Paediatrics Flashcards
Respiratory Disorders
Respiratory Disorders
Neonatal Problems - features + management
- Transient Tachypnoea of the Newborn
- Surfactant deficient lung disease
- Laryngomalacia
- Bronchopulmonary dysplasia
Transient Tachypnoea of Newborn
- Path- delayed resorption of fluid in lungs. Most common cause of resp distress in newborns. RF: C-section
- Pres - raised RR, CXR- hyperinflation + fluid in horizontal fissure
- Mx - obs, supportive, supplementary O2. Normally resolves within 1-2d
Surfactant Deficient Lung Disease aka. ARDS
Path - insufficient surfactant. RF: premature, male, diabetic mother, C-section, 2nd born prem twin
Pres- tachypnoea, intercostal recessions, expiratory grunting, cyanosis
Ix- CXR - ground glass w/ indistinct heart border
Mx - maternal steroids during pregnancy. O2, assisted ventilation, surfactant via ET tube.
Laryngomalacia
- Defect in larynx –> stridor, difficulty feeding, poor weight gain, apnoea, cyanosis, GORD
- = most common cause of stridor in neonates
- Conservatively managed
Bronchopulmonary dysplasia
- any infant w/ O2 req at 36w post-menstrual age = bronchopulmonary dysplasia.
- RF: prematurity, artificial ventilation, O2 toxicity, infection. Maternal steroids help reduce risk.
- Increased risk severe bronchiolitis + other resp infections.
- Ix: CXR widespread opacification +/- cystic changes
- Mx: ventilation + supplementary O2 as needed
Common Respiratory Infections of Childhood - organism, presentation, management
- Whooping Cough
- Croup
- Bronchiolitis
Whooping Cough
- org: Bordatella Pertussus
- Pres - 2-3d prodromal coryza –> coughing bouts, worse at night, insp whoop, apnoea, vomiting. Cough can last up to 3/12.
- Ix - marked lymphocytosis, PCR + serology
- Vaccination - infants (2,3,4/12 and 3-5yr) and pregnant women (16-32/52)
- Mx - <6/12 = admit. PO macrolide if onset within 21d. household prophy abx.
- School exclusion 48h after started abx or for 21/7 after symptom onset if no abx
Croup - viral laryngotracheobronchitis
- Org - parainfluenza virus
- Pres - 6/12 -3y. Stridor, barking (seal) cough, worse at night, fever, coryzal symptoms
mild - occassional cough, nil signs at rest
mod - stridor, retration at rest but no agitation/distress
Sev - significant distress, tachycardia,, hypoxaemia
- Ix - clinical diagnosis. CXR - subglottic narrowing (steeple sign)
- Mx - All = single dose PO dexamethasone. mod/severe/<6/12/known airway abnormalities = admit. High flow O2, nebulised adrenaline.
Bronchiolitis
Path - RSV. Worse if: bronchopulmonary dysplasia, congenital heart disease, CF
Pres - <1yr, coryza, cough, SOB, wheeze, insp crackles, feeding difficulties
N.B. can be low grade-temp BUT high fever or focal crackles sould make u suspect pneumonia
Ix - immunofluoresence of nasopharyngeal secretions
Mx - Admit: apnoea, unwell, severe resp distress (grunting, marked recession, RR >70), central cyanosis, O2 <92%.
Supportive: humidified O2 via headbox, NG feeding if unable PO, suction for upper airway secretions
What is the difference between viral episodic wheeze and asthma? How are they managed?
Viral Episodic Wheeze
- wheeze in response to viral infection. common in <3yrs.
- RF: maternal smoking, prematurity
- Mx: salbutamol PRN (NB steroids do NOT help)
Asthma
- Mostly in children >6. More likley asthma if: wheeze when otherwise well, in response to trigger/emotion, fam hx of atopy.
