Paediatrics Flashcards
1
Q
Acute epiglottitis
What is the most common causative organism?
A
Haemophilus Influenzae Type B (HIB)
2
Q
Acute epiglottitis
What are the signs and symptoms?
A
Intense swelling of epiglottis and surrounding tissues
Very acute onset (few hours)
High fever >38.5C
Immobile child, sitting propped up with mouth open
Child unable to speak or swallow, often drooling
Absent/slight cough
No preceding coryza
3
Q
Acute epiglottitis
What is the management?
A
IV or oral (if tolerated) antibiotics - cefuroxime for 3-5 days
Intubation
Blood cultures
Rifampicin prophylaxis for close contacts
4
Q
Nephrology
What are the 3 main renal causes of oedema in children?
A
Nephrotic syndrome
Nephritic syndrome
Henoch Scholein Purpura (HSP)
5
Q
Nephrology
What causes increased interstitial fluid?
Pathophysiology
A
Lymph drainage (lymphoedema)
Venous drainage and pressure (obstruction e.g., venous thrombosis)
Lowered oncotic pressure - low albumin/protein (malnutrition, decreased production or increased loss)
Salt and water retention (in the kidney due to impaired GFR or due to heart failure)
6
Q
Nephrology
How does nephrotic syndrome cause oedema?
A
Increased loss of albumin/protein in the kidneys –> low oncotic pressure –> oedema
Heavy proteinuria and hypoalbuminaemia
7
Q
Nephrology
What are the three types of nephrotic syndrome?
A
Congenital NS (<1 year old)
Steroid sensitive NS
Steroid resistant NS
8
Q
Nephrology
What are the features in the clinical presentation of steroid sensitive nephrotic syndrome?
A
- normal BP
- no macroscopic haematuria
- normal renal function
- no features suggesting nephritis
- responds to steroids
- “minimal change” on histology
9
Q
Nephrology
What are the features in the clinical presentation of steroid resistant nephrotic syndrome?
A
- elevated BP
- haematuria
- renal function may be impaired
- features may suggest nephritis
- failure to respond to steroids
- histology - various, underlying glomerulopathy, basement membrane abnormality
10
Q
Nephrology
What is the peak age of onset for steroid sensitive nephrotic syndrome?
A
2-5 years old
11
Q
Nephrology
What gender is steroid sensitive nephrotic syndrome most common in?
A
Male
12
Q
Nephrology
What ethnicity has a higher incidence of steroid sensitive nephrotic syndrome?
A
Asian sub-continent
13
Q
Nephrology
What is the prognosis of nephrotic syndrome?
A
- recurrent relapses common, about 5% continue into adult life
- normal renal function steroid responsive
14
Q
Nephrology
What is the treatment of steroid sensitive nephrotic syndrome?
A
For first episode:
- prednisolone 60mg/m^2 for 4 weeks
- prednisolone 40mg/m^2 on alternate days for 4 weeks
Consider: sodium and water moderation, diuretics, Pen V, measles and varicella immunity, pneumococcal immunisation
15
Q
Nephrology
What is the clinical presentation of acute glomerulonephritis?
A
- haematuria (often macroscopic)
- proteinuria (varying degree)
- impaired GFR
- rising creatinine
- salt and water retention - hypertension and oedema
16
Q
Nephrology
What is the most common cause of acute glomerulonephritis?
A
Group A B-haemolytic streptococcus, nasopharyngeal or skin infections e.g., tonsillitis
17
Q
Nephrology
What is the underlying pathophysiology of acute post-streptococcal glomerulonephritis?
A
Antigen-antibody complexes in the glomerulus and complement activation
18
Q
Nephrology
How does acute post-streptococcal glomerulonephritis present?
A
Presents 10 days after the infection with clinical nephritis
* haematuria
* swelling
* decreased urine output
* oedema
* hypertension
* signs of cardiovascular overload
19
Q
Nephrology
What is the management of acute post-streptococcal glomerulonephritis?
A
Fluid balance: measurement of input/output, fluid moderation, diuretics, salt restriction
Correction of other imbalances: potassium, acidosis
Dialysis if needed.
Penicillin for streptococcal infection.
20
Q
Nephrology
What is the prognosis of acute post-streptococcal glomerulonephritis?
A
95% make a full recovery
Not recurrent
No long term implication for renal function if full recovery
21
Q
Nephrology
What investigations are performed for acute post-streptococcal glomerulonephritis?
A
FBC - mild normocytic, normochromic anaemia
U&Es - increased urea and creatinine, hyperkalaemia, acidosis
Immunology - raised ASOT/antiDNAse B titre, low C3 and C4
Throat/other swabs
Urinalysis - haematuria (macroscopic usually), proteinuria (dipstick, protein:creatinine ratio), microscopy (RBC cast)
22
Q
Nephrology
What is Henoch-Schonlein Purpura?
A
It is a vasculitis of the skin, joints, gut and kidneys
23
Q
Nephrology
What is the renal presentation of Henoch-Schonlein Purpura nephritis?
A
Variable
* haematuria/proteinuria
* nephrotic syndrome
* acute nephritis
* renal impairment
* hypertension
24
Q
Nephrology
What are the differences between nephritic and nephrotic syndrome?
A
Nephritic: acute onset, decreased GFR, reduced urine output, haematuria, hypertension, some proteinuria, normal/slightly low albumin, high creatinine, red cell casts
Nephrotic: more insidious onset, decreased or normal GFR, normal urine output, little/no haematuria, normal BP, high proteinuria, hypoalbuminaemia, hyperlipidemia
25
# Nephrology
What are the **long term complications** of a UTI?
Kidney scarring, hypertension and chronic kidney disease
26
# Nephrology
What are the **signs and symptoms** of a **UTI** in a child under 3 months old?
Most common on top:
* fever
* vomiting
* lethargy
* irritability
* poor feeding
* failure to thrive
* abdominal pain
* jaundice
* haematuria
* offensive urine
27
# Nephrology
What are the **signs and symptoms** of a **UTI** in a child older than 3 months old that is **pre-verbal**?
Most common on top:
* fever
* abdominal pain
* loin tenderness
* vomiting
* poor feeding
* lethargy
* irritability
* haematuria
* offensive urine
* failure to thrive
28
# Nephrology
What are the **signs and symptoms** of a **UTI** in a child older than 3 months old that is **verbal**?
