)
Meconium ileus
Necrotising enterocolitis
Ductus arteriosus
Prostaglandin (E2)- keeps DA patent (if associated CHD eg. TGA)
Indomethacin (or ibuprofen)- close DA (used in patent DA)
Burns
In adults, IV fluids should be given in second or third degree burns that cover 15% body surface area or more. In children, IV fluids are recommended when burns cover 10% body surface area.
Calculate fluid bolus in children ie. emergency (not maintainance/replacement fluids)
20 ml/kg over less than 10 minutes
Newborn Resuscitation
Newborn resuscitation helps to establish breathing and circulation.
- Dry baby and maintain temperature
- Assess tone, respiratory rate, heart rate
- If gasping or not breathing give 5 inflation breaths (open up lungs)
- Reassess (chest movements)
- If the heart rate is not improving and <60bpm start compressions and ventilation breaths at a rate of 3:1
Neural tube defects antenatal screening
would present with isolated high AFP and normal oestriol, hCG and inhibin A.
Intestinal atresia
Usually occurs on 1st day of life (as opposed to malrotation with volvulus which also causes bilious vomiting in neonates)
The diagnosis of intestinal/duodenal atresia is further supported by the presence of the ‘double bubble’ on the x-ray.
NB- double bubble is for duodenal atresia (D for D), jejunal would show an air fluid level
Curling’s ulcer
Stress ulcers may occur in the duodenum of burns patients and are more common in children.
Tachycardia
Hypotensive
Haematemesis
