Paediatrics Flashcards
Give 3 signs of respiratory distress in a child.
- Tachypnoea, RR 40-60.
- Subcostal and intercostal recession.
- Stridor.
- Tracheal tug.
- Cyanosis.
Describe the epidemiology of ADHD.
5% school aged children.
M:F = 4:1
Describe the aetiology of ADHD.
- Genetic and environmental.
- Neuroanatomical and neurochemical factors too.
- CNS insults e.g. FAS or premature.
What are the 3 core behaviours of ADHD?
- Hyperactivity.
- Inattention.
- Impulsivity.
(HII)
ADHD core behaviours: give 3 signs of hyperactivity.
- Fidgety.
- Talkative.
- Noisy.
- Can’t remain seated.
ADHD core behaviours: give 3 signs of impulsivity.
- Blurts out answers.
- Interrupts.
- Difficulty waiting turns.
- When older, pregnancy and drug use.
ADHD core behaviours: give 3 signs of inattention.
- Easily distracted.
- Not listening.
- Mind wandering.
- Struggling at school.
- Forgetful.
- Organisational problems.
What is the diagnostic criteria for ADHD?
6/9 inattentive symptoms and 6/9 hyperactivity/impulsivity.
The symptoms are present before 12 years and occur in more than one place and in a primary setting. There is clear evidence that symptoms interfere with social/academic function.
What tools can be used in order to diagnose ADHD?
- Clinical interview - are there any RF’s for ADHD?
- ADHD nurse classroom observation.
- Questionnaires (SNAP).
- Quantitative behavioural (QB) analysis.
Describe the treatment for ADHD.
- Education.
- Parenting programmes and school support.
- Medications e.g. methylphenidate.
Why is it important to do a cardiac assessment before prescribing medications to help treat a child with ADHD.
Some ADHD medications can affect HR and BP and so it is important to do a cardiac assessment first.
Describe the epidemiology of ASD.
1% prevalence.
Boys>girls.
Give 4 signs of ASD.
- Communication problems.
- Social interaction difficulties.
- Social imagination difficulties.
- Sensory issues.
ASD signs: what communication problems might a child with ASD show?
- They may find non-verbal communication very challenging.
- Lack of desire to communicate.
- Tendency to communicate needs only.
- No understanding of jokes, very literal.
ASD signs: what social interaction problems might a child with ASD show?
- Overly friendly or overly shy.
- Struggles to understand social roles.
- Often no desire to interact with others.
- Touches inappropriately, plays alone, poor eye contact, finds it hard to take turns.
ASD signs: what social imagination problems might a child with ASD show?
- Struggles with change.
- Obsessions/rituals.
- Repetitive with play.
- Unable to play or write imaginatively.
Describe the treatment for ASD.
- Education and games to encourage social communication.
- Visual aids and timetables.
- Parenting workshops and school liaison.
There are no medications available for ASD.
What are the liver dependent clotting factors?
2, 7, 9 and 10.
Name 2 coagulopathies.
- Von Willebrand disease.
- Haemophilia.
Briefly describe the pathophysiology behind Von Willebrand disease.
Bleeding disorder due to an abnormality of vWF. vWF acts as an adhesive bridge between platelets and the damaged sub-endothelium. Without it it takes longer for bleeding to stop.
Describe the treatment for VWD.
There is no cure.
Pressure should be applied to try and minimise bleeding and tranexamic acid can be taken.
Describe the inheritance pattern seen in haemophilia.
X linked recessive.
Haemophilia A is due to a deficiency in which clotting factor?
Factor VIII.
Haemophilia B is due to a deficiency in which clotting factor?
Factor IX.
Give 3 signs of haemophilia.
- Easy bruising.
- Haematomas.
- Mouth bleeds.
- Joint bleeds - prophylaxis should be given to prevent this.
Give 2 causes of thrombocytopenia in children.
- ITP.
- Marrow failure.
Give 3 signs of thrombocytopenia.
- Petechial rash.
- Bruising.
- Bleeding.
What diagnosis would you suspect in a child with a single figure platelet count but is otherwise well?
ITP.
They would have a normal blood film and clotting, just very low platelets.
