Paediatrics Flashcards
allergy, ige v non ige
In an IgE-mediated food allergy, reactionsusually happen within a few minutes of eating the food. Common symptoms are reddening of the skin, an itchy rash, and swelling of the lips, face or around the eyes. A rare but more serious reaction is anaphylaxis (described in ‘What will happen when we see a healthcare professional?’).
The other type of food allergy is called a non-IgE-mediated food allergy. This type of allergy is not caused by IgE antibodies (it is usually because of cell reactions in the immune system).Non-IgE-mediated reactions often appear several hours or days after the food is eaten and can cause symptoms over a longer period, such as eczema, diarrhoea, constipation and, in more severe cases, growth problems.
at what age should a child begin to walk?
walk alone by 15 months
see GP if not by 18 months
when should children be able to copy a shape?
at 6 months - usually copying a circle first
what is an examples of a double syllable babble?
ba-ba
which hormone precipitates puberty
GnRH
at what age does a child develop a mature pincer grip?
9-12 months
what is a child’s red book?
child’s weight and height, vaccinations, other important info
gross motor development newborn
limbs flexed, symmetrical pattern
marked head lag on pulling up
gross motor development 6-8 weeks
raises head to 45 degrees in prone
gross motor development 6-8 months
sits without support
gross motor development 8-9 months
crawling
gross motor development 10 months
stands independently
cruises around furniture
gross motor development 12 months
walks unsteadily - broad gait, hands apart
gross motor development 15 months
walks steadily
gross motor development 2.5 years
run and jump
vision and fine motor development 6 weeks
follows moving object or face by turning head
vision and fine motor 4 months
reaches out for toys
vision and fine motor 4-6 months
palmar grasp
vision and fine motor 7 months
transfers toys from one hand to another
vision and fine motor 10months
mature pincer grip
vision and fine motor - 16-18 months
marks with crayons
vision and fine motor 4months-4 yrs
brick building
vision and fine motor 2-5 yrs
pencil skills - line, circle, cross, square then triange
hearing, speech and language newborn
startles to loud noises
hearing, speech language 3-4 months
vocalises alone or when spoken to, laughs
hearing, speech, language 7 months
turns to soft sounds out of sight
polysyllabic babble
hearing speech language 7-10 months
sounds used indiscrimately at 7 months
sounds used discriminately to patient
hearing speech language 12 months`
two or three words other than dada or mama
understands name drink
hearing speech language 18 months
6-10 words
is able to show 2 parts of body
hearing speech language 20-24 months
joins two or mroe words to make simple phrases - give me teddy
hearing speech language 2.5-3 yrs
talks constantly in 3-4 word sentences
understands 2 joined commands
social emotional behavioural 6 weeks
smiles responsively
social emotional behavioural 6-8 months
puts food in mouth
social emotional behavioural 10-12 months
waves bye, plays peek a boo
social emotional behavioural 12 months
drinks from cup with two hands
social emotional behavioural 18 months
holds spoon and gets food safely to mouth
social emotional behavioural 18-24 months
symbolic play
social emotional behavioural 2 years
toilet training
pulls off some clothing
social emotional behavioural 2.5-3 yrs
parallel play
interactive play
takes turns
define acute epiglottitis
rare but serious infection caused by Haemophilus influenzae type B. Prompt recognition and treatment is essential as airway obstruction may develop. Epiglottitis was generally considered a disease of childhood but in the UK it is now more common in adults due to the immunisation programme. The incidence of epiglottitis has decreased since the introduction of the Hib vaccine.
clinical fx of acute epiglottitis
rapid onset
high temperature, generally unwell
stridor
drooling of saliva
‘tripod’ position: the patient finds it easier to breathe if they are leaning forward and extending their neck in a seated position
diagnosis acute epiglottitis
direct visualisation
a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
in contrast, a posterior-anterior view in croup will show subglottic narrowing, commonly called the ‘steeple sign’
management acute epiglottitis
immediate senior involvement, in those able to provide emergency airway support (e.g. anaesthetics, ENT)
endotracheal intubation may be necessary to protect the airway
if suspected do NOT examine the throat due to the risk of acute airway obstruction
the diagnosis is made by direct visualisation but this should only be done by senior staff who are able to intubate if necessary
oxygen
intravenous antibiotics
3 dxx for acute scrotal problem
Testicular torsion- puberty
Irreducible inguinal hernia - <2 yrs
Epididymiris
Chickenpox spread
Resp route
From someone wirh shingles
Infective 4 days before rash until 5 days after rash first appeared
Incubation period - 10-21 days
Chicken pox clinical features
fever initially
itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular
systemic upset is usually mild
Chicken pox management
keep cool, trim nails
calamine lotion
school exclusion: NICE Clinical Knowledge Summaries state the following: Advise that the most infectious period is 1–2 days before the rash appears, but infectivity continues until all the lesions are dry and have crusted over (usually about 5 days after the onset of the rash).