Most common on top:
* frequency
* dysuria
* dysfunctional voiding
* changes to continence
* abdominal pain
* loin tenderness
* fever
* malaise
* vomiting
* haematuria
* offensive urine
* cloudy urine
29
# Nephrology
When should you request a **urine sample**?
When a child presents with:
* symptoms and signs of UTI
* an unexplained fever of 38C or higher
* an alternative site of infection but remains unwell
30
# Nephrology
What is the **initial management** of a child <3 months old with a UTI?
Any infant under 3 months old with a suspected UTI should be referred to paediatric specialist care and urine should be sent for urgent microscopy and culture
31
# Nephrology
What is the most common **causative organism** for UTIs in **girls**?
E. coli
32
# Nephrology
Which **causative organism** of **UTIs** is more commonly found in **boys**?
Proteus
33
# Nephrology
Which **causative organism** of **UTIs** may indicate **structural abnormalities**?
Pseudomonas
34
# Nephrology
What is the **management** of a UTI in **infants under 3 months old**?
Minimum 2-4 days IV abx followed by oral
35
# Nephrology
What is the **management** of a UTI in **a systematically well child, no significant fever and no systemic features**?
3 days oral abx
Advise to return if no better at 24-48hrs
36
# Nephrology
What is the **management** of a UTI in **a systematically unwell child, fever >38C +/- loin pain**?
7-10 days oral abx
Consider IV abx
37
# Nephrology
What is the **management** of a UTI in **a systematically well child, no significant fever and no systemic features**?
3 days oral abx
Advise to return if no better at 24-48hrs
38
# Nephrology
What is classed an **atypical UTI**?
When it involves:
* septacaemia
* requires IV abx
* poor urine flow
* abdominal mass/bladder mass
* raised creatinine
* failure to respond to treatment with suitable abx within 48hrs
39
# Nephrology
What is classed as a **recurrent UTI**?
2+ episodes of UTI, at least one episode included systemic symptoms or signs
OR
3+ episodes of UTI without systemic symptoms/signs
40
# Nephrology
What **investigations** are performed in a **UTI**?
Ultrasound renal tract
Micturating cystourethrogram
DMSA scan
41
# Nephrology
What **investigation** is performed when **vesicoureteric reflux** is suspected?
Micturating cystourethrogram
42
# Nephrology
What is **vesicoureteric reflux**?
Retrograde flow of urine from bladder into ureter/pelvicalyceal system/intrarenal system
It is associated with UTIs
43
# Nephrology
Which **investigation** is done to look for renal scarring?
DMSA scan
44
# Diabetes
At what age is **Type 1 Diabetes** most commonly diagnosed in children?
2 peaks: 4-5 years and 10-11 years
45
# Diabetes
What is the **pathophysiology** of **Type 1 diabetes**?
Autoimmune destruction of the insulin-producing pancreatic Beta cells
Associated with HLA types DR3 and DR4
46
# Diabetes
What are the **presenting features** of **type 1 diabetes** in children?
Polyuria
Polydipsia (extreme thirst)
Weight loss
Tiredness
47
# Diabetes
What conditions is **type 2 diabetes** associated with in children, on presentation?
**Hypertension** - 44% have it on presentation
**Kidney disease** - 25% have it on presentation
48
# Diabetes
What are the **risk factors** for **type 2 diabetes** in children?
Obesity, girls, non-white ethnicity and deprivation
49
# Diabetes
What is the **pathophysiology** of **type 2 diabetes**?
Diminished response to insulin --> insulin resistence
It is initially countered by an increase in insulin production to try to maintain glucose homeostasis.
50
# Diabetes
How is **type 2 diabetes** diagnosed?
Oral glucose tolerance test
51
# Diabetes
What are the **criteria** for a diagnosis of **diabetes**?
Diabetes symptoms AND:
* a random venous plasma glucose of at least 11.1 mmol/L OR
* a fasting plasma glucose of at least 7.0 mmol/L OR
* who hour plasma glucose of at least 11.1mmol/L two hours after 75g anhydrous glucose in an OGTT
HbA1c of 48mmol/mol or more, but a lower value does not exclude
52
# Diabetes
What is the **management** of **type 1 diabetes**?
| Not in DKA
**Insulin**:
* started on 0.5-0.8 units/kg/day
* 50% long acting and 50% short acting for meals
* pen therapy to start with, pump later if needed
* blood glucose testing at least 5 times a day
53
# Diabetes
How does **diabetic ketoacidosis (DKA)** present?
* nausea and vomiting
* abdominal pain
* hyperventilation
* dehydration
* reduced level of consciousness
54
# Diabetes
How is the severity of **diabetic ketoacidosis** graded?
Mild = pH <7.3 or plasma bicarbonate <15 mmol/L
Moderate = pH <7.2 or plasma bicarbonate <10 mmol/L
Severe = pH <7.1 or plasma bicarbonate <5 mmol/L
55
# Diabetes
How is **diabetic ketoacidosis** managed?
Fluids
Insulin - slow 0.05-0.1 units/kg/hr
Monitor glucose hourly
Monitor electrolytes, especially K+ and ketones
Very strict fluid balance
Hourly neuro obs
56
# Diabetes
What are the possible **complications** of **diabetic ketoacidosis**?
Cerebral oedema, shock, hypokalaemia, vomit aspiration, thrombus
57
# Diabetes
What is the **initial management** of **type 2 diabetes**?
**Metformin +/- insulin **
**Consider GLP-1 agonists:** Liraglutide (>10 years), semaglutide (>18 years)
**Diet:** calorie/carb reduction and weight loss
**Lifestyle:** physical activity, sleep, screentime
58
# Diabetes
What are the **autonomic symptoms** of **hypoglycaemia**?
* irritable
* hungry
* shaky
* anxious
* sweaty
* palpitations
* pallor
59
# Diabetes
What are the **neuroglycopenic symptoms** of **hypoglycaemia**?
* confused
* drowsy
* hearing or visual problems
* headache
* slurred speech
* unusual behaviour/moodiness
* coma
* seizures
60
# Diabetes
What is the **management** of **mild-moderate hypoglycaemia**?