What can trigger acute ITP?
Viral infection.
What is the most common cause of anaemia in children?
Iron deficiency.
Give 3 signs of anaemia in children.
- Pallor.
- Irritable.
- Lethargy.
- SOB.
- Tachycardic.
What is the treatment for iron deficiency anaemia?
Ferrous sulphate tablets.
Why does the treatment for iron deficiency anaemia sometimes fail?
Treatment can often fail due to non-compliance.
Give 3 signs of beta thalassaemia major.
- Severe anaemia.
- Jaundice.
- Splenomegaly.
- Failure to thrive.
Describe the management of beta thalassaemia major.
- Genetic counselling.
- Blood transfusions.
- Iron chelation.
What does a low reticulocyte count indicate?
A production problem e.g. infection, renal disease, drugs, marrow failure/infiltration.
What does a high reticulocyte count indicate?
A degradation problem e.g. bleeding or haemolysis.
Give 3 consequences of sickle cell disease.
- Anaemia.
- Infection.
- Painful crises.
- Stroke.
- Acute chest infection/infarction.
- Splenic sequestration.
Describe the inheritance pattern seen in sickle cell disease.
Autosomal Recessive.
What is the affect of sickle cell disease on Hb and reticulocyte count?
Low Hb.
Raised reticulocyte count.
Describe the treatment for sickle cell disease.
- Hydroxycarbamide.
- Transfusions.
- Stem cell transplants.
What can trigger spherocytosis?
Parvovirus infection.
Describe the inheritance pattern seen in hereditary spherocytosis.
Autosomal Dominant.
How can spherocytosis be treated?
Splenectomy - can increase RBC survival.
What type of leukaemia is most common in children?
ALL.
Give 3 symptoms of ALL.
- Anaemia.
- Bleeding.
- Bruising.
- Bone/limb pain.
- Infections.
- Tired.
Describe the treatment for ALL.
2 years combination chemotherapy.
CNS directed therapy.
Give an example of a live, attenuated vaccine.
MMR.
BCG.
Rotavirus (oral vaccine).
Give an example of an inactivated vaccine.
Influenza.
Diphtheria.
Name 5 vaccine preventable diseases.
- Tetanus.
- Diphtheria.
- Whooping cough.
- Polio.
- Measles.
- Mumps.
- Rubella.
What virus can cause croup?
Parainfluenza virus.
Name 2 respiratory infections that are common in paediatrics.
- Croup.
- Bronchiolitis.
Give 3 signs of bronchiolitis.
- Recurrent cough.
- Noisy breathing.
- Crackles and wheeze.
- Use of respiratory muscles.
What viruses can cause bronchiolitis.
- RSV = main causative organism!
Also: rhinovirus, influenza, adenovirus, parainfluenza virus.
What is croup?
Acute larygnotracheobronchitis - trachea, bronchi and larynx are all affected.
You do a lumbar puncture and find raised proteins and low glucose. Is this likely to be due to a bacterial or a viral infection?
Bacterial.
Give 3 signs of immune deficiency.
- Frequent infections.
- Infection with unusual organisms.
- Severe infections.
- Failure to thrive.
How much should you feed to a neonate?
150ml/Kg/day.
(Day 1: 60ml/kg/day Day 2: 90ml/kg/day Day 3: 120ml/kg/day Day 4: 150ml/kg/day)
What fluid would you give to a neonate?
0.9% Sodium Chloride + 5% glucose +/- KCl
How do you calculate the rate at which to give maintenance fluids to a child?
100ml/Kg/day for first 10Kg.
50ml/Kg/day for the next 10Kg.
20ml/Kg/day for every Kg after that.
When taking a history from a teenager, the HEADDS framework can be used. Describe this framework.
Home.
Education.
Activity.
Drugs/alcohol.
Depression/suicide.
Sexuality.
Radiology: give 5 ways in which imaging a child differs to imaging an adult?
- Size.
- Growth plates.
- Skill sutures.
- Ossification.
- Congenital problems e.g. dextrocardia and osteogenesis imperfecta.
When might an abdominal XR be indicated on a child?
- Abdominal distension e.g. obstruction.
