Paediatrics Flashcards
What is the most common cause of neonatal infection?
Group B streptococcus = Strep. agalactiae
What are the commonest causes of neonatal jaundice to happen within 24 hours of birth?
- ABO incompatibility (more common, usually milder, DAT positivity, can occur in the first pregnancy)
- rhesus incompatibility (DAT positivity, can’t occur in the first pregnancy)
- G6PD
- sepsis
Early onset: can start in first 24h of life, but also on day 2 or 3
What are the commonest causes of neonatal jaundice to happen within 14 days after birth?
- biliary atresia (conjugated bili)
- breast milk jaundice (unconjugated bili)
Breat milk jaundice treatment: although stopping breastfeeding is the most rapid way to reduce bilirubin levels, in majority of infants, interrupting breast feeding is not necessary or advisable. The baby is usually well and the jaundice subsides by 6 weeks- 4 months
When should a child be referrel for delay in developmental milestones?
- unable to hold objects placed in hand by 5 months
- unable to reach for objects by 6 months
- not sitting by 12 months
- not walking, no speech by 18 months
- unable to put words together by 2 years
- unable to run by 2.5 years
What are the clinchers for cystic fibrosis?
Physiopathology: CFTR gene > abnormal chloride channels in the epithelial cells > abnormal fluid production > increased thickening of mucus > increases chances of pulmonary infections
Screening test: heel prick test
Diagnostic test: sweat test
Lungs and digestive system worsen over time.
Abdominal distention occurs from malabsorption.
Faltering growth if untreated.
Recurrent and persistent chest infections.
Management: chest physiotherapy to cleat the mucous, oxygen if low saturation, antibiotics in acute exacerbation or as prophylaxis in childhood, bronchodilators in patients with reversible component of airway obstruction
Common organisms
- childhood/ early teenage years: Staph aureus
- teenage years/ adult life: Pseudomonas
What is most common cause for eye discharge under 12 months?
Blocked nasolacrimal duct.
Treatment os massaging of the ducts and reassurance.
If a child has purulent discharge with either swelling of the eyelid or an injected conjunctiva, they must be seen in secondary care.
What are the directives for urological imaging in children?
BELOW 6 MONTHS OF AGE:
- USG always during acute infection (within 6 weeks) + MCUG if USG is abnormal
6 MONTHS TO 3 YEARS:
- no image if typical UTI
- USG if atypical UTI (perform during acute infection) or recurrent UTI (perform within 6 weeks)
- DMSA 4-6 months after infection if atypical or recurrent UTI; and consider MCUG for those
ABOVE 3 YEARS
- no image if typical UTI
- USG during infection if atypical UTI
- USG within 6 weeks if recurrent UTI + DMSA 4-6 months after recurrent infection
Remember:
- DMSA to look for renal scarring
- DMSA during an acute infection is always the wrong answer
- MCUG after 3 years old is always the wrong answer
For typical ITU above 3 years old, no scans are required. If patient remains asymptomatic after treatment, a repeat mid-stream urine culture is unnecessary.
Which congenital heart defect is mostly associated with Down syndrome?
Atrioventricular septal defect (systolic murmur)
What to suspect in a child with failure to thrive and iron deficit anaemia?
Poor nutritional intake or coeliac disease
How to calculate fluid ressuscitation?
For severe dehydration, correct with IV fluid (Hartmann’s)
IV bolus 10ml per kg
How to calculate fluid for maintenance?
Holliday-Segar formula:
first 10kg = 100 ml/kg/day
next 10kg = 50 ml/kg/day
remainder = 20 ml/kg/day
To calculate the rate (ml/hour), divide the total amount by 24kg.
In neonates, what are common causes of conductive hearing loss?
Conductive hearing loss: sound waves cannot pass from the outer ear to the inner ear, usually because of a blockage
Effusion from a middle ear infection can result in reduced transmission of sound to the inner ear.
In neonates, what are common causes of sensorineural hearing loss?
Sensorineural hearing loss: lesions in the cochlea or auditory nerve
Ototoxicity from aminoglycosides
Congenital infections such as congenital cytomegalovirus
What are clinchers for epiglottitis?