Check blood glucose
Glucose tablets, gel, glucose containing food or drink (not chocolate)
Check glucose in 15 minutes
Follow up with longer acting carb (bread or a biscuit)
61
# Diabetes
What is the **management** of **severe hypoglycaemia**?
Glucagon injection
62
# Diabetes
What are the **short term complications** of **diabetes**?
Hypo/hyperglycaemia
DKA
63
# Diabetes
What are the **long term complications** of **diabetes**?
Microvascular: albuminuria, retinopathy
Macrovascular: hypertension, hypercholesterolaemia
Blindness, kidney failure, heart disease, stroke, amputations
64
# Disability
What are the **five** types of **impairments**?
Physical
Sensory
Learning
Neurodevelopmental
Emotional/Behavioural
65
# Disability
What is **WHODAS**?
* A generic assessment instrument for health and disability
* Used across all diseases inc., mental, neurological and addictive disorders
* A tool to produce standardised disability levels and profiles
* Directly linked at the level of the concepts to the International Classification of Functioning, Disability and Health (ICF)
66
# Disability
What **six domains of functioning** does **WHODAS 2.0** cover?
**Cognition** - understanding and communication
**Mobility** - moving and getting around
**Self-care** - hygiene, dressing, eating and staying alone
**Social** - interacting with other people
**Life activities** - domestic responsibilities, leisure, work and school
**Participation** - joining in community activies
67
# Disability
What is the **definition** of **quality of life**?
The degree to which a person enjoys the important possibilities of his/her life
68
# Disability
What are the **three B's** of **quality of life**?
**Being** - who one is
**Belonging** - how one fits into the environment
**Becoming** - how to have purposeful activities in order to achieve one's goals
69
# Limping child
What are the **4 modified Kocher's criteria** used when assessing for likelihood of **septic arthritis**?
Modified Kocher's criteria:
* Fever >38.5C
* Inability to weight bear
* CRP > 20mg/L
* WBC >12
70
# Limping child
What is the **pathophysiology** of **Perthe's disease**?
Avascular necrosis of the femoral head
71
# Limping child
What are the **common causes** of a **limp** in a child **under 3 years old**?
Septic arthritis/osteomyelitis
Transient synovitis
Fracture/soft tissue injury
Developmental dysplasia of the hip
Toddler fracture
Non-accidental injury
Others:
* malignancy e.g., leukaemia
* non-malignant haematological disease e.g., haemophilia/sickle cell
* metabolic disease e.g., rickets
* neuromuscular disease e.g., cerebral palsy, spina bifida
* limb abnormality e.g., length discreptancy
72
# Limping child
What are the **common causes** of a **limp** in a child **between 3-10 years old**?
Transient synovitis
Septic arthritis/osteomyelitis
Fracture/soft tissue injury
Perthe's disease
Others:
* malignancy e.g., leukaemia
* non-malignant haematological disease e.g., haemophilia/sickle cell
* metabolic disease e.g., rickets
* neuromuscular disease e.g., cerebral palsy, spina bifida
* limb abnormality e.g., length discreptancy
* inflammatory joint or muscle disease e.g., JIA
73
# Limping child
What are the **common causes** of a **limp** in a child **older than 10 years old**?
Septic arthritis/osteomyelitis
Slipped upper femoral epiphysis
Perthe's disease
Fracture/soft tissue injury
Others:
* malignancy e.g., leukaemia
* non-malignant haematological disease e.g., haemophilia/sickle cell
* metabolic disease e.g., rickets
* neuromuscular disease e.g., cerebral palsy, spina bifida
* limb abnormality e.g., length discreptancy
* inflammatory joint or muscle disease e.g., JIA
74
# Limping child
What are the **ACR criteria** for the diagnosis of **juvenile idiopathic arthritis**?
* age at onset <16 years
* arthritis in one or more joints
* duration >/= 6 weeks
* exclusion of other forms of juvenile arthritis
75
# Limping child
What are the **three types** of **juvenile idiopathic arthritis** and how do they present?
**Polyarthritis**: 5 or more inflamed joints, usually medium-sized joints (knees, ankles, elbows)
**Oligoarthritis**: <5 inflamed joints
**Systemic**: arthritis with characteristic fever
Morning stiffness, gradual resolution of pain with activity. Painful or decreased range of motion, especially in internal rotation if hip affected.
76
# Limping child
What are the **features** associated with **systemic juvenile idiopathic arthritis**?
* Pyrexia
* Salmon-pink rash
* Lymphadenopathy
* Arthritis
* Uveitis
* Anorexia and weight loss
77
# Limping child
How does **septic arthritis/osteomyelitis** present?
* Usually febrile
* Most common <4 years old
* Pain
* Inability to weight bear
* Child often looks unwell
* Swollen, red joint in septic arthritis
* Passive movement of the joint is incredibly painful
* Femoral osteomyelitis presents similarily but there is some passive range of motion unless the infection has extended into the joint
78
# Limping child
What **investigations** should be performed when you suspect **osteomyelitis**?
MRI
79
# Limping child
How is **osteomyelitis** managed?
IV cefuroxime for 6 weeks first-line
If known staph. auerus then flucloxacillin for 6 weeks OR clindamycin if penicillin-allergic
80
# Limping child
What **investigations** should be performed for **septic arthritis**?
**Joint aspiration** for culture, also shows raised WBC
**CRP** and **ESR** raised
**Blood cultures**
**FBC**: raised WCC
81
# Limping child
When should you suspect **septic arthritis** rather than **transient synovitis**?
When the child has a high fever and/or is systematically unwell
82
# Limping child
How does **transient synovitis** present?
* Typically acute onset following a viral infection
* No systemic upset
* Age 3-8 years old, peak at 5/6 years
* More common in boys
* No pain at rest and passive movement is only painful at the extreme range of movement
* Limp/refusal to weight bear
* Low-grade fever in minority of patients
* Recurs in up to 15% of children
83
# Limping child
How is **transient synovitis** managed?
It is a self-limiting condition, requires only oral analgesia
84
# Limping child
How does **Perthe's disease** present?
* 5 times more common in boys
* Peak age 4-8 years old
* Around 10% of cases are bilateral
* Hip pain: develops progressively over a few weeks
* Limp
* Stiffness and reduced range of movement
* Widened joint space on x-ray, later changes include decreased femoral head size/flattening
85
# Limping child
How is **Perthe's disease** diagnosed?