- Abdominal pain of unknown cause.
- Constipation.
What are the 3 main differentials for a limping child?
- Infection e.g. sepsis/osteomyelitis.
- Trauma e.g. NAI, fracture.
- Tumour.
What is the likely cause of a limp in a child aged 0-3?
- NAI.
- Osteomyelitis/septic arthritis.
- DDH.
What is the likely cause of a limp in a child aged 3-10?
- Trauma.
- Transient synovitis.
- Osteomyelitis.
- Perthe’s disease.
What is the likely cause of a limp in a child aged 10-15?
- Trauma.
- Osteomyelitis.
- SCFE.
- Perthe’s disease.
What must you remember to consider as a differential in a limping child?
Intra-abdominal pathology e.g. hernia, testicular torsion.
Why might you want to ask about socioeconomic class and smoking status in a child presenting with a limp?
Social deprivation and passive smoking are RF’s for Perthe’s disease.
What investigations might you want to do on a child presenting with a limp?
- General observations e.g. HR, BP, T, RR, O2 sats.
- FBC, BM, ESR and CRP.
- XR - AP and lateral views of the the joint and the joints above and below.
- USS - effusion in joints?
- CT/MRI.
Describe Kocher’s criteria.
T>38.5
CRP>20
ESR>40
WCC>12
Cannot weight bear
3/4 = septic joint.
Give 3 signs of septic arthritis.
- Systemically very unwell.
- Pain at rest.
- Raised WCC and CRP.
What is transient synovitis?
Acute onset joint inflammation following illness often respiratory.
How does transient synovitis differ from septic arthritis?
Transient synovitis: no pain at rest, XR normal, USS may show effusion, rest, physiotherapy and NSAIDs often help.
What is DDH?
DDH - developmental dysplasia of the hip.
Abnormal relationship of the femoral head to the acetabulum -> aberrant development of the hip.
Give 3 risk factors for DDH.
- Female (M:F - 1:8).
- First born.
- Breech birth.
- Family history.
What tests can be done on clinical examination in the neonatal period to pick up DDH?
- Ortolani test.
- Barlow manoeuvre.
Can be confirmed with USS.
What 3 lines can be drawn to aid diagnosis of DDH?
- Hilgenreiner line
- Perkin line – perpendicular to Hilgenreiner line.
- Shenton line.
Describe the management of DDH.
- Pavlik harness.
- Surgical reduction.
What are the 2 main risks associated with the surgical management of DDH.
- Avascular necrosis.
- Re-dislocation.
What is Perthe’s disease?
A self-limiting idiopathic disease characterised by avascular necrosis of the femoral head.
Describe the management of Perthe’s disease.
Contain the hip, either on their own or with the aid of plasters, brace, physiotherapy or surgery.
Give 3 risk factors for Perthe’s disease.
- ADHD.
- Deprivation.
- Passive smoking.
- LBW.
- Short stature.
What is SCFE?
Slipped capital femoral epiphysis - a fracture through the growth plate leads to slippage of the femoral head through the zone of hypertrophy.
Through what zone of the physeal cartilage does the femoral head slip through in SCFE?
The zone of hypertrophy.
Who is likely to be affected by SCFE?
A pre-pubescent obese male.
How does SCFE present?
The patient may complain of a several week history of vague groin or thigh discomfort. In 40% this will be bilateral. They may have a waddling gait and a decreased range of motion.
What is the treatment for SCFE?
Surgical pinning of the hip.
What is chondrosarcoma?
A malignant neoplasm of cartilage.
What is the criteria for making a clinical diagnosis of juvenile idiopathic arthritis?
Joint swelling/stiffness >6 weeks in children <16 and no other cause is identified.
What symptoms are associated with JIA?
- Fever.
- Salmon-pink rash.
- Uveitis.
- Pain.
- Morning stiffness.
- Swelling.
Describe the non-medical treatment for JIA.
- Information.
- Education.
- Support.
- Liaison with school.
- Physiotherapy.
Describe the medical treatment for JIA.
- Steroid joint injections.
- NSAIDS.
- Methotrexate.
- Systemic steroids.
Give 5 potential consequences that can occur if you fail to treat JIA.