immunocompromised patients and newborns with peripartum exposure should receive varicella zoster immunoglobulin (VZIG). If chickenpox develops then IV aciclovir should be considered
Common complication of chicken pox
Secondary bacterial infection - cellulitis, or necrotising fasciiits
NSAIDS increase risk
Rare complications chicken pox
pneumonia
encephalitis (cerebellar involvement may be seen)
disseminated haemorrhagic chickenpox
arthritis, nephritis and pancreatitis may very rarely be seen
Measles
Prodrome: irritable, conjunctivitis, fever
Koplik spots: white spots (‘grain of salt’) on buccal mucosa
Rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent
Mumps
Fever, malaise, muscular pain
Parotitis (‘earache’, ‘pain on eating’): unilateral initially then becomes bilateral in 70%
Rubella
Rash: pink maculopapular, initially on face before spreading to whole body, usually fades by the 3-5 day
Lymphadenopathy: suboccipital and postauricular
Erythema infectiosum
Also known as fifth disease or ‘slapped-cheek syndrome’
Caused by parvovirus B19
Lethargy, fever, headache
‘Slapped-cheek’ rash spreading to proximal arms and extensor surfaces
Scarlet fever
Reaction to erythrogenic toxins produced by Group A haemolytic streptococci
Fever, malaise, tonsillitis
‘Strawberry’ tongue
Rash - fine punctate erythema sparing the area around the mouth (circumoral pallor)
Hand foot and mouth disease
Caused by the coxsackie A16 virus
Mild systemic upset: sore throat, fever
Vesicles in the mouth and on the palms and soles of the feet
Congenital heart disease acyanotic
Most common causes
ventricular septal defects (VSD) - most common, accounts for 30%
atrial septal defect (ASD)
patent ductus arteriosus (PDA)
coarctation of the aorta
aortic valve stenosis
Congenital heart disease types cyanotic
tetralogy of Fallot
transposition of the great arteries (TGA)
tricuspid atresia
Referral points for development problems
doesn’t smile at 10 weeks
cannot sit unsupported at 12 months
cannot walk at 18 months
Causes of constipation (<3 complete stools per week) in children
Idiopathic
dehydration
low-fibre diet
medications: e.g. Opiates
anal fissure
over-enthusiastic potty training
hypothyroidism
Hirschsprung’s disease
hypercalcaemia
learning disabilities
Constipation in children management
If faecal impaction is present
polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated
Gastroenteritis children
main risk is severe dehydration
most common cause is rotavirus - typically accompanied by fever and vomiting for the first 2 days. The diarrhoea may last up to a week
treatment is rehydration
Chronic diarrhoea children
most common cause in the developed world is cows’ milk intolerance
toddler diarrhoea: stools vary in consistency, often contain undigested food
coeliac disease
post-gastroenteritis lactose intolerance
How common eczema
occurs in around 15-20% of children and is becoming more common. It typically presents before 2 years but clears in around 50% of children by 5 years of age and in 75% of children by 10 years of age
Clinical features of eczema
itchy, erythematous rash
repeated scratching may exacerbate affected areas
in infants the face and trunk are often affected
in younger children, eczema often occurs on the extensor surfaces
in older children, a more typical distribution is seen, with flexor surfaces affected and the creases of the face and neck
Eczema children management
Avoid irritants
Simple emollients (19:1 ratio with steroid)
if a topical steroid is also being used the emollient should be applied first followed by waiting at least 30 minutes before applying the topical steroid
Wet wrapping
Oral ciclosporin if severe
Most common cause of vomit in children
GORD
Hard to tell GORD in children why
Around 40% of infants regurgitate their feeds to a certain extent so there is a degree of overlap with normal physiological processes.
Risk factors of GORD in children
preterm delivery
neurological disorders
Clinical features GORD in children
typically develops before 8 weeks
vomiting/regurgitation
milky vomits after feeds
may occur after being laid flat
excessive crying, especially while feeding
GORD children management
advise regarding position during feeds - 30 degree head-up
infants should sleep on their backs as per standard guidance to reduce the risk of cot death
ensure infant is not being overfed (as per their weight) and consider a trial of smaller and more frequent feeds
a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum)
a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents
NICE do not recommend a proton pump inhibitor (PPI) to treat overt regurgitation in infants and children occurring as an isolated symptom. A trial of one of these agents should be considered if 1 or more of the following apply:
unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
distressed behaviour
faltering growth
Complications children GORD
distress
failure to thrive
aspiration
frequent otitis media
in older children dental erosion may occur
Head lice treatment
treatment is only indicated if living lice are found
a choice of treatments should be offered - malathion, wet combing, dimeticone, isopropyl myristate and cyclomethicone
household contacts of patients with head lice do not need to be treated unless they are also affected
Migraine without aura children
ibuprofen is thought to be more effective than paracetamol for paediatric migraine
NICE CKS recommends that triptans may be used in children >= 12 years but follow-up is required
Infantile colic
relatively common and benign set of symptoms seen in young infants. It typically occurs in infants less than 3 months old and is characterised by bouts of excessive crying and pulling-up of the legs, often worse in the evening.