- Can be atopic (+ve skin prick + raised IgE) or non-atopic (-ve skin test + normal IgE)
Long term management
- >5yrs old same as adults
- <5 yrs old
1. SABA
2. SABA + 8/52 trial moderate dose ICS (if resolves sx + sx return within 4/52 of stopping then re-start longterm at low dose)
3. SABA + lowdose ICS + LTRA
4. Stop LTRA + refer to paeds
Acute attacks
Assessment- similar to adults but different HR + RR cut offs for severe attack:
-HR >125 (>5yo) or >140 (1-5yo);
- RR >30 (>5) or >40 (1-5)
Management
Moderate: SABA via spacer (or close- fitting mask if <3yo) up to 10 puffs (if nil controlled -> hosp) + PO steroids 3-5d
Severe or life-threatening –> immediate hospital transfer
Steroid dose: 2-5yr (20mg OD), >5yr (30-40mg OD) for 3-5 d
Sore throat/tonsilitis/pharyngitis covered in ENT.
What are some complications that can occur post strep infection in children?
Post infectious glomerulonephritis
- 2-3/52 post infection (covered in renal)
Rheumatic Fever = multisystem immune response
presentation:
- Acute (2-6/52 post-infection): fever, malaise, endo/myo/pericarditis, migratory arthritis, HF, erythema marginatum (pink border + fading centre)
- Sydenham Chorea (10%), 2-6/12 post infection): involuntary movements, emotional lability, subcut nodules extensor surfaces
- Chronic (80%) - mitral stenosis
Management:
- Acute: bed rest, anti-inflammatories +/- steroids
- Ongoing: monthly ben pen injection to avoid recurrence (for 10yr of till age 21) +/- surgical valve repair
Scarlet Fever
- Presentation: fever, malaise, headache, N+V, sore throat, strawberry tongue (initially white coated), rash (flushed w/ circumoral pallor; sandpaper texture)
- Diagnosis: throat swab
- Mx: PO pen V for 10d
- Notifiable disease. School exclusion for 48h after starting abx.
What are the following?
- Kawasaki Disease
- Reye Syndrome
Kawasaki Disease = systemic vasculitis, age 6m-4y
Presentation = CRASH and Burn
- Conjunctivitis, Rash, Adenopathy (cervical, often unilateral), Strawberry tongue + other mucous membrane changes, Hands + feet (red/oedematous/desquamation). Burn - fever for >5d
- Complications: coronary artery aneurysm (33%) (echo to ix), MI, sudden death
- Management:
- IV immunoglobulins (within 10d)
- Aspirin high-dse (only time this is given to children)
Reye Syndrome
- Swelling in liver and brain
- Occurs in children/teens following viral infection if given aspirin
Febrile Seizures
- Pathophysiology
- Presentation
- Investigation
- Management
Pathophysiology
- Epileptic seizure w/ fever (+ no intracranial infection)
Presentation (6m-6yrs)
- Viral infection + fever
- Brief generalised tonic-clonic seizures
- N.B. if still drowsy 1hr post-seizure this is not consistent + should make u think ?CNS infection
Management
Acute:
- Manage seizure acutely (as per status)
- Find source of fever + tx as needed
- Anti-pyretics (not useful prophylactically)
- Teach parents how to manage seizures: if >5m buccal midaz + 999, protect from injury, do not restrain, once finished put in recovery position + observe
Prognosis:
- 1 in 3 have further febrile convulsion. Risk reduces w/ age (rare >6yrs)
- Risk of further seizure higher is: young child, short duration of illness prior to seizure, lower temp, +ve fam hx
- Complex seizures have 10% risk of later epilepsy: focal, prolonged, repeated within same illness
Cardiology
Cardiology
Give features of innocent murmurs in childhood
Types of Innocent Murmur
- Venous hum - turbulent blood flow in great veins= continuous blowing noise below clavicles
- Still’s murmur - low-pitches at lower left sternal edge
Characteristis
- Soft-blowing in pulmonary area OR short-buzzing in aortic area
- Postural
- Localised w/ no radiation
- No diastolic component
- No thrill
- No added sounds (eg. clicks)
- Asymptomatic child
- No other abnormality
Give examples of Acyanotic and Cyanotic Congenital Heart Defects
Acyanotic
VSD (30% - most common)
- loud pansystolic murmur (if small) or HF, SOB, tachycardia, hepatomegaly (large)
- Ix: echo to diagnose
- Mx: reversal of shunt at 3-6/12 to avoid Eisenmenger (reversal of shunt due to pulm HTN)
ASD
- mostly asymptomatic, ejection systolic murmur at left sternal edge, can present in adulthood
- Ix: Echo
- Mx: surgery at 3-5yr (prevent HF + arrhythmia)
Patent Ductus Arteriosus
- Normally closes w/ first breath
- RFs: premature, maternal rubella in 1st trimester
- Pres: Left subclavicular thrill, continuous machinery murmur, large vol bounding collapsing pulse, wide pulse pressure, heaving apex beat, cyanosis if left uncorrected
- Management:
- Indomethacin or Ibuprofen (reduce PG synthesis + so close duct)
Coarctation of Aorta
- Pres depends on severity. Neonates can: HF, acidosis, poor lowr body perfusion. Some are asymptomatic. Radio-femoral delay.