Using a plain x-ray
Technetium bone scan or MRI if normal x-ray and symptoms persist
86
# Limping child
What are the **complications** of **Perthe's disease**?
Osteoarthritis and premature fusion of the growth plates
87
# Limping child
How does **slipped upper femoral epiphysis (SUFE)** present?
* Usually 11-14 years
* More common in obese children and boys
* Bilateral in 20-40%
* X-ray shows displacement of the femoral head epiphysis posterio-inferiorly
* May present acutely following trauma or more commonly with chronic, persistent symptoms
* Hip, groin, medial thigh or knee pain
* Loss of internal rotation of the leg in flexion
88
# Limping child
What **investigation** should be performed for **slipped upper femoral epiphysis (SUFE)**?
AP and lateral views - diagnostic
89
# Limping child
How is **slipped upper femoral epiphysis** managed?
Internal fixation - single cannulated screw placed in the centre of the epiphysis
90
# Limping child
What are the **complications** associated with **slipped upper femoral epiphysis**?
Osteoarthritis, avascular necrosis of the femoral head, chondrolysis, leg-length discrepancy
91
# Spots and rashes
What is a **macular rash**?
A non-palpable rash with colour changes in limited areas
92
# Spots and rashes
Give two causes of a **macular rash**
Measles, rubella
93
# Spots and rashes
What is a **papular rash**?
A palpable rash with raised, solid lesions and colour changes in limited areas up to 0.5cm
94
# Spots and rashes
What can cause a **papular rash**?
Pityriasis rosea
95
# Spots and rashes
What is a **vesicular rash**?
Elevated lesions that are filled with clear fluid <0.5cm
96
# Spots and rashes
Give **three** causes of a **vesicular rash**
Chicken pox, herpes simplex, herpes zoster
97
# Spots and rashes
What is an **ulcer**?
A skin or mucous membrane lesion occuring as a result of the loss of superficial tissue, usually involving an inflammatory process
98
# Spots and rashes
What is a **plaque**?
A differentiated area on a flat skin surface area or a mucous membrane
99
# Spots and rashes
Give an example of a **plaque**
Urticarial plaque
100
# Spots and rashes
What is a **nodule**?
A circumscribed swelling or an elevated lesion
101
# Spots and rashes
What is **petechiae**?
A small red or purple spot that is not elevated and does not blach when pressure is applied
Usually the result of haemorrhages from tiny blood vessels in the skin
102
# Spots and rashes
What can cause a **petechial rash**?
Meningococcal sepsis
103
# Spots and rashes
What are **crusts**?
Hard outer layer of lesions which may be due to dried serum or pus from ruptured vesicles
104
# Spots and rashes
What can cause **crusts**?
Impetigo
105
# Spots and rashes
What are **blisters**?
A fluid-filled structure within the epidermis or under the dermis
106
# Spots and rashes
What can cause **blisters**?
Bullous impetigo, bullous pemphagoid
107
# Spots and rashes
What are **café au lait spots** and how do they **present**?
Birthmark
* flat patches on the skin
* light brown but can darken with exposure to the sun
* more common in African Americans
* usually present at birth
* tend do persist, life-long
108
# Spots and rashes
What skin lesion is associated with **neurofibromatosis**?
Cafe-au-lait patch - more than 5 is suggestive of neurofibromatosis
109
# Spots and rashes
How do **strawberry naevi/marks (infantile/capillary haemangiomas)** present?
* Not at birth, develop rapidly in the first month of life
* Increase in size until 6-9 months old, then regress over few years
* Erythematous, raised and multilobed tumours
* Common sites: face, scalp, back
* Present in around 10% of white infants
* Risk factors: female, prematurity, mother undergone chorionic villous sampling
110
# Spots and rashes
What are the **complications** of **strawberry naevus**?
Mechanical e.g., obstructing visual field or airway
Bleeding
Ulceration
Thrombocytopenia
111
# Spots and rashes
What is the **management** of **strawberry naevi**?
Normally self limiting, 95% resolve before 10 years old
If treatment required due to complications, propranolol
112
# Spots and rashes
What are **port wine stains/naevus flammeus** and how do they **present**?
Birth marks
* often unilateral
* deep red or purple in colour
* do not spontaneously resolve, darken and become raised over time
* female predisposition
* 65% on head and neck
* may be associated with glaucoma
113
# Spots and rashes
What is the **management** of **port wine stains**?
Pulsed dye laser or cosmetic camouflage
114
# Spots and rashes
What are **Mongolian blue spots/congenital dermal melanocytosis** and how do they **present**?
Birth marks
* appear at or shortly after birth
* bruise-like, flat skin markings
* commonly at the base of spine, buttocks, back and shoulders
* seen in children with darker skin
* usually fade before adolescence
115
# Spots and rashes
What are **milia/milk spots**?
Small, benign, keratin-filled cysts that are common in newborns and often found around the nose and cheeks
116
# Spots and rashes
What is **erythema toxicum neonatorum** and how does it **present**?
Blotchy, red rash with small bumps that can be filled with fluid
Not infectious, self limiting
Occurs in up to 50% of all babies born at term
Usually between days 2-5 of life
117
# Spots and rashes
What **organism** is **chickenpox** caused by?
Varicella zoster virus
118
# Spots and rashes
How does **chickenpox** present?
* Small, itchy blisters
* Start on the chest, back and face then spreads
* Fever
* Tiredness
* Headaches
* Symptoms last 5-7 days
119
# Spots and rashes
How does **chickenpox** spread?
Through airborne droplets 1-2 days prior to rash starting, as well as contact with blisters
Infectious until all the lesions have crusted over (about 5 days from rash onset)
120
# Spots and rashes
What is the **management** of **chickenpox**?
* keep cool, trim nails
* calamine lotion
* school exclusion until lesions have crusted over
* if immunocompromised, or newborn with peripartum exposure --> varicella zoster immunoglobulin (VZIG), if chickenpox develops then consider IV aciclovir
121
# Spots and rashes
What are the **complications** of **chickenpox**?
