Paediatrics Flashcards
What are the components of the APGAR score and when is it performed?
Appearance Pulse Grimace Activity Respiration Performed at 1st and 5th minute of life
Outline the components of APGAR that would score 0 for each domain
Appearance: blue all over Pulse: absent Grimace: absent Activity: absent Respiration: absent
Outline the components of APGAR that would score 1 for each domain
Appearance: blue in extremities, pink body Pulse: less than 100 Grimace: only on aggressive stimulation Activity: some flexion Respiration: slow, irregular
Outline the components of APGAR that would score 2 for each domain
Appearance: pink all over Pulse: over 100 Grimace: cry on stimulation, coughs well Activity: flexes arms and legs, resists extension Respiration: strong cry
What are the ranges of a normal APGAR score?
8-10
List aetiology/risk factors for neonatal sepsis
Ascending infection from mother (chorioamnionitis) Group B Strep E. coli Coag -ve Staph H. influenzae Listeria Pre-labour membrane rupture Prematurity Parenteral antibiotics used in mother
List clinical features of neonatal sepsis
Seizure Stiff limbs Cyanosis Cap refill greater than 3s Temp less than 35.5 or over 37.5 Difficulty feeding Severe chest indrawing Resp rate over 60 Lethargy
Neonatal sepsis is defined as early onset if it occurs when?
First 48-72h of life, mainly due to bacteria acquired before and during delivery (Group B Strep)
What investigations would you order for neonatal sepsis?
Bloods: FBC, CRP, culture, glucose
Swab virology
LP for gram stain, cell count, protein, glucose
Urine and stool culture/microscopy
Outline management of neonatal sepsis
IV benzylpenicillin + gentamicin empirically
Vancomycin/teicoplanin/amoxicillin
List aetiology/risk factors for neonatal seizures
Reduced PaO2
Infection
Hypoglycaemia
CNS injury (haemorrhage, hydrocephalus)
Outline management of neonatal seizures
ABCDE approach, turn on side EEG and ECG monitoring IV phenobarbitol Phenytoin/clonazepam/lorazepam Pyridoxine
Jaundice after 24h is usually physiological. Why?
Immature liver can’t process high Br
Increased RBC breakdown
Starts at day 2, peaks at day 5, resolves by day 10
Visible jaundice on day 1 of life is always pathological. True/False?
True
List causes of jaundice on day 1 of life
Rhesus haemolytic disease
ABO incompatibility
G6P deficiency
Spherocytosis
Define prolonged jaundice in a neonate
Lasts over 14 days in a term baby or 21 days in a preterm baby
List causes of prolonged jaundice in a neonate
Infection Exclusive breastfeeding Hypothyroidism Cystic fibrosis Biliary atresia Galactosaemia
List clinical features of neonatal jaundice
Yellow tinge to skin/sclera Drowsiness Short feed Altered tone Seizures
What investigations would you do for neonatal jaundice?
Serum Br if less than 35w gestation or less than 24h old
Br using TCB if over 35w gestation or more than 24h old
FBC, blood groups and film
Coombs test (rhesus haemolysis)
Outline management of neonatal jaundice
Phototherapy using plasma Br treatment guide
IV Ig may be warranted
Exchange transfusion via umbilical vein/artery prevents further increase in Br
What is kernicterus?
Br -induced brain dysfunction
List clinical features of kernicterus
Sleepy Poor suck "setting sun" lid retraction Odd movements Cerebral palsy Deafness Low IQ
What is the pathophysiology of rhesus haemolytic disease?
RhD- delivers RhD+ baby and may produce anti-D IgG against RhD (isoimmunisation) if blood mixes
In subsequent pregnancy, these antibodies may attack a RhD+ foetus
List aetiology/risk factors for rhesus haemolytic disease
Threatened miscarriage
Antepartum haemorrhage
Mild trauma
Amniocentesis, CVS
List clinical features of rhesus haemolytic disease
Jaundice on day 1 of life Yellow vernix Heart failure Hepatosplenomegaly Bleeding CNS dysfunction Kernicterus Stiff, oedematous lungs Hydrops fetalis
Outline management of rhesus haemolytic disease
Keep baby warm Exchange transfusion Phototherapy Anti-D Ig for Rh- mother Hydrops fetalis: ventilate if required, vitamin K
What is neonatal respiratory distress syndrome?
Increased work of breathing due to insufficient surfactant, potentially leading to respiratory failure
List aetiology/risk factors for neonatal respiratory distress syndrome
Prematurity Maternal diabetes Males 2nd twin C-section delivery
List clinical features of neonatal respiratory distress syndrome
Worsening tachypnoea (RR over 60) Increased effort, grunting Cyanosis Nasal alae flaring Intercostal recession
Outline management of neonatal respiratory distress syndrome
Wrap warmly, incubator
Monitor ABG’s, give O2, support ventilation
Prenatal betamethasone/dexamethasone may prevent RDS
Give surfactant via ET tube
What is necrotising enterocolitis (NEC)?