- Damage.
- Deformity.
- Disability.
- Pain.
- Bony overgrowth.
- Uveitis.
Define child development.
The biological, psychological and emotional changes that occur between birth and adolescence as the individual progresses from dependency to increasing autonomy. It is a continuous process with a predictable sequence however each child’s development is unique.
Give 5 influences on a child’s development.
- Genetic factors.
- Stimulating environment.
- Pregnancy factors e.g. premature? Mums health?
- Healthy attachment.
- Medical conditions.
- Abuse/neglect/domestic violence.
- Healthy peer relationships.
- Education.
- Nutrition.
- Parenting style.
What are the 4 domains of child development?
- Gross motor.
- Fine motor and vision.
- Speech, language and hearing.
- Social interaction and self care skills.
What are the developmental milestones for gross motor function?
- 3m: lifts head on tummy.
- 6m: chest up with arm support, can sit unsupported.
- 8m: crawling.
- 9m: pulls to stand.
- 12m: walking.
- 2 years: walking up stairs.
- 3 years: jumping.
- 4 years: hopping.
- 5 years: rides a bike.
With regards to gross motor development, at what age would you expect a child to do the following:
a) walking.
b) jumping.
c) crawling.
d) walking up stairs.
a) Walking - 12 months.
b) Jumping - 3 years.
c) Crawling - 8 months.
d) Walking up stairs - 2 years.
What are the developmental milestones for fine motor and visual function?
- 4m: grabs an object using both hands.
- 8m: takes objects in each hand.
- 12m: scribbles with crayons e.g. circle, cross, square.
- 18m: builds a tower of 2 cubes.
- 3 years: builds a tower of 8 cubes.
With regards to fine motor and visual development, at what age would you expect a child to do the following:
a) drawing with crayons.
b) building a tower of 8 cubes.
c) takes an object in each hand.
d) builds a tower of 2 cubes.
a) Drawing with crayons - 12m.
b) Building a tower of 8 cubes - 3 years.
c) Takes an object in each hand - 8m.
d) Builds a tower of 2 cubes - 18m.
What are the developmental milestones for speech, language and hearing?
- 3m: laughs and squeals.
- 9m: can make sounds such as ‘dada’ and ‘mama’.
- 12m: can say one word.
- 2 years: can form short sentences and name body parts.
- 3 years: speech is mainly understandable.
- 4 years: knows colours and can count.
- 5 years: knows the meaning of words.
With regards to speech, language and hearing, at what age would you expect a child to do the following:
a) form short sentences and name body parts.
b) knows colours and can count.
c) laughs and squeals.
d) has mainly understandable speech.
a) Forms short sentences and name body parts - 2 years.
b) Knows colours and can count - 4 years.
c) Laughs and squeals - 3 months.
d) Has mainly understandable speech - 3 years.
What are the developmental milestones for social interaction and self-care skills?
- 6 weeks: smiles.
- 6 months: finger feeds.
- 9m: waves bye-bye.
- 12m: uses cutlery.
- 2 years: undresses, feeds toys.
- 3 years: plays with others, names a friend.
- 4 years: dresses with no help, plays a board game.
With regards to social interaction and self-care skills, at what age would you expect a child to do the following:
a) uses cutlery.
b) plays with others, names a friend.
c) smiles.
d) waves bye-bye.
a) Uses cutlery - 12 months.
b) Plays with others, names a friend - 3 years.
c) Smiles - 6 weeks.
d) Waves bye-bye - 9 months.
What does ‘The healthy child programme’ encourage?
- Encourages care to keep children healthy and safe.
- Promotes healthy eating and activity.
- Identifies problems in children’s development.
- Identifies ‘at risk’ families for more support.
- Ensures children are prepared for school.
Give two examples of concerning child development with regards to gross motor function.
- Not sitting by 12 months.
- Not walking by 18 months.
Give an example of concerning child development with regards to fine motor function.
Hand preference before 18 months.
Give two speech and language examples that may suggest concerning child development.
- Not smiling by 3 months - blindness? ASD?
- No clear words by 18 months - ASD? Language problems?
Give two examples of concerning child development with regards to social development.