Occurs in up to 20% of infants
Investigations jaundice children (more than 14 days)
conjugated and unconjugated bilirubin: the most important test as a raised conjugated bilirubin could indicate biliary atresia which requires urgent surgical intervention
direct antiglobulin test (Coombs’ test)
TFTs
FBC and blood film
urine for MC&S and reducing sugars
U&Es and LFTs
Causes of prolonged jaundice in children
biliary atresia
hypothyroidism
galactosaemia
urinary tract infection
breast milk jaundice
jaundice is more common in breastfed babies
mechanism is not fully understood but thought to be due to high concentrations of beta-glucuronidase → increase in intestinal absorption of unconjugated bilirubin
prematurity
due to immature liver function
increased risk of kernicterus
congenital infections e.g. CMV, toxoplasmosis
Juvenile idiopathic arteritis
arthritis occurring in someone who is less than 16 years old that lasts for more than 6 weeks. Pauciarticular JIA refers to cases where 4 or less joints are affected. It accounts for around 60% of cases of JIA
Featured of pauciarticulae juvenile idiopathic arthritis
joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows
limp
ANA may be positive in JIA - associated with anterior uveitis
Features of systemic onset JIA
pyrexia
salmon-pink rash
lymphadenopathy
arthritis
uveitis
anorexia and weight loss
Contraindications ro lumbar puncture
focal neurological signs
papilloedema
significant bulging of the fontanelle
disseminated intravascular coagulation
signs of cerebral herniation
Meningococcal septicaemia investigations
a lumbar puncture is contraindicated - blood cultures and PCR for meningococcus should be obtained.
Meningitis management
- Antibiotics
< 3 months: IV amoxicillin (or ampicillin) + IV cefotaxime
> 3 months: IV cefotaxime (or ceftriaxone) - Steroids
NICE advise against giving corticosteroids in children younger than 3 months
dexamethsone should be considered if the lumbar puncture reveals any of the following:
frankly purulent CSF
CSF white blood cell count greater than 1000/microlitre
raised CSF white blood cell count with protein concentration greater than 1 g/litre
bacteria on Gram stain - Fluids
treat any shock, e.g. with colloid - Cerebral monitoring
mechanical ventilation if respiratory impairment - Public health notification and antibiotic prophylaxis of contacts
ciprofloxacin is now preferred over rifampicin
Organisms meningitis children
<3 months - group B strep, e.coli and gram neg, listeria monocytogenes
1 month - 6 yes - Neisseria meningitidis is, step pneumoniae, Haemophilus influenzae
>6 urs - Neisseria or step pneumonia
Osgood schlatters disease
(tibial apophysitis) is a type of osteochondrosis characterised by inflammation at the tibial tuberosity. It is a traction apophysitis thought to be caused by repeated avulsion of the apophysis into which the patellar tendon is inserted
Management is supportive
Causes of paediatric GI disorders
Pyloric stenosis
Acute appendicitis
Mesenteric adenitis
Intussusception
Intestinal malrotation, hirschdprung’s disease, oesophageal atresia, meconium ileum
Biliary atresia
Necrotising enterocolotirs
Perthes’ disease
degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years. It is due to avascular necrosis of the femoral head, specifically the femoral epiphysis. Impaired blood supply to the femoral head causes bone infarction.