Secondary bacterial infection of the lesions most common, NSAIDs may increase the risk
Other:
* pneumonia
* encephalitis
* disseminated haemorrhagic chickenpox
* arthritis, nephritis, pancreatitis (very rare)
122
# Spots and rashes
How does **measles** present?
CCCK: cough, conjuctivitis, coryza, Koplik's spots
* infective prodrome until 4 days after rash starts: irritability, conjuctivitis and fever
* Koplik's spots (white spots on buccal mucosa) develop before the rash
* rash starts behind ears then spreads to the whole body
* rash = discrete maculopapular rash, becomes blotchy and confluent
* desquamation of the rash that spares palms and soles may occur after a week
* diarrhoea in about 10%
123
# Spots and rashes
What **investigation** is performed for **measles**?
IgM antibodies - detected within a few days of rash onset
124
# Spots and rashes
How is **measles** managed?
Mainly supportive management
Admission if immunosuppressed or pregnant
Notifiable disease so inform PHE
125
# Spots and rashes
What are the **complications** of **measles**?
* Otitis media = most common
* Pneumonia = most common cause of death
* Encephalitis = normally 1-2 weeks following the onset of illness
* Subacute sclerosing panencephalitis = very rare, may present 5-10 years following illness
* Febrile convulsions
* Keratoconjunctivitis, corneal ulceration
* Diarrhoea
* Increased incidence of appendicitis
* Myocarditis
126
# Spots and rashes
How does **rubella** present?
* non-photogenic rash that starts on face and spreads
* rash is vague, lacy, ill-defined and not itchy
* rash lasts for 3 days
* lymphadenopathy
* fever
* sore throat
* fatigue
127
# Spots and rashes
What are the **complications** of **rubella**?
* Bleeding problems
* Testicular swelling
* Nerve inflammation
* In congenital rubella syndrome: miscarriage, cataracts, deafness, problems with heart and brain
128
# Spots and rashes
How does **slapped cheek syndrome/erythema infectiosum** present?
* mild feverish illness, headache and coryza
* rash appears after a few days - bright red cheeks, may spread to rest of the body but rarely involves palms and soles
* child begins to feel better as the rash appears
* no school exclusion
* common in 5-15 years old
* rash lasts 1-3 weeks
129
# Spots and rashes
What **organism** causes **slapped cheek syndrome**?
Parvovirus B19
130
# Spots and rashes
What are the **complications** of **slapped cheek syndrome**?
* Suppresses erythropoiesis
* Pancytopenia in immunosuppressed patients
* Aplastic crises in sickle-cell disease
* Hydrops fetalis (crosses placenta in pregnant women, causes severe anaemia --> heart failure --> accumulation of fluid in fetal serous cavities, treated with intrauterine blood transfusions)
131
# Spots and rashes
How does **roseola infantum/exanthem subitum** present?
* usually 6 months - 2 years old
* high fever lasting a few days **before** the rash
* rash is maculopapular, starts on torso then spreads to face, neck and arms, fades within 2 days
* nagayama spots = papular enanthem on the uvula and soft palate
* febrile convulsions in 10-15%
* diarrhoea and cough
* child feels better as rash appears
132
# Spots and rashes
What **organism** causes **roseola infantum/exanthem subitum**?
Human herpes virus 6
133
# Spots and rashes
How does **hand, foot and mouth disease** present?
Start with fever and feeling unwell, sore throat and oral ulcers
Rash appears 1-2 days later = vesicles on hands, feet and mouth
134
# Spots and rashes
What is the **management** of **hand, foot and mouth disease**?
Symptomatic: hydration and analgesia
No school exclusion as long as the child is well
135
# Spots and rashes
What **organisms** commonly cause **hand, foot and mouth disease**?
Coxsackie A16 and enterovirus 71
136
# Spots and rashes
How does **mumps** present?
* high fever
* malaise, muscular pain
* parotitis - unilateral initially then bilateral in 70%
* headache
* joint pain
137
# Spots and rashes
What is the **management** of **mumps**?
Rest, paracetamol and notify PHE
138
# Spots and rashes
What are the **complications** of **mumps**?
* orchitis - 4/5 days after the start of parotitis
* hearing loss - usually unilateral and transient
* meningoencephalitis
* pancreatitis
* can be associated with a fall in fertility
139
# Spots and rashes
How does **molloscum contagiosum** present?
* often 1-4 years old
* common in children with atopic eczema
* after contact with contaminated surfaces e.g., shared towels
* characteristic pinkish/pearly white papular with a central umbilication, up to 5mm
* lesions in clusters anywhere other than palms and soles
140
# Spots and rashes
How is **molloscum contagiosum** managed?
Self-care advice
* reassurance
* self-limiting within 18 months
* discourage scratching, consider emollient or mild topical conticosteroid to allieviate itch
141
# Spots and rashes
How does **impetigo** present?
* more common in warm weather
* golden, crusted skin lesions typically around the mouth
* very contagious
142
# Spots and rashes
What is the **management** of **impetigo**?
* hydrogen peroxide 1% if not systematically unwell or at risk of complications
* topical antibiotic creams: fusidic acid (first line), mupirocin
* extensive disease: oral flucloxacillin, oral erythromycin is penicillin-allergic
* school exclusion until lesions crusted over or 48 hours after starting antibiotics
143
# Spots and rashes
What **organisms** cause **impetigo**?
Staphylococcus aureus or streptococcus pyogenes
144
# Spots and rashes
How does **scalded skin syndrome** present?
Peeling skin over large parts of the body
Skin looks like scalded/burned
145
# Spots and rashes
What **organism** causes **scalded skin syndrome**?
Staphylococcus aureus
146
# Spots and rashes
How does **orbital cellulitis** present?
* age 7-12 years old
* redness/swelling around eye
* severe ocular pain
* visual disturbance
* proptosis
* ophthalmoplegia
* eyelid oedema and ptosis
147
# Spots and rashes
What **organisms** cause **orbital cellulitis**?
Staphylococcus aureus, Haemophilus influenzae B (not common due to vaccine), Streptococcus (less common than staph)
148
# Spots and rashes
How does **scarlet fever** present?
* 2-6 years old
* fever for 24-48 hours
* malaise, headache, nausea/vomiting
* sore throat
* strawberry tongue
* rash: fine punctuate erythema (pinhead), first on torso then spreads, rough sandpaper texture, desquamination later on around fingers and toes, perioral sparing
149
# Spots and rashes
What is the **management** of **scarlet fever**?