- No response to carers interactions by 8 weeks.
- No interest in playing by 3 years.
Give 5 causes of developmental delay.
- Genetics.
- Pregnancy.
- Factors around birth.
- Factors in childhood.
- Environmental.
Causes of developmental delay: give examples of genetic causes.
- Chromosomal disorders e.g. Down’s syndrome.
- Single gene disorders e.g. Duchenne.
- Polygenic e.g. ASD, ADHD.
- Micro-deletions or micro-duplications.
Causes of developmental delay: give examples of pregnancy related causes.
- Congenital infections e.g. CMV, HIV.
- Exposure to drugs/alcohol e.g. FAS.
- MCA infarct.
Causes of developmental delay: give examples of birth related causes.
- Prematurity.
- Birth asphyxia (due to hypoxia).
Causes of developmental delay: give examples of medical causes that may occur during childhood.
- Infections e.g. meningitis.
- Chronic illness.
- Hearing or visual impairment.
- Acquired brain injury.
Causes of developmental delay: give examples of environmental causes.
- Abuse and neglect.
- Low stimulation.
How might you investigate someone’s child development if you suspected that there was something wrong?
Thorough history and examination. Tailor any investigations to the child e.g.
- Boys not walking by 18m check creatinine kinase for Duchenne.
- Focal neurological signs -> MRI brain.
- Genetic testing.
- Unwell, failure to thrive -> metabolic investigations.
There is no ‘developmental screen’, investigations need to be tailored towards to the child.
Define childhood disability.
Someone who has a physical or mental impairment that results in a marked, pervasive limitation on activity. For example, Down’s syndrome and Cerebral Palsy.
Give 3 factors that influence childhood disability.
- Environment.
- Social background.
- Impairment.
Give 3 signs of down’s syndrome.
- Learning/developmental delay.
- Hypotonia.
- Short stature.
- CHD.
- Brushfield spots.
What is cerebral palsy?
A permanent, non-progressive cerebral pathology that leads to handicap and disability in children.
A non progressive developmental disorder of movement and posture.
Give 3 causes of cerebral palsy.
80% antenatal - hypoxia, infection, haemorrhage, ischaemia.
10% peri-natal - hypoxia, infection, haemorrhage.
10% postnatal - hypoxia, infection e.g. meningitis, haemorrhage, encephalopathy, trauma.
Describe the support that is offered to someone with cerebral palsy.
- Physiotherapists for mobility and hand function.
- SALT for communication.
- Feeding support.
- Sleeping support.
Support for children with disabilities needs to be holistic, child focused and with an MDT approach.
Name 3 embryonal tumours.
- Wilm’s tumour.
- Neuroblastoma.
- Rhabdomyosarcoma.
Give examples of children who are at increased risk of cancer.
- Down’s syndrome children are at increased risk of leukaemia.
- Immunocompromised children are at increased risk of lymphoma.
An abnormal red reflex in a child may be a sign of what paediatric malignancy?
Retinoblastoma.
Give 5 signs of ALL.
- Fever.
- Fatigue.
- frequent infections.
- Bruising.
- Bone pain - not wanting to weight bear.
- Anaemia.
- Lymphadenopathy.
- Hepatosplenomegaly.
What investigations might you do in a child to determine whether they have ALL?
- Blood film.
- Serum chemistry.
- CXR.
- BM aspirate.
- Lumbar puncture - see if disease is in the CSF.
Describe the treatment for ALL.
5 phase chemotherapy.
A stem cell transplant may be needed for high risk or relapsed patients.
The treatment is 2 years for girls and 3 years for boys.
Treatment of ALL: what are the 5 phases of chemotherapy?
- Induction.
- Consolidation.
- Interim maintenance.
- Intensification.
- Maintenance.
Give 5 signs of CNS malignancy in children.
- Early morning headache.
- Headache that is worse on lying down.
- Vomiting - especially in the morning.
- Papilloedema.
- Squint.
- Nystagmus.
- Ataxia.
- Personality or behavioural change.
Describe the general treatment for CNS malignancies.
- Surgical resection + VP shunt (reduces the risk of coning).
- Chemotherapy.
- Radiotherapy.