- rapid onset
- high temperature
- stridor
- drooling of saliva
- difficulty speaking
- muffling or chances in the voice
Summon the most experienced anaesthetist to intubate before obstruction occurs.
What are clinchers for pyloric stenosis?
- epigastric mass / olive-sized abdominal mass
- vomit after every feed
- constipation
Next step of action - serum potassium
Next most urgent investigation - serum potassium
Next step to help diagnose the condition - abdominal US
What mumur is characteristic of persistent ductur arteriosus?
Continuous “machinery” murmur, which is best heard at the left infraclavicular area or upper left sternal border
How to differentiate Von Willebrand disease, haemophilia and DIC?
VWD
- platelet-type bleeding (mucosal bleeding)
- aPTT prolongued
- bleeding time prolongued
Haemophilia
- factor type bleeding (deep bleeding into muscles and joints)
- aPTT is prolongued
DIC
- bleeding everywhere (venepuncture sites, GI tract, ear nose throat, skin: purpura)
- aPTT prolongued
- bleeding time prolongued
- PT prolongued
What are the features of Henoch-Schonlein purpura?
HSP
- purpuric rash
- abdominal pain
- arthralgia
One rare complication is intussusception, which can present as severe abdominal pain with rectal bleeding and fever.
When and how to treat primary enuresis?
Younger than 5y - reassurance
Older than 5y
- infrequent betwetting (less than 2x week) - reassurance
- if long-term treatment required - enuresis alarm (not suitable for patients with daytime symptoms) + bladder training + oxybuynin
- if short-term control required (eg: sleepovers) - desmopressin for 3 months (orally not intranasally)
Referral to secondary care or enuresis clinic if children above 24 months old + primary bedwetting + daytime symptoms
How does TCA overdose present in paediatrics? Which tests should be ordered for investigations and how should it be managed?
Presentation: child who takes unkown bottle of medication and later becomes lethargic
ECG: widened QRS, peaked T waves (indication of hyperkalaemia)
Investigations: urea, electrolytes, toxicology screen, ECG, ABG
Tt: sodium bicarbonate and correction of electrolytes
What are the clinical features and management of GORD?
CLINICAL FEATURES
- gagging or choking during feeds
- recurrent vomiting
- cries shortly after feeds
- faltering growth in severe cases
MANAGEMENT
- trial of thickeners (Carobel)
- alginates (Gaviscon)
- PPI (Omeprazole) for 4 weeks
How to differentiate GORD from cow’s milk allergy?
Milk allergy has additional clinical features, such as loose and frequent stools, perianal redness, blood or mucus in stool, pruritus, urticaria, angioedema
How to diagnose coeliac disease?
TTG IgA (tissue transglutaminase) positive
or EMA (IgA endomysial antibody) positive
plus IgA deficiency positive
if IgA deficiency is negative, request IgG instead
Also: alpha-gliadin antibodies positive
What is secondary enuresis, its causes and management?
Secondary enuresis happens when a child of any age, who has previously been dry for at least six months, is now wetting the bed consistently at night with or without daytime symptoms.
Causes could be emotional upset, UTI, constipation, or polyuria due to diabetes mellitus.
Management is referral to secondary care, for a paediatrician to further investigate.
How to differentiate ALL, AML, CML, CLL?
ALL (acute lymphoblastic leukaemia)
- children - up to 15 yo
- less acute onset
- gum hypertrophy
AML (acute myeloid leukaemia)
- adult 20-30 yo
- very acute onset
- gum bleeding
CML (chronic lymphocytic leukaemia)
- middle age 40-50 yo
CLL (chronia myeloid leukaemia)
- old > 60 yo
How to differentiate lymphangioma from branchial cyst in a neck mass?
Lymphangiomas (congenital malformations of the lymphatic system) are brilliantly translucent when subjected to light test.
How to differentiate Meckel’s diverticulum and intussusception in a child with painless rectal bleeding?
Meckel’s rule of 2
- between 2-3 yo
- mostly male
- approx. 2 inches long
- around 2 feet away from ileo-caecal valve
What are the clinical features and treatment of Scarlet fever?