Oral penicillin V for 10 days or azithromycin if allergic
School exclusion until 24 hours after starting antibiotics
Notify PHE
150
# Spots and rashes
What are the **complications** of **scarlet fever**?
Otitis media (most common)
Rheumatic fever - usually 20 days after infection
Acute glomerulonephritis - usually 10 days after infection
151
# Spots and rashes
What is the **pathophysiology** of **scarlet fever**?
| In terms of causative organisms
Reaction to erythrogenic toxins produced by Group A haemolytic streptococci, usually streptococcus pyogenes
152
# Spots and rashes
How does **acanthosis nigricans** present?
Symmetrical, brown, velvety plaques found on the neck, axilla and groin
153
# Spots and rashes
What are the **causes** of **acanthosis nigricans**?
* Type 2 DM
* Gastrointestinal cancer
* Obesity
* Polycystic ovarian syndrome
* Acromegaly
* Cushing's disease
* Hypothyroidism
* Familial
* Prader-Willi syndrome
* Drugs: combined oral contraceptive pill, nicotinic acid, steroids, insulin
154
# Spots and rashes
What is **tinea capitis** and how does it present?
Fungal infection of the scalp (scalp ringworm)
* scarring alopecia
* if untreated, a raised, pustular, spongy/boggy mass (kerion) may form
155
# Spots and rashes
What is **tinea corporis/ringworm** and how does it present?
Fungal infection of the trunk, legs or arms
* may be after contact with cattle
* well-defined, annular, erythematous lesions with pustules and papules
156
# Spots and rashes
How is **tinea capitis** managed?
Oral antifungals (terbinafine or griseofulvin) and topical ketoconazole shampoo
157
# Spots and rashes
How is **tinea corporis/ringworm** managed?
Oral fluconazole
158
# Spots and rashes
What is **tinea pedis** and how does it present?
Athlete's foot
Itchy, peeling skin between toes
159
# Metabolic bone diseases
What are the **criteria** for diagnosing **osteoporosis** in children?
1 or more vertebral fractures
OR
Size adjusted bone density <-2.0 SDS plus one of:
* 2 or more long bone fractures by age 10
* 3 or more long bone fractures by age 19
160
# Metabolic bone diseases
What are the **inherited/congenital causes** of **osteoporosis**?
Osteogenesis imperfecta
Inborn errors e.g., galactosemia
Haematological problems
Idiopathic
161
# Metabolic bone diseases
What are the **acquired causes** of **osteoporosis**?
Drug-induced - especially steroids
Major endocrinopathies
Malabsorption
Immobilisation
Inflammation
162
# Metabolic bone diseases
What is the **mode of inheritance** of **osteogenesis imperfecta**?
Usually (85-90%) autosomal dominant, there are some rare recessive genes
163
# Metabolic bone diseases
How does **osteogenesis imperfecta** present?
* Bone fragility, fractures and deformity
* Bone pain
* Impaired mobility (ligamentous laxity and sarcopenia)
* Poor growth
* Deafness, hernias, valvular prolapse
* May have blue sclera
* Bones also brittle
164
# Metabolic bone diseases
What is the **pathophysiology** of **osteogenesis imperfecta**?
Abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides
165
# Metabolic bone diseases
Describe the first 4 types of **osteogenesis imperfecta** in terms of **severity**
I - mild
II - lethal
III - progressively deforming, severe
IV - moderate
166
# Metabolic bone diseases
What **medication** is used to treat **osteogenesis imperfecta** and what does it do?
Bisphosphonates
* increases bone mass
* reduces fracture frequency
* increases vertebral height
* suppresses bone markers
* reduces pain
* increases mobility
* does not affect growth
167
# Metabolic bone disease
What is **rickets**?
A condition characterised by inadequately mineralised bone in developing and growing bones, resulting in soft and easily deformed bones
168
# Metabolic bone diseases
What is **rickets** caused by?
Vitamin D deficiency
169
# Metabolic bone diseases
What are the **risk factors** for **rickets**?
Dietary deficiency of calcium
Prolonged breastfeeding
Unsupplemented cow's milk formula
Lack of sunlight
170
# Metabolic bone diseases
How does **rickets** present?
* Aching bones and joints
* Lower limb abnormalities (toddlers: genu varum/bow legs, older children: genu valgum/knock knees)
* Rickety rosary - swelling at the costochondral junction
* Kyphoscoliosis
* Craniotabes - soft skull bones in early life
* Harrison's sulcus
171
# Metabolic bone diseases
What does vitamin D do?
It makes calcium more available by increasing calcium absorption from the gut and increasing calcium release from the bone
Maternal vitamin D influences bone size and mass in childhood
It has a role in immune function/tolerance
172
# Metabolic bone diseases
What are the **complications** of **vitamin D deficiency** in newborns?
Severe, life threatening:
* cardiomyopathy
* hypocalcaemic convulsions
Severe:
* clinically apparent rickets e.g., metaphyseal swelling, bony deformity
Moderate:
* radiological or biochemical changes
173
# Metabolic bone diseases
What **biochemical disturbances** are seen in **rickets**?
Low PO4 (fasting)
Serum calcium variable
Raised serum alkaline phosphate
In vitamin D deficiency: raised PTH and low 25 OH-D
174
# Microbiology
What is the most common **causative organism** of a **UTI**?
E. coli
175
# Microbiology
What is the **first line treatment** for a **UTI** in neonates or infants who are acutely ill, have suspected pyelonephritis or are vomiting?
IV cefuroxime for 7 days
Oral switch trimethoprim
176
# Microbiology
What type of bacteria is **E. coli**?
| Gram staining and cocci/bacillus
Gram negative rods/bacilli
177
# Microbiology
What type of bacteria is **Staphylococcus aureus**?
| Gram staining and cocci/bacilli
Gram positive cocci
178
# Microbiology
What is the **antibiotic management** of **bacterial meningitis/meningococcal sepsis**?
First line: IV cefotaxime
179
# Microbiology
What **investigations** should be performed for suspected **bacterial meningitis/meningococcal sepsis**?