Why are there fewer chemotherapy options available for children with CNS malignancies?
Because there are fewer chemotherapy drugs able to penetrate the BBB.
Give 5 signs that lymphadenopathy may be due to malignancy rather than a benign cause e.g. infection.
- Enlarging node without infective cause.
- Persistently enlarged.
- Unusual site e.g. supra-clavicular.
- B symptoms e.g. fever, weight loss.
- Abnormal CXR.
What is the treatment for lymphoma?
Combination chemotherapy.
High dose therapy and stem cell transplantation is offered to those who have relapsed.
Give 5 differential’s for abdominal mass in children.
- Hepatoblastoma.
- Wilm’s tumour.
- Neuroblastoma.
- Lymphoma/leukaemia.
- Constipation/bowel obstruction.
- Enlarged kidneys - polycystic.
What investigations might you do on a child with an abdominal mass?
- USS.
- CT.
- Biopsy.
What is are neuroblastoma tumours?
Tumours arising from neural crest tissue in the adrenal medulla and sympathetic nervous system.
Give 2 signs of a neuroblastoma tumour.
- Abdominal mass - often crosses the midline and envelopes major vessels and lymph nodes.
- Symptoms of metastases e.g. bone pain, weight loss, pallor, limp, hepatomegaly.
Describe the treatment for a neuroblastoma malignancy.
- Surgery - localised primaries can often be cured with surgery alone.
- Chemotherapy - can be given before and/or after surgery to control disease.
- Radiotherapy for high risk groups.
What is Wilm’s tumour?
Nephroblastoma, malignancy arising from embryonal renal tissue.
Give 3 signs of Wilm’s tumour.
- Abdominal mass.
- Haematuria.
- Abdominal pain.
- Anorexia.
- Anaemia.
Describe the treatment for Wilm’s tumour.
- Chemotherapy - before and after surgery.
- Nephrectomy.
- Radiotherapy for higher stage disease.
Describe the aetiology of retinoblastoma.
- Mutations in RB1 (tumour suppressor gene) located on chromosome 13.
- Familial (AD).
- Sporadic.
Give 3 signs of retinoblastoma.
- Loss of red reflex.
- Pain around the eye.
- Poor vision.
Describe the treatment for retinoblastoma.
Laser therapy is 1st line!
Chemotherapy and radiotherapy may also be indicated.
Phototherapy.
Surgical repair/removal.
Give 3 late effects of cancer treatment in children.
- Endocrine related e.g. growth and development problems.
- Intellectual.
- Fertility problems.
- Psychological issues.
- Cardiac and renal toxicity.
Define osteoporosis in children.
> 1 vertebral crush fracture OR
Bone density 2 long bone fractures (before age 10) or >3 fractures (age 19).
Describe the aetiology of osteoporosis in children.
- Inherited/congenital e.g. osteogenesis imperfecta, inborn errors, idiopathic.
- Acquired e.g. drug induced, malabsorption, immobilisation.
What investigation might you do to determine if a child has osteoporosis?
DEXA scan.
What is osteogenesis imperfecta?
An AD inherited osteoporotic condition that leads to bone weakness in children. It is due to a defect in type 1 collagen genes.
Describe the aetiology of osteogenesis imperfecta.
AD inheritance in 90%.
Give 5 signs of osteogenesis imperfecta.
- Bone fragility.
- Fractures.
- Deformity.
- Pain.
- Impaired mobility.
- Poor growth.
- Deafness.
- Blue sclera.
- Bruises.
What classification is used in osteogenesis imperfecta?
The Sillence classification.
Describe the treatment of osteogenesis imperfecta.
MDT approach - physicians, surgeons, physiotherapists, OT’s.
Bisphosphonates e.g. pamidronate.
What is Rickets?
A disorder of bone mineralisation, it leads to bone weakness.
What is the main cause of Rickets?
Vitamin D deficiency.
Give 4 signs of Rickets.
- Rachitic rosary.
- Limb deformity.
- Weakness.
- Misery.
What might you find when examining a child with Rickets?
- Metaphyseal swelling.
- Bone deformity e.g. bowed legs.
- Motor delay.
- Hypotonia.