Necrosis of bowel mucosa
List aetiology/risk factors for NEC
Prematurity
Weight less than 1500g
Enteral feeds
Mucosal injury
List clinical features of NEC
Abdominal distention
PR blood/mucus
Tenderness +/- perforation
Shock
What investigations would you do for NEC?
Faecal culture
Abdo and lateral XR shows loops of bowel
Crossmatch blood
Outline management of NEC
Stop oral feeds, continue breastmilk Probiotics may help Barrier nursing Metronidazole + penicillin + gentamicin or cefutaxime + vancomycin Laparatomy if progressive distention/perforation
What would be a sign of potential meconium aspiration?
Baby born in meconium-stained amniotic fluid
Define prematurity
Birth occurring before 37 weeks’ gestation
Pre-term: 32-37w
Very pre-term: 28-31w
Extremely pre-term: 23-27w
List aetiology/risk factors for prematurity
Previous preterm birth Multiple pregnancy Smoking + illicit drugs during pregnancy Early pregnancy (within 6 months of last one) Infection Cervix/uterus//placenta pathology Injury, trauma Maternal diabetes/hypertension Pre-eclampsia
Outline general management of a premature birth
Monitor airway and breathing
Keep warm - incubator, baby bag, radiant heater, skin-skin contact
Resuscitation if over 23 weeks
Low-pressure CPAP
How is a baby defined as being small for gestation?
Birthweight less than 2.5kg
Does vary
List aetiology/risk factors for being small for gestation
Constitutionally small Intrauterine growth restriction Malformation Twin pregnancy Maternal disease
What is Hirschsprung’s disease?
Congenital absence of ganglia in a segment of colon
List clinical features of Hirschsprung’s disease
Infrequent narrow stools
GI obstruction
Megacolon
Faeces felt per abdomen
What investigations would you do for Hirschsprung’s disease?
Barium enema
Sigmoidoscopy, biopsy of aganglionic segment
Stain for ACh-esterase
How is vomiting described in midgut malrotation/volvulus?
Bilious “fairy liquid green” vomit
What is gastroschisis?
Paraumbilical evisceration of abdominal contents
What is exomphalos?
Ventral defect of umbilical ring causing herniation of abdominal viscera
List clinical features of diaphragmatic hernia
Difficult resus at birth
Respiratory distress syndrome
Bowel sounds in hemithorax
Cyanosis
List aetiology/risk factors for cryptorchidism
Prematurity Small for dates Family history Hormone imbalance Maternal alcohol/analgesics/smoking Gestational diabetes Incomplete migration during embryogenesis
Outline management of cryptorchidism
Orchidopexy (fix within scrotum) early on in life
What is the commonest intra-abdominal tumour of childhood?
Wilm’s nephroblastoma
What is congenital adrenal hyperplasia?
Increased androgens cause decrease in 21-hydroxylase, causing decrease in cortisol and increase in ACTH, leading to hyperplasia and overproduction of cortisol precursors
List clinical features of congenital adrenal hyperplasia
Ambiguous genitalia Vomiting Dehydration Precocious puberty Hypospadius Cryptorchidism
What would levels of Na and K be like in congenital adrenal hyperplasia?
Hyponatraemia
Hyperkalaemia
Which drugs are used in adrenocortical crisis?
Fludricortisone
Hydrocortisone
What are orofacial clefts?
Failure of maxillary and premaxillary processes to fuse during week 5
Usually causes cleft lip and/or palate
List aetiology/risk factors for orofacial clefts
Genes Benzodiazepines Anti-epileptics Rubella Trisomy 18
List clinical features of foetal alcohol syndrome
Microcephaly Short palpebral fissure Hypoplastic upper lip Absent philtrum Small eyes Reduced IQ, learning difficulty Cardiac malformations Growth retardation Epicanthic folds
List the main acyanotic congenital heart defects
Ventricular septal defect Atrial septal defect Patent ductus arteriosus Coarctation of aorta Aortic stenosis Aortopulmonary window
List the main cyanotic congenital heart defects
Tetralogy of Fallot
Transposition of the great vessels
List clinical signs of ventricular septal defect
Harsh loud pansystolic “blowing” murmur
Thrill
Left ventricular hypertropgy
List clinical signs of atrial septal defect
Pulmonary flow murmur Widely fixed split S2 Cardiomegaly Globular heart (primum defect) RVH +- incomplete RBBB
List clinical signs of patent ductus arteriosus
Systolic pulmonary "machinery" murmur Collapsing pulse Thrill Increased S2 Failure to thrive
List clinical signs of coarctation of aorta
Systolic murmur at left back
Radiofemoral delay
Increased BP in arms
Rib-notching on XR
What are the components of tetralogy of Fallot?