- Surgical management
Aortic Valve Stenosis (5% of CHD)
- Associated w/ William’s syndrome, coarctation, Turner’s syndrome
- Mx: delay valve replacement if possible; If gradient >60 may need balloon valvuloplasty
Cyanotic
*Tetralogy of Fallot (presents at 1-2/12) *
- Features: VSD, overriding aorta, RVH, Pulmonary stenosis
- Present: Cyanosis (tet spells - tachypnoea, cyanosis, LOC when upset/pain/fever)
- Ejection systolic murmur, R to L shunt
- CXR: boot shaped heart on ECG. ECG: RVH
- Mx: Surgical repair. B-blockers during cyanotic episodes.
Transposition of Great Arteries (presents at birth)
- Path: aorta leaves RV; pulm trunk leaves LV
- Pres: cyanosis, tachypnoea, loud S2, prominent RV impulse, Egg-on-side CXR
- Mx: Duct dependent = prostaglandins, then surgical correction
Tricuspid Atresia
Cyanosis, SOB, tire during feeding, poor weight gain
Give examples of duct-dependent heart defects
Which heart defects are associated with Down Syndrome and Turner’s Syndrome?
Duct Dependent - give prostaglandins acutely
Cyanotic: Tansposition of great arteries, pulmonary atresia,Tricuspid atresia, Severe Tetrallogy of Fallot
Basically all cyanotic heart defects –> supportive care plus prostaglandin E1 to maintain PDA
Other: Hypoplastic left heart, coarctation of aorta, Critical Aortic Stenosis
Down Syndrome
All down syndrome babies have echo at birth
Main one:
- AVSD –> blue + breathless presentation
- Manage: diuretics for HF, surgery at 3-6/12
Other: ASD, VSD, tetralogy
Turner’s Syndrome
- Coarctation of aorta
- Bicuspid aortic valve (aortic stenosis)
What is acrocyanosis?
Acrocyanosis = peripheral cyanosis around mouth + extremeties (hands + feet)
- Seen in health newborns immediatley after birth
- Due to benign vasomotor changes -> peripheral vasoconstriction
- Can persist for 24-48h
What can cause HTN and HF in children?
Hypertension
- Renal disease
- Coarctation of aorta
- Phaeochromocytoma
- Congenital Adrenal Hyperplasia
- Essential HTN
Heart Failure
Causes
- neonates: duct-dependent disease (when duct closes)
- infants: left to right shunts which have reversed -> right heart failure e.g. ASD, VSD, large PDA
- Older: eisenmenger syndrome, rheumatic heart disease, cardiomyopathy
Presentation
- SOB, sweating, poor feeding, recurrent chest infection, hepatomegaly, raised RR + HR, murmur, gallop rhythm
**Pathophysiology **
- Vit K deficiency - all newborns are relatively deficient –> impaired production of clotting factors
- RFs: breast-feeding, maternal anti-epileptic use
** Presentation **
- Can range from minor bruising to intracranial haemorrhage
- e.g. blood in stools, urine or oozing round umbilical cord
Investigation
- Clotting profile
**Management **
- prevented by giving all newborns vit K IM or PO
- +/- may need transfusion
GI/Surgery
GI/Surgery
Give differentials for acute abdominal pain in children
Intra-Abdominal
Surgical:
- Acute appendicitis (rare <3)
- Intestinal obstruction
- Intussusception (3m-2y)
- Inflamed meckel’s diverticulum
- Pancreatitis
- Trauma
- Malrotation/volvulus
Medical
- Gastoenteritis
- UTI, pyelonephritis, stones
- Henoch-Schonlein-Purpura
- Sickle Cell crisis
- IBD
- Constipation
- Recurrent abdo pain of childhood
- Gynae probles (if pubertal)
Extra-abdominal
- URTI
- Lower lobe pneumonia
- Torsion (always check for this)
- Hip/Spine pain
- DKA
Describe the presentation and management of the following causes of abdo pain