- Fractures.
- Cupping and spraying seen on XR.
What investigations might you do to determine if a child has Rickets?
- Serum biochemistry e.g. ALP, PTH.
- Bone profile.
- Measure vitamin D levels.
- XR.
Describe the treatment for Rickets.
Treat the underlying problem.
If vitamin D deficiency, give Adcal D3.
What is the role of vitamin D?
It acts to increase Ca absorption at the gut and Ca reabsorption at the kidneys.
Give 3 sources of vitamin D.
- Sunlight!
- Cereals.
- Egg yolk.
- Oily fish.
- Spreads.
Secretion of which hormone will increase in response to low calcium?
PTH.
Increased PTH = bone resorption, Ca reabsorption at kidneys and Ca absorption at gut.
Give 5 differentials for a painful joint.
Life-threatening differentials:
- Leukaemia.
- Septic arthritis.
- NAI.
Pain and swelling:
- Trauma.
- Infection.
- Reactive arthritis.
- JIA.
Pain and no swelling:
- Hypermobile joint syndrome.
- Perthe’s disease.
What investigations might you do on a child who you suspect may have JIA?
- Thorough history and examination.
- Lab tests/imaging in order to exclude other causes.
- Ophthalmology review.
Name 5 types of JIA.
- Oligoarticular.
- Polyarticular.
- Psoriatic.
- Enthesitis related.
- Systemic onset JIA.
Define oligoarticular JIA.
<4 joints involved, often asymmetrical. Normally ANA+ and associated with a high risk of developing uveitis.
Define polyarticular JIA.
> 4 joints involved, often symmetrical and more destructive.
What extra-articular features might you see in someone with JIA?
- Psoriasis.
- Dactylitis.
- Nail pitting.
- Rash.
- Fluctuating fever.
- Uveitis.
Which type of JIA is most similar to ankylosing spondylitis?
Enthesitis related arthritis.
The point where the tendon joins a bone is inflamed.
Which antigen is closely associated with enthesitis related arthritis?
HLAB27.
What signs might you see in someone with systemic onset JIA?
- Rash.
- Lymphadenopathy/organomegaly.
- Fever.
Name a severe, potentially life-threatening complication of systemic onset JIA.
Macrophage-activation syndrome (MAS).
What signs might you see in someone with macrophage-activation syndrome (MAS)?
- High fever.
- Hepatosplenomegaly.
- CNS dysfunction.
- Purpuric rash.
- Cytopaenia.
What is the treatment for macrophage-activation syndrome (MAS)?
- Supportive treatment.
- Steroids.
Give 5 signs of SLE.
- Malar rash.
- Discoid rash.
- Photosensitivity.
- Oral ulcers.
- Arthritis.
- Pleuritis.
- Pericarditis.
- Renal failure.
- Seizures.
- Thrombocytopenia.
What is the most common causative organism of UTI in children?
E.coli.
Give 3 signs of UTI in children.
- Fever.
- Miserable.
- Vomiting.
- Dysuria.
What investigations might you do on a child who you suspect has a UTI?
- Urine dip.
- MCS on clean catch urine. A sample can also be obtained using an in-out catheter.
- USS KUB.
- DMSA - renal scarring.
- MCUG - reflux.
What is the treatment for UTI in children?
IV cefuroxime.
Switch to PO trimethoprim if stable.
How would you treat a UTI that has been caused by ESBL e.coli?
You would give meropenem.
ESBL bacteria are resistant to all penicillins and cephalosporins.
Name an organism that commonly causes osteomyelitis in children.
Staphylococcus aureus.
Give 3 signs of osteomyelitis in children.
- Joint pain.
- Lethargy.
- Fever.
What investigations might you do on a child who you suspect has an infected joint?
- XR.
- MRI.
- Blood cultures.
- Joint aspirate.
How would you treat a child with osteomyelitis?
IV cefuroxime or IV flucloxacillin.
6 weeks of treatment, can switch to PO when improving.
What bacteria commonly causes meningitis in children?
- Neonates: GBS, E.coli, lysteria monocytogenes.
- 1m -> 6 years: Neisseria meningitidis, S.pneumoniae, H.influenzae.