Blood clutures, EDTA blood for PCR, CSF
180
# Microbiology
What are the **most common causative organisms** of **meningitis** in children 0-3 months old?
Group B streptococcus (most common cause in neonates)
E.coli
Listeria monocytogenes
181
# Microbiology
What are the **most common causative organisms** of **meningitis** in children 3 months-6 years old?
Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae
182
# Microbiology
What are the **most common causative organisms** of **meningitis** in children >6 years old?
Neisseria meningitidis
Streptococcus pneumoniae
183
# Microbiology
What **antibiotics** should you use for **prophylaxis** of contacts with a child who has been diagnosed with **meningitis**?
Ciprofloxacin or rifampicin
184
# Microbiology
What type of bacteria is **streptococcus pneumoina/pneumococcus**?
| Gram staining and cocci/bacilli
Gram positive cocci in pairs
185
# Microbiology
What is the most common cause of **lobar pneumonia**?
Streptococcus pneumonia/pneumococcus
186
# Microbiology
What is the **management** of **streptococcus pneumoniae pneumonia**?
IV benzylpenicillin if severe
PO amoxicillin if mild
187
# Faltering growth
Define **faltering growth**
Failure to gain adequate weight or achieve adequate growth during infancy or early childhood
Significant interruption in the expected rate of growth compared with other children of similar age and sex during early childhood
Fall across 2 centiles on the growth chart
188
# Faltering growth
What are the **concerning features** of a child with **faltering growth**?
* 10% loss of their birthweight in a newborn
* No return to birthweight by 3 weeks of age
* Fall across >1 centile, if birthweight was below 9th centile
* Fall across >2 weight centiles, if birthweight was between 9th-91st centiles
* Fall >3 weight centiles, if birthweight was above 91st centile
* Weight is <2nd centile for age, independent of birthweight
189
# Faltering growth
What are the **4 types of causes** of **faltering growth**?
Poor intake
Malabsorption
Excessive expenditure
Abnormal appetite/growth and psychosocial
190
# Faltering growth
What are the **causes** of **poor intake**?
Breast-feeding poorly
Bottle feeds too dilute
Juice drinker
Exclusion diets
Cleft palate
Neuromuscular disorder
Vomiting
Eating disorder
191
# Faltering growth
What are the **symptoms** of **GORD**?
| Respiratory, oesophagitis, regurgitation and neurobehavioural
**Respiratory**:
* aspiration pneumonia
* bronchospasm, wheezing
* apnoeas, cyanotic episodes
* cough, stridor, hoarseness
* otitis media, glue ear
**Oesophagitis**:
* chest and epigastric pain
* irritability
* anaemia, haematemesis
* dysphagia
* peptic stricture causing obstruction
**Regurgitation**:
* poor weight gain
* nausea, vomiting
**Neurobehavioural**:
* infant spells (including seizure-like events)
* Sandifer's syndrome
192
# Faltering growth
What are the **causes** of **malabsorption**?
Enteropathy, liver disease and pancreatic disease
193
# Faltering growth
What are the **causes** of **pancreatic insufficiency**?
* Cystic fibrosis
* Schwachmann-Diamond syndrome
* Isolated enzyme deficiency
* Chronic pancreatitis and failure
194
# Faltering growth
What is the **presentation** of **pancreatic insufficiency**?
Fatty, greasy stools that smell foul and float, diffiuclt to flush
195
# Faltering growth
What **investigations** should be performed for **pancreatic insufficiency**?
Check faecal elastase, formal pancreatic function studies and trial of Creon
196
# Faltering growth
What are the **causes** of **diarrhoea**?
Allergic, coeliac, infective, post-infective
197
# Faltering growth
How does **cow's milk protein allergy** present?
IgE mediated - rapid onset, anaphylactic type symptoms
* Constipation
* Iron deficiency anaemia
* Vomiting
* Smelling of lips or eye lids
* Asthma
* Wheezing and coughing
* Eczema
* Skin rash
* Colic
* Diarrhoea
* Refusal to feed
* Blood in faeces
198
# Faltering growth
What are the **infective** causes of **diarrhoea**?
**Enteroviruses**: rotavirus, adenovirus, picornavirus
**Bacterial**:
* toxins - clostridium difficile, staphylococcal
* secretagogues - cholera
* inflammatory - salmonella, campylobacter
**Parasitic**: giardia, entamoeba histolytica
**Others**: TB, opportunistic in immunocompromised, herpes, CMV, HIC
199
# Faltering growth
How is **post-infective** diarrhoea caused?
Infection-related mucosal disintegrity --> immunological antigen exposure --> mucosal (allergic) inflammation --> secondary disaccharidase deficiency --> diarrhoea
200
# Faltering growth
How does **coeliac disease** cause **faltering growth**?
Prximal small intestine damage due to tissue transglutaminase --> malnutrition and malabsorption
201
# Faltering growth
How does **coeliac disease** present?
* Fatigue
* Iron deficiency anaemia
* Osteopenia/osteoporosis
* Mouth ulcers
* Dental enamel defects
* Failure to thrive
* Short stature
* Delayed puberty
* Nausea and vomiting
* Abdominal pain
* Bloating
* Diarrhoea
* Constipation
* Hepatitis
* Weakness
* Parasthesia
* Dermatitis herpetiformis
* Behavioural changes
* Subfertility and recurrent miscarriages
* Malnutrition
202
# Faltering growth
How do you test for **lactose intolerance**?
Lactose hydrogen breath tests
Trial off milk
203
# Faltering growth
How does **inflammatory bowel disease** present?
Long history of faltering growth of weight loss, pain, loose stools, frequency and urgency, PR bleeding, FE deficiency anaemia
204
# Faltering growth
What **investigations** should be performed for **IBD**?
CRP
ESR
FBC - anaemia and thrombocytosis
Albumin
Faecal calprotectin
205
# Faltering growth
What are the causes of **excessive energy expenditure**?
* Congenital heart disease
* Chronic renal failure
* Chronic respiratory disease e.g., CF
* Chronic inflammation
* Tumours
* Other catabolic states
206
# Faltering growth
What are **non-organic causes** of **faltering growth**?
* Poor parental understanding
* Low income
* Poor social support
* Deliberare starvation
* Maternal anorexia
* Parental psychiatric illness
* Emotional neglect
207
# ENT
What causes **acute otitis media**?