5x more common in boys
Perthes’ disease clinical feature
hip pain: develops progressively over a few weeks
limp
stiffness and reduced range of hip movement
x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening
Perthe’s disease diagnosis
Plain x ray
Complications of perthe’s disease
OA
Premature fusion of growth plates
Staging perthe’s disease
Stage 1 Clinical and histological features only
Stage 2 Sclerosis with or without cystic changes and preservation of the articular surface
Stage 3 Loss of structural integrity of the femoral head
Stage 4 Loss of acetabular integrity
Management perthe’s disease
To keep the femoral head within the acetabulum: cast, braces
If less than 6 years: observation
Older: surgical management with moderate results
Operate on severe deformities
Pneumonia in children
Strep pneumoniae
Amoxicillin first line
Males puberty
first sign is testicular growth at around 12 years of age (range = 10-15 years)
testicular volume > 4 ml indicates onset of puberty
maximum height spurt at 14
Females puberty
first sign is breast development at around 11.5 years of age (range = 9-13 years)
height spurt reaches its maximum early in puberty (at 12) , before menarche
menarche at 13 (11-15)
there is an increase of only about 4% of height following menarche
Rickets in children investigations
low vitamin D levels
reduced serum calcium - symptoms may results from hypocalcaemia
raised alkaline phosphatase
Rickets in children management
Vit D
Septic arthritis in children
Very rare
More common in boys
Join aspiration for culture, raised inflammatory makeees, blood cultures
Symptoms and signs septic arthritis children
Symptoms
joint pain
limp
fever
systemically unwell: lethargy
Signs
swollen, red joint
typically, only minimal movement of the affected joint is possible
Criteria for septic arthritis
The Kocher criteria for the diagnosis of septic arthritis:
fever >38.5 degrees C
non-weight bearing
raised ESR
raised WCC
Slipped upper femoral epiphysis
Rare hip condition
typically age group is 10-15 years
More common in obese children and boys
Displacement of the femoral head epiphysis postero-inferiorly
May present acutely following trauma or more commonly with chronic, persistent symptoms
SUFE features
hip, groin, medial thigh or knee pain
loss of internal rotation of the leg in flexion
bilateral slip in 20% of cases
SUFE investigations
AP and lateral x ray - frog leg
SUFE management
internal fixation: typically a single cannulated screw placed in the centre of the epiphysis
SUFE complications
osteoarthritis
avascular necrosis of the femoral head
chondrolysis
leg length discrepancy
Pyloric stenosis in children
typically presents in the second to fourth weeks of life with vomiting, although rarely may present later at up to four months. It is caused by hypertrophy of the circular muscles of the pylorus.
Features pyloric stenosis
projectile’ vomiting, typically 30 minutes after a feed
constipation and dehydration may also be present
a palpable mass may be present in the upper abdomen
hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
Diagnosis pyloric stenosis
USS
Management pyloric stenosis
Ramstedt pyloromyotomy
Threadwords spread
Swallowing eggs that are present in the environment
Sx threadworms
perianal itching, particularly at night
girls may have vulval symptoms
Diagnosis threadworms
applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs.
Management threadworms
combination of anthelmintic with hygiene measures for all members of the household
mebendazole is used first-line for children > 6 months old. A single dose is given unless infestation persists
Transient synovitis
Aka irritable hip
acute hip pain following a recent viral infection. It is the commonest cause of hip pain in children. The typical age group is 3-8 years.
Features transient synovitis
limp/refusal to weight bear
groin or hip pain
a low-grade fever is present in a minority of patients
high fever should raise the suspicion of other causes such as septic arthritis
Transient synovitis diagnosis
excluding septic arthritis and other serious diagnoses in children who present with a limp. They suggest:
fever is a red flag, indicating the need for urgent specialist assessment
children may be monitored in primary care (with a presumptive diagnosis of transient synovitis) ‘If the child is aged 3–9 years, well, afebrile, mobile but limping, and has had the symptoms for less than 72 hours
Transient synovitis management
Self limiting
Analgesia and rest
Whooping cough causative organism
Bordetella pertussis
Whooping cough immunisations
infants are routinely immunised at 2, 3, 4 months and 3-5 years. Newborn infants are particularly vulnerable, which is why the vaccination campaign for pregnant women was introduced
neither infection nor immunisation results in lifelong protection - hence adolescents and adults may develop whooping cough despite having had their routine immunisations
Whooping cough features
catarrhal phase
symptoms are similar to a viral upper respiratory tract infection
lasts around 1-2 weeks
paroxysmal phase
the cough increases in severity
coughing bouts are usually worse at night and after feeding, may be ended by vomiting & associated central cyanosis
inspiratory whoop: not always present (caused by forced inspiration against a closed glottis)
infants may have spells of apnoea
persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope & seizures
lasts between 2-8 weeks
convalescent phase
the cough subsides over weeks to months
Whooping cough diagnostic criteria
Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:
Paroxysmal cough.
Inspiratory whoop.
Post-tussive vomiting.
Undiagnosed apnoeic attacks in young infants.
PCR and serology or nasal swab culture
Whooping cough management
infants under 6 months with suspect pertussis should be admitted
in the UK pertussis is a notifiable disease
an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
household contacts should be offered antibiotic prophylaxis
antibiotic therapy has not been shown to alter the course of the illness
school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
Complications whooping cough
subconjunctival haemorrhage
pneumonia
bronchiectasis
seizures
Vaccine whooping cough
Women who are between 16-32 weeks pregnant will be offered the vaccine