- Intussusception
- Meckel’s Diverticulum
- Mesenteric Adenitis
Intussuception (3m-2yr)
Path- telescoping of prox bowel into distal segment
Pres - paroxysmal severe crampy abdo pain w/ recovery between episodes but increasing lethargy. Refusal of feeds/vomiting. redcurrant jelly stool, abdo distension, shock
Ix Abdo USS = donut sign
Mx- IVI, rectal air insufllation, operative repair
Meckel’s Diverticulum
Path- ilial remanant of vitelline duct containing ectopic gastric/panc tissue
Rule of 2s: 2% have them, within 2ft of ileocaecal valve, 2inches long, presents <2yrs
Pres - asymp or severe rectal bright red bleeding w/ acute reduction in Hb, can also –> obstruction, volvulus, intussuseption
Ix- technetium scan if stable(shows increased uptake by ectopic tissue), mesenteric arteriography in severe cases
Mx - surgical resection
Mesenteric Adenitis
Path- inlamed lymph nodes
Pres - sore throat/cold, then abdo pain +/- fever, nausea, diarrhoea.
Mx- diagnosis of exclusion. pain relief
What are the following conditions?
- Pyloric Stenosis
- Necrotising Enterocolitis
- Malrotation
Pyloric Stenosis
Path= hypertrophy of pylorus
Pres - 2-4w old, projectile vomiting 30mins after food, dehydration/constipation, palpable upper abdo mass
Ix Hypochloraemic Hypokalaemia Alkalosis. Diagnosed w/ USS
Mx- surgery (Ramstedt Pyloromyotomy
Necrotising Enterocolitis
- Can cause death in premature infants
- Pres - feed intolerance, abdo distension, bloody stools –> abdo discolouration, perforation + peritonitis
- Ix- AXR: dilated bowel loops, bowel wall oedema, intramural gas, pneumoperitoneum, Rigler sign (air inside + outside of bowel wall),
Mx - abx +/- surgery
Malrotation
Path - congenital malotation predisposes to volvulus + Ladd bands (can -> obstruction)
Pres-
1-3d old: obstruction or volvulus +/- blood supply compromise
later: bilious vomiting (dark green) - any child w this needs urgent upper GI constrast study ?rotation; UNLESS vasc comp -> urgent laparotomy, abdo pain
Mx - surgical correction (often appendix removed at same time to avoid diagnostic uncertainty later in life)
What are the following?
- Hirschpung’s Disease
- Rectal and oesophageal atresia
- Henoch Schonlein Purpura
Hirschprung’s Disease
- Path- aganglionic segment of bowel. RF: male, Down’s syndrome.
- Pres - neonatal: failure or delay in passing meconium. Older: constipation, abdo distension
- Ix- AXR, rectal biopsy (gold standard)
- Mx- initial: rectal washouts/bowel irrigation. Later: surgery to affected bit of colon
Rectal atresia
- Rare. Failure to mass meconium. Needs surgical tx.
Oesophageal atreisa
- Presents w/ polyhydramnios in preg, absent somtach bubble on antenatal USS. NG passed after birth doubles back on itself
- if not picked up antenatally -> persistent salivation/drooling, choking when feeding + cyanotic episodes
- (if associated w/ tracheooesohageal fistula the NG still doubles back but stomach bubble present)
- Mx - suction + surgery
Henoch-Schonlein-Purpura
Path - IgA mediated small vessel vasculitis. Normally occurs post-infection. Small overlap w/ Ig nephropathy (buergers)
Pres - palpable purpuric rash over buttocks + extensor surfaces, abdo pain, polyarthritis +/- features of IgA nephropathy
Mx - analgesia for arthralgia, supportive management of nephropathy
Prog- self-limiting, 1/3rd relapse, monitor BP + urine in case of progressive renal involvement