Normally preceded by a viral URTI which disrupt the microbiome and allow bacteria to grow
Bacterial causes: Streptococcus pneumoniae, Haemophilus influenza
208
# ENT
How tos **otitis media** present?
* Otalgia (pain)
* Some children may tug/rub their ear
* Fever in about 50%
* Hearing loss
* Recent viral URTI symptoms
* Ear discharge if tympanic membrance perforates
209
# ENT
What might you find on **otoscopy** in **otitis media**?
* bulging tympanic membrane
* opacification or erythema of the tympanic membrane
* perforation with purulent otorrhoea
* decreased mobility if using a pneumatic otoscope
210
# ENT
What is the **management** of **otitis media**?
Self limiting, analgesia
Antibiotics (amoxicillin or erythromycin/clarithromycin):
* symptoms >4 days and not improving
* systematically unwell but not requiring admission
* immunocompromise or high risk of complications
* younger than 2 years with bilateral otitis media
* perforation and/or discharge in the canal
211
# ENT
What is **glue ear**?
Otitis media with an effusion
212
# ENT
How does **glue ear** present?
* Peaks at 2 years of age
* Hearing loss on 2 occasions 3 months apart
213
# ENT
How is **glue ear** managed?
Conservative
Grommet insertion
Adenoidectomy
Hearing aids
214
# ENT
What are the **causes** of **epistaxis**?
Nose picking, inflammation, foreign body, trauma, bleeding diathesis
215
# ENT
How is **epistaxis** managed?
ABCDE
Medical: topical naseptin, silver nitrate cautery
Surgical: electrocautery
216
# ENT
What is **laryngomalacia** and how does it **present**?
Congenital abnormality of the larynx
* infants present at 4 weeks old with a stridor
* stridor worse on feeding and exertion, also when supine
* normal voice
* failure to thrive
* increased work of breathing
217
# ENT
What is the **management** of **laryngomalacia**?
* Close monitoring
* Monitor weight
* Antireflux
* NG tube
* Surgery
* Normally self limiting, stridor lessens and is gone by 2 years old
218
# ENT
How does **croup** present?
* peak incidence 6 months - 3 years
* more common in autumn
* stridor
* barking cough (worse at night)
* fever
* coryzal symptoms
* increased work of breathing
219
# ENT
What is the **management** of **croup**?
Single dose of oral dexamethasome (or prednisolone)
Emergnecy: high-flow oxygen, nebulised adrenaline
220
# ENT
What is the most common **causative organism** of **croup**?
Parainfluenza viruses
221
# ENT
What is the **most common** causative organism of **tonsillitis**?
Streptococcus pyogenes
222
# ENT
How does **tonsillitis** present?
Swollen, red tonsils, pus may be present, may have a fever
223
# ENT
What is the **management** of **tonsillitis**?
If bacterial suspected, penicillin-like antibiotics
224
# Neurology
What is **cerebral palsy**?
A group of motor impairment syndromes secondary to non-progressive lesions or anomalies in the brain, arising in the early stages of development
225
# Neurology
How does **cerebral palsy** cause **undernutrition**?
Inadequate intake as a result of self-feeding inadequacy and/or oro-motor coordination difficulties
Dystonia:
* extensor patterns, limiting oral movements becoming stereotyped and abnormal
* tactile hypersensitivity may be greatest around the mouth
Postural deformity: control of head/trunk/compression abdomen
Drug treatment: baclofen/diazepam/tone/sedation, anticonvulsants/sedation have an effect on appetite
Impaired hand function
Immobility
Vision impairment
Deafness
GORD
226
# Neurology
What are the **consequences** of **undernutrition** in **cerebral palsy**?
Poor growth
Reduced muscle strength
Poor circulation due to reduced activity
Increased susceptibility to infection
227
# Neurology
What are the **causes** of **cerebral palsy**?
**Antenatal** (80%): cerebral malformation, congenital infections (rubella, toxoplasmosis, CMV)
**Intrapartum** (10%): birth asphyxia/trauma
**Postnatal** (10%): intraventricular haemorrhage, meningitis, head trauma
228
# Neurology
How does **cerebral palsy** present?
* abnormal tone early infancy
* delayed motor milestones
* abnormal gait
* feeding difficulties
* learning difficulties
* epilepsy
* squints
* hearing impairments
229
# Gastroenterology
How does **malrotation/volvulus** present?
* Neonate (3-7 days old)
* Bilious vomiting, abdominal distension
230
# Gastroenterology
How is **malrotation** diagnosed?
Upper GI contrast study
231
# Gastroenterology
How does **Hirschsprung's disease** present?
* More common in males
* Associated with Down's syndrome
* Failure or delay to pass meconium in the neonatal period
* Constipation or abdominal distension in older children
232
# Gastroenterology
What **investigations** should be performed for **Hirschsprung's disease**?
Abdominal XR
Gold standard for diagnosis = rectal biopsy (aganglionic segment of the bowel)
233
# Gastroenterology
What is the **management** of **Hirschsprung's disease**?
Rectal washouts and bowel irrigation
Surgery to affected segment of the colon
234
# Gastroenterology
How does **meconium ileus** present?
Delayed passage of meconium and abdominal distension
Majority have cystic fibrosis
235
# Gastroenterology
How does **necrotising enterocolitis** present?
usually pre-term infant
abdominal distension
bilious vomiting
236
# Immunisation schedule
What **immunisations** are given at **2 months old**?
6 in 1
Oral rotavirus
Men B
237
# Immunisation schedule
What **immunisations** are given at **3 months old**?
6 in 1
Oral rotavirus
PCV
238
# Immunisation schedule
What **immunisations** are given at **4 months old**?
6 in 1
Men B
239
# Immunisation schedule
What **immunisations** are given at **12-13 months old**?
HiB/Men C
MMR
PCV
Men B
240
# Immunisation schedule
What **immunisations** are given at **2-8 years**?
Annual flu vaccine
241
# Immunisation schedule
What **immunisations** are given at **3-4 years**?
4 in 1
MMR
242
# Immunisation schedule
What **immunisations** are given at **12-13 years**?
HPV
243
# Immunisation schedule
What **immunisations** are given at **13-18 years**?
3 in 1
Men ACWY