Ventricular septal defect
Right ventricular hypertrophy
Pulmonary stenosis/RVOT obstruction
Overriding aorta
List clinical signs of tetralogy of Fallot
Ejection systolic murmur
Boot-shaped heart on XR
R-L shunt
Cyanosis
Which virus causes measles and what is the incubation time?
RNA paramyxovirus
Incubation 7-21 days
List clinical features of measles
Conjunctivitis
Koplik spots: “grain of salt” spots on buccal mucosa
Rash behind ear on days 3-5
Rash spreads confluently down body
Neck spasms
May lead to fits, meningitis, encephalitis, deafness
Outline management of measles
Isolate, ensure adequate nutrition
Continue breastfeeding
Treat secondary infection
Immunisation is 80% effective
Which virus causes mumps and what is the incubation period?
RNA paramyxovirus
Incubation 14-21 days
List clinical features of mumps
Infective 7d before + 9d after parotid swelling
Malaise
Painful parotid swelling
Fever
Which virus causes rubella and what is the incubation time?
RNA virus
Incubation 3-4 weeks
List clinical features of rubella
Infective 5d before + 5d after rash
Macular rash
Suboccipital lymphadenopathy
Which virus causes erythrovirus infection?
Parovirus B19
List clinical features of erythrovirus
Mild acute infection Malar erythema (slapped cheek appearance) Glove + stocking rash Arthralgia Aplastic crisis
Which virus causes hand, foot and mouth disease?
Coxsackie virus A16
Enterovirus 71
List clinical features of hand foot and mouth disease
Mildly unwell
Vesicles on palms, soles and mouth
No crusting
Which syndrome involves trisomy 21?
Down’s syndrome
List clinical features of Down’s syndrome
Flat facial profile Excess neck skin Dysplastic ears Muscle hypotonia Widely spaced toes High arched palate Simian palmar crease Brushfield spots on iris
Which syndrome involves trisomy 18?
Edward’s syndrome
List clinical features of Edward’s syndrome
Rigid baby, limbs flexed Low-set ears Receding chin Proptosis Rockerbottom feet Cleft Umbilical/inguinal hernia Short stature Fingers cannot be extended
What is the karyotype of Klinefelter’s syndrome?
XXY or XXYY
List clinical features of Klinefelter’s syndrome
Small firm testes Small penis Reduced cognition Reduced libido Gynaecomastia Delayed/reduced sexual maturation
Which syndrome involves trisomy 13?
Patau syndrome
List clinical features of Patau’s syndrome
Cleft Microcephaly Omphalocele Hernias Congenital heart defects Dextrocardia Capillary hemangiomata Polycystic kidneys Flexion contractures Narrow fingernails
What is the karyotype of Turner’s syndrome?
XO
List clinical features of Turner’s syndrome
Short stature Hyperconvex nails Wide carrying angle Inverted nipples Broad chest Ptosis, nystagmus Webbed neck Coarctation of aorta Absent/rudimentary gonads Delayed/absent puberty
List aetiology/risk factors for acute bronchiolitis
RSV
Mycoplasma
Parainfluenza
Adenovirus
List clinical features of acute bronchiolitis
Coryza before cough Fever Tachypnoea Wheeze Intercostal recession Poor feeding Dehydration Cyanosis
Outline management of acute bronchiolitis
Neb salbutamol +/- dexamethasone may help
Oxygen
NG tube support
Which organism causes whooping cough?
Bordetella pertussis
List clinical features of whooping cough
Apnoea
Bouts of coughing worse at night or after feed
Vomiting
Cyanosis
Inspiratory whoop
Subconj haemorrhage if persistent coughing
No fever or wheeze
What investigations would you do for whooping cough?
Nasal swab culture
PCR and serology
Lymphocytosis typically seen
Outline management of whooping cough
Erythromycin
School exclusion
Vaccination prophylaxis
What is cystic fibrosis?