- > 6 years: Neisseria meningitidis.
What investigations might you do on a child who you suspect has meningitis?
- Thorough history and examination.
- Blood cultures.
- Lumbar puncture.
- EDTA blood for PCR.
Describe the treatment for a child with meningitis.
IV ceftriaxone (80mg/kg/od) or cefotaxime (50mg/kg/tds).
Prophylaxis is needed to prevent further spread.
Dexamethasone is given to reduce swelling.
Who must you notify when you diagnose a child with meningitis?
Public Health England.
Give 3 bacterial organisms that commonly cause pneumonia in children.
- Group B strep in neonates.
- S.pneumoniae.
- H.influenzae.
- K.pneumoniae.
- M.pnuemoniae.
Give 5 signs of pneumonia in children.
- Fever.
- Miserable.
- Rapid breathing.
- Cough.
- Poor feeding.
- Lethargy.
What investigations might you do in a child who you suspect has pneumonia?
- CXR: look for consolidation.
- Blood cultures.
It is often difficult to get a sputum sample.
Briefly describe the treatment for a child with pneumonia.
If acutely unwell: IV benzylpenicillin.
If stable: PO amoxicillin.
What is the difference between wheeze and stridor?
Wheeze: polyphonic noise heard on expiration.
Stridor: monophonic high pitched noise heard on inspiration.
Describe the aetiology of recurrent wheeze.
- Persistent infantile wheeze.
- Viral episodic wheeze.
- Asthma.
What is persistent infantile wheeze normally associated with/exacerbated by?
Persistent infantile wheeze tends to affect the small airways. It is associated with parental smoking or post-viral infection.
Are inhalers likely to help a child with persistent infantile wheeze?
No. Inhalers are unlikely to help; symptoms will improve as the child gets older.
What is viral episodic wheeze normally associated with/exacerbated by?
It normally follows a URTI. The child will have no interval symptoms.
Are inhalers likely to help a child with viral episodic wheeze?
Bronchodilators may help but there is no benefit from inhaled steroids.
Symptoms are likely to improve with age.
How would you manage an acute exacerbation of asthma in a child?
- O2.
- Beta agonist nebulised.
- Prednisolone 1mg/kg.
If still not improving…
- IV salbutamol bolus.
- Aminophylline/MgSO4/salbutamol infusion.
Inhalers: name 2 ‘preventers’.
ICS act as ‘preventers’ e.g. beclamethasone, budenoside.
Inhalers: name 2 ‘relievers’.
Beta agonists e.g. salbutamol.
Muscarinic antagonists e.g. ipratropium bromide.
Describe the step-wise approach to asthma management.
SABA -> SABA + ICS -> LABA + ICS -> LABA + increased dose of ICS -> LABA + daily PO steroids.
Give 3 long term risks of systemic steroids.
- Adrenal suppression.
- Growth suppression.
- Osteoporosis.
Why might asthma treatment fail in children?
- Adherence.
- Wrong diagnosis.
- Environmental factors.
- Choice of drug.
- Bad disease.
Name 3 URTI.
- Rhinitis.
- Otitis media.
- Pharyngitis.
- Tonsillitis.
- Laryngitis.
Name 3 LRTI.
- Bronchitis.
- Croup.
- Epiglottitis (bacterial).
- Tracheitis.
- Bronchiolitis.
- Pneumonia.
Would you expect a patient with bronchitis or with bronchiolitis to be hypoxic and tachypnoeic? Explain why.
Bronchiolitis.
Bronchiolitis affects the respiratory portion of the airway, where gas exchange takes place therefore you may see hypoxia and tachypnoea.
Bronchitis affects the conducting portion of the airway and so is unlikely to have these effects.
Give 3 signs of bronchitis in children.
- Chronic cough.
- Cough worst at night.
- No fever.
Name 4 LRTI that could be caused by RSV.
- Acute bronchiolitis.
- Wheezy bronchitis.
- Asthma exacerbation.
- Pneumonia.
- Croup.
Why are infants more susceptible to descending infection?
Infants have a poor innate immune response and so are more susceptible to descending infections.
What virus commonly causes croup?
Parainfluenza virus.