CLINICAL FEATURES
- rash and fever caused by toxins released by bacteria (group A streptococcus pyogenes)
- sore throat
- widespread rash (starts on torso and 2 days later spreads to extremities)
- strawberry tongue
- cervical lymphadenopathy
- tonsils covered with pal exudates with red macules on palate (Forchheimer spots)
TREATMENT
- penicilin V for 10 days
What are the RED FEATURES of the NICE traffic light system?
They are a very effective way of identifying a child who needs admission or a face-to-face assessment.
- pale or blue skin
- unable to rouse
- continuous crying
- RR > 60 ipm
- moderate to severe chest indrawing
- reduced skin turgor
- fever > 38C in infants 0-3 months
- non-blanching rash
- bulging fontanelle
- neck stiffness
- focal seizures
What is Kawakasi disease, how is it diagnosed, and how is it managed?
KD is a febrile systemic vasculitis mostly in <5 yo
DIAGNOSIS
Fever > 38,5C for more than 5 days + 4 features below:
- conjunctivitis
- polymorphous rash
- extremity changes: erythema of palts and soles than later leads to desquamation
- mucous membrane changes: red, fissured lips, strawberry tongue
- cervical lymphadenopathy
COMPLICATIONS
- coronary artery aneurysms
TREATMENT
- high dose aspirin - reduces risk of thrombosis
- intravenous immunoglobulin - if given within first 10 days, reduces risk of coronary artery aneurysms
How to malrotation and volvulus present, and how to differentiate from intussusception?
Present with green, bilious vomiting, blood per rectum, sudden onset, “double bubble” sign with distal gas in abdominal X-ray.
Volulus happens in neonates, as intussusception most likely occurs in 6 months or older.
Also in intussusception, vomits are initially nonbilious, though they can later become bilious, and there is a sausage shaped RUQ mass in the abdominal USG.
When shouldn’t a neonate be vaccinated for varicella zoster if their mother develops it?
If the mother’s onset of rash is > 7 days before delivery or < 7 days post delivery, VZIG and isolation are not necessary.
Up until 7 days before birth, if the mother develops a rash, she will create IgG antibodies and transmit those through the placenta to the fetus.
Giving a newborn older than 1 week VZIG prophylaxis is not associated with better outcome.
What are the clinchers for innocent murmurs?
Mnemonic “S”
- sensitive (changes with position) or supine (hear loudest in supine position)
- soft blowing murmur
- systolic murmur
- short
- left sternal edge
What are clinchers for croup?
- barking cough
- stridor
- mild fever
- coryzal symptoms
Upper respiratory tract infection.
Caused by parainfluenza virus.
Peak incidence 6 months to 3 years.
Treatment: self-limited, recommended dexamethasone
What are the 5 most common childhood viral rashes, and how to differentiate them?
Common features: flu-like symptoms such as runny nose, cough, temperature 38C or above, sore throat, loss of appetite, swollen neck glands
Roseola
- sudden high temperatures
- non-itchy pink/red spots or patches on chest or legs
- spreads to the rest of the body
Parvovirus B19 (fifth disease)
- bright red rash on both cheeks (slapped cheek syndrome = erythema infectiosum)
- spreads to the rest of the body
- may be itchy, specially on the soles of the feet
Measles
- red-brown blotchy rash on the head or neck (often at the hairline and behind ears)
- spreads to the rest of the body
Rubella
- red/pink spotty rash which starts behind the ears
- spreads to the rest of the body
- very unlikely if had botch doses of MMR vaccine
Hand, foot and mouth disease
- painful ulcers on the tongue
- grey blisters on hands and feet
Management: paracetamol/ibuprofen + adequate hydration
When to worry - MENINGITIS
- non-blanching red pinpricks rashes
- quickly spread turning into red or purple blotches
- stiff neck
- bothered by light
- uncontrollable fever
BACTERIAL RASH - Scarlet fever
- Strep A bacteria (also cause of strep throat)
- flu-like symptoms
- rash appears 12-48 hours after flu symptoms
- small, raised bumps on chest, abdomen and limbs
- skin feels rough, like sandpaper
- tongue: white coating, strawberry tongue
- cheek: no rash, but can look red
- treatment with amoxicillin over 10 days
https://www.nhs.uk/conditions/rashes-babies-and-children/