Autosomal recessive mutation in CFTR gene on c7 that codes cAMP Na-Cl channel, causing impaired exocrine function and increased viscosity of secretions
List clinical features of cystic fibrosis
Meconium ileus as neonate Recurrent chest infections Clubbing Steatorrhoea Failure to thrive Malabsorption Short stature Delayed puberty
What investigations would you do for cystic fibrosis
Cl sweat test over 60 mmol/l
Immune reactive trypsin neonatal screen
Outline management of cystic fibrosis
Chest physiotherapy, postural drainage
Increase calories and fat intake
Treat organisms/bacterial colonisation
Pancreatic enzyme supplements
List features of acute severe asthma
Too breathless to talk/feed Use of accessory muscles to breathe RR over 30 (over 40 if under 5yo) HR over 120 (over 140 if under 5yo) PEF less than 50% predicted SPO2 92%
List features of life-threatening asthma
Silent chest Poor expiratory effort Altered consciousness, confusion Cyanosis PEF less than 33% predicted SPO2 92%
List clinical features of pyloric stenosis
Vomiting after feed, projectile NOT bilious Constipation/starvation tools Always hungry Olive-sized pyloric mass
What metabolic disturbance may occur in pyloric stenosis?
Hypochloraemic hypokalaemic alkalosis
Outline management of pyloric stenosis
NG tube
Pyloromyotomy
What is intussusception?
Small bowel telescopes by invagination, usually at ileo-caecal region
List clinical features of intussusception
Abdo colic pain Episodic crying Drawing legs up, pale-looking Blood-stained "redcurrant jelly" faeces \+- vomiting Sausage-shaped mass felt
Outline management of intussusception
Air insufflation works in most
Laparoscopic resection/laparotomy
List typical causes of bruising in neonates and infants
Haemorrhagic disease of newborn Haemophilia Thrombocytopenia ITP Birth trauma Congenital infection (Rubella) Accidental/non-accidental injury
What is fragile X syndrome?
Stretch of CGG repeats in FMR-1 gene on Xq27 results in cognitive impairment
List clinical features of fragile X syndrome
Learning difficulty Large, low set ears Big jaw Long, thin face High arched palate Big testes Hypoonia Autism
List clinical features of Noonan syndrome
Ptosis Webbed neck Pectus excavatum Short stature Pulmonary stenosis Down-slanting eyes Cardiac defects
List the main causes of bacterial meningitis
Neonates: E. coli, Listeria, Group B Strep
Children: H. influenza
Young adults: N. meningitidis
Adults: Strep. pneumoniae
List clinical features of meningitis
Unusual crying, poor feeding, vomiting Tense fontanelles Stiff neck (after 18mo), photophobia Opisthotonus Pink maculo purpuric rash Sepsis, shock, seizures Kernig sign: resistance to extending knee with hip flexed Brudeinski sign: hip flexion on bending head forward
What investigations would you do for meningitis?
Lumbar puncture
FBC, U+E, blood + urine culture, stool virology
Gram stain
What would CSF show in bacterial meningitis? (describe appearance, cells, glucose and protein levels)
Appearance: turbid
Cells: polymorphs
Glucose: less than 1/2 of blood
Protein: raised
What would CSF show in viral meningitis? (describe appearance, cells, glucose and protein levels)
Appearance: clear
Cells: mononuclear cells
Glucose: more than 1/2 of blood
Protein: low
What would CSF show in TB meningitis? (describe appearance, cells, glucose and protein levels)
Appearance: turbid/viscous
Cells: mononuclear cells, variable polymorphs
Glucose: less than 1/2 of blood
Protein: moderately raised
Outline management of meningitis
ABCDE, O2, fluids Benzylpenicillin before hospital Ceftriaxone + dexamethasone IV \+ ampicillin if Listeria Chloramphenicol if cef-allergic \+ gentamicin if E. coli
What is a febrile convulsion?
Single seizure typically lasting less than 20 mins, usually occurring in a child with preceding febrile illness/temp rise
Outline management/advice for febrile convulsion
Lie prone
Paracetamol syrup
Consider blood tests if worrying signs
Lorazepam/diazepam if unresolving
What organ is represented by a “sail sign” on a neonatal XR?
Wide mediastinum enables identification of the thymus
List all the respiratory conditions you can think of that may cause respiratory distress in a neonate
Respiratory distress syndrome Bronchopulmonary dysplasia Meconium aspiration Transient tachypnoea of the newborn Infection Pneumothorax Pulmonary hypoplasia Congenital diaphragmatic hernia
How does hypothermia lead to hypoglycaemia in a neonate?
Increased metabolic rate
Increased uptake of glucose
Increased use of glycogen stores
HYPOGLYCAEMIA
How does hypoglycaemia lead to hypoxia in a neonate?
Reduced surfactant production
Increased work of breathing
Respiratory distress
HYPOXIA
How does hypothermia lead to hypoxia in a neonate?
Increased metabolic rate Reduced O2 consumption Increased resp rate O2 demand greater than supply Anaerobic respiration Metabolic acidosis HYPOXIA
When does intraventricular haemorrhage typically occur in neonates?
Day 1 of life
May present within 72 hours
